#1883 Take Your Hands Off It: The Settings
Jenny on why diabetes overwhelm means doing less, not more: basal first, stop fiddling, fix timing, and trust good settings enough to take your hands off. Part 1 of 2
Take Your Hands Off It: The Settings
Cold Open & Sponsors 0:00
Hello, friends, and welcome back to another episode of the Juice Box podcast. My diabetes pro tip series is about cutting through the clutter of diabetes management to give you the straightforward practical insights that truly make a difference. This series is all about mastering the fundamentals, whether it's the basics of insulin, dosing adjustments, or everyday management strategies that will empower you to take control. I'm joined by Jenny Smith, who is a diabetes educator with over thirty five years of personal experience, and we break down complex concepts into simple actionable tips. The diabetes pro tip series runs between episode one thousand and one thousand twenty five in your podcast player, or you can listen to it at juiceboxpodcast.com by going up into the menu.
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. The show you're about to listen to is sponsored by the Eversense three sixty five. The Eversense three sixty five has exceptional accuracy over one year and is the most accurate CGM in the low range that you can get. Ever since cgm.com/juicebox.
Today's episode is also sponsored by the Tandem Mobi system, which is powered by Tandem's newest algorithm, Control IQ Plus technology. Tandem Mobi has a predictive algorithm that helps prevent highs and lows and is now available for ages two and up. Learn more and get started today at tandemdiabetes.com/juicebox. The podcast is also sponsored today by US Med. Usmed.com/juicebox or call (888) 721-1514.
US Med is where my daughter gets her diabetes supplies from, and you could too. Use the link or number to get your free benefits check and get started today with US Med. Jennifer. Yes. Welcome back.
Hello. How are you?
Oh, you know how I am. I'm doing great.
You're good.
Welcome. You. That's what's important.
I'm doing fine. It's oh, it's summer has started. It's the last day of school.
Okay. Alright. Is this really the last day of school for your kids?
Yeah. They're done at half day today, and then they're done. It's the end.
Congratulations to them. Another year? I imagine they passed?
They they passed. Excellent.
I never knew. At the end of the year, I was like, not sure how this is gonna go.
Yes. They have passed. They have moved on. They have been we've been told that they are absolutely ready for the next journey forward next fall.
Well, I trust the teacher that said that, so I think you're gonna be fine. I do too. Do they have good teachers? Do you like them?
They do. We've yeah. They have exceptional teachers that are really fantastic.
Well, that's a
great age.
Great time great time in life. A lot I of am gonna just ask you a few questions.
Yay.
And then later, while recording with Erica, I'm gonna ask her similar supporting questions to the question that I asked you, and this will all make sense in a second.
So Fantastic.
Overwhelmed: Where Do You Start? 3:39
When it comes to diabetes care, when you see somebody who's overwhelmed, just overwhelmed, and we're talking about settings, what do you think that they should be looking at? And I know this is a very broad question. I really just want you to start talking. I'm not looking for you to say anything specific. So we've got overwhelmed people, and you look at their graphs, and they seem wonky, and it's hard to see what's going on.
What do you look at first? Just go ahead.
Sure. So first, I look to see if there is too much interaction, honestly. Right? Is it their interaction? Many times, those who are overwhelmed often are interacting too frequently and not trusting as we've talked millions of times already about.
They're not trusting the settings that are there either because they are poorly set by another practitioner or, you know, by them after not having great help from another clinician to get things set the right way. So they've turned knobs and adjusted settings, and then it becomes a daily kind of thing. So when I when I look at data along with somebody who's pretty overwhelmed, it's usually do things look like they could be easier by just dialing back? Not specifically dialing back insulin, but dialing back their interactions. Okay.
Right? The touch The manipulation is too much. So not only am I not getting a clear picture of what actually their system is doing, especially if they're using one of, you know, the automated insulin delivery systems we have now, but I can't also tell what the setting should be.
Okay. Do you think this would go for people who are MDI or just on a manual pump as well? Touching it too much usually one of the the keys?
Yes. Okay. Definitely. I think MDI is a little harder to evaluate mainly because unlike a pump where it captures all of the little ups and downs with insulin delivery. Mhmm.
MDI, you have to really rely on the person's account of what they've put in and where they've put in and how much it actually is. But the interesting thing about CGM data today is if you don't have a pretty nice looking flow over the course of a day, and it is really variable, like big roller coasters up and down, even with MDI, you can also get a sense that there's a lot more manipulation there than needs to be. And I don't mean manipulation like bad, bad, bad, like slap the hand, but it's more manipulation because they don't know what else to do. Okay. And they don't know how to smooth it out, which you can have smooth data with injections as well as a pump.
Okay. But it starts with knowing that your settings are in a good place. And to do that, sometimes you have to be willing. I think the willingness is the hard part to step back and see what the settings you have are doing Mhmm. To then step in and make a slight adjustment at a time.
Start With Basal 6:47
And, you know, we've all where do you start there? We've always talked before about where do you start? It's with basil.
Yeah.
Let's look at just the basil to begin with, and what does it look like it's doing?
Mhmm. So people can get into a situation where maybe they were set up incorrectly Mhmm. And then things bounce around, and then they go back and touch settings or add or subtract insulin in places. You get variability up, down, up, down, up, You start chasing. You get low.
You're eating food. You're going up. You're not bolusing again. This whole thing starts. At some point, you have to just stop, take your hands off it, see what it's doing, and then make an adjustment.
First adjustment, basil.
Correct. Okay. Absolutely. Because basil basil really does lead to enough background smoothing. And if it is not set well enough for you, absolutely all the other pieces can be thrown off.
Mhmm. Right? If you are planning to exercise first thing in the morning, for example, and there is no bolus in the picture, there's no food in the picture, you're just waking up and going out for a walk fasted, but your basal hasn't been tested, then you won't have any idea what to do with what ends up happening to the glucose shift Mhmm. During the walk or the run or the bike or the yoga or whatever, the soccer game, whatever it is. If you don't know the base, then how are you going to adjust the variables that you're adding in?
Right. When you finally see somebody get their basal right, do they stop worrying the touchers or do they just shift to something else?
Like, the touchers.
The touchers. That's not the right word.
It's a funny word, though.
I don't know. You should hear the thing in my head that I came up with next. I saw it's worse than that. So
The manipulator?
They're fiddling with it too much.
The fiddler. That's there you go. The fiddler. That's better. Yeah.
Fiddler is not the second thing I thought of. Seriously, like, when when you've got your hands in it too much and you finally meet somebody like you or you go to your physician, your physician says, This is all out of whack. Let's they're gonna tell you, like, let's basal test first. Right?
Mhmm.
And get basal nice and stable again. Do those people generally in your experience step back or do they just I'm trying to figure out if they're just fiddlers by nature. Do you know what I mean? Like or can they wait then to see the next thing? What do you what what's the experience you have with people?
I think it can go many ways, definitely. We all have a different perspective on where we want things to be. Mhmm. Right? And how we think about getting it there.
And there are people who are much more willing to say, okay. I can step back for a bit because I've been given direction now. Before, I had no idea. I had nothing to start with. You've given me some direction to get started and have that base, that foundation Right.
Hold me. And I think one of the places that basal adjustment helps things get a little bit easier, so to speak, is usually the overnight time.
Okay.
And that being a big complaint and a big reason most people love their CGM, if we can get that overnight well set, it then leads into where you start your day. Mhmm. And even if those basils in the day yet aren't quite right, if you've had a stable overnight, that leads you into starting the morning in a place that's not too high, it's not too low, extra insulin, that then you're you're gonna be less likely to manipulate or fiddle
Yep.
With extras right away in the morning. Okay. Extra carb, extra insulin. What do I do? Where do I, you know, titrate this?
Whatever. And as you can see then that flows through the rest of the day.
The Tennis Ball in Space 10:32
I also think that's where the overwhelm comes from too. Yes. Because you start adding all of these different, like, small decisions and they all knock you. I I I would think of it a little bit as like a you know, if you think about traveling through space, if I if, you know, if we could go out into space right now and just take a a tennis ball and just just let it go.
In a drift?
It's going to go in a direction forever and ever until something intersects it and knocks it off. And the more things that touch that tennis ball, the further off course you get. It's sort of how it seems to me. Like, go, well, I've learned I've gotta get up in the morning and bolus. Okay.
Fair enough. That works. But what happens if you're getting up in the morning having a couple of carbs, then you're putting in insulin, then you're changing the setting, and then you just keep touching that tennis ball, and we don't know where it ends up all of a
sudden. Correct.
Yeah.
Absolutely. And I I think there is a inherent desire to even if you weren't the controlling type of personality before diabetes was in the picture Mhmm. You usually learn to be controlling, and you can be controlling to a degree that's not healthy. And then and you can be controlling to a degree of just knowing healthy healthy habits.
Yeah.
And the control of those habits keeps things on that steady path. I love the idea of a tennis ball in space that's just floating around and never gets hit by an asteroid. Right? Like Straight line. Lovely.
All the way to forever. Forever.
Wherever it's going. But it our day is also in life not like that. There will always be some type of variable potentially thrown in even if you have the plan for the day set in front of you.
But you don't need to be one of them. But yeah. Yeah. Right. Right.
Yeah.
You shouldn't be the asteroid Mhmm. All the time or the the asteroid belt kind of always, like, ducking and dodging something. Because if you are, then that's where so much of your brain power goes.
Yeah.
And it can become really not only defeating, but it can be a huge energy sock.
I also think it just starts piling confusion on top of confusion because you don't see where it's coming from anymore. Yes. Honestly, it just feels like you're being shot at from all sides. You're getting hit, but you can't you can't hear the bullet, and you don't know which way it's coming from. And why is it, you know, it's it's on my left, it's on my right, it's above me.
And then then boom, you're overwhelmed, you shut down, and now you've shut down with bad settings. And, you know, and they're so wacky your doctor can't figure them out. You can't figure them out. What I'm telling you is that I see people because of these conversations I've been able to have, this feels like it could just be like a momentary problem. But if you get caught in that wrong trajectory, you could stay there forever.
Like, because I've seen it happen to people. Like, they just
Mhmm.
They become complacent in such that they feel like, well, this is just what this is. There's no getting out of it. There's no answer. I don't have an answer. The doctor doesn't have an answer.
This must be what diabetes is. Then the brain fog comes in and all the other stuff. And before you know it, you're just you're adrift. You know?
Right. It's constantly being on the defensive.
Yeah.
Really. Right. It's constantly waiting for the next, like, the next thing to hit, and then assuming you have the right trick in the bucket to pull out to hit it with so that you don't get sidetracked by that next thing, but that's not what ends up happening. So, I mean, settings in general base Basil to start with. Yes.
Right.
And then you really do have to take some time out to say, you know what? There are always going to be birthday parties. There are always going to be vacations. They're always going but not, for the most part, not day after day after day.
Yeah.
So make the effort to find something that has a structure in a couple of days.
“We Have to Start Over” 14:14
Yeah. When things would get out of hand with Arden when she was younger, before I even knew what I was talking about, I would say to my wife, we have to start over.
Yes.
I'm like, we have to stop and start over because there's too much happening right now. We'll never make sense of any of this. Mhmm. And that's where the ideas that I talked about in the podcast, you know, for all this time came from. Like, I realized I was like, okay.
Well, if the basil's right, a lot gets better all of a sudden. Right? Mhmm. Carb ratios work better. Sensitivity, you know, factor works better when when basil's right.
So let's get the basil right. And, you know, again, without a CGM, I don't know that I ever would have figured that out to perfectly honest.
Right.
So then, you know, we talked about what gets better when the basal's right. What gets better when your carb ratio is more accurate? Diabetes comes with a lot of things to remember. So it's nice when someone takes something off of your plate. US Med has done that for us.
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Ratios That Work (Until Vacation) 17:24
You have confidence with the majority of the things that are your day to day norm. Mhmm. Right? And as adults, there's not a heck of a lot of growth that ends up happening unlike kids. Kids settings will shift and change, not that adults won't, but less frequently, so to speak.
And if you do test within a time period to see that your carb ratios are in a certain place, then you can count on those ratios working for days, weeks, months at a time. They should really work. Where it gets thrown out is you test for two days on the apple first thing in the morning. You measured it. You weighed it.
You've got your ratio figured out for that. But now you go on vacation for the next week to wherever, and the apple is no longer your breakfast. And there are a whole host of other things in the picture. Well, this is where it doesn't mean that the ratio is wrong.
Right. It just doesn't work for this meal. It worked for the apple.
It worked for the apple and or it worked for your typical foods at lunchtime, your typical foods at dinnertime. And those ratios, there's a little wiggle room to them. Right? They're not hard set started set in stone. You're a one to 10.
I mean, right, there's a little bit of wiggle there. But in general, I think it's the other pieces that often end up had you been on a good trajectory of habit, you get thrown off by the variables of vacation, illness, digestion looks different, whatever. And then you come out on the other side of that thinking, well, now I have maybe bad habits coming out of that. I'm adjusting this way. I'm throwing in more insulin here because that clearly didn't seem enough or it was way too much.
And then on the back end when you're adding your apple back for breakfast, you don't trust it.
Yeah. It's an it is super interesting that because I've I've lived through it and I've talked to a bunch of people that have. It really should be just as easy as, I'm going to a restaurant now. This food is just gonna hit differently.
Yes.
I'm a very sedentary person, and I'm running around on the beach for the last five days. It's not a thing I usually do. Why am I getting low all the time? You should be able to just see it, turn it on, turn it off, but, boy, that's not how it works in people's minds. You know?
It's not.
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And, you know, outside of just the settings, there are settings once they are in a good place. There are adjustment strategies as well Okay. That you will typically also find advantageous. Right? And it takes experimentation.
This is not a one and done. Gosh. I tried this. It worked, and I'm gonna go forward and just use this all the time for exercise. Exercise of one thing versus another is going to require a different type of strategy.
But once the base is set, now you've got again that foundation. It's like very solid to build your strategy off of. Right. And then you don't end up making little nudges here and adjustments there and plugging in and adjusting that and taking more away, which again is just it's not purposeful and it makes it worse.
The Hardest Part: Pre-Bolusing 21:30
Guess the next thing to talk about, I think is maybe the most difficult part, again, based on conversations, but also based on watching my daughter, is pre bolusing a meal. It's incredibly difficult for people to remember to do. It's incredibly difficult to want to do. I saw Arden the other day. She just finished a college semester.
Yay.
Yeah. So she's she's so close right now. And so she slept in. And I was recording with somebody and somehow the conversation got around to, like, touching it too much, like, touching the CGM and looking too much and everything. I stopped and I said, I honestly don't know the last time I saw Arden's blood sugar.
It was, like, 02:00 in the afternoon at that point, and Arden's still asleep. And so I opened up my phone, and for the last I think it was five and a half hours, I apparently did look around 8AM, and I put in, like, point two or point three of insulin or something while she was sleeping. I mean, to adjust, a one ten blood sugar. You you know what I mean? And I just felt it I could see it was heading in the wrong direction.
I put a tiny little bolus in, and I didn't look at it again. And the person asked me, how did you manage to not look at it again? I said, well, my alarms haven't gone off. So it's in between 70 and for me, it's between 70 and one twenty. And I was like, so there's no reason to look.
The thing I expect is happening is happening, you know.
Right.
The person was, like, stunned. They're like, you're between seventy one twenty for, like, five and a half hours. Like, well, she's on automated system. Her settings are great. She's not eating.
She's sleeping. Like, you know?
Right. There's nothing happening.
I'm at the point now I with automation and good settings, I don't know how long you couldn't fast for, but
Mhmm.
I've seen it go for twenty four hours without a problem when somebody's sick or something like that. But nevertheless, she gets up and then 21 years old does not pre bolus enough for her food.
Right.
And I watch her blood sugar just go whoop. It's heading up. The algorithm's pushing back, pushing back, pushing back. She gets to two twenty. It comes back down again.
And I'm gonna tell you that I wish she would pre bolus, but that's still gonna be like a 6.4 a one c, you know, over over the long time. And to be able to just walk away from that and say that is a big step for me even because when I was in control of it, I would have thought, like, we cannot I don't want this to happen. And by the way, I don't want it to happen. I don't think it should happen. And if she would have pre bolus 10
It wouldn't have.
It would not have happened. Mhmm. But I also think she'll get there one day. Yes. And so and I've had conversations with people, Erica being one of them, about this topic.
And I asked her, like, I said it to her one day, like, why would I'm trying to wrap my head around, like, why would people with type one not just pre bolus once they know to do it? And she said, Scott, I have trouble doing that. And she's like, I've had diabetes for, like you and Erica are in a race. You both have had diabetes for, like, over thirty five years. Right?
And she was like, I've had diabetes for, you know, almost four decades, and I struggle with that every day. She's like, it's not a thing your brain wants to do or mine at least. So, anyway, when you talk to people about pre bolusing, I'm sure you explained that to them, but is there a way you can get them to it? Is have you figured anything out?
Some of the way is especially with those who are fiddling
Mhmm.
As much. Some of it's actually bringing up data and looking at it together in a framework of what are they eating, you know, if it's about the same like, I usually look at the same time of the day. Right? Focus in one place before moving on. And for people that are more visual, it's interesting to see how they react once you show them their own data and the timeline of the bolus and the carb entry both went in here, and your blood sugar is going up within five minutes or ten minutes of that entry.
I can tell without asking you. I can tell that there was no pre bolus there.
Mhmm.
The c I mean, the CGM data may not be accurate number wise all the time, but that trend line should be a really good friend.
Yeah.
It is telling you the direction your glucose is going. Mhmm. And that for many people, it's an eye opener of, well, gosh, how do I stop that? And for the fiddlers, it's I just add more insulin.
Mhmm.
I get add more. I add more. I'm like, this is not a more insulin because if we look at the data on a day where you were willing to hold your hands off
Yeah.
Did the blood sugar actually respond eventually and come back down? Then it's not a more insulin issue. Timing. Instead, this is timing. Yeah.
It’s Timing, Not More Insulin 26:10
This is you ate within five minutes of taking that bolus, and that was definitely noticeably not enough time. Mhmm. So let's let's do an experiment. Right? And, again, I would say most people are very willing to at least experiment with prebolising.
Try. Yeah.
And try to. Right? And once you start seeing progress and you start seeing that positive result, it builds positive reinforcement. Certainly goes a long way. Right?
It builds that. And for many people will then become enough of a habit that they keep doing it because they see the results that they want. And as we started out with, like, the overwhelm Mhmm. Drops down because they aren't having to follow-up outside of alarms Yeah. Wherever those are set.
And I would say that some people even then step in and say, well, maybe I'll adjust my alarms to be a little bit tighter so that I can take that overwhelming look at the data, look at the data, look at the data, do something about it. I can take it out of the picture because I've got my alarm set, if it goes off, then I need to pay attention to it. But, otherwise, my settings are doing what they should be doing. My ability to pre bolus or time this well, it seems to be working out. Mhmm.
Most of the time, it decreases that load of interaction.
Yeah. I don't know that we I because some people are great multitaskers. I don't know if you if you I've been looking into this lately, and I'll probably bring it up when I talk to Erica. The human mind can actually only focus on one thing at a time. Even when you think you're multitasking, you are swapping one thing out of the spotlight for another thing.
There's a a bubble around the focus of things that you can hold in your head, and it's only, like, three or four things. Like, so when you start thinking about actual life and then you add diabetes on top of it, that's already too much. You can't then go adding more stuff on top of diabetes. Like like, diabetes is enough already. Don't give yourself 50 extra things to think about.
Right.
Why People Won’t Pre-Bolus 28:17
I'm gonna try to figure my way through that. But back to the idea of pre bolus thing, I think it's interesting that I'm trying to understand the psychological aspect of the person who tells me, I know I could wait, but I don't want to. Like, I it's one thing if you're eating because you're getting low. I that's different. But if you tell me, I'd love to have a handful of pretzels tonight while I'm watching television.
Well, then grab a handful of pretzels, put the insulin in, and wait. Right?
Like Right.
That doesn't seem insane to me. I was like, but people's answer back, and this is the thing I'm gonna have to dig in with Erica a little bit, but I am gonna I wanna ask you from your perspective too. What is that, like, that feeling? Maybe you don't experience it of, like, I don't wanna be told what to do by diabetes because I think that's what it is after talking to people. Like, I don't want diabetes to dictate how I eat my damn pretzels, but I don't know if I'm right about that.
It's just me talking to people.
It's a situation of where are you socially in that moment.
Okay. Yeah.
I can definitely tell you that it is while I'm over the I don't care if I'm sitting here and everybody else is eating, like, that's well beyond me any anymore at this point. But I can understand the perspective of you grab the bag of popcorn or whatever from the cupboard, and you're gonna watch the movie, and it's starting right now. And you wanna dig into the popcorn. Yeah. Right?
I get that, and and I think it's harder to wait when you see everybody else is digging into that popcorn right now. And there is no there's no need for them to wait. There's no need for them to take anything else into consideration when you're the one sitting back and
Does it hurt?
And waiting.
Do you know what I mean?
It's an emotional feeling of just, I guess, you feel irritated that they can't wait for you. So I think there's a piece there. Like, why don't they just get, like, I'm not eating yet. Can't they just wait like that? Can we all do this?
And some families do. Mhmm. I will say that's that's the way that some families work it or they work the parents work the pre bolus in so that by the time they're all sitting down, the pre bolus has already been working, and then the child can start to eat with the rest of the family and whatever. Right? But I think there there is twofold.
And then there's the personal attack on yourself, like, and now I have to sit here and I'd really like a piece of popcorn. Right.
Also, and Erica Erica talks about that body grief too. Yeah. That sadness that your body doesn't do what it's what it's supposed to do or what you would expect it to. I should say too, for me, I could sit and wait, but I don't have any of those outside pressures. I'm not looking.
I don't have that feeling of, oh, I can't believe I can't just start. Like, I'm deciding instead of being told. Maybe that really is the answer. Hopefully, we'll come to a way to figure out their way around that. Yeah.
I have a couple more for you. Do you have time?
Okay. Yes. I've got some time.
What Automation Handles (and What It Doesn’t) 31:14
So if auto modes are supposed to carry, like, a little bit of a load, what's the algorithm actually handling, but what is it not handling? Where should our effort be put in, and where should it not be? Big question maybe.
So it is it's a really it's a big question because I I know that algorithm in general doesn't speak to the algorithms that are available. Each of them has their own set of rules that it follows
Yeah.
In terms of how it's going to step in and help to handle things with and for you. Right? I think a good example in this conversation does go along with what you said about what you watched with Arden the other day. Right? It's okay.
She didn't pre bolus when she got up. She wanted to eat right away. That's what she did. She's young. Her brain isn't fully formed yet in the track of I can do this because this is important.
Right? So she ate. Her blood sugar went up, and you watched. You you sat on your hands despite Scott in younger ages with a younger daughter, you would have stepped in and also done something. But you also have a couple of things in hand here.
One is an algorithm. That's an aggressive algorithm. Your algorithm, you trust the settings Mhmm. Because you know what she needs. And you could watch and you could wait knowing that despite not liking the 200 blood sugar that it was going to address it, and you wouldn't have to step in and help.
And it was also not going to cause her to go low.
Right.
So I think there are a couple of things to define within an algorithm. It's what kind of algorithm is it? How heavy handed can or can it be or how heavy handed could you set it up to be? Mhmm. Some of them are adjustable, others are not so much.
And then when we're talking about food, none of the algorithms will really hold your blood sugar without announcing food.
Yeah.
Across the board, DIY, the open source, as well as the FDA approved systems. What people adjust is their expectation of target range.
Mhmm.
That is what I have truly seen is parents who are stepping back from navigating with their teenagers and letting them take over and letting them figure it out with some of the set guidelines that they've done. They have to widen their their target range. They have to widen it and say, you know what? My kid isn't gonna pre bolus for thirty minutes. They're sitting down at lunch, and they only have fifteen minutes to eat.
School doesn't do anything because they don't step in and help anymore. My kid boluses as they walk to the to the, you know, cafeteria. But my settings are really good, and I'm okay allowing them to get to one sixty, one eighty because I know that the algorithm will carry it out as long as they at least announce the food.
Yeah. It's difficult to expect a a child or an adult, honestly
It is.
To do that. It is interesting when you're doing it for somebody else. Like, you brought up popcorn at the theater earlier. We'd be driving to the theater, I'd ask Gardner, are you thinking of getting one of those slushie drinks? And if she said yes, I just threw in 10 carbs in the car.
And then, like, as we were walking through the door, I bolus for, like, more, and then hit her, like, a third time when we sat down, and she wasn't gonna do that. You know what I mean? And I don't know that I wanted her to, to be perfectly honest. So No. Then there is a separation later when you have to say, well, they're their own person.
They're getting older, etcetera. When people are still doing things manually and they shouldn't have to be, like, what do you think that's them trying to protect themselves? Like, what do you see from people? Like, when you're going, god, stop touching it. Like, we got it set up.
Like, it should be working. What's the feeling you get back from people?
I get a sense from looking at so much data
Mhmm.
That what people are doing manually that steps outside of what they should be doing is much relative to expectation. And, again, kinda goes back to which a lot of this does is what is their target? What are they aiming for? What range are they aiming to stick in? And what are they willing to wait to see happen before they step in?
Right? They're doing a lot manually of a little bit a little bit a little bit. I see it across the board in a lot of the systems and even, you know, the open source systems that you can step in as a caregiver remotely and add a bolus or nudge it or enable something or disable something. Well, some of that's necessary depending on the situation you know is coming, but a lot of the manual manipulation, you're stepping in before you're even allowed the system to do something to help you. Mhmm.
You're not using the technology to your advantage.
Yeah.
And then you have to start thinking, well, do I have to go back to the basics? Am I doing this more and more and more recently because I don't trust my settings? Then, gosh, step back and reanalyze your settings. Yeah. Get back to just normal, you know, meals without going vacation meal and see is it the fact that I've been eating vacation meals more.
That's the problem. And my settings when I eat normal chicken and broccoli Right. Goodness. They look just fine.
I hope it's comforting to people to know that there's still times when I look and I think this needs, like, an extra unit and a half here. Mhmm. I think. But I gotta wait a minute to find out for sure. It's too soon for me to decide.
And the difference between now and ten minutes from now is not gonna be that big of a deal. There are just times I look and I go, oh god. Like, we got arrows up. This is all wrong. More insulin.
Blah blah blah. But there's also times I go, I feel like more insulin, but let's wait a minute and see. Or if I put in an amount here, is it an amount the algorithm can take away on the back end? Because then I'm not as scared.
Right.
Am I pushing it to a point where the insulin on board is gonna be too great for the algorithm's ability to take away basal later to balance it if necessary? That's happens pretty fast in my head, but it still pauses me sometimes. So I'm like, I'm not sure. You know?
And what you have and what all people should get to the point of understanding, and we've talked about many, many times, is just understanding your insulin action.
Yeah. Yeah.
Right? Because you have that in what you've just described, you can take the scenario happening right now. You can look at what's happening. You can say, give like a whole extra unit, but it's subconscious, honestly. It is.
The way that your brain thinks through
it Yeah.
Yeah. You can see what's already been happening. You know the algorithm that that Arden is using, and you can say, I can hold off because I'm either expecting in the next fifteen minutes of waiting that the system's got it and I'm good. Or if I am thinking in the direction that maybe we undercounted or maybe we misjudged or whatever that I could throw in an extra unit. And yes, based on her insulin needs, the system can subtract enough or suspend enough or whatever.
So it will catch it and I won't even need to step in there either.
Right.
But you have to understand insulin and how it works Mhmm. How to time it, and you have to understand your algorithm and what it's going to do and not do for you.
What “Done” Looks Like 38:41
Okay. My last question for you is MDI manual pump algorithm based system, doesn't matter to me. When you see somebody who has it set up and it's working right, their CGM is working right, you know the data you're getting back, everything looks solid, like, when you see that, what does that look like day to day life? Like, what does a well set up running system look like as far as people's interactions and their outcomes?
Right.
How do I know I'm in the promised land? I guess. You know what I mean?
Yes. How do you know that, like, there's not much work to hear to do here. Please be on your way
and come back. Yeah. How do I know I'm done? Yeah.
Yeah. Yeah.
Yeah. That that's my question. What's what's done look like?
And done being, like, short term. Yeah. Right for now. Right? You're done.
Right.
Right. Right.
It looks like, I guess, defined by the person's target range. Are they nicely rolling through that target range? Can you see where the meal entry was? Can you see where the bolus was? Does it look like there's a nice swing up that should happen if you are eating carbohydrates?
There is a bell curve that happens in the aftermath of a meal. You can see in the data where the insulin really took hold
Mhmm.
And the action of the system if they're using an automated system or even with multiple daily injections, can almost see the peak and the clearance of that and where the basal, which is well figured out in either scenario, where it caught that and then things just sat nice and stable for them.
Okay.
Right? So it is a lot more, I say, gentle rolling hills.
Mhmm.
And when I look at automated systems and the data, I can typically tell when somebody is stepping in mainly because when I look at their total daily insulin use, automated systems, especially the the open source systems, have little tiny extras in assistive that it pops in along the way. It's always giving and taking. All of the algorithms are Mhmm. Of any system. But you can see it's got tiny little nudges to things on their typical day to day, and it's smooth transition of data.
Okay.
Whereas larger boluses in between, and the frequency of those boluses that are not coming from a system generally tends to create a lot more jagged looking Up and down. The up and down. The true roller coaster, I say the Rocky Mountains, it's up, down, up, down, up, down kind of look. And those boluses are often much larger than what the system would auto populate in.
Yep. Okay.
And all of the systems also give I should not say all of them, but some of the, you know, other systems like Tandem, for example, the the Control algorithm. The nice thing about looking at the data is actually that it tells you when the bolus was overadjusted or underadjusted by the user. So Control IQ has automated give that it will pop in as needed as well as positive temporary basal changes. But anytime a bolus is requested based on a blood sugar, if the system was gonna give a bolus, it has information about whether that bolus was overridden or underwritten by the user.
Oh, nice. Yeah.
Which is quite nice.
Yeah.
So
Okay. We have all this as good as it can be. What are the things we can't fix? Like, what are things that are gonna happen even with great settings and even with great timing? Like, what are the just the, like, okay.
I have to just give myself over to like, what do you think of when I ask you that question?
What You Can’t Fix: Illness & Growth 42:28
Yeah. I think it makes me think of the times that you do have to do some fiddling. You do have to do some stepping in. Honestly, that's not incorrect. Illness, growth times where because you know that more is needed or less is needed.
Let's say illness, for example. More is needed, but the base settings weren't adjusted to accommodate for illness. Mhmm. So you may have to step in, and you may have to do things more frequently. And in that, I usually tell people to also get an idea of about how much did you nudge in or about how much did you pull back because going forward, at some point, you're going to get sick again.
Yeah. Something's gonna happen.
Right? And something's gonna happen, but now you have a base to use rather than just fiddling every fifteen minutes with more more more or adjusting with temporary rates or adjustments or whatever they are. Right. You can use that to have something to start with the next time. Gosh.
Last time I had a cold, I needed 10% more insulin. I use this much more in a temporary basal really helped. Great. That should mean you're not fiddling as much then.
Yeah. I can't thank you enough for doing this. I I like this is a different kind of conversation around stuff that we talk about all the time. Hopefully, it helps people think about a different way. I would urge people if any of this made sense to you and you wanna dig deeper into any of it, the pro tip series that Jenny and I made will probably help you walk it through, more granularly.
Yeah.
Wrapping Up & What’s Next with Erika 43:55
Yeah. So Awesome. Thank you very much. And then the next part that people hear either I've worked it out so that in editing, you've gone back and forth with Erica, or the next part right now is gonna be Erica kind of addressing the mental health side of, you know, some of these things. Questions like, you know, okay.
I've, you know, I've I've reduced the load on myself here, but I still feel overwhelmed. What can I do to help with that?
So No. I'm super excited that you're gonna add that piece in with this because I think that overwhelm is a real it is a real thing. And even with settings adjusted well, we have to also know, as we just talked about, how to address a variable and then getting off of that roller of adjustment again and finding some ability to step back and feel okay just settling.
And yeah. Yeah. I would like people to know and if you're comfortable sharing how you feel as we go out here, even though you're, I think, very good at this, obviously, and you've got a ton of practice and time and professionally and personally, you still feel that overwhelm too, I would imagine.
At times, I do. I think that my overwhelm is more relative to a busier life in general.
Mhmm.
Right? I compare my navigation before children to navigation now with kids that are really busy. Right? And being the taxi driver and the parent that does things at school as well as working full time and, you know, all of the things I think that that's where the piece of navigating almost like a third child. Right?
Could my consideration of diabetes is kind of like a kid that doesn't really grow up. You do have to still always step in and take care. There's more there to consider because as you mentioned, we can only have one or two things on our mind
Yeah.
To navigate in the clear moment. Right. And mom, I need this, and I didn't get that for the project and, like, whatever. And I'm like, I just really need the bowls for dinner. Yeah.
Like,
that's all. Jenny, what I hear you telling me is that diabetes is like a it's a child you have that never stopped in its pants. Is that what you're telling me?
There you go. You always have to you always have to change its diaper at some point. Yes.
Anyway, you'll know if you have a baby. I'll see you later. Jenny, thank you very much. I appreciate The conversation you just enjoyed was brought to you by US Med. Usmed.com/juicebox or call (888) 721-1514.
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- When management feels overwhelming, the first move is often to do less, not more. “Fiddling” — touching settings and stacking insulin all day — usually adds variability instead of removing it. Taking your hands off and watching what your settings actually do is a real skill.
- Basal first. A well-set basal is the foundation that makes carb ratios and correction factors work — if it’s off, everything downstream gets thrown off, and a stable overnight tends to set up a calmer day. Always test and adjust settings with your care team.
- The CGM trend line is your friend — it shows the direction glucose is heading. A rise right after eating usually points to a timing problem (pre-bolus), not a “more insulin” problem. Confirm any changes with your provider.
- Automated systems still need you to announce food, and changing manual settings in auto mode may do little. Knowing how insulin acts and what your specific algorithm does (and doesn’t do) is what lets you wait instead of over-correcting. Discuss your settings and targets with your care team.
- Some things can’t be “fixed,” only managed — illness and growth will need extra stepping-in. When that happens, note roughly how much you adjusted so you have a starting point next time instead of fiddling from scratch. Work those adjustments out with your care team.
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