Scott Benner 9/21/23 Scott Benner 9/21/23

#1007 Diabetes Pro Tip: Bump and Nudge

In this episode of the Juice Box podcast, Scott is joined by CDE Jenny Smith for the eighth installment of the Diabetes Pro Tip series, titled "Bump and Nudge." They discuss the concept of bumping and nudging blood sugars and its importance in managing type one diabetes. Scott emphasizes the statement that avoiding high blood sugars is key to maintaining good control.

You can listen online to the entire series at DiabetesProTip.com or in your fav audio app.

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

Scott Benner 0:04
Hello friends, and welcome to the diabetes Pro Tip series from the Juicebox Podcast. These episodes have been remastered for better sound quality by Rob at wrong way recording. When you need it done right, you choose wrong way, wrong way recording.com initially imagined by me as a 10 part series, the diabetes Pro Tip series has grown to 26 episodes. These episodes now exist in your audio player between Episode 1000 and episode 1025. They are also available online at diabetes pro tip.com, and juicebox podcast.com. This series features myself and Jennifer Smith. Jenny is a CD and a type one for over 35 years. This series was my attempt to bring together the management ideas found within the podcast in a way that would make it digestible and revisit double. It has been so incredibly popular that these 26 episodes are responsible for well over a half of a million downloads within the Juicebox Podcast. While you're listening please remember that nothing you hear on the Juicebox Podcast should be considered advice medical or otherwise, always consult a physician before making any changes to your healthcare plan or becoming bold with insulin. This episode of The Juicebox Podcast is sponsored by assenza diabetes makers of the contour next gen blood glucose meter and they have an amazing offer for you right now at my link only contour next one.com forward slash juice box free meter you can get an absolutely free contour next gen starter kit that's contour next.com forward slash juice box free meter while supplies last US residents only. The remastered diabetes Pro Tip series from the Juicebox Podcast is sponsored by touched by type one. See all of the good work they're doing for people living with type one diabetes at touched by type one.org and on their Instagram and Facebook pages. This show is sponsored today by the glucagon that my daughter carries G voc hypo pen. Find out more at G voc glucagon.com. Forward slash juicebox. Jenny Hello how are you? I'm good. How are you? Scott so good. Yeah. short episode going over the idea of bumping and nudging blood sugars, which is something we talk about on the podcast all the time. I'm a huge believer in the in the infuriating statement that you won't get high if you never get high. Sure, that's not as easy as it sounds. But that's how I think about it in my head. Right? So I want you to fight with a high blood sugar if I don't experience a high ledger. Of course, that's not always going to work. I'm not saying that. But I am saying that it's avoidable a lot of the time.

Speaker 1 3:05
I think of it as bumping and nudging just bumping and nudging it could be bumping that term. I love that. But I love it right? Yeah, you can do it with insulin can also do it with food. You can also do it with a deficit of insulin, which you can create with a Temp Basal. We're going to talk about it all right now.

Jennifer Smith, CDE 3:24
You can also do it with exercise.

Scott Benner 3:27
Do you know I just I just interviewed somebody who you won't hear for six months. But a girl who has had type one diabetes since she was a little kid and she's like she was so compliant, like with whatever her mom asked. So she needed like celery all there for blood sugar was high. But if she wanted, but if she wanted a cookie, she would go exercise and then come back and say to her mother, I just ran around the house this many times. So went up and down the steps this many times I would like my cookie now. And this is back. This was back when she was doing oh gosh, the words just slipped out of my head. What was the old timey insulin, regular insulin regular and mph? That's what she was talking pH. So back then she would do a little exercise to get her cookie. But you know this by the way, this girl is delightful. You have to find the episode with her.

Jennifer Smith, CDE 4:17
My, my mom would do the same thing with me. We're at my grandparents house, usually in the summertime for a couple of weeks. Usually at that time of the year. It was rainy, at least several days out of that time and I couldn't do anything outside. She would have me run around my grandmother's kitchen table and they had a pretty big dining room because it was a farmhouse. And I would literally my mom would be you need to run around. You need to move you need to move and I was like, okay, at that point. That's all move. You know, there'll

Scott Benner 4:47
be a snack after this. I guess it's all right. So yeah, yes. Okay, so, so basically, we'll start with this if you have a glucose monitor. You can't think about the alarms. The way you're thinking about them right now you have to your low alarm, you should put wherever you think you need to know like, whatever it gives you enough time to react, I don't care what that is, that's up to you completely ours is at 70. Some people put theirs at 60. You know, at whatever, I don't care, it's the high alarm that I care about. Because you need to be able to react to a rising blood sugar quickly, you react to it quickly, you're able often to react to it with less insulin, under percent, right, it takes less insulin to stop a 120 Diagonal up than it does to stop a 150 or a 180, straight up or 202 hours out. You could have avoided the problem that you're having now 45 minutes ago, if you knew it was coming, right, right, right now people will say, but Scott, I don't want this thing to alarm all the time. And it's gonna bother me and my kids at school, and I hear all your complaints, put them away. And here's why. Eventually, if you listen to these podcasts long enough, these concepts will lead to a world where you don't really ever leave your 120 blood sugar. So you won't get a ton of alarms. And on the days when that happens, I don't know mute your phone, but don't make a bad decision to avoid a problem that I think is avoidable. And so I know I've said this a million times, but it belongs in this episode. And I know I talked about driving a lot. But when you're driving, and you find yourself just kind of drifting off of the road, you don't turn the wheel 90 degrees to the left to avoid the curb. It's this almost imperceivable turn of the wheel, you're just nudging it back the tiniest bit. Yeah, that's how you avoid swerving into the oncoming traffic, because you've only turned it a little bit. This is how you stay off the diabetes rollercoaster. It is that simple, right? So you stop a rise before it can happen. And you use such a small amount of insulin that the likelihood of being low after you've done that is mostly imperceivable. Right? How much? Does that make sense to me? Where should this be on the Mount Rushmore of diabetes thoughts?

Jennifer Smith, CDE 7:10
I think it should be right there taught along with the early the early information of insulin use, it really should be, it should be it should be right there with when you're prescribed insulin. This is our target for high blood sugar should really in my professional opinion, it should be ratcheted down, we should not be being told that post meal blood sugars of 200 or 220 for kids is appropriate only because it's safe.

Scott Benner 7:47
Right and safe. And as much as you're not going to have a seizure.

Jennifer Smith, CDE 7:51
Correct? Correct. I mean, am I saying that you're aiming for you know, no rise at all? No, am I saying that you're aiming to to stay, you know, if you've been consistently rising to 250, and your alarm isn't set to 250, or 300, maybe you bring it down to 200 for a little bit, and then maybe you bring your high alarm down to 180, or you bring it down to 160. But as you do that, like you said, you're gonna see, it takes a lot less to address arise, then it does to correct a blood sugar that's already too high.

Scott Benner 8:24
And in the beginning, this will take more of your effort. But as time goes on, it takes nothing. It really does. I know sometimes I'll explode a Bolus out on screen when I'm doing a talk, right? And when you blow it up like that, and show all the decisions that were made you think, Wow, this does look like a ton of effort, right? So I always have to start by telling people what you're viewing up here encompassed about three seconds of my thoughts spread out over five minutes. Right, right. You'll spend more time in initially then, then you will one day. And so it's the same with this idea. I know it feels like if you set it at 120 it's always going to be beeping, but one day it won't be and And wouldn't you rather be bothered even on a on a bad day on a quote unquote bad day wouldn't shouldn't be bothered? Wouldn't you like to be bothered five times to bump a 120 back down? That might take up 20 minutes of your overall day than to be stuck in a 300 blood sugar and everything that comes with it all day long, right? All right, little bits of effort. Little bits of insulin, way better way, way, way, way better to avoid the highs because you can't get high if you never get high. You can stop it from happening. Does it always work? It doesn't always work. But mainly, I will say this, Arden spikes about twice a day. And it's timing stuff where we don't have the ability to do what we're doing. But when I tell you aren't in spikes, I'm talking about 150 170 You know, and we get it right back again. So imagine if you had to 180s or to 160s in a day and the rest was between 120 and 70. That's where you get an A one. See it's in the fives, right?

Jennifer Smith, CDE 10:15
Well for clarification to even about art and spikes, if not that you've waited until she's 170, to address it, but you've gotten the alert, the rise is happening, you've addressed it, you've probably taken a correction at like 120 or 130. Because you see the trend happening, she may still get to 151 70 before that insulin starts to working. But the curve down is probably more like an up down almost like a roller coaster. Right? But you're addressing it so that that ride down then is nice and smooth into the end versus staying way too high. And crashing from Bolus, Bolus, Bolus, Bolus, oh, no, I'm like 50.

Scott Benner 10:55
And because I reacted sooner, I still am keeping mainly the balance of the insulin action, carb impact. I'm still keeping them pretty well balanced. I obviously missed a little bit in the carbs. Got ahead. But I got back in the game soon enough that I'm not going to create a crazy low later. And then you come in for like a nice landing afterwards, which I somebody just texted me the other day and says, Can you please like, tell me what that means. And I always like I think, just put your hand up high, and then dip it down and then bring it flat again. And like that's sort of like this. That's what you're trying to make happen. Right? You're trying to come in the end

Jennifer Smith, CDE 11:27
of a roller coaster is what I explained. Yeah, kind of where you're the rush of that ride down and then you like roll into the station. Yeah, that's it exists nice and flat and smooth and perfectly

Scott Benner 11:37
bringing in for a nice landing. Right? So okay, so, so sure you can bump in nudge that way, right. But what if I'm at the tail end, for example of meal Bolus, and I'm noticing I'm 110 151 100, I'm starting to drift down. But I'm so far past this Bolus that I'm now in that space where people do the thing, they can just go, I hope this stops. Right, right? Wouldn't that be nice of this that what I like in that situation is a Temp Basal decrease, decrease, right, take away some of the Basal rates. So now Jenny can see me which is a little unfair, but I'm holding both of my hands together palm the palm, and I'm pushing it them. Basil is so important to think about like this on one side is the impact of your body and carbs. And on the other side is the impact of the insulin. And when you push at the same rate, no side wins, like I'm not going wildly one way or the other. Right. But all of a sudden, we get to a situation like I just described where, okay, the insulin is winning a little bit, right, the carbs that were there can't hold up the insulin that's left behind. So we start drifting towards a lower blood sugar, we'll just use your pump to tell it to use less insulin, take away a little bit of the force of that insulin has now maybe you'll catch it with a Temp Basal, and maybe you won't. But in certain situations, it's the best way to start. You know, I forever see people who are like, Oh, I'm heartbroken. I had to give my kid juice overnight. And you look and you see this 90 blood sugar that was just drifting down, that later, by the way, turned into a 180 because they put all this juice in. So you could have in that situation, if you really felt like you needed the juice bump with the juice, you don't have to drink the whole thing, drink enough to bring it back in for a nice landing. Or if you're far enough ahead of insulin impact. Try dialing back your your Basal and see if that doesn't catch it in your natural body functions don't kind of pull you back up again.

Jennifer Smith, CDE 13:38
And if you're in evaluation time period as just a kind of an aside in the overnight, if you give that little nudge with juice comes up a little bit and it drifts down and you give a nudge again and it comes up and it drifts back down. That's basil, you're in basil only unless you have a correction from earlier that brought you down so much. That's still working. Basal only that's a good you've got too much Basal. There's too much there, up, down, up, down, up down and it never stays stable. You got too much.

Scott Benner 14:11
The remastered diabetes Pro Tip series is sponsored by assenza diabetes makers of the contour next gen blood glucose meter and they have a unique offer just for listeners of the Juicebox Podcast. If you're new to contour you can get a free contour next gen starter kit by visiting this special link contour next one.com forward slash juice box free meter. When you use my link you're going to get the same accurate meter that my daughter carries contour next one.com forward slash juice box free meter head there right now and get yourself the starter kit. This free kit includes the contour next gen meter 10 test strips 10 lancets, a lancing device control solution. And to carry case but most importantly, it includes an incredibly accurate and easy to use blood glucose meter. This contour meter has a bright light for nighttime viewing and easy to read screen it fits well in your hand and features Second Chance sampling which can help you to avoid wasting strips. Every one of you has a blood glucose meter, you deserve an accurate one contour next one.com forward slash juice box free meter to get your absolutely free contour next gen starter kit sent right to your door. When it's time to get more strips you can use my link and save time and money buying your contour next products from the convenience of your home. It's completely possible that you will pay less out of pocket in cash for your contour strips than you're paying now through your insurance. Contour next one.com forward slash juice box for E meter go get yourself a free starter kit. while supplies last US residents only touched by type one has the back of people living with type one diabetes. Take for instance, their D box program touched by type one knows firsthand the intricacies of living with type one diabetes, and so their team has created a D box which is a starter kit that provides important resources and supportive materials to individuals with diabetes. They want you to thrive. The D box is completely free and available to newly diagnosed people. All you have to do is go to touched by type one.org. Go to the Programs tab and click on the box. While you're there. Check out all the other resources and programs available at touched by type one.org. Speaking of support, touched by type one.org is available in English and Spanish. Don't forget to find them on Facebook and Instagram too. You do not want to miss what touched by type one is doing. When you have diabetes and use insulin, low blood sugar can happen when you don't expect it. G voc hypo pan is a ready to use glucagon option that can treat very low blood sugar in adults and kids with diabetes ages two and above. Find out more go to G voc glucagon.com forward slash juicebox G voc shouldn't be used in patients with pheochromocytoma or insulinoma. Visit G voc glucagon.com/risk. I say a lot that if you find yourself when you find yourself boasting too often, your Basal is probably too low. If you find yourself out and doing to address in that situation too often with food, your Basal is likely too high. Right?

Jennifer Smith, CDE 17:41
Right. And you want to stop nudging as much as you can.

Scott Benner 17:45
We all want to go to sleep and nobody wants to drink juice in the middle of the night. And we're trying that's all the things we're trying to avoid right here. And I know a lot of it still sounds like oh, yeah, buddy, that. That sounds nice. But how do I accomplish this? I think that by now you're getting towards the end of this series. I think Jenny and I have laid it out pretty well, a couple of different ways here. So an important to remember. Because if you've ever spoken to me privately, if you've listened long enough, I will beat into your head over and over again. It's about timing and amount. It's about timing about even with basil. Even though you don't think of it the same way. Because basil doesn't all go in at the same time. If your Basal rate is too high, you have too much insulin and at the wrong time. So we've I've simplified diabetes down to like a handful of ideas that are sometimes so distilled, that even when I say them out loud, I go, does it just sound ridiculous to people when they hear it. But please trust me. At the end of this series, I'm going to go over all these ideas in simple sentences. It'll be a very short episode, you remember those sentences, apply what you've heard here. You're going to be on your way I you know, I can't promise but I swear I've seen it happen enough that I believe

Jennifer Smith, CDE 18:56
a little print off sheets got,

Scott Benner 18:59
oh, I don't want to give it away. Come back. I know.

Jennifer Smith, CDE 19:05
Well, the full full ideas are really behind all of those little simple statements. So if you had just a little simple statement, you're like, I don't even know what that means.

Scott Benner 19:12
And those reminders, I actually I use them too. So I've had times where I'm like what is happening? Because it's life, right? Like stuffs going on. You don't know like, why am I bolusing all the time. And I actually stopped myself one time and I remember standing in my kitchen thinking what would I tell someone if they asked me this? And I know that's ridiculous, but I was like, oh my god are basil needs to be increased. Boom. And there I was. I was like, Oh, that was so I should have listened to me. But like for days, I was like what's the problem here? So you're gonna you'll get those like simple ideas broken down into sentences that you can kind of repeat and keep in your head, you know that that'll should reignite the ideas that you heard in the podcast. Okay. So, to go over this again because in a different episode Do you need to think about how food affects your blood sugar? Sure, you need to think about how in some affects your blood sugar. Sure. But always to remember that you need to understand how the food affects the insulin so you can reverse engineer ideas. You're so used to thinking, I have this high blood sugar and I'm trying to force it down with insulin. Well, what if you have a low blood sugar and you're trying to force it up with food? I don't want to use too much. That starts us off on that roller coaster right we forget to believe that what we know is going to happen is going to happen we put in this food for low blood sugar, we shoot up now our insolence miss time, we eventually put in enough insulin it gets miss time with the food, the food now digest to your system. All the insolence left, you fly back down again, oh, my God, what do I do, I throw in more food than I wait and I get high. And then and then you start looking at the garage and thinking I just gonna pull the door down, start the car, put on my favorite album and go to sleep. But we don't need to do that. What we need to do is to bump and nudge with the food as well. And so this is crashing and nudging

Jennifer Smith, CDE 21:03
with the food might actually be a little different. If you know and pay attention to in those, let's say the drops where you're going to nudge with some food. Why is it declining? Is it truly basil, like we talked about overnight, right? Where you meet need a lot less nudge, little incremental nudge versus you've got three units of iob. And you're dropping? Yeah. And the drop is actually happening a lot more precipitously, right? You're really like coming down? Well, that little nudge of three sips of juice. If that's not the time to like nudge, you need a little bit more aggressive nudge than that.

Scott Benner 21:44
Yeah, I tell people all the time, if you see a 65 and it's really stable, and you want to try to check your basil law for half an hour to see if it comes back up right on. But if it's a 65 and dropping like a stone for the love of God drink a juice, eat a banana, shut your basil off, like like, you know, like you've really messed up somewhere so, but it's just not quite right. But the opposite idea that is not I'm gonna quote a mom that I spoke to. She said, Why did I always give the whole package of gummy bears? Why did I just automatically think because I opened the package. He had to eat all of the gummy bears. Why not two bears or three? Because 15 carbs? 15 minutes?

Jennifer Smith, CDE 22:21
15 carbs? 15 minutes. Right?

Scott Benner 22:23
Right. Bad advice you got from a doctor one time.

Jennifer Smith, CDE 22:27
And it was again, it comes to the safety. Right? It comes to the safety piece of this is an easy rip off. Non in the moment. This is just please do this because it will at least alleviate the law. Right? You'll be safe.

Scott Benner 22:42
It's jamming on the brakes 100 yards before you have to stop because you can't be 100% Certain you're gonna be able to stop but before you get 100 yards away because the doctor is not with you because they don't know the situation. Because they don't want you calling them on the phone every five minutes. Now I Bolus because I'm going to tell you when some people start explaining to me their bosses. I'm like, Look, I'm good at this. But that is hard to get straight in your head when someone's and you know, they're keeping something they're forgetting something. And so you're like, I can't make sense of this. Like show me a graph. Like when did you eat and sometimes they don't even know.

Jennifer Smith, CDE 23:15
Right? I like that's the reason I like little tiny like the Jelly Belly jelly beans, they're a gram of carb a piece. Skittles are a gram of carb apiece, they're an easy way to nudge with food in a accounted way. Rather than like sips of juice where you're like, I don't know, I might have had a bigger SIP or a little or SIP or a whatever my SIP might be the whole container. I don't know.

Scott Benner 23:41
I'm telling you again, Ninja like level of understanding, I can sometimes stick a straw on Arden's mouth from a juice box as she's drinking it. I just go and that's enough. And that's just something that comes with time, right? Like you're not going to figure that on day one. But the idea that it might not be all of it. And this and I alluded to earlier, it's gonna sound a little crass, but there are times when you just have to have the balls to wait. Like you can't just, you can't just over treat an 85 You know, what do you mean? Like I said it before, I've saw a woman online who told who once said that. That's a mom, and I'm sure she was scared out of her mind. I don't mean to make light of her. But she's like, I saved my kid's life last night with a juice box. And a kid was like 110 Diagonal down. I was like, wait a minute, you may very well have been on your way to the greatest night's sleep ever. You're never going to know right? And because this wasn't like what you were talking about. It wasn't like a big Bolus that was gone wrong. This was just like a drifting blood sugar. And I was like, Oh, you gotta wait the you know, you have to. And so let's talk about here like because we're gonna try to bump an agent in and out of an area. What is that area? And so, I mean, I'm sure to define your target. Yes. What is it you're going for? Right, like, I don't need Arden's blood sugar to be 85 constantly. I don't feel that way. But I don't like her blood sugar to be under 70. But I gotta tell you that if she drifts under 70 for a couple of minutes, I'm not running around looking for the glucagon, you don't even I'm like, let me see how I can just get this to kind of gradually come back up again. Same thing if she gets the 114. It said, Senegal, I really missed this. But you know what, now I'm only an hour and a half past this Bolus, I really do have to wait a second to see what's going on her or I have to decide I'm not going to look at this 140. And I may need to redress with food later. Right.

Jennifer Smith, CDE 25:35
Right. Right. So absolutely. And you know, that also speaks then to the benefit of now we've got the CGM, right, because with a CGM, you can see more often what's happening that 140 hour and a half after eating, it might be a stable 140 You don't know whether the next three blips are going to start a downtrend or they're going to start an uptrend or they're just going to kind of stay stable. So you have to really have that same thing with your 70 before if she's laying on the couch watching a TV program at 70. Okay, yes, she's not out running a marathon. She's not gonna go to the amusement park and walk around for four hours. She's sitting on the couch. Yeah.

Scott Benner 26:15
Even even when Arden is like incredibly active on a hot day playing softball, I still like a blood sugar right around 90. And so if I see 90 trying to get away from me, it's it could be just you know, you have a Gatorade with you take two splashes of Gatorade, then go back to the water, or, you know, have half of this juice box or are you hungry? You know, sometimes people are hungry. You don't think about it like that. Because you have diabetes, you always think about food as being this like surgical strike. But if you're playing you know, a sport, maybe it would be nice to take a bite of a banana every time you sat on the bench or something like that, right? Performance

Jennifer Smith, CDE 26:49
energy is different than blood sugar, strategy energy. For athletes,

Scott Benner 26:53
there's about 1000 different ways to think about bumping and nudging your blood sugar around so I want you to open your mind to it think differently. Try to really make sense of it. Jenny's got to go she's got a life. Okay, she's got she's got to work. And so I'm gonna let her go and say thank you. Absolutely. Always, always nice to me. I'll talk to you soon. I want to thank assenza diabetes for sponsoring the remastered diabetes Pro Tip series. Don't forget you can get a free contour next gen starter kit at contour next one.com forward slash juice box for E meter while supplies last US residents only. If you're enjoying the remastered episodes of the diabetes Pro Tip series from the Juicebox Podcast you have touched by type one to thank touched by type one.org is a proud sponsor of the remastering of the diabetes Pro Tip series. Learn more about them at touched by type one.org. A huge thank you to one of today's sponsors G voc glucagon find out more about Chivo Capo pen at G voc glucagon.com. Forward slash juicebox. you spell that GVOKEGLUC AG o n.com. Forward slash juicebox. Jenny Smith holds a bachelor's degree in Human Nutrition and biology from the University of Wisconsin. She is a registered and licensed dietitian, a certified diabetes educator and a certified trainer on most makes and models of insulin pumps and continuous glucose monitoring systems. She's also had type one diabetes for over 35 years and she works at integrated diabetes.com If you're interested in hiring Jenny, you can learn more about her at that link. I hope you enjoyed this episode. Now listen, there's 26 episodes in this series. You might not know what each of them are. I'm going to tell you now. Episode 1000 is called newly diagnosed are starting over episode 1001. All about MDI 1002 all about insulin 1003 is called Pre-Bolus Episode 1004 Temp Basal 1005 Insulin pumping 1006 mastering a CGM 1007 Bumping naj 1008 The perfect Bolus 1009 variables 1010 setting Basal insulin 1011 Exercise 1012 fat and protein 1013 Insulin injury and surgery 1014 glucagon and low Beegees in Episode 1015 Jenny and I talked about emergency room protocols in 1016 long term health 1017 Bumping nudge part two in Episode 1008 teen pregnancy 1019 explaining type one 1020 glycemic index and load 1021 postpartum 1022 Weight Loss one 1023 Honeymoon 1024 female hormones and in Episode 1025, we talked about transitioning from MDI, to pumping. Before I go, I'd like to share two reviews with you of the diabetes Pro Tip series, one from an adult, and one from a caregiver. I learned so much from the Pro Tip series when our son was diagnosed last summer. It really helped get me through those first few very tough weeks. It wasn't just your explanations of how it all works, which were way better than anything our diabetes educator told us. But something about the way you and Jenny presented everything, even the scary stuff. That reassured me that we could figure out how to deal with us and to teach our son how to deal with it too. Thank you for sharing your knowledge and experience with us. This podcast is a game changer 25 years as a type one diabetic, and only now am I learning some of the basics, Scott brings useful information and presents it in digestible ways. Learning that Pre-Bolus doesn't just mean Bolus before you eat but means timing your insulin, so that is active as the carbs become active, took me already from a decent 6.5 A one C down to a 5.6. In the past eight months, I've never met Scott. But after listening to hundreds of episodes and joining him in his Facebook group, I consider him a friend. listening to this podcast and applying it has been the best thing I have done for my health since diagnosis. I genuinely hope that the diabetes Pro Tip series is valuable for you and your family. If it is find me in the private Facebook group and say hello. If you're enjoying the Juicebox Podcast, please share it with a friend, a neighbor, your physician or someone else who you know that might also benefit from the podcast. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast. If you're living with diabetes, or the caregiver of someone who is and you're looking for an online community of supportive people who understand, check out the Juicebox Podcast private Facebook group Juicebox Podcast type one diabetes, there are over 41,000 active members and we add 300 new members every week. There is a conversation happening right now that would interest you, inform you or give you the opportunity to share something that you've learned Juicebox Podcast, type one diabetes on Facebook, and it's not just for type ones, any kind of diabetes, any way you're connected to it. You are invited to join this absolutely free and welcoming community.

#1006 Diabetes Pro Tip: Mastering a CGM

Understanding the value of CGMs is an important aspect of managing type 1 diabetes.

You can listen online to the entire series at DiabetesProTip.com or in your fav audio app.

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Scott Benner 0:03
Hello friends, and welcome to the diabetes Pro Tip series from the Juicebox Podcast. These episodes have been remastered for better sound quality by Rob at wrong way recording. When you need it done right, you choose wrong way, wrong way recording.com initially imagined by me as a 10 part series, the diabetes Pro Tip series has grown to 26 episodes. These episodes now exist in your audio player between Episode 1000 and episode 1025. They are also available online at diabetes pro tip.com, and juicebox podcast.com. This series features myself and Jennifer Smith. Jenny is a CD and a type one for over 35 years. This series was my attempt to bring together the management ideas found within the podcast in a way that would make it digestible and revisit double. It has been so incredibly popular that these 26 episodes are responsible for well over a half of a million downloads within the Juicebox Podcast. While you're listening please remember that nothing you hear on the Juicebox Podcast should be considered advice medical or otherwise, always consult a physician before making any changes to your health care plan are becoming bold with insulin. This episode of The Juicebox Podcast is sponsored by assenza diabetes makers of the contour next gen blood glucose meter and they have an amazing offer for you right now at my link only contour next one.com forward slash juice box free meter you can get an absolutely free contour next gen starter kit that's contour next.com forward slash juice box free meter. while supplies last US residents only. The remastered diabetes Pro Tip series from the Juicebox Podcast is sponsored by touched by type one. See all of the good work they're doing for people living with type one diabetes at touched by type one.org and on their Instagram and Facebook pages. This show is sponsored today by the glucagon that my daughter carries G voc hypo pen. Find out more at G voc glucagon.com. Forward slash juice box.

Jennifer Smith, CDE 2:25
What's on our agenda today

Scott Benner 2:26
we are going to talk about continuous glucose monitors.

Jennifer Smith, CDE 2:30
That's a big topic it is right.

Scott Benner 2:33
So I tell a story that I think is going to fit here in this episode. We were in my daughter's endocrinologist visit a long, long time ago, probably a decade ago. And the nurse practitioner asks me Are you going to get one of these CGM M's. And that's how new the whole idea was. And I said, I don't know what you're talking about, you know. And so she begins to tell me a story about this 17 year old kid in the practice, who loves m&ms but can't seem to eat them without a spike. So he gets the Dexcom, which I think back then would have been the seven plus maybe 10 years ago was that the first one with a seven seven.

Jennifer Smith, CDE 3:11
I know that in 2006 is when I got my first CGM and the seven was on the market, along with whatever came with Medtronic and then Abbott's navigator had come out. And that's actually the first CGM that I had. And I loved it. It was unbelievably accurate.

Scott Benner 3:29
Yeah, I remember that one, too. Yeah. So it probably was

Jennifer Smith, CDE 3:31
the seventh when

Scott Benner 3:32
you were there. And so she's telling us about this thing called Dexcom. I don't know what it is. I don't know what she's talking about. The letter CGM mean nothing to me. It's like Chinese, right? I just I was like, it could have been any language except English. I didn't know what she was talking about. But then she tells me this story. And she says that the boy gets the glucose monitor. And he goes home to the grocery store and buys those little single serving packs of m&ms. But he grabs seven of them. And the first day he goes home and he eats the m&ms as he always would, he puts in his insulin as he always would, and he watches his blood sugar go up. And it kind of stays up after that. So the next day, he thought, Okay, I must need more insulin. So it gives himself more insulin, his blood sugar goes up less. So the third day he thought he had it fixed. He's like, This is it. I just need more, but give himself more. He barely goes up at all, but then he crashes low later. So the kids like Okay, so the next day a little sooner, a little less, a little more. And he messes around back and forth, back and forth with this, and then she looks at me, I'll never forget the look on her face. Because she was astonished, right? And she goes, I saw his graph. He put his insulin in, ate the candy and his blood sugar never moved. And she's telling me a story about that. And all I could think in my mind was well if that's possible with that, then that's possible with anything. Like that's what I left with that feeling of like there's information coming back to me that can do that. That's amazing because I used to be one of those guys. People, we'd go into the, I don't really show them the pump anymore. But we used to go in and they download your data. They'd look at, you know, your boluses and all this stuff and where your blood sugar's were and she'd say to me, Hey, you tested she, you know, Arden ate lunch at noon, then you test it at 1230. She's like, why would you do that? And I said, Well, don't you want to know what's happening? Like, like, I want to know what's happening. So it was a number of years later that she she said back to me, she was I realized, now prior to you having a glucose monitor, she's like you were doing it yourself. Like you were trying to act as a glucose monitor. You were figuring out what was happening, which made sense to me back then.

Jennifer Smith, CDE 5:35
My finger sticks prior to CGM, on average were about 14 a day,

Scott Benner 5:41
I'd have to say that's where we were to, because I literate

Jennifer Smith, CDE 5:43
similar as you. I wanted to know where things were not only before, but especially after because it's a learning piece. Yeah, it's just like the m&ms. It's how did this work or not work? And what do I need to do to make sure that it works the next time because I like this, or I like to do this kind of exercise or whatever it is.

Scott Benner 6:03
I was so amazed. Just doing that just you know, it fried my mind back then like to test and go but but she went to 300. And then 45 minutes later, she was 340. But then she fell in like all that stuff. It was it was interesting information. It was valuable. But it wasn't enough. Right. Right. Like it was It wasn't enough to make sense. At least for me. I couldn't make sense of it still.

Jennifer Smith, CDE 6:25
Because you literally when you do finger six, then you have to do the connection of the dots yourself. Yeah. And I couldn't do nothing in between.

Scott Benner 6:32
I couldn't make that leap. I just couldn't figure out what, like what you're like those gaps. Like I couldn't figure out what it was. And it's not Jurassic Park, I couldn't just use frog DNA to fill in the gaps. Right? Because you see the gap. You see what happens and they're they're, you know, they're making babies by themselves. And it's just it's not good. But you don't want to fill the data in with something unknown is what I'm getting at. So I did as best I could. I heard her story. Oh, my goodness, I ran to get a CGM. You know, we got the Dexcom right away. I can still remember sitting in that we the endos office, right. And the nurse practitioner put it on for the first time and Arden didn't like it. And I remember breaking my heart. Like I remember thinking like oh, God did that hurt. You know and and now you know with the G six Arden Arden honestly says like, I can't even I don't feel it at all. Yeah, it just it's but back then, you know, there she was. Gosh, I don't know it'll four or five years old right? When you have diabetes and use insulin, low blood sugar can happen when you don't expect it. G voc hypo pen is a ready to use glucagon option that can treat very low blood sugar in adults and kids with diabetes ages two and above. Find out more go to G vote glucagon.com forward slash juicebox G voc shouldn't be used in patients with pheochromocytoma or insulinoma visit G voc glucagon.com/risk. There she was four or five years old, this little dress and she's so like sitting up on the table and trying to be tough and everything and oh, and it wasn't good. But we stuck with it. Because of what I was getting back from it. I just found it to be amazing. And now today, today, I think that if you're listening to this podcast and is of any value to you, I have to give half of the credit to the Dexcom. And the other half of it's on the pod like I I took those two tools and figured out how to use insulin with them.

Jennifer Smith, CDE 8:39
But you also have to give yourself a big part of that credit because you took tools. It's like any kind of tool, you could have a hammer as one of the simplest tools that there is. And if you don't put it to use. It's a great tool, but it doesn't do anything else for you except sit there.

Scott Benner 8:57
Well, you're very kind I was avoiding saying something nice about myself. But let's do that for a second. But let's let's translate it out to the people listening. My goal with this podcast is just to be your Eminem story, right? Like, I want you I want to hand you off tools that you then take home and learn how to become proficient with right I'm not I'm not gonna stand with you forever, Jenny can't come to your house, right? But we're gonna, we're gonna throw these tools. Somebody said to me once can you come live with me with me? I started thinking there might be a number or I'd say yes to that. But I don't know what it is exactly. How much would it cost for me to abandon my family? And guys, I'm leaving. But But But seriously, I genuinely mean that like you, you're gonna get these tools. You learn how to use them in situations and before you know it they work in more and more what you would have called complex or difficult situations is exactly the same thing. When people come to me and say, Sure this is great, but how does this work during hormonal time or during a growth period during illness or during you know, when your daughter is playing softball, I always say the same thing. exactly the same way. This tool

Jennifer Smith, CDE 10:02
makes me more comfortable, of course, right? Especially when I mean, we talked already about insulin. And it's actually, I mean, this tool shows you not only effective food, but more. So how to be more comfortable with insulin use. Yeah. No, it does.

Scott Benner 10:20
So not unlike the first time I thought about an insulin pump. And while everyone else was yelling, oh, you won't have to inject so much. I was thinking, Oh, I could manipulate the Basal insulin. Like that seems like the exciting part to me. And we CGM and you probably you've heard people say this before if you have considered a glucose monitor. But the most exciting thing about a CGM isn't the number that it shows you. I'm sitting here now Arden's blood sugar 75. She got insulin for lunch, I'm going to find out when 47 minutes ago, she was 9547 minutes ago when we put the insulin in. She's 75 now. So that's comforting to see that she 75. But what you don't hear me talking about when I tell you that is that there was a moment when she was 89 Diagonal down and she was drifting down. But she wasn't falling that fast. I could see how quickly she was falling. That's the information from the CGM. That's just mind blowing. Sure, she's going down. But she's going down at a speed I'm comfortable with based on the food that I know is going in, because that battle is about to start really happening, the foods really going to kick in. And the second. I love that she's drifting down at that moment, because you know, when lunch hits her, I like like, you know, we've talked about before, I like the insulin to have momentum. Right? If you think it's about the number you're misunderstanding the CGM. If you think about the m&m story, you have to know it's about timing and amount. It's about speed and direction. Right? Like, which way is my blood sugar moving? And how fast is it going? When you know that it's everything, it's the difference between treating a 75 blood sugar and leaving it alone. So I can see right now Arden's blood sugar is steady, which means I want you because

Jennifer Smith, CDE 12:14
the trendline is horizontal, and her arrow is probably horizontal. And

Scott Benner 12:19
that arrow is still telling you something, right? Like even being horizontal, it's telling you we're steady and Dexcom gives you the breakdown of what that means study could still mean plus or minus a point every five minutes. But great, you know what I mean?

Jennifer Smith, CDE 12:36
But it's happening so, so slowly, at that horizontal arrow, they usually say that it's less than a point a minute, right? And so and that's where to bring in that that angle, the arrow that you saw with the ad something blood sugar, I mean, had it been angled up or angled down, it's still the same rate of change, right? It's about one to two points per minute.

Scott Benner 12:56
Yeah, yeah, it's it right. And so when people talk about, Scott, I don't know I don't understand how you don't count carbs. So here's here's a way I don't count carbs. That remastered diabetes Pro Tip series is sponsored by assenza diabetes, makers of the contour next gen blood glucose meter, and they have a unique offer just for listeners of the Juicebox Podcast. If you're new to contour, you can get a free contour next gen starter kit by visiting this special link contour next one.com forward slash juice box free meter. When you use my link, you're going to get the same accurate meter that my daughter carries contour next one.com forward slash juicebox free meter head there right now and get yourself the starter kit. This free kit includes the contour next gen meter 10 test strips, 10 lancets, a lancing device control solution and to carry case but most importantly, it includes an incredibly accurate and easy to use blood glucose meter. This contour meter has a bright light for nighttime viewing and easy to read screen. It fits well on your hand and features Second Chance sampling which can help you to avoid wasting strips. Every one of you has a blood glucose meter, you deserve an accurate one. Contour next one.com forward slash juice box free meter to get your absolutely free contour next gen starter kit sent right to your door. When it's time to get more strips you can use my link and save time and money buying your contour next products from the convenience of your home. It's completely possible that you will pay less out of pocket in cash for your contour strips than you're paying now through your insurance. Contour next.com forward slash juice box free meter go get yourself a free starter kit. while supplies last US residents only time reached by type one has a wide array of resources and programs for people living with type one diabetes. When you visit touched by type one.org. Go up to the top of the page where it says programs there, you're going to see all of the terrific things that touched by type one is doing and I mean, it's a lot type one at school, the D box program, golfing for diabetes, dancing for diabetes, which is a terrific program. Just click on that to check that out, both for cause their awareness campaigns and the annual conference that I've spoken at a number of years in a row. It's just amazing, just like touched by type one touched by type one.org, or find them on Facebook and Instagram links in the shownotes links at juicebox podcast.com. To touch by type one, and the other great sponsors that are supporting the remastering of the diabetes Pro Tip series touched by type one.org. Sure I go historical I look at a plate and I say I think this is 10 units, right? But Arden had pancakes this weekend. Big homemade not measured pancakes. And I have a feeling that pancakes are going to be 12 units ish. So I double her Basal rate for an hour and a half. 15 minutes before she gets the pancakes her blood sugar is already 78 Then she's coming out of bed 10 minutes ish before the food starts. I do the 12 unit Bolus. But I take out one unit that I've added from the Basal right so now it's an 11 unit Bolus I extended out 80% Right away 20% over an hour. Now I'm creating kind of like that blanket events on like we talked about. Now if I get it wrong, I adjust. The most times I expect by getting it wrong means I won't even be aggressive enough. And I'll have to come back and bump it down again. When I see a diagonal up arrow 30 minutes after pancakes. I say to myself, ooh, I messed this up. Maybe I shouldn't have extended the Bolus or maybe I should have put more up front. But anyway, I'm going to bump that arrow back down again. In this situation last weekend. I was so aggressive that I had to bail on the Temp Basal rate. So about 45 minutes after Arden ate. She was 70 which was fantastic. But I was like I still have insulin going. I don't need any more clearly. So we cancelled the Temp Basal rate. And she wrote low forever. I mean, it was was great. 85 like right in there. Right.

Jennifer Smith, CDE 17:29
Healthy. That's not low. That's right. Healthy. She wrote health lower

Scott Benner 17:33
than you. Yeah, of course. I definitely misspoke. They're lower than you would expect after pancakes. Yep. But But I had a great blood sugar. Because I was able to use what the CGM was telling me and what the CGM was telling me was she was starting to drift lower from like 90, and I read that drift as these pancakes are through her now to enough of a degree that we shouldn't be going down anymore. Right. Alright, so I bail on the Temp Basal. I don't shut her Basal off, I just go back to the regular Basal rate. So we're going along like that for hours. I mean, hours and hours. Now there's nothing. There's nothing now I know the insulin is gone from the pancakes. Now I know the pancakes are definitely out of her body. And at some point, that arrow kind of diagonals down a little bit. And we were getting ready to go out to the mall, her and her friend. So I said to her, Hey, take your vitamins, the little gummy vitamins, they must have like six carbs and she pops her vitamins and we get in the car. The arrow kind of bangs back up a little bit again, right in that 75 area. So we get to the mall. And I'm like, Okay, I'm gonna ride this out to see what happens. Like, I'm not panicking here. But we were there for about 20 minutes or so. And I wasn't sure if like the excitement of the shopping was going to make her go up or not. And it didn't. She was walking around. And my wife and I left her alone. Went did something else. And I texted her at some point. Hey, I think you should shut your Basal off for a half an hour. And she did. And we stayed right at like at the whole time she was shopping without the CGM. There's just in my opinion, I don't know how to make any of that happen. Like maybe there's a way. But if there is a way you're listening to the wrong podcast, because I can't quite figure it out. Right, right. So I think those CGM are absolutely stunning. I want to know how you talk about using a glucose monitor with with your patients.

I want to know how you talk about using a glucose monitor with with your patients.

Jennifer Smith, CDE 19:36
One of the big things I usually say when people are really either considering one or they have been using one for a long time, they've may not really be using it to their benefit. Let's say they're looking like you kind of alluded to just the number, right? What's the number? What's the number? They're not learning from it because there certainly is some optimization when you start using a continuous monitor but of any form of technology. GM I have said this before, I mean, if I were to have to choose between a pump or a CGM, I would say please let me keep my CGM. Right, right. Because even then, if I had to go back to multiple daily injections, I can micromanage that as long as I know the direction of where things are headed. I can you know, and with a pump, then it just brings in more precision. So using a CGM, along with a pump is a another huge beneficial tool, you know, to management. So I guess as far as that it's really helping people to learn what is what's the benefit of that trend that they're seeing? And I think, in the end, many people I find, tend to overreact to the trend too. And you know, oh, my goodness, I you know, things are going up or going down? Well, you do have to make you have to make some considerations within that trend then to because have you just eaten? Is there a load of insulin here? Have you just exercise all of those variables that could be there? There a reason for some of that trend? That trend just like the guy with the m&ms, right. He knew something was going on with his m&ms. He didn't want to be high. So he was like, awesome. I'm gonna use this and fiddle with it and figure it out. So you know CGM is can give you that figuring piece that you don't have with finger sticks alone. I mean, you know, again, doing a million finger sticks before I actually had a CGM. per day, I was still missing all of the pieces in between. I was missing. When did it start to rise? Or when did it start to fall? Yeah, I know that I'm like, 40 points higher now than I was after I ate my meal. But why and where did the rise actually start? Right. So those are some of the biggest pieces. And I think getting people over the over the overreaction to the trending is something it's hard for many people to be able to try to say, okay, things are rising. You eight now let's do some self experimentation. Let's see. You know, is this happening today, around 80% of your most common foods, which most people have about 20 to 25 foods that are pretty common for them to eat over and over. Use your CGM to your advantage. That's 85% of your management then is figuring out and that's the reason that you have outside of not, let's say carb counting in the real sense of doing it. You have a sense just based on the meal because you've done it so much. You can say this should probably be about 12 units, or that's more about five units. I mean, Ginger actually does the same thing. She doesn't really carb count. Truly, she's like this green apple that I eat every morning with peanut butter takes two units. Yeah, you know. And using a CGM, then I think that's the biggest thing for management is the fingering that it allows.

Scott Benner 23:06
Yeah, so I think that you hear a lot of people in the beginning talk about like that anxiety, right? There was a huge concern in the beginning of CGM, a lot of old school people in the in the diabetes space were like, This is gonna make people crazy. They're just going to stare at that thing all the time. And that probably did happen to some people. But again, it's like I say all the time, like if you're looking at what's happening to your blood sugar and thinking of it as a mistake, that's your mistake. Right? It should be like let me experience this let me see what this is. Let me see what happens when I put the insulin in here versus in there. And that quickly died down i You quickly heard even some of the more ardent I don't know what to call them. But naysayers calmed down after a while, you know, and saw the value in it. I thought the most important thing was to explain to people that it's not just an alarm for when you're allowed. And I use that phrase in anytime I speak somewhere on this podcast. I say, Look, if you're looking at your CGM as a don't die alarm, you're making a huge mistake. But it is it is the it is the very least of what it does. And so I mean, it's cool that it tells you oh my god, oh my god, your blood sugar is getting really low really fast. That's amazing. Don't get me wrong. It's gonna it's gonna help can't

Jennifer Smith, CDE 24:15
turn one of those alarms off that it's always there. No matter how much you hate that, that noise. It's, it's there. The FDA

Scott Benner 24:21
tells them look under 55 We're gonna bang and we're gonna bang an alarm in people's ears and there's nothing they can do about it and fair fair, right? But that's what you're looking at it as it's incredibly short sighted. When people say to me all the time like Arden's tolerances are. Her low alarm is set at 70. And on my phone, her high alarm is 120 on her phone, it's 130. So I like to have a if she's raising up, I like to be able to think about it for a couple of minutes before I involve her in the conversation. I don't want her beeping at 120, right. But people say Oh, it must be all the time. It must be beeping constantly. And I'm like, No, it never beeps. And that's actually how Don't worry, I'll get back to my thought about moving down the hi Dexcom alarm after these messages from Omnipod and Dexcom. Let's start first with Omnipod. The tubeless insulin pump that Arden has been using since she was four years old over a decade now, choosing on the pod all of those years ago was, and remains to this day one of the best diabetes decisions that my family has ever made. And I'd like to tell you why. Without the pod, you do not have to disconnect for activity. With a tube pump, you'll have to take your pump off to play soccer or to go swimming to take a shower, you know, and if you're an adult, and you're having adult time, you might want to take it off for that too, but not on the pot on the pot is always with you. And why is that important? Because you're always getting your Basal insulin. It's a completely under appreciated idea. But when you take your pump off for half an hour, an hour, two hours to go play a sport, you're not getting insulin. And sure while you're running around, it might seem like oh, this is fine. But eventually you're going to experience a high blood sugar from that getting a constant flow of background insulin is incredibly important. And only Omni pod allows you to wear their device throughout your life without having to take it off for any of the you know, activities that you enjoy so much. I want you to go to Miami pod.com forward slash juicebox. Or to the links in your show notes or at juicebox podcast.com. You can do that today. And absolutely for free. And with zero obligation on the pod, we'll send you out a pod experience, get a free demo of the pod that you can actually hold feel touch, keep it in your hands, see what it is. And then where it you get to test drive it before you buy. It's a nonworking pod Don't worry, it doesn't have insulin or, you know, a cannula or anything like that. But it's an exact replica of what you'll be wearing. So you can feel the weight and the size and decide for yourself if you'd like to try it, my omnipod.com forward slash juice box. Now on to Dexcom. The Dexcom G six continuous glucose monitor is without a doubt, the Cadillac of continuous glucose monitors. Everything you hear me talk about on this podcast is predicated on the data and information that comes back from Ardens Dexcom G six, we don't need a big long ad for this dexcom.com forward slash juice box get started right now. You need to see what direction your blood sugar is going and how fast it's getting there. And you want to be able to see your loved ones remotely with an Android or iPhone. Come on dexcom.com forward slash juice box get going today. If you've been hesitant, please trust me when I tell you there's absolutely no reason to not move forward with Dexcom. There are links for all of the advertisers that juicebox podcast.com Or in the show notes of the podcast app that you're listening to right now. I implore you don't wait another second. Go to Bliss with Omni pod. Get the information you need from DAX calm and support dancing for diabetes.

Unknown Speaker 28:31
It must be beeping constantly.

Scott Benner 28:32
And I'm like no, it never beeps. And that's actually how the kind of this way that we talked about doing this here. This being fluid. It it makes diabetes a very much a very much a smaller part of your day because you're not thinking about it. Because when it does beep, you know, oh, it's trying to leave this tight range. I'll just bump it back down again. Right when you put that threshold up at 400 because you're like I don't want to hear this thing beep. Well, that means that by the time you think to look at it two hours later and your blood sugar's 280. Right now you're dead. Yeah. And now you've all this mistimed insulin. Now you're putting in a bunch of insulin to bring it down your insulin resistance so it doesn't work as well. Suddenly, you're going to be low later, later, you'll feed the low, you won't have the Bolus you get on the roller coaster. I'd rather know now I talk about it in a million different ways. I open bills. I don't think I can pay you on day one, because I want to know what they are right. I want to know when her blood sugar is trying to go over 120. And if you do that, there's a great episode way back in the podcast with a scientist from Dexcom. There was a study done the lower you lower your high alarm on your CGM the lower your agency goes yeah because you react sooner with less insulin stopping arise and staving off a future low because you're only using a tiny bit events when we talked about before you're gonna listen through these things again, they're going to make total sense to you. I want to address when people say why don't want to wear a bunch of stuff You know, some, some adults just don't want to wear things. That's fine. But I hear a lot of parents. I don't want to look at her. I don't want to look at him and see him attached to something I don't he's not a robot. He's not like that kind of stuff. Arden hated that CGM. The first day she put along right. And I wouldn't think she thinks twice about it anymore. Not even a little bit. She rolled out that she rolled out the door this morning for school. In a pair of leggings. You can see her CGM on her hip. She doesn't care. She's wearing a top that doesn't go all the way down to her to her belt, her her on the pod is sticking out like in that gap of space on her belly. She doesn't think twice about it. You can make those things normal and they will be you know, at some point. So I don't know for me, CGM is about reacting. And instead of, you know, appropriately

Jennifer Smith, CDE 30:51
reacting rather than, rather than being you're being proactive, really, if you have a CGM, you can be proactive, rather than having to always be reactive at the like you said, Have you CGM set at 400. And you're finally seeing it at 280. Because you're not feeling the greatest? You could have been proactive well above are well ahead of that, right.

Scott Benner 31:14
And that proactiveness, by the way, takes less time and less of your involvement than it does to be to 80. And fighting with it for hours after that. It seems it seems counterintuitive, because people say to me all the time, you must be so involved all the time. And I'm like, Man, I don't think about diabetes for more than about 10 minutes a day. You know, like on the really bad days, 20 minutes, but but I'm not mired down in it. Like there's no hand wringing in my house all day long, like staring at big numbers wondering when they're going to come down, or they're going to make lows. We just don't have that. I mean, don't get everyone. I'm generalizing to make my point. It happens sometimes, right? But but as a day to day idea, it is not something that occurs here. And I if you've heard me speak somewhere. In my slide presentation, there's a picture of Muhammad Ali standing over top of someone he's just knocked out. And I always start that part by going Has anyone ever been in a fistfight? And inevitably, it's always a little kid who's like, I have, like going off into the background. And I was like, Well, you shouldn't hit people. But but but you know, I tell people all the time, like you, you want to act, like like we talked about, you want to react, but really, you want to be able to act be first, right? You want to make a decision first, because besides stopping an arrow, there's the concept of cause and effect. Right? And there's this idea that, you know, people always run around yelling, well, that's just diabetes, every time something happens, they don't understand that was just diabetes. And I always say that when you're saying, well, that's just diabetes, what you really mean is, I don't know how to use insulin correctly. Right, right. Right. And so your blood sugar doesn't go up to 400. Because the diabetes fairy tapped you on the head. Like, there's a reason I don't know what it is. Maybe you might not know what it is. But there's a reason. So at the very least, if you act first, then with some some confidence, you can say that what happened next was a result of your action. At least you're not always covering your face in defense, like, like a boxer who just can't, can't get a punch anymore, right? diabetes is not pummeling you in the face. You you maybe you hit it too hard. Maybe you end up with a 65. You didn't mean to, but at least you know, wow, I put that insulin in here. And I got to 65. Next time, I'll use less. Next time, I'll do my Pre-Bolus, five minutes shorter, whatever it ends up being I don't know. Right? Right. But I'm a big fan of acting first, and then taking that feedback and making a better decision next time with it.

Jennifer Smith, CDE 33:41
Absolutely. And that's why I think it's, it's when you're especially if you're new to CGM, or starting out, sort of over with a CGM, or you haven't used it consistently on a day to day basis, because you have felt more frustrated about it, I think, if you get it down to some basics of use to begin with, and like you said, kind of tighten up those targets. Even if it's just a short time period, you can designate and say, Okay, for the next seven days, I'm gonna have my target set the high alert for 130 in the low alert set for maybe 70 or even 80. If you're hypo, you know, hypo unaware or you just really worried or whatever about the lower end, because tightening it up helps but also then fitting in more of your more more of your regular habits. In that testing time period, your typical foods, the things that you like to eat for breakfast or lunch or for dinner or for snacks. Because if you're committing to using something by applying it to your body, and you know being a robot, essentially,

Scott Benner 34:48
for a pound. That's right, exactly.

Jennifer Smith, CDE 34:50
If you're committing to using it, then get everything that you should be getting out of using it and there's

Scott Benner 34:56
a there's a way to start in my opinion. I'm interested in what you think But I think that when you first have a CGM on and you're accustomed to wearing it finally, you know what this information means. The first thing you do is you get your basil, right? Like to me it's basil. First, make sure your basil is right. And I tell people all the time, if you haven't had insulin or food for three or so hours, and your blood sugar is not 85, your Basal is not right. And so and so, if you're 180, or 200, shoot lower, I don't like don't shoot for 85 right away, shoot for lower and keep kind of just cranking it down and cranking it down. After you've got your basil. In a situation where you're staying pretty stable most of the time without getting low. That's then you can start thinking about Pre-Bolus. And then and then the CGM can really help you with that, too. If I'm 120 and I haven't had food or insulin for hours, when I put in some insulin here, how soon before I started seeing a diagonal arrow is it 10 minutes 1520. Some people say a half an hour, everybody's numbers different. So once your basil is right, and you can trust the cause and effect that I've Bolus now and it took 15 minutes, let's say for my blood sugar to start going down. Within reason trust that that's probably your Pre-Bolus 15 minutes right when your blood sugar is in range. Now keep in mind if your blood sugar is higher, you'll be more insulin resistant that Pre-Bolus Time won't be the same but but for the for the sake of the conversation. Now you have your Basal rate. Now you know your Pre-Bolus time. Now you can start using insulin. And being a little more aggressive with it. I've put a Pre-Bolus in I'm 90 Diagonal down, I've started to eat my blood sugar shot up. Now here's where the CGM becomes incredibly helpful. So you've you've got your insulin and you've eaten, but you're going up. Are you going up? Like a sharp a sharp incline, right? Or is it what I call the prices right? You know, the prices might the the which is at the miner, the climber, the gates like yo lay he and he's got the pic in his hand. He's going back and forth. And it's it's this very gentle grade that goes on forever. And you watch it the whole time. God, he's gonna stop, he's gonna stop. He's going to stop. Oh, he'll definitely stop. There's no way he's gonna fall off the edge. It's not gonna happen through the whole thing. And it just keeps going. That's that CGM line that it tricks you. Because you keep thinking it's not on a crazy incline. I'm not shooting up. I'm just climbing it's going to stop in a minute. But no, it's not. So not most of the time. Most of the time, I find a gentle grade up means not You almost got the amount, right. And your Pre-Bolus deficit. Right, right. And your Pre-Bolus might have been not quite long enough, right? The sharp up is a complete. I just thought the curse but it's a complete cluster. Like you have not you didn't have nearly enough Pre-Bolus And you did not use nearly enough food. So there is nothing about your Bolus that even gave resistance to that carb impact at all. So you can even

Jennifer Smith, CDE 37:58
more often with that arrow up more often it's a Pre-Bolus. Especially if you are using a ratio for your carbs and counting your carbs and whatnot. Most often, if you have a pretty significant quick, straight up or double up arrow, within 30 minutes, 45 minutes of a meal. There's a deficit there and or the deficit is more because you did not Pre-Bolus There wasn't time like that tug of war between the insulin that you said, you know, in a podcast before, there was not enough time to let insulin get the upper hand,

Scott Benner 38:34
right. And I'll tell you that that exact situation, that scenario you're describing. That taught me how to over Bolus. So once the first time I put in insulin and her blood sugar started to shoot up, I just made the leap. I was like I missed big time. And I didn't just put in like another half unit. Like I crushed it, I was like I'm going to stop these errors. If I have to feed them later, I will but I'm not going to let this blood sugar go up like this. And so I realized a meal that I thought was going to take five units with no Pre-Bolus needed eight units. And so that taught me in the future when I don't have time to Pre-Bolus I'll just give eight units for the five unit meal because I can create that action of insulin and overpower this even without a Pre-Bolus if I use too much, it's a little more I call it like that's definitely more of a pro level tip kind of a situation I'm like you're you're more of a more of a diabetes ninja. Once you're doing stuff like that i i Hold that up with the same ideas after you've had a 30 too low and you start coming back up again and you Bolus like when you're 50 Diagonal up like you're a ninja at that point. You're just like, right

Jennifer Smith, CDE 39:39
you're like yeah, I need a lot more because I know I ate 60 grams of carbon I really only needed like 50 and

Scott Benner 39:46
start knowing how much insulin to Bolus to overcome not Pre-Bolus thing again, you've been at this a while but I learned that from the Dexcom like I never would have liked so you know when you see those arrows Flying up? Not it's not what was me time, right? It's what is happening. But what what could I do next time? Over bossing is an incredible tool. So an over

Jennifer Smith, CDE 40:10
Bolus thing in the way that you're doing it is very I think we talked about this before probably is, it's actually what John Walsh from pumping insulin, he calls it a super Bolus, right, right. And he does it in a little bit more of a calculated way. He says, you know, you take the Bolus that suggested by your pump for the food that you're going to eat or the calculated, let's say, you said, Okay, she needs five units for this all the time. Well, today, there's no time to Pre-Bolus. And usually, you would have done a 20 minute Pre-Bolus For that five units. Okay, he says, You're then going to take the insulin and basil that's running behind that meal for two hours. And you're going to actually add it on to that five units, or whatever your pump is suggesting. So maybe if your basil is running at a unit an hour, that's two units of extra insulin, you're gonna pop that on top of the suggested Bolus. But then behind the scenes, and you probably do this a lot, too. With that heavier Bolus up front, you're like, I'm probably going to need to watch and do a Temp Basal decrease for a little bit after because I know that this is too much in the end result, right? We don't want to cause a low. He says to start by just taking the basil down to zero for about two hours. Yeah. And then evaluating I've got people use it and say, you know, I tried it. The Super Bowl is part of it works. But I don't need to turn my basil completely off. led to do a 50% Basil instead of 100% off. Yes.

Scott Benner 41:27
And that's where the Dexcom again comes in incredibly handy. You need it when you need it. You don't when you don't, right. And then I consider that idea trading Basal for Bolus, like there. There are times where I think, oh, Ardens you know, Basal rates. 1.4 an hour, I just Bolus a unit and a half. Listen, there's going to be a moment, right? There's a moment for everybody. And there's going to be a moment where you see the arrow up, put in the insulin, five seconds later, the arrow flattens out and you go, Oh, my God, I didn't need that insulin, right. That's when I'll trade the basil for the ball. So you

Jennifer Smith, CDE 41:59
can always say cut it out the basil off. Do you know that? Do you know that if you don't have a CGM, you don't know don't know when that transition was happening. Right? If you had none, and you were very aggressive about just finger sticking, you're like, oh my gosh, you know, 20 minutes ago, it was here. And now it's like 50 points higher. I have to slam this with more insulin. Yep. Awesome. But if you're not willing to do finger sticks, then like every 20 minutes after that, to see where things are going. You never know when that horizontal is coming, or when a downtrend is coming, either.

Scott Benner 42:30
Yep, I am right now texting Arden while you and I are talking. So what I say it has now been an hour and 12 minutes since she got her Bolus for her food. I got a little I didn't panic. But because you and I were talking and I could see what was happening. I shut off for the very tail end of her extended Bolus and her Temp Basal. Yep. And now she's 105 Diagonal up. I'm bolusing that, because I'm putting in the insulin that I bailed on from the extended Bolus and the Basal I should have trusted myself, right. And so instead, I'm putting it back again. And I will stop this diagonal up arrow around 115 120, she'll float there for a while, we'll come back down. I expect you to be at five by like an hour and 45 minutes from now.

Jennifer Smith, CDE 43:17
And the interesting thing about that, too, is what you're saying in terms of her management. And I know her agency has been like in the 5% for a long keynote for a long time. But the bigger beyond that, and we had a whole we had a whole we did a whole long podcast about eumc. And kind of what that all means right? But I think bringing in to the fact here CGM translates into that CGM, because what we're really hoping for is more gentle rolling hills within our target, rather than these major rises and falls of a roller coaster. And if you start to analyze your data in CGM, you can actually start then to be able to say, Okay, I need to tighten things up here. I've got an awesome looking a one C, but I have a huge what's called standard deviation, which speaks to the variability between highs and lows, right. So you may have this awesome looking a one C. But if you're going up and down, and you look like a big jagged, you know, roller coaster or mountain range, that's not helpful. Your standard D deviation value should actually be low, which means the variance between the highs and lows are also more gentle, rolling,

Scott Benner 44:29
rolling, rolling, right? And the way I found to say that to people is that if you were 350, and then 60, and then 350, and 60, all you're doing is tricking the a one C test if it comes back and tells you hey, you have an average a one C of seven, which you do when you average 60 and 350. Again, but you also have a you're also not living in a healthy way in any specific way. So don't let that number for you. And Jenny's right there is an episode called all about a onesie that she and I did probably more than a year or so ago. Yeah. And I'll link it in the show notes, you can find it. But I have Arden's last five days. And her. Her let's see, her average blood sugar over the last five days has been 114. She has been in range 56% of the time, which probably seems low, except that her ranges from 70 to 120. That's another thing you need to be careful of when you look at these reports. If you have your high set at 300, and your low set at 60, and you tell me I'm in range 100% of the time Well, I'm sure sure you are. Yeah, I mean, good.

Jennifer Smith, CDE 45:37
Standard deviation within that time and range,

Scott Benner 45:39
right? What what is that and standard deviations? Just a simple mathematical idea that I didn't understand in school and still don't understand now. But it's a basic, right? It's it's an average, is it an average of maybe it's a mean, I don't know. See, I didn't pay attention to math. You know, it's funny, you were talking about Walsh earlier talking about like all these ideas about like, over bowl, his Super Bowl is, and I call it over bolusing. And when I think about all I think about is more like the word more just pops into my head more insulin and a half. He's over there, like with his college degree being like, what you want to do is for two hours, and this is I'm like more?

Jennifer Smith, CDE 46:16
Right? But you've also figured it out. I mean, you're more is not a dangerous more. It's not a random more No, it's not a random you've figured it out in your you know, this is your diabetes may vary. You've figured it out in in Ardens diabetes, you know how much more to give, it's not like you're slamming in five more units you're like, she needs based on experience about a unit more, or she needs based on experience two units more based on what went in what has transpired up to this point.

Scott Benner 46:46
So people who listen to the podcast know that if this wasn't a special episode called diabetes, pro tip, continuous glucose monitor, I would just call it Roger Moore. Because you have no idea how many times I hear from people they're like, could you just make the title something about what's in and I'm like, No, I can't that's not fun at all. I want to talk for a second about what happens when you get your brand new, shiny Dexcom on and it tells you your blood sugar's 90, but then you test with your meter and your meter says your blood sugar's 140. niggle I don't know which one of these things to believe. So I think it's important to note that a CGM is measuring interstitial fluid around your meter is measuring your blood.

Jennifer Smith, CDE 47:28
Thank you for bringing that up. Yeah, both of them

Scott Benner 47:31
have an FDA requirement of only being within 20% of range. So if if a meter says your blood sugar is 100, it could very easily be 80, or 120, or somewhere between 80 and 120. As people living with type one diabetes, and the 2000 z's, you're gonna have to accept this is pretty much the best we have right now. And not to make yourself mental. So imagine that your CGM tells you you're 100. But it's off by 20%. High. So you're really 120. And your meter says you're 140. But it's really off by 20%. Low. So you're really 120. They both agree the numbers you're seeing don't agree. You can not spend a ton of time being upset about that. No, you have to pick something and believe in it. And I know that's crazy. But I tell people all the time, there's somebody online, it's like look at my meter says this and my Dexcom says this, and I'm like you're holding a brand new Dexcom G six in your hand. And a meter that was made 12 years ago. And you're telling me I believe the meter and I always asked him the same thing. Why did you decide to believe the meter over the CGM? Is it because you had it longer? Because it's testing blood? And that seems like something that's more accurate to you like what is the random thought your brain has had that's made you decide that one of these is more accurate than the other one? Which do you I test sometimes when I don't when I'm

Jennifer Smith, CDE 48:54
so really I mean blood glucose is the first line of glucose change it is first interstitial glucose follows blood glucose. And so with those random, you know, differences, most often I would say people on G five and G six, for the most part have pretty good accuracy finger stick to actual CGM, where I think a lot of discrepancy can honestly come in is from a finger stick value of let's say it's telling you 140. Right, and you're looking at your CGM, and it's 100. Well, as we kind of started out saying, it's not about the number on the CGM. It's about the trend. And like you do very often you're saying okay, now there's a trend going up, you know, you just bolused what you missed giving before because you started to see a trend up. Well, her fingerstick might actually be reflecting a higher glucose than what the CGM is showing right now because again, glucose changes first in your bloodstream screen. And so CGM is going to leg especially in those time periods of more significant glucose change such as after food or after or during exercise, that that can be a varying time. So finger stick 140, your CGM is trending up, or you've got an angled arrow heading up and it's telling you you're 102. And you're like, Huh, what do I do about this? The CGM just hasn't met yet the glucose value in the bloodstream, it will catch up, right? It will, it's just that it hasn't gotten there yet. Because really, if you think about the way that glucose sort of moves in a simplified form, it moves out of the bloodstream sort of has to move through insert interstitial fluid before it gets to the cells to get absorbed, essentially, I mean, that's simplified, but so your, your, your interstitial fluid is also always for the most part gonna leg, especially in special times, like food and movement.

Scott Benner 50:53
And I'll tell you to and to circle back around to the idea of the quality of your meter. Arden's had an on the pod forever, like since she was four, so she's going to be 15 Soon. Point is, that thing's been around a long time. It's got an old freestyle meter in it. They've always been kind of wonky. And now we're using the Contour. Next One, it's the little tiny meter that's going to start calling accurate on the market. Yep. So when Omnipod decided to switch over to dash, which should, you know, you might be listening to this, and dash might be a thing already, but it's about to happen. They're gonna offer you a free Contour Next One meter to come with it. So I've been using it for a few months to get my head around it. It's spectacular. Like what a great accurate meter. It's absolutely insane. Like I just compared to what was in that PDM. It was nuts. how much better it was? Well, and this brings

Jennifer Smith, CDE 51:47
up for the people to who might still be using a G five, or a CGM. That requires calibration. What you calibrate with. Yeah, that really makes accuracy on the CGM hold better,

Scott Benner 52:01
right? Right. And if you're calibrating with a Band Meter, say you have a G five, it still asks for calibration. And the G five says it's 90, but you've tested with a 10 year old meter, it's like it's not it's 150. What if you really are 90 and now you're telling the G five everything you think is wrong? You're 150. But the algorithms like that's not right, we're nine. And did you confuse it? And then it blows up?

Jennifer Smith, CDE 52:23
Three, three, question marks for three hours. You're like, calm down,

Scott Benner 52:26
and then you go this something wrong with a CGM? Actually, no, it was you, you put the wrong information. And so none of this technology is obviously Perfect, perfect. But again, I always like to say you're not boiling your urine to find out what your blood sugar is. So you're doing right, yeah, right. You're doing greatly. i All I can say for sure, as we as we kind of come up on the end here. And I'm gonna ask you to kind of sum up in a second. But what I can tell you is that, as I've said, before Arden's a once he has been between five, two and six, two for five solid years. And it's going to be a lot to do with the tools that you hear is talking about here on the podcast and how I've learned to implement them. But how I learned to implement them was the information coming back to me from ordinance glucose monitor. So if you have an opportunity to get one, and I know they're not covered by everybody's insurance, and they can be expensive, but if you can get one you absolutely in my opinion should do absolutely will just change your life. So Correct. Yeah.

Jennifer Smith, CDE 53:20
I 100% agree. Yes.

Scott Benner 53:22
Did we forget anything? Because at this point, people who listen, probably aren't surprised. But I don't pretty play on these with Jenny. She put on her headphones. She goes, what are we talking about? I'm like CGM. And she goes great. And then we just started talking. But But again, I like the way these conversations flow. So Did I forget anything? That is like wildly wrong?

Jennifer Smith, CDE 53:43
I don't think so. I, I do think that if, I mean, this is just from an education standpoint, your own education with your CGM. If you really need some pointers, I mean, it's helpful to look or ask more of your care team. You know, if you do need some pointers, some some endos. And CDs are really awesome. Some don't know much more than just telling you how to slap it on. But look beyond I mean, because there is there's a wealth of of benefit to knowing. And some of it is self experiment, experimentation. In fact, I think a lot of it's self experimentation. But if you need some help with looking at things, I think searching out somebody can be helpful.

Scott Benner 54:27
Yeah, yeah, somebody who can look at the graph and just make sense of it in a second. We've talked about before I can at this point, I can look at someone's three hour graph and go, is this where you're putting the insulin and they're like, how did you know I'm like, Yeah, because it should have been here. And it wasn't enough and this would have stopped that and like, it's pretty easy to see after you can see it right. It's like those, you know what it's like, it's like those posters that you look at it. You're like there's somebody tells you it's a tree and it's a sailboat and you stare at it long enough, it turns into a tree. I think that's what happens like after you look at it long enough. I don't People can get scared of the idea of data. I don't like the word because I think it I think it scares people off. Like, you need to understand the data. Well, that sounds scary to me. It does, right? Right, there's a little line on your thing. Okay, that line tries to go in a direction, you look and see where you put the hands on. And you see how harshly the line tried to go in that direction, you make a better decision next time.

Jennifer Smith, CDE 55:20
You know, I think that actually brings in one point that we may have missed is that, especially Dexcom does allow you to use event markers. So if you are really wanting more, you know optimization, and you're the only one who can really look at your your lines and your info. Using the event markers. I know in G six at the at the bottom of your at least your screen on your on your phone app, you can just choose events, you can log things like food, or exercise or illness or even alcohol and like your your cycle or monthly and all that kind of stuff. It'll put little marks on your actual trend graph. And that way you can make more sense of the if you're again, the one that's really trying to look back for what what happened, why did it happen, you

Scott Benner 56:08
don't have to remember that I ate lunch at 1130 You can just say food and maybe the amount of carbs and make a note about what the food was. Right? And that helps you when you look back. See again, that's well more way better thought out than I can ever be. But that makes a lot of sense. And that's why you're here. You're the you're the smart part of this conversation. I'm the chit chatty part of the conversation.

Jennifer Smith, CDE 56:30
We're both important for reasons. Yeah,

Scott Benner 56:33
I'm pretty sure that's true. Okay, I think you'd have to go in a couple of minutes, right? So I'm gonna let you go now and say goodbye. I want to thank smz diabetes for sponsoring the remastered diabetes Pro Tip series. Don't forget you can get a free contour next gen starter kit at contour next one.com forward slash juicebox free meter, while supplies last US residents only. If you're enjoying the remastered episodes of the diabetes Pro Tip series from the Juicebox Podcast you have touched by type one to thank touched by type one.org is a proud sponsor of the remastering of the diabetes Pro Tip series. Learn more about them at touched by type one.org. A huge thank you to one of today's sponsors G voc glucagon find out more about Chivo Capo pen at G Vogue glucagon.com forward slash juicebox you spell that GVOKEGLUC AG o n.com Ford slash juice box. I hope you enjoyed this episode. Now listen, there's 26 episodes in this series. You might not know what each of them are. I'm going to tell you now. Episode 1000 is called newly diagnosed or starting over episode 1001. All about MDI 1002 all about insulin 1003 is called Pre-Bolus Episode 1004 Temp Basal 1005 Insulin pumping 1006 mastering a CGM 1007 Bumping nudge 1008 The perfect Bolus 1009 variables 1010 setting Basal insulin 1011 Exercise 1012 fat and protein 1013 Insulin injury and surgery 1014 glucagon and low Beegees in Episode 1015 Jenny and I talked about emergency room protocols in 1016 long term health 1017 Bumping nudge part two in Episode 1008 teen pregnancy 1019 explaining type one 1020 glycemic index and load 1021 postpartum 1022 weight loss 1023 Honeymoon 1024 female hormones and in Episode 1025, we talked about transitioning from MDI to pumping. Before I go I'd like to share two reviews with you of the diabetes Pro Tip series, one from an adult and one from a caregiver. I learned so much from the Pro Tip series when our son was diagnosed last summer. It really helped get me through those first few very tough weeks. It wasn't just your explanations of how it all works, which were way better than anything our diabetes educator told us. But something about the way you and Jenny presented everything, even the scary stuff. That reassured me that we could figure out how to deal with us and to teach our son how to deal with it too. Thank you for sharing your knowledge and experience with us. This podcast is a game changer 25 years as a type one diabetic, and only now am I learning some of the basics. Scott brings useful information and presents indigestible weighs, learning that Pre-Bolus doesn't just mean Bolus before you eat but means timing your insulin so that is active as the carbs become active, took me already from a decent 6.5 A one C down to a 5.6. In the past eight months, I've never met Scott. But after listening to hundreds of episodes and joining him in his Facebook group, I consider him a friend. listening to this podcast and applying it has been the best thing I have done for my health since diagnosis. I genuinely hope that the diabetes Pro Tip series is valuable for you and your family. If it is find me in the private Facebook group and say hello. If you're enjoying the Juicebox Podcast, please share it with a friend, a neighbor, your physician or someone else who you know that might also benefit from the podcast. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast. Jenny Smith holds a bachelor's degree in Human Nutrition and biology from the University of Wisconsin. She is a registered and licensed dietitian, a certified diabetes educator and a certified trainer on most makes and models of insulin pumps and continuous glucose monitoring systems. She's also had type one diabetes for over 35 years, and she works at integrated diabetes.com. If you're interested in hiring Jenny, you can learn more about her at that link. If you're living with diabetes, or the caregiver of someone who is and you're looking for an online community of supportive people who understand, check out the Juicebox Podcast private Facebook group Juicebox Podcast type one diabetes, there are over 41,000 active members and we add 300 new members every week. There is a conversation happening right now that would interest you, inform you or give you the opportunity to share something that you've learned Juicebox Podcast, type one diabetes on Facebook, and it's not just for type ones, any kind of diabetes, any way you're connected to it. You are invited to join this absolutely free and welcoming community

#1005 Diabetes Pro Tip: Insulin Pumping

Remastered Diabetes Pro Tip: Insulin Pumping
Scott and Jenny Smith, CDE share insights on type 1 diabetes care

You can listen online to the entire series at DiabetesProTip.com or in your fav audio app.

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Scott Benner 0:04
Hello friends, and welcome to the diabetes Pro Tip series from the Juicebox Podcast. These episodes have been remastered for better sound quality by Rob at wrong way recording. When you need it done right, you choose wrong way, wrong way recording.com initially imagined by me as a 10 part series, the diabetes Pro Tip series has grown to 26 episodes. These episodes now exist in your audio player between Episode 1000 and episode 1025. They are also available online at diabetes pro tip.com, and juicebox podcast.com. This series features myself and Jennifer Smith. Jenny is a CD and a type one for over 35 years. This series was my attempt to bring together the management ideas found within the podcast in a way that would make it digestible and revisit double. It has been so incredibly popular that these 26 episodes are responsible for well over a half of a million downloads within the Juicebox Podcast. While you're listening please remember that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making any changes to your healthcare plan or becoming bold with insulin. This episode of The Juicebox Podcast is sponsored by assenza diabetes makers of the contour next gen blood glucose meter and they have an amazing offer for you. Right now at my link only contour next one.com forward slash juicebox free meter you can get an absolutely free contour next gen starter kit that's contour next.com forward slash juice box free meter. while supplies last US residents only. The remastered diabetes Pro Tip series from the Juicebox Podcast is sponsored by touched by type one. See all of the good work they're doing for people living with type one diabetes at touched by type one.org. And on their Instagram and Facebook pages. This show is sponsored today by the glucagon that my daughter carries, G voc hypo pen, find out more at G voc glucagon.com. Forward slash juicebox. If you're living with diabetes, or the caregiver of someone who is and you're looking for an online community of supportive people who understand, check out the Juicebox Podcast private Facebook group Juicebox Podcast type one diabetes, there are over 41,000 active members and we add 300 new members every week. There's a conversation happening right now that would interest you, inform you, or give you the opportunity to share something that you've learned Juicebox Podcast, type one diabetes on Facebook. And it's not just for type ones, any kind of diabetes, any way you're connected to it, you are invited to join this absolutely free and welcoming community. We are back talking about insulin pumps today. Awesome. And the idea of pumping in general not any specific pump, although we might go over the ones that are available at the moment. So we discussed in the MDI episode that it's tough to get an insulin pump right away, you'd have to be have great in insurance, you'd have to be able to get over the what do we want to call them roadblocks that some endo offices put up to you getting? Right getting in? It's on top. But But congratulations if you've gotten that far and you're thinking about getting an insulin pump. Why do you think? Well, do you think let me ask you, do you think pumping has advantages over MDI and if so, what are they?

Jennifer Smith, CDE 3:54
Yes, I mean, a broad a broad statement. Yes, there are advantages. I think there are pros and cons to everything. But there are a lot of pros. I think one of the biggest ones is precision in dosing. I mean, you know, from the standpoint of injections, we can dose accurately, like, quote accurately, to the half a unit with an injection, right? I mean, I've even got a couple of friends who still do MDI don't like pumping and, and they've sort of figured out how to get that quarter unit in an injection. But is that accurate? No, it's not like the pumped accuracy, you know, pumpkin, pumpkin, pumpkin get down to the point 05 Or the point 025 of a unit. That's, that's precise, that's miniscule, you know, and for the broad spectrum of people that need insulin in different doses, the very, very little to the adult who Who is very, very sensitive for whatever reason, that can be important. So,

Scott Benner 5:05
okay, and I agree, I think that when, especially when they're younger, I've used Mo, I've had moments with art and where it's a point one or a point to Bolus that can really move somebody and the, you know, obviously, the lower your body weight, the more that kind of precision makes incredible differences. I guess the con to that can be if you are so small, it's possible that it might be difficult to set your Basal rates up. Because if your Basal needs are that little in the beginning, you can do that I've seen people do all kinds of crazy stuff, like set a Basal rate on for one hour off for the next one, back and forth. And that's, there's a way to get through that. I think if you have a smaller child and you want to pump, there's a way to accomplish it.

Jennifer Smith, CDE 5:53
There is Yeah, absolutely. So precision, definitely. And then, you know, I, the icebergs that kind of pop up in your day. You know, you I know your strategy. And a lot of people strategy is kind of the navigation of blood sugar, right? And utilizing the smart tools on an insulin pump smart being things like the extended Bolus and the temporary Basal feature. You cannot do that with an injection. You just can't. And that is that's another huge pro pop.

Scott Benner 6:27
Yeah, I can't say I agree anymore. I am in full agreement. I didn't understand at all about pumping. When Arden was injecting, right. There were just a lot of words, I didn't understand people were talking about bolusing and all that. And what's that? What's an insulin to carb ratio? I have no idea. I know a little bit from objective, but it was so much more specific talking about with pumping ahead its own language. And I've mentioned before that as we were in Arden's pump class at at her children's hospital, and I recognized that insulin was going to be used, like fast acting insulin is going to be used as Basal insulin. Yep. And that I could turn it off and turn it back on and increase it and decrease it. I'm telling you angel saying like, light bulbs are going off, like everything happened. I was like, okay, immediately. Yes, please. I genuinely think that before you have a pump, and for a lot of people after you have it. People just believe the pump is a way to avoid injecting. And I want to I want to, as we do the overview about in some pumping today, I want to show them that it's just so much more than that. So it is

Jennifer Smith, CDE 7:34
yeah, absolutely. And I think another piece to definitely clear up, even for anybody who might be listening to these that doesn't necessarily interact or is a caregiver for somebody but with diabetes, but they've come across it because they just want information. A pump is not the magic, do it all. You don't plug it in, and it takes care of everything that is is not the case. And for those who might be newly diagnosed in our hearing oil pump is like the magic thing. It does all these ones. It does what you tell it to do. And it does it based on the parameters you set within the pump. Yeah, there's it's it's personal input is what makes the pump as beneficial as it can be. So you can then see that if you don't know what you're doing. It could be not that the best thing.

Scott Benner 8:29
Sometimes you hear people say I've had this pump for a month, and I'm thinking of going back because I think they have doing what I need. Yeah. And I think they had that expectation like, look, I bought the pump, I put it on why did my agency not go down? How come my spikes aren't going away? Why is my blood and in some cases, people's blood sugars get worse in the in the in the beginning because they don't get their basil setup correctly, right. Or, or I think for some people, your insulin needs change, sometimes greater or lesser, when you go from injecting the pumping

Jennifer Smith, CDE 9:02
because of the precision, especially if that Basal, sometimes with the imprecision of an injected Basal insulin, and the fact that it isn't based on your physiologic need and the change through the course of the day, that Basal insulin could be off via injection at a time when you need less insulin. And so things look like they're happening around a Bolus when it really isn't the Bolus is problem. It's the Basal. So getting that Basal set is huge. It's like the foundation of a house

Scott Benner 9:34
and the opposite as well to not instead of the Bolus is problem. You can't you can't give the Bolus credit. Sometimes Sometimes you have a lower stable blood sugar that you think you made this scrape Bolus off Bolus but but your 11 Me or your Lantis you have too much of it or it's just it's working stronger at that point or something like that. So when you switch to a pump, and you go to these more precise Basal rates, using a fast acting insulin in the background And then if you don't have that correct at that number, you don't you no longer have that sort of like, I don't know what to call it like when you inject Basal insulin, it's just sort of a is it a catch all? Is it a is it it's a blanket of insulin that you may or may not? Yeah, good way

Jennifer Smith, CDE 10:18
to think about it. It's kind of a blanket of insulin. But it's not a blanket that's always warm and cozy at the right places through the course of the day. I mean, I My example is, before I started pumping, I was using Lantis was my Basal insulin, and I took it in the evening, if I did not have a snack, when I went to bed after taking it, I could have bet a million dollars that I didn't have that I would have a low blood sugar between two and 3am.

Scott Benner 10:47
And that's because your new Basal insulin starts coming online, and it works.

Jennifer Smith, CDE 10:51
And it worked the way that it did, I needed less insulin at that time, but Lantis didn't know that Atlantis was like, Hey, you put me in here, I'm gonna get this, I'm gonna do my thing that I was supposed to be doing right. So I needed at that dose for the rest of the day. But I didn't need that dose for that action time of the morning. So that's

Scott Benner 11:10
our first kind of lesson here. With pumping when you get an insulin pump, your Basal rates need to be dialed in. And there's two things about that. The first thing is, and this of course, is not true for everybody. But I do meet a lot of people whose doctors under whelmed them with Basal insulin, when they put them on a pump i because they don't want to cause a low, they don't necessarily tell you that going out of the office or you don't expect it. And so you get hot, you get home, you're high all the time. And it doesn't ever occur to people that it's basil. So get on a pump, get the basil right, I think the next thing is done

Jennifer Smith, CDE 11:47
one comment about that as adjustment factor. And you mentioned it before insulin means may change going on a pump, we usually find give or take, we usually find that when you start on a pump, your Basal injected insulin dose in the pump will need to be about 10, sometimes 20% less than what you were injecting in your Basal dose. So let's say your Basal insulin is giving you 20 units a day via Lantus or levemir, to you know, to jail or whatever it might be 10% less than that is two units less, okay, so we would actually dose your basil in the pump on 18 units across that 24 hours versus 20 units. Because it's it seems to be that the body responds better to that one type of insulin or rapid and coming in at one precise point in the body all the time, rather than being injected like all over.

Scott Benner 12:47
So then it can really be either then you can you can get your pump set up with Basal insulin and find yourself high all the time and realize your Basal is not enough or, or too low or where you have to come in. So that is why doctors start that way. Because I guess more over the likelihood is you'll need less. But for the people who that's not true for it's the situation I described. Right? So what we're really saying is, you're not going to know until you know, but but figure it out, get it in there and figure it out. I also want to know what you think about multiple Basal rates in the beginning, because in my mind, I think you set one up, and then you start adjusting off of that one. Right?

Jennifer Smith, CDE 13:25
Agreed? Absolutely. Even when I started pumping, you know, as an adult, once there were finally pumps, like I'm ePad. So it wasn't about tubing. I wanted that pod. But when I started doing that, you know, I actually did I started on one solid Basal rate. And I was already an educator. So I knew about poems, I just, you know. But yeah, you have to test you have to evaluate and see what does that one salad basil? Where do I need it to be less? Where do I need it to be more right for how long?

Scott Benner 14:00
Yep, I think we're going to talk about the adjustments in our own little piece of this. So okay, so let's, we'll move on now to to the idea of bolusing. So I want everyone to understand that, that doctor, your doctor is going your pump trainer, whoever you talk to is going to do their best based off of what they know about you to set up an insulin to carb ratio in the pump. But it is incredibly important to know that that is a number that is not completely made up. But it is a guess on some level. And so if you're putting insulin in for a Bolus, and you just you say to yourself, Man, I counted these carbs 100% correctly, and it's telling me three units. But I used to eat this food on injections and I had to inject four units or two units or it was different in some way. I just think it's incredibly important to remember that your doctor just did the best they could putting that in there. And this becomes where sort of the next step of how people We'll get confused starting pumping, because things don't go the way they expect. And they never diagnose the idea that it's the it's the insulin. And I mean, this series is obviously, it's all about timing and amount, right? You're using the right amount at the right time. Their minds. I think Siri just heard me say something. Sorry, Siri wasn't for you. But it says, Hey, Siri, have it's obviously it's all about timing. Shut up, Siri. Oh, wait, sorry. My point is, is that you're our brains somehow focus on the idea of the pump, specifically and not and we forget about the insulin. So I got on a pump and something didn't go the way I wanted. There's something wrong with the pump. That's the LEAP you make. It's the it's, it's very likely the insulin. So you can't jump over the obvious answers to get to the other ones, then then we run into the problem that people don't want to make insulin adjustments in their pumps in the beginning. So for all of you listening, who are about to start pumping, or a noodle pumping, and you're seeing something in your heart, you know, isn't right. I would implore you not to sit around for three months waiting for your next endo appointment. Right? Okay. So if you're not, if your blood sugar's high, you probably have not enough insulin, it's possible that you know, you haven't timed it, right. But there's safe ways to make small adjustments to your insulin on your own. Right. And so and so. Would you talk to me about how you would How would you if someone called you and said, Hey, I don't know what to do. And you you looked at their graph and said, I think your Basal insulin needs to be turned up or turned down? What percentage do you tell them to move at the remastered diabetes Pro Tip series is sponsored by assenza diabetes makers of the contour next gen blood glucose meter, and they have a unique offer just for listeners of the Juicebox Podcast. If you're new to contour, you can get a free contour next gen starter kit by visiting this special link contour next one.com forward slash juice box free meter. When you use my link, you're going to get the same accurate meter that my daughter carries. Contour now next one.com forward slash juice box free meter head there right now and get yourself the starter kit. This free kit includes the contour next gen meter 10 test strips, 10 lancets, a lancing device control solution and a carry case. But most importantly, it includes an incredibly accurate and easy to use blood glucose meter. This contour meter has a bright light for nighttime viewing and easy to read screen, it fits well in your hand, and features Second Chance sampling, which can help you to avoid wasting strips. Every one of you has a blood glucose meter, you deserve an accurate one contour next one.com forward slash juice box free meter to get your absolutely free contour next gen starter kit sent right to your door. When it's time to get more strips, you can use my link and save time and money buying your contour next products from the convenience of your home, it's completely possible that you will pay less out of pocket in cash for your contour strips than you're paying now, through your insurance. Contour next one.com forward slash juice box for E meter go get yourself a free starter kit. while supplies last US residents only touched by type one has a wide array of resources and programs for people living with type one diabetes. When you visit touched by type one.org Go up to the top of the page where it says programs there you're gonna see all of the terrific things that touched by type one is doing and I mean, it's a lot type one, it's school, the D box program golfing for diabetes, dancing for diabetes, which is a terrific program, you just click on that to check that out. Both for cause their awareness campaigns and the annual conference that I've spoken at a number of years in a row. It's just amazing, just like touch by type one touched by type one.org or find them on Facebook and Instagram links in the show notes links at juicebox podcast.com To touch by type one and the other great sponsors that are supporting the remastering of the diabetes Pro Tip series touched by type one.org What percentage do you tell them to move at it depends

Jennifer Smith, CDE 19:41
on what the overall picture looks like you know if there are small if there are small, less aggressive looking changes to their blood sugar's but it's in a Basal only time period and you can tell that obviously something is wrong. We recommend making an adjustment If there's more than a 25 to 30 point shift up or down from a set blood sugar, so let's say if you're testing the overnight, you go to bed at this rock solid, you know, 102 blood sugar, but by you know, and that's 9pm. But by 1am, your blood sugar's at 201. That shouldn't happen on Basal insulin, that's there's something incorrect there. So, you know, with a shift like that, we would bump basil probably by like a point one in that time period to offset the incoming flux of or incoming need for extra insulin. Usually, if it's a smaller incremental change to blood sugar, you know, you're going from a blood sugar of 102 to 152, you probably don't need that much of a change. And so maybe more of like the point 05 In a rate, smaller increments to the point zero to five, which most of the pumps on the market can do, not all of them, but some of them. So that may be something that you play with, especially if you feel like you're pretty sensitive to small changes in dosing, then you may want to start smaller and make an adjustment up or down,

Scott Benner 21:11
right. And so again, it's a good place to point out that the numbers not important, because we can't tell from one person to another. And I'll give you an amazing anecdote about that I was with a group of people this past weekend, there was a college age kid there who in my best guess was 610, and must have weighed 230 pounds. And his Basal rate was lower than my daughter's who is five, six and weighs 125 pounds, my daughter is also growing, and you know, gets a period and things like that. So you can't, you can't reach out into the public into back to your doctrine. So just tell me how much to turn it off. You know, like, you have to pick an increment. That's not, that's not crazy, it's not dangerous. Obviously, you're not going to take 8.5 Basil and make it a one. You know, you're right, you'll try point six, you know, like, if you're, if you're a little high, try point six. And then if you do it for a few hours, and nothing's going on. I mean, try point seven like and you know, we might get to a point where you Oh, now I'm a little too low. And then again, I'll dial it back point six, five and, and make that decision on your own like, think it

Jennifer Smith, CDE 22:22
certainly communicate with your provider, if you want some assistance, saying, hey, you know, even calling your endo office, most often you get connected with a nurse, the nurse is then going to relay your message to the Endo, you might get a call back, hopefully 24 hours, maybe 48. Or, you know, whatever it might be, but at least you're acknowledging, hey, I'm seeing this issue. I'm making my adjustment because I'm the one living with diabetes 24/7. I'm just I'm telling you, so that if you've got any additional feedback,

Scott Benner 22:50
great, I'd love to hear it. Yeah. But you can't. You definitely can't do what happens to some people where you just freeze because I want you to really consider what we've been talking about what you've been listening to going back to your doctor four times a year, and saying, Hey, look at 90 days worth of my blood sugar's and adjust this and make it correct. It's just they're not guessing. But they're just doing their best and their best is limited because they're not with you. And so I know your that it's probably happened to you before you sit and you stare at these blood sugars. And you think, well, this isn't what I was told. But just remember, you're getting this machine and it needs to be dialed in. You just you have to get it right, you got to get it running, right so that you can start enjoying the benefits which are significant. Once you get it going. And I will say that I was one of those people who got a pump for my daughter when she was four years old. Oh my god, over 10 years ago. Wow. Yeah. And, and I slapped it on her. And then I stepped back and I looked at her blood sugar and I looked at her agency and I'm like, okay, just start going down. You know, like here comes Everybody get back this this this Oh, my gosh, back then this 8.9 A one C it's going to be magically lower. Well, it did go down a little bit. But not a lot. It only went down a little bit because I guess I was able to bumper insulin a little more. That's where we started right? Well, I guess a little more because back then if you missed on a Bolus, doing it again meant injecting again, and no one never wanted to do that. So you just waited and hoped and crossed your fingers right? But now I could give a little more in a little more but in honesty, just adding an insulin pump without understanding it did not bring Arden's a one seat down that that far.

Jennifer Smith, CDE 24:33
I think it's kind of like I mean, the adjustment is kind of like getting wheels aligned on a car. Right? I mean, if you have if you want to ride this straight line, you have to do these incremental adjustments so that you're not consistently like veering off the road.

Scott Benner 24:52
You got to rotate your tires. You need to get your your ball bearings all straightened down everything that was just the extent of my knowledge of cars. That's what You've heard but you want, you know the engine, I joke a little bit I understand. So people who really understand cars, there's tau in Canberra, there's these, these tiny adjustments that get made to your front wheels that keep your car moving straight. And it's the same situation. Those again, just like bumping and nudging blood sugars, these are tiny adjustments to get you where you want to be. And the difference between being 190 all day long and 90 all day long, could just be point one, a half a unit of a change, depending on your size and your weight, your needs, the tiniest amount. And just imagine that, you know, we talked about it all the time, if you if you don't have enough Basal insulin going when you Bolus, a lot of your Bolus is just replacing the Basal you don't have. And so

Jennifer Smith, CDE 25:46
that's why Bolus isn't there. You're wondering, well, why I didn't even eat at this point today. And what's happening here?

Scott Benner 25:54
Why is this happening now? And so so you need to get these things straightened out. Now. I guess moving on to the idea of bolusing. Yeah, before when you had your shots, you were counting your carbs, doing your thing sticking in your pan or your needle and pushing it in there and just hoping you know, hoping for the best right? You are now opening yourself up to an entire world of Pre-Bolus saying and and doing it with different and what Pre-Bolus Pre-Bolus boluses all the things you're pumped, you know, well, first of all, Pre-Bolus is not a setting. It's just the idea of putting in your insulin and giving it a head start over the food that you're about to eat right. But an extended Bolus. So we're talking right now it's 11am. And 40 minutes ago, Arden texted me and said lunch is soonish I want you to really hear that. She didn't say she didn't say in 10 minutes. Right? She didn't say 20 minutes from now she said soonish and I know based off of how this year is going at school, we're going to Pre-Bolus here. When you have diabetes and use insulin, low blood sugar can happen when you don't expect it. G voc hypo pan is a ready to use glucagon option that can treat very low blood sugar in adults and kids with diabetes ages two and above. Find out more go to G voc glucagon.com forward slash juicebox G voc shouldn't be used in patients with pheochromocytoma or insulinoma visit G voc glucagon.com/risk. And I thought about what was in her meal. There's not anything incredibly like simple sugary, that's going to spike her right away and she was 106 when we did this. So she'd been a little resistant towards the end of her period this week. We did a Temp Basal increase of 40% for an hour and a half. And so that takes Arden's Basal rate from 1.4 to whatever 40% More of that is for an hour and a half. And then I did a 11 and a half unit Bolus. We did 20% of it upfront and the balance over an hour. So 20, whatever 20% of 11 and a half and 11 and a half units is goes in when she pushes the button. The balance of that goes in incrementally over the next 60 minutes coming online and getting active along the way. And now it's 40 minutes later and Arden's blood sugar is stable and 90. And she probably started eating 20 minutes ago or so. I'm expecting the food to begin to impact her right now. Right right. And so we got we got momentum on our side for the insulin, we've got her going down. You know we've got that tug of war set up we've we've given you know, we've we're letting the insulin cheat. And we're going well, now, I'll tell you right now, if 20 minutes from now she starts curling back up. I might you know if there's any time if there's any extended Bolus left, I might cancel it and put it all in at once. If the extended Bolus is over, I'm gonna go I might have missed a little bit. There's all kinds of different adjustments you can make to change the timing and the amount of the insulin. I want you though to talk about first about extended boluses and I want you to talk about it the way I know I can't which is technically in smart play.

Jennifer Smith, CDE 29:19
I think you give very good description. I think the biggest thing to understand to begin with when with an extended Bolus is that all pumps can do them. They all term them or call them something a little bit different. And it really just kind of boils down to how you're telling the pump to give this this dose for a meal whether you want it all up front, meaning like you'd give an injection you get this whole normal amount of insulin deposited under the skin all at one time. That's normal and extended allows your pump to drip drip, drip drip almost like your basil is dripping all day but in an The time period you've defined whether it's 30 minutes an hour or three hours, you told the pump I want to deliver 11 units over the course of some now, and some in an hour time period. That's what we kind of refer to as a dual wave Bolus. Being you get some normal upfront, meaning a bump right now like an injection, and then the rest of the the meal like you said, 2080, right. 20% Now is the normal 80% over an hour. So your pump is now saying, Okay, I'm going to drip drip, drip drip drip this 80% in and by the end of an hour, that whole extra 80% will have been dripped in. But it's action time then is pushed out, because you didn't deliver it all right now that last pulse of insulin at end of our one still has now an active insulin time for whatever you have set in your pump, three hours, four hours, five hours out from that last active pulse. So I think that's the important thing to know about extended boluses some people first start to think of them as Okay, well, I'm going to get some insulin, but then three hours from now it's gonna give me the rest of my insulin. That's not how extends work. They always give some and extend some drip drip. Or you might want to say, for this meal, I'm eating a big ol plate of broccoli and a chicken breast. There's carb in that broccoli that you do have to count and cover. Is that broccoli going to hit you like white rice? No way. It certainly isn't. So a meal like that. You may say okay with these really low glycemic carbs. I'm going to extend the full Bolus, something we call a square Bolus, you take that meal that suggested as a Bolus, and you drip drip, drip the whole amount of it out over your designated time period. And there are different reasons for all of

Scott Benner 32:00
those. Yes, and you got to figure them out. And you can I was with a person eating low carb this past weekend, I Vicki and we sat down at a restaurant, she had a meal that you would expect had almost no carbs in it, but a ton of protein. She sat she ate it, she sat and ate it. We got in the car drove away. It's now 20 minutes or more past when the food was and she grabbed her PDM from around the pot and gave herself insulin. Because she does know she needs insulin for that protein. And but she didn't need it. If she would have Bolus and sat down or Pre-Bolus sat down, she would have gotten incredibly low. Yeah. And she it was amazing to see somebody figure that out. I was and I'm going to add what I learned about that to me like how the protein needs more later. Absolutely. It

Jennifer Smith, CDE 32:48
takes into the immune takes into the fact that we know these things from a set of rules. But I mean, the classic your diabetes may vary. Your diabetes bolusing strategy will vary. Well, yeah, not not me. It will vary. I mean, I my breakfast every morning, I've got a friend who eats the same exact breakfast after talking to me, she was like, Wow, that sounds awesome. I like it. I want to give it a try blah, blah, into them. Now she loves it her Bolus strategy for it. similar, but not 100% of what I do. It's different because physiologically, she's different. Yeah.

Scott Benner 33:28
And so if you've ever heard me speak live somewhere. There'll be a moment where someone in the audience asks the, you know, the question, how much how long, you know, and I go, I don't know, figure it out. You know, I

Jennifer Smith, CDE 33:41
think places there are some starting Oh, sure. Things. Yeah. It's like kind of like, you know, the How much do you adjust the basil up? Oh, point point. Oh, 5.1. It's a starting place, right? Sure. Give it a try. If it doesn't work. Okay. Next time you adjust different,

Scott Benner 33:57
right. And I'm more aggressive. Like when I adjust Basal rates, I adjust them like 30% of the time, because I'd rather cause a low and then back down from the low to find a level spot than to stay high for several days, I didn't nickel and dime the high, right? Because also because I feel like you're getting a more accurate depiction of what's happening. If you're using more insulin, when you're using less insulin than there could be resistance going on and maybe, you know, maybe in

Jennifer Smith, CDE 34:22
the field too, then that you have to correct and so you never really get a true picture of what does the Basal adjustment really just do because now I'm high and I want to correct and I'm not going to leave it Hi. So I don't understand what the Basal I know. I just know it's not enough,

Scott Benner 34:35
you'll get a look into my parenting style that way too. Whenever my children asked me something, I respond immediately with no, and then we work backwards from now. And so I sort of do the same thing with the innocent I slammed the insulin, and then I work backwards from there to find a level spot. I wanted to say about insulin action time. It's another idea of settings in your pump, right? So there's an amount of time that they, you know, insulin should work in your body, like how long from when you put it in to when it stops working. And you'll see people say all different kinds of numbers, you know, for hours, you know, it's different for me here and there. Same insulin, you know, they're using one kind of insulin. Some personal say, Well, my action time is four hours by x times three hours. Arden uses a Piedra, and her insulin action time in her pump is set at two hours. And so I have found that when you Bolus Arden that Bolus stops having any effect on her in by two hours. Wow. Most of the time. Some of the time now, I don't know how to tell you the difference. But most of the time, it's Yes. Last night it was now last night I couldn't get Arden's blood sugar to budge off of one ad, it didn't matter what I did, she had incredibly Karva, terrific afternoon. Like I said, she still has her period. And you know she's going along. Now there's a moment where I'm like pushing and pushing and pushing. And I'm finally that guy. This is enough, like this incident is going to start working eventually. And it did later at night after a hot shower. Her blood sugar started coming down and we had to catch it and it was hours and hours later. That doesn't make Ardens insulin action times six hours. Right? That's a specific situation. Most times insulin I put in now doesn't cause her to get low two hours later. Now keep in mind, insulin on board is calculated by the insulin action times set up in your pump. Am I right about that? Correct. Can you explain that for us, please? Yes.

Jennifer Smith, CDE 36:35
So insulin on board specifically uses your active insulin time that you have set in your pump. So for Arden, two hours, if she were to get a Bolus now for you know, at 11:07am. Two hours from now at 1:07pm, the pump would no longer identify active insulin on board from this Bolus, which means that if she chose to Bolus at 115, it's only going to factor in blood sugar and the carbs she tells it she's eating to give a Bolus suggestion. However, with in active insulin time, let's say, you know an hour from now somebody's birthday comes up and they bring a bagel, big old treat to school and she's like, Hey, Dad, I'm totally,

Scott Benner 37:24
I'm going to eat another 30 I'm gonna eat another 30 carbs over overtop of what we just Bolus for an hour ago.

Jennifer Smith, CDE 37:30
Exactly. But that was an hour ago. So your pump still assumes, hey, there's still insulin on board from this Bolus that she gave an hour ago, there's this much active insulin left. Important thing about iob is that you have to feed the pump information in order for it to consider iob information being blood sugar, and carbs. If carbs are a piece in the picture here, right? Because if you do not feed the pump, a blood sugar, it doesn't know the effect of the insulin on board that's still left. And to calculate the next Bolus correctly, it sees the insulin on board, but it may not be able to adjust because it doesn't have a pinpoint of glucose value to now say, okay, she was an hour ago at 82. Now she's at 179. That insulin on board that's left is coming into the picture but the pump also sees a higher blood sugar. So it's going to say, okay, she's high. She wants to eat this much more. This is how I'm going to calculate the Bolus despite there being active insulin left

Scott Benner 38:43
but in a situation where like for instance, now Arden's blood sugar's 111. Okay. And I'm seeing a curve up on her CGM, but her pomp right now if you test it right now say she didn't have a CGM she tested right now for that, you know, surprise treat an hour later. And and it says, Oh, your blood sugar's 111. You have all this insulin on board from the meal, go ahead and eat that you don't need insulin for this or you don't need you don't need as much insulin for that. That would be stalking. Now that would be okay. And that's a word that doctors are going to throw at you. And they're going to mean for it to scare you. And maybe maybe it should in the beginning. I'm not 100% Sure, but what they're going to tell you, you can't stack insulin because eventually it's going to it's going to catch up to you and it's going to make you low. I say to that. Yes. If you don't need the insulin, if you do need the insulin, it's not stalking it's bolusing. Knowing the difference is the is the trick, I guess it is to go back to I'm going to layman's terms a little bit more about insulin on board and action time if I can. So if you decide that your insulin action time is three hours and by you I mean the doctor sits down says that's is what it is for most of my kids this age, so I'm going to set it for three hours for you. But your insulin action time is actually less or more, then your pump is going to make decisions based off of that number. It doesn't make it right, I want to be clear to everybody, the pump doesn't have a magic sensor that's in you somewhere that knows that it's telling you the right thing it's making, it's making a static decision from a static number. That's not necessarily correct, it's probably a good guess, it probably won't hurt, you know, it's going to err you on the side of caution a lot. It's going to keep you from being, you know, from getting low.

Jennifer Smith, CDE 40:35
And I think that's a good, that's a it's a very good point to bring up. Because what we've actually found, especially in the community of people who are doing the do it yourself looping types of pumps, which is a whole nother broad topic, but I bring it up in this mainly because what we've found is that the action time of rapid acting insulin is actually beyond what most people have it set in their insulin pump. And the reason that we have it set for less time and an insulin pump, is because we inherently do not want to run high blood sugars. And so if we give the pump and active insulin time of three hours, when really that Bolus is probably lasting about four hours for us. What it means is that at three hours, and one minute after this Bolus was delivered, if your blood sugar is still high, your pump now no longer sees any active insulin and it can Bolus you more aggressively for the blood sugar that you now want to drive down. Right. Whereas if you had it set for four hours, at three hours in one minute, you were like I'm high, I want to Bolus to get this blood sugar down. Your pumps give me like, oh, let's be a little conservative here. Because you still have this like quarter of that last Bolus still working.

Scott Benner 41:57
If you have an omni pod, your pump is going to be completely self contained, it will adhere to your body, the insulin will be in there and all the smarts and everything and you'll use a wireless controller to tell it hey, I want you to change my Basal or put it a Bolus or something like that. All other pumps have tubing and an infusion set, right. So you'll have an infusion set that will put your cannula in tubing will run to the pump, and that pump will have its insulin in it, you'll need to keep that with you. It'll be clipped to somewhere, right. And that's

Jennifer Smith, CDE 42:29
a good point to make to about the difference Omni pod, the PDM does not have to be on your person for the pod to continue delivering. That's a big question that a lot of people have, well, I don't want to carry around this extra thing all the time. You don't have to once the pot has been told what to do. It does it as soon

Scott Benner 42:46
as it beeps and it recognizes the signal you're done. Actually you can walk away from if your insulin starts in like say you're putting in 10 units delivering right. As soon as it starts delivering, you could you could run to you could run across the state and your PDMP in your house and the insulin will keep delivering Yes. It's also important to talk about their about pumping in general is that to bathe or swim on a tube pump, you're going to have to disconnect to most of them for most right. So even in more aggressive like sports, for instance, like give, there's a lot of people who disconnect to go play soccer or football or something like that. With Omnipod you'll always be wearing it. I think to me, that's a huge point that made me want to do it. Because you always hear people say like, oh, I went to the beach and I got high. I get high at the beach. And I always think back to someone who was on the show. I think it was just a few episodes ago, where he said if you put a pencil in your back pocket, and then rob a bank pencils don't cause bank robbery. And, and so the beach doesn't make your blood sugar high, taking your insulin pump off major blood sugar high. Right, right, like that kind of an idea. So just understand that there's different ways to manage with different pumps. I'm not telling you which pump they get.

Jennifer Smith, CDE 44:07
And that's a lifestyle look, right. And that's the biggest thing when I work with people. They're always like, what what do you think is the best? There isn't a best, there's the best for me. Yep, there's the best for you. You need to take a look at you know the pros and the cons of all of the pumps. What are the what's the pump that has the most pros for your life 100% navigate your lifestyle your needs, you know an athlete, I've got a lot of athletes who really prefer Omnipod because of the tubeless piece I've worked with a lot of triathletes who really they need I mean from going from a swim into a bike into a run. They need something that's a seamless management then they're not having to clip in and pop in and reload and you know everything. So there. I think it takes a lot of examination of your lifestyle. Yeah,

Scott Benner 44:55
no, absolutely. There's no I would I would jokingly say that you know you I'm sure you think that I think you should get an omni pod. And probably if you ask me my personal opinion, I would say yes, right? Not just because they advertise on the show, but because ardency just wanted for 11 years. And it has been nothing but absolutely fantastic for us. But I completely agree with Jenny, you should decide what works best for you. You really have to do that. Not everyone's going to see the same pros and cons as everyone else.

Jennifer Smith, CDE 45:24
And all of the pumps despite delivery, and mechanism of driving insulin, they all do have some features that are different and may apply better to your lifestyle, then another brand.

Scott Benner 45:37
Absolutely. So. So again, figure it out for yourself, do your due diligence, do your homework. Yeah, I think the greatest thing about the on the pod might be is that they offer a demo, they'll send you one to your house and let you try it like that's where it and the other companies are at a loss, they can't really do that. Because of the way there's a setup

Jennifer Smith, CDE 45:55
very big and expensive. Let me just send you this. I'll send it back to

Scott Benner 45:59
you. Please, please give it back. And a couple of other ideas. And he's right, so what I was getting to whether you're using an omni pod, or you're using another one, there's going to be some adhesive of some sort, you know, a simple preparation, like we talked about back in the MDI episode. I think I don't over prep art and skin bright, clean skin.

Jennifer Smith, CDE 46:21
Dry without lotion or anything on it, you're good.

Scott Benner 46:24
Put it on, you could see. You know, if you have soreness with a pump, right, it shouldn't hurt. No, right? So it should not. So be careful. Like if you start if you have soreness that you know, I mean, after it first goes on, obviously, you know, it's not fun to have a hole poked in you. And that's going to be done by any one of these pumps. But an hour later, whatever it is, if it's hurt, so it's hard to bend your arm. Sometimes the cannula can hit a nerve, or muscle like looking up again. All of these companies will if you call them up and say, Look, I had to put it in an infusion set and it hurts so bad. I took it out. Can you send me another one? Generally speaking, they're their customer service is good, they will

Jennifer Smith, CDE 47:07
correct and that's it's really important because it can affect absorption at the site. If you've got a site that isn't it that's hurt, or you know, maybe getting infected or for some reason there's irritation under the site. If that site is bothering you, there, that's not good. Remove it, pop in a new one do something

Scott Benner 47:24
yeah, don't sit in pain. And that I think that's important. Tubing is something I don't completely understand i How much tubing do I need is it just as much to get me to where I want to store my pump?

Jennifer Smith, CDE 47:41
Correct. It's it's in that depends you know, tubing comes in many many different lengths for the tube pumps being of which there are only two on the on the market either tandem or Medtronic or the tube pumps that are available now, at least here in the States. So the tubing length depends on exactly where you're going to move that pump to and pop it in. If it's in a pocket, you may need short tubing 18 inches. If you're going some some of the guys I work with, you know where the shirt stays around their lower leg to keep their shirts tucked in, well they end up just clipping their pump down their leg and then they can easily lift up their pant leg to Bolus during the day. So if that's the case, you probably want 40 plus inches Oh tubing to kind of reading how tall you are. Right You know, if you're Shaq, you probably need like inches but yes

Scott Benner 48:34
and and the two pumps also when you go to put them on they have to be primed, which means that you have to fill all of that tubing with insulin rack before you can put it on the on the pod self Prime's so you when you know tubing, and there's no tubing. There's a tiny little cannula that that obviously goes under your skin and stays there. Yep. So, again, there you go. There's pros and cons with all of them. You know, I hear people say that. So Omni pod has a failsafe, right? If it gets around too much electrostatic electricity, and it and it affects the internals of it, it will shut down and ask you to write to change it. Yep. I've had it happen in 11 years, six or seven times, you know, it's happened. And people go well, that doesn't happen with a two pump and I'll say Well, yeah, and my daughter has also never walked past a drawer in the kitchen and gotten her tubing caught on it and yanked out her infusion set right that's the tube pump version of that to me like they all have something if you're looking for something right if you're looking for perfection. Don't Don't ask a machine to do anything.

Jennifer Smith, CDE 49:40
salutely and I think you know one even that might be going towards the tube pump potential need would be if for some reason, the angle of the cannula is a concern or an issue for you. That is one I would say potential drawback of Omnipod is that there is only one cannula When it comes on every pod, it's exactly the same cannula. And it goes in exactly the same angle for every single person, which may not again, your diabetes will vary because your body physiology may be very different. So you may need to choose a pump. Despite not wanting to being you may need to choose a pump. That's too because you need a different type of cannula or what's called infusion set. You may need something to go in at a 90 degree angle versus an angled, you know, you may need a steel cannula versus a plastic cannula for various body reasons. So there are a lot of considerations.

Scott Benner 50:37
Absolutely. But don't take, don't keep this in mind, no matter what pump you're thinking about. I know this is gonna sound a little dirty, but it's it ends up being true. Companies have salespeople, salespeople influence doctors, doctors get stuck prescribing things, the same poem right over and over, you walk into an office and say I want it on the pod and the guy goes, no, no, you want one of these? Trust me. You don't need to trust him. You know, you can say that you appreciate your input. But I'd really like to try the on the pod or vice versa. I don't want it on the pod. I really would like to try that. Eastland you can you can you can speak up for yourself, please, please do that. Absolutely do that. So at the very end of this I want to talk about about something that can't, it doesn't happen with injections that could happen with a pump, right. So as long as you inject your insulin with your injections, you remember to put in your Atlantis you'll ever mirror your true zebra, whatever it is. And you you know, remember to put in your insulin for your food or your high blood sugars. You're watching the needle go in your arm, you're pushing the button, you pull it away, you know the insulin is in there. With any insulin pump, the possibility could exist that your cannula could get bent, that your tubing could get kinked that the pump could I don't know, the batteries could die like like, you know, on the pot doesn't have batteries. And there's the but the other ones, there's mechanical,

Jennifer Smith, CDE 52:03
leave the house and totally forget that your reservoir only had five units and for the rest of the day, you actually needed 20 units. And now you have no incident you're

Scott Benner 52:12
and you're in trouble. Right? Right. So these are things that can happen when you try i We have a radius in my mind if I'm more than 30 minutes away from my house for any extended period of time. I bring insulin and another pump with us. The other day, we drove an hour and a half to something stayed there all day had all this extra diabetes supplies with us didn't need one of them. You know, most of the time you don't need it. But when it happens, it happens. Now, in 11 years, I'm happy to tell this story in 11 years, we've had one insulin delivery problem with Omnipod. And it wasn't the pump it was us. We changed a pump by sight. And it you know it was at a pool. Right so we put it on and I she got back in the water and I think the adhesive didn't have time to adhere and it loosened up a little bit and it pulled her cannula out through the course of a day right along July day of swimming. We got home her blood sugar was still fine now, was it still fine because the cannula was still in it hadn't worked its way out yet because she was so active during the day. She didn't need as much as I don't know. But what I can tell you is, is that overnight Arden's blood sugar started to skyrocket. And I kept bolusing. And it took me a while to figure out that my Bolus is weren't doing anything. That's not going to happen to you injecting, right and so is it is it I actually saw a person say the other day, I'm scared to get a pump because of that. And I think if that's why you're scared, I think you're worrying about things you don't need to worry about. But you do need to be aware of them. Correct, right? Your tube, tube kings, something happens, you're not getting insulin delivery, you're also don't have any slow acting insulin. And so when you lose your pump, you lose your slow and your fast acting, you can go from everything's right on to DKA. Pretty fast, quick.

Jennifer Smith, CDE 54:07
Exactly. Absolutely. And that's, it's a really good piece, you know, to discuss because it's one of the primary things when I work with starting somebody on a pump that we discuss, right in the pump training is the risk for DKA or the risk for a pump malfunction and how do you how do you navigate that without having such tremendously high blood sugars that then take forever to bring down because you're at such a deficit of insulin right? I mean, our our recommendations really are with a pump, an odd high blood sugar or now with the use of a CGM blood sugars that are like you said, just all of a sudden skyrocketing and there should be no reason for that skyrocket like you didn't go eat the whole Dairy Queen cake and just not Bolus for it right. There is something wrong you Bolus from the pump. If that initial Bolus doesn't start make a dent in that glucose within the next 30 to 60 minutes, you change everything out, you change the site, the tubing, the reservoir, the pod, whatever, you might even change the insulin, you know, especially if it's been a day at the beach and your insulin hasn't been kept change the insulin out really important

Scott Benner 55:17
I bail on in a pump site. As soon as, as soon as I know too, I will sometimes if I if I get stuck number, but it's not too high. Sometimes I'll inject a little bit. And if you inject instead you go, Oh my God, it started moving right away, maybe I'm gonna get off this pump site like a little sooner. And that's, you know, to just go over a couple of like ideas, you can't keep reusing the same site over and over again, they eventually become less effective. For reasons we talked about in other episodes, you have to understand that when you when you put in an insulin pump, you've you've a needle has poked a hole in you and left behind a piece of plastic in most cases, right. This plastic is a foreign body. It's an irritant, right, it's an irritant. I remember discussing with Aaron Kowalski from the JDRF, one time that he thinks one of the most ignored technologies for people with diabetes that we don't spend enough r&d time on is cannula, materials, and how to make them less irritating to the body. Because when your body thinks it's injured, it sends white blood cells to the place it believes there's an injury. And I don't know anything technical, but in my mind's eye, in my mind's eye that draws cartoons of what I think the world looks like, and how I understand things. There's little white blood cells, sort of like the beginning of Jurassic Park, when they show that cartoon to explain that I know DNA, in my in my mind, I see little white blood cells coming and attaching themselves around that cannula and making my insulin not flow correctly. I know none of that's probably technically correct. But I do know that when when a place gets irritated like that, that insulin becomes less effective. And there are times you have to bail on a site sooner than you want to.

Jennifer Smith, CDE 57:03
There could be and it's also a good just around site change itself to be very aware that the potential for that new site to be less absorptive, from really what you're talking about, there is inflammation. Anytime you introduce something underneath the skin, you ask your body to become irritated. And inflammation is what follows. So absorption at that site is significantly decreased. Everybody's a little bit different. Some people it's for about an hour, some people it could last as long as four or six hours, that inflammatory response. It's also I guess, for those who are using a continuous glucose monitor, you know that two hours sink in window? Yeah, it's a big reason for that to our sink in window, besides that sensor needing to get wet. You've put something to sit underneath your skin, your body's got to get used to that and you don't want glucose values coming in from a site that's probably injured. Right? So same with a pump, you really have to pay attention. What do your site changes look like? How does your glucose level change around site change times? And is this normal? Is this a normal flux in glucose? Or is my gosh, my blood sugar's never 300 after I change a site, right, therein lies the difference of change it out or figure out how to navigate the site change, so you don't have a high blood sugar.

Scott Benner 58:25
And I think it's incredibly important to know that while this may sound scary, that you'll figure it out very quickly. It's not something that's going to dog you for your entire existence. There's little is the word peccadilloes, there's small things about everything that you have to you have to figure out along the way. And the only way just like we talked about within something, the only way to figure it out is to do it. Let it go the way you didn't expect, you know, suss out what happened and fix it next time.

Jennifer Smith, CDE 58:53
But I think just the fact in you know, this episode, especially talking about these little pieces, it's really, really important because these are pieces that are often not talked about from an endo education standpoint. They're not they're missed. They're things that you've figured out along the way. And you've talked to other people, and you're like, Ah, I'm not the crazy, man. This is what's happening. Right? Me, me, too. I mean, I, I could have sat and asked my endo about it. But there are things that in interjecting and working with other people and my own self experience. I'm like, I'm not crazy. This is what happens. And I'm not the only one great

Scott Benner 59:34
example, that when Arden was younger, and we changed her pump, she'd get high. And people say oh, that's a thing. That's a pod chain tide only happens with Omni pod and blah, blah, blah. And I'm like, you have to Bolus boring with Bolus with the old pod before you change the new pod because the new pod won't work and everything. None of that was the truth. You want to know the truth. Arden was incredibly nervous. To get her insulin pump changed when she was little, and the adrenaline would hit her and shoot her blood sugar up. And one day, Arden stopped being nervous about having her insulin pump changed. And that all stopped. There was no magic. So people had had imagined this entire story around this. And I started buying into it. At first I was like, oh, obviously, the pump doesn't work right away. And, and all this. And by the way, it doesn't it that's not an unnecessarily incorrect statement. There. Like you just said new inflammation. There's an injury, you do sometimes need more insulin upfront, and I don't disagree with that. But the LEAP she got wasn't the pump change. It was it was adrenaline. And I still, like we talked about earlier, a new pump. As soon as I put on a new pump, I double the Basal for an hour, like right, just to get it going. But But I started thinking down the it's again, this cause and effect, it's the pencil in your pocket, right? Like, I changed the pump in her blood sugar went up, obviously, the pumps not delivering insulin anymore. Make sense? didn't end up being correct. Right? Right. So just you'll figure it out.

Jennifer Smith, CDE 1:01:09
And my experience was coming from a tube pump to Omnipod. So I had experience with site change from a tube standpoint on to Omnipod. And I'm glad that I had that because I do experience that site change inflammation. And I had experienced it on a tube pump with the cannula. And so I knew it was likely going to still happen on Omnipod. Yep. So, you know, again, your experience is

Scott Benner 1:01:34
gonna be different from somebody else's. It's 100% Right? Ah, good. Oh, did we didn't miss anything? Do we do okay? I think I like what you said at the end. I appreciate it because I wanted this to be a real world conversation, not some like shiny. Oh, you'll get a pump and you'll love it and it's gonna and by the way, you will love it. It's in where you won't. I don't know who you are. You know, I can tell you it's been an amazing experience for us. I believe wholeheartedly that the Omni pod is one half of the reason that we are able to keep Arden's a one, see where it is

Jennifer Smith, CDE 1:02:07
where it is. Absolutely. population of people that come off of a pump is small. But there are people who I've got a good friend who pumped for years and was like, Man, she had a major issue with her pump and she was like, No, I'm, I want to make sure I know I'm getting my insulin. She's been on bolusing she's gone through pregnancies with bolusing via MDX. It works for her. But again, that's her choice. And most people will stay on their poem. Listen, here's

Scott Benner 1:02:37
the here's the key, be happy, be healthy. That's all I care about doesn't matter to me what you do, just no differently than the way I talked about using insulin. I talk about pumps and glucose monitors the exact same way. I want you to know how it works. I want you to know what to do when you try it. And once you try it, if you don't want to do it, whatever, man, I don't care. You know, like, I'm not going to tell you what to do. I'm here telling you, you shouldn't make decisions based off of bad information when you have good information, make good decisions, do whatever you want. I want to thank assenza diabetes for sponsoring the remastered diabetes Pro Tip series. Don't forget you can get a free contour next gen starter kit at contour next one.com forward slash juicebox for E meter, while supplies last US residents only. If you're enjoying the remastered episodes of the diabetes Pro Tip series from the Juicebox Podcast you have touched by type one to thank touched by type one.org is a proud sponsor of the remastering of the diabetes Pro Tip series. Learn more about them at touched by type one.org. A huge thank you to one of today's sponsors G voc glucagon find out more about Chico Capo pen at G voc glucagon.com. Forward slash juicebox you spell that GVOKEGLUC AG o n.com. Forward slash juicebox I hope you enjoyed this episode. Now listen, there's 26 episodes in this series. You might not know what each of them are. I'm going to tell you now. Episode 1000 is called newly diagnosed are starting over episode 1001. All about MDI 1002 all about insulin 1003 is called Pre-Bolus Episode 1004 Temp Basal 1005 Insulin pumping 1006 mastering a CGM 1007 Bump and nudge 1008 The perfect Bolus 1009 variables 1010 setting Basal insulin 1011 Exercise 1012 Fat improved Between 1013 Insulin injury and surgery 1014 glucagon and low Beegees. In Episode 1015, Jenny and I talked about emergency room protocols in 1016 long term health 1017 Bumping nudge part two, in Episode 1008 teen pregnancy 1019 explaining type one 1020 glycemic index and load 1021 postpartum 1022, weight loss 1023 Honeymoon 1024 female hormones and in Episode 1025, we talk about transitioning from MDI to pumping. Before I go, I'd like to share two reviews with you of the diabetes Pro Tip series, one from an adult and one from a caregiver. I learned so much from the Pro Tip series when our son was diagnosed last summer. It really helped get me through those first few very tough weeks. It wasn't just your explanations of how it all works, which were way better than anything our diabetes educator told us. But something about the way you and Jenny presented everything, even the scary stuff. That reassured me that we could figure out how to deal with this and to teach our son how to deal with it too. Thank you for sharing your knowledge and experience with us. This podcast is a game changer 25 years as a type one diabetic, and only now am I learning some of the basics, Scott brings useful information and presents it in digestible ways. Learning the Pre-Bolus doesn't just mean Bolus before you eat but means timing your insulin so that is active as the carbs become active. Took me already from a decent 6.5 A one C down to a 5.6. In the past eight months. I've never met Scott But after listening to hundreds of episodes and joining him in his Facebook group, I consider him a friend. listening to this podcast and applying it has been the best thing I have done for my health since diagnosis. I genuinely hope that the diabetes Pro Tip series is valuable for you and your family. If it is find me in the private Facebook group and say hello. If you're enjoying the Juicebox Podcast, please share it with a friend, a neighbor, your physician or someone else who you know that might also benefit from the podcast. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast. Jenny Smith holds a bachelor's degree in Human Nutrition and biology from the University of Wisconsin. She is a registered and licensed dietitian, a certified diabetes educator and a certified trainer on most makes and models of insulin pumps and continuous glucose monitoring systems. She's also had type one diabetes for over 35 years and she works at integrated diabetes.com. If you're interested in hiring Jenny, you can learn more about her at that link.