#1763 Defining DIabetes: Sliding Scale

Summary

Juicebox Podcast: Type 1 Diabetes

Episode #1763: Defining Diabetes—Sliding Scale
Host: Scott Benner
Guest: Jenny (long-time diabetes educator and person with type 1 diabetes)
Date: February 7, 2026

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Episode Overview

In this episode, Scott and Jenny revisit the "Defining Diabetes" series to break down the term "sliding scale," a historically common method for insulin management in Type 1 Diabetes. Their discussion blends personal experience with practical explanations, comparing past and present approaches, and examining why sliding scale is still in use today despite improvements in diabetes management technologies.

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Key Discussion Points and Insights

1. What Is "Sliding Scale" Insulin Dosing? (01:39, 02:41, 06:17)

• Definition:
  A sliding scale assigns fixed insulin doses to specific blood glucose ranges and fixed carbohydrate servings at set meal times. Adjustment for high blood sugars occurs by adding set units of insulin based on the degree of elevation.

  • Jenny explains:

    "You get a set amount of insulin for a meal. Breakfast is three units, lunch is five units, dinner is six units. That’s your dose for the food… If your blood sugar sliding scale corrective was also another math part to add to that. If your blood sugar is here to here, add one unit. If blood sugar is here to here, add two units or three units." (02:41)

  • Scott summarizes:

    "Put it real black and white for me… I’m at the doctor and they’re just gonna say, hey, put in this much insulin at this time, eat at this time, eat this much food. If your blood sugar is 150 to 199, I want you to do this much. If it’s 200 to 250, I want you to do a little this much. That’s it. That’s a slide, and that’s it." (08:48)

• Background:
  Sliding scale was the standard before rapid-acting insulin analogs and intensive management techniques (e.g., carb counting and algorithmic pumps).

2. Personal Experience with Sliding Scale (01:39, 03:50, 04:03)

• Jenny recounts:

  • She used sliding scale until rapid-acting insulins like Humalog became available when she was in college.

  • Her regimen required all food to be weighed and measured; her mother played a significant role in managing her meals.

    "My parents, especially my mom was kind of the controller of the food… everything was weighed and measured… It made it workable in my brain at that age." (04:03)

• Physical activity:
  Jenny, as a child and teen, noticed that despite all the measuring, activities like dance and biking with her dad added unpredictability—even though she followed instructions closely.

  "With those variables, I saw that if I just stuck with the schedule that I was given, it worked out pretty well. Now, what happened in between finger sticks, I don't know. There was no CGM to say, gosh, this dose really is the right one for you." (04:03)

3. Sliding Scale Today: Why Is It Still Used? (05:20, 06:17)

• Access Disparities:
  While many have transitioned to more precise management methods (pumps, CGMs, carb counting), sliding scale persists—often due to limited access to technology or advanced diabetes education.

  "It’s access to technology. It’s access to a clinical service that has encouraged you to be able to be better because they’re providing you the ability to have technology. And many people don’t have that. So sliding scale is what it is." (05:20)

• Variations in guidance:
  Jenny notes that not everyone receives detailed education about matching food intake to insulin; some are told simply to take a specific dose for a meal, with little carbohydrate guidance.

  "With some sliding scale people that I’ve worked with, they’re not even given as much detail as I was… There's not as much detailed 'your meal has to consist of this much food because we're expecting three units to cover your food.'" (05:20)

• Sliding scale on modern technology:
  Some people use sliding scale principles with insulin pumps, setting manual insulin doses or using pumps for set corrections instead of full carb counting.

  "I would even say that there are some people that might be using their pump as sliding scale instead of carb counting… They may actually just be dialing in a manual dose of insulin." (06:37)

4. Precision, Challenges, and Lifestyle (07:34, 08:20)

• Pros and cons:
  Even with meticulous management, sliding scale's lack of flexibility can result in "yo-yoing" blood sugars unless people are exceptionally careful.

  "There’s a lot of yo-yoing that goes on… Unless they’re willing to get… You know, I have a couple of friends who use MDI and do very well with it, but theirs is a precision." (07:34)

• Modern MDI users:
  Some do well by custom-tailoring fixed doses to their habitual foods, not by calculating carbs every time.

  "Most of them have also found that their most common foods, they’ve just figured out the dose for it. They don’t necessarily have an insulin-to-carb ratio." (07:34)

5. Technological Evolution and Limitations (09:34, 09:43)

• Old insulins and methods still in use:
  Some regions or economically disadvantaged groups continue to use regular and NPH insulins, requiring "very old school" sliding scale management.

  "Are there places in the world where people are still using, like, regular and NPH?" – Scott
  "Oh, absolutely… Yes." – Jenny (09:43-09:44)

• Lifestyle adjustments:
  In the past, the unpredictability of older insulins meant fixed snack times and meal schedules, rigid adherence, and individual improvisation for activities.

  "With even the intermediate acting cloudy insulin… I had a very different snack in the afternoon depending on whether I was headed to a sport after school or not." (10:30)

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Notable Quotes and Memorable Moments

• On how sliding scale feels today:

  "It’s like hearing somebody uses a fax machine. You’re like, what? … But is that still pretty common?" – Scott (04:54)

• On food aversions:

  "I’ve never had cottage cheese in my life." – Scott
  "You’ve never had cottage cheese?" – Jenny
  "And as you’re talking about it, it makes me feel icky. I just wanted to say that." – Scott (08:20-08:27)

• On adaptability:

  "You kind of figure out as you go." – Scott (11:06)

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Timestamps for Key Segments

• [01:39-03:50] — Jenny’s early experiences and shifting away from sliding scale
• [04:03-04:54] — How meticulous food management worked with sliding scale
• [05:20-06:17] — Why sliding scale is still in use; access disparities
• [06:37-07:34] — Sliding scale applied to modern tech (CGMs & pumps)
• [07:34-08:20] — The challenge of achieving tight control with sliding scale
• [08:48-09:14] — Sliding scale broken down in “black and white” terms
• [09:43-10:30] — Continued use of old insulins in some populations
• [10:30-11:08] — Adjustments for sports, snacks, and unpredictability

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Tone and Style

The conversation is open, conversational, and honest—balancing Jenny’s educational expertise and lived experience with Scott’s approachable curiosity, including playful detours about food preferences and personal anecdotes.

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Takeaways

• Sliding scale insulin dosing, while outdated by current standards, is still widely used due to gaps in access to technology or diabetes education.
• Managing diabetes with sliding scale can work for some—especially with strict routines—but lacks the precision and flexibility of modern methods like carb counting and algorithmic pumping.
• Knowledge, resources, and technology access are crucial for advancing beyond sliding scale to individualized and dynamic diabetes care.

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Transcript

[A]

Friends, we're all back together for the next episode of the Juice Box Podcast. Welcome. Managing diabetes is difficult, but trying to do it when you don't understand the lingo, that's almost impossible. The Defining Diabetes series began in 2019 and today we're adding to it. Go to juiceboxpodcast.com up in the menu, click on Defining Diabetes and you'll see a complete list of all the terms that we've defined so far. Check out my Algorithm Pumping series to help you make sense of automated insulin delivery systems like Omnipod 5 Loop, Medtronic 780G, Twist, Tandem Control IQ, and much more. Each episode will dive into the setup, features and real world usage tips that can transform your daily type 1 diabetes management. We cut through the jargon, share personal experiences, and show you how these algorithms can simplify and streamline your care. If you're curious about automated insulin pumping, go find the Algorithm Pumping series in the Juice Box podcast. Easiest way juiceboxpodcast.com and go up into the menu. Click on series and it'll be right there. While you're listening, please remember that nothing you hear on the Juice Box Podcast should be considered advice, medical or otherwise. Always consult a physician before making any changes to your health care plan or becoming old with insulin. Jenny, we're going to define sliding scale and I'm going to ask you to go back into your wayback machine back till you were how old. When do you think is the last time you did that?

[B]

Oh my God. Sliding scale use. Was trying to think. I was in college when I stopped using sliding scale because rapid acting insulin Humalog came out. So it would probably have to be trying to think I was working. Funny, the memories that come in. I was working at a plasma donation center when I read an article on my break about Humalog.

[A]

Really?

[B]

It's really interesting. Yes. And then I had a doctor's visit coming up very soon and I went to him with the article. You know, like Internet and stuff was very microscopic at that time. So I brought him the article. So I wasn't like the crazy person, you know, and I was like this, this is what Jenny needs right now because R and L is not working very well for Jenny. So.

[A]

And please ignore that I stole this magazine from the plasma center.

[B]

But yeah, sliding scale probably until I was. Sophomore, junior in college I think is where I was using that. And it's really, it's the best that you could have had outside of using a pump eventually that was programmable in a way that could Manage better, really. It's just. You get a set amount of insulin for a meal. Breakfast is three units, lunch is five units, dinner is six units. That's your dose for the food. And it's given to you with the expectation that your education included. Your meal will consist of this much food. Don't veer from this because your insulin is dosed according to what we told you you needed to eat. And then if your blood sugar sliding scale corrective was also another math part to add to that. If your blood sugar is here to here, add one unit. If blood sugar is here to here, add two units or three units. And so it was. It was management that was very wide. It was not the precise that we can have today.

[A]

Do you remember back, I know you're a particular eater. I don't mean that in a finicky way. I just mean you do a good job with your intake. So I imagine your sliding scale for your food worked pretty well, am I right?

[B]

It did. And because my parents, especially my mom was kind of the controller of the food until I went to college, everything was weighed and measured. And like, we had a bouncy scale that sat in the kitchen table and everything got measured, everything got weighed. And it was thankful that I had really good educators, too. That made it. It made it workable in my brain at that age, too. Like, this is just the way that it works. And look, with all the activity, I mean, I danced, I was in volleyball, I was a cheerleader, I biked with my dad. I did a lot of things. And so with those variables, I saw that if I just stuck with the schedule that I was given, it worked out pretty well. Now, what happened in between finger sticks, I don't know. There was no CGM to say, gosh, this dose really is the right one for you.

[A]

But is it fair to say that most. See, I don't think this is true because I talked to so many people who are on a sliding scale right now. Like, it happens. It happens to Canadians a lot, depending on what province they live in. And I am surprised more and more about Americans that I hear who are like, oh, no, I'm on a sliding scale. I'm like, how's that possible? It's like hearing somebody uses a fax machine. You're like, what? Right, But. But is that still pretty common?

[B]

It can be. You know, we. Especially what I do with the clients that I am able to work with. Yeah, I see a lot of people who have access, really, I think is what this speaks to. It's access to technology. It's access to a clinical service that has encouraged you to be able to be better because they're providing you the ability to have technology. And many people don't have that. So sliding scale is what it is. You're told to have a dose of insulin. And what I've come to see too, with some sliding scale people that I've worked with, is they're not even given as much detail as I was given when I was using sliding scale. Right. It's eat breakfast, take three units of insulin. There's not as much detailed. Your meal has to consist of this much food because we're expecting three units to cover your food.

[A]

Okay.

[B]

Right.

[A]

If you met somebody today who had access to insurance and they could get what they needed and they were on a sliding scale, would you tell them, I think you shouldn't be doing that, or would you say, I mean, is it different now that there are CGMs? Are there people out there on sliding scale? We're in a CGM probably. Right.

[B]

I would say that it defines sliding scale in a little bit of a different way then. So those people are MDI still. Right. They may have a cgm, which gives them more access to information about what their doses that are set doses provide in control. I would even say that there are some people that might be using their pump as sliding scale instead of carb counting. They may actually just be dialing in a manual dose of insulin. And then potentially they might have a correction factor put into their pump so the pump then automatically gives correction. That could be another way of navigating sliding scale with a little more precision. But in general, sliding scale is usually multiple daily injections with a set amount of insulin and then a corrective factor that's a set dose based on blood sugar value.

[A]

You think there's a lot of yo yoing that goes on for people who are managing like this?

[B]

Very likely. Unless they're willing to get. You know, I have a couple of friends who use MDI and do very well with it, but theirs is a precision. They've learned how to look at their CGMs, they've learned how their insulin works for them. They've learned the timing of their dosing. Even though they are using kind of a sliding scale, most of them have also found that their most common foods, they've just figured out the dose for it. They don't necessarily have an insulin to carb ratio. They've just been able to say, well, gosh, my bowl of cottage cheese with pineapple Always takes four units. I'll take four units if my blood sugar's high. I add a little bit more to this.

[A]

Right? Okay. I've never had cottage cheese in my life.

[B]

You've never had cottage cheese.

[A]

And as you're talking about it, it makes me feel icky. I just wanted to say that.

[B]

Well, that's okay. It's not. I. Yeah, it's all good. I don't know why it even came to mind. I was just trying to think of, like.

[A]

It was nice. I just. I was like, oh, I've never had that. There you go.

[B]

I did make you eat a tomato, though.

[A]

I did. I did have a tomato. Where was I? I was a. I was. We were on vacation and tomato came out and I was like, all right, I'll eat it. And I did. And I sent Jenny a picture of it.

[B]

I said, look, yes, I ate the tomato.

[A]

I don't know if that episode's out yet or if people have context for that yet or not. So sliding scale is like. Like, put it, like, real black and white for me. Take all the. The nuts and bolts out of it. Like, I'm at the doctor and they're just gonna say, hey, put in this much insulin at this time, eat at this time, eat this much food. If your blood sugar is 150 to 199, I want you to do this much. If it's 200 to 250, I want you to do a little this much. That's it. That's a slide, and that's it.

[B]

And there's basal insulin behind it. So usually the basal insulin is also once a day at this point. Right. And then meal times are covered with a sliding scale, which tends to work a little bit better at this point because many people, not everybody, but most people are using rapid. They're not using the older R insulin, which took longer.

[A]

I was gonna say, are there. I don't want to muddy the two. So let's just say we're done talking about that now. But, like, are there places in the world where people are still using, like, regular and mph?

[B]

Oh, absolutely.

[A]

Really?

[B]

Yeah, absolutely, yes.

[A]

Well, and then they're on a. Like an old school sliding scale at that point.

[B]

And then they're on very old school sliding scale, kind of similar to mine. It was just very structured. There was not. There was not deviation from timeframes or where snacks were gonna happen or anything unless there was exercise. In the picture that you.

[A]

I remember Mike always. He kind of paused for a minute when he was drawing up his Insulin. And I did ask him one day, what are you thinking about? He's like, I'm trying to figure out how active we're gonna be today. And that was kind of the end of it. Like, it was in the morning and he was just. It was weird to watch him. He'd, like, pull on that and he'd be like, you know, meanwhile, it wasn't. Obviously his outcome was terrible, so it wasn't working for him. But that was, I think, the extent of his training. I'm making. I'm making air quotes.

[B]

I mean, you know, the old school stuff again with even the intermediate acting cloudy insulin, the N and the R, whatever. Like, I had a very different snack in the afternoon depending on whether I was headed to a sport right after school or not. So snack for sport was this type of intake so that I wouldn't drop because I was on the tail end of my intermediate acting insulin and it would encourage me to have a low.

[A]

And I did all those things that.

[B]

You kind of figure out as you go.

[A]

Okay, thank you. I appreciate it.

[B]

Sure.

[A]

If this is your first time listening to the Juice Box Podcast and you'd like to hear more, download Apple Podcasts or Spotify, really any audio app at all, look for the Juice Box Podcast and follow or subscribe. We put out new content every day that you'll enjoy. Want to learn more about your diabetes management? Go to juiceboxpodcast.com up in the menu and look for Bold Beginnings, the Diabetes Pro Tip series, and much more. This podcast is full of collections and series of information that will help you to live better with insulin. Hey, thanks for listening all the way to the end. I really appreciate your loyalty and listenership. Thank you so much for listening. I'll be back very soon with another episode of the Juice Box Podcast. If you have a podcast and you need a fantastic editor, you want Rob from Wrong way Recording Listen. Truth be told, I'm like 20% smarter. When Rob edits me. He takes out all the, like, gaps of time. And when I go and stuff like that, and it just. I don't know, man. Like, I listen back and I'm like, why do I sound smarter? And then I remember because I did one smart thing. I hired [e-mail].