#1849 Bolus for Zaydino

Summary

Juicebox Podcast: Type 1 Diabetes

Episode #1849 – Bolus for Zaydino

Host: Scott Benner
Guest: Natalia, mom to 7-year-old Zade (“Zaydino”)
Date: May 13, 2026

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Episode Overview

In this episode, Scott Benner sits down with Natalia, a mother raising her 7-year-old son, Zade (“Zaydino”) in Hong Kong after his Type 1 Diabetes diagnosis. Together, they explore the practical challenges of everyday diabetes management for young children—especially around food, routines, and insulin dosing. The episode focuses on “real life” bolusing struggles (with pizza, eating out, weekend disruptions, and more) and offers accessible, actionable advice to help families feel less overwhelmed and more empowered in their diabetes care.

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Key Discussion Points & Insights

1. Life After Diagnosis: Establishing a Routine

• Natalia shares the diagnosis story:
  • Zade was diagnosed at age 6 after suddenly appearing weak, thirsty, and needing to urinate often. Diagnosis came quickly, leading to a stressful initial hospital stay. ([22:11])
• Transition to management at home:
  • Began with multiple daily injections (MDI) for 3 months, then switched to Omnipod 5 pump, which was life-changing but brought its own challenges (e.g., skin irritation, pump site management). ([03:52–04:26])
  • "We started putting him on the Omnipod 5. That has been helpful, but, yeah, he has his moments of not wanting it… his skin started getting too red and too inflamed over time." — Natalia ([04:14])
  • Solution for skin issues: unscented basic body wash recommended by pediatrician resolved irritation quickly. ([04:34–04:55])

2. Food, Routine, and Blood Sugar Challenges

• Weekdays vs. Weekends:

  • Weekdays: Predictable meals, structured school schedule, consistent activity → stable BGs.
  • Weekends: Less activity, special foods (cereal, restaurant, pizza) → challenging highs. Zade sometimes prefers staying home to avoid eating challenges. ([05:33], [06:36], [08:00])
  • “His daily routine—breakfast, lunch, dinner… everything is fine. But the weekends come in, and it just goes through the roof.” — Natalia ([06:18])

• Struggles with eating out and “fun foods”:

  • Natalia feels anxious about carb counting for restaurant/party foods (pizza, hot dogs, fried foods). She limits high-carb, high-fat foods, fearing post-meal spikes.
  • “If he can’t eat a pizza, I don’t allow him the pasta… why don’t we stay home and just eat what I can in a bigger quantity?” — Natalia ([05:38])
  • “Going out to dinner is more difficult… I like how you said it turns it into an all-nighter.” — Scott ([10:38], [10:54])

3. The Impact of Activity

• Major insight: Lack of activity/resistance to insulin on weekends is a prime driver of blood sugar variability.
  • “When you have less activity, your body becomes more resistant to insulin. It’s just kind of the way it works.” — Scott ([15:37])
  • Zade is much less active on weekends (relaxed/indoor), altering BG response even to the same meals. ([06:50], [07:37])

4. Insulin Dosing, Carb Counting, Fat & Protein

• The challenge with pizza (and similar foods):

  • Natalia admits she often underestimates insulin needs during weekend or restaurant meals.
  • “I started dosing him extra, good… That was the first time I did that. I was scared something would happen but everything was okay and it worked.” — Natalia ([15:19])

• Bolus math & meal composition:

  • Scott explains why restaurant foods spike BGs: higher carbs, more hidden fats, slower digestion, carb miscalculation, algorithm limitations.
  • “If you don’t start incorporating the impact of the fat… the carbs aren’t going to really matter.” — Scott ([17:16])
  • Techniques discussed: Use Scott’s “bolus estimator” (juiceboxpodcast.com/bolus4) to factor fat/protein into dosing; possible to use “fake carbs” to “trick” the pump algorithm when true extended bolus isn’t available.
  • “Omnipod 5 doesn’t do extended boluses in automation, so you’re just going to have to make the 0.43 bolus at an advantageous time.” — Scott ([59:05])

• Practical demo of bolus estimator:

  • Together they plug Zade’s insulin-to-carb ratio, current BG, meal carbs, fat, and protein amounts into the calculator, discussing example numbers for pizza, fries, cheese, etc. ([50:44–55:15])
  • Key teaching: It’s not just about carbs—fat/protein impact, timing, and amount are the critical variables.

5. “Invisible Variables” and the Diabetes Learning Curve

• Everyday factors: Hormones (growth spurts ahead!), stress, temperature, routines all impact blood sugar unpredictably.

  • “That’s why people say, ‘I do the same thing every day and I get a different outcome.’ But you’re doing the same thing every day, the day’s not the same.” — Scott ([49:22])

• Settings and learning to adjust:

  • Omnipod 5’s algorithm is helpful, but you still need to understand its limitations and manually intervene at times.
  • As Zade grows, insulin needs will increase and dosing flexibility will improve.
  • “When the basal’s wrong, nothing else works.” — Scott ([65:34])
  • “Everything is timing and amount.” — Scott ([36:54])

6. Encouragement & Mindset

• Natalia’s progress and persistence:
  • Scott reassures her that with attention, good questions, and effort, she’ll keep getting better: “Wake up six months from now, look back on yourself today, you won’t recognize yourself.” ([66:48])
  • “Listen, Natalia, seriously… You’re going to be fine because you’re paying attention and you ask the right questions. That’s pretty much it. And you’re trying.” —Scott ([66:17])
• Natalia responds:
  • “Just trying my best.” ([66:33])

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Notable Quotes & Memorable Moments

• On discovering skin care that works:
  • “I tried everything… What really worked, I took him to his own pediatric doctor… a very basic body wash, no fragrance… that overnight, literally worked.” —Natalia ([04:34])
• On extended bolusing with the Omnipod 5:
  • “All I would do is like an hour after he eats, I’d bolus 0.4. That’s it.” —Scott ([34:44])
• On invisible impacts:
  • “You’re doing the same thing every day, but all the things that are happening are not the same. It’s the unseen stuff.” —Scott ([49:22])
• On diabetes in Hong Kong:
  • “We don’t even have pumps over here. We have to order them from other countries… So they don’t even have… support.” —Natalia ([38:58])

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Practical Walk-Throughs (Key Timestamps)

• Routine/meal breakdown: weekday vs. weekend – [07:21–10:38]
• Activity influencing BG – [06:40], [15:37]
• Restaurant/“event” food struggles – [13:50–19:04], [45:00–48:14]
• Bolus estimator demo:
  • Using the “bolus4” estimator for meal dosing with fat/protein ([50:44–55:15])
  • Extended bolus workaround ([34:44]; [59:05])
• Dosing for high-fat/high-carb meals (e.g., pizza, fries):
  • Example with numbers ([45:00–49:22]; [60:06–61:23])

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Actionable Takeaways

• Stable routines (meal, activity) = easier predictability.
  • But weekends/social events require more flexibility and, often, more insulin—plus smarter bolusing and an eye for fat/protein content.
• Manual intervention may be needed (with or without extended bolus feature).
  • Use timing and extra bolus (often 60–90 mins after a fatty meal) to manage late spikes.
• Lean on tools like the Bolus Estimator:
  • Plug in carb, fat, protein, and trend data to better plan dosing for mixed meals.
• Don’t fear iteration.
  • Trial and error (e.g., practice pizza!) refines understanding—“a couple pizzas to figure it out.”
• Basal settings matter.
  • “When the basal’s wrong, nothing else works.”
• Be patient and kind to yourself.
  • Mastery comes with steady effort and time.

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Episode’s Title: "Bolus for Zaydino"

Natalia shares a sweet moment at the end, explaining Zade’s school nickname “Zaydino” and how he will enjoy seeing an episode named after him ([67:52–68:02]).

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Further Resources Mentioned

• Juicebox Podcast Bolus Estimator: juiceboxpodcast.com/bolus4
• Pro Tip Podcast Series with Jenny Smith (Start at Episode 1000 or find in the menu at Juiceboxpodcast.com) ([63:50])
• Settings Simulator and other calculators: Available on the Juicebox Podcast website menu.

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Final Encouragement:
“You’re going to be fine because you’re paying attention and you ask the right questions.” – Scott Benner ([66:17])

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For families and caregivers:
This episode is a masterclass in “real life” diabetes management—especially if you’re feeling lost in parenthood, numbers, and nutrition labels. Natalia’s openness, and Scott’s clarity and empathy, make it a go-to for any parent trying to be “bold with insulin”—and bold with hope.

Transcript

[A]

Welcome back friends to another episode of the Juice Box Podcast.

[B]

Hi guys, my name is Natalia and I live in Hong Kong. I have a seven year old boy now who is a Type one diabetic. He was diagnosed last June.

[A]

I created the Diabetes Variables series because I know that in type 1 diabetes management, the little things aren't that little and they really add up. In this series we'll break down everyday factors like stress, sleep, exercise and those other variables that impact your day more than you might think. Jenny Smith and I are going to get straight to the point with practical advice that you can trust. So check out the Diabetes Variable series in your podcast player [e-mail] if you're looking for community around type 1 diabetes, check out the Juicebox Podcast. Private Facebook group juicebox podcast type 1 diabetes but everybody is welcome. Type 1 type 2 gestational loved ones it doesn't matter to me. If you're impacted by diabetes and you're looking for support, comfort or community, check out juicebox podcast type 1 diabetes on Facebook. Nothing you hear on the Juice Box Podcast should be considered advice, medical or otherwise. Always consult a physician before making any changes to your healthcare plan. This episode is sponsored by ABLE NOW Tax Advantaged Savings Accounts for Eligible Individuals with disabilities. If you or your child lives with diabetes, you may qualify for an ABLE account because of ongoing medical needs and many people in the diabetes community do. With ABLE now, you can save for future expenses without affecting eligibility for certain disability benefits such as Medicaid. Learn more and check your [e-mail] you spell that a b l e n o w.com today's episode is also sponsored by usmed.com juicebox you can get your diabetes supplies from the same place that we do and I'm talking about Dexcom Libre, Omnipod Tandem and so much more. Usmed.com juicebox or call 888-721-1514. The podcast is also sponsored today by Omnipod. Check out the Omnipod 5 now with my link omnipod.com/juicebox. You may be eligible for a free Starter kit. A free Omnipod 5 starter kit at my link. Go check it out. Omnipod.com Juicebox terms and conditions apply. Full terms and conditions can be found@ omnipod.com juicebox hi guys, my name is

[B]

Natalia and I live in Hong Kong. I have a seven year old boy now who is a type one diabetic. He was diagnosed last June. So I would like to just. I have some questions Which I would just like to talk about. Ask Scott about. Let's see how it goes. So. So thank you for having me, Scott. Really appreciate it.

[A]

Yeah, I appreciate you doing this because I know it can feel exposing to come somewhere and say, I don't know what I'm doing. And, you know, because you said right before we started to record, like, I don't even know if I have anything to say at certain points, but I don't think that's the value in this conversation. Also, I'm just going to reiterate, although I said it at the beginning of every episode, not a doctor, not advice, but I'm happy to try to talk to you about it and see if we can figure something out. So.

[B]

Great. Thank you.

[A]

No, it's. It's a pleasure. I appreciate you allowing it to be recorded so other people could hear. So your son's seven and he was diagnosed 10 months ago. Is that about right?

[B]

Yeah, it's 10 months already. Wow. Yeah, it's been 10 months. I mean, every day has been like a roller coaster. In the beginning, we were on, you call it the mdi, the injections. So he was on it for three months. And after that, we started putting him on the OP5, omnipot 5.

[A]

Okay.

[B]

So that has been helpful. But, yeah, he has his moments of not wanting it and not liking it, so. Because his skin started getting too red and too inflamed over time.

[A]

Yeah.

[B]

So, I mean, it's been taken care of. Now it's doing much better.

[A]

You figured out how to prep the site so that it doesn't happen?

[B]

Yeah, So I tried everything. And then we have a good support group also over here, which they keep telling us what to do. But what really worked, I took him to his own pediatric doctor and she just gave, like, to put, like, a very basic body wash. You know, no fragrance, all that kind of stuff. And literally, that's the one that overnight, literally worked.

[A]

Oh, so that's awesome.

[B]

Said to put the skin prep spray and the nasal spray and all these kind of things and use different patches and the prep and the first and the last. I just left everything.

[A]

Yeah, because you got a good result with the one I. Right. Why complicate it?

[B]

Yeah.

[A]

I would have asked you, do you use alcohol to clean the site?

[B]

So now I use the alcohol once before I put it on the text command that, and nothing happens. He's absolutely fine.

[A]

Oh, there you go. Sounds like you might have found the answer.

[B]

Yeah.

[A]

You wrote to me. Is that right?

[B]

Yeah.

[A]

Why don't you Go over that email for a second. Just tell me where you're at and where the struggles are.

[B]

Okay, so the thing is that daily routine, I'm just. See, he's diabetic. He's growing up, and he's at an age where he wants to do his own things also. Can't blame him. But it's just a scary fact that when we go out, that's the problem where we go for a restaurant. And now he's getting so scared that I have to count everything what he has. And he loves eating. So if he can't eat a pizza, I don't allow him the pasta, I don't allow him the hot dogs. You know, so then it's just like, why don't we stay home and just eat what I can in a bigger quantity? So, you know, that's become a thing. So I was just a little worried. How do I, like, embrace all that? Because his levels would go to, like, a 22, you know, that's like a 400.

[A]

Yeah.

[B]

It would, like, hit the roof for hours. And to get him down six to eight hours would go nowhere, you know, so his daily routine, breakfast, lunch, dinner, school snack, coming home, snack, everything is fine. But the weekends come in, and it just goes through the roof.

[A]

Okay, well, I'm gonna ask you a few questions first.

[B]

Yeah.

[A]

So on the weekends, does he become more sedentary?

[B]

What would that mean?

[A]

Well, does he not move around as much on the weekends as he does during the weekend?

[B]

Relatively, yeah.

[A]

Okay.

[B]

Yeah, he's mostly home. He just likes to relax, do nothing. Or we just go out for, like, a walk to the park, so. But nothing much.

[A]

But not as much as getting up, running to school, running around at school, all that stuff. Okay. All right, so I'm gonna take some notes. Not usually something I do, but. Okay, so during the week, he's moving more. Weekend, yeah, he's more still. Okay. And does he eat differently on the weekend than he does during the week? Like, you know, during the week, is it simpler?

[B]

So in the morning, his breakfast would include a normal egg or a milk or a bun or a bread, because even the cereal spikes him a lot. Oats spike him a lot. So that's been cut down to maybe on the weekends I give him cereal, but the problem is he's not so active. So the cereal goes even higher on the weekends.

[A]

Yeah. So cereal he's not getting during the week?

[B]

No, he's not getting during the week.

[A]

More like you cut out for a brief second. But during the week, like an Egg, Something like that.

[B]

Yeah. For the egg. Or a half glass of milk with a bun and butter. So everything is like, you know, I got it portioned.

[A]

Yeah. So you would call the week more knowable.

[B]

Manageable.

[A]

Yeah.

[B]

Yeah.

[A]

Well, because you're doing the same thing over and over again, too.

[B]

Yeah, I see.

[A]

Okay. Is there any chance that on the weekend you're just not counting the carbs as well as you are during the week? Or do you think it's more about the makeup of the food?

[B]

So on the weekend I can. I'm counting the carbs, but it's like, since there is. I feel he's very, like, you know, if there's activity, he works very well. The levels work very well with him. But when it's not and he's sitting, he's just watching, so it suddenly just spikes out of the blue. Even if it's the same breakfast? Yeah, even if it's the same one. Weekends treat him differently.

[A]

Yep. Okay. And on the weekend, what are we eating? I guess maybe take me through an average day of his meal during the week and an average day during the weekend and do breakfast, lunch, and dinner.

[B]

Okay. So the weekday.

[A]

Mm.

[B]

He loves eggs. He loves milk and bun or bread and butter. So these come to around 24 carbs, because the bread I get is, like, less in carbs and stuff like that. So that's like, morning. Is that egg, milk, bread in some form. And yogurt, the small baby yogurts, which he gets. And then he has a snack, 10 o' clock in school that I try to make it as free carbs because then the nurse has to keep running to him to give him the dose, which I don't want. So it's mostly like a seaweed or cheese or cucumber or something around these things mostly. Then he has lunch. Lunch is his turkey sandwich or a roast beef sandwich or an egg sandwich would just literally a slice of turkey, cheese, butter. That's it. And apple. He loves, like, one apple and one sandwich. Even on the weekends, if he's home, I make the same thing for him at home for lunch. And then he has a snack which is like either crackers or, as you also said, the Ritz crackers affects your daughter. It hits her a lot. I was hearing you say that once. So, you know, stuff like that, like just crackers and biscuits and. Because when he comes home, he likes to have his stuff. So fruits, milk, whatever he wants to eat, I doze him accordingly. And then dinner is mostly the basmati rice, because the Sticky rice. Take him to another level.

[A]

Yeah.

[B]

Then it's like homemade. Either grilled chicken or chicken with some kind of tomato and onions. All home cooked. So it's all pretty much like manageable, very easy to make and with some cucumbers and carrots and that's about it.

[A]

Going out to dinner is more difficult.

[B]

So dinner. I have tried. Now we don't go out for dinner because the dinner foods make him. It's like a whole nighter. So it's really hard for that to work out. So we do lunch outside.

[A]

Okay.

[B]

And dinner is mostly home. Yeah.

[A]

When you have gone out to dinner in the past and it's been difficult. I like how you said it turns it into an all nighter. What kind of food was doing that?

[B]

So mostly living in Hong Kong. We get like Chinese food, Japanese food. So it's mostly sushi or Chinese food, you know, with the sticky rice and nice little gravies and chickens and fried chickens and Korean fried chicken. So stuff like that. And if everyone's having it, it's hard to keep him away from all that. So now we also try not to order and have that kind of food.

[A]

Sure. Well, that's nice of you to do it with him. How big is your family?

[B]

I have a daughter and this is my son. So two kids and my husband and me.

[A]

Okay. The four of you. Okay. So do you understand what's happening and you're having trouble impacting it, or are you having trouble understanding what's happening? As I told you earlier, ABLE now is sponsoring this episode. ABLE now, of course, tax advantaged ABLE accounts for eligible individuals with disabilities. If you or your child lives with diabetes, you may qualify for an ABLE account because of ongoing medical needs. Many people in the diabetes community do. With ablenow, you can save for future expenses without affecting eligibility for certain disability benefits such as Medicaid. And thanks to updates to federal law, ABLE accounts are now available to more people than ever before. That means more individuals and families can use ABLE now to save and invest funds in. An ablenow account can be used for a wide range of everyday needs, including education, transportation, healthcare, assistive technology and more. There's no enrollment fee and you can open an ablenow account with a small initial contribution and build from there. Learn more and check your [e-mail] that's ablenow.com a b l e n o w.com this episode is brought to you by Omnipod. Would you ever buy a car without test driving it first? That's a big risk to take On a pretty large investment, you wouldn't do that, right? So why would you do it? When it comes to choosing an insulin pump, most pumps come with a four year lock in period through the DME channel and you don't even get to try it first. But not Omnipod 5. Omnipod 5 is available exclusively through the pharmacy, which means it doesn't come with a typical four year DME lock in period. Plus you can get started with a free 30 day trial to be sure it's the right choice for you or your family. My daughter has been wearing an Omnipod every day for 17 years. Are you ready to give Omnipod5 a try? Request your free starter kit today at my link omnipod.com Juicebox terms and conditions apply. Eligibility may vary. Full terms and conditions can be found@ omnipod.com juice juice box find my link in the show notes of this podcast player or@juicebox podcast.com I just find like

[B]

I feel I'm dozing wrong because I was hearing you with your fat, protein and all these talks about it.

[A]

Yeah.

[B]

So I just wanted to ask the carbs. Like for example, we were on our Singapore trip right now. We were on a good vacation. He was actually okay.

[A]

Yeah.

[B]

His highest took on on the trip would be a 180 which I wouldn't consider high. So he was like active. We were eating, we were going places and walking and doing many things. So that was I think working out so well for him that we would tell our friends also who we stayed with were like, sorry, but you know, we are staying away from such and such foods. So they took us to places where we would have grilled chicken or you know, some kind of healthier options. And then once when we went for the pizza and all the western, you know, all the high fat foods, I tried to manage like from one slice of pizza, I cut it into a quarter pizza a slice. And so you know, I was trying to manage with that with a grilled chicken being pushed in with little veggies pushed in, which I can't do all the time. If we're going to a pizza pasta place, you only get that kind of food. Right. And what happened on our vacation is I cannot count because in the restaurants there is no count for it. I started dozing him extra good. I feel that was the first time I did that. I was scared something would happen but everything was okay and it worked.

[A]

Yeah.

[B]

So since I've come back, I feel I am giving. I'm just throwing in an extra 5 if I'm at home. I'm throwing in an extra 10 if I'm out.

[A]

Yeah.

[B]

But still avoiding the full, you know, like three slices of pizza and fried stuff.

[A]

Let me run over a couple of ideas for you. Okay.

[B]

Yeah.

[A]

So the first one about the activity, that's very real. Okay. So when you have less activity, your body becomes more resistant to insulin. It's just kind of the way it works. Right. I can get you a more technical answer, but it's about how the glucose is handled by your body. Okay. So we are in this Omnipod 5 setting.

[B]

Yeah.

[A]

And it's adjusting to your daily needs.

[B]

Yeah.

[A]

And so during the week, I think you're getting a. There's a combo of a number of things here.

[B]

Yeah.

[A]

He's eating the same stuff over and over again. And you sent me kind of a sample menu. He's eating things. Perfectly honest with you. Very healthy choices. You know, I'll read for people. Turkey, roast beef, eggs, apples, fruit, you know, basmati, rice. Great pivot there, away from the white rice, meat, vegetables, eggs, like, stuff that's not terrible to bolus for because they're not very high in fat, they're not fried, it's not processed food. Right. It's as helpful to the process as possible, these types of foods. So you've got the food on your side and then you have the exercise on your side, the activity. On top of that, the Omnipod 5 is saying, okay, this is about how much insulin we need for these days. And you start to pick up a rhythm. It Monday, Tuesday, Wednesday, Thursday. Right. Then all of a sudden on Saturday, he stops moving. You lose the value of the exercise. And on top of that, you're making maybe the same decisions with the food. And it's going okay right up until you try to go out. And then, you know, you see chicken, pizza, all that stuff there. Right.

[B]

Yeah.

[A]

Yeah, that all sounds about right. Right. That's how it's going.

[B]

Yeah.

[A]

Okay, so I understand that when you get out of the house, it's hard to count carbs. Yeah, just how it is. Right. But what it's going to take is practice. Yeah, it's not a great answer. I mean, I could tell you right now, you probably could open up an AI app on your phone and tell it where you're at and probably get a more accurate feeling for the carbs and everything. But if you don't start incorporating the impact of the fat that's happening to his blood sugars, the carbs aren't going to really matter.

[B]

Yeah.

[A]

You know, I mean, not that, not that it's not going to be helpful.

[B]

Yeah.

[A]

You know, if a chicken sandwich out at a restaurant is actually 60 carbs and you were guessing 40, of course that's going to be a big deal.

[B]

Yeah.

[A]

But if there's, I don't know, 7, 8, 9 grams of fat in it, that could end up costing him another unit of insulin. And the timing gets changed as well.

[B]

Yeah.

[A]

And do you understand why that is? Because it changes the, the digestion process.

[B]

Right.

[A]

Okay. So you eat all those carbs and one of the ways those restaurants make flavor is with sugar. So there's probably more carbs, probably more sugar, and on top of that, more fat. A lot of it ends up being fried, which you're not frying anything at home. You take in that kind of oil, the grease, the fat, etc, and it slows down your digestion. So those carbs, which are probably more than you guessed to begin with, are sitting in his stomach and impacting a longer timeline. And that's how you said, you know, it turns into an all nighter. Right. Because those carbs are in there impacting him all night long. There are ways to stagger your boluses to get in front of those rises and the long digestion.

[B]

Yeah.

[A]

So did you find the calculator? I'm. I think I'm supposed to call it an estimator. Did you find the estimator on my website?

[B]

Yeah.

[A]

You did? For the fat and protein and did that help you?

[B]

Yeah, it was just too much, so I didn't.

[A]

Oh, you got a little overwhelmed by it. Okay, yeah, we'll talk about it now. That's okay. So can you tell me how much he weighs?

[B]

He weighs around 20 kilos. 20 kilos, that'd be into 2.24 pounds, so around 40 something.

[A]

Oh, oh, I forgot. You said he was seven. He's little.

[B]

Yeah.

[A]

How old's your daughter?

[B]

She's 10.

[A]

Oh, you have a young family still. Yeah, yeah. Lovely.

[B]

Yeah.

[A]

Was the diabetes a surprise or is there autoimmune in your family?

[B]

Oh, that's another story. No one has it in the family.

[A]

How about other autoimmune stuff? You see thyroid or celiac, anything like that with people?

[B]

Nothing. Nothing?

[A]

No.

[B]

Or as I joke with my mom that maybe our grandmothers had it and they never knew about it, so.

[A]

Yeah.

[B]

I don't know.

[A]

What's your background, what culture?

[B]

I'm originally from Pakistan.

[A]

Yeah. Do they talk about their health, the family? You've probably heard me talk about US Med and how simple it is to reorder with usmed using their email system. But did you know that if you don't see the email and you're set up for this, you have to set it up? They don't just randomly call you. But I'm set up to be called if I don't respond to the email because I don't trust myself 100%. So one time I didn't respond to the email, and the phone rings at the house. It's like, ring. You know how it works. And I picked it up, I was like, hello. And it was just the recording. It was like, US Med doesn't actually sound like that, but you know what I'm saying? It said, hey, you're. I don't remember exactly what it says, but it's basically like, hey, your order's ready. You want us to send it? Push this button if you want us to send it. Or if you'd like to wait. I think it lets you put it off like a couple of weeks. Or push this button for that. That's pretty much it. I push the button to send it, and a few days later, box right at my door. That's it. Usmed.com juicebox or call 888-721-1514. Get your free benefits checked now and get started with usmed Dexcom Omnipod Tandem Freestyle. They've got all your favorites, even that new eyelet pump. Check them out [e-mail] juicebox or by calling 888-672-101-1514. There are links in the show notes of your podcast player and links@juicebox podcast.com to us Med and all of the sponsors.

[B]

Oh, yeah, we do all their checkups and stuff, but it's just been like, we've been here, what, 16 years now in Hong Kong. So, like, both my kids have been born here. So it's just like he. Overnight, he was looking weak. And it just so happened that after school finished last year year, I took him to the pediatric. And she said, just do some blood tests. And overnight, like, the blood test was in the morning. The doctor called at seven in the evening and said, take him right now. His level was something like 40.2.

[A]

Okay.

[B]

And it was just like an ICU. It was an overnight thing. Like, no one even saw it coming. But I guess the symptoms I was telling my doctor were there where he was thirsty overnight, you know, all night long, going to the loo every now and then. So the signs Were there, but I didn't know what it was. So because of that. Yeah.

[A]

Did it come on very quickly or in hindsight, had he been losing weight for a while or sick for a while?

[B]

He was looking weak since a month maybe.

[A]

Okay. Feels like you caught it pretty quickly.

[B]

I wouldn't say that, but, yeah, that's what everyone says. But, yeah, I felt so bad when that happened, but, yeah, that's pretty common.

[A]

Just so you know.

[B]

Yeah.

[A]

Yeah. Most people talk about that and. And have that feeling. Yeah. I'm noticing here on your menu that you sent, you have different carb ratios for. Is it different times of day?

[B]

Yes. So for the morning, it was just something that the. What you call the diabetic educator we were in touch with. She said this because he was going a little high and low at different times.

[A]

Yeah.

[B]

So we just changed this around and we just did it like 19, 31, 41, according to Morning, afternoon, night.

[A]

Was that before the pump or after the pump that they noticed that?

[B]

After the pump, yeah.

[A]

Okay.

[B]

Actually, even before. Sorry. Even before the pump, the endocrinologist had him with, like, it was pretty much same, but it just wasn't. You know, the curve was just going up and down a bit. There was no consistency.

[A]

So let's talk about that before we get into the menu. So if these variable insulin to carb ratios were set prior to pumping, then what they were doing is trying to probably get in front of problems you were seeing at meals based on injected basal insulin, which doesn't work as stably as it does from a pump.

[B]

Yeah.

[A]

So I also would wonder if maybe you don't need to find out what his carb ratio is and set something a little more stable because you have insulin correction factor here of one unit moves him 41. One unit moves him 19. So you have it more aggressive at breakfast. At 19, it's aggressive for the snack. It gets less aggressive at lunch and then actually, oddly much less aggressive at dinner.

[B]

Yeah.

[A]

So is he getting high at night before bed?

[B]

Not at all.

[A]

No. Okay.

[B]

He gets low. Like, low is what I would call it. I know there are different lows, but he goes around 90, 72 in this range, but it's still manageable. But sometimes he just goes low. He has, like, few sips of juice and he's back. Okay. And then he's sleeping.

[A]

70 and falling or just 70 and stable and you get nervous about it.

[B]

I used to get nervous even less than 72.

[A]

Okay.

[B]

But now I let it go to 70.

[A]

Okay. You're getting it yeah, it's hard. Takes time. Took me. I was crying for two years. Just so you know, the first two.

[B]

Yeah. Like today I tried to do that with the nurse in school because I've told them at a 5.3, make sure you give him juice. Make sure you do this and you stop and do this, this, this. So today when he was on a 4.9, they panicked and they're like, he's 4.9, he needs juice right now. I was like, no, let's wait because I'm seeing him. He pulls up himself.

[A]

Yeah.

[B]

So, you know, I mean, I'm just trying. Just slowly, slowly. And they're trying. So it's like a whole. It's like a village.

[A]

I understand. It takes time. I hope you take some comfort in the knowledge that eventually you will get better at this and it will feel easier. I don't think it's actually easier, but it's going to feel easier. So do you know what his total daily insulin is right now? About how much does he use in 24 hours?

[B]

Oh, I forgot. Let's see, one second.

[A]

Take your time, please.

[B]

So he would be like, total daily would be roughly around three or four units a day.

[A]

And that's of bolus insulin.

[B]

Yeah.

[A]

And then how much basil is he getting?

[B]

I think basil also is around 3. That's the background one. Right, with the automatically it being given to him. Yeah.

[A]

Do you know what his basal rate set at in the pump?

[B]

Basal rate.

[A]

So how much insulin does he get every hour from Basil?

[B]

Every hour? 0.05.005, yeah.

[A]

Do you think he's honeymooning? Are there times when you think like, oh, gosh, he doesn't really need insulin?

[B]

No, not really, No. I think he needs it. Yeah.

[A]

Okay.

[B]

Like I would say the Night Touchwood, so far, since this week, since we've come back, has been the best ever. Where he is literally on a 90, 108 would be his highest. So he would just be like, nice, flat line, nice.

[A]

Okay, well. And are there times of the day where he's just not getting basil too? Can you see with the pump, does it cuddle away at times?

[B]

Sometimes, yeah.

[A]

Okay.

[B]

Or maybe an hour or so. But yeah, not more than that. It just keeps giving it.

[A]

Okay, give me one second. I'm having a studio built in my house for the podcast and right now they are like cutting into the wall. Got so loud. I was afraid it was going to bother you.

[B]

No, no. So 820. You can see he's got a point zero five today and then at 9:15, he's got another 0.05. So it's like almost an hour later.

[A]

Yeah, it's tiny bits. He's getting tiny.

[B]

Yeah. Really? Less.

[A]

Yeah. Well, I'll tell you, the other thing to find some comfort is that as he gains weight and his insulin needs grow with that, this all gets a little easier, too. Like, when you're working with these really small numbers, there's a lot less room for, you know, making a mistake. But also the good news is it's not a ton of insulin. So if something goes wrong, it should be fairly easy for you to get in front of it one way or the other. So I have a, like an estimator on my website that starts with someone's weight and sort of gives you like a breakout of where you might expect their insulin to be. If I make him highly sensitive, that puts him at like, theoretically like nine units a day. And I have a slider. I can make it less aggressive, but when I do that, it wants to put less basil on. Takes this basel to about 0.15 an hour. So you are not far off at all, from what you're seeing, being pretty accurate to what the math would tell you.

[B]

Yeah.

[A]

Which is kind of great. So 44 pounds, seven units a day total. This has him about 0.15 an hour. But there's an argument to be made that, you know, he's probably getting that much sometimes and nothing other times and balancing out to what you said, like three. So let me take a little calculator here for a second. Do the 0.15 times 24, and sure enough, that's 3.6 a day. So again, so the numbers are lining up. So I'm fairly comfortable that, like, based on his weight at least that your settings are pretty good. Okay, so I like that.

[B]

Okay.

[A]

Now, the sensitivity factor, if it's working for you, I'm certainly not going to tell you to change it. Whatever you're seeing is much different than what the math says. So I say just go with what's working for you.

[B]

Okay.

[A]

On that spot.

[B]

So how would that change?

[A]

It's going to take more insulin to move him as he gets bigger.

[B]

Okay.

[A]

That's all. And I think there might be a time when you'll just pick one because you have it at 18 right now.

[B]

Yeah, 18. Yeah.

[A]

Is that. That can't be right, though. You think one unit moves him 18 points?

[B]

Oh, good question. Like, when he's high, he doesn't even do that. So I had started giving him like 0.5, so he can come down nine units. But that's not true.

[A]

What I'm going to tell you is that at this little bit of insulin, his insulin sensitivity, the math says it's like one unit moves him 250.

[B]

Wow. Okay.

[A]

I don't know what to tell you about what to do or not do with that. Especially when it's Omnipod 5, because Omnipod 5 has. Let me pull this up here. I'm a little embarrassed. I just made a video for Omnipod about this, and now I'm having to check my own thing to make sure. To make sure I'm about to say the right thing. I feel silly. But that's okay because I stood in a studio and said it over and over again all day while they were way too close to me with that camera. I'm not going to lie to you. I was uncomfortable at points. I didn't like to see my face that big. You know what I mean? When they were working on it, I said, please. They were like, oh, it's going along great. We can't wait to send it to you so you can see it. And I was like, do I look old? It's all like. That's all I kept asking. I was like, do I look old? I look old, don't I? Just don't tell me it's okay. So I have another calculator here, estimator, about how to bolus, Right. So your insulin to carb ratio. And we need to kind of pick one. So let's just go with breakfast for a minute. And we're gonna say 19 for the carb ratio. I mean, I'm gonna put the 18 in for your sensitivity and say that his blood Sugar Target is 90. Okay.

[B]

Okay.

[A]

And now I'm gonna look at his breakfast. Here you say there's 24 carbs for breakfast, and there's an egg, there's milk, there's a bun, there's bread in there. And you are giving him 1.3 units, which, by the way, in this calculator with your settings, it's 1.26. So 1.3. Exactly the same thing.

[B]

Oh, okay.

[A]

What I'll say is the milk. High fat milk, low fat milk. Do you know how what kind it is?

[B]

It's full fat. Yeah.

[A]

Okay, so we're gonna do some more Gazintas here and try to figure out. You think it's a cup of milk?

[B]

Half a cup. Okay, so on the true calculation on the packet, it says, like one cup is around 12 grams of carbs.

[A]

Okay, but how much fat is in it?

[B]

See, now that's the thing. I don't calculate at all.

[A]

Is that bolus working for you or is he getting high later?

[B]

It's working.

[A]

How high does he get after breakfast?

[B]

Mornings he would start at 90. Maybe 90 or 108. And the best thing is I pre bolus him 20 minutes. That is the game changer.

[A]

Very nice. Yeah. Have to be.

[B]

So he goes up to 144 or 162.

[A]

Okay. So he's not moving much at all on that.

[B]

Not bad. Yeah. Not bad. Yeah.

[A]

Let me just say this. At some point, when he goes to 140 or 160, the algorithm is coming in and giving him more insulin to bring him down.

[B]

Yeah, probably right.

[A]

So a cup of whole milk has 8 grams of fat. There's 4 grams and a half a cup. Just adding that to this doesn't change anything. But there's butter on the bun.

[B]

Yes.

[A]

I'm gonna see what happens here. Look for the fat in a tablespoon of butter. Gonna try to make. So here you go. A tablespoon of butter. Do you know how much fat's in a tablespoon of butter?

[B]

How much?

[A]

12.

[B]

I don't even add that. Wow.

[A]

So if I have 16 in fat and I re simulate it again, it's not a lot, but it adds a 0.38 bolus over time.

[B]

There we go.

[A]

And I'm going to guarantee you that if you go look at what's happening. He's going up and, you know, 140 or so, which, by the way, is great. You're doing terrific, by the way. I have a feeling when we get to the end of this conversation, I'm going to find out that you're a bit of a type A personality. To tell you. I'm going to start asking you what you went to college for, and it's going to be accounting or something like that.

[B]

And so don't ask me, because you're almost right. Okay.

[A]

All right, everybody. Natalia is an actuary or an engineer. And it's not that bad.

[B]

It's not that bad.

[A]

It's not that bad.

[B]

Just finance.

[A]

Yeah, There we go. Okay. Yeah. So when I put in the fat for that meal, the initial bolus is still at 1.26 or 1.3, but it's asking for 38, so.04 units over the next three hours. Omnipod 5 doesn't do extended boluses.

[B]

That's my biggest concern. I've been Hearing so many podcasts. A few. But how do I do it?

[A]

All I would do is like an hour after he eats, I'd bolus point four. Okay, that's it. What I would really do, since we're talking about it, is I do it one morning the way you always do it. 1.3. And then I'd wait to see when does he start to rise? Okay, I'm going to make up a number. Say he starts to rise 75 minutes later. I'd put in the 0.4. I would pre bolus the meal. You're doing a great job pre bolusing the meal. I'd pre bolus the meal. Then I'd pre bolus the fat rise with the 0.4. And you can use my estimator, it's juiceboxpodcast.com forward slash B O, L U S. The number four. Bolus four.

[B]

Yeah.

[A]

And all I did was put in insulin to carb ratio 19. Insulin sensitivity 18. I made the target 90. I put in 24 carbs from your thing here and I put the fat in 16. And it gives you a little, you know, there's a meal wave and the Warsaw wave. It kind of breaks them out for you. It tells you about how long to stretch them out.

[B]

Okay.

[A]

And that's it. Like, so I'm going to do it again with you though. I'm going to look at the next meal.

[B]

Okay.

[A]

This poor kid, you're giving him seaweed for snack. Is that what he used to eat or is that a diabetes thing?

[B]

It's a diabetes thing, but he's loved it.

[A]

Anyway, listen, it sounds like you're all going to be healthier by the time this is over.

[B]

Yeah, seems like it.

[A]

So now let's do the turkey or sandwich and the apple again. Okay, tell me, what kind of a rise do you get from that, if any?

[B]

So that would be lunch, right?

[A]

Yeah.

[B]

So lunch is also okay because luckily it's a 15 minute eating window and then they get to play for like 25 minutes. Okay, so that really works for him.

[A]

Oh, and that's why your carb ratio is weaker.

[B]

Yeah, he would go too low then.

[A]

I see. So you're getting around that by weakening the carb ratio and that's working for you. Okay.

[B]

Yeah.

[A]

But also on the weekends when you're trying to have lunch and it's pizza, that's also why you're struggling with the pizza, because your carb ratio, he's getting half the insulin for twice the carbs.

[B]

Yeah, you're right.

[A]

So yeah. So everything is settings. It's all timing and amount. Okay. Okay. So I guess I'm going to talk to that part of your brain. Everything is timing and amount. Okay. So you, you look at that 24 carb breakfast, you see the problem you're having with it. You realize in that scenario it's not accounting for the fat that probably caused you the problem. Also, nothing you hear on the juice box podcast should be considered advice, medical or otherwise. Always consult a physician before making any changes to your health care plan. Now, on the lunch one you've got the carb ratio goes from 19, one unit covers 19 to one unit covers 31. And you have found a great balance there because of the activity. But at that same time of day at a pizza restaurant, you are not only don't have the activity, but you've added fat that you're not accounting for lesser quality food. And for every car be eats, you're getting half the amount of insulin. In a scenario where you probably need more, you are starting with less and not accounting for the pizza. That makes sense.

[B]

Yeah.

[A]

Okay, look at it.

[B]

What do you think of it that way?

[A]

That's okay. That's what I'm here for. Yeah, my silly brain's not good at much. Natalia. This it understands.

[B]

That's a lot to understand. It's way more than we understand.

[A]

Listen, I sincerely mean this. I'm not denigrating myself, but I'm probably not nearly as intelligent as you are. I'm not good at math. Whatever degree you have I couldn't possibly get. All I had was a kid with diabetes before all this stuff existed. And my desire to really pay attention to it and try to figure out what was happening. And then I saw what I saw. And contextually I speak about it very differently, which I think is why, you know, when I stand up in front of a crowd and I say things like all the silly T shirt slogans I say about diabetes, that comes from like, kind of like the. I think I talk in pictures. But then over the years making these episodes and bringing my friend Jenny in and talking about it with her, like, she really like helped reframe me the way I think about it. And I was able to kind of rewrite the way I think about it too.

[B]

Yeah, it's great. The work you do is great over here because in Hong Kong, we don't have the exposure. You know, we just have very, I would say a very. I mean, we don't even have pumps over here. We have to order them from other countries. So they don't even have the whole thing where they have that support over here. Like you're saying take in the fat, taking this, taking that.

[A]

No one's going to tell you about that. You know, I've done a couple of zoom chats with expats in Hong Kong a couple times around diabetes. Nice little group of people. So I understand why the lunch works and I understand why you also are less aggressive at snack time afterwards. That all makes sense. But now at dinner that part throws me off because rice, meat, you know what, it's just not a lot of carbs really. You're doing meat and veggies with some rice. Basmati's got. The index on the basmati is lower and you've got the 41 working. Is he super active after school? Does he come home and run around and everything?

[B]

Excuse me. So he's basically, he has football when he comes home on Thursdays and he has other activities going on. So he's quite like all over the place until like we're ready to eat dinner by 5:30.

[A]

Okay. That's why you're getting away with the insulin to carb ratio of 1 to 41 at dinner time. Plus you're doing most of your carbs are from vegetables and rice at dinner as well. Yeah, yeah, yeah. Okay. And there's not a ton of fat in. No, there's no fat really in what you're eating at dinner time.

[B]

Yeah, I avoid doing all those things. So it's either rice or it's roti, the homemade ones. So we use the whole meal. Yeah, yeah, we use that for that. So, okay. He was tested for the celiac disease. He had the whole endoscopy and stuff done where he was cleared from it. So we've kept it as normal, no gluten free or anything going on. So I mean, I don't see that that's affecting him.

[A]

Yeah, no, it seems like you're okay there. Also a lot of those gluten free prepackaged meals are a lot more carb heavy than you think too.

[B]

I agree. Yeah.

[A]

So I'm glad you don't have to use them. But now I think what we got to figure out is this vacation menu here are the weekends, like, you know what I mean? Because I mean, I'm happy to walk through it with you, but you already know the problem, right. Carb ratio is wrong and his activity is different. Yeah. So the bigger question is then if the pump is already set up, you don't want to be changing constantly you know, your settings and everything.

[B]

Yeah.

[A]

I think, Honestly, when you're 19 and 31, you could just do the math and find out what the difference is so that when you dial up the insulin. Hmm. How are you going to do that? You're going to have to either lie about how many carbs it is or just put in extra.

[B]

Yeah, just fake carbs. Right.

[A]

But I'm not sure what the algorithm is going to handle better, because what we would prefer is that on Saturdays, you know, at that time of day, that his carb ratio was more like 19 than 31. If you're gonna go do those kinds of meals.

[B]

Yeah.

[A]

But you're also gonna want to really look at the fat on some of these things. Like, let's just use the pizza, for example. Like, I've never been to Hong Kong, so what am I getting for pizza there? Is it like pizza.

[B]

We have Pizza Hut.

[A]

Yeah, yeah.

[B]

Do Pizza Hut. Yeah.

[A]

Okay, so let's take a look at that real quickly.

[B]

And I don't even use the manual mode, so I don't put it on the extended bolus. I don't know if that impacts it or me. Just making it 60, 40 is also the same thing. Or not.

[A]

You know, putting a manual Mode, making it 60, 40. Impacting what?

[B]

I'm sorry, Impacting his levels.

[A]

I mean, I think what's happening is you're trying to eat stuff with more fat, more protein. The pump itself believes that his total daily insulin is seven on a day when it's going to end up being more like 12.

[B]

Yeah.

[A]

You know, so you've got everything going against you. You're changing how you normally live. And the algorithm doesn't know it's Saturday, and the algorithm doesn't know you're going to Pizza Hut. Right. So. And you're counting carbs and not covering the fat, too. So just because I'm on the website here. Cheese pizza, pepperoni supreme. Meat lovers, which one would you.

[B]

So just plain cheese, cheese.

[A]

Okay. I asked for the nutrition levels, and Pizza Hut's trying to sell me a pizza. Hold on a second.

[B]

Oh, wow.

[A]

And the calorie information, and I clicked on it and it says, what's my zip code? Am I gonna have to give it my zip code to get the calorie information?

[B]

Wants you to get one.

[A]

It does.

[B]

Huh.

[A]

Silly little website against tricking me. All right, I have to find a better website than the Pizza Hut website.

[B]

I got a 12 inch, 8 slices, 1 carbs, and pizza Hut pepperoni pizza. Okay.

[A]

Gosh, there's so many different kinds of pizzas.

[B]

Pizza Hut.

[A]

You should come here and have a pizza. In New York, Philly.

[B]

Yes.

[A]

Have you been here?

[B]

I've been to New York. My husband's family lives there, so.

[A]

Very nice.

[B]

Been there a few years ago, but with kids, coming all the way to

[A]

America is a bit much just for pizza. You don't think it's, like, it's going

[B]

to be worth the trip generally? I mean, like, it's. We have other places we can go to.

[A]

All right.

[B]

I've lived in Arizona with my uncle for like, one semester of college. I didn't like it.

[A]

I came back too hot, right?

[B]

Oh, just like I was 15. Probably missing home. Yeah.

[A]

Not looking for that. The only thing I really know about your part of the world is I do keep grass lizards from Japan. The little green ones with the super long tails.

[B]

Oh, wow.

[A]

Hold on one second. Let me tell my wife that my dog ate. Okay. My dog got sick. He had to have his medicine today.

[B]

Oh, wow. Okay.

[A]

My wife's like, did he have his medicine? Okay, so 12 inch medium pan pizza.

[B]

Yeah.

[A]

So just using the pizza, I'm going to make an example here for you. If we put him at 31 for his insulin to carb ratio, and then we say that he has. And is one slice true or is he gonna have two slices?

[B]

Two, yeah, two.

[A]

Two slices.

[B]

Okay, let's see how it goes. Yeah. 60.

[A]

Yeah, this says 27 here, but we'll go with 60. And now the fat is 20. And believe it or not, there's protein in it. There's 11 grams of protein in it. So you're getting 22 of protein. We haven't even talked about what protein does yet.

[B]

Okay.

[A]

But protein gets stored as glucose.

[B]

Glucose. Yeah, I was hearing your thought.

[A]

Yeah, you see, you kind of have to do that there, too. So 60 carbs, 20 fat, 22 protein. Right. Is 1.9 units up front and 0.43 units stretched out. So you're probably doing two units if you're counting all that correctly. And it really is more like 2.4. But I think the greater point is that that's at the insulin to carb ratio of 31.

[B]

Yeah.

[A]

If you change his carb ratio to 19 and do the same math again.

[B]

Yeah.

[A]

This goes from 1.9 up front to 3.1 up front.

[B]

Okay.

[A]

And 0.7 over the four hours. So that's almost a four unit bolus. 3.86. 3.9. 3.9 bolus, up from 1.9 that you were using Before. So you're using half the insulin that you need and not trying to impact the fat at all. So basically think of it this way, you gave the pump 2 units of insulin to do the job that it needed 4 units of insulin to do.

[B]

Right.

[A]

And on top of that, it doesn't consider fat the way you and I are talking about it. So as he's drifting up, it's not treating him like the food's the issue, it's just treating him like he's drifting up. So you've got this accelerant on his blood sugar, this, you know, this fire you've lit in his belly of fat and protein and carbs and all this other stuff, and you're handing the pump a garden hose and telling it to put it out. It needs a fire hose.

[B]

Yeah.

[A]

And so instead of putting that burden on the pump, which, by the way, what does he get to after the

[B]

pizza, how high he goes to? He's been to a 22, which is around for you, 400.

[A]

Okay. So what I would do there is of course not as long of a pre bolus for pizza because you don't want him to get low first. And that pizza does not go in and start working as quickly as some of these other foods do. Right, Right. So maybe a slightly shorter pre bolus again, the timing and the amount to get the bulk of that insulin where you need it to be. But then when you start to see that first rise, you're going to have to bolus again. And whatever that pod's going to do, I mean, with a kid who's using seven units a day, it's probably hitting him with like 0.05. 0.05. That's not going to do nothing. No. Especially when you're two units deficient already. Yeah, right. So I think that's your answer there with that food, which is use the more aggressive carb ratio and account for the fat and the protein.

[B]

So does this make sense if I change the 31 to a 19 next time I do this when he has his pizza and then I. For the weekdays, I change it back.

[A]

Yeah, I mean, you can. Whatever is workable for you. Yeah, yeah. Whatever works best in your life.

[B]

I'm just asking, should it have a consistency or is okay to just keep changing it?

[A]

Well, I mean, listen, there's an argument to be made here. Taking the weekend out of it or taking the pizza kind of extra stuff that you don't usually taking that out of the conversation for a second. There's an argument to be made here that you're. It's got nothing to do with the carbs. It has to do with his activity. Activity.

[B]

Okay.

[A]

You're managing lows from activity by using less or more insulin at meals. That's all that's really happening here. Everything's timing an amount. It's the right amount of insulin at the right time. And the timing has a lot to do with the variables around you. Right. Is he active? Is he not active? For some people, it's heat. Are they hot? Are they cold? Are they, you know, whatever people's variables are. You know, for ladies, a lot of times, a lot of hormonal stuff, right?

[B]

Yeah.

[A]

That's why you hear people talk about diabetes like, this way. Like it's unknowable. Like, oh, I do the same thing every day and I get a different outcome. Yeah, but you're doing the same thing every day, but the day's not the same. It looks the same to you because all you're talking about is eggs and milk and bacon and 8 o' clock in the morning. You're not talking about hormones, you're not talking about growth hormones, which he's. By the way, you're not going to see yet. But in a couple more years, wait till you see his blood sugar go up overnight when he goes to sleep. That's going to be fun. So it's the variables around it that change the impact, the invisible impacts, really. But that's why when people say I do the same thing every day and I don't get the same outcome, they're wrong. They're doing the same thing every day, but all the things that are happening are not the same. It's the unseen stuff. And for you, I can see why this would have gotten past you, to be perfectly honest, because they got you those carb ratios set up and you're like, wow, this is working. And then why the hell doesn't it work on Saturday? That doesn't make any sense. Then all of a sudden you say, oh, it's diabetes. It's just. You can't know. But we looked at it for five minutes and you know now, so it's pretty much it. I mean, there's. I hate to say it, there's not a lot to it. You know what I mean? Which is why I can hold it in my head. Trust me, if there is more to it, I'd be the wrong person to ask.

[B]

Can I just ask you to repeat this whole thing with the bolus? I opened your bolus estimator.

[A]

Yeah.

[B]

So can we, like, walk through this together?

[A]

Sure, sure. Yeah. So at the top there, there's insulin to carb ratio variables. Yeah, yeah. And there's insulin sensitivity.

[B]

So we put in 31 here, right?

[A]

Yeah.

[B]

And then SF is 18. The target blood glucose would be.

[A]

I made it 90.

[B]

Okay.

[A]

Yep. And then you kind of scroll down a little bit and put in carbs. By the way, I'm not boasting because I don't know how to code, so it was Claude that did it. But once you leave the website and come back, it'll leave his carb ratios and his sensitivity, all those numbers you put in, it'll remember it when you come back to the website, but it doesn't store any of your data.

[B]

Okay, so what is the calc cap? What does this mean?

[A]

Okay, so I'm not going to lie to you. It's a simulation. It'll halt if the output exceeds it. So it's kind of a safety that's built in.

[B]

So it's. I don't have to put anything.

[A]

You can just leave it at. It should be at 25, right?

[B]

25. Yeah.

[A]

Just leave that. The FPU adjustment factor, if you want to sit down and really read and understand the Warsaw Method, which it's probably not going to be necessary for you with such a little kid. It's such a little weight. But there are some people who need a different adjustment factor to make the Warsaw Method work better for them. I'm going to tell you right now, I'm not the right person to ask about that, but it's set at 50 as a default. If it's working for you, I'd leave it there. Okay.

[B]

Okay, let's leave it. Yeah. Okay.

[A]

And then carbs. Fat, protein.

[B]

So, carbs, we have 60.

[A]

Yep.

[B]

Fat, we have 20. Protein, 20, 22.

[A]

Now, I did not fill in the current BG number there. Okay. So. Because we're just talking, like, theoretically. But if you put in there, he's 150, like, I'm still looking at your bolus with 60, 20, 22 as the settings, and it's 1.94 and 0.43 meal wave 194. Warsaw, 1.43. But if I suddenly make his blood sugar 150, then of course it's going to add a correction in. The initial bolus went up to 5.27 to cover his higher blood sugar.

[B]

Oh, wow. Okay.

[A]

You're not just bolusing for the food. If he's 150, you're bolusing for the Food and the elevated number.

[B]

Okay, so let's go through with this. So current BG we kept at 150. Then the IOB units.

[A]

If he's got insulin on board, you can put it in there. So it's part of the. Part of the thing. But, you know, also, if it's been a few hours since he's eaten and he's got a stable blood sugar, I'm going to kind of assume that the insulin's already done what it's going to do.

[B]

Okay.

[A]

And it actually does help you there. You can put in a. An arrow for the trend arrow. Because right Now I have as 150. It's a five to seven bolus. Also, let me mention, with the 150, when I take the 150 out, not only is it a 1.94 initial bolus, but it says make the pre bolus nine minutes. You put the 100 and 50 in, and you'll notice when you re simulate it, it turns the pre bolus into more like 15 minutes, which it's telling you is like, look, you want to try to get that 150 number down more before you start eating, is what it's saying.

[B]

Right?

[A]

Yeah. And don't take any of, like the 15 or the 9. It's not gospel. It's right. It really is just, you know, a place to start to think about it. Anyway, if you make the arrow stable, that's one thing. If you make it a rising arrow.

[B]

Okay, so whatever it is, I see from the controller. Okay.

[A]

And actually, when you scroll down, it says show calculation steps. If you want to click on that, it shows you all the math that it's taking into account. And you can continue to scroll down. And there's an incredibly technical explanation of what this thing is doing.

[B]

Okay, great. I didn't know how to use this. Yeah. Okay, so mean wave would be 5.27 units. That would be.

[A]

Yep.

[B]

Up front.

[A]

Yep. What it's saying there is, it would like to see 0.43 units spread out over four hours.

[B]

Over four hours.

[A]

But you don't have that ability.

[B]

Okay.

[A]

So there's where you're going to have to just pick a time to jump in and put in the little bit of extra to try to stay ahead of the. Now listen, if 90 minutes later, you're not seeing a spike and it never comes, well, then, okay, the bigger bolus did it. But if you see it, I get excited.

[B]

In two hours, I said, I think I did it. And then the fourth hour comes.

[A]

I think I Did it? Nope. Well, see also on the aid systems, all of them, right. There's this sort of like, in plain language, the algorithm believes that you've given it the right amount of insulin and that you've accurately described the impact that it's going to see. You know, if your pre bolus gets him to, I don't know, 85 and he's super stable, well, then the algorithm's working off the bolus, so it'll oftentimes take the basil away because the bolus is basically handling the food and the basal needs all at once right now. Right, okay. So if it's doing that and you're wrong, or there's other impacts from food, then not only is it not enough insulin, but it's also probably got a deficit of basil, so there's nothing there to stop the rise from happening. Right. And then it starts to just like the way I think about it is this basal insulin. If you think of the blood sugar as a number, I think of basil as just enough weight to keep that number where you want it to be. So think of your, you know, your left hand is pushing up and your right hand is pushing down. And so the body is, you know, natural body functions are making your blood sugar go up. Right. You're not making insulin. You eat a cookie, your blood sugar is going to go up. Without insulin, it's never going to stop. Right?

[B]

Yeah.

[A]

So you need to put enough basil on top of that just for your body functions to keep you level. So think of it as like resistance that keeps the number where you want it. That's basil's job. Keep you at a number that you want stably. So the basil's doing that, you take that basil away, there's nothing stopping that number from rising all of a sudden. And so when you bolus on an algorithm, you put in all this insulin and it's saying to you, okay, well, we have a stable number. So the insulin that's in there is not only handling the food or the correction that we asked for, but it's also handling the basal needs. So you'll see that a lot of the algorithms just shut the basil off, and sometimes there won't be basal insulin happening for an hour or two.

[B]

Yeah, yeah.

[A]

Right. And just imagine if you didn't use enough insulin and it's shutting the basil off because it believes you when you told it how many carbs and what's the impact gonna of this food? So it's taking insulin away on the other side, then that fat rise comes in and hits you, and you've not only don't you have anything currently laying on top of it to stop it, but you haven't had anything there for hours. So you're deficient on top of that. Does that make sense? It does. Right? And then that's where the rise comes from.

[B]

Yeah.

[A]

Yeah.

[B]

This is the information I feel I was missing. It was just not making sense.

[A]

Sure. No, I understand.

[B]

Yeah.

[A]

That's it. What I just said to you right there. I don't want to give away the whole secret. That's pretty much why people listen to the podcast.

[B]

Yeah.

[A]

The idea that nobody talks about this part of it. I mean, you could get lucky and get an endocrinologist that would explain it to you, but mostly it doesn't.

[B]

Yeah.

[A]

I'll tell you, I'm giving a talk tomorrow at a hospital and I said I'd like to talk about this. And they were like, oh, we don't tell anybody to do that. I was like, yeah, that's going to be a problem. You know, So I think that's it. I mean, in all honesty, like, I would imagine this weekend's going to go way better for you. Might be pizza time again, who knows?

[B]

I hope so. Yeah. So is this what you said is like an extended bolus? Basically?

[A]

Yeah. If you had a regular pump. Right. Like that wasn't running an algorithm or. There are some algorithm pumps that handle extended boluses. Off top of my head, the tandem does.

[B]

Yeah.

[A]

Yeah. So if you had a tandem pump, you'd say, look, I want to do this exact setup. I'd want to do 5.27 up front, 0.43 over four hours, and. And then it would do that there.

[B]

Okay.

[A]

But Omnipod 5 doesn't do extended boluses in automation, so you're just going to have to make the 0.43 bolus at an advantageous time, which would be before you see the fat rise, but not so much before that it makes you low.

[B]

Okay.

[A]

All right. So the timing of that is going to be a little bit of. You're going to have to have a couple of pizzas to figure that out.

[B]

Yeah.

[A]

You know what I mean?

[B]

I have to go through it. Yeah.

[A]

Little practice pizza, we'll call it.

[B]

Okay, sure.

[A]

All right.

[B]

Thank you so much.

[A]

Oh, you're welcome. Same thing with all this other stuff. If you're doing chicken and it's a chicken tender or chicken nugget.

[B]

Yeah. Oh, the breadcrumbs and stuff.

[A]

Yeah. But don't forget too that. Because they probably deep fry them. There's going to be fat there.

[B]

Yeah.

[A]

So look for the French fries. French fries puff. Right. A cheeseburger and fries. I don't know if you guys eat meat, but a cheeseburger and fries, you're gonna get the fat from the meat and the fat from the fries. It's gonna be a double whammy of fat. And trust me, just for fun sometimes. Which, by the way, is why I set this simulator up so people could look at it.

[B]

Yeah.

[A]

Like, you have this set up now, 60 carbs, 20 fat, 22 protein, 150 blood sugar, and you're seeing what it is. But just imagine for a second. Let me just Google, like, Hold on a second. I'm just going to use McDonald's because I don't. Because it's something everybody knows.

[B]

Like, he's even stopped having chicken nuggets because. Just too scared of it.

[A]

Yeah. No, no, but you're going to have it now. I can hear you thinking about it. I know you're going to be okay.

[B]

Yeah.

[A]

Large McDonald's french fry, 23 to 24 grams of total fat, 66 grams of carbs. So if we add, say he has what you just described now, but with a McDonald's fry on top of that, takes it to 126 carbs and it takes your fat to 85.

[B]

Yeah.

[A]

Okay. Now I'm going to ask you, without thinking about the numbers for a second, just use your old brain. If he had French fries, how much insulin would you give him for French fries?

[B]

0.51.

[A]

Yeah, right. It takes his bolus up to 7.4 initially and 1.3 over time. So where you would have added 0.5 or 1, you would have really needed two, almost three units.

[B]

Yeah, yeah.

[A]

And that's the kind of stuff, like when people say, don't have any luck at restaurants. This is what they're not doing now.

[B]

There had to be a reason.

[A]

Yeah. This is it.

[B]

Yeah.

[A]

All right, you're done. I fixed it. We're all good.

[B]

Thank you so much.

[A]

What time is it where you are?

[B]

It's so simple.

[A]

Well, listen, once you hear my dumbass explain it to you, you actually start thinking, huh? Maybe it is simple.

[B]

No, I'll use the calculator. And really, I mean, now it's making sense so slowly. Let's see.

[A]

Also, when you go to my website, up in that menu, this is for you or for anybody listening, not only is there, like in a little a 1C estimator up there, there's a Basal estimator, if it explains how the math works behind basal insulin, where you can just, you know, put in your weight, and it'll give you some suggestions about where to start looking. There's also the bolus estimator that we were just using. There's also just a fat and protein estimator. It doesn't do the whole. Like, the whole meal, but it shows you how it works. Just adding fat and protein to your carb ratio to give you some examples of it. And then there's the settings simulator, which is literally just. You set your weight, and then it gives you a starting point for everything from carb ratio, basal sensitivity factor, like kind of the whole thing. So as he's growing, you might want to go to that simulator once in a while and just kind of check yourself like, maybe our settings have moved because he's going to gain weight, he's going to keep growing, and those doctors are never going to mention these settings again to you.

[B]

Yeah, that's every three months I have to go to them, but it's just like, you know, you should do better. And I'm like, how? You know, they don't teach the how.

[A]

Yeah, yeah, yeah. Well, go back and look at that setting simulator. Like, if things are getting wonky, then just go look again. Anyway, I think those things should be helpful to people. Again, they're not. There's disclaimers all over the stuff. It's for educational purposes. You should talk to your doctor first. I barely graduated from high school, okay? So I'm not. I'm not joking.

[B]

That's fine. All right. Whatever you make of yourself, I believe that, too.

[A]

But I just want you to know where you're getting that estimator from. That came out of my brain, so be careful. All right? Do you have any other questions or anything else you'd like to talk about?

[B]

Just one more thing. I. For the longest time, I thought Basil was just background insulin he would get only at night. I think it's because of the injection time where Tresiba was just given one unit at nighttime. So I don't know why that has been stuck in my head. And when I talk to people, they're like, oh, you should turn up the temp, Basil. And, you know, I was like, how is that connected to bolus?

[A]

So, well, listen, now that you've talked to me, go listen to the Pro Tip series, okay? Okay. It starts at episode 1000 where you can go to my menu and go down to Pro Tips. Jenny and I walk through the whole thing and and if you just listen to it straight through, I'm going to tell you right now, you listen to that thing straight through and halfway understand it. It's an A1C in the sixes. Okay, okay. And we'll go over all that stuff. But it's funny because I actually did add there's an interactive defining diabetes page on here, which it's just definitions because I did find that people, like, would say, like, well, I didn't know what basil was. And I have kind of colloquial ways of talking about it. And the basil I just did with you, I just think of it like basil holds you at a number.

[B]

Yeah.

[A]

And you decide what you want that number to be. I don't care. If you want to, you know, away from food and away from, you know, active bolus insulin. If you want to try to be 80, there's a basil that holds you at 80. If you want to be 90, there's a different basil that'll hold you at 90. And then once that's done, that's done. But if that's wrong, try to imagine that the basil. I know these are big numbers because he's so small, but try to imagine your basil is supposed to be one unit an hour, but you have it set at point 0.5 an hour.

[B]

Yeah.

[A]

So you're deficient every hour a half a unit of basil. You probably got a high blood sugar on top of that. But then you go to bolus for food, and then even if you have your carb ratio right, and you've counted the carbs correctly and you say, okay, well, this meal is four units. Well, it's four units. But you're deficient a half a unit of basil every hour for the last four hours. So your four unit bolus might not even touch your food. You replace the basil and the need that you have with the higher number. You probably didn't even put in any insulin to cover the food. So. So just remember it this way, when the basal's wrong, nothing else works.

[B]

Okay.

[A]

Okay.

[B]

And the way to see that is in the nights or during the day as well.

[A]

It's just easier at night to look at and then kind of work off it during the day, kind of adjust off of it. But Omnipod 5 is going to make the changes for you anyway. There's not a lot you can do about it, but you could, if you really wanted to teach yourself on the weekends, you could put them into manual and try to get your settings right to, you know, kind of give yourself A. I don't know, like, you could basal test in manual. You know, you could do a little testing in manual just to see how good your settings are.

[B]

Right.

[A]

You know, and then after that, it sounds like you got the pre bolusing down already. You got, you know, most meals you need to pre bolus.

[B]

Yeah, for all of them. I do it. Yeah.

[A]

Yeah, and that's pretty much it. Listen, Natalia, seriously, I'm going to tell you something I. I don't tell everybody, but when I hear it, I say it. You're going to be fine because you're paying attention and you ask the right questions. That's pretty much it. And you're trying.

[B]

Just trying my best.

[A]

Yeah, no, you're doing great. And it's going to work out because you're paying attention and you're asking good questions, you found good information and you're putting in the effort. I guarantee, you wake up six months from now, look back on yourself today, you won't recognize yourself.

[B]

Yeah.

[A]

You know. You okay? Are you sleeping?

[B]

Yeah.

[A]

Yeah. You're getting good sleep? You're not, like, up all night long?

[B]

Me? No, I get good sleep.

[A]

Good, good. And the algorithm probably helps you with that. The Omnipod 5 is a lifesaver there, I would imagine.

[B]

It's just that the whole house has iPads ringing if it goes below four, so, I mean, that's the time we wake up. And by default, we give the juice and stuff. So, I mean, I guess it's a way of life now.

[A]

Yeah, it is. You'll be okay. You really will be.

[B]

Yeah. Yeah.

[A]

I appreciate you doing this with me. I hope this went kind of the way you were hoping.

[B]

Really, really good. Yeah.

[A]

Oh, good.

[B]

I had no idea what would come out of it, but, yeah, that's excellent. I look into it now. I know which direction to go with, but thank you so much.

[A]

You're welcome. You're very welcome. Hold on one second for me, okay?

[B]

Yeah.

[A]

All right. I'm sorry. I started the recording. Back up, everybody. So I'm still here with Natalia. We were talking about what to name the episode, and I said, oh, you never said your son's name or I would have this episode, Bolas 4. And his name. But you said it's okay. So what's his name?

[B]

His name is Zade, but everyone in school call him Zaydeno. So if I show him that, he would be really happy.

[A]

He'd be very funny. So spell the nickname. Spell it.

[B]

Z A, C, A, Y, D, I,

[A]

N, O, D, I, N, O. Okay. And I wanted to put this here so that all of you, when you got to the end, you're like, why the hell was this episode called that? So. So that's exactly what I'm going to call. I'm telling the editor right now. Rob, this is Bolas for Zaydeno Z A Y D I N O okay, thank you so much again. I'll let you go. A huge thanks to my longest sponsor, Omnipod. Check out the Omnipod 5 now with my link omnipod.com sponsor juicebox. You may be eligible for a free Starter kit. A free Omnipod 5 starter kit at my link. Go check it out. Omnipod.com Juicebox terms and conditions apply. Full terms and conditions can be found@ omnipod.com juicebox A huge thanks to today's sponsor, Able Now. Able now offers Tax advantage Able Able accounts for eligible individuals with disabilities. If you or your child lives with diabetes, you may qualify because of ongoing medical needs. With ablenow, you can save for a wide range of disability related expenses without affecting eligibility for certain disability benefits such as Medicaid. And thanks to recent federal law updates, more people are eligible than ever before. Learn more and check your [e-mail] you spell that A B L E N O W.com there's links in the show notes and links@juicebox podcast.com the conversation you just enjoyed was brought to you by usmed usmed.com juicebox or call 888-721-1514. Get started today and get your supplies from US Med. I can't thank you enough for listening. Please make sure you're subscribed or following in your audio app. I'll be back tomorrow with another episode of the Juice Box Podcast. If you or a loved one is newly diagnosed with type 1 diabetes and you're seeking a clear, practical perspective, check out the Bold Beginning series on the Juice Box Podcast. It's hosted by myself and Jenny Smith, an experienced diabetes educator with over 35 years of personal insight into type 1. Our series cuts through the medical jargon and delivers straightforward answers to your most pressing questions. You'll gain insight from real patients and caregivers and find practical advice to help you confidently navigate Life with Type 1. You can start your journey informed and empowered with the Juice Box Podcast. The Bold Beginnings series and all of the collections in the Juice Box Podcast are available in your audio app [e-mail] in the menu. Have a podcast? Want it to sound fantastic? Wrongwayrecording.com.