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- [00:00]
A
Hello, friends, and welcome back to another episode of the Juice Box Podcast. My Diabetes Pro Tip series is about cutting through the clutter of diabetes management to give you the straightforward, practical insights that truly make a difference. This series is all about mastering the fundamentals, whether it's the basics of insulin or dosing adjustments, or everyday management strategies that will empower you to take control. I'm joined by Jenny Smith, who is a diabetes educator with over 35 years of personal experience, and we break down complex concepts into simple, actionable tips. The Diabetes Pro Tip series runs between episode 1000 and 1025 in your podcast player, or you can listen to it@juiceboxpodcast.com by going up into the menu. 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 Juice Box podcast type 1 diabetes on Facebook. Nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise. Always consult a physician before making any changes to your healthcare plan. The show you're about to listen to is sponsored by the Eversense365. The Eversense365 has exceptional accuracy over one year and is the most accurate CGM in the low range that you can get. Eversensecgm.com Juicebox Today's episode is also sponsored by the Tandem MOBI system, which is powered by Tandem's newest algorithm, Control IQ Technology. Tandem MOBI has a predictive algorithm that helps prevent highs and lows and is now available for ages 2 and up. Learn more and get started today at tandomdiabetes.com Juicebox the podcast is also sponsored today by USMED usmed.com Juicebox or call 888-721-1514. US Med is where my daughter gets her diabetes supplies from, and you could too use the link or number to get your free benefits. Check and get started today with U.S. med. Jennifer.
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B
Yes.
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A
Welcome back.
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B
Hello.
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A
How are you? Oh, you know how I am. I'm doing great. You're good, but how are you? That's what's important.
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B
I'm doing fine. It's. Oh, it's. Summer has started. It's the last day of school.
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A
Okay. All right. Is this really the last day of school for your kids?
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B
Yeah, they're done at half day today and then they're done at the end, congratulations to them.
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A
Another year, I imagine. They passed. They.
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B
They passed. Excellent.
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A
I never knew at the end of the year, I was, like, not sure how this is going to go.
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B
Yes, they have passed. They have moved on. They have been. We have been told that they are absolutely ready for the next journey forward, next fall.
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A
Well, I trust the teacher that said that, so I think you're going to be fine.
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B
I do, too.
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A
Do they have good teachers? You like them?
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B
They do. We've. Yeah. They have exceptional teachers that are really fantastic.
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A
That's a great age, great time, great time in life, a lot of fun. I am going to just ask you a few questions.
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B
Yay.
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A
And then later, while recording with Erica, I'm going to ask her similar supporting questions to the question that I asked you. And this will all make sense in a second.
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B
So fantastic.
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A
When it comes to diabetes care, when you see somebody who's overwhelmed, just overwhelmed, and we're talking about settings, what do you think that they should be looking at? And I know this is a very broad question. I really just want you to start talking. I'm not looking for you to say anything specific. So we've got overwhelmed people and you look at their graphs and they seem wonky and it's hard to see what's going on. What do you look at first? Just go ahead.
- [04:09]
B
Sure. So first I look to see if there is too much interaction, honestly. Right. Is it their interaction? Many times. Those who are overwhelmed often are interacting too frequently and not trusting, as we've talked millions of times already about, they're not trusting the settings that are there, either because they are poorly set by another practitioner or, you know, by them after not having great help from another clinician to get things set the right way. So they've turned knobs and adjusted settings, and then it becomes a daily kind of thing. So when I. When I look at data along with somebody who's pretty overwhelmed, it's usually. Do things look like they could be easier by just dialing back, not specifically dialing back insulin, but dialing back their interactions. Right. Their manipulation is too much. So not only am I not getting a clear picture of what actually their system is doing, especially if they're using one of, you know, the automated insulin delivery systems we have now. But I can't also tell what the settings should be.
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A
Okay. Do you think this would go for people who are MDI or just on a manual pump as well, the touching it too much, usually one of the keys?
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B
Yes, definitely. I think MDI is a little harder to evaluate, mainly because unlike a pump where it captures all of the little ups and downs, with insulin delivery, MDI you have to really rely on the person's account of what they've put in and where they've put in and how much it actually is. But the interesting thing about CGM data today is if you don't have a pretty nice looking flow over the course of a day and it is really variable, like big roller coasters up and down, Even with mdi, you can also get a sense that there's a lot more manipulation there than needs to be. And I don't mean manipulation like bad, bad, bad, like slap the hand, but it's more manipulation because they don't know what else to do and they don't know how to smooth it out. Which you can have smooth data with injections as well as a pump, but it starts with knowing that your settings are in a good place. And to do that sometimes you have to be willing, I think the willingness is the hard part, to step back and see what the settings you have are doing, to then step in and make a slight adjustment at a time. And you know, we've all, where do you start there? We've always talked before about where do you start? It's with basil. Let's look at just the basil to begin with and what does it look like it's doing?
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A
So people can get into a situation where maybe they were set up incorrectly and then things bounce around and then they go back and touch settings or add or subtract insulin in places you get variability. Up, down, up, down, up, down. You start chasing, you get low, you're eating food, you're going up, you're not bolusing again. This whole thing starts at some point you have to just stop, take your hands off it, see what it's doing and then make an adjustment first adjustment Basil. Correct.
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B
Okay, absolutely. Because basil. Basil really does lead to enough background smoothing. And if it is not set well enough for you. Absolutely. All the other pieces can be thrown off. Right. If you are planning to exercise first thing in the morning, for example, and there is no bolus in the picture, there's no food in the picture, you're just waking up and going up, out for a walk, fasted, but your basal hasn't been tested, then you won't have any idea what to do with what ends up happening to the glucose shift during the walk or the run or the bike or the yoga or whatever, the soccer game, whatever it is. If you don't know the base Then how are you going to adjust the variables that you're adding in?
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A
When you finally see somebody get their basal right, do they stop worrying, the touchers, or do they just shift to something else like the touch? The touchers. That's not the right word.
- [08:28]
B
It's a funny word, though.
- [08:30]
A
I don't know. You should hear the thing in my head that I came up with next. I saw it's worse than that. So the manipulator, they're fiddling with it too much.
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B
The fiddler, that's. There you go. The fiddler. That's better. Yes.
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A
Fiddler's not the second thing I thought of. Seriously. Like when. When you've got your hands in it too much and you finally meet somebody like you, or you go to your physician, your physician says, hey, this is all out of whack. Let's. They're going to tell you, like, let's basil test first, right. And get basil nice and stable again. Do those people generally, in your experience, step back or do they just. I'm trying to figure out if they're just fiddlers by nature. Do you know what I mean? Like. Or can they wait then to see the next thing? What do you. What's the experience you have with people?
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B
I think it can go many ways. Definitely. We all have a different perspective on where we want things to be right and how we think about getting it there. And there are people who are much more willing to say, okay, I can step back for a bit because I've been given direction now before. I had no idea, I had nothing to start with. You've given me some direction to get started and have that base, that foundation, hold me. And I think one of the places that basal adjustment helps things get a little bit easier, so to speak, is usually the overnight time.
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A
Okay.
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B
And that being a big complaint and a big reason most people love their cgm. If we can get that overnight, well, set. It then leads into where you start your day. And even if those basils in the day yet aren't quite right, if you've had a stable overnight, that leads you into starting the morning in a place that's not too high, it's not too low, extra insulin, that then you're going to be less likely to manipulate or fiddle with extras right away in the morning. Extra carb, extra insulin. What do I do? Where do I titrate this, whatever. And as you can see, then that flows through the rest of the day.
- [10:32]
A
I also think that's where the overwhelm comes from too. Yes, because you start adding all of these different, like, small decisions and they all knock you. I, I, I would think of it a little bit as like a, you know, if you think about traveling through space, if I, if, you know, if we could go out into space right now and just take a, a tennis ball and just, just let it go, it's going to go in a direction forever and ever until something intersects it, knocks it off. And the more things that touch that tennis ball, the further off course you get is sort of how it seems to me like, oh, well, I've learned I've got to get up in the morning and bolus. Okay, fair enough. That works. But what happens if you're getting up in the morning, having a couple of carbs, then you're putting in insulin, and then you're changing a setting and then you just keep touching that tennis ball and we don't know where it ends up all of a sudden?
- [11:16]
B
Correct. Yeah, absolutely. And I think there is a inherent desire to, even if you weren't the controlling type of personality before diabetes was in the picture. And you usually learn to be controlling. And you can be controlling to a degree that's not healthy. And then you can be controlling to a degree of just knowing healthy, healthy habits. And the control of those habits keeps things on that steady path. I love the idea of a tennis ball in space that's just floating around and never gets hit by an asteroid. Right. That would be lovely. All the way to forever, forever, wherever it's going. But it's our day is also in life, not like that. There will always be some type of variable potentially thrown in, even if you have the plan for the day set in front of you, but you don't
- [12:07]
A
need to be one of them. But yeah, right, right, yeah.
- [12:11]
B
You shouldn't be the asteroid all the time or the, the asteroid belt kind of always like ducking and dodging something. Because if you are, then that's where so much of your brain power goes. And it can become really not only defeating, but it can be a hu, Sock.
- [12:30]
A
I also think it just starts piling confusion on top of confusion because you don't see where it's coming from anymore.
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B
Yes.
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A
Honestly, it just feels like you're being shot at from all sides. You're getting hit, but you can't, you can't hear the bullet and you don't know which way it's coming from and why is it, you know, it's, it's on my left, it's on my right, it's above me. And then. Then, boom, you're overwhelmed. You shut down. And now you've shut down with bad settings, and, you know, and they're so wacky, your doctor can't figure them out. You can't figure them out. What I'm telling you is that I see people because of these conversations I've been able to have. This feels like it could just be like a momentary problem, but if you get caught in that wrong trajectory, you could stay there forever. Because I've seen it happen to people. They become complacent in such that they feel like, well, this is just what this is. There's no getting out of it. There's no answer. I don't have an answer. The doctor doesn't have an answer. This must be what diabetes is. Then the brain fog comes in and all the other stuff, and before you know it, you're just. You're adrift, you know?
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B
Right. It's constantly being on the defensive.
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A
Yeah.
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B
Really? It's constantly waiting for the next. Like, the next thing to hit, and then assuming you have the right trick in the bucket to pull out, to hit it with so that you don't get sidetracked by that next thing. But that's not what ends up happening. So, I mean, settings in general, Basil, to start with. Yes. And then you really do have to take some time out to say, you know what? There are always going to be birthday parties. They're always going to be vacations. They're always going. But not for the most part, not day after day after day. So make the effort to find something that has a structure in a couple of days.
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A
Yeah. When things would get out of hand with Arden when she was younger, before I even knew what I was talking about, I would say to my wife, we have to start over.
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B
Yes.
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A
I'm like, we have to stop and start over because there's too much happening right now. We'll never make sense of any of this. And that's where the ideas that I talked about in the podcast, you know, for all this time, came from. Like, I realized, I was like, okay, well, if the Basil's right, a lot gets better all of a sudden. Right. Carb ratios work better. Sensitivity, you know, factor works better when. When Basil's right. So let's get the Basil right. And, you know, again, without a cgm, I don't know that I ever would have figured that out, to be perfectly honest.
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B
Right.
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A
So then, you know, we talked about what gets better when the Basil's right. What gets better when your carb ratio is more accurate. Diabetes comes with a lot of things to remember, so it's nice when someone takes something off of your plate. US Med has done that for for us. When it's time for Ardyn's supplies to be refreshed, we get an email rolls up and in your inbox says hi Arden, this is your friendly reorder email from usmed. You open up the email, it's a big button that says click here to reorder and you're done. Finally, somebody taking away a responsibility instead of adding one. Usmed has done that for us. An email arrives, we click on a link and the next thing you know, your products are at the front door. That simple usmed.com juicebox or call 888-721-1514 I never have to wonder if Arden has enough supplies. I click on one link, I open up a box, I put this stuff in the drawer and we're done. US Med carries everything from insulin pumps and diabetes testing supplies to the latest CGMs like the Libre 3 and and the Dexcom G7. They accept Medicare nationwide over 800 private insurers and all you have to do to get started is call 888-721-1514 or go to my link usmed.com juicebox using that number or my link helps to support the production of the Juice Box podcast. This episode is sponsored by Tandem Diabetes Care and today I'm going to tell you about Tandem's newest pump and algorithm. The Tandem Mobi system with Control IQ technology features Auto Bolus which can cover missed meal boluses and help prevent hyperglycemia. It has a dedicated sleep activity setting and is controlled from your personal iPhone. Tandem will help you to check your benefits today through my link tandomdiabetes.com juicebox this is going to help you to get started with Tandem's smallest pump yet that's powered by its best algorithm ever. Control IQ technology helps to keep blood sugars in range by predicting glucose levels 30 minutes ahead and it adjusts insulin accordingly. You can wear the Tandem MOBI in a number of ways. Wear it on body with a patch like adhesive sleeve that is sold separately. Clip it discreetly to your clothing or slip it into your pocket. Head now to my link tandomdiabetes.com juicebox to check out your benefits and get started today.
- [17:24]
B
You have confidence with the majority of the things that are your day to day norm, right? And as adults there's not a heck of a lot of growth that ends up Happening, unlike kids, kids settings will shift and change. Not that adults won't, but less frequently, so to speak. And if you do test within a time period to see that your carb ratios are in a certain place, then you can count on those issues working for days, weeks, months at a time. They should really work. Where it gets thrown out is you test for two days on the apple first thing in the morning, you measured it, you weighed it, you've got your ratio figured out for that. But now you go on vacation for the next week to wherever and the apple is no longer your breakfast. And there are a whole host of other things in the picture. Well, this is where it doesn't mean that the ratio is wrong.
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A
Right. It just doesn't work for this meal. It worked for the apple.
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B
It worked for the apple and. Or it worked for your typical foods at lunchtime, your typical foods at dinner time. And those ratios, there's a little wiggle room to them, right. They're not hard set start in stone, you're a 1 to 10. I mean, right. There's a little bit of wiggle there. But in general, I think it's the other pieces that often end up. Had you been on a good trajectory of habit, you get thrown off by the variables of vacation, illness, digestion, looks different, whatever. And then you come out on the other side of that thinking, well, now I have maybe bad habits coming out of that. I'm adjusting this way. I'm throwing in more insulin here because that clearly didn't seem enough or it was way too much. And then on the back end when you're adding your apple back for breakfast, you don't trust it.
- [19:16]
A
Yeah, it's, it is super interesting that because I've, I've lived through it and I've talked to a bunch of people that have. It really should be just as easy as I'm going to a restaurant now. This food is just going to hit differently.
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B
Yes.
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A
I'm a very sedentary person and I'm running around on the beach for the last five days. It's not a thing I usually do. Why am I getting low all the time? You should be able to just see it, turn it on, turn it off. But boy, that's not how it works in people's minds, you know.
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B
It's not.
- [19:41]
A
Yeah. Today's episode is sponsored by a long term CGM that's going to help you to stay on top of your glucose readings. The Eversense 365. I'm talking of course about the world's first and only CGM that lasts for one year. One year, one CGM. Are you tired of those other CGMs, the ones that give you all those problems that you didn't expect? Knocking them off, false alerts, not lasting as long as they're supposed to? If you're tired of those constant frustrations, use my link eversensecgm.com juicebox to learn more about the Eversense 365. Some of you may be able to experience the Eversense 365 for as low as $199 for a full year. At my link you'll find those details and can learn about eligibility. Eversensecgm.com juicebox check it out and you
- [20:37]
B
know, outside of just the settings, there are settings. Once they are in a good place, there are adjustment strategies as well that you will typically also find advantageous. Right? And it takes experimentation. This is not a one and done. Gosh, I tried this. It worked. And I'm going to go forward and just use this all the time for exercise. Exercise of one thing versus another is going to require a different type of strategy. But once the base is set now you've got again that foundation, it's like very solid to build your strategy off of. And then you don't end up making little nudges here and adjustments there and plugging in and adjusting that and taking more away. Which again is just, it's not purposeful and it makes it work.
- [21:30]
A
I guess the next thing to talk about, I think is maybe the most difficult part, again based on conversations, but also based on watching. My daughter is pre bolusing a meal. It's incredibly difficult for people to remember to do. It's incredibly difficult to want to do. I saw Arden the other day. She just finished a college semester. Yay. Yeah, she's so close right now. And so she slept in and I was recording with somebody and somehow the conversation got around to like touching it too much, like touching the CGM and looking too much and everything. I stopped and I said, I honestly don't know. The last time I saw Arden's blood sugar, it was like 2 o' clock in the afternoon at that point and Arden's still asleep. And so I opened up my phone and for the last, I think it was five and a half hours. I apparently did look around 8am and I put in like 0.2 or 0.3 of insulin or something while she was sleeping. I mean to adjust like a 110 blood sugar, you know what I mean? And And I just felt it, I could see it was heading in the wrong direction. I put a tiny little bolus in and I didn't look at it again. And the person asked me, how did you manage to not look at it again? I said, well, my alarms haven't gone off, so it's in between 70 and for me, it's between 70 and 120. And I was like, so there's no reason to look. The thing I expect is happening, is happening, you know.
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B
Right.
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A
The person was like stunned. They're like, you're between 71, 20 for like five and a half hours. Like, well, she's on an automated system. Her settings are great, she's not eating, she's sleeping, like, you know, Right.
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B
There's nothing happening.
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A
I'm at the point now, I. With automation and good settings, I don't know how long you couldn't fast for, but I've seen it go for 24 hours without a problem when somebody's sick or something like that. But nevertheless, she gets up and then 21 and a half years old does not pre bolus enough for her food. Right. And I watch her blood sugar just go, it's heading up. The algorithm's pushing back, pushing back, pushing back. She gets to 200 money, it comes back down again. And I'm going to tell you that I wish she would pre bolus, but that's still going to be like a 6.4 A1C, you know, over, over the long time. And to be able to just walk away from that and say that is a big step for me even, because when I was in control of it, I would have thought, like, we cannot. I don't want this to happen. And by the way, I don't want it to happen. I don't think it should happen. And if she would have Pre bowl is 10, it wouldn't happen, it would not have happened. But. But I also think she'll get there one day. Yes. And so, and I've had conversations with people, Erica being one of them, about this topic, and I asked her, like, I said it to her one day, like, why would. I'm trying to wrap my head around, like, why would people with type 1, not just pre bolus, once they know to do it? And she said, scott, I have trouble doing that. And she's like, I've had diabetes for, like, you and Eric are in a race. You both have had diabetes like over 35 years. Right. And she was like, I had diabetes for almost four decades and I struggle with that every Day, she's like, it's not a thing your brain wants to do, or mine at least. So anyway, when you talk to people about pre bolusing, I'm sure you explained that to them, but is there a way you can get them to it? Have you figured anything out?
- [24:41]
B
Some of the way is, especially with those who are fiddling as much as some of it's actually bringing up data and looking at it together in a framework of what are they eating? If it's about the same, I usually look at the same time of the day, focus in one place before moving on. For people that are more visual, it's interesting to see how they react once you show them their own data. And the timeline of the bolus and the carb entry both went in here. And your blood sugar is going up within 5 minutes or 10 minutes of that entry. I can tell without asking you, I can tell that there was no pre bolus there. I mean, the CGM data may not be accurate number wise all the time, but that trend line should be a really good friend. It is telling you the direction your glucose is going to and that for many people it's an eye opener of, well, gosh, how do I stop that? And for the fiddlers, it's I just add more insulin. Like, I add more, I add more. I'm like, this is not a more insulin. Because if we look at the data on a day where you were willing to hold your hands off.
- [26:00]
A
Yeah.
- [26:01]
B
Did the blood sugar actually respond eventually and come back down? Then it's not a more insulin issue. Timing instead, this is timing. This is you ate within five minutes of taking that bolus and that was definitely noticeably not enough time. So let's, let's do an experiment. Right. And again, I would say most people are very willing to at least experiment with pre bolusing.
- [26:27]
A
Try. Yeah.
- [26:28]
B
And try to. Right. And once you start seeing progress and you start seeing that positive result, it builds. Positive reinforcement certainly goes a long way. Right. It builds that. And for many people will then become enough of a habit that they keep doing it because they see the results that they want. And as we started out with like the overwhelm drops down because they aren't having to follow up outside of alarms, wherever those are set. And I would say that some people even then step in and say, well, maybe I'll adjust my alarms to be a little bit tighter so that I can take that overwhelming look at the data, look at the data, look at the data, do something about it. I can take it out of the picture because I've got my alarm set and if it goes off, then I need to pay attention to it. But otherwise my settings are doing what they should be doing. My ability to pre bolus or time this well, it seems to be working out most of the time. It decreases that load of interaction.
- [27:37]
A
Yeah, I don't know that we. I. Because some people are great multitaskers. I don't know if I've been looking into this lately, and I'll probably bring it up when I talk to Erica. The human mind can actually only focus on one thing at a time. Even when you think you're multitasking, you are swapping one thing out of the spotlight for another thing. There's a bubble around the focus of things that you can hold in your head, and it's only like three or four things. So when you start thinking about actual life and then you add diabetes on top of it, that's already too much. You can't then go adding more stuff on top of diabetes. Like. Like, diabetes is enough already. Don't give yourself 50 extra things to think about.
- [28:16]
B
Right.
- [28:17]
A
I'm gonna try to figure my way through that. But back to the idea of pre bolusing. I think it's interesting that I'm trying to understand the psychological aspect of the person who tells me, I know I could wait, but I don't want to. Like, I. It's one thing if you're eating because you're getting low, that's different. But if you tell me, I'd love to have a handful of pretzels tonight while I'm watching television, well, then grab a handful of pretzels, put the insulin in and wait. Right. Like, right. That doesn't seem insane to me. I was like. But people's answer back. And this is the thing. I'm gonna have to dig in with Erica a little bit. But I am gonna. I wanna ask you from your perspective too, what is that, like, that feeling? Maybe you don't experience it of, like, I don't want to be told what to do by diabetes because I think that's what it is after talking to people. Like, I don't want diabetes to dictate how I eat my damn pretzels, but I don't know if I'm right about that. It's just me talking to people.
- [29:15]
B
It's a situation of, where are you socially in that moment?
- [29:18]
A
Okay.
- [29:19]
B
Yeah, I can definitely tell you that it is. While I'm over the. I don't care if I'm sitting here and Everybody else is eating. Like, I. That's, you know, well beyond me any. Anymore at this point. But I can understand the perspective of you grab the bag of popcorn or whatever from the cupboard and you're going to watch the movie and it's starting right now and you want to dig into the popcorn. Right, I get that. And, and I think it's harder to wait when you see everybody else is digging into that popcorn corn right now. And there is no, there's no need for them to wait. There's no need for them to take anything else into consideration when you're the one sitting back and does it hurt and waiting?
- [30:05]
A
You know what I mean?
- [30:06]
B
It's an emotional feeling of just, I guess you feel irritated that they can't wait for you. So I think there's a piece there. Like, why don't they just get, like, I'm not eating yet. Can't they just wait?
- [30:20]
A
Like, together?
- [30:21]
B
Can we all do this? And some families do. I will say that that's the way that some families work it, or they work the parents work the pre bolus in so that by the time they're all sitting down, the pre bolus has already been working. And then the child can start to eat with the rest of the family and whatever. Right. But I think there, there is twofold. And then there's the personal attack on yourself. Like, and now I have to sit here and I'd really like a piece of popcorn.
- [30:47]
A
Erica talks about that body grief too. Yeah, that sadness that your body doesn't do what it's. What it's supposed to do, or what you would expect it to. I should say too, for me, I could sit and wait, but I don't have any of those outside pressures. I'm not looking. I don't have that feeling of, oh, I can't believe I can't just start like, I'm deciding instead of being told, maybe that really is the answer. Hopefully we'll come to a way to figure out their way around that. Yeah, I have a couple more for. Do you have time? Okay.
- [31:13]
B
Yes, I've got some time.
- [31:15]
A
So if auto modes are supposed to carry like a little bit of the load, what's the algorithm actually handling? But what is it not handling? Where should our effort be put in and where should it not be? Big question. Maybe.
- [31:28]
B
So it is, It's a really, It's a big question because I, I know that algorithm in general doesn't speak to the algorithms that are available. Each of them has their own set of rules that it follows in terms of how it's going to step in and help to handle things with and for you. Right. I think a good example in this conversation does go along with what you said about what you watched with Arden the other day. Right. It's okay. She didn't pre bolus when she got up. She wanted to eat right away. That's what she did. She's young. Her brain isn't fully formed yet in the track of I can do this because this is important.
- [32:12]
A
Right.
- [32:13]
B
So she ate, her blood sugar went up and you watched, you, you sat on your hands despite Scott. In younger ages, with a younger daughter, you would have stepped in and also done something. But you also have a couple of things in hand here. One is an algorithm that's an aggressive algorithm. Your algorithm, you trust the settings because you know what she needs. And you could watch and you could wait, knowing that despite not liking the 200 blood sugar, that it was going to address it and you wouldn't have to step in and help. And it was also not going to cause her to go low.
- [32:52]
A
Right.
- [32:53]
B
So I think there are a couple things to define within an algorithm. It's what kind of algorithm is it, how heavy handed can or can it be or how heavy handed could you set it up to be? Some of them are adjustable, others are not so much. And then when we're talking about food, none of the algorithms will really hold your blood sugar. Without announcing food across the board, diy, the open source as well as the FDA approved systems, what people adjust is their expectation of target range. That is what I have truly seen is parents who are stepping back from navigating with their teenagers and letting them take over and letting them figure it out with some of the set guidelines that they've done. They have to widen their, their target range. They have to widen it and say, you know what? My kid isn't going to pre bolus for 30 minutes. They're sitting down at lunch and they only have 15 minutes to eat. School doesn't do anything because they don't step in and help anymore. My kid boluses as they walk to the, to the, you know, cafeteria. But my settings are really good and I'm okay allowing them to get to 160, 180, because I know that the algorithm will carry it out as long as they at least announce the food.
- [34:15]
A
Yeah, it's difficult to expect a child or an adult. Honestly, it is to do that. It is interesting when you're doing it for somebody else. Like you brought up popcorn at the theater earlier, we'd be driving to the theater and I'd ask Garden, are you thinking of getting one of those slushy drinks? And if she said yes, I just threw in 10 carbs in the car. And then like, as we were walking through the door, I Bolst for like, more and then hit her like a third time when we sat down. And she wasn't gonna do that, you know what I mean? And I don't know that I wanted her to, to be perfectly honest. So no, then there is a separation later when you have to say, well, they're their own person, they're getting older, etc, when people are still doing things manually and they shouldn't have to be like, what do you think that's them trying to protect themselves? Like, what do you see from people? Like, when you're going, God, stop touching it. Like, we got it set up like it should be working. What's the feeling you get back from people?
- [35:06]
B
I get a sense from looking at so much data that what people are doing manually that steps outside of what they should be doing is much relative to expectation. And again, kind of goes back to which a lot of this does is what is their target, what are they aiming for, what range are they aiming to stick in, and what are they willing to wait to see happen before they step in? Right. They're doing a lot manually of a little bit. A little bit. A little bit. I see it across the board in a lot of the systems and even, you know, the open source systems that you can step in as a caregiver remotely and add a bolus or nudge it or enable something or disable something. Well, some of that's necessary depending on the situation you know is coming. But a lot of the manual manipulation, you're stepping in before you're even allowed the system to do something to help you. You're not using the technology to your advantage.
- [36:10]
A
Yeah.
- [36:11]
B
And then you have to start thinking, well, do I have to go back to the basics? Am I doing this more and more and more recently because I don't trust my settings? Then, gosh, step back and reanalyze your settings. Get back to just normal, you know, meals without going vacation meal. And see, is it the fact that I've been eating vacation meals more? That's the problem. And my settings, when I eat normal chicken and broccoli.
- [36:36]
A
Right.
- [36:37]
B
Goodness, they look just fine.
- [36:39]
A
I hope it's comforting to people to know that there's still times when I look and I think this needs like an extra Unit and a half here, I think, but I gotta wait a minute to find out for sure. It's too soon for me to decide. And the difference between now and 10 minutes from now is not going to be that big of a deal. There are just times I look and I go, oh God, like we got arrows up. This is all wrong. More insulin, blah, blah, blah. But there's also times I go, I feel like more insulin, but let's wait a minute and see. Or if I put in an amount here, is it an amount that the algorithm can take away on the back end? Because then I'm not as scared, Right. Am I pushing it to a point where the insulin on board is going to be too great for. For the algorithm's ability to take away Basil later, to balance it if necessary? That's happens pretty fast in my head, but it still pauses me sometimes and I'm like, I'm not sure, you know,
- [37:28]
B
and what you have and what all people should get to the point of understanding, and we've talked about many, many times, is just understanding your insulin action. Yeah, yeah, right, because you have that in what you've just described. You can take the scenario happening right now, you can look at what's happening, you can, hmm, give like a whole extra unit, but it's subconscious, honestly, the way that your brain thinks through it.
- [37:55]
A
Yeah.
- [37:56]
B
You can see what's already been happening. You know, the algorithm that, that Arden is using. And you can say I can hold off because I'm either expecting in the next 15 minutes of waiting that the system's got it and I'm good, or if I am thinking in the direction that maybe we undercounted or maybe we misjudged or whatever, that I could throw in an extra unit and yes, based on her insulin needs, the system can subtract enough or suspend enough or whatever, so it will catch it and I won't even need to step in there either. But you have to understand insulin and how it works, how to time it, and you have to understand your algorithm and what it's going to do and not do for you.
- [38:41]
A
Okay, my last question for you is MDI manual pump algorithm based system doesn't matter to me. When you see somebody who has it set up and it's working right, their CGM's working. Right. You know, the data you're getting back, everything looks solid. Like when you see that, what does that look like day to day life? Like, what is a well set up running system look like as far as people's interactions and their outcomes.
- [39:09]
B
Right.
- [39:10]
A
How do I know I'm in the promised land, I guess. You know what I mean?
- [39:14]
B
Yes. How do you know that? Like there's not much work to hear to do here. Please be on your way.
- [39:19]
A
How do I know I'm gone? Yeah. How do I know I'm done? Yeah. That's my question. What's what's done look like and done
- [39:25]
B
being like short term for now. You're done.
- [39:29]
A
Right, Right, Right.
- [39:30]
B
It looks like I guess defined by the person's target range. Are they nicely rolling through that target range? Can you see where the meal entry was? Can you see where the bolus was? Does it look like there's a nice swing up that should happen if you are eating carbohydrates. There is a bell curve that happens in the aftermath of a ME meal. You can see in the data where the insulin really took hold and the action of the system, if they're using an automated system or even with multiple daily injections, can almost see the peak and the clearance of that and where the basil which is well figured out in either scenario where it caught that and then things just sat nice and stable for them. Right. So it is a lot more I say gentle rolling hills. And when I look at automated systems and the data I can typically tell when somebody is stepping in. Mainly because when I look at their total daily insulin use, automated systems, especially the, the open source systems have little tiny extras in assistive that it pops in along the way. It's always giving and taking. All of the algorithms are of any system but you can see it's got tiny little nudges to things on their typical day to day and it's smooth transition of data.
- [41:00]
A
Okay.
- [41:01]
B
Whereas larger boluses in between and the frequency of those boluses that are not coming from a system generally tends to create a lot more jagged looking kind of the up and down the true roller coaster. I say the Rocky Mountains, it's up, down, up, down, up, down kind of look. And those boluses are often much larger than what the system would auto populate in.
- [41:26]
A
Yep. Okay.
- [41:28]
B
And all of the systems also give, I should not say all of them, but some of the, you know, other systems like Tandem, for example, the Control IQ algorithm, the nice thing about looking at the data is actually that it tells you when the bolus was over adjusted or under adjusted by the user. So Control IQ has automated give that it will pop in as needed as well as positive temporary basal changes. But anytime a bolus is requested based on a blood Sugar. If the system was going to give a bolus, it has information about whether that bolus was overridden or underwritten by the user.
- [42:09]
A
Oh, nice. Yeah.
- [42:10]
B
Which is quite nice.
- [42:11]
A
Yeah. Okay, we have all this as good as it can be. What are the things we can't fix? Like, what are things that are going to happen even with great settings and even with great timing? Like, what are the. Just the. Like. Okay, I have to just give myself over to. Like, what do you think of when I ask you that question?
- [42:29]
B
Yeah, I think it makes me think of the times that you do have to do some fiddling. You do have to do some stepping in. Honestly, that's not incorrect. Illness growth times where you might be fiddling because you know that more is needed or less is needed. Let's say illness, for example, more is needed. But the base settings weren't adjusted to accommodate for illness. So you may have to step in and you may have to do things more frequently. And in that, I usually tell people to also get an idea of about how much did you nudge in or about how much did you pull back? Because going forward, at some point you're going to get sick again.
- [43:10]
A
Yeah, something's gonna happen.
- [43:11]
B
Right. And something's gonna happen. But now you have a base to use. Rather than just fiddling every 15 minutes with more, more, more, or adjusting with temporary rates or adjustments or whatever they are, you can use that to have something to start with the next time. Gosh, last time I had a cold, I needed 10% more insulin. I use this much more in a temporary. Basil really helps. Great. That should mean you're not fiddling as much then.
- [43:37]
A
Yeah. I can't thank you enough for doing this. I like this is a different kind of conversation around stuff that we talk about all the time. Hopefully it helps people think about a different way. I would urge people, if any of this made sense to you and you want to dig deeper into any of it, the Pro Tip series that Jenny and I made will probably help you walk it through more granularly. Yeah, yeah. So awesome. Thank you very much. And then the next part that people hear, either I've worked it out so that in editing you've gone back and forth with Erica, or the next part right now is going to be Erica kind of addressing the mental health side of some of these things. Questions like, okay, I've reduced the load on myself here, but I still feel overwhelmed. What can I do to help that?
- [44:16]
B
No, I'm super excited that you're going to add that piece in with this because I think that overwhelm is a real. It is a real thing. And even with settings adjusted, well, we have to also know, as we just talked about how to address a variable and then getting off of that roller of adjustment again and finding some ability to step back and feel okay, just settling and.
- [44:41]
A
Yeah, yeah. I would like people to know and if you're comfortable sharing how you feel as we go out here, even though you're, I think, very good at this, obviously, and you've got a ton of practice and time and professionally and personally, you still feel that overwhelmed too, I
- [44:54]
B
would imagine at times I do. I think that my overwhelm is more relative to a busier life in general. Right. I compare my navigation before children to navigation now with kids that are really busy. Right. And being the taxi driver and the parent that does things at school as well as working full time and, you know, all of the things, I think that that's where the piece of navigating almost like a third child. Right. My consideration of diabetes is kind of like a kid that doesn't really grow up. You do have to still always step in and take care. There's more there to consider because as you mentioned, we can only have one or two things on our mind to navigate in the clear moment. And mom, I need this and I didn't get that for the project and like, whatever. And I'm like, I just really need to bolas for dinner here.
- [45:52]
A
Jenny, what I hear you telling me is that diabetes is like a. It's a child you have that never stops its pants. Is that what you're telling me?
- [45:59]
B
There you go. You always have to. You'll always have to change its diaper at some point. Yes.
- [46:05]
A
Anyway, you'll know if you have a baby. I'll see you later. Jenny. Thank you very much. I appreciate it. 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. The podcast episode that you just enjoyed was sponsored by Eversense CGM. They make the Eversense 365. That thing lasts. Lasts a whole year. One insertion every year. Come on. You probably feel like I'm messing with you, but I'm not. Eversensecgm.com juicebox head now to tandomdiabetes.com juicebox and check out today's sponsor, Tandem Diabetes Care. I think you're going to find exactly what you're looking for. At that link, including a way to sign up and get started with the tandem mobi system. Okay, well, here we are at the end of the episode. You're still with me. Thank you. I really do appreciate that. What else could you do for me? Why don't you tell a friend about the show or leave a five star review? Maybe you could make sure you're following or subscribed in your podcast app. Go to YouTube and follow me. Or Instagram TikTok. Oh, gosh, here's one. Make sure you're following the podcast in the private Facebook group as well as the public Facebook page. You don't want to miss, please. Do you not know about the private group? You have to join the private group. As of this recording, it has 74,000 members. They're active. Talking about diabetes. Whatever you need to know. There's a conversation happening in there right now and I'm there all the time. Tag me, I'll say hi. If you'd like to hear about diabetes management in easy to take in bits, check out the Small Sips. That's the series on the Juice Box podcast that listeners are talking about like it's a cheat code. These are perfect little bursts of clarity. One person said I finally understood things I've heard a hundred times. Short, simple, and somehow exactly what I needed. People say Small Sips feels like someone pulling up a chair, sliding a cup across the table and giving you one clean idea at a time. Nothing overwhelming, no fire hose of information, just steady, helpful nudges that actually stick. People listen in their car, on walks, or while they're actually bolusing anytime that they need a quick shot of perspective. And the reviews, they all say the same thing. Small sips makes diabetes make sense. Search for the Juice Box podcast, Small Sips, wherever you get audio. 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 gaps of time. And when I go and stuff like that and it just. I don't know, man. I listen back and I'm like, why do I sound smarter? And then I remember because I did one smart thing. I hired Rob at wrongwayrecording. Com.