November 18, 2025 • 42 mins
In episode 61 of Think Like a Pancreas—The Podcast, clinicians, Jennifer Smith, Tavia Vital, and Dana Roseman share proven strategies for effective glucose management starting with the essentials of insulin timing. They offer practical advice to help you optimize your insulin delivery system, making it work for your unique needs.
Just as strong relationships rely on clear communication, so does successful diabetes management. Jenny, Tavia, and Dana explain how to use what you know to confidently handle unfamiliar foods and navigate holiday gatherings. They further share the importance of using pre-boluses and recognizing post-meal glucose patterns to make your diabetes care less stressful and more predictable
MEET YOUR HOSTS:Jennifer Smith, RD, LD, CDCES is the Director of Lifestyle and Nutrition for Integrated Diabetes Services. She is renowned for her expertise in nutrition, diabetes education, and athletic performance. With a Bachelor’s Degree in Human Nutrition and Biology from the University of Wisconsin, Jennifer is a Registered Dietitian, Licensed Dietitian, Certified Diabetes Care & Education Specialist, a certified trainer for insulin pumps and continuous glucose monitors, as well as a published author. Having lived with type 1 diabetes since childhood, Jennifer offers unique insight into day-to-day diabetes management, pregnancy, sports nutrition, and technology integration.
Dana Roseman, MPH, CDCES, RDN, LDN, is the Director of Technology and Applied Research for Integrated Diabetes Services. She is a Certified Diabetes Care & Education Specialist and Registered Dietitian with a Master’s in Public Health from the University of Illinois at Chicago, a Bachelor’s in Science from the University of Texas at Austin, and clinical nutrition training from UT Southwestern Medical Center. Diagnosed with Type 1 Diabetes, she has spent nearly 20 years improving diabetes care through technology, research, and patient education—including expertise with insulin pumps, continuous glucose monitors, and hybrid closed-loop systems. Dana serves as Research Information Liaison for the Dallas JDRF, is active on nonprofit boards, and empowers people with diabetes to thrive physically and mentally, making her a leading voice in diabetes innovation.
Tavia Vital BSN, BA, RN, CDCES is the Director of Intensive Diabetes Management for Integrated Diabetes Services. She earned a Bachelor of Science degree in Nursing from Regis University in Denver, Colorado after receiving a Bachelor of Arts degree in Spanish from the University of Iowa. Tavia is a Registered Nurse, Certified Diabetes Care and Education Specialist, and Certified Trainer on most makes/models of insulin pumps and continuous glucose monitoring systems. Having lived with type one diabetes for over 40 years, she understands that each person’s experiences and needs are unique. She strives to be an expert resource on intensive diabetes management options.
WHAT YOU’LL LEARN:
✔️ The basics on how insulin works.
✔️ Your blood sugar level must go up before it goes down after eating.
✔️ How to use what you know mixed with of the box thinking to create bg success.
✔️ How to best put clothes on your breakfast carbohydrates
✔️Your AID system doesn’t always know best.
✔️ BG levels won’t always be perfect no matter how hard you try.
CHAPTERS00:13 Welcome and Introduction
04:29 Understanding insulin get the optimal glucose excursion after a meal.
09:12 Using preferenced meals to guide you when eating something new.
11:13 The same meal. The same time. Different results. What now??
15:44 Slowing the rise of standard breakfast foods.
18:57 Mastering the “suspension” of insulin before meals in AID systems.
23:22 When you don’t have time to wait for targeted bg levels to bolus.
24:30 The secret to great blood sugar levels during the holidays.
28:21 Pre-bolus guidelines.
30:55 Benefits of Loop or Trio for insulin, bolus timing, and food coverage.
36:53 The super-bolus.
40:24 Your diabetes may vary.
RESOURCES MENTIONED
Glucose Goddess—Jessie Inchauspe https://www.amazon.ca/stores/Jessie-Inchauspe/author/B093K86K1Z
John Walsh—Pumping Insulin https://www.amazon.ca/stores/John-Walsh/author/B009KTDCKM
CONNECT WITH US
🔵Website: integrateddiabetes.com
🔵 Follow on Social Media: @integrated_diabetes_services and @ integrateddiabetesservices on Facebook
🔵To work with the Integrated Diabetes Services Team , visit https://integrateddiabetes.com/how-to-start-the-process/ , or email info@integrateddiabetes.com<
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:10):
Welcome to Think Like a Pancreas, the podcast, where our goal is to keep you informed, inspired, and a little entertained on all things diabetes.
The information contained in this program is based on the experience and opinions of the Integrated Diabetes Services clinical team.
Please discuss any changes to your treatment plan with your personal health care provider before implementing.
(00:35):
Hello, ladies.
Hi.
Hi there.
It's exciting to see you again today, and I'm Jennifer Smith, a Registered Dietitian Certified Diabetes Care and Education Specialist with Integrated Diabetes Services. Excited to chat with my colleagues, Dana and Tavia, today all about something we find very, very important as we move forward with all the technology that we've got in use today.
(01:00):
I have always taught a lot about insulin use, right?
Insulin use and understanding the timing of our insulins today and everything, but there's kind of a little deeper dive to take with that because of our AID systems or automated insulin delivery systems and kind of all of the ones on the market, using them a little bit differently in respect to understanding the insulin timing and knowing what to do with how your system works.
(01:26):
Yes?
And being successful with it.
And one thing, I'll just introduce myself. I am Dana Roseman, Director of Technology and
Applied Research at Integrated Diabetes, and I would say that, try to remind people
all the time, and I'm sure you do the same, that we have all these fancy algorithms and
fancy pumps and these amazing continuous glucose monitors, 24-7 alerts and alarms,
(01:49):
but the insulin that we're using is still the same insulin we used, what, 25 years ago?
And it's no faster now than it was back then.
100%.
In fact, that's kind of funny.
You're saying 25 years, and I'm thinking, has it been really that long that we've had rapid insulin?
I mean, I don't know.
I guess I switched to ultra-rapid earlier than that.
I know maybe not everybody uses the ultra-rapids, but I mean, it's not like it's magically faster.
(02:11):
No, you're actually right, because I think it was about 2000 when I went to my doctor and said, there's this new, more rapid-acting insulin, Humalog, right? On the market, and I had been still using R-insulin up to that point and was frustrated.
And so he's like, sure, I can write you a prescription for that.
But it has, it's 25 years since those more rapid than R-insulin came out.
(02:36):
And now understanding them, even with the Fiasp and the Lyumjev of the more ultra-rapid actings, and then how do they work when we're using automated systems?
And then how do they work when you need different kinds of foods?
That's the other challenge.
It's not just, let's learn this one rule and apply it.
And I'll introduce myself quick.
I'm Tavia Vital.
I'm a registered nurse, certified diabetes care and education specialist with Integrated also, and I'm the director of intensive management services.
(03:03):
Meal composition matters so much, and we can't expect the insulin to work differently just because we're eating differently.
I do try to remind people the same slow insulin that we're wanting to bring down a high blood sugar of 250, but we're so frustrated it's taking that long to bring that high blood sugar down? Same insulin we're using for food.
(03:26):
It's not going to work any faster.
Nope.
It certainly is not.
And that's, you know, again, understanding system to system, because there are nuances to each of the systems and how it accumulates insulin on board or IOB and how we watch and then interact with that.
And then the bolus timing around meals or the adjustment for exercise with these different types of systems.
(03:49):
Dana, I know you have probably a list on your desk, as organized as you are, for things with all the systems.
The organized person is usually Tavia.
That's true.
Tavia is usually our secretary and like, "I got it all. I'll send you an email."
Thankfully.
Thankfully.
Everyone needs a Tavia.
But I think with the differences, it would be kind of nice to just go through each of the different systems on the market, as well as even the DIY systems and give an idea about, you know, bolus timing and considerations of how does a system work?
(04:21):
And as a human, how do we interact with it to get the results we want?
And I'm thinking, wouldn't it be great
I think if we start in the very beginning, right?
So if somebody wasn't even on a smart system, if they were on MDI, what do they need to know about how their insulin works to consider adequate, appropriate pre-meal bolus or injection timing?
(04:42):
Right.
I--not only to get it right, but to have the most optimal glucose excursion after a meal, you have to understand how your insulin works.
Right.
So we sort of breezed over it that, you know, we're going to be focused in on like Humalog, Lispro, Novolog, and all the different renditions of the different names of the same kinds of insulin, right?
Right.
And then we'll also consider what are, what's the slight differences with Fiasp or Lyumjev that's, that are also now available.
(05:09):
Right.
But at the end of the day, if your glucose is, let's say it's at target and it's steady, if you're on MDI or taking injections, you have your baseline basal injection that you do every day, and that is there holding you steady.
And then you take your dose for that meal of your rapid acting insulin.
And the goal is that that dose prevents you from getting a spike after your meal and lands you back down in four or five hours back at your target without a low.
(05:37):
I might put the caveat, an extreme spike, because I don't want to give anybody the expectation that even people who don't have diabetes never get a spike.
Right.
And also, what should the excursion be?
Right.
Right.
I get the question very frequently, well, my blood sugar is going up high.
And then we look at the graphs and see, well, but it is without corrective action coming back down.
(06:00):
Great.
Right.
Then what should the rise after a meal be?
And the expected with the standard intake of carbs, proteins, and fats at a mealtime should be somewhere between on the low end, maybe a 30 point rise.
And on the high end, it could be 70 or 80 points.
So if you're starting, as you said, Tavia, with like a 100 blood sugar and you eat a standard meal, the excursion could be 180.
(06:25):
Absolutely.
But then for two hours, if it's a standard rate of digestion kind of meal, it really can go up.
And this is the challenge point, right?
Because anybody who's working really hard on their diabetes doesn't want it to go above a certain threshold.
Everybody sort of has their own threshold, right?
So we're going to focus in on the standards of care guidelines that say you're trying not to go above 180 after meals.
(06:49):
If you're trying not to go above a lower number, it's the same concept, but just in your own mind replace the 180 with 160 or 140 or whatever it is.
But it's not flat.
That's the most important thing.
It's not flat.
In fact, my diabetes educator for me, when I was probably in my early 20s, I think mid 20s, maybe early 20s.
She made me a post-it note and she drew a hill and she did before meal, after meal, four or five hours later and wrote, it must go up before it comes down.
(07:20):
Love that.
Because I didn't want high blood sugars at that stage of my life.
I was so fearful of having high blood sugars that I was like way stacking my insulin because I didn't want to rise.
I didn't want to spike.
But I didn't have a concept of realistic expectations of that four to five hour action time of the original dose of insulin.
And I think you bring that in, in a good place of this discussion, because even if you are again, MDI, the timing makes a difference.
(07:45):
But as we move into using these AID systems, the same concept really is there.
How the system, after you pre-bolus and count your meal well and take your dose and know your ratio and all that kind of stuff, the system is going to help on the backend.
And it depends how much it's going to help depending on the system.
(08:05):
And I think that's where we really wanted to focus on how much is that algorithm going to help on the flip side, if we've done everything right on the front end, which is also tough to do.
Right.
And this is, I think, conversation expecting that the settings are where they should be.
I was thinking about that when Tavia was talking about MDI and that basal rate that's keeping you kind of steady, which is unusual because most people have a little bit too strong of a basal insulin on pumps and on MDI.
(08:38):
But yes, I was thinking that assumes that the settings are optimized.
Yes.
Right.
And we're talking about known meals, right?
So it isn't realistic to expect that every meal under the sun that someone can throw at you or that you could choose to eat in the moment, that you're always going to know the perfect pre-bolus time to stay within your target glucose after.
(08:59):
It just isn't realistic to think that if you're not making any insulin.
Right.
I can say, though, that your typical meals, and when I have a chance to work with somebody, I usually encourage them to figure out your most well-done meals, right?
And those people have the same.
Right.
You're going to use them over and over. Figure them out because that's 80% of your management is what you do over and over.
(09:23):
But you also can take what you learned in those circumstances and apply them when you're eating out or eating at a friend's house because those meals are still your preferences.
So if you're going out for dinner and it's a meal, you're likely to pick similar things that you know that your taste buds like.
(09:46):
And it could be close enough as an estimate to use as a reference, is my point.
And I love that you said that because so often I talk to someone and says, well, how do you know if you're eating bolus or pre-bolus when you're eating out because you have no idea what you're going to eat?
And I'm like, well, you kind of do because if you hate, you know, curry, you're not going to get a curry.
(10:08):
You're just not.
And if you are a vegetarian, you're not getting a hamburger.
So you kind of know what you're going to eat.
So I do always push back a little bit.
Yeah.
Yeah.
It's a great place to start is your known foods, again, tested and true basal rates and ratios and all those kinds of things.
And then start making some notes about what you're kind of seeing.
And then as we move into using automation and using the technology we have at our fingertips today, I think one of the best pieces of technology that's been around for a long time is absolutely a CGM.
(10:38):
No, absolutely.
Your CGM trend? It can teach you so much.
And if you know how to interact with it, then you're going to be able to see what your system is doing and make proper adjustments.
Right.
If I was on a deserted island, the one piece of diabetes technology besides insulin is absolutely my CGM.
100%.
Agreed.
(10:58):
Agreed.
Coconut water for lows, just in case.
Yeah.
Just in case.
I think that could be arranged.
Not the strange berries on the bush that you're not quite sure whether they're going to kill you.
Right.
Right.
Maybe.
And I think it's also important to know that to not get discouraged if it doesn't go well every time you try the same meal.
I think that's one of the most frequent complaints that people I work with have is, I eat one of two breakfasts every single day.
(11:22):
Right.
And it doesn't work out the same for me every day.
And even if I eat the same breakfast and I do my pre-bolus time at the same time. So what are some of the contributing things that you guys help explain to people when this is happening to them?
When they're using the automated systems, especially?
What are some of the factors that- I think breakfast in particular is super tricky, especially for young children because there's a huge rush to get out the door and everybody is trying to maximize their sleep-in time.
(11:49):
And so the pre-bolus I think automatically is shorter in the morning just because people don't want to wake up.
Right.
If you're having a bowl of Cheerios, you absolutely know that that's going to raise your blood sugar very rapidly, if not for a long pre-bolus.
But if you're waking up at 6.30, breakfast at 7, that's tough.
(12:09):
I know with a lot of automated systems, we need to be very thoughtful about how much insulin is being taken away before a meal.
And I know that this happens quite often with Omnipod 5.
I just happen to notice it a lot with Omnipod 5 system is that the system is suspending quite often, especially in the early morning hours as you're getting up because that target is a little bit higher than where you want to be.
(12:36):
You're kind of floating into breakfast and that insulin has been suspended.
And without a pre-bolus, you're just going to have a higher spike than you want to.
And the timing of that is so key, especially if you start the morning with a very processed kind of typical American diet of, you know, waffles, pancakes, bagels, you name it.
Right.
Cereal's a hard one for most people.
(12:58):
Yes.
One of the challenges is being able to see what your pump system is doing.
Absolutely.
So whatever it is, so like Omnipod 5, you can see on the app, if you push the view graph button, you can see on the screen if it's been suspending.
Right.
They call it pausing for that one.
Right.
You can see how long that red line has been there.
And that's going to give you a little clue about what to expect next.
(13:20):
If it's been suspended for over, would you say half an hour?
That's what I see.
Sure.
Then I'm going to expect a bigger rise after that meal if it's not accommodated for by either pre-bolusing longer or if also it's reducing the suggested bolus because perhaps the target set at 110 and the glucose coming in is 100.
(13:43):
If the dose is being reduced by the algorithm and the settings, then you need to consider if it's something that's going to digest really quickly, do you need to add that reduced part back in?
Or is it just simply add another five minutes onto your pre-bolus time to help get the insulin in just a little quicker because you're coming in the gate with much insulin active in the body?
Or perhaps add something to your meal that will slow down that digestion, some fats and protein to slow it down.
(14:07):
I think that's a valid point because a lot of people with automation feel like, well, I have my settings set.
Maybe they've had them set on MDI or on a conventional pump that wasn't automating anything.
Then you come into using a system and you start to see these changes that are frustrating and great in terms of looking at what the system has been doing.
(14:30):
I love the graphical visual.
I try to teach everybody no matter what system they're using, look at the screen, see what the pump was doing before you came into this mealtime, whether it's breakfast or dinner or lunch or whatever it is, but especially breakfast time.
If you can't because your system is an adapted system like Omnipod 5 and Medtronic 780, then there's nothing you can do about what it's taking away, especially in that fasting time period.
(14:57):
In general, it's taking it away.
It's doing you a favor.
It's saving you, but you do have to learn that it's okay to step outside the box of what you've learned and say, well, when I was using just a regular pump, my basal was this amount at this time of the day, and my blood sugar is going up more now because I'm always paused.
(15:19):
You may actually have to nudge with a little bit more insulin or take that foot-on-the-floor kind of bolus of a certain amount.
There's a bit of fudging that comes with using all these systems that allow that.
Absolutely.
Right.
Yeah.
They help you to optimize what's going to be your outcome, and that is based on what your goal is.
(15:43):
What are some things you guys share with people can help slow down the rise of a standard toast or cereal or things?
Protein and fat.
Protein and fat, like peanut butter or nut butters, avocado toast.
Getting some seeds and nuts for fiber. Just really having a nice balanced composition is how I think Jenny and I would phrase it, and having kind of not just a carb-rich breakfast.
(16:08):
Because also, especially for breakfast, you're going from a fasted state.
Your body is really hungry, pun intended, for those calories and glucose molecules, so it's going to convert that really quickly compared to the rest of the day.
Right.
I mean, that is really ...
I mean, breakfast is breaking a fast.
It's- Absolutely.
(16:30):
Opening up your body.
You're waiting for glucose.
It is.
It is.
It says, feed me, and then that rapid digestion when you put something in your stomach first thing in the morning.
Actually, you know, some of the fun things from even like the glucose goddess kind of ideas are like put clothes on your carbohydrates.
It's essentially put ...
That's what she says, right?
(16:52):
Yeah.
I like it.
It really is.
It's putting the fats and the proteins in the meal, and if you're really trying to time especially that breakfast to get less of a peak after and allow some time, maybe mornings, as you said, Dana, often they're really hard to get pre-bolus, especially that rush of getting people and kids out the door and whatever's happening.
You may need to start with your eggs before you put the toast in, or a big spoonful of peanut butter before you put anything in.
(17:20):
It gives a little bit more time before that insulin actually gets movement.
Or even drink your milk before you start the meal instead of afterwards.
Just small things like that.
Right.
And these small things that we're talking about, I mean, it's the difference in some glucose levels after meals of like 30 to 150 points.
Absolutely.
It's amazing.
Sometimes I would even say, you know, bolus when you're brushing your teeth, you know, and if you can.
(17:43):
And just not as you're walking into the kitchen. Find a time in that morning routine that makes more sense.
It even counts for intermittent fasting, you know, people who don't eat breakfast but maybe break their fast later in the morning.
And this would also apply to all of that.
I've even had, you know, a number of families who, it is a rush to get out the door and they try to let their children sleep kind of as long as possible.
(18:05):
So then, you know, 15 minutes before you're going to wake your kid up, as long as your blood sugar is looking okay, bolus for the breakfast, you know, you're going to serve your child.
Get that kind of rolling.
And I get a lot of kids, you know, like to alternate different foods that they're eating in the morning.
But again, you kind of know what they're going to gravitate towards.
And I would say most any meal is going to have 15, 20 grams and you can cover that.
(18:29):
You can always put at least the minimum that you know is a sure thing.
Like if you have a toddler that sometimes eats double and sometimes eats a quarter of a, you know what I mean, like chances are good.
You could at least put the minimum amount in that you're pretty confident with.
And if you are only putting the minimum in that you're pretty confident with and they refuse it, worst case scenario, you only have 10 grams of carbs to compensate some other way.
(18:52):
You know what I mean?
And chances are high that they're going to eat in the morning most of the time.
And I would say that's also really helpful of what we were talking about with the AID systems in these suspensions that happen very commonly going into a meal.
You just have to replace that insulin to avoid that higher number than you have.
(19:12):
And the suspension is definitely something that is a little bit different in each of the systems.
You know, we kind of start with Omnipod 5, which truly just has a suspend or a give back to base or a little bit extra give, right, or the pause, right, the pause in insulin.
And other systems do that adjustment in a different way.
They also have a different way that they predict where the blood sugar is going to go in a different timeframe.
(19:37):
And that means the difference in how you learn to work with your system.
First thing is test your settings.
Second thing is really know your algorithm.
How does it work?
How can you learn to work with your system?
And why?
Yeah.
Right.
Yeah.
I think I'm oftentimes explaining to folks that, you know, with the Omnipod 5, with Tandem, with Medtronic, you know, when you're under the target that the system has set, the system thinks you're low.
(20:06):
You may not feel low at 100, but if that is under that 110 or 112.5 for Tandem, you know, number, then you're getting less insulin and you may feel like that's not correct or what you want, but that's what's happening.
Correct.
And, you know, Tandem definitely has less of a just pause as your glucose is kind of trending under that 110.
(20:30):
But it also has a really nice visual.
It does.
And you can see it's step down approach to taking basal away, but not just pausing it.
Yeah.
Likewise, step up kind of way of what we call positive temping.
Right?
And you can't really see that visually on Omnipod 5.
You can see the pause, but unless you go into delivery, the insulin delivery history, you never really know what the adapted extra give is when your blood sugar is trending up which is really too bad.
(21:01):
You do have to go on a little scavenger hunt.
Yeah.
Under those auto events.
And the Tandem, another thing that I like about what you can see, like if it is down titrating is in the app, you can see how much, like not just the visual, you can see how much it's giving.
And it will ask you questions when you go to bolus.
(21:21):
It will ask you if it should reduce the dose and you can choose to either reduce it or not reduce it, get the full amount, which is very helpful.
Very helpful to add that correction or choose not to.
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(21:49):
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(22:10):
Yeah.
And especially, you know, from the morning time, as you mentioned before, if you can see how much it is reducing it by, and you know that you've been suspended, that's not the scenario where you would want it to reduce that bolus.
You 100% need it to give everything it should for these carbs because with suspended insulin, now you're already sort of taking from Peter to like Paul, right?
(22:34):
You're taking from both Paul and Peter if you don't take the extra at that moment, right?
Exactly. So, yeah.
I also think it's important to just remember where are you starting from?
Where's your starting blood sugar, right?
And if you're closer to target, well, that makes things a whole lot easier, but starting a meal, bolusing when you're already higher than you want to be, unfortunately, that is just not set up for success.
(22:58):
Right.
You're going to have to expect it after the meal to go up before it comes down.
And the only way around that is to correct, wait until it comes down to a more safer or closer to target glucose, and then take the pre-bolus and then wait for that, which can be impossible on a really busy day.
You frankly just can't do that sometimes.
(23:18):
Absolutely.
Sometimes you have to choose it and say, in an ideal world, I'd have an hour to figure this out, but I have now, my glucose is 220.
And so I'm going to take my bolus and I'm going to take the correction with it.
And I have 20 minutes to eat.
So I can start with my non-starchy veggies and I can eat my protein and I can eat the carbs at the tail end.
(23:39):
And that will at least buy me 10 or 15 minutes of insulin getting in my system.
And just those little things will still help come off quite a bit off the top.
If that's all you have to work with time-wise, it's a choice.
But sometimes you might just be like, this glucose really sucks.
And I have to go present in a meeting in front of a whole bunch of people.
(23:59):
And I'm just going to have to tolerate the fact that my glucose is above target right now.
I'm going to shove this little food lunch break that I've got down the hatch, go prepare, and I can be all mad about my high blood sugar later.
And it just is what it is.
But then you don't like waste eight days on the fact that that really sucked.
It just, yeah.
Right.
It just is what it is.
In reality, that's how the insulin works.
(24:19):
Yeah.
That's the time you move forward.
And if you don't count the time, that's what's going to happen.
Correct.
It's just how it is.
And I think that plays into kind of, you know, what we were hoping to maybe touch upon is the holidays are tricky with foods and we're going to have some really tricky blood sugars too.
But the holiday ought not be kind of, you know, affected by that is my hope.
(24:40):
And that people can still enjoy family time and special foods and not have diabetes kind of mask the day.
And I think that's also where knowing your AID system well enough comes into play.
If you have these things that you've figured out, like, you know, I have one of my favorite people from eons ago when Tandem first had Control IQ, right?
(25:00):
She had things nailed.
She had a favorite Friday fish fry that she would go to with her husband.
And she had it nailed with just a conventional pump. Temp basal. Temp bolus.
I just like choosing days of the week for certain things like that.
Right.
Yeah.
And, you know, and so with Control IQ, she was after a week or two on it, she's emailing me.
I really, really like this, but she's like, Jenny, my Fridays suck.
(25:22):
Can you like, what should I do?
And I said, well, you know what?
You have the ability to go back to manual mode on Friday nights.
You knew what worked.
You had a system.
Just use manual mode and Saturday morning when you wake up, go back to automation.
So I think in you're bringing up the holidays, it's a similar thing of saying, well, you know what?
Automation serves me really well.
(25:43):
But in this, I need to know the parameters I can make work well for me with my system.
The great thing about Tandem now is that you've got access to temporary basals.
You know, I was just thinking that.
It's a lovely thing.
You still have the protection of automation.
Don't be afraid to pop a positive temping behind Thanksgiving or any holiday that you're just gnoshing all day long.
(26:06):
Right.
And I think that is that plays into knowing your system, what features are really available to you for kind of honing in on some of these bolusing techniques that we're talking about.
And some of the AID systems have them.
And unfortunately, some of the AID systems in automated mode or in the closed loop or whatever you want to call it, just don't have a way of tweaking those.
(26:30):
Right.
Well, like with Tandem, one great benefit is extended bolus also.
So if you're going to be eating a larger meal, it's going to take longer to digest.
And so even if you nailed your carb estimate for this amazing meal, you can't possibly take all that insulin up front or you're going to tank later.
And then you're going to rise for several hours after that, after that big bolus kicks in and then it wears off while you digest.
(26:53):
So you can use a feature like extended bolus in the Tandem.
In other pumps that don't have that, you might consider splitting the dose.
Right.
And I was just going to say, we tend to have to manually split the dose or manually, not in the manual mode, but kind of, I don't know how to say that, that it's not confusing.
You're in charge of entering those.
Remembering to move them later.
(27:14):
And then for me, I'd need to set like some very loud alert that goes off twice so that I don't forget that secondary bolus.
Right.
I usually tell people to use their phones, you know, reminder.
Yes.
Or even, you know, being comfortable enough to say, this is a day that manual mode would work better.
So you have access to an extended bolus and a temporary basal, and it often will work out better because you might be food overloaded.
(27:41):
You might be a lot more sedentary.
And so just keeping insulin in the picture and understanding how it works for you may be an advantage.
I mean, I can say, and since we're all using DIY systems, I can see that's definitely where the DIY systems kind of shine.
Well, there's just more options.
There are.
I mean, Loopers, certainly, I mean, eons ago, I think we've all been using Loop or another type of system for a long enough time to have grown with all of the iterations of adjustment and everything.
(28:11):
And they've grown in benefit, but it still boils down to understanding how does a system work with what I'm telling it to do for me?
Well, and I would say that, you know, with some of the open source DIY and now the upcoming twist system, you know, there's a lot of people who get confused because there's a timestamp on the bolus.
(28:33):
And oftentimes people think that that means they don't have to pre bolus.
And so, you know, again, it goes back to the slow insulin that we just happen to call fast acting insulin.
Right.
Yeah, absolutely.
There's still a in all of these systems, there is still a pre bolus necessary.
And, you know, we were chit chatting before kind of starting recording even about the iLet.
(28:54):
And the recommendation there is, well, no pre bolus.
Well, quite honestly, if you don't pre bolus for that bowl of rice? Oh my goodness!
You have not know after you use it for a bit, how long of a pre bolus is it that's needed to prevent a rise, a big rise, right?
More than you want rise right after your commonly eaten meals.
And then you can use that information when you go to a large family meal or something and say, OK, I've found what I eat at restaurants with this pump.
(29:21):
If I pre bolus my normal 20 minutes before, then I go low and then I'm high later.
So with this pump, with my body, with the way that I digest food, this big meal, then maybe I shrink my pre bolus time.
I mean, those are the things you have to learn ahead of heading into like the holiday eating is going to be challenging for anyone.
(29:41):
But putting together the pieces that you know and that you understand.
So let's say you're at somebody's house and they have a tray of desserts out and you decide you're going to eat some.
You have to know that if you eat sugar cookies, let's just say that's an easy one that's going to digest quickly, right?
Like that's you can expect you need a big pre bolus for that to not make your glucose be really elevated.
(30:04):
And if you had like a cream cheese or a cheesecake, there we go.
That one isn't going to go quickly, right?
That's going to take longer.
And so just understanding what the food is, is it carby?
Is it a ton of protein?
Is it a ton of fat?
Is it all of it together?
That directs you with one dose? Long pre bolus? Short pre bolus? Split doses? Extendended bolus? Temp basal behind it.
(30:29):
And you use the same, like you were saying earlier, Jenny, you use what you learn and then apply it to the new foods you haven't yet eaten, right?
You're not aiming for perfect, but you're going to be in the ballpark.
But yeah, you'll be much, much closer.
I mean, it also, you know, in talking about all the systems and the benefits, I think they all have pros and cons to them.
And that's why it's so wonderful.
(30:51):
We have so many options to choose from.
I mean, in terms of like special fancy features, what do you guys like the most in terms of insulin and bolus timing and food coverage with like the loops and the trios?
What do you guys like the best?
Well, I like the ability to manipulate insulin for higher fat meals that are maybe going to be digested in two, three, four hours.
(31:15):
I live in Texas, Tex-Mex is a factor of my life, and that has a high fat component.
And using that, knowing what's going to happen to my food in the future is so key.
But I think we can kind of create some of these in all of the systems.
But, you know, again, it goes back to how do we manipulate and how do we use our tools?
(31:37):
Right, like in tandem, you can do a profile that's stronger also.
So if it's going to be a high fat meal and you have tried, you know, X percent more positive temp basil hasn't covered it for you in the past, you could set another profile, a duplicate profile, set the basil rate higher, set the correction factor stronger, might even need the carb ratio stronger.
(31:58):
I mean, you could turn that on those types of meals with a loop.
You could do a custom preset previously called Temp Overides, and you could slide that insulin picker and say, I want it to be 20 percent or 40 percent or whatever you need more insulin.
You could adjust down the target so that it helps with that insulin resistance for a little bit.
And you can pick how long you want that override to last.
(32:22):
And you can turn it off if you don't need it anymore.
Yeah, and cancel.
And so you can use the carb absorption time in Loop, which is nice. So if your standard meal is the default three
And Twiist. you can do that and Twiist as well.
Yes.
Beautiful.
So you could pick the five hour or change it to six or seven, whatever you found that works for you.
In other cases, you can use that same tool.
And that is, I think it's a unique thing with the DIY systems is the way that it actually does pay attention to the entry of food.
(32:47):
None of the FDA approved systems really pay it outside of Twiist.
Twiist has the Loop profile, right, or the Loop algorithm in it.
So it does pay attention.
But otherwise.
And a temp basal branch.
And a temp basal branch, right.
But at least it's paying attention to that food entry and the expectation of how long the system keeps a watch on the food as impacting what's happening to the glucose.
(33:11):
Whereas the Omnipod, the Medtronic and the Tandem, you enter the carb and the system sees it, but it only sees the decay of insulin after that in accordance with your blood sugar.
It doesn't factor in that, gosh, the absorption of this food was five hours because it was a whole bunch of stuffing with gravy and like fatty butter.
(33:31):
Right.
I mean, everyone who uses insulin or is a caregiver of someone who uses insulin knows that different food hits differently.
And so I never find this is a surprising topic to people.
I think that it's just hard to apply some different strategies, right?
And one thing I like to just remind people is, you know, you're going to have a different approach to foods that you would also eat to raise your blood sugar if you were low.
(33:57):
So I was just thinking about the sugar cookies that Tavia was talking about.
I mean, if your blood sugar was, you know, 60 dropping, you would find something fast acting to eat knowing that it was fast acting.
Well, that's kind of the same approach to taking your insulin ahead of time in preparation of what you definitely know is going to be fast acting sugar.
100%.
What about in Trio?
(34:18):
What are good features of Trio?
We didn't really give some ideas of how to use some of the features there.
Well, in terms of Trio, you know, I just love the protein and fat way of managing your macros and your bolus, but also the unannounced meal bolus is factoring in a whole different level of kind of control after a meal that maybe a lot of folks would appreciate.
(34:41):
I like the extra dials in Trio that you have adjustable from your self-understanding.
And it does, I mean, it's a stepwise approach to using these systems, right?
But Trio, because of those different things that you can adjust, even with the SMBs or the unannounced meal entries and that kind of stuff, the way that you can tell the system how much give to add in as glucose is shifting for you, it makes a huge difference.
(35:11):
And having different, you know, things set up for particular circumstances, like a holiday meal versus just your normal business day or whatever, it makes a big difference.
And you can be as detailed or as simplistic in your approach as you want if you use the tools to your advantage, like the reduce bolus button that will be my friend for large meals because I have it programmed for what my expectation is of, instead of the whole bolus for this food that I know is going to take a while, I hit reduce bolus, it reduces my suggested bolus by X percent.
(35:44):
I get that first part up front and then Trio hangs on to it.
And then as it identifies that the digestion is occurring, then it can apply parts of that remainder of the bolus.
And then it still has SMBs it can apply.
And after a certain time frame, it can add in the unannounced meal bolus if it's already surpassed my expectation for how long this digestion will go on, you know.
(36:09):
And I know in part the Medtronic system does have that missed meal kind of ramping up of insulin, but I don't think any other commercial system has that reduced bolus automatically as an option.
And that is also great for folks that are starting GLP-1 use or any sort of other adjunct therapy with their insulin because food's going to hit a little bit differently.
(36:29):
Or even those that eat a little bit more of a high fiber.
My preferred is actually most of my meals, I use the reduced meal button in Trio mainly because of the high fiber, low glycemic hit of the majority of my meals.
And it just it works out so much better.
(36:49):
I don't know.
I don't think I really ever use like the super bolus one.
No, I've never used that.
I have enough like I don't I don't have food like that typically.
So I mean, I guess if I was going to go for like an apple cider donut, which I never even got one this year.
Well, we might want to explain that to folks, because that's something you could really do in kind of any system.
(37:12):
I mean, yeah, so it's it's taking some of the missed basal that you foresee when you're taking a meal and front loading it to your bolus.
If you're having a meal kind of like what Tavia was describing earlier, you know, you're walking into a meal and you expect that rise pretty rapidly.
Can we front load with a little bit extra insulin, even though the system's not suggesting that?
(37:35):
And that can be a really fantastic thing to do with some of the higher glycemic foods that you just expect are going to raise your blood sugar a little bit.
And you can add on to the bolus, even if your basal wasn't suspended.
That's the idea of super bolus.
I don't know if it's official or not, but when I learned about super bolus, the definition at the time was, you take an hour to two hours max of basal.
(37:57):
Yeah. Well, because we used to use it with old, old pumps, right?
That weren't automated. We did drop that in to get that front loaded and then the pump would suspend behind.
So you don't get that double portion.
And it kicks in on the front end a little bit harder.
It is.
I mean, you can read about--its John Walsh, is really the one who coined the term in his Pumping Insulin book.
Right?
Eons ago.
(38:17):
And that was the idea was take an hour to two of your known basal coming forward after this meal.
Correct.
With kind of a key word being known basal.
Your calculated amount.
Right?
Yeah.
I mean, it should be pretty well figured.
Yeah.
Yeah.
I mean, and now the concept with AID systems is really that you can still do that.
(38:38):
And with the smarter AID systems like loop and especially trio, if you're front loading and it sees a drop, it takes that into consideration and does a lot more suspend for you earlier to save you the harm of a drop that then you end up having to treat after taking more than the bolus was recommended to begin with.
(38:59):
So.
Right.
Right.
Which can happen from time to time.
Well, we might want to touch on AAPS just using almost kind of similar to Tandem that you know, you have the ability of these different profiles, which can really do very nicely for different kind of high fat meals, high protein meals that that might hit a little bit differently.
(39:20):
Right.
Use both.
You could use the boost feature, right?
Oh, right.
Right.
Yeah.
Yes.
Absolutely.
Super, super triple bolus.
Yeah.
Yeah, it is.
And although we don't have it here in the US, you know, the CAM APS, the FX system, their algorithm is really kind of interesting.
(39:40):
It's along the parameters of almost like a loopy kind of sort of automated, adapted system together.
And they have two features.
One is an ease off where it nudges away a bit gently or a boost feature that actually has a heavier give in a time period of knowing you need more.
(40:03):
There are systems around the world that we don't even have access to here in the US, but have similar fancy features.
Exciting.
Yeah.
No, and it's exciting to live in the time that we are with systems like that that continue to be adjusted and changed and help us adapt.
I think as what we need to acknowledge is that there's still a human feature to all of these.
(40:27):
And we really do have differences in terms of even how we absorb our insulin, how we digest our food.
I mean, such a difference.
Right.
So knowing you, you know, again, it's kind of a marriage, if you will, of a good marriage.
You both work together.
There's a give from both parties and you have to understand you and what you tell the system so the system can do its part for you.
(40:50):
Well, this was way fun.
I hope everybody can gather some good, useful tips, especially with the coming holidays of whatever you celebrate, that you have a little bit more knowledge about how to look at your data and use your CGM trends and use your system's algorithm the best that you possibly can.
And enjoy some good food.
(41:10):
Enjoy some good food.
Absolutely.
If you need some help learning a little bit more, if you've kind of gotten out of this, well, gosh, I really don't know what my system is doing.
I've just kind of let it do. Certainly give us a call.
Integrated Diabetes certainly has several more clinicians just like us, very knowledgeable about all the different systems on the market.
And we would we'd love to be able to help you.
(41:31):
So thanks.
Happy pre-bolusing!
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(41:57):
Our team of clinicians, all living with type 1 diabetes, understands the challenges firsthand.
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From glucose management to self-care strategies, the latest tech, sports and exercise, weight loss, type 1 pregnancy and emotional well-being.
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(42:17):
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(42:39):
And don't forget to think like a pancreas.
Welcome to Think Like a Pancreas, the podcast, where our goal is to keep you informed, inspired, and a little entertained on all things diabetes.
The information contained in this program is based on the experience and opinions of the Integrated Diabetes Services clinical team.
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(00:35):
Hello, ladies.
Hi.
Hi there.
It's exciting to see you again today, and I'm Jennifer Smith, a Registered Dietitian Certified Diabetes Care and Education Specialist with Integrated Diabetes Services. Excited to chat with my colleagues, Dana and Tavia, today all about something we find very, very important as we move forward with all the technology that we've got in use today.
(01:00):
I have always taught a lot about insulin use, right?
Insulin use and understanding the timing of our insulins today and everything, but there's kind of a little deeper dive to take with that because of our AID systems or automated insulin delivery systems and kind of all of the ones on the market, using them a little bit differently in respect to understanding the insulin timing and knowing what to do with how your system works.
(01:26):
Yes?
And being successful with it.
And one thing, I'll just introduce myself. I am Dana Roseman, Director of Technology and
Applied Research at Integrated Diabetes, and I would say that, try to remind people
all the time, and I'm sure you do the same, that we have all these fancy algorithms and
fancy pumps and these amazing continuous glucose monitors, 24-7 alerts and alarms,
(01:49):
but the insulin that we're using is still the same insulin we used, what, 25 years ago?
And it's no faster now than it was back then.
100%.
In fact, that's kind of funny.
You're saying 25 years, and I'm thinking, has it been really that long that we've had rapid insulin?
I mean, I don't know.
I guess I switched to ultra-rapid earlier than that.
I know maybe not everybody uses the ultra-rapids, but I mean, it's not like it's magically faster.
(02:11):
No, you're actually right, because I think it was about 2000 when I went to my doctor and said, there's this new, more rapid-acting insulin, Humalog, right? On the market, and I had been still using R-insulin up to that point and was frustrated.
And so he's like, sure, I can write you a prescription for that.
But it has, it's 25 years since those more rapid than R-insulin came out.
(02:36):
And now understanding them, even with the Fiasp and the Lyumjev of the more ultra-rapid actings, and then how do they work when we're using automated systems?
And then how do they work when you need different kinds of foods?
That's the other challenge.
It's not just, let's learn this one rule and apply it.
And I'll introduce myself quick.
I'm Tavia Vital.
I'm a registered nurse, certified diabetes care and education specialist with Integrated also, and I'm the director of intensive management services.
(03:03):
Meal composition matters so much, and we can't expect the insulin to work differently just because we're eating differently.
I do try to remind people the same slow insulin that we're wanting to bring down a high blood sugar of 250, but we're so frustrated it's taking that long to bring that high blood sugar down? Same insulin we're using for food.
(03:26):
It's not going to work any faster.
Nope.
It certainly is not.
And that's, you know, again, understanding system to system, because there are nuances to each of the systems and how it accumulates insulin on board or IOB and how we watch and then interact with that.
And then the bolus timing around meals or the adjustment for exercise with these different types of systems.
(03:49):
Dana, I know you have probably a list on your desk, as organized as you are, for things with all the systems.
The organized person is usually Tavia.
That's true.
Tavia is usually our secretary and like, "I got it all. I'll send you an email."
Thankfully.
Thankfully.
Everyone needs a Tavia.
But I think with the differences, it would be kind of nice to just go through each of the different systems on the market, as well as even the DIY systems and give an idea about, you know, bolus timing and considerations of how does a system work?
(04:21):
And as a human, how do we interact with it to get the results we want?
And I'm thinking, wouldn't it be great
I think if we start in the very beginning, right?
So if somebody wasn't even on a smart system, if they were on MDI, what do they need to know about how their insulin works to consider adequate, appropriate pre-meal bolus or injection timing?
(04:42):
Right.
I--not only to get it right, but to have the most optimal glucose excursion after a meal, you have to understand how your insulin works.
Right.
So we sort of breezed over it that, you know, we're going to be focused in on like Humalog, Lispro, Novolog, and all the different renditions of the different names of the same kinds of insulin, right?
Right.
And then we'll also consider what are, what's the slight differences with Fiasp or Lyumjev that's, that are also now available.
(05:09):
Right.
But at the end of the day, if your glucose is, let's say it's at target and it's steady, if you're on MDI or taking injections, you have your baseline basal injection that you do every day, and that is there holding you steady.
And then you take your dose for that meal of your rapid acting insulin.
And the goal is that that dose prevents you from getting a spike after your meal and lands you back down in four or five hours back at your target without a low.
(05:37):
I might put the caveat, an extreme spike, because I don't want to give anybody the expectation that even people who don't have diabetes never get a spike.
Right.
And also, what should the excursion be?
Right.
Right.
I get the question very frequently, well, my blood sugar is going up high.
And then we look at the graphs and see, well, but it is without corrective action coming back down.
(06:00):
Great.
Right.
Then what should the rise after a meal be?
And the expected with the standard intake of carbs, proteins, and fats at a mealtime should be somewhere between on the low end, maybe a 30 point rise.
And on the high end, it could be 70 or 80 points.
So if you're starting, as you said, Tavia, with like a 100 blood sugar and you eat a standard meal, the excursion could be 180.
(06:25):
Absolutely.
But then for two hours, if it's a standard rate of digestion kind of meal, it really can go up.
And this is the challenge point, right?
Because anybody who's working really hard on their diabetes doesn't want it to go above a certain threshold.
Everybody sort of has their own threshold, right?
So we're going to focus in on the standards of care guidelines that say you're trying not to go above 180 after meals.
(06:49):
If you're trying not to go above a lower number, it's the same concept, but just in your own mind replace the 180 with 160 or 140 or whatever it is.
But it's not flat.
That's the most important thing.
It's not flat.
In fact, my diabetes educator for me, when I was probably in my early 20s, I think mid 20s, maybe early 20s.
She made me a post-it note and she drew a hill and she did before meal, after meal, four or five hours later and wrote, it must go up before it comes down.
(07:20):
Love that.
Because I didn't want high blood sugars at that stage of my life.
I was so fearful of having high blood sugars that I was like way stacking my insulin because I didn't want to rise.
I didn't want to spike.
But I didn't have a concept of realistic expectations of that four to five hour action time of the original dose of insulin.
And I think you bring that in, in a good place of this discussion, because even if you are again, MDI, the timing makes a difference.
(07:45):
But as we move into using these AID systems, the same concept really is there.
How the system, after you pre-bolus and count your meal well and take your dose and know your ratio and all that kind of stuff, the system is going to help on the backend.
And it depends how much it's going to help depending on the system.
(08:05):
And I think that's where we really wanted to focus on how much is that algorithm going to help on the flip side, if we've done everything right on the front end, which is also tough to do.
Right.
And this is, I think, conversation expecting that the settings are where they should be.
I was thinking about that when Tavia was talking about MDI and that basal rate that's keeping you kind of steady, which is unusual because most people have a little bit too strong of a basal insulin on pumps and on MDI.
(08:38):
But yes, I was thinking that assumes that the settings are optimized.
Yes.
Right.
And we're talking about known meals, right?
So it isn't realistic to expect that every meal under the sun that someone can throw at you or that you could choose to eat in the moment, that you're always going to know the perfect pre-bolus time to stay within your target glucose after.
(08:59):
It just isn't realistic to think that if you're not making any insulin.
Right.
I can say, though, that your typical meals, and when I have a chance to work with somebody, I usually encourage them to figure out your most well-done meals, right?
And those people have the same.
Right.
You're going to use them over and over. Figure them out because that's 80% of your management is what you do over and over.
(09:23):
But you also can take what you learned in those circumstances and apply them when you're eating out or eating at a friend's house because those meals are still your preferences.
So if you're going out for dinner and it's a meal, you're likely to pick similar things that you know that your taste buds like.
(09:46):
And it could be close enough as an estimate to use as a reference, is my point.
And I love that you said that because so often I talk to someone and says, well, how do you know if you're eating bolus or pre-bolus when you're eating out because you have no idea what you're going to eat?
And I'm like, well, you kind of do because if you hate, you know, curry, you're not going to get a curry.
(10:08):
You're just not.
And if you are a vegetarian, you're not getting a hamburger.
So you kind of know what you're going to eat.
So I do always push back a little bit.
Yeah.
Yeah.
It's a great place to start is your known foods, again, tested and true basal rates and ratios and all those kinds of things.
And then start making some notes about what you're kind of seeing.
And then as we move into using automation and using the technology we have at our fingertips today, I think one of the best pieces of technology that's been around for a long time is absolutely a CGM.
(10:38):
No, absolutely.
Your CGM trend? It can teach you so much.
And if you know how to interact with it, then you're going to be able to see what your system is doing and make proper adjustments.
Right.
If I was on a deserted island, the one piece of diabetes technology besides insulin is absolutely my CGM.
100%.
Agreed.
(10:58):
Agreed.
Coconut water for lows, just in case.
Yeah.
Just in case.
I think that could be arranged.
Not the strange berries on the bush that you're not quite sure whether they're going to kill you.
Right.
Right.
Maybe.
And I think it's also important to know that to not get discouraged if it doesn't go well every time you try the same meal.
I think that's one of the most frequent complaints that people I work with have is, I eat one of two breakfasts every single day.
(11:22):
Right.
And it doesn't work out the same for me every day.
And even if I eat the same breakfast and I do my pre-bolus time at the same time. So what are some of the contributing things that you guys help explain to people when this is happening to them?
When they're using the automated systems, especially?
What are some of the factors that- I think breakfast in particular is super tricky, especially for young children because there's a huge rush to get out the door and everybody is trying to maximize their sleep-in time.
(11:49):
And so the pre-bolus I think automatically is shorter in the morning just because people don't want to wake up.
Right.
If you're having a bowl of Cheerios, you absolutely know that that's going to raise your blood sugar very rapidly, if not for a long pre-bolus.
But if you're waking up at 6.30, breakfast at 7, that's tough.
(12:09):
I know with a lot of automated systems, we need to be very thoughtful about how much insulin is being taken away before a meal.
And I know that this happens quite often with Omnipod 5.
I just happen to notice it a lot with Omnipod 5 system is that the system is suspending quite often, especially in the early morning hours as you're getting up because that target is a little bit higher than where you want to be.
(12:36):
You're kind of floating into breakfast and that insulin has been suspended.
And without a pre-bolus, you're just going to have a higher spike than you want to.
And the timing of that is so key, especially if you start the morning with a very processed kind of typical American diet of, you know, waffles, pancakes, bagels, you name it.
Right.
Cereal's a hard one for most people.
(12:58):
Yes.
One of the challenges is being able to see what your pump system is doing.
Absolutely.
So whatever it is, so like Omnipod 5, you can see on the app, if you push the view graph button, you can see on the screen if it's been suspending.
Right.
They call it pausing for that one.
Right.
You can see how long that red line has been there.
And that's going to give you a little clue about what to expect next.
(13:20):
If it's been suspended for over, would you say half an hour?
That's what I see.
Sure.
Then I'm going to expect a bigger rise after that meal if it's not accommodated for by either pre-bolusing longer or if also it's reducing the suggested bolus because perhaps the target set at 110 and the glucose coming in is 100.
(13:43):
If the dose is being reduced by the algorithm and the settings, then you need to consider if it's something that's going to digest really quickly, do you need to add that reduced part back in?
Or is it just simply add another five minutes onto your pre-bolus time to help get the insulin in just a little quicker because you're coming in the gate with much insulin active in the body?
Or perhaps add something to your meal that will slow down that digestion, some fats and protein to slow it down.
(14:07):
I think that's a valid point because a lot of people with automation feel like, well, I have my settings set.
Maybe they've had them set on MDI or on a conventional pump that wasn't automating anything.
Then you come into using a system and you start to see these changes that are frustrating and great in terms of looking at what the system has been doing.
(14:30):
I love the graphical visual.
I try to teach everybody no matter what system they're using, look at the screen, see what the pump was doing before you came into this mealtime, whether it's breakfast or dinner or lunch or whatever it is, but especially breakfast time.
If you can't because your system is an adapted system like Omnipod 5 and Medtronic 780, then there's nothing you can do about what it's taking away, especially in that fasting time period.
(14:57):
In general, it's taking it away.
It's doing you a favor.
It's saving you, but you do have to learn that it's okay to step outside the box of what you've learned and say, well, when I was using just a regular pump, my basal was this amount at this time of the day, and my blood sugar is going up more now because I'm always paused.
(15:19):
You may actually have to nudge with a little bit more insulin or take that foot-on-the-floor kind of bolus of a certain amount.
There's a bit of fudging that comes with using all these systems that allow that.
Absolutely.
Right.
Yeah.
They help you to optimize what's going to be your outcome, and that is based on what your goal is.
(15:43):
What are some things you guys share with people can help slow down the rise of a standard toast or cereal or things?
Protein and fat.
Protein and fat, like peanut butter or nut butters, avocado toast.
Getting some seeds and nuts for fiber. Just really having a nice balanced composition is how I think Jenny and I would phrase it, and having kind of not just a carb-rich breakfast.
(16:08):
Because also, especially for breakfast, you're going from a fasted state.
Your body is really hungry, pun intended, for those calories and glucose molecules, so it's going to convert that really quickly compared to the rest of the day.
Right.
I mean, that is really ...
I mean, breakfast is breaking a fast.
It's- Absolutely.
(16:30):
Opening up your body.
You're waiting for glucose.
It is.
It is.
It says, feed me, and then that rapid digestion when you put something in your stomach first thing in the morning.
Actually, you know, some of the fun things from even like the glucose goddess kind of ideas are like put clothes on your carbohydrates.
It's essentially put ...
That's what she says, right?
(16:52):
Yeah.
I like it.
It really is.
It's putting the fats and the proteins in the meal, and if you're really trying to time especially that breakfast to get less of a peak after and allow some time, maybe mornings, as you said, Dana, often they're really hard to get pre-bolus, especially that rush of getting people and kids out the door and whatever's happening.
You may need to start with your eggs before you put the toast in, or a big spoonful of peanut butter before you put anything in.
(17:20):
It gives a little bit more time before that insulin actually gets movement.
Or even drink your milk before you start the meal instead of afterwards.
Just small things like that.
Right.
And these small things that we're talking about, I mean, it's the difference in some glucose levels after meals of like 30 to 150 points.
Absolutely.
It's amazing.
Sometimes I would even say, you know, bolus when you're brushing your teeth, you know, and if you can.
(17:43):
And just not as you're walking into the kitchen. Find a time in that morning routine that makes more sense.
It even counts for intermittent fasting, you know, people who don't eat breakfast but maybe break their fast later in the morning.
And this would also apply to all of that.
I've even had, you know, a number of families who, it is a rush to get out the door and they try to let their children sleep kind of as long as possible.
(18:05):
So then, you know, 15 minutes before you're going to wake your kid up, as long as your blood sugar is looking okay, bolus for the breakfast, you know, you're going to serve your child.
Get that kind of rolling.
And I get a lot of kids, you know, like to alternate different foods that they're eating in the morning.
But again, you kind of know what they're going to gravitate towards.
And I would say most any meal is going to have 15, 20 grams and you can cover that.
(18:29):
You can always put at least the minimum that you know is a sure thing.
Like if you have a toddler that sometimes eats double and sometimes eats a quarter of a, you know what I mean, like chances are good.
You could at least put the minimum amount in that you're pretty confident with.
And if you are only putting the minimum in that you're pretty confident with and they refuse it, worst case scenario, you only have 10 grams of carbs to compensate some other way.
(18:52):
You know what I mean?
And chances are high that they're going to eat in the morning most of the time.
And I would say that's also really helpful of what we were talking about with the AID systems in these suspensions that happen very commonly going into a meal.
You just have to replace that insulin to avoid that higher number than you have.
(19:12):
And the suspension is definitely something that is a little bit different in each of the systems.
You know, we kind of start with Omnipod 5, which truly just has a suspend or a give back to base or a little bit extra give, right, or the pause, right, the pause in insulin.
And other systems do that adjustment in a different way.
They also have a different way that they predict where the blood sugar is going to go in a different timeframe.
(19:37):
And that means the difference in how you learn to work with your system.
First thing is test your settings.
Second thing is really know your algorithm.
How does it work?
How can you learn to work with your system?
And why?
Yeah.
Right.
Yeah.
I think I'm oftentimes explaining to folks that, you know, with the Omnipod 5, with Tandem, with Medtronic, you know, when you're under the target that the system has set, the system thinks you're low.
(20:06):
You may not feel low at 100, but if that is under that 110 or 112.5 for Tandem, you know, number, then you're getting less insulin and you may feel like that's not correct or what you want, but that's what's happening.
Correct.
And, you know, Tandem definitely has less of a just pause as your glucose is kind of trending under that 110.
(20:30):
But it also has a really nice visual.
It does.
And you can see it's step down approach to taking basal away, but not just pausing it.
Yeah.
Likewise, step up kind of way of what we call positive temping.
Right?
And you can't really see that visually on Omnipod 5.
You can see the pause, but unless you go into delivery, the insulin delivery history, you never really know what the adapted extra give is when your blood sugar is trending up which is really too bad.
(21:01):
You do have to go on a little scavenger hunt.
Yeah.
Under those auto events.
And the Tandem, another thing that I like about what you can see, like if it is down titrating is in the app, you can see how much, like not just the visual, you can see how much it's giving.
And it will ask you questions when you go to bolus.
(21:21):
It will ask you if it should reduce the dose and you can choose to either reduce it or not reduce it, get the full amount, which is very helpful.
Very helpful to add that correction or choose not to.
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(22:10):
Yeah.
And especially, you know, from the morning time, as you mentioned before, if you can see how much it is reducing it by, and you know that you've been suspended, that's not the scenario where you would want it to reduce that bolus.
You 100% need it to give everything it should for these carbs because with suspended insulin, now you're already sort of taking from Peter to like Paul, right?
(22:34):
You're taking from both Paul and Peter if you don't take the extra at that moment, right?
Exactly. So, yeah.
I also think it's important to just remember where are you starting from?
Where's your starting blood sugar, right?
And if you're closer to target, well, that makes things a whole lot easier, but starting a meal, bolusing when you're already higher than you want to be, unfortunately, that is just not set up for success.
(22:58):
Right.
You're going to have to expect it after the meal to go up before it comes down.
And the only way around that is to correct, wait until it comes down to a more safer or closer to target glucose, and then take the pre-bolus and then wait for that, which can be impossible on a really busy day.
You frankly just can't do that sometimes.
(23:18):
Absolutely.
Sometimes you have to choose it and say, in an ideal world, I'd have an hour to figure this out, but I have now, my glucose is 220.
And so I'm going to take my bolus and I'm going to take the correction with it.
And I have 20 minutes to eat.
So I can start with my non-starchy veggies and I can eat my protein and I can eat the carbs at the tail end.
(23:39):
And that will at least buy me 10 or 15 minutes of insulin getting in my system.
And just those little things will still help come off quite a bit off the top.
If that's all you have to work with time-wise, it's a choice.
But sometimes you might just be like, this glucose really sucks.
And I have to go present in a meeting in front of a whole bunch of people.
(23:59):
And I'm just going to have to tolerate the fact that my glucose is above target right now.
I'm going to shove this little food lunch break that I've got down the hatch, go prepare, and I can be all mad about my high blood sugar later.
And it just is what it is.
But then you don't like waste eight days on the fact that that really sucked.
It just, yeah.
Right.
It just is what it is.
In reality, that's how the insulin works.
(24:19):
Yeah.
That's the time you move forward.
And if you don't count the time, that's what's going to happen.
Correct.
It's just how it is.
And I think that plays into kind of, you know, what we were hoping to maybe touch upon is the holidays are tricky with foods and we're going to have some really tricky blood sugars too.
But the holiday ought not be kind of, you know, affected by that is my hope.
(24:40):
And that people can still enjoy family time and special foods and not have diabetes kind of mask the day.
And I think that's also where knowing your AID system well enough comes into play.
If you have these things that you've figured out, like, you know, I have one of my favorite people from eons ago when Tandem first had Control IQ, right?
(25:00):
She had things nailed.
She had a favorite Friday fish fry that she would go to with her husband.
And she had it nailed with just a conventional pump. Temp basal. Temp bolus.
I just like choosing days of the week for certain things like that.
Right.
Yeah.
And, you know, and so with Control IQ, she was after a week or two on it, she's emailing me.
I really, really like this, but she's like, Jenny, my Fridays suck.
(25:22):
Can you like, what should I do?
And I said, well, you know what?
You have the ability to go back to manual mode on Friday nights.
You knew what worked.
You had a system.
Just use manual mode and Saturday morning when you wake up, go back to automation.
So I think in you're bringing up the holidays, it's a similar thing of saying, well, you know what?
Automation serves me really well.
(25:43):
But in this, I need to know the parameters I can make work well for me with my system.
The great thing about Tandem now is that you've got access to temporary basals.
You know, I was just thinking that.
It's a lovely thing.
You still have the protection of automation.
Don't be afraid to pop a positive temping behind Thanksgiving or any holiday that you're just gnoshing all day long.
(26:06):
Right.
And I think that is that plays into knowing your system, what features are really available to you for kind of honing in on some of these bolusing techniques that we're talking about.
And some of the AID systems have them.
And unfortunately, some of the AID systems in automated mode or in the closed loop or whatever you want to call it, just don't have a way of tweaking those.
(26:30):
Right.
Well, like with Tandem, one great benefit is extended bolus also.
So if you're going to be eating a larger meal, it's going to take longer to digest.
And so even if you nailed your carb estimate for this amazing meal, you can't possibly take all that insulin up front or you're going to tank later.
And then you're going to rise for several hours after that, after that big bolus kicks in and then it wears off while you digest.
(26:53):
So you can use a feature like extended bolus in the Tandem.
In other pumps that don't have that, you might consider splitting the dose.
Right.
And I was just going to say, we tend to have to manually split the dose or manually, not in the manual mode, but kind of, I don't know how to say that, that it's not confusing.
You're in charge of entering those.
Remembering to move them later.
(27:14):
And then for me, I'd need to set like some very loud alert that goes off twice so that I don't forget that secondary bolus.
Right.
I usually tell people to use their phones, you know, reminder.
Yes.
Or even, you know, being comfortable enough to say, this is a day that manual mode would work better.
So you have access to an extended bolus and a temporary basal, and it often will work out better because you might be food overloaded.
(27:41):
You might be a lot more sedentary.
And so just keeping insulin in the picture and understanding how it works for you may be an advantage.
I mean, I can say, and since we're all using DIY systems, I can see that's definitely where the DIY systems kind of shine.
Well, there's just more options.
There are.
I mean, Loopers, certainly, I mean, eons ago, I think we've all been using Loop or another type of system for a long enough time to have grown with all of the iterations of adjustment and everything.
(28:11):
And they've grown in benefit, but it still boils down to understanding how does a system work with what I'm telling it to do for me?
Well, and I would say that, you know, with some of the open source DIY and now the upcoming twist system, you know, there's a lot of people who get confused because there's a timestamp on the bolus.
(28:33):
And oftentimes people think that that means they don't have to pre bolus.
And so, you know, again, it goes back to the slow insulin that we just happen to call fast acting insulin.
Right.
Yeah, absolutely.
There's still a in all of these systems, there is still a pre bolus necessary.
And, you know, we were chit chatting before kind of starting recording even about the iLet.
(28:54):
And the recommendation there is, well, no pre bolus.
Well, quite honestly, if you don't pre bolus for that bowl of rice? Oh my goodness!
You have not know after you use it for a bit, how long of a pre bolus is it that's needed to prevent a rise, a big rise, right?
More than you want rise right after your commonly eaten meals.
And then you can use that information when you go to a large family meal or something and say, OK, I've found what I eat at restaurants with this pump.
(29:21):
If I pre bolus my normal 20 minutes before, then I go low and then I'm high later.
So with this pump, with my body, with the way that I digest food, this big meal, then maybe I shrink my pre bolus time.
I mean, those are the things you have to learn ahead of heading into like the holiday eating is going to be challenging for anyone.
(29:41):
But putting together the pieces that you know and that you understand.
So let's say you're at somebody's house and they have a tray of desserts out and you decide you're going to eat some.
You have to know that if you eat sugar cookies, let's just say that's an easy one that's going to digest quickly, right?
Like that's you can expect you need a big pre bolus for that to not make your glucose be really elevated.
(30:04):
And if you had like a cream cheese or a cheesecake, there we go.
That one isn't going to go quickly, right?
That's going to take longer.
And so just understanding what the food is, is it carby?
Is it a ton of protein?
Is it a ton of fat?
Is it all of it together?
That directs you with one dose? Long pre bolus? Short pre bolus? Split doses? Extendended bolus? Temp basal behind it.
(30:29):
And you use the same, like you were saying earlier, Jenny, you use what you learn and then apply it to the new foods you haven't yet eaten, right?
You're not aiming for perfect, but you're going to be in the ballpark.
But yeah, you'll be much, much closer.
I mean, it also, you know, in talking about all the systems and the benefits, I think they all have pros and cons to them.
And that's why it's so wonderful.
(30:51):
We have so many options to choose from.
I mean, in terms of like special fancy features, what do you guys like the most in terms of insulin and bolus timing and food coverage with like the loops and the trios?
What do you guys like the best?
Well, I like the ability to manipulate insulin for higher fat meals that are maybe going to be digested in two, three, four hours.
(31:15):
I live in Texas, Tex-Mex is a factor of my life, and that has a high fat component.
And using that, knowing what's going to happen to my food in the future is so key.
But I think we can kind of create some of these in all of the systems.
But, you know, again, it goes back to how do we manipulate and how do we use our tools?
(31:37):
Right, like in tandem, you can do a profile that's stronger also.
So if it's going to be a high fat meal and you have tried, you know, X percent more positive temp basil hasn't covered it for you in the past, you could set another profile, a duplicate profile, set the basil rate higher, set the correction factor stronger, might even need the carb ratio stronger.
(31:58):
I mean, you could turn that on those types of meals with a loop.
You could do a custom preset previously called Temp Overides, and you could slide that insulin picker and say, I want it to be 20 percent or 40 percent or whatever you need more insulin.
You could adjust down the target so that it helps with that insulin resistance for a little bit.
And you can pick how long you want that override to last.
(32:22):
And you can turn it off if you don't need it anymore.
Yeah, and cancel.
And so you can use the carb absorption time in Loop, which is nice. So if your standard meal is the default three
And Twiist. you can do that and Twiist as well.
Yes.
Beautiful.
So you could pick the five hour or change it to six or seven, whatever you found that works for you.
In other cases, you can use that same tool.
And that is, I think it's a unique thing with the DIY systems is the way that it actually does pay attention to the entry of food.
(32:47):
None of the FDA approved systems really pay it outside of Twiist.
Twiist has the Loop profile, right, or the Loop algorithm in it.
So it does pay attention.
But otherwise.
And a temp basal branch.
And a temp basal branch, right.
But at least it's paying attention to that food entry and the expectation of how long the system keeps a watch on the food as impacting what's happening to the glucose.
(33:11):
Whereas the Omnipod, the Medtronic and the Tandem, you enter the carb and the system sees it, but it only sees the decay of insulin after that in accordance with your blood sugar.
It doesn't factor in that, gosh, the absorption of this food was five hours because it was a whole bunch of stuffing with gravy and like fatty butter.
(33:31):
Right.
I mean, everyone who uses insulin or is a caregiver of someone who uses insulin knows that different food hits differently.
And so I never find this is a surprising topic to people.
I think that it's just hard to apply some different strategies, right?
And one thing I like to just remind people is, you know, you're going to have a different approach to foods that you would also eat to raise your blood sugar if you were low.
(33:57):
So I was just thinking about the sugar cookies that Tavia was talking about.
I mean, if your blood sugar was, you know, 60 dropping, you would find something fast acting to eat knowing that it was fast acting.
Well, that's kind of the same approach to taking your insulin ahead of time in preparation of what you definitely know is going to be fast acting sugar.
100%.
What about in Trio?
(34:18):
What are good features of Trio?
We didn't really give some ideas of how to use some of the features there.
Well, in terms of Trio, you know, I just love the protein and fat way of managing your macros and your bolus, but also the unannounced meal bolus is factoring in a whole different level of kind of control after a meal that maybe a lot of folks would appreciate.
(34:41):
I like the extra dials in Trio that you have adjustable from your self-understanding.
And it does, I mean, it's a stepwise approach to using these systems, right?
But Trio, because of those different things that you can adjust, even with the SMBs or the unannounced meal entries and that kind of stuff, the way that you can tell the system how much give to add in as glucose is shifting for you, it makes a huge difference.
(35:11):
And having different, you know, things set up for particular circumstances, like a holiday meal versus just your normal business day or whatever, it makes a big difference.
And you can be as detailed or as simplistic in your approach as you want if you use the tools to your advantage, like the reduce bolus button that will be my friend for large meals because I have it programmed for what my expectation is of, instead of the whole bolus for this food that I know is going to take a while, I hit reduce bolus, it reduces my suggested bolus by X percent.
(35:44):
I get that first part up front and then Trio hangs on to it.
And then as it identifies that the digestion is occurring, then it can apply parts of that remainder of the bolus.
And then it still has SMBs it can apply.
And after a certain time frame, it can add in the unannounced meal bolus if it's already surpassed my expectation for how long this digestion will go on, you know.
(36:09):
And I know in part the Medtronic system does have that missed meal kind of ramping up of insulin, but I don't think any other commercial system has that reduced bolus automatically as an option.
And that is also great for folks that are starting GLP-1 use or any sort of other adjunct therapy with their insulin because food's going to hit a little bit differently.
(36:29):
Or even those that eat a little bit more of a high fiber.
My preferred is actually most of my meals, I use the reduced meal button in Trio mainly because of the high fiber, low glycemic hit of the majority of my meals.
And it just it works out so much better.
(36:49):
I don't know.
I don't think I really ever use like the super bolus one.
No, I've never used that.
I have enough like I don't I don't have food like that typically.
So I mean, I guess if I was going to go for like an apple cider donut, which I never even got one this year.
Well, we might want to explain that to folks, because that's something you could really do in kind of any system.
(37:12):
I mean, yeah, so it's it's taking some of the missed basal that you foresee when you're taking a meal and front loading it to your bolus.
If you're having a meal kind of like what Tavia was describing earlier, you know, you're walking into a meal and you expect that rise pretty rapidly.
Can we front load with a little bit extra insulin, even though the system's not suggesting that?
(37:35):
And that can be a really fantastic thing to do with some of the higher glycemic foods that you just expect are going to raise your blood sugar a little bit.
And you can add on to the bolus, even if your basal wasn't suspended.
That's the idea of super bolus.
I don't know if it's official or not, but when I learned about super bolus, the definition at the time was, you take an hour to two hours max of basal.
(37:57):
Yeah. Well, because we used to use it with old, old pumps, right?
That weren't automated. We did drop that in to get that front loaded and then the pump would suspend behind.
So you don't get that double portion.
And it kicks in on the front end a little bit harder.
It is.
I mean, you can read about--its John Walsh, is really the one who coined the term in his Pumping Insulin book.
Right?
Eons ago.
(38:17):
And that was the idea was take an hour to two of your known basal coming forward after this meal.
Correct.
With kind of a key word being known basal.
Your calculated amount.
Right?
Yeah.
I mean, it should be pretty well figured.
Yeah.
Yeah.
I mean, and now the concept with AID systems is really that you can still do that.
(38:38):
And with the smarter AID systems like loop and especially trio, if you're front loading and it sees a drop, it takes that into consideration and does a lot more suspend for you earlier to save you the harm of a drop that then you end up having to treat after taking more than the bolus was recommended to begin with.
(38:59):
So.
Right.
Right.
Which can happen from time to time.
Well, we might want to touch on AAPS just using almost kind of similar to Tandem that you know, you have the ability of these different profiles, which can really do very nicely for different kind of high fat meals, high protein meals that that might hit a little bit differently.
(39:20):
Right.
Use both.
You could use the boost feature, right?
Oh, right.
Right.
Yeah.
Yes.
Absolutely.
Super, super triple bolus.
Yeah.
Yeah, it is.
And although we don't have it here in the US, you know, the CAM APS, the FX system, their algorithm is really kind of interesting.
(39:40):
It's along the parameters of almost like a loopy kind of sort of automated, adapted system together.
And they have two features.
One is an ease off where it nudges away a bit gently or a boost feature that actually has a heavier give in a time period of knowing you need more.
(40:03):
There are systems around the world that we don't even have access to here in the US, but have similar fancy features.
Exciting.
Yeah.
No, and it's exciting to live in the time that we are with systems like that that continue to be adjusted and changed and help us adapt.
I think as what we need to acknowledge is that there's still a human feature to all of these.
(40:27):
And we really do have differences in terms of even how we absorb our insulin, how we digest our food.
I mean, such a difference.
Right.
So knowing you, you know, again, it's kind of a marriage, if you will, of a good marriage.
You both work together.
There's a give from both parties and you have to understand you and what you tell the system so the system can do its part for you.
(40:50):
Well, this was way fun.
I hope everybody can gather some good, useful tips, especially with the coming holidays of whatever you celebrate, that you have a little bit more knowledge about how to look at your data and use your CGM trends and use your system's algorithm the best that you possibly can.
And enjoy some good food.
(41:10):
Enjoy some good food.
Absolutely.
If you need some help learning a little bit more, if you've kind of gotten out of this, well, gosh, I really don't know what my system is doing.
I've just kind of let it do. Certainly give us a call.
Integrated Diabetes certainly has several more clinicians just like us, very knowledgeable about all the different systems on the market.
And we would we'd love to be able to help you.
(41:31):
So thanks.
Happy pre-bolusing!
Thanks for tuning in to Think Like a Pancreas, the podcast.
If you enjoyed today's episode, don't forget to like, follow or subscribe on your favorite podcast app.
Think Like a Pancreas, the podcast is brought to you by Integrated Diabetes Services.
Where experience meets expertise, passion meets compassion, and diabetes care is personal because we live it, too.
(41:57):
Our team of clinicians, all living with type 1 diabetes, understands the challenges firsthand.
We're here to help no matter where you are in the world.
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(42:17):
We offer consultations in English and Spanish via phone, video chat, email and text.
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On behalf of Think Like a Pancreas, the podcast, I'm Gary Scheiner, wishing you a fantastic week ahead.
(42:39):
And don't forget to think like a pancreas.
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