#78 Think Like a Pancreas Chapter 6: Basal Insulin Dosing with Shannan

Who's ready to think like a pancreas?! This is the sixth episode in our 10 week, Think Like a Pancreas Book Club Series and today I am covering chapter SIX called, Basal Insulin dosing. My guest for this one is my good friend and T1D mama, Shannan. This chapter gives great, step by step instructions on how to do basal testing whether you are on MDI or an insulin pump. Getting those basal settings correct is so very important and definitely the first step you should nail down when building a solid foundation for better, more stable diabetes management.

Listen, if you have type 1 diabetes or your kid has type 1 diabetes or someone you love has diabetes or perhaps you have type 2 diabetes and are taking insulin, I can confidently say you need to own a copy of this book and actually read it. I call it my diabetes bible and refer back to it often! It will teach you how to manage your insulin better and empower you to make all those hundreds of daily diabetes decisions faster and with more confidence. I sure do hope you will follow along with us. See links below to get your copy from Amazon or get your signed copy from the author, Gary Scheiner, on his company's website,  integrateddiabetes.com. Enjoy!

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OTHER INFO MENTIONED IN THE SHOW

Shannan's other Episode: https://www.sugarmamaspodcast.com/68-when-your-kid-is-in-a-huge-clinical-research-trail-for-teplizumab-an-interview-with-my-buddy-shannan/

Episode on Alcohol and T1D: https://www.sugarmamaspodcast.c

Transcript

Katie: 0:00

You're listening to episode 78 of the sugar mamas podcast. And today we are going over chapter six of the book, think like a pancreas by author Gary Scheiner, chapter six is called basil insulin dosing. And honestly, I think this is probably the most important chapter of the book because getting your basal insulin settings right, is really probably the most important or definitely step one before you try to get anything else. Correct. So I hope you enjoy it. I get to chat today with my very good real life friend, Ms. Shannon Kritzer. Shannon has been on another episode with me and I will link to that in the show notes. Her daughter, Delaney has T one D and has been in a huge clinical research trial for the drug Teplizumab. And on the previous episode, Shannon came on and told listeners all about it. Of course in the show notes as well. We'll be links to where you can buy your very own copy of the book. So you can follow along with us. All right, we're gonna jump right on in, enjoy. You're listening to the sugar mamas podcast, a show designed for moms and caregivers of type one diabetics here. You'll find a community of like-minded people who are striving daily to keep their kids safe, happy, and healthy in the ever-changing world of type one. I'm your host and fellow T one D mom, Katie Roseboro. Before we get started. I need you to know that nothing you hear on the sugar mamas podcast should be considered medical advice. Please be safe, be smart, and always consult your physician before making changes to the way you manage type one diabetes. Thanks. Everybody. I am here with my very good buddy, Ms. Shannon crier today. And today we're going over chapter six of think like a pancreas, which is called basal insulin dosing. It is, I don't know. It's Shannon. You can give your opinion, but I feel like perhaps the most important chapter in the book, because basal you gotta get your basal insulin doses, correct. Before you can expect to do anything else properly, which is not easy. Yeah. Not easy to do. Not easy to do, but Shannon, introduce yourself. I know you, but tell the listeners who you are and what your connection to type one diabetes. Gosh.

Shannan: 2:24

Awesome. Well, I am Shannon and my connection to type one diabetes is my daughter. Delaney. She is 10 like Sarah, and we were just going about our life and. One week, everything changed. And I looked down on a Wednesday after she was in my room, like the third time at like 11 o'clock at night. And mom, I have to go to the bathroom again. She's like in tears. And I was like, it's fine. Go to the bathroom. And then I was like, girl, I think you have diabetes. She walks in and I was like a, she has diabetes, like. He's like a message straight from heaven. And immediately I started Googling things and I just kind, I hit my husband, obviously. I had just had surgery, so I like laid up in bed and I was like, oh my gosh, that's what it is. And he was like, go to bed and I stayed up half the night looking at stuff new at that point, have a close cousin who has type one. And I started asking her questions and she was like, is this for you? I was like, no, I think Delaney has gifted. And so for like the past seven to 10 months we actually thought she had a D because she was showing signs of either, you know, quote, unquote being bored or just. Spacing out in class and her teachers that was like COVID forward. And so her teachers looped with them from second grade to third grade. They knew her very well and were very open with us about like, I mean, she's, she's looking out the windows a lot more often. It wasn't impacting grades. I'm also a teacher. And so that's one of the things that we'll say in a meeting with parents and, and other educators, you have a, a whole team that comes together before you kind of do anything educationally it wasn't impacting your grades. So everybody just kept, like, I think it's fine. I think it's, she's growing. Jeff had had strokes like a year before that. And so everybody just kept saying like, and then COVID, and then all this, like, you're fine. You're fine. But I never, it never settled on me. That would just, she had changed. There was a, a difference in her. And so we try, one of my little sisters in my sorority was a, a school psychologist. I contacted her, we tried a bunch of organic supplements and different vitamins. And finally that Wednesday I contacted my pediatrician actually sent an email the middle of the night and said, just call for blood work. We'll go. The following was spring break. We'll go next week. And we didn't make it till next week. And I my husband's type two. And when we were coming home from dinner Saturday night, he was like, I, why is she taking a nap? he was like, in the middle of the day we had just eaten and she was like RO pale. And finally Remembered that he had a finger stick. And so we checked it and it was 500 and said, Hmm. Okay. Let's not panic. It was like nine o'clock at night by then she's crying. I'm mom trying to keep everything calm. Like it's okay. Let's paint your finger nails. I dunno what to do. And we just decided you know, I looked up stuff real quick, text my cousin. She was like so I don't know how to tell you this. But the only way to get that down is insulin. So if you have any, go ahead. If you don't I'd go onto the hospital. Reading problems was of course listed as one of the, the signs for DKA. She wasn't having any of those. And so she made a little pallet on the floor and I slept with her on the pallet, on the floor and didn't sleep actually just kept my hand on her and woke up the next morning, thinking like, let's get a fasting, blood sugar. If it's, if it's over what it should be, then we'll go. And it had not come down very much. So off we went and she took like a champ. She the nurse gave the first shot. My husband gave the second she gave the third and. Has not looked back. So in that respect, everything was kind of a breeze. It was, it was more of a struggle, like to get to that. It was almost like, Ugh, now I have an answer gonna move forward. But, but then it was fight with insurance fight for Dexcom, get the correct medicine, get used to all the words. Like the, the language is totally different, you know, I'm mixing up the basal and bulls and

Katie: 6:42

You mean the words you weren't actually mixing up the insulin, right?

Shannan: 6:44

no, correct. Yes. That was a good clarification question. But I ju I couldn't get the words correctly. And then I didn't know about any podcasts or, or forums or whatever. Everything. You know, listens to the words you say. So shortly, some things started popping up on Facebook and Instagram. And so then I started like reading things and everything started. I'm a, I'm kind of just a data nerd. I like information. And so I just dove straight in. Within 10 days we were signed up in a clinical trial. And I just sat at the feet of the doctors and nurses and clinicians and asked every question I could. And so very quickly started to understand things. And this is one of, like we said in the beginning, one of the single most important things that you can do. And I wanted to get it correct very quickly. And the doctors were like, it's okay. You don't have to, It's gonna take time. And in my head, I was like, I don't have time. I don't. I already researched all the long term effects. I don't have time, so let's get down a business. So.

Katie: 7:48

I think, I think of all the things type one diabetes has been the biggest lesson in patients for me, because I also feel like I never have the time or wanna take the time, which I'm sure is a product of my generation being on that borderline millennial, you know gin for me. And yeah, this is something that you cannot rush through and unfortunately you have to do basal testing quite frequently. we'll talk about that later, but yeah, it's absolutely important. Well, before we dive into all the basal testing information just, I, I always, I always ask people to di about diabetes, obviously, because you know, it's a type one podcast, but I just give us like a few fun, interesting facts about you and your family, like outside of diabetes.

Shannan: 8:31

Outside of diabetes. I, my father worked for a company that is kind of known as the second military and we moved around a lot. And so my the school I entered in ninth grade was my 12th school. And so I had the privilege of, of getting to know a lot of people a lot of, of churches and companies and, and my cuz my mom of course worked for various companies as, as we went, you know, moving around spent a lot of time in cars, traveling to see family. So mostly only on the east coast. So that was an interesting part of childhood. My husband and I actually met in S. 10th grade. So when we were 16 started dating. And so yeah, so we're a hundred now, so it's been a long time. It's been a long time so we often, he asked me to marry me with, you know, a little note over, around the dog. That said, will you marry me check yes or no? So kind of like a nod back to when you're so immature and 10th grade. Like, I don't know if she likes me or if she doesn't, you know,

Katie: 9:35

that is so cute. Hmm.

Shannan: 9:37

fun. And then otherwise we kind of have gone back and forth between being an outdoor family, being an indoor family. My husband like I said earlier has type two. And so he has actually had some maybe not even necessarily related to type two, but just some medical challenges and Brooke, his humorous phone arm, wrestl. And that was horrendous. And it was very complicated but it, that fixed. And then shortly thereafter a disc ruptured in his neck. And so then he had to have a fusion and then the fusion, of course, I would never recommend it to anybody. And so then the one below it ruptured. And so you had to go in and have a different one, but this one is more medically advanced. And so it has, has worked. And so we went from being, you know, kind of an outside family to kind of an inside doing things. And then as Delaney got older, of course she wanted to be outside. So we've kind of gone outside again. So it's been, it's been wild and interesting. Our families are both here, so that's been. Being able to be around family and especially after a diagnosis like this to be able to just say to the grandparents, like, you can keep her alive for six hours. I just have to go, have dinner with my husband and, you know, enjoy the night or whatever. So and I'm a teacher and he does a bunch of math and financing stuff. And so I also am not going to go back to education next year and so, or, or school anyways. so this is a fun new venture that we're gonna be on me being at home and kind of doing some consulting for an amazing writing company. But also homeschooling her. So I'm gonna have some more time to do a bunch of basal testing so that we can, we can knock it out of the park, right.

Katie: 11:18

Yeah, absolutely. I know I have a hard time with the afternoon basal test, cuz Sarah's usually at school or we're on the go somewhere. It's like always one thing after the other. All right. Let's jump in. So chapter six, basal insulin dosing. The goal of the chapter and let me know if you agree, but I mean it's. Again, he just really stresses how important getting the basal settings correct are because it's the foundation, you know, it's like if you try to build your house on sand type of thing, like it's gonna crumble immediately. Well, you need a solid basal foundation to build the rest of your diabetes management plan and program around or else everything else is gonna kind of fall, fall outta place. So it's, this chapter is teaching you how to fine tune basal insulin dosing for both MDI that's multiple daily injections. So people who are doing shots and people who are on a pump so how to fine tune your basal rates if you're using a pump, would you agree that that is the goal

Shannan: 12:14

I would, I would, but I also think it is I was thinking about the beginning of our diagnosis and, and not understanding the, how the two of them work. And, and as I said before, we were in a clinical trial pretty quickly. And one of the doctors was explaining it to me and it was like, you know, just a cloud of fire coming down. And I was like, oh, it's like your car's alignment. It like holds you in place. And they're like, wow. Yeah, it is And so I've always thought about that. If, if, if the alignment is off, then I'm going too far down in this case, or. Too far up. And that was interesting for me to see. So then looking back, you know, pulling up the clarity app, like I could very quickly see like, oh, it was off, you know, these two or three or four days. And then it went back to being correct. And that then starts peeling back the onion layers of, okay, well that must be hormones and that must be sleep or that must be stress or a

Katie: 13:13

Yep. It's the second Tuesday of the month who knows? It could be anything. Yeah, I absolutely love the alignment analogy. I maybe you've shared that with me before and I forgot, but I feel like that's a amazing way to think about it. That's exactly right. And you every now and then you gotta go into the shop and get it tuned up and adjusted just like you gotta do with some basal testing and make. Tweaks here and there. Okay. So just as a reminder to everybody, I feel like we've covered this in a few of the previous recordings with the, the earlier chapters, but your basal insulin. So whether you're getting that through an injection of long acting insulin, or you're using basal rates on your pump, that should keep you steady. It should keep your blood sugar steady. Within about a 30 point range in the absence of food, Boless insulin or rapid acting insulin and in the absence of exercise. So if all those things are taken away, food Boless insulin and exercise, your basal insulin alone should keep your, it should match what the liver is putting out in terms of glucose into your bloodstream. And it should keep your blood sugar levels steady throughout. It's definitely best to try to fine tune basal settings before you even attempt to adjust like bolus or, you know, start messing with your insulin to carb ratios which is why the author put this chapter first in the book. And before like the next chapter is on the art and science of bolus calculations. So but this comes first, cuz you gotta get this right first. I just wanna make a quick note. There's gonna be some math in this episode, not a ton, but there will be some math. And so you know, you're gonna hear me talk about like different levels and just because this is what Shannon and I use. I'm gonna talk in terms of milligrams per deciliter. But if you're listening and you use millimoles, the way to go from milligrams per deciliter to Millis per liter is to divide by 18. Okay. So if I said a hundred milligrams per deciliter, if you divide that by 18, it would be 1.8. So just keep that in mind. I just don't think, I think it would add like 20 extra minutes to the episode if I said both all the time. So everybody keep that in mind. Okay. So Shannon, what basal basal insulin where you guys put on a diagnosis?

Shannan: 15:26

So she was pretty high. Her A1C was 13.9 and so she needed a whole bunch of stuff. And she was, she had just crushed into the DKA threshold. But it was, it was. Good. We took her in that morning. You know, so they were throwing a bunch of insulin in her and basal Atlantis of course at the hospital, but then the insurance, you know, quickly switched it to basal Glar, which is fine. And so she was on 15 units of basil GLA. That's kind of the standard. They kind of go in the middle of, of the calculations that we'll get to. They kind of go in the middle of that and start with 15. And within probably I wanna say three weeks, but it could have been a month. It was too much. And so whether people wanna. You know, say, oh, your bit, your body finally got a little bit of relief and your pancreas was like, whoa, thank you for hearing my cry for help. Regardless of what it was, we backed off. I mean, I, I, by that point we were in the clinical trial. So I had access to some doctors and I said, listen, she is, is low all the time. Like I can't like, I'm not sad cuz now she's not high, but obviously that's gonna, those first couple of months, lows, frighten, you, they frighten you with the lows in the beginning. And I think that that is important cuz now you have this, this life altering medicine sitting in your hand. Send you home with, to be a doctor to your child when you've never done this. And so they were very quick to say, all right, let's, let's back off two units for this next week. Let's see what happens. I didn't even make it a week. I remember like two or three days later saying like it's still too much. And so he was like, well, let's just back off one this time and backed off one. I didn't even call the next time. I was backed off another and we kind of landed somewhere between like five then seven and depending. And I would not say everybody should take this advice, but depending on what her line looked like that day is what I gave her that night. I would not take that advice now I would say to wait to see what, like the next day entails and. Like I said earlier, I'm a dad mongrel. And so I, I wrote down for months what everything was. I know you can pull it up in clarity too, but I, I didn't wanna have to pull it up on my phone. I'm blind. So I'd have to make it like font size, 58 to be able to see it on my phone. So I wrote it down and so it was easier for me to see. And so then I could kind of see a week at a time or different foods impacting. And by this, by that time in our diagnosis, I had read this book and this was a, a earth shattering chapter for me. It was so monumental. So. I then very quickly said you have to get me on a pump as soon as you possibly can. I cannot wait for all of the, the things that you're saying she has to have a pump. This is going to be better for her. And so it was hard for me to understand it at first, but again, when, when I got into it and finally understood and made that alignment reference in my head, it kind of all became clear. So.

Katie: 18:37

Yeah. we did not have that experience at all, which I find interesting. Like we, I, I don't even remember what our initial dose was. I wanna say it was eight units of basilar somewhere around there, and we never had to back down on her. We only had to keep going. That's not true. That's not true. I think there was a couple times where we had to take it down by like one, but for the most part, it was just, it's just been a linear up for Sarah in terms of basal insulin, which, you know, makes me think that we never really went through a honeymoon period or anything like that. But yeah, I, I definitely, I remember it diagnosis just being so confused about why do we need these two types of insulin, you know? And once I got this book again, like you said, it's kind of earth shattering and started reading and realizing like, oh, the liver, the liver's why we need VA insulin. Like the liver's always dumping out glucose and you have to have your basal running in the background to combat that Even if you're not gonna eat anything. Right.

Shannan: 19:32

you guys switched long acting didn't you?

Katie: 19:34

Well, we, yeah, we switched just because the Besla was burning, like when Sarah would actually get her Basaglar at night, it'd be like, it burns mommy. It burns. So I just brought it up to the doctor and she was like, well, we can try something else. And that's when they put us on SBA, which was just the best, I mean, CEVA was, is just an amazing long acting insulin. And it just did. I felt like it helped us so much to hold her numbers steady, especially at night, which is a major bonus. And I, any, anybody that's newly diagnosed that I talk to, I'm like, look, I know you don't know anything about all this stuff right now, but like, if you were, your insurance will cover Truva I would try to get on that long acting insulin. And I've had multiple, multiple people tell me the exact same thing that once they got on Truva things just kind of leveled out so much smoother and better for them. Yeah. All right. We're gonna jump into some math, everybody. It's gonna be super fun. We're gonna, we're gonna keep it to a minimum though, just because I know it's hard to listen to math, but we're gonna start with people who are MDI or multiple daily injections. So, you know, this is how most of us start out is doing shots. Hold on one sec. I gotta text Sarah and tell her to eat some Skittles.

Shannan: 20:40

I will also inject here while you're checking your kid that I think one of the most important things, like when I, finally found this book and got to this chapter, the one of the opening lines says, make one adjustment at a time, evaluate that result. And then use it for a time being before moving on. I think that was such wisdom. Because as I said, just a second ago, I would make an adjustment each night and that was confusing me. That was, that was changing everything from one day to the next and. I know you and I joke that, Hey, it could be a random Tuesday that bottoms out. Yes. There's a lot of variables that will affect your day to day diabetes management. I loved how, when I did get to this chapter, that that was the, I mean, I think it's like one of the first two or three sentences, make one adjustment at a time, reflect on that, look at it. And that's when I decided to keep that log. I don't do it now. I didn't do it for six months. You know, I did it for probably a month, month and a half. But it was so important for me to see yeah, she, I used more bolus, you know, that following day, what I pulled back from basil, that doesn't make much sense. And like you said, I didn't understand the liver and I didn't understand the other, you know, cheese takes 140 hours to digest and pineapple takes one, you know, I didn't understand all of those things. And that's why I love when you say on the podcast, like. One bite of the elephant at a time. Like it's not, everything is overwhelming right now. You're going to make it it's okay. And, and that was that I just loved that part of this chapter. And finally, when I got to it, I was like, oh, okay. And then yes, I saw all the math and close the book and put, teach.

Katie: 22:36

No, I can't do math. Heavens. No. All right. Let's let's jump back in. Sorry everybody, you know, those lows, they gotta, you gotta stop and handle those. She they're like out Galvan around the town with her dad. So anyway, she got the text. She did, she did text back and say, okay. Alright. So if you are on injections if to determine your initial basal insulin dose, You kind of need to estimate like the total daily insulin that you're getting first, like the total daily requirements and you know, doing that is a little bit more predictable when you have type one, as opposed to type two. The book talks about that a little bit, but we're, we're not really gonna dive into anything about type two, just because we, this is a podcast for, parents and caregivers of T one DS. But there is gonna be a little math. You're gonna have to convert your kids' weight into kilograms. So to go from pounds to kilograms, you have to multiply by 0.454. Okay, so just keep that in mind. So basal insulin typically accounts for 40 to 50% of your total daily insulin needs. There's an awesome table, table six two in the book that really breaks this down more. I've said it before, but if you like, don't just listen to Shannon and I, and take our word for it. Like, you're definitely gonna wanna get a copy of this book so you can see all the awesome tables that like break this stuff down for you. They're very straightforward and, and pretty easy to read, I'd say. So your basal insulin, like I said, is like 40 to 60% of your total daily needs your bolus or mealtime insulin, usually accounts for 50 to 60% of your total daily insulin needs. Interestingly enough, basal needs are typically greater in those following a low carb diet. Which I, that surprised me when I read that. And then just in general, basal needs tend to go down as we pass from middle age to. Older age. So let's see if we were gonna determine total insulin needs. Let's see. Hold on. I'm gonna go to table six, two in the book while we're talking.

Shannan: 24:37

Delaney is actually probably that example. At this moment she was not at diagnosis. She had lost so much weight and because of my surgery, I suppose I was just out like a light, but that table actually is kind of her right now. She's not in the book. It uses that reference of that young man and she is 101 pounds right now. He's 105. So she's very close to what that table describes

Katie: 25:05

Mm.

Shannan: 25:06

as an adolescent. Don't talk to me about that.

Katie: 25:10

I know I'm like, I'm like the chart makes you pick, is your kid a young child or an adolescent? And I'm like, I don't know. What, what, what, what age do you turn into an adolescent? And apparently it's 10 years old. So Sarah is an adolescent on this point in time. And so is Delaney. And I'm sorry, we're on table six one right now, which is on page 1 55, but to get total daily insulin requirements to get kind of an estimate for Sarah, like you would. Multiply these factors in the chart by her pounds and kilograms to get a range. So for Sarah who's 70 pounds in kilograms, that's 31 point 78. I chose that she's moderately active, which that was kind of a hard choice choice for me. It kind of depends on the day as to whether or not she's, you know, moderately active or very active, but I just kinda looked at the overall picture and chose moderately active. So for her her total daily insulin needs, it's a pretty big range. It would be somewhere between 24 and 47. Which I looked it up. I pulled up her like most recent data and she's actually somewhere between 35 units to 40 units in total insulin needs that's basil plus bolus. So that actually falls in the range that this chart calculates for us. And then he goes one step further. And this now we're moving over to table 6.62, but to get basil, which again would be like 40 to 50% of that. You could do it one ways you could just take. 50% of what your total need would be, which for Sarah, that would be a range of 12 to about 24 in basal insulin. Which when we were on MDI towards the end, she was close to 12 units of Truva. And then if you look at the chart it's and you calculated it out, it's pretty much similar to what it would be if you just took 50%. It's like between 10 and 22 units of basal insulin. So I, I did the calculations in the chart, it lined up with what Sarah's getting right now based on her weight and her level of activity. So did you, you don't, you don't need to walk us through all the math, but did you what did you find for Delaney? Like when you calculated it out and then looked at what she actually does need, did it line up?

Shannan: 27:17

so it didn't sure. But I have a reason for that. We were in this clinical trial and the drug actually kind of protects some of the beta cells that at diagnosis you may or may not have, we had to go through a qualification period and everything, and she did qualify because she was still making some of them. And it's a blind study. So you don't know if you're going to get the drug or not, but she is still producing them. And so the ho at the end of the study, you will find out whether you did or did not, but she had all of the you know, kind of signs. Signals that she did receive the drug. And so I do believe that that has kind of helped protect what her body is making. And so sometimes we you know, calculate very accurately and, and I have thought like, well, this doesn't have cheese in it, so you're gonna be fine. Or this does, and we're gonna have to give another, you know bolus later and, and whatever. So let's see how it goes or whatever. But it was, it was almost less than 50% of what you just said for Delaney, which is wild because I know people don't know our children, but Delaney is a head taller than Sarah. And

Katie: 28:31

what like 30 or 40 pounds heavier.

Shannan: 28:33

yeah, I mean, it would definitely, it. In my head, it would make more sense for us to be even a little bit higher than you just for size. Right. But such is not the case. I know will one day be there, so I'm not it's not like a, for kind of an impact that they think that this drug might have on her body. But what she uses currently is anywhere for basil anyways. Is anywhere shockingly between three units a day. And I think the highest I look back on clarity as well. And I think the highest we were on was like 10.7. So it's, it's minimal, which is crazy. I also think because of that and, and you and I have shared this outside of this, but I think it fluctuates a lot more for us because her pancreas is like, let me help you a little bit. Let me give you some, some assistance, which I'm appreciative of. Unless it's 10 30 at night. I don't want it to work. I just wanna sleep.

Katie: 29:32

Right. I don't need this party right now. Pancreas, you can simmer down.

Shannan: 29:36

Yeah. Come in at the cupcake part. Don't come in now.

Katie: 29:39

yeah, that's wild because right now I, I, I mentioned earlier that when we were on MDI, she was like, towards the end, before we got on a pump, she was on like 12 units of basal. And now looking at her total basal needs on the P on the pump. It's higher. It's 14 to 16. That's the range depending on the day. So yeah, that's wild to me that Delaney's at like four or five on a, on most days. Yeah, it is crazy

Shannan: 30:03

Wow.

Katie: 30:04

insane. Okay. So.

Shannan: 30:06

of, I will say all of the calculations, however, are still accurate. When, so when I'm in a time that I'm confused about something, or it seems like everything is kind of shifting I will do the calculations and they're correct. And I have to rely on the calculations. I do. I know that they're accurate. Math is math is math. Everybody will tell you that. And so. You know, I think, I think that property that the doctors use is effective, but I think the caveat is again what he said at the very beginning, which is adjust it one step at a time and then reevaluate it when you need to reevaluate it next.

Katie: 30:48

absolutely. We'll talk a little bit more about that later. But fi so, okay. You've kind of figured out you've done a rough estimate of how much basal insulin your kid might need. Of course your endocrinologist is gonna help guide you in kind of deciding where in the range. You're gonna start that some people might wanna start you on the lower end. Some people might wanna start you in the higher end or in the middle. That just depends on what you guys decide with the doctor. But if you need to fine tune, just like, I mean, just like Shannon said, I would venture to say that almost a hundred percent of people that leave the hospital with one basal dose are gonna end up being on another very shortly. And then you're gonna have to make adjust adjustments really for the rest of, of your, their life. It just never ends. So you definitely need to know how to fine tune your basal insulin needs. So first, we're gonna talk about how to do that. It's called a basal test, and we're gonna talk about how to do that if you are MDI or shots. Okay. And then later in the episode, we'll talk about how to do that. If you're on a pump So the main goal is to find the basal insulin dose that keeps blood sugars steady while you sleep. And there, of course there's a range. It's like a 30 point range. So up or down is fine, 30 points, but anything more than that, or, you know, is, is changes, need to be made. So. You know, this is something that when we left the hospital, like everybody was telling us, you might have to give her a snack at bedtime to hold her steady throughout the night. And after a couple weeks of doing that of, you know, here's some peanut butter crackers before you go to bed or have some chocolate milk. I was like, are we really gonna have to have her eat a snack every single night for the rest of her life before she goes to bed in order to keep her blood sugars steady? Because we were seeing this giant drop, you know, she'd start off at like, I don't know, somewhere between one 50 and 200. And then by 3:00 AM, she's at like 60, 70 or 65. And I'm like, I guess we gonna need to give her a bigger snack. You know, that's kind of what we thought initially. And then finally, I don't even remember if I figured it out myself or if I asked the endocrinologist, but it's like, you know what, maybe instead of feeding her more food, I should just take her insulin insulin dose down. So it's not. Dropping her so much in the middle of the night. And then we could all get a little bit more sleep. So I started doing that. I think I just did one, you know, unit at a time. So if we were at eight, I took her down to seven and then you know, so on and so forth until we got to a level of, and you just kind of have to be brave and put your kid to bed without giving them a snack at first and see what happens. So we started doing that and realized, oh, she, she stayed a little steadier tonight, but she still dropped and we had to treat a low. So let's take it down even one more the next night until eventually it's like, oh my gosh, she didn't even have to eat a snack in this line is like pretty straight, not perfectly straight, but it's pretty straight and we're sleeping at night. So for everybody out there, that's listening who is still feeding their kid a snack before they go to bed. You don't have to do that. you do

Shannan: 33:41

and my kid, that was, that was a point of hate for her. I don't really want, I mean, I don't use that word lightly, but she dreaded getting ready for bed because we had this great. She's always been a great sleeper. Thank you, Jesus, for that. And this obviously rocked our world. We were not getting sleep right after diagnosis. And so it was a new routine that we were having to put in. She would eat dinner. We eat generally somewhere between five and six. And then very shortly there, she goes to. Like I said, I'm a teacher, so I'm up by, you know, five 30 or six getting her up around 6, 15 30. And she, so she's in bed by seven 30 and not asleep by then. But you know, still young, she's not in a high school, so don't send me hate mail, but she hated that she was like, no, I don't wanna have a snack. I'm not even hungry. And then I was like, okay, well you can have a cheese stick. She was like, I don't want a cheese stick. I don't want anything. It just became this like, Ugh, no. And I'm the same way. I don't wanna eat something after I've eaten, you know, dinner two hours later have another snack. I mean, if I'm up five hours later sure. But not two hours. And so. But they did, they told us like, give her a snack. They suggested milk. We did milk. We did are not a milk drinking family. And so she hated that right off the bat and had, I think had it twice and it spiked her a lot. And so, like you said, we had the same thing shooting straight up and then coming straight down. So I, I don't know when we stopped it, but I do know that very quickly, she, she would go into tears. That would be an anxiety point of all of this. And I was not in the mood to add anything else with involved in tears. I don't do well with tears anyway, so I didn't wanna add anything else.

Katie: 35:38

hear ya. I hear ya. Well, I'm glad we both figured it out and I'm hoping some light bulbs are going off for some listeners out there. So again, if you're watching the CGM graph at night then, and you are rising or falling more than 30 points something needs to change. You either need to take your basal insulin up. If, you know, if you're rising more than 30 points or you need to take your insulin down, if you're dropping more than 30 points, but I wanna talk us specifically about. How to these are the steps to do basal testing on injections. Okay. These are on page 1 58 of the book. I'm just gonna read through'em. So get ready to listen to my voice for a hot second, so, you know, your day's over it's the evening you take your usual dose of long acting, or if you take yours in the morning, you've already done that. You, you eat dinner. Okay. So, and you take your usual dose of wrapped, rapid acting insulin for your dinner meal. You wanna choose something that's fairly healthy. And then know when the, when the test starts which is about four hours after you've eaten your last meal and taken your last bolus. That's when the test starts because you don't really want any or very little food digesting, and you don't want any rapid act in insulin, still working in the system. So you bolus for dinner, you eat dinner. And then you wait four hours and at that four hour, mark is the start of your basal test. So no more calories or bolus insulin after dinner. That's one of the rules. So stick to water and diet sodas, but be careful about caffeine because caffeine will raise your blood sugar. So you probably wanna avoid that. I just wanna make a point here. No more calories also means like, not even pepperoni or cheese sticks or anything that's carb free because protein in the absence of carbs will also raise your blood sugar. So the book says if you normally exercise after dinner, it's okay to do that, but keep it light and moderate. For kids, I would say it's probably best to do a basal test on a night that they don't have like a really rigorous sports practice. So like a rainy day would be a good, a good choice or a day off. Of course you wanna use your CGM graph to evaluate the data. And if you have a CGM that you have to calibrate, you wanna do that within four hours after eating dinner and then try not to calibrate it again until the morning. I have a rule that I calibrate my CGM as little as humanly possible. Every time I calibrate the thing it seems to mess up, but that's just me. If you don't use a CGM and this is very important, you wanna test your blood sugar before bed. You want, you have to wake up in the middle of the night and test it also. And we'll talk about why that's important in a minute. But, and then you also wanna test your blood sugar first thing in the morning. Let's see you stop the basal test. If your blood sugar drops below 80 and you eat a snack and then you're gonna try it again. Another night you stop the basal test. If your blood sugar is over 2 hours after dinner, or at any point during the night. So you, if, if it's over two 50, you give a correction dose and you're gonna try again another night. Okay. It's okay. You got your whole life to try to figure this thing out. So just cancel it and try another night. Here's a thing that is worth chewing on if your numbers are consistently high or low at bedtime that keep you from doing the basal tests. Like if you have to keep canceling because of lows or highs, then that probably means you need to make some changes to maybe the food choices you're eating at dinner before a basal test or tweaking your insulin to carb ratios. So think about that. Let's see Shannon has already mentioned this a few times, but if you determine that changes need to be made to your basal insulin, so change things in small amounts, one bite at a time. So the author, Gary suggests you just start with just changing it by 10%, either up or down, and then test it another night to see if you might need to change it. Another 10% so Shannon, what do you think a good meal to eat before a basal test would be.

Shannan: 39:27

I definitely think that this can be different for each kid and dependent upon age. But for us, whenever we have done it, it has been like, you know, a grilled or baked piece of chicken. Butter doesn't really affect her, but any oils that we use. So like if I put olive oil and like pan and kind of stick it in the oven for a little bit to, to cook that is worse than my husband, just putting stuff on the grill and flipping it over. So our kind of go-to is carrots and potatoes and like the little baby new potatoes and grilled chicken. And again, that doesn't work for everybody. I think that everybody has to. Look at the patterns. And you know, when some, if somebody is three years old in doing this, I think that's, astronom astronomically different than somebody who is, you know, a 15 year old boy who plays football like you must have, and good luck with you cuz your kids are two boys that love to play baseball. They're burning a million calories a day. So when they have a double header at, you know, ninth grade, good luck, I don't, I'll send you some money so you can afford the the food bill. But I think something that is, is lower carb, easily digested something that's gonna kind of be out of the system. I think it would be obviously a tear, anything with cheese. I am, my kid takes forever to digest cheese. And then honestly, any of the grain type breads, which. Formally, we would eat a lot of that was that is, from sprout it's healthier for you. Because white is like just sugar at this point when you put, put it in the toaster. But it's harder for the body to digest. And, and any kind of grain bread is like an eight, seven to eight hour digestion for her. And so I think before you actually do a basal test, you've got to unfortunately understand even a little bit, cuz I'm still learning. I'm I'm still watching you know, Bri cheese is much different from Parmesan cheese graded on top of, you know, an Italian dish. So annoying. Isn't it? Can we just.

Katie: 41:35

it really is

Shannan: 41:37

don't need to be like, like basal testing has gone really well for us. But that is, that's just annoying. Isn't it to have to think about what I'm gonna feed my child before I do this test. That's, you know? Okay, well, we'll, we'll watch it. And if you have any cheese and it's gonna mess it up for us, for us, let me always say that it's different for us, but.

Katie: 42:00

Yeah, I, yeah, no, I, grilled chicken is definitely our go-to as well. We usually do like Sarah loves broccoli, which I'm extremely grateful for. So we usually do like grilled chicken broccoli and maybe some rice or a roll. That's easy for me to carb count like that comes out of the package and tells me how many carbs are in it. So I'm not like you definitely don't wanna go out to a restaurant before a basil test. I would avoid like really high fatty foods because fat can rec havoc on your, it can make you insulin resistant and cause you know, blood sugars to, to go up. So you know, no pizza, no fettuccini Alfredo, no takeout food. Just try to eat a home cooked meal. That's fairly healthy. Okay. I wanna talk about why you need to do that finger stick in the middle of the night, if you are not on a CGM. And it's because, and Shannon and I both looked up on Google, how to pronounce this word properly, but it's the smoke. So some Moogy.

Shannan: 42:54

So Mo yes, some Mogi.

Katie: 42:57

Okay. The Mogi it is spelled S O M O G Y I, and it's called the Sammo phenomenon. So what the Sammo phenomenon is is that, so if you're starting like, say you're starting, you know, a little higher, let's just start at 200. If it, if it drops at night and typically it's below 70 milligrams per deciliter, it will actually cause your body, your body kind of goes into like, Almost like a stress response because your blood sugar's getting low. So it causes your body to release some, some stress hormones. And that those hormones will raise your blood sugar because those hormones tell the liver to dump out more glucose into your bloodstream. So. If you don't do that middle of the night finger prick, like let's say you start at 200 and then you wake up, you know, then you drop below 70 and then you wake up at two 20. You're gonna think like, oh man, I even went up a little bit. I need to, you know, take my basal rate down which is only gonna make it worse. Right. Because then you're gonna drop even lower and then probably have an even bigger rebound high after that. So gone undetected, the Somo phenomenon can lead to incorrect basal dosing decisions. So I think that's so important to know. And I've seen this a few times on our CGM, have you guys, I've definitely experienced the rebound high. Like if Sarah goes low and then she'll rebound up to, you know, we'll treat the low and I, I have a number in mind to where I think she's gonna land. But then that re those. Yep. Those hormones will cause her to go even higher than that. It's called a rebound high. Have you got, you've got, you should say Shannon's showing me her graph. So clearly you've experienced

Shannan: 44:29

Last night. And it's, what's so weird is that it doesn't, the liver is so helpful. Thank you, Louie. The liver. I don't know what should we name him? Right. Thank you, Louie. The liver, we appreciate you. But sometimes it does. And sometimes it doesn't. I find that if she's sort of going low last night from, from too much insulin. And so we are on a pump now and I'm so thankful for it. So we suspended insulin for a minute, gave her a little snack. And we were not Baso testing last night. So I gave her a snack and she kind of, and this was already like when she was in bed, but she's like, mom, mom, I feel low. And she is like too lazy at that point to get up and go get her devices they're away from her. So she can't get them in the middle of the night. So I look and whatever anyways. So I, I gave her what I thought was a very appropriate amount. She started coming up, I turned the insulin back on everything was going fine. She Rose A. Little bit. And then I closed my eyes. And what everybody doesn't know is I've had a migraine for two days. And so I just went to bed and I got an alert alert a couple hours later that she was going high again. And I look at it and I was like, that's so weird. She been high twice. What happened? So she went high. She still was experiencing low from the insulin. So what I gave her, popped her up. The insulin still brought her back down and then the liver was like, oh no, let me help you now. And then she went hot way high, much higher than she should have. And finally, thankfully all the good insulin worked itself out and maybe it was better as asleep cuz I've probably overtreated or done something wrong anyways. But yes. And I also think that the Dawn phenomenon also for a lot of people everywhere, but I think especially in adolescence is insane. I cannot, breakfast is such a treat for us.

Katie: 46:25

Yeah. Dawn phenomenon for those that don't know is like there's for a lot of, especially younger, you know, younger people that in the morning, as soon as you wake up your body releases. Or it actually starts a little earlier than you wake up. I think it starts at like three or 4:00 AM for most people that experience it, but you'll see like a steep rise in blood sugars because of all the growth and stress hormones that the body's putting out that is called the Dawn phenomenon. I think I've also heard it called feet to the feet to floor phenomenon, something like that.

Shannan: 46:55

It just takes more her, her, when we have done basal testing, that is I, I can drop her between like 12 and three in the middle of the night. Because she, she automatically is kind of lower and that's she has some dips, but man, once four o'clock hits, it's like four to eight and her body just loves to drink it. So anyways, but yes, she, she starts rising at that point because of let's say it again. So moggy.

Katie: 47:26

Is

Shannan: 47:27

No, I messed it up.

Katie: 47:31

I dunno,

Shannan: 47:32

that's.

Katie: 47:33

Google's lying to us. Google's probably like, I've never heard this word either. I don't know how to say it okay. We are, this is about the halfway point. Well, not the halfway point, cuz we've been chit chatting, but we are gonna transition to insulin pumps now. So everything we just talked about was for MDI and I, I just wanna say it one more time. You've done a basal test. Good job for you. We're so proud of you. The way you know, that you need to make changes is if it rises or falls more than 30 points. So if you go to bed at a hundred and you know, it rises to one 30 and then kind of comes back down and floats in that range, you're actually fine. You don't need to make any changes. Just if it goes, rises or falls more than. 30 points. So it's just not gonna be perfect. Unfortunately there's no basal insulin dose. That's gonna hold you steady without any change at any point in time. Hey guys, it's Katie. And before we start the show, I just wanna take a second to tell you about buy me a coffee, buy me a coffee is a no strings attached way to support this podcast. Every single donation given whether it's a one time gift or a monthly membership. Goes to making this podcast come to life each and every week, it helps fun things like the physical and virtual equipment needed to produce a podcast, such as a website. I use pod page for that, a recording platform. I use squad for that, a podcast hosting platform. I use buzz sprout and editing software. I use a script. I truly appreciate support from listeners like you. So from the very bottom of my insulin cartridge, if you're feeling generous and you wanna check it out. Thank you. All right. Now let's get back to the show and my conversation with Shannon. All right. So we're moving on to pump users finding out, figuring out what your initial basal doses for pump users. So the thing with pumps is that you don't have that long acting insulin anymore. You no longer take an injected form of basal insulin. You, you use what is called a basal rate which is tiny pulses of rapid acting insulin. So like typically it's Novalog or Humalog, some people use FIAs P so it's tiny pulses of that insulin every few minutes, all day long. And that is. Called a basal rate. The beauty about pumps is that you can set different basal rates for different times of days. So if you notice your kid needs less insulin at night, you can lower the basal rate. And if they need more insulin during the day, you can take it up. I mean, conceivably there's 24 hours in a day, you could have 24 different basal rates in your pump. Absolutely do not recommend that. That will drive you insane and stress you out. The author has some recommendations later in the book that we'll talk about about, what's kind of like reasonable for a basal rate program in your pump. But, but this is interesting. AB most pump users require about 20% less basal insulin than those who are taking an injected basal insulin. And that's just because that rapid acted insulin just works a little bit quicker. So, and it gives absorbed faster. So typically your basal needs go down. When you get on a pump a little, at least initially. All right. So when you start out on a pump, author recommends just starting with one flat basal rate. I know that's what our endocrinologist recommended for us. When we started on a pump, we just, the rate was the same for the whole 24 hours. I think it was like 0.3 when we first started somewhere around there. But if you, I don't know if you don't have the guidance of your endocrinologist, which I don't know anybody that wouldn't, but if you're trying to kind of figure out or double check your endocrinologist, maybe what the initial basal rate would be. You wanna add up all the units of. Insulin. So that's basal plus bolus. Okay. So your total insulin that you take in a day, you know, do it over a couple of days, so you can get an average and then you wanna take half of that total. Okay. And then you multiply by 0.8 to take away the 20%, and then you divide by 24 because there's 24 hours in a day. And this will give you a very rough approximation of kind of what you or your kid might need, but it's a really good place to start. So for example, like if your total basal plus bolus was 40 units a day you would divide that by two, which would be 20. You would multiply it by 0.8 to take away the 20%, which would be 16. And then you would divide 16 by 24. So that would give you a basal rate of 0.65 units per hour. So that's what you would start out. Um, You can also use a body weight formula. So anybody who's going just straight to an insulin pump without ever being on injections, which I don't know anybody that's ever done that, but maybe it happens, but you actually take your weight in pounds divide by 10 and then divide by 24. So for Sarah she's 70 pounds divided by 10 would be seven divided by 24 would be 0.30 would be her initial basal rate, which is what they started her on in the hospital. Of course she weighed a lot less back then, but whatever, anyway so again, just like with injections, when you're on a pump, your basal insulin is gonna have to be tweaked. It's gonna have to be fine tuned, even if you're on a hybrid closed loop system. So even if you're on like a tandem pump with control IQ, or you're one of the lucky ones that's been trying out the new Omnipod five system with their you know, hybrid closed loop system, or if you're doing the DIY loop program, which we actually just switched to about a week ago, you are still going to have to basal test and find out what your settings need to be to kind of fine tune it and tweak it. I'm just gonna, I'm not gonna talk long about this. Hold on. I'm a little congested today. Sorry. I'm not gonna talk long about this, but I will tell you that we have you know, you think you, you think you have it all set up. And when we were on the Omnipod pump using the regular PDM to control it, we had these settings that were working really well for us. And now we've moved over to DIY loop and surprise, surprise. Everything has changed. And there's many reasons for that, which I'm not gonna explain right now, cuz it would require about three more episodes to talk about, but it's like, it's just a never ending game of testing and adjusting retesting and adjusting some more. Anyway, but again, just like on a pump, you know, just like with injections on a pump, your basal insulin should match the glucose output from your liver and it should hold your, your levels steady in the absence of food Boless insulin. And then also in the absence of exercising, all right, we're gonna jump into how to do basal testing when you're on an insulin pump. And then I don't know about you, but basal testing is still very intimidating to me. And it became a lot more intimidating to me when we got on a pump because with injections, you know, unless you split your insulin dose, you're really just having to figure out one number. What's that Nu one number need to be for my long acting dose, but with a pump, you know, it's like, you gotta look at the whole day and figure out hour by hour, what your kid needs and if it's working for them that's, that has been the hardest part of switch. From injections to a pump for us is figuring out these basal rates.

Shannan: 54:36

I think the same, but I also think it's empowering because you also then have the capability to, to be more precise. I. Like I said, I love data. And it gives you so much more information. My kid needs hardly anything in the middle of the day. I don't know why I can in my head try to come up with a logical explanation, but that would probably be stupid of me to do because then the liver's gonna help me out a little bit and I'm gonna be mad. And then because of, you know, our beta cells being a little bit protected, they'll help out and then I'm wrong. So all I know is that for whatever reason in the middle of the day, she doesn't need much. And. So I gotta gotta back off. So and, and I wasn't able to figure that I thought it was an insulin, a carb ratio when we were NBI. And then when we switched to the pump and I saw, I was every day, temp nasal down, temp, nasal down temp does dam around 10 or 11. So that she didn't drop low before the end of the school day. like I said, I'm not the most intelligent person. I teach reading, not math here. Okay. But it finally dawned on me like, oh wait, I could, that's when I finally went to two what are they called? Segments? On the P and, and that was my first change. So, like I had a segment that was from like, I wanna say it was like three 30 or four all the way through the next, like 10 30, the next morning. It was one rate. And then the next segment was a different rate

Katie: 56:10

Okay. I gotcha. So that's when you transition from just having one flat rate to like changing it a little bit. I gotcha.

Shannan: 56:16

But I did not basal test that. I just went off the fact that I knew she was going low every day and what she was. And I asked her several times, like, can you just have a low card meal for me at lunch a couple of days to let me see this, and then you go back, you can have ravioli the next week if that's what you want. I don't care. But I have to see if you're going low because of the basal or, or what you're eating. And she is so kind. So she said, yes. And I saw it was the basal pulling her back down. The, the insulin carb was fine. And so A not official basal test. So, but that is hard like you and I have said like, it's real easy to do at bedtime, but what are you gonna do in the middle of the day when all the friends are like, let's,

Katie: 56:58

Yeah.

Shannan: 56:59

we're in the middle of a basal test.

Katie: 57:02

Sorry guys. You know what? I should make a shirt that says, sorry, can't basal testing.

Shannan: 57:07

That's awesome. I'll buy it.

Katie: 57:08

Okay.

Shannan: 57:09

You can, your Amazon site. That's fine.

Katie: 57:12

I will. I'm gonna, I'm totally doing it. Okay. Yeah. I, I agree. Basal testing is it's definitely easy at night. I mean, you could turn every night into a basal test if you wanted to eat, you know, a healthier meal every night of obviously we don't do that. We go out to eat and we enjoy ourselves sometimes. But anyway, you know, nighttime nail those nighttime numbers down first and then just move throughout the day. Like, and this, this is covered a little later in the chapter, but you definitely wanna start with nighttime, like, right. We all need sleep. You wanna get that right. Make sure those levels. Yep. And then go from there. So, you know, go from the morning segment, you know, from like 7:00 AM to noon. And then maybe from once you can kind of get those levels, right. Go from noon to five in the evening. And then, you know, maybe even five to 10 and then 10 to seven would be like your nighttime anyway. So, but anyway, it's a good place to start is definitely those nighttime and afternoon is so hard. It's so

Shannan: 58:04

Well, I told her I don't know, a couple weeks ago that I wanted to do an afternoon basal testing sometime this summer, I'm not gonna try to do it, you know, we're, we're. Recording this towards the end of the school year. And I don't want to do it towards the end of the school year for a million reasons, myself included. But in the summertime to do like an afternoon one, I said, you could sleep in and then we can have a delicious breakfast. You can have pancakes, you can have what, you know, we'll make waffles, whatever you want. And then after about two o'clock, we're not gonna eat anything, but I'll let you stay up late. And then whatever we want, we can have an ice cream sundae. We can have a banana split. We can. So two is all about that. So how to know what she'll pick.

Katie: 58:49

can we come over that day? And maybe we could just do like a group basal test

Shannan: 58:53

Yes. And like, it'll be a good distraction. Like I told her, I was like, we'll think of games that we could play that, you know, are not gonna be high activity. Like we can, you know, walk Lulu that's, you know, I'm just walking the dog. I have a, we have a very small dog. It's not like. Henry who's, a large beast. We're gonna chase after him. Mine's not going to pull us everywhere. You know, she loves UNO and UNO flip and we have another one. I can't remember the name of, but just other things. And then I told her, I was like, we can pick a movie. And so, you know, I think that's a good way, especially for younger kids to get them not only involved in it so that they can see it. And hopefully they're, you know, they're, you're definitely paying attention more to it than they are, but hopefully they're also gaining some knowledge. I mean, Delaney and I, you and Sarah, they, we have great relationships with our kids. And so hopefully I'm presenting it in, in a positive way so that she is able to see, you know, this isn't, I'm not doing this begrudgingly. There's no like, you know, type of a feeling, I don't know a word better. So there's some

Katie: 59:55

That

Shannan: 59:58

It's Onia for all those listening, the reading teacher can come out and give a lesson on it, but that, you know, like that has got to, if my mom ever told me when I was 10 years old, that we're not gonna eat from two to eight o'clock, I would be like, what? You're crazy, what? I'm not eating dinner that doesn't even make sense.

Katie: 1:00:17

I would've been the same way. I love, I always have always loved food. I, to this day, I still love food. I can count on half of one hand, the number of times I've fasted in my life. So yeah, admittedly, the idea of basal testing is very um, I don't love it. It's intimidating. But I, I do think it's important though. And I'll talk about some kind of ways that we can Sarah and I kind of do some modified vasal testing here and there to kind of tweak things, but all right, let's jump in how to do this for an on an insulin pump. This is a long list. Again, strap, buckle up, buttercup strap in for the ride. There's lots of nose and don't on this list. So go back and rewind if you need to listen to it again, but again, no food should be digesting. You wanna wait four hours after your last bolus and meal or snack and then observe what happens. The meal or snack before basal testing again should be low and fat fairly on the healthy side. You don't wanna consume any calories again, during the basal test, that includes protein. Unless of course your blood sugar drops below 80. That's one of the rules of the test. You can have water or diet beverages, but you want to avoid caffeine since it can increase your blood glucose. You also don't wanna consume alcohol, which for our kids, hopefully that's not an issue but for all the adults listening, don't drink alcohol immediately before or during the test. Because alcohol and I did a whole episode on this, but alcohol can reduce the liver's normal glucose secretion. So

Shannan: 1:01:42

fascinating to listen to. I listened to it twice. It was so

Katie: 1:01:47

it, it was definitely, it's definitely fascinating. It's crazy. Happens to our body when we drink alcohol. But, and then also of course, most alcohol has carbs anyway. So anyway, just don't drink alcohol people before you do a basal test. You don't wanna have any bolus insulin working during the basal test. So again, you need to wait four hours since your last bolus of rapid acting insulin, or if you are on regular insulin, which I don't know any kid that is, but if you are, you need to wait six hours, cuz regular insulin takes a little longer to get outta the system. If you use an extended bolus at your last meal, so if you used your pump and you did an extended bolus with it, you actually have to wait four hours after the completion of the extended bolus delivery. So keep that in mind, if you extended the bolus for three hours, then that means you're gonna have to wait seven hours to start the basal test. Okay. So I would recommend not doing that. Let's see, do not perform the test. If you had a low blood sugar level within the past within the previous four hours, because we just talked about rebound highs and how your body dumps out hormones to cause you know, to increase blood sugar levels. So just don't do it. Just cancel the test for that day. If you have a low do not bolus during the test, unless your blood glucose rises above 250, do not perform the test. If you're sick. Okay. Like this goes for injections as well. Like don't perform the test. If you're sick, do not run the test. If you're taking a steroid medication in because steroid medications can cause blood sugar levels to go up. Unless of course there's an exception. You are taking those steroid medications all the time. Like if that's part of your normal routine anyway, then you can go ahead and basal test while you're taking those meds. You wanna avoid testing just prior to, or at the start of your menstrual cycle. You want to allow basal insulin to be delivered at its normal rate. So don't try to change things right before you do a basal test. Don't place the pump into suspend mode or stop insulin just before or during the test. Do not disconnect the pump just before or during the test, do not run a temporary basal rate just before or during the test. Chapter eight of the book talks about how to use temporary basal rates appropriately, but don't do it before you basal test do not change your infusion set or your pump site just before or during a test. If your pump has a hybrid or closed loop capability, then you want to turn off, you wanna turn the, that off four hours before starting a basal test until the test is complete. And the reason behind that is because those systems automatically adjust basal rates. Accordingly, whether your number is high or low and you don't want that happening, right? So you wanna turn it off four hours before. Again, you can perform light or moderate exercise soon after your pre-test meal or snack, but only if you normally do this. So if you've never run a 5k in your life, basal testing day is not the day to go out and try to run a 5k. Okay. It's not the day to try to get healthy people. We just need to know what the right basal rates need to be. And then you just wanna perform your usual daily activities. So, you know, like you said, go for a gentle walk with your dog, pick up around the house, whatever you would normally be doing that day. That's not out of the ordinary. You can continue on as, as you normally would. Again, you wanna start by testing basal rates at night. It's the easiest to do because you're fasting anyway. And everybody needs basal sleep and then, then move to the morning segment the afternoon, and then the evening. Okay, before we jump into uh, the steps to follow which we'll breeze through those pretty quickly. But I, I was just laughing to myself, reading that list when I was making it, cuz like poor women that are on their menstrual cycle. Like there's like two days out of the month that you can do a basal test, basically. It's like, don't do it. If you're sick, don't do it. If you're stressed, don't do it. If you're on your period or right before your period, it's like, okay. So when can we actually do a basal test?

Shannan: 1:05:35

I was attempting to do one earlier in the month and sent my cousin who I just have the greatest respect for, because she just rolls with all the punches and nobody would ever know that she struggles. But she has type one. Obviously she has struggled. So and I was like, okay, help me out real quick. Is it the week before, the week of, or the week after where X and Y and Z happens. And I was asking now, I have apologized with a text ahead. I'm like, I'm so sorry that this is gonna take our, our cousin relationship to the next level. but I just have to know, because is, is what's happening to my daughter now, Dela 10, she has. Started her period yet, but I can a hundred percent see a week during the month where everything changes and I just want to be helpful in looking forward for her sake so that she doesn't, she feels really, really sick and just yuck when she gets kind of much above 200 we keep our settings pretty low. And I am not afraid of the insulin. I'll just catch it at the bottom and she knows that she's okay with it. And so, but at the same time, I don't wanna have to ask her let's basal test to find out what's happening this month, this week. Now I just want to find the pattern so that I can see if it is a pattern and then I can make the change to kind, I mean, that's my job as a mom, I'm to, to intercede for her right now. And hopefully by the time she's 18 and. Tear drop wants to leave my house. I can say, all right, here's a notebook have at it. You know, here's all my notes for the last eight years. If you mind don't tell me

Katie: 1:07:18

Oh my gosh. I know. She's gonna be like, thanks, mom. Roll her eyeballs and probably check'em in the

Shannan: 1:07:25

that I have high expectation that she's gonna open it up. She's gonna read it, implement everything and move on the same way. Come on. Right.

Katie: 1:07:33

trash you're right. You're right. Totally. You're so right. Shannon.

Shannan: 1:07:37

So we'll

Katie: 1:07:37

right.

Shannan: 1:07:38

that morning that she leaves and I'm like crying because she's definitely not gonna do that.

Katie: 1:07:45

Sounds good, but they're gonna figure it out. That's my hope. At least that's what I keep telling

Shannan: 1:07:49

Yes.

Katie: 1:07:50

All right. To start. So to start a basil test on a pump, it's pretty similar then when you're doing injections, but we'll go through the steps really quickly. Again, you wanna check your blood sugar manually or using your CGM. If your blood sugar is over 250, you want to cancel the test and to give a correction for the high blood sugar. If your blood sugar is less than 80, cancel the test, correct. The low. If your blood sugar is just right, like Goldilocks in the three bears, you wanna continue with the test. And again, if you're not using a CGM check, your blood sugar manually every two hours. during the day, you know, if it, if it's nighttime, then you can. I would imagine you can just check it again in the middle of the night. So before bed, middle of the night and first thing in the morning but if you're awake, I, he recommends doing it every two hours. So you can run the basal test for longer, longer periods of time. If you can tolerate the extended fast, there's really no limit. If you're fine fasting, you could go all day. If you wanted to you, you can also break it up into smaller segments for younger children, which is definitely what we'll we do here in our house. And I'll talk about that in a little bit. But the same rules apply. So if your blood sugar rises or falls more than 30 points during the basal test, if you are on a pump, then something needs to change. So if it rises more than 30, your basal rate is too low. If it's falls more than 30, your basal rate is too high. So you can adjust, you know, by that 10% rule, 10 to 20%, depending on like the amount of change, you know, if, if it only rises by like, 40 points that's on the low end, right? So you probably wanna start by just changing it like 10% and seeing then, but if it rises like 150 points, then you could probably go a little higher and change it by 20%. But you know, start small. I would absolutely recommend starting small. And of course, talk to your endocrinologist, if you have any you know, worries about any of that of, you know, ideally you would adjust and then retest the next day, if possible, that's hard to do with kids. They, they just get tired and they're over it. And I just hate being the puppeteer all the time, where I'm like controlling what she's eating and stuff. So we don't usually do that. We'll wait a little bit longer and, and then try again, but just continue to do adjust and in small doses and retest until you get reasonably steady, steady results. Let's see Shannon it's confession time. You've talked about it a little bit. Let's let's talk about, I was gonna ask Shannon, do you actually basal tests like this? And I'm gonna answer for myself. I, we, and this is a little sad and I hate to admit it, but we've never done an official, official basal test where we like, okay, this was our last bolus in our last, except for at night, except for at night, we've done plenty of basal tests overnight. Like again, again, I've already, I've already said it, but any night can be a basal test if you've eaten a healthy meal the night before or the, the meal before. so in, during the waking hours, we have never done an official basal test. We do kind of some modified basal tests, which I'll talk about but are, what do you do? I mean, say I know you basal test at night, but during the day, how do you kind of modify it to, so it's not so burdensome and grue, you know, not gruesome, but burdensome and just hard on Delaney.

Shannan: 1:10:58

right. So the first segment that we did was the first thing in the morning for whatever reason several Saturdays in a row, we didn't have to be out and about anywhere. We had things to do just around the house and then stuff in the evening. And so she, I noticed. This one particular Saturday, she woke up and she was just like, can I like just watch TV and just lay in bed and snuggle sure. Go on, have at it. Like, that's what I would wanna do right now, but I'm gonna do laundry. So she laid there and laid there and I kept thinking like, oh, she hasn't asked for food. Okay. Let me pretend that everything is fine. And so I kind of secretly did it on my own. She finally, she was up at like, I don't know, 8, 8 30. And then she didn't even ask for food until lunchtime. And so I knew what my results were from whatever time I wanted to create a segment. I think his book says 7:00 AM to 12 is the next kind of thing to focus on. But I also knew that her lunch, what her lunchtime at school was. And I really wanted to know that time from the time she eats breakfast until she eats lunch. Is that time period? Correct. So I checked that one off my list. And so I said to her, I'm like, you didn't even know this, but you just did an amazing basal test. We got some great results. I'm so proud of you. I like went ahead of myself, like child psychology and was like, okay, let's do that next week. But as soon as you get up, let's have something that's kind. You know, easy on you. And we kind of have those for days that she's like take has a test in the morning or whatever. So like giant spike, giant drop. Let's have that, like as soon as you wake up and then we'll go, you know, through the afternoon, let's do until the end of school. So the segment in my head I'm really looking at is post her lunch at school until kind of the end of the day. I already know at three o'clock, when school is done, her blood sugar, sugar goes double arrow up. I'm so glad I'm done with school. And now my body wants all the things. It's gonna be different for everybody. I know you doesn't Sarah, like start to come down. Like her stress level is higher. And so that keeps her up higher during the day.

Katie: 1:13:15

Yeah. During the school day, she needs more insulin cuz she, for whatever reason, she's just more on edge, I guess, which makes me sad. I mean, it could be other reasons too, but cuz she always seems happy when I pick her up. But yeah, her insulin needs are, are higher during the day

Shannan: 1:13:27

Yeah. So it's just different for everyone. So, but I knew that from, from, you know, not, not scary watching it, but just seeing the trends. And so she, she was like, yeah, let's see. She was like, actually excited about it. And so I just went with it. So we did that next segment. The hardest one right now I CA and I so far have, have, like I said, I have a plan for the summertime where we'll have a big breakfast and again, like, hopefully it's, hopefully it's not pancakes cuz she had that. And if you haven't heard the alarm, we're it like double up right now. So maybe we'll pick something else that she was.

Katie: 1:14:04

when you were, when you were saying that I'm like, oh, we might wanna do like yogurt and

Shannan: 1:14:09

Yeah. The parfaits we'll have the parfaits. Right. But I can't get like a, a solid, like, you know, two o'clock to eight o'clock-ish. Right. Like I can't get that time period yet. And that's okay. Like, I, I love how you always say like have realistic expectations, know that this work is. Every day, this is, this is lifelong. You're always learning. And for me, that exhilarates me because I like to watch that I like to learn about it. But I really wanna find that time of day. That's the worst time of day for us. And I feel defeated in that because I'm constantly chasing the low or chasing the high. And then I'm like, okay, temp basal up 25. Okay. That was not enough. Okay. Do a bolus instead. And then I'm calculating, subtracting what I just gave as the temp basal. And then I just give up and I'm like, whatever So I'm excited for that portion of the day to. Tested. And then I won't feel so bad if I see a day that we've had that just did not go well. I will let least know that the majority of the time I can ch in the other segments of the day, I can change confidently by, by five or 15%, depending on for her the time of the day. And I can know that I can find success. I don't have that time period figured out. And that is I'm excited for it. I can't wait. So

Katie: 1:15:37

That's the hardest time of day for us too, because we are always on the go. I mean, we're always on the go, the boys have baseball. Sarah has dance, we're going to a friend's house. it's always something. And I know that's just an excuse and I do need to make it happen. But anyway, I'm just agreeing with you though. That's also a very challenging time of the day for us too. We do the same thing in the morning on the weekends if she wakes up and she's just not saying anything about wanting breakfast, I just don't mention it. And I see how long we can go before she talks to me about it, about food. And I kind of consider that like a mini basal test of our things right in the morning, I was actually watching it this morning. And like I said, Sarah's doing the DIY loop situation right now. It definitely wasn't an official basal test cuz I did not turn off. Loop before we started, but loop has this interesting thing on this website called night scout. If you set it up where you can see, like, if it, it it'll tell you whether or not the loop is giving your child less or more insulin than what you've told it, she needs. So this morning I'm watching the line and she's starting to go down and I'm seeing that loop is taking, you know, backing off on the basal rate. So it's lowering the basal rate, but she's still going down. So that tells me that her basal rate is definitely too high in the morning. Cause you know, she's still going down and the loop is basically turning off, pulling back. And so I'm like, okay, we need to make some adjustments. So I went in right there and and fixed it. But and then in the, what I do in the afternoon for school is she eats lunch really early at school. She eats lunch at 10 o'clock, so I'll give her just normal lunch, what she would normally eat and.

Shannan: 1:17:10

not lunch. That's breakfast.

Katie: 1:17:12

I know. And so, so that would mean her basal test would officially start at two if we wait four hours. But that's right when she has snack. So those days I'll pack her like a super low carb snack, like maybe some cut up cucumbers and carrots that she or not carrots, cuz those are kind of carby but I've put cucumbers in her lunch. She loves cucumbers. Thank God. Maybe, maybe a cheese stick, which I know that, you know, that can cause things to go awry, but it's a lower carb snack. So I kind of consider that a modified basal test where now, and then she doesn't get home from school until four. So I can kind of do like a two hour basal modified basal test from two to four to kind of see if things are where they need to be. And, and then again in the evening we just haven't even tackled it yet. Cuz. Because we just haven't, but we need to, so maybe over the summer would be a good time when we have less activities going on. I wanna talk about, cuz I know we need to wrap up here soon. We we've both got places we need to be and things we need to do, but so important. We've talked all about how to basal test, how to know when you need to make changes based on what you see during the basal test. But here's a super important question is when do you actually make those changes? And you, like, let's say you're, you're watching and you start to see a drop at like three o'clock in the morning and you, you know, that that's when it starts. You actually don't make the change at three o'clock. You want to make it one or two hours before you start to see that drop. So he recommends an hour for children or for very active or lean adults. And then two hours ahead of time, if for just like kind of mostly normal quote unquote normal adults So that's what we do like this morning, that drop that I was talking about, started around 3:00 AM. She started to go down. So I actually went in already this morning and starting at 2:00 AM. I made a, it was about a 15% adjustment to her basal rate. I took it down

Shannan: 1:19:08

How long did you have to wait before you had to intervene with juice or food or Skittles or whatever you saw it going down, you said around three. So did you, she woke up and you intervened or it went rapidly. It wouldn't be rapidly.

Katie: 1:19:21

no. She went down, she woke up and it was probably another hour and a half before I actually had to intervene. So

Shannan: 1:19:27

I think that's always important too. Is like, how fast is it? Is it a two point drop every hour? Is it a four point drop every five minutes? Because I mean, if you had said like, oh, well, I mean, when she woke up, it was like seven 30 and I've, you know, gave her some juice real quick, the morning, whatever, pull you back up. Because that has also, again, I, I mean, I guess if it's dropping two points an hour, you're not, that's not gonna be within that 30 point differential. So, I think you also have to pay attention to how fast it's dropping too.

Katie: 1:19:59

yeah, I agree. I agree. Yeah. Like what's the rate of change. That's a good point. You might need to, I guess, make the change a little earlier on. If you notice it's falling faster or make a, more of a change you'll, you'll have to play around with it and figure it out. But all right. Last thing I wanna mention. Two, two last things I wanna mention are just a random comment of you never want a basal test the first night or two when you get on a pump. So if you're switching from MDI to pumping dude, definitely don't basal test those first couple of nights because it takes a little bit for that long acting insulin to completely get out of the system. So your results wouldn't be accurate anyway. And then I wanna say too, like earlier in the episode, I kind of joked about there's 24 hours in a day. So conceivably on a pump, you could have 24 different basal rates. But that is not normal. If you have multiple, multiple basal rates running. You're probably making up for something else. That's not right. Like maybe some car ratios or something along those lines. Because the author makes a very big point of a quote unquote normal basal pattern is gonna have one peak. So one time of day where the insulin need is a little higher and then one valley. So a time of day when the insulin need is a little lower and then everything else just kind of follows on one line. Again, you guys go get a copy of the book because he gives you some amazing charts and some amazing graphs. He gives you all sorts of examples for everything we just talked about. He always gives examples to go along with it. So you're gonna wanna get the book to read those examples and look at the graphs and the data. So you can actually see it, you know, on a graph of what he's talking about. So woo Shannon girl. That was my longest episode yet. And I'm glad it was with you because, you know, I love you.

Shannan: 1:21:41

was a lot of information, but I think it is wildly important. And I think that you know, if I haven't figured out the daytime, I can, I can adjust things relatively quickly. Even if I, whether I'm MDI I, or, or pump I can adjust things relatively quickly and. You know, outside of Horman, which require a whole nother episode, but outside of that, you can get ahold of it relatively quickly, you know, two to four hours. And, and you can be back in a sitting position where you feel that it is controlled. Overnight is just another story. I, think every parent would be like, please just get me to a point where I can sleep through the night. I don't even mind waking up at two in the morning to, to check you know, leaving the hospital. They tell you to do that. So my alarm was set. I woke up at two o'clock for good gravy, a long time, longer than I should have three months, four months. And I think I asked you, I was like, so how long did you guys like wake up at two in the morning and you were like, oh, we dropped that real quick. I was like, oh, and I was like, this huge weight lifted off my shoulder, but I still wake up at two in the morning. And now I can, you know, I have all the technology now, so I can look at it real quick on my watch and I can see that she's still fine and, and roll over and go back to sleep. But you know, I think it's so important for you to get a great night's sleep. So I think that is the, the, what I would say to parents or caregivers is find that first, make sure that you get that correct. Because when you're not getting sleep, you're not making sound decisions for anything, whether it's a child with diabetes or whether you're just trying to solve a problem in your marriage, you're outside of lack of sleep. You're not going to make sound decisions about a lot of things.

Katie: 1:23:28

I recently reread one of my favorite fiction novels, which it's a fiction novel, so it's fiction. But the couple, the married couple in the book is like going through a divorce and she's talking with one of her friends and her friend is like, what would you say is the reason why, you know, that led to you guys getting a divorce? And the, the main character says lack of sleep. And I, I just couldn't, it couldn't be more true. Like if you're not sleeping, you just can't possibly function well. And, and, you know, you can go a couple nights if not sleeping well, but it's gonna catch up with you eventually. It's gonna make you sick. In fact, I had, I'm currently getting over a really bad cold that I think was due to lack of sleep because the transition over to this whole loop situation, I was just losing sleep. And and I think it affected my health, honestly. And, and so I, I absolutely agree. Get your basal settings right at night.

Shannan: 1:24:19

And reach out for help. He has so many, I mean, this book is a huge resource um, podcasts and other, other journal things that you can read. Those are great resources. He has. what's

Katie: 1:24:31

He has type one type one university.

Shannan: 1:24:33

Yeah. And there's so many, you can, you can call the people at your endocrinology office. I know sometimes they, they give you a high five if you're under seven and they're like, no, you're doing great. And that's fine if that's your goal and you're sleeping through the night. Good job. Yes. But if you want different results, if you are looking for something different from what they're, you know, quote unquote, okay. With then push for it, advocate for yourself. And, and your mental health as well as obviously your child's long term health. But I know Delaney was not sleeping well prior to, and if she has had a week where everything has kind of been off, we haven't been able to, properly insulate. Is that the word for hormones insulate for hormones, this insulate performance? She feels it she's waking up in the middle of the night. She one night she couldn't go back to sleep. I didn't know whether I would send her to school on time or do I do I say suck it up, buttercup? You know, would another kid be going through this without diabetes? Is it because of diabetes? Do I make her single out? I mean, there's just so many layers of questions. So having that control and being able to allow your child and yourself, the amount of sleep is just gonna be better for your, for everyone's overall health.

Katie: 1:25:48

Mm-hmm

Shannan: 1:25:49

So ask for help, ask for help from whoever call Katie.

Katie: 1:25:52

No, no. Did not call Katie call Gary. No, actually I'm, I'm grateful you brought that up. I had a note here at the end, but I'm grateful you said it. But yeah, he, Gary, they work nationwide, worldwide, actually virtually. So if you need help from hi, his team, like integrated diabetes services is the name of their company, their website. I will put a link in the show notes. I'll put a link into there. I'll put their phone number in the show notes. Like they're more than happy to help you. I don't think they're gonna keep you forever and you're gonna have to pay a million dollars. I think their goal is to get you as independent, as possible, as quickly as possible. So they're, they're a great team. So if you need help, reach out. All right, Shannon, we gotta wrap it up. Girl. I can hear my children they're home now. So I know that at any minute, they're gonna bust through the store, but thank you so much for just thank you. I appreciate it. And happy Saturday.

Shannan: 1:26:43

Yeah, happy Saturday. Go have fun the rest of your day. And thanks for doing this. I know it's a help to so many people.

Katie: 1:26:49

Thank you. Bye.

Shannan: 1:26:51

Bye.

Katie: 1:26:52

All right, that is it. For the episode today, don't forget. I will put a link in the show notes to where you can find help from the amazing diabetes educators at integrated diabetes services. While you're there. You can also purchase your very own copy of the book. Think like a pancreas. And if you purchase it on the integrated diabetes.com website, the author, Gary Scheiner will sign it for you. Don't forget. I'll also put a link in the show notes to that other episode I did with Shannon. Be sure to check that out, you will not believe the things that they had to sacrifice in order to go through this clinical trial. And my dog is barking in the background cause he wants to come inside. So if you hear that Henry says, hi, okay guys, I will chat with you soon, but until then stay calm and Boless on.