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Scott Benner 0:00
Hello friends and welcome to Episode 420 of the Juicebox Podcast today is another episode about the Do It Yourself algorithm called loop.

If you've been following along in this series, it began back in April of 2019, with Episode 227, and that one's called diabetes concierge. Then I spoke about loop again in August 2019. In Episode 252, a loopy few months, February 10 2020, Episode 304, a loop de loop. And then in March of 2020, we had a two parter number 312 and 313. Fox in the loop house parts one and two. And that fox we're talking about is Kenny Fox, gentlemen has been on the show a couple of times, and who you may know, I really liked Kenny because he understands the loop. And he talks about it in a way that I dig on. So I asked Kenny to come back because I think I've made some big improvements with how I think about loop. And I wanted to check in with Kenny. With all that considered. This is Episode 420. Fox in the loop house, part three. Please remember while you're listening, that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, please always consult a physician before making any changes to your health care plan, or becoming bold with loop.

This show is sponsored today by the glucagon that my daughter carries g Volk hypo pen, Find out more at G Vogue glucagon.com forward slash juicebox. Have you ever wondered if that blood glucose meter that you're using is accurate? Well, it might not be. But I can tell you for certain that we love the Contour Next One blood glucose meter for exactly that reason, its accuracy. I also love its bright light for nighttime checks how easy it is to use and carry. And of course, those Second Chance test strips. Check it out at Contour Next one.com forward slash juicebox. And if you're a US resident living with type one or caring for someone with Type One Diabetes, please consider supporting the T one D exchange by going to T one d exchange.org. forward slash juicebox. And joining the registry, you too can help T one D research. All these links are at Juicebox Podcast comm or right there in the show notes of your podcast player. Let's get to Kenny right now. I'm just gonna cut the music off and start no messing around.

Recording when I start the recording. All right. Last night, I ordered a new mic for the house here. Because finally after what feels like about two years, Arden's like, Okay, I'm gonna come on the podcast. And I was like, finally, geez. So, so I'm gonna get another microphone, like so if I buy this microphone, that's it, you're definitely doing this right, because she's vacillated a great deal. I don't know if she's embarrassed, or she's afraid of what she thinks she's gonna say, I have no idea. I was like, I don't care what you say. You can say whatever you want. You know, like, I just want to chat with you a little bit. And then I want to talk about, you know, what you've learned so far about diabetes and what you think you still need to know. And we'll go over some stuff. I was like, that's all I just want to talk. She's like, Okay, all right, I'm gonna do it. But I think she's planning on using it as a they have to do a certain amount of Oh, my God, why can I not think of a very simple word. If you send somebody out into the world to do a nice thing. In exchange for that, you get hours to put in the service or somebody service hours, they have to have a certain amount of community service hours to get it done, to get to graduate. So she's like, do you think that would be community service? I said, Ask your you know, ask your counselor, the counselors like it would definitely be

Kenny Fox 4:30
nice, nice.

Scott Benner 4:31
Anyway, Kenny, you're back. I am back. It feels like it's been a minute since you've been here. But that is sometimes on purpose. I feel like I could talk to you every month and it would be valuable. But your last two episodes. The Fox in the loop house episodes have been very popular. People tell me about them a lot. And I've grown in my understanding of the loop and how I use it. I know you have. So I thought end of the year would be a great time to have you back. So thanks very much. Yeah, I appreciate it. I think we should probably start. Do you agree with the beginning of the pandemic? Yeah. Is that a good place to start? It is. Alright. So I was perplexed by Arden's blood sugars for about three or four days. And I was feeding her insulin almost constantly. And not a little bit a lot. It was bad. And I don't know, you know, for all the things I say on the podcast, and the things I mean, are the things I usually do, I should have just turned her insulin back. But instead, I just kept thinking, you know, something odd happened, or this was gonna be momentary. And finally, like, two, three days into it, I realized that the, you know, stressors of being at school, and getting up and going to school and all the things that come with leaving the house, disappeared for Arden, like she's more comfortable in our home, on a laptop talking to her teacher, and maybe comfortable is not even the word I'll have to ask her when she comes on the show. She might not even be aware of it, right? But there's just not that adrenaline I guess from being up and being moving and having to run from class to class. And it turned out that Arden's insulin needs, at least at her basil level, had significantly dropped because she wasn't at school. And I was in the middle of trying to figure it out. And you just kind of messaged me, I don't know, we were just talking, I guess about something. And I mentioned that this was happening and you're like, Hey, I'll I'll lend a hand if you want. I was like, Okay, sure. Sounds good. It's one of the perks to having my podcast Ken. Right. You are literally one of the perks of my podcast, for me personally, and for everyone listening. And so we looked at it for a while. And you said let's try and what did you want to try?

Kenny Fox 6:59
We tried to cut and basil was looking at just your nightscout graph and look like he had a lot of negative. It shows the nightscout as negative iob. In Salaam born overnight, especially but like EDC Arden's blood sugar was dropping, but it wasn't just dropping with positive insulin it was dropping with negative. So Luke thought, hey, you based on the basil rates you have in here, we should have taken away enough insulin that she should be going up. And she wasn't. So that was kind of an easy indicator that basil was too much. And so we ended up cutting it back, I think at the from where you had it in the daytime, like for handling that school stress was I was almost in half, it was a lot It was like 30 or 40%. And then I think I just also happen to coincide with a because you know, Arden loves that we talked about this herd cycle where she needed less insulin too. So it kind of compounded the effect of having Basal too high very temporarily, but we cut it back quite a bit.

Scott Benner 7:59
The Kenny's on a storyteller he took he told the end at the beginning, but that's fine. So first, I want to ask you to describe negative insulin on board for loop. But how people can think about that as well away from loop.

Kenny Fox 8:15
Yeah, so basil, if you think of basil as like we've talked about before just meeting the body's need for insulin like just normal sugar production. If you can find that spot where you're just matching the body's insulin needs, then you should be fairly level and that would be a situation like overnight, you'd have zero. Insulin on board insulin on board would be any insulin above or in the case of negative insulin or below the basil needs of your body. So it's any extra or in loops case, less. So what that means is in an order, like if you didn't have any food or anything stress or whatever, trying to raise your blood sugar, then most of the time when you have positive insulin on board, you give a bolus or the system increases loop gives more insulin, you should expect at some point your blood sugar to come down. And then once you hit zero insulin on board, you've kind of reached that status level where you've your body's insulin needs are being met with the amount of insulin in your in your body delivered in the background as basil so that should be level your blood sugar should mostly level out. Negative insulin on board would mean that this that you've reduced how much like you're not meeting the body's need for insulin at some point. Often because like in loops case, they've it's reduced. The basil rates pick something lower than your scheduled normal need for insulin to the point where you have less in your body than what you should need to keep you level. And if all that's right, if your basal rates are right, what should correspond with that negative insulin board is your blood sugar will start to rise Because you don't have enough, sometimes it happens right away. Sometimes it's a little bit of a delay, maybe you're exercising or something. And once you slow down, it kind of catches up with you. But the idea is that if you have negative insulin on board, your blood sugar should go up. And that for like a normal pumping situation, just like these in the PDM. For example, if you're waiting, if you have really good basil, and you're flat overnight, and in the morning, you wake up. But let's say you want to be a little bit higher before you give a nice big bolus for a bowl of cereal or something in an hour, you could turn your basil rate down, you could do a Temp Basal have zero, for example, for an hour, well, that would should make your blood sugar drift up because you're you've turned off the basil, you've cut it off, you don't have enough in your body. And it's not enough to just let it turn back on to level you out. Once that Temp Basal of zero is is off, you actually need to give the insulin you're missing that last hour to level it out. So in that situation, you would have a negative insulin onboard situation, even though you're not looping, you might not call it that, but you'd kind of need to give that last hour of basil. plus whatever your you know, that would level you out. And then you're gonna need to give the insulin you need for your food. And loops, just tracking all of that for you by modulating the basil rates up and

Scott Benner 11:19
down. And so if we had Arden settings correct, when she was showing negative insulin, there's just no way she should be falling her blood sugar, it should at least be stable and most likely rising. Correct? Yep.

Kenny Fox 11:33
Yep. So that's a nice, objective way. It's one of the few objective things in diabetes, it seems like and loop helps extrapolate that is like, oh, our basil is wrong. And there are a couple situations where that might not be the case. Like if you're, you know, laying on a sensor at night and dropping, because of a compression, but, or maybe even exercising, it might not drift up as fast as you'd think. But other than that, like it really should be, you should really see up when you see it and negative insulin on board, but at a minimum, Yeah, a little bit of a levelness, as you shouldn't be dropping anymore. And so it's nice is like, okay, that's, that means basil somewhere, is too strong. So if you have multiple rates, then you might have to look, in the last, you know, five or six hours insulin last six hours. So you might want to look at your basal rates in the last four to six hours and try to figure out which one is the culprit, you know, How bad is it how fast you dropping? I have

Scott Benner 12:30
to say that this whole concept has, for me, raised my understanding of insulin significantly. And again, I 100% have to thank first the loop, you know, algorithm, because I began to see these things. As soon as Arden went to loop and you, if you go back in the podcast, you've definitely heard me talk about how fascinating I found it to watch the loop takeaway basil, to give it back, you know, just to sort of, it was like a self driving car, you know, it was seeing that it was seeing the road curve a little down or a little up and it was just going with it. And it was and it was not just going with it. But it felt like it had it felt like it had a crystal ball. You know, like it was like, Well, I'm gonna give her more now. But our number really had only moved a little bit. You know, blood sugar goes from 85 to 89. And all of a sudden, her basil goes up a little bit, and you're like, let's not even arise. And it can be scary at first because you think No, don't give more. She's only 89. But it It knows. And you know, and it knows based on what it's done in the past, and what the expectation is based on the setting you put in. And I think this is important for people if they're gonna use an algorithm or not to really understand basil insulin in a different way. And not just how much basil insulin Do you need, oh, I use 20 units a day, that you know, I inject basil and I use 2020 units a day or I have a pump. And my basil is point five an hour, but it's point four an hour overnight. And that's it that that is I now understand that that in itself is such a rudimentary way of thinking about basal insulin, you really have to step back and believe that in every moment of your life, your basal insulin needs are slightly different. They might almost be in perceivably different, but they're constantly fluctuating somehow sometimes they get real super stable. You know, when you're sleeping, or you know, you just haven't had a lot of activity, there's no food and you know, no insulin you But the truth is, is that the needs change almost constantly. And you can see that because the algorithm is like ooh, more or less, more or less. It's not something you could ever duplicate with your you know, with your hands and your eyes. It would just be it would be your entire life. You know, you'd have to sit there and stare forever and you still wouldn't know that things needed to know to make the decisions in a timely way you could kind of catch them. But it would never be out of head like this is. So I don't really know another way to say that for the people listening. But you have to get it out of your head that your basal insulins definitely point five, or it's definitely a unit, because it very well may not be. And then you can extrapolate that idea to when you have food in your system. And I just did this last night because Arden had a cheeseburger and french fries from five guys. And I crushed it with a good Bolus up front. Her first two and a half hours after the food bank, there was a milkshake in there too, by the way, Kenny, actually double bacon cheeseburger, barbecue sauce, Cajun fries, and a milkshake with Oreo cream and Oreo cookies, the crumble part. So I crushed it the first two and a half hours. And then she got into this 130 space that was trying to go up. I tell you, if I did nothing, her blood sugar could have easily been 300. But I kept adding carbs. And this is still where I have a shortcoming. I need to figure out a way to translate fat and protein into a number, a carb number. That's still something I'm trying to figure out. But I just and

Kenny Fox 16:22
that's that's important, because loop is expecting. So it like kind of, I don't know, it sees in carbs, I guess that it understands the world and understand your blood sugar movement based on carbs. So yeah, figure out your way. And it changes I think for everyone and even meal to meal, it's a little bit of a, maybe there's an exact science to it. But we've kind of settled on 25% or so of all the fat grams and the protein grams. So if you had like a nutrition label, I would like take that, add it all up divided by four and add that as some extra carbs into the carb entry. And usually, if you're adding in fat and protein, you'd either want to do a four hour entry to mix all those carbs together. So that way the because the fat and protein is going to hang out a while. So use the pizza icon to make it longer. Or you can do kind of what you ended up doing in reaction last night, which is you could take kind of that fat protein representation and entering the cars. But you could do it ahead of time you could enter change the time on the entry and put it out in the future by like an hour and a half or two hours where you think that fat and protein is going to kind of show its head. And so you could you could put that number out out ahead of you. And then as she starts to come up, we'll see Oh, I have carbs coming. I can go ahead and give more insulin ahead of time. But you ended up doing it reactively, which is you know, sometimes that happens. We get that with Cassidy as a torturously underestimate the delayed impact of the cheese in a case of DHEA. So I, I tried to add more upfront, but oftentimes it's just like, Oh, she's going up. So then I just add some carbs and, and Bolus and I wouldn't call those fake carbs. It's, it's how Lupe sees everything. You can't call it fat and protein. And so he legitimately needs to be handled with some representation of carbs. So I think, I think what she did was was perfect. I mean, pica added more, but that's I

Scott Benner 18:21
didn't do enough, because I ended up fighting with it for an hour or so where she was kind of that 150 160 back to 150, where I could see the the Bolus pushing her down. But it wasn't winning the fight to bring her back to normal and the fat and the protein still existed. And so yeah, you're telling me just for fun, just to make a round number. If I thought, if I could count 100 grams of fat and protein in a meal, I take 25 divided by four, make it 25 and tell the loop, there's 25 carbs during the fat and protein rise, and that probably would have done it for me.

Kenny Fox 19:01
Yeah, something like that could be, you know, good. Some people use like I used to use 50% of protein and 30% of fat. You know, but I think like 25% is a good start, if people find that their carb ratio works well with basic carbs. And then when they add the fat and protein things get out of whack and 25% isn't enough and try 30 you know, like, whatever it is, or do more for protein. But yeah, find a balance some number that represents that as best you can. 25% just a good starting point. Just add it all up and divided by Ford

Scott Benner 19:34
inserted in there. So this meals like mind numbing to people because I think it was like 85 carbs I put in for the food. Right? And so you're telling me that I could have said 85 carbs now you know, let's say noon. And then I could have let that pump in and then told it 25 carbs for the fat and protein but given it a time of 230 You too, right? And it would not have given her the insulin. But at 230, if she would have rose, it would have got more aggressive.

Kenny Fox 20:08
So you would look at the, it's best to experiment with this at home, rather than sending a kid to school and trying it for the first time. But you'll see the prediction will adjust it'll, it'll see a rise coming. And so it will sometimes or usually offer insulin upfront, I usually don't take it, I say I just don't Bolus after I enter that future carb entry. And then I let Luke kind of spread it out over time, because then as soon as your blood sugar starts to dip a little, it'll pull basil back. And then when that starts to come up, usually corresponding with that rise that you're expecting, then it'll start, it'll start giving insulin right away. So it won't, it will give insulin before the 230 mark that you answered it. If the prediction allows it, if it says you're going to be high enough, and not go underneath your suspend or whatever you can do that sometimes what people have to do for certain longer meals, like maybe a pasta or something that doesn't have as many carbs up front. You may it may be safer to use an override, we've talked about overrides before. That is 100% insulin needs, it doesn't change anything around your insulin needs. But it just has a higher correction range, like maybe like I think yours is like 85 9095, somewhere in there, less than 100, maybe you would have a correction range, then you could set an override that would have a range of 95 to 105, maybe a little bit higher than normal for like an hour or two. And you could turn that on. And what that would do is loop wouldn't would be would not be giving you extra insulin for that future rise until your blood sugar came up high enough into that range. So instead of at 85 or 90, it would have to wait until your blood sugar was into or above that range of 95, let's say before it gave extra insulin. So sometimes you're like, well, it's hard to model how you think every meal is gonna go. So sometimes you just need loop to chill out in the middle, right the first couple hours. Yeah, so raising that correction range for an hour, a loop can't give more insulin until your blood sugars into that range. So you might just want to wait, you might want to wait it out. Like we do that with pasta. pasta is just I don't know, depends on the process. Sometimes it hits right away, most of the time it waits, it's seems like it's almost free for a few hours in my daughter. So we'll set a higher correction range, but I still want to have all the carbs entered because they will show up, it just might show up later. So same with fat and protein, you might, it might be safer to just kind of add that buffer for an hour, if you're worried about a low coming so and the other way you could answer it would be either that like a 230. Or you could have put, you know, the 85 plus the 25. all into one entry and just made it have an absorption time of four or even five hours. And so that would naturally give less, it wouldn't give the insulin for all 100 carbs or 105 carbs up front. I guess it'd be a little more than that. But you know, it wouldn't give all the insulin up front because I would expect it to be spread out a little more. So either either way is fine. Whatever people find easiest or most representative of the food, I think for like the meal you're talking about having it separated would be good. I always separate the carbs from the fat and protein and make a future entry for donuts from a donut shop. Yeah. Because if I give it all up front, she'll drop like a stone in the beginning. But there's always a rise like 90 minutes later. So not that we have done it's a lot. So

Scott Benner 23:46
I like I said at the beginning of this. Whereas when I was talking about putting in the 25 and telling it two and a half hours later, you said do that, but then don't give any insulin that it suggests for it, which is basically like giving the loop walking around money that it can spend wherever it wants to.

Kenny Fox 24:04
Exactly Yeah, yeah, you get to let the blood sugar play out a little bit. Before Luke gives too much insulin like it's because it's going to use the trending information if she started. If Arden started dropping a couple of points, a couple of readings right after you gave the 8087 carbs for the meal. It would be wouldn't give as much insulin or may not give any extra until she starts trending back up again. For those extra 25 cards we talked about,

Scott Benner 24:32
let me ask if I do that. If I say hey, 25 more carbs. Not till 230 it says I don't know let's say it says that's six units and I say no no zero don't put anything in. Even if 230 comes and for some reason I was wrong about that need and her blood sugar never goes up. It doesn't give her the insulin.

Kenny Fox 24:53
So even five minutes after you said no loops gonna check the prediction if the prediction still says needs, maybe she starts dropping the next reading and says, Okay, well, instead of six units, she probably needs two, it will give, you won't give the two, but it'll give as much of the two as it can, right. So in the case of like normal loop with Temp Basal, it'll kick up the Temp Basal rate, and it'll start trying to give that to, and then if she drops again, in the next five minutes, it'll probably say, Oh, nevermind, and cut it back to trying to give one. So that basil rate of shift down in the case of auto Bolus, it would give whatever percentage you're, you're letting it so you know, maybe it'll give half if you have it set at 50%. So if she needed 60 units, in the next five minutes, if it still thought she needed six units, it would give her three minutes, which is why I suggested increasing the correction range, because sometimes, sometimes you need it to play out a little bit. So But typically, if you're putting it out two and a half hours, there's usually kind of a dip in the middle, in the prediction, that will be low enough that it will restrict loot from giving too much. But that's why it's an experiment based on the food I think in the case of, of your meal last night, I think, yeah, maybe it would have given a little bit more insulin upfront, if you said, Hey, don't Bolus for it. If so would have given some decent deliveries, but it wouldn't have been a ton and she didn't drop. So she probably wouldn't have dropped very much either. probably would have been timed just enough to kind of catch that rise that was coming. Yeah,

Scott Benner 26:22
actually, as we're talking about this, I realize this is a similar way to how I handle Pre-Bolus Singh meals when her blood sugar is lower. So if Arden's blood sugar is like 65, and we're eating in 20 minutes, but she's not dropping. We don't you know, she doesn't do anything about that she just waits to eat, but we still want to get some insulin going. And so sometimes you'll tell the little part of it. Yeah, right, you totally pay, like this meal is going to be 10 and carbs gonna be 25 carbs. And it you know, I guess for art and let me just use a round number for a it's a it's a 10 carb meal would probably want, I don't know, Arden gets a unit per for carbs. So you'd probably want like two and a half or so units. But I don't want you to have the whole two and a half. It doesn't matter because it's not gonna want her to have any. Because yes, because she's under the number. So what I usually tell her to do is even though it says zero, go ahead and Bolus a unit, like you put manually inserted unit. If there are times when I forget all the time, yeah, there. But there are times when you forget to look back. But it doesn't matter because as soon as she pumps hits 85, it puts the rest of it in for me.

Kenny Fox 27:33
Correct, because that's where your correction range starts. Yes. And so now it has the green light, as long as the the rest of the prediction, as well as her current blood sugar is all above her correction range of 85. Plus, then it's like, Alright, I'm allowed to give insulin and I know you need some. So here it goes. And that's why correction range is an interesting one. And I did took me a long time to realize that's what it was doing. So there are some people who may be usually they have little ones, they may set the correction range up at 120. So then they start a meal at 75. And it loop won't give insulin for you until their blood sugar is going to be up to 120. So that can sometimes be a long amount of time for the food to really get ahead of the insulin. So then they get upset to the end of highlighter. But what you're watching is that there's there's a bigger space for you to kind of see this happening where your blood sugar is at 75. But Luke can't give more until you're over 120. And so that's the correction range in effect. And that's it's not just or lupus aiming to put you. It's also a restriction on when and how it can give insulin,

Scott Benner 28:45
you basically gave them momentum away.

Kenny Fox 28:48
Well, yeah, in that case you did because it's so much higher. But you also get to see that that's why sometimes bumping up the correction range with an override is useful is maybe you you want that to happen. Or maybe in the case of someone with a blood sugar a child with a correction range of 120, they may want to have temporarily have a lower correction range at the beginning of a meal, they might want to just set it you know, to like 90 or something for an hour. And then and then once she once that person crosses 90, then loop can start giving the insolence here getting a little bit ahead of it that way, or do what you did, and which which we do too is just, we know a little bit better than loop loops, really concerned about that suspend, like don't don't give any insulin if they're too low, but we know they're eating so it's fine. Just give a little bit of insulin anyways, manually. That way you're not totally behind when the food kicks in.

Scott Benner 29:41
To me, that's just the loop version of how do I used to talk about it? So you're basically you're, you know, she's 65 In this scenario, you know, she's not falling, you still need the Pre-Bolus so you just, you know, you Just override the pump and do it anyway, you're just like, Okay, well, the

Kenny Fox 30:03
pumps not gonna suggest that either right into the blood sugar, and they're gonna say, Nope, zero, but then you have to remember to come back and give it and the beauty with loop is you told loop about the carbs, right? It's expecting the rise. And so when it shows up, it will take action, but it takes action based on what it knows the carbs and also and basil and everything else, but also the correction range when it can engage. So that's another restriction. Yeah,

Scott Benner 30:28
that's also a situation where I trade a lot of the Pre-Bolus time for the number. So if she's 65, I don't need like a 15 or 20 minute Pre-Bolus anymore, because the 65 is the Pre-Bolus. Meaning if I was going to put the insulin in at 5pm, and I didn't expect to just start working until 515. And she was going to eat at 520 or 525. And her blood sugar was 100. Well, then I like that because then by 515 are blood sugar's moving a little bit, she's 98, you can tell it's getting ready to kind of it's drifting down. By the time she puts the food in her mouth, maybe she's 95, and the insulin is really coming on board. So that's where a nice Pre-Bolus works, because her blood sugar help is helping by being 100. But if your blood sugar 65, you can almost push the button five minutes before you eat. And that way the food goes in turns the 65 into a 7585 95. Right, as the insulin comes on board, then you start the fight around there. It's all about where you're starting the fight between exactly

Kenny Fox 31:30
yeah. And and loop is very sensitive to where that fight happens. I think that's kind of the most frustrating thing for people when they start looping is two things, one, the fat and protein, you really have to accommodate for that and loop. If you don't want to be really angry with loop and being high, especially when you're listening to this podcast, you're used to, you know, correcting if you need to, but keeping things in line. And loops recommendations can often be a little light upfront if you're on the lower end of the spectrum. And so it's gonna give insulin later, but then that fight might happen at a higher number in this case you wanted it to but in other cases it won't. And then once that battle happens, it loops usually pretty happy with it, because it's waiting for the entire meal to resolve over the next few hours. It's not in any hurry to bump it down. And so it just happens. Whereas if you with you can do this with loop or with the PDM or MDI Either way, it's easier with with loop, you can give a little bit of a manual Bolus, if that fight that tug of war is happening at 160. And you'd prefer it to be a little lower, or you see it starting to get up there earlier, you can catch it the better, right? Yeah, you can give a little bit of insulin loops going to disagree with you and not recommend anything. So in return, it will cut the basil back it'll it'll turn the basil either off or lower after you manually Bolus, but that's okay. Because you're you're wanting to kind of reset the fight you're wanting to kind of push it back down a little bit. And by Luke cutting basil, it should prevent the low that would happen later from all that extra insulin you gave that you're usually not patient enough to wait for anyways. So yeah, it can it helps balance it. But where that fight happens, loops, usually fairly content with just letting it resolve because eventually, according to what it knows, you'll be back in range. But we would prefer to have the most of the meal at a number. That's a little bit lower sometimes. So yeah, it is. It's all about the timing.

Scott Benner 33:33
Do you imagine that in the beginning when people start using the loop, and it happened to me as well? Where if I'm not considering protein and fat and later rises, or I've got my settings wrong, and then I try to do that thing where I come back and I try to fake carb, I'm like, Oh, she had 10 more carbs. And then it takes away the basil because it's trying to do its thing now it believes these 10 carbs are going in, and you keep going up and up that frustration really does come from I think I got it through not not specifically understanding how the algorithm was working and what it was trying to accomplish. And then I just couldn't imagine it. I couldn't break free from my, my, my knowledge of how it worked when I was pumping, and that if I gave extra insulin, I still had the basil. And you know, so I think that now that I understand better. I don't run into that as often. I think I'm incredibly good at using loop now.

Kenny Fox 34:32
But yeah, I mean, your last few weeks have been great.

Scott Benner 34:35
Yeah, I just I you know, and it's interesting you say that because maybe two or so weeks ago, Arden started using a birth control pill to regulate her periods. So she's getting this very low dose of estrogen I guess or hormones. I think I'm right when I say

Unknown Speaker 34:53
less, you should probably look

Scott Benner 34:54
at me and it did increase her needs. So Arden's basil need one From like point nine to 1.5 to combat the pill, but her meal ratio didn't change. And her correction ratio didn't change the insulin sensitivity, actually, excuse me, I did have to make it slightly stronger. Maybe

Kenny Fox 35:17
not a lot, though. It did a few points. Yeah,

Scott Benner 35:19
from like 43 to 40, or something like that, if I'm remembering correctly. It took me about two days to figure it out after the pillow kicked in. So the first couple days were wonky than about day three and four of the pill I could really, like make the adjustments. And I think by day five, I

Unknown Speaker 35:34
had it.

Kenny Fox 35:35
Yeah, I mean, I think a lot of the challenge people have with at the beginning is their bezels are often wrong. Like we've talked about before, I I prefer the idea of at least starting with a single Basal rate so that it's easy for you to see at least the lowest parts of the day, where that negative insulin on board might show up, or you may have the basil off, or maybe it's too strong. I do find that that number of basil typically for most people does apply. All day like it's it's kind of a, I call it a floor like I don't have a metabolic metabolic floor, where if you give no matter what you should see blood sugar stop falling when you hit zero, and so on board or negative at pretty much every hour of the day. But there are situations where you would need more than one. But if you start with one tune to that like weakest part of the day, and then you know that you're pretty close, typically, secondary basal rates are not that far off from the main one that you find. And then at least that gets you in the ballpark. And now, what like like what we found with Arden, when we started at being in the pandemic is, after pulling away that stress that you were trying to combat, you're actually combating that stress and other stuff with basil. So her carb ratio ended up being almost half of what you had it. And that's actually not uncommon, from what I see with those with teens is the not in your case, necessarily. But a lot of people are too afraid of or just can't fathom that their kid went from 10 or 12 to one carb ratio. And a couple years later, they're down to like a four or five, six to one carb ratio. So instead they increase the basil. And then when you get to loop, you find that the basil is a little bit too weak for part of the meals, and then it causes lows later, because your Basal is too strong. And you're you're definitely not winning with loop because it's expecting to see carbs, and you're not matching it with the appropriate amount of insulin and the settings are off and all this stuff goes on. That's so yeah, that's a big problem.

Scott Benner 37:42
Yeah, I end up saying that to people privately all the time. Because though, first they come in there, the telltale is always a real jagad graph real high, low, real high real low,

Kenny Fox 37:53
and not enough insulin with the beginning of the meal, and then too much at the end with basil being too high.

Scott Benner 37:58
And then so you just say, look, this is either it's gonna be I always say we're gonna start with your basil, we're gonna find out if it's too high, or it's too low. And I just asked this simple fishing question like, do you find yourself feeding insulin more frequently, or bolusing for highs more frequently, because I can't be there. And I can't just sit and watch it forever, right. So if they find themselves feeding lows, I go, okay. And that to me, says, you know, maybe the bass was too high. And if it's, we're always bolusing ago, maybe the bass was too low, and we just start there. And then I just, I take the person's weight, and it gives me an average understanding of about where their basil is gonna fall for most people. Some people don't correlate to their weight at all. But I find that many people do around point one per 10 pounds. But then once you get over a unit that seems to not play out exactly the same angry, right? And so but again, there's nothing scientific about that. It's just just experiencing a lot of people's graphs, right? So you know, you my kid weighs 50 pounds, you know, they're not in, you know, puberty yet. All right, so you've got their Basal at point, one, five, probably not enough. So let's try point three, and then you see it get a little better. And I keep moving up, we'll go point four, you know, maybe point four or five. Now this looks pretty stable. Okay, now we have some stability at a lower number. Let's look at how long your Pre-Bolus in. A lot of people like to say they Pre-Bolus but then they always say, You know when I can? And I'm like, yeah,

Kenny Fox 39:29
that means not that off. That's what that means.

Scott Benner 39:31
And so Mike Well, we're definitely going to Pre-Bolus now, five minutes. Yeah, let's start at 15 minutes. Now you need to remember we just took your basil from point 152 point four, five, your meal ratios are probably going to be lower, you know, weaker than you think. So if you're doing one to 10 it might end up being I don't know, one to 12 or 13. I don't know we're gonna find out you know, so pick a meal that you're really good at bolusing at and You know, let's cut it back a little bit, cut it back a little bit. Now we get the Bolus, right, then all jump up, they don't have to correct later the corrections don't cause lows. And they stay off that whole roller coaster. And that's it. Like I'm, there are times that I help somebody. And when it's over, like, you know, you know, it's like two or three days later, and you've talked to me a handful of times for a couple of minutes. And they're like, look at this graph. There are times where I act like Yeah, that's great. You did a great job. Isn't this wonderful? And why hang up the phone? I think I can't believe I did.

Kenny Fox 40:31
I have a lot of those conversations. My wife is you gotta you gotta come look at this. I just replied back. Oh, yeah, good job. And then I see what I just didn't like 24 hours or 48 hours. That's pretty cool. Because it's really important that people understand that when your settings are off that when you're, it's like your meals are like mediocre, they're okay ish. But yours, you know, late, low, later, high, early, whatever, but generally not too bad, then we need to increase basil, or decrease. So you got to trade it with the current ratio, you do often flip those up and down in reverse of each other. So it's important to as long as you're in a pretty decent spot of control. Most of the time, it's really important that they remember that. So if they find that looking at negative insulin on board or learning, excuse me track the iob. overnight and Luke because you have so much more data than just a graph to look at. And you figure out what your basil is. And I can do that with a fair amount of precision. If you're running a single basil rate, it's pretty easy for me to figure out how much higher or lower you need to be based on the exact amount of insulin on board. And that happens in those waves overnight. Yeah. You just once you make that change, so you don't have a so much struggle the rest of the day, you got to make sure you're adjusting your carb ratio after you're like, Oh, look, I found my basal rate. You got to make sure you change your carb ratios, or you can be fighting highs or lows depending on where you're at. And

Scott Benner 41:55
I think it's important to know that we're talking about right now if you're in a place of just dumpster fire, and you're trying to find it, that all counts for that if you're in a situation like Arden was recently where she started the birth control pill, but she still it but her settings were rock solid before then her all of her needs just increased. Like Yes, there's a concrete thing that happened. It's not variance or, you know, what we alluded to, you know, when we started and never got back to which was when Kenny and I were looking at Arden's numbers way back at the beginning of the pandemic, she was in her easy week. So Arden has like three different weeks every month, she has an easy week where her blood sugar is super simple to take care of. Then she has sort of a pre menstrual week where it's more difficult, it kind of ramps up and gets more difficult as her period approaches. And then as the period begins, it actually starts to get easier again. And then it gets easier and easier as the period progresses. And then it goes back into that easy week. So we were in the easy week when we set it up. And Kenny set up a single basil system, which What do you think it for five or six days? It looked like Arden didn't have diabetes? Right?

Kenny Fox 43:09
Yeah, I mean, you had he had standard deviation. And like the 20s, you had super high time and range. You know, I like I didn't I don't have that many weeks that are for that length of time that are that stable. And that was that was pretty good. And like we figured it out. I mean, we had to dial things back a little bit every day. Right. And, and it but it was Yeah, it was pretty solid. It was much different than the days you before when you were struggling.

Scott Benner 43:36
But but it was super steady and super low. And and before I get into this, I want to I want to ask a question, and I'll answer it as well. How frequently does your daughter's blood sugar out of nowhere surprising to you drop low.

Kenny Fox 43:53
Drop low. Yeah. Oh, hardly ever

Scott Benner 43:55
meet. So

Kenny Fox 43:56
I find that when you have basil pretty steady and you trust. And you've seen over time, especially with the precise loop data you get in terms of insulin on board. When you see a drop in like like 3am, for example. It's I mean, I, I don't even get out of bed, if it's a 55. And it won't go from 85 to 55 in two or three readings. unless she's laying on the sensor. Something's wrong. It just doesn't happen. So I tried to explain it to people that once they have a good basil rate, good settings, those drops are not something you run and treat, like maybe you fingerstick that's probably a good idea. But you're going to have much more consistency than you thought some people are struggling enough that that dumpster fire situation where they're used to seeing ups and downs so much that Yeah, but once you have good settings there's I mean, there's not she doesn't just drop, right isn't unless the stem usually when I'm struggling with the technology itself. It's not It's not our blood sugar.

Scott Benner 44:55
Right, right. I had to yell into the shower for my wife. The other morning. We were up earlier and the kids are still sleeping, and I just yelled, she's not really 55. And I just kept Oh, yeah. Yeah, she doesn't worry when it beeps,

Kenny Fox 45:07
my wife doesn't wake up to the beeping. So I roll over and look at the drop and look at her in some onboard on my phone and go and not worried about it. And then I go back to sleep. And then if it beeps again, then I'll get up and check because it means we're struggling with the sensor. It's what actually grandma's dealing with right now we have my wife's 94 year old grandmother living with us. And she has type one diabetes, and I have her looping. And the sensor we put on your sensor last night and just ended up it's reading low a bunch, so we just had to go figure out if it was real or not. But it was it's unusual for us to see those kinds of drops unless it's the sensor kind of just having its moment.

Scott Benner 45:45
I'm actually gonna put a G six on as soon as you and I are done. Awesome. Yeah, this is gonna go up after the other ones. I can just say whatever I want here. And then I'll get back to my thought. Kevin Sayer, I'm going to record with Kevin Sarah this afternoon, Kevin's going to talk about some things that Dexcom is doing. I'm going to kind of in tandem be wearing a G six, two. So people who listen to the podcast can see what a functioning pancreas looks like, I pushed Dexcom to to let me do that. Because I think it's going to be incredibly helpful for people who have stress about small rises and things like that, where they think if that lines not completely straight that, you know, it's very unhealthy where it's very helpful.

Kenny Fox 46:31
I mean, I've worn a sensor, you know, with a little bit of time left on my daughter's transmitter before. Yeah. And, and I've had one of my oldest son when my daughter was first diagnosed were one. And just to kind of get an idea of like, what is normal, like, I'm a little overweight. So like, well, I'll check my son too. And these numbers are very close to mine, like, you know, it's, it's comforting to see that, you know, you can hit like higher numbers 130 4050 very briefly, then some of these patterns that you see, are real, like they're not just something you're doing wrong. So for example, if I ate a bunch of ice cream, right before I went to sleep, I stayed higher for many hours, longer than I would have if I had just stayed awake, you know, that growth hormone idea when you your body's doing its thing, when you go to sleep, your digestion is affected and all kinds of stuffs happening. Yep, that will keep you higher, I wasn't just making up that my daughter was shooting up out of nowhere. It wasn't something I was gonna attack with basil. It was it was variable based on the food and the she ate and how close to sleep. She ate it. Because I saw the same thing for me. And so now it's like, okay, and it's not. It's not unusual, it's not different. When other people are telling me you have to increase basil or whatever, they don't really know what they're talking about, like this is what a normal pancreas would do for an eight year old or,

Scott Benner 48:00
or someone who's older than that. So it doesn't really matter. Jenny said this recently that when you fall asleep, all your body functions slow down.

Kenny Fox 48:08
Yeah. And I was like, everything's just different.

Scott Benner 48:09
Yeah, it's why you get heartburn, if you eat something, and then go to sleep, because your body's in the middle of processing the food. And suddenly you take the power away from it that it needs to process the food? And it's Yes, and just, you know, I'm sure that's not a very technical explanation of it. But yes, so I, I just thought, you know, there are so many people listening this podcast, it's just gonna give a great opportunity for a lot of people to have that experience that would not normally have that experience. So I contacted Josh from sugar mate who I didn't know previously. And he set me up so that I can live stream my blood sugar on my blog, so that people can actually go right to it, watch it all and put the foods that I'm eating so that people can see what happens. And yeah, and then I thought,

Unknown Speaker 48:52
wow,

Scott Benner 48:54
what if, after that, I took volunteers who were like, I'm really good at bolusing for pizza, or I'm really good at doing this and let them kind of run like little, you know, basically showcases where they say, Alright, I'm gonna Bolus this pizza here. And you get to watch it if you want to, and then see where the insulin goes. And so people can kind of have that experience. But But back to just me wearing one without diabetes. It just really occurs to me that people need to see that because there are too many people freaking out about a 130 blood sugar that lasted for 45 minutes. Like, there are some people who put graphs up in my Facebook page. And they're like, I don't know what I did wrong. And I look at it. I think they put the wrong graph up. I don't see where you did anything wrong. You know, like it went to 130. And it came back down and it didn't get low. It looks pretty good. You know,

Unknown Speaker 49:43
how do I say that? Yeah.

Scott Benner 49:45
How do I stop that from happening to me be more perfect, I guess. But that wasn't terrible. And right. And a lot of the things you're achieving with insulin are superhuman compared to what a pancreas would do.

Kenny Fox 49:57
Yeah, the idea you get the people that are shooting for like an 80s blood sugar. They think that means all day every day, and that's what would normally happen. And that's not really what would happen with a functioning pancreas either. And, you know, some people have it's, I found it useful for me because I put it on my son who kind of a similar build. So I'm assuming similar genetics to my daughter. And you know, where does he fast overnight? Well, his fasting blood sugars like in the 90s, not in the 80s. So here's a one see, if I got it, check is probably a little bit higher, probably in the high fours, low fives. So I don't think my daughter would normally be someone who would have a four and a half or a four a one see that some people try to shoot for that, or I think a little bit crazy. But some people would my third child, he, his blood sugar will be tested as always lower 70s and 80s. So you know, some people would and some people wouldn't have a certain number. So I thought it was comforting for me to say, Oh, I can keep my daughter's a one C, you know, like between five and five, six so far. That's probably where she would be without diabetes. So that was comforting to me. I don't need to try and push the envelope lower. I have no desire to do that. Because especially after watching my son, like his average blood sugar was kind of in that. That same range. So I'm like, Okay, well, I'm I'm doing okay, so

Scott Benner 51:21
yeah, well, if, if people want to check it out, it's Juicebox Podcast comm forward slash CGM live. And whenever I have a volunteer, there'll be a live graph there. So

Kenny Fox 51:33
yeah, it's pretty cool. Yeah,

Scott Benner 51:35
I thought that that was a good use of it. And Dexcom has this. It's, it's, you know, text. The reason I have it is because Dexcom starting a program that I actually think they announced they're announcing today, that is called Hello, Dexcom. And so you'll be able to go into a doctor's office, if you had type two diabetes, and just say, I'd like to try a Dexcom CGM. And they'll give you this little package that has a sensor, an applicator and a transmitter in it. And you can try it for 10 days without a just like that. That's wonderful. Yeah. So that, you know, was like, Well, let me take advantage of that. I was like, Can I get one I have an idea.

Kenny Fox 52:15
A family members that are struggling with type two M just started wearing, like a Libra or something. And when they see test gear, and they understand that, like, you get readings all the time, and those benefits, they, they, they kind of want it, but it's hard for them to get started. So and see and try to measure if the additional cost or whatever might be worth the change. And I think being able to try it out would be a big deal.

Scott Benner 52:40
Yeah, I also think that Dexcom is gonna make a pretty big push into the type to market. So maybe that maybe they'll be able to get bonuses though, to cover and I agree, my brother has type two, and I wish I could get him a CGM. He definitely needs one. Anyway, give me give me one second before you get to your thought. Sure. All the stuff we just talked about, about basil and, you know, settings and everything. It's why and tell me if I'm wrong. When people say to me during activity, my blood sugar falls all the time, like how am I ever gonna get my blood sugar to stay up? During, you know, my kids, you know, soccer game or something like that? And my my core answer, the thing I just want to say is, we'll get all your settings right, and your blood sugar won't fall when you're running around. Do you feel that that's

Kenny Fox 53:28
true? I feel it, that's critical to having a chance at getting it right. So again, understanding of insulin on board is as critical and it's really only super valuable if your basil is right. Because then you know how much more insulin is in your body. What I find with exercise, something I cover when I'm helping people is exercise does a couple things, right? It slows down your digestion because all the blood flow goes out to your muscles instead of your stomach. So what you were eating is no longer being processed as quickly. So that insulin on board and the active carbs as represented in loop are going to be mismatched plus you're moving around so that increases your sensitivity. So going into activity with insulin on board, you can kind of gauge like how much is too much based on the activity that's more of the art form of it. But you know, if you have more than a maybe one hour of basil equivalent insulin on board going into some fairly intense activity, you're likely to drop even if you have carbs on board. So what I do in loop is is I will take any active carbs My daughter has especially if it's not planned, I'll take the any kind of active carb entries, I'll make them longer, like go from three hour to four hour for example. And then I might even cut back some of those carbs or if I plan to the activity ahead of time, I would probably enter fewer carbs for the meal prior to any activity because Because activity also consumes some carbs for energy. So it's going to eat up some of those, as well as stretch out what we have. So I will, I will enter fewer carbs ahead of time, I'll stretch them out. And then if there's still a decent amount of insulin on board going into the activity, I'll maybe give a couple of carbs on an entered are not going to put them into a loop, I might put one gram in as an entry, just so I know, hey, that's where I gave the granola bar or something. And then if I miscalculated chins up high later, I know which were to go in and add a couple more carbs. And for that granola bar, whatever, it is a caver. And so it's just balancing that food and insulin, but your your food impact slows down at the insulin is a little more effective. But if you can enter with if you have really good basil settings, and you can go into activity, you know, with zero insulin on board, like waking up in the morning and going for a run, I would tell you that with loop you, you could set a higher correction range, and you probably should when you're exercising, but you might not have to like you could probably do a run at 90, and not worry about dropping if your insulin on board is zero and your basil is right, especially with loop in case there is a little bit of a dip, it will pull it back, you might see a little bit of negative insulin on board and you might kind of stay flat and then once you stop running loop will give you the extra insulin for that negative on board if you end up having a little bit. But and people can exercise pretty stable if you can, like I'm talking about use the insulin on board to find your basil almost every time. And if it's too if your basil is too much, even just by one click of the basil rate. It has dramatic impact on activity actually just helped. Someone has a CDE with her, I think six or seven year old, having crushes at recess at school. And we simplified the basil rates and mostly dropped the ones that were running during the day at school to match what was working overnight. And then she gave us a couple of carbs on entered. And recess was fine. Like that was that was in less than 24 hours. I was after school in the afternoon, she was posting a message, we chit chatted across Facebook overnight, and then by the next day like it was looking better. And she understood the mechanics after I explained what I just said, like what happens during activity. So yeah, I think with the right settings, you have a much better chance of not crashing during activity and being nicely in range and being able to perform your best, right

Scott Benner 57:32
and settings means not just your basil, but your carb ratios understanding the impact of the foods that you're using the correct amount of insulin, so that you don't have a bunch of insulin leftover after a meal. And that's it. I feel so badly by the way. Great job that that's really cool. So you're telling me the kids blood sugar wasn't just magically falling at 9:45am? It's not about that the the diabetes fairy was not tapping him on the shoulder or on the shoulder as they're running around.

Unknown Speaker 58:01
Right? Um,

Scott Benner 58:02
I just I feel badly. When when I understand and it happens, it gets thrown in my face almost every day, like how many people are just either struggling wildly with these fluctuations, or almost as odd to me having success by mistake? Yeah, like the people who use who are MDI who use way too much basal insulin, and just basically are feeding their lows at mealtimes before they happen. Yep, you ever seen that? Like, every meal is do or die. And it has to go into the rarely certain time or they experience a low because they're, they've blanketed themselves with so much basal insulin, that it's just a matter of time before they crash. But they can find a way to put the food and that to me seems absolutely just, I would think that would take every ounce of energy out of me if I had to live that way.

Kenny Fox 58:58
The two wrongs to make a right or multiple wrongs to make a right. The chance goes up with something like a like loop. Because you can have your ISF off to you have more settings to kind of mixed together in the wrong way. Something that we'll maybe we'll talk about some of the time because it takes a while and I'm going to try and do we have a YouTube page the group of us have it's called looping learn on YouTube. And then we have a Facebook group too. But I'm trying to put together some shorter videos on this instead of my long, long presentations I've done before but ISF is, is critical in loop because it loop is tracking when you enter a meal. I'll give the short version when you enter a meal and you Bolus for it based on the carb ratio, that's great. But then as soon as the meal progresses loop is trying to track like how many of those carbs have shown up again why it's important to have fat and protein in the mix is astounding. To see like you told me this is a 30 gram meal. When are those 30 grams done? And it does that based on your basil has to be right. Otherwise it might be hiding carbs or showing more carbs. If your basil is not right, it'll use the carb ratio. How much insulin Have you given or how much insulin does it take to kind of counter what's happening, but it's also using ISF how much your blood sugar is moving. And that concept a little bit hard to explain. But it's using ISF also as a measure for if your blood sugar goes up or down, how many carbs has it seen. And so as the meal progresses, once you once it's seen 30 carbs, it thinks your meal is over. So if your ISF is too low, let's say dramatically too low, and you enter 30 carbs, you Bolus the full amount and loop. If you have a way off, it may be inside of an hour loop will say oh, I've seen all 30 carbs. Well, we all know there's not really anything but maybe juice that you could have a 30 grams, that would be completely done affecting your blood sugar in an hour. But based on your settings, lupus said Oh, it's over now. So it's probably thinking you're going to go low, because you have all this insulin leftover from your meal Bolus, and the food's gone. So at least what it thinks is gone, and then you end up drifting high. So then what people often do is they will lower their ISF more thinking, Oh, it's a sensitivity problem. And eventually, they can kind of get it to where it's not awful because they have their ISF solo at the meals absorbing a radical amount of time very short. But then it's low enough that Luke can still correct that rise. Because it thinks your sensitivity so low, it'll give more insulin to kind of keep that that rise from happening even though loop is saying your meal was over in an hour or hour and a half and that's not really realistic. So that you can end up with two wrongs make a right and that situation same with having your basil too high to compensate for maybe not enough carb ratio that can help for most of the day you can kind of be okay if you had ISF too low basil too high and carb ratio too weak, you can sometimes get a balance where, you know most meals are like okay, but you're not really seeing the success you'd like to see and consistency that you'd like to see. So it's to me it's more levers to mix up. Now.

Scott Benner 1:02:13
Can you put into words for me what you look at when you're adjusting someone's basil insulin on loop?

Unknown Speaker 1:02:19
Sure, yeah.

Scott Benner 1:02:26
We don't usually think about that meter that we use, right? I know for us Arden's doctor just gave it to us and walked around with it for years, used it all the time counted on it, and never once asked myself, is there a meter that's more accurate than this is the one I'm using even accurate at all. And then I checked into it. And when I did, I immediately went to the Contour Next One blood glucose meter. Eventually they became sponsors. And here I am today talking about them. Go to Contour Next one.com forward slash juicebox. To learn all about the Contour Next One meter, the strip programs that they have, and you may even be eligible for a free meter. There's a lot to learn on the webpage. Really good stuff there. I love the meter because it's easy to use, and even easier to use in the dock. It's simple for Arden to carry and the test trips allow for a second chance test without interfering with accuracy. So that means you hit some blood don't get enough, you can go back and get more and still get a great test. I'm telling you this meter is absolutely terrific. This stuff is completely inexpensive and there's just no excuse to be carrying around a janky old busted up meter that you've never even looked into when you can have the Contour Next One. g vo Kibo pen has no visible needle, and it's the first premixed auto injector of glucagon for very low blood sugar and adults and kids with diabetes ages two and above. Not only is chivo hypo pen simple to administer, but it's simple to learn more about. All you have to do is go to G Volk glucagon.com forward slash juicebox g vo shouldn't be used in patients with insulinoma or pheochromocytoma. Visit evoke glucagon.com slash risk.

Can you put into words for me what you look at when you're adjusting someone's basal insulin on loop?

Kenny Fox 1:04:34
I kind of created like a quick four step process. But there's a lot buried in each one of those steps. So first thing is always

Scott Benner 1:04:43
candidates. Do you have a quick four step process that has 75 sub steps?

Kenny Fox 1:04:48
Right? Yeah. And once you understand how to work that's it. I kind of just do it without thinking but essentially it's a look at their settings. So the Profile Editor in nightscout will tell you what their settings are And then I go look at Basal. So we'll scroll back and nightscout, the first 24 hours. And you can also run this report and knightscope, call it day to day report. But you have to check the iob box, you can see what's the iob, that loops reporting all day long. And I'll look for negative and so important, if I can find some and see that they're dropping, when that's happening, then we know it's a basil problem. So then we'll try to like, estimate what the basil rate should be if they have multiple rates, kind of take an average of that time frame where we saw that situation occur. And we'll pick a number in there. If we're really not sure, you can just take all your basil rates and look at your total amount of insulin and just take the average for the whole day and start there. But we always always check basil using the insulin on board, so I check for negative insulin on board, adjust basil. And then if you check the CLB box in the day to day report, or you like hover over that loop pill and nightscout obsessively after meals, you can kind of see how many carbs loop is reporting back at a given timeframe. And so if meals look like the carbs on board is just happening really quickly, like the meals are being sucked up and absorbed very fast. But blood sugar is still higher than most likely you start with needing more insulin. So we'll usually adjust the carb ratio to be more aggressive in that case. If you're seeing lows at the beginning, then we'll weaken the carb ratio. But again, this all depends on how much we just changed basil during the day, so we might have to let it play out first and then adjust. And then I also look at ISF. It my rule that I have that seems to work pretty well is one to you know, maybe to basil rates what we start with one, and then is a carb ratio should be pretty close to the same like breakfast and lunch and dinner like maybe breakfast will be a little stronger and dinner could be a little bit weaker. But I mean really they should be fairly close for most people unless they are fighting significant morning rise situations that you've covered in other podcasts. And then ISF should be you should have it's easier to just dial in your settings if you have one ISF that covers your whole mealtimes anytime you could be entering carbs, so kind of wake up to go to sleep one ISF. And then I tend to encourage people, what I find works is to have a couple of blocks of ISF overnight, maybe like in two or three hour blocks, and the strongest or lowest ISF setting will probably be right after you go to sleep. And then it could get weaker, and every couple hours until you wake up and then you have that that weak one. Now some people don't need that. But that's kind of like a starting place is just make a couple of ISF blocks. So we do that. And then the last one is pretty much like we talked about the beginning, fat and protein, like you have to have some representation of fat and protein in and then you know in your carbs. And then you also have to make sure that you're using, like I noticed you were doing these last couple weeks is mostly just using the three hour absorption time I used to when we started use the two hour absorption time thinking Oh, a bigger spike loop sees a bigger spike, it'll give me more insulin. Want to Be bold with insulin. So I want to give more upfront, but you find out that a lot of foods lasts a little bit longer than that. And so you need that three hour time is really good for most things. And because I talked about how carbs absorb as you go, in theory, you could have a five or a 10 hour absorption time on your meal. And if it was really, you know, an apple that was done in an hour to

about two hours loop will seal those carbs in two hours and you'll be fine. So you could have a longer absorption time and get in less trouble than if you had to short and then all of a sudden there's still carbs around but loop thinks well you said it was only two hours long and it's lasting for then it's not going to try and help you anymore because it thinks well that carb entry has timed out so yeah, yeah, Basil carb ratios, a couple ISF blocks mace mostly one during the day, and then adding fat and protein in for for for that stuff. And then the last kind of pro tip one is more like a what I call being bold with loop would be super bolusing. Like it's okay, to manually Bolus if something's not going right. And if you're starting a meal and you think it's going to be kind of spiky, it's okay to give a little bit more upfront with a meal like for cereal. I'll give a Pre-Bolus and then I'll give an once you start sit down to eat. I'll give about three hours equivalent of her basil because I figured that food will last three to four hours. So I'll give her all three hours of her basil, insulin. Right now as a Bolus, as she starts eating a loop turns off the basil for those three hours. And she ends up having a pretty steady line through the whole thing. So

Scott Benner 1:10:07
you put that basil in, and then let the loop backwards manage.

Kenny Fox 1:10:11
Exactly, yeah, cuz it's not gonna be bold for you. It's not, it doesn't care if you're gonna go if you're predicted to go to 250, as long as you're going to come back down where you're supposed to come down. So I've just come to be okay with saying, you know, what I know a little bit better than looping the situation. So we'll be a team will work together, I'll give the insulin I think she needs now to fight that high glycemic food, that initial spike the carb count still, right? It's just how fast and hard it's going to hit. So I'm going to hit back. And I'll let Luke kind of balance it. And the risk is that you have to keep her it link near her. So that that keeps working. And the whole system has to stay functioning. But I know I did it. And so if something went wrong, I didn't know what to do to fix it. So you just build your kind of the things I I'll step people through over a period of a day or two.

Scott Benner 1:10:58
Yeah, you just made me think of like, I'm always like, how do you walk away from this thing after pancakes, but stay with it after a salad? Like Like, I need the connectivity right now. Like we need the kids stay with

Kenny Fox 1:11:11
me. But that's the word the horizon stuff will be nice to stay connected. No

Scott Benner 1:11:15
kidding. Hey, a couple things. First of all, there's a pro tip I did with Jenny Smith. It's Episode 263. It's called diabetes, pro tip fat and protein. If all this fat and protein talk has rattled your brain a little bit, Jenny, and I kind of simplify why fat and protein are important in Episode 263. And I want to say that what Kenny was just talking about putting in, you know, to kind of be bold and crush some sort of a number, if you have to, you can't just put in, you know, you can't look at a 160 blood sugar and know that a unit would make it 90 and put in just the unit because then loop believes that it has too much insulin that takes away your basil. So you're basically they're just trading the basil for the Bolus, and you're not affecting the number. I used to just open the loop up. So basically put the, you know, make it impossible for the loop to turn off the basil. And then correct until the last time you and I spoke and you were like, Listen, you can just you can just over Bolus, this whole thing. And that way even when it takes the basil away. You've still replaced it. You still win. Yeah. And that works terrifically.

Kenny Fox 1:12:22
It's nice because you don't have to remember to close the loop again. That's that's the biggest hassles, you can't just remotely open and close it. So yeah, that's, that's a big deal. And the other, you know, humping that I hope people try to pick up as they go into loop and you can balance how much time you end up spending on it. But when you're high, just like when you are using an MDI or pump or whatever, it doesn't really matter. If you can try and figure out why. Again, once you get that stability, and you figure out your basil is it's most of the time is the food to blame, right? It's you didn't you underestimated the carbs or the fat and the protein. And so you just need more insulin. And if that's the case, you can go back into loop and either add carbs like you did yesterday. Or you can edit the current carb entry and just add some more carbs to that. Or maybe you need to make it longer. Maybe it was a three hour entry. It used to be a four because of the fat and protein. You can do those kinds of things and and fix the situation if you can figure out what's wrong. If you can't figure out what's wrong. That's where you need to kind of guess as to how much more maybe to give as a correction Bolus, just the way I do it. And let Luke kind of just take the basil away. And then we'll kind of find a happy medium at some point. Like sometimes it's more than a couple hours of basil Holmes, this four or five hours of basil. Because I know when other meals coming same thing I would do on MDI, like if she was 160, and didn't seem like she was coming down, but we know we're going to eat an hour or two, then I'll just give most of what I think she'll need for dinner, for example, now in the afternoon. And then whatever incident on board is present. When you start the meal, you can say okay, well, that's not her carb ratio, she needs a little bit more because you've used up some of that insulin on board, but you can check the insulin on board right before a meal. But with lube, it's doing that for you you've Bolus manually, it turned off the basil. And then when you go to enter carbs for dinner, it's like oh, you need more. So I took away too much. But it didn't know about the carbs. So people freak out when they manually Bolus or if they were to manually Bolus a high and I just call it an early Pre-Bolus for whatever's next. It freaks out because the prediction shows such a low number maybe like a negative 150 or something. But that's not that scary because you know, you're going to be inserting carbs in an hour when you're going to eat well, that number will come right back.

Scott Benner 1:14:39
That's funny you bring that up because what I was gonna say is I think I did my first episode about looping back in April of 2019. You and I are talking in December of 2020. And for the first at least six months, I felt like I was fighting with it the entire time. And right now I can tell you that I feel like I use lube as well as I use the other You know, the bolt with insulin system if we're gonna call it something that I talked about on the podcast, I can do either of those things equally well at this point. And to prove it. I will tell you about Thanksgiving morning, which will roll into what you just said. So on Thanksgiving morning, my family has a my wife's family had this tradition of eating these cinnamon rolls in the morning. And I'm not talking about their mom was not some master Baker. They were buying like, you know, those really crappy cinnamon rolls that come in like the cardboard tube and you just dump icing on top of them. So my wife buys them because I think it makes her feel like she's eight years old. And should we have them on some holidays? I figured out how to Bolus from there. No problem. So Arden's upstairs getting dressed the cinnamon rolls in the oven, and I give her a text. I'm like, Hey, we're gonna Bolus for the cinnamon rolls now. And I gave her a number. Well, she responds back, I can't. I'm like, I don't know what that means. Like what is I can't mean you know, and and so I'm like, just Bolus this. And what I thought when she said I can't, I thought maybe it didn't want to give her the insulin like I don't know, I was cooking. You know what I mean, for for Thanksgiving candies, I wasn't really paying much attention to anything. So I was just like, just manually put it in, like tell it to manually Bolus seven carbs. And a little more time passes. You know, and while we're having this exchange in, you know, on text messages, time is passing. And as time is passing, the muffins or the cinnamon rolls are baking. And then she finally says, No, I don't have enough insulin, this pump is empty. I can't and I was like, Oh, geez, I was like, Alright, well, Bolus is much of it is this left in the pump, and then get down here and we'll switch. And I thought I did a good job at the pod that came with a pod change. But I'm telling you, she's eating this cinnamon roll that was just him. I said, 60 carbs in it, you know what I mean. And for the first hour, I was I had it, her blood sugar wasn't moving, everything was great, then all of a sudden, it jumped and we had the highest blood sugar we've had in forever, it must have been close to like 280 with dinner coming in a couple of hours. And I just I turned that 280 back into a 94. And I didn't even think twice about it. I was just like, here's what we're gonna do. We're gonna go back to manual open the loop up Bolus this much. I'm basically going to put you into a nosedive, and we're gonna pull it up with dinner. And it's exactly what we did. It worked phenomenally. And that on Thanksgiving was the time I thought I really do understand all this now, because I close that loop back up went right back into loop and her blood sugar never went up from there.

Kenny Fox 1:17:39
Yeah, I mean, it's it's a, I was trying to actually explain that same concept to my test endo. Just last week is this Yeah, I mean, if you're hi Bolus for the next thing coming and create that nosedive and put the food in at the right time. And you're okay. And then it works. Not looping. And looping and looping, you may have to give a little bit more or you went to a little bit more patient, because if you do it manually, if you didn't open the loop, then then loops gonna pull the basil back, right, which is fine, it might just tag us to take a little bit longer to create that nosedive, or you may just need to give a little bit more. But in either case, the beauty of it that is easier for people to access, being that bold, is that loops done the math for the most part. So when you go into enter the carbs, it'll tell you how much more or less you might need. So I recommend zero, or whatever it is, that might be okay, but you'll you don't have to worry about, well, how much is left? And how much do they really need? And how many carbs did I give earlier? You don't have to track all that math, the math is in the system. So but you can but you have to create the nosedive loops, not going to do it right.

Scott Benner 1:18:47
So I've learned that a dive and did exactly what you said, close the loop up before the meal, and then put in the carbs. I was still I was still Pre-Bolus thing in my mind. You know, I put in the amount of carbs that I thought she was going to eat about 15 minutes before even though she was dropping, and then loop she was just like, well, I'm only I only want like a unit right now. And I was like go tell it the bullet. So she's like 130 and she's falling. And it wanted a unit. It's like it must feel pretty comfortable that she's gonna stop. So I'm like, Okay, put in the unit. close that up. And then as she was eating and she leveled out, I said, Hey, check for suggested insulin. And there was a bunch of suggested insulin. I said, Go ahead, put that in now. And then that was it. So it was a kind of a hybrid, I use the loop and I used what I knew from before it.

Kenny Fox 1:19:35
You have to be willing to accept the fact that you can no more than loop sometimes. And sometimes you'll find out that you know what you entered plays out and what was in the prediction was actually more accurate than you care to admit that they were going to in fact come down in another 20 or 30 minutes on their own. You didn't need to give them an extra unit manually, but but you sometimes need to know better than Luke because for example with food, when your settings and everything else, if you don't put enough in, you're gonna be high. If you know the food is spike here, it's gonna hit sooner lube only has one model for carbs, it just assumes all carb entries are going to impact your blood sugar in the same way in the same timing. So you have to know if it's a, if you need more upfront, like super bolusing, or you expect to spike and you need to give insulin anyways, even though it doesn't suggest any more, you need to give less, because it's a slower meal, you may have to still know just just enough to be a little bit smarter than loop. And then you can work together when you know where it shortcomings are.

Scott Benner 1:20:38
Can I ask you one last question that before I let you go? How much of all this that, you know, and now I know and other people know about using loop, which, you know, is, is quite a steep learning curve, how much of it's going to apply to control like you or on the pot horizon or some of the other, or I'm sure Medtronic will have one at some point that people will like, and and you know, how much of this knowledge will translate out to those retail systems.

Kenny Fox 1:21:10
Yeah, so we have a on the loop and learn YouTube, we had a recorded meeting with someone I forget their name, but they're really deep into this closed loop predictive stuff. And he walks through the different kind of methods for building these closed loop systems, the approaches. And loop is more of a with a called predictive model, where it's basically you tell it everything, and it's trying to predict out what's going to happen over the next six hours. And some of these other systems have, they like to take a hybrid approach where they're a little bit predictive based on what you've told it. And then in other areas, it tries to do its own calculation, like risk analysis, if it can give you more or less. And so control IQ and horizon both and we just had an interview with someone at Omni pod that talked about that one that's kind of VP over horizon has done all the clinical trials. And she talked about how it works a little bit. And so the system to try to do their own learning. I'm not a big fan of because I don't feel like they're not going to show you behind the curtain and you're not really going to understand what's happening. But they're, they're mostly controlling Q and horizon both seem to heavily rely on the total daily dose that it either sees, or that you give it to start with more than your settings, control. IQ uses your settings as a starting point. I think horizon does as well. And I don't know for sure, but I think control IQ leverages those settings, pretty like it uses it a fair amount. But at some point, after a few days in or weeks in the system, we'll use more of what it's seen, and your total daily dose that you're getting, as its guide for how much you can give the correct and suspend and all of that. And you pretty much are setting your car ratio. So that's important to set your carb ratio. But it's not necessarily totally relying on your sensitivity and basil as much as you'd like. But those basil settings and all that stuff will kick in, in a open loop situation where the Dexcom is not giving you readings are something where it can't do its thing that's its fallback. So it's still important to make sure that those settings are tested every once in a while. But not as much as I would like I guess is my answer, but they still use it. And so that's my concern about the upcoming commercial systems is there, they're going to be better for most people, because most people are not listening to this podcast or looping Yeah, and understanding insulin and how to use it. And so they're begging these systems to basically handle bad settings from doctors and people and just trying to take it over, as best they can and learn you. But the downside of that is that you can't be as precise and if you end up being sick or you have hormone swings, or other situations where your needs overall you're gonna be using more or less in a significant way. Those systems will take days to catch up with you. And so you'll probably be like she mentioned the lady mentioned with the horizon interview, is you just have to make your carb ratio lower and Bolus a little bit more change your correction factor and and just manually Bolus until it figures you out. So it'll use some of our settings and I think the principles and understanding that we know about insulin will still be useful but if they're trying to make something that you can mostly just enter carbs and walk away from it and achieve a moderate a one C and timing range and not go low.

Scott Benner 1:24:50
I do think it's gonna be amazing for most people, honestly.

Kenny Fox 1:24:52
Oh, yeah, I mean, you're gonna get people that you know, a win seasons 789 and more or there's highly variable and it's going to stable them quite a bit. And you can see the data from the horizon clinical trials that she was able to share. There'll be more as they publish. And same with control IQ that they achieve pretty good results. I mean, it's, we would love it if you could lower the targets and take a little more risk of potential hypose. I think some of us would prefer that, but they're doing really good work at all the closed loop system so far that I've seen other than, you know, the older Medtronic con is doing really well in that regard.

Scott Benner 1:25:29
Yeah, I mean, you're trying to, but you have to think of the bigger picture you're trying to reach the masses of people with with type one, and give them all successes that will lead to long life like it really is what you're shooting for, right is to make their day to days easier and make their life longer and healthier. And they're definitely I listen, I sent an email. I'm, I don't know how you got Dr. Lai. I've been trying to get trying to lie on the show for a while I don't get anybody response, your Facebook,

Kenny Fox 1:25:57
talk to Joanne

Scott Benner 1:25:59
Facebook pages swinging a pretty big, you know what I mean? Over there. And so I don't know, I might ask the wrong person. But anyway, that's, that's pretty much how I've thought about it too. And, and I definitely want to listen, horizons got the algorithm built in to the circuit board, which means you don't have to have any connectivity to your phone for the algorithm to run. moment, the most Bolus and a set

Kenny Fox 1:26:29
change settings,

Scott Benner 1:26:31
and styrofoam that is absolutely huge. So I would like that I'm going to be

Kenny Fox 1:26:36
if I could push the lube algorithm onto the pot, and then I I'd be much happier.

Scott Benner 1:26:40
Like you could sneak sneak into on the pot up there in Boston and make yourself a couple you should see, Kenny, I've seen their production facility. It's automated. And it's stunning. It looks like it's out of the future. It's absolutely amazing. Trust me, if you snuck in there, you just get wide eyed and go, Holy God, this is crazy. And you definitely would not figure out how to do what you wanted to do. But it's really cool. I hope to see it again. One day really. I actually tried to interview the guy who set the whole floor up. Because he I think he might be brilliant. He's just a manufacturing guy. I think they got him from Pepsi. I think he used to set up the manufacturing floors for Pepsi Cola. And

Kenny Fox 1:27:23
that's intense. Yeah, I

Scott Benner 1:27:24
think that's who I gotta try harder for him. Actually, I'm gonna get him in 2021. He's an interesting person. I met him once. Anyway, all right, well, let me let you get back to your life and tell you thank you very much for doing this. I hope you have a Merry Christmas and a Happy New Year. This is gonna come out in December very soon. And I just really appreciate you giving so much time and and sharing so much of what you've learned about loop. It's really been valuable for me and for a lot of people who are listening.

Kenny Fox 1:27:50
Thanks. And for those juice boxes out there, you know, feel free to practice with that super Bolus as you come up on holiday meals. Depending on how the holidays look for you. Yeah,

Unknown Speaker 1:27:59
get a little bold with loop, right?

Unknown Speaker 1:28:01
Yeah. All right.

Scott Benner 1:28:02
Did you just name the episode a little while ago, Kenny. You might not you knocked your name right off the episode. Good job. This was gonna be something you know, cutesy about Fox. And instead, I'm calling it bold with loop.

Kenny Fox 1:28:20
I guess you could do Fox and loop house three bolt with loop. But it's a long title.

Scott Benner 1:28:24
It's not a Schwarzenegger film.

Kenny Fox 1:28:27
But you gotta be able to find all of them. Right. So

Scott Benner 1:28:29
yeah, I see. I got to keep it together. You're right. All right, Kenny.

Kenny Fox 1:28:33
Bolus loop. That's kind of what I've been. I've make a little like, out of my mind. My little catchphrase that I've been trying to share with people sometimes it listened to the podcast and lupino

Scott Benner 1:28:42
Yeah, no, I listen, I I tell people all the time. That's absolutely true. I have a mantra, it's, it's I'd rather stop a lower falling blood sugar than fight with a high one. That Yeah, everyday with diabetes, thinking about that.

Kenny Fox 1:28:54
And it's about finding a way to become a team with loop rather than feel like you're fighting it. You know,

Scott Benner 1:28:59
I'm there. I have to be honest, I want to thank Gina who forced me to do this a year and a half or more ago, and you who've come on and talk about and all the other loop users who came on helped me work through it and Katie for coming on and explaining what loop was, I just, it's been a process and I think we've been able to pull a lot of other people along with us. So and I hope for everyone else, they're hearing the value of, of algorithm based pumping. I think it's a, it's gonna change everybody's life and 2020 one's gonna, I think it's gonna really explode for people with type one. It's exciting.

I'd like to sincerely thank Kenny and all the people who've been on the show over the last year and a half for helping me understand the loop DUI algorithm better. And they do really hope that all of you listening understand that as these algorithms become more and more available in retail pumps. It's gonna be lifetime Thanks also to the Contour Next One blood glucose meter. You can check them out at Contour Next one.com forward slash juicebox. And of course, the T one D exchange can be found at T one d exchange.org. forward slash juice box. I'd also like to say a huge thank you to one of today's sponsors, g Vogue glucagon, find out more about chivo Kibo pen at G Vogue glucagon.com forward slash juice box, you spell that GVOKEGL Uc ag o n.com forward slash juicebox. At this point, there are a lot of series within the podcast I mentioned at the beginning. And I'd like to mention again, the algorithm pumping series, which goes Episode 227-252-3043 12 313 326 and of course this episode 420 but I'd also like to tell you about the after dark series 274 about drinking with type one 283 about weed smoking 305 about trauma and addiction 319 about having sex with Type One Diabetes from the female perspective. Episode 336 is about depression and self harm. Episode 365 is sex again, but this time from the male perspective. Episode 372 talks about co parenting and divorce Episode 384 bipolar disorder Episode 393, bulimia and depression and Episode 399. A tea one who was addicted to heroin, I really think the series within the podcast are incredibly valuable. Don't forget to also look for the pro tip episodes that begin at Episode 210. And of course, sprinkled throughout defining diabetes short episodes to take everyday diabetes terms and put them into an easy to understand definitions. And they're not just definitions, but Jenny Smith and I talk them through. And if you don't know, Jenny, you really have to find those defining diabetes, pro tip episodes. And even the Ask Scott and Jenny. Thanks so much for listening. As the sixth season of the Juicebox Podcast winds to a close I find myself really looking back and reflecting. And I'm just very grateful for everyone listening for all the hard work you do sharing the show and for this connection that we've built. I'll be back soon with another episode.