Omnipod, Juicebox Podcast, Dexcom, Interview, Type 1 Diabetes, Pre Bolus, Ask Scott & Jenny, Loop Scott Benner Omnipod, Juicebox Podcast, Dexcom, Interview, Type 1 Diabetes, Pre Bolus, Ask Scott & Jenny, Loop Scott Benner

#282 Ask Scott and Jenny: Chapter Seven

Answers to Your Diabetes Questions…

Ask Scott and Jenny, Answers to Your Diabetes Questions

  • Are growth spurts a gradual increase or all at once? Strategies for evening spikes.

  • Any tips for being bold with insulin with the Medtronic 670G pump in auto mode?

  • Let’s talk about tricks for Loop, being flexible and learning from your experience.

  • Let’s talk and compare Control IQ, Basal IQ, Medtronic 670G and Loop.

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DISCLAIMER: This text is the output of AI based transcribing from an audio recording. Although the transcription is largely accurate, in some cases it is incomplete or inaccurate due to inaudible passages or transcription errors and should not be treated as an authoritative record. Nothing that you read here constitutes advice medical or otherwise. Always consult with a healthcare professional before making changes to a healthcare plan.

Scott Benner 0:00
This episode of Ask Scott and Jenny on the Juicebox Podcast is brought to you by companion medical makers of the in pen. To learn more about in pen, go to companion medical.com or click on the links in your show notes, or Juicebox podcast.com. Are you wondering why I want you to visit companion medical.com? Well, that's simple, because in pen is America's only FDA cleared smart insulin pen and app system. When you get to companion medical.com, you'll discover that in pen combines an innovative diabetes management app with a Bluetooth enabled pen injector. This will simplify the constant tracking monitoring and calculating required for insulin therapy within Penn MDI users are able to live life less complicated. Welcome to Ask Scott and Jenny. These are the episodes where Jenny Smith from integrated diabetes services. Now Jenny, you may know has had diabetes for decades. She's a pump trainer. She's a CDE. She's I think once she went to the moon, I don't remember exactly, but she's done a lot of different things, right? She's also a nutritionist. Listen, she's everything you want. Why are you arguing with me? No, you're not arguing me. And anyway, Jenny and I. We answer questions from you guys. They're left on the boat with Vince on Facebook page. I asked for them every once in a while. I do it real slick. I go like this. Yo, does anybody have any questions for me and Jenny? And then people leave questions and then we answer them. Anyway, today we're going to talk about growth spurts, the 670 g from Medtronic loop tips and a little bit about control IQ. What do you think of that? Hmm? Okay, then. Please remember that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise. And always consult a physician before making any changes to your health care plan. or becoming bold with insulin.

Laura says kids and growth spurts Is it a gradual increase or an all at once change? Is that something that you notice they need more of all the sudden that she gives her example toddlers for him was five, still close to some still close to the same ratios? ISF and bazel. From when he came out of honeymooning. I know he's gonna hit a growth spurt soon. And I guess she's looking for like, How do I know when it happens? And what do I do? And I think this falls under the auspice of those of the idea that I just want somebody to tell me how much or when, like, you know, do you mean like, give me a number or an idea? And I don't know that there's a specific answer. I have a general answer. But I wonder what you think about and what you see.

Jennifer Smith, CDE 2:59
Yeah, and my answer is probably similar to your general answer, honestly, there's not a, there's not going to be a specific like, you're always going to see 25% more insulin needed, right. I mean, it could be over several growth spurts that you notice, gosh, he always need like an extra point one added or an extra 25% or whatnot. But it's, it's not that cut and dry by any means. one specific time though, that most parents with kids with diabetes, and parents of teens with diabetes will notice the heaviest impact of growth. With a surge for only, you know, a short amount of time is evening, where their kids go to bed, they've had things really nicely contained. And all of a sudden they get these like spikes. Almost as soon as the kid is snoring, like their head hits the pillow, they're snoring, and up it goes they've been at this beautiful 111. And up it goes and they fight it and fight it and fight it. And it could be an all night fight depending on how strong the growth surge is. And in those instances, it's okay, let's try it. I usually encourage people to try first a temporary bazel increase rather than shooting it with like a dose of three units of insulin and then chasing the drop down. Attempt bazel increase, you know, that might be significant. Maybe it's 50%. Maybe it's 100% more for a time period. See where it levels off? When does it start coming down? You can always shut off attempt it is all right. So and then if you learn from that, let's say two nights in a row, you start to see this surge on the second night when it gets going. You hit that Temp Basal again, similar to the night before if it controlled Well, if it wasn't quite enough, and you still fought a high pump it up even more. But then once that growth spurt is sort of reversed They may need not as much like as the Temp Basal you are giving to offset the rise. But their overnight needs may definitely go up, you know, they were at point to their growth spurt needed a 50% increase overnight for that time period. And now instead of being at point two an hour, now they're at point three or point three, five. And that might be where they sit for a time period until another growth spurt happens is

Scott Benner 5:28
that going to be because there's more body mass, like you've actually grown? There's more of you, or

Jennifer Smith, CDE 5:34
potentially or just the changes that right? I mean, in little kids, especially little kids, I sometimes, you know, with mine, especially my almost three year old, sometimes he wakes up in the morning, and I'm like, you grew right? You just like, all of a sudden, he just let you look bigger, you look like your cheeks are slimmer, or you know, he just looks bigger. And, you know, so sure it can I mean, it wasn't technically overnight that he just shot off. But those, you can suddenly kind of see it and people who are attuned to their kids, especially parents, with little kids who you're following so many more things than just which truck they want to play with, you know, staring at them constantly. And, you know, I mean, with diabetes, you pay attention to so many things. So you could like I said, you could see a tremendous need in a spur period, and then it levels off, but it doesn't come back down to where they were before the growth spurt. Right?

Scott Benner 6:32
I have to say, I think the idea of looking for physical clues is brilliant, because I know our son, his calves would get thicker. Like all of a sudden, you'd look at him and his calves would be out of proportion with the rest of his body larger. And then sure enough, he would get taller. It was almost like his body was like, okay, we're getting ready to do this. You know, like, and it would store things in certain places or something would get bigger sooner. It was just really it never failed as he was growing and I have to say to door jamb that you don't mind drawing on with a pencil is great as you have children, a few people have younger kids. I'm sure you're doing this, but it gets really fun. A decade later, when you're like stand there for a second, you know, and and you get to see how they move up. I would say the answer to this question to me, is the core of the of the podcast, right? Oh, hold on a second. Arden needs a little help with their balls for a second.

Unknown Speaker 7:26
That's okay.

Unknown Speaker 7:29
What is six times

Jennifer Smith, CDE 7:30
we don't use the door jamb we use a my mother in law when our first was born bought us this like measurement tree, and you put it on the wall and kind of pop it in. And same thing, same idea, you just push the hash marks on to the tree as the child grows. But the nice thing is that we've used one side of the tree for Oscar and the other side of the tree for Conan. So we can see where they both are. And it's kind of fun to now be able to see where was Oscar? And is Conan meted out the same? Or is he getting bigger faster? Or are they growing about the same? It's kind of fun? It really

Scott Benner 8:08
is. I have to say my wife has told me without a doubt if we ever sell this house, she's like, you have to pry that board off the wall and replace it for the new owner because I'm taking it with me. And I was like, Okay, yeah. So anyway, what I was going to say is that I think this is one of those questions that if you just caught me, if you texted me real quickly and asked me this question, I would say to you, this is why the podcast is terrific. Because you are running into an insulin need. And it's saying to you, I need more insulin, give it more insulin. Try not to worry about why just it does. And when's it gonna start? When's it gonna stop? I don't know. It does kind of suck. I'll tell you like, you know, because after four or five nights of this, and it goes away on that six night when you're finally like, I trust this is going to happen, jacking up bagels and bolusing and everything. And then it turns out, the growth spurts over now you're waking up somebody at one of the morning going, hi, would you like a chicken sandwich in the banana? It's a it sucks. But it works well for those six days. And in my opinion, it's better than being high for six days and just saying, oh, it'll come back again. Right. You know, I just think that's how I would handle it.

Jennifer Smith, CDE 9:15
Correct. And anything, you know, you bring in a good point, in just the comment of when it comes back again, because it will little kids grow and grow and grow and grow and even teens, you know, up to a certain point, girls grow for less time than teen boys do. I mean, teen boys can grow up and into even like 18 to 20 years, some boys. I mean, most often majority is done by like 18 years. But most girls are pretty done growing up by about 16 years old. You know, they look

Scott Benner 9:53
so much older than the boys even when they're 1314 like in that range toe,

Jennifer Smith, CDE 9:57
right. So you know know that In the nature of all the testing and the things that we've talked about in the other podcasts and the figure out the bazel, and figure out the ratios and all that kind of stuff, it's it's not a number that's gonna sit there until they're well into their adulthood, when maybe a variable component of their lifestyle changes, where they will need to make an adjustment. Kids needs change. That's the simplest way to say kids needs change. So don't think you're crazy. If you go for a couple of weeks, you're like, I got this. It looks like it's working magically. And then, like, professionally, I get these emails. They're like, I thought we had this all figured out. It was all working beautifully. And now the last three nights, this is happening again. I'm like, Okay, well, we need to adjust. Right.

Scott Benner 10:47
So Jenny answers those emails by how do you think we stay in business? It's gonna keep it's gonna keep changing. But But no, I genuinely think that's a great answer for that. Okay. Richard says, any tips for being bold with insulin while using Medtronic 670 gene auto mode, you basically can't adjust the bazel other than temporarily turning on the target of 150 bg instead of 120. And it auto calculates bolus based on carbs, BG or a combination of both. It won't do a correction bolus, unless you tell it your BG is above 150. It adds up to great time and range stats for me range being 70 to 180. But I'm spending a lot of time at the upper end of that range. And I'd like to be closer to the 120. I know Arden and Jenny are Potter's but I think Jenny's colleague, Gary uses 670 g maybe? Well, Richard, I don't know how comfortable I am with everyone knowing so much about our lives. But But I am going to have, I finally have some insight into this automated pumping thing. My brain is starting to almost get all around it. But Jenny is going to go first because I've never seen the 670 g before.

Jennifer Smith, CDE 12:03
Yeah, so the 670 G. M. I said it's hard to sit too long, if it is a long pause, because I have to, I have to be kind of, you know, good in the way that I explain it. Because the 670 g can be phenomenal for some people knock the majority of people. But for some people, it does work quite well. Who does it work quite well for? If you have a pretty structured life, if you have a pretty typical breakfast, lunch dinner, you always go to the gym between four and 5pm. You know, it can be a really good system for holding you a lot more stable, it does do a really nice job, for the most part, again, in those in that type of a life for the overnights, similar to the other, you know systems that do something like this with the augmentation to the bazel and how it goes up and down. But I can see that the 670 for a good majority of people with the variability of today's lifestyle. It doesn't meet need. And for run really specific group. Women in pregnancy it doesn't meet need because it doesn't target the right blood sugar, at least not right now. Nothing Medtronic isn't working on that, from what I understand future iterations will have lower targets and different things to it. But the current 670 You know, it targets the 120. I would say for most people who are having success with it. They're typically getting an average blood sugar of about like 130 ish, not really 120 even though technically it's targeting that. And this question kind of alludes to that piece is that it's really not allowing any corrections unless you're above a higher number than you really want to be at anyway. Right. Right. And it's only correcting you down

Unknown Speaker 14:07
to 150.

Scott Benner 14:08
Yeah. Okay. So it's

Jennifer Smith, CDE 14:10
never really getting you too that that technical target. The other component to the system is that it's, it's not using your current manually set bazel profile to work off of with its increasing and decreasing of insulin dosing through the course of the day based on glucose change. It's I we kind of call it the secret sauce of whatever Medtronic has figured out in their algorithm. The system a couple of days of manual mode use gets an idea of your average of insulin need and kind of like a sensitivity and your sensitivity to insulin and what it does, then use it Essentially doses your insulin along the course of time in a day, based on what it is seeing your sensitivity look like. So really the only factor that in auto mode 670 is using is your insulin to carb ratio. If you've got it set at a one to 10, you're going to get dosed off of a one to 10 along with where your blood sugar is, and that kind of stuff. But even your ISF or your sensitivity correction factor, that is not what auto mode is using. So, you know, it's kind of a long,

Scott Benner 15:40
but it's a limit. It's, I mean, I guess you'd call it a limitation of the system. But not a limitation. I guess it's how it was designed to work. It's not working the way and I see the problem. If you're at that top end of that range, or 175, and you're heading up. And without intervention, you're going to get to 240. But it only intervenes enough to try to get you from 175 back to 150, then that's where it won't work, right. Don't forget what companion medical wants you to know, they want you to know about the in pen. The pen is not just this beautiful Bluetooth enabled insulin pen. It's also an app that works in Congress in Symphony in think of another word that means like all together between your app, the pen, and your dexcom continuous glucose monitor. The app is going to give you an at a glance, look at your current status, from last dose to active insulin to recent doses. It has a dosing calculator to help take the guesswork out of dosing. That's a huge help for MDI, right. You'll be able to enter your blood glucose and what you intend to eat. And the correct dose will be recommended to you by the Impact app. I come on. If you're MDI, you got to admit this seems it seems like a leap, right? Here's dosing, reminders and reports and temperature alerts, there's a whole bunch of stuff but you'll learn all about it when you get there. When you get to companion medical comm so for those of you looking to take a pump break, for those of you who are already doing injections, and just wish you had a little more judge get out I mean, in pencil way to go. I want to thank them, of course for sponsoring this episode of the Juicebox Podcast. And I will thank them by reminding you to go to companion medical comm to find out more. Oh, there's extra time in pen is terrific. Why are you not trying the in pen, go get in pen today. companion medicals.com or on the links to wait hold on a second get even deeper. Check it out today at companion medical.com.

Jennifer Smith, CDE 17:55
Many people who will complain in auto mode about getting what we call kicked out of auto mode and kicked back to manual. What two scenarios one in the example you give as blood sugar is rising, and the system is micro bolusing. Along the way, they don't call it temp increase, they just call it this micro like bolusing along the way that the system will only micro dose for a set amount of time. Yeah. Before it says Nope, can't help you anymore. And out of auto mode, you get kicked back into manual mode. Okay. So on the opposite end of that if you're like low, and it can only adjust so much in a low time period. So you could get kicked out of auto mode as well.

Scott Benner 18:47
On purpose,

Jennifer Smith, CDE 18:49
you can you can choose to turn auto mode off going back to manual mode, which is I've got a couple of people that I work with who've been using 670 for a number of years already. And they've figured out the tweaks and the tricks and the things which we actually have on our website. I've got a lot of little tips for you if you are using the 670 These are some of the little nuances and this is how to like do it better essentially. But some of the people I work with just when they see a higher blood sugar and they know that this system isn't gonna adjust it as well. They just go back to manual mode, they add a corrective and they take care of it and then they go back to auto mode once the cyst once you're brought back to where you kind of want to be. Yeah,

Scott Benner 19:36
I see with what I see with lupus. I now have figured out two things when it looks like it isn't going to stop arise and how to get out of opening the loop. So as soon as I see that up, then I go Hmm, that's not working. For some reason. I bolus what I think is a significant amount I bolus an hour's worth of her bazel Plus, whatever I think the rise needs to correct. So it'll be sometimes sometimes I'll be like, open the loop and bolus four units, which is, which is a lot of insulin to try to stop. Because what you're really looking at is a 135, diagonal up, which doesn't make any sense to put in for it. But it does if you understand what the algorithm is going to do next. So you're going to open the loop, it's going to go back down to your base, you know, base, I'm going to try to stop the rise anymore, it's just going to go too far. Now, I think it's like 2.4, something like that an hour. So it'll go to that. So I've put in enough insulin to stop the stop the arrow, stop the momentum, bring it back. And then when I get momentum coming back down, I figured out and I can't obviously pass this on to any of you. But I can look at the Dexcom graph and go close know when the court follows it now, right? And so you close it now. And it's almost like, it's almost like flying or landing an airplane without your, without your gauges, I guess like you just look at the ground and you go, I gotta start pulling up right now this is it. And, and it works. I can't believe I can't believe I figured something out about looping, to be perfectly honest, you know, a workaround for it. And it's a workaround, that doesn't cause a problem later. The only way you can get messed up coming out of open loop is if you're if you close the loop, and then go right into a meal again. Because then right, then you'll put in, and this just happened while we were doing this, you'll put in art and just put an ad carbs for a large lunch and had a bagel involved in it. And she said, it didn't give me any insulin because we just came out of open loop. And I was like, That's alright, because I wanted this to be 11 units. So still put in the car absorption is 40 over two hours, 40 over three hours, which by the way, spreading out your carb absorptions stop multiple different stops, it stops it from shutting off bazel because it thinks oh I have to stay on for a long time you trick it. You're smarter than the loop, damn it. And then so you get up 40 and 40. And then I just told her Bolus all 11 units. So now it has the 11 units to work with. It has the absorption times in and then it will make decisions about bazel based off of those other two things. And more importantly, I win Jenny.

Unknown Speaker 22:25
Important. Right? Oh, wait, yeah, Arden wins because she's healthy.

Scott Benner 22:32
I defeated that damn thing. I feel like I beat a robot in a sci fi movie. You know, like, like, it came at me with like a spitting action a torch. And I was like, I'm gonna die. And then it was over. I won.

Jennifer Smith, CDE 22:42
I was just like, I can't move on. Yeah, but that was I know. And why why are you winning? You're winning, because you've watched and you've learned?

Scott Benner 22:49
Absolutely, it took me a while. I am telling you this in October. And when did Arden go on loop? It's got to be like six months ago a while right? And, and people at that time were like, oh my god the boat with insolent guys looping. We'll all have great directions for looping in just three days. And then you all emailed me for months. Like tell me what to do with looping. I was like, I am still. And so when I tell people, it, they're never mistakes. It's always a learning situation. I that's exactly what I did. I hate to say it because I think it sounds a little douchey. But when I don't know what to do with diabetes, I go back to what we talked about in the podcast, I just, I revert back to the basics. And I go, okay, what's happening to me here, and then I apply one of those protip episodes until I know, it's, it's a little strange, because I'm the one that said it the first time but it's a great example of how in the middle of life, you can forget things you know, you know, like just because it comes at you from a slightly different angle all of a sudden, and it doesn't look the same as you expect it to you panic and you go different thing don't know what to do, and it's over. But I just kept applying the tenants of the podcast until I figured out the loop thing. So I am so close to us doing that.

Jennifer Smith, CDE 24:01
You know the same thing. I mean, I learned I've learned a lot over now two years Actually, today is my two year anniversary of using loop.

Unknown Speaker 24:10
This is your loop version started

Unknown Speaker 24:11
on Halloween.

Unknown Speaker 24:14
Yeah, by the way,

Jennifer Smith, CDE 24:17
it was what actually you know, to be quite honest, as most people do, you know, I actually I started in closed loop the evening of October 30. And by like the morning of the 31st I was like

Unknown Speaker 24:31
coupon open loop like

Jennifer Smith, CDE 24:35
so I closed it and it was it was actually really great. I mean, I got a chance to trick or treating with my boys and whatnot. That evening. It was was really cool to be able to watch the system and I would have usually applied like some type of temporary bazel or just plan to like steal candy out of there like buckets as We are treated along the way. And it was really fun that Halloween because I didn't feel the need to pay attention, nor did I get any alerts while we were trick or treating, because Luke was doing a great job. And so I don't I think it was kind of a fun day to have started it. So

Scott Benner 25:23
don't test yourself a little bit, right? Don't Don't

Jennifer Smith, CDE 25:25
Yeah. But again, learning, you know, I learned, you know, like my coffee in the morning, I typically found pre loop I had they have a half a unit of insulin to cover. Well, that wasn't based on carbs. It was just what I had learned to utilize. Right? Well, now in loop, I had to actually go back and figure out how much does that equate to as far as like a carb entry for loop to really cover this? Yep, the right way to offset that like caffeine rise and everything. So there is there's relearning to using these hybrid closed systems, whether it's the six, seven dg or loop or open APS or whatever, there are pieces of things to learn that you weren't applying before. Or maybe you were you just have to learn them in a new way with the system. I

Scott Benner 26:18
think that's that's it. Arden right now is at lunch. She's 75 her blood sugar 75. Here's how the morning when she got up in the morning with a pod that only had a couple of units left in it. So we swapped it running out the door, swap it as she's getting that little bit of a rise from the morning, right. So I see like a 120 is starting to creep up. She was one on one while she was getting dressed all sudden, she's 120. I threw in a unit from the old pod because I didn't want to waste it took off the old pod put on the new pod, looked at what insulin was pending for lube, bolus pending insulin. Then she started we drive into school and I just noticed that I felt the number jumped too much. And I was like open the loop and Bolus two units. So now I'm thinking about pod change insulin right. So we Pre-Bolus two units I comes in perfectly forget to close the loop this morning, I'm running around doing a bunch of stuff we forget to close the loop. So then something hits her where she needs more bazel loops, not closed doesn't work, she starts going back up again. 134 diagonal up at 9am. Now I'm like Oh, she's got to eat an hour and a half. reopen the loop Bolus more 91 diagonal down when she wants to eat. And then you heard the rest. We closed the loop tried to do 80 carbs, it didn't want to it didn't want to give it to her. So I gave him the sweet we set up the the absorption times and gave the insulin anyway. And now she's eating and she 75. And I'm telling you two months ago I don't even know where her blood sugar would be with loop right now it would have been a disaster. But I needed that disaster to happen. So I could wrap my brain around the whole thing really. So I'm very, I'm doing very well with it now. Like I can't wait to see what hurry once he ends up with being three full months of this kind of new space. Alright.

Jennifer Smith, CDE 28:06
And it kind of goes along with I think one of the last times we did a we did a chat like this there was we kind of both talked about like taking a hit. Right. And so I actually for our newsletter for October newsletter, I actually did an article about what you can gain like taking a step back in order to take two steps forward. You can learn from the hits that you end up taking Well, my blood sugar did do great for, you know, this five mile run that I planned. Okay, well, what did you do? What didn't work and plan accordingly for next time you you can learn from taking some steps back

Scott Benner 28:47
hundred percent you have to stop every once in a while you just have to broaden your scope and stand back and see the whole picture. Because you're just telling the fight. You know, it's funny. The it's a completely strange, I thought but I think in my mind, it's the same thing. Phillies hired a new manager the other day, Joe Girardi he was really successful manager with the Yankees for a decade, you know, left there. And it's been out of baseball for a couple of years. And he said, I heard him in an interview. He goes sometimes when you're in it, it's hard to see it. You know, he's like you're in this fight. And you're so focused on winning, or I guess in this situation, you're so focused on your blood sugar being where you want to be, you don't see how it is you're losing or winning. You don't know why anything is working or not working. You're just swinging hands, you know. And so I think that's a perfect scenario. I think you got to step back and just look at the big picture sometimes. All of these things that have been on T shirts for the last 50 years have been there for a good reason. It had everything we just said about 670 G and looping. does it apply to basal IQ as well?

Jennifer Smith, CDE 29:55
I think it probably will apply more to control IQ. Okay. Which is basically like you really is only a predictive low glucose suspend, right? So the system is looking for glucose to be less than 80 within the next 30 minutes. And if the trend in glucose is happening such that that's going to be the case, then it predictively suspends the insulin delivery on a basal level. But the interesting thing about it is that it actually doesn't do only bazel suspension. It also suspends an extended bolus. So if you are using bazel, like you, and you have a trend happening, and basal IQ kicks in, and you've got an extended bolus, your extended bolus will be stopped. And so once these like you kick things back on, you have to remember to go back in and either resume an extension of what was missed, or just Bolus for the rest of what was missed, depending on how long bazel iq was kicked off. So that's a kind of a nuance to that system and control IQ will be, I would say, closest in similarity to 670 G. Neither of those systems are by any means close to looping in any sense, you know, loop open APS, Android APS, I, the the current approved, hike, sort of hybrid clothes are just not, I mean, from the basic information about the research of the control, like you, and the people who have used it in the trials, it seems to do a good job. Again, it's conservative, similar to the six, seven dg in what it does, but some of the factors that it uses to adjust. From what I understand it does use your set bazel in the background to adjust off of rather than its own secret sauce of applying a bazel does use your current sensitivity factor as well as your carb ratio. So that, in my opinion clinically, and like if I was going to use it personally, I think that those are big steps beyond 670. Because it's using some things that is, as we've talked about, if you know that your settings are good, why wouldn't you want a system to work off of what you already know, is working to a degree, right?

Scott Benner 32:27
It seems like these systems are, are set up. I'm sure there are people who have been living their lives in the two hundreds and the three hundreds who are on these systems and think this is amazing, right? It's just not the next level of what can be done. Okay, and I'm assuming they were set up on purpose like that. That's what they were made for. And they're probably doing a really good job for the people that are working for.

Jennifer Smith, CDE 32:46
Correct. Yeah.

Scott Benner 32:53
Huge thanks to em pen from companion medical for sponsoring today's show. And of course, the Jenny Smith from integrated diabetes. Did you know you can hire Jenny, you can go to integrated diabetes.com and then find Jenny. I don't know what you'll do it. You'll figure it out. And then you can email her also right there in the show notes. There's Jenny's email address. That's probably easier. You click on that you send an email. Here's the email says, excuse me. Hmm, I'm composing. Dear Jenny, I heard you on the Juicebox Podcast comma. I love you exclamation point. Can I please give you money to help me question mark, and then you sign your name and she'll get back to you

About Jenny Smith

Jennifer holds a Bachelor’s Degree in Human Nutrition and Biology from the University of Wisconsin. She is a Registered (and Licensed) Dietitian, Certified Diabetes Educator, and Certified Trainer on most makes/models of insulin pumps and continuous glucose monitoring systems. You can reach Jenny at jennifer@integrateddiabetes.com

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Omnipod, Juicebox Podcast, Dexcom, Interview, Type 1 Diabetes, Pre Bolus, Ask Scott & Jenny, Loop Scott Benner Omnipod, Juicebox Podcast, Dexcom, Interview, Type 1 Diabetes, Pre Bolus, Ask Scott & Jenny, Loop Scott Benner

#267 Ask Scott and Jenny: Chapter Three

Answers to Your Diabetes Questions…

Ask Scott and Jenny, Answers to Your Diabetes Questions

  • Let’s talk about standard deviation and target range.

  • Let’s talk about Loop and absorption time to better understand food impact, glycemic index and extended bolus.

You can always listen to the Juicebox Podcast here but the cool kids use: Apple Podcasts/iOS - Pandora - Spotify - Amazon Alexa - Google Play/Android - iHeart Radio -  Radio Public or their favorite podcast app.

+ Click for EPISODE TRANSCRIPT

DISCLAIMER: This text is the output of AI based transcribing from an audio recording. Although the transcription is largely accurate, in some cases it is incomplete or inaccurate due to inaudible passages or transcription errors and should not be treated as an authoritative record. Nothing that you read here constitutes advice medical or otherwise. Always consult with a healthcare professional before making changes to a healthcare plan.

Scott Benner 0:00
This episode of The Juicebox Podcast is sponsored by in pen from companion medical. Please remember that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise. And to Always consult a physician before making any changes to your healthcare plan, or becoming bold with insulin. MDI users, this one's for you. How would you like to live your life less complicated? You can do that within pen in pen is a reusable injector pen that has its own smartphone app. They talk to each other through the Bluetooth. that Bluetooth is magic, isn't it? You know what the app does? I'm going to tell you a lot of battle over the next few weeks on these Friday shows. But for right now, dose calculator dose reminders reporting actually tells you if the temperature of your insulin has gone out of range. Not only that, it connects to your CGM. Ooh, I got you there tonight, an app on your phone that connects to your continuous glucose monitor that connects to your insulin pen. Now you want to know more about indepen don't you? Check out companion medical.com. Welcome to ask Scott and Jenny. In today's episode, I Scott and Jenny Jenny Smith from the diabetes Pro Tip series in defining diabetes. You know Jenny, Jenny works at Integrated diabetes. She's a CDE, a registered pump trainer CGM trainer dietician, she has type one. Her favorite candy is dark chocolate peanut butter cups. And if Jenny was a professional baseball player, she'd be Hank Aaron.

In today's episode of the show, Jenny and I are going to be taking questions from you the listeners. In this episode, we're going to talk even more about understanding standard deviation and absorption times for loopers. Now that absorption time for lupus thing, don't get confused and think if I'm not looping, this doesn't work for me. It's also going to be able to inform you about how to understand your extended boluses. Trust me, it's all about timing and amount.

mirdif asks one interesting journey after we did standard deviation in a defining diabetes. I get this question a lot now. So obviously we there's something we didn't say there. We caused more questions than then

Jennifer Smith, CDE 2:42
then I think I read this one, what three day

Scott Benner 2:45
target for standard deviation? And if you set your targets tightly for alert purposes, will it look like your standard deviation is greater? Will that not affect the value of murder? We did talk about this in the office? Because I've had the same thought. But I won't. Yeah, I'll let me go over it one more time in case we missed something in that episode.

Jennifer Smith, CDE 3:03
Yeah, so standard deviation really speaks to the variance up down. So even if you had your target set, let's say, in your CGM, you have your target set from 80 to 120, let's say a very tight target, okay. But you have this roller coaster that's happening this up, down, up, down, up, down, up down, you know, from, you know, on the low end, maybe in the 50s. And on the high end, maybe up to like the 120s, you're still you're going to have a higher standard deviation, because the variance even within that target that you're still meeting, you're still having a roller coaster. Now the standard deviation is going to get higher. If you have more variance, let's say even if you're your target is that 80 to 120. And you're going from 50 all the way up to 300. And way back down and way back up to 250 and back down, then the standard deviation is even going to be larger than it was with a roller coaster within a target. The aim for standard deviation. I'm always kind of cautious to say we're aiming for a standard deviation of this solid rock, you know, this one number. The lower the standard deviation, the better. That's that's the easiest way to say I mean, if you're looking at a standard deviation of 70, you've got a heck of a lot of variance you do. Your CGM graph probably looks like a roller coaster at an amusement park, right? That's not what we want to aim for. Even within a tight target. You still don't want all of this happening. You want more gentle rolling hills from you know within less or within a tighter range, right? That's going to bring the standard deviation down. So if you have you know, a target range set from 150 to 180. And you're meeting it and your standard deviation is 21. That's a beautiful standard deviation, but your target is leaving you high. Right? So you're doing a good job of keeping things to a minimum as far as excursions, but you just need to ratchet your target down to keep that same low standard deviation. So I hope that makes sense. I'm going

Scott Benner 5:29
to share what we do because it's by no means the rule but it's a place where I've become comfortable with living life and finding a balance. Right. So Arden's target is set at 70. And 120. I'd love to be between 7120 as much as possible, it's not as much a target as it is. alarms for me, like when do we have 120? So I know what to do, right. I love for Arden standard deviation to be lower than it is. But in honesty, I tried just not to go over 40 Like that's like, and that's not great. Yeah, but it's, it's I shoot for more like 35 I try not to go over 40 If you look at Arden's graphs, they're interesting in that 18 hours of the day, her blood sugar is like 80. You know, most of the time, there's two meals that are varying cause a variance Right. And, and she'll jump up usually, it's like 181 60, conventional pumping, I was able to get down a little more quickly. But we're doing now not as fast. But conventional pumping, I didn't have 18 hours of ad that was solid. So in my mind, it's a bit of a trade off, and I'm learning how to do the meals better. I think that you should think about standard deviation more in the context that Jenny put it in. You don't want it to be 70. Not good. Right. But if you're shooting for 20%, or something like that, probably not that realistic. So I've heard under 40. I don't know where I've heard that from is that a reasonable like Mendoza line for

Jennifer Smith, CDE 7:13
under 40? Absolutely. I mean, if you're really it, I usually with the with the people that we work with trying to aim for, you know, the 30s or without consistently running just way too low with little deviation, the 20s can be great, as long as like Arden is kind of hovering at that at with little deviation. Great. That would be awesome. You might be in the 20s. But you know, 30s is kind of where we aim. Overall, with a little bit lower or whatnot. Depending on what situation in life you might be at two, with the women that I work with through pregnancy, we aim lower, tighter overall everything.

Scott Benner 7:55
Let me give you an example because I'm looking at a live grant for art and for 24 hours, right? So in the last in the last one day Ardens a one C has been 5.8 with an average blood sugar of 119 that put our standard deviation at 42. Now if you go out over 90 days, Arden's averaged a one C is 5.6. Over 90 days, her average blood sugar's still 115. But her deviation will probably go up. It does. So it goes it says 45 Over the last 90 days now we are still learning some things and so we have some more prolonged blood sugar's but for instance, in the last seven days, her standard deviations 38. Right. So as I get better at it, you know, over the last 90 days, because you know of this loop thing, you know, you see it come down, I will get the deviation consistently under 40. I think it's going to be more consistently like 35 Once I figured out the meals, but then, you know, I think Jenny's Right. Like once you have the tools in place and things are working. I see standard deviation not as a target. I see it more as See, I don't want to call it a report card, because I don't mean it like that. But I think of that more something you look at later to say, oh, things are getting better, not something right day to day. It's like a comparison

Jennifer Smith, CDE 9:19
almost to say this is where I was this is where I am now. Oh, it looks like it has improved.

Scott Benner 9:26
I would look at if you're looking day to day, I just look at average blood sugar, and I try to keep it lower. And then I look at at deviations like high high deviations. Obviously I don't want a low blood sugar. So I don't have a lot of problems with lows. But I don't want to see big spikes that lasts too long or big spikes. Right. So Meredith, I hope that answers some question and then I'm about to tell you something about in pen. And I think I should first warn you it's possible the information could blow your mind. So I don't know what you want to do put a hat on or hold your hands in the side of your head or something like that, but When you Bolus within Penn say you're having some food, right? And you look at your plate and you're going 10 times, you decide that's 35 carbs, you go into the in pen app, tell it 35 carbs, and it tells you how much insulin to inject, right? Hold yourself tight now because the here's the rest of it. Now pen users, no, you have to prime your pen a little bit. So you prime the Impend, and then dial up the insulin that the app tells you, let's say it tells you a 3.5 units, you inject those 3.5 units, the in pen actually can see the difference between the prime and the 3.5. And it doesn't. So you know, I'm saying like, when it's calculating how much insulin you have, it's not saying like 3.5 plus the priming amount of insulin it know, how does it know? The fascinating, right, like just boom, I don't understand. I mean, for a pen user, or somebody who's doing injections, this is an incredible leap. Your insulin on board is being kept by an app on your phone. And it can see the difference between the priming of your pen and the Bolus. Get out of here. You obviously need to know more companion medical.com. There's links in your show notes at Juicebox Podcast comm. And one more thing, starting I think next week, maybe the week after these ads are actually going to be a conversation within pen user and world champion, paddle boarder, Fiona wild. Fiona is going to tell us what she loves about it. And it's enough of me telling you what I can, you know, read in a PR kit. Let's hear from a real user. I'm wondering about carb types, oh, entering into a loop. I get confused about what to put when I'm eating a combo meal. For example, what if I'm having pizza and fruit or a burger and veggies or, you know, like yogurt fast carbs plus protein? She said I thought maybe since Jimmy was a dietitian too. This might be something she can help decipher how to Bolus for different combinations. So what Matty's bigger question is and how this will work out for the rest of you is she's really asking about absorption time, I think in loop right, to

Jennifer Smith, CDE 12:15
an glycemic index to a conventional pump system. Yeah, in game

Scott Benner 12:19
conventional pump system, it's going to be glycemic index. And the idea of extending boluses or temporary or something like that. So it's, it's crap, slightly different tools, same reason. But to give people context, you don't listen, who don't use the looping system, you will tell the loop Hey, I'm eating 35 carbs now. And then you have to tell it how long you expect it to be in your system, how long you expect it to take to absorb is that one hour, 30 minutes, two hours, three hours, like that kind of thing. If you get that absorption time wrong, when you put the setting when you put the carbs in the loop, it really big causes a lot of high blood sugars when you get it wrong the wrong way. So do you have any thoughts on this? Because I'd actually love to hear them. I'm gonna sit back and listen like a listener for a second.

Jennifer Smith, CDE 13:03
It's a very good question. I think that the icons that are within the fast moderate and slow groupings, if you are a looper and using them are defined by like a glycemic index nature, right there fast ones are going to get absorbed pretty quickly loop says they're two hour moderate or like a three hour really slow, which would be like high fat, really high protein kind of meal would be a slow absorption, right? icons like a lollipop, a taco or pizza. Okay. Now, most mixed meal, she brings up a good question. Most mixed meals that are a content of carbohydrates, and protein and fat and healthy fiber. Good example being something like grilled chicken, steamed veggies, and maybe like quinoa or brown rice or something like that, right? That's a good mixed meal, a three hour absorption would be a good place to start. It's mixed. You've got a little bit of everything. Now, on the flip side of that, let's say you have like a thumb size of grilled chicken, one broccoli spear and a plate full of brown rice. Hmm. Question time there is based on the content, right the content but the portion that's the glycemic load. It's not only glycemic index, but it's the amount if you've got a plate full of high index carb that you're eating, very minimal little other things that's no longer a combination meal. That's more like a two hour that's like it's fast now rice is as an example in this can be a can be a bad example because some people's experience with rice can be longer impacting same thing with pasta. Some people get really quick impact from pasta some people get really like long drawn out. And I mean if I went into it further, some of It has to do with cooking method and again what you eat with it and whatever. But in a simple answer, most combination meals that are not heavy simple carb should be about a three hour absorption for our absorption would definitely be those Merle meals like she's saying, let's say I'm eating a big old cheeseburger and french fries but I'm also having an apple on the side, that's still a fairly long digesting meal. A trick or a tip that might work it let's say you're eating the apple First eat the apple, put it in as a 15 gram you know kar Bolus absorption two hours. And then when you go ahead and Bolus for the rest of the combo meal, or go ahead and rest as the rest as a four hour absorption. That way, you're kind of addressing both types of food and the way that they may be being digested because of how you've kind of eaten them. Whereas the apple at the end of the meal sitting on top of the burger and the French fries and whatnot. Group it in and to for our absorption.

Scott Benner 16:10
I was gonna I was gonna say to rice so at home. I only use a basmati rice. It's okay, and that does not impact Arden nearly like if we were to go to a Chinese restaurant, she was just going to grab like white rice, right? It's just it's easier. You know, bread with no high fructose corn syrup. Great way to cut yourself a break. And pasta, I use dreamfields It does not hit Arden nearly like other pasta does. Both in intensity and time. So there are sort of ways to like cheat around it with certain foods and what you said about about cooking methods I just made I just made another another note for myself about something we could talk about in the future. Because that's really interesting.

Ask Scott and Jenny was brought to you today buy in pen from companion medical, please go to companion medical comm or click on the links in your show notes of your podcast player, or the ones you can find at juicebox podcast.com. For more information. Just think about what it would mean if your insulin pen could keep track of your insulin on board and so many other things. Just like a pump. The impact is fantastic. It's like that little train that just keeps going get any mean climb and Chugga chugga chugga that thing you don't I mean, it's like no stopping us. Now that's not the train. But if the train could sing, you know if the little engine that could could sing I imagine it would sing ain't no stopping us now. What would that even sound like? I'll leave you with that thought. As it fills your head all day long and torments you. You know what? That's not fair. You need to get that out of your head. Do this instead, think about this companion medical.com with links in your show notes for juicebox podcast.com

About Jenny Smith

Jennifer holds a Bachelor’s Degree in Human Nutrition and Biology from the University of Wisconsin. She is a Registered (and Licensed) Dietitian, Certified Diabetes Educator, and Certified Trainer on most makes/models of insulin pumps and continuous glucose monitoring systems. You can reach Jenny at jennifer@integrateddiabetes.com

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Omnipod, Juicebox Podcast, Dexcom, Interview, Type 1 Diabetes, Loop, Algorithm Pumping Scott Benner Omnipod, Juicebox Podcast, Dexcom, Interview, Type 1 Diabetes, Loop, Algorithm Pumping Scott Benner

# 252 A Loopy Few Months

Could this be the future of type 1 diabetes management???

Scott and Jenny Smith, CDE break down Arden's experience using DIY loop for 14 weeks.

You can always listen to the Juicebox Podcast here but the cool kids use: Apple Podcasts/iOS - Pandora - Spotify - Amazon Alexa - Google Play/Android - iHeart Radio -  Radio Public or their favorite podcast app.

+ Click for EPISODE TRANSCRIPT

DISCLAIMER: This text is the output of AI based transcribing from an audio recording. Although the transcription is largely accurate, in some cases it is incomplete or inaccurate due to inaudible passages or transcription errors and should not be treated as an authoritative record. Nothing that you read here constitutes advice medical or otherwise. Always consult with a healthcare professional before making changes to a healthcare plan.

Scott Benner 0:00
Jenny, Normally we'd be recording pro tip episode here. Yeah, but I have never gotten such incredible feedback from people wanting more information as I did. When I told people I'm gonna try looping with Arden,

Unknown Speaker 0:15
I'm sure cuz you've got such

Jennifer Smith, CDE 0:18
a following that people are like, oh, let's do it Scott's way, you know, Scott's way it really works. And then they're like, God looping.

Scott Benner 0:26
What happened? I'm not sure. But what I am sure is that I want to talk about it. But I want you here to correct me or two. Help me, because this is the first thing that I've noticed about looping, okay. And I'm probably gonna jump around a little bit. But the first thing that I noticed is that for most people, most people living with type one and using insulin. Over three months ago, Katy de Simone came on the podcast and explained to me what DIY looping was. If you haven't heard that episode, go back. Now just stop this right now go back to Episode 227. It's called diabetes concierge, you're going to want to listen to that first, if you haven't. But if you've already listened to diabetes concierge, this is what you've been waiting for. This next hour with Jenny Smith isn't just my first reactions about looping. It's my first, second, third, fourth, fifth and 30 100 and 23rd reaction, this is a summation of the last three and a half months using the DIY loop. It's gonna be the good, the bad, the ugly things, I figured out things that I don't yet understand where I think I want to go from here, for us, and what I think looping, perhaps I should say, algorithm based insulin pumping, whether you consider that to be a closed loop or a hybrid loop, whatever it is the idea of an algorithm making decisions based on your blood sugar. Anyway, whatever you want to call it. I'm also going to tell you my ideas about what this means for the future for all of us. And I received your beautiful email, and this episode is dedicated to you and your family. It has never been more important for me to say that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise. And always consult a physician before making any changes to your health care plan. This is Episode 252 of the Juicebox Podcast. Let's call it a loopy few months. And I want to be absolutely sure that you understand that what we're about to talk about has not been approved by the Federal Drug Administration, the FDA has not approved this, this is completely do it yourself. Long, silent pause. So that can sink in. This is the first thing that I've noticed about looping, the first thing that I noticed is that most people living with type one and using insulin who aren't listening to this podcast, I think looping is going to be just an amazing thing for them. And and now looping, looping. Yeah, closed loop. I'm talking about any pump company that comes its algorithms write an algorithm that speaks to your CGM and your pump and makes bolusing and bazel decisions based on this algorithm,

Jennifer Smith, CDE 3:20
right, and makes it more intuitive. Right, right.

Scott Benner 3:23
Yeah. So what I'm saying is, it's not just the what I've tried, which was the you know, the Do It Yourself looping off of, you know, that not just that untied pool is, from what I understand taking that very algorithm through the FDA. So it's not going to be much different between what tide pool comes up with, from what I understand. Yeah, you have to assume that you have to assume that on the pod is going to come up with their own algorithm. And they're also one day going to allow the Omni pod to talk to the tide pool algorithm. So those options exist to I'm sure Medtronic will make one mess it up. And I don't know, you

Jennifer Smith, CDE 4:02
know, Medtronic does have a, they have kind of a, an agreement along with tide pool now as well, just like Omni pod does. So, I mean, we'll kind of have to see, you know, I mean, Medtronic system works for some people, not the majority, but it does work. And for those, that's awesome. I've worked with people that Medtronic current system works really nice and clean for but as far as like the targets, I think that's the other piece within like a looping type of system or this kind of algorithm. People want to be able to set their own targets. They want to be the decision maker for themselves. They don't want a system saying you have to target a blood sugar of 120 Well, I want to target a blood sugar 90 instead. Right?

Scott Benner 4:49
Right. I think rightfully I'm sorry. My camera's not I think rightfully so. I think rightfully so as well. Like, you know, you should be Yeah, you should be I didn't realize I was on you should be able to you should be able to make decision for yourself. Now, here's, here's my high level kind of look down on this from my. So I guess I have to say this first, I imagined that the podcast feels very like freewheeling and fun and like that, and that, you know, I'm just saying whatever I'm thinking, which is true to a large extent, except that when it comes to management ideas, I don't say anything on this podcast that is not battle tested, dude. Like, like, we haven't like, I don't come up with an idea on Tuesday, and then record it on Thursday, I come up with an idea on Tuesday in February, I use it for six months, make sure it works. 100%, right, that I can explain and talk about it. Yes, it only after I know what I'm seeing back over and over again. And I can explain it to you in a way that's simple to understand. But I'm not with you. And if you misunderstand it, I don't want that to happen. So having Kate, you know, having Katie Come on from and talk about looping a few months ago, and then me at the end saying, All right, we'll give it a try. That was real time. And then two weeks later, you guys all started emailing and going like, what do you think of looping and I was like, I don't know anything about it. I've never responded to so many emails with the words, I have no idea. I'm the wrong person, the wrong person to ask. I don't know anything about this. And so let me I'll explain to people,

Jennifer Smith, CDE 6:21
I feel like I've dipped my toe. But I'm not fully like immersed in the pool yet. So please don't ask me questions, right?

Scott Benner 6:28
That's even way too polite. I was confused. Right? So it turns out that

Jennifer Smith, CDE 6:34
amongst your many text messages, I wasn't doing

Scott Benner 6:38
any I don't understand what this is doing. Why is this like this? Why in God's name, would the number go down? if the power goes up? That doesn't make any sense. Anyway, we'll get to all that. But so so in the first three days, no lie. Without my ability to text Jenny, I would have stopped. Swear to God, I would have tried it and went well. I would have stopped in the second three days. Arden came to me and said these words word for word. Why are we doing this? We are so much better at this than this is? And I was like, okay, and she was and I hate carrying this thing around with me. And I was like, Yeah, and I said what thing and she goes the Reilly link, and she was and I don't even like the name of it. I was like, Okay, so now we call it the thing. And it's been renamed in the app the thing. So that's funny, all due respect to I'm assuming somebody's child named Riley that they named this after I pop. Right?

Jennifer Smith, CDE 7:30
Back me correct. Yeah, yeah. So

Scott Benner 7:32
Uh, huh. Apologies. We call it the thing. So, you know, that was the first six days Jenny kept helping me, but everything. So there are settings in this in the loop system, right. And I wanted to bring them up. And I had them in front of me. And then I I got rid of it for some reason, because I wasn't thinking so let me pull this back up. And here it is. So there are settings inside of the the algorithm app, right, the loop app correction range, suspend threshold, basal rates, delivery limits, insulin model carb ratio, insulin sensitivities. And if those aren't right, you might as well just fall on the floor and die. Like because this thing just doesn't it does nothing if these settings aren't right. So okay, so that's fair, right? The settings need to be right. And

Jennifer Smith, CDE 8:30
the reason is because of the algorithm the way that it's written, right? The algorithm is basing all those five minute loop decisions and adjustments on your settings. So if you have these way off settings that you were on your conventional pump, you are managing, but you are hyper managing, right? You are consistently adjusting and Temp Basal and negative doing something and whatever. Well, the algorithm doesn't know you are doing this.

Scott Benner 8:59
I made a note here, right. I started to say that the algorithm is smart, but dumb, and then I realized, Oh, no, it's the difference between booksmart and streetsmart. Right? The when the settings are right, the algorithm is brilliant, but and uniform, right. But anytime something changes, it's dumb, it doesn't know it changed, right? Like You don't? Do you know what I mean? Like so all of us here with the podcasts, right? If you had a stressful moment, or ank, you know, adrenaline in a sport, you'd say, Oh, I know this is about to happen and your Temp Basal up, right? The algorithm doesn't know you're about to get upset or excited or you know, whatever.

Jennifer Smith, CDE 9:38
And it doesn't adjust until it sees a change. And

Scott Benner 9:41
the problem ends up being is that by the time it sees the change it takes for what the people listening to this podcast are going to think of as forever to fix it right because we crush high blood sugars, because we're good at it and we smack them back down again without getting low. This thing takes, sometimes it could take six hours to get a 170 blood sugar back down again. And, and if you're listening to the podcast and having this success, you're thinking I'm not doing that that's not right. So I thought the same thing I thought I can't, like, I don't want to do this. How do I, you know, can I fool this thing? And then you start going down that path God that path, which will. So we'll get to Anyway, back to the beginning. You've got to get the corrections, right. The first thing that Jenny just alluded to, I had a problem with was I had Arden's bazel setting, you know, in a in a conventional pump system, set at one point for an hour during the day. And I think overnight, it was something like point nine. Well, we do Jenny's words to me, where you do a lot of Temp Basal thing. Did you ever wonder how much you do? And I thought, No, I have no idea. So it turns out my 1.4 in the conventional pump set up. That was just where I started from. And that worked fine. That number was great when there was no food present and everything. But as soon as something came in, I'd OPT down and I was being reactive to it a fluid. Well, on loop Arden's daytime basal rate is 2.35. And I just moved it up last night to like 2.4 or five an hour, overnight, it's only like 1.2. Okay, but there was a significant difference. So now I'm starting with the idea, my basal rate is 1.4. And I put it into the loop like that Arden's blood sugar goes up to 300 and sits there all day. And I'm like, this doesn't make any sense. So Jenny helped me with a simple old school diabetes math equation to help me figure out the base rate, tell us what that is, please,

Jennifer Smith, CDE 11:51
to figure out the basal rate, how did we

Scott Benner 11:53
do that that day, do you remember you were like, I'm gonna whip out like an old timey math equation and help you like, like,

Jennifer Smith, CDE 11:59
guess the basal rate. But you can essentially take your total daily dose that you're using, and multiply it by about point four.

Scott Benner 12:12
And that comes up with your hourly basal rate,

Jennifer Smith, CDE 12:14
it gives you your units per day, it gives you your bazeley units per day, essentially. So if you take, you know, four times, you know, 30, or essentially, let's see, 30.4 gives you so if you had 30 units a day times point four, it gives you that you would need about 12 units of bazel a day, and then you can kind of break that up. And as we know, physiologically, you need adjustments through the course of the day, you need two units through the course of this part of the day, or you know, you need point nine through this portion of the day. And that takes bazel testing. I mean, true, true bazel assessment is based on looking at what's happening in a bezel only time period, right. And in order to really do that, in looping, a lot of people try to bazel test in closed loop, you really can't do that, because you're getting this, you're getting an offset of what loop is doing with its algorithm to keep you stable, right. So in order to really bazel test in loop, you have to open the loop, and you have to do it well in advance of looking at a bazel segment time. Because otherwise, you may have positive temp insulin or negative temp insulin that's still impacting where you think now I'm only in bazel, because I opened the loop. That's not true. It's several hours before the impact of any temping up or down is cleared. And you're really just on your standard bazel at a circulating level.

Scott Benner 13:53
So if you use if you try this, there are documents that have been lovingly and painstakingly put together online by wonderful people. And it's going to tell you right up front that you have to start with the loop open right with it. Yeah, not doing all that it does, so that you can get this right. If you don't listen to that, you might as well again, just drop on the floor and die, because it's just not going to work. Just give up if you're not going to follow the instructions. Here's the thing that had that happened to me with the instructions. And I'm concerned that may happen to many of you listening, is that I think that one of the reasons this podcast works for people is because it's broken down distilled down into very easy concepts, right? Because some people's minds don't work the same. So I'm going to tell you, I marked myself as a fairly bright person. But there are things I can't do. I've told you guys before, I can't do simple algebra. I could you can explain to me nine different ways I don't understand it, you start putting a letter next to a number and my brain goes, I don't care. And then that's the end of it, right? So I read these loop docs, which are again, beautiful, they're brilliant. And I read through them and I get to the end and it's as if I do didn't read anything. It's like, I felt like I was in eighth grade and someone was trying to teach me pre algebra again. I was like, yeah, it all made sense. I don't know. And so I kept reading and kept reading and I thought, Okay, I'm going to have to figure this out for myself, or I'm not going to be able to explain it to everybody else. Right. So we hammered through this for you guys. Okay, like we stuck with this because we wanted to stop a number of times. But here's the thing about it. Once we got the, you know, suspend threshold, right, and then Jenny helped me get the bezels. Right. And we got the delivery limits, right. And you know, pick the right insulin model, which was very helpful through the docks. carb ratios was interesting, because I didn't know Arden's insulin to carb ratio. So we just had to keep going. No idea, right? So we just kept getting

Jennifer Smith, CDE 15:49
No, I just give her 10 units for her pancake meal with strawberries. I don't know what that ratio is. And I was like, okay, go back, count the car, divided into how much you gave, get a basic carb ratio, play with it, see if it's working and adjusted up or down.

Scott Benner 16:05
I was almost embarrassed. I was like, How can I be so good at something. And now when I'm up, I'm like, and I'm like, you know, I don't know. I was embarrassed by it. I was like, I don't know where insulin to carb ratio almost found myself apologizing at one point. The truth is, I didn't need to know it the way we were doing it. You know, the way you guys all do it listening. I needed the note for this. So Jenny's like just, you know, we kind of reverse engineer it, like she said, counted the carbs, you know, how much would we use for this? How much, you know, base would go on and I kept adjusting, I eventually found it. It was much lower than I thought it was going to be, again, to our earlier point about bazel. I think it's set at like six and a half. So you know, her ratio, yeah, one car per six, or one? Yeah, one unit for six and a half cars. I never would have guessed that. But it just goes to show how much, you know, Temp Basal when we were doing anyway. So we got that set. And then the first success came. And I'll tell you, when the first success with looping comes with any of these algorithms come, you're going to be so happy that you're not going to care about the problems, because you're going to go to sleep at 11 o'clock, and wake up at six o'clock. And to a graph that looks really nice overnight. Because once these settings are right, loop, adds and takes away bazel and just keeps you steady without variables without food variables. It's just amazing. Okay, so make sure you hear what I think.

Jennifer Smith, CDE 17:31
Did me that overnight.

I think you texted it to me and you're like,

Scott Benner 17:37
let her wake up. This is genius. I'll tell you, I'll tell you anything. It's you know, Arden's asleep right now. Amazing, right when, like, you know, obviously her settings change for when she's awake, and that we have them set as like 7am for the school year. But all I do in the morning is I get up in the morning, I walk in, I push an override button, and I set everything 30% back and I call it sleep in I've named it sleep and she sleeps in perfectly with that as soon as she wakes up, you shut the override off. But here's the thing. The override are part of a branch. Now listen, if you don't know this, forget, forget, I can't explain it to you. But forget loop if you if you can't follow this long, but there are different branches. So imagine there's a build of the of the out of the app. And then there's like additions you can make to it. One of them's called JoJo, I believe it's named after Katie's dog. Again, I don't know why you people don't just pick more simple names for things. But I understand it must be like a programming thing. I'm okay with it. Right. So this Jojo addition, or branch allows you to basically turn up or down the power of the loop settings, it is the best way I've come to understand it, right Think of it as volume,

Jennifer Smith, CDE 18:45
it's kind of sense. It's kind of volume or sensitivity, you're telling loop to be more sensitive or be or that you're less sensitive within a time period, essentially, I think of it is

Scott Benner 18:57
bolder, not as more

Unknown Speaker 18:59
or less.

Scott Benner 19:01
Boom, right? So I've set up I've set this thing up where I push it basically it takes 30% of the boldness of the of the algorithm away, and rd can sleep in in the morning. It's amazing, right? That's been incredibly helpful. If it was not for the Jojo branch, I would have quit. And I'm now going to tell you super seriously, if you don't let me make adjustments to what this algorithm thinks. I don't want it. I want to sleep. But I don't want what comes next, which is the problem around meals. So once again, for most people living with diabetes, and keep in mind what that means, right? If there's 20,000 of you listening to this podcast right now, right? There's still a million and a half more people living in the world who have type one or more at this point. All those people are going to be helped by this by this algorithm or any of the algorithms or algorithms I believe that the pump comes He's going to come up with it's going to be an amazing improvement to their life. Mm hmm. But if you're a person who sees a 140 blood sugar, and looks at it and thinks I have completely this up, I'll bleep that out later. Okay, if you're one of those people, right, you're going to hate the way this thing takes care of meals. Now you can Pre-Bolus still,

Jennifer Smith, CDE 20:18
but sometimes you can't a couple of ways. There are a couple of ways to Pre-Bolus with Lou. But yes, we sell them. Do you know what they are?

Oh, yeah, well, I mean, one way and, and again, many of these, I've not only learned, but also, you know, people have been like, Hey, I'm doing this. I'm like, Oh, that's interesting, you're kind of doing it a different way. But the two main ways. One is the premium button. That second little icon next to the Bolus icon on the bottom of your screen, looks like a little timer on a plate. Essentially, when you hit that, it allows loop to aim for a lower glucose in a timeframe prior to eating. So if you're using Pre-Bolus, thing, 30 minutes before you start to actually eat your food, the pre meal technically takes care of it in what I personally and professionally feel like is a little bit more precise manner. Because it's only look where your glucose goes. Now, where do you want me to aim for it to get to which is lower than what your overall daily correction or target ranges, right. So if your target during the day is 100, you might have your pre meal set to 75 or 80, let's say, and lupus say okay, I see now you want to get to 75, you hit the premium button, it's aiming for that it starts to give you additional insulin in the timeframe before you actually now choose to bolus and eat. So 30 minutes from now you've gotten a little bit extra insulin added in to get you moving down. Thus, almost like a Pre-Bolus. But a little bit more intuitive because it's just basing it on blood sugar. And it's getting you to a value that you want to start with by a trend down. The other nice thing about the algorithm is it takes into consideration that extra it's added when you do choose to Bolus. So you're never going to have kind of a too much there. Because it's considering now what's the trajectory of the glucose? How much has actually been added in to kind of get you here? How much are you eating? You know, all of these factors are considered in this algorithm that, thankfully, uh, well, thankfully, you're not painfully our human brain is just not meant to think like that conscious. And you

Scott Benner 22:31
are going to find that. And that's the biggest problem. Jenny's gonna fall for chair. She's laughing so hard. That's the biggest problem when you try to imagine how to outsmart the algorithm. Yeah, because it's thinking about things you're You don't even know exist, let alone can't bring yourself to think about because we're just people. And so. And that ends up being one of the issues. The pre the pre meal button works pretty well, for us. But the biggest problem is, is that we had gotten so good being bowled that Yeah, I didn't even have to Pre-Bolus sometimes, like, I just could look at a meal like we don't I've spoken about it here. But I don't talk about it too much. Because it's double extra ninja level, right. But like, I can, you know, five minutes before a meal, go this meals, eight units. But if I just use 11 and a half and double or bazel, I don't even have to Pre-Bolus like I can, I can send so many. I can send so many soldiers in that when you start fighting back. You just can't win like right. And so I know how to do that for her. So but so we're now seeing spikes at meals that we didn't see before by sure there's so much stability the rest of the time. That ardency one c didn't change. It's right. I think it was five for this time, right? So on looping new is five, four to five I think was five three not looping last time. Lows still happen with loop, I'm not going to tell you like I still see lower, not like crazy lows, but she'll go down to 50 sometimes it it'll try to stop her and it can't. So what I think is that in those moments when you need the algorithm to be aggressive, and it's set up aggressively, and then all of a sudden, there's a significant variable in your life that causes a time of day when you usually need a lot to not need a lot. It can you can start you know a quick low comes out of nowhere. I'm not blaming the algorithm, it's you know, it's just like us.

Jennifer Smith, CDE 24:24
And I kind of explained that in terms of loop can only negative temps so much to prevent, right. So if there is a load coming into a drop loop, we'll do it fast. It sees you know, okay, you've got the suspend threshold set here. You've got this much insulin on board it can negative temp and or zero temp as much as it possibly can. But it may not be able to shave off enough in a timeframe to stop a true drop. It does its best, right? I mean, I have to say that my looping almost two years now, I can say that my lows overnight are less than the five fingers on my hand.

Scott Benner 25:09
Oh, yeah, I believe that. And I

Jennifer Smith, CDE 25:10
think I mean, the lows overnight are definitely the huge fan of daytime lows, I would definitely say, are more my user fault, then loops fault. It's more my I've forgotten to set my workout target or my override, I've forgotten to do this in enough time I've forgotten to account for something, you still have to mentally think about things in order to tell loop to do the right thing. Or so that it can do the right thing. But overall, the nighttime is like,

Scott Benner 25:40
Yeah, it's great, incredible. So it's funny because I Jenny just led me to tell you, like, I wanted to let you know like that this is not a magic bullet, like, and I am so concerned that people think oh my god, one day, my Dexcom is going to talk to my pump that's going to talk to an app on my phone. And I'm never gonna think about diabetes again. Right? I am here to be the wet blanket on that party. And tell you that that is not going to be the case. It's not Yeah. But I am. Let me say this again, after being with this for months. This is the future. I'm 100%. certain of it so much. So that I'm already I'm telling you, if you want it, I believe this is

Jennifer Smith, CDE 26:21
how you buy stock in tide pool about that.

Scott Benner 26:25
I'll tell you why. I don't know I'm not about that. Exactly. But here's the problem that this is going to happen. This is where my concern comes in. And why I will keep talking about this periodically, right is that doctors already can't help you very frequently with your settings, right. And the settings they're trying to help you with now with your pump are childish compared to the settings in the loop. And so if doctors can't do what they can do, now, I can't see how in the hell they're going to do it with loop, right? And then my fear is, is that someone's going to put this thing in your hand that if it's set up correctly, and you give it enough time is going to end up being a major addition to your life and your health. And you're going to have the thought I had in the first three, six and 10 days, which is this is impossible. And it doesn't work. Because if the if the settings are wrong, it will appear not to work because it isn't it isn't working.

Jennifer Smith, CDE 27:22
And unfortunately, taking that then to your doctor and saying I I can see the benefit to this, but it's not working what is wrong. And because most clinicians, it's unfortunate the system that we have in our health care, right? And what's driven by insurance and coverage and what they can, what they can, you know, tell you yes, do this, I support you in doing this. And I know all about it, and I can help you learn how to use it, unfortunately, because it is as of yet FDA approved. Unfortunately, many doctors are like, I'll support you in your decision to use it. But I can't teach you anything about it. I don't understand it myself. And I think well as a physician, then if you're willing to say, Okay, I'll continue to write your scripts for you. And we'll continue to look at the data together. I think it's honestly in their best judgment to learn about it. Even if they can't outright say, Hey, here's the pump for you. You need to be looping even if they can't legally tell you to do it. If you've chosen to do it. I think that educators and NGOs really need to get on board with learning. What are these systems doing? Why are people choosing to use them outside of the current FDA conventional pumps? And who could it be beneficial for I can definitely say I mean, there are there are some people that probably don't have enough kind of together to understand and use lube. In fact, there are some people that I think pumping is also in general too much. And it gets a good clinician to be able to help talk that out with a person. But I also think that our clinicians need to learn more about it. In fact, that's my presentation with Gary in Houston to add, this weekend is about loop and how clinicians can learn and be comfortable and where the resources are and how to talk to patients about it. And be informed.

Scott Benner 29:30
So you guys listen to this on Tuesday. And just last weekend, Jenny gave this talk that she just spoke of to the American Association of diabetes educator she's telling them that I made a panic phone call to somebody I know at tide pool and I was like, if your documents aren't right, this thing is going to crash and burn you got to make sure you're explaining it to people correctly. I gave them and it's so much so and I hope this Gosh, I hope this doesn't sound egotistical. Like I there are enough people listening to this podcast now that I feel a responsibility to understand it too. Because I'm telling you, it's the way it's the future. I'm like, imagine yourself before you found the podcast before you sent me your email. It's like, Oh my God, my eight, one C is six, it used to be eight and a half before that, if I could have given you something that would have not let your blood sugar go much over about 170, most of the time would have brought it back down without getting low. And you could have slept through the night, I you would have said to me, please give me that. And so, you know, you have that perspective, when you're thinking about loop loop is astonishing. It's amazing. It's fantastic. My concern is that if you are have been listening to those podcasts for too long, your expectations are going to be higher than what it can do at the moment. And and that's because and here's why you say, Well, that doesn't make sense, Scott, I'll just tell it to turn up the volume. You can. So it's like, it's like it? I don't know how to put it exactly. It's there to stop you from hurting yourself kind of a situation, right? So if so, here's what happens. I give Arden or insulin. And you know, we miss on the carb count or something and I start seeing her blood sugar go up and I tell our Oh God, we're gonna have to add more insulin. You put in, you think yourself I know, right? Oh, I know, for certain three more units is going to stop this and bring us back level. You put those three units in through loop and loop takes away your bazel. Right, and you're like, you, I'm gonna do a lot of bleeping this thing, because here's me in the kitchen. I'm like you. I need the bazel and I need the bowls. What are you doing? Then you start thinking maybe I can make enough of a bolus that it couldn't possibly take it all away. And I've been trying that lately to like her basals, you know, 2.5, you know, around two and a half, right? Three more units. What if I put in five and a half units is a bolus and even if it took the bazel away, the bullets would still overwhelm it, that still doesn't work. So every time you try to like outsmart it, because of what the settings are telling the algorithm it outsmarts you,

Jennifer Smith, CDE 32:01
outsmart you? That's right.

Scott Benner 32:03
A little over a year ago, so many people approached me about bolt with insulin t shirts that I made them, but I found a local printer made them and let you guys ordered them through the website. And I mailed them out myself, which took up a lot more time than you might expect. So I stopped doing it. But then the emails came again, I want to share it Where are the shirts and it's like, oh, okay, so I researched for a very long time. Found a company that has quality materials with great printing, that also does printing and shipping so that I'm not the middleman. Anyway, shirts are back. And now you have more options for what you want the shirt to say. Go to Juicebox podcast.com. Scroll down a little bit, click on March. Check it out. You're gonna find Be bold, bold with insulin, stop the arrows, new bump and nudge shirts are coming. There's t shirts in different sizes, colors, men, women, children, stickers for your laptops, coffee mugs, these really cool drawstring bags, and even flip flops. And if you're looking for something that's not there, send me an email. I mean, if you want a T shirt that says trust that what you know is going to happen is going to happen or one of the other, you know, Wavy Gravy kind of things that we talked about here on the podcast, let me know, these items only exist because you asked for them. So I want to make sure that I'm giving you what you want. Just send an email if you have an idea. Last thing, Jenny Smith is here again helping out if you want to learn more about Jenny, go to integrated diabetes comm if you want to hire Jenny, that's the same place to do it. Integrated diabetes.com there's also a link in your show notes.

Jennifer Smith, CDE 33:51
The way that the algorithm route algorithm is set up and it knows what your settings are, right. So if in the setting of the rise that you're seeing happen, you're like I need more insulin at that point is the right thing to really do would be to hit the Bolus button. You know that middle I call it the carrot. That's like a Double Down Arrow orange. When you hit that, if loop is seeing, hey, yeah, there's more insulin needed here. It will suggest a bolus. If the Bolus suggestion is still zero based on the active insulin. In parentheses above, you'll see pending insulin. And you can always also take the pending insulin because that is a calculation that loop has already figured in to need. So if it's pending insulin is 1.2. But it's recommending nothing as a bolus right now you can input the 1.2 and take that as a bolus. Because at least you're working within loops, algorithmic fingerings you're working within it looked and saw that you're going to need this much more. It's going to dose it out over a time period. It's not recommending it as a bullet point. You could take it. And if you haven't screwed loops back.

Scott Benner 35:04
And I'm glad to know that because I didn't know that. And I'll definitely try that. Because otherwise you can't. It's like playing chess against a computer. You're like, Ooh, this will work and the things like, Oh my god, I'm so much smarter than you. No, it won't. And like, so you can't, you can't fool it. Now I have found ways you can use the Jojo brands and jack up the intensity override, right? And then what other people will tell you is you can lie about carbs. So yeah, right. So you can pretend you can say to yourself, I think I need three units. Here. I'm six and a half, I am a unit for six and a half carbs. So if I tell this thing, I need 20 more carbs, it'll give me about three more units. That does work sometimes. But the problem

Jennifer Smith, CDE 35:46
and another like aside to that just for evaluation, let's say you didn't give the three extra units. Let's say you watched to see what loop is doing. And at the end of the day, when you click the lock the bottom graph the active carbs, when you tap on that, you'll see all the carbs that you've entered for the day, you'll see what you entered as an absorption time. And down below each you'll see what did loop see as carbs that were absorbed? And how long did it take loop to see the absorption over? Right? So when you look at that, let's say you put in 60 grams of carb and loop actually saw 80 grams of carb. But you know, it was 60. You know, it was definitely 60. Well, in that setting, then Lupe was seeing the need for more insulin. So it offset it with a lot more insulin, just in a slower manner. As you said before, the manner is going to be slower than you think. No, I want that three units right now because I know that I need it, right?

Scott Benner 36:46
That really is the sticking point around food is that if you're being bold, it stops you from being bold in any moment, like but to Jenny's point. If your settings are right, and you kind of the contract, it will bring your blood sugar back down at some point. And so it's just not as quickly as I want it to be. And now what will happen is, is you might go out into the world and you'll talk to people who are looping and they're like, Hey, what's the big deal? Like it comes back down? Well, those are people who didn't find the podcast who were just like, this is amazing. My blood sugar wasn't 400. So I get their excitement. And I stand by it. But I also stand by everybody else who's listening who's like look, I am not okay with that. And I can tell you this. I am slowly understanding that it might be okay if Arden's blood sugar goes to 140 for a little while and comes back. I don't want it to happen. But I'm, I'm not having a panic attack about it. Right. I'll give

Jennifer Smith, CDE 37:38
you all I'll give you a little okay with that is even in pregnancy, which is the tightest like blood sugar control that we aim to manage in, even in pregnancy, going up to 141 our post meal is okay. So, now we want to be at two hours post meal 120 or less, but even going up to 140 in pregnancy in that sticky like control it like a crazy person. That's okay. So just to let you know, that's okay. Don't worry, I'm okay.

Scott Benner 38:10
I'm feeling okay. I'm not. And I'm not giving up on the idea that I don't want those spikes. But I also saw those spikes with what we were doing before like I was never perfect with it like there are people. Listen, you can go online and find parents who are managing I think pre pubescent kids with flat lines that are amazing. I've never like shot for that to be perfectly honest, like but I'm not okay with an elevated blood sugar lasting for multiple hours. Right, Jenny brought up absorption time. That's still one of the things I'm trying to understand better because we started shortening our absorption time to two hours, which made it more aggressive up front. Yeah, but then sometimes what will happen is that then, you know, outside of two hours, when the food still exists, it thinks it's gone. And it doesn't. So something I've been doing a lot of different things trying to break up absorption times, like put in a bolus for two hours and then put in one for three or four hours. Like just trying to make that work that way, I will figure this out. At one point, I swear to you, there'll be a moment where I will talk about this algorithm with the ease that I talked about everything. But for you people who are so impatient, it's not going to happen this quickly. Like I'm going to need a year, you know what I mean? Like, really being immersed in it. I understand it much better now than I did a couple of months ago. But you know, when I say something to you, like, I don't know, like what are the things we say on the foot, like if when I say stop the arrows and then explain it in a sentence and a half in a way that paints a picture in your head so that you know how to do it. I don't have those ideas yet around loop. So I'm sorry, but apologies but it's gonna take more time. Here's what I can tell you. If you can get the settings right. It's worthwhile. If you can handle a couple of meal spikes while you're figuring out to sleep overnight. It's pretty great to sleep. I'd forgotten how great it was to sleep. It's pretty great when I was young I used to work in a pet shop and the man who owned it would eat pizza once in a while. And I'd look over at him he was incredibly happy and he would say, better than sex. And sleep is better than sex.

Jennifer Smith, CDE 40:15
The only thing that I that I would compare to that, or have you ever had the dark chocolate, Justin's brand Peanut Butter Cup, I haven't. Oh my god. They're wonderful.

Scott Benner 40:24
Jenny's husband just realized how easily he could be replaced. So it's after not sleep. Like I always say this about sleep. less sleep is better than broken. Sleep. Broken, sleep is terrible. Go to sleep, wake up two hours later, stay awake for 15 minutes, go back to sleep wake up in an hour. And my life wasn't even like that. At this point. Like I there were nights I slept to the no problem. But I'm talking about sleeping through the night, every night for a week, then two weeks than three, then a month. It's magical. Right? Right. Yeah. So I'm not taller from it, but I do feel a lot better. So it's great. And not only that, but it gives me the confidence to know that Arden is gonna go away to college, like I expected on you know, I'm assuming I'm gonna send her on her the horizon system from on the pod. I'm hoping to love that when it comes out. And and that she's going to forget being able to sleep but not be in danger overnight. Right, right. And so this is worth me understanding, I am going to keep doing this. It doesn't stop me from being able to talk about the other stuff. So all of you who I've been speaking to you privately or all the episodes you've heard before, I have not forgotten how to be bold with insulin. I know all the steps I could, I could tell them to you in my sleep. Okay, so that's no problem. Right before Jenny and I started recording.

Jennifer Smith, CDE 41:44
I think actually, Scott, that's a really good point to bring up is not forgetting how to pump conventionally, right? Because you will, at some point perhaps loop might fail, you might have to rebuild it, it might for something your computer might crash and you can't rebuild it for a week, you're going to have to go back to conventional pumping, pumping, you're going to have to remember how to pump using your brain using the algorithm that is in your brain, right. And so not forgetting those steps is really, really important. And I think that's a piece that and I hesitate saying this, but I bring it up as just a point to consider for people who are new to pumping. To begin with. I think New pumpers should try to consider some time of learning how to pump with their normal pump, they should learn those factors, they should learn what attempt B is a look like why to use it, how to use an extended bolus, what their typical food does their exercise, how to conventionally pump and use their brain to pump before they switch on to loop pumping. Because there's a lot that comes with using pump be using loop intuitively and understanding it that comes from having used a pump previously, the way that you do you know, like you being bold with insulin, learning all of those factors, learning how to adjust while it changes with loop. Conventional pumping teaches you a lot to be able to loop better.

Scott Benner 43:22
If you were diagnosed today, someone slapped a loop on you put the made the corrections perfectly say there's a way to know them perfectly. And then the zombies come six months from now you're gonna be dead Three days later. You're not gonna know what the hell to do with your insulin. And so it's it's, it sounds like an old timey idea, because I've had that thought before. People say you have to use needles before you can pump that I don't believe I think you can start with pumping. Right? But but I get the idea behind it, where it came from. And I don't think it's an old timey thought to say right now you need to understand how insulin works before you just try to jump right looping system like that's 100% I agree with that. Because there there are settings here that you can't imagine what they do. I'll tell you right now, I understand the mathematical part of it. I understand the bright people who are better at math than me but ISF right instance x insulin sensitivity setting in the in the loop, right, the lower you make the number the stronger it is. And I get that negative. I understand math and everything but who sets something up for a layman and doesn't think more is more, I'll make less more I'll make a lower number greater power I get again, if you're a math person, don't come at me I understand. But for most people, they see 70 as stronger than 60. Not 50 is stronger than 60. So wherever did that because it not because you can't figure it out when someone explains it to you like I understood it when it was explained to me. But when you're intuitively trying to run through everything that's happening in your brain, you're like make that higher. That's brain says it to you right it doesn't say turn it to 50 or something 60 instead of setting? I know,

Jennifer Smith, CDE 45:04
I know, it's a hard it's a hard point, I would say you're not alone, whether you're a math person or not, I think the figuring of what that means for insulin effect is it's counterintuitive in the human brain. It just is.

Scott Benner 45:21
Yeah. So So however the algorithm thinks about it, I don't care. But they should put a goof like me in charge of making the upfront thing that you look at like, right? Like where I would just be like, turn it towards boulder? Not not know. So I think that it's, I want to say this at some point in this episode. And here's the part. The people who did this, I'm sure are too many to count at this point. And I'm sure someone knows everybody who's had a hand in this. I don't know any of them. But I think they're all just saints.

Jennifer Smith, CDE 45:53
Like, it's phenomenal. Yeah,

Scott Benner 45:55
right. It's awesome. This is astounding. This was put together by people in the world living with diabetes, right? And amazing. And then made available to other people, which, again, amazing and then supported by other people. And I've seen them on Facebook supporting other people. And I know how tiring it can be to have somebody come to you at eight o'clock in the morning. And they're like, I don't understand any of this. And you and they want you to talk them through it. And then by the time you get them to talk through it for other people ask you, because that happens to me. Except I don't have to do it in like this very incredibly, like, technical way. I'm just like, Hey, you know, all carbs aren't created equal? Stop the address, you know, right. And here's what that means. I can literally teach you how to do what we do in like, an hour over the phone. And so, but you can't learn loop in an hour over the phone, like, yeah, isn't gonna work that way.

Jennifer Smith, CDE 46:47
Now, I will reiterate what Katie and Kate and everybody else who's you know, helped build it. Read the loop docs. And like you said, you have to read them and digest them. If you're somebody who grabs it by reading it, and you're like, get it. Totally, that's awesome for you. I have had to read and read and go back and reread and make sure that I've got it because you know, in what I do, there are a lot of people that come to us who want help understanding. So I have to be able to spit it back out in like we talk about, you know, on the podcast, in layman's terms in an understandable one or two sentences. This is what this means. This is how to make it work for you

Scott Benner 47:27
an incredible skill to do like I at some point realized I was not giving myself enough credit for how I can talk about diabetes, it is hard to take something so complicated and make it simple. And I'm not Yeah, I'm not at that place yet with loop. Katie said to me, she's like, read the documents. How's it Katie? I did check. Read him again. I'm like, I only read them once. I was like I said, they're making me feel stupid. You know, like, and, and I was and he said to me, that's when I said, I'm like, that's why the podcast is so popular. Because it takes these complicated things and makes them easily digestible. I mean, I knew that, but I don't think I appreciated that completely until I tried to read those loop docs, like seriously. Yeah, I relate it very much to my son who's astonishingly good at math. And if he explained something to you, really difficult to understand the math and you don't grasp it immediately, he looks at you like you're an idiot.

Jennifer Smith, CDE 48:17
Like you don't like what I just told you. His

Scott Benner 48:19
brain understands it right away. And so there are times I think that some of the people who understand the loop dogs really well are like, No, no, it says it right there. And I'm like, Yeah, I see that, like, I understand all the words. You know, I just don't, I don't understand what it means. Okay, let me make sure I have everything here for my stuff.

Jennifer Smith, CDE 48:38
I'm kind of like that I'm more of a shomi person. I'm I mean, I can read it and learn. I mean, obviously, I made it through college and, you know, internship and did all of the stuff that you have to do by just reading and learning. But if somebody like sits down, and shows me how to change the tire on the car, I've got it, I got it, you showed me where to put this, whatever, it would probably take me an hour worth of reading, like where to put the jack how to put the how to get the lug nuts off, it would take me an hour to read through it and then be like, what did that say to do again, and I'd have to go back to the pictures and relook, but if you show me 1015 minutes, I've got it.

Scott Benner 49:15
There's nothing more valuable than a good teacher. But seriously, you know, like, it's just, it's 100%. So here's something interesting. I was interviewing somebody, I forget her name, and I apologize a couple of weeks ago, and I was at the point again, where I was like, I am gonna quit this loop thing. Like I got to that spot again. And she said something to me. That made instant sense. So there's correction ranges, right, like so. So when my brain with that, I thought, Oh, I want my daughter's blood sugar to stay between 70 and 100. I'll set the production range between 70 and 100. And it never worked. Like it was never she was never in that spot. There came a time when I thought maybe I'll just lie and say I like it's keeping her at 120 What if I just told her I wanted it to keep it Add with that keep it at 100. Like I started thinking about how to trick it. And she said to me, don't think of it as the target range. Think of it as when the bazel turns off and turns on. And I don't know why. But I was like, Oh, that's brilliant. And I made slight adjustments to it, and adjustments to how I thought about things based on that one sentence. And I thought that is, and it made a difference for me. And I don't know why it was just, I thought about it differently. I used to think I used to think, okay, I'll set it from 70 to 100. And that's where the loop will keep things, but it never really did that. And then when I started thinking of it, as this is the Basal shuts off at 72, Basal turns on 100. It's like, Oh, so if I drop the high number down more than when I get to 90 diagonal up, it'll come on and bring me back, but I'm waiting till 100 or 120. And that's how I'm getting to 160. Right, because Basal doesn't work that quickly. Now, the one thing we have not spoken about yet. That I want to tell you is amazing. So I'm using the night scout out night scout app. Now, to watch Arden's loop. I want to I want to say, visually, I hate it. I just I like it. Okay, but I'm getting used to it. And it's not just a new thing. I don't know what it is. There's a lot going on, but part of it I love is this, it shows you your basal insulin, visually. So you can see on on this app, as it gets stronger. It's basically, you know, like a stalagmite like it's, you know, pushing Is that the one that goes down, whichever one goes down from the root,

Jennifer Smith, CDE 51:32
slide type, I think, yeah, I think like type comes up. I don't know. I'm not a rock person. But

Scott Benner 51:38
yeah, one or the other. I swear to you, I'd call this episode. I'm not a rock person. It's like an icicle, right. So coming down. So when the thing that's not his, you set these Max bazel rates, right. So I think we have Arden's set at like seven an hour. And there are times that when her blood sugar tries to jump up, this thing's like boom, no way, seven units an hour, it might only stay on for 10 minutes like that, right? Right. And then then maybe it comes back to five, and then it goes to three, and then maybe her blood sugar keeps rising and it pushes it back again. And then all of a sudden it thinks No, I have it, it reads the data from the Dexcom and says, Oh, no, I've got it. Boom, right back to normal. And the same thing with like, you start getting low and it starts taking it away a little bit at a time, then all of a sudden it might take it all away. Yep. fascinating to watch. You will learn more about manipulating insulin watching the that bazel on nightscout, then Yep, I don't it's it's it's a learning tool in and of itself. It's really spectacular.

Jennifer Smith, CDE 52:39
And if you wanted a little bit more I know, Nathan is wonderful. Report wise, I think there are good reports in two places. nightscout is one of them. But tide pool also from my, from my learning perspective, as well as from teaching people, you know, a clinical perspective, I like tide pools Daily Report For for loop, because on the daily report on the bottom, you can still see the bazel right, you can see that what I call it looks like a cityscape, you know, the UP DOWN nature of what loop has been doing. But because tide pool online is interactive, you can hover your mouse over the actual bazel rate. And you can see what the temping was that happened. You can also see what pro What was your program bazel you know, if it was program 4.9, but it was temping you at 3.3 for how long was attempting you add that anything from a learning perspective? If you're looking for a trend that might be happening, you know, overnight, or during the daytime, always after breakfast, it seems like you're getting these tremendous High temps to get things contained in kind of learn from that and say, Do I need to setting adjustment loop looks like it's working really, really, really hard for me consistently at this time of day. Maybe something's off my bazel might be off, my ratios might be off something might need evaluations. But I think only from actually visually being able to hover over and see what was the bazel. That loop was kind of instituting nightscout isn't as interactive like that you can't once a report is generated. It's sort of like a flat report. You can't hover over anything and see extra data.

Scott Benner 54:23
Yeah, so if that's an amazing point, and I want to add to it that if so if you're a person who's Temp Basal, like we talked about on the podcast, and the first way you got to do it was I said, Dude, don't worry, Temp Basal is a great idea here because you can always bail on it, you can always shut it off. Like I always say, like, you know, if you think this is gonna be a carb heavy meal, and it's six units, but you think it might be eight, then double the bazel you know, or something like that for an hour because you can always shut it off. Having a gremlin inside of a phone every five minutes, turning it up, turning it down, shutting just like exactly what she could see right now. It's my God, I'm never gonna forget it had that. It is. It's undescribable. Like, it's just it's everything, this thing's ability to Basal up Basal down double bazel, triple bazel, zero bazel. It's

Jennifer Smith, CDE 55:20
I've never really considered it a gremlin. That's kind of a, that's a really humorous way to think about it. I've actually thought of loop as more of like, a broom. I feel like it's sweep, I feel like it sweeps up the things in the background that I can't consciously pay attention to all day long. I mean, if I was going to loop as a conscious human human brain all day, which is what I thought I was doing conventional pumping, I was doing a lot of micromanagement all day long. And I just I got used to it. It was my day to day, right, as you did with artists find it easy.

Scott Benner 55:53
But

Jennifer Smith, CDE 55:54
yeah, but with loop, it's kind of like there's this little like cleanup crew in the background being like sweep, sweep, sweep, sweep, sweep. Oh, we got to sweep up a whole load more here. You know, whatever. It's, I feel like it's like the cleanup crew.

Scott Benner 56:07
Okay, listen, we'll have a vote later of cleanup crew. But, but no, seriously, it's just changed. You have to go? No, I'm good right now. Okay, because we're just a couple more minutes. And I'll let you go. So it, it's, I want to kind of go over everything again, just wrap up. The part we haven't talked about is that you if you want to do this DIY, you have to download their stuff to do you have to have a Mac computer, you have to understand a little bit of how to use Xcode. You know, you have to get this code offline, you're taking full responsibility for this, right? Like you're This is not FDA approved, no one's going to help you with it, you're on your own. But if that scares you, I think you should realize that whenever tide pool gets this thing through the FDA, when on the pod gets horizon on the market, when you know t slim when all these companies do this. This is in my opinion. Amazing. It's absolutely, and I don't think everyone's going to do it, I would understand why you wouldn't. But it's it's it is the future like is what you could still do what you do fine with needles, you can still do but pump I'm not telling you to change. I'm telling you, this is a leap. And that's what you're looking for in technology, you're looking for a real substantial leap forward. So correct, even if you don't want to do it now. Take a look at it again, when it gets to the FDA.

Jennifer Smith, CDE 57:33
Well, and I think that's where these companies are going, right? I mean, even with horizon with the control IQ with tandem with Medtronic 670 current, you know, 670 G and whatever they come out with going forward. Being FDA approved, they're essentially they're seeing the light, they're seeing that people need more help, because it takes up a lot of our life. It does it mean diabetes is no turn off, there is no unplugged from it, go lie on the beach and drink a Mai Tai, that doesn't happen. And so we need a system that is going to be the cleanup crew, we need a system that's looking at things is consistently adjusting and correcting based on all those variables from that podcast that we did. I don't know two months ago now right on variable.

Scott Benner 58:25
Love that episode, by the way. That was Jenny's idea. Thank you, Jen.

Jennifer Smith, CDE 58:29
Awesome. Yay, yeah, it's it's like that we need the we need to clean up or the Gremlin or whatever in the background being like, I gotta fix this. This is happening. Take care of this, you know, um, so yeah,

Scott Benner 58:41
and I would I would guard against like, you know, getting out a crystal ball and trying to see the future a little bit, which is a little bit of what I think my job is with this podcast is that you also have to think you can't just slap a coupon and then never think about it ever again. Because Because you'll because the same things we talked about at the beginning of this podcast all those years ago will happen to you again, all of a sudden 150 will be okay, then when 80 will be okay, then 200 you'll think it's not that bad. And then eventually, you'll be automating your death instead of manually, like, like, you know, managing it. So you just have to, you're always going to need unless something happens that stunning in our lifetime, technologically. You're always going to need to be involved to some degree but lupa is like Jenny saying going to give you long gaps of not having to be that concerned. And if those gaps start at night, that's a pretty great place to start.

Jennifer Smith, CDE 59:34
So because as we said before, that's a third of your management. Yes,

overnight is a third of your a one fee. Wait, right? Yeah,

Scott Benner 59:42
yeah, it's just it's it's there. I mean, if you're looking for the, you know, I can't recommend or not recommend anything. I'm certainly not going to recommend you use something that's not you know, FDA approved. But and nothing you hear on this podcast is certainly advice but I can tell you, for I'm going to keep doing it. So, I, I can't, I'm going to keep doing it for Arden and I'm going to keep doing it for for you guys so I can try to figure it out because I want to be able when this thing comes through the FBI, I want to be able to, I want Jenny and I to be able next year to sit down and do a pro tip series on looping. And that will make looping as easy for you as we've made being bolt. So that's my goal. I'll be awesome. Thank you, right? It's almost Jenny doesn't get sick of me. Okay, so did we miss anything that you can think of? I

Jennifer Smith, CDE 1:00:34
don't want any that's the beat. Those are the good.

Right? Like I just want an overview.

Yeah, follow up

Scott Benner 1:00:40
to what it's like to start loop. I didn't miss it. Correct?

Jennifer Smith, CDE 1:00:42
Yeah, I don't think so.

Scott Benner 1:00:44
All right, you guys have a great week. I'm gonna say bye to Jenny privately. I'm gonna shut this recording off. Now.

Don't forget, if you're looking for Juicebox Podcast merchandise, go to Juicebox Podcast comm scroll down to the merge button, banner, whatever it is, you'll see the big word merchant click on it. Thanks so much, Jenny for coming on and helping me begin to sort through my thoughts about looping. I expect this episode to be the first of many as I tried to kind of make my way through this new management idea. As 2019 progresses and even into 2020. I'm going to have on some other people who've been looping longer than I have, maybe to help me answer questions or clarify things. The podcast is not going to change, don't worry about that. It hasn't had a big, you know, tectonic shift. All you guys who are bold, are still going to be talking about that stuff all of the time. doesn't go away, please don't panic. This is just me trying to understand what I do believe might be the next step. In Type One Diabetes Care, to be perfectly honest, when on the pod releases horizon, I have every intention of having art and try it. I want to end with sincerely thanking and making sure that everyone who's listening understands the incredible undertaking that is this, do it yourself loop system. There are countless people out in the world, putting countless hours of effort into this, not just the design of the algorithm. But you know how you are able to download it implemented to help you understand the more, you know, complex parts of just getting the algorithm onto your phone. It's not intuitive for most of us, and there are amazing people out in the world helping others. Their efforts are a shining example of what the diabetes community can be at its best. So I don't love loop. I don't think looping is perfect. There are things about it that I downright despise. And there are things about it. They're absolutely amazing. But I don't want anyone who's been involved in this to take any of my opinions good or bad as either a slight or critique. It's certainly not this thing is spectacular. The people who worked on it are angels. And it's just not 100% for me, but I absolutely do find it valuable and worth pursuing farther. So for the time being, I am going to try to continue to figure this thing out. And I will report back to you as my thoughts become clear. For those of you who I think may have been hoping for me to say yes, definitely do this or No, don't do it. That's not up to me. I tried really hard here to give you this information in this hour that I think is enough for you to make a clear decision for yourself, which as we always say on the podcast you should be doing anyway right you should be making these decisions on your own. All I've done here is report my experience and the rest is up to you.

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