Algorithm Collection

Hello, everybody, welcome to Episode 312 of the Juicebox Podcast. Today’s show is part one of a two parter with Kenny Fox. Now Kenny’s name might not ring in your head like, oh, Kenny Fox says that like Brad Pitt, but for diabetes? Well, no. But what Kenny is, is the data of a little girl who has type one diabetes, who really dug in to the DIY loop. And he understands it in a way that I find it inspirational. Now, Kenny and I are going to walk step by step through every setting in the loop, talk about it and kind of a big picture way. If you’re not into a do it yourself algorithm for insulin pumping, I get that you don’t need to be I’m not telling you to be. What I am saying is listen to the episode anyway. Because it’s just another way of thinking about how insulin works. This episode of The Juicebox Podcast is sponsored by Dexcom. The Contour Next One blood glucose meter, and touched by type one, you can always go to touch by type one.org Contour Next one.com or dexcom.com, forward slash juicebox. To find out more about the advertisers. There’ll be a little more about them later in the show. But for now, I think we should get to it. We’re going to start right at the top by saying nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, please consult a physician before making any changes to your health care plan, or becoming bold with insulin. And today. Also remember that what we’re talking about is an algorithm that Kenny and I downloaded from the internet. It doesn’t belong to a company, you just completely do it yourself. It has not passed through the FDA. So understand that while we’re talking. Now that aside, using the algorithm. And watching the data come back from it and seeing how it reacts will absolutely supercharge your understanding of how insulin is working in your body. I’m telling you to watch a an app a computer algorithm decide about insulin. It just elevates your understanding. At least it did for me. It’s taken me a while to figure looping out and I’m probably not all the way there. But I’m getting closer. And I’m going to keep having these conversations with people who are ahead of me until we’re all at the same level together. Luckily, I found Kenny and Kenny understands looping. And that’s why this episode is called Fox in the loop house. Part One.

My name is Kenny and I am into computers and technology and helping people. My daughter Tessa was diagnosed with Type One Diabetes last year, about a year ago. I have four kids ages 865 and two and Tessa is the number two child she is six years old. Okay,

that’s a six. She’s had type one for a year when she’s diagnosed, how soon until you discover there’s a do it yourself algorithm that helps insulin pumps talk to glucose monitors.

Well, it was kind of in the emergency room. So is when we went in for diagnosis. I spent a couple hours here there about four hours I spent the first part of it just googling and trying to figure out what diabetes was if there’s any kind of cure what would work. Then I quickly realized there was no option there. So then started searching for diabetes technology and kind of found Dexcom found your podcast has mentioned somewhere in there I vaguely remember. And then I found looping and Katie’s post about fine tuning settings. And that sort of oriented me to what the mechanics kind of involved might be with insulin and the body and Bazell testing and all that kind of stuff. How long after

test this diagnosis? Did you end up with a CGM and a pump?

We got one, about three weeks into diagnosis probably would have been another week earlier if I had just said Yes, right away. But instead I was like, Well, how much does it cost? And you can never find out those answers until you just say well give me the prescription and we’ll see how much the bill is. So yeah, I’ve only just just just put it on there. And then I’ll, when they call me and tell him how much it is we’ll figure it out. But by the time I got the call back to tell me how much it was and all that I started listening to your podcast and it was like, Well, obviously I’m doing this so just send it to me. So yeah, so we got that about three weeks in. We started pumping about six months. in I think it was like June ish to the month of June pumping with an omni pod. I think we were probably only the first few people to ask for an omni pod with our particular Kaiser, Southern California. Group and then I was just waiting for the right link because only reason we didn’t start looping right away. So I got it later on July 3, I think I started and we started looping.

So tell me, you said you think you’re one of the only ones you mean, like in the practice, a lot of people didn’t use on the pods.

Yeah, it wasn’t typically approved pump get this extra exception process to go through and actually talk to Syrah and she she’s the one that I think really pushed it to finally make it like they had a known process for how to get an omni pod very easily. I just asked for rather than having to fill out a bunch of extra paperwork or something.

So it was an insurance thing more than

Yeah, yeah. And then our endo are. We see the nurse practitioner most of the time, she’s like, wide just haven’t really helped a lot of people with the Omni pod. So it’s kind of up to you. Okay.

We’re not gonna help you. Little did you know, back then they weren’t gonna help you anyway, you were just

Yeah, right.

So, okay, so you’re pumping chest for a month, and then you get your Reilly link, and you’re off to the races with loop. How long ago was that?

Um, yeah, so it was July and it’s March now.

So hold on August, September, October, November, December, January, February, March, that you’re saying?

Yeah, the infamous got math.

All right. Gosh, it’s so easy. If you have enough fingers. It’s very simple. So So eight months, so you’ve been doing it less time than I have? Is that right? Yeah, yeah. Ah, but you’re way better at it than I am, aren’t you?

I don’t know. Probably. Yeah.

Oh, look at you. Right. That’s nice. I’m so accustomed to discussing things with women. And they’re, they’re much more demure. Kenny like you were really like, Yeah, probably am, buddy. But, but but ladies are always sort of like, I don’t know, like, it’s, um, there’s a whole research on that, that we’re not going to get into now. But anyway, women, they say you should stick up for yourselves at your jobs more because men will stick up for themselves, even if they don’t believe in themselves, even if we’re wrong, right. Whereas women who do believe in themselves sometimes won’t. So stick up for yourself, just like Kenny did. Now let’s find out if he can back it up. To Kenny, you and I have messaged a number of times, which I feel like is a bit of an understatement. More than more than a number of times. Have we actually spoken voice to voice once?

We did once when you were heading out to a conference, I want to make sure our didn’t.

Yes,

leave setup was all solid. Alright, so Okay.

So here’s what so has your path gone through the same iterations of this software that mine has pretty much right?

Yeah, yeah. Okay. All right. So,

up until now, you’ve heard on the podcast, Katie came on, she described what looping was, I think I had a conversation with Jenny, somewhere along the way, I’ve had a meltdown conversation with somebody where I was like, I don’t know what I’m doing. Now, please keep in mind for everyone listening, that I just can’t record every day as I’m learning something. And I really, I do want to say this here. Because sometimes these episodes get listened to, you know, not in the order, I hope they get listened to. But when you began listening to this podcast five years ago, if you did, I already had a plan in place. Like I started, you know, the podcast, when I already solidly knew what I was doing. When we decided to try any kind of, you know, an algorithm based loop. I didn’t know what I was doing. And so I’ve been learning it. And you guys have been really cool about it. Because in the beginning, when I said, we’re gonna try this loop thing, people just inundated me with, like, explained to me how to do it. I was like, I don’t know how to do it. I can’t explain to you, I, what I found was they were accustomed to me knowing the answer. And I was accustomed to knowing the answer sometimes, or most of the times as well. And so I’ve been purposefully spreading out these episodes, to give me time to learn in between them so that I’m not saying I don’t know, for two years, you know what I mean? And then suddenly, no, one day, so it’s a weird thing. It’s not exactly a documentary of us figuring out Luke that you’re listening to but so I’m a little further along. Now. I’d actually say I’m a lot more further along now than I was in the last episode, which, while you would have heard it a few weeks ago, if you’re listening now, in you know, March, it was recorded six months before that. So I’m a little ahead of last time any of you heard me talk about it? I’m going to start by saying that when the Omni pod horizon comes out, we’re going to try it. If I don’t like the on the hot, the on the pot horizon algorithm, I’m going to try the tide pool algorithm when it comes out. And I’m going to, I’m going to devour all of it. Because this Do It Yourself experience has cemented in my mind that an algorithm based pump matched with a Dexcom transmitter and glucose monitor sensor is it’s better at enough than I was with less work and the things it’s not good at. I’m learning how to stop it from not being good at that. Do you feel more comfortable than that? If you describe how you use it, how do you how do you feel about it?

I think I think I would try some of the newer ones too. But I’m, I’m pretty comfortable with it as it is, it’s probably has some pros beyond what we were doing. Before that we had actually better numbers, I guess, on shots, and maybe even a little bit on the PDM. Then when we started doing loop, but what kind of the goal was to make this a little bit less mentally taxing, but also allow me to let her go to school and be with grandma and grandpa or whoever, without worrying as much. So that’s helped a lot to you. But then what I didn’t expect the reason why I would stick with some kind of system. But why I really like loop other than the obvious like I can see everything that’s happening in real time, which no other system at the moment has through nightscout. That’s a big deal and watching how school goes, especially because she’s only six. It’s also like the overrides the things that allow us to manage and make Sick Day management easier when you really have sick days that we’d like with higher beegees until after we started loop. And our settings are fairly dialed in by the time sickness showed up this winter fall and just using the overrides intelligently, as made our sick days look a lot like our regular days, probably like 90% of the time. So to me just a lot easier. So I wouldn’t, I would want a system that would do that. But I could, knowing what I know now I could probably use any system and kind of mess with profiles and things of that nature to get a similar effect. Yeah,

I’m starting to feel that way through. Let’s let me clear up a couple things just to be sure. Is your daughter still honeymooning?

No. So we had honeymooning on and off for probably after the three or four months, and I and I kind of found a little pattern with that, too. Like whenever honeymooning was happening, it would sort of pull her blood sugar down, but you’d mostly notice it. When she was eating, she’d just fall immediately. And he like another hundred grams of carbs just to bring her up very slowly. And I think I read an article somewhere that was talking about how the body’s like neutral state is 72, sort of like where you wouldn’t see any insulin or glucagon in the bloodstream. And so after I read that the next time she had a big honeymoon spell lasted almost a week, where she was just on her basal insulin, but no, nothing no Bolus thing unless something out of control was, she would just fall rapidly and then level out right around those 17 depending on how accurate the sensor was at the time. And if I just didn’t treat it and just waited, she would like level out and hang out down there. She’d do it at night, you know, my alarms would be going off because she’d be showing 6869 like a blood test. And she’s in the 70s I just finally had to turn my alarm down to like 65 or something after I knew the sensor was accurate. And she just cruise down there all night. And if I tried to give her honey or something to treat, she just come right back down within 1520 minutes. So we had a few honeymoon periods. And I haven’t seen any for a good six months or so. It’s interesting. So you saw stability to lower number during the honeymoon. And if you tried to put in carbs, you think her body was pushing it back down again? Yeah, because we had we had bazel locked in probably a week after we had probably less than a week after we had the Dexcom. We were close. So we had to back off just a hair on the lantis. But and we’re having pretty stable nights. But yeah, the what I so I just trusted that the bezel was right. And if I just like waited, as after I read this article, it just Yeah, she just cruised kind of flat around the 70s it was pretty amazing to watch because you could see like a minus 15 or 10 point drops, and all of a sudden she just stopped and stay there. So it was it was pretty, a little scary at first but but once I saw it, we just wrote that whole week out like that I’d let her come down and didn’t panic until she hit 60 or something like that.

Nice. Arden had an illness recently that was one of those that you couldn’t really see on her. You know what I mean? Like there was no huge change in how she was or how she felt or anything like that. But her blood sugar’s were lower constantly for like two weeks like she didn’t need the we went through about four or five days where bolusing for food was like a crapshoot, like do Is she gonna need this, how much of it like that kind of thing. And then she, you know, whatever was going on, it stopped and we’re back in it. But more importantly to our conversation here. An experience just yesterday that I’m going to start by telling you about and then if it’s up if it’s okay with you, I’d like to walk through the settings of the loop loop algorithm and talk about each one of the settings with you and how you think about them. Sure. Cool. So the thing that happened yeah. Yesterday right? So Arden poor Arden Arden had her period. This whole this whole podcast. She’s gonna listen back. Like, are you kidding me? Arden has her period right? And it got a little heavy. And so I over the weekend. Now I flew Friday morning to Atlanta to give a talk. Which by the way went great and thank you Atlanta. That was really wonderful. I got to meet Jenny in person for the very first time. And got down there Friday. Went to bed, got up, get my talk came home. Get up Sunday morning. My wife and I are going to drive two and a half hours to see my son play in his second start as a college baseball player. Now, excuse me his third start that we were going that that we were going to see it for the second time because Saturday I didn’t go I was obviously in Atlanta and he was playing in Washington. So while I was speaking to a large group of people, my son got his first ever collegiate hit playing baseball, which was really interesting because my wife texted me something. I think it had a curse in it too. So I can’t read it to you. But he got a double for his first hit. I read it and then got a little like weepy in front of people. for a split second, I had to pull myself down, which is very interesting. Anyway, I, you know, I finished my talk up, I got on a train, I get to the airport, I come home, I walk into my house at 10 o’clock at night, and my wife and I are going to get up at seven in the morning to drive two and a half hours to a different baseball field to see him play. But Arden’s not feeling well, because of her period, she’s tired, and she doesn’t want to come. So luckily, there was no weirdness going on with her blood sugar’s like there had been prior weeks, it’s been incredibly steady. And I set an override and a temporary target. And I set that out, like for forever thinking that way she could sleep as long as she wanted. And you know, least nothing there would shut off or go back to the you know, normal settings. And I figured she’ll get up later in the morning and she’ll know, she’ll text me and I’ll tell her what to shut off and she’ll be fine. And she’ll go about her day and she’s gonna do homework and hang out around the house. So this is damn near embarrassing, and hopefully she’ll hear this years later and actually be a little embarrassed by it. But at 430 in the afternoon yesterday, Arden sent me a text and said, I’m up. Like what? So turns out she was sick to her stomach the night before and didn’t go to bed till like three in the morning. And still she slept over 12 hours, which is insane. But, you know, at least it’s a little better than had she gone to bed at 11 and slept till four. But No kidding. I am going to pull this up. I scraped because I had been watching the entire time I was going I want everyone to keep in mind. There were telephones in Arden’s room that I could have bled to wake her up. I could have sent you know, Find My iPhone to wake her up. My neighbor knew Arden was by herself here, you know, like we didn’t just like abandon her in her bed, like kind of a thing. You know, both sides of my house are being watched by my different neighbors. But I am going to admit I didn’t think she’d sleep till 430. But I am looking at this graph. 24 hours I left the house and her blood sugar was

at

and it never went over 110 it never went under at the entire time. She slept from 8am till 430. And I’m going to tell you right now, Kenny, I used to be really good. And I still am really good at using insulin with a pump and a CGM. But I could not have done that.

That’s pretty, it’s pretty unreal. I wish my kids would sleep 12 hours and keep their blood sugar in range

just to leave you alone. Right. But I could not have accomplished that. Without that algorithm. There’s no way she would have had to gotten up. I mean, not that that would have been the biggest thing in the world. But my point is, is that that she could not have slept, but ended up honestly being eight hours with us not in the house without any intervention whatsoever. And that’s the loop. That’s what me understanding the loop is what made that happen.

What kind of override Did you set a higher or lower one?

Lower, I took insulin away. So her so Arden’s daytime settings are more aggressive than her overnight settings, mainly her basal rate, and her insulin sensitivities are stronger during the day than they are overnight.

School and weekends are just

Well, this weekend. It’s just for school. And excuse me school and weekends while she’s awake. The problem is during the weekend if she sleeps in her daytime settings that begin at like 7am are viciously too aggressive for her to be asleep with. Gotcha. Alright, so inside of the settings of the loop, and for clarity, we’re using the Omni pod with the Dexcom gs six you are as well. Yes. Okay. There are there’s a setting for correction range, suspend threshold bazel rates, delivery limits. Insulin model dosing strategy carb ratios, insulin sensitivity. And Kenny and I are going to go through all of them now. Exciting. Yeah, I it is actually kind of exciting because I think you know way more about this than I do because your brain works more technically than mine does. But I’m hoping I’m hoping for today you’re going to be the technical side. And I’m going to be the, the blue collar side, you’re basically Jenny for this looping episode. Okay. Okay. So let’s just start at the top correction range. When I got loop initially, what was told to me was, you know, this is the bottom and the top of, you know, like it, it was, it was explained to me as target. So, you know, I’m shooting for between 80 and 100, for example, or from between 90 and three, I don’t care if it was a target range. But as time passed, and as people came onto the podcast and spoke with me and I met people privately, I began to think of correction range as when the when I want the insulin to turn on and turn off, its its aggressiveness, its corrections. Somehow, that tiny difference in language was a big deal for me, because I wanted Arden’s blood sugar to be no lower than 70. And no higher than 95. Like That was my you know, like, that was my pie in the sky hope, right? But it didn’t work that way. And I’m going to tell you what I ended up changing it to, but tell me what yours is and how you think about it.

It’s, it’s still like a target, but it’s where it’s where the blood sugar should land after the time insulins all done. So when it expires, when the insulin action time is over. So that’s the unfortunate part about that is it’s doesn’t, doesn’t try to keep you in a range at the moment, it’s more concerned about where you’re going to end up. And that’s a little frustrating, I think, for, you know, probably juicebox folks, like when we were on shots, we would her carb ratio, I use Tesla’s carb ratio stronger than probably what it needed to be because a carb ratio, strictly speaking, is you start at one number you eat, and then you end up at the same number eventually, which would be when insulins done, you know, a long time in the future. But I’m not happy with the spiked comes with that even with a proper Pre-Bolus. So we always dosed a little bit heavy, knowing that she’d probably be eating in three, three and a half hours, no big deal. And so that’s, we were always thinking in blocks of more like, three or four hours, not five or six hours, which is how long loop says, at the instant. And the last. So having a target way out there six hours is, can be a little tricky. So I still use the target country correction range as where I want her to end up because that’s, like, overnight, that’s really applies. But you have to get used to reading the prediction line, and then figuring out how to tell loop everything that you know, so that where you end up even in the middle of that is sort of where you want to be and still try to shoot for a landing. That makes sense.

So this is super interesting, because I’m gonna learn something here from you for sure. Because I’ve come to ignore, ignore the prediction line completely. I act like it’s not there. And it’s telling me nothing, but you’re getting a lot out of it. So this is this is gonna be terrific.

Yeah, I had to get a lot out of it. But eventually, I figured I couldn’t have the same experience that you and I were both dealing with when we started which is sort of yelling at loop and fighting with it. So I did figure out how I could tell loop what I knew. So that prediction on looked reasonable that I mostly agreed with it. And if I didn’t agree with it, then I needed to figure out why. Either I didn’t agree with it, and why loop thought otherwise. And eventually, some of those things, you know, mostly if it’s around food, once you get most of settings close. It sort of helps me figure out how do I change things in the moment when things aren’t working the way I want to, to get that line to look right and not not be too wrong.

While I was in Atlanta, I was talking through something with with Kelly Arden just came through a she’s a lower number. She was like 65 as they were going to food. And so putting in, you know, the the carbs, the accurate carbs. This thing didn’t want to give her insulin right away. Oh, yeah. Right. So I told Kelly, like, just you know, we’re gonna, you’re just gonna manually bolus enough insulin now. And you know, so there’s at least a Pre-Bolus going on, then come back around and check the pending insulin in a little while she starts going up and then you can put the rest in. But I used the sentence. The Loop thinks, and that’s where Kelly was. Wait, what? Yeah, I said so. So I said, there’s what you know is going to happen from your history with insulin. But at the moment, the loop doesn’t know that. It’s not, you know, it’s not a it’s not a living, breathing thing. It’s an algorithm. And it’s taking these settings, and it’s taking what you’ve told it. And it’s saying, based on what my settings aren’t what you said, you just took in as carbs. This is what’s going to happen. You don’t need this insulin right now. But, you know, differently, you know, you know, something it doesn’t know. But this is what loop thinks. And I was like, now here’s how to tell it something to make it think what’s true, instead of what it thinks.

Yeah, exactly. Meant to think like that.

It’s so funny, because you said, Yeah, exactly. And my wife was like, this thing is bullshit. What? So we two different conversations. And I said, No, no, I swear to you, I’m being as clear as I can be about this right now. This is as clearly as I know how to speak about it right now. So so. So for clarity, where do you have your correction set for your daughter,

usually around 85 to 100, during the day, overnight, 80 to 90, I think right now, I just changed it to 8585. Since we’re on the United spoken about this route using the feature testing branch for call automatic bolusing. And that helps keeps us I can give her like a single number target and sort of try to shoot for 85 overnight, for example. And it does a pretty good job. But she has such low basal rates we can get into later. But with a traditional loop, but the bazel modulation, it just doesn’t, it’s too slow to act, because her basal rates are so slow, so low that it would take you know, 2030 minutes to give her a little tick of insulin from the Omni pod over over 20 or 30 minutes that it’s I prefer the auto bullets like Oh, she needs it. She needs it now. So I couldn’t give it to her. So I can, I’ve now changed it from a range of, you know, 1520 points to five points or so

yeah, so Arden’s right now is set it at seven to 95 during the day. And that started with me just like going alright, I, when I have it at 85, she gets a little low, sometimes I make it at six, she’s getting a little low last time, let me make it at seven, then I’m starting to like feel like I’m fine tuning it. But I believe that after this conversation with you, I’m going to decide that there’s a different setting I should be looking at instead of this correction range, but but we’ll get to that. So. So for clarity, if you set your range at whatever, you set it at 90 and 150, you think I want to live between 90 and 150. That’s not how this thing is thinking this thing is thinking that often the future based on everything that’s going on right now, eventually, I want to keep you from going under 90. And it could be talking about hours from now is that right?

It might even be not even under 90, but it might usually what happens after you’ve done your initial bowl. So usually when you set up carbs, it initially tries to say, okay, you want to end up at the bottom to the middle or the bottom of that range you’ve set when it’s choosing how much insulin to give you. But once you’re past that, it’s mostly shooting for either the middle or the top of that range. So if he’s at 90 to 150, and you end up at like 180, it’s really only a target to bring you down by the time the insulins done kind of around 151 3140, probably in that range. So if you prefer to be more like a 100, but you use 150 as your top range, you’re more likely going to be sitting especially overnight, let’s say around that upper line. So if you were to enter, it’s a prediction or to enter into that range, it’s not going to take any action, it’s like it’s fine, as long as you’re going to land somewhere in here. Now you don’t 150 it’s cool with that, if you’re going to under 90, and it tries to back off, if you’re going to get over 150, it thinks then it’s going to add some more. But if you’re gonna land anywhere in that range, it’s not going to take a whole lot of action. So if you want help to get lower into the 110 100, somewhere in there, instead of 150 you should probably have your target market where you’d ideally like to be but balancing like you mentioned, the risk of kind of going low if you shoot too low.

Well tell me why you wouldn’t just make the correction range 85 and 85. My top and bottom goals are 85 and 85.

Why would Yeah. So normally, it’s just the amount of like, back and forth the amount of work I guess Luke puts into it. So if it’s if the correction if the prediction kind of moves up or down a couple points away from that line, it’s going to try to do something so it’s going to change the basal rate temporary basal rates using and what the Omni pod. This is the issue we both struggle with early on was every time that bazel rate changes every time Luke makes a change the timer that the Omnipod uses to start delivering on that rate sort of resets. So if you need a couple of you know, deliveries point 05 within a certain hour, let’s say then that amount, how fast that’s going to tick. That counter starts over every time it changes. So it’s like hey, if you need five in an hour I’m going to spread it out every 12 minutes, and then the loop changes

the Yeah, easily again, and then it starts all over again. So you’re never really getting as much of it through that model is through the Basal model,

not as quickly Yeah, so what will happen is if it changes again, so if you need like five in an hour, it’ll do every 12 minutes or so, let me just start over as is okay, and 12 more minutes, I’m going to give you something more than in five minutes sleep makes a change again, then it’s the counter starts over. And once that calculation for how often that happens was fixed, at least what would happen is in five more minutes, it’ll probably pick an even higher rate. And if five more minutes, they’ll pick an even higher rate. But for someone with a lower insulin need, whether your basal rates are higher or low, but you don’t need very much, it may take three, four or five cycles before that first delivery is fast enough that it actually gets in there, if it keeps changing every five minutes. So if you pick a range, it’s more like it’s less likely to have to change, if you’re going to land somewhere in the range you picked. It’s like, Okay, I’m good, I’m just gonna stick with this one, for a little while, that’s kind of most of the reason otherwise, it’s more, I just don’t care if I’m 100. Or if I’m at five, I’m fine with either, so then you would just leave it there.

So we’re gonna jump around in the settings a little bit like the next setting in the, you know, when you look at it would be suspend threshold. But yeah, I’m gonna skip over that for now. Because I think that what we’re talking about leads into insulin model. And if you disagree, then obviously, I don’t know what the hell I’m talking about,

well suspend, suspend is easy enough suspend is in that situation you gave with Kelly loop is really concerned with you not going low. So if 60 whatever it was below, your suspend, that’s why it wasn’t giving insulin, it doesn’t care that if she doesn’t have a Pre-Bolus, the prediction, you might even show she’s gonna go to 200 loops, not worried about that, I just worried about the fact that she’s currently low, so I shouldn’t be giving more insulin, which is a little frustrating. So that’s, that’s really where suspend is, if any part of that prediction line is going to go below suspend, then you should probably, it’s going to stop giving insulin so you want to make sure you’re not seeing lines dropping that you don’t agree with you don’t think she’s gonna this year she was gonna go low, then you probably need to fix some settings. Otherwise, that suspend threshold is gonna like banging your head against the wall. Why is it cutting insulin when it shouldn’t be?

Quick hitting ads today, the dexcom g six continuous glucose monitor, you want to check it out. It’s at dexcom.com forward slash juice box. type that into your browser right now. If you’re not good at typing, click on the link in your show notes. It’s right there in your podcast player. There’s notes in your podcast player, just find them and click last thing you could do is go to Juicebox podcast.com. And click from there. All of these options are viable ways to get to the sponsors. While you’re there, check out the Contour Next One blood glucose meter, go to Contour Next one.com there’s a little button at the top, you can find out if you’re eligible for an absolutely free meter. This meter is by far the most accurate one that my daughter has ever used in her entire time with Type One Diabetes. Lastly, if you’d like to see some lovely people doing wonderful things for people living with Type One Diabetes, check out touched by type one.org. I’m doing you a favor. I’m shortening up all the ads today. You can do me a favor and click on the links dexcom.com forward slash juicebox. Contour Next one.com touched by type one.org. That’s all I’m asking today. No big sell. Just go check them out. book I’m done before the music. It’s like you owe me almost how there’s so much time left. It’s kind of weird, right? touched by type one.org helps people living with Type One Diabetes, amazing organization. Contour. Next One best blood glucose meter I’ve ever seen Dexcom g six continuous glucose monitor game changing technology for type one diabetes. There I said I wasn’t gonna tell you more about there’s just weird. What I was gonna jump to next is insulin model. So yeah, so that’s, I guess for conventional pumpers. That’s insulin on board measurement. The idea that insulin lasts in your body for X number of hours. It’s it’s based in that idea, but not really like good. So this is more about the pump. I’ve come to think of it as the window of time that the pump considers the insulin for like, like if you Bolus and your model said it six hours, which I think is the default, right in the, in the in the algorithm. You know if that’s a scenario, it’s thinking, Oh, you definitely won’t be high six hours now because we put in enough insulin right now. But if your settings are wrong or the foods you know, whatever, you’re dehydrated, all the other things variables that the the algorithm can consider. That’s not going to work for you. And so that’s why you see some people with the loop. They’re like, Well, my blood sugar went up to 180. And it sat there for like, five hours. And then it but it did finally come back down. And you hear them say that, like, that’s some sort of a win, which I think for a lot of people, quite honestly, is a win. But for you, and I’m probably most of the people listening to this podcast, like, I don’t want my budget to be 174 or five hours. And Kenny was the first person to say this to me, because steadfastly, everyone I spoke to said, don’t touch the insulin model. Six hours, leave it at six hours, leave it at six hours. And Kenny was first starting to say to me, like, yo, mine’s not at six hours. And this works a lot better for me. So mine is set. ardens is set at five hours and 15 minutes, I think. And yours is five, is that right?

Yeah, so hopefully I don’t get in trouble.

First of all, this Kenny’s not in any way related to the to the the looping, like the people writing these algorithms. You’re just the person using it.

Right? I am. And I would love to meet the people that are Katie and Kate and others. So um, yeah. So mindset at four and a half hours. And I’ll tell you how I got there. So before? Really?

Good. Tell me.

Yeah. So when we were on shots, I found apps like extra up and some others that would let me track insulin on board, I just found this cool app. And honestly, I was too cheap to buy a phone that would be useful with the approved dex comm app for my daughter. So I just grabbed my old android phone down next trip and said, Okay, well, that means I have to build a nightscout site. So I’ve built a nightscout site. So we put extra bond extra put all these like cool knobs and levers I had to Google about every time I was trying to figure out what these different pieces mean, and one of them was insulin duration. So what I did is I just once we got the bazel locked in, on my daughter, I would just watch, obsessively every day, when the insulin onboard time when the heard line would stop moving even just one point, like just nice and flat. And so it was between four hours, and like 15 minutes and four and a half hours somewhere in there. You know, we had to give some sensor lag and other variables, some sway there. But I ended up just dialing up from four to about four and a half on extra nightscout. And so I could with confidence know, when she would level out. So like, you know, if she didn’t have a snack between lunch and dinner, she would level out right around five or six, and I could watch the iob number go down down down to zero. And sure enough, she’d be flat, I wouldn’t treat no matter how fast she was falling zero would be, she was fine. It was fine. Basal was fine. Everything’s happy, she’s nice and level. The other benefit to that was I was always tracking how long it would last. But then it also allowed us to do things like treat and I know how much to treat for so I’d look at how much insulin was on board. If she was starting to go lower than I wanted to, you know, at that kind of three, four hour mark, knowing that I give him too much insulin most likely for that meal. And then I would just turn that insulin on board number into a carb ratio, and say here have this many carbs, and then she would level out. And you know, once the insulin board time was done, when it was zero, she would turn off level out. So that kind of predictability was important and comforting. And also, let me have the confidence to change the duration of insulin action in a loop. But I didn’t do it initially, I really wanted to give lupus as a chance to kind of prove itself and say, Well, maybe six is right. And I read Katie’s post about why messing with the insulin reaction time is could be bad. But frame that conversation she’s having around the fact that pretty much every endo will have you set your pump insulin action time to something like two and a half, three, three and a half hours, which is obviously not right. So when they when you get into the loop group and you read the docs and people are really hard about Hey, you got to stick with six hours. It’s because people are convinced over you know, years of time that insulin only last two or three hours and that’s not the case. So and six is definitely safer than say five or four and a half it would safer to over represent how much insulin is in your body while annoying and possibly keeping you high. If it’s not actually how long it lasts. It’s still safer than under representing the insulin so and for some people I’ve helped out five and a half, six hours is about right so we don’t really mess with it. But there’s still a chunk of people that five is probably like a really good number that gets it pretty close. So I was just watching all that’s all I could watch on shots and so I knew that number going in or most people don’t really have a sense for that. What that number should be so you can test for it. But yeah, I changed mine to four and a half.

So I think that it’s it’s pretty obvious. If you listen to the podcast that my concept is I try very hard to break the wall between the the time I don’t know how to put this, let me get up to give me a second Kenny. So obviously, everything about insulin you do now is for later insulin doesn’t always work exactly the way you want it to in the moment you put it in your body, right, it always takes time to build momentum or power, it peaks sometimes, you know, it’s always, it’s always about later about later. But I feel like this is gonna be a ham fisted explanation, because it’s still something I’ve been mulling over my head for a while, I don’t think I’ve ever said it out loud. But I think of the management of insulin, like the momentum of a car climbing a really steep mountain, you need to get to a pace and stay at that pace. And it’s going to become more and more difficult as you go. But if you just keep this pace up, you’ll make it to the top. And so I like the idea of there being active insulin all the time when it’s needed. And it’s so that so that the food or your body function can never really overpower the insulin that’s active. And that so that the insulin is not overpowering the body function, I don’t want anybody low all the time. Not saying that. I’m just saying that when you accelerate, and then take your foot off the gas, you drift back, and then it takes more effort to get going again. And so you know, instead just put your foot at one spot on the accelerator and head up the mountain. And I know that’s not 100% clear. But that’s the background way I think about using insulin, it’s the closest thing to creating constant insulin action so that what’s happening now with food is being in real time impacted by insulin because there’s always insulin coming from the past to help you now. So instead of putting in insulin now for later, I think of it as putting in insulin later before for now.

Constantly, that makes sense. Yeah, it’s way I have a really old big RV. And so driving up a hill, yeah, if you back off just a little bit, someone cuts you off or something you’re, you’re now Don’t slow the whole time up the hill just to make it up. So you get to keep your momentum going to stay ahead of it. Wait, I found with diabetes, you always have to be kind of looking ahead a little bit always planning ahead and looking ahead, like if you know you’re going to eat, you might as well give some insulin, but getting looped to kind of agree with you on that. Or, or to know when to how to use loop to be bold, so that you can keep the insulin moving when you need it just takes a little bit of practice.

Yeah, it’s just sort of this. It’s tough because I try to say things a lot of different ways so that it eventually hits everyone. But I’m always talking about insulin for now is for later. And I know this is gonna sound like the same thing. But it’s not if you just kind of like, you know, just microdose a mushroom right now and listen to what I’m saying for a second, okay? insulin for now is for later, but insulin before is for now. And that’s probably more how I think about it than how I teach it. I teach now for later, but I think before for now. And so the minute you start taking away insulin now, you’re just gonna be getting, you’re just gonna get high later. And and I hope that makes sense.

It did to you, which is in the same way, in the same way, if driving my big vehicle, you take away the speed at the bottom of the hill, it’s gonna affect how easily I can make it up to the Hill, right? I just don’t have the power of momentum to push me up an hour.

Or if you don’t have that momentum going. The minute you come up on a speed bump or a branch to drive around, yeah, you’re gonna lose your, your momentum. And now all of a sudden, the detour wins. Like, right, like, all of a sudden the meal wins or the you know, the spike in your adrenaline wins, that thing wins. Because you’re it’s the same reason why at the end of the story that I just, you know, I told you the beginning Arden’s blood sugar, no lie 8am till 4:30pm while she slept right in that tight range, but when she woke up, she says to me, Hey, I’m gonna get a bowl of cereal. And all I told her was this, that’s fine, your blood sugar is going to get high. Here’s our goal. I’d like to try to keep it under 180 get it back down without you getting low. Now keep in mind, I’m not there. My daughter’s about to have Froot Loops. She’s not going to measure them. I’m not asking her to okay. And so I told her, you’re going to get high. And she said on Pre-Bolus. And I said, Yeah, not gonna matter. Because you’ve been living on a deficit of basal insulin for the last eight hours, right? The before is not strong enough to handle the now and you were going to Pre-Bolus and we’re gonna smash most of it. But unless you’re willing, but you’re at so I can’t have you wait 30 minutes. I can’t tell her to put in you know, 11 units of insulin and wait a half an hour because if she doesn’t eat that cereal the exact right time, and God knows what that is that insulin is going to crush her. And I’m going to come home to a puddle of a kid on the ground, right? Or at the very least my neighbor is going to be handling something I’m pretty sure he didn’t think he was going to be doing on Sunday. So I said, Look, we’re gonna deal with it, there’s gonna be a spike, right? So we’re going to, you’re going to go downstairs. The first thing I asked you to do, Kenny, I don’t know what other people think of in this situation, like you would think Pre-Bolus thing. I said, Go make sure the cereal is not stale, because you don’t need it all the time. And make sure the milk is fresh. Because the last thing we need is 10 units of insulin going in you and then you saying this milk doesn’t smell right. Because I don’t know how to eat that fast. You know what I mean? So, um, so she checks all the food, all the foods, right? I’m like, I cool. You know, go ahead and put in, you know, this, I think we use a massive amount of carbs, like 80 carbs or something like that. And it wanted to give her 10 units ish, like, right in that space. And I was like, Yeah, go ahead and do it. And I said, try to wait 1015 minutes if you can, and but I don’t want you to wait much longer because we’re there. And she did. She ate and it held on for a while. Right that Bolus thought for a little while but all of a sudden 15 I think no fifth is longer that 3530 ish minutes later, we got the dreaded 126 diagonal up now I know everybody’s different. But 126 diagonal off means to me they penciled in their

index column showing a diagonal year you’re having a problem Next comes arrow changes after two readings that are equivalent to like a diagonal so like if more than five like six to 10 points every reading it needs to have those in a row before it changes the reading hundred percent to a Yeah, which is way too slow. I like using extra power I get to see the plus and minus that. Reading the reading and I don’t have to worry about the stupid next Camaro so while

that super stiff line is still there, right on a second Arden’s talking to me here. While that’s super stiff line is there at 105 or 95, or whatever. I’m like, That’s not right. There’s no way that that cereal This Pre-Bolus has not been alive in here long enough to to hold back Froot Loops and milk, even for 15 minutes. So I’m like it’s gonna go up. Oh, wait, I’m gonna go to lunch right now. Excuse me for a second Kenny. You guys is interesting artists coming out of gym. Then how are we gonna do this? With the carbs and like this. I’ll talk you guys through this Hold on one second. I can finally talk about a loop thing about a lunch. Arden’s leaving gym right now. And she was away from her CGM. So her blood sugar went from like 75 to 60. While she was in gym, she feels fine. She’s going to eat that’s not an issue. I’m not worried about that. So we’re going to tell the loop that she’s going to have 35 carbs. We’re going to tell the loop to consider those carbs as a two hour impact. And then we’re going to tell it 40 carbs and consider that as a three hour impact. So Arden has Zell’s and a chocolate chip cookie, a half of a bagel, a pretty big bag of grapes. A Clementine a bag of popcorn? I can try to guess those carbs for everybody if you want. I’m gonna guess the actual test hitting carbs. Yes, I’m guessing the bagel at 25 I’m putting the putting the grapes at 15 to 18 now we’re at 35 or 40 the cookies are gonna be another five for the chocolate chip. I’m at 45 the puzzles are probably 10 more I’m at 55 the tangerines like 12 or 15 I’m at 6570 I don’t know popcorns 10 at ardens. Carberry shows 7.42 to one now as soon as it tells her that it says Of course not to give her insulin because their blood sugar 60 Yep. So I’m gonna say when are you going to eat? Do when do you begin eating?

So have you tried not giving Pre-Bolus in the situation since you’re on the automatic Bolus will give a fair amount pretty quickly and then just text her and say hey, give the rest later.

So I think of it just like that. But opposite. So if she tells me she’s going to start eating right now. Like right now right now we’re going to Bolus

Oh, yeah, that

would just give it Yeah, sure. We’re gonna put in probably like, I’m gonna guess like five or six units right now. And then I’ll let the auto Bolus do its thing a little bit or will check for pending insulin and just do the whole thing,

if that makes sense. Well, the wonderful thing about the auto bolus is that since it loop doesn’t use increased Temp Basal at all, there’s not going to be a whole lot of pending unless, I mean for three hour, I guess there technically might be some pending, but there’s almost never any pending, it’s always recommended Bolus. So she can always just tap her watch her her phone and just hit the bullet screen, it should just have a recommendation. So if an even more insulin, there’s always a recommendation with the auto Bolus branch, which I really love, because my six year old, I can just say, Hey, Bolus, and she just turns the watch over tops to Bolus green. If there’s something there, she takes it. And then nightscout I can see if there is a recommendation before it would, you know, increase the Temp Basal rates? And it would it would loops like I got it, don’t worry about it, I’ll, I’ll take care of it. I’m like, yeah, you’ll take care of it eventually. But I don’t, it’s not fast enough. But I can’t tell my daughter to pull it put this much in and trust that she’ll hit the right number, using the watch or her phone. So now there’s always a recommendation if she needs more. So I can say hey, I think you need all of it right now. So just just hit your watch. And she handles it just fine.

So what I ended up saying is she said, I meeting like right now I’ll be putting food in my mouth in three minutes. So I said seven units. Eat as soon as possible. Let’s talk again in 15 minutes. But you just said you can see you can see recommended insulin on nightscout. I need to let you I need to let you dig around in my nightscout apparently I don’t think I see that.

Well you have that loop pill right underneath the time underneath the clock.

Right. Okay, let me

think. So if you hover over that loot pill with your mouse or if you use it on your phone, you just kind of tap on it. You should get like a list of information in that hover area. And one of the things you should see at the very end of it. It only shows up when there’s a recommendation below you’ll see the last things are listed in that list of all kinds of crazy information. So is a recommended Bolus

I see the loot pill so right now I have four minutes ago squiggly squiggly line 103 what is squiggly line 123 mean?

The I forget that icon squiggly line I think means everything’s Oh squiggly line 103 got it. Sorry, five minutes ago or four minutes ago, a squiggly line means eventually. 103. So the the end of the prediction line is 103 at the moment.

It is I’ll be

Yeah. All right. And but that will only update you know she’s updating it on her phone so you won’t see the next update until you know the next sleep cycle till next time it uploads night to night scout. So even though her prediction line probably doesn’t look like that because she’s put in, you know, seven units. You’ll get the update eventually and you’ll see the the eventual number will update.

Okay, so Arden’s all squared away. Let’s go back a little bit here. So insulin model, when you have yours, even lower than mine is what’s the intention of making the insulin model a shorter time period. And that’s where we’re going to pick up in part two, which will be out in just a couple of days, it’s going to give you enough time to absorb this, maybe go back and listen to it again. And then we’re gonna get through the rest of the settings list on loop. Hope you found this interesting. I just think Kenny speaks so wonderfully about loop. He’s very clear. He understands exactly what he’s saying. And he’s helping me a lot to bring things into focus. If you agree, definitely check out part two. Coming up, I think Thursday night. Thank you very much to the sponsors. dexcom. Contour Next One blood glucose meter and touched by type one. Check them at a touch by type one.org dexcom.com forward slash juicebox. Contour Next one.com. Of course, there’s always going to be links in the show notes of your podcast player. And at Juicebox podcast.com. I appreciate you supporting the sponsors. If you’re looking for more episodes about loop, check out Episode 227 diabetes concierge. Episode 252. A loopy few months Episode 304. loop de loop. It bears repeating that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, please always consult a physician before making any changes to your health care plan. We’re becoming bold with insulin. A huge thanks to all of the people. Most of whose names I’m sure I don’t know, who have put their blood sweat, tears time, effort, heart and soul into this algorithm. It’s hugely, hugely, hugely appreciated by me and I’m sure by everyone else

Hello, everybody, welcome to Episode 313 of the Juicebox Podcast. Today’s show is part two of a two parter with Kenny Fox. Now Kenny’s name might not ring in your head like, oh, Kenny Fox, is that like Michael Jordan for diabetes? Well, no. But what Kenny is, is the data of a little girl who has type one diabetes, who really dug in to the DIY loop. And he understands it in a way that I find it inspirational. Now, Kenny and I are going to walk step by step through every setting in the loop, talk about it and kind of a big picture way. If you’re not into a do it yourself algorithm for insulin pumping, I get that you don’t need to be I’m not telling you to be. What I am saying is listen to the episode anyway. Because it’s just another way of thinking about how insulin works. This episode of The Juicebox Podcast is sponsored by Dexcom. The Contour Next One blood glucose meter, and touched by type one, you can always go to touch by type one.org Contour Next one.com or dexcom.com Ford slash juicebox. To find out more about the advertisers, there’ll be a little more about them later in the show. But for now, I think we should get to it. We’re going to start right at the top by saying nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, please consult a physician before making any changes to your health care plan, or becoming bold with insulin. And today. Also remember that what we’re talking about is an algorithm that Kenny and I downloaded from the internet. It doesn’t belong to a company, you just completely do it yourself. It has not passed through the FDA. So understand that while we’re talking. Now that aside, using the algorithm. And watching the data come back from it and seeing how it reacts will absolutely supercharge your understanding of how insulin is working in your body. I’m telling you to watch a an app, a computer algorithm decide about insulin, it just elevates your understanding. At least it did for me. It’s taken me a while to figure looping out and I’m probably not all the way there. But I’m getting closer. And I’m going to keep having these conversations with people who are ahead of me until we’re all at the same level together. Luckily, I found Kenny and Kenny understands looping. And that’s why this episode is called Fox in the loop house. Part Two. So insulin model, when you have yours, even lower than mine is what’s the intention of making the insulin model a shorter time period.

So whenever I try to deal with loop, I’m doing my best to represent reality. So because I know that her incident her bonuses and stuff with good bazel only last four and a half hours. That’s why it’s four and a half hours. It’s not just to get like a performance out of it, it’s because I really think that the that’s how long the insulin last. The rest of the model is a little interesting. If you see that top option is always that Walsh model, it’s always got the line like higher than the rest of them. That’s kind of what the pumps use it. It’s more like a I don’t know, like a straight line steady decay of insulin or insulin is really kind of peaky, right, it’s slow to start, it hits hard kind of around an hour ish hour and a half. And it stays strong for an hour or two. And then it kind of fades. And so these other models more more accurately represent like how much insulin is left, because it’s kind of more initially and then less later, where that wash model stays really high. And so that’s why the that’s one reason, even endocrinologist know that insulin lasts longer than three or two or three hours. They like to set people at like a three hour because for most of that curve, a three hour four hour Walsh model will accurately represent how much instance on board until of course, you get to the end when you say hey, it’s over after three hours, and there’s still two more hours left. And so then people are like, Oh, well, why do I says no more instance on board? Why do they keep dropping? Why is my blood sugar keep dropping? Well, it’s because there really is more insulin on board but your pump is lying to you. So you either got to have your pump lying to you the whole time until the very end when zero is zero, or and then you can kind of just round down or you set it shorter and then it’s like kind of accurate most of the time and then at the end, you still have insulin on board left for another hour too. So it’s a tricky thing.

Is this a case of because insulin works in choppy like ways, not smooth ways that you’re going To have to lie to yourself or lie to the pump, or have the pump lied to you, however you want to think about it one way or the other. So let’s lie on the more

cautious side. Yeah, I think for a lot of NGOs, they use the instant action time of three hours to give people permission to bolus when they’re high, like, hey, if it’s close to zero, go ahead and correct because after three hours insulins mostly done, rather than tell people, hey, this is how long it’s been last. And if you see this number, round down, a better idea would be to use a better tool. But those are limited, right? You can use nightscout has a better, like in insulin action calculator, extra spike, these other open source apps and loop their insulin models they use for how insulin hits indicators is much more accurate than what comes standard in most pumps, where it’s just a matter of getting these tools.

And what I would do prior to loop is, I just wouldn’t pay any attention is on onboard.

Exactly. Yeah, it becomes so inaccurate that you don’t trust it anymore. So no one looks at it, which is what we’ll talk about, we get to base rates and stuff like that’s, that’s the the piece people kind of ignore they people look at it and go, Oh, wow, there’s a lot of insulin on board when someone’s falling, but then they don’t really look at it other than that,

yeah, I just think of it is, I don’t know, like, it’s like putting out a brush fire to me, like, I’ve always got to charge toes ready. But I’m not always squirting it, I turn the water on when I see the flames. And so like it just, you know, I go I put something out, I keep walking around, there’s more, there’s more carbs, more more insulin. Now stop again, it’s just to me. Diabetes is like a common sense. Like you can use insulin in a common sense way. It’s when you get out of balance or out of rhythm, that everything gets messed up. And then common sense doesn’t seem to apply anymore. Which is why I always tell people like when you get when you start bouncing, the best thing to do is to get low, get down, get steady and start over. Because you’re just you’re trying to you’re trying to grab sunlight otherwise, you know, yeah, like it’s just it becomes it just becomes an endeavor. That doesn’t make sense. Okay. Kenny, also, by the way, at the beginning of the podcast, we’re gonna let people know, this is an algorithm that you downloaded offline. It didn’t come through a company it has not by anybody except the people who wrote it, who, by the way, are really brilliant people, but are not the FDA. And that you’re not a doctor by any stretch of the imagination, or am I? We have no, not even close. Right. And that none of this is advice. We’re just talking through how we do it people should you know, definitely be precaution. You know, take precautions. Keep in mind that when I started the loop with my daughter, I had Jenny to talk to by text, I was able to reach out and speak to Katie, and had I not I don’t think I would have made it two days. Honestly

with it. It was it’s very frustrating to start to or it could be scary depending on which way you’re coming from

hundred percent. Okay, so what should we talk about next? Do you think basal rates?

Well, real quick on the model only thing left is that peak, you don’t really see it much. But it’s mostly like supposed to represent when insulin is at strongest. I use the adult one for my daughter, not the child one. So the child one has like a 65 minute insulin peaking and the adult 175 I feel like a little over an hour’s when I see insulin pulling her down the best. So I went ahead and did that. You also see that if you extend the peak out and use the adult one instead of the kid one, you’ll often get larger initial bolus recommendations, just because of the way the math works. So I use both a lower insulin action time and the adult peak that’s a little higher. a fun thing if you want to test or kind of play with the shorter da instant action time without or peaks. without, you know, really testing it like an open loop or with your PDM or whatever is you can when you do the build. And there’s a screenshot in that loop docs on how to change the insulin action time and peak, Katie had a great suggestion, just take one of the models you’re not using, for example, we don’t use vs. So I took the settings for Fiesta, and I changed it. So I just changed the peak to be what I wanted it to be like matching the adult one for example. And then I change the insulin action time to you know, the five hour one or the four and a half, whatever you’re going to test. That way once you build your app, you can just switch between the models, and like use them for what you want to use them for. So if you want to try a five hour interaction time, and then find it’s like too much, it’s too aggressive or whatever it is, then you can just go into the settings and just tap and use the different model. You don’t have to go back and rebuild. Sometimes building causes a lot of stress for people. So if you can do it once then you can just kind of toggle back and forth without having to do a new build. It’s helpful. I guarantee you just spoke about most of the people’s understanding as well. If they’re getting into that Lu customisations. Yeah.

Okay. sila rates is good. Yeah, rates is the next place to go. So you just said something, you know what? Maybe it’s not maybe those things strategies the next place to go. So that’s a cool one. Yeah. And here’s why not all of you who even download loop are going to have this setting. So in very basic terms, if someone has written a program, it’s an app, right? And this app is an algorithm that takes the data from the Dexcom, and sends it to your insulin pump, and makes these insulin decisions happen around it. There are other people working on additions to the idea. So there’s sort of a basic one, is that called the is that always dev? Is that the one that’s being constantly being developed? Or am I speaking wrong here?

Yeah, you’re right. So the master one is the one that you know, is should be the most stable, it’s kind of the one people would mostly download. Typically speaking, Dev is where all the is where some of the playing, there’s actually like, kind of sort of a layer beyond that, like a what they call like feature testing, someone might build a little, a little change, they want to try, and they’ll build that. And then once they kind of test it, it looks good. And they kind of put it into Dev, and that’s where all kind of the fun stuff, the new stuff comes together, and hangs out for a while while people use it and make sure that all those new features don’t just work, but they work well together. And then eventually, that gets promoted up to master after it’s,

everything looks good and proven out. So the very first time someone mentioned to me about an automatic bolusing. So right now, this this, this, this master branch of loop does not does not give you boluses of insulin, it manipulates your basal rates to try to try to get you to where it wants you to be. But I was somewhere a number of months ago, and some guy says to me, yo, have you seen this Auto bolusing? You know, addition to the loop? And I said no. And he told me about it and helped me check it out. And I forget if it wasn’t written by a man named Ivan, maybe Ivan. Yeah. And Ivan’s was cool. And you could turn it off and turn it on. But the ways to make it work were a little too detail oriented for me. So I was able to make it work pretty well. When there were carbs present in her body, it actually had a setting for like, have this work while carbs are present, or while carbs aren’t present. And I couldn’t make it work without carbs. And I and I could make it work with carbs. But when I tried to leave it on constantly, overnight, her blood sugar would be like, you know, 80 and all of a sudden it would like be giving her insulin. Oh my god. That’s no good. So we got away from that. When an auto brand showed up. Did Pete right it? p pizza and the main steward and developer of lupia. Right. So Pete wrote this one, I gotta tell you, I’ve been using it for a while now. As a matter of fact, I got a note from Kenny and Kenny, he’s like, yo, you seen this developer? This, uh, Audubon springs from Pete and I was like, already got it. And so yeah, you were ahead of it. I was surprised. Sometimes I sometimes I’m out the right out in the forefront. The flag I don’t even have a sword. I’m just running ahead with the flag. So I’m the first guy to get shot Kenny.

Someone has to be

shoot the guy with the flag first. So. So anyway, we’re using that. And I have to say, it’s pretty Skippy. So Am I understanding it right that when and insulin is pending, or when the you know, the loop is telling you, we think you’re going to need another half of a unit soon. It will give you 40% of that.

gas. Yeah, exactly. So like the by default. So instead of increasing basal rates, it only decrease your basal rate, it will never increase. If you need more insulin, instead of ramping up your temporary basal rate, it will give you a bolus. But then just for safety, there’s a a number you can actually change it to in the code, but it just uses 40% of whatever loop thinks you need. And it gives you that as a Bolus in the next five minutes. So I’ll give you another 40% of that. So it kind of its slows down. So I mean, in theory, if your insulin need was the same, for let’s say half an hour, because that’s how long loop kind of can can give you a basal rate for it would give you it end up giving you less insulin over that half an hour because you’d never get to 100%. You know, 40% 40% 40% just gets smaller and smaller and smaller, but never really gets to zero. But it gives you a lot more up front. So Pete did some cool math was basically saying that if you had consistent insulin needs and you’re going to run a single basal rate, increased basal rate for half an hour. You’re basically getting 17% of what loop thinks you need every five minutes. If you just held steady for that half hour and then but With the auto bullets, you’re getting 40% of it kind of right away. So you know, within the first 10 or 15 minutes, you’re still way ahead in terms of like timing of the insulin, but after about 20 minutes, you’re kind of about the same amount of insulin delivered. Unless you count the fact that we might change the base rate every five minutes, in which case you go back to what I mentioned before, where it starts counting over again to redeliver. So

right, so using Arden’s current situation, which, by the way, please believe me, no one set up just because it works perfectly during Kenny’s conversation in mind right now. Like, so I want you to know, first she comes out of gym, you know, she’s lost connection, Toradex calm, while she was disconnected the loop had taken her bazel away completely, so she didn’t have any insulin coming in. And she gets back over finds out, hey, my blood sugar is actually you know, 60 I want you to know that we checked that with a finger stick. So she whipped out the Contour Next One meter, she checked her blood sugar, she’s definitely 60 she feels fine. You know, I didn’t share everything. She said in the tax. She’s like, I don’t feel dizzy, I feel 100% fine. She was you know, 15 or 20 minutes before that, like in the low 70s. And most of your like, the kid just went the gym class with a 70 blood sugar. But it also is because I knew that for the time prior to that she did not have a glut of even bazel running because this 85 blood sugar that was trying to drift eventually to 60 which it did over a number of hours. Loop has been taking away bazel for a while now. So I was pretty certain that even if she kind of got a little lower, it wasn’t going to be a crashing low. It’s just going to kind of like float down, which is exactly what happened, which is cool. But I just want to be clear we you know, I my daughter seven units of insulin based on the hope that her CGM pop back on it was right which by the way, it did pop on and it was right she it had her at 64 the the meter header at 60. You know, I’m that makes me comfortable. You might imagine the next reading drifted down to about 60 and then come back up to the meter. Yeah, we’re at 60 right now. And but here’s the great thing. She’s now been eating for quite some time. So just like we talked about earlier with the cereal, like where you know, she looks like she’s 85 or 90, but the cereals in there. Clearly, she’s going up because she’s eating the cereal, but the glucose monitor has not adjusted out of it yet. And we gave her some crushing amount of insulin vino for the cereal. And it still didn’t help by the way Arden’s coming out of that cereal, she still at one point was 171 error straight up. And the way we stopped that was by opening the loop. And hitting her with a big bolus of like three more units, she eventually had 13 units for that cereal, which, ironically, is how much I would have given her without loop. And I don’t know why I didn’t just do that it was because it was because I wasn’t with her and nobody was around. But we stopped that cereal spike at like 185 200. And that space, it it leveled out. And as soon as it started to come back down again, we close the loop right back up. So the loop could start taking away bazel. Because those three units were too much they were enough to stop the spike. But they weren’t going to be needed moving forward. And because ardens bazel rates like 2.5 an hour, I just basically I threw in an hour’s worth of bazel to stop the spike, and then took away an hour’s worth of bazel. And let that three units act as the bazel.

Does that mean we do something very similar. When I see a spike like that, I just don’t bother to open loop because one, I can’t do that from the watch. I’m not going to bother my six year old to say Come over here. Let me have your phone. And then I’ll do that. But also I know exactly what you said, which is that what I’m giving ultimately is probably too much unless it’s unless I miscounted the carbs. So that’s one of those situations where it’s like, well, if I miscounted the carbs and I’ll go in and edit or add a carb entry kind of back in the past to kind of stack on top of the meal. But But even before I can even figure that out, it’s just a big bullet. So you just need to stop the arrow, give it a big bolus, let Luke cut bazel I don’t care if it cuts bazel or not. And if I think I miscounted the carbs then I go back and I add carbs. If I didn’t miss count the carbs and just missed Pre-Bolus or whatever Miss timing, then I just let loose cut the bazel because for the same reason, she’s going to go low eventually if it doesn’t, so I just let it do it. That may mean you get a couple more ticks up versus open looping. But I just I let it ride. I just give a big enough Bolus to stop it in its tracks and loop cup bazel and hopefully land safer or safe safely or safer than she would have otherwise. I’ve done

that too. I don’t it’s funny, isn’t it like what you just said makes complete sense they but I would have been uncomfortable giving her five units to stop a one at going up. Even Yeah, even though I think you’re not wrong. I think it probably would have gone the same way. So I’ll try one day like I just like having the bazel back there.

Oh, it definitely helps. Yeah, it makes it makes a difference.

So, so now right now at this meal, we’ve put in seven units for what I’m guessing is like 80 carbs. But at ardens ratio. She has more than that she needs more than that. Now I’m going to tell you right now I’ve seen it work enough times, going back to Pete’s Auto Bolus, those things strategy to tell you that if we don’t do anything else, that Auto Bolus is not going to let her go over about 170. That that’s what I know is going to happen based on what because I’ve watched I’ve let the auto Bolus do its thing a number of times, so I can watch it. And so if there’s a if there’s a reasonable Pre-Bolus, you’re starting with a lower number like this, it’s going to stop her up in there, and it’ll get her back down again. But the truth is, is that as soon as Arden’s blood sugar adjusts, in a way that makes me comfortable that we’re seeing some sort of upward mobility, you know, movement in her blood sugar, I’m going to ask her if she finished all of her food. And if she did, then she’s going to put in probably three more units on her own put in the rest. Yeah, yeah, it’s so it works. And I don’t know, the technical side of it is lost to me. I don’t know the changes that they’ve made in the basic Master, you know, version of this since we first started. But when we first started this, I think I’ve updated the master vert, you know, loop, maybe once or twice in the last nine months, the first two goes of it that I was using, were really, night and day, not nearly as good as what this is.

Yeah, yeah, it was a big, big one was how, how loop assumed that the only pod was delivering those basal rates, how it calculated when to start and stop its delivery. That was the big thing that was off a lot of the Medtronic pumps that had been used before, they instead of they just do it differently, they start, they restart the counter, but then they start a little sooner, without getting the detail to start sooner in like the Omni pod and a couple other of the Medtronic pumps so that and I think they sort of knew about it. But didn’t think it was that big of a difference in the amount of insulin delivered and how much difference that would make. But with especially with littler kids like us, it made a huge difference, it would say that she’d have a larger percentage of insulin on board then than she really did, because it thought it delivered insulin and it didn’t. So that that was probably the first big change. And the second big change was a the car model how loop expected the impact of carbs the hit, I thought it would be kind of steady like all those 80 carbs, we hit evenly, evenly raise the blood sugar across those two or three hours, instead of like more accurately modeling that most food hits faster sooner, and then it kind of steadily goes down. And so those were the two like significant changes that you probably experienced. And I did too, that sort of made me start to trust the system a little bit more.

So let’s jump to base. All right, let me ask you, for me, you heard me break Arden’s Bolus into two different decision making entries? Yeah, well, actually, it’s one it’s so she makes an entry. So she said whatever it was, if it was 35 units, two hours, it means it says two or however much it thinks she should have, I always tell her just choose zero and enter it, then get that Yeah, put in the next one that it bundles them all together for the next one, so that you don’t have to watch insulin, so that it doesn’t deliver the first few units of insulin for the two hour model. And then you have to sit and wait for the to do that. So instead you deliver nothing on the two hour or whatever the first time because you’re thinking and the adult delivered on the second go round. But I do that, so that Luke has a better understanding of exactly what you just said, some of these carbs are going to hit faster, some of them are going to stay with her longer. And that used to keep the bazel from going away. And it still would if I didn’t have the dosing strategy of auto Bolus on. Because I have auto Bolus on it’s now taken her Basal away, but it’s going to try to come back with Bolus if it needs it. Whereas if we didn’t have auto Bolus on that thing I just did with a two hour and three hour would have tricked the loop into keeping the bazel on.

Yeah, so like that three hour people find what those carbs is that if you put a longer absorption time, the initial impact is less you get less insulin recommended up front, typically you’ll get the most insulin recommended up front on a two hour. But on a three hour let’s say it’s going to last longer, and it’s going to the carbs have a chance of outlasting sort of the peak Enos of the insulin and Luke knows that so that it will offer more insulin later to kind of help compensate for that. So sometimes when people find themselves kind of high at the end of a meal, it may not be because there wasn’t enough insulin it may just be that you needed more insulin but you needed a little bit later and you seem to totally pay This food actually is lasting longer than I thought. And it will often recommend another Bolus once you modify that absorption time. In the past like, Oh, this one, I thought it was two hours, it’s probably more like three, you change it, it’ll probably give you a bolus recommendation in most cases. So but doing the like, representing the food properly is isn’t is important. And it’s kind of a new thing I had to learn with lupus like, I don’t know, how long does something take to eat night last in your system? So

no, I know. It’s interesting. I just, I kind of blank I do two and three hours. And it works every once in a while. If it’s something like rice, like with a Chinese food, I might do two, I might do two and four hours. But it’s you know, it’s not always perfect. Again, I want everyone to keep in mind that Arden’s a one c does not come from an 85 line that never moves. Like to be perfectly honest, like, because she was sleeping in. And you know, it all, you know, it all went well for me this weekend. But that’s not normally what her it’s not normally. Yeah,

it looks like for eight hours, you know, and I think that’s part of the secret sauce or magic sauce of like a control IQ or some of these other algorithms is they you just enter carbs. And you don’t talk about absorption time even like open APS and other systems, they have other algorithms, they tend to handle the dynamic carb things looks like a little bit better. You don’t have to worry about how long the food is necessarily. I think that’s that’s pretty magical. But loop is, lets you kind of see all the pieces like it helps you understand, like, biologically what’s happening.

I think that that’s really why I’m telling people about I always talk about glycemic index and glycemic load with people like you really need to understand the impact of the food. You know, it’s how, how hard is it hitting? How long is it hitting? How long could it go? You know what I mean? Like, is this a? Is this a food that can only make it two rounds? Or is it going to go the full? You know, is it gonna go the full way? Is it gonna crush you? Is it gonna come out like Conor McGregor? And just like jump through the air and, you know, jam its face into yours? Or is it gonna go a little slower and you know, start more of a seductive dance with you before it starts the pummel you.

Yeah, like juice or candy or glucose tabs like I enter those 30 minute absorptions. I mean, they’re probably more like an hour, but I do it as 30. So that loop doesn’t try to overcorrect those. But I mean, generally speaking, like juices, kind of a hit quick and go away fast. You don’t want to put a play introduces a two hour and she’s just having it just for fun. Or having grapes by themselves. And that’s it. Yeah, they don’t last two plus hours and loop will end up making her golo kind of later that when you know because it just thinks the carbs are gonna last longer, and they don’t.

So let’s talk about the basal rates then. And I guess we have to talk about them in two different ways. Like, do if you’re using an auto Bolus pizza? And if you’re not, so if all right, I don’t know, though, it’s funny. I have no

basal rates to just bazel Yes,

I haven’t changed ardens bazel rates, since we went to the auto mode, the only thing to understand is that is is how it makes up for stuff, it doesn’t make up for bazel anymore, with anymore.

So I think this is where this is where I think this is where I start with most people that I end up helping out is uh, basically you know, is like switch your body needs some and you and Jenny have talked about that multiple times. So it’s like if you didn’t eat, or run around or whatever, and just kind of fasted all day and watch TV or something, you should be able to stay flat. Same with overnight. And so that’s kind of the goal with Basal. And so but what I’ve found out get into like how you track it here in a second. But what I found is most people have like one bazel rate, maybe a couple but if you start with one, you end up able to see when those other changes show up. And I came to this just because on shots, Tessa was level that the basal rate and the insulin on board calculation worked all day, every day at any time. Day or night, it would always end up zero ended up being zero when she had no insulin on board. It was everything was done. So I just came from the mindset that she only had one basal rate, but I got the pump and start playing with it. And it just would mess up the math for tracking how long the insulin was working. So I just kind of stuck with one. But I found that with other people, it works pretty well to you just pick one. And then you can kind of see if you need another one. But you start with one I guess I just heard the other day that the sugar surfing guy, Dr. Ponder, I think sort of thinks the same thing. And what I think actually changes throughout the day, which we’ll get to in a minute is sensitivity not bazel but when in a world of dumb pumps, all you have for automation is basal rate changes. So I think people are in one sense programmed to think oh, it’s probably bazel but really what I think doctors and people are compensating for with base rates is often sensitivity changes not bazel but yeah, so Basal is is what is supposed to be but loop sees Basal as neutral as free insulin as zero doesn’t track it. It trust that you said hey, I need this much insulin. Kind of as a baseline for my body. And so it doesn’t really keep track of that. So if you have bazel too high, you may end up with the insulin on board number may show that you have zero or maybe even a negative number. And really, you’re falling you actually have more insulin in your body than loop is aware of. But because I trusted you, I said, Hey, you said you need to this much insulin all day. So like, that’s, that’s what I’m giving you. So when you do an override, and you increase those bezels, it also can kind of complicate that calculation. So yeah, I think that’s kind of the main thing is, is Basal is free, so you don’t really track it. So what I do to test bazel, with closely if I find the search with like the tandem system as well, is you can test bazel without testing bazel in a closed loop. And it’s pretty awesome, because you can look at that insulin board calculation, you know, assuming that interaction time is reasonable, anything six is a fine place to start six hours. But if you look at the insulin on board, overnight, you should get to kind of where you want to be in that correction range we talked about, and iob needs to be pretty close to zero and flat. If I obese, not zero, meaning like just bazel is all you have running at night, and you should be flat. If it’s not zero, then something’s wrong with your bazel. If you’re constantly have positive insulin on board, like a bigger number more than zero, then your basal is probably too light, because it loop is constantly having to add more insulin to kind of push you down into your range. And if you’re especially if you’re above the range, you want to be insulin on board, that’s a positive number, especially at night should always mean you should be falling. But if you’re not, then something’s not Luke doesn’t know what it should know. And then the weird one that really throws people off is the negative insulin on board when you see a negative number in there. Negative is is a deficiency of insulin, you and Jenny have talked about that a little bit before where if you turn your let’s say your level when you wake up at 80, but someone wants to be at 100. When they Bolus they could turn their pump off, they could do a zero beta rate for a little while and you’ll drift up. That just means your body has less insulin than it really needs just to hold you level. And that’s on purpose. So negative insulin isn’t a bad thing. But when you see negative insulin on board, you should always see you know, giving some room for sensor lag, you should see either right away or pretty close. Blood Sugar readings should start going up when you see a negative insulin onboard situation. If it’s not going up when it’s negative, then you’re not representing the insulin properly in the body and loops gonna loop thinks you need more insulin you don’t. So what happens oftentimes is people are falling, the blood sugar is falling and there’s negative insulin on board means their bases are too strong. So as soon as you start curving up, let’s say you treat a low loops like oh, yeah, I expected you to come up not knowing that you actually gave carbs. And so it’s going to try and fill in that negative because what should work in this situation I talked about where you turn your pump off before breakfast, you actually can’t just turn your basal back on, otherwise, you’ll still keep drifting up because your body is missing the insulin, it needs to kind of maintain that balance. So loop tracks that negative amount how much you’re missing. And it’s going to fill it in for you to try to level you out. And then also correct for any, you know, upward momentum. So what ends up happening is you know, getting slammed back down, because you have too high of a bazel you have negative insulin on board and you’re falling, and then you correct but don’t tell loop about it. And then it’s Oh, good, you’re coming back out. Let me give you more to level you out and it’s pushing you back down again. So you end up in this cycle overnight, we’re constantly trying to bring someone up and lips pushing them back down because he thinks you’re missing insulin, but you’re really not. And that’s what that negative insulin on board will tell you. And so you have to adjust your bazel. So that insulin on board is 00 means level, negative means up and positive means down, obviously, without food. And that will tell you so you can kind of scan your day and look for points in time where loops thinks you’re kind of around zero and see what the behavior is of your blood sugar. And then you can know if your basal is too high or too low, and starting with a single basal rate will help with that because the insulin runs for four or five, six hours. So feel really high basal rate to catch a nighttime rise like most kids do. And then you cut it back later the insulin that you gave is still running you know until four or five in the morning and it’s you’re still gonna end up with this like negative iob and falling kind of situation. And it’s not the not because your your little basal rates during those eight hours are are too heavy. It’s because the heavier when you ran from like 10 to midnight, was probably a little bit too strong and it’s just causing an impact later on the night. That was a lot but hopefully that makes sense.

No, it doesn’t. And I think it’s important for people to understand the idea of like sensor like the CGM is reporting behind time a little bit.

A little Yeah.

So by way of an example because you spoke there for A few minutes when you began speaking, Arden’s Dexcom was telling me her blood sugar was 58. But it’s not because she’s had food in her for 35 minutes. Right. And so I’m not panicking. It’s, even if it’s, it’s not 58. But let me jump to the end of the story, but it was stable at you know what I mean? So I know this food is now going to do what I expected to do, right? Like trust what you know is going to happen, it’s going to happen as food went indoor, it’s going to start impacting her as you were speaking, the Dexcom flipped over to 66. So obviously, her blood sugar didn’t magically go from 58 to 66. In five minutes, it has been trending up. Like you said, it’s now gotten two reports in a row to its to the text comms algorithms now gotten two reports in a row that it believes. So now it’s going to start reporting it right. Exactly. Yeah. And so as soon as that happened, it took a little bit of more time for nightscout to know it. So I can kind of see it on a on a different screen, someone watching everything while we’re talking for this explanation. As soon as nightscout knew her blood sugar was 66. It put her bazel right back on again. Like immediately, and now I shouldn’t be right. And now in truth, this is the moment we should be bolusing that other insulin right now, whatever more insulin I believe she needs for her food. This is the time to put it in probably sooner even. But now for I can be certain with the data. I have backed it. Now’s the time. But we’re gonna let it go for a little bit just to see the loop does to let let it see what loop does. Now if she jumps from 66 to 90 next time or something like that. I’m bolusing right away. Oh, yeah, maybe even a little bit extra, right. But if she just drifts a little bit here, I’m going to be interested to see because the auto bolus is going to kick in because we only use seven units for something we told her that we told the loop and the loop believes needs 10 units. What’s your suspend set up? 6060

Okay, yeah, so it will it could even start giving. That’s why it turned the bazel back on. Okay.

Right. Yeah, I used to have it at 55. But I she was getting low too much when it was 55. Where’s yours? 70.

Okay, yeah, 70. Because again, bazel and curvaceous are locked into the base of the big one. And you got to make sure you you believe that loop will drop you the other big one will be sensitivity we get to but yeah, if you’re, if you’re not getting down where you want it to be like a lot of people will drop their suspend lower. And I think 60 or 65 is, is fine for the most part. But I find if I’m trying to push that kind of ad overnight, and lose my overcorrect a little and then I get woken up at my 70 alarm. So I just put the suspend a little higher so that mostly so I don’t get woken up as often.

I believe that I listen, I believe in our basal rates really well, like Arden got up this morning. 630 she didn’t eat anything until, you know, just now. Right? And so and you know, she got down to 60 with Jim. So I believe in our basal rates. Perfect. Yeah. And overnight. She’s, it’s gorgeous overnight.

So I think what’s nice about loop and that neutrally makes us all nicer people and talking about having tools is you have an insulin board calculator, right there. So you can see in nightscout, especially, but you can see on your phone too. It’s called active insulin in the loop app, as you can objectively measure your basal rates, which is nice. It’s not dislike, well, I think it’s fine. It’s you can at any point in the day, if you see zero and she’s not level, then you can kind of question without the bezels right. And I think the other fun thing that comes into play is that idea of school for a lot of kids maybe makes them go up oftentimes, like stress or something maybe work for some people. Once you I’d like to try to tell people get your basal rate, like create a baseline where like to say, like weekends and not school will not work. So you know what normal life is so that you don’t have to worry about crushing someone you know, on a weekday, if you can avoid it. And then you play with overrides the override feature increases your basal rate or decreases it however you set it. And use overrides for school and work that way. You can if you feel like maybe you’re not as stressed at school or at work one day, and you’ll end up meeting it you can just simply cancel the override and kind of go about your day and be fine. But if you need it, then it’s there to use it and you don’t have to keep fiddling with your settings every Sunday night or Friday night. Things like that.

Okay, let’s jump ahead here. So to insulin sensitivity now, yeah, it’s funny. insulin sensitivity is wildly different for so many, you know, for everybody. Right? Ardennes during the day is 59. And overnight, it’s more like 64. But I’ve spoken to people who have their sensitivity, like you know, it’s 120 and so can you. I’ll tell you how I think of insulin sensitivity and then please you tell me how you think of it and you know, etc. in my mind’s eye, it’s just sort of the amount of insulin it takes to impact me. You know, mean like just like this, what what’s gonna knock me over? Like, you know, you can give me 59 and 59 will do what it’s supposed to do. But if it was at 6565, wouldn’t do it 65 would be like getting shoved by a six year old. But 50 nines, you know, like me pushing against somebody who’s my, my weight, like, it’s, it’s the, and I know this is it’s not it’s not clear, because I’m never clear on insulin sensitivity, like, you know, I’m sure there’s a really technical way to say it, I’m sure you’re gonna say it in a second. But I find a lot of people get confused by it, and no more so than the idea that a lower number is more powerful.

So yeah, that’s weird,

right? So a lower No, it’s a very basic mathematical idea. But still a lower number is more powerful. So my daughter, five 737 pounds, insulin sensitivity 59, during the day, your daughter, you know, much less. You know, wait, I would imagine

what’s hers that? So she’s her sensitivity during the day is about 200. And I would probably say realistically, it’s probably about 225 250. So it’s probably more sensitive. But I’ve looped dialed it down just a hair, because to make it behave a little more the way I’d like I use that as kind of a, an aggressiveness number to some degree to make loopback a little bit faster than maybe it would normally without causing so much of a low. Yeah, so sensitivity is yes, how much insulin it takes to move you a certain amount of points, your your blood sugars or how much insulin it takes to move you. So yeah, I think it’s, it’s, that’s a good way to look at it.

So how so I guess the next question is, and I want to talk about overrides more specifically, but the next question is this. Once I found we had Arden’s settings close in loop, then I began to adjust them sort of like an equalizer on a 1991 rack system. Okay. Like I’m like, I don’t know what treble point oh, nine is, but what happens if I push it up a little bit? Yeah. Right. Or what happens if I push this down a little bit like that? I, once I was close, then I could start fine tuning without knowledge, then I could start going correction range. Let me try 87 to 85, whoo, that was better. You know, you know, bazeley I wonder what 2.3 does versus 2.2. That kind of stuff. But starting out. You cannot adjust loop to ear? Did you know what I mean? Like it’s just you have to start somewhere near? Near good. Somewhere near good. Right. And so my question is, do you know if I came to you today, and I was just like, guy on the street and I say, Kenny, hey, I really want this to work for my daughter. Do you know how to help somebody set this up? Like do you know how to go from scratch? Quick kidding. Add today, the dexcom g six continuous glucose monitor. You want to check it out. It’s at dexcom.com forward slash juicebox. type that into your browser right now. If you’re you know not good at typing, click on the link in your show notes. It’s right there in your podcast player. There’s notes in your podcast player, just find them and click last thing you could do is go to Juicebox podcast.com and click from there. All of these options are viable ways to get to the sponsors. While you’re there, check out the Contour Next One blood glucose meter, go to Contour Next one.com there’s a little button at the top, you can find out if you’re eligible for an absolutely free meter. This meter is by far the most accurate one that my daughter has ever used in her entire time with Type One Diabetes. Lastly, if you’d like to see some lovely people doing wonderful things for people living with Type One Diabetes, check out touched by type one.org I’m doing you a favor. I’m shortening up all the ads today. You can do me a favor and click on the links dexcom.com forward slash juicebox Contour Next one.com touched by type one.org that’s all I’m asking today. No big sell. Just go check them out. Look I’m done before the music it’s like you owe me almost tears there’s so much time left it’s kind of weird, right? touched by type one.org helps people living with Type One Diabetes amazing organization. Contour Next One best blood glucose meter I’ve ever seen. Dexcom g six continuous glucose monitor game changing technology for Type One Diabetes there. I said I was going to tell you more about it. Weird. Do you know how to help somebody set this up? Like do you know how to go? Yeah Rach

for Yeah, so it took a while a sensitivity was a weird one to wrap my head around to so the my process is look at basal rate, subtract iob. I go back to someone’s graph if they’ve been running it for a little while. Helps I find closed loop is helpful, more helpful than an open Id be a little harder to see it on normal graph, but you could still probably get close. But I like to find how the neg makes sure that negative means up and positive means down and that they’re kind of at their range, where they’re supposed to be especially overnight. And then we just try to find what I call like that one magic bazel rate. And we pick one that works mostly overnight is easiest way to observe it, run that one all day. And then make adjustments from there we carb ratios and sensitivity sensitivity. I mean, it’s so hard to like, really, I’m not going to stop my six year old and doing a sensitivity test that’s even longer than a bazel test. So I once we get overnight solid iob, zero means flat, everything’s dialed in, I just tell people, hey, turn your sensitivity more aggressive to a stronger a lower number, until you start to see that line that’s fairly flat for you start to wiggle start to go up and down and go above your the range you set. And below that range, you set it to make sure it also goes below but doesn’t go below, then it’s um, you might still not have a strong enough bazel. But basically turn the sensitivity too strong to where you can see that it’s obviously too strong and then kind of back it off a little bit. And that’s kind of what I use for daytime ISF because I find that people are more sensitive during the day than they are at night. So you find what works overnight, make it too strong and back it off a notch. And the reason why people are more sensitive during the day I think is because growth hormones exists kind of overnight for everybody, me included, were growth hormones, I was reading some studies on this trying to figure out why this rise at night happens for my daughter that just kills me. So what I said earlier is that no matter how much I bolus her during those rises is IRB of zero was still zero. So the interaction time worked well. That seemed to indicate to me that she actually only had one bazel rate or not, it’s crazy, intense rise period. So what I found is growth hormones don’t make you go up necessarily, but they do make you more resistant sensitivity. But that means something else must also be pushing you up, which I’ve kind of found a correlation between how close dinner is to sleep or how heavy dinner is to sleep. And so it’s probably just this weird digestion process you have when you’re sleeping, that stretches out how long the carbs last, and the carbs kind of have a more of an impact because all these growth hormones released during your REM sleep cycles during the early hours of sleep. And so you have more growth hormone in your system at the beginning. So there’s just more resistance there. So the only way to really model that and loop is to make the sensitivity, lower a lower number in those first hours of sleep. And then I sort of like ladder it softer and softer or a higher number as the night goes on to sort of mimic the idea that there’ll be less growth hormone in the body. And so I might start with like a 200 during the day, and go all the way down to like an 80, which is less than half of what her sensitivity is, you know what, like nine or 10 o’clock when I know she’s gonna be asleep, and then ratchet it back up. So you know, 115 131 6180 and then when she wakes up, it’s I usually have around 200 or so. So and I found that to be helpful and to help Luke kind of semi automate and for some people automate those nighttime rises, but it’s really not a bazel change as much as we’re programmed to think, Oh, that’s a rise, I need to get more bazel if you use increase bazel there instead of sensitivity, you may find that negative iob and falling kind of at three or four or 5am instead of just making a loop more aggressive because that sensitivity is really only comes into play when you’re out of range. Do you that’s kind of the cool part about sensitivity is if you’re in your range at you know nine o’clock at night, and she’s asleep, and great loop doesn’t do anything. So if I made the ISF too strong, it’s not a big deal. She’s in range. But as soon as she’s out of range and loop kicks in, you know, puts the pedal to the metal a little bit more. It could be an x faster.

Yeah, it could it could be but oftentimes it’s not there in those first hours. So it’s, it’s, as you mentioned, like how much insulin has taken knock you over. So it’s but I think it varies throughout the night more than the day. But that’s kind of how I approach sensitivity. It’s interesting that just because your child is younger and growing, you’re having the exact opposite experience night today than we are. Get like Yeah, a little bit. Yeah, when Arden’s asleep, she just doesn’t need. She needs less sensitivity, not by a lot, by the way, like listen to what you’re doing, you’re going from like, you know, in the hundreds to double digits and you’re bounced around, we’re really only moving between, like, you know, 59 and 65. Like it’s not it’s a pretty

tight tolerance. But how many basal rates Do you have during the day?

Just one,

just one. Okay. Yeah, yeah, one during the day one at night. Yeah, I’ve seen that. If someone’s not really going through a growth period I’ve seen unit with me too. So I wore a sensor for a few weeks. And I sort of like helped prove this theory out by, you know, all for the case of science, having a lot of ice cream before I went to bed, and I could see my blood sugar rise and sort of stay up and kind of in waves like kind of matching my sleep cycles, kind of stay up a little bit longer and take longer to come back down then if I didn’t eat something right before I went to sleep, so I was able to sort of mimic the same process as my daughter, but unless eXtreme Scale one because I’m not type one and two. I’m not growing like you said the volume of growth hormone in my body is probably much less than someone who’s actually growing. So the sensitivity will be different.

We’re growing just not in the same way.

So yeah, exactly. When you’re having ice cream at you know, eating like a whole bunch of ice cream at 10 o’clock at night. That’s Yeah, we’re definitely growing that stuff not to be questioned, I guess

I am pretty certain that I’ll be wearing a Dexcom Pro in a little while.

So that I well, then you should for science, eat something really yummy before bed and see how that happens. I will be

Yeah, I’m gonna be wearing the same thing. Like I just I was talking to Rick Doubleday the other day. And I said to him, when we got done, I was like, I’d love to wear a sensor for a while if I could, you know, to really understand, you know, better what I’m looking at. And

so I think Neil is fun is did this and you should eat something similar to what Arden does when she eats it. And you’ll see the absorption time play out in both of you. Yeah, it’ll look a little different. But you’ll see the food stop at kind of the same time.

That’s exactly the stuff I’m excited to look at.

It’s amazing. Yeah, we ate uh, you know, again, for science ate a breakfast sandwich from McDonald’s. And it lasted a long time on those chicken ones. And, yeah, you could see kind of the initial carbs. And you can kind of see the sustained fat and protein in both of us. And actually, in one of those cases where we tried it, her blood sugar ended up way better than mine, on average, so. But it’s fun. I do think

there’s many times where I’m doing a better job for art, and then my body’s doing for me. Yeah, so interesting enough for art. And by the way, is her sensor went to 75. And then the next adjustment was only to 79. But it did just Bolus 1.15 units a little while ago, then the 79 jumped to 94, diagonal up

high. So you’re above suspend, and it’s like, Hey, I know you need more for the carb ratio. So it gave it to you. And it popped

on like, so I’m gonna see if I can raise her with a text. If I can, I’m not gonna bother. But if she answers this text,

I mean, just take the recommended bullet, because all you’re gonna ask her to do

it, ask her if there’s any insulin that’s being recommended right now.

And you can actually you can try it hover over the loot pill with your mouse. And you can see at the very end of that little hover box that pops up, it’ll tell you if there’s a recommended bolus.

Well, so the little loop thing I have right now says, See, I don’t even understand this, the loop has put your

mouse over that box and you should see another box pop up.

I only have it on my phone,

I do with my Okay, then tap this tap on the loop pill and you shouldn’t need so you can refresh that page if it doesn’t pop up right away. But p tap on the thing that has the loop put the number in the squiggly line, you shouldn’t get a little hover box to pop up. I don’t know I said you need somebody to refresh it.

It’s my fingers too fat.

That can happen to a lot of pills. They’re crammed together. little boxes just says loop device loop. You should see something like on the hover it’ll tell you how long ago the Temp Basal that it’s currently running insulin on board carbs on board. Predicted minimum and maximum.

Let me go over to my iPad. Let me see if I can make that work. Yeah. Yes.

So bring it up on your computer and you can look at it and it’s easier

to figure out how to do that. I got I don’t Yeah, I don’t even remember how to bring it up on my

computer. I’m remember her sight. Are you kidding me?

Wait, isn’t it at the play here it is.

Roku app.com

typing, which is always the best thing to do on a podcast. Yeah, people love it. And really, they’re huge fans. Oh, here she is. She said what? Okay, so I’m going to ask her is the loop recommending any 1.8 do it. There you go. There we go.

Now it takes all of it instead of auto Bolus would just give 40% of that right. And then again,

which it would likely do again the next time the CGM turned over correct. Yep. So Yeah, there you go. So when, listen, I you know, we’re not going to be recording when this is all said and done. I’ll remember what happened. I’ll tuck in at the end. But look at what happened like Arden’s a Urban’s blood sugar has been right around at all morning five or six hours that she has been awake. She went to lunch, or she went to the gym, her blood sugar went to 60 she just ate a bagel grapes, puzzles, a chocolate chip cookie, popcorn. And a What did I say? tangerine? Something like

that. Clementine. Yeah, time. Right.

And she ate that stuff. It’s 1255. Right now here. And that conversation began. Back here.

Noon.

Yeah, two minutes after 12. So it’s, it’s, it’s, it’s almost an hour later. And we have gracefully gone from 60 to 95. And even if she makes it to 150, which I don’t think she’s going to normally she wouldn’t be coming out of a low, we would have Pre-Bolus sooner, and this wouldn’t be happening like this even. But this is astonishing for the situation. You know, but if you don’t understand how this thing works, none of that’s gonna matter. Like it? Yeah, for sure. It’s damn near impossible. And so, but I also think that for those of you who aren’t considering any kind of closed loop system, whether it be loop or tandem or horizon, when on the PI puts it out, or you know, whatever else. Understanding what Kenny and I are talking about here today will help you make better informed decisions even without a an algorithm, I think, because just watching and you heard Kenny allude to it earlier, just staring for a little bit and watching what happens is such a teaching thing. And when I watch Lupe, take bazel away, give bazel back make a small bump with now with the the automatic bolus or before the automatic bolus when it would kind of ratchet up the bazel. It was fascinating to watch loop take bazel from like 2.5 and make it seven but only for like eight minutes and then bring it back again. And like I was like, Oh my gosh, this is really I’m learning a lot from watching that, you know,

yeah. And like I said, we had slightly better numbers in terms of standard deviation and a one C and time and range. When we were on shots, because of the same principles that once I figured out how to apply it to loop. Yeah, it’ll just make your life easier. Being able to track insulin on board is really kind of magical in terms of figuring out your basal rate and just knowing when, when the drop stops, you just got to know and how much to correct for and, and all that it’s just it’s really empowering or most people are just kind of, again, being dynamic about how you talk about in with juicebox. But like at the same time, if you kind of know when it’s going to stop, you can be aggressive and be more aggressive because you know how much insulin is working? And if you overdid it, you know how much to correct for a lot more precision in that approach.

I think that loop is going to represent, you know, I shouldn’t even say look, I think that algorithms in general, but for everybody, but for us specifically, I think it’s going to represent a mid fives a one C. Just base I think so what I’ve seen and what I know.

Yeah, as I tell people like if they’re in the sevens now like if you can just get the settings right and moderately Pre-Bolus then, and don’t learn not to overcorrect, you’ll get sixes pretty easily it shouldn’t be that that complicated. And that’s what I’m seeing with some of these people, once we figure out especially like, people that have their kids and they get really stressed at school and just need a lot more insulin these overrides work super well for that. And then, and then they ended up having, you know, like I Oh, there’s one person I’m working with now that was in kind of a seven range and is now looking trending toward kind of a 6.2. You know, and and they just have even before that before their stats changed just by making some of the changes I talked about. They just have more, it’s more predictable. And now it’s not as crazy, you know, at least when they’re high kind of know why it happened. So. So that’s pretty great.

It’s amazing. Last thing I want to bother you about is overrides. And I don’t know that I think about them correctly. So let me just tell you how I think about them. And you correct me if I’m wrong? Sure. I, I know I don’t understand exactly what they do. But when I said an override for art and whether it’s a decrease like you know, instead of it 100% of, you know settings, I go to 80% of settings or 50%. That’s a decrease in insulin power. Or vice versa. If you go to 120 It’s a 20% increase, like that kind of thing. Is it just an across the board increase? Is it literally like the correction range stays the same? The suspend threshold stays the same. But this is an increase of bazel rate. insulin sensitivity is the heart rate show carbery show is that in

Yeah, yeah. And the kind of the tricky thing about using them is that once you turn one on any like entries like carbon trees in that time have that Change applied to them. So if you used too strong of one, and entered carbs or a low one, some people get a little too extreme and they go, Oh, they’re falling. So I turn an override on, which is not the time each and an override on but they’ll do like a 20% or something really small and then enter like lunch. Well, then it thinks that lunch needs 20% of the insulin, your carb ratio, like 80%, less than what you’d need. And so there’s no way to really go back and fix that. So you, you’d have to basically know that that happened and add 80% more carbs to that carb entry to get something equivalent. That’s a tricky part. But yeah, an override changes everything, which is good and bad. I think there’s a lot of cases where you only want to change one or two things, but because bazel and insulin on board, that bazel calculation is so important. I try to tell people that the override is should only be used in cases when bazel actually changed. Otherwise, you end up throwing off the math if you use like if you’re stuck high and you’re frustrated, and you use a 200% override 100% more than normal, you’re doubling everything. Later on, you’re probably gonna end up loops gonna think you’re gonna land and you’re not because you actually have more insulin in your body than you told it because all of a sudden, you told that your basal rate doubled. Yeah. And so yeah, you end up with a problem where lube would have landed you if the math had been right, but you won’t, because you lied to it for a little while. So

the only time the only time I really use it is sleeping it. So like I said, Arden’s like 1.4 overnight cheese 2.5 during the day, that 2.5 kicks in at 7am. So usually she’s drifting, I have Arden pretty consistently drifting to 70, when she wakes up in the morning for school at seven. So if I set an override at 6am, I set it about 50. So about 50% of power, this, that’s enough to get in front of the drift, so she doesn’t drift to 70. And so that when 7am comes, and the insulin sensitivity goes from 64 to 59. And more importantly, I think in that situation, that bazel bazel jump up, it keeps the bazel back at overnight,

and yeah, 50 percents about what your nighttime is compared to your daytime, right.

And that’s and that’s how I do it. Now, the longer she sleeps, the less she needs. So if she’s just going to sleep till nine o’clock that works, but if at nine o’clock, she’s still sleeping, it maybe has to go to 40 or 30. Like you really, because at that point really consider what’s happening. She has not had food, and she’s not having any like body impacts on her blood sugar. Now for sometimes eight 910 a dozen hours like in a really sleeping in situation. You keep taking it away and taking away. The key is that when you wake up, it’s got to go right back on. And when you Bolus, like you said before, it’s not just for the carbs. It’s not it’s and it’s not unique to Pre-Bolus still, you’re not just Pre-Bolus for the carbs. You are you’re also have to replace all that deficit that comes behind because basically, it’s a paper tiger at that point, right? Yeah. Like any food you take in is just going to overwhelm you because there’s just no insulin happening in your body. That was just enough insulin to basically keep, you know, like, like a, you know, a corpse from blood sugar going low. It’s just not a living person. Right then nothing’s happening inside of her in this scenario.

Is Arden have a drop in the morning before she wakes up? And then like a rise after she wakes up? Typically? No, not at all.

Okay, that’s good. You see that sometimes my settings take care of all of that. Okay, yeah, um, it used to be before loop. She’d wake up in the morning at seven. When her Basal went up with Bolus in the morning with Bolus, the rise.

Like she does have that rise. Yeah, she

has it but we don’t see it any longer. It doesn’t actually happen. Because we’re basically constantly like I said, you know, we’ve been talking for a while, like I said a long time ago, because I’m thinking about now as before, not now for later. And yeah. So I’m, I’m a head of that I Pre-Bolus. spikes I Pre-Bolus rises, if you’ve heard me talk about, you know, like, extended bonuses. People talk about extended Bolus is one way the way I talk about them is Pre-Bolus in the food, and then Pre-Bolus thing, the spike. Yeah, exactly. Yeah, just always. It’s a time travel movie, you know, what’s going to happen in the future. You’re just you’re just always bettan you know, on the right team to win because you’ve got the almanac, and you know, who’s gonna win? So

yeah, so when I use overrides, it’s really like bazel changes. So what what’s kind of fun with overrides if you have your basals dialed in, like I said, using the IP math, and typically people have the same bazel overnight as during the day but not always. If it’s good, then what should happen with overrides and a lot of people don’t experience when their settings especially bazel is not right. Is this doesn’t work but if you can look overnight, and my daughter typically runs around 80 to 90 overnight, and if for some reason she’s not if she’s hovering around 100 or Hundred and 15 with some positive insulin on board, that means that her, her insulin needs have shifted maybe just for the day maybe because she’s sick, I don’t know. And I’ll just run an override of about 1020 30% increase. So 120 or something like that. And then I’ll run it. And, and I’ll leave it on for breakfast and breakfast is sort of like the maker break like was this for reals or is just temporary. And if she doesn’t go low from an increased override at breakfast, then I run that override all day long until I see her until I see that negative iob and blood sugar falling sort of situation again, where things sort of settled back at over. So I just roll over out of bed, look at nightscout see where she was at. If I get woken up with a 120 or 130 alarm overnight, and Luke can’t keep her under that number, then I know her insulin needs have gone up a significant amount like she’s probably sick. So she probably needs like a 130 or 140 or more to and then I just run that all day long. Again, checking it with breakfast. And and that’s how we kind of get mostly normal days like I get ahead of it, I see the increase happen overnight, that shift sort of happens in that two to 4am timeframe, most of the time. And I just put an override on the compensate because her basal needs went up, but I don’t think it’s going to stick around for the next few weeks. And it usually lasts a day or two, sometimes a week if she’s actually sick. But I always use that overnight as a measure to say how much more or less does she need. And use an override and I don’t really mess with my base settings often because they usually work occasionally, if you get up to like 150% override, because she’s sick. Sometimes the carb ratio has to be weakened a little bit because doesn’t scale up quite perfectly. But I’d say 9090 plus percent of the time, it’s just a 1020 30% override for the day, and then the day looks normal again. And then I watched the numbers overnight and wait for it to shift again. And then I cancel it and then we go back to normal settings. And it’s it’s really kind of magical to be able to see the patterns. Once you get some consistency. You can see those patterns coming and get ahead of them. Yeah,

well, listen, I can’t tell you how thrilled I am that you found the podcast and and reached out to me because I think that I listened, I edit these shows, obviously. And then I listened to them for sound. So I end up hearing them two or three times. But I’m gonna listen to this one dozen times, because this was a terrific conversation. I just I can’t thank you enough. And can I can I ask you, right here, start thinking about how we could take a person who knows nothing about any of this? How do you explain this to them? Like that’s the thing. That’s next, right? Because you and I are involved. You know, and everyone listening, you know, is involved with their kids, hopefully, but everyone wants to not be and they don’t want to burden their children with teaching them all of this like is, is an algorithm based insulin pump ever going to be? You know, I guess skinned in an app where you don’t need to understand what’s happening behind the pretty picture on the front. Like I hope so.

I think the hard part right now is the settings have to be like that’s why I think control IQ seems to be working so well compared to like a Medtronic where it’s trying to figure out your settings. But then control IQ just trust your settings. So you have to if you can get it close, then you’ll get good results. Just like loop if you can get it close, you’ll get safe and good results. But I think the real trick will be how can could that Medtronic idea of just figuring it out for you ever work? I’d love it. I’d love for that to be true.

Yeah. Okay. All right. Okay, I’m gonna ask you to hold on for one second. I’m a thank you first and, and I’m gonna ask you because I’m gonna ask you a question. I’m not gonna let anybody hear the answer to I just like the screw with the episodes. So. Alright, guys, Kenny’s done, but I’m not done with Kenny. I think it’s pretty fair to say that Kenny will be back on the podcast at some point. Kenny could be Jenny loopy. loopy Jenny. Kenny could be loopy Jenny. Kenny Jenny. Kenny loopy Jenny Jenny loopy Kenny. Kenny Jenny late. I’ll work on it let you know. huge thank you to Dexcom the Contour Next One blood glucose meter and touched by type one. Please go to touch by type one.org dexcom.com forward slash juicebox or Contour Next one.com. To find out more about the sponsors. Continued gratitude to the community that has put so much time and effort into the DIY loop. Talk to you again soon.

Hello friends and welcome to Episode 420 of the Juicebox Podcast today is another episode about the Do It Yourself algorithm called loop. If you’ve been following along in this series, it began back in April of 2019, with Episode 227, and that one’s called diabetes concierge. Then I spoke about loop again in August 2019. In Episode 252, a loopy few months, February 10 2020, Episode 304, a loop de loop. And then in March of 2020, we had a two parter number 312 and 313. Fox in the loop house parts one and two. And that fox we’re talking about is Kenny Fox, gentlemen has been on the show a couple of times, and who you may know, I really liked Kenny because he understands the loop. And he talks about it in a way that I dig on. So I asked Kenny to come back because I think I’ve made some big improvements with how I think about loop. And I wanted to check in with Kenny. With all that considered. This is Episode 420. Fox in the loop house, part three. Please remember while you’re listening, that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, please always consult a physician before making any changes to your health care plan, or becoming bold with loop. This show is sponsored today by the glucagon that my daughter carries g Volk hypo pen, Find out more at G Vogue glucagon.com forward slash juicebox. Have you ever wondered if that blood glucose meter that you’re using is accurate? Well, it might not be. But I can tell you for certain that we love the Contour Next One blood glucose meter for exactly that reason, its accuracy. I also love its bright light for nighttime checks how easy it is to use and carry. And of course, those Second Chance test strips. Check it out at Contour Next one.com forward slash juicebox. And if you’re a US resident living with type one or caring for someone with Type One Diabetes, please consider supporting the T one D exchange by going to T one d exchange.org. forward slash juicebox. And joining the registry, you too can help T one D research. All these links are at Juicebox Podcast comm or right there in the show notes of your podcast player. Let’s get to Kenny right now. I’m just gonna cut the music off and start no messing around. Recording when I start the recording. All right. Last night, I ordered a new mic for the house here. Because finally after what feels like about two years, Arden’s like, Okay, I’m gonna come on the podcast. And I was like, finally, geez. So, so I’m gonna get another microphone, like so if I buy this microphone, that’s it, you’re definitely doing this right, because she’s vacillated a great deal. I don’t know if she’s embarrassed, or she’s afraid of what she thinks she’s gonna say, I have no idea. I was like, I don’t care what you say. You can say whatever you want. You know, like, I just want to chat with you a little bit. And then I want to talk about, you know, what you’ve learned so far about diabetes and what you think you still need to know. And we’ll go over some stuff. I was like, that’s all I just want to talk. She’s like, Okay, all right, I’m gonna do it. But I think she’s planning on using it as a they have to do a certain amount of Oh, my God, why can I not think of a very simple word. If you send somebody out into the world to do a nice thing. In exchange for that, you get hours to put in the service or somebody service hours, they have to have a certain amount of community service hours to get it done, to get to graduate. So she’s like, do you think that would be community service? I said, Ask your you know, ask your counselor, the counselors like it would definitely be

nice, nice.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

you basically gave them momentum away.

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

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

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

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

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

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

But yeah, I mean, your last few weeks have been great.

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

less, you should probably look

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

not a lot, though. It did a few points. Yeah,

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

had it.

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

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

and not enough insulin with the beginning of the meal, and then too much at the end with basil being too high.

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

that means not that off. That’s what that means.

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

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

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

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

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

Drop low. Yeah. Oh, hardly ever

meet. So

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

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

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

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

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

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

Yeah. And I was like, everything’s just different.

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

wow,

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

how do I say that? Yeah.

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

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

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

yeah, it’s pretty cool. Yeah,

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

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

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

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

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

Right? Um,

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

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

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

Sure, yeah.

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

I kind of created like a quick four step process. But there’s a lot buried in each one of those steps. So first thing is always

candidates. Do you have a quick four step process that has 75 sub steps?

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

you put that basil in, and then let the loop backwards manage.

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

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

me. But that’s the word the horizon stuff will be nice to stay connected. No

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

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

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

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

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

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

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

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

I do think it’s gonna be amazing for most people, honestly.

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

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

talk to Joanne

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

change settings,

and styrofoam that is absolutely huge. So I would like that I’m going to be

if I could push the lube algorithm onto the pot, and then I I’d be much happier.

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

that’s intense. Yeah, I

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

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

get a little bold with loop, right?

Yeah. All right.

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

I guess you could do Fox and loop house three bolt with loop. But it’s a long title.

It’s not a Schwarzenegger film.

But you gotta be able to find all of them. Right. So

yeah, I see. I got to keep it together. You’re right. All right, Kenny.

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

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

And it’s about finding a way to become a team with loop rather than feel like you’re fighting it. You know,

I’m there. I have to be honest, I want to thank Gina who forced me to do this a year and a half or more ago, and you who’ve come on and talk about and all the other loop users who came on helped me work through it and Katie for coming on and explaining what loop was, I just, it’s been a process and I think we’ve been able to pull a lot of other people along with us. So and I hope for everyone else, they’re hearing the value of, of algorithm based pumping. I think it’s a, it’s gonna change everybody’s life and 2020 one’s gonna, I think it’s gonna really explode for people with type one. It’s exciting. I’d like to sincerely thank Kenny and all the people who’ve been on the show over the last year and a half for helping me understand the loop DUI algorithm better. And they do really hope that all of you listening understand that as these algorithms become more and more available in retail pumps. It’s gonna be lifetime Thanks also to the Contour Next One blood glucose meter. You can check them out at Contour Next one.com forward slash juicebox. And of course, the T one D exchange can be found at T one d exchange.org. forward slash juice box. I’d also like to say a huge thank you to one of today’s sponsors, g Vogue glucagon, find out more about chivo Kibo pen at G Vogue glucagon.com forward slash juice box, you spell that GVOKEGL Uc ag o n.com forward slash juicebox. At this point, there are a lot of series within the podcast I mentioned at the beginning. And I’d like to mention again, the algorithm pumping series, which goes Episode 227-252-3043 12 313 326 and of course this episode 420 but I’d also like to tell you about the after dark series 274 about drinking with type one 283 about weed smoking 305 about trauma and addiction 319 about having sex with Type One Diabetes from the female perspective. Episode 336 is about depression and self harm. Episode 365 is sex again, but this time from the male perspective. Episode 372 talks about co parenting and divorce Episode 384 bipolar disorder Episode 393, bulimia and depression and Episode 399. A tea one who was addicted to heroin, I really think the series within the podcast are incredibly valuable. Don’t forget to also look for the pro tip episodes that begin at Episode 210. And of course, sprinkled throughout defining diabetes short episodes to take everyday diabetes terms and put them into an easy to understand definitions. And they’re not just definitions, but Jenny Smith and I talk them through. And if you don’t know, Jenny, you really have to find those defining diabetes, pro tip episodes. And even the Ask Scott and Jenny. Thanks so much for listening. As the sixth season of the Juicebox Podcast winds to a close I find myself really looking back and reflecting. And I’m just very grateful for everyone listening for all the hard work you do sharing the show and for this connection that we’ve built. I’ll be back soon with another episode. Transcribed by https://otter.ai

Hello friends, and welcome back to another episode of The Juicebox Podcast. It took some time, but I got Kenny Fox to come back. If you’re not familiar with Kenny, go look for Fox in the loop house part one, two and three. Those are episodes 312, 313, and 420, if you’re interested in looping, you should listen to the fox in the loop House series straight through. Today, Kenny and I are going to talk about night scout and data tracking. We’re going to talk about basal adjustments and insulin on board Kenny’s new coaching service, understanding loop predictions and adapting to stress and daily routine changes. Please don’t forget that nothing you hear on the Juicebox Podcast should be considered advice medical or otherwise. Always consult a physician before making any changes to your health care plan or becoming bold with insulin. Don’t forget to save 40% off of your entire order at cozy earth.com All you have to do is use the offer code Juicebox at checkout. That’s Juicebox at checkout to save 40% at cozy earth.com when you place your first order for ag one with my link, you’ll get five free travel packs and a free year supply of vitamin D drink, ag one.com/juice box. This episode of The Juicebox Podcast is sponsored by Medtronic diabetes and their mini med 780 G system designed to help ease the burden of diabetes management, imagine fewer worries about mis Bolus is or miscalculated carbs, thanks to meal detection technology and automatic correction doses, learn more and get started today at Medtronic diabetes.com/juice box. Today’s podcast is sponsored by us Med, US med.com/juice box. You can get your diabetes supplies from the same place that we do. And I’m talking about Dexcom, libre, Omnipod, tandem, and so much more us, med.com/juice box. Or call 888-721-1514, if you’re looking for community around type one diabetes, check out the Juicebox Podcast, private Facebook group. Juice box podcast, type one diabetes. But everybody is welcome. Type one type two gestational loved ones. It doesn’t matter to me if you’re impacted by diabetes and you’re looking for support, comfort or community, check out Juicebox Podcast, type one diabetes on Facebook. Ken, you are on three of maybe the more popular episodes in the podcast about algorithm pumps. So let me see, do you know the episode numbers, or should I look for them?

I remember they’re, like, almost a year apart. I remember that part. I just looked at the numbers this morning. They’re in the hundreds, like 300 or something. Wow. So

you were on originally, episode 312, Fox in the loop house part one. We did part two. Episode 313, so it was just one after the other. Was probably just a thing. I split up into two, but then we had you back again on episode 420, for Fox and the loop house part three. Your last name is Fox, and we talked about loop, and for some reason, that’s the title that came to me. So there’s no other reason why they’re called that, but they’re very popular, because I think not only do they do a good job of going through what loop is and how you use it and how I used it back then. But also, because a lot of that information, I think it grows people’s understanding just of how algorithms work in general. And you can apply that to honestly, if you’re on control IQ or, you know, Medtronic or omnipotent, like wherever you’re finding your algorithms at, you know, I don’t know what else is there now. Twist is coming, and I let. No, I let. I guess you can’t really do much with but, you know, like all these different algorithms that are out there, the way they work informs you about how you think about insulin, and then you can kind of reverse engineer what you’ve learned and put it back into your management I think that’s where, like, the leveling up comes from. Do you agree?

Yeah. I mean, we tried the control IQ for six weeks, we had a pump given to us, and we tried it out, and we got similar results to loop using some of the same techniques and the base understanding that comes with using a system like loop, and you can definitely translate major pieces of this to other systems. I’ve helped a few friends on Omnipod five, and just adding things like knowing that fat and protein needs some insulin and carbs can really help balance out that total daily dose piece of the algorithm sometimes people end up staying higher just because they’re not bolusing enough, and therefore it thinks they need to hire basal. And you can fix that by just making sure. You dose more, and you dose more by adding in the fat and proteins. It helps pretty much in any system that we’ve used before. And the twist one will be using a form of loop when it comes out.

Oh, that’s awesome. See, I just learned something. Though it’s awesome using tide pool. Tide Pool loop. That’s excellent. Okay, great. Anyway, so listen, even if you’re not a looper, my point is, check this out if you’re using trio. If you’re using, I mean, what else is there that’s DIY at this point,

Android, APS, trio, the main ones, yeah,

loop. Or one of the, one of the systems that you can get retail. I think the information here is going to help you in one way or the other. So let’s just jump right in. Tell me where you want to start.

I guess I’ll start a little bit with me. I been in the DIY community for a while, helping out, doing videos on loop and learn and on the podcast with you, and just helping people in the Facebook groups. And late last year, I got laid off and decided I wanted to take my coaching skills. I was doing financial coaching, budget coaching for couples, and that was fun, but it was kind of a little side hobby, and I thought I could probably do this and teach people how to use loop better and do it all the time, and help more people that way. So that’s what I’m trying to do. We’re starting off early 2025 with a course on how to change your settings, how to know how to read the data and know how to change your settings and loop. And we’ll go from there, see how it goes. Help

people your web address because I want you to say it, because I’m I’m delighted by it,

because a lot of people reach out to me, saying, Hey, listen to your episodes on the podcast. You know the podcast is Juicebox Podcast. In case you don’t know, I went ahead and just leaned into Fox in the loop house. So my website is Fox in the loop house. Calm. You can find me Fox in the loop house on Facebook and Instagram and YouTube, so just lean into that identity piece of it, since that’s where a lot of people find me. So I thought I’d just go with it, and you told me I could years ago when I mentioned it. So you made my

day when you told me that was the URL. I have to say, it’s like, oh, that dumb thing. I thought up, I’ve reshaped Kenny’s life with it. I

thought I was a little dumb too, but I couldn’t think of anything better, and that’s how people know me, plus it has my name in it. And so it means I don’t have to worry about, where do I slip my name in, or making a whole LLC, or whatever I need to do for that, because my last name’s in there. Well,

the way I have to tell you, the way I think it occurred to me back in when I when I thought of the title, was that to me, like the DIY algorithms, you know, are this not siloed, but a thing that not many people knew about? So I thought of it as almost the club. And then I was like, oh, and Kenny’s like, he’s going into that house and, like, showing it to people. And then, I don’t know, then your name was Fox. And I was like, this is good enough. I like this. I like, I like the idea of you, like going into this place. It probably seems secretive to other people. It isn’t, but maybe it feels like unapproachable, and you were just in there going, like, look, here’s all the eggs. Let me show you. You can just have them too.

And back then, it was a little chaotic. It’s definitely matured, you know, the loop and learn groups. Got a whole group of volunteers, and so sure, we’re funneling information a lot easier to people, but definitely back then, it was a little chaotic. So little fox and the hen house sort of play on words. Works out how it

felt to me. So, oh, so that’s awesome. Okay, so let me ask before we jump right in, doing financial coaching for people, there must be things that you’ve learned about how people learn and how they’re motivated that you’re moving over to this. Am I wrong?

No, I mean, part of it is just communication. When I was doing the coaching, I tried to make sure that, like, both the husband and wife, for example, if it was they were married, were both showing up because they’re both trying to engage in goals, where you’re going stuff you’re trying to achieve, and putting people on the same page, even if one person that wasn’t totally bought into it, at least they heard the words, had a common vocabulary to like work through problems together, and so I thought about doing the same thing for loop coaching, making sure that you know both parents are there, or that the type one is there, maybe with their spouse. I haven’t carried that over, but it has been good to reinforce, or I’m finding that people reinforce the same language and words that I’m giving them with their kid, if they’re old enough to start taking it in, and so they’re picking it up on their own. It’s been good that way. That’s

excellent. I’m just it’s interesting to see how people’s careers build and and sometimes lead to similar but different things. So this is the

well, knowing that you need to acknowledge the emotional side of things too. I’m a little more technical and just trying to solve the problem, but trying to make sure you they people feel heard, and that they can express their concerns, that you can empathize with them, gets you a lot further. And they and they, they listen, they take stuff in better. Yeah, so it works all the way around. Cool. So where

are we going to start? We’ll start with night scout. Diabetes comes with a lot of things to remember. So it’s nice when someone takes something off of your plate. Us. Med has done that for us. When it’s time for Arden supplies to be refreshed, we get an email rolls up and in your inbox says, Hi, Arden, this is your friendly reorder email from us med. You open up the email. It’s a big button that says, Click here to reorder. It, and you’re done. Finally, somebody taking away a responsibility instead of adding one. US med has done that for us. An email arrives, we click on a link, and the next thing you know, your products are at the front door. That simple, US med.com/juice, box, or call 888-721-1514, I never have to wonder if Arden has enough supplies. I click on one link, I open up a box, I put this stuff in the drawer, and we’re done. Us. Med carries everything from insulin pumps and diabetes testing supplies to the latest CGM like the libre three and the Dexcom g7 they accept Medicare nationwide, over 800 private insurers, and all you have to do to get started is call 888-721-1514. Or go to my link, us, med.com/juice, box. Using that number or my link helps to support the production of the juice box podcast. Today’s episode is sponsored by Medtronic diabetes, who is making life with diabetes easier with the mini med 780 G system. The mini med 780 G automated insulin delivery system anticipates, adjusts and corrects every five minutes. Real world results show people achieving up to 80% time and range with recommended settings, without increasing lows. But of course, Individual results may vary. The 780 G works around the clock, so you can focus on what matters. Have you heard about Medtronic extended infusion set? It’s the first and only infusion set labeled for up to a seven day wear. This feature is repeatedly asked for, and Medtronic has delivered. 97% of people using the 780 G reported that they could manage their diabetes without major disruptions of sleep. They felt more free to eat what they wanted, and they felt less stress with fewer alarms and alerts you can’t beat that. Learn more about how you can spend less time and effort managing your diabetes by visiting Medtronic diabetes.com/juicebox

uh, yeah, I’ll just kind of mostly step through the modules of my course at a high level, and so people can get an idea of what we’re going to cover. And it’s a lot of this stuff. I’m not worried about keeping the information locked up behind my portal. The information is free. The DIY system is free and open source. If someone wants the help to be with me or my community, then that’s when they can show up. So we’ll cover, you know, most of what I cover here, if it’s helpful and it helps people, then that’s great, well, but usually, yeah, I just kind of call it Module Zero, as we kind of start with night Scout, because we’re going to be looking at that a lot. It’s your dashboard, it’s your view into all the data, especially as a caregiver, but loop only holds only shows you about six hours of information in the past, so you can’t always go back and, you know, look at how the morning went, or your overnight basal was by the time you’re off work or school’s over or whatever. So night scouts, where we’re going to live, there’s just a few things. I don’t take a lot of time to teach people how to use night scout. We kind of just do it as we go, and it’s integrated into the process because through repetition. But there’s a couple annoyances I’d like to highlight for people that people don’t like about night scout. One, it’s busy, and can’t really fix that, because there’s a lot of data that’s important. But what we can do is make sure that some of your like pills, a little squares, little nuggets of information on the screen are turned off that you don’t need, and then make sure there’s stuff that is on that you do need. Some people use their night scout and don’t have the prediction visible or the basal rates visible, so they’re missing out really important pieces of information when they’re doing it. So we just go through the settings and figure out that one. But there is this one cool setting that if you’re using night Scout Pro. It’s built in otherwise, if you have access to your little configuration variables that you have to go in and tweak. There’s this one called device status, one word, underscore, days. And what that does is, on that first screen, that dashboard of night Scout, you can actually see two days worth of information on the lower graph, and it shows you, like a little snippet, you know, the bigger version on top. It’s like a smaller section of time. But what you do is you scroll backwards and you click and drag on that bottom section of night scout. You can only go back 24 hours before you lose the kind of prediction information, all the details. But if you add this variable, device status, underscore days, and change it to two, you get two days of information there. Well, 48 hours. That’s really helpful. If you know you’re trying to figure out there’s a pattern, and I feel like most patterns you would look at are within the last two to three days. So if you can access most information, you pretty much don’t need to leave that front screen of night Scout, which people appreciate, because while the reports are useful, they don’t want to really want to go digging into it. They just want to pull it up and take a look at it. So okay, that’s one of them, and then the other one, the other big one, is the alarms. It makes a nice, loud, annoying alarm that’s hard to tune out in night Scout, but most people have Dexcom follow, or they’ll using the loop follow app or something else that has alarms, and they just don’t need them. So they might remember to go into the menu on the side and check all the. Boxes and turn them off. But then you got to do it. Every time you are on a new device or whatever, it goes off. When you’re in a meeting. You have it up at your computer at work or whatever. If you go into your configuration variables, you can find all the things that say alarm, and it’s usually like a ON, OFF or true, false option. You can go turn those off. I walk through those, I’m going to put out a little cheat sheet for how to just buzz through and turn these things off on my website at some point, so everyone can go look at it, but yeah, just turn off the alarms by default. And that way, if you want them on, you can turn them on if you want them on for the school nurse, and you can talk to them and have them turn them on, but at least they’re not on all the time. And you pull up night scout on your phone, and all of a sudden there’s an alarm going off when you’re in the middle of a meeting or whatever. So that’s kind of the big stuff.

How do you turn off that crazy music that plays when it loses its signal? Yeah, that’s the

alarm. So there’s a setting in the back that’s time ago or time ago, urgent and time ago worn. So if you find those, if they’re not defined in your Heroku, for example, you can just go into the configuration variables and set those to false. I can, I’ll put the I’ll add those to the list as well. Those are the sneaky ones that you can’t turn off from the main menu screen in night Scout, you only turn off, like the highs and lows, but you can turn off. There’s a few more that are hidden in there, like when loop is not looping, or and a few others. So yeah, that annoying music is those alarms. And I think most people are already have alarm fatigue, and they don’t need it startling them when it turns on after like, 10 seconds of loading the screen. So that’s that’s a big one. And then the last couple things, just make sure you can see in night Scout that I think is really cool since we talked last four years ago, now that when you start a new pod, or when you start a new Sensor Loop, picks up on that and updates this little section called the cage, or cannula age and sage sensor age, and it updates that in night scout. So now you can see how old the pump is and how old the sensor is, which is super helpful, because you as the caregiver don’t have that information readily available, index con follow or anywhere else. So I find it useful. When you’re looking at maybe sticky highs, you say, well, How old’s the pod? If the pods getting to be closer to that three days, then you know we’re increasing our chances that there’s a problem there. Or just, uh, just for planning for the rest of the day, like, do we need to change the pod or the sensor before Tesla goes to school or whatever? So that information is helpful to have, and now it doesn’t require manual logging, which I used to do, but now you just use loop, and as you change those devices, it uploads this night Scout, and it’s nice and available for you. That’s a really practical one for people. Cage

and sage are big parts of how I use night Scout, and they’re a huge help with me, especially when Arden’s not living here, and you can say to her, hey, look, I don’t know if you saw this or not, because I know you’re busy and everything, but your pod’s going to expire at five in the morning. Please don’t go to bed with that pod on. And you know, there’s been times where she said, Okay, great, I’ll, I’ll do it before I go to bed. And there’s times when she goes, I’m gonna get up at five in the morning and change my pot. That’s my plan. And I’m like, Okay, fine, you know. But at least you can kind of remember and remind, I guess, a little bit. But your point about using it for, hey, why is this not working all of a sudden? Like, I do it all the time, you know? I’m like, the Bolus happened. Nothing worked. I don’t know why. Oh, look at this. This pod’s two hours from being shot like that kind of thing. Or I don’t trust this number, all of a sudden, and I can’t see her Dexcom, so I go look and, oh, the sensor has been on for nine and a half days, or something like that. During COVID,

my wife’s grandmother was living with us. She couldn’t go anywhere in other facilities or whatever, and she has type one. I never really got good at managing it. And she ended up kind of forgetting to take her insulin over time and almost in DKA. And we sort of fixed that at home, got her drink water, and then from there, kind of took her management over and added, slapped a Dexcom on her, slapped a pod and loop on her, real fast, and then got those devices covered through her insurance, and had her looping. And at some point she ended up leaving our house too. So that became even more critical to know, like, when do the devices need to be changed? We found a nice place that would, without charging us extra, would take care of changing the hardware. They were super willing to do that. And so we just night scout was important to be able to track when those things changed. And so having those pills was pretty was pretty critical for that. So definitely nice for a caregiver perspective, for sure,

and I realized we didn’t do this. But if you are listening and you’re like, Oh, this is all exciting. I don’t know what night scout is. It’s an app that I have on my phone, for example, and it just lets me see in real time, Arden, who’s using trio, not loop, but in real time, it lets me see where she Bolus is how many carbs she put in the things that Kenny just discussed. It lets me see when her basal gets ramped up or taken down, etc. It’s pretty awesome. Yeah, it

is intended as like a dashboard for caregivers, right? And we used it when Tessa was on shots at the beginning. And we would log all the shots and stuff in an app, and open another open source app, and it would push it up to night Scout so I could see when my wife was giving injections or Tessa was eating. I mean, sometimes we forget to enter it, but it was helpful for me to learn from afar while I was at work, just to see all that data laid out. And so it’s really intended just for logging data, and yeah, now it’s a dashboard you can use for having automated. Stuff like loop and trio upload data to it so you can see data in real time, which, you know, I take for granted after almost six years of using it, that people don’t have access to, that you can’t get the T connect data or the Omnipod data in real time to be able to see, did your kid Bolus and how much and what did they enter? Did they, you know, enter too much, or whatever that is. Yeah, you can make a lot of decisions on that. I have to

admit, it’s not a thing I look out every day, but when I need it, that it’s there is irreplaceable, honestly. So, yeah,

awesome. Yeah, that’s it for night scale, I mean. And then after we kind of get that settled so everyone can see what they need to see, and I don’t have to worry about them saying, Well, where is that we’re all set up. Then we start getting into the basics. Rather than go over the kind of core of the prediction pieces, which I do cover later, actually just start with basal. Because people want actionable stuff. They want to make sure that their settings are right. And as you’ve discussed multiple times, the basal is foundational right if you don’t, if you don’t build your diabetes house real well, which is on the foundation of basal then kind of everything is suspect, everything’s out of control. Loop gives us a lot of data. I covered this in our one of our other episodes, so feel free to go back and listen to it, you know, for extra information. But we do cover how you can see when your basal is probably too strong or too weak in loop, because it gives you all this information to be able to see where it is. Using insulin on board a while ago when Arden was looping and we helped dial in some crazy basal changes for Arden basal information, I had a very similar think when we were working together, talking a little bit Arden’s needs were dropping. And there’s another kid I’m helping right now, who’s 11, and he just went through, like, a big growth spurt, like all at once. There’s no wouldn’t matter what system he was on, it couldn’t have he just had his he has basal rates increase like a half a unit now, more than half a nice coming up on doubling his basal rates all in about 48 to 72 hours. Just wild. But the mom’s saying, Well, what do I do? And I can go back and look at this information. We’ll talk about how to get it and give a good guess about where to set the basal. I mean, I wouldn’t normally like nudge basal more than, you know, point oh, five or point one on the pod. We only had to change it, like point 4.5 in a single day, which once we did that went from cruising in the three hundreds and stressed and bolusing all the time just trying to get them to everything settling down to the 90s again, so within a few hours. So it’s a definitely useful information.

How do you do that? How do you look at the information and say, Hey, normally I would turn this dial very slightly to be careful, but in this situation, I feel very comfortable moving at this because what? Because I saw,

yeah. So the iob overnight is one of them. And I think one of those things that’s helpful is that I try to keep a pretty simple basal profile. I on the podcast before, we were using one basal rate. And I, you know, I’ve come to learn that that is a little more common with the younger kids, but also more common with, like, mild honeymoon. We were out of like, major honeymoon, for sure, but having slight variations in your basal rates. Totally fine. People shouldn’t feel bad about that. I used to be a pretty big proponent of one, just to kind of get people to simplify. And I think keeping this simple as you can is good. And so when things change, I just kind of changed all so that’s the first thing I do. Is pro Tesla. She’s got, I’ll explain this a little bit, but I have some like normal stuff, but we’ve only got one rate, maybe two rate, maybe the night and a day rate. And you kind of play around with that looks like. But when I find a pattern that works for Tessa, it’s about a point one an hour difference. She uses, like a one and a half units an hour. It’s a lot, but so like, a 10 20% difference or something between night and day for her has been working in the last few years. And so when I look at this data, I’m going to talk about, I’m just to make the change everywhere. All the rates change when I look at it overnight. So here’s how I do it. In loop, it’s modeling insulin pretty well six hours, nice even like small decay rate. It’s got a pretty accurate representation based on the like, if you open up the paper inside your insulin vial and actually look at the graphs in there, it shows the insulin last six hours, and loop uses a pretty close line to that. And so what I’ll do is I’ll just grab the bottom section of night, scout the lower graph, and just slide backwards and look at the history, and we just look at, you know, how the night went, especially, you know, 345, AM, multiple hours away from food or anything else you might have messed up with the fat and protein and whatnot from dinner, and see where everything settles out. And look at how much insulin on board there is as you go across that line. If you’re pretty flat and have consistently, like, positive insulin on board or negative instant on board, you’ll find that there’s generally around the same number kind of across that line. For example, the kid I was helping with earlier had over a unit on board just and he’s like, high at like, 170 and just constantly over a unit, and whenever it would get under that, his blood sugar would go up. And so what we do is we can use that information to say, Okay, well, obviously the basal is not right. So how much insulin is this? How much more we have to move the basal up to make this? Instead of one unit on board, how about zero units on board? Like be nice and flat and level. So. And so we just take the kind of average iob in units and divide it by the length of time that insulin lasts, which is the DIA duration of insulin action at six in loop. So we just take the iob and you divide it by six. So an easy example is point three units of insulin on board that’s keeping you level, but usually probably a little higher than your correction range. Divide that by six, and you get a unit per hour. You just divided units by hours, and so you get a point, oh, five unit per hour, basal rate change that you should make. And if you make that change, that point three units will actually turn into zero insulin on board, and you’ll be level and probably more likely down into your range. And if you’re seeing negative, you just add the negative in front of the answer there, and that means you need to decrease your basal rates by point oh, five units per hour. It works out pretty well in the case of this kid with like, one 1.2 ish insulin on board was at a point two change in insulin needs. So that’s, I mean, that’s a pretty dramatic change that would take some guts to modify without a lot of experience, but instead, you can supplement that experience with math. So yeah, point two unit per hour basal change. So we bumped his basal rate up, and then Bolus a little heavy, because the insulin on board isn’t real, right? The insulin on board says he’s got a unit, but that’s really should be, you know, your new kind of zero set point. So you Bolus little extra to get him down. And as Luke turns the basal off to get him down, the numbers sort of like fix themselves, the iob becomes a little more accurate. And then, you know, within a couple hours, he’s down in the 90s, instead of, like the 170s when he woke up. So then you can go about the rest of your day with more confidence. And in his case, he kept needing more and more insulin as the day progressed. And then you could see it in the nighttime numbers for sure. And then you get a nice number again. You make the modification increase the basal rates, and then the next and the rest of the day is, you know, mostly good till the evening, when he’s starting to need more again. And so he did his three days in a row. For Tessa, it’s usually like kind of a day, and then hold that for a day or two. And then we’re done times a week. And then, you know, maybe it’ll change back down or up, but you get some consistency. Sometimes you gotta change it every day. Sometimes it’s, you know, a week or two without having to make a whole lot of change. But that’s basically the math that gives you. It’s the only real objective thing you get with the data. The rest is kind of art. You’re gonna be tweaking carb ratios and ISF and dealing with activity and counting food is difficult, but the basal stuff is pretty objective. When you look at that information. Do you work with adults ever? Yeah, I’ve had a couple of adults that I’ve helped this year trying to figure out my course content. They’ve had a lot of, lot of fun, lot of learning, and it’s been great. Naturally, the caregivers ended up coming to me, because, similar to you, we’re parents, that’s what we do, and we talk from a perspective without trying, because that’s what, that’s our lived experience. But yeah, I get I get both.

Now you were just talking about how to make this adjustment. Are you planning on just taking people for coursework, or are you going to do a la carte too? Can someone get a hold of you and just say, like everything’s upside down here? I don’t know. Why? Could you just figure it out and tell me? Why? Do

a quick look? Yeah, I’ve done that. That’s kind of been my MO. Throughout my time in the DIY space has been someone asking for a lot of help and to get all the information and context. You know, maybe they’ll, they’ll reach out to me, or I’ll say, Hey, if you want, you can send me your night scout. We’ll take a look together. I’ll ask a couple questions around, like activity and other stuff that may not be obvious, and it within a few minutes, I can take a good stab at, you know, doing this math and a few other adjustments to get people in the right way. I don’t know if I’m going to be offering that as a service, kind of standalone, probably, but most likely to be the course. And then I’ll have a I’m going to create, like a little support group on the back end that’s pretty affordable, so people get through the course. If they want to keep hanging out for not too much. We can hang out and, um, go over that stuff regularly, but I’ll probably open up the doors for just a quick check in. And I don’t mind people messaging me occasionally. If I have space, I’ll, I’ll message them back, but that time is going to become a little more, a little more limited. And the other thing is, I can, I have a couple of videos on loop and learn right now, and I’ll put a few more on my YouTube channel in the near future that are just me talking through that exact scenario, somebody sending me something, ask them a couple questions and make some changes. So again, none of it’s hidden. It’s all it’s all up there on on the YouTube. So you can kind of see me talking out loud with someone on the phone, usually a parent, and the adjustments we made. So yeah, yeah. Well, I

mean, there are going to be some people who definitely just want to understand and the course, makes a lot of sense for that. And I wonder if the people who are just really flustered, if you could unfluster them a little bit, if that wouldn’t open up some mental space for them to say, hey, you know what? I could learn more about this. Like, maybe just get out of the hurricane long enough to, like, settle yourself and think All right, now let’s figure out how not to get back in the hurricane again. But I don’t know if it’s possible to do the figuring while you’re spinning is what I’m saying. It

helps. It does help. I’ve seen it help people. I That’s why I just reach out sometimes and help people, because they are spun up so much they can’t take in any more information. They’re. Fighting the system. They were maybe fighting it before loop or something big happened, like these basal rate changes, this puberty stuff kicking in, and now they they feel like loops been great for years, and now they’re sideways. So it’s definitely something I’ll be looking into. You guys can pay attention to my website and see if I offer that. Right now, I’m just focused on trying to get the course out the door, but it’s definitely I love meeting people and hanging out for a bit and putting them on the on the right way, so they feel like they can walk away and have things a little more sane, so they can start to make more mild adjustments, right? Yeah, it’s been fun.

Okay, do we have more in this section? Or can I ask a disjointed question before we move forward?

I would just highlight a couple things in the basal just so people know if they have kids with low basal rates. I remember doing that being the point 1.1 5.2 those kinds of things. And with this kind of exacting math loop does with the insulin on board. It expects zero insulin on board to make you level. And sometimes your kids just live between the rates their actual basal needs are just between what the Omnipod can deliver, which is a benefit to something like a tandem or something else where they have smaller increments, you can step up the basal. So if you guys are in that boat, just like give yourself a little bit of break, use the numbers the iob to help guide you, and just pick on which side of the of the fence you want to be on, on the slightly heavy basal or a slightly lower basal. And just try to maybe adjust the carb ratios and other things to kind of compensate knowing you’re either heavy on the basal or light on the basal, it’s a tricky spot to be in to get it just right, considering loop kind of really wants it to be exactly right. It’s not very forgiving in that sense. So I think that’s important to know. I was going to ask you a question about this. One thing I find challenging lately, as test has hit puberty, more near 11. You had mentioned before that sometimes Arden would get real sensitive in the evening, going to bed. I experienced for the first couple times in the last few weeks, like just a big drop, a big it looks like you collect a bunch of negative instant on board in loop terms, where blood sugar just drops and falls out, and we treat it. And she comes back up, and she goes back to sleep, and then she’s fine, but it’s just crazy. It’s like, almost like she didn’t need any insulin for like, a half an hour or an hour. Did you ever experience any of those weird drops? I hadn’t had those in my six years of doing this until just recently. I

don’t know how to explain them, other than it feels like when she closes her eyes and relaxes her insulin needs go down. So

I don’t know the whole night, though, right? I think you’ve expressed it’s the whole night, though.

Arden uses a different basal rate from bedtime until she wakes up, right? Yeah, and if she sleeps in, then that’s the only time you have trouble, because the the new basal rate comes on for like, general days, you know, the day she wakes up. But if she’s suddenly like that, I don’t have a class, I’m gonna sleep till noon. I almost have to remember to get up in the morning and do it like I’ll do a Temp Basal through night scout and take her basal down to another level for a few hours, and then hopefully I notice when she wakes up, because I want it to go back to where it is as soon as she’s awake. So to be honest, I don’t exactly know, but to me, that’s what it feels like. There are things that I’ve seen in throughout this time that I just trust now, like, here’s an example of one, if your blood sugar stuck a little high and you go make a number two, I expect your blood sugar to come down afterwards. I don’t know why. I don’t even think I care why. I just know that I’ve seen that so many times it happens. I mean, Arden’s a young person living in the world. She’s got anxiety and stress like everybody else, and I expect that part of her settings are due to that. And I expect that when she closes her eyes and relaxes, that her needs change drastically, pretty quickly as soon as she falls asleep. The problem with a 20 year old is they don’t just like go to bed every night at 10 o’clock. I found myself like I can’t turn the basal down too early in the evening, because what if she sits up till two in the morning? That’s a different problem, right? So I look a lot at the when she goes to bed, and the insulin on board. Even though you’ve explained it to me in the past, I think somewhere in here, I’d love for you to explain again, how you use the insulin on board number to fix a low blood sugar. Like, how do you know based on negative iob that this many carbs is what? Anyway, we’ll get to that. But like, let’s not forget to get to that. It’s a note I made. She goes to sleep. She seems to relax. That happens. I think the same thing. When people say they get in the shower and their blood sugar goes down, I wonder if the hot water doesn’t just hit the back of their neck and they just forget about their worries for a while, and suddenly they’ve got more insulin than the adrenaline and stress. Yeah,

I’ve, I’ve appreciated that more. I used again, used again, used to be kind of like, oh, we always need a lower basal rate during the day than we do at night or a flat one. But I have seen working with people more intensely that I even have a friend as an adult, same thing, going to work, going to school, raises their blood sugar. They just need more insulin as a result of what I can only imagine is. Stressed. My daughter, Tessa, got the same problem when we moved across the country just in August and started a new school, and she was super amped up to go to school. I think she was just excited to have a different school. She’s kind of partially hybrid home school before now she’s going to public school and middle school, right? And she just needed more insulin, you know, for the first few hours of the day, and then she would get off, you know, we’re not the bus, so we get her from school, and then her blood sugar would kind of drop. So definitely, and it’s like gone away, that that impact has disappeared, yeah, as we’ve gone through the school year. So it’s definitely, there’s definitely other things to pay attention to that you got to watch out for. I have a question for you real quick, though, does Arden need the same increase in basal on the weekends, or is it just

school days on the weekends or school days. Yeah, her basal, her No, her daytime basal is seven days a week, so whatever her level of life is, it’s pretty consistent with her. I mean, I’ll joke, like, not just joke, but you can see her walking to a test because her blood sugar just like, like, if she leaves her dorm room and she’s going to a test, I watch her blood sugar start to rise. It can go from 80 to 160 and the algorithm jumps in and it’s like, Hey, what’s going on? And it’ll like, hold at 160 now my inclination in the past would be like, let’s Bolus. But what I’ve learned to recognize is that when the test is over, it comes back down on its own. So,

yeah, that adrenaline or something like that, that’s causing that rest. I

wouldn’t ask her to touch that. It’s just a benefit of using an algorithm that you you know, because, you know, without that algorithm, you wouldn’t just be 160 it would be 300 you know, like it would just keep going, because it’s, it’s pushing, it’s pushing with basal, it’s pushing with boluses, etc. It’s magical. Kenny,

yeah, it’s nice to have an algorithm, I kind of call put a lid on it, right? So even with that, with Tesla, when she has basal right knee changes overnight, or this growth spurt thing we were talking about earlier, yeah, he was 170 which is obviously a problem, if the target and loop is like 100 but what would it have been if you tried to sleep the whole night. You know, without that, with just a regular pump or shots or whatever, making that adjustment would be very difficult to do. I wanted

to go back to one more thing, that if you are listening and you have a smaller child who’s experiencing overnight growth spurts like what I just said might sound crazy to you, because your kid might go to sleep and their blood sugar shoots up all the time, but Arden’s beyond that. Now it is really interesting. The thing that you mentioned earlier about basal rates, because I can even though it’s been years since we recorded those episodes together, I remember you advocating for one basal all day long. And I don’t know if I said it out loud in the episode, but I do remember thinking, Well, that’s easy for you to say, because your kid hasn’t hit puberty yet, I

think you did. I think you sneak it out, or maybe it was after the call or whatever. But yeah,

you know, your bigger picture understanding has to evolve, as you know, if it’s a kid, growth spurts happen, I mean, but also could just be weight gain. If you’re an adult, you gain 20 pounds, like a lot of these things are going to change for you. I just saw something really interesting the other day where, when Arden would make the trek home from school and drive herself, her blood sugar, she I noticed her having to Bolus a little more. But the other day, she made the trek home, and my wife was with her, and my wife, I think she suckered my wife into driving and like, she didn’t need as much insulin for the ride home, because, I think just the she wasn’t, you know, hold on to the steering wheel, staring at the road, trying not to die, like, you know, like it’s just it was more relaxing to be in the other seat. So there’s a lot of stuff that’s going to impact your insulin needs.

Maybe, maybe when it starts settling and she’s driving, you’ll feel like she’s matured in her ability to drive. It’ll correspond, right? I

don’t know she’s a good driver. I just think she might be a fairly aggressive driver.

Nice, nice. Yeah. I mean, I’ve seen I was counting through my messages, like, a year or two ago, and I think I have more than 600 different people or more that I’ve like, gotten messages from in Facebook over the years. And so, yeah, since those episodes, I’ve seen a lot more graphs, a lot more ages, and then experienced more too with my own daughter. So it’s definitely, like, opened it up. But you know, the idea of keeping it simple is definitely guiding for a lot of people. Hey,

let me jump in here and ask you a question with opening up box in the loop house. Calm, you’re not a doctor, I guess is my statement. Like, so like, how do you set something like this up? Like, what, what was the back room to getting something like this set up? A little

bit of concern. I definitely have a lot of like, notices that say, Hey, I’m not a doctor. Everyone understands that. And when I’m going to be talking about whether it’s one on one or with the course, I’m always talking about how this is what I do for my daughter, this is the and then we’ll talk about the data. I don’t get into the code, but I do reference the algorithm, so part of it’s just strictly teaching math and function. And I’ll reference some, you know, studies and things like that, just to look at, like the facts. And then I’ll tell how I apply it to Tesla’s life and the numbers we just talked about and why that math. Works, and so I might make suggestions, say, if this was my daughter’s graph, or I’ve seen something like this before with my daughter when she was that age, if it if it applies, I might change something like this based on the information we just described. So I’m definitely trying to stay clear of saying you need to change this. But this is why the emphasis is on educating people how the system works, and then how I tend to apply it so people can keep up. Because I do find that, in general, my drive to do this lately has been, I just feel like I’m not working quite as hard as some of these other people that are trying putting in more energy and effort into looping and getting worse results. And I don’t think that’s fair, and I think I’ve settled on, I worked on dialing back my own involvement, and we do just a couple things that with you understanding builds on. But the couple of things is, wake up in the morning, scroll back, look at night Scout, try to see if we need any basal changes, or if she’s starting to run higher. Then I check to see if her pods leaking first, and we address that. And then, you know, we just avoided a catastrophe for the rest of the day, or running higher or running lower. And so it really only takes a minute, maybe less longer if you have to go, you know, change the pod, yeah, but we do those things. And then the rest of the information I can just glance through the rest of the day, maybe end of the day, take a look at the meals, and we’ll talk about how we adjust meals a little bit. But I kind of have a certain order. I go through the settings and prioritize those, but the big ones, the basal every night, if it’s just a couple minutes. Once I started doing that and making the adjustments, ever since I was on the last podcast four years ago, I’ve just gotten better at it. If I can teach people to do the same thing, I think they’ll be able to put in less effort and get better results, or at least the same results with less stress, they’ll know what to what to change. That’s one of the feedbacks I’ve gotten from people is, hey, how do we feel at the end of this? Like, your numbers may not have improved dramatically at the beginning, but the amount of energy and effort it takes to get those numbers is significantly less. You’re like, No, I know what to change now. I know right. Basal, I know that’s a carb ratio, and I can make the change. And then we adjust, and we move on, rather than mentally, like mulling it over in your head for way too long, trying to figure out what it is. Yeah, that’s really what a lot of people get out of the initial modifications, is just knowing where to start. It’s interesting

to hear you talk about it, because you sound like me talking about making the podcast. There’s a way I do it. I don’t know. It just works. Here it is. I don’t care. Try it yourself. You know, take some of it, take all of it, do whatever you want with it. I do get the same kind of responses back. It’s great, like, so in the end, you’ve, you’ve got this compendium of information in your head, and you’re just going to share it back with people and and let them try to put it into play and see what they do with it. I think it’s awesome. So yeah, this is

exactly like the podcast is trying to zero in on loop and and slightly more technical, just so I feel like I can talk objectively about it, and people can make their own decisions. I love it. It’s a fine line to walk, but you’re my inspiration, Scott.

People need the help. Like, they just do, you know, we went from just fast acting insulin and in a pump, you know, however many years ago, and people would just go, like, I don’t know what’s happening. Like, it’s all over the place, like, you know, nobody helps. Doctors don’t help you. Like, you know, then that’s your hell. That’s you go live that life, and you say to yourself, like, well, that’s just diabetes. I guess this is what it is. And then that’s the level of torture that you now live with every day. And I came along and said, like, I don’t think that’s right. I think you should maybe move some of these settings around. Learn how this insulin works a little bit, and then these algorithms came along, and it’s great for the people it works for, but for everybody else, you know, they used to say, well, that’s just diabetes, and now they say the thing doesn’t work. Like, you know, I bought the thing. You told me it works. It doesn’t work. And now they’re just, that’s their hellscape, and it goes on forever, like, people need to understand how insulin works, no matter where they’re using it. And, you know, I think this is awesome. I’m really excited that you’re that you’re doing this. Do you think we stop here, call this an episode and move to the next thing? Or do you think we keep talking? I’ll

add one more thing, and then, yeah, we can probably go on to, like, food in a different one. I think one of the things you mentioned here is like clarifying things for people, looking at the all the variables that exist, I think with loop, loop is unique in that it’s trying to model everything. Is just trying to you, just tell it, and it trusts you. And so it puts the settings out there, and it calculates everything with a fair amount of accuracy, as long as you, you know, do your part. There are other systems that try to handle the fudge factor, which is great, try to help the fuzziness of all the stuff you’re entering. But what’s cool about loop is, once you settle on like you get basal rates kind of dialed in. It seems to me, when I’m talking to people about this, that it kind of clears the fog. What people say is, Oh, I see so many more things now. So they level their basal rates out, kind of find what works, and they understand what the basic pieces of the data they’re seeing in loop is like, Oh, well. Now I see when there’s a bad pump site. Now I see when activity is causing a problem. Now I see when fat and protein is causing the problem. I found the same thing for me. Is once, you know, you talked about fat and protein, and we had pretty good settings, that was like, Oh, now I know why there’s a rise, you know, 345, hours after a meal. So instead of looking at a meal on a graph as like, oh, well, there’s two hours. I don’t the meal seemed fine. I don’t know why we’re going high now and now, as you can see, those pieces, once you understand what the variables are, and you get really good basal. It sort of clears the fog, and people can now know what those things are very quickly, without too much energy, and they can just fix it. They can address it. We can add more carbs or fat and protein or whatever we’ll talk about that later, but that’s the clear and the fog thing. People need the help. I think because of that, there are systems, DIY systems, that are working on adding layers on top of those basic models to help with that fuzziness, to help to the point where maybe you don’t even have to enter carbs, like with trio and all that kind of stuff. But I think to start with loop helps you learn. So either you can learn it by listening, you can learn by watching the videos, or you could try loop out for a little while, and it’ll force you to see variables that maybe you didn’t quite see so clearly before that have been talked about on the podcast all over the place, especially in like the pro tips and those kinds of things. And you’ll just be able to see them working and then be able to address them without really spinning your wheels a lot. So I think that was that’s been helpful. The way loop is designed, it really externalizes and draws the picture of all these other things that you can then see. So

I really enjoy talking to you, because you do a very good job of contextualizing the thoughts in your head. Whereas I can tell you that by watching night Scout, I’ve learned a lot about diabetes, but I don’t know that I can tell you what, like, I watch the graph, and I look at the graph and I go, Oh, I think the pods going bad, or, you know, like that kind of stuff. It didn’t happen the other day, like, I said to Arden in the middle of the day, she’s home, and I was like, I don’t like this pod. Something’s wrong with a pod. And she’s like, it’s fine. Leave me alone. I was like, Okay, fine. I pinged her a couple times during the day. I was like, Look, that Bolus was too big for what just happened here, and it didn’t move. There’s something wrong with the site. The site’s not right. Blah, blah, I got such a begrudging text from her. A couple of hours later, my pod just errored, and I was like, do I be an adult here? How do I handle this? Exactly? And I just responded back, Scottie knows. I mean, I guess I could really, like, talk it through, but I don’t know mathematically. Like, what did I just see that told me that, but I can just tell you that things were happening. There were Bolus is happening and basal adjustments happening, and the results were not matching my expectations. And I was like, this has got to be a site.

Yeah, there is a lot of that. For sure. I have the same kind of thing, and I’m working on trying to articulate what it is that I’m seeing. But part of it is just, I think everyone else is pretty sharp at picking up those things. Once you can get the basal pretty good, like, Oh, now you have more consistent. We’ll talk about meals next time. But once you get consistency in your meals, then you when you lose it, like something’s wrong, exactly we discussed, like you’re, yeah, there’s a big Bolus, but it just didn’t move. That’s strange. And I see the same thing when the pod site. And I get pushed back. Now that my daughter’s 11. She’s like, I don’t really want to change it. So I’m like, Well, looks like there’s some staining around the the tape on the on the pod, it’s probably leaking. Well, can we just run it for a while? Sometimes we do, right, but at least I know what’s wrong once, if she ends up high. Okay, well, we need to change it. And, you know, yeah, let’s Bolus it and get it back down. And it’s not confusing, it’s annoying, but it’s not confusing, and I let her make that decision. So

yeah, okay, yeah. Well, we’ll get to that, because, like you said, once you can clear out some of that noise, everything comes into focus much easier. So we’ll do that in the next one. Thank you.

Welcome back, friends. You are listening to the Juicebox Podcast. Kenny Fox is here again. Today. We’re going to talk more about looping food and carb ratios, fat and protein management, nighttime, blood sugar rises, loops, carb entry, options and adjustments and the broader understanding of diabetes, like recognizing patterns, food digestion and insulin interactions. Kenny is awesome. Check out all of the fox in the loop house episodes to learn more about looping and using insulin in general. Please don’t forget that nothing you hear on the Juicebox Podcast should be considered advice medical or otherwise, always consult a physician before making any changes to your health care plan or becoming bold with insulin when you place your first order for ag one, with my link, you’ll get five free travel packs and a Free year supply of vitamin D drink. Ag one.com/juice box. This episode of The Juicebox Podcast is sponsored by cozy Earth. Use the offer code juice box at checkout at cozy earth.com and you will save 40% off of your entire order. Are you an adult living with type one where the caregiver of someone who is and a US resident, if you are, I’d love it if you would go to T 1d exchange.org/juice box and take the survey. Today’s episode of The Juicebox Podcast is sponsored by the ever since 365 the one year where CGM that’s one insertion a year. That’s it. And here’s a little bonus for you. How about there’s no limit on how many friends and family you can share your data with with the ever since now app No Limits ever since, if you or a loved one was just diagnosed with type one diabetes, and you’re looking for some fresh perspective. The bull. Beginning series from the Juicebox Podcast is a terrific place to start. That series is with myself and Jenny Smith. Jenny is a CD CES, a registered dietitian and a type one for over 35 years, and in the bowl beginning series, Jenny and I are going to answer the questions that most people have after a type one diabetes diagnosis. The series begins at episode 698, in your podcast player, or you can go to Juicebox podcast.com and click on bold beginnings in the menu. Hey Kenny, welcome back. Hey Scott. I appreciate you coming back and doing more content for me here on the whole loop thing, and also spending time telling people about what you’re up to, and hopefully they’ll find some value in in your new website. What’s it called again? Box the loop. House, calm. Box in the loop house.com. So what are we going to talk about today?

Want to talk about food, mostly meals and carb ratio, and maybe any other settings around that. Okay,

is it important to start with what kind of food you’re eating, or does it not matter if a low carb person or eating an American diet or something else?

Good question. People that eat low carb do struggle a little bit and may have to do a couple little tweaks, but generally, the rules that I set up here will apply to anyone eating anything. We personally kind of eat around the gamut. We’ve done low carb here and there. We’ve done it’s kind of standard American diet. My daughter just went to a new school, and she’s eating the cafeteria most days for lunch. And that is best, definitely standard American diet food, pizza, french fries that apparently count as vegetables and check a nice box on the list for us to eat healthy. And she even has a juice box of chocolate milk occasionally with her lunch, so she eats that. But then at the same time, at home, we largely eat whole food, vegan kind of super clean stuff. So I’ve seen the impact of all the different kinds of food, and what we’re talking about here should apply to anything. Okay, and

I might get back to asking you about how the algorithm handles carb ratio for stuff that I assume is harder to Bolus for, that food at school versus what you’re getting at home.

Yeah, we can start with a little bit of that. The trick here is that loop models all meals the same to a degree. So it just expects you fit the meal into a certain amount of time. For anyone that’s used loop, you get to tell it, if it’s a fast, a medium or a slow meal, and it’s going to fit the entire expected carb impact, the lift on your blood sugar, inside of that window, or we’ll talk about the modified window, but it’ll fit it inside basically a short, a medium and a long amount of time. And most of that lift is expected at the beginning, and then it kind of fades throughout the whole thing. So there’s no way to say this is a higher glycemic food, other than messing with the duration of those particular foods. But in general. You put in a taco or a three hour entry, and it’s just going to look the same. It’s going to expect the same rise and the same fall at the same time at the beginning of the entry, as it will for no matter what you’re entering. That will change as we move throughout the meal, but at the beginning, it’s all going to look the same. So that can be a little tricky, and I’d say a good caveat for those that are listeners of the podcast, you tend to know what stuff is higher glycemic, what’s going to hit a little harder. So there will be times where you know you might need to Bolus a little bit extra up front, and you’d rather let loop take away basal for the beginning of the meal, in return for a little bit bigger Bolus, or you need to pre bullish longer. Those kinds of things based on the type of food. All loops worried about is that you don’t go low and it’s going to treat every meal initially the same.

Is your daughter making decisions like that at school? Is she looking at a plate of food and thinking, at home, this would be 40 carbs here, I’m going to say it’s 50. Or is it more or less not about the type of food, but more about where she is, like, I’m here, I’m dealing with this more complex carbs, maybe this more processed food, so I’m just going to be more aggressive. Is there a way you guys think about it?

We have a somewhat unique situation now, in that her PE, she has a very short like half of her PE, a half hour right before lunch, and then a half of PE right after. Oh, so it’s definitely changed the way we handle some of the more challenging meals, like pizza, french fries, juice box and chocolate milk with fruit and vegetables mixed in there. Yeah, we just enter what it is, what I count it to be with her, she’ll send me a picture, a text at lunchtime, and then we’ll just send back the number. And by now, she knows most of the meals, and she’ll enter them, and we just say, if it’s all you know, like a long entry, which most of them are, because of the fat content in the food, plus she’s going into fresh activity right after she eats. So stretching out the impact of the food has been helpful, and it doesn’t usually give everything up front. And that works out because she starts shooting up because she has no Pre Bolus, and then immediately levels out because she’s moving, and then it all kind of settles at the end of the day. So it works out that we don’t really Pre Bolus going into lunch a lot of times. And so I try not to modify what we count when we go into any meal. Instead, I might say something like, you know, it’s going to be 80 grams long, or pizza, you know, make sure you give at least this much insulin and

the activities helping her as well right now, yeah, I help her

just via text. Yeah, for the most part, she just I give a reply back with the amount, and she enters it and moves on. And I would say, by now, midway through the school year, she’s sitting down, sending me a picture, entering what she thinks it is, Bolus, saying what she needs to Bolus, and then whenever we get around to replying, then she edits the entry if needed, but she’s getting it right most of the time now, oh,

that’s awesome. So the there’s the thing that, if you don’t use loop. You don’t know. You could Bolus at 1130 for 35 carbs, and then 1015 minutes later, say, Oh, that was, should have been 40 carbs, and go back and edit that Bolus, tell it it’s 40 carbs, and it makes an adjustment with the insulin. Yeah,

that’s pretty huge. I think it’s really useful for and practical. It’s very different than any other system, but it’s helpful for kids that might not eat it all, or Tessa says she maybe doesn’t have enough time to finish her food as she heads off to the next class, or PE or whatever it is. And so she can say, oh, never mind. I really only had, you know, half of whatever it was, and it, you know, will might predict a low if you had dosed for all of it. But at least the system is going to know, and it’s going to do its best to turn off the basal. And so it’s really helpful when you need to pivot. And then maybe she needs to eat something, because she’s going to eventually drop from that extra insulin that it gave. But now we’re just, we’re just telling the system exactly what happened, right? We entered 50, changed it to 30, and then she entered 10 carbs as a you know, maybe low or preventative low treatment. And so now it thinks there’s a total of 40 carbs consumed here instead of the original 50. And so it’s not likely to, you know, give too much insulin, maybe even not even recommend any insulin for that second entry to try to catch the low. So it’s smarter about what’s happening, because we told it really what happened. So I find that super helpful, but you can spend a lot of time fiddling with editing carb entries when you’re guessing, because a lot of our entries are guesses, you know, right?

I have to admit, that’s a feature of loop that I was a big fan of. So that’s pretty awesome. So I guess, like, big picture, talk about how loop handles a meal, like, just kind of like, Let’s build it up from the ground for understanding for people, this episode of The Juicebox Podcast is sponsored by Eversense 365 and just as the name says, it lasts for a full year, imagine for a second a CGM with just one sensor placement and one warm up period every year. Imagine a sensor that has exceptional accuracy over that year and is actually the most accurate CGM in the low range that you can get. What if I told you that this sensor had no risk of falling off or being knocked off? That may seem too good to be true, but I’m not even done telling you about it yet. The Eversense 365 has essentially no compression lows. It features incredibly gentle adhesive for its transmitter. You can take the transmitter off when you don’t want to wear your CGM and put it right back on without having to waste the sensor or go through another warm up period. The app works with iOS and Android, even Apple Watch. You can manage your diabetes instead of your CGM with the ever since 365 learn more and get started today at ever since cgm.com/juicebox, one year, one CGM,

yeah, I think what sets loop apart from I think all the DIY systems do this, but from the FDA approved systems, they don’t express or give us any detail about how they function. So we can’t assume this is how it works. But in loop, it uses what’s called dynamic carb absorption. So you’re going to enter the meal, it’s going to give you a Bolus recommendation, probably in line with your carb ratio. In most cases it should be, unless you’re, you know, it adapts to you falling or rising. So it may add a little more or a little bit less, which is nice. But then what it’s going to do is not just going to say, okay, great. Here’s your Bolus. Let’s move on. It’s going to say, Okay, now I’ve seen this 50 grams you’ve given. Now let’s make sure that that 50 grams goes away. And it’s going to try to track the meal throughout the whole progress, the whole duration of that meal, that time entry you gave it. And what it’s doing is it’s checking to see how your blood sugar is moving. Is the the main thing there’s, there’s two components. There’s one that has to do with, you know, your carb ratio and how much insulin you have. Obviously, you shouldn’t go super high if you dose the right amount. So there is an assumption there that as long as you don’t go down too much, you should be there’s food there. But then if you also go up, which most food makes your blood sugar go up, because it’s hard to time against the insulin, there’s that second component. And so as your blood sugar rises, it says, Oh, hey, that’s food. How much is that food? And it will say, you know, maybe that rise, depending on your settings, may say that rise you just saw was one or two carbs. So it’ll say, Okay, you had 50 grams. Now we’re down to 48 and then we move on. Your blood sugar moves up again a little bit, and now we’re down to 46 and maybe you hold steady for a while. So now we’re down to like 40 a couple hours in. So it’s subtracting the grams from the carb entry as you go. And so what you’ll see on the main loop screen is there’s active carbs as well as active insulin, same as iob or cob carbs on board, insulin on board, but it’s tracking both the insulin on board as well as the carbs on board. And what you’ll find out is that as long as there’s a pretty good balance of the insulin on board and the carbs on board, or as loop says active insulin or active carbs, you know, roughly to your carb ratio, then the prediction will be happy. So an example would be, if you answered 10 grams, or there’s 10 grams of active carbs, and your carb ratio is 10 to one, and you have one unit on board, then in general, the prediction will be happy. You’re probably going to go up, come down, and land where you should, you know, there’s some other variables in there, but that’s generally what’s happening. So it’s trying to maintain a balance of insulin on board to the active carbs as you move throughout the process, so when that imbalance is off. So whether that means you like spiked up real fast and lube said, Hey, that was a lot of carbs. Maybe that was the bulk of the juice or the soda you just drink. So now the active carbs might drop real quick. On that loop says, Hey, we just gave this insulin, and can’t get rid of insulin super fast, unless you turn off the basal. So now there’s too much insulin for the number of carbs left in this meal, and so it’s going to predict a drop. And that can be frustrating for some people, where you end up higher initially with your meal, and yet, loop is saying you’re going to go low, and that can be quite obnoxious for a lot of people.

Does that eventually work itself out normally? Or does that is that a situation that lands you with a higher blood sugar that doesn’t come back down for hours and hours?

Yeah, if your settings are good, and we’ll talk about how to get there, then it often should work itself out, right? For example, soda or fruit might be kind of a quick hit, and then it’s not going to last super long, so you’re going to see most of the carbs a lot sooner than you would if you had a piece of pizza. So it should work out pretty well if your settings are relatively dialed in, okay? But the trick is, if you end up having a couple settings off. Let’s say you have too weak of a carb ratio, or we’ll talk about this more in the next session, a little bit more. But if your ISF is too low, which plays into this calculation, then when your blood sugar pops up initially, loop might be subtracting too many carbs. You might go from 50 to 30 in a matter of an hour and like well, that doesn’t make sense. Like, whatever you ate is probably going to take longer than than, like, two hours to for you to digest. So now loop thinks you have, like, way too few carbs active and that, and therefore way too much insulin, because you just Bolus for all of it. And so it’ll take a while for loop to think, Oh, you’re going to go real low, and you’re not. So that’s the tricky thing. So we have to pay attention to the settings we’re using to get us to a point where the meals are absorbing. These are the term loop uses when it drops or sees the carbs, using the term absorb as if you like, digested it basically, so it’s you want to make sure the absorption rate is, you know, reasonable, not not occurring super fast and not taking, yeah, super long when you

talk about, I want to make sure I understand the phrasing and the people listening understand the phrasing. When you talk about the carbs going away. The idea is I put in that this is 50 carbs, and my my ratio is one to 10. So we put in five units of insulin. Now it’s five units of insulin is in for this 50 carbs, and as your blood sugar moves or doesn’t move, the expectation is okay, we’ve made it a certain amount of time, and we’re still level. So this much insulin is gone, and that much insulin was supposed to cover this many carbs. So this many carbs have been absorbed, so now they’re kind of out of the picture, and we’re left with what’s left on both insulin and carb side, and those two keep decaying until eventually they’re both out of your system. Is that, is that the idea? Yeah,

that’s generally the idea, yeah, and rises will decay the carbs faster. And then, of course, turning off the basal will decay the basal iob faster, right? So those are the tricks sleep can use. And this is more important when you get into longer meals, right? Because you might have pizza or pasta or something like that that maybe doesn’t some pasta might not hit a whole lot at the beginning. It may be more in the middle or at the end, or something like that. And so if you stay level, it’s like, oh, well, I’m not seeing all the carbs I thought I’d see at the beginning. So it might start predicting, like, a little bit of a dip in the middle of your pasta you’re having this. It’ll turn off the basal. But then eventually the pasta kicks in and you start rising slowly. And so then it says, oh, okay, yeah, I was still expected there to be, you know, whatever, 60 more carbs left in this pasta. And looks like some of it’s coming. So I can probably start giving insulin for this now. So there is a window. The safety mechanism is the window of time that we’re that you enter, whether it’s a short, a medium or a long meal, you’re giving loop an amount of time, one, to spread out the expected carbon pack for safety, and two that when you get to the end of that time window, if, let’s say you don’t delete, the system doesn’t see all of the carbs, it says, hey, you know, we saw 40 out of the 50 you entered. And we’re coming up on the end of our time here. Let’s not expect that there’s another 10 carbs and or, or even when you get to the very end, obviously it’d be like, Nope, I saw 40. You said 50, I’m not going to expect a rise, and then dose for those 10, as soon as your blood sugar starts going up, just for safety reasons. That’s why you got to have that time limitation there.

Yeah, so if you overestimate the amount of carbs, but the system feels like we’re at the end of this meal, and it didn’t see all those carbs, it might hold out basal longer, for example, to stop you from getting low, or something to that effect, right? Exactly?

Yeah, you’ll see instant on board be like, there’s not enough carbs to match up to this. So it’ll probably pull back, even if you start going up. So if you you entered pizza as a lollipop or something, and the shorter entries, and it gets the end of that time, and then, you know that second wave of your fat and protein for pizza kick in the system’s like, well, you don’t have any more carbs left, because I ran out of time to see them, and so you start going up, and it’s not going to give you enough insulin to make you happy with the result, because it’s going to simply be, for lack of a better term, correcting, as much as I don’t like using that term. It’s going to be correcting based on your sensitivity and not expecting any carb impact. But if you go back and say, Oh, whoops, I entered the pizza we ate short, I’m going to make it longer. Go back to maybe a five hour absorption, for example, from a two then loop will say, Oh, okay. Now our window of time is longer to look for this pizza, and you’re going up, and let’s see, we’ve only seen it. Starts doing the math as long your prediction what happened in the last hour or two? And says, Okay, we’ve only seen, you know, 30 carbs of our 50 for this pizza. So you got 20 left. Let’s go ahead and start dosing for that. And you’re gonna get a lot more insulin that way, instead of just a mild correction, which I think for general diabetes management, whether you’re using loop or not, is the best way to think about how to quote, unquote correct. So instead of worrying about correcting, we’re going to think about, what did we get wrong? So if you’d only Bolus for 30 carbs, but the pizza really has fat and protein and needs another 20, then. This would be the time you go in and dose for that, which is likely to be a much larger Bolus than if you had just said, Well, my doctor told me to use a correction number of x. You know, might only be one unit, but you really needed two or three for all these carbs. So I feel like it’s a much more accurate and helpful way to approach management, whether you’re using an automated system, or just, you know, bolusing with your pens, or whatever, either way you want to make sure you’re addressing the actual issue, not just correcting randomly.

Yeah, take a sidebar for a second. Tell me why you don’t like the word correcting because of

mostly what I just mentioned. So correcting, when you’re diagnosed, you get started with a general correction number to play with. And it’s, it’s blind, it’s you’re picking a number out of the air to correct because you’re high, because you need something to go off of. But if you can take a step back and understand some of the variables at play early on, as fat and protein is the one that people need to become aware of, and you adjust for that, you’re going to get better results. One, because you expect it. It’s no longer a correction. It’s a expected rise that you’re dosing for. And two, you’re going to get a more accurate and often larger when necessary, or smaller when necessary, dose of insulin to take care of the problem. Or, for example, if you under counted a meal, you went out to eat and you guessed what it was, and you’re like, No, it there’s a high likelihood i Under guess the amount of carbs or fat and protein in that particular meal. So it would be best if I thought, how many carbs did I miss on that? And probably 15 more. So then in dose for that a couple hours after you’ve had Mexican food, rather than just using some random correction value that you’ve been given or sometimes playing with

also, I think maybe in a similar vein, tell me what people should be thinking when they Bolus for a meal. See the blood sugar rising and the basal is not there, and they think to themselves, I still need this basal. Why is the basal not there? If the basal was there, I wouldn’t be rising so quickly. Like, what should they actually be thinking? Instead of, hey, the dumb machines not working, they should be thinking,

Okay, so the initial answer would be, until you’re used to looking at the prediction and understanding all the elements, we’re going to go through, all the variables. It might just be in a loop situation, just give more insulin and then take your time to figure out what’s wrong. That’s the way I react to situations sometimes, if it’s not apparent to me, but if you’re in the middle of a meal, you might want to look at the prediction as the prediction say you’re going to go up eventually, but you’re going to go low here in the next hour. Might be because you have a nice, long, slow entry for your food. And maybe that’s not totally accurate for the type of food you have, or you might not have enough active carbs. You might see that, hey, you entered food like two hours ago, and it’s a nice, long meal, but yet, loop says, like, 80% of all your carbs are already absorbed, and it’s not expecting a whole lot of lift left in your meal. So I think the appropriate response is, one, we got to give more insulin. Two, we got to figure out, how do we fix that? We’ll go over that. But you might look at your carb ratio. You might look at your ISF, the way I do it when we’re high, the situation you’re talking about, yeah, my step is always look back overnight, like we covered in the last episode, make sure your basal is pretty good, at least based on the relatively uneventful night. Make the adjustment if you didn’t already check the pump site, just in case, if you’re higher. And then you step into how confident Am I in the food I just entered? Right? If it’s stuff you’ve had before, you know how to account for it. It’s fine. Then you move on to the next step. But if it’s something out you’ve never had before, or a new meal you’re making, then you might want to adjust your carbs if you think it should be higher or lower than what you’re talking about. And then after that, you might take a step and say, fat and protein here. And how do we want to address this? And we’ll talk about how I enter that here in a minute, but we’ll enter some carbs to represent the fat and protein impact. If you’ve done all that, then it’s like, well, am I going high pretty frequently with food? Maybe we need to address the carb ratio and at the very end, Oh, yeah. And double check your carb absorption. If you’re using too short a meal or too long a meal, we can look at that usually too short is what people would do, because you’re three hours out from a meal, and you use something like a fast entry and loops like, Okay, we ran out of time for this, but we should not have run out of time. You extend it. And then finally, it’s okay. We’ll play around with the sensitivity factor, and we’ll get to that probably in the next episode, and talk about how that helps with the with the meals. So that’s my progression of how to step through from a high what you go through. But again, the initial gut reaction is, if you think you need more insulin, and you’re generally pretty good at guessing those things, just give it. And then we’ll figure out how to tweak loop later.

Can you put a number on high after a meal? Meaning, if there’s 21 meals a week, where do you. You not see your daughter crest most of the time. What number does she not get over during a meal? Normally, I

would say, as she has grown larger and using a lot more insulin, she’s also she’s less sensitive to insulin. She’s also less sensitive to food. So we Pre Bolus, but it’s not super aggressive, maybe a few minutes, sometimes, 10 or 15, but not super often. And I would say 151 60 is I I’ve learned to let those go and let lube kind of deal with it. I don’t love it, but it’s not super common to hit quite the 160 number without a Pre Bolus, I should say. But when she was younger, without a Pre Bolus, that would have been much higher. So I think it’s a little contextual, but yeah, we’re hitting one over 160 especially with any kind of speed, any kind of rise. Then I’ll Bolus, and then we’ll double check. And usually it’s a text to Tessa to say, so what did you eat? Again? Yeah, how and again? Goes back to my my order there. How confident are we in the food? Well, if I didn’t see it, then I’m less confident in what’s entered. So I’ll ask her what it was, and she might tell me what it is and be like, oh, yeah, you probably under counted that, you know, for example, if not, then is

that where you lean when you see a 160 like bad count, not bad Pre Bolus.

That’s a great question. I’ve talked to some people about this before. If it’s a higher glycemic food, then no, like, if we didn’t Pre Bolus a higher glycemic food, then I’m more apt to say, Okay, let’s just give a little extra insulin, let loop, turn off the basal. But we probably just didn’t time that, right? Yeah. So there’s definitely a timing issue that those that are familiar with the podcast should be comfortable with right now to go, well, we just messed up the timing on that. Otherwise, if it’s a home cooked, you know, fairly mild meal, and we’re getting to 160 that’s a little unusual even at the beginning, right? Well, look at the carb counts, or I’ll often just look at the site like I mentioned my list of things I go through. Yeah.

I texted Arden recently, and I said, Did you just eat a bag of sugar? She goes, No, and I said, was it two bags of sugar? What like? What am I like? What am I like? What rocketing Am I seeing here? Higher glycemic, quicker acting sugars are probably going to need a longer Pre Bolus, so that the action of the insulin is really ramped up and vibing, you know, on your side of this thing, because this, this sugar, is going to go in and you’re going to jack up really quickly. So you need a lot of power from that insulin to stop that. If it’s a more balanced meal, and you see that rise like that, then your expectation is, we miscounted the carbs. That’s right,

yeah, okay, yeah. I think I’ve heard you say that before. You know something, I’ve

said something like that before, but it fits very well in this conversation. So, yeah, okay, what else you

got there is a little bit of a trick. I don’t actually have in my notes here, but there’s a little bit of a trick when they’re younger, especially when they’re more sensitive to everything. You can do some small things like, hey, ask your kid to eat the like lower glycemic foods first on their plate and kind of rotate around, just to give you some more time for Pre Bolus or no Pre Bolus, and it’s effectively like a mild Pre Bolus. There is some tricks for that, but the timing issue is important to not to know when it’s a panic of we underdose versus just didn’t time it. Well, I think that’s a good highlight that I probably don’t spend enough time talking about. So thanks for bringing that

up. No, of course, I’m gonna you brought something up that I’m going to highlight here for a second back in 2024 in episode 902. I either got a lot of crap from people or a lot of love from people for having a woman on who calls herself glucose goddess on Instagram, right? And in the end, what she was really talking about was the order that you ingest food in and how that can impact the glycemic impact on you, right? Like, how it can lessen the glycemic impact on the person eating. And I have to tell you, like, if you look past the idea of like, some people jump to conclusions that she was saying stuff that she wasn’t saying. If you go listen to what she talks about, about eating in a certain order, the responses and the replies I got back from people overwhelmingly, were this really worked for me. So if it’s a thing you’re interested in, there is an order you can kind of eat your meal in that might help that glycemic impact be lessened. So, yeah, we

use that, or tried to remember to use that when Tessa was younger, 567, it made a big difference too. Yeah, even if it didn’t change the it did adjust the glycemic impact. But it was also just practically something to do when socially, it was a little bit of a burden to try and Pre Bolus, right? It buys you, practically speaking, it buys you more time till you get to the thing that really needs more insulin, right? But like she covered that episode, it really does change how the food hits if you put something else in your stomach first and then get to the sugary stuff that may require the insulin sooner,

also. So she’s a lovely accent. So if you just want to hear a lovely accent for a while, go listen to Jesse. And I know too. But anyway, I didn’t, I didn’t mean to take us off track there, but, you know, it came up and again, like, I got a lot of good feedback about that episode from people. So yeah, it’s

a really cool trick. I think it was sprinkled into one your earlier episode, which is why we started trying it, yep, but it was, that’s a long time ago now.

Yeah, no, which I listen? I’ve brought it up in the past because, and, you know, in fairness, the way I heard about it was just online. People were like, you know, if you eat this before that, then, and then Jenny would start talking about, I think it really hit me more when in one of the Pro Tip series, pro tip episodes where Jenny said to me, like, hey, you know, here’s the reason that pizza takes so long in your system. And she started talking about how, like, the cheese and the grease slowed down digestion. And I was like, oh, that’s, that’s the first time I really wrapped my head around that was, I mean, it’s a long time ago now, but it’s important to remember, because I don’t know how you’re supposed to do all this, if you don’t recognize that french fry, that’s deep fried, is going to impact you later, when you don’t expect it to, and you know, like it don’t expect it to. If you’re going by what your doctor said, which was like, count the carbs, put in the insulin, everything’s going to be fine. You count the carbs, you get them right. You put the insulin in, and, you know, lo and behold, 90 minutes later, blood sugar’s going up with some speed and steadily, and seems like you can impact it. And you can’t figure out why. Understanding fat and protein is a is a big deal. Yeah, it

is a big deal. I’ll mention how we tend to dose for fat and protein. And a lot of this has derived from experience, and then a lot of stuff on the podcast. She had a couple people on one lady, I remember talking about the Warsaw method, the kind of fancy calculation for converting, basically, kind of calories of fat and protein into some kind of carb equivalent. Yep. Episode 471, 471, yeah, yeah. She I like how she simplified it. And so I kind of use something similar. So what we do for fat and protein, this is the way I have test to do it, is we’ll do the fat grams and the protein grams, add them together, and then just divide it by three. It’s a simple math step. I think, more appropriately, the fat needs a little more insulin than the protein. So you might do like a 40 or 50% of fat grams as carbs and then protein, maybe more like 20. But for Tesla, what I tell her to do is, hey, if you have a nutrition label or you start guessing on her own, which she’s learning to not just carb count, but fat count and protein count. You know, same thing you do is, over time, you acquire a little mental database of this stuff. And just say divide by three is a place to start. It works out well enough. But if the meal is going to be higher fat, you know, restaurant food, for example, is usually much more fatty, then you know, you can round up, or you can do a more precise calculation, or whatever works. But I find that 1/3 of both is a good place to start. And then we use longer entry. So the pizza icon in loop is five hours. We use that for most food, especially if the fat and protein kind of quote carbs represents, I should come up with a better number. But you know, at least 10 to 20% of the total carb count is fat and protein. It’s probably better to use something a little bit longer, whether it’s four or five hours in time on loop. That’s helpful. And there’s a couple different ways that we approach how we enter the food. I’ll give you the complicated way that’s probably the best, and then we’ll step into the kind of practical way. What I have tested do, to keep it simple for her, you could take the different absorption times you could enter, you know, really short, maybe one or two hour absorption and loop for all the sugars, and then you could do three hours for the remaining carbs. And then you could move out into the future with loop. You can enter food and change the time that you’re going to quote, consume it, basically when the impact is going to start. And you could still roll it out to the future two hours from right now, and put in your fat and your protein representation as a nice, slow pizza entry, which is great. So then you had nip having like three or four entries just for one single meal, which creates a nice profile, a predicted rise for loop to play on to handle the meal really well. But that’s a lot of entries, and practically speaking, is just not something we do a whole lot. So then the next most easy method that we use with good success, but it’s really only something I do when I’m entering the food is we’ll enter the carbs as one entry, and if it’s a lot of, you know, pretty basic glycemic carbs, we’ll do a three hour entry. If it’s a there’s a lot of fat involved in the meal, we’ll use a longer one. So you kind of play with that first entry, the right now entry, and then we’ll do a future entry two hours ahead. And we did a nice, long, slow absorption the pizza icon, and enter that fat and protein calculation. I mentioned the 1/3 of the fat and the protein grams, yeah? So we do two entries per meal. That works great. I was gonna say,

Jenny loves that one. Yeah. She talks about that a lot. Yeah.

It’s the best balance I find. But when I’m texting Tessa, I’ve done I’ve had her say, Hey, do this entry and this entry. Tell her two entries and she’ll do it right. But we’ve played around with ever since the defaults in loop changed from a four hours as a long entry to five. It’s a better representation of a long meal. So what we often do is we’ll just do the whole thing as one entry, so the carbs, and then a third of the fat and protein, added it into the carbs and just put it in as a pizza entry and answer it and go. And Tess is typically eating enough now and frequently and enough volume that it’s fine. It doesn’t usually cause a problem when she was younger and more sensitive. I think the split entry that I just mentioned. The second option, it creates a nice spread out impact, so it’s less likely to Bolus too much on a little kiddo. So those are the two methods we use. I would say we use one entry a lot, and then if she starts to get a little bit high, like four or five hours after the meal, and loops kind of running out of time. We’ll talk about the time here in a second. But if it’s running out of time for the entry, then we’ll go ahead. I’ll add a few more carbs later. You know, kind of as as a second entry after the fact. Yeah, because it does happen that it’s not the pizza entry is not long enough for really long foods. It’s it’s good enough for most of them, but it’s not long enough for most really long meals. What’s

your expectation when you talk about now that she’s older? Why do you think her sensitivity is different with age? I mean,

she’s using more insulin and in loop we’ll talk about in the next session here. There’s an idea around carb sensitivity, and you can get to it using the settings we have. But all that to say is I think her carb sensitivity and insulin sensitivity are lower, and they tend to scale together. So just in practice, I’ve seen her spike less as she’s used more insulin, or there’s more more forgiving if we don’t Pre Bolus, I can get we can catch up with it a little faster. Do you think that’s body mass? I think so. I think both body mass and insulin resistance slash sensitivity, because she’s on the like 90% of her growth chart that she is taller and bigger for her age, but her insulin needs are from what I’ve seen from other 1011, year olds, a good amount more, maybe 20 to 50% more than in the average too. But I’ve just noticed it when she started using more insulin in the last year, year and a half, it just started getting easier. And the other people I’ve been helping over time is as they use more insulin, things get a little bit easier. In terms of the responsiveness is less extreme on both ends of both heavy Bolus or the spiky foods, it just tends to like be more mild over time.

Is forgiving? The right word? It’s more forgiving? Yeah, I

think so, okay, all right, yeah, I think. I think another way to think about it is one gram, let’s say one Skittle would move Arden’s blood sugar a lot less now than it did when she was,

oh yeah, four. Yeah, right. Oh no, sure. I could, like a quarter of a juice box could fix Hello, at some point now you just need to drink the whole thing. And yeah, exactly, and hope that that was enough sometimes. Okay, yeah, think that

plays into it. So the more technical piece we missed, a little bit, I’ll mention a bit, is the absorption time. This is one of those things that can feel a little funny when you enter three hour or five hour, whatever duration you’re going to use. Loop says, Great, I hear you on the like three hours, let’s say, but just in case you’re wrong, like spike might be too much. Again, it’s a very hypo sensitive system. It’s going to say, I see your three hours, but I’m going to add 50% to this, what I’m calling the window of time to see the food. So the three hours becomes four and a half. You’re adding one and a half hours to that. So half of the three, you know, add 50% so you’re at four and a half hour window. So whenever you say this is a three hour food, you’re really telling loop. I’m giving you four and a half hours to see this meal. But loop is also spreading out the expected rise from that food over four and a half hours, not the three that you entered. So that can feel a little funny when you’re telling it one thing, but it’s kind of doing another. But that’s important to know that that’s your maximum window for seeing those carbs, and that’s why I mentioned the five hour the slow option being better for longer meals, it gives you about a seven and a half hour window of time to see all the food. But if it’s fatty enough. Jenny’s covered it plenty on the pro tips. It’s going to last longer than that, seven and a half hours. So sometimes you do need kind of a second entry to cover the fat and protein, which is why that option two, as I discussed, for entering carbs, often works out better. Is you’re moving the fat and protein out two hours for the lift, that rise that’s supposed to happen, and then you’re basically giving an extra two hours a runway to see all that impact. So it’s that’s pretty helpful,

trying to see if I can see back far enough last night to tell you that we went out last night kind of late, like 9pm to like, a bar restaurant that had French fries, and you. Arden’s blood sugar was 70 when we got there. It was 124 five hours afterwards, and as soon as her algorithm kind of gave her a little bit of a low at like 230 in the morning, she wasn’t actually low, but she kind of went back down to 70, so it kind of took away some basal once it felt like the meal was over, and like to try to stop the low, but as soon as it took the basal away, she shot up to 200 and that is because that fat is still in there from the French fries and the meal from like six hours prior. Now the Arden’s using trio, not loop, but it attacked it just with basal, and inside of 35 minutes, went from 70 to 200 and back down to 90 again, just with basal. And if I showed you the the night Scout, you’d see that she hadn’t had basal running since, my gosh, she ate at 3pm so there’s a Bolus at 3pm she had only had basal maybe twice, between 3pm and 9pm and then after bolusing at 9pm didn’t have basal again until the spike at 3am and then, like around midnight, yeah. And then eventually, overnight, after the food was all gone, then her basal came back on and started working the way you would expect it to. Again, there’s an argument to be made that that meal had something to do with her blood sugar for about 10 hours, like, like, watching, yeah, it’s really, really something else. We’ve

gone out to restaurants and had a meal that we thought was relatively contained, but it basically sent her higher. Like, you could have argued it was basal, but we knew it was the food until she woke up the next morning. Like it created this resistance that had a little bit of a not massive, but lingering resistance, where she might float around 120 or 100 and her target was more like 90, and Luke’s just trying to, like, knock it down most of the night, and it didn’t quite stick until she woke up. And, you know, does then the next day, everything’s fine. The next night, everything’s fine. No need to change basal, but it was just the food. So, yeah, I can stick around for a long time. So a lot of tests, entries are longer. I’d say that, like, a lot of days, more than half of her entries are using that pizza icon, and the meals are kind of stacking on top of each other. So she has active carbs all day long. And that’s part of the thing we discussed. Where it once you get the basal right and you dial it down to where it needs to be, you’re clear in the fog, you can see more variables. Fat and protein is a big one, where now you can see that you’re not covering that with basal. A lot of people and doctors, I hear them do the same thing. I talked to some endos up at our diabetes camp. And anytime there’s kind of this pattern of going up, which might mean that you’re just eating the same thing every day, and there’s fat and protein, any mystery that they don’t understand, they tend to attack with a little bit of a basal increase. And then when you change up your rhythm, what it is is you’re eating, you end up going low over time. So pulling that mystery away, understanding what that is is huge to being successful and being able to eat whatever, whenever. Yeah,

I think so too. You were talking earlier about how Tessa just starts to, like, understand to make that second Bolus, maybe, or the fattest. I was going to talk about how excited I was the first time that I saw future Bolus is set up by the algorithm, and I knew that meant art and put a fat count into her initial meal. And I was like, oh, god, she’s doing

it, yeah. And then the next time they don’t, but, yeah, no,

trust me, she’s not super consistent with it, but I’ve seen her do it a lot, you know. Where I’m not misremembering, this is in loop as well as trio. Or just it is, right? Like you can say, there’s this many carbs in the meal, this much fat in the meal, this many.

Yeah, I think trio gives a spot to actually enter those breakouts, whereas loop you have to just enter carbs, right? Yeah.

So with, with trio, like, she can say, like, this meal is 50 carbs, but I think there are 25 gram, you know, grams of fat in this meal, too. And then it will set up boluses out in the future, almost like every hour for a number of hours. And when I see that pop up on the night Scout, I’m like, Oh, she’s thinking about it

wonderful. Yeah, it’s wonderful. Yeah. And then growing up is, is good. It’s, it’s tricky. I did have a couple people say I don’t want to learn how to count all over again. It’s like, well, I mean, you learn carb counting pretty fast. You can start looking some things up and figuring out the fat and the protein. So, yeah, it’s, it’s a good adjustment. Just

say to you, listen, I, in my mind, I just say to her, like, deep fried, if you’re gonna have something deep fried, like, just, I don’t at least 20, you know, for fat, like, just do that. And so another

thing I see is people entering fake carbs to fight a high, which can be fine to use if you feel it’s needed, or if you feel like you under counted a meal. I find people make that a habit. Sometimes they start entering fake carbs when they running higher, or they start under counting things when they put stuff in loop, when they think. Settings are. I don’t know if they think of their settings as being awful when they’re running lower is they’re adjusting their carb counts, and that can be fine in the moment, but if you really want to use the system and the data to make a decision, you’ll eventually need to go back and fix those. And one way you can do that is looking at the ice screen, which is the insulin counter action effect, or most people know it, as you tap on that green graph of carbs and you get a list of all your carb entries the carbohydrate screen. That screen is helpful if your settings are relatively decent, but what you may have to do is you go back in and you delete the extra carbs you put in and get everything back entered the way you think is right, and then you can tweak your settings and come back and look at that screen again and use it as a guide for oh, if I gave more, if I had a stronger car ratio, how many cars would loop? Think these meals took, for example, and if I change my ISF, what does that do? So it’s a good learning screen, but you have to make sure that you’re putting in reasonable amounts and not just pivoting based on you know how the day feels. It’s fine to do in the moment, especially if your kids like mine, and she’s texting me, I’m like, Well, I guess you have been running lower, and I don’t want to text her two or three times to adjust her basal. I don’t want to bother her. So I might say, Sure, we’ll take 10 carbs off lunch. But we don’t do that very often. It’s usually like, lower your basal by, you know, point, oh, five, and then, you know, then give her the real carb counts, and then we move on. Kind of what I do at lunchtime, so that’s something to pay attention to. I see a habit people develop.

But even though Kenny, when you talk about, like, counting carbs, you’re still just estimating based on your knowledge, right? You’re not actually, like, calling the school and being like, how much, how many carbs are in this like, you’ve figured it out over time, or did you call them initially?

The school actually has a meal plan set up, and so every food that they have, I can go on the website and look at their estimated fat, protein and carb counts. They have nutrition facts posted for everything. I don’t know how accurate they are and how consistent they are in their portions, but it gives me some place to start, and then we adjust from there.

Okay, sure, that makes sense. Yeah. What do you got left here

one tip that I think has been really helpful for people, and a better tip for managing those night time rises. You mentioned the last episode when your kid goes to sleep, especially when they’re younger, and they go shooting up. I had a way of managing it, and just this year, I learned some information that actually made it make more sense. So I was reading about circadian rhythm of your body for health reasons. And one of the things I mentioned is that when we eat in the morning, our body will, you know, digest the food, convert all of it right now, all the carbs to sugar and use it, you know, power our brain, our muscles, all that throughout the day. As we get closer to sleeping time, our body knows that we’ll be fasting, we’ll be not eating overnight. And so what happens is a portion of the food we eat starts to be stored as fat for consumption later. And I feel like that hit me. Was like, Oh, that explains why, if we have the same food at lunch as we do a dinner, for example, the spike isn’t as strong at dinner most of the time, and we’re often fighting lows before bed, or sometimes fighting lows before bed. Just feels like the food doesn’t hit the same from lunch as it does to dinner. And so what we’ve been doing is using, I didn’t want to back off on the carb ratio. A lot of people weaken the carb ratio for dinner as a result. But what I found works now to represent this biologic effect is that you just use longer absorption. So if you use a medium, like a taco entry at lunch, then try the pizza one, like a four or five hour absorption at dinner. If you normally use pizza like a five hour absorption at lunch, then try six when you go to have it for dinner. And so what happens is you get less insulin up front. Hopefully it generally helps mitigate the lows you have before bed at the same time, saves a lot of active carbs and a nice long window of time. Or when that rise does show up after your kid goes to sleep, or you go to sleep, either way that it has a lot of active carbs that it still expects to show up and can start hammering away at that when the rise occurs. So it’s created a lot more consistency for us and for the other people I’ve mentioned this to where now it’s not again, we’re doing fat and protein and everything in those entries, but it creates a lot more consistency where I don’t have to be manually bolusing a really aggressive rise loop already wants to give, in my case, multiple units as she’s going up. So I don’t have to be like, Oh, here’s a five unit Bolus to try to knock down this rise that’s coming the system wants to do it. And so if I don’t pay attention, it’s usually relatively contained. It might not be perfectly in time and range, but it’s much better than it used to be when we started loop. And I just felt like the magic was having that Apple Watch where she could go to sleep, and then as soon as she goes to sleep, I would just like take the watch and Bolus a bunch of units while I’m trying to clean the kitchen or do laundry with my wife as the kids are in bed. I just thought that was magical, but now if we sort of represented this rise more appropriately and mitigated the lows before bed, that now I don’t have to do that as much anymore.

Okay, I feel like we. Should say, because we haven’t so far. For people who haven’t used loop, when you hear Kenny sing, like, pick taco or pizza for so there’s little emojis in the in the app that signify different absorption times for the food. So that’s what he’s saying. Like when he says, Pick taco or pick a pizza. Are those the ones you use most of the time.

Yeah, I’m using taco and pizza. Yeah, the lollipop is considered the fast stuff. The default for that is 30 minutes of absorption. Now, it got changed in the last couple years. I always make it longer. I change it in the code and make it, you know, one and a half or two hours. We tend not to use that. I do use that for fruit. That’s the one thing that’s tricky in here. He’s just talking about food that has a lot of fiber. And one of the tricky things I found about fruit is you might look up like, what’s the carb count for a medium apple? And it’ll tell you something like 20 or 25 grams of carbs. But that’s only true if you were to blend it up with an industrial blender and smash all the cell walls that contain all the sugar into bits and extract every ounce of sugar out of it. But I know my kids not chewing her apple that thoroughly to extract all the sugar found in that Apple, right? So I find that’s one reason that fruits and vegetables are a little more variable and should be, usually be less than whatever I Google, or whatever the amount of carbs it should be, is that my kid’s not going to chew it up the same way. So I’ll use a shorter time entry, so that there’s less chance that, like, four hours out loop thinks that, oh, we haven’t seen all the carbs for that apple. So if you keep it short, loop limits the amount of time it’ll expect that fruit to hit. And so then you don’t have to worry about over counting it quite as much. And then I also usually pick a number less than whatever it is I look up for most foods that I again, don’t think she’s going to be chewing like she’s a high speed blender. You

know, it’s interesting. While we’re talking today, a couple of things are occurring to me. The one is that there could be people listening who are just like this Kenny guy is overthinking all this. You know, I don’t see any of the things that he’s talking about, but I would ask you to believe that, and maybe this is okay, but frequently, some of the successes you have with diabetes are by mistake. And you know what I mean, just like, just like, the failures are not always obvious where they came from. But you could not understand some of this and still be seeing stability and thinking like, Oh, I understand this, but you could just be getting lucky. Like, look what we talked about, like the circadian rhythm of like, how your body stores food depending on what time of day it is. Like, that’s the thing that you might have built up a rhythm with, and not you might not know that you understand that rhythm, right, like, so it’s just, it’s interesting to me, because I feel like as much as this conversation is about how loop works and how to use loop, it’s really just as much, if not more, about how your body works, how it interacts with the food and your exercise and the other things that impact your blood sugar and How insulin work, like the loop is almost inconsequential in the conversation. As crazy as that sounds like, that’s not really what you’re learning about while you’re talking Does that make sense?

Yeah, that’s exactly right. And loop, because of its design, is a little more simplistic in terms of, like, just modeling everything, so we just adjust the understanding to make loop kind of do what we understand. And yeah, I think, like the circadian rhythm thing was just something I encountered this year for another unrelated reason. I just happen to have diabetes experience to layer on top of it. So it’s, it’s a lot, it’s, it can feel technical, but once you wrap your head around it, it’s something you you can adjust to pretty well. And like I said before, with any system that you’re managing with. You understand these variables, you can use that system to your advantage in that way. And you mentioned activity, and I’ll just throw that in here too, that sometimes you need to not enter all the carbs in for activity. And we’ll cover that more in more detail, but that’s one space that I find some parents with active kids. They just they don’t do that fat and protein thing we talk about for like, lunch at school, for example. Yeah, they’ll do it for dinner, because those rises are going to show up, for sure, but they won’t do it at school. But yeah, exactly. It’s just, this is all about understanding biology, and the more we can understand it, the better decisions we can make with whatever system, however we’re managing diabetes.

I think I’d like to make this point, to simplify, if you want, if you’re a baseball person, you watch baseball on television, you wonder, like, in the last handful of years, like, Where’d all these guys come from? That throw 98 miles an hour from like, I used to be a special few people, right? You know, you need to be Nolan Ryan. You need to be like, a guy like that. Like, to be that special. Where that came from is a lab out in Seattle called driveline, who figured out that, yeah, Nolan Ryan was special, but it might have had a lot more to do with, like, how his fingers were shaped, or how his arm moved, and that’s a thing we could teach to other people. So, like, there are a lot of big, strong guys who are built about like this, that if we teach them the correct mechanics, turns out that ball comes out just the same, right? So it’s not as. Magical as you thought it was back when it was a handful of people in the league who are special at this. We can teach you how to throw the ball this way, and they’re doing it now. Diabetes, to me, is kind of the same way, like you can’t look up and just think, oh, some people are just better at this than I am, or it just works for them. You know what I mean? Like, there is a way to have the same results that you’re seeing with other people all the time. It’s the basis for the podcast, you know, for my money, like, you know, if you’ve listened for a while, you’ve heard me say forever that when I started this, people told me that I couldn’t share my daughter’s successes because it would make others feel badly. And what I said was, I think it should make them feel like it’s possible, and they should maybe try to figure out what the hell I did. So like that, to me, is what we’re talking about here. Like Kenny’s not a special person. I mean, listen, he’s delightful and he’s eloquent. He talks about this stuff in a way that is obvious, that he has a deep understanding of it and a lot of practice with it. But you don’t need to understand it as well as Kenny does to have the results that Kenny’s having with his daughter. That’s my expectation. So you know, Kenny, people have been listening to this podcast for a long time. You You understand this in a completely different way than I do, like my brain does not work the same way yours does. And the truth is, is that if somebody told me right now at the end of this recording, go back and tell me everything Kenny said, I won’t be able to do that, but I can listen to you translate what you said into how my brain works, and then use that in my daughter’s life. So I think a lot of people are have that possibility in front of them as well. I appreciate you doing this. Yeah, yeah, that’s great. Yeah. It’s awesome. Thank you. I’d like to thank the ever since 365 for sponsoring this episode of The Juicebox Podcast, and remind you that if you want the only sensor that gets inserted once a year and not every 14 days, you want the ever since CGM, ever since cgm.com/juice box, one year one CGM. Hey, thanks for listening all the way to the end. I really appreciate your loyalty and listenership. Thank you so much for listening. I’ll be back very soon with another episode of The Juicebox Podcast. If you’re looking for community around type one diabetes. Check out the Juicebox Podcast, private Facebook group. Juice box podcast, type one diabetes. But everybody is welcome. Type one type two gestational loved ones. It doesn’t matter to me if you’re impacted by diabetes and you’re looking for support, comfort or community, check out Juicebox Podcast. Type one diabetes on Facebook, the episode you just heard was professionally edited by wrong way recording, wrongway recording.com, you.

Friends, we’re all back together for the next episode of The Juicebox Podcast. Welcome, guys. Kenny Fox is with us again. You can find Kenny at Fox in the loophouse.com and today he and I are going to talk about the loop algorithm and understanding insulin sensitivity factor. Nothing you hear on the Juicebox Podcast should be considered advice medical or otherwise, always consult a physician before making any changes to your health care plan. Don’t forget to save 40% off of your entire order at cozy earth.com All you have to do is use the offer code juice box at checkout. That’s Juicebox at checkout to save 40% at cozy earth.com AG, one is offering my listeners a free $76 gift. When you sign up, you’ll get a welcome kit, a bottle of d3, k2, and five free travel packs in your first box. So make sure you check out drink AG, one.com/juice, box. To get this offer. Are you an adult living with type one or the caregiver of someone who is and a US resident? If you are, I’d love it if you would go to T 1d, exchange.org/juice box and take the survey. When you complete that survey, your answers are used to move type one diabetes research of all kinds. So if you’d like to help with type one research, but don’t have time to go to a doctor or an investigation and you want to do something right there from your sofa, this is the way t 1d exchange.org/juice, box. It should not take you more than about 10 minutes. This episode is sponsored by the tandem Moby system, which is powered by tandems, newest algorithm control iq plus technology. Tandem mobi has a predictive algorithm that helps prevent highs and lows, and is now available for ages two and up. Learn more and get started today at tandem diabetes.com/juice box. The show you’re about to listen to is sponsored by the ever since 365 the ever since 365 has exceptional accuracy over one year and is the most accurate CGM in the low range that you can get ever since cgm.com/juicebox, Ken, welcome back. Hey, Scott. What are we going to talk about today? I just, I decided with you, I’m just going to say what are we going to talk about today? And let you

take the wheel. You got it all right. So I think I want to talk about ISF. We covered basal and then meals, and we didn’t talk about the carb ratio last time as much. But I think people have a pretty good understanding of I want more insulin for the first few hours of my food, and it can tweak the carb ratio from there. So really, what’s left is in terms of main like core settings, we’ll talk about ISF, which is insulin sensitivity factor. That one is, I think, one of the more misunderstood variables. I’ve heard doctors and other folks talk about it in the same way they talk about basal when they don’t understand something, when they understand why you’re high. A lot of people go to, I don’t know, let’s just change the basal. Once you get into looping and you can wrap your head around basal changes, it often becomes, well, ISF is even more mysterious. I don’t understand this one, so let’s change that one. If stuff’s not going the way I want, that’s a little bit tricky of a situation when you’re when you’re like that. And so we’ll try to demystify that a bit more. Okay. Do you find that same problem when people are not understanding it’s easier to see when they first start out, but they start attributing certain problems that from an experienced person don’t make sense, but they just start messing with things because they don’t under it’s the thing they least understand.

I think that you get frustrated and they just start turning knobs, pushing buttons. That’s fair. I think they don’t know why they’re doing what they’re doing honestly. And listen, in fairness. There are times when I make adjustments and I’m like, I think this might be it, but I’m not 100% certain. I mean, look, can I look at basal and say, you know, at times where there’s no active insulin and no food involved, and can I look and say, Hey, her blood sugar has been sitting at 110 at this time of night, for example, really consistently. I’m gonna, like, tweak the basal here and see what happens. Yes, right? But it’s harder to see, like, insulin sensitivity stuff and correction factor like that. I think is harder for people to see. Do you not agree that one? Yeah,

yeah, I agree. Because I think basal we can, I think, relatively quickly, wrap our heads around, especially at night. That’s a nice one. Sensitivity is a challenging one, also, because when you first get diagnosed, you’re talking about making corrections. So you like, here’s your long acting or your basal settings, here’s a carb ratio to start with, and then here’s this correction factor, or this number you’ll use to calculate how much extra insulin to give if you end up higher. Then you should be a few hours after eating, or just a few hours after your last dose. What happens is, we take that idea over to an automated system like loop. One of the things loop is doing is it’s making those small adjustments. If you’re if it thinks you’re going to end up a little higher, a little low. It’s doing that every five minutes, so you end up needing to use a number that’s much larger than the number you might use when the doctor says, Hey, try this out. You know, you consult that number couple times a day. You’re not looking every five minutes. You’re looking every couple hours to see if you need to make a correction, potentially, and using that number then. So I think that’s a one, one big difference between the idea when you use it or shots or MDI, or even standard pumping, versus using it in a system like loop. You

know, when people get put on a regular system where they’re doing MDI, and someone says, We think that one unit moves your blood sugar, I don’t know, you know, 200 points, so your insulin sensitivity is 200 Sure, they probably try that in the beginning, right? They’re probably like, Oh, my kids, got a 300 blood sugar. I want it to be 100 I’ll put in a unit, because they said it moves 200 doesn’t take you long to figure out that, like, higher blood sugars kind of need more insulin, okay? If that’s true, and I want to move 50 points, and I need a quarter of unit, that usually works if I’m, you know, I’m 100 and I’m 150 and I want to be 100 a quarter of a unit kind of moves me that way. But you don’t really see the full picture or the full value until you’re on an algorithm, and that thing isn’t making these big, sweeping decisions like that, like, you know, I’m trying to move a number this, you know, 200 points when it’s trying to move a number 10 points, when it’s trying to move a number 20 points, and there’s a fraction of an amount of that insulin, like, there’s where it becomes, I mean, another level tool, because you’re never going to, as a person with a syringe or even with a manual pump, say to yourself, I want to move just this much, and it’s 15 points, and my pump is not even set up to, like, correct that Number. So I don’t think it comes into people’s minds that often. Yeah, and

you’re probably going to wait and see how things settle before you make a decision to add more or take away right insulin. So yeah, that makes sense. You’re just not going to make the decisions that fast. One, because you have a life to live. And two, you do need to let stuff kind of play out. And there’s so much very variability that in food or whatever else is going on that doesn’t make sense for you to try and do, you know, quarter unit or 10th of a unit, two weeks all the time,

even if you were a machine in your mind, and you could make sense of that bigger picture, you can’t take insulin away in a manual pump. Well, you can, but now you’re setting, like, Temp Basal offs and, you know, but if you’re MDI, you’re you’re done, like, the insulin is in, it’s in, right?

Yeah, you’re not gonna set a 30 minute half hour, 30 minute Temp Basal off, and then come back and check it again, and then you end up a little high. So you’re not gonna play with it that often, like a system would. And I

think for those reasons, that’s maybe the least considered setting sometimes for people, and it ends up being very important. Yeah, I agree. And once you see it work on an algorithm, you level up your understanding of it too. Why would you settle for changing your CGM every few weeks when you can have 365 days of reliable glucose data? Today’s episode is sponsored by the ever since 365 it is the only CGM with a tiny sensor that lasts a full year, sitting comfortably under your skin with no more frequent sensor changes and essentially no compression lows. For one year, you’ll get your CGM data in real time on your phone, smart watch, Android or iOS, even an Apple Watch predictive high and low alerts let you know where your glucose is headed before it gets there. So there’s no surprises, just confidence, and you can instantly share that data with your healthcare provider or your family. You’re going to get one year of reliable data without all those sensor changes. That’s the ever since 365 gentle on your skin, strong for your life. One sensor a year that gives you one less thing to worry about, head now to ever sense, cgm.com/juicebox, to get started, let’s talk about the tandem Moby insulin pump from today’s sponsor tandem diabetes care. Their newest algorithm control, iq plus technology and the new tandem Moby pump offer you unique opportunities to have better control. It’s the only system with auto Bolus that helps with missed meals and preventing hyperglycemia, the only system with a dedicated sleep setting, and the only system with off or on body wear options. Tandemobi gives you more discretion, freedom and options for how to manage your diabetes. This is their best algorithm ever, and they’d like you to check it out at tandem diabetes.com/juicebox, when you get to my link, you’re going to see integrations with Dexcom sensors and a ton of other information that’s going to help you learn about tandems. Tiny pump that. Big on control tandem diabetes.com/juicebox the tandem Moby system is available for people ages two and up who want an automated delivery system to help them sleep better, wake up in range and address high blood sugars with auto Bolus.

In our previous talk, we discussed a lot of variables that I think you made a good connection of. It’s really applies to however you manage. If you can start to understand those, we start to remove what I kind of call the fog, and you can really see what the settings need to be, because you’re like, Oh, well, I’m high because, oh, I forgot to handle fat and protein to my meal or basal was off last night. So it’s probably not going to be so great today, things like that. Maybe your pump site is not working as well as it could. So that’s going to be once you remove all of those. Then we can talk about sensitivity. And we talk about sensitivity, the number is, I’ll use the word points. I like using the word points as well. How many points is your blood sugar going to move given one unit of insulin? And what you need to remember is you need to consider the entire runtime of that insulin, or the duration of it, which should be about six hours, and loop models that so to do an ISF test, you’d have to get kind of high, have really good basal, have no other fat and protein going on. So it’s really got to be quite a few hours since you ate last, and then give half a unit, or a unit, and then wait five, six hours, see how far your blood sugar drops. And then you can, if you did a half a unit, you’d have to, you know, double it to get to the right number. And so it’s a really difficult test to do, because who really wants to sit still and have really perfect basal for the, you know, first for a 678, hour duration. You know, it’s interesting

when you talk about it in context of the algorithm, of any of these algorithms, right? Like it makes so much sense, because you know that that those little machines are tracking all of the different boluses and all of their different outcomes and and making sense of them when you try to imagine doing that manually. I mean, you can maybe keep track of a couple like, you know, like I Bolus at 8am for breakfast, then I Bolus again at 10 o’clock for this, and then I had lunch at one. At one o’clock, I’m five hours after the eight o’clock Bolus. Like no one’s in their mind juggling all that anymore and all the implications and the different timelines that the insulin is running on it’s why all these systems are just so next level. So I would need a computer right now, if you’re looking for that kind of control and that kind of consistency, then, yeah, I mean, you need something smarter than you to track it. That’s for sure, smarter than me, for sure. We

talk about points, just in case people aren’t tracking we’re talking about milligrams per deciliter for those using Imperial numbers and millimoles for those that are not. And it’s an easier way to say it, because if you start trying to talk about the ratios here in an audio setting, you’re not going to be able to track all this stuff. So I have a video that’s been up on YouTube about how ISF affects carb absorption, and we’re gonna talk about that here in a second. So you guys can go see that a few more visuals. But the big challenge we have when we talk about using ISF, or figuring out ISF in loop is one, you first have to shed the idea that it’s the same number that I’m going to use like I would if I checked my blood sugar every couple of hours and was high and wanted to nudge blood sugar down. And two, it’s going to be even bigger. If you think, Well, how much will my blood sugar come down if I dose the unit and waited six hours when I really didn’t have any of these other things we’ve been talking about active that’s when it’s like, Oh, I’d probably come down quite a bit. The ISF number you’d think of would be a fairly large number, which means you’d move a lot of points given one unit of insulin compared to what you’d use in a situation where you’re high, you’re usually addressing something like food or some other issue where you do need more insulin. I think a lot of people, at least those that listen to the podcast, get a very intuitive sense, after some practice, that even if they don’t know what that variable is, they might need a decent amount of insulin to bring it down, or may want to bring it down sooner than six hours. So what loop is looking at is is a much larger number than what you’re used to. When I see people bring over their settings from a previous pump set up, it ends up causing a little bit of problem because the number ends up being too small. And it’s not a problem always of too much in terms of a correction, like getting high, and the loop just gives too much insulin. That does happen. But I think a more common situation is it’s just a little bit too strong, a little bit too small of a number, and it negatively impacts how loop tracks meals. And that’s really like the in my mind, the largest or most significant thing that ISF does during the day. But before we dive into that, it’s easier to talk about the easier situation, which is night time, like you talked about identifying basal overnight. At night, you’re not running around, you’re not eating anything. You might have some some hormone stuff going on overnight, but it’s not as significant. So what I like to do is all use ISF overnight, and I’ll often make it a little bit stronger, so where I get the system to respond the way. I would, which is you have a little bit too much insulin, enough insulin that after six hours would probably make you a little low, but not so much that once your blood sugar starts trending down, Luke predicts, Oh, this isn’t going to go well. We’re going to go low, and it starts turning off the basal. And so it’s kind of like a like a mild crush and catch situation, like you talked about here.

Is it easy to go too far with that, to where it can’t catch it.

Yeah, I think it, I don’t know. It’s super easy. If you move things in steps of 5% 10% at a time, and kind of nudge the numbers down, then I think you end up being in a situation where that’s not going to be the problem. One thing to look for is if you see, even if your basal is not perfect, but if you see loop giving Bolus is and then start dropping, and it’s not turning the basal off to be able to catch it, it just goes down so fast that even though it turned off the basal, it couldn’t catch it. And again, there’s no obvious basal problem. Then, yeah, you’ll need to back it off a bit. Okay, that said, I think for other systems like Android APS or trio that use the O ref based algorithm that’s different from loop. I think it works better, from what I’ve heard, to use a single sensitivity number across all 24 hours. And I think you could do that with loop too, if you had pretty good basal and we go with a number that works across both day and night. I think you can do that, but I’d like to use slightly lower numbers at night, just in case things go wrong, like Tessa has a basal increase need and she starts kind of drifting up. And I want loop to kind of keep it contained, to keep it from getting up over maybe 121, 30, even if it’s like a big change in basal needs. And so I just give loop a little more permission to kind of hammer out that blood sugar, but starts to drift high, but if it starts causing any problems and it can’t catch the resulting drop, then definitely back it off. It’s definitely the safest thing to do is to leave it as a larger number overnight, rather than smaller. You know,

you talk about pretty frequently the idea of giving loop the autonomy to make a more aggressive move if it needs to. But I think that could be confusing to people. So like, if they’re wearing a regular pump, and their basal, empirically, is one unit an hour, we just know that it is, you know, for the conversation, if they make it 1.25 an hour, they’re going to get low pretty quickly in a couple of hours. If you tell loop, you know, if you’re saying to yourself, I think my basal is one an hour, but you tell loop it’s 1.25 Are you saying that loop is going to push, push, push until it sees a low and then take it away and then next time not push is hard because you’ve given it like a wider decision tree to use right like, as far as the amount of basal goes. But it doesn’t necessarily mean it’s going to use all of it.

Basal is tricky. Basal, unfortunately, with the way loop is built. Right now, if the basal is off, if you went with a one and a quarter instead of a one heat at an hour, at some point, you’re very likely to go low, because loop is assuming that the insulin on board that it sees of, let’s say zero, is going to keep you flat. But if your insulin, if your basal is too high, you’re going to just start drifting down and loops like, Well, no, you should be straight, and you keep dropping. It’s like, No, you should be straight and you keep and you keep dropping. And then if you look like you’re going to drop below the glucose safety limit, then it starts to turn the basal off, and you start to get negative insulin on board. But it’s still always like, Well, you said basal was one and a quarter, and we now have negative insulin on board. You’re going to go up. And so as soon as you do start coming up, when you treat the low, then it comes back. You end up hit. You end up getting over treated. Yeah, so basal is a tricky one. That’s not as safe a one to overstate, there’s some work being done right now about trying to adjust how the negative insulin on board affects the prediction so loop doesn’t think you’re gonna come shooting up and then hammering you with us quite as much insulin and send you back low. But yeah, there’s not a lot of forgiveness in the system, as it’s designed today, around basal. This is why I like to turn down the sensitivity, because it only comes into play if your blood sugar, you know, is higher than the defined range. Basically, if you’re high, if you’re low, or you’re in range of where you told the system you want to be, then the there’s no correction or sensitivity nudges that need to happen so it stays out of the way, so it’s a little safer in that sense, that you can hover around your range, and it’s not going to just all of a sudden shoot you down low, okay, but if you start creeping up a little bit, it can nudge a little bit with sensitivity number. I just

want to make sure people understood that, so you can’t just tell that. You know, I know my basal is one, but here take more in case you want to use it a different way. It’s not going to work that way. It’s going to push you too low. Going to push you too low. Correct with sensitivity, though, if you say a unit moves you 100 points, and you then come back and tell them, like, hey, you know what? Instead, like, let’s say a unit moves you a different amount, so that you have a little more autonomy in here. So if you wanted it to have more autonomy, and you were one unit moves you 100 points. Would you want to make it one unit makes you 90 or moves you 110 to make it more aggressive?

More aggressive would be 90, the smaller number. And the nice thing is, loop has other pieces to its prediction, one of them being momentum. So if you’re if it does. Does get you with an amount of insulin for the 90 and you start dropping, loop does presume, oh, well, you’re moving down. You’ll probably keep moving down a little bit. So that tends to push the prediction down a little bit lower, faster. So it’s not going to just give the 90 dose and then wait for it to settle. If you start moving down right away, it’s going to try to pull back. So that’s why it’s a little bit safer to do. But more aggressive is definitely a smaller number that you’d pick.

Okay, I just listen. I want to be clear. I know that I just wanted to say it out loud so that people could hear it right. Because I get the idea of like, oh, I want to give it a little more, a couple more bullets in its bag if it wants to pull it out and start and start shooting. It doesn’t work there. Now this might be, I don’t want to get too far off the course here, but if your insulin to carb ratio is, you know, one unit covers 10, you know, you change it to one unit covers nine because you want to be a little more aggressive, that’s still a thing that the loop could probably adjust within. Is that fair? Yeah,

we talked about meals before. And so if your blood sugar starts to, let’s say nine. One to nine is too much, and you’d have drifting a little lower. There’s still kind of speed and momentum pieces that we’ll talk about more detail later. But moving here, where loop would be like, Oh, you’re running a little lower. We should probably turn the basal off, and then you still have the the time window, the absorption time we talked about, that loop will expect that food. But if the nine is too much compared to the 10, you might run a little lower, but there’s a chance that you might not go low, and that loop will maybe give you a little bit too much insulin here and there, but still maybe catch it. And then when that time window runs out, it’s like, okay, well, we’re done looking for those carbs. So it can cause a problem, but it’s less likely I think, okay, I appreciate you

going over that with me. Go ahead, please go back to the course you were on when I took you off course.

The sensitivity stuff’s good. The other thing to remember about, about the sensitivity is that when actually, when loop doses, let’s say automatic Bolus, when it gives the insulin that it thinks you need at nights. And use the example, it’s only going to give a fraction of that. So if we’re using a one to 100 and you end up drifting up and it wants to give you, let’s say the recommendation is as much as a half a unit. It’s only going to give a fraction of that. So the default setting would be, like 40% so less than half of that half unit, so like little less than a quarter unit, is what it would give. And then the next time, it will only give 40% of what’s left of that recommendation. And if your blood sugar starts to curve and starts or start to come down, that recommendation will kind of disappear or will drop significantly at any given point, loops not really giving all of the whole one to 100 or one to 90 sort of sensitivity calculation, which is good, and this is also a good time to mention that there is a algorithm experiment, piece of loop, like an extra little algorithm, modification you can use that will change how that dosing occurs. It will either do 40% which is the standard automatic Bolus, or this one called glucose based partial application, which we referenced before, but it gives a smaller percentage of that recommendation when your blood sugar is closer to your defined range versus and then as you go higher, it’ll give a higher percentage of that recommendation. So even though you’re dialing down the sensitivity, it’s never really going to give all of the insulin right away. So that’s the other reason why you can say, well, if I turn it down a little bit lower than maybe it should if you were to do a full six hour test or something, there’s a lot of play in there, because the system is not going to deliver in its confidence, not going to deliver everything. So it has time for your blood sugar to start to level out or start going down, and then take appropriate action. So it’s something to remember. We’re talking about sensitivity, and why I think it’s kind of forgiving, especially at night. Yeah, to dial it down. Okay, thank you. Daytime is the trickiest part, and honestly, probably the more important one. What’s interesting that I learned a couple years ago from some people smarter than me is that, if you take the sensitivity and you divide that by your carb ratio, and we’ll talk about all the units, it gets a little crazy. You end up with, instead of a nice sensitivities of points per unit and carbs is grams per unit, per unit per gram. I forget which one, but if you divide the sensitivity by carb ratio, you end up getting a points per gram, which basically says, if you have one gram of carbohydrate, how many points is that expected to raise your blood sugar? And so now operates off this assumption that a certain amount of carb is going to raise your blood sugar a certain amount. So if you ever go into loop and you enter 10 grams, and then you see the prediction says you’re going to go up to a certain number, let’s say 500 that’s the assumption, if you don’t give any insulin. And I always wondered, how did it come up with that number? Well, it’s using your sensitivity divided by your carb ratio. And so with that expectation, when your blood sugar does go up after you enter a meal and start eating, as your blood sugar goes up, loop says, Hey, that rise equates to this many carbs. Now. Says, Okay, let’s say it’s five carbs. It’s going to subtract five carbs from the active carbs, from the carb entries we discussed last time. And so that’s how it’s one other main piece, how it’s subtracting the active carbs, or the carbs being absorbed, as the other term loop uses. It’s tracking the meal progress based on how much your blood sugar goes up, is one of those major components. So if you have your sensitivity set to too small of a number, this affects your points per gram. The short version is, without trying to talk about all the units, because you really got to see it on the page, is that when your sensitivity is too small, loop sees a lot more carbs when it goes up. And the picture I like to give is a small child might have a sensitivity of 200 or more, and you give them one Skittle, and their blood sugar pops up maybe 15 points for that Skittle, you grab a middle schooler or high schooler, some bigger person, give them a Skittle and their blood sugar is long gonna pop up a couple points. They just don’t go up as high for each gram you give them, or we discussed before. You know, you used to have to save Tessa from a low with just a couple grams, and now it takes quite a bit more if she’s going low with any substance. I think that’s an important concept to wrap your head around, that the less sensitive you are to insulin, the smaller that sensitivity, the less sensitive you are to carbs as well. There used to

be times where I’d be like, just drink a quarter of this juice box. That’s all, yeah, take three sips. That’ll fix it. Now I’m like, just here. Just drink it. Drink the whole thing, yeah, just drink this, and then we’ll see what happens. And we’ve talked about it already, I think, but just over, like, go over it again, mostly that’s body mass, or it’s also the amount of insulin you think. Do you think some people are just making more insulin as they’re younger or more newly diagnosed, and then that goes away over time too. Like, what are all the variables that you think impact

that? Yeah, that’s a good question. I think, I think it’s all of those things. I think when Tessa was younger, she probably still had some beta cell function. There’s even times, I think recently, it’s been a while since I’ve seen this, but I thought I would try to get an ISF test in while Tessa was sleeping. I just give her some of her like, honey. I give her at night, while she’s sleeping, she’d never wake up and her shoot her blood sugar up, and then I could give her some insulin and kind of see how far she comes down, you know, maybe, like, three in the morning or something. And I’ve seen it where I give her the 345, grams of honey, and she pops up and pops right back down. Like, well, obviously there’s some body function here that’s taking care of this, because it wasn’t loop and it wasn’t me, so I think that plays into it, and why, I think it’s also difficult to get these tests in. But I’m sure body mass is a big one, right? It’s there tends to be a relationship between body mass and how much insulin you generally use and how much basal you often use. I think those are two big pieces, and then there’s always, like diet plays into it too. How much you’re know you can modify your insulin sensitivity with reducing fat in your diet, as a recent study that was coming out, so reducing the your fat intake will improve or increase your insulin sensitivity. So I think there’s a lot of factors that are really hard to nail down, but I think body mass as a good placeholder, at least in my mind, from a little child to a big child or an

adult just changes. Oh, there’s too much to think about. Again. That’s all there is.

There’s a lot to think about. So the main thing that I want to use, that I encourage people to try to use the daytime ISF for one, let’s just acknowledge that it’s really hard to test for, and it’s a pain in the butt. So what I like to do is I use the sensitivity during the day. I make one rate that covers the daytime, or at least the hours that you could be entering and eating carbs, and then use that number to help you get to the absorption you want. So we talked about using the ice cream all the absorption stuff in the last episode. So I think most people, especially listen to the podcast, will have a good sense for how much their carb ratio should be. Generally, like, if you’re not getting enough in the beginning of your meal, you end up a little high with proper pre bossing. And so you they people tend to adjust that down. I think people end up with a fairly aggressive carb ratio if they’re listeners of the podcast. And most people that come to me are in that boat too. And so once you feel like the beginning of the meal is good, but then you’re noticing that either the carbs are absorbing too slow, meaning loop gets to the very end of the time window for your food, and it still didn’t see nearly enough carbs, or the opposite, you get to the end of the time window, and loop saw way too many carbs being absorbed for that meal, that’s going to be a sensitivity problem. So I like to find a sensitivity number that helps us get to where most of the list of cars on that carb screen are absorbing pretty well, all within their expected time frames, not too long, not too short. And just change that one number and dial it in. So if we’re happy with how much in summer getting the beginning of a meal, and you adjust the sensitivity to get to a spot where loop says, Yep, that meal is over at the right time. Most of the time, you’re not going to get it all perfect, but you’re going to get it done pretty well. I think that’s a guiding principle that’s helped me and helped others when I talk about how to use sensitivity, because you can talk about, you know, how much is it correct and how much is it fixing things? Yes, I think if you get the meals mostly finishing right, and you do a pretty good job of counting the meals and the fat and the protein, that’s like the major variable we have to deal with in the day. So if we can just nail that, and I think everything else kind of falls into place. And you know thing, you might go a little higher, a little lower here and there for some other reason, but meals are going to look good, and loop is going to do what you want it to do the vast majority of the time. Yeah,

do you think you could go back and do this manually? Oh, like just being on MDI. You mean, I put tests on a manual pump. How much of this do you think you could mimic per success?

I think a fair amount of it, because you’ve covered most of the core components with Jenny talking about fat and protein. And if you can take care of pretty good carb ratio and expecting the fat and protein and dosing for it, I think you’re going to get very similar results to what loop will do with decent settings. I think the biggest thing that loop makes a big difference is protecting against lows. Like you mentioned before, you’re not gonna sit there and turn off the basal all the time, right? The other one, someone mentioned to me that was working with they came from the tandem pump, and we did the had the same problem when we were using the tandem you could only extend meals in the tandem pump like they have one extension running. You can do the same with any any pump. You can’t extend another Bolus on top of a currently running extension. And that’s kind of the for me, kind of the magic with loop, with the way Tessa eats sometimes, is she’ll have decent amount of fat and protein for multiple meals in a row and so but they’re overlapping each other. You want the insulin to extend and handle that fat and protein over a fairly long period of time, but then she ends up eating again, and the fat and protein impacts not done. Release the dosing for it’s not done. And so what loop and other systems like this help with is you can just say, enter a long meal, a pizza icon, you know, the long meal, and then enter another long meal. She gets seconds, enter another long meal, and loop sort of handles that extension in response to blood sugar. And if you get this ISF stuff working well, then, you know, four hours after she’s eaten, it’s going to, know, a pretty good amount of insulin to give for the fat and protein without giving too much. And that’s, I think, what takes a lot of the burden off or managing food with a system like this, is that you don’t have to worry about, are we extending? Is this to the extension still going? And do we need to cancel that extension and add more insulin in to cover the last extension, and then also extend into this food. So I think that that really helps a lot with how Tessa eats, just that she makes she doesn’t eat frequently, or meals are overlapping with each other with respect to the fat and protein window of time that the impact is there. And so it’s just it helps a lot for tracking meals that way or lack of tracking. I don’t have to do the tracking. We just enter it and move on so we could do it. But I don’t know how well Tessa could do it on her own, whereas, right now, she just enters it and she moves on with her day, and it’s usually pretty fine. What about you? What about you guys? You know, our needs a lot different, right? She spreads out her meals, sometimes fairly frequently. Yeah.

Kenny. I mean, could I go back and do it again with the same success if you give me a child young enough that doesn’t have opinions and, you know, doesn’t fight back, you know, when you say, do something right, I could easily do it and probably have better outcomes, but I think I’d be exhausted again. I think

I was thinking the same thing, you lose sleep. I think the sleep I think the sleep part is a part I didn’t think about till just now is, yeah, that part is the initial magic sauce for most people, right at any automation system, is it can go to sleep and it morning turns out better than it would have if I had just gone to sleep with a regular

just 1,000,000% like the the process seems to be is, you know, you have a diagnosis, or, you know, whatever, you’ve been at it for a while, and you just aren’t having a ton of success. Somebody slaps you on one of these algorithms. And then eventually you’re like, oh, it’s not perfect, but I’ll tell you overnight, I’m sleeping again. And then you kind of like, come back to life a little bit. You can start paying attention a little to what’s happening. I do think that if you took it all away, the first thing that would happen is my sleep would get dinged. You know, I am almost 20 years older than I was when she was diagnosed. I would find myself making those concessions in the middle of the night. I’d be like, Oh, it’s only 170 I gotta get some sleep. I think you’d slip back into that pretty quickly. Then I think that starts to impact the daytime again. And before you know it, you’re starting the day with a high blood sugar, not enough insulin, everything starts shooting up, and you’re off to the races, and you can’t figure out what the hell is going on. And then you struggle all day with it, which makes you exhausted, which then puts you overnight again, into a bad situation. Try to keep up with it the best you can. If I didn’t have to sleep, if I wasn’t older, I know more now, like if you put me just in charge of somebody’s blood sugar, I think I could manage it with an inch of its life, but I don’t know how long I could do that before I dropped over dad. I just think that there are so many people out there who are not using this automation or not using it effectively, and you have no idea how much your life would change if you if you had it. And it was and it was working well for you. I really

like how you talked about that with the last episode of your caregiver series. That was great. You guys really hit that pretty good is the lack of sleep is significant burden on caregivers, especially. But you know, just as much with the people with diabetes, once they’re in charge of their own blood sugar,

it just runs you down. There’s no way to get ahead. After a while, you think, no, it’s okay. I’ll figure it out. But, man, I don’t know. Like, you know you’re not a machine. You just can’t stay ahead of it forever. So right, yeah,

I think the last thing I’d like to drill home with people is this is the most hard to grasp and see, because it’s not as visually obvious a lot of times. And so my sequence of going through to figure out what might be wrong, we use the iob overnight, especially as our guide to say is basal right or basal wrong. We make basal adjustments based on we see inappropriate negative insulin on board, or those other data points we talked about in the first episode. Then if they’re running high, then before you make any changes, check the pod site, make sure it’s working. And then we lean on food. Are we counting things? Well, are we not forgetting to enter food? Are we adding fat and protein, all that food stuff called Food accuracy? And then if we’re doing a pretty good job of counting, then, then you got to mess with the car ratio. You’re going to get better results. If you’re running high or running low. Once basal is good, yeah, to just make sure you get enough insulin with your food. And then, as a last resort, like if you mess with all that stuff and you tinker with it, or you just don’t think any of those things need to change, because everything else looks good. Then you start playing with the sensitivity. You look at the arboration of the carb List screen and how absorption is going on, and you tinker with the ISF. But it’s something that I find with a with a kid that I don’t have to mess with very often, Tessa or any child, really, when you’re starting younger, their sensitivity is only going to go to a smaller number. It’s only going to drop as they get bigger. So that’s one thing, is that if you can get a pretty good number eye sensitivity number during the day that works, then chances are you don’t really have a question of whether or not it needs to go up or down. Most of the time. You’re just going to say it just needs to go down if it needs to change at all, because they’re just going to keep growing and getting bigger. So it is make it easier until your kids done growing, you know, early 20s or something, and then they then maybe can go up and down a little bit more. But with kids, it’s pretty simple. It’s only going to go down, and I really only mess with it a couple times a year when all the other stuff’s not helping. So don’t let the ISF confuse you and wear you down and keep playing with it all the time. Like pick a season where you have your basal dialed in and meals are looking pretty good those first few hours. You’re happy with your carb ratio and you’re counting. And then play with it and get it dialed in, and then you don’t, don’t mess with it too often. Couple times a year, revisit it and move it down a little bit. I don’t want it to drain anyone’s brain too much. People spend a lot of time thinking about the stuff they don’t yet understand, which I appreciate. There’s a lot of people that come talk to me, but I think you can just let it go a little bit and make some other adjustments, and you’ll probably be

okay. I’m adept at turning the knobs and making things work out, but if you listen to the voice in my head while I was doing it, you wouldn’t hear this, like, quiet confidence of like, Oh, I see this number and this outcome. So I know I’m gonna make this that I’ve learned over time. Her blood sugar has been too high lately. I think I need a little more insulin sensitivity power. Here. I’m going to take it from where it is and make it a little more aggressive. Yeah, I don’t think it’s the basal. I know we Bolus well for the food, so I’m going to try this here. But you, if you’re a person who isn’t sure if their carb ratio is right, doesn’t understand the impacts of food, basal is off by a little bit, imagine if your insulin to carb ratio is one to 10, but you have it set to one to 15, and your basal is a unit an hour, but you have it set at point eight, five, and your insulin sensitivity is like, who knows? By then, the basal is off, the carb ratio is off. All your meals are moving you around in ways that you know you can’t know. Forget being on an algorithm for a second, you’re going to get out of whack. And then how would you even figure out the insulin sensitivity? Like, in my mind, the basal has to be right, no matter. I think basal is always first, right. So always, yeah, your basal is first, right? Excellent, great. You eat foods that aren’t high in fat, that you’re really good at bolusing for that. You really know the carb counts for you count the carbs. You look at the insulin, you say, you reverse engineer. You say, Look, I know this meal for sure has 50 carbs in it and whatever, like, you know, two units always covers this. So great. So your insulin to carb ratio is one unit for 25 carbs. But that doesn’t mean that the next meal you’re gonna have is gonna hit the same way as that meal, but it’s a great starting spot. The thing again, like Kenny keeps mentioning it, because I don’t think people appreciate it enough. But if you don’t understand the impacts of fat in your food and how it’s pushing blood sugars up or holding blood sugars up, you really are at a loss for figuring this whole thing out. I. Know, as crazy as it sounds, but I think the one thing that throws more people off than anything else is the fat in their food.

Oh yeah, for sure. Like someone I’ve been working with for the full eight weeks of my session with them, and they were near the end, and their 11 year old was munching on a bunch of nuts, like fattier nuts and cashews or something like that. And they’re like, yeah, she didn’t really enter those a whole lot, or just the carbs for them, and then they should just ended up high, like, couple hours later. Like, do you think it was the nuts? It’s like, yeah, that’s like, the only reasonable explanation here, that you just kind of drifted up high and then ended up a little bit higher at dinner time. So it’s just one of those things that I think happens the most frequently. Yeah, is the easiest thing to under count. And I think if you get that right, the sensitivity, if it’s just in the ballpark of where it needs to be to help loops. Be to help loop see the meal, then you’ll be much better off those those things are, are the basics. The basal has to be right, and if it’s not, then you know, you can’t really go tweaking other knobs too much until you get that dialed in with confidence, which when we covered in the first episode, I think it’s one of the key things when people are working with me is I really try to hammer in on that, using the iob and getting the basal pretty right, and having confidence that it’s that it’s right, and then you can mess with other stuff. That way, you kind of have an order that you go through for this stuff. And I really like your idea of using predictable meals. I’ve had a lot of situations in the last few weeks where a nice, predictable meal turned out to not do what it normally does, and that told me that either the site was bad or some big setting needed to change that I just didn’t like usually carb ratio. Just didn’t know. Tesla wasn’t feeling well. She said she was feeling fine, but she needed a lot more instant for her food that day. Yeah, and you just, you had to catch it. So predictable, meals are a great way to just calibrate off of I don’t know where else you’re

supposed to start, because this idea of fasting, for a really long time, I don’t know who you tell me the kid you’re gonna say, Look, tomorrow morning, we’re getting up, we’re not eating. We’re gonna get your basal worked out, like I say, figure out basal overnight. Get it close, adapt it for the morning. Once your basal is good, look harder at your carb ratios over predictable meals. Excellent. We got that. Now let’s look at a blood sugar that’s went up the foods out of our system, but, you know, it never came back down from 180 great time to check your insulin sensitivity. Go ahead and throw a unit in and or a half unit and see where, where do you land? And don’t wait like, an hour or two, like, really, just, you know, wait a few hours, like, where does it land? It’s not going to be perfect, you know, if the unit moves you 50 points, and it’s about at, you know, you went from 180 to 130 and it’s just resting in there. You know, there’s a great place to start, to start with, yeah, and if you’re on an algorithm, and you’re close enough, like you said, then the algorithm there will kind of make up the difference for you, because it’ll push a little bit more when it needs to push. I mean, how long do you think Kenny with the service you provide? How long do you think people have to work with you before you before you can get them in a place like that? Yeah, what

I’ve seen this year with the groups that I’ve gone through, it’s been about week six or so of pretty dense conversation for the first three, four weeks, training and stuff, and then some messaging in between. But after about six weeks, they kind of get how to do the basal they’ve they’re have a good understanding of the carb ratio and even have a good guess when it’s sensitivity. If they move through that list by week eight, they’re pretty solid. Those last couple weeks are just kind of letting them practice. And we go over some other topics that like. We’ll cover some other pieces around the algorithm just to improve their understanding. But it’s the core of it is probably about six weeks. And I emphasize that the program is training. It’s like educational. It’s going to be videos that you can watch, but then we’re going to do like group calls. It’s going to be a group coaching. You’re not going to be left to just watch a video. You’re going to have access to someone to ask questions and to if anyone else wants to share, you can see their data. I know people really appreciate me showing Tess data so they can kind of understand, like, it’s not all sunshine and rainbows all the time, and how and when I would make changes, and just, you know, real life stuff that comes up. And so, yeah, it’s about six to eight weeks. The whole program right now, I’m planning on running it for a full eight weeks. But it’s, it’s really start to kind of get it after about six you have time to practice. Have something go wrong, have an illness show up, have a pod site go bad, those kinds of things. There are a few people that made it the whole time and just didn’t have anything significant that needed to change. And so right after we were done, and they called me and we worked through it, but a lot of it’s just practice, and most people have setting changes, even just a small basal change, sometimes every couple days, sometimes multiple times a week. Sometimes you wait a week or two before you have to change anything. I think that’s really important for people to see, and if they just don’t need a change, it takes a little longer to practice all the stuff that you’re learning. Tell people how to find you box in the loop house, com, you can sign up to get my email newsletter, so you’ll know when classes open up, they’re only going to open up a couple times a year. So you can jump in. You want to do some one on one instead of going through with the group. You can also find that information on my website, Fox and loop house, calm, awesome.

I told somebody today, I’m like, Oh, I can’t talk. I’m I’m recording. And they said, with who and I. Said Kenny. And the response I got back was more Fox in the loop house. I was like, yes, but that’s just funny. I can’t believe I tagged you with that. I’m so sorry. Like that I tagged you with that moniker, but, uh, I’m glad people know you that way. It’s awesome. Hey, I’m gonna roll with it. It’s fine, excellent. Is there anything we missed that we should have talked about here that we didn’t? No, that’s good. Awesome. All right, thank you, man,

Welcome back, friends to another episode of The Juicebox Podcast. Kenny is back, and don’t forget that you can find Kenny at Fox in the loophouse.com today, he and I are going to talk about some details around how the loop algorithm works. We’re going to talk about correction ranges and overall, this is just a nice episode to make you even more comfortable with how the loop algorithm functions. Nothing you hear on the Juicebox Podcast should be considered advice medical or otherwise, always consult a physician before making any changes to your health care plan. A g1 is offering my listeners a free $76 gift. When you sign up, you’ll get a welcome kit, a bottle of d3, k2, and five free travel packs in your first box. So make sure you check out drink a G one.com/juice box. To get this offer, don’t forget to save 40% off of your entire order at cozy earth.com All you have to do is use the offer code Juicebox at checkout. That’s Juicebox at checkout to save 40% at cozy earth.com my grand rounds series was designed by listeners to tell doctors what they need, and it also helps you to understand what to ask for. There’s a mental wellness series that addresses the emotional side of diabetes and practical ways to stay balanced. And when we talk about GLP medications, well, we’ll break down what they are, how they may help you, and if they fit into your diabetes management plan. What do these three things have in common? They’re all available at Juicebox, podcast.com, up in the menu. I know it can be hard to find these things in a podcast app, so we’ve collected them all for you at Juicebox podcast.com Today’s episode is sponsored by the tandem Moby system with control iq plus technology. If you’re looking for the only system with auto Bolus, multiple wear options and full control from your personal iPhone you’re looking for tandems, newest pump and algorithm. Use my link to support the podcast tandem diabetes.com/juicebox, check it out. The show you’re about to listen to is sponsored by the ever since 365 the ever since 365 has exceptional accuracy over one year and is the most accurate CGM in the low range that you can get ever since cgm.com/juicebox, have you heard me talk about how I I don’t even know how I accomplished getting Victor Garber on the podcast and like, the first two years of the show, right?

Oh, yeah, yeah. And then you only recorded one side, or something like that. My side.

I just recorded me. It was horrifying. And he was nice, of course, he came back and did it again, but, yeah, I got like, you know, like, the first, like, genuinely famous person who has type one diabetes to come on the podcast, and super excited. And he’s like, you know, doing it in between shooting a TV show and something else he’s doing. And, you know, right, I have somehow his home phone number, like, this whole thing has been very kind, and the whole thing recorded, and I get done, and I’m like, Oh, God. Like, oh, it’s like, his voice isn’t there. I didn’t know what to do, so I actually called the number I had for him and said, I’m so sorry. I just wanted to let you know this is, you know, a huge mistake on my part, but, you know, and I explained it to him, and he goes, Oh, he goes, we’ll just do it again. And I was like, Oh, thank you. Just so nice.

Just really trying to nail down any other like celebs or athletes or anything.

No, I haven’t, I have to tell you. And by the way, Kenny, we’re being recorded. I might leave this in. I don’t find that episodes with famous people are any more or less popular than episodes with people who, you know, just want to be on the podcast. So it’s a lot of work and effort to get people on, and then sometimes they don’t know the first damn thing about their diabetes. They just happen to have it. And then people get frustrated by that, and I also think it can put them in a bad light, and I think that’s unfair to them as well. So and some of the other famous people that people want to have on I’ve been around, and some of them are just boring, like, and then they they’re so, like, guarded, and they don’t want to say anything. So it just ends up being not good. I loved there are some people with a measure of fame who I thought had been great on the show. Charlotte Drury was awesome. And the girl from the TV show with the witches, Jennifer stone, she was awesome on the show. She was on Wizards of Waverly Place. Oh yeah, she was really I thought she was terrific. I’d have her on like, every week if I could. I don’t think she would want to do that. But anyway, Kenny pack for Episode Four. What are we talking about? Today? We’re

going to talk through a little bit of detail around the algorithm, how it performs. I want to talk about kind of the basics that make up that crazy line people see that is the the future. Answer that loop predicts, and then how and when loop adjusts, how, when it can take away basal, and how and when it it gives insulin extra insulin. And that will basically talk about correction ranges. Is all this will be a good episode for just some of the mechanics of how it works and what to expect. Kind of bullet expectations around when loops going to do stuff, and can help explain why people get confused. Okay,

you dive in. I think we’re gonna keep doing this the way we’ve been doing it. Obviously, the bulk of the information is coming from you. We’re working from your notes, and I will say things that I find useful along the way.

All right, sounds good. Other the basic prediction elements people can find this if they tap on that graph on the same like the home screen of loop, that blue one gives them four pieces they can toggle on and off. It doesn’t actually turn anything off. It’s just letting you see what each piece is, how it’s influencing the prediction. That’s probably the easiest place to see it and loop docs, it’s covered a fair amount, but we’ve talked about insulin, and people mostly understand how insulin works. It’s, you know, got kind of a peak around 90 minutes and fades over six hours. So that’s kind of understood, and we’ve talked about that. We talked about the food in episode two, about how loop just assumes that your food impact is going to be spread out over a certain time window based on the absorption time that you enter, with most of that impact being expected up in the front part of the meal. So those two pieces, most people know pretty easily, and usually when you toggle those on or off in your prediction, you’ll see pretty dramatic changes, because those are kind of the main things and influencing where your blood sugar is going, whether you’re using loop or not, food and insulin. And the last two pieces are the ones that I’d like to take a couple minutes just to cover real fast. And it’s we have the retrospective correction, which is a big, fancy word that basically just means we’re looking back at the last, I think it’s 60 minutes or so, and looking at what happened versus what loops thought what happened at a high level. It’s just saying, hey, in the last 60 minutes, How often have I been right versus what actually happened? And based on that difference, let’s say you end up higher than loop predicted, then it’ll say, Okay, let’s raise the prediction up a little bit higher to make up for the fact that that didn’t, it wasn’t what loop expected. And so it’s not a huge modification. It does just kind of bump the prediction up, but usually a couple points. Nothing crazy.

Is that there to help with? If it’s the third day of a site versus the second day of a site like that kind of stuff is like, because it looks back and it says, What? Like, I thought you’d be 160 by now, but you’re 170 I’ll be a little more aggressive. Or you’re lower than I expected, I’ll be a little less aggressive. Is that really what it’s doing this episode of The Juicebox Podcast is sponsored by Eversense 365 and just as the name says, it lasts for a full year, imagine for a second a CGM with just one sensor placement and one warm up period every year. Imagine a sensor that has exceptional accuracy over that year and is actually the most accurate CGM in the low range that you can get. What if I told you that this sensor had no risk of falling off or being knocked off? That may seem too good to be true, but I’m not even done telling you about it yet. The ever since 365 has essentially no compression lows. It features incredibly gentle adhesive for its transmitter. You can take the transmitter off when you don’t want to wear your CGM and put it right back on without having to waste the sensor or go through another warm up period. The app works with iOS and Android, even Apple Watch. You can manage your diabetes instead of your CGM with the ever since 365 learn more and get started today at Eversense cgm.com/juicebox, one year, one CGM. Let’s talk about the tandem Moby insulin pump from today’s sponsor tandem diabetes care, their newest algorithm control iq plus technology and the new tandem Moby pump offer you unique opportunities to have better control. It’s the only system with auto Bolus that helps with missed meals and preventing hyperglycemia, the only system with a dedicated sleep setting, and the only system with off or on body wear options. Tandem mobi gives you more discretion, freedom and options for how to manage your diabetes. This is their best algorithm ever, and they’d like you to check it out at tandem diabetes.com/juicebox when you get to my link, you’re going to see integrations with Dexcom sensors and a ton of other information that’s going to help you learn about tandems, tiny pump that’s big on control tandem diabetes.com/juicebox the tandem Moby system is available for people ages two and up who want an automated delivery system to help them sleep better, wake up in range and address high blood sugars with auto Bolus. It’s really

just in the. Last hour. It’s just saying, hey, stuff didn’t go quite the way we expected, and so we should probably add or subtract some points based on that. Okay, so it’s not anything bigger for the bulk of the day. I mean, it will help throughout the day. So even if you end up going lower and loop thinks you’re going to go higher, it does kind of temper its rise prediction based on the fact that you are a little bit lower than loop expected, or maybe a lot lower than loop expected. That’s really all it’s doing. It’s nothing super fancy in the code. You can some people played around with extending the window of time. It looks, I think, actually, retrospective correction is looking back the last 30 minutes, and it pushes the influence over the next 60 minutes. So it’s a very mild like bump in blood sugar over the next 60 minutes of the prediction. So nothing too big, but there is an option that’s available in the current version of loop called integral retrospective correction. It’s basically just using slightly more aggressive calculation to say, hey, you were higher than expected or lower than expected. Let’s move your blood sugar a few more points than we did with the regular version. It does help a little bit more. It can be more aggressive when my daughter was six, seven years old. This feature has been around for quite a few years, but it just got added to the main branch as an algorithm experiment, just so people know where to find it in the settings. But when I had it on when she was younger, I felt like the spikes up from, you know, just being a little kid eating food and jumping up real easy would make loop over correct when I had that feature on and ended up causing a low that wouldn’t have been there if I used regular retrospective correction. So just be careful with turning it on, and try not to mess with too many other things at once. And run it for a day or two and see how it goes. But for the most part, people appreciate the change, because the biggest issue is when you’re stuck high or stuck low, and so making this system be adjust more aggressively based on, hey, you were really low instead of high, or you’ve been high instead of going low, is helpful just to turn that up a little bit. So

when you talk about that, like, how many people do you expect are actually digging around in the code and making changes, versus the people who just kind of use it out of the out of the box, as it were, oh yeah,

changing the code. Very, very few people. That’s why it’s nice that the integral retrospective correction feature was added as an option to turn on in loop. So people can, if they want to play around with it, they can. They don’t have to do any extra coding to add it all in. So

is there a setup that you prefer for people to start with? Like, you know, we talk about like, you can turn this on or you can turn that on. Do you have like, in your mind, a checklist of like, yes, this on, no, that not on. Like, when you set it up for someone? That’s a

good question. So if we’re talking about added features, would be one thing we can look at where they kind of called Code customizations, the new build scripts that have been out for a while now add the option to say, Hey, I just want this customization by either typing in a series of numbers in your X code build, or adding a couple of phrases to your browser build, I really like the bulk of the ones that are available in the loop and learn script. And there’s actually a bunch on the loop and learn.org page under code customization that tells you, like, hey, copy and paste this block of text into the browser. Build to get you started, and you kind of tweak the ones from there, the ones that come to mind as the ones I find the most useful is allowing you to enter carbs further into the future. There was a restriction added a few years ago to limit insuring carb entries more than one hour in the future, because some people had some problems where they put a large carb entry way out, and the system just kept dosing and dosing and dosing every time their blood sugar would go up. So I understand the safety, but we talked about in episode two about fat and protein, and that impact is showing up around 90 minutes two hours. So it’s really helpful to be able to put fat and protein entries out a couple hours from now, so you don’t have to think about it later. And so there’s a customization for that that kind of reverses that safety constraint. I think that’s one of the biggest ones. There’s a few others. If people eat large meals, if they’re always eating more than a regular eating more than 100 grams, then you can there’s a warning that shows up in loop that says, hey, you’re entering a large meal. Are you sure about this? And it could be bothersome, I guess, if you ate low carb or high carb, and you were or were not getting those warnings. So you can add a warning that says, hey, 50 grams is a large meal. Double check if this is right. The default is 100 and the one you can change to you is 150 and then the other one that I really like is the changing the lollipop, the fast entry time from what is currently the default of 30 minutes. I think it set the two hours. And the customization I like to do 90 minutes. But if you’re not going to mess with the code, you just want to click a button, then the two hour absorption time for the fast entry I find more useful just because there are things like fruit and other stuff like that. That’s I think it fits better. The idea behind the 30 minute absorption time was that it was a safe way for people to enter low treatments. If they made a really short absorption time loop, would expect a rise, and then that rise would have. Because you treated with something really quick. And this actually goes into the retrospective correction. The idea was in retrospective correction wouldn’t kick in and try to over correct because it expects you to kind of jump up real fast from like a glucose tab or juice or something. But with a 30 minute absorption, it would fade super fast. So even if you took a bunch of carbs, loop, wouldn’t really have a long enough time window to see all those carbs and try to dose for them, but at least it would say, Hey, you’re going to bump up real quick, and that’s okay. I expect that, no problem, and it wouldn’t be any retrospective correction coming in, which so I appreciate the idea. I really just think loop needs a dedicated low treatment button that does that because there’s too many other use cases for fruit and maybe really quick acting candy or drinking juice, just on its own, just because you want to a better fit, is the two hour time frame. So those are the main ones I’d say are a big deal

in that scenario. The treating a low blood sugar, I would set like overrides. Instead of it correcting and targeting. I don’t know what whatever I had at targeting 85 or 90, I would set the target to more like 150 or 160 because it’s the worst thing in the world. It’s like, you get low. Finally, you get our blood sugar to come back up. And you know that a lot of that number is probably going to get eaten up by the insulin that caused the low. At least, you want some time to wait and see if that’s what’s going to happen or not. And then you’re just like, oh, we fixed it. And then all of a sudden, you’re like, why is it Bolus thing? Why? Like, no, not yet.

So yeah, we’ll get we’ll get to that here in a sec, but actually we’ll break down why that works, and when you’d use it, which activity is a great time? Or treating a low is a great time to use a higher direction range or target override. That’s really going to be probably the core of what we’re going to talk about here. But before we leave the customization. Since you brought it up, I’m checking here, and I’d say some people really find the profile save and load feature. If you miss having be able to load profiles of different basal rates and carb ratios. I don’t use that one, but I know a lot of people do. That’s a big one. The other stuff is, is all fun? There’s a live activity. It’s a geeky iOS feature that’s existed for the last two versions. Or you can create, like, a widget that you put on your home screen on your iPhone that pulls in loop data more frequently, so you don’t actually have to open the app and kind of see what it’s doing. So you can turn that on in the customization. That’s more of a new feature that I think people are are liking. I i added it just the other day for my daughter, and she thinks it’s kind of fun to look at so well, thank all right, I may get her to look at her numbers. I guess that’s great, right? So

Kenny, living through the time where that’s still fun, that’s awesome for you.

Yeah, we’ll see it’s but I’m it’s changing already. So, yeah, retrospective, correction, just again, just trying to make adjustments for what really happened versus what loop thought would happen. The last piece of the prediction element is, oh, momentum. That’s right. So momentum is kind of what it sounds like. It’s the idea that if your blood sugar is moving up quickly or moving down quickly, it’s probably not going to really slow down a whole lot. It’s going to keep doing that for at least a little while. So this piece is really influential, sometimes more influential than I would like, where, if you start going up quickly, it makes sense that the whole prediction would kind of like slide up, would aim up a little higher, because you’re accelerating from, like a steady number to a more faster rise number ends that would often, not always, but often result in loop dosing a little bit extra, which is great, right? You’re going to eat food, you go up a little faster than expected, and loop should add a little bit of insulin. And if you drop relatively quickly, you start picking up speed. As your blood sugar is dropping, it’s going to shift the whole prediction down a lot lower. And so it’s loop is far more likely to turn off the basal, which, again, is something we really want. If you’re dropping relatively quickly, you’d like the system, even if it’s just one reading, you want the system to think, oh, maybe we should turn off the basal. And so I think that’s, it’s a really big deal. It’s influential in the system. It tweaks the first like, I think it’s 30 minutes or so of the prediction fairly aggressively, depending on how fast you’re moving, and if you’re steady, it’s not really going to change the prediction elements a whole lot, because it’s going to say, Okay, we’ll just keep going flat for a while. So that’s a big piece. And I think some people need to realize that that isn’t always a setting problem. If they end up going a little bit higher, a little bit low because of the momentum. Sometimes momentum is very influential. If you have a sensor that’s kind of jumpy, or if you were exercising, or you had something like juice, or something that hits kind of fast, so sometimes you don’t have to, like, panic about, oh, I need to change all my settings because I went a little low or went a little high. Sometimes it’s just because loop over corrected or under corrected based on the speed of your blood sugar, and they just influence the prediction a lot. So don’t panic. Don’t basically what I like to tell people, how

many times do you want to see something go unlike you expected before you start thinking about settings?

Good question. I mean, I still think there’s a lot of trust. What you know is going to happen, is going to happen right layered into this like last night, Tessa is is fighting an illness, a stomach bug, so she’s needed a lot less insulin for her food, and her basal is dropped a little bit, and I’m expecting it to go back up now that she’s eating more and feeling better. At her. She got a little sticky last night, she got high, kind of Rose of, she went to sleep, kind of went up to like 171 80, and I gave significant boluses, enough that I should have expected it to start coming down within an hour or hour and a half, and it didn’t. And I because I even got impatient and gave more in less than an hour, and it just leveled off, and then kind of started to go back up again to, like, 190 so at that point, it’s either going to be, in my mind, it’s either I totally miscounted the food, which she had a really light dinner, so that probably shouldn’t be it, or it’s going to be bad pod site or basal. And the site’s relatively new. She didn’t do anything physical yesterday that would have, like, nudged it or bumped it and tweaked it. So I went with, I don’t know it’s probably the basal. Now, normally I would wait, normally I would Bolus a bunch more, wait for it to settle, and then look at her iob, like we talked about in the first episode, and adjust basal based on that. But I was tired, I wanted to go to bed, so I threw on I increased her basal a couple clicks and Bolus a little bit more, and then I set an override, which we’ll talk about here, in a second of slightly higher correction range, in case I increase the basal too much. So for me, I only waited a couple of hours, maybe three or four hours, but I would say, in general, usually at least a whole day, if not a second day, is fine as a guide. But I’m getting to the point where I can usually make adjustments within the same day, within a few hours or half a day goes by and suspect there probably needs to be something to change. And I’d say 80, 90% of the time, I’m right. There’s still times when I change a setting, it’s like, oh, well, I didn’t need to do that. Some of it, you just have to make sure, as a caregiver, especially, that you’re getting all the information. So my go to when we’re running higher, for example, or even lower, actually, is fine. I just double check, Hey, what did you actually eat? You didn’t send me a picture of it. What have you what kind of activity were you doing? Were you moving around? I didn’t know about it. And just try to eliminate those obvious variables. And then if nothing crazy comes up, then we might make a change, especially if it’s like known meals we talked about before, then I’ll make adjustments very quickly. We have a certain set of food Tesla tends to eat on Sunday, so if Sunday morning doesn’t go well by lunchtime or before, we’re changing settings where I’m checking the pod or whatever, because it’s very mild food, it’s like a smoothie, basically. It’s very easy to for us to dose for and it doesn’t cause a problem. So if there is a problem, we know we need to change something. So definitely dependent. Is that a fair answer? Yeah,

it is. I mean, that there’s no, like, rock solid, like, it’s this many hours. I also think that it’s important, you know, to kind of reiterate something you said a little while ago, that if it’s just a thing that’s happening in one scenario, if you’re always in that scenario, then fair enough. Maybe your settings need to be changed. But if that scenario only pops up every four days, there’s still consistency there. But maybe you have to make a physical adjustment to your approach instead of an adjustment to settings. If that’s not a thing that’s happening at every meal. Yeah,

and food. Food is the single largest variable, right? And we’re gonna get it wrong. Get it right, it changes that. So it’s you always kind of want to blame the food, you know, check the basal, check the pod site, then blame the food first. And if it’s not reasonable to blame the food, then you can move on to settings. But usually that’s where most of our adjustments stop. Right? Was basal. Right? Is the pod site looking okay? And where do we mess up in the food? And that’s kind of the end of the conversation, right? Make an adjustment and move on.

So I hear, okay, well, speaking of that, go ahead and move on. So that’s the basic elements

of the prediction. And now we can talk about when loop makes adjustments. There’s a section called Automated adjustments in the loop docs. I have a video on loop and learn about this as well. I think it’s called something like, how does the loop algorithm work? And it’s one of my videos where I step through this section of loop docs. I’m just going to cover it briefly, because a lot of it would be visual, and graphs are super helpful. But the four basic changes loop can make is it can decrease the insulin it gives which, by and large, is kind of intuitive. Is if your prediction says you’re going to end up lower than your range, that you’ve defined the correction range that you set in the system says, Hey, I kind of want to be in this range. We’ll talk more about what that means in a minute. But you’re oftentimes, people are picking, kind of, you know, 100 to 115 or 120 or like an 80 to 85 to 100 or 90 to 100 sort of numbers for this sort of range. And so if your prediction says, in six hours, you’re going to going to end up a little bit lower than your correction range, then it makes sense. The only way to get your blood sugar up is to turn down the amount of insulin you’re getting. So it turns down your basal pretty obvious. The next one is increasing your basal rate. If you’re using Temp Basal mode, or if it’s auto Bolus, we’re going to give insulin automatically. The initial description of that is an oversimplified version, is if your blood sugar is current, blood sugar is higher than your correction range, and your prediction is all. Higher than your correction range, and you’re going to end up higher than your correction range. It’s all high. Then obviously loop says you should have insulin, and so it will dose that for you that’s allowed to do that, and we’ve talked about it before, where there’s automatic Bolus, which does 40% of whatever that recommended amount is to get you from where you’re predicted to be to where your correction range is. And then there’s the glucose based partial application, gbpa. Fancy version of Audible is it just says, Hey, if you’re really high, if you’re higher than your correction range substantially, then we’re going to increase the percentage that’s going to get you to your correction range faster. That’s all. It’s just how much it’s going to give so again, loop says you might need a unit to move you from where you were predicted to be to where you want to be, and it’s only going to give, you know, a little less than half of that 40% so just on its own. And then in next five minutes, it’ll do it again and again and again. But if you were to check the Bolus button, that orange double arrow in lube, you’d see the full amount and say, hey, yeah, you can give a unit and it will, you know, let you dose it. Otherwise, automatically, it’s just going to do a portion of that. So pretty simple, the zero basal rate, or turning off basal altogether, is the third option, and that’s if any part of your prediction, whether it’s the end or like the near term, or somewhere in the middle, if the prediction line goes under your glucose safety limit. That’s kind of like a like a hard stop, the hard ceiling for your blood sugar. So if you’re predicted at any point to go below that line, that number, then the system just says, All right, we’re going to turn off the basal altogether. That’s the most we can do to put the brakes on this thing and it turns it off. So that can be a little frustrating for some people, when they’re using these long absorption times and doing fat and protein like we discussed, where you start to kind of dip down a little bit, and that momentum kind of makes a lower inflection point in the prediction where it’s dipping down low, and so then it turns off the basal but that’s also a really cool feature, because you the fat and protein impact of these longer meals, or pasta or something like that. It’s spread out and can be a little unpredictable. So sometimes any movement down can force the basal off, and that’s okay, just know that’s that’s happening, and no big deal. So those three are pretty easy to understand. When you’re high, you need more insulin wants to give you more. When you’re a little bit low, we’re gonna end up a little bit lower than desired. It’ll pull back your basal. And when you’re going to go lower than your glucose safety limit, then it just turns it off. The more useful example that you see in loop Docs is something called resume basal rate. When does loop decide to just leave the basal rate on and run life as normal? And some of these you only see more frequently at night. But if you’re the oversimplified version is, if your blood sugar and the whole prediction are all kind of hanging out inside your correction range, let’s say 100 to 110 then Luke just says, okay, like we’re good. We’re going to land in the safe zone. And our whole predictions in the safe zone. So cool. We’ll just turn on the basal and, you know, just run do nothing, which is great. Sometimes it seems like that doesn’t happen very often, but that’s what it’s going to do. But the other interesting part about when loop chooses to just turn on the basal rate and essentially do nothing is a situation where your blood sugar might be in or maybe slightly above your correction range, but your prediction goes below your correction range. So let’s say you’re starting at like 120 your correction range is 100 to 110 and you’re like, we entered fat and protein and stuff, so you’re going to see a dip in your prediction value. Just say, Oh well, the prediction is going to dip down to like 80. Nothing crazy. Not going to turn it off or anything. But then it very quickly rises back up again because it’s waiting for the rest of that fat and protein to show up. And so let’s say your eventual blood sugar is like 150 so you you do need some insulin to avoid going high later. And in that situation, you might even check the Bolus button and loop and it’ll say, Yeah, sure. You need, like, a unit. That’s cool. You could deliver it if you wanted to. It’ll give you a warning on the Bolus screen that says, hey, like, you could give this unit, but your prediction says you’re going to go below your your range. You said you wanted to kind of stay in just heads up, like, be careful. But that also means that same warning means that automatically, loop won’t choose to give that insulin. So even though your prediction loops even recommending a Bolus, the system won’t give the insulin for you. It’s just going to say, Cool, yeah, you you could use a unit, and it wouldn’t send you below your safety limit. But I the system are not going to be responsible for create, making this prediction come true and pushing you below your safety your range you want to be in. So it won’t give any insulin. Those are situations where people can sometimes get frustrated and be like, Why does loop predict or recommend a Bolus, but it’s not giving anything. And that’s kind of that, that thing where the system is going to air on the side of caution, but if you checked for a Bolus and you really wanted to give it, you can go ahead and give it.

I think my most frequent text sent during high blood sugars is suggested. That’s all it says, just Yeah. But. Ever suggest that just do it? Yes, yeah. And, I mean, listen, I understand why the it’s not just Luke, by the way, I recall on Omnipod five the same thing, you know, and I’m sure on others as well. So I get it, but that’s where you have to come in and say, I mean, I’ve lived through this before. I know what’s gonna happen here, like this thing thinks it’s coming down, it’s not coming down. There’s not enough basal to make it come down, one way or the other. I need to get this insulin in somehow. I would also say that in some of those stuck situations, I’m a fan of pushing, just pushing the basal and but there are times that I look at all the insulin on board, and I factor in how long the food’s been in, or you know what it’s doing, and there’s no basal, and I think to myself, I know, if I just put the basal back on here, with all these other things happening, blood sugar is going to start falling immediately. When it happens, it almost feels like it happens too quickly. It feels like you’re balancing on a line, and you’re never gonna fall, unless somebody blows on you, and then, like, for sin, you tumble right off. You put that basal on, and you get a diagonal down arrow in, like, 510, minutes. Just crazy, yeah, but I don’t know. Like, there are times I think, like, Am I seeing what I’m seeing, or have I just waited so long that this was about to fall anyway? And now it feels I can never tell, but, yeah,

that would peak is hitting or something, but it always feels like, you know, you’re you did something, and all of a sudden it changes in five or 10 minutes or 15 minutes, I

swear to you, I don’t know. I don’t know if it’s like, I’m like, is it the thing I just did, or was this gonna happen anyway? And you know, she doesn’t get low afterwards, so I guess whatever. But yeah,

it works out. I have another scenario to talk through. But I think if we take a look at this discussion here, where you know you’re gonna probably not, you could be high, or you could just be, like, a little higher than your range, and your prediction drops in the middle somewhere. It’s a good time to talk about something you could do if you knew this was going to happen if you knew the rides can become a little more soon, a little sooner than than loop expected, you could do one of two things, right? You could take the recommendation which is a good place to start if you want to kind of be hands off a little bit more, you could set an override. So we’ll talk about overrides for a second. Overrides allow you to temporarily change the sort of settings that loop is using. And the main thing I use overrides for is just simply it says, In the override screen, when you set one up in the heart icon in the main screen, it calls it target, but the target is the same thing as correction range. I don’t know why the text is inconsistent, but if I use the word target or correction range, they’re interchangeable. But essentially, what we’ll do is we’ll create an override that maybe has a lower target, like a target, say test says gluco safety limit is 70. I have one called Target 71 just remember what it does and all it does that slides that correction range down to 71 for like an hour. What that does, in the case we described where, like, you’re just dipping down to like 80 and coming back up, is it says it moves that that line, it moves the correction range. Now your entire blood sugar prediction is above this correction range, and so now it’s in a situation that we talked about earlier, which is, oh, I can give insulin automatically. It’s, it’s cool, everything’s above the range. I can go ahead and dose automatically, but less aggressively than I would if I just hit the Bolus button and gave it. So I’ll do that for certain meals. I’ll do a going into a meal. In case the loop aims a little bit lower and and if she’s kind of coming down into a meal, it can be more aggressive in giving insulin sooner. So she pops if She slides down, she has PE before she eats lunch. And so if she’s diving down, the momentum of her blood sugar drop will usually tell loop not to give any insulin, or maybe give less when she at times she gets the cafeteria. So if I if I just pop on the target 71 for an hour, when I happen to notice it, it’s the nice thing about running it for an hour is if I notice it while she’s dropping, or I notice it right around lunchtime, I can put it on or she can do it. I’m trying to teach Tessa to do this too. Is that if she does dip down, and then once she starts eating, starts to level out edge. Let’s see she levels out at 75 Well, her normal correction range is like 85 or 87 so loop wouldn’t be allowed to give any insulin automatically, and Tessa’s not going to check for a Bolus after she’s eating and talking with her friends and doing her thing. So if we put on an override that bumps the range all the way down to like 71 once she hits 75 and levels out, at least loop can start giving some of the insulin lower numbers sooner. And it’s totally appropriate, because loops being safe, saying no, she’s dropping into this meal. So I don’t want to give anything, but I know she’s walking across campus and in line and getting her food, she’s not running anymore in PE by time she slows down then eats, the system can start to deliver at a lower number as she starts to come up, so at least we’re not totally late to giving insulin sooner. So that’s a really neat tool. When you think about when loop is allowed to give insulin automatically, versus not the other. Your scenario would be, let’s say you start at this like lower number, like Tesla was at 71 and you’re going to go, your prediction is set to go higher than your correction range, but you’re starting under your correction range. So loop might suggest some insulin, but in most cases, it won’t suggest a whole lot. And automatically, the system is not allowed to give anything until your blood sugar gets up into your range. Well, that could be 1520 minutes after your maybe 30 minutes after you’ve already entered the food. And so now you’re really late to the game getting insulin, and you’re the food’s got a head start, like too big of a head start, so you start shooting up well past your correction range, and the loop starts finally dosing. So that’s why it’s nice to be able to lower that number and but conversely, like we discussed a little bit ago, and when you’re treating a low or going to be active or something like that, you kind of create your own activity mode, if you will, in loop. And I create a couple of target based overrides to just change the correction range to, like 150 I ended up just recently creating a 180 and, like a 220 which initially was like, I don’t want Tesla’s blood sugar to be that high, but it is serving a purpose, where I put those on the essentially, what you’re telling loop is, even if you predict a rise loop, even if you say you’re going to go to, like, 250 your only thing you can do is turn on the basal. That’s the most help you can give. And it can’t dose until blood sugar gets to and the prediction, but I can’t the current blood sugar has to get to or above that number. So if I set it at 150 if she hits 145 and the prediction says she’s going to go to 300 the most loops doing is turning on the basal. It’s not dosing at all, which may be going into activity or treating a low during activity. That’s really what you want, because she might level out real quick and kind of not need any extra insulin, even though loop thinks that she does. So we’re kind of moving the line. Say, Luke, when can you engage fully? When can you actually add insulin? Is super helpful. And then the other reason why I created a higher one like the 220 recently, is if that eventual number, that Prediction number, sometimes I don’t want the basal on at all, and I can’t, I don’t want to bother Tessa to say, turn your basal off. So if I set a really high number, higher than that six hour prediction is currently set, then loop will say, Oh, not only can I not give insulin until I hit like 220 but the prediction is and then, you know, we’re going to end up at 120 but now the target’s being changed at 220 well now I need to turn off the basal. The only way I can get from 120 to 220 is just to turn it off. And so I had to create a couple of really high ones this year just to make sure that I get the basal off before PE, when she’s entering PE, before lunch, because sometimes I loop would just leave the basal on, which is great. It’s not adding any more insulin, but I need it off off. So we got to have a higher target range for, like, two hours. So those that’s why I’m using, that’s how I’m using the overheads. Mostly it’s just target based. We’re moving or moving the line. I

think those overrides are awesome. I don’t know if everybody uses them. And actually, even while you’re talking, I’m wondering, I mean, the people that are here to, like, find out more about how to use it, obviously they’re thrilled to hear it, but I worry for the people who are like I just thought this thing worked better, and I didn’t really want to get into all this. They might worry that it’s too in need of adjustment. But I don’t find it to be that way. I think if you have good settings, and you understand the impacts of your food, and you you know, you pre bullish your meals, I think loop works like, you know, out of the box, you know really well, but these overrides once you start seeing repeating issues, right? Or things where, like, you know, this happens here, you know, off top of my head, like, you know, periods is a great example, right? You hear people talk all the time about, like, oh, well, can the algorithm? Either talk about all different kinds of algorithms, like, I have shifts in my activity, like, I’m very active during the week, and then suddenly I’m sedentary, or vice versa, and they just want the algorithm just magically, no, and it just never going to work that way, not anytime soon, at the very least. So, you know, awesome to be able to say, I know insulin needs have just gone down. I’m just going to set an override. I’m going to set a different target and a different, you know, whatever basal, you know, settings, and I’m gonna let that override run for a while during an illness or during the next two days or the next three hours, or it’s awesome. I think it’s a fantastic feature set inside of loop. I also, you know, wanted to ask you not to pivot too hard. But do you use the pre meal button in loop ever? I

don’t like it at all. Actually, the downside is, when we change used to be used to enter the number into most of the settings, like the pre meal, and they changed it so that it’s just like a scroll wheel to pick the numbers you want. So there’s no way to clear it out if you set it. So every time I’ve actually done this where I actually deleted loop altogether and started from scratch just because I wanted the pre meal to not work. So when we set up, when I walk someone through setting up loop, I say, just don’t, like, skip that screen, don’t enter anything in pre meal, and move on. And what will happen is that pre meal button will stay gray and disabled, so you can’t turn it on. And the reason why, well, here’s how it functions. It’s a 60 minute run time, and it’s supposed to be some kind of lower target range. And so it will. Help in the situation. And we discuss, or should we turn it on? It’ll start to dose at a lower number. The annoying part is that it turns off once you enter food. It’s the idea, I think was like, Oh, it was like a little tiny Pre Bolus, you know, like, aim a little bit lower as I approach a meal. But that’s just going to give you, like, tiny amounts of insulin to nudge your blood sugar down from prediction of 100 to prediction of 75 not a big adjustment. So it’s really not effective for that use case, in my opinion. But as soon as you enter food, it turns off. It’s like, oh, well, now you’re eating. So now we turn off where? Whereas the 60 minute target, lower target ice set runs for 60 minutes no matter what, if you use the pre meal button after you enter food, then it would do the same thing you could enter the food, hit the pre meal button, and then it would stay on for 60 minutes. And that would effectively be the same, same thing, but I just avoid using it. It is a convenient button. I really wish it wasn’t like you could set whatever override you wanted to that pre meal icon would be cool and it behave however you wanted. But I just, I try not to enter it at all, and don’t use it. But it does work well if you’re going to do it after you eat your food, not as a pre meal, but as a post meal.

Your answer really is interesting to me, because I had a similar I thought, where I was like, this is going to be awesome, and then it didn’t end up being awesome. So yeah,

yeah, if the pre meal button Bolus, the set amount of insulin or something, you know, that would be cool. But the other thing is that it’s so easily bumped, it can turn off any existing overrides. So if I have a target 71 on for Tessa, and she bumps it on her watch, or bumps it in the app, it turns off whatever overrides running, and it runs that, which is, again, super annoying. I’ve had it happen on the watch a few times, and that’s the reason. Main reason I don’t use it is I’d set like a some kind of different override, and all of a sudden I see it’s off because she bumped the pre meal on her watch. You know, there’s

a use in there, just, I don’t know, it just needs to happen differently. I think, yeah, I agree. I see the idea of, like, let’s be more aggressive now. We’re gonna eat in 20 minutes. We’re gonna eat an hour. Like, I’m 120 I’d love to be a drifting 80 when I get to the food, or something like that. But it just didn’t, didn’t end up doing that. But anyway,

yeah, I encourage people sometimes to pre meal like or Pre Bolus like you would with any other system, is you can just give insulin approaching a meal without entering carbs, especially if you kind of generally have an idea of how much you’ll need, and you can just give it loop will predict you’re going to go super low, because it’s like, well, you don’t have any food here to hold up all this insulin, but you know you’re going to enter it eventually. And so I think people freak out and say, What? Loop won’t let me Bolus. I was like, well, just, just throw in a couple units, and you know, then when you get to the food, you can answer it, and loop will give you, it’ll adjust what it thinks based on how much insulin is left from that Bolus and the food you’re answering. So I like to give people permission to defy the system a little bit and give too much. I hope people on the podcast don’t, aren’t too shy to doing that, like you have to do that on new pod five or random or whatever occasionally as well. So yeah, but you can Pre Bolus. It’s no big deal

right now. There’s definitely times when the system breaches its limits and your needs are still there. So

yeah, you know stuff that the system doesn’t. So yeah, right. It’s limits.

About making a decision is what I was gonna is what I meant. But yeah, it just it gets to the point where it’s like, look, I think I’m doing the right thing, so I’m not gonna do anything else. If you know something that I don’t know, and we don’t have function to explain it to the system, like, then you’re gonna have to make an adjustment on your

own, right? Yeah, and sometimes that means being creative on how you express that. We’ll talk about exercise in a later episode, and that’s where you can kind of tell loop what’s going to happen if you feel like it. Otherwise, you can just use these overrides to get around it. The other thing overrides do is you can use percentage changes. The percentage changes are it modifies all of your insulin needs by a certain percentage. So if you do 110% then I’ll give you 10% more basal, 10% more aggressive ISF, and 10% more aggressive carb ratio. And those can be helpful. You just have to be real careful with those. I think I’ve come to avoiding using those during the day, because what happens is, at least for most people, I see is the scale doesn’t always work out, like sometimes it does, but sometimes 10% more aggressive carb ratio is way too much than just a 10% nudge in basal, for example, for like a little kid, I find it not super helpful. Like the balance doesn’t work out. And when you go back and change your carb ratios, or go back and change your basal, Luke’s gonna say that one segment where you ran 110% for a little while also adjust. So let’s say you’re changing your carb ratio from 15 to 12. Well, at that point of the day, loops. Gonna say, Well, when you enter this food, it was 10% stronger than 15. Now it’s 10% stronger than 12. So you can’t go back and fiddle with your settings and try to find the right setting, because you had an override on for part of the day. So I don’t like percentage based overrides very often. I will use them most commonly when Tessa is asleep and she’s across the house or she’s not with me. Maybe she’s sleeping somewhere else at a friend’s house, or whatever, and I can see her basal needs have changed either up or down. So I’ll take a guess at how much. Need to dial basal back or increase basal using a percentage based override. But I try to make sure it ends by the time she wakes up, so that she’s not entering food with those changes. And then I’ll text her and say, Hey, I need you to change your basal to whatever. Sometimes, if I’m sleeping in the same house and she’s just too far, I don’t want to get out of bed and put my feet on the cold floor. I’ll grab my phone and do a remote override for a percentage change. So that’s that’s how I try to use them. You can use percentage based overrides during the day. It just gets a little tricky. Let me

say that I the place I’ve run into trouble with that is like, say, you try to use a very aggressive temp override to break a high blood sugar, and then somebody eats. And you told the thing, like, Let’s go 150% of your normal power, and then all of a sudden, you Bolus for carbs, and it’s giving you 150% of your carb ratio. That’s that’s the problem? Yeah, yeah. That’s not great. The remote thing through night Scout to change this stuff. Awesome. Like, just super

helpful. Yeah, yeah. I just, but you can also get yourself in trouble in that same scenario where it’s like, oh, we’ll just need to, just need a little more basal right now, maybe we missed on the fat and protein. I don’t want to bug test it ends from our carbs. And so the thought would be, hey, let’s put on like, 120 130 150% override for like an hour. But then she does something like, oh, eat something and and now you’re, you’re really like, coming down with a vengeance. So I’m

a much bigger fan of the remote overrides when, like you said, when it’s not possible that something else is going to happen in that time, like, you know, overnight, like, all the time. I’m, I’m like, Look, I love her blood sugar here, but she’s just riding a little too low. So I just want to take a little bit of the basal away, for example, like, just so it kind of rises up a little bit awesome for that. You know, 110 blood sugar, super sticky. I wish it was 90. A little aggressive. There, she’s asleep. Nothing’s gonna happen. She’s not gonna be bolusing. It’s awesome. There. I do hear people, by the way, say, especially adults will hear this and think, you cannot go touching somebody’s insulin without them knowing. I agree. But Kenny’s point is he made earlier too. Is like, sometimes kids just don’t look again. So even if you text and say, hey, look, I’ve made your basal more aggressive, or I’ve done this, like, be careful, it kind of falls out of their head sometimes. So that’s not a great protection either. In the end, they need to get what they expect is going to happen. You know, you can’t go changing the game and telling them and not telling them, that’s not cool, right? And adults seem to know that adults living with type one diabetes seem to reactionarily, know that, maybe more intrinsically than a parents who are helping kids with diabetes. And I know this has nothing to do with loop, but I’ll add this here because I think it’s important. I’ve talked to enough adults with type one. They’ll tell you, like, when somebody goes to touch their settings, like, you know, like, I’ve had adults say, like, look, I was the doctor’s office. And Jenny said it to me recently. She’s like, if the doctor ever said to me, give me your controller, I’ll change your settings. She goes, I wouldn’t let that happen. She’s like, that’s me. And she started to explain that, and I and her explanation, I don’t want to bastardize here. There’s a thing that happens with people with type one like that insulin is affecting them in a way. You shouldn’t get to say what’s going to happen to it, unless they agree to it. And anyway, sometimes the remote stuff can make that a little tricky. I think,

yeah, definitely. And that’s why I like starting with just target base changes. It’s you’re not modifying settings really. You’re just kind of changing when the system is going to respond. In case you made the wrong decision, it’s easy to back out of the other thing, we’ll use targets for that I find, especially parents. If you’re not confident in your basal settings, like last night, I increased test is basal a fair amount, point one, five, all at once, and I wasn’t sure it was going to be wasn’t going to be too much, so I set an override that ran for the whole night. It changed her correction range from 87 to whatever, just like 95 to 100 to 110 just a little bit higher than normal, just in case I was wrong. Case I put too much basal on and I didn’t know. So if your confidence is shaky and you’re worried about lows, and just nudging the correction range up just 1015 points can make a really big difference. Because if she if I did increase the basal too much, she probably would have been running under that number of 100 she probably would have been in the 80s or 90s, whereas, if I left it as a correction range in the 80s, she might have been in the 70s, or maybe even a little bit lower if I went to overboard. So that’s helpful. And the first time I created that slightly higher correction range was when she had her first sleepover while she was looping with my sister. I was like, you know, I like, everything is probably fine, but let’s just, let’s give a little more room for loop to catch a low and I’m comfortable with her running at 110 Right? Or if she’s running a little bit higher because her basal is off, she’ll be at like 120 but not like 150 so using a slightly higher correction range when you’re less confident in your settings is a good thing to use, and it’s great for sleepovers or just for anything that you just are not confident in. You want to let the system play around. I really encourage. Rich people to do that. When they start looping the first day they first night, they run it. I think it works best if they just run closed loop and set a correction range that’s fairly wide, like maybe 100 to 130 or something like that, or 140 somewhere in that range. Or it’s not super high, but they can let the system play and move and adjust, but give them room in case they have their basal too high or something like that. So correction ranges are pretty powerful tools.

Is Tesla’s range wide? Or is it very tight, like, is her range 89 to 89

Yeah, perfect. I don’t like the one number or really tight ranges, because I feel like not. You know, the predictions are just models of what should happen, and they move enough that if the prediction kind of moves to 90 now, loop wants to, like, maybe add some insulin. If it moves to 87 it wants to take some away. I feel like loop is, like, gyrating too much. It’s making too small an adjustment. Plus or minus, you don’t really get a good sense of your settings. It’s trying to hit this, like magical one number. It’s really difficult to do. So I like to create at least a range of some kind. So at night, sometimes down as low as a five point range, but typically like kind of a five to seven or eight point range. And then during the day, it’s more like a 15 point range. So right now it’s like 87 to 93 or 95 I think, at night, and then during the day, she’s running an 87 to 100 or some people, I’ll suggest, like a 90 to 110 or something like that. So when there’s more variability in the day, I like to give a little bit more range the system to play with, and not overreact either direction. That’s kind of the way I approach it. And then along those lines, is because the correction range effects of that prediction interacts with the correction range for the full six hours of that prediction. I find it’s really tricky to get the system to do what you want it to do. If you set a bunch of correction ranges, people like to set, oh, I’m going to set, you know, a correction range that’s higher right a PE time or whatever, it doesn’t really do what you want it to do, because loop is is looking six hours ahead and starts aiming for the correction range at six hours ahead of right now. So that means six hours before PE loop is aiming for the 150 which, you know, in theory, is kind of nice, but ends up not really doing what you want. I tend to tell people once you just start with either one or two ranges. I like to do, if you want a tighter range at night, create a night range that starts at midnight. That means that starting at 6pm so starting at dinner, it’s sort of aiming at this lower number and then have it run until 12 one, two o’clock, somewhere in there, because six hours before, let’s say two o’clock is 8am from basically 6pm the night before, all the way through to 8am loop is aiming at that lower range for Tessa, and starting at 8am It starts aiming at the higher range that we have set. Now it does change how the system reacts, like we discussed about what, what number the system can automatically dose if your prediction is dipping and those kinds of things. It does mean that she’s the system slightly more responsive. It’s reacting at like a lower blood sugar number from like breakfast until like lunchtime, yeah, which I find useful. Most people struggle with breakfast, but then by the time lunch comes around, we’re still aiming for the higher numbers. So just pick one to two ranges, midnight to noon, one two somewhere in there, and then starting from there to midnight, and that will usually get you kind of a nighttime slash mildly more aggressive day, morning to kind of a nicer, wider range in the afternoon, until about dinner time, it tends to work out pretty well. So figure out where you want to be. Some people just like to have a higher nighttime. That’s fine. Then adjust it up. It won’t make a big difference. Try not to make them radically different. But, uh, yeah, one range or two ranges is enough. And then use overrides for more specific times, like PE, it just gets you. The override takes over the entire correction ranges. Oh, okay, well now I’m not looking six hours ahead. I’m looking right now. What are we doing right now with this override? Well, it’s on So

Ken, I’m gonna go back in a series Full of the thoughtful things that you said. I’m gonna go back and listen to this part again myself, because I think you might have just like opened up my mind a little bit on the correction range thing that was really awesome. Thank you.

Yeah, it’s more influential than I tend to think. And it was kind of hard to wrap your head around for a while, especially because you have to think about it in kind of six hour chunks. You can check out, I’m gonna do that that that’s really awesome. Listen to it. Check out the loop, docs page on automated adjustments, or you can watch video, you know, keep an eye on my my website, YouTube channel, Fox and the loop house. I’ll probably try to do some smaller or updated segments on this topic, because it’s really useful for people to right. Just know how to apply the overrides. And then the last thing I’ll leave you with, as I think about it, is sometimes, because you have remote access to this stuff, I find some parents tend to obsess over looking at the numbers. And it might set, you know, a target six, a millimolar, or target seven millimolar, or target, you know, 121, 3141, 50. And they’re constantly changing because you’re like, Oh, I think loops gonna gonna do this, and I don’t want it to or they’re gonna come up on PE and do that, try to. Not let this it gives you the opportunity to drive yourself crazy and just set an override and let it run, and if you need to cancel it, cancel it. But try not to play around with setting so many overrides that you start driving yourself crazy. But you also need to make sure you have a few of these overrides pre built that way. If you’re going to be setting things remotely as a parent, they’re available in your list if you don’t make the override, if I don’t set create a one target, 150 and a target 180 they’re not there for me to pick remotely. I could they’ll test it and make one up. But again, we’re trying to do this to minimize diabetes interactions, so it just needs to be made. So go ahead and make all the overrides you think you might need. Put them in the order, like the target based ones on the top, so you don’t accidentally bump the percentage changes, and then you’re going to go

stop setting up an impossible parlay. Is what you’re talking Yes, yes,

yeah. It’s been a couple of clients of mine. We’ve had to work on that where it’s like, okay, you’re setting overrides every like, 15 minutes or so. Like, just pick one and let it go for a while and try not to look at the numbers for a little while. Like, it’s it’s good, but you can the remote accessibility makes it so that you can obsess over the wrong things, right?

So Kenny, tell people again where to find you. Box in

the loop, house.com, I’ll also be on Facebook, YouTube, Instagram. Try to do more educational videos. If you want to see some of the video content that’s already been created, hop over to loop and learn. Org and the YouTube page that goes with that. There’s a series on there that has has me listed as well. But yeah, if you want to come check me out and see what the courses or classes I’m offering, I’m going to open those up a couple times a year. You can find all the updates to that on my website, and love to see you there. Awesome.

And we’re going to do more of these together. Is that right? Yeah,

we’ll have probably another series of three or four. We can go over, maybe a Q and A episode, if people have questions after these ones come out, awesome. See where it goes. Listen,

you know, because my camera’s on that I look super handsome today, and I have, I really do, this is my best day this week, and I have an event, so I’m gonna go, because I don’t want to get sleepy and then people not see me in my glory, because I think I’m really like, I’m popping today. Kenny, I don’t know if you look fantastic. I can tell. Yeah, thank you. I didn’t want to take want to take this away you. You as well, look awesome. But I’m just, I’m looking at myself, and I’m thinking, if this angle is how the whole world saw me, I could probably be a model take a picture. It just, it’s unfair, because if I start turning my head one way or the other, it all goes away. I’ve been looking at you and me for the last hour, and like five times I thought this is a good day for me, because I don’t have that many of them. Ken,

I just want to be clear about that. I want to say it didn’t want to distract from, yeah, you

know, you didn’t want to you don’t want to come off like you’re hitting on me. I understand. Okay, well, thank you so much for doing this, man. I really do

appreciate it. You got it? You

Hello friends and welcome to part one of my Omni pod five series with Carrie Birgit. Before we get started today with part one of this three part series, I’d like to tell you that insolate has paid the host of this podcast that’s me Scott Benner and my guests Carrie Berg get a fee to create this content. Carrie is an omni pod ambassador with an ongoing commercial relationship with insolate. This podcast provides general information discussions about health and related subjects. This information the other content provided in this podcast or in any linked materials are not intended and should not be construed as medical advice. Nor is the information a substitute for professional medical expertise or treatment. Never disregard professional medical advice or delay seeking it because of something that you’ve heard in this podcast or read in any length materials. The opinions and views expressed on this podcast and website have no relation to those of any academic hospital, health practice or other institution. Please speak with your healthcare team if you or any person has a medical concern. And before making any changes to your diabetes management, you can always consult the Omnipod five automated insulin delivery system User Guide for more information. In short, nothing new here on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making any changes to your health care plan. You are about to listen to on the pod five pro tip overview. The second episode is on the pod five pro tip settings. And the third episode is on the pod five pro tip connectivity. Please listen to them in order as I think that is how they’ll best serve you. If you’re listening in an audio app, these three episodes went up at the same time. So there’ll be right next to each other, or you can find them at juicebox podcast.com, forward slash Omni pod five.

My name is Carrie forget, I am a nurse and specialty nurse and diabetes care. I work at the Barbara Davis Center, which is in a diabetes Center in Aurora, Colorado. It’s part of the University of Colorado Anschutz Medical Campus. And I love my job, I love working with families who have kids with type one diabetes, because I get to help them figure out how to make the most of their lives and still have a great life, even though they’re having to deal with type one diabetes, which can be really challenging. You don’t have type one, is

that correct? That is true. I do not have type one, how did you make it to this kind of work?

My background as a nurse actually did not bring like prepare me at all for type one diabetes care. But when I first I’ve been a nurse for 17 years, and when I first started nursing, I worked in the hospital. And I didn’t love it because it was I didn’t get to know people enough I was it was too much just put a bandaid on things and not really get to know or help or be a part of anybody’s life. And so then I started working as a public health nurse where I would did a home visiting program for young mothers. And so I would go into their homes and support them throughout their pregnancy with health education. And I got to work with them until their child was two years old. So I did that for about seven years. And while I really loved that, too, I was kind of like, well, I think I want something that’s a little bit more clinical, but not back in the hospital. And I had a friend from nursing school who had type one diabetes. And I learned a lot about it from her and was just amazed at how how smart she was and how hard she had to work to manage her diabetes, but also how much self care and commitment it took. And so then when I was looking for another career, the Barbara Davis Center came up and, and I was like, you know, I think I think this is this is the place for me because, you know, I don’t want a job where I’m the, quote nurse who’s, you know, in charge, and I just tell people what to do No, like I want I want, I wanted a place where I could connect with people and come alongside them and support them and be a team

to help him because he gets to make a real tangible difference in someone’s life. Right? It’s not, it’s not like emergent care where you just kind of run in and do what you got to do with leave. But you get to know people and see where their struggles and their strengths are. And then and then and lift them up a little bit, which I think is what we’re going to be able to do here with these episodes. So I appreciate you very much taking the time to let us know about yourself. We basically have our topics broken down into a couple of headlines right. So the first one we have here is what do we need to know before we get started with the on the pod five. And I want to ask you first, how many families have you been involved with so far with on the pod five

Well, I’ve been working with Omnipod, five for over two years now, because I got to work on the clinical trial, which was the study that you do before the device is commercially approved. So I had about 30 families that were in the child from our center, and I was the primary nurse for that study. So I got to train them on the device and teach them how to use it. And then we got to work together to figure out how to use it best. So that’s been for the last two years. And then now that the device is commercially available, we’re rolling it out in our clinical practice as well. And we’ve had over 250 new prescriptions for it, and just these last couple months, and then over 80 have started the system. So there’s been a lot of a lot of kids and families that I’ve worked with on the system,

that’s perfect. So you’ve got to, you’ve got a couple of years worth of knowledge that we can pull from here, it’s going to be terrific. We’re gonna start simply getting things laid out, right. And person wants to start with Omni pod five, what do they need? They need on the pod five? That’s pretty obvious. But they’re also going to need a Dexcom G six CGM. Is that correct?

That is true. Yeah, the Omnipod. Five works with the Dexcom G six, and you do need that Dexcom G six in order to use the system. In the automated mode,

it’s important to remember that these are separate items. You don’t get a Omni pod five prescription that ends up bringing you a Dexcom. So if you have the G six, all you need is the Omni pod five, if you have neither, then you’re going to need to talk to your health care provider about getting a prescription for each. Yes,

very important point. Okay. The other important point about that is that the Dexcom G six is it really is a separate device in the fact that you need to use it on your own cell phone with the G six mobile app, there is no way to download the G six mobile app on the Omni pod five controller. So that’s also an important piece to to understand and that you can’t use the Dexcom receiver, either if you’re using Omnipod, five, right.

So if you’re already a Dexcom G six user, and you’re using Dex comms receiver, you’re going to need to move your Dexcom on to an app on your phone before you can use on the pod five with it.

Yes, that’s correct. The G six mobile app to be specific. Yeah,

thank you. Now you could use on the pod five, right without the G six, but you would just be using it as a just a regular insulin pump. It wouldn’t be an automated system. That is correct. Yes. Having said that, Carrie, I think if you’re gonna do this, like get all the stuff because, you know, right?

Yes, absolutely. If you’re gonna get Omnipod, five, use it in automated mode, that will definitely be the best way to go. Yeah.

Okay. So does that mean that you can’t use Omnipod? Five, if you don’t have a smartphone? Well?

Well, the short answer is yes. But let me give you the more complicated trail of that. So you do need to have the Dexcom G six mobile app in order to operate the Dexcom G SIX sensor. And as I mentioned before, you cannot use automated mode without the sensor. But if you had the G six mobile app on one smartphone, and the sensor was all up and running, and you had already connected it to your controller, the active sensor session, if you already have the Dexcom transmitter in the Omnipod, five, app, either on the controller or your own phone, then once that’s up and going you don’t need the G six mobile app within range in order for the pod five to operate in automated mode, right?

Well, yeah, we’re gonna go over that probably a number of times. So one of the one of the great things about the system is that it’s, it’s self contained within the things that are on your body. So the the G six, we’ll talk to the Omni pod five, without the controller for the, for the, for the on the pod five there or without your cell phone, those things could be nowhere near you. And the algorithm can run because the algorithm actually lives, like right on the circuit board inside of the on the pod five.

Right, the algorithm is directly inside the pod. So the pod itself that is on your body, each one of those pods has the automated insulin delivery algorithm on it. So the Dexcom actually sends the glucose data directly to the pod. And then that pod uses that CGM information from the Dexcom directly to calculate how much insulin to give. So yes, you do not have to have the controller, the Omnipod five controller nearby in order for the automated insulin delivery to

occur, okay, so we have our stuff, we got it. We got our gadgets and gizmos on our websites and we know what we’re doing and we gotta get started right. So some people are going to train in person with a CDE or a nurse practitioner, whatever they have available to them. Even I guess, I’m guessing through people Then on the pod provides, is that true?

Yeah, there. I mean, it depends on your clinic, there’s a variety of ways that clinics might go about training their patients on insulin pumps in general, a lot of clinics do use the industry trainers. So they’ll have a trainer from Omni pod that covers their clinic. And that would be the trainer that they would gotcha, they would work with you.

Now there’s also like an E learning situation, right? Where you can go online and take a walk through, isn’t that great? I don’t have a job, carry, I don’t have a job. So I don’t get to do things the way other people do. But I hear a lot of people train online with stuff. But that, but I did take the online training from the upon five, and I’m assuming that’s available to other people as well.

Yeah, it’s available to everyone who’s the current Omni Potter, the way it’s designed, actually, is that if you are a current Omni Potter, and your specific healthcare provider has like, given the stamp of approval that they’re good with their patients self starting, then when you get your intro kit from the pharmacy, inside that kit includes a QR code. And it’s just not very complicated, just omnipod.com backslash setup, you go there, and it’ll walk you through the steps of setting up the controller. And then from there, you can access the elearning modules, which will walk you through how the system works, how to program it. And, you know, walk you through the steps of starting it up, right.

So let’s talk about that a little bit. The, I think, the couple of the key words, you and I are going to hit over and over again. One of them’s going to be settings, whether this means your Basal profile, your insulin to carb ratio for your meals, your correction ratio, insulin sensitivity, all these things that I mean, if we’re being honest, I guess a number of people don’t even understand they, they go with whatever set up for them. And then whatever happens happens. But on this automated system, I think the easiest way to consider this is that if your settings aren’t good, it’s going to be like sending, I don’t know, five basketball players out to play a baseball game, right? Like, you know, you’ve kind of got the tools there, you got some athletic people, but they’ve never held a bat before. They don’t know how to throw a ball overhand. And and she you’ve got these things, it’s close to what you need. It’s not exactly what you need. So having your settings correct, is I think, in my opinion, by far the most important step of getting going. Now, how does, how do you do that? When you might be in a situation, I guess what I’m what I’m thinking about is, what happens if someone sees automated system, while an automated insulin delivery system, I’m out of this, but it’s not just going to magically work, you’re gonna have to give it a good starting point.

Yeah, that’s all true. So programming the settings, the initial settings that you have, it’s, I wouldn’t recommend just just blindly programming, whatever you have in your current insulin pump, when you go to start Omnipod. Five, it’s important that, you know, to get off to the best start, you really should have your Basal program representing about 40 to 50% of your total daily insulin needs. And the reason for this is because the algorithm is it’s using this assumption that that’s typically what people require. And so you’ll, it’ll estimate your total daily insulin best. When you first start the system. If you have about 40 to 50% of your total daily insulin coming from that Basal program, or at least that’s what you have programmed in the system. So that’s what it what it assumes. And that’s, that’s pretty physiologically accurate. I mean, that is what you would expect, you know, we have these two types of insulin delivery. When you think about it, for intensive therapy, you’ve got Basal insulin, you know, which is like your background, it’s what’s supposed to help stabilize your glucose levels and manage, you know, the livers role in storing and dumping glucose into the bloodstream. And then you’ve got the Bolus insulin, which is larger doses all at once that, you know, are For if the blood sugar gets high, or if you’re eating. And this is basically how the body works with insulin delivery. So this is trying to simulate those same type of, of structure, right? So look at what your current settings are, and then see how close or far that is. So you can always start from, what is the total amount of insulin that I receive in a day. And then how much of that is coming from Basal quote from the pump, and how much of that is coming from boluses. And, you know, people with diabetes, they’re really smart, and they figure out how to make things work best for them. And on a manual pump. You might be getting some of what might be considered Basal through giving extra boluses and things. So that’s where if if those splits are way off of that, I think that’s a time to go to your healthcare provider and try and reevaluate what they really should be to get off to the Let’s start and then start from there

you carry and kind of put that into layman’s terms for people. And this is something I’ve learned baking the podcast over the years, is there are times that people using insulin arrive at the right destination, but they don’t quite get there the correct way. And just a general understanding of what that might mean is, let’s say you should be using, I don’t know, 24 units of basil a day, I’m obviously doing that. So it’s easy for us to remember one unit an hour, but for some reason, your Basal program is set at point five, and you end up making up that other insulin through manual corrections. Or maybe you’ve figured out a way where you’re your meal ratio is really heavy, but it works because the Basal is light, or vice versa, maybe your Basal is too heavy and you are eating on a schedule and feeding the the insulin like there are a lot of different ways that unbalanced settings can still look okay at the end. But this system is going to learn more quickly. If those settings are as close to right as possible. It can still learn if you if you begin with bad settings, but it will add to the amount of time is that right?

Yes, I’m sitting here like nodding my head, but you can’t see that. But yes, that’s absolutely right. And it’s going back to your analogy of the, you know, baseball players trying to play basketball, or maybe it was vice versa. If you, if you teach those baseball players how to play basketball, they’ll probably learn it eventually. So it’s it’s a similar concept that if it’s not perfect at the beginning, or at least not optimal, it will eventually get there, it just is going to take a little bit longer to figure that out. And I think the other point I would make is that this system really operates off of total daily insulin, that is what it uses to base a lot of its automation decisions on not all of them, because it’s also taking your current glucose level. It’s making these you know, decisions about how much to give every five minutes, but kind of the big picture factor that plays a huge role in that is your total daily insulin. Okay,

and would that be the same for somebody coming from MDI?

Yeah, I mean, it would be the same as somebody coming from MDI, generally, with MDI, you would look at, you know, what’s your, what’s your total long acting insulin dose, and that would typically, you know, be what you would use to figure out Basal settings and a pump. So you just would take that total Basal dose, if it represents about 50% of your total daily insulin, and then you would divide that by 24, to get a starting rate. Okay, so Carrie,

I’m gonna give you a little more anecdotal from my end, which is, I see people frequently going from MDI, to any kind of pumping, and having a similar issue, where settings don’t look the same, you know, and they, they’ll, they run into it in all kinds of different ways. But, but kind of think of it like that. So you know, sometimes people from MDI go to pumping, and it takes them a while to get their settings straight, and fine, you’re on your way to doing that. But that pumps not trying to learn anything from what the settings are that you’ve told them. So have your settings really, really close before you start. And in the next part, we’re going to talk about that a little bit more, but I just wanted to, to make sure to be clear about that. So So let’s, let’s imagine, here we are, we’ve done our learning, we’ve talked to our doctor, we have our settings straight, and we’re sitting together, it’s our Omni pod five, we have our Omni pod five controller, our Dexcom or Dexcom is on our phone, we’re ready to go. Now you need to have the controller with you right to start up, you have to get it going. And earlier we talked about that the system works without being near anything. But there are of course, some things you need the controller for, for instance, you need it to give yourself a tell it how many carbs you’re going to eat, right? You need it to hear alarms and alerts. There are things that if you walk completely away from it, you won’t get alarms and alerts are a big part of it. The ability to control the the system as far as entering carbs is another one. If you happen to be in manual mode, you know, you have access to a few more settings than you doing automated. So those things need to be nearby when you’re making changes or when you need to hear alarms and alerts and the truth is right. You need to hear your alarms and work.

Yeah, the other thing is if you want to see anything, you need to have the controller nearby so you know if you’re gonna go swimming, just leave it on the on the chair and you don’t need to worry that it’s not gonna be able to deliver insulin but generally speaking, you’re gonna want the controller nearby, unless you just want to be completely blind and not know what’s happening. But a couple other just clarifying things there. They’re calling it a controller now so very fancy, no more PDM but controller. That might be the lingo you hear when you like get your intro kit box and stuff. And then also as far as alarms and alerts I did want to clarify. Another reason for having the Dexcom G six app near you is that you cannot program any of the Dexcom CGM alerts on the Omnipod five controller. So that’s another thing to keep in mind. If you want to be getting those Dexcom alerts, you have to have the G six app within range and get it through that app. There’s a couple exceptions. There’s a one LOW Alert on the Omnipod five, four if it predicts your glucose dropping below 55. And then there’s some like pump related alarms and alerts. But I did want to make sure it was clear, because this is a common question that I get that there are no CGM are related alerts, other than that 55 In the Omni pod five app, right?

So there, so you have two devices that are speaking to each other, but they’re giving you their information on their their own separate platforms. Exactly. Alright, so let’s I guess dig in a little bit into this algorithm and what we can expect it to do and what it’s going to do. I feel like I want to ask you it because I can we’ve used on the pot five, and I know a great deal about it. But I think you have a lot more than me, as far as knowledge goes. So there’s a predictive control algorithm, right, and it’s called Smart adjust technology. And we know how it’s going to communicate back and forth with the G six that happens every five minutes to predict where your glucose is going to go. 60 minutes from now, it increases it decreases or pauses insulin, trying to get you to that level that you actually get to program right. So unlike other automated insulin delivery systems, I guess Omni pod five has a 110 target. But it also has other targets.

Yeah, you can program the target anywhere from 110 to 150, and 10, and 10 milligram per deciliter, increments. So 110 121 3141 50. And yeah, that is the only automated insulin delivery system where you can customize the target to what you want it to be. And then additionally, you can also set that target, you can have a different target for different times of day. So if you wanted to run 110 of the rent, 110 target, you know, all day, but you wanted the 130 target overnight, you can do that as well. It does not go lower than 110. No, it does not you cannot program at target lower than 110. Okay, that doesn’t mean your blood sugar will never go lower than 110. But the the target that you program can’t be lower than 110. Yeah.

So that’s as good a place as any to talk about that. So your blood sugar could get lower, and then it’s going to take away insulin trying to get back to the 110.

Yeah, that is correct. But I

think that’s important for people to hear that it doesn’t happen instantaneously. If you were to, I guess there’s a lot of different things right, you could you could make a Bolus for a meal that’s too large for what you ate. And then you might get lower than that. And then this, the algorithm is going to just try as hard as it can to take away insulin take wins under Create a new balance, but you could be lower while it’s doing that. So there are times where you might have to step in and fix a lower blood sugar. There’s it that seems accurate to you. Oh,

yeah, absolutely. I mean, you know, what we see with these systems is they, they do a really good job at helping prevent hypoglycemia, but they don’t eliminate it altogether, usually. So you may still have a few, you know, situations, the example you gave is, is a really good one. Because if you do over Bolus for a meal, for example, once that Bolus insulin goes in the body, you can’t take it out, you know it’s there. So you can’t remove it. All the algorithm can do is just stop the automated delivery in the background. Yeah, so it should help. It should help kind of like cushion the fall if it’s too much Bolus. But it may not always be able to 100% prevent the the low blood sugar entirely. Yeah,

it comes from a personal experience I had with it because when we first got it, I was like, I bet you I could get this to keep a lower number. And I did it. And Arden’s blood sugar was like 85 for like two and a half hours. I was like, See, I trick the algorithm. And then it didn’t it tricked me because because it took away so much of her basil that her you know, once that act of insulin I used in the meal was gone. Then she just started going up and up because I had basically, you know, I had, I had put the algorithm in a situation where it took away the basil for so long that the only thing that was going to happen later was arised. Like that’s the only thing that could happen. Eventually, I basically traded my meal insulin for basil. And it said, Well, we’re going to we’re going to get you back up to 110 and then that rise happened. So I just, you know, I it’s not this stuff’s all really very new to people, you know, and everybody’s kind of had a way they’ve done things and there’s gonna be a different, you know, a slightly different way to do things and these are the things that are gonna get you there. So, alright, so Carrie, we’ve thrown on this. We got our first pod on right. What happened? Yeah, five minutes. Just 10 minutes later, my blood sugar’s perfect.

So I wish Sunday. But so you put your first pot on, right what will happen is the with your very first pod the system, you can go right into automated mode. So that’s another cool thing about this is, even though the system operates off of total daily insulin, you can still go in automated mode with the very first pod, even though there is no insulin history. If you think about it, you might be wondering, wait, you just told me this algorithm operates off total daily insulin. But this is my very first pod. So how would this system even though you don’t program your total daily insulin anywhere in the pot, it’s based on the insulin you actually receive. So that goes back to what I was saying before that it estimates your total daily insulin. And it uses that to determine what they call an adaptive Basal rate. And so I would think of that as like a baseline, it’s your baseline Basal rate that this system thinks you have. And then in then it adjusts up and down from that rate, based on the current glucose trend, recent insulin history, delivery history, all with the goal of trying to reach that 110 target. So the 110 is the brain’s that’s the number it’s using when it’s making these calculations every five minutes. And then, so you go along, and you give your meal boluses, because that’s really important. On a system like this. For one, if you want the best blood sugar control around meals, you should Bolus, you know 10 To 15 minutes before you eat, to get the best control around meals, but also to make sure that the total daily insulin that you need is actually accurate. Because if you miss the boluses, two things will happen. Your your meal control won’t be as good, you’re gonna go high, the system will increase to try and help you so still be better than missing a Bolus if you were on a standard bump. But the total daily insulin will start to be underestimated, then because you’re not giving the Bolus and the automation can only do so much for you. So

so if I, if, again, this is a great example of it’s not, you know, it’s not just like set it and forget it and walk away, you do still have to do the things you need to do Pre-Bolus In a meal is of you know, I think it’s a basic concept. And so what you just said, make sure I understand if I don’t Pre-Bolus a meal, then we’re going to see a big shoot up 2030 minutes after I’ve eaten my blood sugar is gone from wherever it was, you know, 100 and now it’s it’s one ad and on my CGM is telling me I got two hours up. And then all of a sudden, I remember to tell the, the Omnipod five, hey, by the way, 845 carbs. So you’re by doing that by not letting it know that food is happening when it’s happening. It just thought you shot up out of nowhere, and it tries to stop it. And now you’re putting the food in and telling it Oh, no, there was food here. But you’re telling it that there’s food at seven o’clock at night when really the food existed at 630. And then that kind of throws things off is that I understand that correctly? Yeah,

yeah. Yeah, the only thing I would add to that is, it’s just that the time it’s the time doesn’t really matter. So like the algorithm doesn’t really care. When you like to eat breakfast, lunch or dinner, like it’s not going to learn that it’s not going to learn, oh, Scott always eats lunch it at seven, or dinner at seven, you know, yeah. But if you, like you said though, if you don’t eat him, if you don’t Bolus for a meal, your blood sugar will rise. And the algorithm will respond, you know, it will respond and try and increase the insulin delivery, the automated delivery, right? But the other but what happens if you put the 45 grams in an hour later, you’ve got a bunch of insulin on board now from this automated delivery, then you put in the 45 grams, it’s just going to calculate, you know, based on your carb ratio, which is going to be too much, because now you already had this other insulin in there. So it does create this yo yo effect, because if you come in with the meal Bolus after, it’s going to likely be too much. And then you’re going to you’re going to crash down, and then you’re going to treat that loan and you’re going to rise up. So that’s where it goes back again to the pre meal Bolus is is really important. Yeah, because but what I what I was saying before, it was actually more that if you just missed the Bolus all together, the total daily insulin calculation will start to be be off to okay, it doesn’t if you don’t give those boluses it’s not going to know that you require the amount of insulin that you require.

See, that’s a bigger picture idea that’s important. It needs to understand, like I guess in the same breath, if you were a really high carb person for three days, and then decided to eat very low carb for three days, the system isn’t going to magically know that you stopped eating 150 carbs a day versus now you’re having 50 or something like that,

right? Right. No, it won’t, but it will update your total daily insulin every time you change your pod. So this is a very important point because you know, especially with kids, which is What you know, I work in pediatrics and so kids grow and their insulin needs change all the time constantly. And that’s expected. And so a lot of people will ask, well, how, if it’s based on total daily insulin, like how does it adjust as my kid grows, or, you know, needs more insulin, and it does that by updating the total daily insulin with each and every pot. So every pod, it’s going to change the adaptive Basal rate based on the the more recent total daily insulin, so it will adapt over time to changing insulin needs.

Okay, so this first pot is on and it’s collecting data, it doesn’t know anything except the settings that we’ve given it. And it’s just living with you. And it’s seeing what you’re doing. And it’s seeing what’s happening. After that first pod is done, you move to the next one. And that’s where you really start seeing the system working a little more, right, that very, very first pod is a is a collection day, or days Excuse me. Yeah,

and it’s, it’s operating more conservatively, conservatively with the first pod, because it’s only estimating your it’s guessing your total daily insulin. And then in so because of that, it’s just more conservative, it’s a little more constrained on how, how high the adaptive Basal can go how much it can increase the insulin. But then when you change, and you go to the second pod, it starts using your actual total daily insulin, and then those constraints aren’t, aren’t there anymore. So I

see, Carrie, I’ve been told something by my my little birds. And I want to know, if you see any value to it at all, they say, that first pod instead of going the full 72 hours, they say change it after 48, because it’s learned everything it’s going to learn and you want the next pod to get moving to have you heard that at all?

I haven’t directly heard that. But my guess is that comes from the fact that you know, what’s required for the system to start using your actual TDI instead of the estimated TDI after the first pod is at least 48 hours of insulin delivery and A pod change. So that might be where that comes from. But in my opinion, I don’t I don’t know that I would worry too much about that. You certainly could change it after 48 hours and like, make it start using your actual TDI. But there’s also concerns of like, do you, you know, do you really want to change your pod earlier than you need to you only get a certain amount of supplies. So I don’t think it’s essential, or will make a huge difference. But I’m certainly good.

I just wanted to get that in there because the internet always thinks it knows. And so I wanted to see what you thought. Thank you very much. Yeah. I have some questions here. Actually, I want to thank existing podcast listeners, they sent out a ton of questions for this. This person says, I’ve read that the first pot operates at a reduced Basal rate. Is that that true?

Um, I mean, reduce from what I don’t, I’m not sure that that’s actually true. I mean, what I would say is the first pot operates off of more conservatively than it will in subsequent pods. And I would say that the maximum delivery is more constrained. But I wouldn’t say that it is operating off of a reduced Basal rate, because the adaptive Basal rate it determines is based on the total daily insulin estimates. So a lot of that is based on what you have initially programmed for your Basal program,

in a perfect situation, you’re going to put this first pot on, and you’re going to let it do its thing you’re going to live your life and let it learn. Is that correct? Yes, yeah. What if you get into a situation where your settings were way off when you got started? So you’re seeing a high blood sugar that you’re just not okay with? Do you come in and correct it?

Yes. And I would encourage, especially in the first couple of weeks, as it’s getting, you know, adapting and adjusting to your total insulin needs. If your glucose is high, give, give a correction Bolus, it all I can do is help because it does two things, one should help bring your blood sugar down. But then two, it’s it’s adding more insulin in to the total daily insulin. And so you know, that’s going to increase the total daily insulin and then with the next pod, you’re going to have a higher baseline adaptive rate, and it’s all just gonna balance out from there. So the principle of giving correction boluses. Really, really helps. But can I add one more thing about correction bonuses at this point? You’re the

only one here really, I’m just okay. If you don’t, we’re pretty done. You know what I mean? Yeah. So,

okay. And this gets to what you were saying before a little bit in that, you know, people who live with diabetes, really figure out how to make their insulin delivery work for them. And there’s a lot of different ways to get there. As you mentioned, when you’re using a manual pump therapy, and the difference with an automated system is that you now have insulin delivery going on that you aren’t in charge of anymore. And so my best advice for you Even correction boluses is to follow the Bolus calculator recommendation. And I know that’s really hard for for many people because you know how much you need. But with an automated system, you can have a lot of insulin on board from the adaptive Basal increasing that you just may not be acutely aware of. Yeah. So what’s great about the system is if you’re using the Bolus calculator, any insulin delivery that is above the baseline, so this baseline I told you, the system calculates for you, it will factor that into the insulin onboard. Point being you can see how much insulin on board is active. And that includes the automated Basal, which is also different from standard pumps where typically Basal insulin is not incorporated into the insulin onboard calculation. And it is now if it’s, you know, being given to deal with hyperglycemia. So you can follow the recommendation and just be advised that the the correction dose may seem smaller, you know, a lot of people will say to me, oh, my gosh, this thing thought said, I needed point five and I, on my other pump, I would have given two units for this. And I have to tell them blow on your other pump. Your basil was stupid, it wasn’t helping you like it was stupidly delivering point five units an hour, no matter what your CGM was doing. So just keep that in mind and try to work with with the system and not against it. And that will really help with frustration, but also with getting better outcomes to

carry Listen, may I make a mean, let me just be honest here for a second, I fought it. In the beginning, I was like, that’s not what I would do. Or that’s not what I need to have happen, or and it really did just eventually occurred to me, I was like, this thing is gonna do stuff. I’m not going to understand it all. And if it works great, why do I even you know, you know, why am I fighting with it. And I was just applying what I knew prior to what was happening now. And it really did take me longer than it should have to say to myself, This is not an apples to apples situation here, I am not doing manual pumping the way I used to. That’s not what this is, this isn’t even another automated insulin delivery system, right? Because they all work differently. I mean, there’s a number of them that are available, and not one of them is accomplishing what they’re accomplishing in the same way. And so I did find myself having to put away some of my old tools that I thought worked really well. And and look at on the pod five more and try to find the tools that I thought worked better with it. Yeah, you

may need to find some new tools, you know, and you will, but I think that that’s, that’s really, that’s really the key, I think, and in admitted, I mean, that’s hard to do. I mean, you know, when you’ve been spending years and years and years, taking care of diabetes, and then sometimes you’ll you’ll have to let those things go. But that can be in that can be hard to let those things go. So I usually tell people, you know, the system needs time to adapt to total daily insulin as far as thinking about expectations of like, you know, how long is this going to take to get used to this? Most people are asking, like, how long is it going to take for the algorithm to figure out how much insulin I need. And while that’s true, there’s another piece, it’s how long do I give myself to get used to a new type of insulin delivery. So that’s another piece of it is it’s you know, you as the user, you have to figure out where you need to let go and let the system do its thing. And then where you need to give insulin and do your part. And how to find this, like beautiful harmony, where the two of you work together the system and you you know, to get the best out of it. Yeah,

I think we’ll jump into that we’ll do a settings episode where we’ll talk more about how to make those adjustments and even how to talk to your healthcare provider about making those adjustments. I’m just I’m glad you brought that up. Because I feel like what I need to know like if I’m going to recap here is that I’m going to come in with as good a settings as possible. And could that even mean that I start on the pod five in manual mode for a couple of days, say I’m not coming from on the pod dash, maybe I’m coming from MDI or something else, right. If I start in manual mode for a little bit, I’m looking for that stability, right? It’s my basil at a good place where I’m held. I mean, the way I talked about on the podcast is Bezos job is to hold you at a number, right and that number is, you know, can be whatever you you think it is, but if your basil is set correctly, it will hold you away from food, an act of insulin, added number at 90 at 100. You could use a little more basil and have it lower, you could use less basil and have it higher. But stability is the important part. If you don’t have stability, then your Basal is not close to being correct away from food and away from an act of Bolus. You know, your blood sugar shouldn’t be dropping very harshly or jumping up and down your basil. I mean Basil is everything. I think it’s the it’s the bedrock of diabetes. And it’s the way to it’s the way to have success is no matter what you’re using, so maybe I even start on the pod five, in, in manual mode for a little bit, it’s still seeing if my basil is working, it’s still seeing my boluses and my corrections, and it’s seeing my total daily insulin, that would work as well. Right? Yeah,

I mean, you could do absolutely necessary. Right? Right, it’s not necessary. And the only other caution I would give you is that, you know, the system isn’t using the Basal rates themselves. So testing it, that’ll give you a really great base Basal profile for if you’re using it in manual mode, right. But what’s more important for getting the best start in automated mode is really just the total insulin. And so, you know, if your settings are just have gotten off over the years, like, let’s say, you know, per your programmed settings, you only get 25% of your insulin from the Basal rate, I wouldn’t recommend starting Omnipod five, with it like that, you could go into manual mode, tweak it all up, you know, test it out, if you wanted to, but you could also just talk, look at what your actual total insulin is. Because if you have, you know, relatively, you know, good control that you’re happy with overall, you have a total amount of insulin that you’re receiving, and that seems to be working as far as the amount. So you could just re estimate what that Basal really should be based on the total insulin,

can I pick your brain a little more here on that? Yeah. So if my total daily insulin is whatever it is, but my average blood sugar is 180, then my total daily insulin might not be enough. Right?

Right. That is a excellent point. Because, and especially I mean, I see this all the time is, I think this is very, very common in youth, even, especially, most kids are not getting enough overall insulin. And so I will sometimes when, because what I do at my clinic right now in prep for everybody starting up the system is I review, I try any way to review everybody’s current pump settings, and suggest different settings for them, and work with them to you know, what they should program and Omnipod five, and if I see that somebody’s you know, got an average blood sugar of 200. And their last time and range was, you know, 45%, then I’ll look at what their their Basal is, and if it’s, if they’re over Bay’s alized on paper, as in like all they’re getting 60 70%. But really, that represents more of an expected TDI, total daily insulin, then I probably just keep it. So that is an excellent point that just because on paper, the split might look off, it’s all relative to whether the total daily insulin that you’re getting is actually the amount that you need. Yeah,

it just occurred to me that you might be, you know, doing great, you know, and thinking, I’m doing fantastic. You know, my blood, my a one sees a seven and a half, and it’s just my average, you know, insulin intake, and then all of a sudden, you put on this, you know, the Omnipod, five, and you put on a target of 110. But you give it settings that led to a 170 or 180, those two things are in Congress at best. So, yeah, so that makes it there’s going to be an adjustment period is what I keep thinking to say.

Right? Yeah. And it all starts with, I think, if you just remember that it really all starts with what’s your total daily insulin? either? What is it that you’re getting? Or how much is it? Would you really expect that you would need? Because, yes, it is different for everybody. But it’s not a complete mystery, like there are ways to estimate how much you really should be expected to be getting based on just simply based on weight. So like, if you’re really not sure that the amount you get, whether it’s really close to optimal or not, you know, talk with your with your doctor. And in be like, what, how much should I probably actually be getting, you know, and go from there. So,

a minute ago, I talked about being in manual mode. And I just wanted to point out that even if you’re in manual mode, the algorithm is paying attention to your total daily insulin there. But in manual mode, there’s no algorithm to stop you from getting low. It’s just you’re using an insulin pump, just like a regular old insulin pump, then, and I didn’t, I didn’t, I didn’t say that clearly enough. So I wanted to. We have a couple of things here. A person who started on the pod five, and they had, you know, they were like, well, I wanted to be more aggressive. And so they get to their fourth pod and they start making all these changes to their settings, thinking this is going to make it more aggressive. I’m going to increase my Basal the carb ratio, the insulin sensitivity factor, etc. On and on, right, except that’s not how this works. Like after that first pod. You put that for As pylon the algorithm is learning, and it’s adjusting those things. So if you made a change to one of those settings, that change would only be concrete if you were in manual. That’s correct, right?

Partially I mean, if so when you’re in automated mode, I cannot stress enough that it does not care what Basal rates you have programmed. Even with the first pot, it doesn’t care about the actual Basal rates, the profile itself, it’s concerned about the total only to help it estimate your total daily insulin. So I just want to make sure that’s really clear that even with the first pod, the actual rates themselves and the different ones you put at different times of day, it does not use those in any way. So no changing, no changing Basal rates at all, when you’re using automated mode. Those would only be used if you were in manual mode. Okay. But for boluses, if you change your insulin to carb ratio, if you change your correction factor, that will change the amount of insulin that’s recommended for your Bolus doses. And that can actually make a really big difference in your overall glycemic control. Really fine tuning those Bolus doses, because that’s what you have the control over, it’s your job to give those boluses for meals. And so focusing on those actually, I would highly recommend because it can make a huge difference in your overall blood sugar control.

Okay. All right, thank you. I just, I’m trying to put myself in the position of somebody who just comes at it new and doesn’t, and doesn’t quite understand what’s going on. You want to do one more question? Or do you want to move on? Let’s see.

Do you have questions? It’s good for ya. If people are sending a man, you know, then they want them answered. I think it’s that’s good.

I love you. You’re very nice. I’m having a good time. This is the first time recording together. And I feel like we’re doing well. What do you think give them credit

for Yeah, we’re feeling great. I’m feeling more and more normal. And the more we go,

you’re not as nervous any longer. Huh? Cool. Okay.

Settling in.

I’m oddly calm, just so you know,

you do seem very calm. I’m like waiting for the I don’t know, waiting for you to yell at me about something.

Okay, so carry, like, let’s just kind of dig in. Before we move forward, let’s add a little more clarity to total daily insulin in manual mode. So, okay, do you? Do you feel like we’ve covered it all? Or do you think there’s more there? Like, I don’t know, what to add to what you’ve said. So maybe you do.

I mean, I think the point you made of just making it clear that on the pod five, it the pod tracks total daily insulin, whether you’re using manual mode or automated mode, it’s always tracking that. So if you went out of automated mode into manual mode, for whatever reason, for, you know, a week, two weeks, a month, a year, it’s still tracking it. So then if you switch back to automated mode, it’s it’s just going to pick up with that total daily insulin, maybe is the point there? Correct.

I believe that was a perfect explanation. Thank you very much. All right. So let’s run through a couple of questions that I have pretty simple answers. person asked, Will it be possible to decrease to decrease the target blood glucose level from the current bill in minimum values? Now I know the answer to this one. So no, no.

No, the target is 110.

Yes, yeah. And you can go higher, if you so desire, up to 150, I think we’ve set all the way up to 150. If you want to target a 90, it’s not going to do that.

It will not okay. All right. But can I just have one thing about that, please? Because I have stuff to say to go? Yeah, the target thing is fascinating. For me, because I work with a lot of automated systems, not just Omnipod five. And this is something that comes up with every single one, I would just realize that this target is the brains, it’s the brains of the algorithm. It is not, I It’s not saying that your blood sugar is going to be at 110 all the time, and that it’s never going to be under 110, or that you couldn’t possibly ever be under 110. It’s just every time that the algorithm makes a dosing decision. It’s doing it trying to reach 110. That doesn’t mean you’re always reach 110 Or never go below it. Does that make sense? So I would focus when I think about adjusting the target since this is the first system where you can do that. Look at it more from the bigger picture. Like if you’re running high overnight and your target set at 130. Drop it because then the insulin is going to give More in the algorithms gonna give more insulin. So think of it more as like, if you want to try and make the algorithm more aggressive because you’re running high, overnight, drop the target. If you’re running lower than you want to be, I don’t even wherever that might be, like, I just worked with someone the other day who was running at five overnight, which some people would love him, they did not love that. And so we bumped up the target, you know, so in it, it helped bring them up a little higher. So, think of it more pragmatically like that, like, it’s a way for you to influence what it does and less focus on what the actual specific number is sorry,

listen, I think if people listened to this podcast, they’ll understand this. And if they’re new to it, and they’re finding it because of the only pod five episodes, and this might be a little lost on them for a moment. But there are so many variables that go into how insulin works for you. So if you’re a person who does a set amount of exercise every day, your insulin will probably be more effective. If you’re hydrated, well, it will probably be more effective than if you’re not hydrated. Well, if you’re experiencing a fluctuation of hormones, say, at one point, but you aren’t at another point, the insulin is going to have different impacts. And so it’s a lot about your behavior, as far as what you know about that, and what you and what you ask of the system. My point being, if you go along, eating, you know, a house salad for three days, and then on the fourth day, decide, I’m going to have a half a pizza, well go for it, except, just understand that if you are a person who has been eating how salads for a year, your your insulin to carb ratio, for example, is probably more tied into that style of eating. So if you’re going to slide into a completely different style of eating, all of a sudden, that insulin to carb ratio might not be the same for pizza, as it is for something else. And I’m getting a little outside of you know, I’m not a health care provider, etc. But you do need to understand how insulin works, I guess, is what I’m saying. And if you don’t, you’re gonna run into problems. And you could turn to, you know, and think it’s, you know, you could, I don’t know, you could chase ghosts around, you could think you see what’s happening, but you might not be.

Yeah, and then I would just end that statement with I mean, I think that people get more concerned to the target than I think is necessary. That it’s not as big of a deal that sometimes it can be made out to be. And so I try to encourage people not to worry too much about that back to what you were saying, just focus on doing what you can to get the get the best control that you can. And the target is not really the most important factor here.

Well, yeah, my only point was, is that if you’re if you’re targeting 110, and you know, your blood sugar’s rising, and the system says, Oh, it’s coming, you know, that’s happening, I’ll do what I did yesterday. And that’ll work except that you’ve made some, yeah, here’s, here’s a better way to think of it. Maybe, if you are getting low overnight, for example, and the algorithm is stopping that low by taking away basil, you may have had less basil than your body really needs, you know, four or five o’clock, six o’clock in the morning, because of I don’t know, a bed Bolus, she made it about three o’clock, who knows. But when you wake up in the morning, the algorithm doesn’t know to you know, that your toast is going to hit you extra hard now, because you really haven’t had your full Basal for the last three hours. Like you kind of have to know that. And yeah, you know what I mean?

Right? That’s a really good example, because it does show the interaction between, you know, things that the algorithm doesn’t, and that’s a perfect example of, of that kind of perspective. And that, oh, what’s the word like, kind of the vision the that you see that that insight of, oh, look, I’m about to eat breakfast, I see that the system has suspended my basil for the last hour. And if I when I eat this toast, it’s going to have a huge impact because I’ve got very little if any insulin, currently working in the system. So in those cases, you know, Pre-Bolus thing as far ahead as possible, makes a really big difference. Because, you know, you get you make sure you have some insulin starting to work before you, you know, eat, get those carbs in the system. Excellent.

I feel like carrot Tell me something. I feel like we’ve done a good job here. Do you not agree? I do. You’re aware you’re looking at the same notes I’m looking at. And I feel like we covered so much of it. Without getting to it in the notes. Does that make sense to you? Sure.

I haven’t even looked at the notes. So I mean, I’m glad that you think we’re covering it. Carry

on me Uh,

I mean, I’ve looked at the notes, but I didn’t want to make a bunch of noise there right here, but I, yeah, I’ve seen them before. Yes, we’re doing we’re, we’re doing great. Okay.

So I just wanted to sit down for a second and go through a couple of ideas about just making sure people understand what the adaptive Basal rate is. But I feel like we’ve done that. No, I’m just gonna run through them. And you tell me if you think we’ve done it. Adaptive Basal rate is a baseline for automated insulin delivery. It is the insulin delivery calculated in units per hour, then the smart adjust technology continues to change over time as only part five is used. And this is all of course, based on your total daily insulin. Yes, okay. Adaptive Basal rate is based on the total amount of Basal and Bolus insulin delivered in a 24 hour day or the total daily insulin again, and updates with each pod change based on the previous insulin history to best match the user’s needs. That

is true. I’d like to add one thing, because this is a very common question. Can you what how do you know what your adaptive Basal rate is? The short answer is, is you don’t, and there’s no way to know you can’t find it out. So we should probably get that out of the way. Yeah.

Okay. And if for some reason, and I know, it’s not not fun to think of, but if for some reason your controller explodes, like you drop it in the pool, or you throw it across the street, I don’t know what you might do to make it break apart. But if that happens, you are starting over again, when that next pod goes on. Yes, yes, yes. So I want to point out, always know, what you’re like, know, your settings as best you can, right? Right. Like whatever you put into that thing, the first time write them down somewhere, don’t just, you know, don’t just go I don’t know, know what your total daily insulin is like that, I think is incredibly important, right? Because then at the very least, even if you’re just like, I don’t know, any of these settings anymore, you can at least look at the total daily insulin, you could say to yourself, Okay, let me just take 50% of this and make it I’ll break it up over 24 hours and make that the Basal. And I’ll take the rest of this, and I’ll look at some of my carbs, and I’ll figure out my insulin to carb ratio. And these would be good restarting settings. That’s a very basic way to think about it. But as but at least you’ll be getting that total daily insulin set in there. Does that make sense to you? Yeah,

no, it does. And, but the only thing I would add to that is, you know, your insulin needs can change over time. So depending on how long it’s been, since you started, before you broke your controller, I mean, if it’s been a year, and your manual mode, Basal rates haven’t been changed at all, they might be slightly off, if your total daily insulin has actually gone up, and the

number has changed your activity, get a few pounds, lost a few pounds, etc, etc. So

the best way to really keep track of that information is to have your Omnipod five linked to gluco. Because this is one of my favorite things as a healthcare professional, because if you link your Omnipod, five to gluco, which is a data management system that you can summarize, you can get reports that summarize your insulin delivery and glucose control, then you can just log if you break your controller, you can log into glucose, and you can see what the settings were and how much in you can see how much what your average total daily insulin has been okay, and so, and that it’ll walk you through doing that when you go to the setup screens. So I highly recommend doing that and not skipping that part. Because it’s, it’s really cool. And then once you’re set up, it will automatically upload the pump to gluco via the cloud without you having to do anything, you don’t have to manually upload it. And then when you show up to see your your doctor, the data is already there, and everyone is so happy.

I like not having to do anything that makes sense. So so keep track on your own use paper. If you still have a pencil on your house or use your computer or your phone. Most people just use their phones, right, Carrie I sound very old now when I send someone to use their phones. Yeah. So keep track of all your settings. And and utilize glucose. Glucose is free, right?

Yeah. And when you go through the setup, it will it’ll walk you through pairing it and if you don’t have a gluco account, it will walk you through like creating one and everything. Okay.

What can I see? So you’ve had a lot of experience with with the system and with the controller. So what can I see as a user day to day like, what do I have access to? On the comptroller? Yeah, like can I the app itself? Yeah, like like, do I just see oh, it made a Bolus or do I see, you know how much it used?

Yeah, so what you can see on the main screen is you can see this the current CGM glucose value and trend arrow because you’ve, you’ve paired the transmitter into your Omni pod five, so it can the pod will send that deck that information to the PDM so you can MC the CGM data on the Omnipod five app. So you can see the CGM value and current trend arrow. You can see how much insulin onboard you have. And you can see your last Bolus, it’s very similar appearance to the dash interface very, very similar. So you can see the last bullet she gave and how much that was. And then there is a way that you can expand the CGM graph, you can, you can see the last three hours of the CGM values and on that graph, you can also see the insulin on board and the current CGM value as well. And then you can get a visual representation of the automated delivery. So at the bottom of that CGM graph, you can see if you’re in automated delivery, or manual delivery, and then you can also see visually if the algorithm is at maximum delivery, or suspension. So you can see things categorically, but it won’t show you the exact amounts. Okay. However, you could go to the history, if you want to see each five minute, you know, micro delivery that, you know, or adaptive Basal delivery, if you are so inclined. I mean,

I think it’s, it’s pretty obvious, right, that the system is set up to try to take away your burden, and so that you’re not constantly worried and looking and, you know, overwhelmed. I mean, I think, you know, I’m gonna put my my personal opinion in here, I think Omnipod five, for most people is going to be an incredible improvement for them. You know, like, just an incredible improvement and, and getting it set up and getting it rolling is the crux of the whole thing, right? It’s just why we’re talking about it, because what’s beyond this should very well be some fairly smooth sailing, where the algorithms learning and keeping up with you and making adjustments where necessary, and even you’re learning as you go along. How to how to Bolus for your meals better, or how to think about things as far as the way the system works. And, and hopefully you’re, you know, you’re you’re, you’re feeling a weight lifted at some point.

Yeah, I think so. I mean, I think there’s a lot of potential here for a lot of people to get much better blood sugar control than what they’ve been able to, you know, to get on a manual pump, as well as more stability. Because the other thing I think we often don’t talk about is glycemic variability, just the ups and the downs. So sometimes the average looks fine. But when you really go and look at it, you know, yeah, you’re spending 50% of your time high and 50% your time low. So this helps you kind of find the balance and be more stable with less big fluctuations. Yeah. And sleep. That’s the thing,

you stole my thing. Oh, ahead. Go ahead.

I was gonna say that’s, that’s the thing, especially for for parents. And you know, I worked in pediatrics, I always want to give that disclaimer, I don’t really know much about adults. But for parents getting to sleep at night is the constant theme that that I hear, because not only is the blood sugar improved overnight, it’s the stability that you just get to sleep the whole night. And that’s just not something many parents and kids really experience. So I

have never slept so well, as I have, since some automated insulin delivery has become a reality. So and it sounds

overnight, it’s really very exciting. If you think about it, it’s half of your day. So I mean, it’s, it’s also super encouraging that, you know, the nighttime tends to be relatively, like, really reliable, like you can really rely that for almost everybody, like it’s just it is going to help overnight for sure.

I think also, he had kids that go on sleepovers or, you know, adult who’s got a real heavy sleeper or no, you know, next to them or nobody next to them, they’re on the road. I always think that being an adult with type one of living by yourself has got to add an extra amount of anxiety to your life. He got kids going away to college, all these things. It’s just it’s listen, I’m I’m a huge fan of the stuff I have been saying on this podcast for years, that you do not want to get stuck in how it’s done. Because, you know, people are going to make advancements, and you don’t want to be back with like, Oh, I’m still peeing on this test strip. Is that not the way we’re doing it anymore? You know? And so this is, it’s a big deal. It really is. I can’t I don’t think I can quite say enough. What a big deal. Yeah,

it’s a really exciting time, you know, and it’s only going to get more and more exciting as we go. I think I think we’re just at the beginning.

Okay, we’re gonna hammer through a couple of questions here. And then we’re gonna we’re gonna button this up, try to keep it around an hour, right? Okay. Realistically, how long should I expect it to take for the system to adapt, optimize the insulin delivery do its thing What did you see during the during your time with it?

I think a couple weeks is a is a good expectation to set for yourself that you’ve got to give it a couple of weeks, you know, three or four pods for it to really get some time to adapt. And then the other thing is that it’s not even just the adaptive basil and figuring out the total, you know, giving the algorithm time to figure out the total daily insulin. That’s obviously a huge part of it. But it is very, very common. And this has been true with every automated insulin delivery system I’ve worked with, you almost always need stronger carb ratios on an automated system compared to a manual system. And again, like, work with your doctor and look at this stuff, and talk about what your carb ratio should be. But if you’re running high after meals, don’t hesitate to reach out because there is something that can be done, oftentimes, you just need to strengthen the carb ratios. And it’s not a bad thing, it doesn’t mean the system’s not working. It’s expected it’s, it’s a dynamic Basal delivery, that’s totally different than a manual pump, where it’s just statically delivering. So because it’s dynamic, you’re going to have periods where it’s turning off and then turning back on. And oftentimes leading up to a meal, you have less insulin on board, because there’s been suspensions, because you’re getting back to that target. And so, because of that, naturally, you’re going to need a stronger carb ratio than maybe you used before. So keep that in the back of your mind. Because after those couple of weeks, if you’re still running high, or higher than you’d like, or high after meals, specifically, reach out to your doctor and in fine tune those carb ratios, because it can make a huge difference. Well,

it really does depend, I guess, on the person or its individual, how long it’s going to take days, weeks, plus all the other stuff that we just spoke about. Yeah,

I would agree with that. I mean, everything’s individualized. But I would say, you know, give it a couple of weeks. And if you’re not where you want to be, you know, reach out to your health care provider to help you because there’s probably, you know, some Bolus settings that can be adjusted to really help you get where you want to go.

Let me ask you a question. Because you’ve seen so many people on it attached to this idea. Is there something I can be looking for that shows that we’re moving in the right direction, like winds, the winds, the part where I go, Ooh, maybe I will call my doctor here. I think we’re, we’re at a point where maybe we’ve plateaued?

Yeah, that’s a great question. That’s a hard question. Um, I mean, I’m a big, big picture person. I think time and range is the most important thing. And so if your timing range is not getting to where, you know, you want it to be, and you should be able to get it, you know, above 70%, and meet those targets. You know, reach out and, and help have your doctor help you get there.

Okay, I guess in in the end, you can paint that picture to your doctor as well. And let them help you make the decision. If you can’t decide if you’re seeing movement or not. Carrie, I find that thinking about insulin is like a time travel movie, right? Like insulin I use now is for later. But really insulin that’s happening now was from before, and it always helps to have another person to talk about that with. So you don’t get a little lost. You know what I mean? Like, it’s great to talk to your healthcare provider, your nurse practitioner, whoever it is that you’re making those decisions with? Because it’s nice to just have another person to bounce it off of sometimes because, you know, like, at some point, you’re sitting in the theater, and you’re like, I don’t understand how is Neo slowing those down? Like, you know, like, you need somebody else to chat with about it and, and make good sense of it. You sound like you would be a good person to do it. With. Oh,

well, thank you. I really enjoy it. And I do it a lot. So I love working with people to get those carb ratios. Right,

right. So if I even if I start the pod, and I’m like, Oh, God, I used all the wrong settings. I just might have to wait a little longer for it to figure it out.

Yeah, exactly. Yeah, you might just have to wait a little longer, but it will get there. It will all be okay. Okay.

So time settings. bolusing. You know, the way you need to Bolus whether that means amount or timing, timing and amount, such a big deal. And then just let Omnipod five do its thing.

Yeah. And can I make one more comment about that you can make. So the other thing is, like I already told you like, I highly recommend following the Bolus calculator for correction doses so that you can work with the system and not against it. But if you find that it’s always recommending zero, and you’re still running high, again, you don’t have to just sit there, it could be that your correction factor is too high, it needs to be stronger, I find that correction factor is like the forgotten about setting often. In pump therapy. You know, we’re all in manual therapy, we’re always tweaking the basals. And we often change the carb ratios and we hardly ever do anything with the correction factor. And so I see this, you know, 15 year old and they have the same correction factor from when they were six was, like

350 points. Yeah, it’s like I don’t think

that one unit He’s going to drop the 300 points anymore, you know. So the correction factor. Yeah. It needs some attention to sometimes, you know, yeah.

And I know it’s, you know, it’s it sounds super simple. But the idea of, you know, if your correction factor is one unit moves you 50 points, but you haven’t looked at it since you were five years old back when it was one unit moved to 350. Now you’re trying to adjust the high blood sugar, and you have no hope of that working. And on top of that, you’ve told the algorithm this should work. And you’ve given a bad information.

Yeah, isn’t the Bolus calculator is just going to use whatever is programmed in there to as part of his calculation, so Right, yeah, it makes a big difference.

Okay, well, I think this is a great time to break and say that we hope we see you in part two, where we’re going to do a deeper dive on settings. I’d like to thank Carrie Birgit for being on the show today and sharing her knowledge about the Omni pod five with us. And a huge thanks to the listeners of the podcast who shared questions and comments that led to the building of these three episodes. If you’re interested in getting started with the Omni pod five, we’re learning more about it. Go to Omni pod.com forward slash juicebox. And don’t forget that these episodes will be available in your audio app forever. But you can also find them at juicebox podcast.com forward slash Omni pod five. This episode was just part one of a three part series you still have on the pod five pro tip settings and Omni pod five pro tip connectivity to listen to. If you found this episode helpful, and you’re new to the podcast, be sure to subscribe or follow in your audio app for more diabetes and on the pod five context. Thanks so much for listening. I’ll be back very soon with another episode of The Juicebox Podcast.

Hello friends, and welcome to part two of my Omni pod five series with Carrie Birgit. Before we get started today with part two of this three part series, I’d like to tell you that insolate has paid the host of this podcast that’s me Scott Benner and my guests Carrie Berg get a fee to create this content. Carrie is an omni pod ambassador with an ongoing commercial relationship with insolate. This podcast provides general information discussions about health and related subjects. This information and other content provided in this podcast or in any linked materials are not intended and should not be construed as medical advice. Nor is the information a substitute for professional medical expertise or treatment. Never disregard professional medical advice or delay seeking it because of something that you’ve heard in this podcast or read in any length materials. The opinions and views expressed on this podcast and website have no relation to those of any academic hospital, health practice, or other institution. Please speak with your healthcare team if you or any person has a medical concern. And before making any changes to your diabetes management, you can always consult the Omnipod five automated insulin delivery system User Guide for more information. In short, nothing new here on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making any changes to your health care plan. You were about to listen to part two of this series on the pod five pro tip settings. If you didn’t begin with on the pod five pro tip overview you should have that’s the first one, this is the second one. And then the third and final is on the pod five pro tip connectivity. All three episodes came out at the same time. And so they should be in your podcast player in order. They are also available at juicebox podcast.com forward slash Omni pod five. And we’re gonna have to do like a little thing here carry but that pretends we haven’t talked in a while. So hey, Carrie, how are you?

Doing? Great, Scott.

Good. We’re back at you. Oh, my gosh, it’s been so long since I saw you. I’m very excited for us to be together again. Do you think people know we just recorded these all in a row? Probably right.

Probably they probably know. People know things.

Yeah, they know things. People understand. We’re going to really kind of dig down into Omnipod. Five system settings right now. And you know, hopefully everybody’s listened to the first episode. If you haven’t, head back over and take a look. I think listening to them in order would really be most valuable. So Carrie, I guess we should just introduce you one more time. That makes sense. Go ahead. No, I mean, like for people who are like, Oh, why should I even go back and listen to the first one. Scott, who is this person you have with you?

Oh, well, this person, that would be me. So I’m Carrie, and I’m a nurse from the Barbara Davis Center in Colorado. And I work with kids and their parents on diabetes technologies. I literally spend nearly all of my time helping people with their insulin pumps. So yeah, I am.

Okay. And you’ll tell you more about yourself in the first episode, if they haven’t heard it already.

Yes, yeah. So within a rambly way that everyone will enjoy, because

you’re much less nervous now than you were when we started the other one, correct. Yeah, yes. I mean, you need to edit that. No, no, no, no, that’s my favorite part. And that stays in and everybody. Everybody who comes on is nervous in the beginning. So you didn’t get the benefit of what all the other people on the show get, which is like a nice 10 minute conversation where I talk about, like, silly things to get you comfortable before we start, we didn’t jump right in with you, but I thought you did terrific. And you’re a seasoned professional at this point. So let’s, let’s get going with this. Okay. All right. So we’re gonna start with Basal insulin when we’re thinking about settings, right. So the question is, do you program Basal settings when you go through the initial setup, and does changing Basal rates later impact the algorithm?

Okay, so first, yes, you have to program Basal rates in order to use the system at all. And the Basal rates that you program, though, are not used when you are in automated mode. They’re only used when you are in manual mode pump operation, okay. With that being said, with the first pod, it will look at the total Basal that you have programmed to estimate a total daily insulin. So you do want to make sure that you know the Basal rates that are programmed are actually reflective of what you would need so about 40 to 50% of your total insulin needs, but it does not use the actual rates themselves. So important to keep that in mind. So this

is incredibly important for two distinct reasons, right? The first one is that The amount you put in for your Basal rate is going to be where the algorithm begins to understand your adaptive Basal rate as its learning. But probably, I don’t want to say more importantly, but but equally as important, is that if you ever have to go back into manual mode, this is these are the settings that will be used.

Yes. Okay. I would agree with all that. So

I can’t, like, I can’t just like make up a number, like I got to put in a good solid number, best, best, best number I can come up with based on my settings, something I can get from my doctor, is where to begin. Right?

Absolutely. You definitely don’t want to just make something up. Because, you know, if you were in manual mode, those are the rates that you’re gonna get. So yeah,

I just want to be clear, because it’s a it’s almost a, it feels like there’s an interesting duality where you’re like, listen, it’s very important to put in the Basal rates, but the algorithms gonna ignore them pretty soon anyway. So

yeah, right. Yeah. Definitely see that. Perfect.

Okay. So after the first pod system is going to gather up all my insulin history. And it’s going to make an update to this adaptive Basal rate, right? Yep. Okay. So now, once we’re into automated mode, does adjusting the Basal rates do anything for automated? No,

zero nada. Okay. I mean, I don’t know, I can’t emphasize it enough that changing the Basal rates? Does. Absolutely nada. Okay, so

what’s going to happen is I use a pod, the pod learns. And then when I put on a new pod, it makes an adjustment, then based on what it’s learned in the previous pod, is that correct? That is correct. That’s pretty cool, isn’t it? Yeah. Okay. It’s actually, um, I’m like, wow, when you put it like that, who thought of that? I

know, it is actually really cool. Like, how much insulin did you get? We’re gonna update that, that baseline rate,

right? Yeah, it’s just really interesting. So I guess a couple extra points is that it’s going to be really important than for how you Bolus? And you know, covering your carbs correctly, using corrections when you see corrections are necessary. These are all going to help the algorithm to understand what your total daily insulin is. Yes. Okay. That is all correct. All right, good. Look at you. You’re just like, you know, oh, my God.

I don’t even know what else to say,

I’m waiting for when I say something, you’re just like, Yo, Whoa, man, hold on.

I’ll tell you, I will tell you if it’s wrong. All right. So

I’m just going to read this actually, because all insulin delivery methods work in different ways. So keep that in mind that the rates and the ratios you use before may change with on the pod five. And that’s okay. Right. So you got to review your current doses with your healthcare provider, and your Omnipod trainer before you start with Omnipod five. Fairness, okay. Yes, let’s hit a couple of questions from people. This person says when you see that you’re using 50% Less Basal than what you have inputted. So now this person is saying, Look, I told it, my Basal rate was this, but I’m looking and it’s taking basil away. They said, What are they supposed to do? And the way they asked the question was, do I change it to match? Or do I leave it alone? And so I guess what they’re saying is, what if I told it, my Basal rate is one unit an hour, but then they look and they see they’re really getting paid for that just as an example? Do they have to go back in? And tell it? I’m gonna say no, right? Yeah,

well, it depends. It depends on your goal. So as far as the audit, whatever’s happening with your automated insulin delivery, if it’s all working, and you know, you just see that you’re getting half the total amount of basil, then what you have programmed in for manual mode, then, you know, and it’s working, and you’re, you know, getting the control that you know, you want, then yeah, you don’t need to do anything, yeah, but if you were gonna, if you want your manual mode rates to be correct, or as best as they can be, you know, you might want to take a look at those manual rates, and just say, like, Hmm, maybe I’m way off on what these actually should be, if I were to be in manual mode. So I would encourage a conversation with, you know, your healthcare provider about that, because if you weren’t, you know, let’s say you couldn’t get your Dexcom for, you know, whatever reason, because this kind of stuff happens, then you’re going to be in manual mode. So you want to make sure that those manual mode rates are you know, somewhat effective for you

because your insulin to carb ratio correction factor, reverse correction factor all that stuff. You want that right in case you go back into manual. Yeah,

you would want all of it right and you would want your Basal rates to be you know, appropriate for you. You know if you were in manual mode, right,

but but it’s not going to touch the the automation at all me

right changing the Basal rates will not have any impact on the adaptive Basal or how much insulin the algorithm is giving in, you know, the automated insulin delivery algorithm. Gotcha.

Here’s the next question from somebody. They said, Well, what about the max Basal setting? Like, would I be helping the system to deliver more insulin in automated mode? If I jacked up the max Basal?

This is a great question. I get this question all the time? And the answer is no. So the real simple answer is no. If you want me to ramble about a little bit more, I can tell you that the max Basal rate setting is it’s really a safety setting. And it’s a manual mode setting. It’s helping make sure, really like keystroke errors is really what how I tell people, because what the setting actually means is, whatever rate you program in the max Basal setting, the pump will not let you program a Basal rate any higher than that. That includes temporary Basal rates if you were in manual mode. So really, like if you meant to put in point two for Basal rate, and you actually accidentally did 2.0? You know, having this max Basal setting, you know, appropriately set kind of helps prevent that user error. So it’s a manual mode only setting,

which is the safety setting, and it has nothing to do with the impact on the algorithm. Exactly. Gotcha. All right. So target glucose, right? This is adjustable in Omnipod. Five, and I think we want to understand it better. So target glucose anywhere between 110 and 150. And in in 10, in increments of 10. Right, I could do 110 120 4150 That I can adjust. But but that’s you said it in the in the other episode, and I thought you said it really eloquently. But it doesn’t mean you’re going to be 110, constantly, you could end up being lower, you could end up being higher, it’s just the system is always sort of adjusting to get back to that spot of 110. It’s the target of it. Yeah, nothing more or less than that. Is that correct? Yeah,

that’s correct. And so, you know, when I think about the target, if you want to, if you want the adaptive Basal, to operate as aggressive as possible, if you want to get the most amount of insulin that you can go with 110, because that’s the lowest setting, that’s where the you will get the most aggressive insulin delivery. And most people do really well with 110. I mean, I use 110 as the default, unless there’s some other reason not to, a lot of times based maybe on personal preference, if somebody just conceptually is not feeling comfortable with that, and they want it to be a little higher. But really 110 is, that’s your lowest option, that’s where you’re gonna get the most insulin delivery. And then, you know, being able to go on 2131 4150, it also gives you a little bit of input and a little bit of an ability to influence how much automated insulin delivery you get. So instead of being like, ooh, do I want to be at 120? Or do I want to be at 130? I would instead think of it as do I feel like I need more insulin delivery or less insulin delivery than what I’m getting from this automation. And if you’re running higher than you would like at a certain time of day, then doesn’t seem to be really related to the Bolus doses, then that’s just that’s one way that you can directly influence the adaptive basil. And I’m sorry, I keep using like automated insulin delivery and adaptive basil. It’s really all the same thing. I just am referring to the insulin that is automated from the system. There’s

also another value that you’re in control of Right? Correct. Above.

Yeah, and the correct above is used just for correction boluses that you go and give that the user gives but the Bolus calculator. And so because I should mention the target glucose now serves two purposes. In automated mode. It’s the target for the Bolus calculator, but it’s also the target for the adaptive Basal, so they go together. So they’re always there’s just one setting, but they serve it serves both those purposes. Correct above, can go anywhere from 110 to 150. In 10, unit increments as well. Is that so

let me ask you, is that just for automated? Is it just for manual? Is it for both? That’s

for both? Yeah, because it’s a Bolus calculator setting, which is available in both manual and automated mode.

So let me break that down for a second. So if if my targets set at 110, and the algorithm predicts, I’m going to go over 110, it will take steps to stop that from happening. But if I’m 100, and I have a meal, and I put in, I don’t know, 10 carbs, it’s gonna give me the insulin for the 10 carbs. If I’m 110, it’ll give me the insulin for the 10 carbs, but if I’m 140 and I’ve got Am I correct the Bob’s set at 110? It’s gonna give me the carbs plus the 30 points between 110 and 140.

Yeah, think of it this way, whatever the correct above is, that’s when the Bolus calculator considers you eligible for a correction Bolus calculation. So it’s, you know, if you’re correct above is set at 140. It’s not even going to calculate, it’s not even go to the trouble of calculating a correction Bolus for you. So, so the difference between the correct above and the target is that the correct above is when you’re eligible for the correction when the calculator will add in and do that calculation and add it to the dose versus one the target is what it will aim for. So if you’re correct above is 110. I’m sorry, you’re correct. Above is 140. You’ll get the calculation added if you’re above 140, but it’s going to calculate it aiming for the target, which is 110.

Let me ask you a question that I feel like I noticed this when was on the pond five with Arden and I want to make sure I saw it correctly. Let’s say I have a blood sugar that’s sitting at 150. If you go into the into where you Bolus, and you’re correct above is lower than 150. It will actually suggest amount of insulin to you to Bolus Is that correct?

Yes. But it was your question. If you go in, if you say that again, I’m sorry, go actually

right into where you make a Bolus. And you you sort of say to it, like, Hey, I’m here. And it says, I think you should put in point three right now. And that’s even without carbs. I consistently felt like I got that. But it won’t give you the the making up numbers now. But it won’t give you the point three automatically.

Right, right, a Bolus dose has to be directed by the user. So the calculator will recommend to like it’ll populate in the dose row, how much it wants you to give based on the calculation, and then you have to press the button to say deliver it. So the

algorithm will try to give me that insulin over time. It just won’t give it to me all at once unless I override it and say go ahead and put this in.

Well, it’s not really the algorithm though. This is Bolus doses. This is user given boluses. So those are calculated based on your program settings. So the correction factor the target, if it’s a correction dose, so if you if you, if you use the CGM value, if you put a glucose value in the Bolus calculator, then it’s going to calculate a Bolus for the blood sugar correction based on what’s programmed in the pump. If you put in carbs, it’s going to calculate a dose based on the insulin to carb ratio. But keep in mind, it also subtracts insulin on board. So you know, that’s a part of the calculation. So it could be that you put in a high blood sugar and it still populates with zero, or something that seems small. And that’s because if you have a lot of insulin on board, that insulin on board might be more than what the calculated dose is. And so it’s telling you that it doesn’t think you need to give anything more. Okay.

I don’t want to drill down too far into like minutia. But I want to make sure that I’m clear, because if I’m clear that everybody else is going to be clear, too. So if I go into the Bolus calculator, and it says, Hey, you should Bolus point three right now without any carbs being added. Uh huh. Why is it not giving me the point three? Or am I misunderstanding what you said?

Oh, you’re saying why isn’t the algorithm gonna give you the point? Yes, yes. That’s what you’re asked. Ah, okay. Well, because the algorithm has certain I mean, certain constraints, which is why I say, you should go to the Bolus calculator if your glucose value is higher than you want it to be yes. Because I guarantee you that the algorithm is trying to bring the insulin down. But again, it’s still conceptually, it’s Basal insulin, that’s also trying to help with hyperglycemia. And so it’s not necessarily always going to be able to do that without you going in and giving the Bolus and probably get there eventually, but it’ll take longer because it’s every five minutes having to, you know, give these micro boluses. I also think it’s helpful to conceptually look at the Basal delivery, because in the CGM graph, you can visually see that if you’re at maximum delivery, and as far as the algorithm is concerned, and a lot of times in these cases, your glucose is high, and you go and look and you’re at maximum delivery, you realize it’s working as hard as it it actually can. It can’t go any higher than what it’s doing. And so that’s why it probably can’t give that point three, it’s reached its limit. But it thinks based on the settings you have programmed in the Bolus calculator that you probably could benefit from an additional point three, so why don’t you just go ahead and give that point

per Because I probably did not lay it out correctly the first time, that is exactly what I was wondering. Okay. Okay, so let’s dig into carb ratios and correction factor for a second. So we got two settings here, they function, you know, the same way as they would in, you know, in another system, right? So whether you’re using another pump, using an algorithm using ally pod five, or use an MDI, these things mean the same thing. So it’s not uncommon for people to need to do what strengthen their carb ratios when starting on an automated insulin system like Omnipod. Five.

Yes, it’s incredibly common. And almost expected, I think that you’re going to benefit from stronger carb ratios. And I think, and I think the point to see here is that it’s expected and kind of part of it, it doesn’t necessarily mean something’s wrong, if you need to change your carb ratios. The the adaptive Basal is dynamic. And so when you’re coming from MDI, where, you know, you give the long acting dose, and it’s just always there, it’s always there, you know, regardless of what’s going on with your blood sugar, same with a with a standard, a manual pumping, the static Basal is always delivering, but based on whatever is programmed, or whatever you as the user change it to. So with a dynamic Basal, and an automated system, like Omnipod, five, you’re going to have most likely some insulin suspension, oftentimes leading up to a meal. And so because of that, you have less insulin on board at the time of the meal. And so you need more for the Bolus than you maybe did in a non automated system, whether that was multiple daily injections or you know, a manual insulin. So

so the idea here, if I’m, and you’ll stop me if you don’t agree with what I’m saying, but the idea here is you eat a few times a day, right? And so you’re using insulin and taking in carbs. And then that takes hours sometimes to kind of complete its cycle right for the insulin to leave your system, etc. And so the entire time the algorithm is aiming for your target. And it could be adding or subtracting basil to get you there, right, sort of like helping a plan land, except justice. It gets you all where you want to be, and your plane starts coming in. You go ahead and eat again. Because right, I see. Okay, yeah,

that’s exactly right. And so it tends to do a decent job at getting you closer back to that target. Again, by the time it’s time to eat again. And so then, you know, usually need more for that Bolus. So

it’s no real surprise that automated insulin delivery systems do a great job overnight, generally speaking, because you’ve taken away one of the big variables or two of them, which is carbs and and Bolus insulin, meal insulin.

Yeah. And lots of other variables. Like activity and yeah, you know, right. So when you expect Yeah, yeah,

so when the variables are lesser, it’s, it’s shooting out in the distance, and nothing’s gonna change out in the distance. And that’s how you see that stability overnight. When you see Yeah, yeah, absolutely. So that’s also why I say with my daughter, she can wake up in the morning like sleep in. And it’s one of the things that I’ve seen it alleviate, is that she can sleep in and not have food 789 10 o’clock in the morning, and she just sits like very stably the entire time.

Yeah, that is a very great point. And then when she eats, though, at 10, or 11, she probably is has little to no insulin in her body. So it’s helpful to be aware of that when you think about having that first meal, especially in that type of situation. So I love the CGM graph. And I really encourage people to look at it because the visual representation of the insulin delivery is really helpful. Because if you get up in the morning, and you look at the CGM graph from the Omnipod, five controller, and you see a red bar for the last hour with a beautiful, you know, beautiful glucose at you know, 101 10, you know, something like that, you know, that, you know, you’re probably going to want to Pre-Bolus a lot earlier than maybe, you know, you would if you weren’t suspended for a while,

that’s fine. So it’s just important to note, it’s important to note that you’re going to get to sleep in, which is just amazing. Most people using insulin are like, wait a minute, I could like you mean, I don’t have to get up exactly at 7am to make this whole thing work. You know that that’s pretty great. But there’s no real rule of thumb right? To make changes to like insulin to carb ratio and insulin sensitivity factor. This is a situation you go back to your health care provider, you make some you know, they’re probably going to make adjustments with you incrementally until you get to where you need to be, but you’re still looking for about that 5050 breakdown with Omnipod five, yeah,

yep. Okay. Yep. That is typically what you’re going to see. And I mean, yeah, I don’t think you need to worry too much about changing anything with your carb ratios beforehand. preemptively. Just follow up in the first couple of weeks. Tell your health care provider, they need to be helping you they need to take a look and help you like okay, we we started it’s been a couple of weeks. I’ve you know I’d given the time of the system adapting to the total daily insulin. Let’s see what else we might need to tweak with these Bolus settings to really optimize, you know, my outcomes here. Yeah, okay. That’s sooner rather than later is what I’d say. Excellent.

So let’s go over a couple more things. Duration of insulin action. So D Ay ay ay ay. Overall, that setting means the amount of time you expect that insulin is going to have an impact on your blood sugar.

Yes, and that setting specifically is related to the Bolus insulin that the user gives. So this is the duration of I would add in automated mode. Well, it really in manual mode to actually it’s the duration of Bolus insulin action. So because what I want to make sure people know is that if you change the duration of insulin action that’s programmed in the controller, that does not impact the automated insulin delivery. Yeah, it uses its own, you know, understanding of insulin action when it’s calculating its doses every five minutes. So don’t worry too much about that setting. What it could help you with is, if you’re finding that you feel if you feel constrained with your the correction Bolus as you try and give. Sometimes it could be if you shorten the insulin action time that can help. Typically, that set between three to four hours, that’s pretty, you know, common setting, sometimes as low as two. But again, something to talk with your healthcare professional about to, you know, see what would be the optimal setting for you.

Yeah, when I when I was setting up on the modified for art, and I have to admit, that was one of the first harebrained ideas I had, I was like, I’ll just make the insulin, the duration of insulin action so short, that it’ll never want to, you know, it’ll always actually know

everybody thinks that Scott is not just you, and it doesn’t, it’s not just Omnipod five, everyone thinks that for there. Yeah, and then you know, and it can get confusing, because in some systems, that setting does have an impact on the automation. So that’s where it gets to every system really needs to be approached as its own unique things. And for Omnipod, five, that is not going to impact the automated basil or the adaptive basil, but it will be used in your Bolus calculations when it’s factoring in insulin on board.

So let me let me bring up the next one. This is It’s funny, I have to stop myself because when I see the words, reverse correction, I actually read them in my head is reverse correction off, because I’ve never had them on before. But reverse correction. Yeah, tell me what it is. And where would you set it on it? About five? Yeah,

so reverse correction. So here’s what it is. It’s based on that target. Remember, I was talking about the target setting, we talked about how if you program your target at 110, and you program you’re correct above at 110, then anytime you’re above that correct above, you’re eligible for a correction to bring you back down to the target, the reverse correction is the opposite. So if your glucose value is less than the target, then it tries to take away some insulin to bring you back up to that target. So that’s that’s the theory behind it that, you know, if your target is set at 110, and your glucose value that you you know, put in the Bolus calculator is 85, then it’s going to the correction dose will end up being a negative number, because your current glucose value is less than the target. So here’s my suggestions for reverse correction. I honestly, my suggestion is typically to just turn it off, I don’t, I don’t think in automated mode, especially that it is necessary, because you know, you have the adaptive Basal that’s already adjusting the adaptive Basal, to try and keep you at that target anyway, so I don’t think you also need your Bolus doses to be reduced. And then because of how you can have, you know how I just talked about how you can have less insulin on board at mealtime, and often need more for your carb ratio, then it just can make it a little harder if you’re also getting a negative correction on top of that, when you already are going to need more than maybe you did before for your meal Bolus. So especially if you do use a higher target, like let’s say you prefer to have that habit run at 130 as the target, then then I then even more so really look at whether you need that reverse correction because it’s going to reduce insulin if in the Bolus calculator if you’re under 130. So all things to keep in mind doesn’t mean it’s not useful for anybody like, you know, there could be cases where it is useful to have the reverse correction on especially if you’re in manual mode. I think it becomes even more helpful to have that on but my default tends to be Need to turn it off and then like use it if it does seem like by looking at someone’s individual, like personalized data that this could be a useful thing to use. Gotcha.

Okay, so the last thing I want to talk about is extended Bolus. A lot of people are going to use this in regular pumping for you know, high carb, high fat meals, other things that hit later than usual. But in Omnipod, five, when you’re in automated mode, there is no extended Bolus, is that correct?

Yeah, that’s correct. There’s no option to use extended Bolus. It’s a manual mode only setting.

Okay. So in that scenario, would you Bolus, like we like I guess we should under like, understand for a second like so extended Bolus, first of all will work fine. In manual mode, it’s a setting that you can use in manual in automated it won’t. But if you I mean, pizza is the great example. Right? Pizza, Chinese food, it’s where people use the example. You have these foods that sort of digest slower, or they maybe give you an impact 90 minutes later, that kind of a thing. So people use extended boluses to kind of spread their insulin out to hit where they think they’re going to need it. But if but if I’m in automated mode, and I tell you like look, this is you know for sure this pizzas 35 carbs, the the algorithm isn’t going to see it isn’t going to understand that there was going to be like a fat rise later example. So do you just Bolus the fat rise on your own?

Well, I think it’s, I think it’s trial and error. And there’s a few different strategies. I think that that could work for different different people. The first thing I would suggest, though, when you’re first getting started and seeing like, how do I want to handle my, you know, my pizza and my Chinese food. The first thing I would say, is just Bolus normally, because and see how that goes. Because the adaptive insulin works very much like an extended Bolus. So if you think about it, the adaptive insulin is glucose dependent. So as your glucose is rising, your that’s going to start giving you more adaptive Basal, it’s going to increase that insulin, which is exactly what you do when you program an extended Bolus you, you program you, you drag out that Bolus delivery for a longer period of time instead of it all being delivered at once. And so in a lot of ways, it operates in the same way. Okay, so you could just try bolusing up front, and then seeing if the adaptive Basal response is sufficient to to help you manage that, right. If that doesn’t work, you could try splitting, you know, splitting the Bolus giving, you know, half the carbs up front and then adding in another the other half of the carbs a little, a few a couple hours later is an alternative strategy. Gotcha.

Okay. Time in range. I’m gonna ask you right here, but as we’re kind of buttoning this up, right, so the what is the range? Like when you think of time and range? What are you thinking of? Because I have a number in my head, I’m sure other people have different numbers. Yeah, you know, right.

And it’s, it’s completely valid actually, to have your own number in your head of what you have what you hope, you know, to have your blood sugar control that from my perspective, as a as a nurse, and know, in looking at the data and science, the time and range standardly speaking is 70 to 180. And the reason and 180 might sound high, but the reason for that is because it includes post meal, post meal, blood sugars, I mean, you’re going, you’re gonna have a rise in blood sugar after you eat, and then it’s gonna come back down. And so 70 to 180 is the kind of standardized time and range. And then the goal to have glucose levels in that target range 70% of the time, or more. So 70%. Time and range is the

is the goal. Gotcha. Between 70 and 180. Yes, gotcha.

Now, if you’re pregnant, that’s not true. But if you’re not, that is generally the agreed upon like, time and range. Sure.

Let me see what else we have here. I think we might be coming to the end of this actually, I guess let’s say let me say this about settings, right, you’re gonna give yourself the best chance by having the best settings you can have, you know, you and your healthcare provider, figure them out. At the beginning, it might not go exactly the way you expect. So you’re going to need some adjustments, you might need to be correcting some blood sugars along the way talking to your doctor again about you know, here’s what I’m seeing. You know, this seems like we could be doing better, how can you help me, but in the end, everything is settings. And I don’t just mean that for Omnipod five, if you’re on MDI, if you’re using you know dash for using another pump, a different CGM. In general the settings are the most important thing. Now the one thing that only pod five is going to offer you that. I mean, honestly none of the other systems are going to offer you is it it is going to make adjustments as time passes. So start with the best settings you can, it’ll probably hopefully get you there quicker. And if you’re not getting there on your settings, then that’s where the algorithm comes in and tries to learn and tries to do better for you. That’s that’s a fair assessment of the system. Is that correct?

Yeah, I think it’s a great summary. And the only thing I would add to that is, understand that it’s a, it’s a new paradigm, you’re adjusting to a new type of insulin delivery when you start an automated system. And so even though the Bolus doses aren’t automated, you’re still wanting to pair those so that they work in the best harmony with the automated system itself. And so you haven’t have to start using it, to see where that harmony lies. So expect that you may need to adjust those after starting as just a part of adjusting to a new system. Not necessarily like that means something’s wrong with it. It’s part of the process. If is what I would say,

for years on this podcast, I’ve told people that you have to sort of you just have to try and whatever happens is data. Right? And I’ll say data for the people who want me to say data data, no interview argues right, it’s data. So yeah, I don’t look at anything around diabetes as failure I look at as I tried something, here’s what happened. What can we do to impact it differently? The next time, I think that every time you ignore that data, you’re sort of just damning yourself to have to go through that experience, again, until you figure it out. So I like to step back in what I mean, sometimes I like a nice macro approach, like to see the whole thing and just say, okay, you know, I’ve been bolusing x for this meal for so long. Either my carb ratios not right, or this specific meal needs more insulin than other meals, do. Maybe my carb ratio works great for 10 of the meals I eat, but for two of them, it doesn’t work. And instead of trying to beat like a round peg through a square hole, you know, be part of the process, like and I feel like that’s what you were saying that the system does what it does, and then there are things that you can do.

Yeah, yeah, I agree with all that. Yeah. All right, that’s excellent.

Once again, I’d like to thank Carrie for coming on and sharing her on the pod five knowledge with us. I’d also like to remind you that this was part two of a three part series. If you didn’t begin with part one, I’d go right there now on the pod five pro tip overview. And of course, if you’re listening in order, there’s one more episode to go and it’s called Omni pod five pro tip connectivity. If you’d like to get started today with the Omni pod five, go to Omni pod.com forward slash juicebox. And if you’d like to find these episodes online, they’re at juicebox podcast.com, forward slash Omni pod five. And of course, they’ll always be available in your audio app. If you’re listening in an audio app new to the podcast and would like more content just like this, hit subscribe or follow. Thank you so much for listening. I’ll be back very soon with another episode of The Juicebox Podcast.

Hello friends and welcome to part three of my Omni pod five series with Carrie Birgit. Before we get started today with part three of this three part series, I’d like to tell you that insolate has paid the host of this podcast that’s me Scott Benner and my guest Carrie Berg get a fee to create this content. Carrie is an omni pod ambassador with an ongoing commercial relationship with insolate. This podcast provides general information discussions about health and related subjects. This information and other content provided in this podcast or in any length materials are not intended and should not be construed as medical advice. Nor is the information a substitute for professional medical expertise or treatment. Never disregard professional medical advice or delay seeking it because of something that you’ve heard in this podcast or read in any length materials. The opinions and views expressed on this podcast and website have no relation to those of any academic hospital, health practice, or other institution. Please speak with your healthcare team if you or any person has a medical concern. And before making any changes to your diabetes management, you can always consult the Omnipod five automated insulin delivery system User Guide for more information. In short, nothing new here on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making any changes to your healthcare plan. You are about to listen to part three of the Omni pod five Pro Tip series. This is Omni pod five pro tip connectivity, you should have already listened to part one, the pod five pro tip overview and part two on the pod five pro tip settings. These episodes were all released at the same time. So they’re in your podcast player in order, or you can find them at juicebox podcast.com forward slash Omni pod five. Carrie, here we are, we’re going to do the last little bit of our series together. This is our third installment. And this is going to be a lot about connectivity. Right? So yeah, because everything’s on body, right? You’re wearing your CGM on your body, you’re wearing your on the pod five on your body. And they need to talk to each other. And by that, right, we mean Bluetooth connection. Is that correct? Yeah, they talk via Bluetooth. Okay, so you’re gonna hear the words line of sight a lot, right? So I found myself initially, because I heard people say, well, the line of sight is very important. And I was like, Okay, great. What does that mean? What do we have to do? So what I, what I’ve gotten from Omnipod is optimal connectivity, that the devices should be at least three inches apart, with direct line of sight for consistent communication, right? So it’s funny, every time I read that, I hear it the wrong way, at least three inches. So doesn’t, you know, doesn’t have to be. It doesn’t have to be three inches, but it shouldn’t be two inches. What that means. I know that’s awfully simple, but it confuses me every time I read it for some reason. But then the other thing I can tell you is that my daughter wore her CGM on her hip. And she wore the on the pod five in a number of different places, right on her abdomen, etc. And we never had line of sight issues. But so is this one of these things that is best practice, but not necessarily. I might not have a problem with it.

Yeah, I mean, that’s been my experience. So I think the connectivity has been really robust, I really rarely hear of any issues with that, which is awesome. So, you know, I’m a big believer in if, you know, if it’s not broke, don’t fix it. So if you’re not having any issues with the connectivity, there’s no real reason to worry about wherever you’re wearing your devices. This seems to be working, you know, but if you are having issues that might be something to to kind of look at is to improve the to optimize the communication, maybe you do need to reconsider where you’re wearing it. See if you can get better line of sight, really same side of body seems to be another way you can think of it because the line of sight word can be a little hard. I think for some people to really know what we’re talking about. You just want the pod and the Dexcom to be able to see each other and Bluetooth doesn’t really like to communicate through things so like through the body. So even if you’re like on your right arm and right leg that might be better than being you know, on the right arm and the left leg. You know, I saw

someone online say they put it so simply they said listen, if you’re a stomach sleeper, don’t put one of the things on your stomach where you’re going to push it into the mattress and the other thing on your back or you know on the other side of you because that might create a barrier and But I the way you put it just now makes total sense to me do what works. And but if you run into this problem, then line of sight and by run into the issue. What are we really saying you could Oh yeah, come out of automated mode or you’d go into something called I’m losing the thought it’s

automated. Limited. Limited. Okay. Yeah.

So what is yeah, that is that automated limited?

Yeah, so if the pod does not receive information from the CGM, so meaning the communication is impaired, for some reason for more than 20 minutes, then it will go into automated limited mode. And what that is, is, I mean, it’s just like it sounds. It’s still automated mode, but it’s limited because it doesn’t have the main information it needs, which is the CGM. So what it does is it creates a static Basal delivery, it’s still determined its own delivery, but it doesn’t adjust it anymore, because it doesn’t have the CGM. So it will be based on the recent insulin delivery. So basically, like what was happening before we lost the communication, and then it will just deliver that and then once the CGM connectivity comes back, it will automatically go into the full automation. Okay. So that’s what you would see like from the user side, if to give you clues that like you are having issues with the communication if you’re getting these automated limited IDs. And it will also say on the Omnipod, five screen, it’ll say, searching for CGM. Okay, so if you’re not in warm up, because that’s expected if your incense or warm up, because you remember, every time you change your Dexcom, there’s going to be a two hour warmup period before you have any CGM information. So you will be unlimited during warmup. So that’s expected. But if you get limited a lot, and you’re not in warm ups, and that could indicate some connectivity issues.

Carrie, we haven’t been doing this that long together, and you don’t need me anymore. I was going to ask that question to lead

you into your know what you’re gonna say. You’re adorable. I was

going to be like, What about throwing a warmup period? Okay, and then just pause all delightfully. And then you would have come in and filled in that information. Oh, you just don’t need me. It’s done. So I do though. It sounds like our relationship is over. So after 20 minutes without CGM readings, you’re gonna go into automated mode, or excuse me into, into limited, is that right? That’s correct. And then line of sight? I mean, body styles are different, right? So just try to give yourself the best. I mean, I would if it was listening, anecdotally, if this was happening here, I would put stuff at least three inches apart that where they could see each other, and then I would trial and error and move things around and try to try to see what works for us. And and you know, then you find a rhythm. And I think you’re good after that. Yeah, yeah. This isn’t even something that some like, in your, in your experience. Some people don’t experience this at all, I would imagine.

Yeah, I mean, in my experience, most people don’t experience this at all. But um, there’s definitely something to keep in mind, because of just the basic understanding that that is how the system works. The Dexcom talks directly to the pod. And so you want to try and optimize that. But yeah, so it’s not something that I hear of as an issue very often, which is really, really encouraging, I think. Yeah,

so far, I found it to be incredibly reliable. Here’s a question from a listener. They want to know if there’s anything that could happen with missing CGM data that would kick them into manual mode.

Not with missing CGM data. Okay. Yeah. So, but there is one other situation where you, you could need to go into manual mode. And that’s if you have what’s referred to, as you would see on your screen, an automated delivery restriction alarm? You know, there are some safety things built in where if the adaptive Basal has been delivering at a maximum, the maximum rate for too long, or, you know, been suspended for too long. You know, if you’re, if, if it’s not working, it suggests that potentially there’s something wrong that’s outside of the algorithms, you know, ability to fix. And that gets back to a lot of these basics of just, you know, has your infusion site failed, did your pod actually just fall off and you’re actually not getting any insulin at all right? So things like that. So the system will alarm you and say automated delivery restriction, you know, confirm that your CGM is actually as high or as low as we think it is. Make sure your pod is actually in place. And then deal with it, you know, right. And then also it will make you go into manual mode for five minutes just so you can deal with it and then you can put yourself right back in so that’s the only time that you, you know, could be forced to kind of to go into manual mode. Okay.

And you know, I think it’s it’s just worth saying here that you know, if your symptoms don’t match the readings you’re getting, you might want to change the sensor on your CGM. If you’re getting automated insulin delivery restriction alerts, just like you said, the whole point of the system right is about safety. So yeah, pay attention to that. Look for other alerts, and make sure you’re getting your insulin the way you’re supposed to. Yep,

exactly. Yeah, I mean, you’re still relying on the CGM. So if it’s, if you feel low, but the CGM is not showing that you’re low, you should, you should check your glucose and see if you’re allowed, like check with a meter. Sometimes, you can pull that meter out, you know, and use it for that situation.

Now make sure that we we explained automated mode limited properly. I feel like we did, but I have bullet points here in front of me. And I have to be honest with you. I’m not I’m not a details person. That’s a weird thing for me to be saying on those but I am not. So I just want to roll through them to make sure we have them right in automated in automated mode limited. smarter, just technology can no longer fully adjust your automated insulin delivery because the pod is not receiving updated glucose information from the CGM. So that’s a definition there. When the system enters limited state smarter, just talk technology never gives more than the Basal program. Oh, that’s interesting. So Oh, yeah, that is true. I

forgot to mention. So

if we go into limited, and that initial Basal, we set up with one unit per hour, it is not going to go above that in limited mode. Right.

Okay. Yes. But I want to make sure it’s clear, that doesn’t mean that it’s going to deliver that one unit an hour. It just means that that’s it won’t ever go above,

can we, okay, if you’re in in the limited situation, right? After an hour of Miss CGM values, the missing values. Let’s see, advisory alarm happens a lot.

Yes, it just means the system is going to let you know, if you’ve been in limited for an hour, you’re gonna get an alert that’s like, Hey, you’re still unlimited. Do you want to do something about that? And then

that’s the next part here is if that happens, you’re gonna continue to get the insulin but the insulin that the system considers safe until the CGM reconnects, yes. Okay. Well, that’s cool. So that’s that. So that’s based, that’s where that learning comes in to help you in that situation.

Yeah. And it’s also based on recent delivery. So you know, if you are suspended leading up to losing the connection, just keep in mind that it’s, you know, you’re likely not going to be getting very much then because how could it it doesn’t know any information to know whether it can safely start giving you more or not. So

Well, I’m sorry, I didn’t mean to cut you. Oh, no, that’s all. And then so when the CGM comes back, though, we go right back into automated mode. I don’t have to do anything. That

is correct. When the CGM comes back, it’ll automatically go back to full automated mode.

The reason I asked that is because I know when you put on a new pod, it does prompt you and ask you if you want to be in automated mode, that very first time when the new pod goes on. So that’s cool. So if you just lose your CGM data, you’re not going to get nagged about a little just head back to where it belongs. Once the data’s Yep.

Okay, once it’s back, it’s back on its way. Yep. Okay.

I think you said this one, because someone asked the question, how long does this system need to be paused or at max delivery for before? Before they say they’re asking before manual mode kicks in?

So they’re, they’re getting at the automated delivery restriction? And this is just another thing you just can’t know. So there’s, there’s no exact answer to that, you know, there is no fixed time period. It’s based on multiple factors, including how long it’s been at max delivery, but also your glucose level. So I do appreciate that that I mean, that’s a question. If you’re at max, and it’s working, you know, you’re not going to get that alarm. But if it’s not, you know, you will,

and it does say listen, I have a note here it says 97% of patients remained in automated mode through the pivotal trials. So

yes, it’s very, very easy to stay in automated mode. It’s really a non issue. Like, you’re not going to be as long as you’re wearing your CGM. While even if you were, I guess you weren’t, you could just be unlimited all the time, which I would not recommend. But, you know, you’re not going to get kicked out and having to be doing all this work to get back into automated mode. We really don’t see that at all. I mean, I can’t I mean, you’re gonna be in the high 90%. You know, time in automated mode. Yeah. I

think it easily I think this whole conversation points out one of the things that for years leading up to on the pod five, I was always pointing out as a major benefit of it, which is that it’s a completely on body system. And that, you know, of course, we talked about in the first episode, you know, you need you need your controller to hear your alarms. You don’t have to see your CGM, you know, on your phone to, to know what your graph says, etc. But that just if you know, you don’t realize how many times you’re watching television, and you walk into another room, and then you stay there for 10 or 15 minutes or you get Know you head out back and you take a breath of fresh air, not having to take that stuff with you. And the algorithms still working to me is one of the really, most genuinely I’m being genuine here. That’s one of the most exciting aspects of Omnipod. Five to me is that it’s an on body system, and it is working no matter what room you walk into. Or if your cell phone, you know, gets left outside on the patio for 10 minutes or something like that. I think that’s really it’s just a it’s a fantastic aspect of it to me.

Yeah, yeah. It’s really it’s really unique and very cool. Cool. That is the case.

All right. I have a couple more questions here. Carrie, let’s roll through them with me. What does the thinking calculating? Where does that happen? And I feel like we’ve gone over that already. Right. Like the controller’s not part of the algorithm that the algorithm lives right on the pot. Right. Okay. I’ll see. I’m asking questions. And we already answered them all. Maybe we’re so good at this. We didn’t even need these questions. Let’s find out. Yeah, we went through why you might get kicked out of automated mode. Look at us, I feeling very good about what we’ve done here.

Second, you’ve exhausted all the questions. Wow. Okay,

here’s one. Why can the G six receiver not be used while the Omni pod five is being used?

Yes, important question. Okay. So the reason is this, the Dexcom can be connected to one medical device, and one app, the G six mobile app. It when you’re using the Omnipod five, the Omni pod, the pod itself takes the place of the medical device. So the receiver is also a medical device. And so you just can’t. And that’s true for any pump that you’re you can connect to CGM two, you cannot connect any Dexcom to a pump and a receiver.

I don’t know why. But then, but

I don’t know why that is either. It’s just like some sort of regulatory it’s a universal thing, though. Yeah. It’s just like a regulatory thing. I don’t know the reasoning or why why, but it’s just how it is. Yeah. So

if I want to know other things, like people who started with what they would consider a good agency to begin with, you know, there’s pivotal data online that only pods made available, right? So we could put like a link to it here if people wanted to know, these kinds of like, drill down questions. Okay. I personally think even if you will, first of all, you know, even the word good in the question is in quotes, and I would be I’m making quotes myself, and nobody can see me. So if you’re expected outcomes are, I don’t know, like in the sixes, right? And your time and range is already good. Yeah. Maybe you’re not going to see some amazing, like transformation. But I think where you still will see amazing transformation is the amount of effort you have to put in overnight sleeping, just burdened stuff, right. Like, you know, yes, hopefully, you know, I’m saying like, by that, like, forget about

hypoglycemia, because a lot of times you can, you know, you can get a quote really good a one C at the expense of a lot of hyperglycemia. Yeah, and so the other thing you might see is the percent time hyperglycemia might go down, and you might be able to, you know, get to the same, you know, Level Time and range that you want without having to also deal with a ton of hyperglycemia. Yeah,

I, the way that I talked about on the podcast is that you can’t be you can’t have a 50 blood sugar for five hours a day and a 60 blood sugar for five hours a day and a 300 blood sugar for a portion of the day. And then because when you do the math on that you’re a one C might come back. And you might be like, Well, I’ve done a one C 7.2. That’s not too bad. But that’s not that is not safe, it is not healthy, it is not what you’re looking for, you’re looking for stability in that range. And that’s what you’re asking on the pod five to deliver to you. Yeah.

And that’s why I always encourage people to actually focus more on time and range than even a one C, because time and range doesn’t allow you to ignore that piece. Because you you can have an agency of six with the example you just gave. But if you looked at time and range, your time range is probably not 70 in that situation. Yeah. So the time and range really helps you balance this all out to see to find that balance of it’s about stability, it’s not about getting the lowest agency you can possibly possibly get at the expense of kind of hypoglycemia

in just a couple seconds. I’ll tell you a story. There’s a person I helped a long time ago, who came to me and said, we’re fighting a lot of highs and lows, but my kids say once he’s pretty good. And I said well, you know when you get a graph, that’s pretty, you know, like normal one you see most of the times could you send it to me so I look at it she sends it to me it looks at it and I am not over exaggerating. Carrie this kid’s blood sugar went from 62 460 to 400 It looked like the Alps. This poor lady was just she was fighting and fighting, and she just couldn’t figure out how to do it. And I think of her, when I think of this system, I think that kid would just be in a different situation without that, and you took her, I, you know, she might still listen to this podcast, it took her a couple of years to figure it out. And if you’re telling me that my algorithm can, you know, in a couple of weeks, start learning me and stop stuff like that from happening. It’s, it’s this about the greatest thing I’ve ever heard,

it’s life changing, because you know, it’s not also not only about blood sugar numbers, too, it’s about your life and your quality of life. And like, being able to do the things you want to do, you know, in that situation, that kid probably can barely play a sport or go to a friend’s house, if that’s what they’re having to deal with, you know. So that’s a big, big piece of it.

It’s just crazy. So let’s go over one more thing real quickly. And then I’m going to answer a bunch of people’s questions, and we’re all gonna go home. So right activity mode, somehow, we didn’t talk about it through this whole time. Yeah, we didn’t do how do you? How do you implement it?

Yeah, it’s really easy to use, actually. So when you go to the main menu, if you’re in automated mode, you will see a menu called activity, which you just go to that menu, and then you turn it on for whatever duration you want, from one hour to 24 hours. And what it will do is when you have it on, it changes the target glucose for the adaptive Basal to 150. But then, in addition to that, it reduces the insulin delivery. So that’s what distinguishes using activity feature from just setting the target at 150. Is that you know, so it’ll calculate the delivery with the 150, Target, and then additionally, reduce it from there. So what’s going to drastically reduce your insulin delivery? So the concept is that it’s a way for you to, you know, reduce the insulin delivery for a duration of time, when you know, your insulin delivery needs are going to go down. The main example would be, you know, aerobic exercise. Yeah, but

would you agree, and this is me, I’m now just taking what you said, and thinking a little farther, if I use the activity mode. And I thought, well, this worked great. I didn’t get low. But I was higher than I wanted to be. Could I also not change my target, instead of going to activity mode? Because I try 140? Is my target like seemed like that kind of stuff is is? is a good idea? You think? Yes,

absolutely. See the skill sets being on the same wavelength, because I was just going to talk about that that activity feature, it’s one option that you should definitely try for exercise. But if you find that you run too high with it, then you know, you got to try something different. And Alternatively, you could change your target. But the downside to that is, if it’s not regular activity, like if you’re really if you have really routined activity, and you can just program a higher target for that, you know, when you need it for that activity that you do, then that could work. Well. The downside to changing the target is just, if you’re changing it, because you’re like going for a hike, just remember, you’re gonna need to change it back. It’s like a program setting that you’re going to need to to manually change, versus you can just press a button to turn on activity feature, and then it will change it without you having to manually change it. Does that make sense? It absolutely

does. And that goes to what you said earlier about being still being involved and thoughtful and making moves that are going to help you not just saying, Oh, the thing will take care of it. Yeah, yeah. So I just have quick questions from people that to be honest with your kind of yes and no stuff. So I’m not going to burden you with pretending I don’t know the answer to some of them. So is on the pod working on a follow up? Yes, they are. Is there any indication of when the iOS app is coming? There is no timeline, but it is being worked on. And I know a number of people who work it on the pod, and they’re lovely people who seem like they go to work and work very hard. So let’s hope that that works out as quickly as possible. Do they have any future goals for changing the target on the pod is going to tell you that? They want you to remember first of all that the target glucose of 110 is the lowest target glucose on the market in the United States.

That is true. I never thought about that. Isn’t this interesting?

Right? That people can infer what they want here, I guess, but they’re the answer to my question. Are there going to be future changes? Is we currently have the lowest boy that doesn’t say no or yes, that’s it. Does not have exciting All right.

Oh, mystery there. Exactly.

Also, I am realizing that I called the follow up the follow up and it’s on the pod view. I told you the details aren’t my strong suit. That’s being worked on. I think we have everything else. I have one last thing here. And and then I’m gonna let you go So the question is, is there any idea when the FDA will approve for under six years old? This person says they’re getting pushback from their Endo, because their son is three and a half. Now, the answer from Omnipod is they’ve recently published data for that age group, and that they’ve submitted to the FDA for an indication all the way down to carry I really appreciate you doing this with me. I have to say that, you know, this being our first time recording together, I felt a real kinship with you. And I’d like to invite you to come back on the podcast and talk about this and a lot of other things in the future. Yeah,

it was really fun. Thank you so much for having me. I was really I wasn’t sure this was this was a blast. Actually, you weren’t sure real pro because you made me feel really comfortable even though like I really was not. Carry

Listen, let’s be honest with the people that are listening, right? I don’t come off as someone who would have been good like this when you meet me in meetings and other stuff. And you were probably like, there’s no way this guy is going to pull this off. Right?

It was Yeah. It was just such a blast. I really, really appreciate it. All right, podcasts are fun.

This podcasts are fun. This is my wheelhouse carry. I don’t know how this happened. But But nevertheless, here it is. Yeah.

Well, you found it. Thank you. So keep on keepin on

thanks again to Carrie Birgit for coming on the show and sharing what she knows about Omni pod five with me. And thanks to all of you for listening. If you know anybody who’s interested in getting started with Omni pod five, please share these episodes with them. We’ll refer back to them yourself. If you need some help from time to time. Don’t forget these episodes are always going to be available in your podcast player. We’re at juicebox podcast.com forward slash Omni pod five. If you’re interested in more on the pod five content, we’re going to have a lot of it right here on the Juicebox Podcast. The best way to know when that contents available is by subscribing or following in a podcast app to get started right now with Omni pod five, go to Omni pod.com forward slash juicebox. Thank you so much for listening. I’ll be back very soon with another episode of The Juicebox Podcast.

Hello friends, and welcome to episode 794 of the Juicebox Podcast. Kate is here today her child uses Omni pod five, and they’ve done a reset of the Omni pod five. So it’s a big conversation. But somewhere I don’t know about 40 minutes in we’re going to talk about how they started over with new settings. You’ll see. While you’re listening, please remember that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making any changes to your health care plan for becoming bold with insulin. If you’re looking to start with on the pod five, or you’ve gotten started and want to know more, I have a three part series that I produced with Omni pod all about it. You can find it at juicebox podcast.com forward slash Omni pod five, or by going to episodes 736 737 and 738. Do you have type one or are you the caregiver of someone with type one? Are you also a US resident? Well, you’re in luck, because if you go to T one D exchange.org, forward slash juicebox you’ll be able to join the registry. Fill out the survey help people living with type one diabetes, move diabetes research forward, help yourself maybe get involved in research yourself if you want support the podcast so much is going to happen when you go to T one day exchange.org forward slash juice box and complete that survey. This episode of The Juicebox Podcast is sponsored by Omni pod makers of the Omni pod five, and the Omni pod dash. To get started today. Go to Omni pod.com Ford slash juice box. You can be tubeless and automated with Omni pod five or tube listen. Well not automated. Without the pod dash to grade systems. You take a look see which one’s best for you. The podcast is also sponsored today by the Contour Next One blood glucose meter. This is my favorite blood glucose meter. The best one I’ve ever used, held touched, or thought about in my dreams contour next one.com forward slash juice box. There’s a number of reasons to love the Contour. Next One, and I’m gonna tell you all about them in just a little bit. Today’s show is also sponsored by us med. Get your diabetes supplies the same way we do from us med go to us med.com forward slash juice box or call 888-721-1514 When you go to the link or call the number you can get yourself our free benefits check to get started right away. We get on the pod and Dexcom from us Med and you could too as well as a number of other things they’ll tell you about me.

My name is Kate. I have three children, all boys that are 10. seven and five. I am teacher at the school that they go to. And my 10 year old Grayson has type one diabetes and celiac disease

10 Seven, five.

Yes. All boys. All boys. Yep.

I send you a picture what my mom looks like now because that’s your future.

Oh my god. Yeah, the hardest part about setting this up is just like making sure like they aren’t here so that they don’t come in the room a million times.

So while you are getting this together. Yeah, we’re tiny bit of technical difficulties. I thought that I heard a young man yell. Oh my god, the cat got out.

Yeah, that was Grayson. So the little to my younger two boys, I got out of the house because there’s I can’t function with them here. And my oldest Grayson is still here. So I’m like, you have to take the dog like that’s your job, get the dog in your room. And he left the dog out when he was trying to help me with my headphone issues. So.

Okay, and when you say the other two, aren’t there? Yeah. Are they alive? Because it’s, it’s early in the morning. Like, where are they at?

Yeah, I just told them to go, you know, outside. I locked the door and they’ll be fine. They’ll entertain themselves for an hour

in the street. Right? Yeah, absolutely. Well,

I don’t know. No. They’re there at the museum for the for the morning, which is good.

Oh, I’m just putting it together. Now why you can do this. Today’s Columbus Day.

Yeah. So we’re off from school, which is good, because I’m available. I’m not working but also not good because the children are home. So yeah, it’s

not not a real day off. The boys are by themselves or there’s somebody with them?

No, they’re, there’s somebody with them. Okay. They’re supervised by an adult who was surprisingly willing to take them and we’ll see how that goes.

We lived on a very busy road. So okay, yeah, I mean, people might be imagining just like a street where like you But cut through town or something but I’m telling you we lived on a on a five lane road. Oh God, my house. It’s terrible. My house was 25 feet from the sidewalk. And if it was constant traffic, and there during the summer as a matter of fact, like when the sun was shining at the at the front of the house if a truck or tractor trailer would go by and it would eclipse the room it would scare the hell out of you like it was like that. And we want through my younger brother, but naked out. So,

yeah, that’s pretty much what it’s like around here. Like, I live in a neighborhood but people drive really fast. Which is crazy to me. I’m kind of like on a curb. So I feel like you really can’t see the kids if they were happened to run on the road.

Well, if they’re Neko

Oh, yeah, absolutely. They would be like glaring, but they like last year when I moved in here. I bought this thing on Amazon. It’s, it’s uh, it looks like the construction gate. And it goes at the end of your drive. It’s like this big orange. Oh, I know. Yeah. Yeah, Master gate. And so it stops them from like when they’re playing basketball, running into the road, like Chase her ball. Now as you come in the neighborhood, like the lady with the gate, like I went to a block party and people like, oh, yeah, you’re the house that has like that orange gate.

So yes, because my kids will run into traffic. Do you understand? Yeah.

Which makes me sound like a really good parent. So

let’s get this recorded before these kids kill you. Because it’s probably not gonna it’s not gonna take much longer. Oh, no, for sure. Okay, boy, mom, here we go. Your 10 year old is the type one he also has celiac and tell me his name again. Grayson, right? Yeah, Grayson, yeah. Okay. All right. So how long has Grayson had type one?

He was diagnosed in July of 2021. We’re like, just over a year.

Okay, pretty recently, celiac before or after diabetes?

It was they told me, Well, they apparently tested him, like at the diagnosis of the type one, but I didn’t know that. And they called me like, 10 days later to tell me that his celiac

panel was positive. Had you noticed anything about it before?

No. Like he literally had no celiac symptoms at all. It was like, switched on when the diabetes came on?

And is he keeping a celiac diet?

Yeah, yep. So she’s been on that for about a year. Did

the rest of the family change with him? Or did you? Yeah,

for the most part, yes. You know, and that’s like, tricky, because my little boys sometimes don’t understand, like, why can’t you know, we went to like a farm this weekend, for like a fall thing. And they want apple cider doughnuts, but there’s no option that’s celiac, you know, friendly. And so that’s been a little tricky. But over the course of the year, like, I’m starting to learn how to bake things to to supplement the things that they all want. So if one wants donuts, then we can figure out a way to make a doughnut for gray or find you know, an option. We’re lucky to have some grocery stores around that are celiac friendly. So that’s been good. But for the most part, we all eat gluten free.

Okay. What are his symptoms? If he has gluten?

He is like immediately sick, like in the bathroom? Like lots of diarrhea.

Well, that’ll. That’ll make you eat gluten free. That’s for sure.

Yeah. So that I mean, not that I want him to have those symptoms. But I know like people that don’t have bad symptoms, I could see that being hard to stick to, you know, a celiac or gluten free diet, but because it makes him sick, like he doesn’t want to do that.

Well, Caitlin, I now feel absolutely compelled to say that I have learned through the podcast, that even if you don’t have symptoms, you can be doing serious damage to the internal portions of your body, which could lead to things as serious as cancer. And if I don’t say that people with celiac will yell at me online. So I now.

Yeah, I heard that episode where I appreciated the woman. I can’t remember her name, but she came out and I think she had written you an email about how like, you can’t just like eat the cupcake. Yeah, no,

I got the cupcake. I’m not even bringing that up. Caitlin. All right. Well, I’ll bring it up. All. All I did was this guy was having serious mental health issues. The Father Yes. And his son, had I got guests gotten a celiac diagnosis but was having from what I understand, like no symptoms whatsoever. So you could either hand listen, if celiac was a thing, he could eat a handle full of it and nothing happened to him. But then obviously there’s I said obviously because I do not want to get yelled at but obviously there are there are still impacts that can be had even though you’re not seeing them physically, that are fairly serious and up fairly serious up to really serious And I was trying to make the point that while the guy was figuring things out, yeah, maybe just let them have the cupcake. Because also, I would like to say, Kate, that He also described a scenario where the kid wasn’t really having cupcakes. It was just this. He was. You have to go listen to it. He was in a panic.

And yeah, I heard I heard it. I know exactly what I’m talking about. Yeah.

It was like he was he was having real trouble. And he, he couldn’t add one more thing to his plate. And, and he’s like, Well, what about at a birthday party? Like he was crying? Like, what about your birthday party? He wouldn’t be able to have a cupcake. And I was like, Well, does he have a lot of cupcakes? And the guys guys like, No, you I’m like, does he go to a lot of birthday parties? He’s like, No, I’m like, well, then until you can pull this together. What if you just let him have the cupcake. And then the letters came?

Yeah. It’s funny, because the reason why Grayson is still here is because he’s actually going to a birthday party today. And so he’s he’s getting picked up in a little while. And like, it is a thing where like, I have to pack a lunchbox with gluten free pizza, the gluten free cupcakes, they’re going to a sports place where they’re going to drink Gatorade. So I’ve got it, you know, sugar free Gatorade, and you know it, I could see what he was saying where it like feels like another like another hit that you’re like, God, like the diabetes was bad enough. Now this and it’s more annoying sometimes. Because I don’t want to like, bake and cook all this stuff in preparation for my kid to go to a party. You know,

I completely understood which was why he was trying to save him into Yeah, until he was Josh. By the way. Josh has been on twice. He’s an incredibly like, open. empathetic, yeah, person. His episodes are called Josh has all the fields. And Josh has added more fields. So go listen to them. And please don’t write me a note and yell at me. But yeah, but food quality. I mean, I I listen, it’s not the same thing. But Arden has been at college now for about a month. Yeah. And the quality of food at college is not what it was in our house. Right. And we are like fighting with almost every meal Bolus, because the food, the food’s just not as good as what she eats at home. So, I mean, there’s part of me that feels like I’d like to be walking around behind her hand in her lunchbox every time she went through me.

Yeah, you know? Yeah, yeah, for sure. And I think that’s the thing in the first year, like, I definitely understand, you know, from listening to so much of your podcasts, like what needs to be done. It’s just it takes experience to figure out like, how do I Bolus for this thing that he hasn’t eaten before, like yesterday, he had a chocolate pudding. He’s never had pudding before. And like, you know, something happens that you don’t expect you have to figure out like, how to Bolus for each food. And once you have that, you know, under your belt, I feel like eventually it’ll get a little bit easier. But we still are fighting with a lot of, you know, meal Bolus, especially with the gluten free food because it just hits a lot harder.

Yeah, gluten free doesn’t mean low carb. That’s for sure.

No, it’s like twice the carb when people say they’re doing a gluten free diet to lose weight. I’m like, You’re crazy. Like you got it wrong.

Do you remember me saying on the podcast once the doctor made me go gluten free for a month to test something? And I was like, Oh, I’m eating healthy. I gained 10 pounds. I was like, Wait, yeah.

Yeah, it’s definitely not good. And like when I say we eat gluten free, like I primarily eat mostly gluten free, but I don’t eat any of the gluten free products. You know, Grayson does because he’s a kid and he wants a sandwich. And you know, he wants pretzels and things like that. But they they definitely are all made with like rice flour and things that are really hard to Bolus for. So that’s been tricky.

Yeah, you definitely have to be careful. Gluten Free can also mean processed. Yeah, with a lot of those a lot of those prepared foods anyway. Okay. So, keep that’s not really why you’re on today. Right? You’re on because Grayson has been using on the pod five? Yes. Okay. So how was he managing? I almost said straight out the gate. And I don’t know why.

No, that’s what it’s gonna be called, isn’t it?

Oh, no, I don’t think so. Because that’s my phone. Because I said, Hey, how was he managing straight out the gate? And then I thought, there’s a phrase I’ve never used before, but, okay, I didn’t get a ton of sleep last night. So this could get hairy. But no worries, no worries. But when he was diagnosed, and he and he came home, what do you have?

So we left the hospital with pens, you know, pretty much like everybody else. And then I would say within about a month he we got him on to Dexcom which was very helpful. And I’m kind of like the type of person like I don’t like to wait when I like make a decision. Like I knew pretty early on that I wanted him to pump and he was a little bit nervous about that. So we you know, It took some time settling in, but I had joined a local support group and I, you know, was talking to them about pumping and how the, you know, the endocrinologist wants you to wait six months or a year or whatever. And the ladies in the support group were like, No, you don’t have to do that, like you can. You don’t even need to go to the pump training. You just research them on your own, decide what you want and tell them and they’ll order it. And I was kind of like, Oh, I didn’t realize like, I could just tell them what I want to do and skip, you know, their their rules, per se. So probably within like three months, maybe I think November he started on Omnipod dash.

Okay, so in a month Dexcom and a few more months Dash. And then how long ago did you start five?

He was he started on the five at the end of May.

May, June, July, August, seven months ago. About?

Yeah, it’s a pendant lamp. Well, June, July, August, September. Yeah, maybe like five months or so

five, six months? On the five. Yeah. And all right. So when you first started it, you were pretty some it’s it feels to me like you got it right away when it came out. Is that about right?

Yeah. Yeah. Like I said, I’m not super patient. So you know, I was waiting, I got that email that everybody got from Omnipod saying it was available. And I called my endocrinologist that day. And they were like, What are you talking about? Like, they didn’t even know that, you know, it was rolling out. So that was fun. And they didn’t know how to prescribe it. They were like, we don’t have codes yet. Like you just you’ve got to wait. So probably a week went by until my endocrinologist put in the script. And then when it got to the pharmacy, then the insurance became an issue. So I had like a two or three week battle with my insurance company to get them to cover the intro kit, which has like the PDM in it, or the controller. Yeah, I

think they figured that out that all that coatings figured out by now. But yeah, I remember that. Yeah.

Yeah. So like I was calling our insurance company all the time, like, trying to figure out why wouldn’t go through why were the pods covered and not the controller. And finally, one day, I was just so fed up with it. I just told the people there, you know, they are diabetic experts. Like, they were like, no, no, it has to go through DME like it definitely does it. And you know, we’re having this battle. And the lady was thought I was talking about the Dexcom. Like, she was confused. And I was finally like, I just want to speak to your manager, like whoever’s above you like, I just, I’m ready to just move on from talking to you. And my kids thought that was hilarious. And like, called me a Karen, they were like, You asked to speak to the manager? I was like, I’ll do it. You know,

okay, at one time, I said, you know, I need to speak with your manager. And there’s nobody here above me. And I said, I find that completely hard to believe you’re in charge. Even as I was saying, and I bought it sound like a thick, but whatever. Yeah.

Yeah, it’s fine. I’m like, if I’m gonna get what we need here, I’m totally fine with owning that Karen status for a little. So eventually, they, they did. I talked to the manager, and he literally was like, I’m just going to override it. It’s fine. And I no joke had the pump the next day.

He’s like, will you hang up? If I do this?

I know, I’m like, God, I should ask the manager more often because we got what we wanted.

Okay, so on the pod five comes. So the picture we’re painting here, because by the way, all those insurance problems that you just described, where we’re like a launch issue, it doesn’t exist anymore. Like nobody’s gonna tell you, you can have the pods but not like your stuff like that. So. But it’s an indicator of how early on you were into it. So you had it before I even put out those three episodes about starting on the pod five, right?

Yes, sadly, yes. Because we were, I was like, kind of jumping in blindly with what to do with it.

So you know, if you go back and listen to those three episodes that I made in conjunction with AMI pot about starting on a pot five, you’re gonna hear that the closer your settings are to a 5050 split between Basal and Bolus insulin, the easier time that the algorithm is going to have getting itself set up and straight so when you started it the first time do you remember how you had your settings?

Yeah, we definitely I did not put in settings that were aggressive enough for sure. So I think we were definitely also relying on basil.

Krishna one job here kale. You know, and I mean, you didn’t let him down you got on the on the pod five right away when he needed it. Now. This kid can’t hold on to the stock. What do you think he’s doing that I thought right or do you think he’s ignoring it going? Like I asked my son that take the dogs to take take care of the dogs And I come down. I’m like, Hey, you took the dogs out. You just not yet. I mean, you’ve been down here for half an hour. Yes. They don’t seem to be in a hurry. And I was like, well, when they peed on the floor, or whatever they’re gonna do if you don’t let them out like, well, you clean that up. And he was like, no.

That’s about it. Yeah. Well, FedEx truck just pulled up. And so that’s what he’s barking at. And I’m sure like gray clearly has already forgotten that.

He’s been talking for 20 minutes. So yeah, I’m sorry. I apologize. So you I’m sorry. So you said you set it up with your settings. How are you? How are you? I guess my first question is when you were on dash, were the settings like super tight? Was he super stable at a low number or were you still working that out? US med carries everything from insulin pumps and diabetes testing supplies to the latest and CGM, like the FreeStyle Libre three and the Dexcom G six, and we get Ardens on the pods from us med. As a matter of fact, US med is the number one fastest growing tandem distributor nationwide, the number one rated distributor index com customer satisfaction surveys. And they’re the number one distributor for FreeStyle Libre systems nationwide, you’re gonna get better service and better care from us Med and that’s what they’ve given to the over 1 million diabetes customers that they’ve helped since 1996. US Matt accepts Medicare nationwide and over 800 private insurers. 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I think you’re going to be running, not walking to get an omni pod five, for full safety risk information, free trial terms and conditions, as well as a list of compatible smartphones. You can also go to omnipod.com forward slash juice box but I just realized I said free trial terms conditions but I haven’t told you about any free trial. So let me just tell you that you may be eligible for a free 30 day trial of the Omni pod dash now that’s not the only part five not the automated system. But the dash which is an amazing tubeless insulin pump that you control Omni pod.com forward slash juicebox go find out which way you want to go you want to go five you want to go down Ash, you want to try the free 30 days, it’s up to you really get in there, fight for yourself, whether you’re looking into Omni pod Contour, Next One or US med or any of the sponsors, please use my links when you click on my link, it supports the show. Those links are available at juicebox podcast.com. 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I feel like for being in our first year, I was really happy with how we did on dash when he back in April only got to say once T after he had been on dash, you know, for about six months. He was at a 6% which I was happy with. Yeah, and you know, it’s not do I think some people run lower? Yes, I would say he was averaging around like 121 30. Somewhere in there. Which you know, for an active 10 year old it was working for him. It was a lot of work though, for us. Like we were doing a lot of like Temp Basal, like constantly trying to adjust and give a little bit more and take a little way to keep him in range, which was difficult,

right? Which means you don’t know exactly what his settings were because you were adding. Right. Okay.

Yeah, yeah. So I, we had done some basil testing. And at that time, I was working with Jenny. So she was really helpful and helping us kind of tweak things here and there. And I felt like we got to a point where we were doing okay, like his setting seemed good. But I do think looking back now we were probably relying a little bit on his Basal. So his ratio, it was not 5050 When he looked back in his settings, so

you’re saying you had like a heavy Basal rate? Yeah. So yes. Okay. So you were bumping around a lot, because you were feeding the insulin and then going back up? Yes, yeah. Okay.

Which I could kind of do at the time because Grayson went to the elementary school that I work at. So I would like to sneak down to his room and like, give him a little more take a little way. Like I was doing a lot of management during the day at school,

and the kids who were teaching can’t count now, is that correct?

Well, I teach reading, so they, they might be able to count but um, they might be below in reading. So

I don’t know this word but Grayson’s Okay, so everybody’s,

yeah, they totally new like, they do the chaos of like, diabetes. And, you know, sometimes a kid came with me, I’m like, Hey, Grayson’s low on the playground, we gotta go find him. You know,

let’s go on an adventure. Or as I call it at my house, how?

They were fine with they’re like, Oh, we’re getting none of our lesson plan. Right?

Yeah, right. Yeah. You’re not gonna make me read? I’m down. Yes. So when you start it? I mean, I guess just tell me how it went for you the first couple of weeks.

It didn’t go great. In the beginning. Like all of a sudden, we were seeing a lot of highs after meals. And you know, we had some lows, the night time was a little bit better. I know a lot of people have said that too. But what I ended up realizing was that his carb ratio was very wrong for the Omnipod. Five. So we ended up switching I think he was at one to 25 when he was on Dash. And we ended up at like one to 15 Eventually. On Omnipod. Five, like Jenny had told me Jenny was like, I would put it down to one to 20 I’m like, what that’s like, way too much. That sounds crazy. And she was right. And then some because we definitely needed more insulin at mealtimes, for sure.

Yes, she was trying to move you incrementally and you weren’t moving. Were you? I

was just, I was nervous. I was like, Oh, I’ll try like one to 23 like I just did it very slowly.

Do you ever think of this from Jenny’s perspective, because I just occurred to me like, like, your call ends and she just like smacks her head on the desk and goes

I feel like Jedi and I, I feel like we’ve got each other because there was a couple of times I was on the call with her. And like, all three of my kids are jumping on my bad like she’s a boy mom. I’m like, life is crazy over here. You know, she got it.

Yeah. It’s nice. It’s also interesting to hear. She’s very good at what she does. Oh, yeah. Yeah. I don’t even know if how well that translates when she’s on the podcast. But yeah, having her help you with something is a is a hell of a bonus. That’s for sure. Yeah. Okay. So you finally listen to Jenny, you move the carb ratios a little bit. But yeah, I think I’m not gonna say the problem. But the issue here is that the algorithms trying to learn and what you told it up front was pretty far off. I mean, one to 25 versus one to 15. Yeah, it’s a big difference. And yeah, and so you were that far off on the carb ratio. How what about the Basal would you tell the bay Isn’t wasn’t started

the Basal I had him set when he was in manual mode for something like I would say 8.5 units a day. Yep. And I would say averaging now when I look through, he’s getting like 10. How would you like 10 to 11 units of Basal, I believe,

okay. Let’s just tell people 8.5 divided by 24 is point three, five ish. And what are you happy now? More like 10?

Yeah, like, I would say like 10 and a half to 11 Some days.

Let’s say 11 For fun. And we divide 11 by 24. And that’s point four, five an hour. So an extra point one an hour. Which mean, he’s 10 years old. Probably hasn’t hit any kind of puberty yet. What he probably what weighs like 85 pounds, like in that space? Yeah, yeah, I

think he’s 80 pounds right now.

Okay, so yeah, so that’s a fair amount of change point one an hour for basil. And then this is the a big eater. Like, how many carbs is a meal ish?

Um, yeah, he we are definitely not low carb by any means. He’s a big eater. He likes to eat all day long. I mean, I don’t even want to say it. Like, sometimes the school nurse is like, seriously 120 carbs for lunch, you know? Like, he definitely eats a lot of carbs.

Okay, so So that’s interesting, because like that many carbs 120 carbs divided by 25 is 4.8 units. But 20 carbs divided by 15? is eight units.

Yeah. Which he never yeah, like I was eight units is is probably high for what he gets. But like, I would say on average, I try to pack him for lunch, around 80 grams.

Okay, we’ll see. It’s funny. Kate, you’re hearing my statement from a different perspective. You’re like, don’t tell people he eats a lot. I’m not I’m saying look at the difference between how much insulin a meal needs versus what he was getting. So there was a moment where he was getting 40% less insulin than he needed. And point one an hour basil. And then you’re asking the algorithm like keep him steady. But here’s what I told you versus here’s what he needs. Yeah, yeah.

So like, we must have just been doing a lot of corrections and a lot of like, you know, adjustments to his Basal during the day to try to accommodate for all of those things. It felt like a lot of work to keep him in range. And obviously, we just, you know, didn’t have his his settings quite right. Yeah. But of course, when you go to the endocrinologist, they saw as a one C six in April, and they’re like, Okay, yeah, you’re good. Keep doing whatever you’re doing. So there’s wasn’t a whole lot of like, guidance into like, maybe you could change this or that so that you’re not having to like, set Temp Basal all the time,

where you had you listen to the Pro Tip series of the podcast?

Yes, probably like three times through.

Because the one you missed was bumping nudge to the one where I say, Hey, if you’re bumping and nudging a lot, your settings?

Yeah, yeah, a quarter percent? No, I definitely listen to that. What’s funny is like, I think I listened to them too early in his diagnosis where I didn’t fully understand what everything meant yet. I just like stumbled upon the podcast and started listening. And looking back. Now, if I was gonna do it differently, I was listening to like, the defining diabetes, like really learning what all these things are, and then listening to the protests, but that’s why I listened to them more than once. Because six months later, you’re in a different headspace where you’re like, Okay, now I know what he’s talking about. Yeah,

I’ve heard that a lot from people. Okay, I’m just pointing out for people listening, not explaining something UK that you already know, at this point. But if you’re forever fixing blood sugars with a little more insulin or a little more food, then there are settings that you could have that would make stability that would keep you from having to make those adjustments so frequently. Yeah. So.

And the other issue, I think we had to is pretty quickly into starting on Omnipod. Five, the controller started having app errors. So I don’t know if you’ve experienced that, but it would just like it would almost look like it was on a loading screen. And then when it would go through the little loading almost like it was updating it then it would like be really loud and say app error, call it in. And the first time it happened, I hit okay, like I’m gonna call it in and the screen went, that notification went away. And it was working fine. I’m like, Oh, that was weird. I don’t know what that was. And it was already gone. So I’m like, Well, I don’t I don’t know how to like, call that in, you know,

right. Yeah. Go Yeah, it happened. What? Well,

that happened many times. And we made the mistake of just waiting too long to, to correct that and get in touch with Omnipod. And we ended up with a new controller in July.

Okay. All right. So you fought with the problem you didn’t have to fight with, if you were to call them and tell them they would have been like, just give us an update. We’ll give you another one. And 100% Yeah, stick with it for a while. We didn’t have any errors with the controller. But I do remember it beeping at times where Arden was like, why is it beeping? Yeah, the same thing you did. I was like, I don’t know, I don’t have time to figure it out.

And like, I feel like subconsciously, I knew that if he got a new controller, we had to start all over with the learning. And I was thinking that that wasn’t a good thing. I’m like, I don’t want to do that again. And he was in July, he was heading to diabetes camp. So I was like, I really don’t want to start on a new controller, you know, a week before he goes to camp. And so I waited until he got home. And then we started him on the new controller, which actually ended up being a good thing. Because this time i i feel like i put in more aggressive settings. And the learning happened much faster.

Okay. Yeah. So there’s the irony, right? You? Yeah, if you want to just call it about the controller, you would have had to restart. So this is this is I think, if I’m remembering correctly, why was excited to have you on because you had this experience of setting up on the pod five with settings that probably weren’t so good. And then having to restart which made you rethink your settings? Because I’m assuming when you put them in the next time, you use different settings, is that right? Yes. Yeah. In the end, can I ask you Would it have been as easy as just taking his total daily insulin? Dividing it by five by half? Putting? And then like, I don’t know, let’s just make up a number. Let’s say his total daily insulin was I mean, I guess we could actually figure it out. 10. Let’s just say it was 40 units. Let’s I’m sure that was a big number. But if his total daily was 40, then you could take 20 of it. divided by 24. Tell him that is Basal rate is point eight ish. And then tell it the total daily insulin is what it asks for. And then that would have been it like just going to a 5050 on total daily, do you think that’s pretty close to where your settings were?

Where do Yeah, I think I think you could probably do that, like I, I might have made it like far more complicated than it needed to be. When I set up the controller, the second time, I, you know, I want the basil, I can tell you exactly like what hours of the day he runs a little lower and what hours he runs a little higher. So he’s never been on like point three, five every hour of the day. So it’s like lower between 12 and 2am super high in the morning hours, you know, higher Basal between like eight and 10pm when he gets a little bit of a spike from bedtime snack. So I didn’t want to just do that, because I wanted a really good Basal in case I needed to get into manual mode. So I you know, he’s still got that like, very adjusted sometimes the Basal tie some hours, it’s set low, it still looks like that now, gotcha.

No, I I’m, I’m actually just looking at Arden’s Basal right now. And hers is running at like, almost double what it says that she’s asleep at college, or no, she’s on her way to class now. She’s probably on her way to class now. But yeah, I mean, it’s, it’s amazing to watch the algorithm work, right? Like, take it away, give it back, you know, it’s a give you extra give you less, it’s pretty, it’s pretty cool, actually. But, but so in, I don’t want to, I don’t want to be the one that tells everybody reset your system, if it’s not working the way you want it to. Because I don’t know, I don’t know that that’s a cure all. If you’re having if you’re unhappy with how the algorithms work, and maybe there’s other ways that you could be messing this up, too. You can be miscounting carbs significantly, there’s, you know, there’s you could be eating a lot of fatty foods and not covering it. And, like, so I don’t know everybody’s situation. But it is interesting to hear that this happened to you. So prior to the controller change. What do you think? Like, Where were your average? I don’t know how to ask you to measure. Yeah.

Well, so what’s interesting is actually he had an appointment at the endocrinologist in July, like, so three months, you know, into being on the system right around the time when we were about to switch controllers. And we got as a one C back because I was like so curious to see like, what’s going to happen to his agency like now that we’re on this different system. And so going from April to July, he went from a six to a 6.1. Okay, okay. So I mean that a huge,

right, it was a creep, like in that direction.

Yeah. So which, which makes sense, because, you know, I think we didn’t have the settings right, you know, you’re trying something new, it’s, it’s definitely not, you know, just set it and forget it, there’s still a lot of, you know, thinking that has to be done, like you said, you know, get a cell card count, right and make sure your settings are right. There’s still a lot of variables,

putting the putting the six to the six point wine aside for a second. What, what’s the variability like? In the beginning? Like, was there a ton of stability? Where you higher than you wanted to be a great deal of time? Are you finding lows? Like, what was the actual usage? Like, before you made the changes?

I would say we weren’t really fighting a lot of lows. I think the system does a good job of being conservative and avoiding a lot of lows. I mean, the only time we really were seeing lows was like, if he would go swimming, and you know, he. Okay, I lost you. intense activity. Okay, that might have happened. I’m sorry. We were definitely still fighting. So

I’m so sorry. I lost you for a second. I lost you after the word swimming.

Oh, so like, if you went swimming, you know, and he’s in the pool for an hour and was away from his Dexcom. You know, he might come out and end up low, like some things like that, I think are tricky to control. But for the most part, we were still fighting with some highs.

Okay. And high being what, like in your mind, what’s the number that makes it high?

Well, I don’t really like him running over 200. But mostly, it’s like mostly post a meal spikes. And they would last. Yeah, that would sometimes last. Yeah, that’s like I’m looking at his number right now. Like he and part of this too, is just, he’s got, we have other factors because we’ve got the gluten free. We’re still trying to figure out how to Bolus right for that. And like so this morning, he ate a friend of mine big 10 muffins, these gluten free pumpkin muffins. And he ate that. And he’s at 285 right now, which is obviously not not a great number. I obviously missed the Bolus on the muffin.

Also the way you said that was hilarious. You said this morning he ate and you paused and you said a friend of mine. And then you made muffins. And it was great that I loved it because I was like, Well, this morning he ate a person that’ll definitely drive up. Yeah, that’ll

do it. Yeah.

I mean, it’s not a ton of carbs and people but the adrenaline’s gonna be crazy, don’t you think? Yeah, yeah.

And now he’s going to the birthday party. I just saw him leave now. He’s gonna go eat like gluten free pizza and cupcakes. And it’s probably not going to be a great number.

So what do you do? Like you’ve you’ve got a big number, because you missed on a Bolus? Do you correct it? Yes. Just let the algorithm do it. What do you how do you handle it?

No, I, and this is where your episodes would have come in handy when we were getting on Omnipod. Five. But right away, I definitely corrected a high if I saw that he was high. I’m like, I don’t care if the algorithm is going to learn or unlearn or whatever. I’m going to correct it every time. And, and so we always do that. Where things are sometimes tricky is if he’s high, and I go to put in a correction, and it tells me he needs nothing. I’m, I’m always like, Okay, so do I just override this? How much do I decide to give him? And I think in the beginning, that was hard for me to figure out like, should I just give him a little bit more? Because I know he needs more? And I think the answer is yes, it’s just how much so if I give him too much, I think you can end up stacking because the pump is trying to correct the high as well. You have to be careful, like overriding, I learned that kind of the hard way. So if I’m gonna give him a little extra even though the pumps telling me he doesn’t need it, it’s usually like point one like I give him you know, I’m pumping and nudging just a tiny bit because I don’t want to,

well, there’s a balance in what you’re doing, right? Because the the algorithm is correcting at its own speed that could end up taking longer than you want it to. So you you you say well, I want to push it a little harder. But then you also kind of have that in that moment. Now that you’ve added extra insulin. You’ve put in too much insulin, there’s going to be a little later at some point, but you have this odd expectation like oh, the algorithm will stop it. But right you’ve put it into a situation where it can’t stop it. Right. And that’s that’s the one thing about every algorithm based system. It literally like every one of them that people have to understand is that it’s not smart. Like you don’t I mean, like a sentient being. It’s not looking and going okay, well, grace and how Add food at 10. And even though his mom told us that it was 20 carbs, it’s looking like it’s more. So all. You know, it doesn’t do that. It just it, it believes you. Yeah, I mean, 100%. Yeah, it’s like the setting say this, they said this, I believe that we are moving forward based on this as being true. And then that means if your settings are wrong, your carb count is wrong, or you’re eating something that has more glycemic impact than its carbs might indicate or anything like that, you’re not going to get the outcome you’re looking for. And the algorithm is not going to just, it can’t make a conscious leap after that. It just keeps doing what it’s doing.

Yeah. And I think we were relying a lot on an extended Bolus to which worked really well, for the high glycemic foods, all the gluten free foods, like he would eat and then I would just toss in like 10 grams and extend it, you know, almost at every meal, he was having something gluten free. And that worked really well. And so that we had to figure out like, how do we deal with that now that we can’t use extended Bolus when he’s in automated mode?

What are you doing?

So I think part of it was just the carb ratio issue. Like, I think once we will, of course, like if his carb ratio was set at one to 25, and then I’m adding 10 grams, like, I should have just seen that it was really just a carb ratio issue. So now that he’s on a ratio that’s better suited for him, he doesn’t need that extra 10. Okay, I do still think that when he’s eating fat or protein, that’s when I also would have used an extended Bolus, and I just set a timer on my phone. And I Bolus for the app for the cat an hour later.

Okay, that is definitely what I would do with both of those scenarios. But this is the part where we have to tell people, here’s the thing about AMI pod five, you set it up and told it one to 25 carb ratio. Yeah, if you realize, weeks or months later, oh, it should have been 115. Yes, just going in the settings and changing it does not impact the algorithm. It only impacts the settings that you’d be using. If you took the the pump out of the algorithm and used it in manual mode. It doesn’t, it doesn’t relearn because you change your settings. It’s already doing something that I don’t think any of us understand, I believe on the pod calls it proprietary information, how it’s making decisions. So the only real way to make a big change like that is to start over. And people don’t want to do that often. Because it’s because they’ve got this idea in their head like, well, it’s a learning system. And it took six months to get us this far or three weeks to get us this far. However long it took them. And so they’re like, I don’t want to start again. I don’t want to go through that learning again. But the learning, I’m guessing the second time was much quicker for you. Am I right about that?

Yeah, I would say the second time was I not no joke. Like I think within like four days, I felt like we were we were good. It was i i wouldn’t have even really noticed that you had we had reset the controller. If if I didn’t know it, like it happened so fast. And it was easy. And I think a lot of people are going to be put in that situation. What eventually there’s an app, I’m assuming if you switch from a controller to using an app on an iPhone, it’s going to start the relearning over again. Is that right?

Oh, good point. So at some point, when it’s iPhone compatible, you’re saying everyone’s gonna bail from their controller for the most part, and everybody’s gonna get this experience, then?

I think so I feel like Jenny said that that was the case, if you switched over to the app, you would have to start the learning

over again. So I can’t say that with 1,000% certainty, but I think that’s right. And, and the point is, though, if they switch and they still take their bad settings with them, they’re just gonna, it’s just gonna be the same thing over again. But if they learned like you did, Kate, look at you, right?

I know, that.

They learned like you did. And it is interesting, isn’t it? You’re like, I should have just known. It. Just it’s so simple. In hindsight, isn’t it when you’re talking about it? Yes. Yeah. Well, you’re in it. Yeah, it’s not it’s not that simple.

No, it’s not. But now, I definitely do not feel at all nervous about switching to the app at some point. Because if we go in with good settings, I don’t think you’re even really going to notice, quote, unquote, a learning period because your settings are going to be right.

We should I even Oh, I’m sorry. No, no, you finish your thought.

When I set up the basil the second time, what I felt like he normally would use in a day. I even like added a little bit more than that, too. So I like maybe more than I even thought would be cool. racked, because I was like, I just I want it to be aggressive and work from that. And that seems to have worked. So you

were doing that method while you’re cooking. You’re like half a cup of butter plus a little more.

Yeah. Exactly. Just add a little more.

So, see, you’re saying, by the way, nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise. But yeah, what you’re saying was, you’re like, Well, let me just give it a little more to work with. Yes, because your thought was it could take it away, but it has trouble adding. Yes. I don’t know if that’s something I’m allowed to say out loud, legally, or anything like that. But okay,

well, I can say it right. I’m not a doctor by any means. But it seems like I was like, Oh, I think he needs about nine units. So I’m gonna just put in 11 and see what. So and that seems to

have worked. Well. What’s this a one see now on the system?

That’s a good question, because we haven’t had it tested since July. So I’m not sure. Interesting. What he’s out now, but I would say for the most part. He I’m just looking at his Dexcom.

Do you not have clarity setup on Dexcom? I do

have I’m looking at clarity right now. But it doesn’t have.

It’s not. It’s not an estimated anyone see it’s an estimated something else.

But yeah, it says GMI. And I never like when we went for his first a one C test. Well, that I can remember back in April, the GMI said 6.8. And when they tested as a one C they said 6.0. And I was like are you sure? Like?

Yeah, I’ve heard people say that either that estimate comes very close to what they have, or sometimes it doesn’t. So yeah, I don’t know how to explain that, honestly. Yeah.

I mean, he runs about 85% in

range, most of the time, what’s your range set?

His range is set at 70 to one ad. That’s excellent. Which, you know, and I know a lot of people are able to run lower than that. I think the thing that I have found, especially with like a young boy is like, he’s so unpredictable. Like, he’ll be laying on the couch one day, and I’m like, Oh, he’s gonna need more insulin, because he’s playing fortnight and he’s, you know, just hanging around, and then I’ll correct him or whatever. And he goes outside and jumps on the trampoline for an hour and then ends up in a low. So it there’s that unpredictability of kids where I feel comfortable with him running, you know, a little higher, then maybe he will choose at some point as an adult

in case he suddenly decides to play basketball for two hours.

Yeah, and then run past the construction gate into the road you never know.

Exactly. And he’s the older one. So can you imagine? Yeah. All right. Well, this is this is excellent. I’m glad you’re you came on to talk about this. I mean, I’ve seen people online, they’re like, I’m gonna restart it. I’m going to restart it. I listened to those episodes. And now I realized that I didn’t Baba blah, whatever they think I didn’t do. I’m gonna restart it. I’m gonna restart it. I’m always like, I’m not telling you to do that. But I mean, it goes, see what happens. If somebody’s gonna do it and tell me so when I realized you did, and I was like, Oh, this will be great.

Yeah, I’m not even sure how you would restart it. Like, if you had a current controller. I don’t even know how you go about, like,

I’m sure there’s a reset button somewhere.

There’s gotta be there probably is. And, you know, I’m not saying you should do that either. But I think naturally, that’s going to happen. I mean, a lot of people have iPhones. I think that’s one of the benefits is eventually he’s going to be able to Bolus from his phone. Like, I definitely think people are going to start over once. That’s an option.

No, I, I don’t think you’re wrong at all. Actually, I think you’re gonna see a lot of people hear stuff like this or go back and hear by the way, those episodes are episodes 736-730-7738. They’re available. In your podcast player. They’re available. I think I have a page for them on the website. juicebox podcast.com, forward slash Omni pod five. I actually think Omni pod has them on their website. is amazing. Yeah. Isn’t that cool? I think it’s Omni pod.com. Although I mean, just go to mind. You don’t I mean, like, no worries. Yeah,

just go Yeah, you don’t even you don’t need to plug them.

There’s no way they put. If you do juicebox, you end up at my site to start with it.

And those episodes were so helpful, like, even just listening to them. After we had already been on it. It it’s, it still is helpful. Because I think the thing about new technology that makes it so tricky is there’s not a lot of resources. So even the endocrinologist is like not really sure what to tell you. And when I was working with Jenny at the time, she, at that time, hadn’t tried it yet. So she was, you know, using her experience with what she’s been doing with other families to try to help guide us. Yeah, when you don’t, you can’t like pull out a book and read how to do it. That was I kind of felt left to just I don’t know, figure it out, and hope for the best. So once those episodes came out, I felt like I wish I had had those three months early. I’m

glad actually, I wish I had them before Arden started off about five. What do you think of that? Yeah. So an ardent used on the pod five for probably nine or 10 weeks, if I’m right around there. And it worked by the time it learned and we, you know, figure things out. It did exactly what I expected. I was like, this is this is it, this is what they that’s what they told me it would be and it is. And but she said, I, she’s like, I don’t want to carry this controller. And I was like, okay, but she just she had context. From loops. She’s like, Look, I I like running this from my phone better. And right now, you can’t run this from my phone, she does get back to me when this has my my phone is is covered. I was like, okay, so we switched her back over. But it’s neat to see. Interesting to see for me that any problems we might have had, you know, and I don’t mean problems, like difficulties. I mean, like, you know, life with diabetes, with with loop, they kind of were almost the same anomaly part five, and then vice versa, right. Like, it’s, it’s the limitation of an algorithm. Like I said, being stupid at some point and not being able to see, like, oh, he had pizza. This isn’t just 15 carbs, it’s cheese and sausage and stuff like that.

Yeah. And I think, you know, I had talked to some people that were, you know, kind of saying some things like, Well, we still have highs and this still happens, or that still happens. And it’s like, well, it’s not none of this is ever going to be you just, at least for now. Like you turn it on and you do nothing. There’s still a lot of input from the user. And you need, you know, if a high happens, you need to correct it. Like you said, it doesn’t. It’s not a person. And so I think if I had advice would be like going in with the expectation that like, you’re still going to have a little bit of work, but you’re going to get a great night’s sleep. You know, you should take that and run with it. But you’re never going to be able to just turn it on and never think about diabetes ever again.

Yeah, no, I mean, listen, Arden. Like I said the earlier in the episode Arden’s eating at college now, and it’s not great. And so yesterday she had, she had something that drove her blood sugar up, and we fought with it and fought with it. Like she fought with it. I was texting her. And then we got like, super aggressive with it over many hours. And then she sat down to do homework where she’s very sedentary, but also kind of like, I think she’s a little jacked up still from school. You know what I mean? Yep. So over like six hours, we’re pressing against food, and then some adrenaline, and maybe some anxiety even. And then she gets hungry again. And boluses doesn’t wait long enough. Now we’re six or seven hours into this blood sugar. And I’m like Jesus at this all day. And we finally got the drop. And then she goes to bed. I’m thinking like, she’s gonna get low. Like she’s Yeah, definitely gonna get low. And, you know, like, three in the morning. She’s She texted me, she’s like, Hey, I just drank a juice. And I did this. Do you think that’s enough. And the loop was trying its hardest. It was like take it saw the drop coming. It had been taken basil away for an hour. At that point, it still couldn’t stop like a below 60 blood sugar that she had to hit or something. And then, and then, in the course of being tired, I forgot to tell her to like shut off the part where it boluses without food, like so. So the auto Bolus version of lube can micro Bolus with carbs or without carbs. Okay, we’re one or the other or both. And so I should have said to her when she corrected I should have said shut off the corrects without carbs. Because what we don’t want is for her to finally get her blood sugar back up and for it to go over like 110. And if you go oh, no, and then Bolus, which of course because we didn’t shut it off. That’s what it did. Talking about an algorithm being dumb, like, right, like we fixed the low, we’re good. Don’t give her insulin. And then 90, but not even 90 minutes later, an hour or so later, she started getting low again. So you know, is

that like, terrifying for you after her like her prom experience?

I mean, Kate, it is what it is. Right? So yeah, yeah, I just Yes. I just didn’t sleep very much last night. That’s all.

Well, that’s the thing. Like, that’s how I’ve I feel too, like so Grayson goes back and forth between my house and his dad’s house and like, even when he’s not here, you know, you’re still paying attention to those numbers, you know, and it can be a little bit scary, but for the most part, I feel like Omnipod five does a good job overnight of keeping him from getting low unless there’s some other thing happening like last week on Tuesday. I had put on a new I changed his pump and his Dexcom sensor, they just that never happens. But they were both due on the same day. And he was reading high, like over 300 I’m like, What in the world is happening? And this was probably like, between eight and 10 ish PM. And sometimes he does get a little bit high with a pump change. So I was like, Okay, well, maybe just the, you know, the pump is getting on and getting insulin going again. And, you know, so I’m correcting him and, and it’s, it was getting corrections, like it was definitely like, giving quite a few corrections and like, okay, you know, who must really need it. And then it occurred to me, I’m like, this seems really weird, because he’s not usually over 300 At night, so I start finger picking him, you know, every now and again and realize that the sensor was off. And I’m like, oh, no, you know, the sensor was reading a lot higher than what His fingerprints were reading. Yes. So then I’m like, okay, he’s definitely maybe had too much insulin, we need to change the sensor. So this is it. Like midnight, we changed the sensor, and I just didn’t sleep for like two hours. You know, I’m waiting for the warm up to happen. And sure enough, I was trying to like calm myself down and be like, I’m just overreacting. He’s not going to be low. I’m sure it’s probably fine. You know. And when he came back on it, too, am, you know, the Dexcom is just screaming low at me. And I run in there and wake them up. And you know, we’re giving them juice. And it was like, after that I’m like, Oh, my gosh, is is great as all this technology is like you still have to trust your gut like, yeah, it’s still sometimes not right. And that happens well,

so the other day, we were fighting with a high blood sugar. And I finally stopped and I thought her blood sugar should be lower than this. Yeah, it’s, I did everything. I know what I’m like, I know what I’m doing. And I did the thing. And this isn’t where the numbers should be. So I’m starting to decide, is this an insulin delivery problem? Because if it isn’t, then oh, hey, Arden, test your blood sugar. And, and in that scenario, her blood sugar was like, I mean, we were breaking a high like 200 and her blood sugar was more like 180. And it was telling us she was like, 220. And I was like, that’s not right. And, and that’s a big difference, because one ad indicates that we’re we’ve got a fall happening from where we were. Right? Yeah, you have to listen. I there. I mean, I’m a little like, you know, I want to make sure everybody understands, like their sponsors, all these companies, but I’m still going to tell you the truth. Like you know, Dexcom is not always going to be perfect. Your pumps not always going to work, right? You know, like nothing, you know, you might test your blood sugar and be like, oh, you know, it’s, it’s the best that exists right now. And I think that the podcast is supported through advertising through some of the best stuff that exists. So I’m not like, I’m not apologizing for it. I’m just saying you have to use your own common sense still. Yeah, you know, I mean, take anything self driving car, even Lane Assist cars, you see people like, oh, I don’t know what happened. I had an accident. The thing usually tells me if I’m gonna get to the lane, I’m like, that’s what you’re counting on. Like, you know, like, yeah, keep your hands on the wheel look forward. You know, yeah, yeah. And I

think, you know, I said to grace in the morning, like, but the good news, I think it was Wednesday or Thursday that the Dexcom released the g7. And some other countries, I’m like, soon there’s only going to be a half hour warm up and and then I that probably wouldn’t have happened, like I would have seen you dropping and known to treat that faster. So like, it’s it’s always like progressively getting better.

Yeah. No, it’s It’s amazing. I just, you know, you have to listen to an episode once in a while with people who have had diabetes for 50 years and hear them talk about not just not just how they started, but the three generations of technology that came afterwards that right now, if you are you with a kid who was diagnosed, you know, 15 months ago, any of their explanations of diabetes is like, Oh, my God, what? Like, that’s insane. You know, and you’re like, and you’re like, Well, when I switch a sensor, when I switch the thing that sticks to his skin that reads this interstitial fluid and tells us if his blood sugar isn’t if it’s moving, etc. Sometimes there’s a warmup period, and it’s not always accurate right afterwards.

Yeah, yeah, we’re definitely spoiled for sure. I mean, yeah, and that’s why I wanted to try out a new pad five, you know, right away because I knew it was going to create less work. And his even with a little bit of issue with the controller that I probably should have switched sooner. I mean, it’s a one C was still 6.1. So, I mean, we really can’t complain about that.

Would you say overall, you’re very happy kind They’re happy, like, where are you on the on the scale?

I think we’re, we’re very happy with it. And, you know, I definitely wouldn’t go back to, to doing manual right now I think, especially for a child who, like I said, is unpredictable. I think it’s amazing. And you know, I’m curious about looping. And that’s something I’ve read about and maybe we’ll explore at some point in time, but for where we are, is early in his diagnosis. Right now, I think he’s on the best option, and just it being tubeless. Like he, he refuses to try anything that has a tube, like he said, right away, I’m not doing that. Which I get because he plays sports. And that’s what’s important to him. And he doesn’t want to feel like something’s getting in his way. And Omnipod definitely does not get in his way. So

well, I can tell you, I would I mean Arden’s over 18. And I am I am speaking for her, but I don’t think she would leave any kind of an automated system. If loop didn’t exist right now. She’d be like, give me that Omnipod five back right now. You know, and all I’ll work with the controller. I think that I still believe that moving forward, whatever. I don’t know, whatever on the pod five morphs into. I do think that eventually, that’s what Arden ends up on. Because not that I don’t think lupus is terrific. But I mean, there’s just work involved in making it run. And there’s things you have to know that most people don’t know. And she’s not going to at some point in her life, you know, be an app developer, so she can wear an insulin pump. I don’t see her being that person. You know?

Yes, I could see that. Yeah, Grace, kind of like that, too. Like, she makes me laugh when she’s on because she’s kind of like, this is just my life. Like, what do you want me to say about it? You know, and he’s kind of like that, too. Like, yesterday, I introduced him. I was really excited. I introduced him to a friend’s daughter, who also has diabetes and celiac. And he just was like, shrugged her shoulders like, Yeah, so like, what? She has it too? No big deal. You know? Great. Like, I don’t think he would, you know, he doesn’t care about an an app or being a developer or whatever, just to keep himself in control. Like he just wants to use you want. Yeah, he wants to be a kid. No,

no, I hear you. I listen, I think it’s terrific. i It’s tough, because I assume that people hear Scott tried on the pod five with Arden. And then they switch back and they think something happened. But it’s not the case, like Omni pod five, again, did exactly what I thought it was going to do. It acted exactly the way I expected it to. And I thought it was terrific. I thought it worked fantastic. It’s different, like, you know, because it’s got that, like learning phase to it. And they don’t exactly show you everything that’s happening with the insulin. So you’re guessing sometimes while you’re trying to figure it out, but my expectation is, I mean, I don’t know, obviously, I don’t work there. But my expectation is they’re going to keep fine tuning this thing. And the generations will come in common at one point, you probably won’t give a crap what it’s doing. Because, you know,

yeah, you want I know, that is it is hard to not be able to like see exactly how much he’s getting. Because I get their point. Like, we don’t want you to have to think about it. We don’t want it to be work. But I think there’s a lot of us, like, just out of curiosity, I want to know what his needs are in case, what if I had to do it? Or what if, you know, we had to switch for some reason. And so that’s it is tricky to not have all of that information, but at the same time, it’s working well enough for us that I’m like, Oh, it’s this is fine. Yes. Good

in that scenario, and based on nothing, anyone has said to me like this is my supposition. It’s that the algorithm is making so many decisions and changes that it doesn’t translate right back to your Basal is this and your carb ratio. Is that, like, I don’t I wonder if that’s not the case. Like if what it’s doing just doesn’t simply translate back to manual care. Does that make sense?

Yeah, it does. And the only time

okay, I’m just guessing. But

yeah, in the only time like that I have realized that we I do switch him over to manual is the activity mode is excellent. Like if he’s going to have a friend over and it’s going to be playing or like we went we were hiking yesterday and I popped him over to activity mode. And that worked well. But when he’s going to he plays travel soccer and he’s had a couple of tournaments where even on activity mode, he just was low the whole day. And we just could not keep him up. Like I was just throwing Gatorade at them. And so I talked to the endocrinologist after that and they were like, you know, you might just occasionally either have to switch over and pause insulin during a game or settle really low Basal profile for that type of day and then switch into manual mode just for that day. And we’ve done that. And that has worked. And you know, those are extremes. It’s like a day when he’s gonna have he had like four games in 112 hour period, which is crazy.

Well, I think that a lot of people are going to find just like with regular diabetes care, they’re going to find ways to make these things work for them. And in that, if that works for you, then great. And then somebody else might find a different way to do it or, but it’s not going to be I mean, we’re not up to perfect we’re not up to perfection yet in 2022 Give me yeah, we’re up to this is pretty freakin amazing. And, and I sleep more. And there’s fewer lows. And that’s good stuff, you know?

Yeah. And it’s so for him to be able to sleep through the night like as much as I want myself to be able to sleep. I don’t. In the first year he was there were days where he would end up in the nurse’s office at school napping. Because I would have had to wake them up to treat a low and you know, he’s growing. He’s at that age where he wants to sleep more and not having to wake him up constantly. is so nice. Yeah, that’s been great.

I’ll share this with you last night. While Arden when I called Arden first she called me. And she’s like, Hey, and I’m like, What’s up? And she asked her questions. She’s like, I did this and this, do you think that’s enough? And say, oh, it looks like enough. And then I forgot to tell her to shut off the micro Bolus thing. So you know, anyway, yeah. The next time I had to, I texted her a couple times, she did not wake up. So I called her and woke her up. And it’s like, I mean, you know, it’s four o’clock in the morning, and she’s Yeah. My hay yards. I’m like, we’re gonna have to drink another juice. And then, you know, okay. And then I hear this, like, I swear to God in my head. And I felt I felt terrible. While that was happening. No,

I know. And then she’s got to get up and go to class. Like, that’s tough.

Arden also put herself into something. You know, I don’t think we’ve we haven’t talked about it a whole lot. But Arden did something that I don’t think a lot of people would do. She’s a really good student in high school. And if she were to pursue something on the more academic side, she was thinking about pre law. But instead art and went to school to learn how to design clothes. She was yeah, she went to art school to study fashion. Yeah, and she’s not a out of the womb, talented artist. So she’s got a lot of vision. And she puts things together, but she did not spend her life drawing or painting or working in charcoal. So Arden, like, willfully gave away an academic pursuit that she would have been good at, to go to try to teach herself something artistic. So she’s seated at a desk most of the day, you know, learning how to draw. And in as a as a freshman. And it’s a I mean, it’s, I don’t know if I’ve couched it so that everybody understands correctly. But, you know, this was this was the this was something this is a person in a lane, who said, I’m gonna go way over here into this different lane and see if I can figure this out. That was a pretty big leap. So, you know, on top of all that,

yeah, yeah, it’s not easy. I mean, she didn’t pick the thing that would have bet maybe come naturally, but she’s gonna work hard at it. And, you know, and I, I always feel bad when, like, after Tuesday night, I mean, we were up most of the night and I said to grace, and I’m like, I could not go to work that morning. Because that only after a night like that, am I exhausted, but like the adrenaline of all that happening? Yeah. Was it takes a toll, you know, and I’m like, I’m in front of kids all day. I’m like, I can’t run on on zero sleep. So I called in for the morning and I told him, he could stay home. And he just was like, no, no, I’m not doing that. He refuses to miss school. You know, he just started middle school. He doesn’t. He’s like I literally while he’s having a low blood sugar, he just computer out. He was trying to do his math homework. I’m like, can you not do that right now? Like he he was like, slurring his words. He asked me What’s four plus nine? I’m like, buddy, like, now’s not a good time to do that.

No, I know. Do you know? I don’t know if she said this or not in her last episode. But after Arden had that seizure, and she was rebounding from it. It was Sunday morning. You know what I mean? Or Saturday morning, it was very early on and she was she started emailing one of her teachers. Oh my god. She was like, Hey, I’m not going to be able to get this thing done. I just had a seizure. And oh, and she was being she thought she was being rude. responsible? Didn’t really mean but she was Yeah. Still a little, like, still recovering. Yeah. And the guy, like I emailed her back and he was like, okay, like, are you okay? And you know, like, he was almost saying like, you really shouldn’t be worried about this right now.

Yes, yeah. And they need to hear that, like, I tried to tell him like when you’re like your health is the most important thing. And then school like, I appreciate that. You want to do your math homework, but also you probably can’t, you know, obviously a four plus nine, it’s, it’s hard for you right now. It’s like, not a good time to do that. Anyway,

but I take your point, I’ve seen Arden do the same thing. I’ve seen her have long nights in high school. And I’d be like, if you want to just skip a first class and sleep a little longer. You can? Yes, like, No, I’m okay. And I’m like, All right. I mean, listen, I got up this morning. Not gonna lie. Yeah, I slept like four hours last night. Oh, God. And I don’t feel terrific right now. But I’m working it out. And by the way, I have to get off with you. Because I’m recording again and a half an hour. So Oh, my God. Okay, set up. So this is me, like, I really wanted to talk to you. And I’m thrilled that you came and gave me this, this explanation of how things went for you and for grace and everything. So I just like get you in to the, to the, to the schedule somewhere. Because right now, it’s October 2022. Yeah. And if I gave you my scheduling link right now, like I gave you the VIP link, I think right. So if I gave you if I gave you the scheduling link, you would not find a slot until October 2023.

Yeah, that’s insane. Yeah, that’s, that’s amazing. Well,

and I wanted this story fresh in your head. So like, I can’t wait that long. By the way, man, respect to everybody who contacts me to be on the podcast. And it’s not daunted when I send a link and say, Hey, you’re not going to find a space for about a year. And they’re like, no problem. I always think I always I’m like, thank you so much. It’s just so very kind thing everybody does.

Yeah, I mean, you should feel good about that, like people are willing to wait a year to talk to you. So that’s pretty amazing. Oh,

adults, Kate, who have learned patience, which I am proud to say I have finally learned in my life, are okay with him, like we needed a new refrigerator and I wouldn’t the guys like well, I won’t be here for two months, I was like, that’s fine. I’d like to thank Omni pod makers of the Omni pod five and the Omni pod dash, and remind you to go to Omni pod.com forward slash juice box. I’d also like to thank us Med, go to us med.com forward slash juice box or call 888-721-1514 to get started today. And of course, the Contour Next One blood glucose meter is available at contour next one.com forward slash juicebox. You may be paying more for test strips right now through your insurance than you would at my link. And of course, let’s thank Caitlin for coming on the show today and sharing her story. If you’re looking for the diabetes Pro Tip series, go to juicebox podcast.com and hit the menu at the top. Actually, all of the series and the podcasts are now listed there. Don’t miss it. And if you’re looking for a real supportive place to talk about diabetes, or just watch people talk about it, because sometimes just watching the conversations kind of brings you along with the idea. Anyway, you can do that on my private Facebook group Juicebox Podcast type one diabetes, it’s 100%. Free. It has over 30,000 members in IT people just like you adults living with type one. Caregivers of type ones up jeez, a lot of people who have just become pregnant and gotten that gestational stuff. I type twos are in there any kind of diabetes, you can imagine. They’re there. They’re willing to talk to you. I really think you should check it out. Thank you so much for listening and for supporting the podcast. I’ll be back very soon with another episode. So keep checking that app. You are listening in an app? Aren’t you like Amazon Music Spotify or Apple podcasts? Please tell me you are out overcast. There’s a lot of free. Look, there are a lot of free podcast apps. A lot of them are terrific. They’re great places to listen to podcasts and to subscribe or follow. Please don’t be listening online. What do you like you my grandma? You don’t I mean? Let’s get you. Let’s get you an app. Alright, we’re on your phone, Apple. Android doesn’t matter. Don’t know where to get one. juicebox podcast.com. At the top, there’s links. Go into the Facebook group. Ask them, you can do it. You too, can be in the cell phone age. I’m just kidding. Most of you listen in apps. I just please subscribe or follow that to actually while we’re talking. That’s actually a huge help to the podcast. Subscribing and following in an app is a major help. only bested by sharing the show with somebody else. If you really want to help the podcast share the show. Subscribe today. AP support the advertisers when you can take the T one dc exchange survey like there’s a lot of ways to do it but Subscribe and follow follow and subscribe please

Hello friends and welcome to part one of my three part Omni pod five Ask the Experts series far too often community sourced answers to Omni pod five questions contain misinformation. So today we’re going to help to set the record straight with an expert working at Omni pod. And Eric doesn’t just work there. He’s the clinical services manager. He has type one diabetes, where’s Omni pod five, and is the father of a young child with type one who also wears Omni pod five. On this episode, Eric and I are going to answer questions directly from my private Facebook group about everyday use of the Omni pod five system. insolate has paid the host of this podcast Scott Benner a fee to create this content. This podcast provides general information and discussions about health and related subjects. This information and other content provided in this podcast or in any other link materials are not intended and should not be construed as medical advice. Nor is the information a substitute for professional medical expertise or treatment. Never disregard professional medical advice or delay in seeking it because of something that you’ve heard in this podcast, or read in any length materials. The opinions and views expressed on this podcast and website have no relation to those of any academic, hospital, health practice or other institution. Please speak with your health care team if you or any other person has a medical concern. And before making any changes to your diabetes management, and consulting on the pod five automated insulin delivery system User Guide for more information. Nothing you hear that Juicebox Podcast are read on juicebox podcast.com is intended as medical advice, you should always consult a physician before making any changes to your health care plan.

Well, my name is Eric Davenport. I am a clinical service manager with Omni pod which means that I trained people on Omni pod and since the launch of Omni pod five I’ve trained over 500 people on on the pod five. And I myself have type one diabetes, I’ve used the pod for the past 10 years. And I’ve changed my own pod about 1200 times. And not only that, we just found out my two year old has type one diabetes about two months ago. So he also uses the pod so my love of the Omni pod runs is very multifaceted. Alright, do

me a favor. Now I’m gonna use some questions about that. Put that microphone like straight up to your mouth. Okay, like bring it bring it a little closer to you. Alright, how’s that? Yeah, talk right into the edge of it like, Okay, perfect. Awesome. Yeah, right there is great. I know you’re here so that we can pick through some stuff and and answer questions. But I have to ask you first, I guess. How long have you had type one? When were you diagnosed? I

was diagnosed when I was six. And this year will be my 25th anniversary. So it’s I’ve had it for a long time basically. Don’t remember life without it.

Wow. You’re 31 now? Yep. 31. Yep. How long? Have you been working at insulin?

The past year and a half. So I started in June of 2022 been loving it.

What did you do before that? And how did you make your way there? Yeah, so

I am a certified diabetes educator. And I was previously a diabetes educator at a pediatric clinic in Louisville. And really, since I graduated college, I’ve always known I wanted to be a diabetes educator. So my career has always been in the diabetes field in one way or another, always with the goal of working in peds or some type of I’ve always loved Omni pod. So this has kind of been a penultimate goal for me.

Yeah, tell me how long you’ve been you’ve always wanted to do this, you piqued my interest, because I gave a talk this weekend where I met this young man, maybe 1213 years old. And he told me, I want to be a diabetes educator. So like, how does that like? Is it something to do with your experience or experiences you had with a good doctor or something you wanted to do to help people move forward? How does that all occur to you when you make that decision?

Yeah, so it was an experience I had with a diabetes educator. Growing up so I live in, lived in Cincinnati and went to Cincinnati Children’s. And in college, I got really active I was in like martial arts clubs, rock climbing clubs, and my blood sugar’s were kind of crazy. So I had a meeting with a diabetes educator who told me, why don’t you make a couple of these changes to your diet and your insulin, and it really smooth things out. And I thought that was amazing. If I can change my management through the way I eat, and some timing with my dosing. I thought that was so cool. And I want to learn more about this and I want to help people do the same. So that was the trigger. And that led me to dietetics and we’re working with diabetes. Wonderful.

What did you pick? What did you do in college that got you ready for this? So what was your major?

So I’m a dietitian is my degree so that involves four years of didactic work, and then you do an internship for one year. And that was also very diabetes heavy. I told my, the teachers that were helping me with my rotations, I was like, whatever you can get me in with diabetes, that’s what I want. So I did a couple rotations at some outpatient clinics. And that just kind of confirmed I was like, Yeah, this is it. This is, this is what I want to do. Have

you had that experience where you got to be that person for somebody else, like someone was for you?

Yes, at least I think that I have. So the one of the things that I love about working in the field of diabetes is this just instant bond, it’s this instant connection, because nobody else with diabetes truly understands what it like, is like to have diabetes, except for someone else with diabetes. So there have been many patients that I’ve really connected with. And I feel like my sweet spot when I was in the clinic was the teenage boys. That was their diet, bro. And like, we bonded, and I feel like that really allowed me to gain trust and make some changes in their lives that were beneficial.

Well, we’re gonna try to do that here. Today, we’re going to try to let you answer some questions and hopefully move people along in a way that that helps them, you know, do better for themselves. But great again, before I start, I gotta ask, do you have other autoimmune issues? yourself? Are you just type one?

I do not just type one.

How about in your family line? Do you see celiac thyroid, stuff like that? So

nothing like celiac thyroid, but my mom developed macular degeneration when she was young. She was like eight. And at that point, it is an autoimmune. So that’s where we think the auto immunity comes from, but no other diabetes. So

how many kids do you have?

I’ve got three. So they’re four, two and one. Wow. Yeah.

Which one was diagnosed? The middle one. He’s two, two year old just recently,

just about two months ago, it was actually a crazy story we found out on an Alaskan cruise boat. It was when we discovered it.

It’s always on vacation. Eric, I know was on vacation. Not something you were expecting, though. Or where are you? Maybe.

We know we had done the trial net the audit antibody testing for our older son and our our middle son, he just hadn’t hit that age point yet. So we’re we’re always kind of on the lookout. And he just wet the bed through his diaper three nights in a row. And we’re like, this is kind of weird. Let’s you know, just check in. We will periodically poke their finger if they’re, you know, peeing a lot. Drinking a lot. Yep, that’s how we caught it.

So prior to coming to insulet Were you already using Omni pod? Yes.

So I’ve been on Omni pod for about the last 10 years, maybe a little longer.

Wow. That’s a good long time. I think about how long my daughter has been using it since she was four. And sometimes I go to do the math on it. Like, I forget how old she is even so she’s 19 i My best guess is that Arden’s been using an omni pod every day for 15 years? That’s awesome. Yeah, it’s been terrific, like the entire way. Actually, I say this a lot. But it bears repeating here, just like a friend in the journey, you know, just consistent does what I expect it to do, does it? Well, you know, that kind of stuff is. You can’t you can’t say enough about just getting what you expect. And absolutely, yeah, so anyway, I you obviously, Where is your son, MDI, or what’s he doing?

Yeah, he’s on Omni pod. And we’re very lucky to have the resources that we do. Obviously, my wife and I know a lot from experience. And then one of our best friends is his endocrinologist. So he’s been a longtime family friend of ours, and is his Endo. So we worked with him a couple of days after his diagnosis, and when we got back from vacation, initiated a monopod. Okay, so he’s,

I didn’t mean to cut you off. I apologize. But your Omnipod five, is he or is he using a dash? He’s Omnipod. Five, guys. Okay. Yeah. All right. Cool. So you’re both using a G six right now? Because that’s what the pot five for the moment, right? Yes, six. Okay. All right. Great. I think I know enough to get this done. Eric, I appreciate you sharing all that with me. Yeah, so the idea behind these episodes, is we’re going to be talking to different experts inside of insolate. And kind of going over the questions that we hear people ask me all the time, so a lot of the questions. I see people online, Facebook, Instagram, Tiktok. They’re all kind of asking the same things. And I’m sometimes stunned by how, like somebody will say something like it’s just rock solid fact. And I’ll think that’s not right. Like, I know, that’s not right. Like, I’ve made a fairly comprehensive series about Omnipod five and I’m certain that that’s not correct. But there it is out in the world. Like, you know, somebody has As inexperienced they they make a leap. And they decide it’s it’s a truth, and then they share it online. And the next thing, you know, people are running around saying stuff that, you know, not always accurate. So we’re gonna go through some things here that we’ve heard people ask and say, and I’m gonna get your feedback on them. Great. Sounds good. Yeah. All right. So basic one all the time line of sight. Does the Omni pod five, and the Dexcom G six need to be in what they call line of sight? Do they need to be able to see each other to operate?

Yes, you’re exactly right. So for best connectivity between the Dexcom and the pod, they do need to have this line of sight and be able to see each other and the way I like to think about this is if the Dexcom and the pod can see each other on your body enough to throw a baseball back and forth without a body part blocking it. You’re gonna get some good connection. Okay, and

I’m imagining a pod in a CGM having a catch right now. I’m sorry, I yeah, I didn’t really mean to talk. It just kind of popped into my head. Okay. I know. Yeah. And so this is a Bluetooth connection, is that correct? Correct.

So it’s Bluetooth, which is why they need to be able to see each other because Bluetooth doesn’t really like to communicate, you know, through like water or body parts. So that’s why they need to both, you know, be on the front, both on the back or the same side. Every

time I do an episode was somebody from Dexcom, someone will send in a question, can you please make it work while you’re swimming? And eventually, someone online came in and said, like, we’re not going to be able to change the physics of it. So I don’t think that’s gonna happen. But it’s a very common question, like, people don’t understand why or how Bluetooth works. So why would you know that? So I guess the idea here is like the mass of your body, the Bluetooth can’t just travel through it. Right? That’s correct. But what happens though, when, you know, somebody comes on, I see it all the time in the Juicebox Podcast, Facebook group, like people come and say, hey, you know, what about line of sight? And you know, I do I have to wear this thing on the same side as the other thing. And someone will say, I don’t, and it works fine. But they don’t consider like, what is it? They’re not thinking of when they talk about that? Yeah. I mean,

don’t get me wrong, the range on the pod is, is great. But we’re thinking of what’s best practice. Because if that connection is not great, if they can’t see each other, you just won’t be in automated mode as long as you possibly could be. So that’s why we just recommend this line of sight, because we want people to be in automated mode as much as possible, it’s just going to lead to the best results. Okay.

And, and so, I mean, the next part here is that diabetes is, you know, it’s a bit of a science experiment all the time. Right. So is there is there is it a hard and fast rule? Is it an FDA requirement? Is it like, or is it just you guys saying, Look, this is probably how it’s going to work best. So best practices, but people are still going to try things.

When I’m training somebody, I want to set them up for the best success as possible. So I’m going to set them up with these guidelines of you know, let’s make sure they can see each other so that they’re getting the best results they possibly can, right.

And now if if they don’t follow this advice, and they have trouble, this is one of the reasons you want good line of sight. Because you’re you’re counting on the data from the CGM to get to the pod so that it can make insulin decisions. What what happens if, like, I don’t know what happens if line of sight works fine. But then in some contortion, I’m watching a movie and I’m all like, you know, turned sideways and it suddenly stops working. And I don’t have line of sight. What happens then to the automation.

So the worst thing that’s going to happen is if this connection is lost, that the person will enter automated mode limited, and it’s giving just a more conservative basis of insulin to prevent people from having lows when it’s not making these automatic changes. Basically, the pod doesn’t want to give you extra insulin or take it away if it doesn’t know your number. So that’s the worst that’s gonna happen. You’re still getting insulin. It just might not be as good as it possibly could be is

limited automated, not manual. Like it doesn’t go back to your like core settings, right? It’s still doing something. Can you tell me more? Yeah, absolutely.

So what it does is we have your Basal that we set when we start the pod, right, we put in whatever your Basal pattern is, and then when it’s an automated mode, the pod is deciding what your Basal rate should be based on a lot of factors. So all that limited does is it chooses the lowest of these Basal rates. So whatever that adaptive Basal rate was that the the automated mode was deciding on, versus your Basal that we set in the pod, whichever one is lower, it’s gonna keep you there until you have a Dexcom number and then boom, it goes right back to automated I see

so so it’s got a, a scale that it can kind of go on and it goes more are conservative when it doesn’t have the number because, and this is me extrapolating. But if your blood sugar’s 130, and you know, I don’t know your targets, whatever it is, and you don’t need insulin and suddenly that CGM value goes away. This, you don’t want the pod to just be like, here’s more insulin because you could be going down while you don’t have that connection, you’re 130 When you come back into connection could be anything. Right? Exactly. If it’s a little higher, okay, you know, not the worst thing. But if it’s lower, and we’re bolusing on top of it, now we have a problem. Now you might have enough insulin going that the algorithm can’t take enough away to make up the difference is that about right, exactly. That’s,

that’s exactly it. Since

we’re talking about this error, can you give me some examples of where I can where the CGM and the Omnipod? Five so that it has great line of sight?

Yeah, sure. So let’s say you have the sensor on your stomach, that would allow you to put the pot anywhere on the front of your body. So you could do the pod on the other side of the stomach, you could do the pod on either one of your legs on the top of your thigh. And that would all give you great line of sight and good connection.

Is there a minimum distance, the sensor and the Omnipod? Five should be from each other? There’s

no minimum distance, but there is a hold on. Let’s, let’s say that over because I had that flipped in my head. Yeah, so the minimum distance they need to be apart is three inches. Okay, so we just wanted to be at least three inches apart. So you could even do the same side of your stomach, as long as they’re that three inches distance, and you’re good to go.

Makes sense. Okay, thank you very much. We’re gonna move on now. I appreciate that very much. Yeah. I have a statement here that you hear sometimes, like my Omnipod, five controller is near my Dexcom. So shouldn’t I be able to see the sensor values? Like right there? I guess, bigger question is, where do we see what we see? And what do we use for our Dexcom? is there’s a lot of people say like, well, I want to use my Dexcom receiver. But that’s not the case. Right? You need to be using Dexcom on your phone app to use Omnipod. Right?

Correct. So this question is kind of getting at two things. It’s one, how does everything communicate and talk to each other? And then two? Can we use the receiver. So let’s talk about the transmitter first with the having the controller next to the sensor. So the number that you see on your controller or your Omni pod app is actually coming from the pod itself. So the sensor is sending the numbers to the pod, and then the pod is sending the numbers to your controller or your app. So it’s kind of like a middleman between the between the sensor and the controller. So holding it next to the sensor actually is not where that numbers coming from. You’d want to hold it next to the pod. And then that would allow it to connect better to get that

number. But that’s interesting, because that’s the thing I already know. It wouldn’t have occurred to me to ask the question that way. So yeah, people are taking on the pod five controller and saying, I want to see my CGM value, and they’re holding it to the to the transmitter for the CGM. But that’s not how it’s talking. Right. Got it. CGM talks to the pod pod talks to the controller. Exactly. Right. Oh, that’s excellent. And for people who don’t know, one of the really terrific things about Omni pod five is that the algorithm itself lives inside of the pod. It’s not in the controller, right, which actually, I think really does lead into the next question that you hear so often, which is, I have to have this controller near me for this to work, right? It’s it’s everyone’s initial concern when they when they take a look at a system and they see that it’s wireless, you know, tubeless, wireless, not connected to each other. Does this controller always have to be with me, but talk about that a little bit? Yeah,

look, this is one of my favorite things about this system is that, like you said, all that technology to make those automated changes are built into the pod, which means that you don’t have to be next to the controller or to the phone app to be getting your insulin and those automated changes. Now, obviously, you want to have them with you as much as possible in case you’re going to eat or need to Bolus or change the pod. But if you’re away from the controller in the app, you’re getting the insulin, and you’re getting those automated changes. And I see this in in my life constantly. Like I said, my two year old is on the pod. He is just crazy running around outside all the time. And we just leave his controller in the kitchen where we know where it is. But we’re confident that while he’s out running around the backyard away from it, he’s still getting the insulin and those automated changes. So that gives us some peace of mind and some confidence. Well,

not just that honestly. But you’re talking about what you love about it. Yeah, one of the other things that I think is amazing is I get in the shower, it still works. I you know like that is to me fantastic. I go out and I play soccer, maybe or something like that in my activities. It still works It wasn’t that long ago that people were running around with, like fanny packs with things stuck in them to make their stuff work, you know, or Yeah, I mean, I’ve, I can’t tell you how many times I’ve hung things over fences at softball fields or run to the other side where my daughter was. So you still had like, the idea that none of that is a problem with Omnipod. Five, I think is really fantastic.

It’s, it’s amazing. Another person that comes to mind on this topic is I work with a lot of people that have very physical jobs, construction workers, people that work in assembly lines and factories, and they don’t want the controller with them, because they just don’t want their something in their pocket being cumbersome and potentially getting damaged. So they’ll leave that controller, you know, in a in a locker or an office or something while they’re doing their job. And then they know that they’re getting these automated changes, and it’s helping prevent loads while they’ve got the super activity while they’re working. So it’s, it’s

those real world applications that make you realize, like, Gee, my kid could go out on recess and not have to take the controller with them or not have to have their phone with them. And the and the algorithms still working, it’s still saying, Hey, I think we might be getting low. Let me take take away some insulin, or, Hey, you’re going up for all this adrenaline. Here’s some back, you know, right. Now, the one thing you lose, though, I want to be clear about this. So if I don’t have my phone, or the Omnipod, five controller with me, do I get alarms,

you will not get alarms unless you hit 55. If the blood sugar hits 55, then the pod beeps. But outside of that you don’t get alerts for your blood sugar, if insulin is low, anything like that. So with that point, it is important to have your devices with you and near you. So you get those alarms. But if you’re away from them, you’re still safe and getting those changes.

It’s one of those things the way I think about it is it’s great that it works. But being completely honest, I don’t know how long I’d be away from it. Like if it was 15 minutes here or there. I think maybe I’d be like, okay, but but I want to make sure I go over that again, because I want to make sure people understand. You may for example, people will laugh, but my daughter’s alarms are set at 70 for low and 120 for high. So So if if Arden’s on Omnipod five, and she goes over 120 She’s not going to know what if she doesn’t have her phone for her Dexcom app to beep or the Omni pod five controller? That’s it? Correct. But for safety reasons, even without controllers, even without phones, if you go to 55 or under the pod itself beeps Yes,

the pod and the controller beep. Okay, everything screams at you then your phone, the controller, the pod it let you know, it’s fantastic. It really

is terrific. Okay, it is. Yeah, no, I mean, it sounds like I’m just like, Oh, that’s fantastic. But if you’ve lived with this long enough, you’d know how valuable that is. Because yes, it’s nice to say, Oh, I always have my phone with me. And you do for the most part a lot of people do for the most part, but you still walk away, you know, you go do something or you go, you know, I’m gonna go move the laundry. And then the next thing you know, you’re like, Fine, I’ll make the bed and you know, like before you know it, you’ve been, you know, in the bedroom for a half an hour, you don’t realize it. So really fantastic stuff. So Eric, your son was diagnosed pretty young, like my daughter was Arden used MDI for the first for two years, I guess till she was four years old. But your son went pretty quickly from MDI, to Omnipod. Five. And I was just wondering what that transition was like.

Yeah, so he was using MDI for about three days before his first endo appointment. And then, with his Endo, he made the decision to transition into being on Omni pod. And it has been such a blessing. Wow, that short period of time he was on injections, he would fight the shots. And it was it. He didn’t want to take them and there was crying involved. So now it’s one click for three days, and he barely even notices the pod. And it’s, it’s great because he can be running around outside and we have the controller inside and a safe place. And we know that while he’s out there doing his thing, he’s still connected with the sensor. He’s getting those automated changes. And then if we’re gonna give them insulin for lunch, we just run out there, you know, pointed at him get within 20 feet and give him that insulin and have him come in. So

I that’s interesting. You bring that up because I’ve, I’m a big believer of not wanting the kids that feel impacted constantly. And so being able to be a distance from the pod and deliver a Bolus, for example, I think is a big deal. Like I don’t I don’t quite know how to quantify it but stopping a person and saying, stop doing what you’re doing stand here for a second so I can do this. I don’t love the way that feels. So Right. Yeah, that is a really terrific aspect of it. Like you know, you’re not tethered to it. So you don’t have to say hey, come over here. Hey, hand me that thing. You know, like, whatever it’s a, it’s a, it might seem like a small thing to people. But for someone like me who’s lived through it for so many years with my child, I’m going to tell you, it’s, it’s a big deal. And much easier. Yeah, well, easier to but not it’s not as impactful on them. I think so it’s what I experienced with my daughter, he’ll

he’ll actually celebrate when we give a Bolus because he knows he means it means he’s getting to eat. So there’s a confirmation B, but when the Bolus is given, it goes beep. And when he hears that he goes, yay, because that means it’s done to eat. Yeah,

finally, hungry. I forgot to bring this up. But I know this is another thing that I hear people kind of confused about all the time, if you’re using. And I’m not sure if we talked about it, but I just want to go over it again, just in case we didn’t Dexcom receiver or Dexcom on the phone, one or the other not both, right.

So it can only be on the Dexcom or the Dexcom can only be on the phone app, we cannot use the receiver. And the reason being is that it can only connect to one medical device and the receiver is a medical device and the pod is the medical device. And the receiver will basically stop that connection between the pod and the decks calm.

Eric, we’re doing great. Have you ever made a podcast before you’re doing really well? Yeah,

this is my first time on a podcast. It’s a lot of fun. Excellent.

Oh, you’re having a good time?

Yeah, I’m having a great time. Look, I love talking about Omni pod. You

know, it’s I’m not often right, that you get to apply your professional craft at something that helps people helps yourself and makes you feel good about it. Right.

I mean, I love this product. It’s life changing. It’s life changing for me, my son, the people I work with. So yeah, it’s the super fun to talk about, because it’s something that I could talk about all day. I love it. Yeah.

Can you give me some examples of ways that Omnipod five has helped you? Like in your personal life? Yeah,

absolutely. With me, personally, I, before Omni pod five, I was checking my blood sugar constantly. I tried to keep a low frequency, but with that can come a risk of low. So I was constantly checking, it felt like every 30 minutes. And that can be very mentally draining very time consuming. So what Omnipod five gave me was time and mental burden just lifted. Because now I can go, you know, I can go without checking my Dexcom constantly and know and feel confident that it’s got me covered because it’s working on those automated changes in the background. Then I remember very poignant Lee the first time, I didn’t know my blood sugar immediately in my head, it surprised me. And also was it was a cool little celebration. I was on a road trip. And I had been driving for a couple hours. And then I realized, what’s my blood sugar. And then I looked at it, it was great. I was like, Oh, this is awesome. I

tell people all the time, like use your alarms to give yourself that comfort. Yeah, you know, like, I don’t like like for me a high alarm. I want it to be at a reasonable level where I can do something about it if things are getting away. But that the opposite of that feeling is that when the algorithms helping you and it’s keeping you between those alarms, you don’t hear them for so long. It is putting it first like why am I not hearing those alarms? And it’s because the algorithms keeping you in a range fantastically? Yeah, absolutely. Really. And

I think sleep is another big one for me and something I’ve seen with my patients do I sleep deeper? Because I don’t have to worry about Lowe’s quite as much. Yeah.

Did you notice a reclamation at that point, like once you go on to Omnipod? Five, like did you wake up one day and say I feel more well rested than I have in the past?

Yeah, it was actually the first couple of days I woke up in the low hundreds. And I was like, wow, I slept through the night without having to wake up and check it. Typically, I would, you know, rustle in the middle of the night like we all do. But at that point, put a glaring phone to my face to see what my blood sugar was, which is very interrupted to sleep. So at that point, after a couple of nights of feeling it out and getting confident I was able to just sleep without having to check the Dexcom and I did I do remember feeling waking up and being like wow, this is great. I feel more rested my

exact experience. You had my exact experience. And I had I had done this thing where I sort of I guess I lied to myself. And I told myself like you’re one of those people you don’t need to sleep as much you’re okay you know and it because it’s for your kid I mean for me it was for my kid you’re doing it for yourself and now for yourself and your child but I really was I wasn’t right. I was I was not as well as I could have been my health wasn’t as well. I wasn’t the same person without that sleep. And you don’t realize it because sleep is interesting as you lose it you kind of drift away from who you are, but you don’t see it happening. Right You know, and before you know it, you’re a version of yourself that you would prefer not to be, but you think, well, this is how it has to be, but not with Omnipod. Five sleep as well. I don’t want to rate them. I don’t want to rate the values of Omnipod. five employees sleepy pretty high up on my list. It’s a big one.

Yeah. And I think a lot of people trade, the fear of going low as staying high while they sleep, which is also just not great for sleep either. You know, you’re not going to sleep well, if you’re, you know, high.

So no, no, exactly. Right. Yeah. People don’t think about how blood sugars alter them. Like we all think about, oh, you get low, you get dizzy, you don’t make sense. That kind of stuff. Your blood sugar starts going up significant effects on who you are, how your brain works. And a lot of other things you muscles in your head so much. Another thing I hear Eric talk, okay, hear two people talking about? Is there. I think they can kind of get confused because there’s on the pod Dash. And there’s on the pod five, right? So if I have a bunch of Dash pods, and I want to go to five? Can I just use my old pods? No, correct?

No, you cannot. So Omni pod five are the pods that work with the Omni pod five system. And I’ll just say make sure that what you pick up from the pharmacy is Omni pod five pods. Because sometimes the pharmacies do mix them up. Or they might have you know, a back sock of Dash that they accidentally give you and you’re going to try to get it connected for a while and get frustrated. But this because you have the wrong pod. So you can look on the box, you’ll see the five in each little pod package has an omni pod five on the upper corner. So just double check and make sure you’re getting the right thing.

So that could go either way. I might I might want to ash pods. Somebody might hand me a five by the shade or vice versa. Okay, yeah. So here’s the thing that I’ve heard people say that I have to be honest, I think of it as like a positive. So I confused usually when they say it. Yeah. But you’ll hear people say sometimes like, look, sometimes I want to take this off. And you know, the truth. Like from my perspective, one of the wonderful things about Omnipod. Five is the constant insulin delivery. Yeah. And I think that, I think that that can be a confusion for people who think like, well, you know, I used to have a two pump. And so how will you know, what do I do? And I mean, what is it exercise swim? Maybe I’m being intimate with somebody like that kind of stuff. But I always think like, don’t take it off. Like, you know, you need that insulin, you need that background insulin all the time. I certainly don’t want to be a bummer. But I’ve interviewed a number of people who in just a couple of hours of being disconnected from their insulin have found themselves in DKA. Oh, yeah. 100%. So to me, it’s a benefit that on the pods are always there. And it’s always working. But absolutely. But if I was, if I had that thought in my head, why would I not want to disconnect? Yeah,

so my personal experience, I’ve been on all the pump systems in my days, and this is what drew me to Omni pod was the constant insulin. Because I was so active, I would take my tube pump off for like baseball practice. And then three hours later, I had ketones. So studies have shown that disconnecting from insulin can cause the blood sugar to rise one milligram per deciliter every minute. So getting this constant insulin is going to lead or can lead to better clinical results, better blood sugar results. And one of the really cool things that the Omni pod five has that can kind of mitigate this fear or idea that people have is activity mode. So this is a mode that can be initiated for any length of time up to 24 hours to tell the pod, hey, I need less insulin during this time. So when you are being active, doing whatever it is, the pods going to back off of the algorithm be a little bit more conservative. So it’s not going to cause or it can prevent causing a low while still getting that continuous insulin for the best results.

Yeah, it just it to me it’s, it’s sort of a no brainer. And and the other thing that you didn’t mention, but I’m gonna say it here, you can be in DKA. With a number that’s not elevated, you could be a dk with 120 blood sugar. It’s the absence of insulin that causes you the problem. It doesn’t always mean that your blood sugar will shoot up. You could be you know, it can go either way. But it’s one of those things that’s it’s just important enough because of how quickly it can turn it. I mean, listen, people have been people have had diabetes for a long time. They certainly had it longer than my kids had it. Although I think I’ve been in the game for a while now. But I’m always worried when I hear somebody say I took off my pump to go play a three hour game of something. It doesn’t sit right with me. So anyway, I pleased. I think

it comes down to the burden to have having to disconnect having to remember to put it back on. You know, why not just have something you don’t have to worry about to get in the shower. You just hop in and get out and it’s fine. Yeah,

because you Don’t know till you talk to enough people, how many people disconnect their two pump, jump in the shower, get out, forget to put it back on, right. And then you know, it’s two hours later when you remember it’s on the sink. And you know, in the bathroom,

you might hear that people with two pumps say it’s convenient to take it off or some of these activities. But the reason it’s convenient to disconnected is because it’s inconvenient to wear it for these things were with Omni pod, it’s always convenient. It’s always on, you’re always getting insulin, and you don’t have to worry about it for whatever you’re doing. It’s right there pumping insulin. That’s absolutely

true. I’ve never I you know, I say these things sometimes. And I wonder what people think. But I can only tell you my experience. My daughter has never said to me this Omni pods in my way. Like never. i She’s played sports, swam, gone to college, driven a car. I mean, a number of years ago, my daughter was two wins away from going to the Little League World Series for softball. And I never heard, hey, this is in my way. That’s awesome. But all the time, what do I hear from people? Oh, my kid’s got a disconnect there to poverty. So they can XYZ it’s it’s constantly it’s all it is that makes total sense to me. Well, this is kind of connected to that loosely. I think I mean, the pun. But for people who might have trouble keeping pods on sometimes. You know, I think it’s incumbent, I think upon me to say that medical devices in general, all sorts of have the same issues with some people around adhesives. And then with some people know, again, my daughter doesn’t use Overlay patches, she doesn’t that I’ve never seen an AMI pod fall off of her. I mean, maybe on the third day, if she swam for nine hours, it was easy to pull off afterwards. But that’s just kind of luck, right? That’s her skin. And he’s if it works really well for her. But for other people, what do you see? And what can help them?

Yeah, so I think the tendency is people think they need to buy these overlay patches, or they need other products that keep it stuck. But I think there’s other basics that we can focus on to help the pod stick as best as possible before we look into using those other things. So I tend to think of three basic things that if we can make sure we’re doing before every single pod, that’s gonna give us the best success. And one is just making sure you have clean skin using an alcohol swab, making sure you put it on or change it after a shower. And because you know, we all have oily skin so that oil can get in the way of the adhesive. So washing that off is gonna give us the best stick, but also making sure the skin is dry. I think the tendency sometimes can be that you use the alcohol swab, you wet it down, you get it good and clean. But then you stick it on right afterwards, you don’t let it get dried, it just falls off. We’ve had this happen with our son before he was being wiggly, and he didn’t want to sit still. And we were trying to get it on really quickly. And we just put the alcohol on and stuck the pot on it just popped right off. Yeah,

what about I just have to ask hair. Some people have to shave first. Yeah, sure,

sure. It that that’s obviously person dependent. And they need to assess that themselves. But Shaving can absolutely be something that can be beneficial and hair can get in the way of that adhesive. You know, we have a whole team of people that their job is to look at, why aren’t these pods sticking? And they see everything from oily skin lotion, too much hair. And they’re assessing why they might not be sticking? And we’ll see all those things.

Are you telling me that I can get a job at insolate where I get to look at pods that have been returned so we can see what happened and I may get one with hair stuck to it.

You absolutely good.

Where can I apply for that job through LinkedIn? I’m super excited. I’m leaving my profession right now that I’m running. Let us thank all the people who do that job right now.

Okay, good luck on that search. Yeah, and I think the two it’s a it’s a it’s an important job. Yeah, he tell us, you know, what’s keeping it stuck?

Well, I mean, you’re, you’re, you know, obviously, you know, if the if the site’s still wet, or if you have hair, but the truth is, is that anything between you, between your skin and that adhesive that’s blocking the path is going to stop adhesion from accidentally Yeah, so a little bit of common sense when you’re looking at it, maybe make some decisions that you know, like I’ve heard people say, what was that one person told me I’m like, Oh, my my stuff falls out. I don’t even think they were talking about Omni pop but my device is falling off all the time. What do we do? And then it was in the Facebook group and it turned into a chat and people went all through it. And you know, by the time you get done here’s what you learned lotion. The person was like rubbing like hand lotion on themselves and then they’re like, I don’t understand it’s balling right off. And, and but it was funny how it took a small village of people to like, get to that idea because it was so a part of the person’s like, I don’t On a routine, they just didn’t even think about it. Like it actually took someone to say, Hey, do you use any body lotion? And then the person was like, Oh my gosh, yeah. And then like it was anyway. So finally thread to watch it, like, learn something about themselves. They didn’t, they didn’t know. You know, it’s really fantastic. So good. So before I go spending a bunch of money on others, I have to say, again, we don’t use overlays. Maybe she’s lucky, maybe your skin’s not that oily. Maybe we just prep it? Well, I don’t know.

I think another thing that can be beneficial, or something to think of is strategic placement. I think that can be important as well, you know, if you have, again, thinking back to my people with physical jobs that are doing construction, they don’t want it necessarily on their stomach, because they’re lifting they’re, they’re moving. So those people tend to put it more in somewhere different, you know, like the back of their arm, or it’s more out of the way, right? So I think thinking about what do you do on a daily basis? Where could it get knocked off? And then maybe let’s think about somewhere else, that could just be another thing to put in place to make sure it’s gonna stay on as long as possible. tastic?

Well, alright, so Eric, we’ve gone through the questions that I have for you. Do you have anything else that you want to leave people with? I mean, you do this every day, right? Talk about it for a second you say you’ve trained over how many people do you think you’ve trained?

Over 500? I don’t know that exact number. But it’s a lot.

Right? You do them in person? Do you do them virtually? How does that work? We

do both. So I’ll go to the clinics will do in person. We’ll also do virtual. So it’s a nice mix. And yeah, we have a lot of fun with it.

So you know, I don’t even think I did this at the beginning. So much like people who listened to podcasts know, there are times I’m like, Hey, we should probably talk about your diabetes at some point. But we should probably say this. Tell me your title again.

Yeah, so I am a clinical service manager is the full title. So

what that makes me think of is that you’re in charge of the lunches at a doctor’s office, but that’s probably not true. So why don’t you tell me what that actually is? Okay. Yeah.

So basically, that means that I train people start them on Omni pod, I follow up with him to make sure that they’re doing well, they’re not having any issues and helping them get through any troubleshooting they might have. And I’m also worked on educating doctors and other providers on what Omni pod is how it works best practices. So it’s both patient and provider facing. Yeah,

that’s really something and you’ve been doing it for would you say over a year now with Omnipod? Yeah,

a little bit over a year. So it was summer of 2022.

That’s amazing. Hey, you get the pods? Like what shape or something are

that well, they they are free. They do come directly from me. Nice perk of the job.

Now I’m really applying Oh, I guess that wouldn’t work for Arden anymore. She’s an adult, but I was gonna say now I’m really applying for that job. Have

you get carrier on him? Yeah.

I would look at the Harry pods for free pods. I just want to be clear. Yeah. Absolutely. All right. Well, thank you so much for doing this. I really do appreciate it.

Yeah, absolutely. Thank you so much. This was a lot of fun. That was my pleasure.

I hope you enjoyed this don’t miss episode to ask the Omni pod five product support expert. This one’s about the top calls that they receive from customers. That episode will be with me and Lindsay Friedman. Lindsay is the Senior Manager of clinical product support at insulin. The third part of this series is not to be missed. It’s with Melissa Lee Senior Manager Instructional Design at episode is going to be called Ask the Omni pod five User Guide expert questions about the algorithm. This one’s a pretty deep dive, especially about how to make changes and adjustments. And Melissa actually wrote the Omni pod five User Guide. Both Lindsay and Melissa have type one diabetes. Whether you’re a current or future Omni pod five user, you also should check out this great content from myself. And insolate episode 736 Omni pod five pro tip overview episode 737 Omni pod five pro tip settings and episode 738 Omni pod five pro tip connectivity that series is with me and a pediatric nurse diabetes educator named Carrie Birgit throughout this Ask the Experts series you’ll hear me refer over and over again to having your settings correct when you initially set up Omni pod five, and my Omni pod five Pro Tip series will help you to do just that. You can find them in the audio app you’re listening in right now. Or at juicebox podcast.com/omni pod five. Interested in getting started with Omni pod use my link Omni pod.com/juice box. Both of those links are available in this Show notes of the audio app you’re listening in right now and they’re also at juicebox podcast.com

Hello friends, and welcome to part two of my three part Omni pod five Ask the Experts series far too often community sourced answers to Omni pod five questions contain misinformation. So today we’re going to help to set the record straight by speaking with an expert who works at Omni pod. And Lindsay doesn’t just work there. She also has type one diabetes, and where’s the Omni pod five. Today, Lindsay and I are gonna go over the questions that she sees most frequently as the Senior Manager of on the pods clinical Product Support Team insolate has paid the host of this podcast Scott Benner a fee to create this content. This podcast provides general information and discussions about health and related subjects. This information and other content provided in this podcast we’re in any linked materials are not intended and should not be construed as medical advice. Nor is the information a substitute for professional medical expertise for treatment. Never disregard professional medical advice or delay in seeking it because of something that you have heard in this podcast or read in any length materials. The opinions and views expressed on this podcast and website have no relation to those of any academic hospital, health practice, or other institution. Please speak with your health care team. If you or any other person has a medical concern, then before making any changes to your diabetes management, and consult the Omni pod five automated insulin delivery system User Guide for more information, nothing you hear on the Juicebox Podcast or read on juicebox podcast.com is intended as medical advice, you should always consult a physician before making changes your healthcare plan.

Hey, everyone, I’m Lindsay Friedman. And my role here at insolate is I am the Senior Manager of our clinical Product Support Team. Some of you may have even chatted with some of them on the phone. So what that means is they are available on our phones when you call in and have questions about things like adhesive or how do I get the best set of Omnipod? Five? They are all licensed clinicians and diabetes educators. Okay,

let me make sure I understand. So you manage a group of people who I have access to through the phone? That is correct. You’re absolutely right. Because I’m a I’m a customer? Well, I guess Arden is she’s an adult. But I mean, let’s be honest, I pay for it. So I have a customer. So when I call I’m getting people who have what kind of a background Tell me again,

the team is comprised of clinicians, so they’re licensed nurses and registered dieticians. And they’re also certified diabetes educators.

Can I ask you a question that has nothing to do with anything? Because I’m interested? Where do I Where do they sit and do that job? Like? Am I talking to them from their living room? Or are they in a matrix farm? Or where are they exactly?

Yeah, it’s a good question. So this team in particular, they all work remotely. So whether that’s from home or in an office space, yeah, they’re all over the country, actually. So you could dial in and get somebody from Iowa or Texas?

Does that make it easier for you just to I was gonna say stock, I don’t know if that’s the right word, but fill your team with like, really qualified people, because they’re not just have to live in a certain place, I guess.

Yeah, I think you could say that. Last time. I was recruiting for this role. I had hundreds of applicants, so definitely makes it easier, I think, yeah, that they don’t have to drive to an

office necessarily. And you have type one as well. Is that right?

Yeah, that’s correct. So actually, this month, diabetes Awareness Month, I will hit 32 years with type one diabetes. So yeah, I was diagnosed when I was nine. And I’m currently in Omnipod. Five user, though I historically was always a tube insulin pump user prior to this. So lots of experience with insulin pumps, how

long have you been with Omnipod? Working for them?

So about two and a half years, two and a half years?

Were you using a different pump while you were working in Omnipod?

So when I first came on board, yes, I was wearing a tube to pump when I first started with Omni pod. It’s funny. I actually was somebody who said no, I’ll never wear a pod. And then I put it on and I literally said I will never turn back. So yeah, definitely a lot of great things and convenience. But yeah, I was wearing a tube insulin pump when I started here. Waiting for Omnipod

five. Yeah, that’s very interesting. So you Omnipod five, your first tubeless insulin pump you’ve ever worn. Correct in how many years? Do you say you have died at 32 years? Yeah. Wow. That’s a long time. Yeah. Can I ask you a couple of questions before we jump into why we’re here? Sure. Any other auto immune in your family?

So personally, I have celiac disease as well. Aside from that in my family, no, I’m kind of like the lone die. Like, aside from the fact that I do have a cousin with type one diabetes, I no one else in my immediate family has any autoimmune diseases or diabetes. Celiac, just me. Wow. Okay,

so do you have brothers and sisters?

I have a younger brother. Yeah, nothing. That’s good. Let’s

call him lucky. I

guess I was special. As a special one.

I always say, does it translate to any other random things happening to you if you won the lottery or anything like that, or No?

No, not that lucky. I’ll take it usually doesn’t

work that way. Okay, so I so your job is you, you oversee that team? So do you actually listen into calls? Like, what is your job entail? I guess, we

work very closely with each member on the team on the team has actually grown quite a bit since Omnipod. Five launched. And we’re really Yeah, looking to do exactly that, you know, understand what the needs are of the people calling us. You know, what kinds of training do we want to make sure we provide our team members to be able to answer people’s questions, obviously, as best as we can. And, you know, we do listen to calls, we listen to calls to hear about exactly that. What are people calling in asking us about? What are they, you know, seeing as common challenges they’re facing? And then what, as an organization, you know, do we do to help support that? And I’ll say, there’s a lot of things actually, I feel like we’ve done in response to what we’re hearing our customers call us about.

Yeah, that’s interesting. I’m going to talk to you more about that as we go along. Because that’s what I was wondering if the calls end up informing how you do your job. So today, we’re going to go through some of the more common, I guess, phone calls, and then try to make sense of them. It just, it behooves us to, to, to be honest, and say a lot of people have the same questions over and over again. Oftentimes, people don’t get the right answers, they end up coming up with the thing they think might be the answer. And then of course, they get online and start telling other people about it. Before you know it, you’ve spread, you know, a reasonable amount of misinformation around and everybody thinks that they know what’s happening when they often don’t. So this is a great opportunity. I really appreciate your time. Yeah, thanks for having me. Oh, please. Alright, so we’re gonna go into the first question. There are posts I see on social media sometimes where people say that the pods are just deactivating unexpectedly. Sometimes people come in, and they answer and they say there’s something to do with a setting called pod shut off. But I don’t know what that is.

It’s got that’s a really great question. And this does come up. And, you know, I’ll say I think this is a setting that people are less familiar with, in general. I’ll start with, you know, what is the setting, I think just to give a brief overview, you know, the setting is actually intended to be I think of what we consider like a safety feature, I kind of tried to think of it in like a car, for example, like these days, you have all these, you know, features that actually might sort of alert you at some point, actually, I was driving the other day, and that do, you need to take a break, no, feature popped up with something, it’s like a coffee break, you get a little coffee cup on the dashboard. But you know, essentially, it’s after, you know, a period of time, if you have not, or the user has not interacted with the controller in any way. So waking it up button pushing. And, you know, the feature is, the setting is set to a certain period of time, if that time passes. So let’s just say for example, that setting is set to eight hours, if eight hours has passed, and you have not interacted with the controller at all, then an alarm will go off to say basically, is everything okay? You know, make sure you react to the alarm. So we know you’re okay, if not, we’re going to deactivate your pod, assuming maybe something has happened. So it’s really a safety feature in that sense. You do not have to use it. But sometimes these settings get turned on accidentally, because maybe you don’t know what it is. And you think oh yeah, I want that feature pod shut off. Whatever that means. So yeah,

I didn’t read the book, but that sounds enticing. I’m gonna do that. Let’s see how long like what am I different options? You said it defaulted for hours. But what are my other options on the that setting? So

you can set it in one hour increments up to 24 hours? So yeah, you have a lot of options. Yeah, and if I think about really why people might utilize this feature, you know, I have also trained on many insulin pumps, including Omnipod five, and you know, it’s one of those things that when you’re setting up a an insulin pump, and you’re thinking about well, why might somebody use this if you’ve got a college student or somebody who lives by themself, you know, somebody who’s again, older and has nobody who’s living with them. a concerned parent, a kid who just went off in is living by themselves. You know, those are some of the the reasons people might utilize this. So again, as that safety feature, if you’re, you know, sleeping and you have a low glucose are not responding to the controller or interacting with it. You know, this would in fact, then shut off if you didn’t respond to the initial alert. So it does kind of it doesn’t I want to say it doesn’t shut off immediately. Let’s say, again, for example, you have it set to eight hours, it will kind of alarm to say, hey, here’s this alarm, it expects that you’re going to respond to it. And then if you haven’t, it will then go ahead and deactivate the control, deactivate the pot. Yeah,

listen, I’m just gonna say that I think if you’re not interacting with your diabetes in every four, eight hours, you maybe should be anyway. So not a bad thing. It’s

mostly it’s primarily utilized for when people are sleeping, I think is what we’ve seen. But

back to when people call and ask you about or when I see online, it basically is that that setting gets set up, they don’t realize what it is. And then it alarms, they don’t interact, the pod shuts off. And they’re like, I don’t understand it. My pod just shut off. But that’s pretty much what that all is.

Yeah, exactly. And so there, you know, there is a way that you can actually check to see if this is turned on. If you go into the settings menu in the controller, and you go under reminders, you’d actually see pod shut off, and it is a toggle on and off. So, you know, we have had people on these calls go in and say, Oh, I didn’t realize that, you know, maybe turn that on when I was setting up my controller. And so now I’m gonna go ahead and turn that off. Gotcha.

Okay. Well, thank you. That was excellent. Very clear. Could you Lindsay, have you ever done something like this before?

I have not actually not not, you know, set up like this now. A lot of people but not like that.

Is it weird? Or is it off putting? Like, no, it’s fine. It’s good, good? Well, I’m glad. Oh,

and I will always say, Scott, because we do have to say this, we say this on the phone all the time. So anybody who calls us will hear this. When we’re on the phones, I think it’s important for people to know, we can’t direct people to actually make setting adjustments. So we can inform you that this is what the setting does. And this is what it means. And then we always have to direct people to work with their healthcare providers, if they want to, in fact, change that. So

wrapped around this idea. I we spoke earlier about sometimes people see things and they think, oh, that’s why it happened. But it doesn’t end up being true in this specific example. I’ve seen people say, Oh, my gosh, the controller was away from the pod for too long. That’s why it shut off. But that has nothing to do with it.

No, no, actually, you know, we do allow for distance between Of course you need your controller near you in case you know, there is an alarm that goes off to hear it or of course you want to engage with it. But this would not be if you are just you know, you left your controller in the other room and we’re away for too long. It’s not just going to deactivate your pod for you.

Excellent. Okay, next question that, let’s see, whenever there is a communication error that can’t be resolved by retrying. The only option is to deactivate the pod. Why does this happen? And is that really the only solution?

Well, Scott, this is probably one of my favorite topics I’m just getting is not a communication errors. Yeah. So I think important to note about communication, of course, the system operates via Bluetooth. So you know, when a communication error occurs, again, I think the way we tried to describe this relay to is from a safety perspective, we obviously want to make sure controller and pod are communicating. And they’re communicating well. So if a communication error occurs, often it means for some reason, there was an inability for the pod and controller to communicate. That can be for a number of different reasons. Again, one thing we think of is Bluetooth technology, there could be interference. Sometimes it’s environmental interference, sometimes it’s other Bluetooth interference that could occur. And so, you know, we really try to navigate these calls by helping people think about the different steps they can take, aside from just we really actually call it it’s oftentimes discarding the pod, it could be deactivate, but I think discard is an important word to keep in mind here too, because I think what people often see on the screen is try again, or discard the pod in these communication errors. And so to answer your question, does, is this the only solution to discard or deactivate the pot? The answer is no. And actually, I will say even personally, that’s always my last option is to hit discard or deactivate. So what people can do is, again, if you think about, there could be some interference. One option is to just sort of get up and move where you are. Even a few feet away. Maybe there’s something right in your surrounding vicinity. Maybe you’re, you know, sitting up against a chair that has something that’s interfering like a metal chair or something like that, moving your location and then hitting try again, often does work. If that doesn’t work. There’s a few other things that you can consider doing. One of them would be too. If you have any pods that you’ve recently attempted to activate, or any pods that you’ve recently discarded, removing those pods from the area are important too. And it’s funny, I actually had this conversation with our engineering department because I really wanted to make sure and when you say how do we, how do we equip our teams, this is one of the things we do is work with our internal teams to really understand what’s going on here. So we can best equip our customers with the right information. So I had a conversation with our engineering department to really try to understand you know, what is happening here, and I’m not a Bluetooth expert, so I won’t pretend to be one. And so you know, working with them, you know, they really share that, when there are other Bluetooth devices in the area, you know, the system is scanning for the pod to connect with it. And that’s, again, Bluetooth technology. So things like even on the smartphone, if you’re using our Omnipod five App on the smartphone, toggling the Bluetooth on and off or temporarily disabling other Bluetooth connections, just to make sure the pod is the only thing that the app is looking for. In the controller, you can’t toggle that that’s why getting away from other connection Bluetooth connections or again, moving locations, is something that can be really helpful.

I’ve found that oftentimes we connect to things through Bluetooth over months and years that we don’t interact with anymore, and just sometimes going into your Bluetooth settings and going I have not been in that car in five years. Delete that one, you know, like that kind of stuff makes it actually run a little better.

Yeah, well, it’s funny, you say that I put my headphones on today to do this. And the first thing my headphones connected to was my iPad, when I wanted it to connect to my computer, so it’s like it remembers stuff

pinging all around and you know, there’s, I mean, as a great example, moving forward, there are going to be some CGM and sensors that you that you are discarding every couple of days, and it leaves its Bluetooth signature behind in your phone. So going in and deleting them as an example is a great way to kind of keep that whole thing clean. Yeah, so So when, when we do get to the like, I guess, what’s the situation where this might happen? Like, when would I see this pop up? I guess what if I haven’t used the controller in a while and I’d go to Bolus or something like that. And then I’m seeing a communication errors that like that kind of an idea.

We see communication errors occur at times when attempting to give a Bolus and that’s where you might see it more like unable to communicate is the language. And in that case, you will get that try again, option. And again, that’s where, you know, one thing to do is move location hit try again, you know, if you’ve tried a couple of those steps, and and our customer service reps or our product support teams will help to walk people through this. The other option they could do is actually what we call power cycle. So really just turn off the controller. And then that sort of reestablishes connection when it turns back on and allows people to go ahead and Bolus, you might also see communication errors when attempting to activate a new pod. And again, that’s really related to you’re just talking about these previously discarded pods. And so, you know, what happens when a pod is discarded? Is the controller sort of I think about it, like a relationship just kind of abandons the relationship. And the pod doesn’t know. So the PDM or the controller is just saying, you know, I’m going to abandon you and the pod has no idea. And so, you know, it could be attempting to continue to communicate versus, you know, when we see like a deactivating a pod like you do every time you change a pod, both sides of the relationship decide they’re gonna split. So it’s an equal, it’s a decision made on both sides, where it’s a clean split at that point. And so those previously discarded pods do have to be removed from the area as well. So we’ll often say, make sure you move them, you know, at least 20 feet away from where you are, to make sure that that controller is really only attempting to connect to the pot in front of you.

I’m laughing for two different reasons. One, I have once opened my backdoor and flung an old pod into the backyard. I was like I think this is too close and it’s what’s interfering with us setting up this next one. And because you set up a scenario where the pod was broken up with but just won’t stop calling so I just need to be very firm with it and let it know I’m sorry but we’re done now. And and to do that would be to create more distance from it just in case it’s still trying to connect. Yeah, I don’t know the technical side of it too, but it always feels like to me like it just has trouble letting go at the end like and it’s not a I would have to say it’s not a common occurrence. I’m not like winging pods into the yard constantly. But I mean It happened a handful of times. So I get that. All right, great. Anything else on that one? Or I have that one covered pretty well with you? I think we’re good, right?

Yeah, I think we’ve covered like, I’ll just put a plug in that we because, you know, we, again, are really trying to be mindful of what our customers are calling us about. And giving them some tools like this, which is great to be able to listen to or reference, we’ve actually got all these steps that they can find on our omnipod.com website. So we’ve tried to put a lot of this stop stuff up on our website to make available to people to find answers, versus necessarily having to call us every single time to ask these questions over and over again.

Okay, so complete the power cycle, toggle the Bluetooth on and off, make sure there are no other pods that have been previously discarded, or whether it’s like 20 feet of you. Yep, pretty much, right. Yeah. All right. Cool. Yeah. All right. Moving on. insolate randomly sent me a new controller, I remember when this happened. I’m gonna I’m gonna, I’m gonna tell a story before we get into this question. So I happen, like, I have a relationship with you guys. And so that people might not believe or understand, but like, I text with people sometimes, like, you know, and I know sometimes when you guys are doing things, and I know the pain of trying to communicate to the public a thing because you’re like, we said this, but not everyone sees it. So you guys went to all this trouble to send out emails and let people know we’re going to be replacing the controllers. Here it is, but then, you know, most people didn’t get the email or didn’t read it or whatever. And, and this question was all over the internet. So okay, insolate randomly sent me a new controller wasn’t random. But I know it might have felt that way when it showed up in the mail. Do I really have to use it? So tell us what happened there and what they need to be doing? Yeah, absolutely.

I’ll tell you what happened there. Before I do that, too. It’s funny you say that, because, you know, one of the things obviously, we’d love to review is, of course, we sent you information about all of this. But you know, easily, I’m sure people get hundreds of emails a day and all of that it’s hard to track. But yeah, basically. So we did send these new controllers out, as part of what we call a medical device correction. If somebody received one of these new controllers, it means their previous controller was part of this medical device correction. And these new controllers contain a fix that was identified as part of this. And so we do recommend that people start to use their new controllers. And, you know, there’s a couple of things, I’ll point out with that as well, because it’s important to know a few things or remember a few things when you’re starting a new controller. But long story short, we do encourage people strongly to utilize those new controllers, if they received them, you know, the other piece will will mention as well as not only the new controller, but also reminding people to use their original charging cables. Again, when we think about losing emails, or, you know, papers that came in the mail, I think sometimes just as easily charging cables, people probably have 510 of them somewhere. But we really do strongly encourage people to utilize their original charging cables. You know, with this as well, as well as the adapter is really important as a part of the notification that came out with this medical device correction.

I see. So use the plug in the cable that we sent you, please. And if we sent you a new controller, go ahead and start using that one. But you know, people are like, I don’t want to it’s going to reset the algorithm. And right, yeah, but in the other episodes in this series ended, it’s kind of covered pretty completely about what happens when you start over. It’s not I don’t think it’s the one I don’t think I know, it’s not the long term process that they imagine. Especially maybe now that they’ve got it all set up, and it’s running really well moving good settings into a new controller, get your right back to where you’re going again. And yeah,

I’ll say, Scott, I did this personally. And, and to be honest, I had the same thoughts. You know, I had been on the controller for months, and I was doing great. And the thought of, oh, I have to start all over again. But you know, having reviewed my, you know, pump settings and my manual Basal rates and carb ratios and everything and ensuring that I’m starting that new controller with updated settings, it was a really smooth transition for me actually smoother than when I first started Omnipod five, to be honest. So I really find that, you know, it works well, if people make sure that they’ve reviewed their settings and their settings they want to transfer over,

right? No, that’s exactly what I would say as well. All right, the next one. Interesting. I use a different word here, but we’ll get to it. It says if I give a large Bolus, the pod seems to leak insulin. How can I stop this from happening? But they’re talking about I mean, you have diabetes. So this is easy to talk to you about but they’re talking about tunneling, right. Do you know what that is? They Yeah, right. So, okay, so you go ahead and tell them what’s happening. If

they can partner here, no problem. So yeah, you’re absolutely right when they’re talking about leaking, it’s generally from the site is whether we’re talking about not, for example, like the pot itself is leaking fluid out, right, and what we mean by this, and you know, I’ll say before I even talk about it, I think it’s important to note site. Finding sites that work well, is not always, you know, the easiest thing depending on how long you’ve had diabetes, or how many insulin pumps you’ve worn, or how many sites you’ve used. So I’ll say, you know, this is something that can just take trial and error to find a site that really works well, sometimes, and some sites just work really well and others maybe don’t. So with this one in particular, you know, what we’re finding here is, when you put a pod on, there’s a couple of things you want to keep in mind, you know, one, you want to make sure you place the pod in an area that has, you know, enough subcutaneous tissue. And if you happen to have more muscle tissue, the making sure the cannula itself in the pod actually insert into more of the subcutaneous tissue. So that’s that more like fat layer. And so why we’re doing this is to avoid that cannula. You know, inserting into muscle, because then what can happen is when you have that pod on, it can really cause what we call this tunneling, where again, then you’ve got this cannula that’s not staying in the subcutaneous tissue, but it’s kind of moving in and out and creates this tunnel, really where insulin can flow back out of. And so to help support that, you know, we talk about pinching the skin up to make sure the cannula really does insert into that subcutaneous tissue, then we also want to make sure that cannula stays stable. And there’s a couple of things that people can do to help ensure that, you know, when we talk about this on the phone, this is something my team absolutely deals with on a regular basis, you know, and helping people find not just leaking, but helping people find sites that work well. And some of the things, you know, we talk about is even pod positioning. So, you know, we think about the way our body is designed, like we all have curves of some sort on our bodies. And so positioning the pod so it really lays flat and doesn’t go around the edge of your body will help ensure that that cannula doesn’t keep pulling in and out with your body’s movement and creating again, that tunnel space.

No, no, I’ve well, so basically, I kind of want to paint a picture for people. So you’re putting a Bolus of liquid under your skin. And if there’s an easy pathway back out, the the liquid will follow that. And now, and then you’re like, oh, it’s leaking, because it seems wet around the thing. So that that’s the positioning part of it, right? Like, if that cannula is rocking around in there making a loose, loose fit, basically, it allows that liquid to move backwards. And the larger boluses can not absorb as quickly so they kind of sit in there as a pool. I mean, that’s obvious. And I’ve, I tell people all the time, like, look for a flatter surface, like a place where it’s not going to rock you know, like where you’re not you don’t you know what I mean? Like? It’s yeah, you don’t want to put the pot on top of a hill and expect it to like, hold on, you want to have a nice flat flat surface. That and the pinching up. I mean, anybody who ever says to me, specifically about Omni pod, I’m not the first thing I say is did you pinch up when you put it on? Always do that. But it’s the thing I’ve been saying for so long and doing for so long. I don’t know if I just always I just assumed like everyone knows that already. But obviously everyone doesn’t know that. So like just kind of collect up a little bit of that top layer of skin around the cannula. As you’re injecting the the cannula in for the auto injector. That’s what you mean when you say pitch up. Right.

You got it? Yeah, you painted a great picture. Exactly. Right. Yeah, I think it’s such an important step. That, you know, when we train when we do training initially, there’s so much to remember. And sometimes, you know, we help somebody put the first pot on and you can forget some of these steps that are really important. And pinching up is definitely one of those.

I think two people can just get like it becomes such a part of your life that you don’t think, oh, yeah, I, I played tackle football this week. And now I don’t seem like my my Bolus just don’t seem to be working right. Because that thing’s been like yanked all over the place. It’s this tiny little plastic tube that’s just under your skin slightly, and you’re yanking all over the place then go on, like I can’t believe it didn’t work. So also, you know, that’s why you hear a lot of people who do activities like hard hitting activities, where they think the pod might get bumped. They’ll do a sports wrap while they’re playing. But I guess also even an overpass or something like that. If you think there’s going to be a lot of like vigor. You could do that as well. i A simple example is that when my daughter used to play softball, she wouldn’t put the pot on her throwing arm. And because she’d throw and then she so that I could feel it kind of pull around a little bit. And so we purposely cap it off that arm that was getting a lot of action. So I guess like, that would work too. Like, yeah, yeah.

And I think to your point, you know, exactly like I said, in the beginning is everyone, you know, sometimes it’s trial and error, you just have to find, you know, what works for you. But some of these steps are really important to help support that process. And to your point, you talked about, you know, over, you know, some of these raps or, you know, the the over tapes or things like that, also sometimes talking with your doctors about what you can do to secure the pod underneath it. So we do have, you know, different adhesive aids, so things that you can actually put on the skin to help make the adhesive adhere better if somebody struggles with that piece, and ensuring that that that pot really stays in place. Again, to avoid that cannula moving. It’s really important.

You know what, I want to keep going with this topic for a second Lindsey, and just it’s come up in another episode in this series, but I think it’s worth covering again, that, you know, sometimes people just feel like they need overlay patches for the devices. And I was wondering, like, how that all works? Like, how do they learn about them? Where do they get them? You know, why are they valuable?

Yeah, that’s a great question. So I can say insolate does have what we call pod pals, it uses the same adhesive as our pod adhesive. So just so people are aware of that. But I will say for Omnipod, five, you may have seen these, if you open your starter kit, and you’re wearing Omnipod five digit, we are providing these overlay patches in the Omnipod five starter kits, if you’ve never used them before, you’re interested in them. There’s also a website, sugar medical, or company sugar medical, that you can look for pod pals on there as well. And really, what an overlay patch is going to do is enhanced the support. So it’s an added layer over the adhesive that helps to secure that adhesive and pot in place. Of course, you know, there are other options as well. So people do work with their, you know, own educators or healthcare providers to find the right overlay patches that work, you had referenced a couple of other things like the wraps. So there are lots of things out there, thankfully, to the diabetes community for, you know, always wanting to ensure they can get the best utilization out of their devices. So there’s lots of options. But yeah, the benefit really would be to help us to continue to secure or further secure the adhesive of the pot itself.

Okay. So prepping the site, you know, making sure that the skin is clean, when it goes on free of oil, hair, those kinds of things are important. Yeah,

so in talking about adhesive in general, which I think is what you’re getting at, you know, there’s some important things to just help secure the pod in place in itself. So, to your point, you mentioned, you know, making sure the skin is free of oils and lotions, you know, really prepping that site. And so a lot of the things we talk about, especially when when people call in and ask for support around adhesive is, how are they preparing their sights. And so, you know, cleaning the skin and you know, if you think about even I think about this with band aids that I’ve put on, you know, if I’ve got lotion on my hand, and that band aid does not stick that well. And so making sure your skin is you know, free of those things. And even things like body hair, you know, you think about putting tape or something on a part of your skin that has a lot of body hair is not going to stick as well. So preparing that skin and possibly, you know, shaving some of the excess body hair in that area, if necessary. So yeah, skin prep is important. Not only does it help the adhesive stick, it’s going to help that pot overlay as well. Yeah, I

can imagine I mean even dry skin, right? Like if you have dry, flaking skin that it sticks to the He’s an athlete, he’s not sticking to you. It’s sticking to the dry skin. Yeah. So yeah, I’ve listened. It’s, it’s, it’s one of those things that you just never would bother to consider, right? Like, oh, I pull the thing off, and it sticks to me. But you know, there’s a lot more to think about than just that. And so when you really apply common sense to it, you think, Oh, that all makes sense. I should probably pay attention to that. Okay, I appreciate you going over that again. Thank you. Yeah, absolutely. I think this might be our last question. So Omnipod five kicks me out of automated mode and puts me into automated mode limited all the time. Is that the same as man? I laughed at the all the time part. Because I imagine it’s not all the time. But is that the same as manual mode? So is automated limited? The same as manual?

Yeah, so in short answer, the answer is no. automated mode is automated mode Limited is not the same thing as manual mode. automated mode Limited is a it’s still part of automated mode. It’s a more conservative mode, if you will, where the system is is potentially using manual mode, sorry, manual mode Basal rates, however, it is not fully in manual mode. And basically what I mean by that is, again, when we think about the system being in more of a conservative mode, what it’s doing is looking at between the adaptive Basal rate and your manual mode, Basal rates, which one is the lower value in that five minute increment, and then it’s choosing that to safely deliver the right amount of insulin to you. So it’s not fully automating, as it does an automated mode, but it’s also not transitioning fully into manual mode. So it is that in between, as part of an automated automated mode system,

what are the reasons that that would happen? I’m assuming if it can’t get CGM data makes one bit of sense. But are there other reasons?

Yeah, so when people say kick me out, that’s always such an interesting term. But yeah, so you mentioned CGM. So in order to use full automation, so to be an automated mode fully, the system does require CGM values. So if at any point there, the system is not receiving CGM values, then the system after 20 minutes will move you over into automated mode limited. Okay, so yeah,

I’m sorry. No, finish your thoughts. Go ahead. Yeah.

So So in answer to your question, CGM is one piece. There’s also something called Automated delivery restriction, which is another feature or alert within the system to notify somebody if they’ve been getting too little or max delivery for an extended period of time. If you you do have to go over to manual mode for that. But if you haven’t responded to the alert quickly enough, that will move you over to automated mode limited as well. So you may see yourself in that if you’ve received an automated delivery restriction, which we do sort of here, people use that as the kick me out, if you will. And so that’s another reason that you might get moved over. But definitely to your point, CGM is the most common reason for somebody to transition over to that automated mode limited,

the first person to ever say kicked me off definitely didn’t have a marketing job. They weren’t, they weren’t like, let me think of the nicest way to say this. So automated mode, everything’s going great. I have a problem with the signal, maybe I get put into limited Limited is just more conservative, because it doesn’t want to make big, like drastic decisions while doesn’t have access to the data. Exactly. Yeah.

It’s operating, you know, in, in this automated mode limited to your point to be safe, it doesn’t have those trending CGM values to know how it should be automating every five minutes then so it is doing this from a safety perspective. And I think I don’t know if you, you know, you talked about this any further previously, but you know, things like, even that CGM warmup period, where of course, there’s no CGM values for those two hours, you know, using the Dexcom G six, then you know, in that case, it’ll put you into automated mode limited. You know, if there’s any reason that the pot in, you know, CGM aren’t communicating for a period of time some sort of again, interference, maybe it’s the placement of the two of them. In that case, you would be in automated mode limited. So to your point, exactly. Missing CGM values is going to move you over to automated mode limited after a period of

time. Two things if this is happening constantly, then you might want to look at line of sight between your devices. Right? Okay. Yeah, because it’s not, it’s not a thing that you expect to happen. Like you. I mean, you as a person who works at insulin and Omnipod. Like, it’s not a thing. You’re not like, oh, this happens all the time. Like, right, like there’s something going on that stopping that connectivity. And I think it might also be important to bring up that even in automated mode limited, you are still experiencing the safety features and the automation. It’s just not as aggressive with the settings.

Exactly. Is that right? Yes. Yep. So, I mean, the one thing that I think it’s important to notice, because you’re not in full automation, you know, the system isn’t obviously going to know if your glucose value is dropping, and then proactively pause insulin delivery. Instead, what it’s doing is, you know, again, using that lower level of Basal between the manual programmed Basal rates and the adaptive Basal rate to make sure it’s always choosing that safer, lower amount. Yeah, it’s

interesting because as a person who’s like my child’s been using automated for a long time, and that’s just such an obvious thing to me. But if it’s a thing that you’re new to, I could see you being confused by that or wondering like what happens in that situation, but it is just it’s how it works. So and it works really well like incredibly well. I will say that that is one of the the things that I hear newer people, like they they bring up as like, a reason why they’re like, Whoa, I don’t know if I want to be in an automated situation, because what if the data is gone? And how does it know? And it’s funny, I wonder if you have an answer to that question, because my answer to the question I don’t think is satisfying. Other than I usually say, it all just works out. I don’t know how to tell you, like, like, it’s been doing it for years. It’s all great. But what how do you answer that specific question?

Yeah, I think, you know, the way our systems have innovated over time has really honestly been incredible to watch. And, and with this, in particular, I think, you know, the system is not just using a moment in time, you know, to determine I mean, of course, from an automation perspective, CGM values, but when we look at something like automated mode limited and adaptive Basal rates, you know, the system is using historic information. So it’s, it’s really starting to see how much insulin somebody needs. And, you know, then being able to automate or even in these automated mode limited, you know, you’re still with that adaptive Basal rate, that adapted Basal rate is using the user’s history, and really understanding what their insulin needs are. And I think, in that case, it is really safely, you know, figuring out what somebody’s insulin needs are, and, you know, again, comparing that to see just what’s going to be the safer amount. So, I think, you know, it’s hard for sure, as even a user myself, I know when I first went on an automated insulin delivery system, to say, I’m going to trust something to take the reins for me, and not need to have full control over it is not an easy thing to do. But I will say, you know, I think with the way, again, systems have innovated over time, and the way that the systems are really using a lot of the user’s history really helps inform it to do the safest thing for you. So I appreciate

answering that. Thank you. Let’s, I just I struggle with I don’t have a technical answer to that question. I only have like a user’s answer, which is, I don’t know, always just sort of works out. So but, but it’s nice to hear you put it in more technical terms. So thank you.

Yeah, I’ll say even to its, you know, whenever I’ve, again, spoken to any of these engineers, I mean, it my head probably spins a little bit when, you know, I mean, obviously, I don’t know, all of the algorithm, you know, specifics and the proprietary information. But you know, there’s so much that goes into developing these systems. And really ensuring safety as a priority, and especially that with, you know, the way the system is designed to keep people safe, and obviously, you know, live life, right, simpler with diabetes.

Lindsay, I have, we have a little time here, but we’re finished. Can I ask you another question? Sure. I don’t know if you’re up for this or not. But let’s see. We’ll find out. Yeah, I guess I could ask you somebody, like, just say, No, I’m not answering that. But I don’t imagine it’s gonna go that way. You know, I eat crackers, but I’ve never thought to work at a cracker company. But But you you have diabetes for a very long time. And you found your way into this as a profession. And I’m wondering if you could tell me a little bit about how that happened. And, and just a little more about how maybe that fulfills you.

Yeah, I love that question, actually. So thank you for asking. You know, I think when I was first diagnosed with diabetes, honestly, my reaction I was young anyway, so at that point, I don’t even know what I was thinking of becoming when I was nine years old. But, you know, as I got older, the more time I spent living with diabetes, and you know, just some of the challenges, you know, I faced and really thinking about how much I’d love to be more connected to the diabetes community and, you know, then going to school, you know, for nutrition. So that’s my background, as I’m a registered dietician, and, you know, just learning more about myself living with diabetes and living with celiac disease. You know, I really started to think I’d love to work with more people, and really help people feel like diabetes, does maybe not have to be such a heavy burden that it can feel like it is or how you can, you know, live with diabetes and live a life that you can engage in, you know, activities and things that other people do. I think, for me, it just became something that I felt like, I really want to work with others with diabetes and share experiences and really help others, you know, live really successfully that way. So I decided, you know, I was in school and, you know, decided to see what I could do to find, you know, jobs in the diabetes space and I ended up up at the Joslin diabetes Center in Boston. And yeah, it was such a great opportunity to really start my diabetes, you know, professional journey there and then move on to the technology space, just because I really love insulin pumps and continuous glucose monitor. So to move into that space as well, but yeah, it’s something that I think just evolved for me over time that I just felt a passion of working with others who live with diabetes, and you know, doing what I can from my own, you know, professional education and personal experience to help other people. So I find

it personally fulfilling to see someone about to go through a tough time that you’ve lived through. And for you to kind of like pick them up and like move them over top of it. Maybe it’s the digital version of like putting your cape over a puddle? I don’t know exactly. But like that idea of like, Oh, I’m gonna save them this horror, that they don’t, they won’t need to go through this because I already did it. I know the answer already. So like, all I have to do is tell them and then they don’t have to go through it. Yeah, I find that to be really kind of lovely, and brings a lot to my life. So I just thought that was interesting. Because the the one thing that everyone in this series has in common like this, ask the expert series, that each one of you is type one. And in not not difficult to reach back into insolate and say, Hey, we need somebody who can speak thoughtfully on this topic, who also has diabetes, and there’s just there you are, do you. So I know that everybody’s remote nowadays and everything. But when you get together with everybody you work whether you like does it feel like a club?

That’s such a good question. I know, I wish we could do it more often, to be honest. But um, but yeah, I think so. You know, it. It just, it’s such a positive environment to be in to work with people. I think anytime you’re doing something that you get to help other people. It just creates Yeah, really uplifting, positive, fun environment. Or at least we make it that way. I’ll just put it that way. But, but yeah, for sure. It’s great to be together, especially with my team. I don’t get to see them in person, often, again, because we’re all virtual. But when we do get together, it’s just yeah, celebrating all of the amazing, you know, things that we get to do and the people we get to help every day. Yeah, yeah,

I wish I’m gonna try to find out maybe how many people at at insolate have type one. Because, I mean, now that I stop and think about it, like the person I interact with, you know, as part of, you know, I don’t know how to put this, like people don’t, I don’t know what people understand about how podcasts work and stuff like that. But you know, there are people that insult the by ads for me, and that we have those conversations, and my direct contact has type one. And you and then Melissa was here and Eric. And I’m like, geez, like, it seems like maybe it’s everybody I know, it’s not but like, that’s really cool the way because I mean, I think you could say, Sure, I imagine the company is open to people with type one filling positions. But I think the story is more about how people with type one are drawn to the work. Like that, to me seems like the the real story here, you know, like, like, how, because I interview people all the time. And they’ll talk about, I was diagnosed at a young age, and I had this endo and the endo was really great. And that’s why I’m a nurse practitioner, or that’s why I became a CD or something like that, or I want to be an endocrinologist because of the impact someone else had on me. And it just seems like this is another avenue for people with diabetes to help other people with diabetes. It’s just it’s Yeah, absolutely.

Yeah, whether it’s you live with type one, or obviously, there’s a lot of people we work with, who have family members, or someone close to them, or someone they know who has diabetes. And so yeah, I think exactly to your point, you know, finding a space that you can work, to continue to make a difference in an area that you’re, you know, familiar with, in one way or another if it’s personal, or, you know, just just your people, you know, while living with diabetes,

I’ve I’ve in the past done speaking work where you, you go to companies, and it’s like their private speaking events are just for the people who work there. And when you when they bring you in, they’re like, Look, you we just need them to understand what diabetes is about. Because to them. They’re just making a widget, you know what I mean? Like they don’t they don’t see the whole, like, what does this do for someone? Like, why is it important to them? How come it needs to work? How come it needs to be comfortable and safe, and they don’t know that they’re just they’re making an item. So I love the idea of bringing more and more people in who have type one already. You don’t need to explain that part to them. So I think it’s a big deal. We kind of briefly went over it before that you’ve been on other systems before and two pumps and other automated insulin delivery systems if I’m not mistaken. I was wondering what the experience has been like using Omni pod five, since you have experienced with others. Great

question. Happy to answer that. So you know since being on Omnipod, five some of the things I think I never expected of being on a tubeless pump was really things like not disconnecting for showers or swimming, I think I probably underestimated how challenging that was. Sometimes honestly, I would disconnect first shower. And then an hour later when I was getting ready realizing I forgot to reconnect. So that’s something that I honestly have absolutely loved about the system is not having to disconnect. Also Omnipod five specifically, I have found the automated insulin delivery system has worked really, really well. For me. Shockingly, when I first started, I couldn’t believe how many 100% time and Range Days I had, without a lot of effort. So I have found it’s really great at protecting me from hypoglycemia, which is something that I had experienced a little more frequently on other automated insulin delivery systems. So yeah, I feel like it’s worked really well.

You have fewer lows on on a pod five than you had in the past? Oh,

yeah, I do. Absolutely. Yeah, I use a lot less a lot fewer glucose tablets, and Skittles and all that other stuff. But um, but yeah, I find I’ve treated far fewer lows.

Have you lost weight? I know, this is so personal. Like, it’s just the way you came on. But a lot of people talk about like a lot of the low snacks they use, they don’t realize how many calories are in them and things like that, too.

Yeah, I wish I could say yeah. I was just wondering, yeah, you have other things influencing, but you know, maybe,

right, No, but seriously, like, it’s just not being interactive with it, like not having to take a glucose tablet or look at or deal with a low. Or we’re even like, I mean, I can’t completely speak to this, obviously, because I don’t have diabetes. And my daughter’s always use the nominee pod. But I mean, like, like my daughter’s 19. She’s used one since she was four. Like, we went from needles to Omni pod in like 2002 1008, maybe. And she’s been wearing it on a pot every day since then. So I don’t know about that. But it as I stopped to think about it like that, oh, I’m gonna jump in the shower. But I got to unhook this and turn this off, or maybe make a Bolus because I know I’m gonna have this off for a while and then forgetting when you jump out and just want to tell off and keep going. And then, you know, an hour later realizing, Oh, my God, my blood sugar’s jumping up. And it just, it’s a lot of time and touching that I think you avoid, is that about, right? Yeah,

no, you’re absolutely right. I would agree with that. And I think to that point, even talking about engaging with the system, you know, I find that I will go aside from eating, of course, bolusing, for eating, but if I’m not eating, you know, for periods of time, that I realized, Oh, I haven’t even like checked where my glucose is, because nothing’s been alerting me to say I’m too high or too low. And I think that’s the other thing, too, is, you know, aside from my Dexcom, that alerts me I’m not getting additional, lots of alerts coming from both systems, which has actually been really nice. So if nothing is alerting me, then I’m assuming all is working well. And a lot of times, it’s Yeah, hours before I realized, Oh, I haven’t even checked where I’m at. That’s

a learned skill that people don’t have right away with that idea of like, I’ll just set the alerts at a reasonable space. And if I don’t hear from them, I don’t think about it. Yeah. How about sleeping any improvements with that?

Actually, yeah, I would say so. Because I really do find that I’m staying in range. When I’m sleeping, that I get, you know, again, far fewer alerts, not that hypoglycemia. And really, this less worry, during the nighttime that I sleep really well, that

that leads to that unbroken sleep. That’s very important. We don’t talk about it enough. But the waking up and going back to sleep is it’s hard on you, especially over time, by the way, whether you have diabetes, or you’re the parent of someone with diabetes, it’s it sneaks up on you, you don’t know how impactful it is until kind of too late sometimes. But then you’re just like, ravaged and look terrible. And you’re like, God, I’m exhausted. That’s great. I

God wants to know, wants to talk to us too much if you haven’t slept that well, right?

No, no, I swear to you. I’ve said this before, but I always thought I was like, like, you talk yourself into believing like, I don’t need all that sleep. Because you don’t have any other options. So it’s the thing you tell yourself, but it’s not true. You definitely need to sleep especially as you get older, you know, it’s more and more important. So. Alright, I appreciate you sharing that. It’s just a unique, unique perspective. So I thought it was worth asking about.

Yeah, again, thanks for asking. I was happy to share.

Thank you again for being on the show. I’ll say goodbye to you a second time.

Yes, thank you.

Well, if you’re listening in order now you’ve heard Eric Davenport, the clinical services manager and Lindsay Friedman, Senior Manager, clinical product support. Now you’re probably thinking Scott, Can it get any better Other than this, I don’t know if it’s gonna get better, but it’s gonna get really interesting with Melissa Lee, Senior Manager instructional design. That’s right, Melissa, not only has type one diabetes, just like Lindsey And Eric, but she wrote the User Guide for Omni pod five, and we’re gonna talk about the question she gets about the algorithm. This is the stuff like you know what you guys are wondering like, well, what if I turn this or I do that what’s gonna happen? Well, this impact automated mode, all that gets covered with Melissa Lee in episode three of Ask the Experts series Omnipod five. If you’re interested in getting started with Omni pod, use my link Omni pod.com/juicebox. And if you’re a current or future Omni pod five user, you will not want to miss my Omni pod five Pro Tip series. It’s a three part series that goes through overview of the system settings and connectivity. Those are in Episode 736 737 and 738. They’re also available at juicebox podcast.com/omni. Pod five. If you’re enjoying this content, be sure to follow and subscribe the podcast in your audio app. We talked about Omni pod and Omni pod five all the time. Thank you so much for listening. I’ll be back soon with another episode of The Juicebox Podcast.

Hello friends, and welcome to part three of my Omni pod five Ask the Experts series far too often, community sourced answers to Omni pod five questions contain misinformation. So today we’re going to help to set the record straight by bringing in an expert who works at on the pod. And Melissa doesn’t just work it on the pod. She also has type one diabetes wears Omnipod five, and she wrote the user manual. So sit back while Melissa and I go over the questions that I see most frequently asked online about the Omni pod five algorithm insolate has paid the host of this podcast Scott Benner a fee to create this content. This podcast provides general information and discussion about health and related subjects. This information and other content provided in this podcast or in any link materials are not intended and should not be construed as medical advice. Nor is the information a substitute for professional medical expertise or treatment. Never disregard professional medical advice or delay in seeking it because of something that you’ve heard in this podcast or read in any length materials. The opinions and views expressed on this podcast and website have no relation to those of any academic, hospital, health practice or other institution. Please speak with your healthcare team if you or any other person has a medical concern, and before making any changes to your diabetes management, and consult the Omnipod five automated insulin delivery system User Guide for more information, nothing you hear on the Juicebox Podcast or read on juicebox podcast.com is intended as medical advice, you should always consult a physician before making changes to your health care plan.

Hi, Scott, thank you so much for having me today. My name is Melissa Lee, and I am the Senior Manager of Instructional Design at insolate. What that means is that I lead all of our training materials and user guides and all of the written instructions for how to actually use the products that we sell it insolate and I’ve lived a type one diabetes for 33 years, I was diagnosed when I was 10 years old. So now I’ve told you that while I’m 44. And I’ve used so much diabetes technology in my life, I have been working in the diabetes med device industry for about eight years or so. And before that I was a blogger and an diabetes advocate and someone who worked in the diabetes nonprofit sector. So I’m a huge proponent of trying to find ways to make these devices actually work for us in our community. Yeah, that’s why I’m in what I do. This doesn’t

happen very often. But we know each other like from years ago, so years ago, yeah, you were doing stuff that back then I don’t think anybody was doing honestly a very, very select group of people were writing blogs, it grew. Eventually Do you know, I have this information because a pharma company told it to me one time, but at its height, at its height, there were over 4000 type one diabetes blogs.

Oh my goodness, I remember when they were

really interesting. And then some people it’s interesting, too, because like, I kind of went with it. I saw blogging sort of be like, this isn’t gonna keep happening. And I went to the podcast, and but you went into industry, you’ve worked at a number of different places. Now. You have. So how did you make your way to Omnipod.

So I, this, this is gonna sound very Goldilocks II, this is my dream job. I am so excited to be a part of insolate. And when when we were when I first joined ID slit two and a half years ago, we were trying to get Omnipod five through, you know, through the FDA and trying to sort of put finishing touches on this product that was going to help so many people and I was so excited to get to use this product because I obviously I’ve used a lot of different AI di systems over the years. I’ve always tried to be an early adopter of whatever’s hot in in diabetes tech. And I mean, I’ve used oh, gosh, I’ve used something like eight CGM ’s and and 16 Insulin pumps. And so Omnipod five was like, I have to try this. I have to get it. So I was one of the first people to get to use Omnipod five and that was really exciting. But you’re still working. I am okay to get to get to actually work on a product that was going to be in people’s hands and changing people’s lives was very meaningful to me with my past advocacy work. You know, for for a lot of the work I’ve done. I just really wanted to know that that what I was working on would really have an impact for people and But it’s been exciting to, to be able to launch Omnipod, five and, you know, in multiple countries at this point and to get to work on all of those launches. So I joined insulet, actually with a slightly different role I came in to be sort of a an disruptor, in the way that insolate had historically rolled out some of the training initiatives that it has done for Omni pod products. As we’re moving into automated insulin delivery, there was this opportunity to really sort of innovate on training for AI D systems, like Omnipod, five, and other future things will roll out. And that was super exciting for me. And then through the process of taking Omnipod, five through the FDA, we identified some needs and developed a new team that I actually had the opportunity to charter. And so my team is instructional design. And we get to do not just the user guides, but elearning and how to videos and all that kind of like this, yeah,

well, no better person to ask them than the person who not just wrote the book about it, but had to write it from the perspective of an actual user, I think that’s a really big point to make, honestly, that you’re not just right. You’re not just somebody who was tasked and sitting down and explaining ABC, but you got to think about it. And you guys have, you know, can you talk about that a little bit like how your experience using the device helps you talk about it to other people?

Oh, absolutely. You know, I think one of the most fascinating things to me, and so as, as someone who has done a lot of diabetes, advocacy, you know, people will come to me, and, and say things like, Well, how do I how do I work for a company? And, you know, will they hire me as a diabetes advocate, and I’m like, There’s not like a, you know, a golden cushion. You sit on all day, and you advocate for people with diabetes, I need people on the engineering team who are advocates for people who have diabetes, I need people on our market access team who are advocates for people who are who have diabetes. So like, I encourage people who are interested in working in the industry, who are part of our community, it has think about like, well, what skills do I have, while I could also be an advocate for people with diabetes. So that experience has been things like, we might be writing at a certain or might be writing about a certain thing, I’ll give you a great example. And maybe people who have used the Omnipod dash system, and they moved to Omnipod, five, they may have noticed small changes in wording, things like instead of saying you have a low reservoir, like we say, on Omnipod dash, we say you have low pot insulin on Omni pod five. And so there were a lot of things that the team at large did to simplify the language that we use, so that more people could understand it, more people could access it. And that means bringing down like the grade level readability of things so that you don’t have to already know what an insulin reservoir is to understand that your pods low on insulin. So that’s some of the stuff that my my team and my colleagues and I have been working on is like, you know, how will we help more people succeed? And, and, and, like learn to use these products? Well,

is that an indication that in in past that there was an engineer speak in the direction? Like was, yeah, there was, I

would say, in and this is really typical of what I’ve seen in medical device is that very often, you’ve got really brilliant systems and engineers, like who do technical writing, who are describing the system functionality. And I like to describe it, like, if, if I were a technical writer, and I were describing how your remote control works for your television that I might say, here’s the power button in the upper left corner, this is what it works, how it works, this is how you use it. Here’s the button right next to it. It’s the source button, here’s the button right next to it, it’s the this button, here’s the button right next, instead of what do I need, as a person with diabetes, I need to know how to turn on the TV, I need to know how to change the channel, I need to know how to increase the volume. And I’ll deal with all that other stuff at the appropriate time for me to deal with it. Like I don’t need to know, these advanced settings as the first thing out of the gate. And so there’s a different approach you take when you’re writing for people who who actually have to use the product in certain use cases. Yeah. And we’ve got lots of teams that kind of work on that. But that’s, that’s a good part of it.

I always say I go to websites sometimes. And I think Did they not use the website after they designed it? Like, you know, like, like, Didn’t someone try it afterwards to see if it actually helped the person who needed it. So let’s take all that experience you have and put it to work on the questions that I see pretty frequently online in the Juicebox Podcast, Facebook group and other places on social media. Some of the things that I read and I think, I don’t think that’s right, but we’ll ask you because you’ll know for sure, ready? You want to dive into this? I’m ready. Okay, here’s the first one. The Omnipod five systems adaptivity is that right? No. Yep, yes. How come I can’t read takes a long time to work restarting mice. system will set me back months. So I guess this is somebody saying, I’m waiting for the thing to learn and do what I want it to do. And now I’m thinking, should I just reset it and start over? Do you hear people talk about that a

lot? Absolutely. You know, I think that I think a lot of people have started products and not just Omnipod. Five, I think this is common across the automated insulin delivery sector, where, you know, we’re working with our health care providers on what those settings should be when we start, but the settings are really optimized for the way we were using standard insulin pumps. And they may not actually be optimized for how these different algorithms work. And so if you’re starting the system, and your settings are not, you know, quite dialed in, where they need to be that initial activity that you experienced, when you started a product like Omnipod. Five, it seems to take a while for you to get to, you know, there are some people who feel like it takes longer than they thought it should to get to where they need to be. And so then they’re afraid to Well, I’d love to move to like the Android smartphone, but then I’ll have to start over on my activity or, you know, insolate sent me a new device because mine broke. And I bet now I’m gonna have to restart that activity. And I don’t want to spend months and months doing that again. So the important thing to understand is that if your settings are pretty well dialed in, it should only take a couple of weeks. And so really, the system looks back over about four or five pods. I mean, it looks, it looks back at your history, but it’s really those four or five most recent pods, that it sort of calculating your total daily insulin based on so what your activity is based on is how much insulin you use in a day. And so if you know that information, then you should be able to kind of like, come back in when you make that transition or, or if you choose to reset your system and be able to come back in, you shouldn’t you shouldn’t take months and months to hit that stride. And you’re adequate. So

that’s a concern that it sounds to me like it stems from. I mean, I’ll give an example. Like, let’s say that your total daily insulin should be 60 units, but for some reason you’re using 40 units, then you never really had a ton of success on whatever system you were using before. And now you move to Omnipod five, and you tell it, hey, I need 40 units of insulin a day. But you need 60. And so it can’t magically know you’re wrong about that. And so you need to come along and say oh gosh, like that’s not right, you Bolus more and then the system sees Oh, wow, okay, they put in more insulin here. Maybe the total daily insulin is more like a larger number, but it’s not going to find out your it’s not going to figure out your 60 in five minutes. And is that right? So you’re

right when you wouldn’t want it to right, Scott, and I get that so scary that it could make a change. That’s very sad. And you know, one of the things that we certainly have heard from people before is, oh, well, you know, what if I, what if I’m sick for a week, or what if I have a really bad weekend, or a really wild weekend, and like my insulin needs were really different, like I don’t want it to suddenly change, but it’s still very well, that’s why it looks back over a few pods, it’s not making a decision based on right now. But if for the last couple of months, your job has been stressful or you’ve been moving or you’re going through a divorce or like whatever might have might have given your body a different level of of need and your insulin, you should see these things slowly get to where you’ve indicated by the amount of insulin that you’re using, that you need to be. And so that’s, you know, reasonably, it’s how you want it to work. But you know, we we tend to be we want that immediate gratification sometimes. So it’s it’s hard. So

then let’s maybe move forward with that assumption that somebody came in, they didn’t use enough insulin to set the system up with and it’s a, an egregious amount, an amount that’s going to take a long time for the system to say, Oh, wow, it’s more like 60. What what do they do in that situation? Like we talked about, like, you might have to reset it if your device changes or something like that. But is there a world where that would be a reasonable way to move forward? Like if you made that mistake? Initially?

Well, you know, we we definitely, as you know, insolate encourages people to talk to their health care team about what the settings are, especially since we’re providing additional education to health care providers as well about the settings, you know, and all AI D systems work a little bit differently. And so one of the things that people automatically think is that they should go in and adjust certain settings, and that that will change what the algorithm is doing. And there are settings you can adjust, but it may not be the first settings that you reach for. And so I think, you know, my first line of defense would be to check those other settings to see if you can, you know, adjust them in a way that will help you get to where you need to be before you go to a hard reset, but a hard reset or just like when you’re switching. You know, we don’t think switching devices is a problem. Obviously there’s, you know, there’s flexibility in the configuration that you use. So if you get a new phone and you want to move to that new phone, like you should be able to do that safely. But, you know, I, I know that some people are sort of like, they may feel like they need to reset often. And I would say if that’s the case, then there’s probably other settings that needed to be adjusted in the first place. That’s,

I mean, just from my perspective, settings are wrong, or the way you’re implementing the insulin is, is maybe a question. We’re gonna get back to this line of conversation. I know later with a with another question, but I’m gonna move forward a little bit here. And then we’ll kind of get back to this and build on a little more. I think we’re gonna like dig into the word learn. Because this next question, I’ve genuinely heard this 1000 times, I heard that on the pod five algorithm will learn me, does this mean that smarter just technology will learn my patterns? And the example given here is, like, you know, that I eat oatmeal in the morning? Or that I go high in the afternoon? Is it going to learn like the, you know, like, out of a movie?

What it feels like? Well, you know, it’s such an honest question, because we’re living in this world where AI is suddenly sort of breaking in. And we’re hearing about all of these like learning tools and and, you know, chat robots and everything that are learning. And it’s not anything like that the way that Omnipod five, and we don’t really say that it learns, but it’s updating it’s, it’s, it’s adapting to you over time. So every time you put a new pod on, it’s looking back over that history. And it’s learning only one thing is updating your total daily insulin, which we call TDI. And so you know, if you mentioned, you mentioned, the person who starts out programs, and that they take 40 units a day. And really, this person’s optimal use might be 60 units a day. So over time, it’s going to, to see that you’re taking more insulin, and it’s going to reset your adaptive Basal rate based on a new understanding based on your last few pots. So the what it’s learning is your total daily insulin, it’s not learning that oh, he does, you know, racquetball on Tuesday afternoon. So I need to make sure that I change your Basal rate. You know, at that time of day, it’s saying, Oh, he seems to be taking more like 50 units a day. So I’m going to take a certain percentage of that, and I’m going to divide it into 24 hours. And that’s you’re gonna get a flat rate. And I think that’s a big piece that people may not understand. Oh, for sure. The adaptive Basal rate is a flat per hour rate. So it’s, it’s the amount that’s designated as your Basal divided by 24. Now, from there, it adjusts up and down based on your glucose. And so that’s why you were compatible sensor with Omnipod. Five so that you can get that information. What’s really interested or interesting about this is that when you look at when the system doesn’t have that data from your sensor, it still can go off of some of what what it’s learned, learned, I say in quotation marks, but it’s still looking at your total daily insulin.

Yeah, that’s really amazing. Honestly, it’s, it’s fantastic. It’s just that when people I think it’s that word I really do. It learns, makes people think just like you said, like, somehow magically, it just, it’s watching everything, and it knows and that’s a great, excellent, I appreciate that very much. It’s a great explanation of how simply the algorithm sees what’s happening and makes adjustments moving forward. And that it takes time and and it can only know what you told it. In the beginning,

I often think about so I have a lot of smart home stuff in my home. And you know, I have a smart thermostat. And I was getting really cranky because I was feeling cold at night, we had a cold front come in, I’m in the Austin, Texas area, we had a cold front end and, and suddenly, I’m very cranky, that it’s that it’s cold, like my system should know that it’s cold, and it should. And then I checked the settings and my thermostat had quote, learned to be at about 69 in the evening. So I’m like, well, that’s too cold when it’s cold outside. So what do I do? I come in and I tell it something different. And then the next night it was 69. Again, what do I do? I come in and tell it something different. And after me telling it a few times it it switches over and now it’s 71 instead of 69. But it doesn’t like it’s not sitting there thinking I bet Melissa is feeling cold because of the cold front right now. You know, I’m just going to nudge it up a little bit cuz she likes her toes toasty. Like it’s not doing anything.

Oh, in the south. It’s so warm in the summer. And then it shifts and it gets cold here in Austin and I don’t want Melissa to be uncomfortable. Yeah, it is hard not to consider. I mean, I don’t think it’s how people consciously consider it. But I do think it’s how they expect it to work. So I appreciate that. We’d

love for it to work, right. I mean, you really love for systems to be able to do that. And that’s not you know, that’s not what we have, right today.

Well, maybe one day you’ll be able to just run out the door and y’all on the pod. I’m gonna go work out and it’ll be like, Don’t worry, I’ll take care of it.

Do you feel like oh, she’s driving past that donut shop again, I’m gonna go ahead and put a little insulin up. I’m

gonna have a doughnut, and then I’m gonna lift weights and then I’m going to do cardio. Work that out for me. Would you please? Yeah, yeah, that’s that’s really. That’s funny. So moving forward, it says you’re sometimes it seems like the system shows incorrect insulin on board. I didn’t Bolus and I’m in manual mode mode. Should I have a zero iob?

In Bolus? Really great question, Scott. I love the folks that are that are looking at this and noticing it because my husband tells me all the time, he’s like you never look at your IOP. One general look at your. So I think that’s great that these people are noticing this and questioning it because it does work differently. So if you’re coming from a standard insulin pump like Omnipod, dash or other other insulin pumps, then iob has often historically been tracked by your boluses. So it’s showing you the amount over since your Basal rates already pre programmed in these systems, then the amount you Bolus as that Bolus decays over the period of time that your insulin is actually working to bring down your glucose, it’s showing you sort of that rate that your insulin is is being used up in your body. And that’s what we expect to see from iob. Well, the way it works in Omnipod five is that whether you’re in manual mode or automated mode, the system knows what it has set as your adaptive Basal rate. And that adaptive Basal rate is obviously going to be going up and down from that flat number we said it was based on your glucose. And so the iob is showing you that whether you’re in manual or automated mode, how much insulin you’re getting, that is above the adaptive Basal rate that’s set by the system. And it can be a little bit challenging because you can’t see what the adaptive Basal rate is. But when you’re in manual mode, and maybe you wake up in the morning, and you see that you have a little bit of iob, what it’s showing you is that your regular Basal for your manual mode program is probably a little bit higher than than the system had set your adaptive Basal rates. So it’s showing you that little bump above what your adaptive Basal rate is, as I OB, I have to tell you that oh, oh, God allows you to like switch between modes without sort of losing how your insulin is tracked. Okay.

Okay. I’ve listened in what I do. I talk about this a lot, actually. And it’s interesting to watch people move from, you know, regular old insulin pumps to, you know, algorithm based systems, because the way I usually put it as before your iob was almost a dummy number, because it really is an indication of decay, but also based on how long you’ve told the pump. Insulin, your insulin action time is like, how long does this insulin last in my system, and you can go into settings and tell it, you know, I think I Bolus and it lasts for six hours. And then somebody else might go and tell it, I think it’s three hours. So you know, if you tell it three hours, and put in five units, three hours later, it’s going to tell you, you don’t have any insulin on board. But if you’re wrong about that, if insulin really lasts and you longer, six hours or whatever, then it would say oh, no, you have insulin left, we’ve only you know only this much of it’s been used so far. It’s it’s been used as such a I don’t know, I mean, here’s how I used to use it, I used to set the number lower, so that the system would always want to give Arden insulin because I was trying to be aggressive. And that doesn’t mean that’s how much insulin is in your body and unaccounted for. It’s just it was the best that those systems can do. New system here, Omni pod five is just thinking on a different level. I know thinking is the wrong word. But it’s considering so much more than what had been considered in the past with builder systems.

So I absolutely and you know, the the Omnipod five Bolus calculator is a smart Bolus calculator, which means that it’s also keeping in mind the trend of your glucose. And so if you’re going in, like the system needs to be able to track that iob in a certain way, in order to make good judgment calls about what you know what the trend of the glucose is, how that’s going to respond based on that insulin that’s that’s actually working in the body. Also,

prior to Omni pod five, most people were not used to doing things where the basil adjusted at All right, everybody, everybody sets their basil and forgets it really. But you know, Omnipod five is saying here, take more basil, no, no, give it back, you know, like here to give it back for a half an hour. And that’s perfect. You know what, and then 10 minutes later, it might say, Maybe I should have done that for 20 minutes instead. So I’ll give a little lecture here to make. It’s constantly making those adjustments in ways that I mean, you can’t wrap your mind around if you just are just a regular person, not a, you know, not an algorithm. So okay, so cool. I’m glad that was a good question. And I do, you know, I want to say you’re 100% right. People online, stunned me sometimes with the depth that they consider these things and they’re kind of personal. I don’t know professional sometimes understand Think of the world and they’ll ask the best questions. And, you know, I have some more here for you. So Well,

I mean, nobody knows our diabetes like we do. Right. And I mean, with all due respect to my healthcare team, like there are decisions that I, you know, I know how they’ve worked out for me in the past. And so when when a system works a little bit differently than your expectations, and you have to manage those expectations, in order to be successful in the system, like, you do so much better when you have this information. And so I love that people ask

it. Yeah, I agree. Okay, next question is, is it true that smart adjust technology learns only when I’m in automated mode? So the question is, can I go into manual mode? And does that keep it from learning? If I’m in manual mode?

No, it does not. So it learns in manual mode, because what is it learning total daily, daily insulin, right, so the next time you could go into manual for a whole pod, or a whole weekend or whatever your whatever reason, cause you to go into manual and you want to use manual mode, you could go into manual mode, and it’s still going when you put a new pot on it, your next pod activation, still gonna update, this is how much insulin they’re using per day. Now, in manual mode, of course, you’re not getting that adjustment up and down, and you’re not getting that adaptive Basal rate that’s been set by the system, but you’re still informing the total daily insulin that’s used. So that’s, you know, that could be a strategy for, you know, sort of, rather than do a hard reset, think about well, you know, is did I think my manual program worked better for me? Do I want to teach the system that that’s closer to my, to my, the amount of insulin I think I should be getting? Yeah,

what about this scenario? So say, I set it up, I set up on the pod five, I didn’t tell it my total daily insulin was what it should be. I’m like, like I described before. And now I’ve been wearing it for a while. And the systems learned, you know, it wasn’t, it wasn’t 40. It was 60. And everything’s copacetic. But then I go back into manual for some reason, aren’t I going back to the old settings that I put in? You are right. And so extrapolating that out to the idea of somebody growing like a child getting bigger, putting on 1015 pounds over a year or something like that, or starting a menstruation or something like a big change in variable? How often do people need to take their total daily insulin out of automated mode and go back and kind of tell manual mode? This is where we are now, like, because otherwise, if they need manual for some reason, they’re very likely not going to have the I’m not even saying the right amount, you could have started on the pod five, and over estimated how much insulin you needed. Right? And absolutely,

yeah, you know, that’s such an important point, Scott, I think, what I would recommend, as, as a person who uses this product is that you should be evaluating your settings with your healthcare team, as often as you did on a non automated system, it’s, the important thing to understand is that changing those manual settings will have zero impact on how the system performs in automated mode. But if you use to go to the endocrinologist, and they you know, or your CDE, or whoever helps you make those settings, adjustments, and that they would, you know, maybe they they tweak this or that or they change your Basal program, they should still be doing that for the times that you want to use manual mode. And what they have now is they actually have the data of what your actual needs are from automated mode to be able to help you make those adjustments in manual mode. Yeah. But making the adjustment in manual mode is not going to optimize. I

have more questions about that that are coming later that I’m actually tickled about getting to because of the frequency that people like literally come to me. I don’t know if you know this, but every once in awhile, people treat me like I’m a customer service representative for Omnipod. And so they come to me and they say, I turned this switch, and I’m like that doesn’t touch auto and they go yes, it does. And I’m like, Well, I can’t argue with you now. But like I know it does. And I send them the information. That’s good, but I can’t wait to go through them. Just so you know, moving forward, I’m going to ask you about every setting and which ones actually impact what once you make changes to them after your setup. So anyway, but first. This question says I’ve heard that the first pod runs off my program basil program, can I continue to make changes to my basil program until I start my second pod to impact the algorithm.

You cannot continue to make changes after you’ve entered that Basal program during first time setup. So on your very first pod, you know, we mentioned that the smart adjust technology algorithm is is looking over your last few pods, right? So if you’re starting the system in your very first pod, it doesn’t have information about your past insulin use, right so the only thing it has to go off is what you told it you use as a Basal program. And so then the algorithm does its some inter Are all math bye bye what you entered it first time setups and said this is my Basal program. And from that very first moment that you activate a pod, it tells your pod, this is what I think their total daily insulin is. And it sets an adaptive Basal rate. If you go into auto mode on your very first pod automated mode, it sets a Basal and adaptive Basal rate that’s based on that amount of insulin, it’s not actually running your your Basal program that you entered. So if you had, let’s say you had six segments that equaled a certain amount of insulin. It’s not running your ATM segment, and then your noon segment and your 5pm segment, it’s running an adaptive Basal rate that’s based on that same total amount of insulin from your Basal program. So basically, the the Basal program that you entered for manual mode setup, you will use it when you’re in manual mode. But the only thing that automated mode is using it for is a reference to just kind of see like how much insulin do I think you’re going to take as an adaptive Basal rate. And this is an automated mode in automated mode. So it’s running the Basal cells that are it’s running similar basals to what you programmed in, but it’s already set that adaptive Basal rate for you. And what that means is that from the moment you finish your first time setup, no change that you make to your settings is going to because you already told the algorithm, you already fired the pistol and it’s running. It’s running down the track, and there’s no calling it back into the style.

I’ve come down to just when somebody asks one of those questions, and there, I just go, No, it doesn’t care anymore. Like it’s Oh, it’s over. Now, you told it what you told it. And it’s now making adjustments based off of what you told it. You can’t you can’t yell Oh, I’m so sorry. I meant to say that that doesn’t work.

Like that’s like when your 10 year old leaves the room after you already gave them an instruction. You’re not You’re not amending it at that point, like whatever they heard is what they heard.

I’m so close to ask, I probably should just jump ahead to the questions, but I’m trying to stay in order here. Is it true that Omnipod five will not deliver any insulin when my glucose value is below my target glucose? That

is not true.

Thank you. So

you feel very vindicated? I do feel

like somebody’s finally standing behind me going Scott’s right. So that’s right.

You know, if you’re if your spouse won’t do it, then the the folks here at insolate? Well, right. So you’re right. Essentially, remember that with with all of these different AI, D algorithms, they’re looking into the future, right. So Omnipod, five is looking out an hour into the future. Now, for those of us who have used CGM for a long time, we know that there’s a big difference between a 100 that’s flat, a 100, that’s dropping and a 100. That’s rising. And if you know that you’re dropping, rising or stable, you’re gonna make different decisions about what you do with your insulin. And that’s true for an algorithm like smart adjust technology as well. So you could be let’s say, Your target is 120. And you could be 105. And you could see that it gives you more insulin than you expect less insulin than you expect no insulin at all, because it’s looking out at where it thinks you’re going to be an hour from now. And so you can’t judge based on just where the number is right now. And remember that it’s not just based on your CGM trend, but also its own internal workings of what it knows about your insulin. So it’s going to be making decisions based on where you’re going to be people who

listen to this podcast will will recognize the sentence. Insulin use now is for later. It’s not for now you don’t Bolus at noon to make a difference at noon, you you know, you make you Bolus at noon to make a difference. 20 minutes from now, that is only the starting of the difference. And then the insulin picks up, you know, momentum and starts working more efficient, as efficiently as it gets in your body longer. And so the algorithm is saying, I think you’re going to be 140 an hour from now, I need to give you insulin now. So that insulins working an hour from now when that rise tries to happen. I think that is kind of next level thinking for a lot of people so I could see why that confusion would happen. You know,

the biggest thing that I imagine people are confused by is that if you go into your history detail, and you click on the auto Events tab and you’re seeing that, you know your some people are seeing and going wow, I was at four and it delivered point oh five units. And like Why did it do that when I was so far below my target and we don’t think about the fact that on a traditional insulin pump, it was delivering that oh point five or 0.05 or whatever, every few minutes no matter what your glucose was because you were getting that consistent basil. So this is just a variable basil that’s going like In the next hour, I think you’re going to have needed me now to deliver a little bit. Yeah,

I find it’s helpful to just think it must think. And then kind of fill in the blank after it’s like, Oh, I wonder why it’s taking my Basal i Oh, it must think I’m gonna get low later. In old school systems. It’s a safety setting. Safety setting. Yeah, right Max Max Basal Max. Bolus, Bolus, right.

Yeah. Because, you know, think about this. You know, we all have that, you know, especially when folks first started out and in some pumps, you’re like, Well, how will I make sure it doesn’t give me more than I that I want? Or, you know, I’m leaving my child with a caregiver, how do I make sure that they don’t accidentally miss finger, you know, one unit into 10 units? Well, if that Max Bolus is set at five units for that small child, then they’re not going to do that. And so the max Bolus and Max Basal are safety settings. The algorithm does not look at them. And you know, and I have a friend that was talking to me about this and saying like, but when I changed it, I saw a change. And to which I say, Yeah, but the system learns your TDI every three days, so you’re gonna see changes regardless.

I was gonna say later that yes, it does.

Very good. It’s kind of like if you told me that you tap danced a jig and sang a C Shanti every three days and it was having an impact on your total daily insulin I would say Well, that’s interesting. Have you tried not singing the sea shanty? And see if you also see a change in your total daily insulin?

Just been the the exercise that was coming from the tap dancing. No, I just people I the way I talked about on the podcast is that people see ghosts all the time in diabetes. Oh, I know what happened. This happened or I did this here. And I’m like, yeah, it’s probably not that I had is so feel disconnected for a second. But I had a person to ask me the other night, I did a I did an Ask me anything online. And somebody showed me this graph. And it was real, like, I don’t know what’s I don’t know how they were delivering their insulin. But it was a pump. I don’t I don’t know which one. And that was a kid high, then low that high then low that Highland? No, no, like, what’s wrong here? And I said, your site’s bad. Like, that’s my first guest. My first guest is bad site. And then here are my other guests is are you not Pre-Bolus thing, and I went through the other things that I thought it could be. And then the person replies back and goes, Oh, this is a really old site. I was thinking of changing it tomorrow. And I was gonna change it now and see what happens. And two hours later, I get a message on Facebook a that fixed it. Like, that’s it.

Yeah. And they could have gotten an adjusted settings that would have like, you should,

you should have heard the things that she thought it could have been, she had these giant ideas of what happened the other day, he was sick and blocked. And I was like, Yeah, I think this like just doesn’t look like it’s working. And sometimes people skip over the obvious to know. Yeah, one

of my one of my favorite stories. A mutual friend of ours, Scott Johnson, I’ve heard him say many times in his diabetes blog, that the caveman who lived is the one who thought ahead of like all the possible things that could go wrong. And that as people with diabetes, we are the caveman who survived. We are the ones who thought before we left the house to grab everything, never thought about this, I thought about this. And so we’re constantly asked to look for ghosts. And I think it’s, it’s, you know, it’s only natural that we’re going to find them when we write. You know, I think it’s important for people to understand that while the max Basal and the max Bolus are safety settings, and the algorithm is not looking at it, but the algorithm is designed and has to be designed with its own internal safety settings. And the reason why you won’t find what those safety settings are in, you know, in the User Guide, for instance, is that in many ways, they’re tailored to you, and your total daily insulin. And so your safety settings may change over time to like I, you know, I’ve had friends asked me about like, well, how come? You have auto events that are like point four units and mine are only point one, five, like, how do I get mine to be point four, it’s like, I have total daily insulin needs that are great advice, what yours are, my system has decided that it is it feels safe for me to go to a certain level. And that’s going to change over time. If my insulin if I dropped, drop a bunch of weight, my I’m going to see that my auto events change in response to that. And that’s again, that’s the way that the system is is looking at your total daily insulin and setting its own safety setting. So if people are getting the automated delivery restriction that’s causing them to like jump in and do their max basil, then what they actually need to do is kind of look at those other settings that impact their total daily insulin and think about those. I

think what a lot of people are learning as algorithms become popular is that they were achieving whatever they were achieving in the past maybe through means that weren’t I don’t know what the right word is they it might have been rigged a little bit but still working for them. Right, like you hear some, some doctors are big fans of over basil and people because they think they’re going to not Bolus correctly with their meals, like that’s actually a thing a doctor will do. And so you could be using more basil than you need as that example, and then moving into a system that doesn’t care about that it actually wants to know what the right answer is not just what we made work over time. And I think that’s, I think people learn that a lot. Moving on to Omni pod five. And I

think about the Have you ever heard the story of the woman who cuts the ends off her pot roast when she cooks it? And her husband says, Well, why do you do that? Just when my mother did that, she always cut the ends of the poppers. And then she asked her mother and the mother goes, well, my mother did it. And they go ask Grandma grandma’s like, at a short pan like

that that story is not only in my book, but it’s in the it’s in the podcast somewhere, because I think it makes the point to people with diabetes, like don’t just do something because somebody told you this is how it how it happens. You know? Yeah, that’s so funny you brought that

may have worked for you when you had a short pan, but maybe you don’t have to do it anymore. Yeah. Oh, there

you go. Omnipod, five, not a short pan, not a short pan. No, BP be completely free to use that in any kind of marketing that you like. So that four people understand what we’re talking about. Next myth, adjusting my Basal rates will help the algorithm in automated mode.

Well, hopefully, if folks have listened this far, and they’re gonna guess what the answer is? The answer is no. But again, as we said earlier, like, it’s still good to make adjustments to your manual mode rates, so that when you go back to manual mode, it’s reflective of the amount of insulin you’re actually using today are important. And so, but no, you know, for, I really feel for health care clinicians, because like, one of the first things they reach for in a lot of products, and what they were trained to do for regular insulin pumps, is to go in and adjust Basal settings. And, you know, that’s, that was the lever, they had to pull. And now that these systems, sort of take over that piece of it, then they, you know, they have to learn to operate it a little bit differently. So, you know, I have heard people say, Well, my doctor told me that I should still, you know, update the basil program. And, and, actually, the doctor may have said that, because of the other reason, which is, when you go back into manual mode, we want you to have this updated rates. But hopefully, they’re looking at your other settings, that would have a greater impact on your total daily insulin,

I just had a conversation the other day on the show where this person told me their nominee, pod five user, and they went back to their physician, because they were like, I think, you know, my settings need to be changed and everything. And she said that they were five minutes into the conversation, when she stopped, the doctrine said, You’re giving me direction about a different system for five minutes, that that person was giving, you know, giving them direction about using a completely different pump than what she was wearing. And she said, the doctor just didn’t know. It was fascinating. I’m sure that breaks your heart as a person who, who’s out there trying to share that knowledge with people. But that actually that could happen, you know, it

breaks my heart, but I have such empathy for my own endocrinologist, because how many different systems does she have to support and remember, these little nuanced details? And you know, I think they do a really good job. And I think all the companies have have really tried to give resources to our health care providers so that they can do that. But I think it’s important, you know, and you would advocate for this, and you always have with helping people people are with insulin, like there’s certain things where it pays for you to understand these nuances so that you can be your own advocate or what needs to happen. So when you have that conversation with your doctor, you might have to say, you know, well, you remember that’s only going to affect manual mode with the system, and then they Okay, well, let’s look at these other settings. Yeah.

So let’s go over it. I’m going to test your knowledge here. You wrote the book. So you should know, what settings can I adjust? In automated that impacts? Automated? Great question, please. It’s the whole reason I’m here today. I’m super excited. So

you know, I think insulin has said really consistently and clearly that, remember that this is a system on the market today, where you actually have different target glucose levels you can choose. And so if you want that, you know how we talked about the system isn’t going to learn that, Oh, I like oatmeal in the mornings, or oh, I go running in the afternoons. But the system can be told that every afternoon my kid has football practice. And I want to you know, maybe Timmy doesn’t remember to use the activity feature because Timmy is 13 and it’s a wonder he remembers to shower. So I’m going to adjust that target glucose in the afternoons to be you know, 131 40 Instead of his usual 110 or whatever that that choice you make is and you can by time of day actually set different target glucose values and so that could that could help in those kinds of situations until Timmy learns to use that activity. feature really consistently. And so, definitely the target glucose is the very first lever that we recommend that you that you tap on. Okay.

But more importantly to my specific question, if I change my target in automated, it changes the automated mode to go for that target. Yes, yes. And I asked that, because, for instance, we’ve talked to just a moment ago, if I change my Basal rate, will that change my Basal rate the target? No, because the algorithms already making new decisions, it doesn’t want you anymore. If you’re just making changes to manual, what what else can I change, if anything in automated that actually impacts automated, so

all of your Bolus settings are very important. Now, obviously, you change your Bolus setting, and you’re going to change how you Bolus in both modes, right. So if I change my insulin to carb ratio, it’s going to apply whether I’m in automated or manual mode when I’m bolusing. But because total daily insulin is what Omnipod five is learning, if you change the amount of insulin, you’re getting in a Bolus, you’re changing the overall amount of insulin you get in a day. That’s your total daily insulin. And so, you know, we’ve said that the that the system is trying to keep you pretty reasonably balanced between Basal and Bolus insulin. And so you know, those folks who may start out over under Basal LD, you’re going to want that Bolus and basil to be a little bit closer together in terms of balance, right, which is, you know, clinically appropriate in and what they strive for in traditional pubs is that sort of like, you know, 40 to 60 5050, kind of like, reasonably balanced, right. And so, changing the amount that gets moved over into the Bolus category or moved out of the Bolus category by changing your Bolus settings can adjust that sort of balance between the Basal and the Bolus as well. So, you know, we have found that many people need to adjust their or, you know, feel comfortable to consider adjusting certain things like their insulin to carb ratio, for instance, or their correction factor in order to just sort of change the amount of insulin they’re getting. And again, you have to be careful, because you’re doing that in both modes. So you wouldn’t want to do anything that, you know, hopefully, you’re working with a healthcare provider on changing the settings, because you wouldn’t want to get a Bolus that was so large in manual mode that that you wouldn’t be able to comment. I appreciate

that was very clear. Thank you. Because I still, there are times that so many people come at me with these kinds of misnomers online that I sometimes I question myself, and I think to myself, like, I made three, like pretty deep dive episodes about Omni pod five. And I really feel like I understand this, and then they’ll tell me something I’m like, I don’t think that’s right. And so it’s great to just hear it one more time, insulin to carb ratio, or correction factor, I changed them. I’m changing them for both. But it’s going to take some time for the algorithm to kind of dole out the insulin and decide where it goes, how much of it goes into basil, how much of it goes into covering a meal or a correction factor? Absolutely.

You know, and also consider that, you know, being on an automated system, you have to consider that when you Bolus that insulin now has to be sort of absorbed into the algorithms math, right. And so some people may see that, oh, well, it stopped delivering basil once I put this Bolus on board. And but that’s what you want it to do, because it’s considering all of that insulin, and it’s when it’s looking at an hour ahead. And so if you don’t like the numbers that you’re seeing, or you don’t like, what it’s the decision that it’s making, then, you know, thinking about, well, how can I get a little more or less Bolus in that in that Bolus by adjusting those settings? I

think a terrific example could be that if you ate a meal with I don’t know, 40 carbs in it, but you for some reason, told it, it was 20 carbs, your blood sugar is going to sit high. And the algorithm is not going to think, Oh, you need more insulin. It thinks we did this already. Like so yeah, it’s going to this is going to work at some point. It doesn’t know you miss that egregiously on the carbs. So

I think you bring up an important point there because you talked about, like, sort of you miscalculate the number of carbs. Well, one thing that we know people do we know because I’m guilty of it, I’ve done it in the past, is they put in fake carbs or ghost carbs. And there are systems where it kind of becomes this sort of community mentality of like, Oh, I just put in some fake carbs. And the question is, like, do you want to have to fake carb every day, every Bolus every meal? Or do you want to make sure that your settings are accounting for the insulin that you actually want to deliver it meals and then not ever think about it again? So back to our earlier conversation about like, do the work get the get the settings dialed in, and then you won’t have to feel like you’re are lying to the system.

And there are times to where there there are nutritional impacts. I’ll I’ll, I’ll talk about something that’s in the podcast that other people can go find there are a ton of episodes about how to Bolus for like protein or fat rises that you might see things that, you know, classically you say, well, there’s no carbs in that, except, you know, I’m not gonna go deep into it here. But if you eat french fries and a cheeseburger and it’s on a roll, then the fat slows down your digestion, and you can see a rise from the fat 6090 minutes after you’ve eaten to Bolus for that isn’t a ghost, it’s an actual impact, but it’s not a carb. And that’s where sometimes you’re just gonna have to up your game and understand the real impacts and the variables that are going on and not sometimes not just say, Well, I don’t know, I counted it, I did the thing. I don’t know why it’s not working. Yeah, I

do the same thing, Scott for coffee, I’ve always had to take a little insulin for coffee. And so I know what my calculation is to do that. It’s not carbs per se, but I know that it’s insulin that I need for the impact it has on my glucose. That’s not quite what I’m talking about in terms of what I’m talking about people saying, Oh, I’m 21 I didn’t

Yeah, no, I know, I know, I’ll clear up just in case I was unclear. But I know exactly what you’re saying. When your settings are weak, and you’re just pretending you ate carbs to give the system more insulin, you just just fix your settings or figure out what you’re doing wrong. Like don’t do that forever. Because that becomes monotonous after a while and then you will forget to do it. And then you know, then you get everything that comes with it. And coffee is a amazing example, by the way, because you can flip a coin meeting someone with type one, some people need to Bolus for it. And some people don’t need insulin for it at all. Yeah, fascinating. So okay. I think we’re down to like our last little bit here. It’s it’s just this these words that are here that make me think about every person I’ve seen online talk about Omni pod five, or God almost anything and diabetes, really, how do I game the system? People are always looking for a way to make the thing work. And you just kind of went over there a little bit with the ghosting the carbs. But there is no gaming the system right like this thing smarter than I am, it’s thinking about more than I am, it’s considering more than I could probably even consider trying to get around, it would probably just be setting up. I setting myself up for failure at some point, I think but I want to know what you think about it? Well,

you know, I and I’m guilty of saying it smarter than me too. But I want to say that a little bit differently, Scott, because it’s not, you know, I gave this system a job. So that I don’t have to think about it. And so if I’m going to come in and just keep fighting with the system to try to try to force fit it to work for me, then I have saved myself none of the trouble that that it was supposed to, like, you know, at the end of the day, like I almost feel bad that I’ve said like do the work because what I’m talking about is a tiny, tiny little Bolus of work to get the settings right, so that you don’t have to do work every day to fight against the system. So I’m going to tell you a little bit a story of how I tried to think, well, you know, I know how the algorithm works, I’m gonna game it a little bit. So when I started the system, I thought well, okay, I know how much insulin I need. And maybe that’s not exactly what, what I’ve dialed in. And so I’m gonna, so I basically lied to it about how much basil that I needed, because I was like, I want the system to like, go and hide, I want to be aggressive, I’m insulin resistant. And within a couple of days, it was like Melissa, you don’t take that much insulin, you need to stop. Now it’s not sassy with me. But it essentially like within a few pods, it had put me at the actual insulin needs that I had. And so all of that like trying to out think it and trying to outsmart it. All it did was was waste my time because the system was adapting to my total daily insulin and it reached its conclusion about the insulin I actually be need for basil and actually Bolus with. And so it it didn’t actually buy me anything to do that. Other than made me feel a little bit foolish in the end for thinking that like I could obscure from the system that is literally its job that I have assigned it is to track how much insulin I take that I could somehow hide from it.

I will I will jump in this pool with you so you don’t feel alone. When I put on the pot five on Arden. I did not make her insulin to carb ratio, aggressive enough. And then to get around it, I thought, oh, I’ll just put it in manual so it can’t cut basil. And then her blood sugar came crashing down. I was like, Oh, this was completely wrong. So I you know, like I did the same thing. I thought oh, I can I’ll get around it. I don’t know. Isn’t that interesting? Like why is the first inclination to people like how do I gain this instead of how do I get this setup correctly so that it doesn’t happen anymore? It is really interesting.

It’s trust though, right though? I mean, how many devices have you and Arden used over all this time I mentioned that I’ve had like 16 Insulin pumps like if we if if I had six? Well first of all if I had had 16 pumps It just always worked, I probably wouldn’t have bounced around until I found the one that I wanted to use. Right. But, you know, we’ve, we’ve been taught in diabetes, particularly for you as a caregiver. But also it counts for me as a as a personal type one, we’ve been taught, like, you’re gonna have to figure this out for yourself. Yeah, it’s all on you, you’ve got this huge cross, you have to bear, you’ve got this burden, you’re gonna have to figure this out. And so like giving up trust to, to a system is, is really hard. And what’s funny is there are places in our lives where we’re more than happy to give up trust, I mentioned that I have a smart thermostat. I don’t check its work every, you know, 30 minutes to see if it made the decision about my cooling habits that I want it to make. I just, I just give it up. But diabetes, we’ve had to, we’ve had to hold so close that, that it’s hard to develop that trust. I don’t blame people for trying to game it. I’m just telling you that if if it if it didn’t work for you and me I you know, I feel like most people are gonna have the same experience.

Honestly, most it’s a great point. The first time I got into a car that said it drove itself. I was like, Cool. And I pushed the button. I was like, let it do it. I didn’t think twice. Right. I saw I saw this. And I’m like, that’s not right.

I know better. I well, you know, think about how many hours and how many brain cycles you’ve given to diabetes? Like how could How could a mathematic equation in a system like Omnipod five be able to do that for you like, it’s a trust exercise. And I think that, you know, it’s important for us to remember it insolate as we’re developing the materials to kind of get you up and running, to think about, like, you know, what will help you feel like you can trust this system. And, you know, and so that’s something we’re thinking about every day. Wow,

that’s amazing. Well, I really do appreciate you coming on and doing this with me. I can’t thank you enough. I also want to thank you for listening to this three part series, ask the expert Omni pod five. If you’re telling me right now. Oh, Scott, I know there are other episodes. There sure are. There was two other ones. Did you not hear them? You gotta go right now. Episode One. With Eric Davenport asked the Omni pod five training expert and Episode Two Lindsay Friedman asked the Omni pod five product support expert. Three essential conversations with three Omni pod employees all who have type one diabetes, and all who were on the pod five. These episodes are of course available in the audio app you’re listening in right now. We’re at juicebox podcast.com/omni pod five. If you’d like to get started with Omni pod five, please consider using my link Omni pod.com/juice box and absolutely do not miss the Omni pod five Pro Tip series and episode 736 737 and 738. They are incredibly important as you set up your Omni pod five system. Thank you so much for listening. I’ll be back very soon with another episode of The Juicebox Podcast.

Hello friends and welcome to episode 662 of the Juicebox Podcast. Today we’re going to speak with Jeremy who is a past guest on the show. Today’s topic is much different than his first topic. We’ll cover that later in the podcast. But today Jeremy’s gonna tell you about how he manages his son’s type one diabetes with tandems control IQ. And let me tell you something, Jeremy is a next level guy, he’s a bit of a ninja. He took what he learned on this podcast, and just kept learning about control IQ, and today he’s going to tell you all about how he does it. While you’re listening, please remember that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making any changes to your healthcare plan, or becoming bold with insulin. After the show today, if you’d head over to t one D exchange.org, forward slash juicebox and fill out the survey, I would appreciate it you need to be a US resident who has type one diabetes, or is the caregiver of someone with type one, it only takes a few minutes T one D exchange.org forward slash juicebox. This episode of The Juicebox Podcast is sponsored by the Contour Next One blood glucose meter, head over to contour next one.com forward slash juicebox to see my favorite blood glucose meter. Today’s show is also sponsored by us med A plus rating with the Better Business Bureau always provides 90 days worth of diabetes supplies, has fast free shipping and accepts over 800 private insurers. And on top of that they take pride in you receiving better service and better care than you’re accustomed to getting with your current supplier. Go to us med.com forward slash juice box to get your free benefits check or call 888-721-1514 Make us med your diabetes supplier. What episode were you on the first time?

Um, it was the after dark divorce episode. Yeah, we

didn’t really talk about like, yeah, okay, so go ahead and reintroduce yourself.

Okay, I’m Jeremy Ross Meyer. I’m a single dad of a type one diabetic named Damon is 13 years old. And we have been diagnosed for four years and our agency has been between 5.3 and 5.8 for over three and a half years.

Wow. And in these three and a half years, have you always been using control IQ or has it been different managed? No,

we we’ve done all three, we’ve done straight pumping with tandem. We’ve done Basal IQ, pumping, and control IQ pumping, all maintaining that same a one C spread very nice. Okay. I mean, sometimes I feel like I was blessed to be able to straight pump because you really really understand what adjustments do to blood sugar. But it you can start anywhere. Really?

Yeah, you could figure it out with needles, you could figure it out with pens, you can figure it out with a pump like it’s all just watching the insulin go in and seeing what it does. It’s I mean, it’s great obviously to be able to adjust your basil on the fly and not have to wait 24 hours to inject the gas to try to make an improvement or change. Just real quick for people. That episode that Jeremy was on before 508 After Dark adult child of divorce you actually came on that one because you started out. Let me see if I can remember this Jeremy, this will be interesting. You weren’t Oh no, I

don’t know if it is that when because you said adult. Oh,

I said the wrong one. Excuse me. Cheese 372 After Dark divorce and co parenting.

There you go start one

second a pot. Actually. There’s a lot of them here. I have one too. I searched divorce in my episodes and came back with four. No, no kidding. All right, yours is 372 about co parenting because if I’m remembering correctly, you are divorced as your child is diagnosed. And and we all get along, right? And you guys actually get along, right? And that’s what you’re talking about. Right? I did get a lot of impact. Impactful letters back from people where they’re like, can you just interview somebody who’s not getting along and how they’re doing it? Yeah. And I said good. Like getting somebody who’s not getting along with their ex to come on a podcast and talk about it as like people are not generally excited to divulge that kind of stuff. But I have gotten a little closer in a recent episode 625 was about divorce and disagreement and that person. Yes.

And it was an excellent, excellent representation of the other side.

Yeah, yeah. So I finally got there. It’s not I’m just saying not easy to get somebody to come on and talk about their spouse or their ex spouse. Yeah. Especially if they’re not getting along very well. All right. So Jeremy, you’re back today? Because? Well, I know you, and I know you, especially through the Facebook page. But through our previous conversations, and we tech sometimes, and you are very good at using control IQ. And, you know, I’ve had somebody on recently to talk about it. And we I thought had a pretty surface conversation about it. And I didn’t know enough about control IQ to push back in certain places. So you’re sort of on here to help me dig deeper? Sure, yeah. So I mean, kind of take it away. Tell me what you what you would tell somebody else if I said, Hey, should I should I try control IQ, what would you say?

So just to kind of give you an idea here, I also am, this is not an invitation to contact me and ask, I also can follow three other children up here in Montana that are on control IQ, I also control their pumps, they’re a onesies are all below seven, as well. So I’ve kind of done this long enough with enough samples to understand what needs to be done with control IQ to get it to work. Not just on my child, but on different age children on male females in puberty out of puberty. But what it really comes down to is that, before we even get into control IQ, there’s a few things that, in my opinion, it doesn’t matter what pump you’re on, that needs to be better understood or mentioned, before we get into control IQ. Stuff like consistency, how you treat lows, what you treat lows with using protein at night, and just allowing basil to do its job. The way that we treat like, between my son and I is we either use mots apple juice, that’s the all natural stuff. Or we use gummies. We know how much apple juice to drink to get to three carbs, we know how much to drink to eight carbs, and it’s consistent. And it works the same way every single time. And you’re going to hear the consistency through the control IQ point of view as well. We know that what a gummy will do to his blood sugar. We know that when he’s dropping this hard he needs this many gummies the longer that you stick with the same sort of thing. The better results you’re going to have instead of just throwing Oreos that your child

then like let me let me make sure because I know what you’re saying. But I want to make sure we’re all clear. Sure there are impacts variables all over diabetes, including the things you don’t think of as being impactful. And the idea of you’re getting low Oh, what do I do doing something consistent breeds a consistent response and more and more importantly allows you to move forward without crazy highs or crazy lows or things that you don’t expect to happen so if you’re consistent with how you bump your your low blood sugars, then you’ll be consistent with what happens afterwards not just like hey this time eat an Oreo next time have a piece of chocolate cake this time yeah cuz soda like that kind of thing. Treat the yes,

there’s always times dt the whole fridge Yeah, right. You know, there’s always those extremely high delta where they’re about to pass out and you just grab anything and everything and throw it down their throat doesn’t happen often. If it is happening often there’s something wrong but moving moving on from that we have to kind of talk about what what I call garbage in garbage out. Which means that you know, you need to be checking your Dexcom ratings, not just doing nothing about them. That starts with a good glucometer and I this is not an ad for

you want me to do the ad Jeremy. The Contour Next One blood glucose meter. Are you about to say that are you about this? It’s a great meter.

I just couldn’t remember what the hell it was called. But you use one thing. But anyways, in the thing that we’ve tried difference. There are tons of third party studies out there that shows that that Contour Next One is the most accurate meter on the market period. Now, I understand there are some people that, you know, can’t afford, you know, something like that, because the strips are fairly expensive. But they’re, there’s so many times that that meter will exactly match Dexcom. It’s not even funny. Yeah, I agree. And then there’s certain things about Dexcom. Like you need I hear I hear a lot of people say, Oh, well, we never calibrate. We’re a family that calibrates with my son. If you do not calibrate, the second it comes on, it will dump Low to low, and it will die. You have to calibrate my son immediately when it comes on. And then you’re good for the first two days. You have to calibrate on the third, then we have to calibrate on the eighth every other fingerstick that we do every single morning this this consistency. And every single night before he goes to bed is normally within five points.

But you still do it, you still do it every time.

You still do it every single time. Yeah, you you have to the center will die. We’ve we’ve heard you know, Kevin Sayer Come on, and say that it’s just it doesn’t work the same way for everybody. We just figured out what works for us. And with a very accurate Dexcom reading from a very, you know, accurate glucometer you can stop the garbage in garbage out. And what I mean by that is only testing the blood sugar in checking Dexcom whenever this site arrows sideways, and making sure you understand how the Dexcom works.

So that the numbers you’re working with are good or accurate. So they can end up making good decisions with Arden’s interesting artists decks, either works, boom, or needs to be calibrated on the first day. Yeah, one of the other. I don’t, I don’t, I haven’t seen a rhyme or reason to it, I would tell you the last six of them we’ve put on I haven’t had to do that. And then before that a couple of them need lit people’s body chemistry is different. There’s all kinds of different things going on. But your your specific point is so incredibly important and valid, which is you are making decisions, measuring a medication based on a number and you might be getting that number with a meter that’s not accurate, or to CGM, that’s not accurate. And then you’re making decisions and, and running forward. I love that you test twice a day.

But here’s the bigger picture. Scott. Yeah, you keep saying that I’m making decisions. Now putting algorithms and control, right? You have bad Dexcom ratings. It’s 100 points higher. And it’s dumping more insulin than it should. Garbage in, garbage out, you have garbage information going into the algorithm, you’re gonna get garbage out. So it is very vitally important to make sure that you have a Dexcom rating that is reliable. Yeah, this is this is this is all algorithms. This is Omnipod. Five, this is control IQ. This is going to be control IQ 2.0. Whatever else comes out from Medtronic, you know, everything is based off of that blood sugar reading. And if it’s not accurate, how can you expect your results to be accurate?

They can’t. And you have to take some responsibility for that yourself.

Yes, yeah, absolutely. Yeah,

there’s, can I take a tiny like, brief little sidebar here on the Sure. I’m forever interested when longtime type ones come on. And they’ll say things like, I didn’t want to get a CGM until there was no calibration needed. Because it’s always the inference is always that it’s such an inconvenience, like, why would I take on this new thing, if it still needed my effort? And I think that’s an old timey way of thinking about it. You know, I think that I mean, a CGM for my daughter is first, right? Like seriously, if the house was burning down and I could grab a pump or a CGM on the way out the door. It would be the CGM, right? Not to say that it’s a one of the other decision. I’m also of course, a huge fan of the pump. But But my point is that is that the idea that if it’s not completely nothing, I have to touch you ever or nothing? I have to think about that. I don’t want to do it. I don’t understand. You know, like, this is just this is where we’re at with this technology and, you know, using Dexcom G sixes, as an example, you know, they tell you, you don’t need to calibrate that means that Got it through the FDA, and you’re gonna be okay. If you don’t calibrate, but you that might be that one day the thing thinks you’re 130. And you’re, I don’t know, 150 or you’re exactly you’re 80 and it says you’re one I don’t know, like it might not.

Here’s the thing, though, Scott, is that if you want better than average control, right, you need to have better than average information going in effort. And in order to get that better than average information going in, you have to calibrate. You hear people all the time saying, oh, Dexcom is 15 minutes behind, not if your line is straight. Not it. That’s only whenever it’s falling or rising. If it’s if you’re primarily straight, and I know and I will get into this later, that I’m not saying my son is straight all day long. He is not he is just like garden, he has trips to 180 Maybe once a day, and he comes back down. I am not one of those people that that craves a absolutely straight line. I do not go nuts. I just don’t allow it to get nutty. In the long run. Yeah.

But your point is, is that when you’re in the middle of stability, and you’re the blood sugar is 96. And it’s been 96 for the better part of three hours. If you’re there’s a way to be certain that that’s true. And by checking out checking with a finger stick and then telling Yes. And then calibrating sometimes,

and that’s first thing in the morning when they first wake up. Okay, that’s how it’s working last a water. Check your blood. He knows every morning glass of water, check your blood. Water gets blood moving, and he doesn’t have anything impacting his blood sugar. Dexcom should be pretty straight on.

Yeah. And it is normally. Oh, yeah, yeah. Okay. Yeah, it’s

like within five point, if it’s within five, we don’t touch it. If it’s within 10. Like if it’s 10 or more, we’re calibrating. And that’s both. That’s way sorry for the swearing. That’s that’s just it’s not acceptable. And I know that may sound extreme, but it’s not. It really isn’t

from your from your experience. What’s my question here? This is just proving out to you over and over again. Yes, but it is not white guys calm would tell you to do is that correct? Absolutely not. Okay.

I’m just like, you know, dumping more insulin on your kids 30 minutes after he just ate is not what an endo would tell you to do. So I guess, moving on more to like the pump. The next thing that you kind of have to remember is that you have to understand the pump that you’re on. Doesn’t matter which pump it is you have to understand how it works. Especially if there’s no algorithm involved. Control IQ is not a miracle machine, like a lot of people think adjustments still have to be close and made and sometimes made often. But you start looking at the tandem and I don’t want to start sounding like a tandem shill, but I am. The big things with tandem is that you can adjust basil in point 001 increments after point one, like Omnipod, or Medtronic can do point 05. That’s a 50 times increase in adjustability. And we all know how much Basil is how and based how important Basil is. Something a lot of people don’t know is that the on a tandem. The carb ratio if it’s under 10 you can adjust it by point one instead of one year if eight isn’t working. And nine is too strong. You can do 8.1 8.2 8.3 8.4 A point but you can do by point one to dial in that carb ratio. Once again, this comes back to consistency. You need to use it you can’t just flop on either or if nines too strong you can’t say oh well I’ll just you know turn their Basal down for a half an hour. No, get it right. I mean, let’s be honest. Our kids normally eat the same thing every morning at breakfast. I tried to offer him a million different things but it’s always pancakes with chocolate chips, strawberries, and milk. Wow. Every single morning a lot of cooking. Well, we always get those frozen. Okay, okay, so pancakes.

Oh, I got your mind Jeremy. You’re whipping up pancake batter and cutting up strawberries and so, so back to that other point. You’re saying that, like, for instance, Arden’s carb ratio is one to four and a half, but it could end up being one to 4.7. Instead, yes. Right. And you have and

it will, it will allow the tandem will allow you to make those 10th adjustments if the carb ratio is under 10. And you may think, Oh, well, you know, that’s just being too picky. Well, no, like, whenever carb ratios get below 10, they get crazy. You know, my son is 13. He, according to his Endo, I don’t really understand it. There’s four stages of puberty. And he’s in stage three, and He’s peeking right now. And he doesn’t understand how he’s still less than 1%. Low. And it’s, you know, he doesn’t understand how he’s 5.6. And he doesn’t understand a lot. But, you know, the proper pump adjustment is one thing, you know,

yeah. So, these, all these little things put together? Or the answer or the answer to stability, right? It’s the Yes, making sure that the data you’re working off of is sound. It’s not just randomly picking an amount of insulin, but actually being able to dial it in very closely. Yes, and it’s consistency with how you are addressing low blood sugars. It’s consistency with drinking that glass of water in the morning, before you test your blood sugar, like all those little things, do you find them to be overwhelming? Or did they just happen? Pretty?

No, they they seem a little at first, and I’ve had a few parents tell me? Well, that seems like a lot. I’m like, No, it doesn’t real after about, you know, a week, you’ll be like, Oh, this makes sense. And the families that I do help, you know, and that they do get this way, you’ll see like a huge improvement. They go, Oh, I get it now. Okay, because you’ll start seeing those improvements. You know, it’s not just in the pump, or the algorithm. It’s how you’re treating everything else.

So when you hear when you hear me say that more effort upfront, saves you a ton on the back end, that’s how you Yeah,

yes. And but the thing is, is it doesn’t become a lot of front, other than the first couple of weeks, while you’re getting used to once you get it, you’re not being strict, you’re not forcing, you know, I’m lucky as hell that my son loves apple juice, and he’s never become bored of it. I asked him like every other month or so hey, do you want to try something else other than apple juice? And he goes, nope, I’m good. Yeah, but, you know, boys, etc, sometimes.

Come tell me if this sounds familiar, you’re all set up with a diabetes supplier. And they’ve told you don’t worry, we’re gonna send you your supplies on time, you’re never gonna have to call us again, this is going to be easy. And then one day, your stuff doesn’t show up. You run out of your Dexcom supplies, your libre supplies, your insulin pumps, and the new ones aren’t there the way they’re supposed to be? So you call them up on the phone? And what do you say? Well, I don’t know what you say. But here’s what I say when it happens to me. Say you guys told me this wasn’t going to be a problem. They say is this always happens at the end of the year? Well, we needed a new prescription. And we reached out to your doctor, but they didn’t get back to us. Then there’s this long pause. Like it’s not their fault. The people who told you they were going to take care of this are now foisting the blame onto someone else. What does that mean that they reached out to your doctor? I don’t know. Does that mean they sent him a fax, they call them on the phone? They send up smoke signals? I couldn’t begin to tell you what my old suppliers did. What I can tell you is what US med does. It’s simple. They get it done. There’s no none of bones. Not supposed to curse don’t Yeah, it’s but you hear what I’m saying? us mad tells you they’re going to take care of it. They’re going to get a script from your doctor than they get a script from your doctor. That’s simple. US med takes over 800 private insurances. They accept Medicare nationwide. And they always provide 90 days worth of supplies with fast and free shipping. carry everything from insulin pumps to testing supplies CGM. They have what you need. All you have to do is go get your benefits checked at us. med.com forward slash juicebox. If you don’t like the internet, you could also call 888-721-1514. Well, now we know where you’re going to get your blood glucose meter at but now we need to decide which one are you going to buy? If you ask me, I’m gonna say the one that my daughter uses the Contour Next One blood glucose meter. I have no copy in front of me. I’m not looking at a website. Let me just tell you why I would pick that eater. First thing that pops in my mind, it’s easy to hold, easy to carry, easy to put in a bag, or pair of pants, or wherever you carry your stuff. And I mean, like a pocket. It’s small, but not too small. It’s easy to read has a bright screen and a bright light for nighttime viewing. The test strips allow Second Chance testing, here’s what that simply means. Should you touch the blood but not good enough, you can go back and get more without interfering with the quality of the test result. And that is not to say that it needs a lot of blood, it actually doesn’t need very much at all. The sample size I find to be very small. This is in fact, the easiest to use, handiest and most importantly, most accurate blood glucose meter that my daughter has ever used, that I have ever used, that I have ever been in the same room with the Contour Next One blood glucose meter, go find out more about it. At contour next one.com forward slash juicebox. When you get there, you’re going to see a very informative website, and easy ways to get yourself a great meter, it’s actually possible that the meter and test strips could be cheaper in cash than you’re paying right now through your insurance for your current meter. And there’s very little chance that that meter is as accurate as the Contour Next One, there’s only one thing left for you to do. Go to a browser type contour next one.com forward slash juicebox. You will also find links in the show notes of the podcast player you’re using and at juicebox podcast.com. And by the way, if you’re listening in an audio after this podcast, please hit subscribe or follow. Alright, that’s it for the ads. Let’s get back to Jeremy he has a lot more to share about how he uses control IQ.

The biggest thing is like we’re talking and once again about pump adjustment is you’ll hear often people will tell you to adjust Basal by 10%. That seems to be a pretty standard adjustment. But I always tell people not to and here’s why. Let’s say your kid is point seven five an hour, and you add 10% to that the math to that is it will end up equaling out point eight to five, I believe. And that will be a difference of point 075, you’re adding point 075 When adding 10% 2.75. So then there are 825. Which tandem doesn’t have a problem doing it can go out to that 1000s Remember, so eight point or sorry, point eight to five plus 10%, they need more, another Basal increase, you’re now at point 907. And that’s a difference of point 082. So you’ve went from an increase at seven five of point 075. And you’ve now increased Basal again by point eight, two or point zero a two. Then from 907, you add 10% You get point 997. Now you’re adding point 09. It’s not consistent. Every single time whenever I first started out, I the best thing like the CD could have told me is every single time or she kind of showed me on an AGP report. And I’ll kind of talk about that a little bit later. But every time you see a change here, I want you to just change the pump by point zero to five. That was my quote, baby step. That’s what she called the baby step to me, but it consists and then it’s consistent point zero to five because you will know what point zero to five does. If it keeps increasing because you’re going by 10% There’s no consistency there, you’re adding more and more and more or taking away less than less. Currently, point 025 is a huge jump for us. Once you get basil dialed in enough. I literally move my son’s basil by five 1000s of a unit of basil per hour. I know exactly what that does. And it’s normally nine out of 10 times enough to get him perfectly back in life. Wow. If you take our Dexcom 90 Day AGP report it is a straight line with very little variation. And it’s all because of the consistency it’s knowing what that point 005 Or a point 01 change in Basal will do and keeping it consistent.

How often do you think you’ve changed his Basal rates?

So I changed them Two days ago, before that I had not touched them in a month and a half to two months, even in full bore puberty. And he’s still his average blood sugar is still down there, very low one, hundreds and zesty is in the mid 20s. That’s excellent. And I wasn’t able to I once you get dialed in and you fully understand how to keep things consistent, things stay consistent. Now I understand there are people in honeymoon that does not apply to you. There are people that you know, have sports does not apply to you while my son is active. Um, that’s it. A lot of it’s about knowing how to treat before sports before jumping on the trampoline before doing all this other stuff. He knows like before PE because he’s moved into independent at school. He knows before PE he goes and asks teacher, Hey, what are we doing today? And if it’s something like we’re playing dodgeball, or we’re running the mile he knows to grab, you know, something out of his bag, and get some carbs move it. And that’s just more consistency. But let’s you want to get into control IQ. Yeah. And I totally know.

I appreciate your overview of how you think about it, though. Yeah, I mean, really, that’s very helpful to me. Because I mean, you’ll admit, I would imagine, maybe you won’t, but you listen to the podcast. So you’re thinking at this. I think you’re taking like, things that I talked about, and you’re being more granular with them. Yeah, much more so than I ever AM. And, and you’re fine tuning things down even farther, like you’re, you keep tightening that that wrench until it’s exactly where you want it to be. It’s, it’s amazing. I mean,

but the thing is, like I said, is that once you get there, you don’t have to do much work once it’s about learning the patterns and staying consistent, right? And looking at the AGP report at least once a week, and saying, Oh, look at that, I might want to scooch that up a little bit. Instead of just, oh my God, what’s going on? It’s like, one day, it’s just random. If it happens two days for me, there needs to be a change. If the third day, it’s still not right, you’re gonna get changed again. You know, something’s gonna change. You know

what my bigger takeaway from this is? That wherever you are. You’re not too far. Why do I how do I say this? Hold on. Let me Thanks, Jeremy. If your management style keeps you at a 200 blood sugar, and suddenly your blood sugar tries to jump to an average to 10 blood sugar, you don’t have to manage much to get back to 200. If your average management keeps you at 150, or 120, or 110, or at whatever your management style is, once you’re there, and you can accomplish it, even when other variables come in and try to move you off of your success. The adjustments to come back to where your norm is, or not these great, crazy things that need to be done. Is that the thing you’re telling me? Yes. Okay. All right. I agree. Okay,

so yeah. Let’s talk about algorithms and how, how at least control IQ works. Because I often see in post, people saying, way, way wrong things. And I often want to correct them, but I often come off as a jerk. And oftentimes Scott has to get on there and say, Oh, well, like Jeremy is a really good guy.

Boys are not well, sometimes boys are not good at communicating and writing

No, no, no, absolutely not. So the first thing that you need to know about control IQ, is there’s three different modes, there’s normal mode, there’s exercise mode, and then there’s sleep mode. We do not we’re not sleeping beauty, we do not use sleep mode, 24 hours a day, there’s a lot of people that swear by it, but my endo would come unglued, and I’m just not going to deal with it. Our results are fine, we don’t have to go there. So in normal mode, this is where control IQ is at 90% of the day if you’re using control IQ as it should be. I’m not saying it’s the right way because there’s many ways to skin a cat. So in normal mode control IQ will target 112.5 I know that’s a weird number, but it is a real number. However, we’ll adjust the Basal based on predicted blood glucose levels 30 minutes out that six readings. Now if you’re maintaining between 112.5 and 160 it will deliver the settings that you yourself or your end have put into your pump, nothing changes, it’s not doing anything but running off the settings inside your pump. Now, control IQ will increase Basal insulin. If the sensor glucose value is predicted to be above 160. In the next 30 minutes, once again that six readings it looks at and says, okay, they’re moving by plus five, the delta is moving by plus five, every five minutes. If I apply that six readings out, are they going to be above 160? Yes or No? If yes, it’s going to start increasing the Basal. Now control IQ will decrease Basal insulin delivery, if the sensor glucose is predicted to be below 112.5. In the next 30 minutes. Once again, six rings out. If you’re 180, and you start dumping by 20s, it’s going to start you know cutting insulin control IQ will stop all Basal insulin delivery if the sensor glucose level is predicted to be below 70 In the next 30 minutes. So if you’re dropping hard, and if it depending on how fast you’re moving, if it thinks that you’re going to be below 70, in the next 30 minutes, it will cut all insulin. Oftentimes, you have to you have to understand that when setting your Basal that while it’s important with control IQ, insulin sensitivity factor is just as important as Basal if not more important than Basal with Ctrl IQ. Okay, because the pump uses the ISF or the insulin correction ratio or the correction factor. However you want to say it to determine how much insulin to increase or decrease when making its modulation to the Basal. So what I like to tell people is to think of it as an aggressiveness knob. If you’re seeing big cycling, which means the start to go high, and then the you start to go low, and you’re kind of riding a wave all night long. What that means is that you’ve actually got two wrongs, which looks like a right. While it’s fairly steady, you’re cycling. And what will happen. This happens I know with loop a little bit too. Not sure about Omnipod five yet. But what happens is if you get the Basal a little loose, you’ll start drifting up, then control IQ will say oh, they’re drifting up, we need to add more insulin, then ISF is a bit too stiff, and it will start sending you a low and you will cut insulin, and then you’re stuck in and then you’ll start going high because of the cost of insulin, then you’ll go low, because you end up cycling,

bouncing. Yeah,

so what looks normal, might be two wrongs look like a right. So and that’s the biggest complaint is that Basal IQ cuts insulin, then they go high. And then they overcorrect and they go low. Right. So your pumps already trying to handle it. And you’re not allowing it to because of your settings.

Are you saying that this becomes obvious when you see basically the settings fighting with each other? There, there’s

they’re not fighting each other. They’re just wrong. They’re wrong, but they’re not fighting each other. It’s just the algorithm responding the way that it was designed to respond.

And using those settings, it makes you it makes you a little too low, it cuts itself off, which makes you too high, it gets aggressive again, which makes you low. And you’re saying that if these two settings were more in line with what you actually needed, there’d be this stability where there’d be some insulin, but you wouldn’t be taking it away and then adding extra and taking away and adding extra time. Yes. Okay. And that process of take even though the algorithm can keep up with the problem, mostly taking away giving back taking away giving back that is not your goal.

No, absolutely not. Okay. So we kind of went over what normal mode looks like exercise mode, in my opinion, my opinion, is completely worthless unless you’re thinking two hours ahead and what 13 year old looks two hours ahead. The way it works is instead of targeting that 112.5 It will target 150 instead, it will still deliver correction doses if you’re predicted to be above 100 ad in the next 30 minutes. It will still increase Basal if predicts the blood glucose to be above 160 In the next 30 minutes. Um will decrease insulin, even if it predicts the BG lower than 160. In the next 30 minutes, it will suspend. If it predicts your blood glucose will be lower than 80 in the next 30 minutes instead of 70, like in normal mode. So, if you know that you’re gonna go on a bike ride into hours, then yes, you can turn on exercise mode, and it will protect you. And it’s great. If you’re running a marathon, you know, an hour and a half, two hours away to turn it on, it works great. But for a lot of parents, they say, Oh, well, it doesn’t work. And that’s because they turn it on right before their kid gets on the trampoline, and then wonders why Johnny goes low on the trampoline. It’s not great for those kids, you know, and those families that are a lot more spontaneous. And you know, I don’t know about a lot of people, but like, my kid has a full size trampoline in the backyard, next to a huge 16 foot pool. And yes, he uses them together all summer long.

Well, I think that it’s funny, because while you’re talking about this, I’m relating it to loop in my head. Yeah. And what I’m thinking is that when I see when I look at overnight, what I want to see is that Arden’s Basal insulin is not being cut away constantly. And exactly, and that there’s no correction, that correction, boluses aren’t happening all the time. And I do want to say that things happen, and you want the algorithm to work. But generally speaking away from impacts, like you know, boluses food, you know, hormones, like in just a normal time, which God knows Jeremy, how often do the normal times happen? But in those normal times, you want your settings to just work there where they are, and the result is low and stable. Yes, yeah. And not low low, like normal and stable.

Yes. And then that moves us into that sleep mode that everybody raves about. So, really quick sleep mode will target a very tight range of 112 and a half to 120. While it’s on but not deliver any correction doses whatsoever. It will however, be much more aggressive with increasing and decreasing the Basal. Once again, that’s where the insulin sensitivity factor comes into great play. You have to have ISF dialed in immaculately overnight, along with basil. But, Damon normally, he gets down in that. Oh, 85 to 95 range all night long. From one week after starting control IQ I slept every single night. I maybe have one or two nights a month where he has a compression low and an alarm goes off. Other than that, if it wasn’t for my sleep apnea, I would sleep all through the night

85 to 95. Yeah, yeah. And you’re doing that not in sleep mode?

No, we’re doing that in sleep. Right? Excuse me, we’re just not in sleep mode. 24/7 like a lot of people do. There’s, there’s a lot of people that that their life is very dense normally on older type ones, or type ones that have the very, very stringent, stringent routine every single day where everything’s the same. We eat the same breakfast, lunch and dinner, we exercise at the same point in time, every single day, there’s not a lot of variation, you’re able to turn that 20 that sleep mode on 24/7. And if you’re these people that have those settings set up just perfectly, there is no reason for control IQ to dump a 60% correction. Right? They do that themselves. They’re already so in tune with themselves. Because they’ve been doing this for so long that they’re making although they don’t believe

that they’re making. They’re making great Bolus is around food. They’re not fast living a lot to begin with.

Exactly. And so they they benefit from Sleep mode being more aggressive and you know, when they’re when they’re awake, because they’re they’re not running away. You know, running 100 yard dash whenever like a 13 year old sees a girl from half a block away.

Yeah, right or going from the trampoline to the pool back of the trampoline or something like that. Yes,

exactly. I say. From there, it’s it’s a lot of it is understanding Dexcom reports and we’re talking about clarity if you don’t have clarity downloaded on your phone. Sign into it. There’s tons of different reports. And yes, they look intimidating at first. Needless to say, the only thing that matters to me on on Dexcom clarity is that AGP report, it’s the very last one, it shows you your average blood sugar at a given time throughout the whole day, then it has a blue bubble around it that shows basically, without getting horrifically nerdy shows you how variable you’ve been around that average blood sugar. And then from there, it’s using those reports to make smart, educated, experienced decisions in a very consistent manner. To get better than average results, you look at the AGP report. And if you start seeing like on a seven day average, you keep raising every single day at 3:20pm. About an hour and a half before that will kick up. You should probably have a Basal segment there. It’s about a lot of people will argue over two or three or one Basal segments in a pump. Yeah, my son has nine. Wow. And the reason that he has nine is because that’s what he needs. And you look at a GDP report, like I said, I can pull up a 30 day graph and it’s straight as can be. And the blue line is very, very close to that red, that red line in the middle. It’s I don’t want to say it’s not rocket science. It’s all with time and experience. And staying very consistent and understanding what each thing that you’re adding is going to do.

I’m pulling up Arden’s AGP report right now. So they’re gonna ask you a question about it. Because what you said was to make you know, you talked about making smart decisions about changes, but who tells you what those changes are? Like, what what about the report says something to you? And says, you know, go ahead, and, you know, this means do a thing. You know what I mean? Like, like, I have Arden’s last. It’s interesting, right? I just, it just popped up her last two days. And she’s not, she doesn’t have any hormonal impact in the last two days, or much less. Her standard deviation cuts in half, when that happens. Yeah, very, very interesting. It’s it can go it can be as high as 40. At times, with still an average blood sugar of 110 to 114. Yep, yep. And then as soon as the birth control pill she’s on goes to placebo, her deviation goes into the low 20s. Yeah, right away. And that’s just,

and I’ve dealt with one other young, young, younger female, she was 13, that it was the same way. It just depending on what type of month it was, and we made those adjustments, and we made a different, you know, deal in the in the pump to deal with that time of the month. And we figured out, okay, every month, she needs this much more three days before she’s really regular. Let’s, you know, treat this the way it should be treated. We know that she’s regular, let’s be brave. And let’s start increasing that insulin the day before, we know we need it. But go ahead and go back to the AGP reports. Let’s

talk about well, I got my glasses, but I’m, it’s hard to count. So I just got old out of nowhere a couple years ago. So I went back and I went to 30 days now. So the last 30 days, the last three weeks, Arden has been trying. So I think everybody who listens knows like we’re trying to regulate Ardens period with a birth control pill, it isn’t going so great. But so I have her average glucose is 122 over the last 30 days, she has been very low 1.4% of the time, which means under 54, low 6.4% of the time, which means 70 under 70. I don’t particularly consider that low, but that’s okay. In target and the target of course is you know 70 to 180 for the report I have 80 Yes 83.4% of the time high over 180 10% of the time and very high point 3% of the time. Her coefficient of variation was 33 over the last month and like I said her standard deviation is 40. When you when you get all that involved now, in truth, I don’t know I haven’t looked back I don’t look at CAP clarity as much as I should, to be perfectly honest. So so when I look at this line that I’m seeing, it appears to be incredibly stable. Right around 100 110. For this last 30 days, I see a little bit of an uptick around 2pm that lasts until about six or so. So if she does get higher, she can go 130 or so in that timeframe. And when I do see the 180s, it’s in that exact timeframe, four o’clock, four o’clock to eight o’clock. Anyway, I don’t know, what do I do with this?

So I focus on the red line in the middle, okay. And I kind of make sure that I understand that where males are and that there is going to be a spike. But in that 30 Day graphic lease, I normally make adjustments on the seventh day or the 14, but the 30 tells a lot. It tells how long have you had this problem. And if so, if you see on the 30 day graph, a slight uptick because I’m pretty I’ve seen AGP reports, and I’m like holy hell, and it takes a good month to straighten that red line out like rubber bands, that doesn’t mean that they’re like that every single day. That just means that your average, that’s where your average is I don’t care about day to day. Yeah, the median, I care about the average over time, because this is a marathon, not a race. And so if I saw on the 30 day graph, a slight increase at 2pm, I would look at my son’s pump. And I would say okay, that basil at 1230, keeping in mind that his lunch is that 1130 At school, I know it’s not lunch, that’s the basil issue to me. And I would literally go to 1230 an hour and a half before two. And I found that all but one of the kids that I’ve helped, or one of the families that I’ve helped every single last one of them, it’s been an hour and a half before the before the event on AGP. So I would go to 1230. And I would literally bump him if it’s just a slight one, I would literally bumped him five 1000s on his Basal. Okay. And it will, at two o’clock it will hit and point 005 isn’t enough to to drive them low. And then the next day, if you look at it, you’re like, Okay, it’s still there. But if I did another point 005 It would be done. You know, and that’s where I go, I don’t get so granular that I go by the 1000s. But I do go by the 5000s or the point one, because I can look at a line and be like, okay, that happened yesterday, too. And at that angle, or that delta the change in in blood sugar reading that that angle is going to need a point one instead of a point 005 It you know, you’ll you’ll get used to it, you’ll you’ll look at a line, you’ll be like okay, that’s happened three days now. That’s that’s going to be a point one instead of a point 005. That’s because you’re staying consistent. And you know what point 005 does, or you know what point one does?

Well, so that’s point

01. Sorry,

now. So when I’m looking at this, looking at Ardens. Also, the other thing we’re doing is it Arden is we’re onboarding more and more responsibility to art. And as it gets closer to her leaving for college, a little bit of her practicing. And I think this is her doing a not great job of Pre-Bolus thing as much as she should for her launch.

So blow your mind. We don’t Pre-Bolus at all ever

anymore. Because everything’s so tight for you. Yes, it doesn’t matter.

It does not matter. Because the other thing that people don’t think about it, lots of people do. I’m not saying everybody but a lot of the things that people don’t understand is they’ll show me a chart. And they’ll say, Well, I dosed correctly for this meal. And look, they’re still 250 At the end of the day. But if you look at the line when they dosed, they were already climbing. And the thing is, is whenever you Bolus with any pump on the market, any pump on the market whenever you Bolus for a meal, the pump assumes a straight line. If you hit Bolus, Ada carbs and hit enter. It’s going to assume it tandem will automatically pull your Dexcom reading into that calculator. And let’s say it was 150 it will assume that your blood sugar is 150 and completely steady. It does not take in in this this goes for Omnipod This goes for everything. It assumes a straight line so if you are 150 and you’re an arrow up, it’s going to a Under Bolus you, if you are 150 arrow down, you it’s going to over Bolus you. So that comes back to like, if you look at the meal and you you’re having ADA carbs, you’re 150. And you’re, let’s say, arrow, Diag, diagonally up. And you’re looking at the Delta and you’re like, Okay, so the deltas moving about point six right now, you have to think 30 minutes ahead, so Okay, so 30 minutes ahead. At 630, that’s six readings time, that’s 30 points more. So you’re gonna have to think okay, so I know my son’s ISF is 55. So that looks like about an extra point seven units of insulin. So what I’ll literally have him do is I’ll say, hey, what does your pump say, to give you? And let’s say it’s, it says, to give him an even for four units just to, you know, throw an easy number out there? I’ll tell him, Hey, can you change that to point or 4.7, please, because he’s going up, the pump doesn’t know he’s going up, it assumes he’s 150 in a straight line. So you add that extra insulin based on time, you’re not going to have the time they won’t even spike. It’s understanding that that pump isn’t going to deliver based on the change of Delta before a meal. And I hope that’s not too. too nerdy.

No. Are you kidding? That’s why you’re here. What are you talking about? That’s exactly why you’re actually I’m also, I didn’t realize that in clarity that we had settings before the reports set where I don’t care about them. Like, like, I want to me a high blood sugar’s 140. That’s yeah, that’s what I bought them. And that’s what I’m looking for.

Hi, so lots of people don’t have that setup. correctly. Now, I understand your idea of a high is 140. And there’s a lot of us that, you know, that is how it is. I prefer clarity to be set to 70 to 180. Okay. And I know that, you know, tell me why everybody here everybody hear me out here is Ada standard says 70% and time between 70 and 180. With a SD or a standard deviation of less than 1/3 of the average BG, that is your target. And here’s why I use that in clarity to make people understand 72% Of all type ones do not meet that very, very loose standard. And I need people to understand that whenever it’s said to somebody to 180, I can say, look, you’re 83% in range right now, between 70 and 180. Remember, 73% of all type ones, don’t even get that. However, you’re doing so much better. Yeah. And if you set it to 140, that’s great. If you can get it’s like it’s 80% in range between 70 and 140. That’s more work than I care to do.

So I just changed it. And I did it for the last 90 days. And in Target Range 83%. So, you know, so

right now like Thaman, let’s do the 90 days, average glucose of 127. Very low point, one, low 1.3%. In target 91.3, highest 7.4 and very high at 0.6.

That’s interesting, our, our high and our very high are very similar. And our targets very similar. That’s interesting, because

we don’t put up with it. And we look at things before they happen and we take care of them before they happen. It’s trusting what you know is going to happen is going to happen. And making sure you do something about it. You know, don’t just I mean, control IQ. Like I said no algorithm is perfect. Yeah, if you just think that you’re going to turn on control IQ or Omni pod five for that matter, or loop for that matter or any other algorithm and just be able to set it and forget it you’re sorely mistaken is not going to work out what control IQ does for me is it provides sleep every night and a reduction in the time that I have to study things and the amount of changes I have to make by a better fold of 90% I still have to do a little bit of lifting care. But that’s like I said before that comes with, with time and experience and understanding how insulin works in your or your child’s body. And taking things in a very consistent manner. Once you understand how that point, you know, one change in Basil is going to hit and you’re accurately able to change basil, or you correct a low blood sugar in a very consistent manner, things become so much easier because you understand what the impact of the insulin or the carbs are going to have. And your outcomes are going to be more precise and better done. Now, this, I know, it sounds like I’m being like, so strict, and everything else I’m not. It’s just understanding it. And like, once I understood it, and I got everything dialed in, I do even less work. Because I’ve done figured it out for my son. And I’ve done figured it out for these other people that they can just go on cruise control. And we know that that whenever a change in basil needs to happen or a carb ratio change needs to happen. It’s not a big deal. Make the small change to make the impact. And let it go. If it happens, again, make that small change again and let it go. It’s not a big deal.

Right. I think I think what you’re saying has far reaching implications to not I mean, is the specific situation you are really motivated guy who’s incredibly smart and tuned into this. Obviously, listen to a great podcast that got you going and you’ve just run with absolutely, yeah. I’m joking. But I’m not joking. I think the podcast is terrific. But you know what I’m saying? So, but what I’m going that is that everyone doesn’t need to do it at the level that Jeremy’s talking about to get the benefit of the of the big picture of what he’s talking about. Because I feel like you’re I almost feel like I’m hearing my voice come back through you on a lot of a lot of points about you know, stay involved. You know, pay attention. Don’t settle for high blood sugars don’t over treat low blood sugars like this. Some of those things are just universally true. Yeah, for people.

But when those things happen, whenever you do give too much insulin or you’re too bold. Don’t let that be afraid. Just that is something that happens. And as long as you say, okay, that happened. Let’s move past it and keep going and don’t get scared with it. If you over treat a low and he goes in your child goes high. That’s okay. That’s one high in the time of their life is a marathon not a race. Don’t beat yourself up. I see all these parents beating themselves up that. Oh, well, we overcorrected. And now they’re high for the next three hours, and I corrected three hours ago. And it’s like, Stop, just stop beating yourself up, take care of it, drop it, learn from the situation and move on. Right, your mental health as a caretaker, is just as important as your child’s health. Yeah. Do not allow your child’s diabetes to take control of your mental status. I mean, I ended up having to go on to Paxil, just to deal with the anxiety. I ended up in the hospital with heart attack like symptoms and ended up being stressed and anxiety. Learn what you can, so you understand what’s going on. keep things consistent. So you have consistent outcomes, make small, impactful decisions and drop things that don’t work. If it happens one day, it’s random. If it happens more than once, change something, don’t wait. And then because you get just the third day, it happens, you get frustrated. The fourth day, you start feeling down that you can’t take care of your child make the change. And if it’s something small, just just try one small thing, and then go okay, that kind of worked. Let’s do it a little bit more, and work your way up to being able to do things by yourself, but don’t allow this disease to overcome yet.

Let me let me get some clarity on something you just said. So are you saying that prior to you understanding all of this, the stress was a lot is the stress still there now? No, no,

we live life man. Yeah. So they know everybody. There’s some people that say, Oh, your son may not must not be doing anything they do. This kid is more active than most. He’s not in any sports. He is. He’s a nerd like me. He’s in all honors classes. He has straight A’s. He’s in the National Honor Society. The kid I can’t even help him. him with his math homework anymore. The kids smart is the web, but he’s still active. He goes for bike rides, he goes, jumps on the trampoline, he wins. He runs around with his brother and sister. He does all types of very active things. He goes to the jump Park. And we do this spontaneously. We don’t do it in fear go, oh, well, we’re gonna go swimming tomorrow. Oh, God, can’t wonder wonder what’s going to happen with his blood sugar? No, take extra carbs go in there. Give him some extra cardio before he jumps in the pool. Let them have fun. Let’s go. Let’s live life. I know it’s terrifying. But the thing is that you got to try. And if it doesn’t work the first time try again. I think a lot of eventually something’s gonna work. Right.

And I think a lot of the mental comfort that comes eventually is from seeing things happen that you expect. And yeah, yeah, and paying attention to the beginning to these things. Your Basal if you’re on it, you know, if you’re on an algorithm, even more so for insulin sensitivity, but still on just a regular pump, insulin sensitivity, carb ratios, correction factors, you get those things close even, and things get better. And then once they’re close, then you can kind of see them a little better, that it’s not so wildly out of tune that you have to guess. I know that all sounds like Yeah, sure. That sounds easy. How do I do that? I mean, you know, I mean, I’ve talked about it a million times in the podcast, I think the way you do it is by getting your basil right? First, then start worrying about your meals, your ratios, and then start thinking more about different impacts and different foods correction factors from there, etc. Like, you do have to it takes time to get it straight, you’re not going to just your doctor is not going to magically set your settings in the right spot. And even if they do, even if they get like a slot machine lucky, you know, the kid’s gonna still grow or you’re even as an adult or going to gain 10 pounds or lose 10 pounds or start walking more sitting more. And then suddenly those settings aren’t right anymore. It takes it takes paying attention. I think one of the most important things you said here’s, you know, you got to take a little responsibility and, and put a little effort into it, you know, and not the kind of effort where you’re just like I’m trying, I’m trying but like focused effort, that that may lead to

a lot of educating yourself properly. Then understanding what is actually going on inside of your child’s body. And understanding what your body, their body, how their body is different than yours. And understand how food digests differently in your body compared to theirs. Do you have a chance to wear a Dexcom? Do it. Scott’s done it. I’ve done it. Lots of parents have done it. Once you understand what it’s supposed to look like. It becomes so much easier to do it yourself.

And it’s a little more relaxing to Yes, we see 140 blood sugar for two hours doesn’t feel like you’ve you know, made some pain and full failure. You just realize that that happens to a lot of people. You know, everyday people would fully functioning pancreas is that are working perfectly. Still see elevated blood sugar sometimes. I mean, I had to eat pretty hard to get my blood sugar to 160. But I still was able to do it with a nerf pizza. You know,

I eat like crap. And that was not an issue with me.

That’s interesting. Yeah, I had to eat so much just to hit 161 time. Other than that, I was eating cereal like, like, I don’t know if you remember at one point, I took two different kinds of sugared cereal, mix them together in the same bowl and eat them. Yeah, my blood sugar did

I think it was what sugar smacks in Fruity Pebbles,

hops or something like that. And my blood sugar never even went up. I was almost disappointed by it. I was almost like, oh, you know? But anyway. Geez, Jeremy, this is great. Like, how long do you think it took you to figure all this out put into practice.

Um, slowly over the course of about two years, I was about 80% there over three years. I was like, completely relaxed and like it is what it is. Let’s fix it move on. And was able to just look at things a lot smoother. Now there are those families out there though, that have those Alpha moms that I love to death, because whenever they get a hold of me, and I’m like, what do you do for a living and they’re like, I’m an accountant. I’m a numbers person. Those people and literally it takes me two weeks to figure them out. Explain what’s going on. And they move right on their way and they still have you know, under seven agencies to this day. I was that person. I am a type of person that while I was the kid that took the VCR apart and put it back together and it still worked missing three parts I need to understand what’s going on. And I’m just one of those people. And I really dove into it. Especially the biology part of, you know, what happens in what what why is his body so much different than mine? And why is it doing this? And understanding what? The tug of war as you describe it? What can I do on each end of the rope to pull harder, pull less or get it right, you know, that’s making small, concise adjustments?

Well, I’ll tell you why we were talking IHS did origins basil. So I look, I looked at that clarity report. And I thought this, like this a one see that I’ve been okay with, which is her right around a six because she’s making more decisions and, and choosing Bolus isn’t things like that on her own. Without too much input right now, I thought, Oh, this is a reflection of that she’s, I don’t know that she’s, you know, just kind of finding her stride with it. But then when I looked at that report, I thought, That’s not fair. Because I have a lot of stability, away from food, that’s still a little higher than I want it to be. So I just changed her basil from 1.1 to 1.2, just to see what would happen. And I’m gonna, I’m gonna watch it over the next day or so and see if I, if I can find some consistency. I mean, we have incredible consistency. But to find it a little lower, would be interesting. And then I think that’ll probably help with the food too. That’s happening. The food impacts that are happening, like I said, between probably around 132 o’clock, and six, seven o’clock in the afternoon. So I appreciate you making me think about it. So I get busy sometimes to get an amen.

Yeah, and I mean, there are and that’s that’s just the basis of it. There are other things that I do that are more on the ninja level than then just the standard stuff. I don’t expect people do that like stuff like understanding like, my son eats the same food at the same time every morning during the weird weekday. So what I literally do is I will just like, you know, you would I purposely make his basil, a little stronger, about an hour and a half before he eats on a weekday. That’s my Pre-Bolus. That is not normal. I don’t teach people that. But the thing is, is like I know that at school, his lunches at the same time, every single day, right? And you can’t get this kid off of peanut butter and jelly sandwiches with a bag of chips, a Diet Coke, and some strawberries. You just can’t get that kid off of that meal. I offer him all different types of things grandma puts in different types of things. It all comes back to peanut butter and jelly sandwich. This is what I want. Maybe he’ll have some pistachios one day.

So you’re upping basil as a Pre-Bolus. Knowing that these meals, these exact meals are going to happen over and over again at the same exact Yes. Okay.

Because it’s it’s it’s literally, you know, knowing or expecting, you know, the day I’m saying I’m getting frustrated. Expect what you know is going to happen is going to happen. Oh, okay.

Yeah, I probably should have come up with a saying that was easier to say there. But well, yeah.

And then, like the only variable I have is after lunch and seeing immediately going to go outside and start chasing girls around, or is he gonna stand and do nothing? Yeah, because Jesus, like, you like the end? I’m like, Dude, why are you dumping? And he’s like, Oh, I ran around and chase girls at lunch. I’m like, Dude, if you’re gonna do that, cut some carbs out of lunch. If it’s 80 carbs covered 50 carbs. I don’t think you can chase the girls all day long.

Jeremy. I don’t think he knows till he sees them.

Yeah, exactly. I know.

That’s amazing. I appreciate you doing this very much. Is there anything else that we should be adding to this thing? Because I’m gonna ask you a question. At the end. I just want to make sure you’ve got out what you want to say.

No, I don’t I mean that that’s a pretty good understanding of control IQ and how I do and how I teach people to do it. And how we how we adjust things to live a more, I guess, productive life while having great blood sugars, and not having to worry all day about diabetes anymore.

Okay. So okay, so if I were to come to you, and I’d said Hey, Jeremy, I use control like you by the way you do. Just out of the goodness of your heart you help people.

Yeah. And once again, not an invitation to start messaging me Do not I got four families on my plate right now.

It’s about enough. Jeremy’s got a job, you know. So, alright, so Well, that’s very kind of you to help people. So if I come to you right now, and I’m like, Hey, Jeremy, listen, I’m on control IQ. But I’m seeing, you know, spikes at mealtimes that aren’t correcting for hours at a time. And I’m getting some lows overnight. What do you look at first, you just pull all

I need from them is the seven day AGP report and they’re pumped settings. No kidding. And then I maybe ask 20 questions about how what do you normally eat? When do you normally eat? What insulin do you use? Is bedtime consistent on a nightly basis? What kind of activity does your child choose to have? Or that type of thing? Or do they are they on their period yet? If so, is it regular? Just the normal questions that, you know, either your CDE or your Endo? Or

should probably should be asking.

And if they ask those questions for a very specific reason, because it paints a picture, at least in my head of when I look at that AGP report. What am I actually seen? Am I seeing basil that’s way off from a kid that has no activity and eats five or six times a day nonregulated in time and whatnot? Do I have a very protein based diet to have a low carb diet? Personally Thaman he eats whatever the hell he wants whenever he wants. Most I’ve ever Bolus for in a single meal was 543.

Wow, 543 carbs.

Yes, you go and look at these dams, and milkshakes at this. This burger shop that’s up here. And they’re just gigantic. And they’re like $17. And they have waffles sticking out of them and everything else and you look at it, you start thinking and you you’re like, yep. And then we came to 547 after staring at it for about 15 minutes. And that’s what we did. And how

much insulin was that for him? No. Sorry, about what

it was. His carb ratio was six or 6.5 at the time. Um, let’s see here. I can divide by 690 some odd units.

Wow. Did a 90 unit Bolus? Yeah. And he wasn’t low. Nope.

You know, did I have to hit it again about an hour and a half later when I knew the fat was going to kick in? Because I trusted that I knew what was going to happen is going to happen. Yes, I did. Do you think control IQ is going to be able to do that? Or Omnipod? Five or loop or anything? No, it can’t you have to be proactive. Do it. override the pump. All pumps can be overrated, whether it has an algorithm or not.

Yeah. Jeremy, I gotta tell you, if I had if I had a diploma for this podcast, you’d be the first one to get it. That’s amazing. I would not have the nerve to give that much. I don’t think and I’m pretty ballsy about it. Wow. That’s, I’m assuming most of his bosses are not nearly that large. But yeah, but that’s a great

example of he sees like 100 car Bolus maybe once every other week. Dinner averages are about 80 to 90 carbs. Lunch is at 90 carbs. Breakfast is 65 Every single day.

Hey Arlindo had Arden just had a lunch. That was a salad. And then she asked for a bowl of vegetables. She had rice basmati rice, corn, steamed corn and steamed carrots. And it’s a pretty big bowl of you know, of vegetables. And I think we bolused I know it was and then we picked 45 for the vegetables which was the carriage the rice and the corn. And then I think the salad was even 20 So she got like 65 carbs for salad and vegetables this afternoon. And her blood sugar still sticking at like 120 so we missed a little bit on

that. That’s fine though that that’s low glycemic food. Do you understand that? But I mean, you didn’t to me you didn’t miss? No, it’s like it might ramble too. I like the 140 is okay. But I’m sure once you saw that you’re like, sticking a little bit. You either let Luke get a little aggressive on the on everything or you told her to take a half a unit.

Yeah, I told her to add, I told her to have three carbs to our last Bolus, which is something you do in loops that you can’t do in, in some of the proprietary algorithms, which I think is if

you can do it in control IQ, you can add carbs to an old but I prefer not to do it, I prefer a straight overwrite, okay, because once again, I know what half of a unit is. Now, if I put three carbs in. If it’s been more than one hour, since the last correction, it’s also going to correct his blood sugar, it’s going to add extra, or it’s going to take away extra depending on delta. So I would rather say okay, I’m looking at his line. It’s fairly straight. I know I OB says he has two units on board, but it’s not real. So I’m going to hit him with point five. Because I know what point five does, right? If I was to put three extra carbs in, it may give him point two, it may give him point seven, it may give him point six depending on which way the arrow is going, which how his blood sugar is going. If he’s had a correction in the last hour, not if there’s been an auto Bolus in the last hour. Not. There’s so much very variability there. I’m not going to deal with that. I know what a half a unit will do. Hit him with a half a unit let him go. I love it. Do we override the pump all day long? Every day? No, no, I don’t either. It is so dialed in that you don’t have to. But when you do, we do.

Yeah. Hey, Jeremy, I have to tell you, I I know that after you talk to somebody the first time you probably Converse back and forth with them and text and things like that and takes some days and weeks probably to adjust it right down. I found myself wishing we could record every interaction you had with somebody just to see how it happens. I know we can’t but yeah, it. That’s the piece that’s missing is that somebody like you remind people you work in a motorcycle shop. Is that right?

Yes. I’m the marketing manager of a Harley Davidson dealership. That’s I actually well, I’m actually from two dealerships here. In town, we own a sister store. I ride Harley’s I own Harley’s, I have a beard. I’m you’re a typical biker, with the weird ass hair cut. And I swear a lot, I drink Mountain Dew a lot. And I talk about how fat I am all the time,

and turns yourself into a pretty damn good endocrinologist. So

yeah, I’m not gonna go into our Endo, not gonna say that you’re not going to work me into that. But I mean, the other awesome thing is like, I may be all those things, I may be a pancreas to my son and a few other kids and whatnot. But to me, giving back to the community is what really matters. And like, I am also a voting board member and a marketing director for the Montana youth diabetes Association, which is after the ADA camp, left Montana and left all the type ones high and dry. All the volunteers that had been going to that camp for since they were kids said, let’s get a camp going and get these kids back to camp in Montana. Very nice. And so we I’m giving back that way I have to, because the community has given so much to me and my son’s health, you know, mostly, you know, the podcast and you and everybody in the group that I have to give back some way that I can.

Yeah, no, I understand feeling like that. I think you’re doing amazing stuff to on top of everything else. And I appreciate you coming on here and sharing this with people because there’s just no, nobody really tells you what to do. They just give you the thing and then it works out as well as it does and then they call that good and and that’s where it stays forever. So

just understanding how the algorithm works and and how it doesn’t work and when to step in and when not to step in and it’s time and experience and not just sitting on things and doing things and trying things and failing and succeeding and you do something enough eventually it’s going to work out. Yeah.

I agree. All right, Jeremy, I can’t thank you enough for doing this man. I really do wish you would have named Good fellows, because when you say his name, that’s what I hear anyway. But that’s not that’s not your problem. It’s mine. I’m glad he’s doing so well and that you’re doing so well. It really is. It’s a testament to what I mean what you can accomplish if you get good information and you want to put some effort into it. It really is. Astonishing. You know, I hope you’re proud of yourself. Seriously. I try Yeah, no, really, man. It’s a it’s really something that you’ve accomplished. So that boy might never know but I know and the people listening now so like I said, I would I would send my first my first ever degree off from the podcast will go to you if I ever make one. Sounds good. Don’t look for me to do that. That sounds like a lot of work. But I really I really can’t thank you enough for taking the time to do this. Thank you very much.

Not a problem Scott.

Well, first we want to thank Jeremy for coming back on the show and sharing what he’s learned about control IQ. And then we want to thank you s med. And remind you to go to us med.com forward slash juice box or call 888-721-1514 To get your free benefits check. Thanks also goes out to the Contour Next One blood glucose meter. You can find out more and get started right now. You can actually buy one right there at this I know you can buy one at my like contour next one.com forward slash juice box alright everybody, thank you so much for listening. What else should I tell you? Oh, there are many other episodes about algorithm based pumping. I have a list of them. In fact, let me tell you what they are. Now what the hell we’re all here together right? What are you in a big hurry to get back to your job? Let’s just listen for another second. Okay, here they are. The first episode I ever done I ever done boy. The first episode the episode. This is going well. The first the first start over. The first episode I ever did about an algorithm was looping it was episode 227 called diabetes concierge. Did one then called a loopy few months episode 252 Then episode three or four loop de loop. Episode Three Tov Fox in the loop house part one episode 313 Fox in the loop house part two, Episode 326. We talked about the mini med 670 G and an episode 420. Fox in the loop house part three. Those are with Kenny Fox, you’ll love those. In episode 537. Haley came on she’s a tandem pump trainer. In Episode 601, we told the story of how I started looping. In an episode called Gina made me loop. Episode 620 was an exclusive interview with on the pod CEO called exclusive on the pod five interview. And of course today, in Episode 662. Jeremy breaks down how he uses control IQ. We’re going to be talking a lot more about these algorithms in the future. So if you’re enjoying these, go check out the old ones. And if you just got done with this and thought I’m not get that algorithm to check out the Pro Tip series, and they will definitely help you pump without the algorithm. As a matter of fact, they’ll help you pump with the algorithm too. But I’m just trying to find a way to mention some more stuff in the podcast. I think you see what’s going on. Alright, thanks again for listening. Your support means everything wonderful ratings and reviews pouring in for the podcast. Downloads and streams are at an all time high. And all of that means that you are sharing the podcast with someone else and for that I cannot thank you enough. It is the most important piece about how the podcast grows.

Hello friends and welcome to episode 924 of the Juicebox Podcast. Today, David’s on the show he’s using Android APS with some refinements. I’m gonna let him tell you all about them. David has a very popular diabetes blog called bionic walkie you can check it out at bionic wookie.com. While you’re listening today, please remember that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making any changes to your health care plan, or becoming bold with insulin. If you’d like to get 35% off at cosy earth.com, you can do that with the offer code juice box at checkout. If you’d like to get a free year’s supply of vitamin D, five free travel packs, with your first order of ag one from athletic greens, you do that at athletic greens.com forward slash juicebox. And if you’d like to save 10% off your first month of therapy, you do that@betterhelp.com forward slash juicebox. David’s terrific, you’re gonna love him. He’s from Australia. Fantastic guy. Wait, do you hear what he’s doing with this Do It Yourself algorithm. It’s really astonishing. This episode of The Juicebox Podcast is sponsored by touched by type one, a fantastic organization helping people with type one diabetes, check them out on their Facebook page, their Instagram page and at touched by type one.org. I’m going to be speaking at their next big event. I hope to see you there.

I’m David Byrne. I live in Melbourne, Australia. I’ve had type one diabetes for 40 years now. Wow. I mean, but in my mid 50s. Now I’ll be in my mid 50s later this month. That’s what my wife tells me

sounds like you’re 54 Yes.

Let’s see. Quite a few Australians know me because I run a website called The Bionic monkey. There’s a Star Wars reference in there. Which is all about diabetes technology. I’ve been living with closed loop systems, self built closed loop systems for about what more than five years now? And I I I’ve ended up coordinating a lot of the Australian community of do it yourselfers. That’s cool.

Okay, so you were diagnosed? Geez, when you were like 14? Yes. Okay. 40 years ago was AD AD AD to Jesus. Wow. That’s a long time ago. Okay. It’s crazy. You. You said you’ve been doing closed loop. So you’ve been doing? What have you tried a bunch of different versions? Or which one did you start with? I guess.

Okay. So I started using a pump in 2010. Just to illustrate a little bit about my life, I’ve done various things during it at my endo had suggested to me a few times that are these insulin pumps, that might be something that you’d be interested in. You’re a really technical guy. But I had been very much in the World of Goo. I know how injections work. There’s going to be this strange thing of something attached to me. What happens if I fall off a boat or I get wet or something because in those days, pumps weren’t waterproof. And then in late, late 2009, I attended a local event where I actually got to see and play with some of the NMS pumps, which were Hey, they were waterproof. And I decided right, this is something I wanted to do. I think that event was in September. Then I organized with my D, my data so they’re getting a pump, but then I had to put it off until February. Because over December that year, I was an artist in residence on a ship traveling up and down the Norwegian coast photographing the Northern Lights. Because as well as working in it, I’ve also spent quite a few years as a professional natural wildlife photographer. Oh, wow. So I’ve done a few different things but so I started pumping and That went on for probably six years. Before I started using libre, that was the first CGM I got access to. That was 2016. And by early 2017, I’d seen the loop system and I’d seen the open APS system and I decided that open APS was the way I want it to go. So I started, I was carrying a little Android phone. And that was being my CGM and feeding the stuff into my little pocket computer that was running the open APS stuff. I was using an old Medtronic pump. And then in 2018, I got a combo pump, which were being sold in Australia at the time, and that’s a pump that has Bluetooth in it. And Android APS could talk directly to it. That’s the accucheck. Yes, the accucheck combo, which has last year it was discontinued. That had

that had Bluetooth in it and 2018.

That had Bluetooth in it in 2011. When it came out, wow. I have no carry. That’s cool. That’s a very old and primitive pump. And the interface that talks to it is quite slow. Because basically it’s pretending to be a person navigating through the menus. It’s not actually sending it direct commands.

Oh, no kidding. Do you? Do you see it happen on screen as it’s not? The screen

is blank at that point. And it goes faster, faster than I would but it’s still slower than if you’re actually sending commands directly to its interest, but it works. Yeah. And that works quite well. So I’ve been using Android by system since 2018.

Okay, so you use open APS still today.

I don’t use open APs. But Android APS uses the same algorithm. Excuse me,

I misspoke. But okay, Android APs.

And I’m not actually using Android APs. At the moment, I’m using something that’s very similar to it, which is a version of the software that we’ve frozen, we use in some clinical trials. Because I’ve been involved in running a clinical trial over the last few years of Android APs. So this is on people in the real world. But it’s a randomized control trial. So it was all at the level that the medicals would actually pay attention to the results rather than people saying, oh, it works for me. I haven’t killed myself. Yeah. Right. And so that’s through a local hospital. And basically it feels like some of the staff there look at my clinical results of me living my own life doing stuff and they say, oh, that’s, that’s amazing results. But we need a clinical trial. So I can actually prove this, this works. And in other words, that I’m not just a freak.

Right? Well, that it doesn’t just work for you and no one else but it is interesting how you are holding up your you are holding up your self as an example. It’s like, Hey, look at this. This is what’s working for me that like yeah, that’s nice. We need to prove it. Yeah. Like I feel like

so the that trials over and I on that one, I was the local technical expert on this hurdle plugs together and oh, when using a different insulin pump for this, so I was the guy who wrote the bluetooth driver to talk to the pump. So I’m fully involved in the technical level as well. Okay.

So let me just for people listening, I want to just make sure that they understand. So loop for example, Arden uses a version of loop. Actually, I think Arden’s using open APS right now. With the auto Bolus version,

the free APS free, six,

free free APS, thank you. Well, I don’t this is the part that this is why you don’t come to me, David on any of this stuff. Arden’s using aren’t using free APS, which is a version of loop that does auto bolusing. We are waiting to see the version that works with Dash pods, which I think they have been getting, I think they’re getting it close to buttoning it up

the loop world is it seems to be a bit fragmented. So there’s various branches and versions that people are experimenting with, which is fair enough. That happens in all systems, but there’s loop and then some guys made a branched version that they called Three APS, which was looped with some extra auto Bolus things. And then they made a different version, which is called free APS x with letter X on the end, and some people refer to it as short in shorthand is fx. And that is the open APS algorithm that It’s also used by Android APs and open APs. But running on the iPhone. It’s basically using all the communication stuff that was set up by Luke to talk to the pumps and the CGM. But they’ve put a different algorithm in the middle. But there’s at least three different systems on on iPhones and to a certain extent, they all look and feel very similar. Yeah. Is there? So it’s a bit hard to know what people are using when they say, Oh, I’m using free abs? Which one?

Trust me, I don’t know that. I know. I think sometimes I just, I, you know, I have people around me that say, Hey, this is the one you should be using right now. Like, okay, fair enough. Do you think there’s a lot of outcome difference between loop Android APS, open all that stuff? Do you think people have basically similar experiences,

I do think there’s a difference. The openaps algorithm, which is called a ref one, just in case, I mentioned that, again, that has a bunch of things. It has SMBs, super micro boluses. So it’s, that’s where it calculates, oh, we need this much basil to do this amount of work, because we think we know where the glucose is going. So we need this much insulin. But the basil is going to take a while to get it in there. So the super micro Bolus will take a portion of that and deliver some of it as a small Bolus now, and then in five minutes, it might say, oh, we need some more. Or it might say, Oh, I better not put too much in because we’ve suddenly changed direction, just as well, I didn’t put it all in at once. So that has made it reasonably fast at reacting to thing. It’s carbohydrate model. Unlike the commercial loop systems, it’s a dynamic one where you tell it how many carbs just like loop, you tell it how many carbs and then it decays those away, it has an idea of how many carbs are on board. And that’s partly affected by what your glucose has been doing. So it basically only decays them away when it says oh, it looks like that that was one of the carb effects going on. Because that wasn’t the same as what we predicted was going to happen without the carbs. But then it has a mode called UAM, which is unannounced meals. Where it looks at what your glucose is doing and says that looks like food, I’m going to treat it like it was food. I have not counted carbs or declared food to my system for almost two years now.

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I have not counted carbs or declared food to my system for almost two years now. I do not carb count. I do not Bolus I just eat and live my life. I don’t know anyone who manages to do that on loop unless they’re low carb. I would probably eat 200 to 300 grams of carbs most days and sometimes I go way over that. So I would not describe So for the low carbon.

So the UAM on announced, what does it stand for?

On announced meals on announced meals.

So, and this is the on the Android aps that you’re using, that hasn’t Yes. Okay. And it sees, so you just eat, and it sees the rise, assumes it’s a meal and hits it.

Essentially, it’s doing it in that cautious way of we’re not going to Bolus everything we, we don’t think this is a 100 gram meals. So we’re gonna give it however many units of insulin right now, it doesn’t piecemeal. But because it can come along every five minutes and dose another little bit more. It reacts fairly well. Now, I knew that the system had this out that the algorithm had this functionality in it back in 2017, when I started and this was one of the things that probably affected my decision as to which system was going to go for it know anyone who went completely Bolus LIS at that point. But it’s always doing that in the background and saying, Oh, you missed a snack, I’m going to follow something for it. And back in those days, I was using jemalloc. That was the fastest instrument we had access to here. When I got access to figures, I thought, Oh, this is great, I’m finally going to be able to try and go hands free. And we were going out for Mexican that night. And that was a disaster. So

it didn’t work out though, you

know, it took a fair bit of fine tuning. First of all, I had to get the dosing adjustments changed for fasp. Because the system was reacting slightly differently. But then I know a lot of people who see what I’m doing, and they come along and say, quite understand, but I want that right. What do I do to plug these things and turn it on? Because I want that? I want that now. And my general feeling is, well it takes a while because you need to know that you’ve got your underlying settings, right? Because what I started with was, yes, I was counting everything, declaring everything I was counting in declare eating protein as well as protein I can declare as as though they were a smaller amount of carbs in the future. On sort of metrics, what the body does, right, I was I was counting and bolting for food. And then I was getting great timing range, everything was going where I wanted. And then I’d start skipping announcing on some snacks, and how it worked. I stayed in range. And then you do it on a biggest accurate meal. And it all goes out the window and haven’t quite got it right. Go back and fine tune. And I went through a phase where I counted and declared the carbs, but I didn’t Bolus. Actually step before that. I counted and cleared all the carbs, but I Bolus less than the full amount with the expectation this system was going to take care of the rest. Essentially, in my mind, when you’re Bolus for something with these systems, the Bolus is really just giving it a heads up. The algorithm should work out what’s going on. And if you’ve told it, what curves are in there, it’s going to do great. It has to guess it all by itself. It might not go quite as well. I actually found if I under counted the curves, the system. It’s almost as though the system says You told me it was this much. And it doesn’t react fast enough. If I over count the carbs a bit. It says oh, you’ve told me it’s this much. But I haven’t seen all of those yet. And eventually, they must have not been there. Because the algorithms always had this thing where it dynamically decays the carbs. So that if you didn’t eat the second course or you dropped your ice cream, it didn’t actually eat it, then it wouldn’t necessarily try and deal with all that food that you might not have actually eaten. It’s fairly flexible in that way. But it was a general process of taking away the bolusing but still declaring the caps clearing all the protein and yes, everything was coming in right? Oh no, I have to tune things. My insulin to carb ratio needs a bit of tweaking or my profile needs a bit of tweaking. And then I think it was November was I made some notes in my diary November was the last time I bought last and then in February was the last time that I declared carbs. Because I’ve gone through Christmas with not bolusing declaring all the food but not bolusing. And this was Christmas, New Year, there was lots of food on the table, and everything sort of went in range. And that gave me the confidence to stay right, let’s, let’s go completely hands free and see what works. And it did me ask you a little bit

about the food you’re eating? So, I mean, is this like a very balanced meal of natural foods and etc? Or is this Captain Crunch? At you know what I mean? Like, are we are you not taking in a lot of high fructose corn syrup? Are you avoiding things like that?

I do have celiac disease, but I’m avoiding things with gluten in them, which means that I tend I tend not to eat too much bread. Maybe my diet isn’t completely typical. I do. I do find I try to eat sensitively. But I don’t all the time, we try to have meat and veggies and a mixture of things. Breakfast is the meal that I probably pay most attention to. Because I always found that I was most sensitive to carbs after fasting. Yes. And that might be because the Gus is all primed and ready to accept these carbs and leap on. There might be one way of looking at them. I have some friends who have children with diabetes and they swear by we give the kids something to line their stomachs that like bacon and eggs or something. And then they can have cereal and it doesn’t spike them through the roof. So my breakfast, I have a standard breakfast and basically yogurt and some strawberries and some psyllium husks. So there’s fiber in there. It’s just a simple, basic breakfast that I don’t have to think about, I can just get up and go to the kitchen and have breakfast and get on with my day. I’m on autopilot. And at that point. It’s not a huge amount of carbs. And once my body’s reacted to that, and I chose that breakfast, when I was still in still counting and bolusing because it was just easy to organize, I didn’t have to think about what’s my carb count this morning, I could just say, I think it’s about 17 grams. Breakfast, it’s not a not a high carb breakfast. But after that, whatever food I feel like eating, whether it’s at an 80 gram block of chocolate, or an apple or sometimes I’ll have a like I said I tend not to eat bread. So sometimes I have things in reps, but the sweet potato wraps because there’s no gluten most of my I tried to go low carb in 2017 I thought this this will help me control my my glycemia which was bouncing around all over the place. But in fact, it didn’t especially help i Then I was actually thinking at the time, I need to lose weight because I was classified as obese at that point. And I didn’t really lose weight. But later on I worked out now it’s about actually about the calories when you’re trying to lose the weight. Just just ate a reasonable number of carbs. But I’ve never really excellent when I say never years ago when I started out it was you inject this much and then you eat this much. We ate to the insulin whereas now it’s if I ate more, I’m going to inject more or more of the point if I ate more my pump will have delivered more insulin by the end of the day.

When you say staying in range, what do you mean by that? What are your goals?

Okay, so I use I’m hesitating a little bit because my brain tends to run in millimoles and I know you’re used to milligrams. So in milligrams the range I aim for myself like the green band on my setup is 70 to 140 Okay. And my target is around 90 That’s where the system’s aiming most of the time.

How often do you get under 60 allow that you need to do something about

let’s say my neighbor brain is saying what 60

I can get up my my chart. I can talk to you like this

three point 3.3 RDL Sorry, I shouldn’t wear the what I should do is one of my friends calls me sir graphology let me pull up a spreadsheet my time in range 470 to 140 is generally averages around 85%. And if I just find this stuff in here, we get my time below range, or all sorts of pretty graphs, here we go um below range for 3.3. That would be around half a percent of the day, on average.

So you don’t, generally speaking, find yourself rescuing your blood sugar with fast acting glucose very often,

every now and then I’ve had some weird things just in the last couple of days where I will, I’ll be low in the middle of the night. And this is hanging out. This is not the way the world works. But it’s a timing thing. With the way I’ve changed a few settings recently, and to do with the high insulin on board that I’ve had the previous night. I’m tuning that. So I’ve generally got rescue curves around. And I always have rescue cows with me if I’m off on a big bike ride. Exercise makes things tricky. But I generally don’t go through them very often,

when you talked about earlier that you had to change your settings to work in this. In this system that you use where you’re you’re basically you’re telling the I guess you’re telling the algorithm look I’m eating, but don’t give me all this insulin or don’t give me any of it, and then it’s on you to use it as you see fit. Are you still doing a? What’s my question here? Did you change your settings to make them so heavy that they wouldn’t work manually? If you went back to just you know what I’m saying?

No, my, the Basal that’s programmed in is my default Basal. If my loop turns off, I know that it will keep me fairly flat, okay with as long as I’m not changing things with food, and so on. So know that all those numbers are traditional numbers. But I’m really confident in them and some of the other things that I tweaked, were tuning the insulin modeling. So for example, the duration of the insulin in the system and the way it decays. So that hours after a big meal, the estimate of insulin onboard is actually correct. And I found that made a big difference to how the system was automatically reacting I can make its predictions actually met reality.

Was that easier when you move to the ASP

I actually found that is I found it easier to chain and notice the differences when I went to Furter insurance. So I’ve used an ace Nova rapid and a Piedra and human log and fierce and Liam Jeff, we can’t get the longevity in Australia. It’s not even it’s not approved as a medicine here, but we’re allowed to import it for personal use. So I got some from a friend in Europe and have done some experiments and it’s quite nice. The faster insulins the decay in insulin happens faster. So it makes a lot of these things more visible.

Right. So it’s interesting. So that so the algorithm, it’s more precise. So yes, yes decision,

I found it easier to make that tuning but at the same time, having tuned the system, I felt like the faster insulin. Let me move into this mode where the system could take care of most things for me. But I have since experimented and gone back to the slower insurance like human logon Nova rapid and life stays the same. Interesting. It’s all it’s all automatic. It does. I do go high after a meal and it takes longer to come down. And looking back in the old days, I probably would have said oh, I’m too high. I need the Bolus I need to correct and get things down whereas now I have confidence in what the system is doing and then that in a couple of hours, it’ll help me down at the right point. I’ll be flat in the morning. It’ll be fine. Oh, yeah, the fat pasta rangelands. Give me more freedom. But I know the the slower insulins work. There is a complication in trying to compare them though because I compared my timing range for a couple of weeks on one versus a couple of weeks on the other. And they were about the same. I was thinking, hang on, this can’t be right that pasture insurance supposed to be better. And then I realized I wasn’t eating the same because I had the faster insulin, it’s Oh, I just ate that and built it, it’ll take care of it. So I will be keeping everything else the same. That’s

interesting. I tried my hardest to switch Arden over to one and she just had the fiasco she described sometimes as burning. But But the biggest problem is that when our pump site came off, it felt bruised. For for a while after that, the loon jab was significantly worse than the ps4, which is a shame because I also talked to a lot of people who don’t have any trouble with it. But

I was aware of these going in because a bunch of people in Europe have been using it for a while and have discovered things about them. So oops, my backgrounds just gone. That’s fine. The with CSVs is Nova rapid with the addition of was it’s nice in a mode as the main accelerant. And yes, a lot of people report stinging, some people will report occlusions sometimes they say the occlusions in the pump. Some of them reports that their site gets red and inflamed, and they have to change the cannula more often. Some people’s report that after some random time, whether it’s three months, six months, or whatever, it’s like it turns into water and it doesn’t work anymore an advocate back to something else. I was aware of all these things before I started. So what I did was I I mixed BS with non accelerated insulin. So if you think about Nova rapid, and VS by the same thing, but BS has some of this accelerant in it, if you mix them together, it’s still the same insulin, but there’s less tolerance spread around. So no doctor is going to say you can do this, but it’s all completely off label. But I used that sort of setup for about three months, and I didn’t have any steam. And then eventually, I changed to 100%. And I didn’t have any stinging and I haven’t had an instinct when it came to being objective. Similarly, Liam, Jeff is the same insulin as human dog. But with the addition of a little vaso dilator trip trip is still I think if I remember that name, right? Anyway. It’s also used in some other therapies as a vaso dilator. And the general reports there seem to be it stings like hell, but you get used to it after six months, and your body adjusts and it goes away. So what I did with him, Jeff was I mixed it with Humalog. So I had a lower concentration. And I did that for a few months before I went 100%. And I haven’t had any singing. I did notice some stinging early on, but it didn’t last long. Sorry. One of the other things relating to that is, little Jeff is available in Youtube 100 as well as new 100. And a lot of people report that the YouTube 100 doesn’t sting as much. Interesting. And that makes sense because the accelerant in that is the same concentration for you 100 And you’re 200 by volume. So when you administer one unit of the you 200 You’re getting half the amount of accelerant than you would with the 100 So it’s the same sort of thing of less accelerant. Right.

Last thing Arden described the longevity is unbearable. Like she she lived with the fiasco for weeks and weeks and weeks before she finally just said this isn’t getting any better. But the the looms if she was like you have to take this off of me I don’t think she made it may be more than an hour or so. Which I found

I exception. I don’t I don’t know if my success with them has been because I took it very slowly. Introduce it slowly or just with a, I was never gonna have a problem anyway. Right? I don’t know.

So this process you use, do other people use it as well? Or is it just worked for you? Like, like, I mean, I mean you’re describing, basically not counting carbs and and not Pre-Bolus thing at all. And you’re doing it just with settings. I mean, you know that sounds a little crazy. So I’m trying to decide if your view given to other people or not.

I started doing this because other people were doing it with some of the faster insurance in Europe. And I’ve, I’ve been doing it for a while and I’ve been fairly vocal in our local community about the fact that I’m operating this way, because someone says, I have to carb count for this and the Bolus are a bit mean sometimes I say the Bolus, what’s the Bolus? That some people have told me since that they’ve basically they’ve been emboldened what I’m doing by what I’m doing. And they occasionally don’t Bolus for some foods, and everything works. And some people don’t Bolus anymore, but they do announce most of their foods or they announced the big meals. So there’s these compromised lines. Because one of the nice things about this is you don’t necessarily have to put everything in go completely hands free. You can do any of those stages along the way. And it’s been surprising for me how many people just pipe up every now and then and say I Yeah, it’s working for me too. And it’s not okay.

Well, we can I guess you can kind of post date a Bolus in loop. So if Arden’s taking in something that I think is like, has a lot of fat in it, or it’s been deep fried or something like that. Those sorts of foods, if she makes a Bolus, and Pre-Bolus is her meal, and then tells the loop, I don’t know an hour from now expect 20 more, you know, the impact of 20 more carbs, for example, I find that gives the loop the autonomy to push harder when it sees a rise than it would if you didn’t put these, you know this empirically in the future. That works really well.

Yeah, I, I used setups like that early on, to try and understand what was going on. And that works quite well. A couple of things to talk about there. So there is a strong sense of yes, this stuff works for me. But maybe it’s just that I’m afraid. I don’t mind being called the freak as long as it’s got us doing it with a smile on your face. I know quite a few other people. I’ve said it’s surprising. This is working for quite a few people. But there’s also quite a few people who say, Well, no, it doesn’t work for me. I’ve tried that and it doesn’t work. Now, I don’t know if their bodies are different. Maybe their bodies are the same and then just not holding the mouse the right way. But I think that’s less likely, then we are all different because that’s the nature of diabetes. We’re all different. I know quite a few people in Europe as saying the totally hands free stuff works. But you have to be using looms, you have to work. And you need all of these settings. And some of them use fairly aggressive setups where they enable some of the automation in Android APs. So for example, when you’re going high, it changes the rates and says we need a stronger profile to try and fight it to bring it down. And essentially they start implementing another level of loop algorithm on top of what the system is trying to do. And that sort of works for them. And I tried doing some of those things early on, but I found it often overreacted. And for me, I found it was better to get the base algorithm doing the right thing. Now, there’s a bunch of people who’ve made variants of Android APS, there’s a dynamic ISF. Boost Ami. There’s a tsunami, there’s a bunch of different variants where people have been changing the algorithm to make it more aggressive. So it said, Oh, it looks like we’re getting food. We’re going to change the rates and dose for for the next half hour or do whatever changes. And if you’ve been using a lot of insulin lightly, we’re going to assume that you’re more insulin sensitive and dynamically change things. People have been doing all sorts of experiments. And a lot of people are quite enthusiastic about other systems that they’re not mainstream yet they’re still experimental versions on the site. I’m probably the unusual thing about me is, I’m managing to do this with the base, the standard stuff that’s been around for a while and not using those advanced algorithms. Yeah. I didn’t mean, I didn’t mention the last clinical trial I was involved in, which is over which was using Android APs. And showing that, yes, it’s safe and effective, and we get good clinical results. We’re lining up to do the next one. And I mentioned before, the researchers tend to look at what I’m doing and say, we need to work out how to do that. You can guess what the next trials about.

They’re gonna try to figure out why you’re not you’re not having to Pre-Bolus your meals.

So we’re gonna have a whole bunch of people in two countries who will be doing that, in a randomized control trial. Wow,

how long does that take to do that? That study?

It’s gonna take about two years to run, I think.

How many people will be involved in it?

It’s less than 100. And they’re not all running at once. That’s why it gets spread out a little bit. But people will be involved in the trial for over six months. Ah,

wow, that’s pretty great. When they get that when these hospitals get this information, what do they do with it? Right, because it’s not like, it’s not like, Android. APS is a company, you don’t go back to them and say, here’s what we’re learning you there’s not a there’s not like a dedicated group of a half a million people sitting in a circle waiting for you to come back with it and tell them what to do. Like, what happens when you get the data? Is it just inform more research? Or you know what I mean? What’s it? What’s the goal of it, I guess?

Well, they call it a hospital. That’s the sort of hospital I’m working with is actually not a hospital. It’s a Medical Research Institute. Okay, that happened that happens to have patients and run endocrinology practice and do all that stuff. And most of the participants in trials, they do lots of trials, most of the participants in trials come from their client base. I see.

Okay, so they have things they’re trying to, to move forward as well.

Yeah. And certainly, the results of this stuff gets fed back to the community. Because this stuff is used in multiple, by multiple software systems, it’s used on some of the iPhone systems. So the three MPs X, for example, that same algorithm. And there’s a general feeling of everyone should be able to benefit from this because the algorithm that’s been used is not some secret sauce, not hoping that type zero have made up in the lab and or am I ever made up in a lab and not telling people exactly how it works, because that’s their secret sauce, this is all open source, everyone can see what it’s happening. So hopefully, new products will come out and be able to take advantage of this because this stuff is really making life easier and better for me and for lots of other people. And it needs to be able to do that for a lot more. Well, everyone deserves one of those systems.

Yeah, that’s the real goal isn’t it is and what I was thinking earlier, while you were talking is even though the even though the retail systems are all really relatively new, in the last couple of years, it’s still kind of astonishing that they can mass market, put it on people and get results like that. Because I mean, like what you’re talking about is I have a system, but now I significantly understand the implementation of how it works. I significantly understand my settings, like really specific stuff that you put a lot of time and effort attention to, while other people are just like, look at buying this thing. It’s on I wanted to go and they’re having reasonable like results for the most part. And that’s astonishing to me, like, I don’t know how you make something that that needs this level of detail. And yet, you know what I mean? Like you don’t ask the people what they eat, you don’t ask them if they’re hydrated. You don’t ask them if they exercise if they don’t exercise and people are, I don’t know, it’s amazing, you know.

I do still tell my system when I’m exercising, I tell it to change targets because I’m managing the insulin on board. And I think most of the commercial systems have that whether it’s ma PS has, you’re going to ease off or a boost. It’s basically gotten a braking and accelerator function and control IQ has exercise mode. And

what I meant is that you can’t you can’t know that when you hand something out to the masses. they’re not they’re not they’re not all doing it the way you are, you know what I mean?

And this is the big compromise that we’re all dealing with. And this is why the commercial systems like this, it’s one of the reasons why the commercial systems don’t have all the functionality that, for example, I have access to because they’ve had to go through the regulators, because the regulators say this needs to be safe or not kill people.

And for everybody, not just people who will take a ton of time to understand it. But you know,

that, unfortunately, some of those regular sheet decisions, I think sometimes because they don’t, it may be because they don’t always include people with diabetes in the decision making process, I think they sometimes end up with less safe things, such as the examples of the Medtronic system. So they had the first commercial, closed loop. And it’s basically, oh, we’ve been working too hard with I’ve been giving you so much extra insulin, and you’re not coming down. So I now need to stop and drop into manual mode and stop helping you because it’s obviously not working. That was some bean counter said, Well, the best thing to do. Whereas if I’m sick in bed with the flu, I want the damn thing to keep delivering insulin. And to help me get through this problem.

Yeah. Yeah, well, no, it’s 100%. I mean, all of them are, I’m assuming, at some point, drawing a line in the sand and saying this is this is, as far as we’ll, we’ll say, we can help. And you know, if something happens past that, it’s got to go back on the user.

Yeah, and I think some of those fall back on the user have been a little bit primitive, in terms of, well, that’s the way it used to work when you had a manual system, or we just say, or the user take care of it again. But the user at that point has gotten used to it doing a lot of work for them. So it’s suddenly a bigger drop out for them and it becomes less safe. So finding a compromise on all of this is a challenge for everyone

Arden’s a college now, and just last night, she had a meal a while she was, you know, she’s in a room working. And I think I’m watching it, like Get away from her. And I sent her a text, and I don’t think she saw the first one. And then she gets this rise that just goes 141 5160 on my garden, you know, but you didn’t put in a secondary Bolus if the meal was and now I’m in a bit of a loss. I don’t know what she ate, you know. So I’m like, if the meal was heavy in this, or this, you know, you forgot your secondary bowl. She’s like, well, it wasn’t. So I’m just going to make a correction here. And I’m like, okay, but I didn’t see it working. And now she’s fighting with it for a few, you know, a few hours in the late evening. And she just, she loses the fight with the Bolus, and she loses the fight with being tired. And she just goes to sleep. And, you know, I tried to wake her up, I, you know, it’s a higher blood sugar, not a lower one. So I’m like, alright, well, you know, I sent her a text like, Hey, you got a Bolus, again, I don’t hear from her, I finally called and woke her up. And I said, Hey, you know, put put some insulin in here. But at that point, David, I don’t know what to tell her. I don’t know what she ate, I can see what the the algorithms been trying its hardest over the last couple of hours. It’s not working, you know, it’s just keeping her level at a higher number. I know she needs more insulin. But I don’t know how much and I’m tired. And you and I got to we’re gonna do this. I’m gonna be up early in the morning my sunlight or doing something later tonight. Like, I’ve been sick recently. And like, I got asleep a little bit here. And so we put in enough insulin, we weren’t as aggressive with it as I would have been if we were wide awake and looking at the same example. But she woke up this morning at like 110. And, I mean, on any manual system, or if a system would have kicked into manual, she would have been, I mean, I’m assuming she would have been 200 Plus, and it would, and she would not have woken up with any kind of resolution to the blood sugar. This doesn’t happen to her all the time. But it’s your point about you know, I know this thing’s gonna do what it’s going to do. And I’m going to end up okay. It’s an amazing benefit, you know. So, anyway, what, what else did you want to talk about? What, what? What made you think I want to come on and talk about this on my podcast?

I think it was probably something I posted in the Facebook group that you responded to and thought he sounds like an interesting person to talk to.

I definitely do that. But I have to admit, David, 45 minutes into this. I don’t especially understand why you don’t have to Bolus. I don’t I don’t know that I Okay. Yeah. I don’t know that. I understand why it’s working for you or the, you know, like if somebody’s listening to this right now. And they’re like, Well, I don’t want to Bolus for For like, this sounds great. Like, what do I do?

Yeah. I don’t have easy answers. But I’ve got some things that might help understanding a little bit. Because I’ve talked to a lot of people who say, How can this how can this work? This person personnel at the CGM is always lagging behind. And then when when in when we inject the insulin, it’s going to take a while to happen. So when the system sees the arm going up, how can it react in time, it’s hard enough for me to Bolus and Pre-Bolus enough for something to act in time. But I think part of it is the way the dosing works. Because it does all these predictions, the RF one algorithm, when using loop, you see the predictions of where we’re going to go. And, or I should say the prediction, singular prediction, it’s a line that goes off somewhere, and it might go down below zero at some point, then come back up three hours later and go sky high, which doesn’t make any sense. Because if the line went that way, you’d be dead by then. The RF one algorithm draws, that’s called an announcer ensemble forecast multiple lines. One of them says, This is where we’ll go. If you didn’t eat any of the food you just told us about. This is where you’ll go, if you did eat the food. This is where you go, this is where you’d go. If we turned off the insulin now. It makes a bunch of predictions. And there’s another line of this is where we go, we’ll go with UAM. So when we think you’re going based on what we’ve noticed about the food, that’s where the longer seat, there’s these massive lines that go up to the right on the graph. A lot of people look at that in different colors, they look at it and say, Well, how do I know which one is right? Well, the system doesn’t know which one is right, because those are all different possibilities. But it plays a safe game, so that any of those are going down into hypo territory, it’s gonna make this decision to try and keep you out of there. It makes a guess as to which one of those is more likely ending point. But that guests may change in five minutes time. Every five minutes is growing new predictions, and saying, Alright, looks like we’re going over there, it looks like we need this much insulin to try and get us back to target. And then, if we ever calculates the we need, oh, looks like we need three units of insulin. And then it might deliver one of those or one and a half of those. And then five minutes later, because I know, I know, no, no, we need 10 units of insulin, if that would start putting some more in. So it actually does that at a much final level. So if I was looking at my CGM and saying, oh, it’s struggling along, it’s going up and down, it’s going up and down at about level, or is that going up? Oh, the next rating comes in. How’s that going? Yeah, I think that’s going up a little bit. I’m going to have to Bolus the automated system. By that point, we’ll have been doing a bunch of little micro boluses. Along the way, saying looks like we might be going up we’ll need a little bit. Looks like we’re going up a little bit more, we need a little bit more. The point is those little bits of insulin already in your system and working. So when we’re looking at things manually and saying, Alright, I need to dose now. We’ve introduced a big delay, and the insulin is going to have to play catch up. So I think that regular dosing actually helps the system stay on top because it’s taken a few choices kind of face to face along the way and added some insulin into the system. already.

It’s almost like it works better when it has the insulin working, and it can adjust by taking away instead of

well. We can never take the internet well. No, no, no, not

not taking away what’s in there. But taking away basil in the future. Do you know what I mean? Like instead of you using a unit of basil over an hour, it’s sometimes it feels like if you just gave it the unit, and then let it decide, okay, well, I’m I’m going to I’ll turn the basil off. I’ll put it back on 2.2. And I’ll bring it like you give it a lot of autonomy that way. And I have noticed that it, it works well. When it has the the insulin at its disposal and then kind of works backwards from that. I don’t know if that makes sense or not. But

it it sort of does in a nonliving environment. It will start off in the assumption that the basil is just constant. Whereas now now we know we can turn that off. Turn it back on in the future. Though historically endos often talk about your Basal Bolus ratio or 50 50% is a nice balance and Crazy Talk as far as I’m concerned, for a start, if you’re eating, if you’re having a high carb day, you’re gonna have a lot more Bolus, that your Basal is not necessarily going to be more. But then it doesn’t really matter if it’s a Basal or Bolus, it’s just insulin that goes in doesn’t matter if it gets given as a bunch of separate bonuses, or as increased by basil. It’s just insulin, as long as this system of tracking when it goes in, we’re getting the right amount at the right time, that mix of which one it is doesn’t really matter. Yeah. Which makes it a little bit hard when you have an endo who says, but the percentage,

but I know something about the setup of on the pod five, they want it near 5050. But then the algorithm almost immediately makes decisions after that and moves things around. So I don’t think you know, it’s something about the way that one set up. It’s important, but you know, when you go back and look at the insulin, it’s not, not always going to be like that. Yeah, I don’t see why that’s I don’t understand why 5050 is important. That sounds arbitrary.

Yeah, I think it’s a historical artifact. When people were dealing with Basal and Bolus injections, that was sort of a guideline as to this sort of works. For most people. That’s a good starting point. But I don’t think it’s the goal that you need to try and get back to right.

Now you need Basal you need and you need the bang, you need the Bolus you need. That’s it. It’s just

well, in today’s world with the pumps, adjusting things up and down, you just need the right amount of insulin at the right time. And the basil and Bolus is all the same stuff. Right? You know, whether you take away what we’re going to give it by default by basil in the future, which is what you were talking about, and answer the same thing?

Well, I think, too, I want to I want to mention that the idea of like, I don’t understand, why do why do I notice things working very immediately on a on a looping system. When we know the data is behind from the CGM when the insulin takes time to work. I don’t know how to describe why that is. But I do know it’s true. Like I do, I do think it’s just, I think the algorithm by by guessing at the future or predicting so many different possibilities in the future, I think it’s somehow shortening the, the distance between what’s actually happening in this moment, and what the data can tell us is happening. Because you can tell me if you’ve seen this, too, you can look at a blood sugar that’s not moving, right? And the algorithm is trying it’s given like with with loop, what is it giving you like I think 40% of what it’s suggesting. So it suggests a unit, it gives you point four, it waits five minutes, there’s still point six less than it hasn’t given you, it gives you another like 40% of that it’s making those Bolus as long the way you look and go, this is not enough, it’s clearly not enough. If you manually in that moment, push up the Basal insulin, or you manually in that moment, give all the suggested insulin, the blood sugar almost turns, I don’t want to say immediately. But it’s shockingly quick after that, like it really does feel like cause and effect in a way that you don’t expect. I’ve never seen that manually working with an insulin pump. But I have I’ve seen it so many times and loop that I trust that that’s what’s about to happen.

And I think that’s largely those earlier doses that I was talking about is been giving you partial doses along the way. And those are all adding up.

Yep. And you’re and you’re this close, but it’s just not tipping. And then you just push a little harder, and then all of a sudden, I see it. So some

of the some of the things that I was adjusting when I was tuning my system and making it more effective is some of the safety limit. You talked to there about the 40%, right? So in the IRF, one system, there’s some controls for what it will do 50% of the calculated insulin, it will do 50% Now and then in five minutes might do another 50% of the new production. But there’s also a limit of it’s essentially borrowing Basal from the future calculates this is how much basil we need. And then they’ll say, All right, I can use the next 90 minutes of that I can bring forward into this initial dose. Yeah. Or maybe the next 45 minutes or maybe the next 120 minutes. So you can make it more aggressive and borrowing stuff in the future. And if you do that too much and your settings aren’t right, then it can end up potentially overdosing and you’ll go low later, right. Right. So the the safety limits are set relatively low initially because they don’t want to overreacting so it was watch the system and see that I can be that I’m going up and I can see what it’s dosing. And I don’t think it’s doing enough, I look at the calculations, there’s all these messages coming out in the logs. If you go and look at the right page in the software, it says, we’ve constrained this because of this. And it’s alright, I’ll increase the safety limits a bit. So there were some tweaking, they’re not just changing my, my ratios, and so on, but also freeing up the system. So it was gonna make the right choices without just opening the floodgates and letting it overdose me too much.

So let me ask you this. There’s a person like yourself, who understands all this and donates the time to it to help themselves out. But generally speaking, how many people do you think are doing this? Even across the globe? Like, how many people with type one do you think are using some sort of a do it yourself algorithm?

Can it be that many? 10s of 1000s at least

okay. I mean, that’s, so that’s one of those things. We’re like, that’s a substantial number. Until you look at the whole of everybody who uses insulin to stay alive. And then you’re like, well, nobody, nobody does it. Why do you think that is? Because, I mean, Arden has been looping for years now. You know, she took a break and did on the pod five for a while, which worked exactly the way we expected it to. But she really did not want to carry around the receiver that was necessary for so bright before she went back to college. She’s like, can I please switch back to to loop? And I was like, Yeah, that’s fine. She’s like, I just like it on my phone. And it’s interesting, because she doesn’t really have a lot of the concern about the, you know, the switches in the lever, she was just like, this is fine, or this is fine. And in her mind, it came down to carry a thing. Yeah, I know how well it works, David, like any of them, like but why can’t we get people onto them? Like, why? Why is there not like a mass get any mean? Like in your Do you have any idea? Well,

I think the commercial loop systems. The good thing about those is they become more accessible to more people easily because the doctors can just basically scribble on the books and say, right, we need to get you this and get you set up, and they’ve got a better chance than not having access to it at all. One of the things that’s changed here in Australia is halfway through this year, we finally got CGM subsidized for everyone was tight one, right. So instead of paying 330 Australian dollars for a month’s worth of sensors, we now pay $32. And, strangely enough, that’s making it a lot more accessible for the companies to introduce their loop systems, because now Medtronic is saying, Well, if you look, here’s what we have to do is that the subsidy is we have to specify which PGM system we’re using. So Medtronic is saying, if you walk into the Medtronic CGM, we will give you a Medtronic seven ATG, we will upgrade you. Because they get to sell sensors. And everyone gets the benefit along the way of all, the closed loop system. ipso Med, you’re in Australia, I had a little crypto pump. And that’s they’ve now got cam APS, which is another closed loop system that runs against that pump that’s now rolling out in Australia. And suddenly a lot more people are saying, Oh, I’ve got access to this stuff. Great. I think I think the uptake of people who are using closed loop systems, I think it’s going up dramatically. And we want to see some more statistics and polls on that to sort of see what’s going on. I ran a poll a couple of years ago on the number of leakers in Australia a couple of 100 at the time, but that was all due itself stuff.

Yeah, I mean, here in America, where things are, I mean, these a lot of these different devices are readily available and, you know, number of people have coverage that would allow them to get them. I just, I don’t know, I, I know. It’s not how things work. But if this if this was me, the minute This was available, I’d be I’d take the day off and just say to myself, Well, I’m gonna sit down and figure out how to make this happen right now. And I don’t I don’t know. I don’t know why. There are so many more people who will never pump even versus the ones who will and there are, you know, at all and all of this stuff in between.

That I think of it as a sense of inertia. Like for me, my my endo suggested quite a few times. This pump might be good for you and I know how this system works. I’m still alive, it’s running fine. But in my clinical results when I got access to a seat to a CGM, and I started being able to look at the data myself and see what was going on, it was, Oh, this isn’t good enough.

Right. Nick, well, back then you just alive is your Mendoza line, like, I’m not dead. This is working well.

Well, I’m not dead. And I got an HBO one see from my doctor when I saw him. And it was a good one this time. So he said, Come back in 12 months time, and oh, look, it was a bad one. It’s come back in three months. And it was, I didn’t know what I was doing differently. Because I didn’t have the tools to see what was going on. Yeah,

even that was random. Hmm. So and yeah. So when you found yourself in that situation, if you were being given the golden ticket, if you don’t have to come back for a year, it doesn’t mean that six weeks from now you’re a one see wasn’t on its way up? And you had no idea really? Yeah, I

had, I had no idea. But I’ve, I’ve got my path results back to 2000 or so. And I can see my HBO one. So he bounced around and got up to 8.1. It was down at seven, it got down to a massively low six when I started on the pump, and it was gradually started creeping up again. But after I started looping in 2017, it went down to 5.8. On down to 5.6. It has never been as high as 5.6 cents. Yeah. So it ranges between 5.0 and 5.4. And you’re active

as well. You have you’re paying attention, you know, all that stuff. Yeah.

I mentioned before my timing range for 70 to 140 is around 85. But my timing range for 70 to 180, which is the more traditional clinical range is about 95%. Right now. And my time below 70 is about 2%.

You know, it’s an I say, I don’t see, we don’t see it. I mean, lows just are very infrequent,

you know, so So I feel very comfortable with where all by senior is I know day to day will go up and down and bounce around. But overall, I’m in a good place. I’m feeling quite good, because I actually had a scare a few years ago with them. That there are sclerosis. So partial blockages around the heart, I didn’t have a heart attack or anything but a random stress. Echo said all that said no more than we went down the investigation path. And I thought I was going to have stents and all sorts of stuff. But I managed to get out of it without that. And this was about the time that I was advancing a bunch of my glucose management. And the cardiologist now looks at and says, Oh, you’re fine. Great. I’ve got the general feeling that health wise, I’m in as good a place as I can be, right? A lot of what I’m trying to do is make sure that it’s there, but also do what I can to make this stuff available to more people.

Back then were you feeding insulin? Did you have a lot of like, Were you eating a lot to stop lows and things like that? Or well,

they actually the heart issue was about two and a half years ago. But I think I’d already started fixing things. But we hadn’t noticed anything. Made an ideal world, you know who maybe it’s already healing. Who knows? There’s we didn’t find it because of how to Tech, we found it because I had a fight because of low blood pressure, which the cardiologist says, Oh, that was probably just that you are exercising more. And so we’ve reduced the blood pressure meds. And I was on mild dose on that. And now I’m on a half a mile dose, right. So we sort of found it by accident. So maybe it was something that was happening earlier. And it’s been getting better through this. But it’s certainly notably been getting better, because we’ve been looking a lot more closely our stuff over the last few years. And everything just keeps staying stable. And that’s

good for you. And that really is wonderful. You don’t do you have any of what we consider. I don’t know issues from diabetes.

We’re trying to avoid the complications that weren’t I want to

say complications. But do you have any do you have anything that you talked that you are dealing with?

This there’s no no. I saw my ophthalmologist a couple of weeks ago and she said Because very nice relinking accent and I’m paraphrasing slightly, but she says there are no diabetes in your eyes. Oh, good. That’s what I like to hear. There’s no effective diabetes, but it sounds funny the way she says it, bro. And it was going back in 18 months out and I’m in fact thing. Her particularly because of congenital thing, we found one of my optic nerves we found years ago, and we started trading that we wouldn’t have found it if I wasn’t having my regular diabetes examinations. So I believe in in my eyes is not an issue. But I feel that my eyes are healthier than they would have been without diabetes, because we wouldn’t have found this thing.

Yeah. So maybe saved you from a from a different issue.

Yep. So the cardiologist says, the heart stuff is not related to diabetes. It’s just stuff that happens when you get older. Although he’s only ever known me when I’ve had normal HPMC, etc, levels. So I don’t know if it was something in the past who knows? I’ve got most of the hand physiologists said, I’ve got the early signs of something that may turn into contracture of one of the tendons on my hand. But it’s something that they can fix. It’s not a thing is it’s just an early sign that maybe that might develop, but that’s about as close to a diabetes issue is I can imagine it sounds.

It sounds pretty terrific. Honestly.

I’m very lucky. Yeah.

Is it in your family at all? Type one? No, no,

no. Well I, I remember, you know, stories about there was an aunt or something or great art, whatever he died or something, but back then. Maybe in the 80s. Going back in time, from what people knew about 10 years ago, if they’d gone back, they might have said she had type two. But if they’d gone back now and done better tests, they might have said, Oh, she actually had type one. Who knows?

Right? How about other autoimmune stuff?

Like celiac disease? Celiac disease is the only thing and that came on after several decades. Okay, so that’s the closest thing to a second autoimmune thing that I’ve got for

you. How about in your family? Do you see any other thyroid stuff for digestive issues? Anything at all with people? Not? Not yet? It’s interesting. Do you have children again?

No, no, I have nieces and nephews, I can wind them up and hand them back. I don’t have my

listen. There are days that sounds right to me. Interesting, okay. Has it been? I mean, you said you, you’ve done wildlife photography and other things like that. I mean, it doesn’t sound like diabetes has stopped you from doing things throughout your life.

No, not, not really. If I was looking at going on a Australian Antarctic Division runs supply trips every year down to the bases in Antarctica. And they have some humanities births on there, where basically artists can go along and record what’s happening, and so on. So there was an opportunity as a photographer to get on to that. So I thought this is exciting. looked into that. And as soon as you’ve got diabetes, you’re not eligible. Because they make you go through all the same medical things, as someone who was going to overwinter and stay there, right. And if you don’t have enough insulin, you’re gonna die, basically. So I was basically not not eligible. So that was a little bit disappointing. But it guess what I found another way, I’ve been to Antarctica four times now. Really? I run photography trips down there.

You make the rules so you, you can allow people diabetes to go.

So yeah, I’ve that also called the travel bug. So I’ve been to lots of places around the world. Whether it’s, you know, jungles in Borneo or up in the Himalayas, with snow leopards in the middle of winter. And most places I go, I need to worry about keeping my insulin. cool enough. There. I need to make sure it wasn’t going to freeze overnight. Yeah. So yeah, I feel that I live my life and diabetes has to come along for the ride. That’s one of the other things that you were asking before, what we what we should talk about. One of the other things that a lot of people might find interesting is Something that I’m not responsible for, but a lot of people seem to associate my name with. And it’s the NuBus G six transmitters. So the X column G six transmitters, they run for 100 days. And then they turn off mailing lists. And in the early days, people were able to cut them open and replace the batteries and seal them up again, and then they’d go for another 100 days. But Dexcom, change things so that you can’t do that. So, I know some I know some people who’ve did some engineering, and they basically they modify G six transmitters now. And we went through a phase where we’re trying to work out how to get this working, I managed to get a bunch of people in the US, including some of the people from the Facebook group, I donated all transmitters, and we sent them over here and then basically pulling them apart and using them as test beds and how to make things work. So what they have now is a system where an old Dexcom J six gets recycle, and it becomes an A novice GC. And the NuBus comes with a battery that sealed in the bottom with clear silicone. But when it’s time to replace the battery, you can actually see that’s where I dig in and dig out the battery and I stick this other new battery and never seal it up again. And it automatically resets. These are really convenient because they have a bunch of other advantages. The transmitter doesn’t timeout after 100 days, pumps out after 190 days because they have a bigger than normal battery. And it doesn’t stop your sensor after 10 days, it stops your sensor after 60 days. So I can run my sensors for 20 days and not have to do any restarts along the way. That’s really convenient.

And you do you notice that it holds up as far as accuracy goes,

Oh, it’s the J six. They didn’t change any of that stuff. Yeah,

right. I just been having the wiring for that long. Oh,

with J five, my record was 53 days. What I’m doing now is I used to run sensors for as long as I could, because we had to pay for them all ourselves, and it cost a lot of money. So you’d be saying alright, is it unstable yet? Is it time to change it? Now I can go another day, and then suddenly it goes out the window. And right now I’ve got this outage I need to start up. So I set up something where I could, if I’ve got two transmitters, I put in a new sensor with new transmitter and I’ve essentially got another program talking to it and I start the session on that transmitter. And then when it’s when it’s warmed up and it’s ready. Hopefully before the old one has completely died. I tell my loop system use that transmitter instead of that transmitter. And it gets gets good data to I don’t have to warm up as long as I’ve done everything right because it’s already warmed up and had the first day of weirdness out of the way before I switch over. So now that we’ve got things subsidized, and they subsidize them for essentially one every 10 days, I’m actually putting a new one in every 12 days. And then I’ll I’ll switch over to the new one. After another day or so, once I know it’s stable, and it’s really nice being able to see two lines and say no that had old sensors going weird or the new sensors going to it. Suddenly, it’s not just finger pricks and CGM. We’ve got fingerprints and two CGM so that we can compare. And it means that my the amount of time my system is actually making decisions and looping is pretty much 100% all the time, because the CGM never actually has to disconnect and warm up, right?

Do you think that G seven will cause problems for the DIY community? Or do you think people will

you know, not especially the g7 is essentially doing some of the same stuff because each, each sensor has its own transmitter. That’s where That’s where this new stuff comes on. Where after 10 days, it’s not the new one. But I’ll keep using the old one for 12 hours. Yeah, so it’s essentially doing the same thing. And but it automatically switches over. Now it it’ll be harder for people to try and extend the system in the way that we’ve managed to do with the newer stuff. Now the reason people associate me with somebody whenever stuff is on my blog, I posted an article saying these amazing thing and works really well because I’ve been testing it for them. And I get people sending me messages saying Hang on, can you sell me one? It’s not mine. I’m not involved.

I’m just using it,

talked about it. But the guys who distribute those, by the way, that they’re not selling them for profit, they’re pretty much essentially giving the way they get donated trans old transmitters that are getting recycled. And they’re just set up little machine shops that have laser engravers and everything out. And it’s all automated home workshops, stuff from people who have diabetes, hell bent.

That can’t afford to do it.

It’s hard, hard to imagine how any of that could be applied to a G six, where everything’s integrated, and then applied, and then you take it off, and then it’s done. G seven, obviously. Yeah, sorry. So I am thankful that we have subsidies here. So if I have to use them one every 10 days, I’ll be able to afford them.

No, it’s amazing. I’ve talked to people just you know, in the last two years in Australia, who are like, I can’t afford anything to those same people sending me notes and say, hey, look, I have a CGM. Now or I have a pump now. It’s like, it’s amazing how quickly things are kind of moving there.

Yeah, exactly. So I think I expect people will be able to use G seven in the with the open source software that Do It Yourself stuff. I believe that’s already happening in your head to talk to them.

Yeah, well, I mean, it’s been out for just a handful of weeks now, right? In Europe. And I mean, my expectation is, it’s going to be the next couple of months, it’ll be in the US. So you’re gonna start seeing it everywhere pretty soon saw as the FDA, I don’t know what the hell they’re, they’re holed up. It’s but as soon as that goes away, I guess we’re gonna see it here.

Now in Australia, because most people are getting it through subsidy. I think introducing it here. It’s not as though it’ll get introduced and sold will cash sales. And then eventually added to the subsidy, I think they’ll be lining everything up so that when it comes here, it’ll be with the subsidy. So I don’t know how long that’s going to take. Yeah. But we’ve only had G six here for about two years. I think you’ve had to do six for longer over there. Yeah.

I know. I hear Canadians often talk about the feels like a chasm of time between when new stuff comes out. And they actually got it. I guess it’s similar. I don’t know. I wish I understood more why that happens. But I just don’t. You would think that people would diabetes everywhere, right? And there’s governments you can charge for this stuff. Like, let’s get going.

Yeah. Life is life is multifactorial. So there’s a limited market in Australia, compared to the US. So all their costs for going through and setting up things with the regulators and importing and doing all those things. There’s more overhead. So are they going to make enough sales for it to happen? Now that things are subsidized, if they can get onto the subsidized list, it’s easier for them to say, alright, we’re going to have a steady supply. Right. So hopefully, that will enable things to move quicker. But But yeah, dealing with different regulators in different places. does add a lot of time. Yeah,

it really does. And in the meantime, there’s people who mean, you would think that if you were the government, why would you not say, All right, well, maybe we were not the maybe we don’t have as many people here with type one. But let’s make it attractive for these companies to come in and service, at least the people that we do have. That part is a little interesting, you know, like,

the other thing is only on Jeff, and Jeff has been available overseas for ages. And, and we’re over here saying it’s really great with important time it used it and it’s great. Why can’t we actually get it properly. And we’re saying the same thing. We had years before fierce was approved here and then still years before it actually became available. But when it becomes available here, again, the drugs subsidized through the pharmacy benefit scheme for PBS. But the price that the manufacturer gets is controlled by the government. Basically, the Australian Government doesn’t pay a lot for the drugs. Right. So that will play into are we going to make enough sales at that price to make it worthwhile to bring it in? Yeah. Novo got to CBRE approved in Australia a few years back. They don’t actually import it, sell it because they’re not going to move enough of it. They sell that I rise adag that mixed one. But not not peintre saber, just as an example, someone said, No, it’s not going to be worthwhile. And there’s all sorts of weird things. Because there’s the way the drug subsidy stuff was set up. There’s, you can’t introduce a newer, or a different form of the same drug. You can’t have too many forms of there’s all sorts of controls without having to get a basically get less money for the drugs. And it’s all this competitive stuff built in. But that actually meant a few years ago that when FISP was introduced here, it was available in out because VSP is actually insolent as part. So it’s not actually a separate drug. It’s the same as Novo rapid, which was already in the list, which was available in prefilled, pens, in pen cartridges and in vials, okay. And then faster is faster acting insulin ESPAR is available in pens, and vials. But they didn’t introduce pen cartridges, because that would be too many. And then they wouldn’t get as much money from the government for the drug. But it’s complicated, it’s

dizzying. Yeah, it really is, um, just, you know, people need stuff, it’d be nice to find a way to get it to them in a way that is affordable, and unreasonable and easy. You know, it’s tough to RDS have to have diabetes. You know, you start jumping through hoops to get things accomplished. And you can see easily why it doesn’t have I mean, to take it out of diabetes for a second, my mom just moved with my brother. And she had to live with him for a little while, while she established residency in a new in a new state before she could go to this place that she wanted to go to and get the assistance she needed. And she, you know, she wanted and everything. And the amount of phone calls and paperwork. If my brother and his wife were not doing this work for him, my 80 year old mother could not accomplish any of this, like there is a system set up for people that they functionally can’t take part in. And you have to have somebody helping you what if you don’t? What if you don’t have someone helping you? Like, then what happens? You don’t I mean, like, it’s, it’s fascinating.

That actually opens up another concern with the fancy technology we use these days. What happens when we get older? Yeah, I think and we go, and we’re going to aged care. That’s, I mean, we have quite a few loopers in Australia who are in their 70s. And I think some are in their 80s. Now, and it’s something that people talk about what’s going to happen later on at some point in my life, and I guess it could happen to all of us what happens if I’m involved in accident, I have a friend from university who has an acquired brain injury, and later develops diabetes, and isn’t able to deal with any of this stuff. Everything has to be through a carer and what’s going to happen when the family carer gets old. So that feeds back into winning to make this technology as accessible to people as possible, so that not just Can people without the background and experience that say I have been using, but also that someone looking after them who isn’t especially skilled and more comfortable.

No. And I think about that. I mean, you have diabetes, I’m sure you think about it for yourself, but as somebody who’s looking at a child with it, I think about that constantly, because my daughter is going to be older, and in need of help at a time where I won’t exist anymore. That’s hard to deal with, you know, like, is she going to meet a person who will help her or, you know, will she have enough money to be in a healthcare system that can help her also, I’ve seen my mom in that health care system. And due respect, they’re not great with giving you a pill when they’re supposed to sometimes, or you know, managing things that are not nearly as complicated as diabetes. So I don’t know. It’s, well frightening idea.

It still comes up every now and then but we still we are hopefully moving away from the world where someone would go into hospital for and they have diabetes for them unrelated thing and the doctors would take and the nurses would take their insulin away and then it’s our youth you need to have your evening insulin there. But you haven’t given me a food yet. The food’s not here. No, no, we need to chat this now. Or you have your food now. We’ll come around later with the insulin. All of this stuff is totally in integrated into into our lives that, like I have a colonoscopy coming up in a little while, and I’m thinking ahead to when it comes to what day is it on? When am I going to be starting my CGM sensor? Where is my prompt site going to be because I’m going to be lying on the bed this way. And they’re going to need to put a cuff there and put a line in here. And it’s no good if I have technology in the way. So all this stuff is tightly integrated into how we live our lives. Yeah. And,

anyway, alright, you’re bumming me out there.

It’s okay, I’m actually participating in a summit in a couple of weeks. One of the big research bodies here is having a series of panel discussions and one of the things we’re talking about is how this stuff integrates. And the reason that’s in my mind is that kind of some of the things we talked about before, some of the design design decisions behind this technology are often made by people who don’t actually live with and don’t actually realize that, oh, it affects this, or that means you’re going to put this site there. For me and Omnipod, I use Omnipod dash every now and then. Not regularly, but I’ve got a couple of boxes. And if I’m going for watersports or something I might change to a a pod on a waterproof looping phone for that weekend. But I need to be very careful about where I put the pod. Because it’s very particular about the radio reception. If someone’s dealing with the PDM, which is the insolent way of doing things, you pick up your PDM. And you also you change a Basal or something and then you put the PDM away. Whereas me I’ve got the looping phone that’s talking to it, and it needs to talk to it every five minutes. And if the part is on my right hand side, and the phone is on my left hand side, and I’m a big bag of water right in the middle blocking radio signals. Things don’t always work neatly and people finding that with the Omnipod five that you need to make. It’s better if the CGM has good line of sight line of sight to the to the pod, it’s the same sort of thing, I have to think about where my phone is where the CGM is and where the pump is. So, flexibility for me the when I’m using a tube pump, I can have my pump in pretty much the same spot every time and the tubing just goes to wherever the site is. So in some ways, a tube to pump is better for me than a pod.

Because you have that that option. Yeah. So you’ll always know where the pump is going to be. And that you just move the site.

Yeah, I mean, there have been times when it’s old enough for these couple of weeks, it’s on my right side. So I need to make sure I put the looping phone in the pocket on my right or a pocket on my left. Whereas these days, it’s just no baby every time my pump lives in little running belt has to be built. Yep, that’s underneath my clothes around my waist. It’s always in the same spot. And then the tubing runs along the belt and then up or down to wherever the site is,

you know, if you tried to make this argument, the art and she’d be like, I don’t know what you’re talking about, but I’m not attaching anything to me. So I can’t get up. It’s just so interesting. What where you’re everybody’s perspective comes from their entry point. Really, you know, yeah, different perspective.

This thing of tubes versus unsheathed I started off with an NMS pump. And I had a a talisman around my neck and an SOS, whatever tells me medical thing. So if I was going, it was in the middle of the night, I was going to the toilet or something and I had to do my pump somewhere. I would probably clip it the bed around my neck. And then the tubing runs down to where the site is. But I always had this extra thing I was carrying around and having to put somewhere or back into a pocket or something. Yeah. But yes, there was something attached to me. But when I started using the looping systems, I no longer had to touch the pump. The pump would hide away in a pocket. And my relationship with it changed. Yeah, because now now the pump is in that little running belt around my waist and including when I go to bed. So if I wake up in the middle of the night and I have to go to the bathroom, I just get up and I walk down to the bathroom. The pump comes with me I don’t have to. There’s no feeling of oh, I’ve got something’s actually the tubing somewhere is comfortable with me. Yeah.

I know some people who put it like on their bedside table or lives in the they leave it loose in the bed with them. I’ve heard people describe what you just described. It’s interesting how it all works differently for

it, find a system that works for you. And I’ve used different systems along the way. And that and they’ve all, whatever I’ve been using at the time has mostly worked for me at the time. But you know, when the pugs were introduced here, a year and a half or so ago there were some people other companies find people with diabetes, who are they become advocates, basically? Yes, it’s wonderful system, it’s changed my life, which is great, and it’s fine. But many times. Some of those people, the first pump, a lot of things they described about, oh, I can change this I can change that is, you can do that on any pump. And they say, but there are no tubes, I don’t have something dangling attached to me. And I say, I don’t have some, I don’t feel like I have anything dangling attached to me anymore. So in fact, when I use a pod, I’m restricted in terms of I need to fill it with the right amount of insulin, because there’s this decision, when I get to the end, have I put enough in it to last the 70 to 80 hours, if I’ve put more in it? Am I going to pull some of that out and put it into something else? Because my insulin doesn’t cost as much here, you can sort of say, well, I’ll just using using new pod and fill it with new insulin. When I was using these new images that I imported, myself, I was a little bit more sensitive, because every drop was was money. The and there are issues, if I have a problem with my site, then I have to put a new part on. Tonight, I put a new cannula in for my pump, and I put it in and it was out that’s not working, I can feel that that’s completely uncomfortable. I took it off and the drop of blood comes out. And it’s no, that’s a bad site, I’ll just put it in somewhere else. And suddenly I’ve wasted 50 cents, or $1 or something on an annual that’s I haven’t wasted a whole pod and then have to ring up and say you know all this hassle about

So David, here’s the other the other side of it. In your in America, you get your your doctor to write you for more pods than you need. And then you draw out the insulin if it’s new, and pop it in the other one and keep moving. Like it’s all the same. But yeah,

I know. But. And there are there are ways around this we live, we each live within the constraints of existence that we’re using. Yeah. But each time we use a pod, and I get to the end of it. And it’s right, I’m going back to my other hub that feels like Old Faithful, comfortable territory going back to my tube pod so that that the pod to me at the moment feels more restrictive. It’s less restrictive, I can go swimming, I can everything keep running. But in terms of general where it doesn’t feel the same, because I’m not used to it.

Well, you’ve just described exactly why all these device manufacturers are so focused on getting people when they’re newly diagnosed as customers, because then this becomes your norm. And you know, it’s hard to imagine otherwise, you know, it doesn’t make doesn’t make the other option. untenable. It just makes it different than what you’re accustomed to. So and you are right, like no matter what scenario you get put in, you do find a way to make it work as seamlessly as possible with your life doesn’t matter if it’s a pumper. A CGM or whatever it is you you fit it in and you make it work. And then suddenly it feels like this is the option, the only option? Makes sense.

Yeah. And different systems have different advantages. And I think a lot of people as you say they get locked into the system that they’re using. And they don’t necessarily realize that the grass might be greener on the other side of of that fence, or maybe on the other side of the highway, maybe just in the next paddock, whatever. So when I started on an LMS pump, I was using the infusion sets that my my diabetes educator had suggested. And I was using them for years. Those were the ones that I used, oh, if there’s a supply issue, and I can’t get those, what am I going to do? I’ll manage to get some or I’ve got an A got out of it. It’s okay. And some of our friends who are interstate they were using some different ones and they were having supply issues and all sorts of dramas. And I realized that well, maybe I should try one of these other ones. Maybe if I wasn’t tied to this one, I’d have some flexibility if there was a shortage Yeah. Now, it’s convenient here that all of our infusion sets are subsidized to the same level once you’ve registered as a pump Use a you can get any of those at subsidized price I say so so I can, in fact switch to a different pump type. If I have the pump, I can buy the other supplies. I don’t need a prescription for each one. But that meant that oh, let’s try the stoop cannula. Let’s try the ankle cannula. I’ll get a box of those and see how they go. So I’ve now used pretty much everything. And I found the ones that I like. And I’ve got to the stage that I get all secondhand pumps of different types, I’ve now used pretty much every type of pump on the market. Yeah, and most CGM. So my decisions about which ones I’m going to keep using is I’ve used some of the others, they don’t necessarily feel right. But sometimes there’s something that oh, that’s nicer, because, for example, I started using the were they the comfort sites, which tenem now call them the very soft Medtronic call them the silhouette, the angled one. And they turned out to be about great. They were nice and comfortable. Manual insertion, which was quite daunting. But once you got that over and done with it was fine. And it actually turned out that I can pack a lot more of them in a camera bag when I’m going to Africa. All sorts of other advantages. It’s so interesting

to hear people talk about these little things. I remember when Arden was really young, and we were looking for pumps. And we were drawn to the idea of the Omni pod, a nurse practitioner who tried everything they could to scare us away from like, don’t use that. They everything they could think of like your daughter is too lean, it won’t work. You’re not gonna like the angle that the cannula goes in on if you don’t like the angle, the cannula goes in on you can’t go to a different set. And I just was like, wow, like I look back on that now. And I realized she was just coming from the perspective that she had, which was, you know, this this back then this insulin pump was brand new. She didn’t have any experience with it. These were her experiences before, she didn’t really know if what she was saying was going to apply to us. She was just like, here’s all the things you should be scared about. And you know, I’m like, Okay, thanks. We tried it anyway. And, and then those things didn’t end up being an issue. And so long story, but in 20 seconds, like two years after Arden started an insulin pump, our our practice, apologized to us. They came to us and said, We’re sorry for how we tried to scare you away from using this pump. Like your daughter is having so much success with it. We’re gonna start talking to other kids her age about it. And I thought like that’s just always stuck with me. Like they were so adamant. They had rules and lists and reasons. They were like, This is why you can’t buy this, this thing and then later, they’re like, Yeah, we were wrong about that. Sorry. Jesus. Okay, what else you’re wrong about, you know, is how it made me feel?

Well, yeah. I, in my own head, I have lots of experience with I’ve used lots of different equipment, different CGM, different glucose meters, pumps and stuff. I’m not necessarily an expert in all of them. But I’ve noticed some of the differences. And I sometimes point those out to people because they haven’t necessarily noticed those. They don’t know those things going in. So try to give people as much information as possible. But yeah, I guess, the track the track there. I shouldn’t necessarily be trying, I shouldn’t be trying to frighten someone away from using something because I find something in issue. I can point out to them that this thing exists, then it might be an issue for them that personify that. That middle ground of trying to scare someone or trying to inform someone is always tricky.

It’s our communication had that person done what you just explained, it would have been completely different. You know, we just said, look, here’s some things that could possibly happen. Here’s why this may or may not be important to you. This pump over here won’t do that. This one will like I would have been like, Okay, that would have been information to take in. But instead it felt like I don’t know, it felt like a scared person or an anti sales pitch. Like you started looking around, like, do they work for somebody like they were so just, you know, pushy. But I don’t think looking back that’s not wasn’t their intention. I just think they had a certain set of pride. I was gonna say priorities, but I think it’s perspective. I think they’ve they had experiences and perspective and they were unknowingly defending that perspective against what they saw as being different. It’s just, it’s fascinating in my heart, I think people should use what works best for them. Like I you know, I mean, I take ads on the podcast, but, I mean, I have to be honest, like, I don’t care if you buy an AMI pot or not, like I want you to have an insulin pump that works for You? And if I’m the pods the one great. I don’t mean like, I’m not. I don’t know, like, sometimes I think that can get blended a little bit like, well, he has ads for Dexcom. But you get a libre. I mean, what do I get?

Well, presumably, presumably, you might not be so comfortable running ads for a company if you had concerns about the product?

Of course, no, there have been plenty that I’ve turned down over the years. And there are some that have been easier to take, because I have that personal experience with them like I can, you know, like when Dexcom comes to me and says, Hey, can we buy an ad on your podcast? I immediately think, what are the reasons why? When anyone comes to me and asks for an ad, I, my first thought is, I want to know all the reasons why I shouldn’t do this, because if they’re too great, or it’s bad for the people listening, I won’t do that. They may, then that may sound like that may sound like I’m protecting you all which I am to some degree, but I’m also protecting myself. Because if I say, hey, use this pen, and you all run out and buy this pen and it sucks. Well, then you’re gonna stop listening to the podcast and be like, Oh, the guy was wrong about the pen. I wonder what else he’s wrong about, like, you know, I mean, like, there’s a, there’s a bit of self preservation in there as well for me, and I have comfort with the things that I advertise for. I mean, like, Chivo Capo pens, a great example, that thing came out. And I was like, well, that’s brilliant. Like, like, Yes, finally a form factor. I can put my daughter’s hand, her friends can understand it and etc. You ever tried to explain the lily red kit to a nine year old? You know,

yeah, we, the only glucagon we have here is the NoVo hypo kit, which is essentially the same thing as the red Lily kit.

They’re gonna keep me because Lily stopping

that? Well, that’s no most product at glucagon product at the moment. Yeah. So it’s no signs that they’re stopping. We don’t have access to vaccine, me or GMO? Or any of those?

Yeah, no. And, guys, I’m sorry.

I was reminded from what you’re saying some of the stuff that comes up on my blog. And what we’re saying about advising other people, is always when I started writing things, and putting it down on the blog, I was always conscious that this stuff is going to be up there. Anyone can read it. Yeah, and I don’t want to be saying the wrong thing. But there’s also this big thing with the, the open source, the do it yourself, equipment of this is not medically approved. If I tell someone, I can’t tell someone, you should, you should build this system and it will work for you. I can’t do that, legally, I will get myself in a lot of trouble. But luckily what I can do and stay on the right side of the law is say, this is what I’m doing. And it’s working for me. These are the things that I’ve noticed about it example, I always try to keep that in mind. And try to not cross the line of giving something that could be misconstrued as medical advice. Always have it in the context of my experience. I write about a lot of technology. But it’s mostly in terms of I have actually used this. This is my opinion of it. These are the things that I’ve noticed. Right. And I think that’s been working very well. It’s quite pleasing when I’m at a diabetes conference. As one of the community advocates there, and I get stopped in the hallway by endocrinologist to say thank you for the blog, I was able to direct some of my patients to it. Yeah. Oh, that’s great.

I completely understand what you’re talking about. And I’m never not knocked over when somebody comes into the Facebook group. And they answer this quick questions about, you know, what’s your attachment to diabetes? Bah, bah, how did you hear about this? When people say, Oh, my doctor sent me hear, I’m always like, Wow, that’s great. Like, just terrific. And, and I take all your points to like, you’re just I’m just sharing what’s worked for, for my daughter, basically, and things that I’ve noticed along the way. And, but the, the feeling of I mean, I guess the way I handled it is I might do a good job of sometimes sounding like, I’m like, Oh, I just thought of this, which has happened a time or two where something’s clicked popped into my head as we’re talking. But for the most part, I don’t say stuff on here, until I’ve seen it work over and over and over again for my daughter. That would be irresponsible. I don’t understand. I couldn’t do that either. So it’s a it’s a great thing. It really

it. It does feel sometimes when I’m moderating some of the Facebook groups. And it does feel sometimes that I’m being very wishy washy with my answer saying, Well, you could do this, but you should see your doctor.

Yeah, I tried to just say if this was me, or the way I see this, it could be wrong for you. I’m only looking at one graph, there’s no way for me to relate. No, you don’t. I mean, like that kind of stuff. But you should be going in this direction.

I guess I just realized, I guess I had a lot of experience in that before the diabetes advocacy because I’ve been involved in amateur photography stuff for a long time, the Australian photographic society and various photo competitions and getting critique on photos. And you learn very early on to give constructive critique, not criticism, per se. And you can always find something constructive to say about pictures, when I’m giving feedback on photos, and it’s something that I still do to some of the camera clubs. I’m very careful to try and give suggestions and things that they may not have thought about. Without saying this is good. This is bad. Yeah. Because yeah, I’m setting myself up for being attacked. At that point,

I tend to lean into the, what is the call? Is it the Socrates questioning method? Or, like the idea of teaching by asking questions, you know, like, oftentimes, it’s almost it’s a version of you can, you know, teach a man to fish kind of a thing. And

I have gotten into trouble with that with my family. At times when they say, don’t ask me another question. Just answer the question.

Well, online, I find, it’s great to say, hey, well, do you think this or this just happened? And then you kind of let that they almost sometimes people know, they just don’t know how to put the pieces together. And you know, I find that pretty, a pretty valuable way to talk to everybody. But, David, I have to jump off in a minute. But this was terrific. I just want to make sure that we covered everything that you don’t have anything left hanging that you that you didn’t get out.

I don’t think so at this point. I think I’ve covered a broad selection. There’ll be something new and different. That’s happening next month, or whatever. But that’s next month, I guess this will this will take a while for this to come out anyway, it’ll still hopefully be fairly up to date when it does.

Yeah, well, because we’re talking about things that are more time sensitive with technology, I will slide up on the schedule. So it doesn’t, doesn’t sound like it came out of left field. But the other things things change quickly, right. Like Arden is off at school right now using arrows pods and, and the version of the loop that she’s using now. And she might come home and over, like the holiday break, and we might switch her to be you know, something different and send her back with something different, I have no idea.

We’ll just reminded me about something that went through my head earlier, when she was saying, I don’t want to carry this PDM I want the system running off my phone. But she’s still happy to carry around an orange link or rolling link or whatever.

So that is the gateway what she’s not happy about it. It was a trust me, she hates that. But But I got her to be okay with that by telling her that eventually there’ll be a system that doesn’t require that. And it’s smaller. And she has it she keeps it in her diabetes bag. And the orange link seems to have a much better a field of coverage than the Riley LinkedIn. So she’s the Riley Link was like you had to bring the bag with you everywhere you went. But now in you know, if she’s in her dorm room, where she’s in our house, she can walk away from the orange link and still has a good connection to it. So that’s become less of an issue over time. And then I assumed we’re gonna go to the dash version and, and lose that. That.

So we never had the arrows here in Australia. So they finally got approved but never sold here. And then eventually they tried to sell but they decided to do it with the dash, they switched over. So the the reason that came to mind is I’ve been an iPhone user for well over a decade. But I don’t use the iPhone for my diabetes, I use an Android phone. So I’m carrying two phones, right? My Android, Android phone is like,

teeny, tiny. Yeah.

Almost the size of my palm, right. And it just had enough battery to run all day. And it’s doing all the stuff. It’s sitting in the background. And it displays an outdoor watch. So I can just see my CGM data at any point if I need it. Yeah, but I’m happy during that second device. Whereas some people come to these systems say I’m an iPhone user. I, I wouldn’t touch Android. That’s, that’s the dark side.

I don’t care about that. You’re basically using your controller as well just didn’t come from a company, honestly. Right by using

and in fact, it’s spades. way hidden in a pocket most of the times, I am a guy, I sometimes wear cargo pants, I have a lot more pocket options than many girls. I do understand this. Yeah.

It just doesn’t want to. I don’t know if you should say like the idea of holding two devices I eat if I offer two phones, she’d be like, No, I don’t I mean, I don’t know why you would. But I mean, she wouldn’t want to do that either. Like she just says she’s trying to be very minimalistic with what she’s carrying. So she’s doing a good job, her bag for diabetes is it’s tiny, it’s got a phone in it, that orange link, G voc meter, the Contour, Next One meter test strips, and, you know, some gummy bears and a juice box and she gets it all into this little tiny thing. It’s pretty crazy. But yeah.

And the other thing that came to mind was sort of paraphrasing. One of the other things we were talking about in terms of people look at the stuff that’s working for me with my hands free loop system. Let’s not loop with a capital hands free looping system. And say, Well, you don’t have to do any work. But then I can point it out to them and various friends of mine, who were there in conversations turn around, say Yeah, but he put in a lot of learning to get there. He did a lot of work early on to work out how to control it. And now he can take the benefit of hands free. So part of the the thing that we’re hoping to get out of things like this trial and other stuff is more knowledge about how to actually turn it on for people without them having to put in all that homework.

Yeah, no, that’s gonna be the next big step right is not having to understand the background to make it do all these amazing things. So I don’t know, like I’ve seen some people try to make that turn that into a business. I don’t know how well that’ll work out as time moves forward or not, but it seems it’s a weird thing to be involved in, you know, setting up a do it yourself algorithm to give somebody else insulin like it’s, I don’t know, it sounds like you’re gonna have to sign a couple of things and say, you’re not holding anybody responsible in the beginning. To get to that what you know,

well, I’m dealing with algorithms to give myself insulin. So if I make modifications to the code, which I occasionally do, it’s, I’m running them, I’ve got a bank of test phones and test pumps here that are running on a copy of my CGM feed to make sure they’re doing the right thing. And eventually, I’ll decide yes, I’m willing to run that myself. Don’t have to go through ethics approval once all sorts of stuff to do that. So when it comes time to running the algorithms through the clinical trials, that will give the evidence for it. Hopefully, at some point, a commercial company will say, Well, we will take that we’ll make a product out of that using that algorithm, which has been proven. So I hope that’ll I don’t care if someone makes money out of selling that. Yeah. Hopefully, it’d be nice if I can earn a living along the way, somewhere as as well as the help I need to do but the end goal is improving everyone’s lives. Yeah,

I always think that like, like when I’m how God what’s his name came along and said, We’re going to bring a version of loop to, to mark it. God white power, the

title tide pool?

I mean, I’m starting to feel like that’s so long ago, I can’t remember the word tide pool is easy to like, and I understand that. You don’t I mean, like I understand the processes. Is, is what it is. But I mean, by the time you get that thing through, there’s so many more versions of it, you think, well, you should have started with that one. You know what I mean? And I guess that’s also if you make that decision, you’ll never get to the end. But it is what’s exciting about people doing it in a in a do it yourself atmosphere is that, you know, I mean, something comes out and they go, Okay, we’ll adapt it, we’ll test it, you know, we’ll get a few people together, we’ll make a beta test out of it. We feel comfortable giving it out to people here, you know, give it a shot like that stuff doesn’t isn’t taking three years when it’s being done by regular people. So no.

So generally, the do it yourself stuff is always gonna be a little bit ahead in terms of features and functions. Sure, hopefully people do it in a safe way. Yeah. Many of us are keeping all the safety in mind when we’re designing this stuff. I’ve seen all the meetings, I’ve heard an endo stand up and ask the question, now that there are all these commercial systems available. Why would anyone why would you use it yourself system that you have to build yourself? And it’s because it’s current technology. It’s not technology from three years ago. It’s got it’s got more features. Not everyone will want to do this, but that’s why I do it. Yeah. There’s

no reason why we should take any kind of options away from people like I don’t care if it gets to Under Yeah, I guess

his his thought is, why do I need to deal with this problematic dry stuff now that there’s a commercial thing. So

I can see feeling that way, I can also see like, I’m not gonna lie to you, it’s still like going into I’m so bad at this, I don’t even know, the program on the Mac that runs the the simulator and then puts it on your phone is called Xcode, right? And so and every time I look at Xcode, I don’t know what I’m looking at. I know where I have to click, and I know what I have to do. But if you asked me to explain any of that to somebody, I’d be like, I don’t know what any of this is. And so I get not wanting to feel like that, because it’s uncomfortable. You know, I, I sent a complete, my daughter got a new, you know, got a laptop when she started school. And then got another one when she started college, and the one that she was done with after high school was shot, it’s basically useless. And she’s like, Well, what do we do with this, and most of the time, we would trade it in for credit or something like that, and try to, you know, make a little money off of it. I was like, keep it, we’ll put X code on it. And you can take it to school with you because Xcode wouldn’t even fit on the laptop that she had, along with all the other things she needed for school, I get not wanting to be involved in all that. But being able to text her last night and say, hey, it looks like you needed a secondary Bolus, or, you know, being able to look at a meal remotely and say, hey, the algorithm is struggling, because I don’t think it has enough autonomy, you should go back to the meal from two hours ago, and tell it it was 75 carbs, not 65 carbs, like that. And then all of a sudden the algorithms like oh, I didn’t know that. And then bang, it works. And like that kind of stuff is. It’s pretty great. I can’t lie about that. You know that stuff is? It’s pretty damn great. So anyway, David, this was really wonderful. I appreciate you doing this with me. I’m sorry. I kept you so long. But thank you very much.

It’s totally 2am

Well, that’s why you don’t know you’re half of you at this point. You’re just like, Ah, it’s all good. But

I’m a night owl. I’m a night owl. Thank you for the chat. No, I appreciate it. For people on the podcast. I

know I’m sure people are gonna love it. I really do appreciate you taking the time. And I know it’s hard to get on the show. And it takes forever. So thank you for being patient.

And people with can message me on the Facebook group on there?

Yeah, and and I wanted to say to your bionic wilkie.com. Is that right? It’s dot com. That is correct. Yeah. Excellent. So people can see some of the stuff you were talking about there. It’s great website. Well, I want to thank David for coming on the show and sharing all that great diabetes knowledge with us some really astonishing stuff in this one. Thanks also to touched by type one. Don’t forget to go to touched by type one.org and find them on Facebook and Instagram. Give them a follow. Check out what they’re doing. Long, longtime supporter of me and the podcast. Hope you can support them. If you’re enjoying the show, tell someone else about it. share this episode with them. Go find the private Facebook group Juicebox Podcast type one diabetes. And of course subscribe and an app. Amazon music, Apple podcasts Spotify wherever you get your audio you don’t I mean, Subscribe and follow. Thank you so much for listening. I’ll be back again very soon with another episode of The Juicebox Podcast.