#312 Fox in the Loop House - part I
Scott Benner
Kenny Fox talks Loop Management
Kenny and Scott talk about DIY Loop and type 1 diabetes. part 1 of 2
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DISCLAIMER: This text is the output of AI based transcribing from an audio recording. Although the transcription is largely accurate, in some cases it is incomplete or inaccurate due to inaudible passages or transcription errors and should not be treated as an authoritative record. Nothing that you read here constitutes advice medical or otherwise. Always consult with a healthcare professional before making changes to a healthcare plan.
Scott Benner 0:00
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.
Kenny Fox 2:50
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,
Scott Benner 3:11
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.
Kenny Fox 3:27
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
Scott Benner 4:15
test this diagnosis? Did you end up with a CGM and a pump?
Kenny Fox 4:21
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.
Scott Benner 5:22
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.
Kenny Fox 5:27
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.
Scott Benner 5:45
So it was an insurance thing more than
Kenny Fox 5:47
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.
Scott Benner 5:58
We're not gonna help you. Little did you know, back then they weren't gonna help you anyway, you were just
Kenny Fox 6:01
Yeah, right.
Scott Benner 6:04
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?
Kenny Fox 6:15
Um, yeah, so it was July and it's March now.
Scott Benner 6:20
So hold on August, September, October, November, December, January, February, March, that you're saying?
Kenny Fox 6:26
Yeah, the infamous got math.
Scott Benner 6:28
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?
Kenny Fox 6:40
I don't know. Probably. Yeah.
Scott Benner 6:42
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?
Kenny Fox 7:27
We did once when you were heading out to a conference, I want to make sure our didn't.
Scott Benner 7:31
Yes,
Kenny Fox 7:32
leave setup was all solid. Alright, so Okay.
Scott Benner 7:35
So here's what so has your path gone through the same iterations of this software that mine has pretty much right?
Kenny Fox 7:42
Yeah, yeah. Okay. All right. So,
Scott Benner 7:45
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?
Kenny Fox 10:25
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,
Scott Benner 11:57
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?
Kenny Fox 12:03
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.
Scott Benner 14:11
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
Unknown Speaker 18:17
at
Scott Benner 18:18
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.
Kenny Fox 18:37
That's pretty, it's pretty unreal. I wish my kids would sleep 12 hours and keep their blood sugar in range
Scott Benner 18:41
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.
Kenny Fox 19:05
What kind of override Did you set a higher or lower one?
Scott Benner 19:08
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.
Kenny Fox 19:25
School and weekends are just
Scott Benner 19:27
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.
Kenny Fox 21:37
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.
Scott Benner 23:09
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.
Kenny Fox 23:23
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.
Scott Benner 24:02
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.
Kenny Fox 25:26
Yeah, exactly. Meant to think like that.
Scott Benner 25:29
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,
Kenny Fox 25:53
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
Scott Benner 26:49
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?
Kenny Fox 27:43
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.
Scott Benner 29:02
Well tell me why you wouldn't just make the correction range 85 and 85. My top and bottom goals are 85 and 85.
Kenny Fox 29:10
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
Scott Benner 30:05
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,
Kenny Fox 30:13
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.
Scott Benner 31:12
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,
Kenny Fox 31:28
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?
Scott Benner 32:19
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?
Kenny Fox 35:52
Yeah, so hopefully I don't get in trouble.
Scott Benner 35:57
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.
Kenny Fox 36:05
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?
Scott Benner 36:17
Good. Tell me.
Kenny Fox 36:18
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.
Scott Benner 39:44
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.
Kenny Fox 41:52
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.
Scott Benner 42:27
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.
Kenny Fox 43:19
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.
Scott Benner 43:33
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
Kenny Fox 46:37
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
Scott Benner 47:03
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?
Kenny Fox 49:32
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.
Scott Benner 49:41
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
Kenny Fox 49:51
Oh, yeah, that
Scott Benner 49:52
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,
Kenny Fox 50:05
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.
Scott Benner 51:10
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.
Kenny Fox 51:32
Well you have that loop pill right underneath the time underneath the clock.
Scott Benner 51:37
Right. Okay, let me
Kenny Fox 51:38
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
Scott Benner 51:58
I see the loot pill so right now I have four minutes ago squiggly squiggly line 103 what is squiggly line 123 mean?
Kenny Fox 52:06
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.
Scott Benner 52:20
It is I'll be
Kenny Fox 52:21
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.
Scott Benner 52:42
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
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