Scott Benner 8/16/19 Scott Benner 8/16/19

#253 Defining Diabetes: Non Compliant

Defining Diabetes: Non Compliant

Scott and Jenny Smith, CDE define the terms at the center of your type 1 diabetes care

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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
Defining diabetes is made possible by Dexcom on the pod and dancing for diabetes, please remember that nothing you hear on the Juicebox Podcast should be considered advice medical or otherwise the Always consult a physician before becoming bold with insulin, or making any changes to your medical plan. Today, Jenny Smith and I will define and then break down in a little more detail, the term non compliant. We did a bunch of definitions. And they've been running Friday's just these little short episodes and people seem to be enjoying them. So far, we've we've done a lengthy time and range, Bolus bazel. Pre I think we've done Pre-Bolus honeymooning, a one C. And I was wondering, there's, there's one I want to kind of slip in here. Because I want to understand it from a clinicians point of view, this is going to be something that it's funny, I don't really think of this as a real thing. I guess I'll say what I think about that in a second. But when your doctor or a nurse or a clinician or someone they call you non compliant, from a medical perspective, what are they saying?

Jennifer Smith, CDE 1:10
Oh, that's a can of worms there,

Scott Benner 1:13
right? It's a beehive, right? But we're gonna, we're gonna pick through this, there's a tiny bit of noise behind me for the first minute or so maybe it's the beehive.

Jennifer Smith, CDE 1:23
Unfortunately, it's commonly still a term that's used as used in regard to a person who does not take a prescribed medication or follow a prescribed course of treatment that the clinician has told them to follow. That's kind of in a nutshell, that's non compliance. Now, if that's the case, as I say that every he died, he presented people with diet type one diabetes, especially, are probably non compliant. Quite honestly. And and I'm not saying that I mean, I am technically, if I were to be considered by my endo as following every rule that he told me to do, and free adjustment, I am not in compliance then. Right. Because I fortunately have I've got a good endo, who is very, you know, happy and willing to work and talk with me on an educated level, and we discuss back and forth. But non compliance comes in when the doctors like set these bezels, or they grab your pump, and they set the bezels for you, and you walk out the door and in your car, you're like, Nope, I'm gonna turn on.

Scott Benner 2:33
Because I know more than the doctor knows. Right. And so technically, you would be called non compliant, right? I it's a very bad term. It's a bad term. It's horrible. It gets hurt is trying, right? Like you're not trying, you're not wrestling. So I think there's a way to get through this. Okay, so best intentions for this just being a definitions episode, it sort of turned into a tiny conversation goes on in about five more minutes, I'm going to cut the music out of the background and let you keep listening. I think that it gets used a few different ways. I think that, that when you hear it as the patient or the parent, it sounds like it sounds like you're you're being jumped on it. And you might be because a bad endo will call you non compliant. If you're not having the results that they want you to have. They never stopped. They think that their direction may not have been very good, right? Like, you know, you told me to do this. And because you're sitting across from the gun, look, I did what you said. But it didn't work. That doesn't make me non compliant that makes what you said, non valuable. Right? Right. Like you gave me You gave me invaluable information, I followed it, I didn't get anywhere you don't know what to say next. So you call me non compliant, there is a medical term for it. For Non compliance. It just means like you said, like, you know, if a doctor tells you to take this pill, you know, every six hours and you don't do it, you're non compliant. You're not you're non compliant for the purposes of their reporting and your notes you were non compliant with with what needed to be done.

Jennifer Smith, CDE 4:08
And I think in terms of diabetes, unfortunately, the fact is that they have a set of goals that they need to check off and want to check off as far as what they've gone over. Many times I feel like they use the term non compliant because they've not physically asked what are your goals? What do you want to work on? What are you trying to achieve and manage and take care of? And if that's not addressed, then of course, you're going to look non compliant because they didn't help you with what you actually needed help with to begin with. So why should you pay attention to what they told you to do?

Scott Benner 4:43
Right percent. I've had somebody tell me they were called non compliant because their blood sugar their agency was six and a half and the doctor told him they didn't want to under seven, they call them non compliant. I think it's just something people throw around. It's a horrible it's a stick to hit people with, you know what I mean? So I think I think that when it Doctor calls you noncompliant because you're not having the outcomes that they want you to have. That's a false narrative. That just means you don't I mean, my experience now for this podcast, if you have the right tools, you can do it. If you have the wrong tools, it doesn't work out, you know, like, you can want me to do what you want. All you you have any idea how many you do, Jenny, Jenny does, I'm talking to all the rest of you, you have any idea how many people I talked to whose basal rates are so wrong, they couldn't possibly get good blood sugars, there's just no way for it to happen. And then they go back to the doctor and say, Look, you know, I'm 200 all the time, but I had this bad low, and sometimes the doctors back there bazel off more like, Oh, my God, it's going the wrong way. And then that same doctor will call them non compliant at some point,

Jennifer Smith, CDE 5:46
right? I think to help with it is,

even if you have no idea where to start and what you need help with, that's important to tell the doctor then I know something is wrong, I need help, or I know something's wrong, every time I go and take a run something is wrong. So you're giving them a focus area, you're giving the doctor something to say, Well, I can educate you about this. So I can give you strategic, you know, I guess guidelines to help with this. And we'll take a look at how it helps the next time. Unfortunately, a lot of times people come into their endo, and they expect the doctor to just say, well make an adjustment here make an adjustment here, oh, I'll see you in three to six months again, well, you're not giving the doctor any direction either then to be able to help you and your goals. And you

Scott Benner 6:33
by the way you could be there are people who are non compliant, by the way that that would be a way to address. And then there's going to be people to who psychologically for reasons of anxiety or stress or depression can't follow through to call that person non compliant. That's criminal, you don't mean so doctors really need to hear that there. There are other ways and better ways to address people and that no one wants to be called non compliant. That's a nice little technical word you use in your reports that shouldn't be said out loud to somebody. If that those weren't words meant for the patient. Those were words meant for your notes.

Jennifer Smith, CDE 7:11
And I don't even think they should be used in the notes. because quite honestly, then another clinician may come in later and think well noncompliant. Gosh, this person is not doing anything that we said. And that may not be the case. Instead, documentation needs to be more specific. It means to say, Well, you know, I talked to the person today because it appears in the records that they're they're missing boluses based on their CGM data, why are they missing boluses this, this topic was discussed, oh, I found out that they're really worried about low blood sugars, they have a high risk job, they've got something else going on. We discussed this, this is more of a psychological we need to overcome this isn't they don't want to take their medication the right way. This is they're trying to figure out a way around it or avoid something else happening.

Scott Benner 8:01
Right? details need to be added? 100% correct. It's just something that gets bandied about. And as if it covers all these different things. And really, it only speaks to one specific situation like like, and then it gets it gets. It gets attached to all these other people and their scenarios, and it just doesn't fit and it's hurtful. It's hurtful to have somebody tell you when you're trying so hard at something for someone while you're not trying. You're like man, you didn't give me any tools. I'm still I'm beating my head against this wall. I'm getting nowhere and you're gonna yell at me afterwards. Why am I coming here? You know, so that's all. I'm only gonna make you do that one today, Jenny, because that one was hard. Oh,

Jennifer Smith, CDE 8:41
that's a good one. No, very, very, very good one, I think.

Scott Benner 8:45
You know, I was looking online for medical definitions of non compliance and everything matches up with what Jenny said. But this one is interesting, it goes on cancer the initial definition to say, the cause or causes may be difficult to ascertain. The patient or client may have values and beliefs about health that are different from those of the healthcare provider or there may be other conflicts in the relationship that work against following the advice offered. In some cases, the patient or client may not have the financial resources, family support, physical ability or emotional stability to perform the prescribed tasks, poor self esteem, negative side effects of drugs and other forms of treatment and lack of progress, after adhering to their prescribed regimen can also lead to non compliance. Since it is assumed that the individual has sufficient knowledge to make the informed decision, lack of knowledge is not considered a likely cause of failure to comply. But that doesn't kind of count for diabetes, right? Because you can tell somebody something it doesn't mean they understood it. The nurse also should be aware that the patient or client may have the necessary knowledge and resources but have made an autonomous decision not to imply that someone Complete idea. I hope you enjoyed this episode of defining diabetes. Remember that it was brought to you by Dexcom on the pod and dancing for diabetes, there are links in your show notes if you'd like to find out more about them. As always, I appreciate you downloading the show, sharing it with others, leaving reviews and all the good things that you guys. I'll see you next week for the next episode.

Defining Diabetes Series

#964 Defining Diabetes: Carb Ratio

#830 Defining Diabetes: MDI

#826 Defining Diabetes: Meet the Need

#818 Defining Diabetes: DKA

#814 Defining Diabetes: CDE and CDCES

#810 Defining Diabetes: Untethered

#795 Defining Diabetes: Kussmaul Respirations

#681 Defining Diabetes: Types of Diabetes

#677 Defining Diabetes: Hypo and Hyper

#672 Defining Diabetes: Antibody

#668 Defining Diabetes: Carb Absorption and Digestion

#664 Defining Diabetes: Dictate the Pace

#660 Defining Diabetes: Black Holes

#656 Defining Diabetes: Barriers

#652 Defining Diabetes: Pump Break

#648 Defining Diabetes: Insulin On Board

#466 Defining Diabetes: C-Peptide and Beta Cell

#463 Defining Diabetes: Crush It and Catch It

#460 Defining Diabetes: MODY Diabetes

#455 Defining Diabetes: LADA Diabetes

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Scott Benner 8/12/19 Scott Benner 8/12/19

# 252 A Loopy Few Months

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Scott Benner 18:57
bolder, not as more

Unknown Speaker 18:59
or less.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Scott Benner 55:53
But

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

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

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

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

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

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

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

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

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

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

Right? Like I just want an overview.

Yeah, follow up

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

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

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

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

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Scott Benner 8/9/19 Scott Benner 8/9/19

# 251 Defining Diabetes: Algorithm

Defining Diabetes: Algorithm

Scott and Jenny Smith, CDE define the terms at the center of your type 1 diabetes care

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Scott Benner 0:00
No Jenny in this episode of defining diabetes, but that's okay, I can handle it. In today's episode, I'll define the algorithm. Defining diabetes is made possible by Dexcom on the pod and dancing for diabetes. Please remember that nothing you hear on the Juicebox Podcast should be considered advice medical or otherwise, the Always consult a physician before becoming bold with insulin, or making any changes to your medical plan. The word algorithm isn't really thought of as diabetes specific, but in the coming months and years, it's going to be the general definition for algorithm is a process are set of rules to be followed in calculations or other problem solving operations, especially by a computer. In Webster's definition, it expands this a little bit, a procedure for solving a mathematical problem in a finite number of steps that frequently involves repetition of an operation, more broadly, a step by step procedure for solving a problem or accomplishing some end. Now, why am I choosing in the middle of all these diabetes definitions to tell you about algorithm? Well, that's simple. In closed loop systems, algorithms are the brain, for example, on the pod is working on their horizon system that they expect to have out in the year 2020. It's a hybrid closed loop system that uses an omni pod, a Dexcom, G six, and an algorithm. This algorithm is designed specifically to take the information from your Dexcom G six be information about your blood sugar, what it is how fast it's moving, what direction it's going, this algorithm takes that information, goes through a bunch of settings, and decides this is how much more or less insulin you need to maintain a steady, stable time and range to avoid a low blood sugar to stop a pending Hi, this algorithm is going to make all of those decisions. So I think it's incredibly important that you know what an algorithm is, because you're gonna be hearing the word a lot. Now be clear about what an algorithm isn't. It's not a fortune teller, it can't see the future. It doesn't know something's going to happen before it does. It can only make decisions based on the settings that you tell it. What do I mean by that, if you're setting say that your insulin to carb ratio is, you know, one unit covers six carbs. And your Basal rate is definitely two and a half an hour. And you count your carbs up and you say, Okay, this is 50 carbs, algorithm. Here it comes but your way wrong, it's 100 carbs. But the algorithm believes you that it's 50 carbs, and it believes that it knows what your insulin to carb ratio is what your Basal rates supposed to be. And so it is possible that it won't be able to stop that high blood sugar, not right away, but eventually it will see that it's happening. And we'll get on it. But it's not a mind reader. It's not a catch all. It's not going to fix everything. These algorithms, however, are in their infancy right now within the diabetes community. And from what I've seen already from a number of them, they're spectacular. So I think it's worth you understanding what an algorithm is, as I believe they're going to have a large part in the way you live your life with type one diabetes in the future, the not so distant future

the T shirts that you've all been asking for and the other swag is now available at juicebox podcast.com. Scroll down, click on merch there you will find T shirts, flip flops, Kid shirts, coffee mugs, stickers. Really nice quality tote bags are always going to be adding more. Right now you can get a shirt that says bold with insulin, stop the arrows be bold, and the brand new Juicebox Podcast logo designed by one of you. Coming soon bumping nudge more insulin and the other phrases from the podcast that you use in your everyday life. So support the podcast. Remind yourself to be bold, grab a t shirt, all you have to do is go to juicebox podcast.com. As always a sincere thank you for listening for supporting the show for telling others about it. And I'll tell you what, I'm not even going to ask you to leave a beautiful review on Apple podcasts or wherever you listen because I've already asked you to buy a t shirt and it would be too much to ask these two things of you. That's what a good person I am. Hey, last thing, this algorithm episode of the finding diabetes it's not you know timing by mistake or anything like that sort of on purpose because going to be talking about something you guys have all been bugging me about for months. Next Tuesday So enjoy your weekend and get ready. The podcast episode you asked for is on its way

Defining Diabetes Series