#1489 Fox in the Loop House: Part 6
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Understanding Insulin Sensitivity Factor
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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
Friends, we're all back together for the next episode of The Juicebox Podcast. Welcome,
guys. Kenny Fox is with us again. You can find Kenny at Fox in the loophouse.com and today he and I are going to talk about the loop algorithm and understanding insulin sensitivity factor. Nothing you hear on the Juicebox Podcast should be considered advice medical or otherwise, always consult a physician before making any changes to your health care plan. Don't forget to save 40% off of your entire order at cozy earth.com All you have to do is use the offer code juice box at checkout. That's Juicebox at checkout to save 40% at cozy earth.com AG, one is offering my listeners a free $76 gift. When you sign up, you'll get a welcome kit, a bottle of d3, k2, and five free travel packs in your first box. So make sure you check out drink AG, one.com/juice, box. To get this offer. Are you an adult living with type one or the caregiver of someone who is and a US resident? If you are, I'd love it if you would go to T 1d, exchange.org/juice box and take the survey. When you complete that survey, your answers are used to move type one diabetes research of all kinds. So if you'd like to help with type one research, but don't have time to go to a doctor or an investigation and you want to do something right there from your sofa, this is the way t 1d exchange.org/juice, box. It should not take you more than about 10 minutes. This episode is sponsored by the tandem Moby system, which is powered by tandems, newest algorithm control iq plus technology. Tandem mobi has a predictive algorithm that helps prevent highs and lows, and is now available for ages two and up. Learn more and get started today at tandem diabetes.com/juice box. The show you're about to listen to is sponsored by the ever since 365 the ever since 365 has exceptional accuracy over one year and is the most accurate CGM in the low range that you can get ever since cgm.com/juicebox, Ken, welcome back. Hey, Scott. What are we going to talk about today? I just, I decided with you, I'm just going to say what are we going to talk about today? And let you
Kenny Fox 2:34
take the wheel. You got it all right. So I think I want to talk about ISF. We covered basal and then meals, and we didn't talk about the carb ratio last time as much. But I think people have a pretty good understanding of I want more insulin for the first few hours of my food, and it can tweak the carb ratio from there. So really, what's left is in terms of main like core settings, we'll talk about ISF, which is insulin sensitivity factor. That one is, I think, one of the more misunderstood variables. I've heard doctors and other folks talk about it in the same way they talk about basal when they don't understand something, when they understand why you're high. A lot of people go to, I don't know, let's just change the basal. Once you get into looping and you can wrap your head around basal changes, it often becomes, well, ISF is even more mysterious. I don't understand this one, so let's change that one. If stuff's not going the way I want, that's a little bit tricky of a situation when you're when you're like that. And so we'll try to demystify that a bit more. Okay. Do you find that same problem when people are not understanding it's easier to see when they first start out, but they start attributing certain problems that from an experienced person don't make sense, but they just start messing with things because they don't under it's the thing they least understand.
Scott Benner 3:47
I think that you get frustrated and they just start turning knobs, pushing buttons. That's fair. I think they don't know why they're doing what they're doing honestly. And listen, in fairness. There are times when I make adjustments and I'm like, I think this might be it, but I'm not 100% certain. I mean, look, can I look at basal and say, you know, at times where there's no active insulin and no food involved, and can I look and say, Hey, her blood sugar has been sitting at 110 at this time of night, for example, really consistently. I'm gonna, like, tweak the basal here and see what happens. Yes, right? But it's harder to see, like, insulin sensitivity stuff and correction factor like that. I think is harder for people to see. Do you not agree that one? Yeah,
Kenny Fox 4:33
yeah, I agree. Because I think basal we can, I think, relatively quickly, wrap our heads around, especially at night. That's a nice one. Sensitivity is a challenging one, also, because when you first get diagnosed, you're talking about making corrections. So you like, here's your long acting or your basal settings, here's a carb ratio to start with, and then here's this correction factor, or this number you'll use to calculate how much extra insulin to give if you end up higher. Then you should be a few hours after eating, or just a few hours after your last dose. What happens is, we take that idea over to an automated system like loop. One of the things loop is doing is it's making those small adjustments. If you're if it thinks you're going to end up a little higher, a little low. It's doing that every five minutes, so you end up needing to use a number that's much larger than the number you might use when the doctor says, Hey, try this out. You know, you consult that number couple times a day. You're not looking every five minutes. You're looking every couple hours to see if you need to make a correction, potentially, and using that number then. So I think that's a one, one big difference between the idea when you use it or shots or MDI, or even standard pumping, versus using it in a system like loop. You
Scott Benner 5:48
know, when people get put on a regular system where they're doing MDI, and someone says, We think that one unit moves your blood sugar, I don't know, you know, 200 points, so your insulin sensitivity is 200 Sure, they probably try that in the beginning, right? They're probably like, Oh, my kids, got a 300 blood sugar. I want it to be 100 I'll put in a unit, because they said it moves 200 doesn't take you long to figure out that, like, higher blood sugars kind of need more insulin, okay? If that's true, and I want to move 50 points, and I need a quarter of unit, that usually works if I'm, you know, I'm 100 and I'm 150 and I want to be 100 a quarter of a unit kind of moves me that way. But you don't really see the full picture or the full value until you're on an algorithm, and that thing isn't making these big, sweeping decisions like that, like, you know, I'm trying to move a number this, you know, 200 points when it's trying to move a number 10 points, when it's trying to move a number 20 points, and there's a fraction of an amount of that insulin, like, there's where it becomes, I mean, another level tool, because you're never going to, as a person with a syringe or even with a manual pump, say to yourself, I want to move just this much, and it's 15 points, and my pump is not even set up to, like, correct that Number. So I don't think it comes into people's minds that often. Yeah, and
Kenny Fox 7:03
you're probably going to wait and see how things settle before you make a decision to add more or take away right insulin. So yeah, that makes sense. You're just not going to make the decisions that fast. One, because you have a life to live. And two, you do need to let stuff kind of play out. And there's so much very variability that in food or whatever else is going on that doesn't make sense for you to try and do, you know, quarter unit or 10th of a unit, two weeks all the time,
Scott Benner 7:27
even if you were a machine in your mind, and you could make sense of that bigger picture, you can't take insulin away in a manual pump. Well, you can, but now you're setting, like, Temp Basal offs and, you know, but if you're MDI, you're you're done, like, the insulin is in, it's in, right?
Kenny Fox 7:41
Yeah, you're not gonna set a 30 minute half hour, 30 minute Temp Basal off, and then come back and check it again, and then you end up a little high. So you're not gonna play with it that often, like a system would. And I
Scott Benner 7:51
think for those reasons, that's maybe the least considered setting sometimes for people, and it ends up being very important. Yeah, I agree. And once you see it work on an algorithm, you level up your understanding of it too. Why would you settle for changing your CGM every few weeks when you can have 365 days of reliable glucose data? Today's episode is sponsored by the ever since 365 it is the only CGM with a tiny sensor that lasts a full year, sitting comfortably under your skin with no more frequent sensor changes and essentially no compression lows. For one year, you'll get your CGM data in real time on your phone, smart watch, Android or iOS, even an Apple Watch predictive high and low alerts let you know where your glucose is headed before it gets there. So there's no surprises, just confidence, and you can instantly share that data with your healthcare provider or your family. You're going to get one year of reliable data without all those sensor changes. That's the ever since 365 gentle on your skin, strong for your life. One sensor a year that gives you one less thing to worry about, head now to ever sense, cgm.com/juicebox, to get started, let's talk about the tandem Moby insulin pump from today's sponsor tandem diabetes care. Their newest algorithm control, iq plus technology and the new tandem Moby pump offer you unique opportunities to have better control. It's the only system with auto Bolus that helps with missed meals and preventing hyperglycemia, the only system with a dedicated sleep setting, and the only system with off or on body wear options. Tandemobi gives you more discretion, freedom and options for how to manage your diabetes. This is their best algorithm ever, and they'd like you to check it out at tandem diabetes.com/juicebox, when you get to my link, you're going to see integrations with Dexcom sensors and a ton of other information that's going to help you learn about tandems. Tiny pump that. Big on control tandem diabetes.com/juicebox the tandem Moby system is available for people ages two and up who want an automated delivery system to help them sleep better, wake up in range and address high blood sugars with auto Bolus.
Kenny Fox 10:16
In our previous talk, we discussed a lot of variables that I think you made a good connection of. It's really applies to however you manage. If you can start to understand those, we start to remove what I kind of call the fog, and you can really see what the settings need to be, because you're like, Oh, well, I'm high because, oh, I forgot to handle fat and protein to my meal or basal was off last night. So it's probably not going to be so great today, things like that. Maybe your pump site is not working as well as it could. So that's going to be once you remove all of those. Then we can talk about sensitivity. And we talk about sensitivity, the number is, I'll use the word points. I like using the word points as well. How many points is your blood sugar going to move given one unit of insulin? And what you need to remember is you need to consider the entire runtime of that insulin, or the duration of it, which should be about six hours, and loop models that so to do an ISF test, you'd have to get kind of high, have really good basal, have no other fat and protein going on. So it's really got to be quite a few hours since you ate last, and then give half a unit, or a unit, and then wait five, six hours, see how far your blood sugar drops. And then you can, if you did a half a unit, you'd have to, you know, double it to get to the right number. And so it's a really difficult test to do, because who really wants to sit still and have really perfect basal for the, you know, first for a 678, hour duration. You know, it's interesting
Scott Benner 11:42
when you talk about it in context of the algorithm, of any of these algorithms, right? Like it makes so much sense, because you know that that those little machines are tracking all of the different boluses and all of their different outcomes and and making sense of them when you try to imagine doing that manually. I mean, you can maybe keep track of a couple like, you know, like I Bolus at 8am for breakfast, then I Bolus again at 10 o'clock for this, and then I had lunch at one. At one o'clock, I'm five hours after the eight o'clock Bolus. Like no one's in their mind juggling all that anymore and all the implications and the different timelines that the insulin is running on it's why all these systems are just so next level. So I would need a computer right now, if you're looking for that kind of control and that kind of consistency, then, yeah, I mean, you need something smarter than you to track it. That's for sure, smarter than me, for sure. We
Kenny Fox 12:35
talk about points, just in case people aren't tracking we're talking about milligrams per deciliter for those using Imperial numbers and millimoles for those that are not. And it's an easier way to say it, because if you start trying to talk about the ratios here in an audio setting, you're not going to be able to track all this stuff. So I have a video that's been up on YouTube about how ISF affects carb absorption, and we're gonna talk about that here in a second. So you guys can go see that a few more visuals. But the big challenge we have when we talk about using ISF, or figuring out ISF in loop is one, you first have to shed the idea that it's the same number that I'm going to use like I would if I checked my blood sugar every couple of hours and was high and wanted to nudge blood sugar down. And two, it's going to be even bigger. If you think, Well, how much will my blood sugar come down if I dose the unit and waited six hours when I really didn't have any of these other things we've been talking about active that's when it's like, Oh, I'd probably come down quite a bit. The ISF number you'd think of would be a fairly large number, which means you'd move a lot of points given one unit of insulin compared to what you'd use in a situation where you're high, you're usually addressing something like food or some other issue where you do need more insulin. I think a lot of people, at least those that listen to the podcast, get a very intuitive sense, after some practice, that even if they don't know what that variable is, they might need a decent amount of insulin to bring it down, or may want to bring it down sooner than six hours. So what loop is looking at is is a much larger number than what you're used to. When I see people bring over their settings from a previous pump set up, it ends up causing a little bit of problem because the number ends up being too small. And it's not a problem always of too much in terms of a correction, like getting high, and the loop just gives too much insulin. That does happen. But I think a more common situation is it's just a little bit too strong, a little bit too small of a number, and it negatively impacts how loop tracks meals. And that's really like the in my mind, the largest or most significant thing that ISF does during the day. But before we dive into that, it's easier to talk about the easier situation, which is night time, like you talked about identifying basal overnight. At night, you're not running around, you're not eating anything. You might have some some hormone stuff going on overnight, but it's not as significant. So what I like to do is all use ISF overnight, and I'll often make it a little bit stronger, so where I get the system to respond the way. I would, which is you have a little bit too much insulin, enough insulin that after six hours would probably make you a little low, but not so much that once your blood sugar starts trending down, Luke predicts, Oh, this isn't going to go well. We're going to go low, and it starts turning off the basal. And so it's kind of like a like a mild crush and catch situation, like you talked about here.
Scott Benner 15:19
Is it easy to go too far with that, to where it can't catch it.
Kenny Fox 15:23
Yeah, I think it, I don't know. It's super easy. If you move things in steps of 5% 10% at a time, and kind of nudge the numbers down, then I think you end up being in a situation where that's not going to be the problem. One thing to look for is if you see, even if your basal is not perfect, but if you see loop giving Bolus is and then start dropping, and it's not turning the basal off to be able to catch it, it just goes down so fast that even though it turned off the basal, it couldn't catch it. And again, there's no obvious basal problem. Then, yeah, you'll need to back it off a bit. Okay, that said, I think for other systems like Android APS or trio that use the O ref based algorithm that's different from loop. I think it works better, from what I've heard, to use a single sensitivity number across all 24 hours. And I think you could do that with loop too, if you had pretty good basal and we go with a number that works across both day and night. I think you can do that, but I'd like to use slightly lower numbers at night, just in case things go wrong, like Tessa has a basal increase need and she starts kind of drifting up. And I want loop to kind of keep it contained, to keep it from getting up over maybe 121, 30, even if it's like a big change in basal needs. And so I just give loop a little more permission to kind of hammer out that blood sugar, but starts to drift high, but if it starts causing any problems and it can't catch the resulting drop, then definitely back it off. It's definitely the safest thing to do is to leave it as a larger number overnight, rather than smaller. You know,
Scott Benner 16:51
you talk about pretty frequently the idea of giving loop the autonomy to make a more aggressive move if it needs to. But I think that could be confusing to people. So like, if they're wearing a regular pump, and their basal, empirically, is one unit an hour, we just know that it is, you know, for the conversation, if they make it 1.25 an hour, they're going to get low pretty quickly in a couple of hours. If you tell loop, you know, if you're saying to yourself, I think my basal is one an hour, but you tell loop it's 1.25 Are you saying that loop is going to push, push, push until it sees a low and then take it away and then next time not push is hard because you've given it like a wider decision tree to use right like, as far as the amount of basal goes. But it doesn't necessarily mean it's going to use all of it.
Kenny Fox 17:36
Basal is tricky. Basal, unfortunately, with the way loop is built. Right now, if the basal is off, if you went with a one and a quarter instead of a one heat at an hour, at some point, you're very likely to go low, because loop is assuming that the insulin on board that it sees of, let's say zero, is going to keep you flat. But if your insulin, if your basal is too high, you're going to just start drifting down and loops like, Well, no, you should be straight, and you keep dropping. It's like, No, you should be straight and you keep and you keep dropping. And then if you look like you're going to drop below the glucose safety limit, then it starts to turn the basal off, and you start to get negative insulin on board. But it's still always like, Well, you said basal was one and a quarter, and we now have negative insulin on board. You're going to go up. And so as soon as you do start coming up, when you treat the low, then it comes back. You end up hit. You end up getting over treated. Yeah, so basal is a tricky one. That's not as safe a one to overstate, there's some work being done right now about trying to adjust how the negative insulin on board affects the prediction so loop doesn't think you're gonna come shooting up and then hammering you with us quite as much insulin and send you back low. But yeah, there's not a lot of forgiveness in the system, as it's designed today, around basal. This is why I like to turn down the sensitivity, because it only comes into play if your blood sugar, you know, is higher than the defined range. Basically, if you're high, if you're low, or you're in range of where you told the system you want to be, then the there's no correction or sensitivity nudges that need to happen so it stays out of the way, so it's a little safer in that sense, that you can hover around your range, and it's not going to just all of a sudden shoot you down low, okay, but if you start creeping up a little bit, it can nudge a little bit with sensitivity number. I just
Scott Benner 19:13
want to make sure people understood that, so you can't just tell that. You know, I know my basal is one, but here take more in case you want to use it a different way. It's not going to work that way. It's going to push you too low. Going to push you too low. Correct with sensitivity, though, if you say a unit moves you 100 points, and you then come back and tell them, like, hey, you know what? Instead, like, let's say a unit moves you a different amount, so that you have a little more autonomy in here. So if you wanted it to have more autonomy, and you were one unit moves you 100 points. Would you want to make it one unit makes you 90 or moves you 110 to make it more aggressive?
Kenny Fox 19:48
More aggressive would be 90, the smaller number. And the nice thing is, loop has other pieces to its prediction, one of them being momentum. So if you're if it does. Does get you with an amount of insulin for the 90 and you start dropping, loop does presume, oh, well, you're moving down. You'll probably keep moving down a little bit. So that tends to push the prediction down a little bit lower, faster. So it's not going to just give the 90 dose and then wait for it to settle. If you start moving down right away, it's going to try to pull back. So that's why it's a little bit safer to do. But more aggressive is definitely a smaller number that you'd pick.
Scott Benner 20:25
Okay, I just listen. I want to be clear. I know that I just wanted to say it out loud so that people could hear it right. Because I get the idea of like, oh, I want to give it a little more, a couple more bullets in its bag if it wants to pull it out and start and start shooting. It doesn't work there. Now this might be, I don't want to get too far off the course here, but if your insulin to carb ratio is, you know, one unit covers 10, you know, you change it to one unit covers nine because you want to be a little more aggressive, that's still a thing that the loop could probably adjust within. Is that fair? Yeah,
Kenny Fox 20:56
we talked about meals before. And so if your blood sugar starts to, let's say nine. One to nine is too much, and you'd have drifting a little lower. There's still kind of speed and momentum pieces that we'll talk about more detail later. But moving here, where loop would be like, Oh, you're running a little lower. We should probably turn the basal off, and then you still have the the time window, the absorption time we talked about, that loop will expect that food. But if the nine is too much compared to the 10, you might run a little lower, but there's a chance that you might not go low, and that loop will maybe give you a little bit too much insulin here and there, but still maybe catch it. And then when that time window runs out, it's like, okay, well, we're done looking for those carbs. So it can cause a problem, but it's less likely I think, okay, I appreciate you
Scott Benner 21:39
going over that with me. Go ahead, please go back to the course you were on when I took you off course.
Kenny Fox 21:44
The sensitivity stuff's good. The other thing to remember about, about the sensitivity is that when actually, when loop doses, let's say automatic Bolus, when it gives the insulin that it thinks you need at nights. And use the example, it's only going to give a fraction of that. So if we're using a one to 100 and you end up drifting up and it wants to give you, let's say the recommendation is as much as a half a unit. It's only going to give a fraction of that. So the default setting would be, like 40% so less than half of that half unit, so like little less than a quarter unit, is what it would give. And then the next time, it will only give 40% of what's left of that recommendation. And if your blood sugar starts to curve and starts or start to come down, that recommendation will kind of disappear or will drop significantly at any given point, loops not really giving all of the whole one to 100 or one to 90 sort of sensitivity calculation, which is good, and this is also a good time to mention that there is a algorithm experiment, piece of loop, like an extra little algorithm, modification you can use that will change how that dosing occurs. It will either do 40% which is the standard automatic Bolus, or this one called glucose based partial application, which we referenced before, but it gives a smaller percentage of that recommendation when your blood sugar is closer to your defined range versus and then as you go higher, it'll give a higher percentage of that recommendation. So even though you're dialing down the sensitivity, it's never really going to give all of the insulin right away. So that's the other reason why you can say, well, if I turn it down a little bit lower than maybe it should if you were to do a full six hour test or something, there's a lot of play in there, because the system is not going to deliver in its confidence, not going to deliver everything. So it has time for your blood sugar to start to level out or start going down, and then take appropriate action. So it's something to remember. We're talking about sensitivity, and why I think it's kind of forgiving, especially at night. Yeah, to dial it down. Okay, thank you. Daytime is the trickiest part, and honestly, probably the more important one. What's interesting that I learned a couple years ago from some people smarter than me is that, if you take the sensitivity and you divide that by your carb ratio, and we'll talk about all the units, it gets a little crazy. You end up with, instead of a nice sensitivities of points per unit and carbs is grams per unit, per unit per gram. I forget which one, but if you divide the sensitivity by carb ratio, you end up getting a points per gram, which basically says, if you have one gram of carbohydrate, how many points is that expected to raise your blood sugar? And so now operates off this assumption that a certain amount of carb is going to raise your blood sugar a certain amount. So if you ever go into loop and you enter 10 grams, and then you see the prediction says you're going to go up to a certain number, let's say 500 that's the assumption, if you don't give any insulin. And I always wondered, how did it come up with that number? Well, it's using your sensitivity divided by your carb ratio. And so with that expectation, when your blood sugar does go up after you enter a meal and start eating, as your blood sugar goes up, loop says, Hey, that rise equates to this many carbs. Now. Says, Okay, let's say it's five carbs. It's going to subtract five carbs from the active carbs, from the carb entries we discussed last time. And so that's how it's one other main piece, how it's subtracting the active carbs, or the carbs being absorbed, as the other term loop uses. It's tracking the meal progress based on how much your blood sugar goes up, is one of those major components. So if you have your sensitivity set to too small of a number, this affects your points per gram. The short version is, without trying to talk about all the units, because you really got to see it on the page, is that when your sensitivity is too small, loop sees a lot more carbs when it goes up. And the picture I like to give is a small child might have a sensitivity of 200 or more, and you give them one Skittle, and their blood sugar pops up maybe 15 points for that Skittle, you grab a middle schooler or high schooler, some bigger person, give them a Skittle and their blood sugar is long gonna pop up a couple points. They just don't go up as high for each gram you give them, or we discussed before. You know, you used to have to save Tessa from a low with just a couple grams, and now it takes quite a bit more if she's going low with any substance. I think that's an important concept to wrap your head around, that the less sensitive you are to insulin, the smaller that sensitivity, the less sensitive you are to carbs as well. There used to
Scott Benner 26:18
be times where I'd be like, just drink a quarter of this juice box. That's all, yeah, take three sips. That'll fix it. Now I'm like, just here. Just drink it. Drink the whole thing, yeah, just drink this, and then we'll see what happens. And we've talked about it already, I think, but just over, like, go over it again, mostly that's body mass, or it's also the amount of insulin you think. Do you think some people are just making more insulin as they're younger or more newly diagnosed, and then that goes away over time too. Like, what are all the variables that you think impact
Kenny Fox 26:47
that? Yeah, that's a good question. I think, I think it's all of those things. I think when Tessa was younger, she probably still had some beta cell function. There's even times, I think recently, it's been a while since I've seen this, but I thought I would try to get an ISF test in while Tessa was sleeping. I just give her some of her like, honey. I give her at night, while she's sleeping, she'd never wake up and her shoot her blood sugar up, and then I could give her some insulin and kind of see how far she comes down, you know, maybe, like, three in the morning or something. And I've seen it where I give her the 345, grams of honey, and she pops up and pops right back down. Like, well, obviously there's some body function here that's taking care of this, because it wasn't loop and it wasn't me, so I think that plays into it, and why, I think it's also difficult to get these tests in. But I'm sure body mass is a big one, right? It's there tends to be a relationship between body mass and how much insulin you generally use and how much basal you often use. I think those are two big pieces, and then there's always, like diet plays into it too. How much you're know you can modify your insulin sensitivity with reducing fat in your diet, as a recent study that was coming out, so reducing the your fat intake will improve or increase your insulin sensitivity. So I think there's a lot of factors that are really hard to nail down, but I think body mass as a good placeholder, at least in my mind, from a little child to a big child or an
Scott Benner 28:04
adult just changes. Oh, there's too much to think about. Again. That's all there is.
Kenny Fox 28:09
There's a lot to think about. So the main thing that I want to use, that I encourage people to try to use the daytime ISF for one, let's just acknowledge that it's really hard to test for, and it's a pain in the butt. So what I like to do is I use the sensitivity during the day. I make one rate that covers the daytime, or at least the hours that you could be entering and eating carbs, and then use that number to help you get to the absorption you want. So we talked about using the ice cream all the absorption stuff in the last episode. So I think most people, especially listen to the podcast, will have a good sense for how much their carb ratio should be. Generally, like, if you're not getting enough in the beginning of your meal, you end up a little high with proper pre bossing. And so you they people tend to adjust that down. I think people end up with a fairly aggressive carb ratio if they're listeners of the podcast. And most people that come to me are in that boat too. And so once you feel like the beginning of the meal is good, but then you're noticing that either the carbs are absorbing too slow, meaning loop gets to the very end of the time window for your food, and it still didn't see nearly enough carbs, or the opposite, you get to the end of the time window, and loop saw way too many carbs being absorbed for that meal, that's going to be a sensitivity problem. So I like to find a sensitivity number that helps us get to where most of the list of cars on that carb screen are absorbing pretty well, all within their expected time frames, not too long, not too short. And just change that one number and dial it in. So if we're happy with how much in summer getting the beginning of a meal, and you adjust the sensitivity to get to a spot where loop says, Yep, that meal is over at the right time. Most of the time, you're not going to get it all perfect, but you're going to get it done pretty well. I think that's a guiding principle that's helped me and helped others when I talk about how to use sensitivity, because you can talk about, you know, how much is it correct and how much is it fixing things? Yes, I think if you get the meals mostly finishing right, and you do a pretty good job of counting the meals and the fat and the protein, that's like the major variable we have to deal with in the day. So if we can just nail that, and I think everything else kind of falls into place. And you know thing, you might go a little higher, a little lower here and there for some other reason, but meals are going to look good, and loop is going to do what you want it to do the vast majority of the time. Yeah,
Scott Benner 30:23
do you think you could go back and do this manually? Oh, like just being on MDI. You mean, I put tests on a manual pump. How much of this do you think you could mimic per success?
Kenny Fox 30:33
I think a fair amount of it, because you've covered most of the core components with Jenny talking about fat and protein. And if you can take care of pretty good carb ratio and expecting the fat and protein and dosing for it, I think you're going to get very similar results to what loop will do with decent settings. I think the biggest thing that loop makes a big difference is protecting against lows. Like you mentioned before, you're not gonna sit there and turn off the basal all the time, right? The other one, someone mentioned to me that was working with they came from the tandem pump, and we did the had the same problem when we were using the tandem you could only extend meals in the tandem pump like they have one extension running. You can do the same with any any pump. You can't extend another Bolus on top of a currently running extension. And that's kind of the for me, kind of the magic with loop, with the way Tessa eats sometimes, is she'll have decent amount of fat and protein for multiple meals in a row and so but they're overlapping each other. You want the insulin to extend and handle that fat and protein over a fairly long period of time, but then she ends up eating again, and the fat and protein impacts not done. Release the dosing for it's not done. And so what loop and other systems like this help with is you can just say, enter a long meal, a pizza icon, you know, the long meal, and then enter another long meal. She gets seconds, enter another long meal, and loop sort of handles that extension in response to blood sugar. And if you get this ISF stuff working well, then, you know, four hours after she's eaten, it's going to, know, a pretty good amount of insulin to give for the fat and protein without giving too much. And that's, I think, what takes a lot of the burden off or managing food with a system like this, is that you don't have to worry about, are we extending? Is this to the extension still going? And do we need to cancel that extension and add more insulin in to cover the last extension, and then also extend into this food. So I think that that really helps a lot with how Tessa eats, just that she makes she doesn't eat frequently, or meals are overlapping with each other with respect to the fat and protein window of time that the impact is there. And so it's just it helps a lot for tracking meals that way or lack of tracking. I don't have to do the tracking. We just enter it and move on so we could do it. But I don't know how well Tessa could do it on her own, whereas, right now, she just enters it and she moves on with her day, and it's usually pretty fine. What about you? What about you guys? You know, our needs a lot different, right? She spreads out her meals, sometimes fairly frequently. Yeah.
Scott Benner 33:00
Kenny. I mean, could I go back and do it again with the same success if you give me a child young enough that doesn't have opinions and, you know, doesn't fight back, you know, when you say, do something right, I could easily do it and probably have better outcomes, but I think I'd be exhausted again. I think
Kenny Fox 33:19
I was thinking the same thing, you lose sleep. I think the sleep I think the sleep part is a part I didn't think about till just now is, yeah, that part is the initial magic sauce for most people, right at any automation system, is it can go to sleep and it morning turns out better than it would have if I had just gone to sleep with a regular
Scott Benner 33:35
just 1,000,000% like the the process seems to be is, you know, you have a diagnosis, or, you know, whatever, you've been at it for a while, and you just aren't having a ton of success. Somebody slaps you on one of these algorithms. And then eventually you're like, oh, it's not perfect, but I'll tell you overnight, I'm sleeping again. And then you kind of like, come back to life a little bit. You can start paying attention a little to what's happening. I do think that if you took it all away, the first thing that would happen is my sleep would get dinged. You know, I am almost 20 years older than I was when she was diagnosed. I would find myself making those concessions in the middle of the night. I'd be like, Oh, it's only 170 I gotta get some sleep. I think you'd slip back into that pretty quickly. Then I think that starts to impact the daytime again. And before you know it, you're starting the day with a high blood sugar, not enough insulin, everything starts shooting up, and you're off to the races, and you can't figure out what the hell is going on. And then you struggle all day with it, which makes you exhausted, which then puts you overnight again, into a bad situation. Try to keep up with it the best you can. If I didn't have to sleep, if I wasn't older, I know more now, like if you put me just in charge of somebody's blood sugar, I think I could manage it with an inch of its life, but I don't know how long I could do that before I dropped over dad. I just think that there are so many people out there who are not using this automation or not using it effectively, and you have no idea how much your life would change if you if you had it. And it was and it was working well for you. I really
Kenny Fox 35:02
like how you talked about that with the last episode of your caregiver series. That was great. You guys really hit that pretty good is the lack of sleep is significant burden on caregivers, especially. But you know, just as much with the people with diabetes, once they're in charge of their own blood sugar,
Scott Benner 35:19
it just runs you down. There's no way to get ahead. After a while, you think, no, it's okay. I'll figure it out. But, man, I don't know. Like, you know you're not a machine. You just can't stay ahead of it forever. So right, yeah,
Kenny Fox 35:31
I think the last thing I'd like to drill home with people is this is the most hard to grasp and see, because it's not as visually obvious a lot of times. And so my sequence of going through to figure out what might be wrong, we use the iob overnight, especially as our guide to say is basal right or basal wrong. We make basal adjustments based on we see inappropriate negative insulin on board, or those other data points we talked about in the first episode. Then if they're running high, then before you make any changes, check the pod site, make sure it's working. And then we lean on food. Are we counting things? Well, are we not forgetting to enter food? Are we adding fat and protein, all that food stuff called Food accuracy? And then if we're doing a pretty good job of counting, then, then you got to mess with the car ratio. You're going to get better results. If you're running high or running low. Once basal is good, yeah, to just make sure you get enough insulin with your food. And then, as a last resort, like if you mess with all that stuff and you tinker with it, or you just don't think any of those things need to change, because everything else looks good. Then you start playing with the sensitivity. You look at the arboration of the carb List screen and how absorption is going on, and you tinker with the ISF. But it's something that I find with a with a kid that I don't have to mess with very often, Tessa or any child, really, when you're starting younger, their sensitivity is only going to go to a smaller number. It's only going to drop as they get bigger. So that's one thing, is that if you can get a pretty good number eye sensitivity number during the day that works, then chances are you don't really have a question of whether or not it needs to go up or down. Most of the time. You're just going to say it just needs to go down if it needs to change at all, because they're just going to keep growing and getting bigger. So it is make it easier until your kids done growing, you know, early 20s or something, and then they then maybe can go up and down a little bit more. But with kids, it's pretty simple. It's only going to go down, and I really only mess with it a couple times a year when all the other stuff's not helping. So don't let the ISF confuse you and wear you down and keep playing with it all the time. Like pick a season where you have your basal dialed in and meals are looking pretty good those first few hours. You're happy with your carb ratio and you're counting. And then play with it and get it dialed in, and then you don't, don't mess with it too often. Couple times a year, revisit it and move it down a little bit. I don't want it to drain anyone's brain too much. People spend a lot of time thinking about the stuff they don't yet understand, which I appreciate. There's a lot of people that come talk to me, but I think you can just let it go a little bit and make some other adjustments, and you'll probably be
Scott Benner 38:04
okay. I'm adept at turning the knobs and making things work out, but if you listen to the voice in my head while I was doing it, you wouldn't hear this, like, quiet confidence of like, Oh, I see this number and this outcome. So I know I'm gonna make this that I've learned over time. Her blood sugar has been too high lately. I think I need a little more insulin sensitivity power. Here. I'm going to take it from where it is and make it a little more aggressive. Yeah, I don't think it's the basal. I know we Bolus well for the food, so I'm going to try this here. But you, if you're a person who isn't sure if their carb ratio is right, doesn't understand the impacts of food, basal is off by a little bit, imagine if your insulin to carb ratio is one to 10, but you have it set to one to 15, and your basal is a unit an hour, but you have it set at point eight, five, and your insulin sensitivity is like, who knows? By then, the basal is off, the carb ratio is off. All your meals are moving you around in ways that you know you can't know. Forget being on an algorithm for a second, you're going to get out of whack. And then how would you even figure out the insulin sensitivity? Like, in my mind, the basal has to be right, no matter. I think basal is always first, right. So always, yeah, your basal is first, right? Excellent, great. You eat foods that aren't high in fat, that you're really good at bolusing for that. You really know the carb counts for you count the carbs. You look at the insulin, you say, you reverse engineer. You say, Look, I know this meal for sure has 50 carbs in it and whatever, like, you know, two units always covers this. So great. So your insulin to carb ratio is one unit for 25 carbs. But that doesn't mean that the next meal you're gonna have is gonna hit the same way as that meal, but it's a great starting spot. The thing again, like Kenny keeps mentioning it, because I don't think people appreciate it enough. But if you don't understand the impacts of fat in your food and how it's pushing blood sugars up or holding blood sugars up, you really are at a loss for figuring this whole thing out. I. Know, as crazy as it sounds, but I think the one thing that throws more people off than anything else is the fat in their food.
Kenny Fox 40:05
Oh yeah, for sure. Like someone I've been working with for the full eight weeks of my session with them, and they were near the end, and their 11 year old was munching on a bunch of nuts, like fattier nuts and cashews or something like that. And they're like, yeah, she didn't really enter those a whole lot, or just the carbs for them, and then they should just ended up high, like, couple hours later. Like, do you think it was the nuts? It's like, yeah, that's like, the only reasonable explanation here, that you just kind of drifted up high and then ended up a little bit higher at dinner time. So it's just one of those things that I think happens the most frequently. Yeah, is the easiest thing to under count. And I think if you get that right, the sensitivity, if it's just in the ballpark of where it needs to be to help loops. Be to help loop see the meal, then you'll be much better off those those things are, are the basics. The basal has to be right, and if it's not, then you know, you can't really go tweaking other knobs too much until you get that dialed in with confidence, which when we covered in the first episode, I think it's one of the key things when people are working with me is I really try to hammer in on that, using the iob and getting the basal pretty right, and having confidence that it's that it's right, and then you can mess with other stuff. That way, you kind of have an order that you go through for this stuff. And I really like your idea of using predictable meals. I've had a lot of situations in the last few weeks where a nice, predictable meal turned out to not do what it normally does, and that told me that either the site was bad or some big setting needed to change that I just didn't like usually carb ratio. Just didn't know. Tesla wasn't feeling well. She said she was feeling fine, but she needed a lot more instant for her food that day. Yeah, and you just, you had to catch it. So predictable, meals are a great way to just calibrate off of I don't know where else you're
Scott Benner 41:39
supposed to start, because this idea of fasting, for a really long time, I don't know who you tell me the kid you're gonna say, Look, tomorrow morning, we're getting up, we're not eating. We're gonna get your basal worked out, like I say, figure out basal overnight. Get it close, adapt it for the morning. Once your basal is good, look harder at your carb ratios over predictable meals. Excellent. We got that. Now let's look at a blood sugar that's went up the foods out of our system, but, you know, it never came back down from 180 great time to check your insulin sensitivity. Go ahead and throw a unit in and or a half unit and see where, where do you land? And don't wait like, an hour or two, like, really, just, you know, wait a few hours, like, where does it land? It's not going to be perfect, you know, if the unit moves you 50 points, and it's about at, you know, you went from 180 to 130 and it's just resting in there. You know, there's a great place to start, to start with, yeah, and if you're on an algorithm, and you're close enough, like you said, then the algorithm there will kind of make up the difference for you, because it'll push a little bit more when it needs to push. I mean, how long do you think Kenny with the service you provide? How long do you think people have to work with you before you before you can get them in a place like that? Yeah, what
Kenny Fox 42:44
I've seen this year with the groups that I've gone through, it's been about week six or so of pretty dense conversation for the first three, four weeks, training and stuff, and then some messaging in between. But after about six weeks, they kind of get how to do the basal they've they're have a good understanding of the carb ratio and even have a good guess when it's sensitivity. If they move through that list by week eight, they're pretty solid. Those last couple weeks are just kind of letting them practice. And we go over some other topics that like. We'll cover some other pieces around the algorithm just to improve their understanding. But it's the core of it is probably about six weeks. And I emphasize that the program is training. It's like educational. It's going to be videos that you can watch, but then we're going to do like group calls. It's going to be a group coaching. You're not going to be left to just watch a video. You're going to have access to someone to ask questions and to if anyone else wants to share, you can see their data. I know people really appreciate me showing Tess data so they can kind of understand, like, it's not all sunshine and rainbows all the time, and how and when I would make changes, and just, you know, real life stuff that comes up. And so, yeah, it's about six to eight weeks. The whole program right now, I'm planning on running it for a full eight weeks. But it's, it's really start to kind of get it after about six you have time to practice. Have something go wrong, have an illness show up, have a pod site go bad, those kinds of things. There are a few people that made it the whole time and just didn't have anything significant that needed to change. And so right after we were done, and they called me and we worked through it, but a lot of it's just practice, and most people have setting changes, even just a small basal change, sometimes every couple days, sometimes multiple times a week. Sometimes you wait a week or two before you have to change anything. I think that's really important for people to see, and if they just don't need a change, it takes a little longer to practice all the stuff that you're learning. Tell people how to find you box in the loop house, com, you can sign up to get my email newsletter, so you'll know when classes open up, they're only going to open up a couple times a year. So you can jump in. You want to do some one on one instead of going through with the group. You can also find that information on my website, Fox and loop house, calm, awesome.
Scott Benner 44:55
I told somebody today, I'm like, Oh, I can't talk. I'm I'm recording. And they said, with who and I. Said Kenny. And the response I got back was more Fox in the loop house. I was like, yes, but that's just funny. I can't believe I tagged you with that. I'm so sorry. Like that I tagged you with that moniker, but, uh, I'm glad people know you that way. It's awesome. Hey, I'm gonna roll with it. It's fine, excellent. Is there anything we missed that we should have talked about here that we didn't? No, that's good. Awesome. All right, thank you, man,
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