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

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

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

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

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

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

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

Unknown Speaker 7:26
That's okay.

Unknown Speaker 7:29
What is six times

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

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

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

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

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

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

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

Unknown Speaker 14:07
to 150.

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

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

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

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

Scott Benner 18:47
On purpose,

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

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

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

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

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

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

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

Unknown Speaker 24:10
This is your loop version started

Unknown Speaker 24:11
on Halloween.

Unknown Speaker 24:14
Yeah, by the way,

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

Unknown Speaker 24:31
coupon open loop like

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

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

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

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

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

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

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

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

Jennifer Smith, CDE 32:46
Correct. Yeah.

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