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Scott Benner 0:00
Hello everyone and welcome to Episode 326 of the Juicebox Podcast. Today's show is sponsored by the Omni pod tubeless insulin pump, and the Dexcom g six continuous glucose monitor, you can check out dexcom@dexcom.com forward slash juice box and find out everything you want to know about the Omni pod, including how to get a free no obligation demo of the pump sent directly to your home at my Omni pod.com forward slash juice box.

You know the podcast is about a lot of different things surrounding type one diabetes. And very often we talk about management. When we do we kind of speak about it on a macro and a micro level right? You know, the idea of using a Temp Basal increase or decrease for instance, that works with every insulin pump. But when you hear me speak specifically about a pump, most of the time, you'll hear me talk about Omni pod, because that's what my daughter has been using for 14 years. Same with CGM, my daughter's had an Dexcom. Since I don't even remember what the first one was called, but a really long time. So when I talk about CGM, you might hear me talk about it macro how to use the data to make good decisions or micro how Dexcom works. But we've never been able to talk about the Medtronic 670 g in a micro way, because I've never used it. So what I did was, I brought Jenny Smith on, because Jenny's worn the 670 G and she trains people on how to use it. So this is Jenny's experience. Please remember that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, please always consult a physician before making any changes to your health care plan are becoming bold with insulin. Of course, you know Jenny Smith from the diabetes pro tip episodes here on the Juicebox Podcast or defining diabetes episodes. We do ask Scott and Jenny together as a matter of fact, this Thursday, there'll be a live ask Scott and Jenny on my Facebook page, that's going to be Thursday the 23rd. He says because he's not 100% sure what today's date is, I'll look for you hold on Thursday, the 23rd at 3pm. Eastern Time on the bold with insulin Facebook page, Jenny and I will be doing a live hour of ask Scott and Jenny. Jenny is a certified diabetes educator. She's had Type One Diabetes for well over 30 years, she works at integrated diabetes. And Jenny is adept at walking people through using different pumps and cgms. And enough of you have asked about 670 G. And I thought well, let me get Jenny on. And we'll find out what her experience was, while she was wearing it. I would like to talk about and do an overview of how it works and how to use it. And what's good about it. What's bad about it about the Medtronic 670 g Ah, so this is not meant to, but start off like this. I think we all know that Jenny doesn't love the 670 G. Like she doesn't hate it. But when you talk about it, there's not loving your voice is what I'm saying. And and but there are plenty of people using it. And they should know how to use it as best as possible. And that's sort of what my goal is for this. I started off by familiarizing myself with the system a little bit online. And I was surprised to see immediately it's going to sound like I'm I'm not a fan. But I don't mean this in any judgmental way other than, you know, ardent users. And on the pod, I open up a little plastic thing. There's a pod inside of it. And that's the entirety of what we use, right. So I'm looking at this and there's a pump itself. There's a reservoir, glucose monitor and infusion set inserting device, there's an infusion set, and I was like, wow, that seems like a lot of stuff. But I get it like you know, it's it's a different situation, a different setup and everything. So anyway, so those are the pieces. There's the pump, the reservoir, the CGM, which is a proprietary Medtronic CGM. Correct?

Jennifer Smith, CDE 4:24
Yep. Got Now today's it's called the guardian. It used to be if you're still using it, you could potentially maybe still have the enlight and the old old one, I think it was called the soft sensor. Okay. So they've had quite a number of up updates. Um, yes. So current is guardian. That is,

Scott Benner 4:46
that is the exact lack of love I was talking about. So then there's the infusion set for people who aren't pumping or using an omni pod is a it's an adhesive thing with a plastic thing on top that Yep, you know, it's like a port. I guess the goes to a piece of tubing, the tubing goes to the insulin pump and you can disconnect that. That set right like to take it you have

Jennifer Smith, CDE 5:07
to take a shower to get in the pool to do all of those things. There's also a little piece that whether most people use it or not, there is a little extra piece that you pop into the infusion site, once you disconnect from the tubing that's supposed to and you you pop it, it's almost like a cap. Yeah, it's you're supposed to technically put it in, in order to prevent extra things from you know, getting in there.

Scott Benner 5:33
So when I disconnect that cap, I'm supposed to cap this like,

Jennifer Smith, CDE 5:36
okay, yes, you're supposed to cap it. Yes.

Scott Benner 5:39
So those are the pieces. And then there's the I'm sorry, the insertion. So it's sort of it to me, it looks like it's maybe palm size, sort of like a cup, I guess you set it on your skin and press on it or squeeze a button or something. Yeah,

Jennifer Smith, CDE 5:51
that would be for one of their one of their infusion sets. In all the pump. companies that have tube pumps have different types of sets dependent on you know, your body type. And what works well for you the one that you're talking about, it usually works with their, it's called the Quick Set, you kind of it comes with this little like, almost looks like a little pod, sort of like a like an alien UFO, almost as what I call, okay, and you open it up and you pull, there's like a little like a lever inside that you sort of pull back and you caulk it essentially. And then when you squeeze the buttons on the side, it pops the infusion set or the in the Yeah, the infusion set underneath your skin. There are other ones like the silhouette, which is more, it's an angle that's not 90 degrees, like the Quick Set. The Neo is another one, that's a 90 degree that they have. And the silhouette is an angled one that does come with an inserter I would say a good a good 75% of people, though, who are using the silhouette are self inserting, they're just pushing that infusion set underneath their skin. They're not actually using the insertion device. I myself when I when I was using Medtronic, I had tried using the silhouette and I wasn't using the inserter I was just doing it myself.

Scott Benner 7:14
So you just Fried my brain a little bit as a person who's never used the tube pump. So you're telling me at some point, there was an infusion set, and it still exists now that I press into my body, like metal with the covering canula on it. Yeah. And that's how it's meant to be used.

Jennifer Smith, CDE 7:33
It is so in two ways that that set in and of itself is it comes with an inserter the inserter. In fact, I think as a visual for people who can't see us talking, the insertion device looks much like the old g five inserter for the sensor. That's what it looks like. It's like it's almost like a thick pen. The infusion set goes into the end of it right. And then the button on the end, you press and it pushes the infusion set under your skin. The big thing with it is that you really it's meant to go in at a certain angle under the skin. And you know, with that device, it's like a very fine rocking of your own hand to keep it at a 45 degree angle. Okay, so you could technically insert it too shallow. Or you could insert it too deep. Not the way that the infusion set is technically supposed to be inserted. I myself found that the inserter did not work well for me. Okay, so I, even my husband, he was like, What are you doing? Now? I'm like, I'm putting my infusion set in. He's like, that's a really big needle. Thank you very much. I'm quite aware of that. So yes, it's a selfie. And it does. I mean, for people who are using it, they get used to it. I can say it's not my favorite thing to do. And of all the set. My favorite set of all, even compared to Omni pod, which you don't get a choice in a sec, right is just what it is. It's built in. I've never had any problems with Omni pod set, thankfully. But my favorite for any tube pump is the one that's called it's a steel canula so it's almost like a thumbtack that sits under the

Scott Benner 9:25
skin. Okay. And you Why do you like it? I like

Jennifer Smith, CDE 9:28
it because it goes in at a 90 degree angle. I had so many problems with kinked bent, problematic tubes that were the typical like Teflon type of canula under the skin. I never I've never in my almost 15 years of using Omni pod now, I have had maybe two kinked sites, maybe two with the two pumps, however, I have had my supply of way more than I've ever wanted. So the nice thing about the steel canula for Medtronic, it's called the shorty for if you're a tandem user, it would be called the true steel. So they both make a completely steel canula pops under the skin like a thumbtack popping into a cork board. There is no hassle to using it, it stays in place. No kinking at all. There's a lot less site irritation for many people with it. There are a lot less site infections with using it. Um, so yeah,

Scott Benner 10:40
I can say that. I know Arden has had one. One Candela problem in the entire time she's used on the pot and I was doing the math on it the other day. She started when she was four, she's gonna be 16 so Wow, it's been wearing

Jennifer Smith, CDE 10:54
almost as long as me

Scott Benner 10:56
Yeah. Arden's been wearing an army pod for 12 years every day. You know? And so we and we've had one and when I look back on it, it happened like it was a pump we put on like at a pool side. And I remember it all being a little like, like I want to get back in the pool. Like you know, like it wasn't

Jennifer Smith, CDE 11:14
like Quick, quick, quick, quick.

Scott Benner 11:16
wasn't, it wasn't it wasn't being done maybe exactly right. But you know, it was obvious the CGM made it obvious that it wasn't working. So right. Actually, it was funny. The CGM made it obvious it wasn't working after we got our away from the pool. It actually turned out that, you know, I think her exercise had kept her blood sugar down for the for the couple of hours away from the pool, then all of a sudden, you could tell, hey, this thing's not working. Right. So anyway, okay. Now, that seems like a lot to me. I'm not here. I'm not here to critique the, I really want everyone to understand it. It's tough, because there's the side of me that feels like um, I don't know, I A lot of what you just said, I think, Wow, a lot of that doesn't seem necessary, but okay,

Jennifer Smith, CDE 12:02
you know, well, and I can say to from, from just giving credit as well, of all the pumps on the system on the, you know, on the market today of which there are only three brands that are out there right now FDA approved, with Abi mipad is the easiest by far. So if you're going to rate them in ease of like, filling using even a canula and a reservoir, Omni pod is the easiest. Medtronic honestly is the second easiest, okay? As cumbersome as it looked to you having never really done it yourself or needing to, it's actually the second second easiest tandems is it's a weird system. I mean, and I say that from the standpoint, it just has a lot more steps in the filling of the reservoir, the filling of the tubing, and every it just takes longer. Yeah. So, um, there's some credit to Medtronic there.

Scott Benner 12:57
Hey, Medtronic, you're not as bad as the tandem when it comes to use. Congratulations. Put that on a box,

Jennifer Smith, CDE 13:03
reservoir and filling.

Scott Benner 13:06
Excuse me, specifically reservoir and filling use that. Wouldn't that be a tagline? Medtronic, we're not as bad as control IQ for filling the reservoir. This is getting out of hand already. I'm sorry, Medtronic. users don't leave. We're gonna get to the good stuff.

Unknown Speaker 13:20
Yeah, yeah.

Scott Benner 13:21
I do. I would, I would be remiss to say that, to not say that I could change it on the pod in about 45 seconds. Like it really doesn't take any time at all. I am. Jenny has a pump changing story that she won't let she won't tell on the podcast. But apparently, you can do it almost anywhere. She's like, I shouldn't tell people that I've done that. I'm like, Okay, well, sorry. You keep that private then. Anyway, Alright, so what the goal of this system and this was, and I I do say this all the time. This was the first like, closed loop system out the door, right? Like, this is the first one that got, you know, FDA approved. Yep. And, and on the market. So points for being first because, you know, just like in the military, or firefighting or anywhere else, stuff first guy through the door doesn't usually end up so good. So. So the point here is, is that, you know, this was early on, how long has this thing been available now?

Jennifer Smith, CDE 14:25
Oh, gosh, um, I even I'd have to check online exactly when

Scott Benner 14:30
it's gonna be a number of years now. Right?

Jennifer Smith, CDE 14:33
Correct. It has been a number of years, I would have to look exactly, but I feel like, gosh, it's got to be at least three. At least two, if not three years, because I'm trying to remember when I did my 670 training, and I feel like it was very soon after my three year old was born. Okay. So that would be about at least three years, I would say,

Scott Benner 15:03
Okay, let's call it. So first things. First. It's a it's a system that's making decisions about insulin on and off, right? does it increase? bazel? It does, it does. Okay. So

Jennifer Smith, CDE 15:15
from Yeah, from that like, kind of like hybrid closed loop system? Yes, it does that, as your glucose changes, it will temporarily increase or do these incremental adjustments up in insulin delivery, as your blood sugar changes and drops, it also does an incremental adjustment down. It also will temporarily suspend based on, you know, where glucose is going to get to it will do a suspend for you. It does not, it does not do, like an automatic Bolus, Bolus Bolus kind of thing. Um, it's it's bolusing. structure is truly around food.

Scott Benner 16:03
Okay. And that's still on you to tell it how much you're eating and all that stuff.

Jennifer Smith, CDE 16:10
It is in fact, that's the only, that's the only setting in the two modes of use of the 670. Pump, which you can use in manual mode, which is just like your normal conventional pump, use all the features all the settings everything you have set work as they normally would, you're the controller in auto mode, when you slip that on, then the only setting that is used for true calculation or exact calculation from a math standpoint, that the user can figure out his carbs, their carb, the insulin ratio stays true to what is set in the pump. So if you have set a one to 14 ratio, the pump is going to use that along with the glucose value to suggest a bolus for that food.

Scott Benner 17:04
Okay, can you adjust the bolus? Can you say, Oh, I would like this to be No you can't. Okay. So in a situation where, you know, you know, like, say the glycemic load of food is going to hit you heavier than the carb count. What do you do then?

Jennifer Smith, CDE 17:21
So that's the there are no longer temporary Basil's there is no longer in extended bolus. And on Medtronic pump, their extended bolus is referred to as either a square wave or a dual wave, right. None of those features are now available once you are in auto mode. So you're right. The hard thing is that for a meal, such as and we've talked about it so many times, but like pizza, right, right. I mean, a lot of people are not going to get the hefty management in the afternoon. And in the aftermath, for fat that they've been used to getting, when they're using maybe an extended bolus for fat or a temporary bazel to offset the later impact of fat, that feature isn't there. As an option with the auto mode, now, as glucose does start to change, you will get those microscopic adjustments in insulin dosing off to accommodate for the change that is happening. But it's not going to be like your very robust, temporary bazel of 60 plus percent above your normal in order to

Scott Benner 18:38
take care of experimental and smaller,

Jennifer Smith, CDE 18:40
correct and correction boluses it's another place to kind of bring in correction boluses are there they're very difficult to navigate within auto mode, okay? Because the system is it's more conservative, right? its target that it's aiming for is 120. And it doesn't really start to adjust or aggressively navigate blood sugars until you're higher,

Scott Benner 19:07
what is higher mean?

Jennifer Smith, CDE 19:09
Right, like the 161 80 range

Scott Benner 19:12
that it starts to crank on the bass or

Jennifer Smith, CDE 19:14
and then it starts to crank based on the trend and you know, it is referring to the trend and glucose that's happening, right. But overall, you're not getting an aggressive enough nature to assist so you know, many people are many people are learning when to potentially shift out of auto mode when to potentially shift back into manual mode or a you know, back into auto mode. So there are some tricks and or tips to using the system to your advantage

Scott Benner 19:51
right I think we'll be talking about that. So I just I I'm trying to understand just one more thing. So yeah, take some when I put a bunch of insulin in For something, right? I don't know how it's going to know. Is there a way to tell it? Hey, this is pizza, it's not really going to hit me for an hour. You can't You can't tell it timelines of food or absorption rates or anything like that. Okay, so this thing throws in, I say I'm gonna eat two slices of pizza. I tell it, it's 60 carbs. It throws all the insulin in, does it then work with the bolus? Meaning does it take the bazel away to let the bolus work? Or is this the basal still stay? in play?

Jennifer Smith, CDE 20:34
kind of depends on what the shift in glucose? Is situation? What's happening? Yeah,

Scott Benner 20:40
so we could so it could take away the bazel. If it thinks you're gonna get low, and then let the bolus try to work. But then that doesn't feel

Jennifer Smith, CDE 20:49
right. Yeah. And yeah, and it does it along with, as I said before, the only true setting that's sort of carried over from your normal setting mode is the insulin to carb ratio, and then it also utilizes the active insulin time that you have set as well. Okay, so that's a piece of, you know, how long should this insulin really be working? If you've got it set for two hours? Well, then the pump is going to think that two hours from now you're clear of any active bolus insulin. So it may allow you to take some correction within the automatic mode. But yeah, it doesn't use your current basal rates, it doesn't use your current sensitivity or correction factor. Again, it targets a blood sugar of 120.

Scott Benner 21:37
So you just said if the action time is short enough, then you know, say two hours than two hours later, you'd be eligible to make a correction bolus,

Jennifer Smith, CDE 21:46
then potentially depending and it'll only suggest correction boluses if your blood sugar is above 150.

Scott Benner 21:53
Okay, so I can't decide. I'm 130. I want this to stop, I'm gonna give myself some it's, I have to be over 150 40 even allow that. Yes, but I could go out of auto mode, and then do whatever I want, then it's just it's all

Jennifer Smith, CDE 22:10
good, then it's just an insulin pump like you're normally using. Yes.

Scott Benner 22:14
But I just thought the problem with that is that it's been making decisions about insulin based on what it thinks is going to happen. And then I come in and make different changes. How do I get back into auto mode without a problem? I don't know about you. But here we are five weeks into our social isolation. I don't think I've been out of my house more than a few times, except the wander around in my yard. And it's starting to get a little weird. It's starting to be difficult to care about things. I don't know how I mean that exactly. Let me let me think it through for a second. I didn't comb my hair yesterday. And I didn't care. And I went outside and my neighbor saw me and my hair was sticking in 16 different directions. I just thought, whatever. I'm worried though, that that attitude is gonna bleed into other parts of my life. And I'm worried that it might for you as well. For instance, were you just about to find out more about ways that make yourself healthier right before all this happened. And now you just feel like you're on pause, just waiting for the world to pick back up again. Well, I know that's true for some things, but it's not for everything. For example, right now, with very little effort, you could get on the pod to send you a no obligation free demo of the on the pod right to your house. It's amazing Miami pod.com forward slash juice box. You go there you fill out your information, and a box will arrive at your home with your Omni pod. Now you'll probably like you know, it'll be on the front step and you'll be shooting it with Lysol and stuff like that. But after you do that, inside, you're going to find an omni pod. And it's all for you to wear to try to test to shower when you can find out how the Omni pod looks on you while you don't comb your hair. For a while you're sitting in a chair, staring off into space. Once you understand how that's gonna work, you'll be ready to wear your Omni pod as you launch yourself back into the world with your new insulin pump, ready to make these kinds of adjustments that you hear us talking about all the time on the podcast. Temp Basal increases, decreases. Extended boluses not having to disconnect your pump for a shower, being able to set up bazel programs which sounds really difficult but isn't but just think of it this way. If you're on MDI and you get low overnight, but not during the day and you think I don't know if I take away my insulin, my basal insulin, so I don't get low overnight. I'll get high during the day but on the on the pod you don't have to worry about that. You could set up one bazel program for the daytime and One for the night time. on time, you need more insulin. And one time you need less. You can keep that pump on while you're showering, swimming, walking around in your backyard, trying to remember what it was like to go to the movies. And then, you know, once everything's back to normal, all the other things that your life is Miami pod.com, forward slash juicebox, get a demo pod sent to you today, you're not doing anything else anyway, please don't put your health on pause. Now, when you get done with that, here's the next step dexcom.com. forward slash juice box. Find out today, why I love the dexcom g six continuous glucose monitor. So very, very much. The information that comes back from the dexcom is not just to keep you safe, it's to keep you healthy, it's to keep you ahead of the curve, that is your blood sugar, you can stop the blood sugar curve a lot easier than you can flatten other curves. By just Pre-Bolus Singh a little bit more understanding where you need more or less insulin, or how some meals impact you differently than others. You can get all of that, and so much more@dexcom.com forward slash juice box. Examples are from my daughter's life with Type One Diabetes, your results may vary links available at Juicebox podcast.com. And right there in the player of your podcast that their show notes look around, you can just touch on it, boom, you'll be right there. At the link you want. It's magical. How do I get back into auto mode without a problem?

Jennifer Smith, CDE 26:35
Yeah, it's a and that is the that is the difference. Sometimes it is just a button push right, it's a turn the auto mode back on. So it seems as though it would be an easy like fix. But when you go back into auto mode, it's then looking at the sensor data for like an accuracy. And then it's evaluating. And it may require some additional information it may ask you to calibrate, it may ask you to add a glucose, which isn't really a calibration, all it's doing is requiring a glucose value to be added. Which kind of goes into a lot of the alarms and things that people get annoyed with within the system. Because it just needs to see that glucose value and reevaluate where things are at this point. So you may get going back into auto mode, some of those some of those alerts and alarms, before it starts doing things. And then they're also limit, you know, to how much in auto mode, the basal insulin will be allowed to increase. And it does, it's interesting, because it does vary sort of person to person. Um, it's about from what we can kind of tell it's about like, two to two and a half times your average izle rate, excuse me, is what it'll allow, as far as an increase in the bazel adjustment that it's giving. And again, remembering that any temporary bazel increase isn't really like a bolus to correct. So if you're seeing a trend that's going up, and you're waiting for the system to kind of kick in, that temporary adjustment is also going to take time to start affecting that blood sugar. So it's like, it doesn't really adjust quick enough. And it's only a portion of how much you would put in if you were making a bolus in that situation. Right. So not only is it a fraction of what you need, but it's going in is bazel. And probably taking up to an hour for to actually be an impact potentially impactful. Exactly. And you're

Scott Benner 29:00
130 is gonna make it 200 by the time it's there. And it's not going to be enough by the time it's there to begin with. Right. Okay.

Jennifer Smith, CDE 29:07
And then and then on the opposite end to you know, if you're looking at like lower blood sugars. And this is true, even in conventional pumps, if you're low, now you need to treat the low, right, you don't expect that a temporary bazel adjustment or even one that's being augmented by an automatic system like this. If you're low, you have to fix it, you can't expect that a temporary adjustment down is going to offset where you are now my blood sugar's 50, it's 50 a bazel off isn't going to turn a 50 into 100 and any kind of reasonable amount of time right now if I ever if I ever right.

Scott Benner 29:41
So when I correct that 50 do I tell it that I did that? Do I tell it carbs? Because I find that to be an interesting problem because they're such quick acting carbs. You know that, you know, within reason if you're if you're you know if you're if you're reasonably good at correcting You're gonna take in enough fast acting carbs to get your 50 back to 80 or 90 or 100. Hopefully, you don't want any insulin for that, because it's that little, that little bumps not going to send you to the moon. So you don't want all of a sudden, I've just taken in 10 carbs, because will it then when you get to 90 start bazeley at the carbs. You're I mean,

Jennifer Smith, CDE 30:23
it's basically not based on any of the carb information it's giving you in fact, if you entered carbs, if it didn't, if it didn't think that you needed a bolus based on where you are, it would offer a bolus, but it's only really, it's not intuitively looking at that carb stamp and saying now I need to change the dosing because there are carbs in the picture. It's only looking at the change in glucose. So if

Scott Benner 30:47
that if that fast acting carbs did cause a rise, then it would start affecting it but not based on the carbs, it would be based on the the sensor data

Jennifer Smith, CDE 30:56
based on the sensor data. And again, based on where does the glucose start to be adjusted by the auto mode system, it has to be a certain height in order for it, or a certain like trajectory towards a high number, that it would start to offset things.

Scott Benner 31:13
What is that number? Where does it start to? Correct? You know,

Jennifer Smith, CDE 31:17
I'm trying to remember whether it's, um, I haven't used the system like personally in a while. And I have to think and I'd have to look that up, actually, and see if I can find that because I can't remember the exact number that it starts to correct. Like, at or above. I do know that you know, if for corrections, as we were kind of just chatting about to some, some users might already be thinking, well, gosh, I just I just enter some extra carbs when I'm high even though I'm not going to eat them. And so it generates the Bolus for me.

Scott Benner 31:54
Okay, so they're

Jennifer Smith, CDE 31:55
doing and a lot of people are calling that like, like ghost carbs, carbs that you aren't eating, but you're just putting them in because, hey, I know if I enter 20 grams of carb, I can get that one unit Bolus that I really need because my blood sugar is higher than it want it to be. But the system isn't offering anything outside of this. So I'm going to enter it in the problem is that it can offset data analysis then. Right. So when a practitioner or a caregiver or somebody is looking at data using it can get very confusing with where to make adjustments. So you know, if you if you did use that strategy, the one thing that we would really recommend doing is making a note in whatever your logging system is. tide pools a nice place to make notes like that, because they pop up right on that daily trend, to be able to say, Hey, I see a 10 gram entry here with a bolus. Yeah, that was a ghost carbs. I've got some people just enter ghost carbs. As a take note, you know. But again, it's it's also kind of, in practice, it's kind of discouraged, even though people do do it very often, well,

Scott Benner 33:10
is it a problem in inside of the system? Because you've now told us that carbs exist that don't exist? So what happens an hour from now if you've right? If you do, yeah, or you vote, right. But you know, your your examples better if I do want to eat, it believes there's carbs in there, and now it's going to change the Bolus somehow, either more or less, or

Jennifer Smith, CDE 33:32
because it'll be insulin on board for a purpose. Right? Right. So it will have effect on you know, auto mode for hours after putting in that corrective ghost carb entry to generate it and it is accumulating, then, you know, if you do that at three o'clock in the morning, you're not going to eat until nine o'clock in the morning. That's not really going to have any major impact overall, other than just hopefully navigating you down safely. If you're trying to stop a rise an hour before

Scott Benner 33:59
dinner, then right? It's gonna get messy

Jennifer Smith, CDE 34:02
and everything gets messed up. Yes. Mm hmm. I mean, and this all kind of goes back to the beginning of what we always educate is get your settings right also, right, before you go into auto mode. Okay, make sure things are good. And it's really I think, in in the the hybrid closed system, that the 670 is, this is even more important. Mainly because before you switch on auto mode, and all the system is gathering like insulin dosing data in the days before you switch on auto mode. So it essentially we'll update its algorithm of insulin use at midnight every night based on your amount of insulin you've used over the years. about the past week, okay, so we've found that it's best. And I'm not quite I don't remember exactly what Medtronic says, I think that they're saying two or three days, we've found that it's most advantageous for people to be in manual mode of normal insulin dosing with well set settings for about a week, before turning auto mode on.

Scott Benner 35:25
You're not gonna buy this thing, slap it on and be like, fix me, right?

Jennifer Smith, CDE 35:28
No, no, it's not. And that's where it is very different comparative to tandems control IQ. Okay, control IQ, you put your settings in all of your settings, work in control IQ mode, you can slap it on out of the box, put in all your settings, turn control IQ, and you're off

Scott Benner 35:45
and running just starts working. Okay. Not so with 676 70 G's actually trying to learn is that it fair statement are now

Jennifer Smith, CDE 35:55
in a very, in a very beginning sort of rudimentary way.

Scott Benner 36:01
Yeah, so it's just collecting data, like you used 50 units on Tuesday, 45 on Wednesday, but all of a sudden to end it. Somehow that's helping it make decisions.

Jennifer Smith, CDE 36:11
Correct. Now, there are there are also some drawbacks to that. Right.

Scott Benner 36:16
I see them as you're talking, but go ahead.

Jennifer Smith, CDE 36:19
Yeah, and and you probably do, I mean, you're intuitive about all of this, because of the years of experience that you have in managing with Arden. But you can see where this leads to, especially from a female point. Right? If you are in that time, potentially, before your cycle start, where you have these high insulin needs. And everything needs to be ramped up. Then what happens when your cycle starts and all of your insulin needs plummet to sometimes for women 10% less than what their standard profile is running for a day or two of their of their first two days? And this thing's made a decision based on when you've been resistant for a whole week? Correct? Right? For people who've been using steroids because they're sick, or people who've had like, an unbelievable amount of stress for the past three days because their father passed away or whatever, well, that could be two things being in auto mode, more aggressive really

Scott Benner 37:19
is so the thing that that is pretty common. Within You know, how people talk about diabetes that I completely discount, I don't pay attention to it, and I don't believe in it. 100% or even maybe 10%. But the idea that, you know, three days makes a trend. I'm like, okay, it makes a trend, it doesn't mean it's gonna keep happening. For all the reasons you just said, like, okay, I finally figured out I need my base, it'll be point five an hour. And then I get that set up and something changes. There's too many variables to say that any one trend is an indicator of the month. Do you mean? Like it just that doesn't make any sense? Male or female? I don't like buying into that at all. What if I just, what if one week I decide, I don't know, man eat more vegetables than red meat? Or then you know what I mean? And then the next week, it's different? I don't know, right? Like, there's just too many, there's too many things, I work a little harder at work this week than I did last week, I get a little more sleep a little less sleep. If you're looking for that, if you're trying to find a repeatable pattern in that. I don't imagine that exists. And if it does, it's well beyond what an insulin pump or me can figure out, you know, so I'm just more well, even

Jennifer Smith, CDE 38:35
for the people who have done the testing. And let's say they'd have for the most part figured out like, I always need about this much more for this time period, or this much less or whatever. Well, for the again, of the woman who sort of figured out her monthly, like cycle changes and how much more she needs and what bazel profile to set on and whatever. Well, what if you start training for a marathon? Or you've decided to now you know, go swimming for an hour every morning? Yeah, that is going to create a difference in need into this next month. And so it probably will look like, well, gosh, everything's different again. Well, you brought a variable into the picture that wasn't there when you were doing the testing to begin with,

Scott Benner 39:17
right? You can't turn to your pump and say, Hey, pump, listen, just you and me this week, I got a report, do it work, a lot of pressure here, my bonuses riding on this, I'm probably gonna be a little jacked up just so you know, 20 more percent. You know, I think I'm gonna have some stress, high blood sugar, there's that doesn't exist. So you need to be able to be flexible. For those things. I don't know, it, just it. I've just never been a fan of the idea that, you know, three days is a rule. It's a rule for those three days. It's not, you know, and so and so, if that's the case, what people always end up doing is spending three days trying to figure out what's going there. Stare at high blood sugars or stare at low blood sugar trying to find out if it's gonna be Um, uh, you know, it's gonna become a thing that they can count on. I'm always just like, I think you should deal with diabetes in the moment. And then whatever happens is now gone. And I don't I mean, don't get me wrong if Arden's needed less insulin on Saturday, and it looks like that's how it's gonna be on Sunday. I remember that. That's part of being flexible, right? Yeah, but I don't but but if I wake up on Sunday, and all of a sudden she needs more insulin. I don't say to myself, well, that's not true. Because yesterday, she didn't need a lot. So we're just gonna watch your blood sugar be 300 all day today? Like, I don't, that's not it. Like, I think diabetes is a in the moment situation. But, but okay. So I've got my, let me ask you this. I say this all the time. And maybe maybe it's not true for this one. And maybe it is I'm going to get your opinion. I think that for most people living with Type One Diabetes, these systems, you know, the 670 g that's available now. And obviously, it's been out for a couple of years, the the tandem system and the, you know, the forthcoming horizon from ami pod, which we should be seeing pretty soon from hope. Well, as long as the code that Coronavirus doesn't keep their own things. So, so those things exist. And for most people living with Type One Diabetes sorted up to like 1.8 million people now and like that habit, for most people, slapping the systems on is probably a huge improvement for them, don't you think?

Jennifer Smith, CDE 41:26
Yes, in fact, we've had quite a number of, I wouldn't say quite a number. But a good enough number of people that we work with who the 670 has smooth things out considerably. It has, you know, they were they were up down roller coasting consistently day to day high to low, high to low, no assistive management to help with that variance in their blood sugar. And overall, while there's weather still probably averaging a blood sugar of 140 to 150, the system has smoothed out the variants, and it's kept them more stable. That's a beautiful thing. Yeah, and, and for most people that that's the case, they're happy with it, getting them to a target of 140, it targets 120. But for the most part, they talk to most people, they're really achieving an average somewhere between 130 to probably 160, give or take, um, but again, stability there. That's a huge piece, right? So

Scott Benner 42:29
if you've gained stability, and you're an average of 160, instead of 220. It's an incredible improvement for you in the moment and probably for your entire life as well.

Jennifer Smith, CDE 42:39
And a lot of people still even in auto mode, they're still reaping the benefit of these, these hybrid kinds of systems, especially in the overnight. Most people without food in the picture, a system like this is a huge advantage for the overnight,

Scott Benner 42:56
get some sleep and you don't get lowest. You're not you don't get those crazy highs overnight is right. What about, I feel like we were missed if we don't mention the Guardian sensor? So yeah, obviously, we're I, my daughter uses the Dexcom g six, they're sponsors of the show. You use the Dexcom? Yep. The the, you know, the scuttlebutt for me from what I see on the street from the kids, is that people don't think the guardians as accurate as the dexcom. Is that Is that a fair statement from what you've seen? Or how do you even I

Jennifer Smith, CDE 43:32
think that's a very fair statement. It is, I mean, even from my personal sensor use of two of their sensors I tried the enlight years ago, I all when I was training, you know, on their pump to begin with. And then when I trialed and the 670 with their guardian, I would say that it's definite, it was an improvement from what I had had with the enlight it was it was definite improvement, but it was still not for me, anywhere near the accuracy or the consistency in accuracy that I get with my dexcom. In fact, when I was using the 670, I wore my Dexcom at the same time, okay, to compare, I mean, when you're wearing like, several things, and who cares about another site, right, like, I'm just gonna be the ultimate like robot person. Right. Right. Right, exactly. So, you know, and I, I mean, I follow there are certain you know, things to definitely make sure that you're getting the sensor to work as well as possible to begin with, from the Guardian standpoint, because it is, I would say the best word for it. It's finicky, comparative to Dexcom. And I personally tried all those tips, tricks, things that could possibly be done, and it never really worked well for me, and I think that that's the biggest hang up then that I had with it in automotive. It is that it drove me crazy with all of the requests for additional glucose entries and calibrations. It wasn't accurate. And thus, in any of these hybrid systems, if you have a sensor that is not accurate, the adjustments in something like auto mode or in control icube closed mode, you're you're not going to get accurate adjustment because your sensors not accurate to begin with

Scott Benner 45:29
when you say it asks for calibrate, so it knows well enough that it's not okay, but it doesn't know where okay is, is that.

Jennifer Smith, CDE 45:37
So for the most part our our go to recommendations for getting your sensor to work as well as possible. We recommend calibrating that sensor. And it does require calibration on like g six for Dexcom. The Guardian does require calibrations. But we recommend calibrating about three to four times a day, at more regular times of day. But the biggest thing is really to ideally do it when your glucose is more stable. In order to avoid what we know, in all of the sensing systems, there is lag time, based on if something is trending down or trending up right now. There's lag that's happening, your finger stick is often either lower, or it could be higher based on what's happening trend wise. So the goal is to try to calibrate when you've got a horizontal kind of angled trend happening. Also, the accuracy of the glucometer that you're using to calibrate with is a big deal too. Yeah, that's a huge deal. I mean, if you're using some off the market, like, well, not off the market, but like random, generic brand. Don't take out, right? Hey, that's easy. It just just don't, don't I and I know that some people it, it's based on what their insurance is able to cover, right? Right, or what they can afford, I get that. But then also understand that your calibration of these systems may actually mess up the natural sensing of what it sees as being

Scott Benner 47:20
you're wearing, you're wearing a state of the art glucose sensing system and calibrating it with something you got out of a bubblegum machine, it's not going to go well, because then you just confuse the sensor by by telling it, you know, let's say the sensor thinks you're 110 you're really 120 and your meters like no, no, we're at, and you put that information in that the sensor is going to go there, and it's not going to know what to do. And it's gonna confess it, you know, and you have to be careful.

Jennifer Smith, CDE 47:48
The thing with Medtronic, it does come with a monitor that connects with the pump, which is nice, it's the best one that's on the market, it's the Contour Next One, if you get it with the pump, use it, because that is the best rated as far as accuracy on the market. And that goes for anybody that's out there.

Scott Benner 48:06
If you want to know why the Contour Next One is sponsoring the show. Now it's because Arden's experience with the Contour, Next One meter has been head and shoulders better than any other meter she's ever used. As far as consistency, ease of use, portability, and end how closely it agrees with the G six is fascinating. I don't know if that speaks well, for the G six or for the meter or for both, maybe honestly, but it's I've never seen so much consistency between technology before. And you know,

Jennifer Smith, CDE 48:40
according to I mean, one of the last conferences I went to, when I was able to fly and actually be within six feet of somebody else. I stopped at the actual the the Roche were accucheck their guide or guide me is also one of the highest rated accuracy on the market. So if you can't for some reason, insurance coverage wise, use the contour that accucheck guide or guide me it is also not very good. Yeah. So but that that goes along with sensor, any sensor that you're calibrating, but definitely one that could have some finicky component to it for The Guardian, try to make sure that your glucometer is a good one. So and then, of course, you know, any sensor, it's the insertion of it. Are you putting it in the right way? are you cleaning your sight? Are you making sure that you're the transmitter for The Guardian needs to be charged? And so unlike Dexcom, which you just slap it on, and it continues to work every time you put it with a new sensor until it's dead at 90 days. The transmitter for The Guardian has to be charged that's just confused me

Scott Benner 49:49
can I try? I can't charge it while it's on my body right Oh no. Then how does so I have to pop it out and charge it. How often do I have to do that?

Jennifer Smith, CDE 49:57
Oh, the charging Another one that I'd have to look back and see exactly, it doesn't take long to charge it. Okay, but I know that it's at least it's at least every five to seven days. But don't, don't you know, directly me on that. But yeah, it is it requires charging and there's like a little, you know, that comes with the system, there's a little charging like, port that you pop it into, and it charges and then it's ready. And then, but if you're, if your transmitter isn't well charged, or it's kind of at the end, you know, don't put on a brand new sensor, and then you're gonna have to pop it out and it just weirds up the system.

Scott Benner 50:37
We're selling the hell out of this thing, aren't we? So? Geez. Alright. So being serious, like, that seems like more work. I so I have to take so every

Jennifer Smith, CDE 50:50
number of days, if you do want a positive, good, it lasts longer than your transmitters. Okay, that's a huge positive. So right in

Scott Benner 50:59
place the actual devices frequently,

Jennifer Smith, CDE 51:02
you don't have to write this set at the transmitter is there you've got it until it's no longer working for you. And that's a nice thing.

Scott Benner 51:10
It's a great point. I only ever have our experiences, I've I've never experienced a gap where we didn't have Dexcom supplies. But I you know that very well, maybe because I'm on top of ordering them or because my insurance doesn't argue about I don't know why there's probably a number of different reasons. But okay, so there's there's the good and bad, so you have to recharge it, but it lasts longer,

Jennifer Smith, CDE 51:32
it lasts longer, it does require some taping, oh, it

Scott Benner 51:37
tries to fall off does it?

Jennifer Smith, CDE 51:39
Well. And all I think all the sensors on the market, depending on body type and what the moisture level and you know, everything in your skin is everybody's a little bit different. I mean, I occasionally in the summertime need to, you know, need to tape down or put up a thing around my decks calm as well. But the Medtronic sensor specifically has to be taped down. It's not a, I could choose to do it. It's kind of a funny, I wish we had like visual. But once the transmitter is popped into this little sensor piece, the transmitter bounces. Like it's like if you imagine a beaver with its tail. The tail is the transmitter

Scott Benner 52:23
Jenny, Jenny is making a hand motion that's making me feel like Has anyone anyone ever been driving in like snow, and you're the back of your car gets like a little light and starts bouncing around. And you know, so she's she's basically saying that, uh, that the back of her tail, the back of the transmitter is bouncing?

Jennifer Smith, CDE 52:43
Yes, if you don't take it. And obviously, you don't want it bouncing because it could easily come disconnected. It's pulling out the adhesive and it's pulling it the sensor wire and all the other stuff. And then that decreases accuracy. So Medtronic supplies you with all of the adhesive tape that you do need to tape it down and keep it in place, they give you directions to tape it the right way and pop it in and everything. So again, it's not extra stuff that you have to remember, it comes with your supplies, but it's an extra piece of use that isn't there for the other sensors.

Scott Benner 53:14
I'm holding in my laughter because I'm trying not to be a hater on this situation here. But my brain is going maybe don't design it to do that. And then or when you design it, you go, Hey, this thing's bouncing around, like who's the person that was like, we'll give them tape? Not maybe we should redesign it.

Jennifer Smith, CDE 53:31
Right, right. Well, the question in my mind, honestly, always comes and this is not specific to Medtronic, but it's any product that comes out on the market. People with diabetes, get it? And they're like, why did they do this? Why is it designed Like this? Like, did they not ask people with diabetes, how their life would work if we did this weird part to it? Right? Yeah. So I I just, I don't know, I'm always like, well, I guess somebody thought it was a good. Yeah.

Scott Benner 54:05
Well, some engineer maybe who doesn't have to wear it, right? Thought about the usability of it, and it works like it works. And that this shape, we can make it rechargeable. And you know, all that I listen, I'm imagining it wasn't by mistake. I don't think they were just like, I don't care, you know, but there's sounds like there were trade offs made. And you know, as we're having this conversation to, I don't know what the date is for g7. But g7 is going to become disposable, right? Like you're not

Jennifer Smith, CDE 54:32
I that's what I've heard as well,

Scott Benner 54:34
yeah, that you're not going to have that transmitter with the battery, you're gonna put it on and when it's over, the whole thing's gonna go in the garbage and you're going to start over again. And it's, it's gonna have enough battery life in it for the life of the sensor. Right. And that's it. So, yeah, I mean, things are moving forward quickly. I think I think from a personal perspective, as I watch Medtronic and their pumps, it feels to me like they're Like they're making a five pound bag of cereal, you know what I mean? Like, it's mass market. Like, like, like

Jennifer Smith, CDE 55:09
the ones that cost like $2 on the very bottom bed, and you're like, well, that's the best deal.

Scott Benner 55:13
But she gets so much of it, right? Like, I feel like they're just, I feel like they're the, they've put themselves in a position where they're giving pumps to more people than the other two companies, right. And so what they're saying is quantity over quality, like, that's how it feels to me, like, we're going to serve these pumps to as many people as we can, it will work for most of them, and it won't work for some of them. And that's just the price of doing business. I don't know I could be wrong. It's just how it feels from the outside. Because of all the things that I mean, listen, Jenny's just been sharing her experience wearing the device, and she's not, you know, and she hears people talk about it as well, and she's doing her job. But there's a lot here that seems fixable. Except it doesn't change ever, it's just sort of like they won't change this thing till they change the system, they're not going to come back and make an adjustment to it or anything like that. They are making them they're pumping them out, no pun intended. And this is what they are until they're done. We're just going to give people tape and then we'll fix it next time, I guess. Right.

Jennifer Smith, CDE 56:13
And we do. And there are I mean, speaking to that, specifically, from what we know, clinically, and the bit that's been shared, they are already on it, as your as a company there, there are products that should be coming out in the future, when I don't have any idea or not privy to that information. But there are, there will be a new sensor that will be more accurate, more user friendly, from what I remember and understand it will not have that beaver tail transmitter kind of piece to it. It will be much simplified. And their next iteration of this hybrid closed loop system that they have, will be more finely tuned with a lot of these pieces that are they're kind of a pain to have to deal with. Right. So they are working on it, as are all the companies out there, right? They're continuing to build and, you know, yeah, make changes and listen. And

Scott Benner 57:18
I meant what I said, when we started out that I think it's, it's not a great position to be in to be first. You don't I mean, because you probably had to do a lot of things to get through the FDA. And that's been softened for the pod and tandem now you know that that stuff is that past been cleared out a little bit for them. So there's a lot of good, you know, somebody's going first is and to be honest, if it was going to be anybody, it makes sense that it was Medtronic honestly because they're well,

Jennifer Smith, CDE 57:44
they're the oldest on the market. Honestly, of all of the pump systems. They are the oldest that is still around. I mean, all the rest are pretty much gone. Right? There are lots of people who love their, their combo pumps and their animists and things so

Scott Benner 58:03
they're all gone. They're all gone. Was it cosmo? What was that one that people? Cosmo's no pump, right. Yeah,

Jennifer Smith, CDE 58:09
yeah. In fact, another Scott Scott Johnson, who has his own little like diabetes blog, and he works with the my sugar group now. Um, he was like, he Bade his Cosmo and

Scott Benner 58:24
as long as he should

Jennifer Smith, CDE 58:25
hoarded supplies in order to keep it going, as long as he could, he could, he probably I don't know what he's using anymore. But he probably go back to because he really loved

Scott Benner 58:34
his cosmos. That's a nice person I've met. Awesome. So what's the overview here of this, if you have the system, and it's not working the way you want it to? You're going to have to go out of auto mode sometimes to address some meals, but not all, or you're going to have to understand that your blood sugars are going to be higher than maybe you want and just let it be.

Jennifer Smith, CDE 58:59
You have some kind of standards of when to go out of auto mode. Honestly, you know, the the initial question you asked a while ago about, well, what if I'm eating this really slow digesting or really high fat meal or, you know, my normal peek is going to be way out here and whatever. And you were used to using a square wave or a dual wave Bolus before you know what it might be best to temporarily switch back to manual mode, use what you knew work from the get go. And then when it's done, switch back to your Mac to your auto mode. I mean, that's, that's really one of one of the settings of switching out of auto mode. Another one might be honestly sick days, high stress, those kinds of things or even like I said, high fat meals etc. Where you really, let's say you always know that when you've got this really nasty, like cold that you use 25% more insulin, you've got a temporary, you've even maybe got a profile set for sick days. Right? You know what, don't hesitate to switch out and go back and use that because you knew it worked.

Scott Benner 1:00:11
Does that system allow for me to set? Could I set up multiple? Like profiles? No, but so I can't have a pizza profile on a regular profile. But see, that was because that would fix it. If I if I suddenly made the sensitivity, and the you know, the insulin on board times differently and changed, like my carpet is

Jennifer Smith, CDE 1:00:29
remember why it's gathering data over the past several days of insulin sensitivity, I keep changing it

Scott Benner 1:00:36
around because it will. Correct. Okay.

Jennifer Smith, CDE 1:00:40
Yeah. But that's a that's a great question. Again, you know, days, I even think of days, like, my brother in law works for Disney. And so we've gone down there more times than I can count. And we've enjoyed the parks and whatnot. And I know that a full day of getting up. This was pre kids, my husband and I were just enjoying the parks as adults like running around like crazy kids trying to get to everything, right. I had to use not only a temporary bazel all day long, but also overnight to avoid running too low. Well, you know, what auto mode would would not benefit me in that scenario. Because I would just be running too low, it would be consistently trying to probably suspend me not just temporarily decrease things. And that is also a limiting factor to the system that is different than the coming hybrid systems that are going to be on the market or are already, there's only a certain timeframe that it will high temp, your bazel for or Low Temp or suspend for before the system kicks you out of manual mode and say, Hey, this is all on you now, okay, you're and it will alert you. It's not like it's all of a sudden gone. And you're waking up at three o'clock in the morning. Great, I would have loved to know that you kicked me out. There's an audit, there's an alert that tells you you are out of auto mode you are back in manual mode. And it's because either you've reached the max amount of insulin delivery in a time period that's divined or you've been suspended or decreased bazel for a certain amount of time as well.

Scott Benner 1:02:23
Interesting.

Jennifer Smith, CDE 1:02:24
So in a day, like I was describing, yeah, that's to switch out of auto mode, go to your Temp Basal that worked. Mine was always setting a Temp Basal decrease of 15% for the whole day that we were the year and into the overnight. That worked beautifully.

Scott Benner 1:02:39
That's it's a great advice. And it also feels like it's, it's a little sad, because you're telling me that this pump that I'm I'm thinking what's gonna stop me from getting high, it's gonna stop me from getting too low, it's gonna be great. It's gonna take my mind off of blood sugars, blah, blah, unless I go to Disney and run around all day, and then it's back on me. Or I have pizza. Or you know,

Jennifer Smith, CDE 1:03:04
and remember, if you are going to Disney today, and the last four days, you were in some type of horrible business meetings that had you all jacked up and insulin needed, it's gonna crush you insulin. sensitivity is Yeah, exactly. You can't whisper and be like, Hey, 670 on vacation. Now I got

Scott Benner 1:03:22
a Fast Pass today. So keep up, right? So keep up with Oh, it's gonna thank No, for the last three days, you've needed more insulin?

Jennifer Smith, CDE 1:03:29
Correct?

Scott Benner 1:03:30
Exactly. So you go from I've needed more situation to I need less situation and it can't, it can't

Jennifer Smith, CDE 1:03:35
adjust it. It can't adjust again, fast enough is kind of the issue, right? And then I guess one of the last ones truly, which we've all experienced on every single pump is an infusion site problem, or a site failure or something, you know, and if you're in that high blood sugar, and you know it's a sight problem, and you go ahead and you change it, it really is best to switch back to manual mode, change out your set your tubing, maybe even your insulin, give a bolus we usually recommend via injection instead of through the new pump site. And then once your blood sugar is back in range, switch back to auto mode, right?

Scott Benner 1:04:15
Okay, I am at pump changes. I do something very similar pump changes. Like I don't rely on the new site right away like I tried to. And I also do not stare at bad sites like when sites no don't. When you know, you know how I say when when when an insulin pump site stops doing what I expect it to do. I do not stare at it for 10 hours wondering if it's gonna get better again, you know, right to bosses. It doesn't do what I want it by time. Yeah, right. Yeah. And it doesn't have it's not like you know, doesn't happen constantly. I'm just saying when it happens. I don't look at a pump and think oh, I have three more hours left on this one. I can't wait. That's an that's a rookie move. Right? Like that idea of like, oh, there's three more hours. Here, I don't want to waste those three hours, there's five more units here, I don't want to waste those five years, I mean, money aside, I understand insolence expensive, you're gonna have diabetes, for abs, you know, I mean, so like it just trying to cheat two hours here and three hours here and four hours here, you might think oh, I'm, you know, I'm saving myself an insulin pump set or something like that every month, what you're doing is you're costing yourself three and then two, and then four, and then six. And before you know it 20 and 25 hours and 30 hours a month of high blood sugars, by trying to sneak an extra two hours out of your pump. You know, I think, I think you have to, if you can afford to, you have to think about it the other way or supplement with injections, if that's crass, not working?

Jennifer Smith, CDE 1:05:40
Correct, or something like you know, a frezza, or something that works very rapidly, and you know, that it's going to work and it's going to get things down, or, you know, whatever, I don't get

Scott Benner 1:05:48
a 180 going, Oh, it's only for eight more hours until the right, come on. You know, don't do that. Just

Jennifer Smith, CDE 1:05:54
don't do it to yourself. Yes, yeah, yeah, exactly. Health is what your

Scott Benner 1:05:59
health is, first health is the goal.

Jennifer Smith, CDE 1:06:01
And I think you're talking to you know, you're kind of like hiding from a situation that you can, you can visibly see, it's there, and you're like, we're just gonna like, it's gonna fix it, kind of like even you know, going along with like the auto mode, we really try to recommend not hiding things from auto mode, too. Right. And one big one that is often forgotten, especially if you've gotten into this routine before having auto mode. And if you were an omni pod user switching to this system, you wouldn't even really think about because you've never disconnected. But when you disconnect from the pump, in auto mode, suspend your pump, so the system knows that you are not receiving insulin, okay? Because if it thinks you're receiving auto mode based adjustments of insulin counts, when you're really not getting them pumped into your body. It may, it will then continue once you do plug back in, it'll continue to think that there's insulin there that wasn't

Scott Benner 1:07:07
okay. So you have to tell it up if you just connect to bathe or something like that.

Jennifer Smith, CDE 1:07:11
You suspend your suspend

Scott Benner 1:07:12
the pump so that it realizes nothing's happening, correct. Okay. Yep. And I'm assuming that's an easy thing to forget to do. But do people forget,

Jennifer Smith, CDE 1:07:21
I would say it's an easy thing to forget to do. I, you know, some people, especially in conventional mode, coming from conventional mode into using an automated mode like this system has, because I'd say probably 50%, at least of people who disconnect from their pump, because their system isn't connecting with a CGM to do anything with that insulin. They're just disconnecting, letting it pump. They reconnect when they're done with their shower done with their swim or whatever. Maybe they're maybe the really meticulous people are remembering to suspend their pump and then remembering to resume their pump. Once you reconnect.

Scott Benner 1:08:03
I used to be surprised by the number of people who would tell me I took my pump off to get a shower and three hours later remembered where I forgot. Yeah, yeah. And I guess and like I said, buy used to be surprised. They used to be surprised because Arden uses a pump you don't disconnect from I never considered it. But you know, after you think about it for a while it's reasonable. You can be rushing around or right doing whatever it's you know, I don't know. To me, it's a selling. Yeah, no, I hear you. Okay. Well, alright, I don't know what we've Do you think we've done anything valuable here, like if a 670 g person heard this, but they'd be like, I've heard something that might help me.

Jennifer Smith, CDE 1:08:38
I think if you're a person currently using it, there are some there are some tips if you didn't know about them already, to maybe put into action to make it work a bit better for you, especially if you're somebody who is using auto mode, pretty much 9095 maybe 100% of the time and you feel like there is something to tweak but you're not quite sure where to start maybe some of these tips. While we spoke about some of the drawbacks, I think the tips that are in here for people who are using it could be an advantage if they're already not trying them. Um, you know, I think another another big one that often times again, with these hybrid types of systems is often a forgotten piece of teaching someone when they start on it is how to treat lows.

Scott Benner 1:09:30
So you're not over treating your lows,

Jennifer Smith, CDE 1:09:32
correct. The age old 15 grams every 15 minutes kind of thing. A lot of people are still following that and on a conventional pump, especially if your settings aren't really dialed in very well. Maybe it does work quite well for you. Maybe you even need to use 20 grams are 25 grams because you're really not sure how much insulin is there and that's always seems to be brings me up and I don't get low again. So I keep using this well, you can guarantee that on any of These hybrid system systems that are augmenting the insulin delivery, right, you have to remember that in auto mode, if your blood blood sugar is decreasing, the system is has already seen that. And if it's decreasing, and you're going to get below a certain value, or to a certain value, depending on the rate of trend, the system is either temporarily decreasing, or it may already be suspending.

Scott Benner 1:10:32
So it's already created a void of basal insulin correct with the food in. And once you stop the drop, there's nothing else there to help with the food.

Jennifer Smith, CDE 1:10:41
Correct. Because that bazel deficit, remember how long into the future that can make a change? So think about under treating your lowest?

Scott Benner 1:10:52
No,

Jennifer Smith, CDE 1:10:52
I think easiest way to say it,

Scott Benner 1:10:54
I think those are the little pieces that that get lost, especially in a low situation, because there's a panic, I got a really lovely note from a person today, just this morning, who said how much the podcast has helped them just with that idea, you know, they used to get low, and then eat a bunch of food. And then just let whatever is going to be be after that instead of recognizing some of this food was for the low. And some of it was because I'm ravenously hungry, because I'm low and I'm scared and all these reasons that this food needs insulin, you know, some of this food needs insulin, right. And the person said that just that idea from the podcast has really changed their, like their days, you know what I mean? Like they're not spiking and dropping and spiking and dropping all the time. And that's the stuff nobody talks about. And it's tough. And not to put that on a pump company, either.

Unknown Speaker 1:11:40
No, no.

Scott Benner 1:11:41
I don't know if people understand like the pump companies, through FDA regulations can't tell you how to manage your diabetes, they can tell you what the pump does, and how to technically make the settings like how to use it. They can't tell you when to use it. They're not allowed. You know, I mean, and that's supposed to be for your doctor, but then your doctor is busy telling you, you know, just keep eating 15 carbs and 15 carbs and fat and carbs. And then you know, see what happens afterwards.

Jennifer Smith, CDE 1:12:07
And along with that, you know, we bring into the picture technology, right? Our technology today using CGM, you have to remember that CGM is leg, especially in times of lower blood sugars or in times of rapidly changing blood sugar values. So if you've treated your low, especially on an automated system like this, if you've treated it, you've you've got to wait, yeah, unless you're willing to do a finger stick and a finger stick to see that things have now up they've stabilized up I'm rising, my blood sugar's coming up. But look at that my sensors still reading at 52. But my finger stick is at three, stop eating your 15 grams every 15 minutes,

Scott Benner 1:12:47
you have to stop caring about this. It's an interesting situation, you've corrected the low. And now you're going to wait for your body to respond, your body begins to respond with a blood sugar that's rising. The sensor doesn't figure it out quickly enough. So you're still looking at the 52 going, I probably need more food. If you fingerstick you might be 65. Right? If you wait 10 minutes, you might be 74. And the CGM might believe you're 74 too. But it's that panic time right in there. Yeah. And I I'm a fan of testing. I like testing in that spot.

Jennifer Smith, CDE 1:13:18
I do too. You know, I do too. In fact, when I you know, in a conventional pump sense, I usually enter the carbs into my PDM. Because when I do that for a low blood sugar, if I enter too many grams of carb, the PDM will tell me I need to Bolus and if I have a certain amount of carbs and it's recommending a 0.0 Bolus, I know that it's at least offsetting enough to bring me up. And potentially if I've got insulin on board, it'll allow me to actually then take in enough carbs to compensate for insulin on board. And the low blood sugar without recommending a bolus, yeah, if you enter it, and you're like, I'm gonna eat 49 grams of carbs to treat this low and your pump is like okay, well you need 2.2 units of insulin. I guarantee you probably need that 2.2 units of insulin even though your blood sugar is sitting too low. I will tell a story sometimes when I'm speaking publicly about the time it It struck me like when I finally figured it out and Arden had a bad low. It came out of nowhere in the middle of the night. And you know, everything you described like she's falling

Scott Benner 1:14:34
so fast that the CGM this is years ago. She was falling so fast. That CGM didn't pick it up right away. It was also I think, two generations of Dexcom ago, it was probably the g4 right, and so she's falling fast. And I catch it. I test she's really low. She's like 36 she takes in 65 carbs, right and the 36 I finger stick it holds wait five minutes the longest five minutes your life you stick again. She's still 36 Okay, she's not falling. You know, you're like, Alright, wait again you wait again you wait again fingerstick 42 going up. All right, the CGM still just yelling low, low, low. Yeah. Because it's just waiting. Yeah, it was. It's a little behind now, right? So I'm like, okay, 36 went to 36 went to 42. I'll wait. And I wait. And then I saw 54. And it was that time it was this one time that I was like, god damn, you know what I'm gonna do. I was like, I'm gonna Bolus. It was like, so she had like 65 carbs. And I think

Jennifer Smith, CDE 1:15:42
you were like 65 carbs was a lot of carbs.

Scott Benner 1:15:46
But the leap is, first of all, you have that adrenaline. You just saw 36 blood sugar. The CGM is yelling low at you. All this is happening. But she's clearly coming up. I didn't Bolus Roth 65 cars. But if I remember correctly, I think I did 40 of them. And I stopped her blood sugar like 170 because trust me, 20 minutes later, her blood sugar started shooting up, right. And even that gives you this anxiety because the CGM is catching up, you know, it's telling you low now she's 54. Now the sudden she's probably 65. Now all of a sudden it goes ooh, 40. And then it shows you arrow straight up and the arrows panicky, you're like, Ah, you know, but because I was testing, I knew what was happening. I was like, Alright, forget this first second, I'm gonna stop paying attention to the glucose monitor for a second. And I'm going to go back to knowing what I know is going to happen. She's got food. She's clearly not low anymore. She's moving up. This is no different than a bad Pre-Bolus at a meal. Like it's almost like I Pre-Bolus too long. Like, right, that's all that's happening now. So like, what do I do next? And what I did next was insulin. And I'll tell you, if you've ever seen me speak, speak live like sometimes like I do. I go out into my my hallway afterwards that I leave Arden's room, and I'm like, hey, my arms over my head. I'm like, Oh, I killed this. Oh, my God, I did such a good job on this. And then I go to bed. And that was it. But yeah, you can't if you over treat Lowe's, especially in these auto system, this one specifically, you're just gonna bounce forever, they get it, then it's, then you're not letting the system do what it's there to do for you either. Right, you know, all right. Well, I truly believe that, you know, Medtronic next system will be an improvement over this one. I 100%. Want to give them credit for doing it first, because I think it's a I don't think that I don't think they had a chance for an outcome any different than the one they got being first and probably I'm guessing, dealing with the restrictions from the FDA that they put on a first, you know, hybrid system. So

Jennifer Smith, CDE 1:17:48
absolutely, I'm quite sure that the that the restrictions and the parameters they had to stay within were outrageous to actually get a system on the market. That could actually, I mean, the first step really was allowing CGM to replace fingerstick. Yeah, it was 100%. And once that was approved, and they were like, okay, now that that's approved, now, we can actually have a system that doses insulin based on CGM values. And that was the huge first step. So I mean, they put a lot into place I, you know, I would not like,

Scott Benner 1:18:26
we all need to appreciate that we all need to appreciate the speed in which things are moving through the FDA now that they did not used to. And I mentioned this to somebody personally, last night, if you go back a couple of years, and the CEO, Shea see from from Omni pod is on the podcast, I'm asking her about like, hey, am I ever gonna be able to control my daughter's pump from a phone? And her answer a couple years ago was like, I mean, we would love that. But I don't know how we're getting that through the FDA. And now the horizon is going to come out and it's going to be controlled through your phone. And it's a couple of years later. And so for new people who are used to like Dexcom, being like, here's the G four, here's the G five, here's the G six, the G seven is coming. That's not how diabetes has worked. Historically, getting new technology to market, so things moving so much more quickly than it used to. It's really yeah, you know,

Jennifer Smith, CDE 1:19:16
and it's making a big difference for people. I mean, really even considering just the 670 system, and some of the pivotal trials and the things that Medtronic came out with even years ago. I mean, they really proved that people who used it with a lot of the strategies of applied management to using it mean they can achieve an A one C, kind of shortly under a 7% sort of in like the 6.8 6.9% range. I mean, a good percentage of time in range. I mean, if you were falling short of that 40% 50% if you're using the system well and auto mode, most often you can get 70 75% in range, with that range being like you know that 70 to sort of 180 ish kind of plays such a

Scott Benner 1:20:01
big but yeah, for a lot of people

Jennifer Smith, CDE 1:20:03
for that that's huge for many people. So you

Scott Benner 1:20:07
have to remember where you're coming from when you listen like when you say, an eight, one c like in the low sevens. It My mind is like, Oh, that's a point and a half higher than I want it to be. But that's for me, a person who's got to see in a one see who's nine is like, wow, just saved my life.

Jennifer Smith, CDE 1:20:23
I'll take it. Yeah,

Scott Benner 1:20:24
yeah. No, 100% No, I, I believe I really do. Like I like to tease Medtronic. Mostly, I like to tease them in case they're listening. Because I am not a fan of what you do in Washington, around insurance and the way you throw your weight around and limit other pumps. So it for that, and I'll bleep this later. I think you're a bunch of it. But you know, for the rest of it. We're just here talking. I agree. Yeah, that's all let's Scott Johnson have his goddamn Cosmo pump. It wouldn't have been that bad. Damn, it. wouldn't know he wasn't taking that much money out of your pocket. Medtronic, he could have let it be. Alright.

Unknown Speaker 1:21:01
Right. You can

Jennifer Smith, CDE 1:21:02
all these other products off the market right here.

Scott Benner 1:21:04
Okay. Huge thanks to my sponsors, Dexcom and Omni pod. You know, we never mentioned it. But the opinions expressed on this podcast are not those the advertisers probably should say that once in a while to take that thought a step further. I'm an idiot. I don't really know anything. So, you know, grain of salt, though. And I'm sure there's a ton of wonderful people at Medtronic. To find out more about the dexcom g six continuous glucose monitor, go to dexcom.com forward slash juicebox. Please use my link, click on it. You know, you can do it right there and your podcast player right now. And to get a free, no obligation demo of the AMI pod sent directly to you my Omni pod.com forward slash juice box. Don't forget Thursday the 23rd of April 2020 at 3pm on the bold with insulin Facebook page. Alive Scott and Jenny. Jenny and I are gonna answer your questions right there on the Facebook machine. And later, you'll hear it on the podcast. It's actually at bold with insulin on Facebook. So I don't know how you do that Facebook calm. There's some slashes in there but you'll find it. What else? I don't know. I hope you guys are being safe and find the things to pass your time and all that stuff. I am recording this right now in a pair of shorts and it's too cold to be in shorts, but doesn't matter because I'm not going anywhere. So at least I'm wearing the shorts