#537 Haley is a Tandem Pump Trainer

Haley White is a PA, T1D and pump trainer for Tandem. She’s on the show to talk about using Control IQ.

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

Scott Benner 0:00
Hello friends, and welcome to Episode 537 of the Juicebox Podcast.

On today's show, Haley joins us. Hayley is a trifecta. She has type one diabetes. She works in the medical field, helping people with type one diabetes, and her side hustle. She's a trainer for tandem control IQ. And she's here today to talk about just that. As you're listening, 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

Unknown Speaker 0:58
plan.

Scott Benner 0:59
We're becoming bold with insulin. If you're new to the show, and don't know where to keep going, like you're like, I like this episode. But what do I do next? Check out Episode 411. It explains how different people listen. People who are more interested in community Some are more interested in management, Episode 411 will point you in the right direction.

This episode of The Juicebox Podcast is sponsored by the Dexcom g six continuous glucose monitor. And you can learn more about it@dexcom.com Ford slash juice box. The episode is also sponsored today by Omni pod makers of the Omni pod dash m the Omni pod promise, which I'll tell you about in just a little bit. To learn more about Omni pod, where to get started today, go to Omni pod.com forward slash juice box. There are links to these and all of the sponsors in the show notes of your podcast player, and at Juicebox podcast.com.

Haley White 2:14
Hi, my name is Haley White. I am a physician assistant at UPMC Children's Hospital of Pittsburgh, and the endocrine and diabetes division. I also work for tandem doing pump trainings and startups and also have type one diabetes. I was diagnosed when I was three, and I'm a former patient at Children's Hospital of Pittsburgh. So I'm happy to be here. And hopefully this information can help others because that's exactly why I got into this field to begin with.

Scott Benner 2:48
That's excellent. I don't want to go too far into your personal stuff because it will take away from our other conversation. But

Haley White 2:53
certainly How old are you now? I am 33. I'll be 34 in November and I will celebrate my 31st diversity in October.

Scott Benner 3:03
Wow. Look at you. That's it. Yeah.

Haley White 3:05
So I was like shortly before counting three is when I was diagnosed. That's a long. Yeah, it certainly is. So like the technology that we have available now is just so obviously so different than what my parents had available. When I was at age, the insulins are so different. It definitely makes management, you know, easier, and much more level. My cousin's daughter actually was just diagnosed last week, she's seven. And I was, you know, telling her that that things are at least a lot better than they, they used to be moving in the right direction. The technology advances are pretty cool.

Scott Benner 3:44
Yeah, it's amazing. How do you end up so you have a full time job at the hospital? I imagine, right? How do you end up doing training? Because a lot of people do this, like, do training for pump companies on like, Is it a side job? Or how do you

Unknown Speaker 3:56
Yep. So usually we'll meet like on evenings or the weekends, things like that. And which is usually more flexible with family schedules as well. I usually do most of just kids patients that are patients at our clinic. But can also do adults as well. So yeah, it works out pretty well, too. With my schedule in their schedule.

Scott Benner 4:19
How many people do you think that you talked to in a month? For tandem specifically? Yeah.

Unknown Speaker 4:27
It really depends. It kind of comes and goes like this month so far, I think I've done four trainings. So it really it kind of varies from month to month, but I would say four, three to four is pretty average.

Scott Benner 4:43
What's the goal of the training? So obviously, it's to see you understand the pump, but more specifically, like where are you trying to get them when you get off the call.

Unknown Speaker 4:54
So we actually will meet in person and the way we do things that children a little bit different than how they do things in the adult world. So if they're new to pump, brand new to pump, we will, I'll actually meet with them first. And they will go on sailing. And they'll practice using the pump, just using sailing for like a week or two. And then they'll come back, and they'll meet with our diabetes educators and kind of review something, see if they have had any issues, and then they'll leave that day, using the pump with insulin in it. So and the other thing we've been kind of doing, which I think will probably change also varies from patient, to patient and family to family. But we have been starting them out on Basal iq, if they're brand new to pump just to get them used to pump therapy in general. You know, it's kind of like getting your driver's license and then buying a Ferrari. So going from absolutely nothing to control. IQ can be a lot, sometimes, depending on the family and patient. So we have been typically starting them out on the Basal iq. And then after they get used to that, then they'll do the upgrade to the control IQ.

Scott Benner 6:07
So there's somebody making a kind of quiet assessment of the people and trying to decide what it is they can handle. Yes, and that's typically the provider, the provider does that. Gotcha. Yeah.

Haley White 6:19
So like I had a patient whose mom has type one has been on a pump. She's on a Medtronic. She's also a nurse, you know, and so we we started him on insulin right away. And on control, like cute right away, because that's obviously a savvy family who is already familiar with pumps therapy in general.

Scott Benner 6:38
I see. So but to my original question, it's interesting, because you have the perspectives of two different entities, like, I just occurred to me, like you have the goals, you have the practice in mind. But then when you work for tandem, you have different goals in mind. So that's the thing I'm interested in specifically is when I you know, I get together with you to do my pump training for control IQ. When I leave, what is your goal? Is your goal for my blood sugar to be in a range? Is it for me to understand how the how the algorithm works? Like what is it you're trying to impart in that first meeting?

Haley White 7:15
Yeah, so that's a great question. So it's really to, to understand how the pump works, and how to use the pump properly and safely. And then the adjustments in terms of getting the blood sugars into a tighter range typically goes back to the provider or the diabetes educators at the hospital. So as a, as a contracted employee, I'm actually not legally allowed to give the patient's medical advice on, like how to do extend boluses or Temp Basal aals? Or, you know, making insulin dose adjustments, etc. but can give that advice as a medical professional at the hospital, if that makes sense.

Scott Benner 8:00
Do you actually, like literally have hats that you take on and off while you're speaking?

Haley White 8:05
Yeah, so I will say, you know, I, you know, I can't say from a tandem perspective, but from a children's perspective, this is typically what I would recommend to my patients, you know, but I would double check with your provider, specifically, because everybody is a little bit different on how they manage things. And I'm sure you know, I say, all day long diabetes is not black and white. And there is a ton of gray. So it is a little challenging, because I'm legally not allowed to give specific advice as a tandem employee. But you know, since I do work for children's, I can kind of throw that in on the side off the record kind of thing.

Scott Benner 8:44
Yeah, I think it's beneficial for people to understand that device manufacturers are prohibited by the FDA from giving medical advice. And so to kind of make it super simple to understand if Ford makes a car, and Ford is Dexcom, let's say, then, I can tell you that the pedal on the left stops the car. I but I can't tell you how hard to push it or when to push it. And that would be a driving instructor who would tell you that? Correct? Yep, exactly. So you can say, Hey, listen, this is where you put the insulin. And this is what happens here. And this is how the algorithm works. But you couldn't say to them, for instance, the algorithm would work a lot better if you Pre-Bolus your meals.

Haley White 9:32
I mean, we do talk about some of those things that of course, we talk about like safety issues. So prevention of decay, prevention of site infection, things like that. So there are some things that we can discuss in terms of management, but really where it gets iffy or we're not really allowed to discuss is like dose adjustments or what specifically to do, if that makes sense. So we can do a little bit of that. But at least I think until you know, my boss hears this podcast, and then I get in trouble. So

Scott Benner 10:07
I think you're gonna get in trouble for being on the podcast.

Hayley White 10:10
No, I just saying unless they're like, Oh, you've been you've been doing that off the record, you're not allowed to do that or something. So, so we'll see

Scott Benner 10:18
Haley, I have to tell you something. It'll be a fun place to put this. I did an amazing interview last week with a person who is in your almost exact situation. Oh, yeah. Your job is not the training part, the part of the hospital? Right? Okay, we got completely done. When we got done. I said to the person, I don't think we should ever share this with anybody. And they go, Yeah, I was just starting to think I'm going to get fired, right? I was 100% going to get fired if I put this up. So anyway, it's interesting to see the back workings of things. But

Haley White 10:50
yeah, and there's obviously some things you have to say in terms of safety as a medical professional. Because once again, because there is, you know, not black and white, like we give black and white instructions, but then there's always a caveat to those as well. So it can you know, that's why diabetes management can be sometimes challenging. So sometimes what you would recommend professionally versus personally could be different. So I always say, Do as I say, not as I do in clinic. But But yeah, that's where it can get a little bit iffy. Okay.

Scott Benner 11:25
Alright, so I think we have some good background on who you are, and how you think about things. So that's perfect. So I want to just jump right into so I mean, I think it's obvious for people who listen that, you know, I have a ton of experience with on the pod. And I have a ton of experience with loop. And Jenny comes on all the time Jenny uses on the pod as well. And then Ctrl IQ comes up. And people are like, you know, I need to know how to use this. Now, in my mind, it's probably not much different than loop, which will probably be not much different than on the pod five, which will probably be not much different to whatever Medtronic comes up with and tide pools, algorithm, etc. I think they're, maybe they get to what they're doing differently. But I think it's more about understanding the settings that, that so for, I've spoken to a number of people on control IQ, who I've tried to help, understanding that I've never seen it in my life never held it never looked at it, never used it. And still, I've been able to help people, but I have to like listen to their stories, and then like, go Okay, well, I think maybe try this, and which is not not a productive way to try to get it to the masses. Right. So I'm hoping that you can, what I would like to do in this episode is to have a real firm understanding of how the algorithm works, and what's and what settings are available to you as the user. So

Haley White 12:52
yeah, so there, you know, I agree, I think all the automated systems, you know, their goal is to obviously get the present time and rates should be higher, prevent hyper, and hypoglycemia. But the algorithms are all a little bit different. So I think the thing that is nice about the control IQ is it does use your program, Basil rates, carb ratios, correction factors. And you can have up to six different profiles. So you could have your primary profile that you typically use day to day, and then you could have, for example, an illness profile where your insulin needs maybe a little bit higher. Or for females, you can maybe have a like menstrual profile, you can have an activity profile, weekend verse weekday profile, you know, grandma's house, profile, whatever, where things may be different. So you can have up to six different ones that are already programmed into the pump. So it's very easy to just go in and turn on whichever profile you want to use. And then the algorithm will use that as a starting point. So the only things that are set in the algorithm are the insulin onboard time and target blood sugar. So the target butcher is actually whenever you're just using it, the primary mode, so there's just your regular mode, there is an exercise mode, and then there's a sleep mode. So for that primary mode, the target is 112 point five, which I know is random. And I believe it was, you know, an engineering thing, how they came up with that number. And that was, you know, where you could get basically the most time and range from the majority of people with you know, last hypoglycemia. But actually in the pump, the pump settings at the target will be 110. So essentially it's keeping you between 110 or 112 point five to 160 is the target range with the algorithm Have them. And then if it predicts, so the other thing about the algorithm is it's looking 30 minutes ahead of time, and predicting what it thinks the blood sugar is going to do based off of the Dexcom values. So for predicts, you're going to go above 160, it'll start to increase the basil rate from whatever your pre programmed Basal rate is. And then if it predicts, you're going to go above 180, it will actually give a correction Bolus, the caveat being, it's only 60% of the calculated dose. And that's usually because it's, you know, as you're writing, it's increasing the basil as well, and then giving the correction on top of that. So it comes out to be, you know, not quite 100%. But it's still more than if they gave 100% of the correction, you know, that would definitely predispose you to drop below. But it's using your correction factor that's programmed in your pump settings, whenever it's calculating that, versus I believe the Medtronic algorithm doesn't use like your pre programmed Basal rates and things like that, and it just pauses comes up with them on your own. Yeah. So. Um, yeah. Okay.

Scott Benner 16:13
So if I put this on a person who's eating like, no carbs whatsoever, they're like, on a really strict low carb diet? Would I if everything was going well? Would I just see a graph? That's just 110 24 hours a day?

Haley White 16:31
Pretty much. Yeah. So as long as they're so bullish thing for, you know, the small carbon take that they are having into account the fat and protein? Yeah, I mean, whenever I don't always eat low carb, don't get me wrong, I love doughnuts, and fried food and all that fun stuff. But during the week, sometimes I do a little bit lower carb. And when I do low carb, I mean, my my tracings are like, pretty straight with very little minimal ups and downs. So that can be achievable with this, if you're doing you know, I think that kind of shows that lower carb is beneficial. Now, of course, in some kids, we don't want them doing super low carb for growth reasons and things like that. But in general, as an adult, you know, lower carb is a little bit easier on blood sugars in general, and then the system is able to make some of those micro adjustments more easily than a bigger adjustment.

Scott Benner 17:29
Okay, so let me let me say this, then, Arden, my daughter, about an hour and 15 minutes ago had two big homemade pancakes and seven strips of bacon, and her blood sugar 75. Right now in super stable, you're talking about? Is that not attainable? With control iQ? Or no,

Haley White 17:48
I mean, so the algorithm will decrease your basil, if you're trending below between 70 and the 112. point five. But that's not to say that you can't, that you're constantly then at like 112, point five, there's plenty of times where you could be in the 70s 80s or 90s. So it's just trying to prevent the low. And then if you if it's predicting you go below 70. That's when it will actually suspend the Basal

Scott Benner 18:19
will that create a highlighter? Or can it cut that off?

Haley White 18:23
So that's a great question. And one thing that I don't love about this system is, you definitely need to treat Lowe's less aggressively than you're used to, which I think is hard for people depending on how symptomatic they are. It's sometimes can be hard for parents, if they're anxious, you know about the low blood sugar or whatnot. But if you do over treat, and then you start to rise, then it may be increasing your insulin again. And if you're way over treat, and you don't dose for the extra carbs eaten, then you know and you're it's trending, it's predicting you're going to go above 180 then it'll give you that micro Bolus. And that often does precipitate another low. So it is really key to treat loads less aggressively and to find kind of what works for you personally, whenever the system does shut off that basil. So not necessarily like there's some times where mine might shut off and if I'm a little tight, I may actually just let it ride and then I'm fine. But if I have a lot of insulin on board or a patient has a lot of insulin on board, and they go you know they're in the 50s or 60s where they're much more symptomatic You know, I'm guilty of overtraining my lows at time. So I do find that you then have to, you know, be proactive and dose for the extra carbs eat and if you know that you overtreated it.

Scott Benner 19:45
Yeah, I find very simply that it takes a little while to figure it out. But after was on loop for a while. I saw there are some lows you treat and don't Bolus for and there are some lows you treat and almost half the Bolus Uh, you know, 60 70% of it pretty immediately.

Haley White 20:04
Yeah, exactly. So, you know, if, if it normally takes you 10 to 20 grams on this system, you know, to bring you up, then I would say subtract that from whatever you did he and Bolus for the rest of it. Even if you're nervous about it, you could always do a little bit less. And then you, you know, as as time, as always, you you see what happens, and then you learn from it and make an adjustment the next time

Scott Benner 20:29
but yeah, that's exactly how I think about. Okay, see, I

Haley White 20:32
think some people think that, you know, like, I actually initially was hesitant to upgrade from the Basal iq, because I love the Basal iq so much. And I was like, Well, I don't want to be necessarily 110. All day, I sometimes like to be a little bit tighter, especially overnight, but you can have lower numbers than just the 1/10. I think that's a misconception that I sometimes hear from people.

Scott Benner 20:57
Okay. Well, yeah, I mean, that's everyone's biggest concern about algorithms is, why can't I move the target? blood sugar?

Haley White 21:07
Yeah. And so I think in this scenario, I hear this a lot also about the insulin on board time being set, you know, with an algorithm, something that something has to be consistent and static, because if you can change the correction factor, the basil rates, the target and the insulin on board, that the math isn't going to always add up. And there's going to be actually a lot like the algorithm is not going to work well in that scenario. So something has to be consistent. So if you think about it, that's why with like Medtronic, for example, you don't have a set basil, it does that for you. But you can adjust your target, you can adjust your insulin on board time, things like that.

Scott Benner 21:48
Either giving you access to the different side of the settings, and then it thinks about it differently and tries to accomplish the same thing. So it's exactly how the algorithm is written to work. And, exactly. So let me ask you question is, does the algorithm work in such a way that if one day, they said, Look, we just need to make this thing more aggressive? Like, we're going to let you set it at 90, if you want your target to be 90 with the algorithm just work the way it works? But But you know, 22 and a half points lower, then, like, Is it just Oh, just an FDA thing? Like, is this just like, I think this is what we can get through the FDA right now? Or do you think this is just how these things are going to stay?

Haley White 22:30
Yeah, so that's a great question. And I think they're looking into that a lot, because they do hear from people that they want more flexibility, whether that's for, you know, like activity, the activity profile, or the exercise profile. It that targets you to between 140 and 160. And some people might want to be higher than that, or some people like I know, you've mentioned with artists, you know, she's pretty stable and can exercise when she's lower. So they are looking into being able to adjust some of those things, but I don't know exactly where they're at in that process. But I do think, you know, to get it approved, initially, they use that, you know, 112, point five, because that was the number where you saw the most time and range without increased hypoglycemia. So it was really a safe option, which, you know, is important, of course, when you're when you're thinking about diabetes management, especially as a parent, is to look at the safety. Oh, and it's

Scott Benner 23:30
so important to remember that this is the first iteration of these things for all these companies like, then we're gonna come out the door going like, you can just set this anywhere between 68 and 150, whatever you want, you know, like, right, do that that's not you have to, I hate to say it like this, you have to teach the masses how to use a thing before you can just do that. Yes,

Haley White 23:51
you're 1,000% correct with that, because, you know, I think a lot of people listening to this podcast, or a lot of people on the Facebook group or, you know, people who are savvy, they do want that tighter control, and they want that flexibility to have that tighter control. But that's not the majority of people. Unfortunately, I would I would love if all of my patients, you know, we're hesitant to upgrade to their control IQ because it targets you to 110 you know, that would be great. Yeah. But that's that's unfortunately not the case. So, so yeah, you're exactly right. They're looking at the like, the average, you know, patient with type one when they're when they were initially thinking about this a 112

Scott Benner 24:31
target, which for you people overseas is 6.2 that target is an A one see a 5.5 if you kept your blood sugar to 112 constantly, you're a one seat would be 5.5.

Haley White 24:44
Yeah, and that's the other thing to look at, you know, it's like it. It's always is very tight control. So sometimes it's like, you know, you have to think about diabetes burnout as well. And sometimes I think if you're expecting perfection, Share with diabetes, you can be setting yourself up for failure and burnout down the road. So, you know, expecting to be 90 all the time, you're gonna be at an increased risk of lows, which come with other consequences as well. So, yeah, it's not like riding at 1.5 is, is bad for sure.

Scott Benner 25:17
I want to say before we move forward, let me put this out there. One, what is it? 1.8 million Americans have Type One Diabetes that the number right now like so.

Hayley White 25:26
Yeah, I believe it's around there. Yeah,

Scott Benner 25:28
I'm gonna tell you that. This is you are right now, Haley speaking on the most popular diabetes podcast in the world. And I don't touch even a small percentage of 1.8 million people. And yet, and so for all the people out there who don't understand this in a bigger way, and who aren't kind of like Zen about it. And just like, oh, put some more in there. Correct. And alone. No big deal. Bolus two thirds that excetera. How much is that? I just Bolus Arden for pancakes. If you think I measured the pancakes, you're out of your mind. You know, I was just like, this much. Yeah. And so yeah, so my point is, you take this control IQ, you take on the pod five, you take Gloop, and anything and slap it on most people, and you've just significantly improved their health in their life. Significant

Haley White 26:19
1,000%. Yeah, exactly. Because we're seeing, like, even in well controlled patients, you know, in the clinical trials, and even in the real life data, I don't know the exact statistics. But it was like timing range went from, you know, like 65 to 75%, or something like that. And so you're already taking someone that's already in range 65% of the time, though, which is, you know, pretty good. Versus there's a lot of people out there who are not in frame 65% of the time, unfortunately. So I have a colleague who says better is better. And I love that slogan, because, you know, it is better than 8.5 8.5 is better than nine. So yeah, if we can take their time and range even from 25% to 30%, would be better. But the patients who don't do well at all who really struggle with bolusing, who, you know, have really poor glycemic control, they're actually seeing a better improvement with this compared to patients who are in tighter control. So they're not obviously having a higher, the highest percent time and range. But the difference in improvement is pretty tremendous. So it's allowed me to be a little bit more flexible with patients who maybe in the past, I didn't feel like we're the safest patient to put on a pump. But with this Dell kanila option. You know, I think this has really been a game changer for patients who are willing to wear a pump with tubing willing to do this, they'll Kiani law. And this, I think, is really going to improve a lot of lives of you know, people with diabetes, not only their glycemic control, but the quality of life as well to not have to think about your diabetes as much. And that's where I really have seen the improvement in my life is I don't have to micromanage or think about it as constantly as I did before and that after 30, you know, almost 31 years. That's huge. So I think that, you know, those two things, and of itself are, you know, just truly spectacular about this system and not all the automated pump. Oh, yeah,

Scott Benner 28:23
no, I mean, overnight, just overnight, if if the automated pumps didn't do anything else, the amount of sleep you were going to recoup, having an algorithm is going to be spectacular. You're gonna be magical. And, you know, little things like Arden went out last night, she was out for a long while in the evening, and she got home. And she was out with friends. They were driving around, I think she was the driver. I think they stopped in places did things hung out talk moved on, they were just out and about, you know, and at one point, I watched her blood sugar look like it wanted to go from 90 down. And then I watched the loop algorithm stop, but it's 72 and bring her back to nine. It was like it saw she was getting lower, and took away all her basil. And she dipped down and came back up very, very smoothly. And all I could think was I didn't have to text my 17 year old daughter while she was with friends and say to her, Hey, stop what you're doing and look at your blood sugar. See this thing? Yeah, grabbed ahold of it was amazing. Yeah, it really is it really Yeah. Like it's impeccable. So they went to a fair after that, or a carnival or something. And there was a time where I saw the algorithm try again, and it wasn't gonna do it. Now, she didn't know that yet. But I know it because I can see it. So I texted her. I said, you're gonna need a little food here. And she's like, great. I was gonna eat anyway. So I see is a Bolus for like 35 carbs. Everything's good. She's on her way. And then she gets home, she gets in bed, and I can see your blood sugar trending down, like she stopped. Now there's probably still some active insulin from the food she ate, you know, etc. And she's gonna get low. So I go into and I'm like, hey, it's really late, but you need some carbs here. And I'm trying not to tell her what to do. So she took in probably more carbs than she needed and fell asleep. But when her blood sugar started to go back up now was I thrilled that Arden's blood sugar was 136 for about four hours overnight. Last night, I wasn't, but keep in mind the scenario, she was asleep, I went to sleep, this thing stopped her blood sugar at 136. And by the time she woke up in the morning, was bringing it back down again. And then leveled her out at 90 and went on went on its way. So these are the things you're looking forward to if you're listening, but but Hayley, for everyone else, okay, for the rest of the people listening to this podcast? How do I tell them? Try an algorithm? Watch your a one c go up. But it'll be easier for you because they're not going to do that. So is there a way in control IQ specifically, for me to be more aggressive with my settings and have stability at a lower number than 112? Like, like so what I hear people say is I put that thing in sleep mode and always leave it in sleep mode. What What does that do exactly for as a jumping in point.

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I don't know why I said that. I don't want you to head over right the second I want you to listen while I tell you about the Dexcom g six continuous glucose monitor. continuous glucose monitor continuously shows you your blood sugar in real time. No testing every couple of hours or guessing or doing that lag. I think my blood sugar's okay. And that's not how you find out what your blood sugar is how you feel doesn't necessarily say where you are. You know I can tell you where you are the Dexcom I'm gonna whip this thing open right now here. This thing being my cell phone to tell you about Arden's blood sugar art in left school today, she can drive now. And she actually she's a good driver. That's not the point. And her and a friend went out for chicken and waffles with real syrup. she handled that Bolus all by herself. And I got to watch it here on my iPhone. Now if I had an Android phone, I could still watch it on my Dexcom follow up but right now today iPhone I can see Arden's blood sugar coming out of school. I see the little dip when she Bolus, I see a tiny little rise. And then I see the insulin takeover come back down again. And I even see a spot a number of hours later, where the fat from the chicken fingers tries to come back and get her again the fat and protein from the chicken fingers. If you don't know about that you should check out the pro tip series. But I see it and I'm able to send our the text and say Hey, your Bolus was really tight. Really great today, but I think we need a little more insulin right here. And she responded back to me. You know what she said? I'm going to get it right out of my text. She said I already did. How cool is that? dexcom.com forward slash juicebox the number your blood sugar is the direction it's moving, and how fast it's going in that direction at your fingertips, whether you're a follower of the person wearing the device, where the person wearing it, everyone using insulin, everyone using insulin can benefit dexcom.com forward slash juice box Omni pod.com, forward slash juice box. Let's get back to Haley, we have a lot more control like you to talk about.

Haley White 35:32
Some people do that, yeah, what the sleep mode does is actually will not give any automated correction. But it will adjust the basil to keep you between 112, point five and 120. So it's a much tighter range. So if you're, if it's predicting you're going above 120, it'll start to increase the basil versus the, you know, typical, the typical algorithm is the cutoff is 160. So it has a tighter range in general. So it's keeping you basically between that trying to keep you between those numbers. Right here, I will tell you anecdotally, most most of my patients have had not only improved time in range, which I would argue, is more important than the agency, but have also had improvement in their agency. So I think, you know, if your settings aren't working accurately, and you're doing your and you're doing what you're supposed to be doing, unless you're a once he was like insanely low, I don't know, like 5% or something super low. There's no reason that you couldn't keep an ANC in the fives or, you know, low 6% that is definitely attainable with this system.

Scott Benner 36:44
So then, can this with the system allow me to keep a five a one. So if that was my goal, like what if I'm pregnant?

Haley White 36:51
Um, yeah. So yeah, great question. So it's not approved for pregnancy, which is part of you know, the reason is because they do want much tighter control during pregnancy, but they basically want you to be low on a lot during pregnancy, which I've never been pregnant, but my colleagues who have type one and have been pregnant, you know, they don't they don't feel great whenever they're like that all the time. So that's, that's one thing to think about. But I don't know, I haven't seen anybody with anyone see a 5%. I would say not to get too into numbers my last day when he was 5.6%. I was only using the system for a month at that time, though. So it's hard to say exactly how much of that was the system. But the problem is it doesn't, you know, you can stay between 70 and the 112. point five. So you probably could achieve an eight one C of five. If you are if you were doing the right things. I just can't say I can't say that from personal experience or professional experience. For sure. But I don't see why you couldn't because it's not like it's not allowing you to have blood sugars in the 70s and 80s.

Scott Benner 38:02
Okay, well, listen, Arden got hurry once he done last Monday and hers was 5.6. Now Oh, look at that where we can be diversity. Oh, she would be. She would just cringe right up into a ball. She heard you say that. But okay.

Hayley White 38:17
Yeah, and I have patience. Do you cringe too, and then Bolus by younger ones. They're the ones that you know, they love that. So I don't even think she saw her meter. If I ever meet her, I won't say that.

Scott Benner 38:27
I, you really want to listen to the episode that I just did with her to understand fully what I've just said. But

Hayley White 38:33
I haven't had a chance to listen to it yet. But I do want to, obviously, I feel like I know her, you know, from listening to some of the other episodes and hearing you talk about her. So you're up to literally Yeah, like hear her speak and everything.

Scott Benner 38:47
But I take your point. And I agree with your point about timing range, right. I do think that the one fear I have about talking about time and ranges, some people set their range between 70 and 400. And go I'm in range 100. But you know, yeah, you're you're right timing range. I think of it less than the way I think of it, I think of 160 is high. I think of 180 is I've made a fairly big mistake. Anything over 180 just doesn't happen. And if it does, we're FUBAR. Somehow like the pot you know, the pot the palm sights bad or like something like that, right? Like I but to tell people that aren't a one C was just five, six, and I want to be clear with you. Arden xavc was just five, six ardens a one C has been between five, two and six two for almost eight years now. And so time and range is super important. But I don't want you to think that Arden's blood sugar doesn't go up because it does, like I got pancakes exactly right today. And so did she. She's still 75 and we've been talking for a half an hour, okay, like I go back in three hours. She hasn't been over 90 or under 75 in the last three hours. And my point is that There are still going to be times when we're going to do pancakes and mess it up. And her blood sugar is going to shoot up like everybody else's does, right. And there's when I know how to circumvent the loop, that's when I know how to say, okay, we're going to shut the algorithm off. Now I'm going to crack this, bring it back down, get it straight, again, let the algorithm take back over, like, I can take a mess up and turn it back into good in an hour. So you know, if my if the insulin is doing what I expect, which is just the way of me thinking about like, if my if the pump sites working the way I want it to. But what can people do? I'm gonna ask this question later. I'm good. I'm so sorry. I said all that I'm going to come back to that question later.

Haley White 40:42
No, that's okay. But can I interject? Just about the timing range for a second? Yeah. So yeah, I agree with you. Because it actually, the timing range kind of default is 70 to 180. For this algorithm, as well as just like the, like Dexcom, clarity report, things like that. And I know, you can customize those as well. And I believe that that's also what the ADA had their range at, when, you know, making recommendations for how often you should be in range, etc. So, I agree, you know, I typically recommend like 80 to 140 would be ideal range. But you have to think if you're consistently even between, you know, 140 and 180, that's still so much better than some people do, you know, not everybody is as savvy as you are, or as you know, they just, there's some people out there who have really awful control. So I totally get what you're saying when you're having a tighter time and range. But you know, I think, and I would argue sometimes, too, like, should we make that lower, but that's what the ABA looked at. And their goal is to be in range 70%, or more frequently. So just kind of wanted to touch base on that a little bit more so that people aren't discouraged thinking like, Oh, I'm in range a lot. But that is 150 or 160, you know, and then feeling like they're not doing enough.

Scott Benner 42:14
And I appreciate you saying that. And I appreciate your perspective. From my perspective. I agree with you. I wouldn't like if somebody told me my blood sugar's you know, 150 constantly, and that's the best I can do. I'd say, that's great. I think that's amazing. Good for you. I also don't think that's the best you can do. So I think that aspirational is important. And that the perspective of this is what the ADA says, the FDA doesn't let me say this, because I work for this company. I don't want to say this, because I don't know, once we start factoring and all that other stuff, we take away good information from people who, okay, it might be over their head, but it also might not be over their head. And if we don't tell them, we'll never find out who's who. And so that's Yeah, that's why I talk about it like this. Like, I'm not saying, like I could be saying something right now that may be over a person's head who's listening, and maybe they'll never be able to put some of those things in practice. But I don't believe that to be true. Like, I think I've seen anecdotally, again, enough people listen to this show, who are the kind of people that the machine would say, Oh, they can't figure this out who have figured it out. And it's harder for them in the beginning, but I just don't, I don't like the idea of not telling them that the idea exists. So my only my daughter's blood sugar jumps up to, we just don't stare at it for five hours. You know, and

Haley White 43:40
that's really the point of this system is that you can trust it to bring you down and you don't have to worry about it as much. And then if it's not coming down, then yeah, that's when you would think well, is this a pump site issue? Or this is a typical What's going on? And so the so yeah, and, and I think that's the subset of people that listen to your podcast also are more high achieving than, unfortunately, some of the sub some patients in general, too, but I do see what you're saying, right?

Scott Benner 44:09
No, but I my goal is to reach those I listen, if if I if you asked me right now how to talk to people about diabetes, I would tell you to tell them to get their Basal insulin right to Pre-Bolus their meals to understand the different impacts of different foods and stay flexible. And I think if you

Haley White 44:26
i i agree, I'm not I talk about this all the time about Pre-Bolus ng and the glycaemic index healthbar to Pre-Bolus, all that stuff. And I agree, like having your basil set. And being accurate is so important. And I think a lot of people don't and sometimes, even as health care providers, we sometimes increase the basil more than it really needs to be in patients who may not have the best habits, because we're trying to compensate for what they're not doing and we're trying to, you know, obviously in a safe manner as well. But then the basil rates end up being a little bit higher than what their true basil needs are. So then if they do go on this system, you know, I will tell them, you know, over time, I think we've compensated, this is what I think your basil rates should be around. And then, you know, try to test to see if that is accurate or not before like going on this type of system.

Scott Benner 45:19
Yeah, oh, no, I can't imagine in your line of work, right, there's that you must walk a line where you go, Okay, this person doesn't Bolus for their food. So how can I get their basil without making them low. So that offset a little bit their bad bolusing habits or that person or this person won't count carbs are this person for the life of them doesn't want to understand that, you know, french fries are going to hit them differently than something else. And they won't see those references. My point is, is those people are always going to exist. But when we start treating everybody, like they may be that person, then no one has an opportunity to have like a solid five, a one c five, a one C with a time and range of like, 90%, if that's what they want, and that's what they're willing to work towards. So my my question about the system specifically is, what are the settings? I'm gonna make notes while you're talking? Like, what are the settings? I have that I have access to if I'm using control iQ? In terms of like, what can you adjust? Yes.

Hayley White 46:21
So your Basal rate, your correction factor, and your sensitivity factor? sensitivity arc, sorry, and your carb ratio, and carb ratio? Yeah.

Scott Benner 46:34
Okay. So, obviously, simple things, starting at carb ratio, if you have your carb ratio, right, then great. But if you don't, then you got to make adjustments to it. But how do you make those adjustments if the sensitivity factor is wrong, or the basil is wrong? So I start with basil, I like the idea of away from food away from boluses. I think your basil should hold you stable at the number you're looking for. So I agree. Yep. Okay, so then the first step, but how do I get my basil set? If, you know if I go into the office, and somebody just says, your insulin sensitivity factors 43. But it's really 40, let's say, and they say, your correction factors one to 100, but it's really one to 80. And they say your basil is point five, but it's really point nine, that's, that's lost, that's lost in the weeds. And it's going to happen, like people are going to go into offices, they're going to everybody's going to do things a little more carefully, carefully leads to up and down, up and down leads that I don't this thing doesn't work usually, right? That's usually what they say the pump doesn't work. Yeah. And yeah. And so I think that people have to have enough autonomy to go home and say, I need to find stability away from food and boluses with my basil, because now I can say, my basil is point nine that I know for sure. Then correction factor, super simple to fix after that, because you just let your blood sugar go up, let it get stable, and then correct it and see what happens. And then you can Yeah, you can hone your correction factor pretty quickly. insulin sensitivity is the one that I have to admit, even I just kind of turn the knob till it works. So how do you

Haley White 48:26
tell Meaning? Meaning because correction factor and insulin sensitivity factor are the same thing. It's just they're different companies use them interchangeably. They use them differently. So they're the same thing.

Scott Benner 48:37
Okay, sorry. So what's it called in in control IQ.

Haley White 48:41
It is correction factor. But it basically is saying one unit of insulin drops my blood sugar by X number. So it's the same as your insulin sensitivity factor.

Scott Benner 48:54
And I think that's really. So what you're seeing there in my conversation just now, is that when I first started using loop for my daughter, I just went from a brand where they call it correction factor to a brand or they call it insulin sensitivity factor. And for months, I didn't understand that those were different things.

Haley White 49:13
Yeah. And that's not uncommon. And I will admit, just as I, I mean, obviously, did I confuse them because I just said that you said, instead of carb ratio, I did them twice. And I use them interchangeably as well. So honestly, there's no rhyme or reason necessarily. If I say sensitivity factor, correction factor, it just kind of whatever comes. And so tandem does call it correction factor. I would say in general, we probably refer to it as sensitivity factor more. I think Omni pod calls that sensitivity factor, but that yeah, that's exactly exactly right. That's one of the confusing things. So I think that is important to note

Scott Benner 49:56
that so then is that then is setting this system up as easy as getting Your Basal, right learning your correction factor, and then understanding the implications of different foods, meaning that if I, meaning that if we decide carb ratio is one unit for, I don't know, you know, it's funny, what's your carb ratio? one unit? To what?

Unknown Speaker 50:18
No, yeah,

Haley White 50:20
my carb ratio varies either one to 10 or one to 12. Yeah. Versus my correction factors like 65. So my correction factors, pretty, I would say, wimpy and conservative compared to like my carb ratios.

Scott Benner 50:36
Can I ask your Basal?

Haley White 50:39
Yeah, so my basals are like point eight, you like most of them are point eight. And my total basil dose is usually about 21 or 22 units.

Scott Benner 50:50
So keeping using that number, basil, point eight correction factor, like one to 10 excuse me, a carburetor ratio ratio one to 10 correction factor, like one for 65. If you just made all of those stronger, would that? Would this pump keep you stable at a lower number? Like if you just said, I'll just make my Basal point nine, I'll make my correction factor a little stronger, maybe I'll make it 60. And I'll turn change my carb ratio one to nine instead of one to 10. would would you just suddenly have? Do you have that kind of control? Or does the thing just keep shutting itself off to try to get back to one?

Haley White 51:30
Yeah, that's a great question. So there's probably a little bit of flexibility there where you can try to find that, you know, those magic numbers that will keep you above 70. But the second that it predicts you're gonna go below 70, it's shutting that insulin off. So you know, and depending for how long it does that, and then if you do end up going low, you know, and if you over trade, then that's when you start to see more of a like roller coaster type of pattern. So it's not as easy as just making them more aggressive. And that's why I think tandem is looking into being able to customize those targets a little bit more for your personal preference.

Scott Benner 52:09
I understand. That's great. I love this conversation, because we're walking people through all the different thought processes they're going to have when they're thinking

Haley White 52:17
Yeah, right, exactly. But I agree with you, I think getting the basil setup is super important. The one thing I like about this system is when you go on your, when you log into T Connect, which is where like, you can download your pump or save your pump information to the cloud, there's actually an app on your phone where you can go in and look at it real time. They're looking into getting a Bolus from phone thing approved. And that's the FDA right now. But when you go and look at your report, it'll actually give you your actual basil doses compared to your program doses. So it basically is telling you what your actual basil needs are based on how the pump is adjusting. And when you look at the download, it'll kind of give you it's it's hard to explain without like looking at it. But it's really nice to be able to sit with families and explain you know, when you see this, when you see this, this is how you know what's going on. But there's basically a baseline, that's your typical basil rate. And then the bar will, you know, be either above or below that if it's giving more or less or you know, there's like a diamond on the report where it'll show up if it's suspending the Basal on its own right. I think that's really helpful to look at overall, this is what the pump has been delivering and this is where my I'm set up something needs to be adjusted.

Scott Benner 53:44
Yeah, I'm very visual to like I remember in the beginning just seeing like, well, it's cutting our basil a lot the basil is too strong. Or maybe the correction factor is too strong. Like that's it like Ardennes is really interesting. Like she's now that she's on birth control and she's become like regulated and stable on birth control because she had that because her her poor Ardennes, like was getting her period constantly. And like literally like 11 days, two days off 11 days, two days off, like it just never stopped. She was just it was killing her. We might as well just cut open her vein and and sped the process up like she was on her way. She's probably anemic and she was feeling awful. She had to get like ferritin and iron infusions, stuff like that. Yeah, so the point the point is, is that now that she's stable with that, her basil is between point nine and 1.2 depending on the time of month, and her correction factor is somewhere between 40 and 43. Now the one thing that I will say is that we are really aggressive with our carb ratio, I think ardens carb ratio is one unit for four and a half carbs.

Haley White 54:56
Oh wow. Right. Yeah, that's, that's quite aggressive. Yes. And so But that's what works. Like, that's what she needs. And that's the thing like, you know what you're doing, you're doing things properly. And that's clearly what what she needs, and it's working for her,

Scott Benner 55:10
I could also probably change her Basal rate to 1.4 an hour and make her carb ratio weaker. And

Haley White 55:19
then the problem is, if she's, you know, not eating or whatever. And let's say you're waiting on a Dexcom supply to come in, and she doesn't, she's not using the loop algorithm, she's gonna be super low. Yeah, exactly. But that's basically what we do for kids who don't go as regularly or who like, vastly underestimate their carbs, we may bump their basis up to try to compensate. But the nice thing about the system is, it's compensating not only with the Basal, but it's compensating, like your carb counting accuracy, could be a little bit off, and it's going to prevent you from going as high as you would without the system. And it's also going to bring you back down to target range much more quickly than if you were to try to do it on your own. That's helpful too, for teenagers who may not, you know, I'm like, I know, you're not going to take your measuring cups to college with you. And you're not going to be getting out your food scale, you know, you're kind of eyeballing things. So I think that's another nice feature of this pump is that it does kind of help a little bit with the, you know, if the carb counting is off a little bit

Scott Benner 56:24
in my mind, the basil and the correction factor, are the tools that get used away from food. And then we show up when there's food and bang very hard on the foods head with a with a an aggressive Bolus. And so, you know, I don't even know it doesn't even matter for factors right anymore. It just means what what, what works is, what do I mean by that? What works is when she looks at a plate and decides on a number of carbs, it translates well with the factor that we have set up right now. And so it's you know, is it real? Like, is she really that? I don't 100%? No, you don't I mean, like, it just I can just tell you it works. And by works. I mean, there's a balance between our, the way we look at food and go, I think that's 60. And what the number says that it works. So I just looked again, she's now like an hour and a half or more outside of these pancakes. And she's finally 97 diagnol. Up. And so yeah, I mean, that's, that's impeccable, we're good. And I'll tell you right now, if that thing gets the 115 and doesn't level off, I'm gonna Bolus, like, you know, because because of what I know, pancakes will do to her, if we miss it. With the loop, we're able to tell it that we think the impact of the food is over a certain time. You can't do that with the control like

Haley White 57:52
No, you can't. And that is something I love about the looping. I think that's a brilliant, like feature. Because what is it like a lollipop, a taco and a piece of pizza or something? Isn't it? Yeah, so it's like easier to think in that terms versus like, you know, go up and go and look up the glycemic index of this food and blah, blah, blah. So that is one thing that I I do really like about the looping that you don't have with the control IQ. The other thing with control IQ is you can still do extend boluses However, you can only extend it out by two hours. So which I find is often not enough. But you know, you can either Bolus the additional what the additional needs later. Or sometimes the algorithm if your settings are right, sometimes it kind of just kicks in and works can pick you up on your own. Yeah,

Scott Benner 58:46
I've listened. Sometimes the algorithm can get it, sometimes it can't. I tried to think of like as a fat, like a fat rise, for example, like French fries is such a good example for that. But in that situation, I just think of the fat is more carbs or more insulin need, and then just come back around an hour and a half or two hours after you're done eating and just Bolus again if you weren't able to stretch it out enough in the beginning.

Haley White 59:07
Right, exactly. So now the other thing you can do, which I don't think is, you know, I wouldn't recommend to most patients unless you for sure know how to dose for something and you know it works. And same thing with activity, you can go and turn the controls IQ off. It's just an easy toggle on the pump, and then do what you need to do extend it out and then after that time, you would just go and turn the control IQ back on. So there's no like really warm up period or anything like that. You just have to simply remember to go in and turn it back on.

Scott Benner 59:43
I think of it this way. If we make no mistake when this happens for us personally and I'm going to guess for many people, you've messed up a meal. Like if you find yourself in that situation you haven't Pre-Bolus or you under Bolus the meal now you're flying high, the algorithm screwed It's like you're 60% of what I think you'll have I'll reassess in an hour, you're gonna be 400 by the time it reassesses. And so like you've messed up now. And now now your blood sugar's flying up, I open the loop, or as you say, like turn off the algorithm for for this, and then I treat it like, you know, like this is MDI or regular pumping, I crushed the blood sugar, and then catch it. And there's a, there's a skill to catching it and when to turn the algorithm back on. And it took,

Haley White 1:00:28
I think that's, I think that's a steep learning curve. But with with trial and error, you certainly can figure that out. The other thing is, you can go in and give a manual correction or a manual Bolus with the algorithm on as well. So that is also an option. Now, the pump will only deliver the auto correction once an hour if there hasn't been any boluses in the past hour. So if you do that is not going to deliver one for another hour. But you can go in and do that. But I think sometimes, you know, I would encourage people to kind of get used to the system first before they're adding in all these extra variables. But over time, I do think you start to learn, just like you do with traditional pumping or with MDI, how certain foods or activities affect your sugar and how to kind of compensate for that.

Scott Benner 1:01:19
Yeah, you can't you first First things first, you got to get your settings. Right. And you got to watch the little exactly how it works. Yeah. Because if Yeah, if this systems working even reasonably well, for most people, it's pretty cool. It's only three ideas. It's basil, correction factor and carb ratio. And then the rest of it is your understanding of how to manage meals and the differences in foods and things like that. Can I go back into control, like you say, an hour and a half ago, ate something I said, That's 45 carbs. And I realize, Oh, it's 55? Can I go edit that? And will it make a change after I edit it? Or? No,

Hayley White 1:01:52
you cannot. So you could go you could just go to that extra 10 grams of carbs. So at that point,

Scott Benner 1:01:58
can you put in a new Bolus and change the time? Like so if it's one o'clock, you put in 40 carbs at at two o'clock, you realize, oh, that should have been 50? Can you go in at two o'clock put in a 10 car Bolus, but tell it It happened at one o'clock?

Haley White 1:02:14
No, you can't. So yeah, so that will Yeah, the later dose then we'll you know, it's then if you dose the extra 10 grams at two o'clock, that it's going to be taken into account for that five hour insulin on board. So yeah, that's one thing that you can't do. Yeah, but it probably has already given you extra. Like, if you're only off by a little bit, it's probably it's already compensated by giving you extra basil. And then if you do go, if it's predicting, you go above that 180, or you go above 180, it's giving you that micro Bolus. So if you're only off by a little bit, I feel like it does a pretty good job of bringing you back down on your own and prevents you from going, you know, into the mid or high to hundreds right? Now, if you're off by a lot, then yes, that is going to be a different scenario. But

Scott Benner 1:03:02
these algorithms are not, they don't think it's important for people understand, I don't care which one you're using, I've even seen on the pod five yet, but I'm going to tell you right now, I can't think on its own. So if it only knows what you tell it. And if and if you for some reason, don't understand that 45 carbs of Fruity Pebbles is more impactful than 45 carbs of I don't know, you know, eggs, bacon, and some, you know, ketchup and whatever else you're, yeah, if you don't know the difference between those two insulin needs, this thing doesn't, it doesn't know you've set these settings up, you've told it This is 45 carbs, and then you put rocket fuel in. So those are the things I think these algorithms are all amazing. And I think that you need, but you're you're always going to need to understand the basic ideas about getting your settings right, and making good solid doses for different foods. If you can do those zactly you're gonna sleep like a baby. It's just so yeah, you know.

Haley White 1:04:03
And, and I think the other thing to kind of add on to that one important thing that I have noticed with this system is just like you said, the pump, you know, the algorithm isn't doing the thinking. So if you take your pump off, and don't suspend the insulin, the algorithm has no idea that it's not actually delivering insulin has no idea that you're in the pool or you're in the shower or whatever. So you definitely need to suspend and then resume insulin after you reattach your pump. I know you've that's something you guys wouldn't have to think about with, you know, with an omni pod, but I think a lot of people with with pumps with tubing are just used to taking it off and not necessarily suspending it. But that's one thing that's important to know because it could be adjusting your insulin, thinking that it's attached to you and it's not so that's one thing. I think it's helpful. The other thing is if For whatever reason, you do want to give like a sub q injection of insulin, if you feel like your site's not working, you just want to give this up to you injection, make sure it's getting into your system, the algorithm doesn't know that you did that either. So the way to get around that, you can just detach, you know, disconnect the pump from your body, let's say you gave four units, put in four units blindly. And then you know, just deliver that into the sink or whatever. And then the pump thinks, you know, it delivered four units, even though the pump didn't deliver it, it's taking that four units into account whenever it's looking at the insulin on board. You know,

Unknown Speaker 1:05:39
we don't get a lot of to pump tricks and tips on this podcast. So that was good. That was excellent. Yeah,

Haley White 1:05:45
yeah. Because there was, like I said, those are things that you just didn't have to think about before, when you didn't have an algorithm, like you gave a sub q injection and went on with your day, or you just take your pump off. I think the other thing with new pump users, I like the suspend feature, because the pump after 15 minutes after it's been suspended for 15 minutes, will beep very loudly. And it's very annoying. But that's a safety feature to say, hey, like the pump is not attached, because I you know, my biggest worry is for kids to like forget to reattach their pump, and then they go to bed and you know, end up super, super high with ketones and whatnot. So I think that's a good habit to get into to begin with. And that also reminded me so this pump is you do have to charge it. And it comes with a charger. Usually, they say a full battery will last about a week or so. But I typically charge mine while I'm getting a shower, since I'm taking the pump off anyways, I take it off, I suspend. And then I hook my pump up to the to the charger just give it a little bit of juice. But it is something that you do have to remember to charge it.

Scott Benner 1:06:55
Yeah. Cool. Is there anything that we didn't talk about? That we should have?

Haley White 1:07:00
Yeah, you know, I feel like there's still kind of a lot of stuff that that we could have talked about. I mean, there's just I could be here all afternoon talking about things. Um, you know, I think, I think the big things are, like he said, make sure your settings are right. Have some patience, if you're switching over, you know, from a different pop, or just getting started, you know, while while things are getting figured out. But you know, I really think this system works really well. If your settings are, are accurate, you're doing what you're supposed to be doing. I think it's safe. And I think it really improves, you know, your quality of life. And I think that is so huge when you have diabetes. I'm trying to think if there's any other kind of big things, the only other thing that I sometimes see, so the insulin on board is set at five hours. And I know some people you know, have their set for shorter if they're on other pumps, or, you know, if they're on MDI, they're not necessarily even taking that into consideration unless they're using an N pen or something. So leading up to starting on this, I think it's a good idea to gradually extend that insulin on board timeout on your pump or your income, so that you can kind of recalculate your settings. Because if your insulin board is, let's say three hours, your sensitivity factor is, you know, calculated. taking that into account, if you're someone who's vigilant and doses every two to three hours, if you're not someone that doses every couple of hours, it may not be as big of an issue. But if you've figured out okay, this is, you know, my sensitivity factor, whenever you know, I have an insulin Board of three hours, that's going to be different than whenever it's spaced out to five hours, often it will probably need to be a little bit more aggressive. If you have good control to begin with. If you don't, that's something else to kind of, you know, like you said it's easy to test after you know that your Basal rates working properly. But sometimes I don't know how other clinics work, but I know sometimes, personally, my patients I might make their crutches after a little bit more aggressive as well, if I know that they don't compound accurately or I know they're not dosing regularly and they're only dosing once a day, based off of their blood sugar to get them a little bit more in somewhere I can, but then I'll tell them that going on to the system like hey, I made your correction factor 30 I really don't think it needs to be that aggressive. Let's try this to begin with. So but that's something that I see some people kind of get concerned about that insulin on board being longer. So that's something that I think can help to re evaluate your settings. spacing that insulin on board out.

Scott Benner 1:09:42
Just time for me to ask you a couple questions. Yeah, sure. Cool. So if put put yourself in this scenario, it's overnight okay. There hasn't been Bolus since 8pm. It's two o'clock in the morning. Now. If blood sugars are going up and going down, like like choppy well You don't even you're not getting that smooth line with your basil. Is that like, what would you look at first and control IQ if it was like going from like, I don't know, super stable, and then suddenly goes up to 140, then comes back down to 80. And back to 140. If this has happening over and over again, what settings are we supposed to be looking at then?

Haley White 1:10:22
So that's when I would really look at the download and see like, what is what is the basil doing? And I would, you know, also want to know, like, What did you have for dinner? And what was your activity like that day? But it really unless you in you know, I'm not someone that's in favor of having like 12 different days or AIDS throughout the day. But unless your bases are really like variable and change frequently? I would say that's pretty atypical to see that pattern unless the, you know, unless unless that's like the reason unless it's food or activity related.

Scott Benner 1:10:57
Could it be the algorithm sick? Could it be a basil is too strong, and it drives you down, and then the algorithm sees it cuts off, and it bounces back up? And the algorithm comes back on? and it drives you back down? Again? Could that be a sign of

Haley White 1:11:10
Yeah, that's a good thought. I think it's it's a much slower, it's typically a slower trend. So when to expect it to be as like, up and down and choppy, it would be kind of more of a gradual rise and decrease. But But yeah, if it's especially if it's shutting off for a longer time, that could then you know, cause you to rebound a little bit higher. So I was you can see on your pump, when you wake up or at any time, there'll be a vertical, like red vertical line on the pump screen when it shuts off your insulin. So you can kind of get an idea of how often it was shutting off. And for about how long and if you're seeing frequent red bars, then I would say it's probably that your Basal is too high.

Scott Benner 1:11:56
But that's probably not correction factor. If I'm seeing the red bars, that's basil.

Haley White 1:12:01
Yeah. Because overnight, so I guess, I don't know, I can't remember what we talked about honestly. So overnight with the sleep mode, it does not give any auto corrections. So it will only adjust the basil. So that's what's one thing, then you can kind of roll out that factor. And assuming you didn't give any correction before bed or anything like that.

Scott Benner 1:12:20
It's more it's more aggressive with basil and sleep mode, right?

Haley White 1:12:25
Yes, correct. You have to today I want to mention about sleep mode. Sorry, I forgot to mention this. So you can pre program the sleep mode, there's two different profiles. So most people will have like a weekday versus a weekend, or they may have like if you do shift work or something. And then it comes on automatically. So you can have it set from like 10pm to 6am, for example, on a weekday, and then, you know, 11pm to 8am, on the weekend or whatever. And it will then turn on automatically. And then depending on your needs, you know, if you're someone who is eating later at night, and or, you know, kids that might struggle with grazing, you may want to start that sleep mode a little bit later, so that they're getting a correction before going to bed versus you know, a younger kid or an athlete who might be prone to like delayed lows, or something like that. You may want to start that sooner so that they're not getting any corrections before bed. So something to keep in mind.

Scott Benner 1:13:27
How does it know? The range? So if we tell it, if we tell it your basis, point one an hour, and it's aggressive, does it tell itself where to stop being aggressive? Do you know what I mean? Like can like if can this thing like if I'm in sleep mode and it sees something crazy coming? Can it change my base little like for an hour where there

Haley White 1:13:49
is a max, a max Basal limit, but you can set in the pump. That is, I think three units per hour. So but if you're someone that's really sensitive and three units per hour is going to you know, really plummet you like a really little kid for example, you could set that max basil at one unit an hour or a third normal base rates point one you could set it at point five units per hour. So I would say two and a half times higher than your typical basil is probably the highest I would set it to start with and then kind of go from there. Like let's go I'm sorry, go ahead.

Scott Benner 1:14:30
I'm just gonna say what if I'm a 250 pound grown man and my basil is two and a half already. is the max still three?

Haley White 1:14:36
Yeah, so that's a great question. So the max basil rate you can have in this pump is insanely 15 units per hour. But I believe that it will still only give three units per hour max if the control IQ is on I have to I could double check off because I was actually getting reading something about this recently. And I know if it shuts you out of the control IQ. So if the Dexcom and the pump aren't reading for more than 20 minutes, it, that's the only time where the control IQ will not work. So I know like with the 670, G and 770 G, like it'll kick you out of auto mode for certain things. This is really the only reason that it would kick you out of the control IQ and then it goes back to your program settings. So I know if it kicks you out, even if your programmed rate is higher, it only goes to that three units per hour. And I think that's a safety thing. But I don't know for sure how high it can go. And I apologize for that. But I can definitely find out for you and let you know,

Scott Benner 1:15:45
you sent me an email packet in the end of the episode. Can I ask a fun question now that we're sorted? Yes. So you're in the business, right? What what's the word on the street about how on the pod five is gonna work? Because I hear people calling it Oh, learning system. You hear people calling it a what? Like a learning system? like it'll it'll make different decisions based on historical data. Is that true?

Haley White 1:16:10
Hell, I. I've heard that too. But I don't know. I haven't had that. be confirmed by anybody that works with an omni pod. Yeah, they won't say anything that way. I know. Some I know. I know. They're so tight lipped. Yeah, yeah. But that's kind of how my tronic is. And I see the theory behind that. But it's kind of there are pros and cons to that as well. So yeah, I mean, I think that people are going to have success with that as well. I think people are going to have success with any sort of automated insulin delivery system, but I am, I'm excited for that to come out. Because I do have some patient to you know, absolutely don't want to being or they've been on Omnipod. So they want to stay with Omni pod, you know, so I'm really, really excited for it to come out. But it should be interesting to see, you know, how it works and everything.

Scott Benner 1:17:00
Yeah, I agree. I

Hayley White 1:17:02
so I do have some patients that do the looping, we just can't obviously, it's recommended.

Scott Benner 1:17:09
weird thing when, when it comes down to that at Arden's appointments, they're like, I need you to look in the app and tell me what the total basil is for the day and what this like they act like it doesn't exist. But then when when that technical parts, I was like, hey, this loop works really great. And I was like, Yeah, like, it's funny when they're, it's it? I understand. Yeah, you know,

Haley White 1:17:29
and the problem is, too, we don't like it's a lot of work on our own to kind of research and learn how it works and stuff like we don't get any formalized education or training on how the algorithm works. Luckily, for me, I have a, a dad with type one, his daughter uses the loop and that, you know, Dad uses it to and he helps actually get people set up on the looping system here in the Pittsburgh area. And so he's a great resource to have that I you know, can shoot him a message pretty quickly. But But yeah, I mean, I agree, I think it works well, once again, for patients who do X, Y, and Z. Some patients still struggle with bolusing or whatever. And then they still have, you know, erratic numbers, because the problem is right with the loop, or I think there's a newer version, you can correct me if I'm wrong, but it only adjusts the Basal is that correct? I know

Scott Benner 1:18:16
that. There's one that corrects the basil. But Arden uses Auto Bolus where boluses Okay, so there is one that it'll it'll Bolus and keep bolusing. So I think it's, I think it's 40% of recommended, but like, let's say it, it wants a unit. It'll Bolus point four. And then the next time it comes around, if it's still reading higher, it'll it'll go again. Now, it still only does like that percentage of the thing. But the percentage is actually customizable. If you're willing to go into the programming, you can change the percentage to if you relax and trust and if you really want

Haley White 1:18:52
me to be nervous as a provider of Well, once again, depending on the families, you know what I mean? Like you have to take that into consideration. Some people are like, super savvy and great with it. So it's very independent,

Scott Benner 1:19:08
you can get into the loop and change that setting. You're You're pretty knowledgeable to begin with, because it's not it's not like Yeah, right. It isn't a door Mark make this stronger. You just have to like knock on it. It's it's hard to get accomplished. But I have three episodes called Fox in the loop house with a gentleman named Ken Fox, Kenny Fox, who's a dad, I understand that you won't understand Luke, listen to those. You'll understand it when it's over.

Unknown Speaker 1:19:31
Okay, yeah. So, um, that's,

Scott Benner 1:19:35
I mean, I really know what you're doing this. I know, you can talk forever because you have like, unlimited points in your head about this. But I

Haley White 1:19:44
know only the only other thing I want to throw in there is the activity mode, just cuz we didn't talk about that at all or that or the exercise note, I mean, right. So that will target you just real quickly between 40 and 160. And we'll suspend on it. Instead of 70, so it is meant to keep you a little bit tighter, it still will give higher basil. So we'll give auto corrections that are 60%, if needed. And the one thing I found is, you have to really start it at least an hour, if not two hours before. And for some people, that's still not enough. And so sometimes what I'll have my patients do is either if they know what to do just turn to control, like you often do what you did before, which is honestly typically what I do. If you're not in, you're just it's new learning either way, then I have them create a separate profile, like an exercise profile, where their Basal rates, correction factors, everything are less aggressive. And they you just have to remember to turn that on. And the activity mode so that it's giving you more time to target you to the 140. But then if you are trending up, it's gonna give you less insulin, so you're gonna have less insulin on board, you know, heading into the exercise, I find

Scott Benner 1:20:51
that people's biggest problem with exercise is they want to do it with a ton of active insulin. Like they.

Haley White 1:20:58
Yeah, and then it's just like that insulin is supercharged. Yeah, you could have like a half a unit on board, depending on your insulin sensitivity. For some people, that's fine. But for me if I have a happy unit on board, my plummet, so yeah, it's I think exercise is a learning curve for some people. But some people like want to turn it on right at the beginning or half an hour an hour before, and it's often not enough. I just didn't want at least mentioned that. Sorry. No, I

Scott Benner 1:21:25
appreciate I'm fascinated always that people don't recognize how insulin works in time, like how they're just like,

Hayley White 1:21:31
Yeah, right, like the basil doesn't affect you right away. Obviously,

Scott Benner 1:21:34
I'll just throw a light switch, and it'll be fine. It's like, that's not there's already the insulin from the last hour that was meant for that. So the thing that I said on here, Haley that I think is important, is that insulin you're using right now is for later. And more importantly, the way you have to think of it while you're making the adjustments is that insulin from before is for now. So you don't get to say I'm going to start running now. I'm going to shut my basil off because you can shut your basil. You can take the pump off and throw it across the room if you wanted to. You're still going to already failed. Yeah, it's too late. Right? Yeah. So you have pre planned for that. And then you get into that's a real human failing of the idea of pre planning. It's why people are so bad at Pre-Bolus thing. And why? You're exactly right. Yeah. And why I tell them all the time, they're like, I don't know what to do here. I'm like you have to pre boss. I don't want to well, then you're gonna buzzers, Hey, hi, I don't know what to tell you. Like, like, this is just how it works. Like, I'm sorry, it sucks and everything. But the insulin is an instantaneous and it's even more so with basil. Because it's not so much of it, it's this little like, like your, your, you know, demean every couple of minutes, you have a little more, a little more a little more, even if you're a unit an hour, you're getting these little spurts over the minute, you you need those spurts to stop so that when your activity begins, the basil is gone. And the way I think of that is like you're creating a black hole, where there's no basil in the future. So you take it away, you take it away at noon, so that at one o'clock or 130, you know, whenever you're going to start and however long you learn it takes for your Basal to stop impacting you after you take it away. When your body tries to fall, it can't because the gravity is too heavy. So you come in or two or two weeks. So you come in and instead of the gravity or the basil pulling you down, it doesn't exist anymore, you just kind of float over that timeline of activity, and then turn your basil back on so that when your activities over and your buzzer starts to go back up again, it's met with the resistance of the basil again,

Haley White 1:23:35
and yeah, in like taking into account your bolusing to within a couple of hours of activity as well like and that is where planning is so vital and important for like tight glycemic control. But yeah, you have to take that into consideration. You know, the one thing I do like about the insulin on board for that this pump is it takes into account the the basil and the Bolus insulin. So if it gives any additional basil, it's taking that into account for your insulin onboard calculation.

Scott Benner 1:24:03
Cool. That's excellent.

Hayley White 1:24:05
Yeah. Which I think is nice.

Scott Benner 1:24:06
Yeah. Hey, listen, when we stop the recording, I'll tell you what I think I know about on the pod size release date. Okay, great. Thank you very much for doing this. I really appreciate it.

Hayley White 1:24:16
Yeah, you're welcome when I'm, you know, hope that it's helpful to some people out there. So thank you so much for having me.

Scott Benner 1:24:21
Thank you. Hey, huge thanks to Haley for coming on the show and sharing all that information about tandems control like you. Thank you so much Hayley. Thanks also to Dexcom makers of the G six continuous glucose monitor. And on the pod makers of the Omni pod dash and the Omni pod promise, learn more about Omni pod at Omni pod.com forward slash juicebox and of course that Dexcom go dig into it right now@dexcom.com Ford slash juice box when you support the sponsors, you're supporting the show, and for that, and so many other things. I really appreciate it. I hope you enjoyed today's episode. We'll be back soon with another

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