← Juicebox Podcast: Type 1 Diabetes
Juicebox Podcast: Type 1 Diabetes
#1440 Fox in the Loop House: Part 5
00:57:57
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- [00:00]
A
Welcome back friends. You are listening to the Juice Box Podcast. Kenny Fox is here again. Today we're going to talk more about looping, food and carb ratios, fat and protein management, nighttime blood sugar rises, loops, carb entry options and adjustments, and the broader understanding of diabetes like recognizing patterns, food digestion and insulin interactions. Kenny is awesome. Check out all of the Fox and Loop House episodes to learn more about looping and using insulin in general. Please don't forget that nothing you hear on the Juice Box Podcast should be considered advice, medical or otherwise. Always consult a physician before making any changes to your healthcare plan or becoming Bold with insulin. When you place your first order for AG1 with my link, you'll get five free travel packs and a free year supply of vitamin D drink ag1.com Juicebox this episode of the Juice Box Podcast is sponsored by Cozy Earth. Use the offer code Juicebox at checkout@cozyearth.com and you will save 40% off of your entire order. Are you an adult living with type 1 or the caregiver of someone who is and a US resident? If you are, I'd love it if you would go to T1D exchange.org juicebox and take the survey. Today's episode of the Juicebox Podcast is sponsored by the Eversense 365, the one year Ware CGM. That's one insertion a year. That's it. And here's a little bonus for you. How about there's no limit on how many friends and family you can share your data with with the eversense now app. No limits. Ever since if you or a loved one was just diagnosed with type 1 diabetes and you're looking for some fresh perspective, the Bold Beginning series from the Juice Box Podcast is a terrific place to start. That series is with myself and Jenny Smith. Jenny is a CDCEs, a registered dietitian and a type one for over 35 years. And in the Bold Beginning series, Jenny and I are going to answer the questions that most people have after a type 1 diabetes diagnosis. The series begins at episode 698 in your podcast player where you can go to juiceboxpodcast.com and click on Bold Beginnings in the menu. Hey Kenny, welcome back. Hey Scott, I appreciate you coming back in and doing more content for me here on the whole loop thing and also spending time telling people about what you're up to and hopefully they'll find some value in in your new website. What's it called again? Boxintheloop house.com boxintheloophouse.com. so what are we going to talk about today?
- [02:54]
B
We're going to talk about food, mostly meals and carb ratio and maybe any other settings around that.
- [03:01]
A
Okay. Is it important to start with what kind of food you're eating or does it not matter if a low carb person or eating an American diet or something else?
- [03:11]
B
Good question. People that eat low carb do struggle a little bit and may have to do a couple little tweaks. But generally the rules that I set up here will apply to anyone eating anything. We personally kind of eat around the gamut. We've done low carb here and there. We've done, it's kind of standard American diet. My daughter just went to a new school and she's eating in the cafeteria most days for lunch. And that is best. Definitely standard American diet food. Pizza, french fries that apparently count as vegetables and check a nice box on the list for us to eat healthy. And she even has a juice box of chocolate milk occasionally with her lunch. So she eats that. But then at the same time at home we largely eat whole food, vegan kind of super clean stuff. So I've seen the impact of all the different kinds of food and what we're talking about here should apply to anything.
- [04:04]
A
Okay. And I might get back to asking you about how the algorithm handles carb ratio for stuff that I assume is harder to bolus for that food at school versus what you're getting at home.
- [04:15]
B
Yeah, we can start with a little bit of that. The trick here is that Loop models all meals the same to a degree. So it just expects you fit the meal into a certain amount of time. For anyone that's used Loop, you get to tell it if it's a fast, a medium or a slow meal and it's going to fit the entire expected carb impact, the lift on your blood sugar inside of that window. Or we'll talk about the modified window, but it'll fit it inside basically a, a short, a medium and a long amount of time. And most of that lift is expected at the beginning and then it kind of fades throughout the whole thing. So there's no way to say this is a higher glycemic food other than messing with the duration of those particular foods. But in general, you put in a taco or a three hour entry and it's just going to look the same, it's going to expect the same rise and the same fall at the same time at the beginning of the entry as it will no matter what you're entering. That will change as we move throughout the meal, but at the beginning, it's all going to look the same. So that can be a little tricky. And I'd say a good caveat for those that are listeners of the podcast. You tend to know what stuff is higher, glycemic, what's going to hit a little harder. So there will be times where, you know, you might need to bolus a little bit extra up front, and you'd rather let Loop take away basil for the beginning of the meal in return for a little bit bigger bolus or you need to pre bolus longer, those kinds of things based on the type of food. All Loop's worried about is that you don't go low, and it's going to treat every meal initially the same.
- [05:49]
A
Is your daughter making decisions like that at school? Is she looking at a plate of food and thinking at home, this would be 40 carbs. Here I'm gonna say it's 50. Or is it more or less not about the type of food, but more about where she is. Like, I'm here, I'm dealing with this more complex carbs, maybe this more processed food. So I'm just gonna be more aggressive. Is there a way, you guys think about it?
- [06:16]
B
We have a somewhat unique situation now in that her pe, she has a very short, like, half of her pe, a half hour right before lunch and then a half of PE right after. So it's definitely changed the way we handle some of the more challenging meals, like pizza, french fries, juice box, and chocolate milk with fruit and vegetables mixed in there. Yeah, we just enter what it is, what I count it to be with her. She'll send me a picture, a text at lunchtime, and then we'll just send back the number. And by now, she knows most of the meals, and she'll enter them and we just say if that's all, you know, like a long entry, which most of them are because of the fat content in the food. Plus, she's going into fresh activity right after she eats. The stretching out, the impact of the food has been helpful, and it doesn't usually give everything up front. And that works out because she starts shooting up because she has no pre bolus, and then immediately levels out because she's moving. And then it all kind of settles at the end of the day. So it works out that we don't really pre bolus going into lunch a lot of times. And so I try not to modify what we count when we go into any meal. Instead, I might say something like, you know, it's going to be 80 grams long or pizza. You know, make sure you give at least this much insulin.
- [07:34]
A
And the activities helping her as well right now?
- [07:37]
B
Yeah, I help her just via text. Yeah, for the most part, she just, I give a reply back with the amount and she enters in and moves on. And I would say by now, midway through the school year, she's sitting down, sending me a picture, entering what she thinks it is, bolusing what she needs to bolus. And then whenever we get around to replying, then she edits the entry if needed, but she's getting it right most of the time now.
- [07:58]
A
That's awesome. So, yeah, there's a thing that if you don't use loop, you don't know, you could bolus at 11:30 for 35 carbs and then 10, 15 minutes later say, oh, that was should have been 40 carbs and go back and edit that bolus. Tell it it's 40 carbs and it makes an adjustment with the insulin.
- [08:16]
B
Yeah, that's pretty huge. I think it's really useful for and, and practical. It's very different than any other system, but it's helpful for kids that might not eat it all. Or Tessa says she maybe doesn't have enough time to finish her food as she heads off to the next class or PE or whatever it is. And so she can say, oh, never mind. I really only had, you know, half of whatever it was. And it, you know, we'll might predict a low if you had dosed for all of it, but at least the system's gonna know and it's gonna do its best to turn off the basil. And so it's really helpful when you need to pivot. And then maybe she needs to eat something because she's going to eventually drop from, from that extra insulin that it gave. But now we're just, we're just telling the system exactly what happened. Right. We entered 50, changed it to 30, and then she entered 10 carbs as a, you know, maybe low or preventative low treatment. And so now it thinks there's a total of 40 carbs consumed here instead of the original 50. And so it's not likely to, you know, give too much insulin, maybe even not even recommend any insulin for that second entry. Let's try to catch the low so it's, it's, it's smarter about what's happening because we told it really what happened. So I find that super helpful. But you can spend a lot of time fiddling with, editing carb entries when you're guessing because A lot of our entries are guesses, you know, Right.
- [09:27]
A
I have to admit that's a feature of Loop that I was a big fan of. So, man, that's pretty awesome. So I guess, like, big picture, talk about how Loop handles a meal. Like just kind of like, let's build it up from the ground for understanding for people. This episode of the Juice Box podcast is sponsored by Eversense. Thanks. 365. And just as the name says, it lasts for a full year. Imagine for a second a CGM with just one sensor placement and one warm up period every year. Imagine a sensor that has exceptional accuracy over that year and is actually the most accurate CGM in the low range that you can get. What if I told you that this sensor had no risk of falling off or being knocked off? That may seem too good to be true, but I'm not even done telling you about it yet. The Eversense 365 has essentially no compression lows. It features incredibly gentle adhesive for its transmitter. You can take the transmitter off when you don't want to wear your CGM and put it right back on without having to waste the sensor or go through another warmup period. The App works with iOS and Android, even Apple Watch. You can manage your diabetes instead of your CGM, which with the Eversense 365. Learn more and get started today@eversensecgm.com JuiceBox One year, one CGM.
- [10:51]
B
Yeah, I think what sets Loop apart from. I think all the DIY systems do this, but from the FDA approved systems, they don't express or give us any detail about how they function. So we can't assume this is how it works. But in Loop, it uses what's called dynamic carb absorption. So you're gonna enter the meal, it's gonna give you a bolus recommendation, probably in line with your carb ratio. In most cases it should be, unless you're, you know, it adapts to you falling or rising. So it may add a little more or a little bit less, which is nice. But then what it's gonna do is not just gonna say, okay, great, here's your bolus, let's move on. It's gonna say, okay, now I've seen this 50 grams you've given. Now let's make sure that that 50 grams goes away. And it's gonna try to track the meal throughout the whole progress, the whole duration of that meal, that time entry you gave it. And what it's doing is it's checking to see how your blood sugar's moving is the, the main thing. There's, there's two components. There's one that has to do with, you know, your carb ratio and how much insulin you have. Obviously you shouldn't go super high if you dose the right amount. So there is an assumption there that as long as you don't go down too much, you should be, there's food there. But then if you also go up, which most food makes your blood sugar go up, cuz it's hard to time against the insulin, there's that second component. And so as your blood sugar rises, it says, oh hey, that's food. How much is that food? And it will say, you know, maybe that rise. Depending on your settings may say that rise you just saw was one or two carbs. So it'll say, okay, you had 50 grams, now we're down to 48. And then we move on. Your blood sugar moves up again a little bit and now we're down to 46 and maybe you hold steady for a while. So now we're down to like 40 a couple hours in. So it's subtracting the grams from the carb entry as you go. And so what you'll see on the main loop screen is there's active carbs as well as active insulin, same as iob or cob, carbs on board, insulin on board. But it's tracking both the insulin on board as well as the carbs on board. And what you'll find out is that as long as there's a pretty good balance of the insulin on board and the carbs on board, as Loop says, active insulin or active carbs, you know, roughly to your carb ratio, then the prediction will be happy. So an example would be if you entered 10 grams, or there's 10 grams of active carbs and your carb ratio is 10 to 1, and you have one unit on board, then in general the prediction will be happy. You're probably gonna go up, come down and land where you should. You know, there's some other variables in there, but that's generally what's happening. So it's trying to maintain a balance of insulin on board to the active carbs as you move throughout the process. So when that imbalance is off, so whether that means you like spiked up real fast. And Loop said, hey, that was a lot of carbs, maybe that was the bulk of the juice or the soda you just drank. So now the active carbs might drop real quick. And now Loop says, hey, we just gave this Insulin and can't get rid of insulin super fast unless you turn off the basil. So now there's too much insulin for the number of carbs left in this meal. And so it's gonna predict a drop. And that can be frustrating for some people where you end up higher initially with your meal and yet lupus saying you're going to go low, and that can be quite obnoxious for a lot of people.
- [14:05]
A
Does that eventually work itself out normally or does that, is that a situation that lands you with a higher blood sugar that doesn't come back down for hours and hours?
- [14:15]
B
Yeah, if your settings are good and we'll talk about how to get there, then it often should work itself out. Right. For example, soda or fruit might be kind of a, a quick hit and then it's not gonna last super long. So you're gonna see most of the carbs a lot sooner than you would if you had a piece of pizza. So it should work out pretty well if your settings are relatively dialed in. Okay, but the trick is if you end up having a couple settings off, let's say you have too weak of a carb ratio or we'll talk about this more in the next session. A little bit more. But if your ISF is too low, which plays into this calculation, then when your blood sugar pops up initially, Loop might be subtracting too many carbs. You might go from 50 to 30 in a matter of an hour. And like, well, that doesn't make sense. Like whatever you ate is probably gonna take longer than, than like two hours to, for you to digest. So now Loop thinks you have like way too few carbs active and that, and therefore way too much insulin, cuz you just bolus for all of it. And so it'll take a while for Loop to think, oh, you're gonna go real low and you're not. So that's the tricky thing. So we have to pay attention to the settings we're using to get us to a point where the meals are. Absorbing is the term Loop uses when it drops or sees the carbs. Uses the term absorb as if you like digested it basically. So it's. You want to make sure the absorption rate is, you know, reasonable, not, not occurring super fast and not taking, yeah, super long.
- [15:42]
A
When you talk about, I want to make sure I understand the phrasing and the people listening understand the phrasing. We talk about the, the carbs going away. The idea is I put in that this is 50 carbs and my, my ratio is 1 to 10. So we put in 5 units of insulin. Now there's 5 units of insulin for this, 50 carbs. And as your blood sugar moves or doesn't move, the expectation is, okay, we've made it a certain amount of time, and we're still level. So this much insulin's gone. And that much insulin was supposed to cover this many carbs. So this many carbs have been absorbed. So now they're kind of out of the picture, and we're left with what's left on both insulin and carb side. And those two keep decaying until eventually they're both out of your system. Is that. Is that the idea?
- [16:32]
B
Yeah, that's generally the idea, yeah. And rises will decay the carbs faster. And then, of course, turning off the basil will decay the basil, the iob faster. Right. So those are the tricks sleep can use. And this is more important when you get into longer meals, right? Cause you might have pizza or pasta or something like that that maybe doesn't. Some pasta might not hit a whole lot at the beginning. It may be more in the middle or at the end or something like that. And so if you stay level, it's like, oh, well, I'm not seeing all the carbs I thought I'd see at the beginning. So it might start predicting, like, a little bit of a dip in the middle of your pasta you're having. And so it'll turn off the basil. But then eventually the pasta kicks in and you start rising slowly. And so then it says, oh, okay, yeah, I was still expected there to be, you know, whatever, 60 more carbs left in this pasta. And looks like some of it's coming. So I can probably start giving insulin for this now. So there is a window. The safety mechanism is the window of time that we're. That you enter. Whether it's a short, a medium, or a long meal, you're giving LIPA an amount of time, one, to spread out the expected carb impact for safety. And two, that when you get to the end of that time window, if, let's say you don't, the system doesn't see all of the carbs. It says, hey, you know, we saw 40 out of the 50 you entered, and we're coming up on the end of our time here. Let's not expect that there's another 10 carbs. And. Or. Or even when you get to the very end, obviously, it'd be like, Nope, I saw 40. You said 50. I'm not gonna expect a rise in the dose for those ten. As soon as Your blood sugar starts going up just for safety reasons. That's why you gotta have that time limitation there.
- [18:11]
A
Yeah. So if you overestimate the amount of carbs, but the system feels like we're at the end of this meal and it didn't see all those carbs, it might hold out basil longer for example, to stop you from getting low or something to that effect.
- [18:26]
B
Right, exactly, yeah. You'll see instant onboard be like there's not enough carbs to match up to this, so it'll probably pull back even if you start going up. So if you, if you entered pizza as a lollipop or something in the shorter entries and it gets to the end of that time and then you know that second wave of your fat and protein for pizza kick in, the system's like, well, you don't have any more carbs left cuz I ran out of time to see them. And so you start going up and it's not going to give you enough insulin to make you happy with the result because it's going to simply be, for lack of a better term, correcting. As much as I don't like using that term, it's going to be correcting based on your sensitivity and not expecting any carb impact. But if you go back and say, oh whoops, I entered the pizza we ate short, I'm going to make it longer. Go back to maybe a five hour absorption, for example from a two, then loop will say, oh, okay, now our window of time is longer to look for this pizza and you're going up and let's see, we've only seen. And it starts doing the math. As long you're prediction what happened in the last hour or two and says, okay, we've only seen, you know, 30 carbs of our 50 for this pizza, so you got 20 left, let's go ahead and start dosing for that. And you're gonna get a lot more insulin that way. Instead of just a mild correction, which I think for general diabetes management, whether you're using loop or not is the best way to think about how to quote unquote, correct. So instead of worrying about correcting, we're gonna think about what did we get wrong. So if you'd only bolus for 30 carbs, but the pizza really has fat and protein and needs another 20, then this would be the time you'd go in and dose for that, which is likely to be a much larger bolus than if you had just said, well my doctor told me to use a correction number of x You know, might only be one unit, but you really needed two or three for all these carbs. So I feel like it's a much more accurate and helpful way to approach management, whether you're using an automated system or just, you know, bolusing with your pens or whatever. Either way, you want to make sure you're addressing the actual issue, not just correcting randomly.
- [20:31]
A
Yeah. Take a sidebar for a second. Tell me why you don't like the word correcting.
- [20:35]
B
Because of mostly what I just mentioned. So correcting. When you're diagnosed, you get started with a general correction number to play with. And it's. It's blind. It's. You're picking a number out of the air to correct because you're high, because you need something to go off of. But if you can take a step back and understand some of the variables at play early on is fat and protein is the one that people need to become aware of. And you adjust for that, you're going to get better results. One, because you expect it, it's no longer a correction, it's a expected rise that you're dosing for. And two, you're going to get a more accurate and often larger when necessary or smaller when necessary dose of insulin to take care of the problem. Or, for example, if you undercounted a meal, you went out to eat and you guessed what it was, and you're like, no, it. There's a high likelihood I under guess the amount of carbs or fat and protein in that particular meal. So it would be best if I thought, how many carbs did I miss on that? And probably 15 more. So then dose for that a couple hours after you've had Mexican food, rather than just using some random correction value that you've been given or sometimes playing with.
- [21:42]
A
Right. Also, I think maybe in a similar vein, tell me what people should be thinking when they bolus for a meal, see the blood sugar rising, and the basil's not there, and they think to themselves, I still need this basil. Why is the basil not there? If the basil was there, I wouldn't be rising so quickly. What should they actually be thinking instead of, hey, the dumb machine's not working. They should be thinking, okay, so the.
- [22:09]
B
Initial answer would be, until you're used to looking at the prediction and understanding all the elements, we're going to go through all the variables. It might just be in a loop situation. Just give more insulin and then take your time to figure out what's wrong. That's the way I react to situations. Sometimes if it's not apparent to me. But if you're in the middle of a meal, you might want to look at the prediction as the prediction. Say you're going to go up eventually, but you're to go low here in the next hour. Might be because you have a nice, long, slow entry for your food. And maybe that's not totally accurate for the type of food you have. Or you might not have enough active carbs. You might see that, hey, you entered food like two hours ago, and it's a nice long meal. But yet loop says, like, 80% of all your carbs are already absorbed and it's not expecting a whole lot of lift left in your meal. So I think the appropriate responses, you know, one, we gotta give more insulin. Two, we gotta figure out how do we fix that? And we'll go over that. But you might look at your carb ratio. You might look at your isf the way I do it when we're high. If you're the situation you're talking about. Yeah, my step is always look back overnight like we covered in the last episode. Make sure your basil's pretty good, at least based on the, you know, relatively uneventful night. Make the adjustment. If you didn't already, check the pump site just in case. If you're higher and then you step into how confident am I in the food I just entered? Right. If it's stuff you've had before, you know how to account for it, it's fine. Then you move on to the next step. But if it's something out you've never had before or a new meal you're making, then you might want to adjust your carbs if you think it should be higher or lower than what you're talking about. And then after that, you might take a step and say, fat and protein here. How do we want to address this? And we'll talk about how I answer that here in a minute. But we'll enter some carbs to represent the fat and protein impact. If you've done all that, then it's like, well, am I going high pretty frequently with food? Maybe we need to address the carb ratio. And at the very end. Oh, yeah. And double check your carb absorption. If you're using too short a meal or too long a meal, we can look at that. Usually too short is what people would do because you're three hours out from a meal and you use something like a fast entry. And Loop's like, okay, we ran out of time for this, but we should not have run out of time. You extend it, and then finally it's okay. We'll play around with the sensitivity factor, and we'll get to that probably in the next episode. Talk about how that helps with the. With the meals. So that's my progression of how to step through from a high, what you go through. But again, the initial gut reaction is if you think you need more insulin, and you're generally pretty good at guessing those things, just give it, and then we'll figure out how to tweak loop later.
- [24:53]
A
Can you put a number on high after a meal? Meaning if there's 21 meals a week, where do you not see your daughter crest most of the time? What number does she not get over during a meal?
- [25:06]
B
Normally, I would say as she has grown larger and using a lot more insulin, she's also. She's less sensitive to insulin. She's also less sensitive to food. So we pre bolus, but it's not super aggressive. Maybe a few minutes, sometimes. Sometimes 10 or 15, but not super often. And I would say 150, 160 is I. I've learned to let those go and let loop kind of deal with it. I don't love it, but it's not super common to hit quite the 160 number without a pre bolus, I should say. But when she was younger, without a pre bolus, that would have been much higher. So I think it's a little contextual. But, yeah, we're hitting one over 160, especially with any kind of speed, any kind of rise. Then I'll bolus, and then we'll double check. And usually it's a text to Tessa to say, so what did you eat? Again and again. Goes back to my order there. How confident are we in the food? Well, if I didn't see it, then I'm less confident in what's answered. So I'll ask her what it was, and she might tell me what it is and be like, oh, yeah, you probably undercounted that, you know, for example, if not, then we'll let it go.
- [26:12]
A
Is that where you lean when you see a 160, like, bad count, not bad pre bolus.
- [26:18]
B
That's a great question. I've talked to some people about this before. If it's a higher glycemic food, then no. Like, if we didn't pre bolus a higher glycemic food, then I'm more apt to say, okay, let's just give a little extra insulin, let loop turn off the basil. But we probably Just didn't time that right. So there's definitely a timing issue that those that are familiar with the podcast should be comfortable with right now to go. Well, we just messed up the timing on that. Otherwise, if it's a home cooked, you know, fairly mild meal and we're getting to 160, that's a little unusual even at the beginning.
- [26:51]
A
Right.
- [26:51]
B
We'll look at the carb counts or I'll often just look at the site. Like I mentioned my list of things I go through.
- [26:56]
A
Yeah, I texted Arden recently and I said, did you just eat a bag of sugar? She goes, no. And I said, was it two bags of sugar? What like, what am I like? What am I like? Rocketing. Am I seeing here? Higher glycemic, quicker acting sugars are probably going to need a longer pre bolus so that the action of the insulin is really ramped up and vibing, you know, on your side of this thing because this, this sugar is going to go in and you're going to jack up really quickly. So you need a lot of power from that insulin to stop that. If it's a more balanced meal and you see that rise like that, then your expectation is we miscounted the carbs. That's right.
- [27:37]
B
Yeah.
- [27:37]
A
Okay.
- [27:38]
B
I think I've heard you say that before. You know something, I've said something like.
- [27:42]
A
That before, but it fits very well in this conversation. So.
- [27:45]
B
Yeah.
- [27:46]
A
Okay, what else you got?
- [27:48]
B
There is a little bit of a trick I don't actually have in my notes here, but there's a little bit of a trick when they're younger, especially when they're more sensitive to everything. And you can do some small things like, hey, ask your kid to eat the like lower glycemic foods first on their plate and kind of rotate around just to give you some more time for pre bolus or no pre bolus. And it's effectively like a mild, mild pre bolus. There is some tricks for that, but the timing issue is important to not to know when it's a. A panic of we underdose versus just didn't time it. Well, I think that's a good highlight that I probably don't spend enough time talking about. So thanks for bringing that up.
- [28:22]
A
No, of course I'm gonna. You brought something up that I'm going to highlight here for a second. Back in 2024, in episode 902, I either got a lot of crap from people or a lot of love from people for having a woman on who calls herself glucose Goddess. On Instagram. Right. And in the end, what she was really talking about was the order that you ingest food in and how that can impact the glycemic impact on you. Right. Like how it can lessen the glycemic impact on the person eating. And I have to tell you, like, if you look past the idea of, like, some people jumped to conclusions that she was saying stuff that she wasn't saying. If you go listen to what she talks about, about eating in a certain order, the responses and the replies I got back from people overwhelmingly were, this really worked for me. So if it's a thing you're interested in, there is an order you can kind of eat your meal in that might help that glycemic impact be lessened.
- [29:27]
B
So, yeah, we use that. Or tried to remember to use that. When Tessa was younger, 5, 6, 7. It made a big difference, too.
- [29:34]
A
Yeah.
- [29:34]
B
Even if it didn't change the. It did adjust the glycemic impact, but it was also just practically something to do when socially, it was a little bit of a burden to try and pre bolus. Right. It buys you, practically speaking, it buys you more time till you get to the thing that really needs more insulin.
- [29:49]
A
Right.
- [29:50]
B
But like, she covered in that episode, it really does change how the food hits if you put something else in your stomach first and then get to the sugary stuff that may require the insulin sooner.
- [30:00]
A
Also, she has a lovely accent, so if you just want to hear a lovely accent for a while, go listen to Jesse and 902. But anyway, I didn't. I didn't mean to take us off track there, but, you know, it came up. And again, like, I got a lot of good feedback about that episode from people.
- [30:13]
B
So, yeah, it's a really cool trick. I think it was sprinkled into one of your earlier episodes, which is why we started trying it.
- [30:20]
A
Y.
- [30:21]
B
But it was. That's a long time ago now.
- [30:22]
A
Yeah, no, we. I. Listen, I've brought it up in the past because. And, you know, in fairness, the way I heard about it was just online, people are like, you know, if you eat this before that, then. And then Jenny would start talking about. I think it really hit me more when in one of the Pro Tip series, Pro Tip episodes where Jenny said to me, like, hey, you know, here's the reason that pizza takes so long in your system. And she started talking about how, like, the cheese and the grease slowed down digestion. And I was like, that's. That's the first time I really wrapped my head around that was. I mean, it's a long time ago now, but it's important to remember because I don't know how you're supposed to do all this if you don't recognize that French fry that's deep fried is going to impact you later when you don't expect it to. And, you know, like, don't expect it to. If you're going by what your doctor said, which was like, count the carbs, put in the insulin, everything's going to be fine. You count the carbs, you get them right, you put the insulin in, and you know, lo and behold, 90 minutes later, blood sugars going up with some speed and steadily and seems like you can't impact it and you can't figure out why. Understanding fat and protein is a. It's a big deal.
- [31:33]
B
Yeah, it is a big deal. I'll mention how we tend to dose for fat and protein, and a lot of this is derived from experience. And then a lot of stuff. On the podcast, she had a couple people on. One lady, I remember talking about the Warsaw Method, the kind of fancy calculation for converting basically kind of calories of fat and protein into some kind of carb equivalent.
- [31:53]
A
Yep. Episode 471.
- [31:55]
B
471, yeah. Yeah. She. I like how she simplified it and so I kind of use something similar. So what we do for fat and protein, this is the way I have tested do it, is we'll do the fat grams and the protein grams, add them together, and then just divide it by three. It's a simple math step. I think more appropriately, the fat needs a little more insulin than the protein. So you might do like a 40 or 50% of fat grams as carbs and then then protein, maybe more like 20. But for Tessa, what I tell her to do is, hey, if you have a nutrition label or you start guessing on her own, which she's learning to not just carb count, but fat count and protein count. You know, same thing you do is over time, you acquire a little mental database of this stuff and just say, divide by three is a place to start. It works out well enough. But if the meal is going to be higher fat, you know, restaurant food, for example, is usually much more fatty. Then, you know, you can round up or you can do a more precise calculation, whatever works. But I find that one third of both is a good place to start. And then we use longer entries. So the pizza icon in loop is five hours. We use that for most food, especially if the fat and protein kind of quote carbs represents I should come up with a better number. But, you know, at least 10 to 20% of the total carb count is fat and protein. It's probably better to use something a little bit longer, whether it's four or five hours in time on loop, that's helpful. And there's a couple different ways that we approach how we enter the food. I'll give you the complicated way that's probably the best. And then we'll step into the kind of practical way. What I have Tessa do to keep it simple for her. You could take the different absorption times. You could enter, you know, really short, maybe one or two hour absorption in loop for all the sugars. And then you could do three hours for the remaining carbs. And then you could move out into the future. With loop, you can enter food and change the time that you're going to, quote, consume it, basically when the impact's going to start. And you could, you know, roll it out to the future two hours from right now and put in your fat and your protein representation as a nice slow pizza entry, which is great. So you end up having like three or four entries just for one single meal, which creates a nice profile, a predicted rise for Loop to play on, to handle the meal really well. But that's a lot of entries and practically speaking is just not something we do a whole lot. So then the next most easy method that we use with good success, but it's really only something I do when I'm entering the food is we'll enter the carbs as one entry. And if it's a lot of, you know, pretty basic glycemic carbs, we'll do a three hour entry. If it's a there's a lot of fat involved in the meal, we'll use a longer one. So you kind of play with that first entry, the right now entry. And then we'll do a future entry two hours ahead and use a nice long, slow absorption, the pizza icon and enter that fat and protein calculation. I mentioned, the one third of the fat and the protein grams.
- [34:52]
A
Yeah.
- [34:53]
B
So we do two entries per meal. That works great.
- [34:55]
A
I'm just gonna say Jenny loves that one. Yeah, she talks about that a lot. Yeah, yeah.
- [35:00]
B
It's the best balance I find. But when I'm texting Tessa, I've done, I've had her say, hey, do this entry and this entry. Tell her two entries and she'll do it.
- [35:08]
A
Right.
- [35:10]
B
But we've played around with ever since the defaults in loop changed from a four hours as a Long entry to five. It's a better representation of a long meal. So what we often do is we'll just do the whole thing as one entry. So the carbs and then a third of the fat and protein added it into the carbs and just put it in as a pizza entry. Answer it and go. And Tess is typically eating enough now and frequently and enough volume that it's fine. It doesn't usually cause a problem. When she was younger and more sensitive. I think the split entry that I just mentioned, the second option, it creates a nice spread out impact so it's less likely to bull us too much on a little kiddo. So those are the two methods we use. I would say we use one entry a lot. And then if she starts to get a little bit high, like four or five hours after the meal and loop's kind of running out of time, we'll talk about the time here in a second. But if it's running out of time for the entry, then we'll go ahead. I'll add a few more carbs later. You know, kind of as. As a second entry after the fact.
- [36:07]
A
Yeah.
- [36:07]
B
Because it does happen that it's not. The pizza entry is not long enough for really long foods. It's. It's good enough for most of them, but it's not long enough for most really long meals.
- [36:17]
A
What's your expectation when you talk about now that she's older? Why do you think her sensitivity is different with age?
- [36:23]
B
I mean she's using more insulin and in loop. We'll talk about in the next session here. There's an idea around carb sensitivity and you can get to it using the settings we have. But all I have to say is I think her carb sensitivity and insulin sensitivity are lower and they tend to scale together. So just in practice I've seen her spike less as she's used more insulin or there's more. It's more forgiving. If we don't pre bolus, I can cat. We can catch up with it a little faster.
- [36:51]
A
Do you think that's body mass?
- [36:53]
B
I think so. I think both body mass and insulin resistance slash sensitivity because she's on the like 90% of her growth chart. But she is taller and bigger for her age. But her insulin needs are, from what I've seen from other 10, 11 year olds, a good amount more. Maybe 20 to 50% more than the average too. But I've just noticed it when she started using more insulin in the last year, year and a half, it just started getting Easier. And the other people I've been helping over time is as they use more insulin, things get a little bit easier in terms of the responsiveness is less extreme on both ends of both heavy bolus or the spiky foods. It just tends to like be more mild over time.
- [37:38]
A
Is forgiving the right word? It's more forgiving?
- [37:41]
B
Yeah, I think so.
- [37:42]
A
Okay.
- [37:43]
B
Yeah, I think, I think another way to think about it is one gram. Let's say one Skittle would move Arden's blood sugar a lot less now than it did when she was.
- [37:52]
A
Oh yeah, four.
- [37:53]
B
Yeah, right.
- [37:54]
A
Oh, no, Sure. I could like a quarter of a juice box could fix. Hello. At some point now you just need to drink the whole thing and.
- [38:01]
B
Yeah, exactly.
- [38:02]
A
And hope that that was enough sometimes.
- [38:04]
B
Okay, Yeah, I think that plays into it. So the more technical piece we missed a little bit, I'll mention a bit is the absorption time. This is one of those things that can feel a little funny when you enter 3 hour or 5 hour, whatever duration you're going to use. Loop says great, I hear you on the like three hours, let's say. But just in case you're wrong, like spike might be too much. Again, it's a very hyposensitive system. It's going to say I see your three hours, but I'm going to add 50% to this, what I'm calling the window of time to see the food. So the three hours becomes four and a half. You're adding one and a half hours to that. So half of the three, you know, add 50%. So you're at four and a half hour window. So whenever you say this is a three hour food, you're really telling loop, I'm giving you four and a half hours to see this meal. But I'm Loop is also spreading out the expected rise from that food over four and a half hours, not the three that you entered. So that can feel a little funny when you're telling it one thing, but it's kind of doing another. But that's important to know that that's your maximum window for seeing those carbs. And that's why I mentioned the five hour. The slow option being better for longer meals. It gives you about a seven and a half hour window of time to see all the food. But if it's fatty enough, Jenny's covered it plenty on the pro tips. It's gonna last longer than that, seven and a half hours. So sometimes you do need kind of a second entry to cover the fat and protein, which is why that option two, as I discussed for entering carbs, often works out better, is you're moving the fat and protein out two hours for the lift, that rise that's supposed to happen, and then you're basically giving it an extra two hours of Runway to, to see all that impact. So it's, that's pretty helpful.
- [39:47]
A
Trying to see if I can see back far enough last night to tell you that. We went out last night kind of late, like 9pm to A, like a bar restaurant that had french fries. And Arden's blood sugar was 70 when we got there, it was 124, five hours afterwards. And as soon as her algorithm kind of gave her a little bit of a low at like 2:30 in the morning, she wasn't actually low, but she kind of went back down to 70. So it kind of took away some basil once it felt like the meal was over and like to try to stop the lower. But as soon as it took the basil away, she shot up to 200. And that is because that fat is still in there from the french fries and the meal from like six hours prior. Now the Arden's using trio, not loop, but it attacked it just with basil, and inside of 35 minutes went from 70 to 200 and back down to 90 again just with basil. And if I showed you the, the Night Scout, you'd see that she hadn't had basil running since. My gosh. She ate at 3pm, so there's a bolus at 3pm she had only had basil maybe twice between 3pm and 9pm and then after bolusing at 9pm, didn't have basil again until the spike at 3am and then like around midnight. Yeah, yeah. And then eventually overnight after the food was all gone, then her basil came back on and started working the way you would expect it to again. There's an argument to be made that that meal had something to do with her blood sugar for about 10 hours. Like, like watching. Yeah, it's really, really something else.
- [41:32]
B
We've gone out to restaurants and had a meal that we thought was relatively contained, but it basically sent her higher. Like you could have argued it was Basil, but we knew it was the food until she woke up the next morning. Like it created this resistance that had a little bit of a. Not massive but lingering resistance where she might float around 120 or 100 and her target was more like 90. And loop's just trying to like knock it down most of the night. And it didn't quite stick until she woke up and you know, it does. Then the next day, everything's fine. The next night, everything's fine. No need to change basil. But it was just the food, so, yeah, it can stick around for a long time. So a lot of Tessa's entries are longer. I'd say that, like, a lot of days. More than half of her entries are using that pizza icon. And the meals are kind of stacking on top of each other, so she has active carbs all day long. And that's part of the thing we discussed where it. Once you get the basil right, and you dial it down to where it needs to be, you're clear in the fog, you can see more variables. Fat and protein is a big one. Where now you can see that you're not covering that with basil. A lot of people and doctors, I hear them do the same thing. I talked to some endos up at our diabetes camp, and anytime there's kind of this pattern of going up, which might mean that you're just eating the same thing every day. And there's fat and protein. Any mystery that they don't understand, they tend to attack with a little bit of a basal increase. And then when you change up your rhythm, what it is, is you're eating, you end up going low over time. So pulling that mystery away, understanding what that is, is huge. To being successful and being able to eat whatever, whenever.
- [43:06]
A
Yeah, I think so, too. You were talking earlier about how Tessa just starts to, like, understand to make that second bolus, maybe, or the fat is there. I was going to talk about how excited I was the first time that I saw future boluses set up by the algorithm. And I knew that meant Artem put a fat count into her initial meal. And I was like, oh, God, she's doing it.
- [43:32]
B
And then the next time they don't. But, yeah, yeah, yeah, yeah.
- [43:34]
A
No, trust me. She's not super consistent with it, but I've seen her do it a lot. You know, where I'm not misremembering, this is in Loop as well as trio, or just. It is, right? Like, you can say there's this many carbs in the meal, this much fat in the meal. This many.
- [43:49]
B
Yeah, yeah. I think Trio gives a spot to actually enter those breakouts, whereas loop, you have to just enter carbs.
- [43:55]
A
But, yeah, so with. With Trio, like, she can say, like, this meal is 50 carbs, but I think there are 25 gram, you know, grams of fat in this meal, too. And then it will set up boluses out in the future. Almost like every hour for a number of hours. And when I see that pop up on the night Scout, I'm like, oh, she's thinking about it.
- [44:14]
B
Wonderful. Yeah, that's wonderful. Yeah. Them growing up is. Is good. It's. It's tricky. I did have a couple people say, I don't want to learn how to count all over again. It's like, well, I mean, you learn carb counting pretty fast. You can start looking some things up and figuring out the fat and the protein. So, yeah, it's. It's a good adjustment.
- [44:31]
A
Just say to listen, I. In my mind, I just say to her, like, deep fried. If you're going to have something deep fried, like, just, I don't know, at least 20, you know, for fat, like, just do that.
- [44:41]
B
And so another thing I see is people entering fake carbs to fight a high, which can be fine to use if you feel it's needed or if you feel like you undercounted a meal. I find people make that a habit. Sometimes they start entering fake carbs when they're running higher or they start under counting things when they put stuff in loop, when they think their settings are. I don't know if they think of their settings as being off, but when they're running lower is they're adjusting their carb counts. And that can be fine in the moment, but if you really want to use the system and the data to make a decision, you'll eventually need to go back and fix those. And one way you can do that is looking at the ICE screen, which is the insulin counteraction effect, or most people know it as. You tap on that green graph of carbs and you get a list of all your carb entries. The carbohydrate screen. That screen is helpful if your settings are relatively decent. But what you may have to do is you go back in and you delete the extra carbs you put in and get everything back entered the way you think is right. And then you can tweak your settings and come back and look at that screen again and use it as a guide for, oh, if I gave more, if I had a stronger carb ratio, how many carbs would loop? Think these meals took, for example. And if I change my isf, what does that do? So it's a good learning screen, but you have to make sure that you're putting in reasonable amounts and not just pivoting based on, you know, how the day feels. It's fine to do in the moment, especially if your kids like mine and she's texting me. I'm like, well, I guess you have been running lower. And I don't wanna text her two or three times to adjust her basil. I don't wanna bother her. So I might say, sure, we'll take 10 carbs off lunch, but we don't do that very often. It's usually like, lower your basil by, you know, 05. And then, you know, then give her the real carb counts and then we move on. Kind of what I do at lunchtime. So that's something to pay attention to. I see a habit people develop.
- [46:26]
A
But even though, Kenny, when you talk about, like, counting carbs, you're still just estimating based on your knowledge, right? You're not actually, like, calling the school and being like, how much. How many carbs are in this? Like, you figured it out over time or did you call them initially?
- [46:40]
B
The school actually has a meal plan set up. So every food that they have, I can go on the website and look at their estimated fat, protein and carb counts. They have nutrition facts posted for everything. I don't know how accurate they are and how consistent they are and their portions, but it gives me someplace to start. And then we adjust from there. Okay, sure.
- [46:59]
A
That makes sense.
- [47:00]
B
Yeah.
- [47:01]
A
What do you got left here?
- [47:02]
B
One tip that I think has been really helpful for people and a better tip for managing those nighttime rises. You mentioned the last episode when your kid goes to sleep, especially when they're younger and they go shooting up. I had a way of managing it, and just this year, I learned some information that actually made it make more sense. So I was reading about circadian rhythm of your body for health reasons. And one of the things it mentioned is that when we eat in the morning, our body will, you know, digest the food, convert all of it right now, all the carbs to sugar, and use it, you know, power our brain, our muscles, all that throughout the day. As we get closer to sleeping time, our body knows that we'll be fasting, we'll be not eating overnight. And so what happens is a portion of the food we eat starts to be stored as fat for consumption later. And I feel like that hit me was like, oh, that explains why if we have the same food at lunch as we do at dinner, for example, the spike isn't as strong at dinner most of the time. And we're often fighting lows before bed or sometimes fighting lows before bed. Just feels like the food doesn't hit the same from lunch as it does to dinner. And so what we've been doing is using. I didn't want to back off on the carb ratio. A lot of people weaken the carb ratio for dinner as a result. But what I found works now to represent this biologic effect is that you just use longer absorption. So if you use a medium like a taco entry at lunch, then try the pizza one like a four or five hour absorption at dinner. If you normally use pizza like a five hour absorption at lunch, then try six when you go to have it for dinner. And so what happens is you get less insulin up front hopefully generally helps mitigate the lows you have before bed at the same time saves a lot of active carbs and a nice long window of time or when that rise does show up after your kid goes to sleep or you go to sleep, either way that it has a lot of active carbs, that it still expects to show up and can start hammering away at that when the rise occurs. So it's created a lot more consistency for us and for the other people I've mentioned this to where now it's not. Again, we're doing fat and protein and everything in those entries, but it creates a lot more consistency where I don't have to be manually bolusing a really aggressive rise. Loop already wants to give, in my case, multiple units as she's going up. So I don't have to be like oh, here's a five unibolis to try to knock down this rise that's coming. The system wants to do it and so if I don't pay attention, it's usually relatively contained. It might not be perfectly in time and range, but it's much better than it used to be. When we started Loop and I just felt like the magic was having that apple watch where she could go to sleep and then as soon as she goes to sleep, I would just like take the watch and Bolst a bunch of units while I'm trying to clean the kitchen or do laundry with my wife as the kids are in bed. I just thought that was magical. But now if we sort of represented this rise more appropriately and mitigated the lows before bed that now I don't have to do that as much anymore.
- [49:59]
A
Okay. I feel like we should say because we haven't so far. For people who haven't used Loop, when you hear Kenny sing like pick taco or pizza for. So there's little emojis in the in the app that signify different absorption times for the food. So that's what he's saying like when he says pick taco or pick a pizza, are those the ones you use most of the time?
- [50:21]
B
Yeah, I'm using taco and pizza. Yeah. The lollipop is considered the fast stuff. The default for that is 30 minutes of absorption. Now, it got changed in the last couple years. I always make it longer. I change it in the code and make it, you know, one and a half or two hours. We tend not to use that. I do use that for fruit. That's the one thing that's tricky in here. He's just talking about food that has a lot of fiber. And one of the tricky things I found about fruit is you might look up like, what's the carb count for a medium apple? And it'll tell you something like 20 or 25 grams of carbs. But that's only true if you were to blend it up with an industrial blender and smash all the cell walls that contain all the sugar into bits and extract every ounce of sugar out of it. But I know my kid's not chewing her apple that thoroughly to extract all the sugar found in that apple. So I find that's one reason that fruits and vegetables are a little more variable and should usually be less than whatever I Google or whatever the amount of carbs it should be is that my kid's not gonna chew it up the same way. So I'll use a shorter time entry so that there's less chance that like four hours out loop thinks that, oh well, you haven't seen all the carbs for that apple. So if you keep it short, loop limits the amount of time it'll expect that fruit to hit. And so then you don't have to worry about over counting it quite as much. And then I also usually pick a number less than whatever it is I look up for. Most foods that I again don't think she's going to be chewing like she's a high speed blender.
- [51:51]
A
You know, it's interesting, while we're talking today, a couple of things are occurring to me. The one is that there could be people listening who are just like, well, this Kenny guy's overthinking all this. You know, I don't see any of the things that he's talking about, but I would ask you to believe that. And maybe this is okay, but frequently some of the successes you have with diabetes are by mistake. And you know what I mean? Just like, just like the failures are not always obvious where they came from, but you could not understand some of this and still be seeing Stability and thinking, like, oh, I understand this, but you could just be getting lucky. Like, look what we talked about. Like, the circadian rhythm of, like, how your body stores food depending on what time of day it is. Like, that's the thing that you might have built up a rhythm with and not. You might not know that you understand that rhythm. Right. Like, so it's just. It's interesting to me because I feel like as much as this conversation is about how loop works and how to use loop, it's really just as much, if not more about how your body works, how it interacts with the food and your exercise and the other things that impact your blood sugar and how insulin work. Like, the loop is almost inconsequential in the conversation. As crazy as that sounds, like that's not really what you're learning about while you're talking. Does that make sense?
- [53:09]
B
Yeah, that's exactly right. And loop, because of its design, is a little more simplistic in terms of, like, just modeling everything. So we just adjust the understanding to make loop kind of do what we understand. And yeah, I think, like, the circadian rhythm thing was just something I encountered this year for another unrelated reason. I just happen to have diabetes experience to layer on top of it. So it's. It's a lot. It's. It can feel technical, but once you wrap your head around it, it's something you. You can adjust to pretty well. And like I said before, with any system that you're managing with, you understand these variables, you can use that system to your advantage in that way. And you mentioned activity. And I'll just throw that in here too, that sometimes you need to not enter all the carbs in for activity. And we'll cover that more in more detail. But that's one space that I find. Some parents with active kids, they just. They don't do that fat and protein thing we talk about for, like, lunch at school, for example. Yeah, they'll do it for dinner because those rises are gonna show up for sure. But they won't do it at school. But. Yeah, exactly. It's just, this is all about understanding biology. And the more we can understand it, the better decisions we can make with whatever system, however, we're managing diabetes.
- [54:19]
A
I think I'd like to make this point to simplify if you want. If you're a baseball person, you watch baseball on television, you wonder, like, in the last handful of years, like, where did all these guys come from that throw 98 miles an hour from, like, it used to be a special Few people, right? You know, you need to be Nolan Ryan. You need to be, like, a guy like that. Like, to be that special. Where that came from is a lab out in Seattle called Driveline who figured out that, yeah, Nolan Ryan was special, but it might have had a lot more to do with, like, how his fingers were shaped or how his arm moved. And that's a thing we could teach to other people. So, like, there are a lot of big, strong guys who are built about like this that if we teach them the correct mechanics, turns out that ball comes out just the same. Right? So it's not as magical as you thought it was back when it was a handful of people in the league who were special at this. We can teach you how to throw the ball this way, and they're doing it now. Diabetes, to me, is kind of the same way. Like, you can't look up and just think, oh, some people are just better at this than I am, or it just works for them. You know what I mean? Like, there is a way to have the same results that you're seeing with other people all the time. It's the basis for the podcast for My Money. Like, you know, if you've listened for a while, you've heard me say forever that when I started this, people told me that I couldn't share my daughter's successes because it would make others feel badly. And what I said was, I think it should make them feel like it's possible, and they should maybe try to figure out what the hell I did. So, like, that, to me, is what we're talking about here. Like, Kenny's not a special person. I mean, listen, he's delightful and he's eloquent, and he talks about this stuff in a way that is obvious, that he has a deep understanding of it and a lot of practice with it. But you don't need to understand it as well as Kenny does to have the results that Kenny's having with his daughter. That's my expectation. So, you know, Kenny, people have been listening to this podcast for a long time. You understand this in a completely different way than I do. Like, my brain does not work the same way yours does. And the truth is, is that if somebody told me right now, at the end of this recording, go back and tell me everything Kenny said, I won't be able to do that. But I can listen to you translate what you said into how my brain works and then use that in my daughter's life. So I think a lot of people have that possibility in front of them as well. I appreciate you doing this.
- [56:38]
B
Yeah. Yeah, it was great.
- [56:39]
A
Yeah, it's awesome. Thank you. I'd like to thank the Eversense 365 for sponsoring this episode of the Juice Box Podcast and remind you that if you want the only sensor that gets inserted once a year and not every 14 days, you want the Eversense CGM. Eversensecgm.com JuiceBox 1 Year 1 CGM hey, thanks for listening all the way to the end. I really appreciate your loyalty and listenership. Thank you so much for listening. I'll be back very soon with another episode of the Juice Box Podcast. If you're looking for community around type 1 diabetes, check out the Juice Box Podcast. Private Facebook Group juice box podcast type 1 diabetes but everybody is welcome. Type 1 type 2 gestational loved ones it doesn't matter to me. If you're impacted by diabetes and you're looking for support, comfort or community, check out Juice Box podcast type 1 diabetes on Facebook. The episode you just heard was professionally edited by wrong way recording wrongwayrecording.com.