Juicebox Method to Loop

To all those who said hi to me from the Juicebox Podcast, thank you! I see you and hear you…(and hello similarly to Sugar Surfers…this post is also for you all…basically for everyone who tends to “know their boluses”.)

You may have heard my jaw drop on the floor just a touch during the podcast when Scott asked if he needed to count carbs and know his carb ratio in order to Loop…and I think it’s time to write up a blog post to help you all transition from what I’ll call the Juicebox method to Loop. Because yes, you need to know your carb ratio and carb estimate. I’ve noticed for many of you this may be quite an adjustment if you don’t have a head’s up about how to make this transition from where you are with insulin surfing.

Why? Because you all have been insulin surfing without settings (and no, I am not typing that in a derogatory fashion). There’s a book called Sugar Surfing that has the same general underpinnings as what Scott his podcast are really good at explaining for the Juicebox method…think dynamically and react according to what you are seeing. Scott’s coined phrase is “Be Bold with Insulin” and it’s allowed a lot of people to transition from feeling like they need a restricted diet to meet A1C goal, and instead eating higher carb meals quite successfully and getting more consistent results. I’m a big proponent to this concept…it is basically the idea of lining up the insulin dosing so that it is most effective against carbs rather than restricting carbs. Even low carbers have also embraced this concept of lining up insulin and carbs appropriately by using R-insulin (slower, longer peak action time) and eating slower foods like proteins and fats…so the concept crosses a lot of user groups similarly.

The rub is that what if someone else was doing the reacting and thinking dynamically for you so that you could take a break? You can’t react while you’re asleep. Your kid doesn’t want to react while taking their math test. And all the button presses you can save?! That’s what Loop does 24/7 even while you sleep.

BUT…to get Loop to react, you need to feed it information about yourself and your diabetes. That information you’re going to feed Loop is your settings; basal rates, carb ratios, insulin sensitivity factor (ISF, sometimes called correction factor). And this is where Juicebox users will perhaps run into trouble because the method approaches diabetes from the end result (how much insulin to give) rather than the beginning (what settings will affect how much insulin to give). So, how can we get you from managing at the end result (insulin) and shift you to the beginning (settings and meal entries)?

Let me give you an example to help illustrate. Enter friend Jane Doe.

I set up a good friend, Jane, on Omnipod Loop before it was publicly released. I’ve known her for a long time and she has a little daughter, Princess Buttercup, with type 1. My intent was to see how the docs would work for Jane and fix places where she told me it was not clear enough to a new user. Also, I wanted feedback on what common pitfalls in the Loop app might be for new Omnipod Loop users and such. She was my canary in a coal mine (thanks Jane!).

Jane had been using the Bold With Insulin approach for eating for a long time. She knew which foods her daughter ate and how to administer insulin. Meals had a predictable good result. But, she didn’t count carbs much and didn’t know her settings really. Her endo had given her some PDM settings, but they were never really tested because she didn’t use them. Meals didn’t use a carb count and corrections for out-of-range or changing BGs were done by “feel” based on how quickly BGs were changing, not through calculating insulin on board and ISF. If she saw a slight climb in CGM, she’d have a manual bolus “feeling” based on so many times she’d corrected before in the same situations. If the climb was steeper, she’d manually give more insulin, also based on previous experience. The only setting that got any kind of real use was basal rates…but even those were frequently being overrun manually with temp basal rates she’d enact herself.

I asked her how new meals that she’d never tried before would go. Jane described that there would be a first guess at a bolus based roughly on similar other meals with those similar types of ingredients. She’d watch the CGM and adjust insulin manually. She’d track in her head how those adjustments worked out and the next time she bolused for the same meal, Jane would try to use what she’d learned from the meal the previous time. This meant that new foods were kind of a learning experiment, but she’d pretty quickly dial-in a “known dosing” for the new food within a few tries.

A couple days into using Loop, Jane was pretty frustrated but I hadn’t known it. She was trying to figure it out on her own (she is a smart cookie) and something just wasn’t clicking.

In almost a straw-that-broke-the-camel’s-back moment, it was a bagel that finally made her ask what was going on with Loop and why this wasn’t working. And that opened up my eyes to the Bold With Insulin approach she’d been using and where that transition needed help.

Here’s the rough conversation (and it would probably be very, very similar to a convos any one of you could have as you transition):

Jane: I’m so frustrated. I can’t figure out where I’m going wrong. She had a bagel. Prebolused. Typically a food I bolus well for, like never above 150. (And a screenshot of a definitely-well-over-150 dexcom graph.)

Me: How many units would you have bolused for normally for that meal?

Jane: Normally, I would have dosed 1.25 units like I did this time, but I would have doubled her basal for awhile. This time when I gave the 1.25 units, Loop suspended insulin while she was waiting out the prebolus time.

And that conversation gave me a lot of insight into the issue.

Carb counts weren’t a big (or even small) part of her method on a regular basis
Bolusing was all being done with tools no longer available in Loop (extended boluses and temp basals)
Carb ratio wasn’t even used…she just had the boluses memorized for given meals.

So how has Jane turned it around? (Princess Buttercup has had a 0.5% A1C drop in two months of Looping now and Jane’s getting sleep)

Jane rolled up her sleeves and got to work on her settings.

If you are in Jane’s shoes and want to set yourself up for an easier transition, here’s a few tips you can do now.

Settings Testing

To transition successfully to Loop, Juiceboxers and Sugar Surfers alike are going to need to do some settings testing and meal deconstruction. Likely in open loop for a bit if you want to keep your frustrations down to a minimum.

This means not correcting immediately when you are testing basal rates for example. This means doing things in a sequential testing route…basals, carb ratios, insulin sensitivities in an ordered fashion. And also, you’ll need to look at how you’ve been successfully bolusing your meals and translate that to Loop.

It may take a couple weeks to finish the route…but the end result will be that you have decent settings to start with and Loop will be a less frustrating transition. Let’s start…

Work on your Basal Rates

Juiceboxers and Surfers have a lot of manual insulin adjustments running frequently. Temp basals and extended boluses are not at all uncommon. Unfortunately, this is also a good chance to have difficulty in identifying if basals (especially daytime basals) are truly set correctly. There’s a high likelihood that all parts of your daytime are touched by insulin remaining from an extended or temp basal that ran within the last 6 hours.

When you get into food habits, and have “known boluses” for them, you can basically have two wrongs making a perfectly great right. For example, send kid to school with her favorite lunches every day and those boluses involving extended/temp basals…you might just be covering not only the food in the meal but also some basal needs from the day at school. Same for the breakfast you’ve been sending her out the door with. Or maybe you’re bolusing less for lunch than you’d typically need because she has PE class after lunch. Those are instances where having two compensating factors are showing a good result in BGs outside a Loop…but you may have problems when you go on Loop without truly knowing you were compensating for a settings issue.

Checking basals is a pretty easy starting place. Basals, in the absence of food and exercise, is the amount of insulin that should keep your blood glucose steady and flat.

So…test that. Go without food and exercise for a bit and see how that turns out. Start easy…these are kids and they won’t want to go without food (I get it). Perhaps start with some distractions to breakfast time. See if you can get 2-3 (or even 4 ?!) hours or so without a meal in the morning. Bribery works wonders here. Favorite video games, money, whatever. 😉 Do you notice a drift? Do BGs start to climb/drop without a breakfast bolus involved? If so, you will need to adjust your basals.

Do this check for a few times of day separately (morning, afternoon, night), if possible. Sleeping basals are the easiest to check since there usually isn’t food involved. But, if you can get a good morning basal test in…that will do WONDERS to helping get you off to a good start on settings during your transition. Did I mention the wonders of bribery? Seriously, if I were to invest money…basal testing is a great place to spend some money on your kid. Huge payback.

And hopefully this is obvious, don’t do basal testing if you are on steroids, medication, ill, or otherwise have something that is temporarily affecting your underlying insulin needs. Bad insulin sites and/or illness will not yield useful basal testing.

Personally, Anna has a basal rate that tends to be higher while she is awake vs asleep. Therefore on weekends (not school days), we can shift the start time of her “I’m awake” basal rate in Loop to match her sleeping-in habits. Anticipating your question: If we forget, it isn’t a big deal…Loop accommodates pretty well. Instead of hanging out at her 95 mg/dl target from 7am-10am on a weekend, she might hang out at 85-90 mg/dl if we forget to tell Loop she’s sleeping in. So, I don’t fret too much about telling Loop those kind of details…it’s up to you how you’d want to deal with that kind of details.

Work on your Carb Ratio

A well done meal bolus should bring you back to target BGs within three hours after a meal and not require low treatments as a result of the meal bolus. Pretty simple concept…difficult in execution for many. There’s a couple insights that really help with “successful” meal time BGs:

Prebolusing
Accounting for fats and proteins in total carb counts
Accounting for fats and proteins in the duration you need to bolus for

The good news is as a Juiceboxer and/or Sugar Surfer, you’re already likely doing those things. You have a good feel for bolusing. That’s a great thing. Don’t let that go to waste. What you need to do though is convert that knowledge into a carb ratio and meal entry so Loop can access that knowledge too.

Start as soon as you’ve completed your basal testing. Then try your meals again. When you have a meal…calculate how much TOTAL INSULIN you use on your Bold or Surfing method for the meal, including extended boluses and temp basals. In the bagel example, total bolus was 1.25 units up-front and another 1.5 units over two hours…so a total of 2.75 units for the bagel.

Now estimate the carbs for the amount of bagel you ate. Let’s say you ate 45g of bagel. Take the total grams and divide it by the total units…that is your carb ratio. 45/2.75 = 16 (rounded off). Therefore for every 16g of carbohydrates eaten, you’ll need one unit of insulin.

As a Juiceboxer, you probably have many meals you already know your bolus strategy for. Write out a list of them, look up some carb counts and do a table of calculated carb ratios. Do as many of your meals as you can think of. They should all roughly average out to about the same carb ratio. This would be an excellent place to start your carb ratio setting in Loop.

If you have meals with heavy fats and proteins, don’t forget that those often need some “equivalent carbs” added to the total count of carbs for the meal. For example, a protein bar may say 35g of carbs on the label…but I know that they are very heavy in protein and therefore I need to cover the carbs in that bar more than just 35g. As a juiceboxer, you’ve already done this by having a larger bolus for that bar than the first time you tried it…now you just need to realize it’s actually a larger carb count because of protein. For us, that protein bar really contains the equivalent of 60g carbs because the protein breaks down into sugar in the blood stream too.

So again…it’s a shift from thinking of things in the end result (insulin) to thinking of things from the beginning (settings and carb entries). Take your known insulin boluses and work backwards to your settings. If you have heavy protein meals, add some to your carb counts (perhaps 30-50% of the protein grams will convert to carb grams for estimations).

Work on Insulin Sensitivity Factor

Now the above example is really super exciting and an example of how great Loop can be…but that success also depended on one more critical factor you’ve yet to set; Insulin Sensitivity Factor (ISF), also called a Correction Factor in some systems.

Basically, your ISF is the amount of drop in BGs you can expect from one unit of insulin. That’s a pretty important value to Loop if you think about it in those terms. An awful lot of Loop’s decisions (in fact EVERY SINGLE ONE OF THEM) will depend on that setting in its calculations.

This ISF is a pretty simple concept, but also the most difficult to “get right” because experimenting and testing can be really hard if any of your other settings are wrong.

Unfortunately, this setting is also the place most new Loopers start with their adjustments (because they assume previous success means their settings were right…so it must be the ISF that is wrong?)…and they do it while in closed loop. Hint: DO NOT BE THAT NEW LOOPER. You may lose your marbles.

Instead, start in the sequence listed above…nail down those basal rates by testing them first or else messing with ISF will be counter-productive and you’ll go nuts.

Once you get basal rates set, you can test your ISF by taking a glucose tab. Get above target and steady at that higher BG for a bit. Now take an amount of insulin that will safely get you back near range. Wait about 4 hours with super chill lifestyle. Don’t exercise, don’t eat, don’t fight with your siblings and for God’s sake don’t get on the trampoline. See how much you’ve dropped in BGs. Take the drop in BGs and divide it by the amount of insulin you gave. If you dropped 30 mg/dl with a dose of 0.50 units, then your insulin sensitivity would be 60. Meaning one unit of insulin would be expected to drop your BG by 60 mg/dl.

I cannot stress enough how important ISF is, and how misunderstood as well. Let’s do some ISF myth busting/confirming:

Dropping the value of your ISF (say going from 100 mg/dl to 80 mg/dl) will be a good solution to a new Looper who is consistently stuck high. WRONG. This indicates more of a problem with lacking adequate basal rates.
Spikes after meals can be dealt with best by changing your ISF. WRONG. Meal spikes should be dealt with by meal entries AFTER you’ve done the work to test your settings as described. Prebolus, adjust carb counts, and adjusting your meal duration (lollipop, taco, pizza icon) are the best way to deal with meals that don’t result in desired outcomes once you’ve adjusted/tested your settings.
Illness, medications, and hormones can all change your ISF. TRUE. If you notice that settings that previously worked in Loop after all that great testing…you may have a hormonal female teen. Or a sick kiddo. And yes…you’ll need to adjust some settings for that. (Make a mental note to read my upcoming blog post about the new Override features in Loop…that’s coming up and can help with those situations.)
Roller-coastering BGs in Loop can be because ISF is set wrong. TRUE. One of the most common issues is impatience in starting Loop…seeing higher numbers than you are used to (blaming them on Loop not being aggressive enough) and therefore lowering your ISF value thinking that will make Loop correct “better”. WRONG. Lowering your ISF value will make Loop lay on more insulin, but unfortunately, it also works in reverse. Every unit Loop suspends is also undercounted as a result of the artificially low ISF value…leading to a rebound BG. You’ll ride a nice wave of high temp basals followed by suspended basals…and your BGs will reflect that same oscillation.

So, if you have tested your basals, tested/calculated your carb ratio, and even tried to take a good swag/test at ISF…yet are roller-coastering? Try raising your ISF value just a bit. If you were at 60, try 65. Keep tweaking slowly and watch for your sweet spot. You’ll find it. Eventually you will find it.

Next Level: Adjust your Meal Entries

Now that your settings are nice and solid…we have a really good place to adjust from. (Really…make sure that you did the work in the steps above. Getting some decent understanding of your fundamental settings will help more complex meal boluses go much better.)

You’re probably wondering right about now “So, I’ve done all that work for settings…but I still don’t quite understand how I’ll bolus for my meals now.” All those awesome extended boluses and temp basal work that you’d been doing and had nailed? How do you recreate that experience in Loop? Meals that tend to stick around longer than just an initial bolus that you used to extend bolus for?

Now that basal rates, carb ratios, ISF are pretty well known, let’s make note of the meals that you normally might give less upfront and more of the total insulin later instead. Like pizza anyone? Chinese food. Quesadillas. Rice (omg, the rice) and sushi.

If you gave all that insulin upfront, you’d be going low early and high later…not the best outcome. Think of it like a game of tortoise and the hare (rabbit).

A quick carb meal like a fruit snack is a rabbit…it can out-run any insulin. It is super fast digestion and uses all its energy very quickly.

A slow carb meal like pizza and pasta is a tortoise. If you gave all the insulin up-front, you’d go low low within about an hour of eating and then be high high for hours later.

As a Juiceboxer and Surfer on a tortoise meal, you’ve gotten accustomed to some insulin upfront but using an extended bolus or temp basal to make sure insulin is still around to deal with those late BG climbs. Loop has a way of dealing with those meals too…it’s actually a pizza icon. Literally. You tell it the total grams of carbs for that meal (remember to add “equivalent carbs” to your total meal carb count if there are fats and proteins) and tap a pizza icon…that is equivalent to telling Loop that you are extending a bolus.

Let’s look at an example, Anna has a bowl of pasta for dinner.

If Anna and Loop had bolused based on carb ratios alone, her bolus would have been 6.25 units. Her carb ratio is 8, meal is 50 grams. 50g/8 = 6.25 units.

But, Loop only recommended 4.85 units up-front. Why? Because I told it this was the kind of meal that was a tortoise. It was going to be sneaking slow at first and stick around for a long time. Loop gave an appropriate amount up-front and then waited like a stealth ninja to deliver the rest when the danger of low BGs had passed.

How did that meal go then? Let’s show that in pictures

And how did that meal do hours later while I slept? Pretty freaking fabulous. As that slow tortoise tried to get to the finish line, Loop kept pushing back. Hours later, Loop had won the war and the tortoise had run out of steam (pasta had finished digesting).

Similarities with Juicebox and Sugar Surfing

All of this reading and do you see it now? Where Loop and the other methods are similar with regards to “nailing” a meal?

They all still involve a bit of learning when encountering a new food. And that is a-ok. Getting friendly with a new meal? Here’s the differences in behavior between the two:

With Loop: You adjust how you enter carbs to fine tune Loop’s insulin deliveries.
With Juicebox or Sugar Surfing: You adjust insulin in reaction to observed BGs. Carb entries are relatively unimportant.

So…in practice these are actually kind of similar, just different where you are adjusting. If you have a meal, you can learn from it in both systems. If you have a meal in Loop and end up stuck on a high later…add some carbs to the meal entry next time (or even edit the carbs mid-meal to help Loop know that perhaps you didn’t quite guesstimate carbs right) and use a longer food icon (move from taco to pizza). How many carbs to add? If your settings homework was done, the Insulin Counteraction Effects screen in Loop can help you TREMENDOUSLY to dial in those meal entries. Loop will help you see just where your carbs impacted you and help you for the next time to estimate total carbs to enter and how long.

If you really want to fine tune, you can do mixed meal carb entries…give a portion of the total carbs to the tortoise and a portion of the total carbs to the rabbit. My teen doesn’t usually go through that much effort, but that’s ok for us. Could we get slightly better results if we were super diligent about telling Loop the exact mix of a meal? Yes…but we’ve decided the effort’s not worth it overall after 2.5 years of Looping…but I’m glad the option is easy to access for those who would want to.

Read the Docs

Don’t forget to read Looptips.org. There are loads of helpful tips about how to deal with situations in Looping. How to do these settings tests. And for Juiceboxers and Surfers especially, work on converting those old bolus techniques into settings and carb techniques. Identify the results-oriented tools you’ve been using (insulin dosing) and back those into settings understandings.

And then recognize that you’ve been doing the work of a closed-loop system for awhile now. Kudos to you. If you can take the time to dial in the settings as described above, you will have successfully developed the tools to let Loop know the needed info so that Loop can take that closed-loop job for you. It can babysit the reactions to BGs now.