[HN Gopher] A DIY 'bionic pancreas' is changing diabetes care ___________________________________________________________________ A DIY 'bionic pancreas' is changing diabetes care Author : sohkamyung Score : 336 points Date : 2023-08-30 12:32 UTC (10 hours ago) (HTM) web link (www.nature.com) (TXT) w3m dump (www.nature.com) | jimkleiber wrote: | My buddy built Loop, the iOS app for managing this (which, thru | another org just got FDA approved). I was living near him in | Oakland when he was first building it and I just feel really | proud of what he was able to do not only for himself but for | others. | | For all of you out there who are trying to use tech to solve your | own problems, please keep at it, one day your work may help | thousands or millions and be featured in Nature. | safepants wrote: | My spouse is also using Loop. It's a huge improvement over just | the pump alone. Even just changing basal settings is easier in | the app versus the pump device interface, which is no longer | required using Loop on iOS with the OrangeLink device. | | https://loopkit.github.io/loopdocs/ They have a new web browser | build method using TestFlight, which no longer requires an up | to date Mac running the latest version of Xcode. The web build | mode also enables someone to update the Loop app using only | their smartphone. Something which is handy for travel or long | periods of time without access to a Mac. It only lasts 90 days | instead of the 1 year of the Xcode build, but is easy to | rebuild on TestFlight. | jfengel wrote: | That's impressive as hell. The FDA is, by nature, a very | conservative and slow-moving organization. They set a very high | standard of evidence for anything that's actually called | "medicine". (As opposed to supplements and devices that pretend | not to make medical claims, in which they are largely | hamstrung.) | | It takes a ton of effort to get FDA approval. Navigating the | process is expensive and aggravating. | nimish wrote: | That's incredibly impressive. Medical device approval for | anything novel is very hard. | ikekkdcjkfke wrote: | A lot of talk about pumps. Is it possible to have caffiene on one | of those pumps? | GiorgioG wrote: | My 11/yo son is a type 1 diabetic. While this seems great...I | can't trust a DIY solution. Beta Bionics has the real deal: | https://www.betabionics.com/ and has been recently given the | green light by the FDA. | dghughes wrote: | Off-topic but that is a very old Samsung phone shown at least | seven years old in the image at the linked article. | Someone wrote: | The second photo has a subtitle "An example of an early OpenAPS | set-up from 2016". | | Chances are the first photo is equally old. | nahsra wrote: | Insulin lowers blood glucose, which of course is a vital tool. | However, there appears to now be shelf-stable glucagon [1], a | hormone which can be injected similarly to insulin and raises | blood glucose levels. | | AFAIK there is only one company, Beta Bionics [2], that is | working on commercialization of such technology with dual pumps. | In this case, you could be more aggressive in either direction of | pushing BG, because you have a safety net. | | Because this feels like a holy grail / functional cure, I'm | surprised the incredible DIY teams out there haven't trained | their guns on doing this. Having both "turn it up" and "turn it | down" knobs seems so much more valuable than squeezing the last | 5% of efficacy of AID systems. I feel like glucagon is obviously | "the answer", but I don't see much talk about it. | | Is the problem that there is no hardware for dual hormone pumps? | I would have thought by now they'd have hacked 2 patch-pump AIDs | to work simultaneously. | | [1] https://www.medscape.com/viewarticle/947962 [2] | https://www.thejdca.org/article/2023/06/05/fda-approves-beta... | TaupeRanger wrote: | The only way to "cure" diabetes is to replace the pancreas or | get the cells to go back to behaving the way they were before | insulin resistance. The 1st is incredibly risky and wouldn't be | pursued for that reason. The 2nd is most likely to lead to a | cure, using a morphoceutical approach that reprograms or | replaces the misbehaving cells. | jeroenvlek wrote: | My wife has diabetes and her endocrinologist told me 5 years | ago that the absence of shel-stable glucagon was the reason her | insulin pump and glucose sensor weren't connected yet. Now she | is actually using AndroidAPS, after I compiled it for her. | | Really happy to see that there are people now working on both | gradients! | gustavus wrote: | So my wife is a type 1er. The way glucagon fits into her life | is that we have an emergency glucagon shot that she carries in | her purse to use in the case of an emergency. The glucagon is | more of an immediate emergency recovery. On the flip side | glucagon doesn't lower the blood sugar which is dangerous when | she is going high. | uberduper wrote: | I may be misunderstanding something here. I'm assuming the | emergency you're referring to is low glucose. Why would you | use a shot of glucagon rather than a dextrose tablet for that | sort of emergency? | db3pt0 wrote: | A glucose tablet and a glucagon shot can both be used in | emergencies, but they are best used to treat different | levels of emergencies. You can take a glucose tablet if | you're coherent and conscious, but when you're incoherent | or passed out from a severe hypoglycemia, someone else | administering a glucagon shot is a lot easier and safer. | cperciva wrote: | Glucagon should probably be a safety net, not something you use | regularly. Taking too much insulin and compensating with | glucagon leads to long term weight gain among other things. | | Dual pumps are being worked on, but it's not yet clear that the | improved glucose control justifies potential long term | consequences. | jablongo wrote: | For some background - I'm a T1D working on a search engine and | conversational interface for integrating a bunch of new data | sources and models into metabolic decision making: | https://replica.health. I've also been a user of and worked on | various open source artificial pancreas systems through the | years, and am currently on Loop. | | >I would have thought by now they'd have hacked 2 patch-pump | AIDs to work simultaneously. | | As you pointed out, the problem is not really hardware. It | could technically be done in a straightforward way using two | independently controlled insulin pumps, but the complexity and | risk of the whole operation goes way up if you are taking way | more insulin. Taking a bunch of insulin and glucagon at the | same time is not necessarily a great idea either - they don't | just annihilate each other without consequence and you could | end up with secondary effects like gaining a bunch of weight. | | >Because this feels like a holy grail / functional cure | | Unfortunately it is not; even dual hormone systems have | problems keeping up w/ the kinetics of glucose absorption and | to address this there is also research into tri-hormonal | systems, w/ amylin as the third hormone. In any case you will | still need some a-priori info about meals and planned | activities, though less so than with a single hormone system. | Integration of exogenous data sources to provide this info to | the APS is what we are working on at Replica. | | Also, hate to be the bearer of bad news but beta bionics has | shelved their dual hormone ambitions for now; their prototype | device soon to be released is insulin-only. On the bright side | there is a small Dutch company whose tech predates beta- | bionics. They sell a dual hormone device and will give it to | you for a ton of $ (and probably have you sign a bunch of | waivers): https://www.inredadiabetic.nl/en/discover-the-ap/ | Communitivity wrote: | So I do not have a medical background. I have however worked | a number of Industrial Control Systems (ICS) projects, and | what you describe kind of sounds like a PID control loop, | which also is not a simple push up/down approach. | | From Wikipedia:"A proportional-integral-derivative controller | (PID controller or three-term controller) is a control loop | mechanism employing feedback that is widely used in | industrial control systems and a variety of other | applications requiring continuously modulated control. A PID | controller continuously calculates an error value e(t) as the | difference between a desired setpoint (SP) and a measured | process variable (PV) and applies a correction based on | proportional, integral, and derivative terms (denoted P, I, | and D respectively), hence the name." | | Getting PID control loops to work has a lot of research | behind it, but it's still hard to get right with new | hardware. I would imagine a PID control loop involving | organics (wetware) would be much order, and harder still a | PID control loop in organics with life-threatening failures | possible. | jablongo wrote: | At this point all the major solutions are using an | algorithm that would probably fall under the umbrella of | "Model Predictive Control" rather than a vanilla PID | controller. An absurd spate of patent trolling occurred | back in the early 2000s related to Controller definitions | like these though. Researchers patented the use of a "PID | controller in artificial pancreas systems" [1][2] which | slowed down the development of APSs by many years. | | The way the Supreme Court recently changed patent law [3] | for software has definitely had a positive effect for APS | development. [1] | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2769814/ [2] | https://patents.google.com/patent/US20150306314 [3] https:/ | /en.wikipedia.org/wiki/Alice_Corp._v._CLS_Bank_Intern... | tremon wrote: | _An absurd spate of patent trolling occurred back in the | early 2000s related to Controller definitions like these_ | | That's good news, right? That means that everything that | people now come up with has well-documented prior art? | idiotsecant wrote: | PID works well for most industrial controls, but it's a | blunt instrument. Its mainly valuable because it's simple | and doesn't really require much knowledge of the plant to | implement. No 'model' is really required, other than the | vaguest knowledge of first order dynamics. Instead of model | knowledge you just iteratively tune it until it works. | | If you need a really optimal control trajectory minimizing | or maximizing for some parameter, you are willing to do the | system identification necessary for it to work, and you | don't much care whether an electrician can understand how | it works model-based controls are much better. as | /u/Communitivity mentioned so called 'model based control' | (which is an umbrella of techniques) is a much more | powerful tool. | agawish wrote: | Sorry I know this is off topic, but I'm a recently diagnosed | T1D and I would like to get more information about Loop and | other loop-like open-source systems. | wombatpm wrote: | My son is T1D since age 7. He is now on the OmniPod pump | and the Dexcom G6 sensor. It's been a very effective | combination that's covered by insurance. The challenge with | the open source projects is limited equipment that can be | hacked. | haldujai wrote: | > In any case you will still need some a-priori info about | meals and planned activities | | Not necessarily, at least not via patient input. In the | albeit small Inreda studies manual announcement of exercise | and meals wasn't required (or an option). Medtronic also has | a meal prediction algorithm on their newest offering that's a | step towards a fully automated process and currently more or | less obviates carb counting but isn't at the point where you | don't have to announce a meal (yet). | | Rather than integrating external data sources the algorithms | are predicting based on historical glucose levels and/or | insulin administration and it seems to be working. | | https://jamanetwork.com/journals/jamasurgery/article- | abstrac... | nahsra wrote: | I think the "no meal announcement" features are really | valuable for traditionally underserved demographics who, | for whatever reason, can't "get good" at managing their | disease. | | The difference between how quickly food and insulin hit | your bloodstream make it seem like there is no way to | "algorithm your way out of" meal announcements. Food hits | almost immediately, and with variable strength depending on | macronutrients in it, and insulin takes ~15 minutes to | start working, and peaks at 1 hour, with no concern about | BG levels. Can you square these 2 for me and make it make | sense? | haldujai wrote: | I think what you're missing for this to make sense is | what is the desired outcome. For type 1 diabetics there | are three important ones: | | 1. Time in severe hypoglycemia - ideally 0% | | 2. Time in severe hyperglycemia/diabetic ketoacidosis - | ideally 0% | | 3. Time in euglycemia (also called time in target) - | clinical target is >70% and for reference the median | healthy non-diabetic is in target ~90-95% of the time. | | Closed loop systems are very good at #1 and #2 as it | takes a while for levels to get to the severe state and | insulin can be administered (or withheld) based on CGM. | | When we talk about algorithming out of meal announcements | it's whether historical patient-specific blood glucose | levels and insulin administrations (i.e. a prediction of | what you eat and when) combined with CGM can keep #3 | acceptable, not necessarily optimal. Medtronic is using | this approach and their newest model more or less | eliminates the need for accurate carb-counting but they | still require meal announcements. The hope/idea is that | this can potentially be eliminated in further iterations. | | Another important thing to keep in mind which is | sometimes lost in these discussions is that we don't | treat numbers we treat patients (i.e. what are the | clinical outcomes). Generally speaking, we assume the | closer to normal the better but we don't have actual data | about how much an extra X% outside of target ranges | matters in terms of clinical outcomes and complication | rates. We only really started getting this data with CGM | and complications in these mild states would require very | large cohorts and long (10-20 year) follow-ups to detect | differences as they're likely to also be mild. | | So while you're absolutely correct regarding the | limitations and that an algorithm cannot outperform | accurate carb-counting and meal announcements the missing | piece is that it may be sufficient. Particularly if said | algorithms result in improved time-in-target for patients | who aren't good at managing their diabetes and find meal | announcements cumbersome. | jablongo wrote: | Agree that patient input shouldn't be necessary, but to | replace it we will need to include other inputs besides CGM | in a systematic way to get the optimal results. My company | is working on how to use contextual info automatically | collected by your devices to help (detected activity, | measured calorie burn, geofencing, data from meal-ordering | apis, etc.). This is especially true given that the CGM | data themselves are lagged due to averaging and/or kalman | filtering going on under the hood. This is a fundamental | problem; Inreda uses two identical CGMs for noise reduction | purposes just so they can get clean data with less of a | lag. | | None of the systems claiming you don't have to do anything | in terms of meal announcement are _working_ in the sense of | achieving euglycemic parity, which should be the goal. I | can say with certainty that the cgm logs from people who | don't announce meals on the Inreda device do not look like | they are from non-diabetics: there are still often large | post-prandial spikes. Inreda likely does better than any | single hormone system, but the problem is not solved in any | sense. | haldujai wrote: | > Agree that patient input shouldn't be necessary, but to | replace it we will need to include other inputs besides | CGM in a systematic way to get the optimal results. | | I'm not going as far as to claim Medtronic's approach (I | believe the only one commercially available with so- | called meal prediction based on historical CGM and offers | full correction boluses) is the optimal one, just that it | is an approach that is at least very good (~80% time in | target) and while it still requires meal announcements | it's just the first step of what they're trying to do. | Clearly we can expect further iterations of these | algorithms as the technology matures. | | > Inreda uses two identical CGMs for noise reduction | purposes just so they can get clean data with less of a | lag. | | Just giving an example that this is possible without | external input or data, your statement was that you will | need a-priori information which is not necessarily the | case. Whether such a system is optimal is a different | question. | | I haven't seen the raw data and highly doubt enough of it | even exists for anyone to make a claim whether or not | such a system can be optimized to the point necessary. | | > None of the systems claiming you don't have to do | anything in terms of meal announcement are _working_ in | the sense of achieving euglycemic parity, which should be | the goal. | | For clarity to any less knowledgeable readers while time | spent in euglycemia is a very important outcome measure | it cannot come at the expense of severe hypoglycemia or | severe hyperglycemia/diabetic ketoacidosis (i.e. an | algorithm that improves euglycemia to 95% but has a 2% | severe hypo time is less acceptable than 80% euglycemia | and 0.5% severe hypo.) | | To my knowledge no system on the market/generally | available right now is claiming to be completely input | free. The closest to my knowledge is again the MiniMed | 780G discussed in my first point which will assuredly be | iterated on. | | Also to be clear I'm not being dismissive of what your | company is working on, it's a very interesting and novel | approach. It may even be necessary to achieve the optimal | product. I look forward to reading about your results | when you publish them. I'm just presenting alternatives | and a brief overview of what other approaches are for HN | readers who are likely unfamiliar with the topic being | discussed. | jablongo wrote: | Really appreciate the pointed commentary on this! Happy | to make further prognostications about the success of | CGM-input-only APSs via email. | | For the record, when I say "Euglycemic Parity" what I | really mean is a sort of Turing test (not time in range), | where a data-driven Endocrinologist is asked to tell the | difference between CGM records from a non-diabetic, and | CGM records from a diabetic equipped with some control | system. Passing this test should be our long term goal | IMO and we will probably have to bring many techniques to | bear to eventually achieve it. | nahsra wrote: | > https://replica.health | | Oh my gosh, this is the startup I considered starting last | year when this issue became personal to me and I wrapped my | brain around the complexity of insulin dosing. | | There are a lot of challenges here but we absolutely need an | external "brain" to correlate many data points, some trends, | and reasonably estimate current insulin sensitivity. | jablongo wrote: | I'd love to chat - send me an email at sam@replica.health . | An accurate time-varying insulin sensitivity model is one | of our big projects. | selimthegrim wrote: | I formerly used to work in the diabetes management space, | and I too would be interested in chatting seeing as I | have acquired some modeling expertise in the meantime. | gitfan86 wrote: | This is awesome. The obvious next step here would be | integration with the pump to send the correct dose after the | user confirms the app is correct in the food they are eating | samstave wrote: | You know what cyberpunk future I am looking forward to ; Bionic | Arms/Limbs whi are chosen to be replaced, but in the place of | the bicep is a blood filtering, monitoring mechanism that keeps | your blood hyper oxygenated and tracked... | | Although, to go along with the cyberpunk theme ; If you want to | kill a Cyborg, you just rip off his arm... | smoldesu wrote: | It's fun to imagine a future where we _can_ design human body | parts better than our body but _can 't_ figure out how to | unplug them without a mess. Damn Magsafe patent still holding | up in 2077... | iaresee wrote: | > Is the problem that there is no hardware for dual hormone | pumps? | | All the well-tested pumps (Tandem, Omnipod, Medtronic) are | insulin-delivery only. | haldujai wrote: | It's not because of pump issues but more glucagon stability | and secondarily whether bihormonal is clinically | advantageous. | | Tandem is working on a dual chambered pump. | | https://diatribe.org/jdrf-and-tandem-diabetes-care- | announce-... | iaresee wrote: | Yea, but "working on" is a bit different than "readily | available and trusted to function well". Everything is | harder with two delivery pumps. | nahsra wrote: | Yes, but the "patch pumps" like the Omnipod are small enough | you think patients might tolerate 2 of them? Maybe they've | already asked, and people wouldn't tolerate it. | iaresee wrote: | Possibly. But it's more than that. You have site issues, | even with one pump, that you need to navigate. There are | only so many viable places on a body to attach a cannula | for good absorptoin and, while small, these things aren't | _tiny_ (especially the Omnipods where the site holds the | cannula, pump and reservoir). | | It'll be a while before we see highly reliable and well- | tested dual-reservoir systems is my bet. | | The complexities of balancing insulin and glucagon in a | two-pump system are also high. And the feedback loop from | sensors that detect BGL aren't super fast. My kid's Dexcom | works on a 5 minute sample loop now. So you can't make | decisions fast and when you do, you can't course correct a | bad decision quickly. | | I love that people are working on this stuff. The folks at | https://wearenotwaiting.net/ are amazing and we even use | NightScout here, but the fragility of the systems are stark | and it'll be a ways to go before it's not just the brave | pioneers pushing these frontiers for T1Ds. | haldujai wrote: | No, there isn't a hardware problem and such systems exist. | Several trials[1-3] dating back several years have looked at | "bionic pancreas" or a closed loop bihormonal system. | | Inreda (a Dutch company) has a CE-marked device[4] that can be | clinically used but one limitation has been glucagon stability | (has to be replenished daily). Tandem in the US was working on | this as well but I haven't heard anything about them in a | while, not sure how far along they are. | | The Inreda product is still in the early stages of testing but | fully functional. Small crossover trials seem promising | (defined by more time in euglycemic state). | | There is a competing approach with "intelligent insulin" or a | self-regulating glucose sensitive insulin formulation that has | different bioavailability depending on circulating glucose | levels rather than relying on a monitor, this is farther out | from clinical use. | | One of the reasons bihormonal pumps haven't entered mainstream | use yet is that it's more expensive/complicated and the current | techniques of algorithmic predictions of hypoglycemic episodes | and insulin delivery suspension are already very good that hypo | isn't much of a problem with modern devices like Tandem's | offering. | | Medtronic has added a meal detection algorithm[5] that's really | good too (the best on the market I'm told by my endo | colleagues) and they say we're getting close to not needing | meal announcement anymore, this practically eliminates carb | counting. It's the first such algorithm to be in clinical use | so we're not there yet but the expectation is that this | approach will get us there. | | The question (for glucagon) then becomes how clinically useful | more time in euglycemia is as the hypo episode problem is | essentially solved, we'll need more data to draw any | conclusions and it will take a while for this particular | question as many of the outcome measures are long-term (i.e. | what are the long-term sequela of mild intermittent | hyperglycemia, it's somewhere between nothing and uncontrolled | diabetes but how far along on that line is the billion dollar | question). | | [1] https://pubmed.ncbi.nlm.nih.gov/28007348/ | | [2] https://jamanetwork.com/journals/jamasurgery/article- | abstrac... | | [3] https://pubmed.ncbi.nlm.nih.gov/24931572/ | | [4] https://www.inredadiabetic.nl/en/discover-the-ap/ | | [5] | https://www.medtronicdiabetes.com/products/minimed-780g-insu... | nahsra wrote: | It's not clear from their site whether the Inreda product | also has CGM built into it, or if it must be paired with one? | | Glucose-responsive insulin also seems like science fiction as | this point, but would be extremely powerful tool. | | I'm very familiar with one of the most popular, closed-loop | system combinations in the USA and I definitely don't feel | the hypoglycemia problem is anywhere near "solved". There is | too much volatility dictating a person's insulin sensitivity | that even today's smartest systems will regularly give too | much insulin, requiring treatment, or too little, resulting | in prolonged hyperglycemia. | | I agree that time-in-range is incredible today with the | technology, comparatively, but there's still lots and lots of | room for improvement. | haldujai wrote: | Inreda integrates the CGM, [1] has more details on the | setup. | | > I'm very familiar with one of the most popular, closed- | loop system combinations in the USA and I definitely don't | feel the hypoglycemia problem is anywhere near "solved". | | I should have been clearer, the moderate to severe | hypoglycemia (level 2 and 3) problem is essentially solved | with the newest generation of closed loop systems. | Hypoglycemia in general is trending towards being solved | particularly with the newest Medtronic devices, both from | studies and what endocrinologists are seeing. | | In some of the recent studies (which again are still small | as these devices are new) I've come across there are no | severe hypo episodes reported and % time in moderate | hypoglycemia was (picking one study) ~0.3%[2]. | | The belief is that further iterations of these algorithms | will continue to improve this hence why I said "solved" as | in there is no strong need for a large treatment paradigm | shift on the basis of moderate-severe hypoglycemia. | | > There is too much volatility dictating a person's insulin | sensitivity that even today's smartest systems will | regularly give too much insulin, requiring treatment, or | too little, resulting in prolonged hyperglycemia. | | Hyperglycemia is a different discussion altogether that is | not addressed by insulin delivery suspension or glucagon. | The MiniMed 780G is probably the most advanced system out | there with minimal patient input and time in target range | is being reported as ~80% which is certainly getting there. | | [1] https://diabetesjournals.figshare.com/articles/figure/F | ully_... | | [2] https://www.nejm.org/doi/10.1056/NEJMoa2004736?url_ver= | Z39.8... | DoreenMichele wrote: | There's a lot more going on in the body than this. Muscle | protein influences insulin resistance. Diabetes is strongly | associated with inflammation which may imply that infection or | pH balance (or both) plays a role. For functional hypoglycemia, | metabolic syndrome and T2D, dietary changes can have | substantial positive impact. | | I'm thrilled to see this is happening, but the chemical inputs | and various metabolic factors are far more complex than "sugar | in, one hormone to lower blood glucose levels and another to | correctively raise it." | brudgers wrote: | My assumption is that the DIY Pancreas community is well- | informed, technically capable, and highly motivated. | | My guess is it hasn't done what you suggest for practical | reasons related to supply chain, intended user base, and | practical engineering considerations appropriate for high | reliability mechanical design for medical use. | | For example, the insulin delivery system has many points of | failure. Any fault or failure is likely to have severe health | impacts on the user. To a first approximation, doubling the | number of pumps doubles the points of failure. | | But I could be wrong. | awaywethrow wrote: | My worry with this approach has been that infusion sites (both | for insulin and glucagon) can become occluded, pulled out, etc. | to suddenly render them completely ineffective, and that | automated detection of these scenarios is not great. | | You need to move forward, and therefore must occasionally have | a foot on the gas (insulin). The gas pedal failing, causing you | to stop moving forward, is not urgently dangerous | (hyperglycemia). However, if your brakes (glucagon) can | sometimes fail completely, that could cause you to die almost | immediately if you're moving too fast toward danger (extreme | hypoglycemia). Given this situation where brakes are | unreliable, do you want your automated control system to rely | on them and push you to dangerous speeds? | haldujai wrote: | > However, if your brakes (glucagon) can sometimes fail | completely, that could cause you to die almost immediately | | Failure detection is via alarms to trigger patient action | based on the continuous glucose monitor (which has a | different set of reliability issues) as well as patient | symptoms. | | Hypoglycemia becomes symptomatic long before blood sugar is | low enough to result in death or serious debilitation and T1D | patients know their symptoms well. The risks are not nearly | as dramatic as you're suggesting as one isn't/shouldn't be | relying on glucagon to prevent severe hypoglycemia, I don't | think any system is designed or being conceived to operate in | such conditions. | | Hypoglycemia isn't really much of a problem anymore with | current CGMs and pumps. | pigeons wrote: | > Hypoglycemia becomes symptomatic long before blood sugar | is low enough to result in death or serious debilitation | and T1D patients know their symptoms well. | | There is a what seems to be a significant number of people | who don't "feel their lows." | | > Hypoglycemia isn't really much of a problem anymore with | current CGMs and pumps. | | Current CGM's can still require hours of "warm up", and | many current pumps still must be removed for things like | swimming so they don't get penetrated with water. | haldujai wrote: | > There is a what seems to be a significant number of | people who don't "feel their lows." | | Severe hypoglycemia to the point of what was described | (death) is not reported in any of the recent device | studies. | | Level 2 or moderate hypoglycemia, very different from | death, is reported at < 0.5% in recent closed loop system | studies. | | > Current CGM's can still require hours of "warm up", and | many current pumps still must be removed for things like | swimming so they don't get penetrated with water. | | Current CGMs are water resistant but conveniently one is | also not administering insulin while swimming either. The | bionic pancreas is also dependent on CGMs and has the | same limitations. | | I'm really not sure what point you're getting at. | Hypoglycemia is not what's being improved upon with | current advancements, it's time in target. | awaywethrow wrote: | > Severe hypoglycemia to the point of what was described | (death) is not reported in any of the recent device | studies. | | Are there large-scale studies that show this for a dual | hormone control algorithm (the context of this thread)? | haldujai wrote: | You seem to be misunderstanding how these devices work. | | Bihormonal pumps do not mean continuous infusions of both | insulin and glucagon. The pumps pulse insulin when you're | high and glucagon when you're low. They're not both | administered at the same time or continuously infused in | a "balanced state". | | The context in this thread: | | > However, if your brakes (glucagon) can sometimes fail | completely | | A bihormonal system would not result in more insulin | being administered than an insulin-only system for a | given blood sugar, if the glucagon pump fails we would | have an insulin-only system where we have plenty of | safety data. There is no mechanism by which a bihormonal | system has higher risk of hypoglycemia than existing | closed loop insulin system. | awaywethrow wrote: | To clarify, the context of this thread / what I was | originally responding to was: | | > In this case, you could be more aggressive in either | direction of pushing BG, because you have a safety net. | pigeons wrote: | OK thanks, I get your points. What I was getting at is a | disagreement with "Hypoglycemia isn't really much of a | problem anymore with current CGMs and pumps." Because | lots of people on current CGMs and pumps still deal with | hypoglycemia, despite these pumps and CGMs making the | situation so much better than otherwise. | nahsra wrote: | The detectability of failure is an excellent point. Anybody | who uses the hardware can confirm it's not 100%. I think your | point helps me re-frame the glucagon as more of an insurance | backstop for when we accidentally hit the gas a little hard, | rather than a permission slip to constantly be going too fast | and constantly be slamming on the brakes. | | Even in this framing, it still feels like an extraordinarily | valuable addition, and relatively low risk. It's also, of | course, more to add to the patient's maintenance, but might | help them or their caregivers sleep at night. | awaywethrow wrote: | > It's also, of course, more to add to the patient's | maintenance | | I agree with all that you've said, and this point in | particular is extremely important. It's also the reason I | moved from a DIY system like the one mentioned here, to a | commercial system, once the latter was available. There is | simply less hardware and software to juggle with the | commercial system. There are fewer knobs, bells, and | whistles, meaning I might not be able to tweak things to be | in as tight control as might be possible with a DIY system | (though with risks!), but overall it's been "good enough" | for me, and greatly reduces the cognitive burden of having | T1D. My experience clearly doesn't match everyone's, but | considering I'm typically someone who loves to tinker, and | has plenty of T1D experience (engineer, 34 years with T1D), | I'm sure I'm far from the only one that feels this way. My | glycemic control isn't significantly better than it was | when I did it via constant monitoring and mental math, but | the cognitive and emotional burden is much lower. | jablongo wrote: | Yea you would need really good failure detection if you were | going to "hit the gas" with a bunch of insulin. Part of the | solution is going to be controlling risk via the dosing | algorithm itself, so you never get in those situations where | you are at risk of severe hypo in the event of a (glucagon) | site failure. | Projectiboga wrote: | I'm a type 1 insulin dependent. The three low tech "hacks" | I've been happy with are the following. First I take a | sublingual Melatonin most nights, Melatonin upregulates the | insulin receptors and lowers my insulin requirements about | 40% by my guess. The second one is dietary I add olive oil to | my lunch and dinner, I feel this provides my body a reserve | of non glucose energy. Finally I use a very small dose of | cannabis most days, I like to get a puff or two and night, | THC protects nerve cells from Hypoxia so I feel this keeps my | brain cells going when my blood sugar gets low. I feel these | three things, give me a leg up on my long term blood sugar | control. I am thankful there are hackers and diy opensource | initiatives. The CGM readers here in America Dexcom, and | Libre both have crazy bad user interfaces. Libre will only | let you pair to a single device, I had their device fail | leaving a functional sensor in my arm, a quick idea I | searched for opensource libre reader app and found two. One | worked and started reading the sensor. Dexcom has the issue | of being a 10 day use cycle so you run out on varying days of | the week. Both take the FDA mandate to have low blood sugar | alarms as a blank check to overide any controls about sound | or do not disturb to bother about countdown to a new sensor. | I liked that external libre2 reader as it was the only device | or official app that can be silenced, but their rigid only | pair with one device still angers me, what if my loved one | want's to be able to scan my sensor? Low blood sugars are | challenging as they affect my brain and I can answer an | amazing amount of questions about my blood sugar wrong if I | get too low, my brain trying to preserve energy can be | dangerous at times. This was an issue more before CGM. Dexcom | decides that it is OK to have a completely automatic warning | at any hour of the night "your sensor will expire in six | hours!!!", that warning has little to do with my care as it | is too late to influence refill compliance and seems to have | been ordered by the executives to some how improve their | pRofItiBiLiTY. I am so much happier on a third party app with | the silent reader as an extra. Sorry if this was long winded, | being insulin dependent has bee a challenge over 40 years. | The first 10 years they hadn't figured out that insulin | reactions are much more subtle on human insulin than the | older pig and cow derived ones were. | jacquesm wrote: | I absolutely love this development. Who better to take charge | here than the people directly affected? They are as motivated as | any to get it right, not because of a financial incentive but | because their life is in the most literal sense at risk of | getting it wrong. Of course the big players will all push the | fear button, but that should be contrasted with the simple fact | that they all have had (sometimes multiple) recalls. | | Do not underestimate how hard it is to do this right, the people | that built these DIY solutions have spent a ton of effort on | them, probably more than the equivalent commercial players. But | long term my prediction would be that the DIY movement will lose | out. The competition has massive lobbying power, a lot of funding | and looks like the safe option to outsiders, especially when | there is feature parity. The main driver for this development was | a simple one: all the parts were out there, but nobody was | willing to take the plunge and build a closed loop system and | have it certified. But that impetus is now gone and future | improvements will be much higher hanging fruit. | | But I'd love for them to stay around to keep the industry on its | toes. Especially because commercial interests are always going to | maximize profits, which for a disease that is so widespread and | that affects so many lives should not be a factor. Incidentally: | a modern insulin pump is a work of art, if you don't know how | they work and you fancy technology I would encourage you to have | a look at this. | tracker1 wrote: | I think it's awesome that DIY options are becoming more readily | available. I'm t2d, but have a relatively hard time with | glucose control overall. If I stick to eggs, meat and green | veg, then I don't need much beyond the weekly Trulicity and | daily Basaglar. | | If I have anything else, beyond the various food intolerance | issues I have, I'm also experiencing Gastroparesis, which means | what I eat may hit sooner, later or much later... as much as | 20+ hours later, so I usually have to take a lighter tough to | insulin and be more diligent about followup checks. It's a | literal roller coaster. At least having a Continuous Glucose | Monitor (cgm) makes it easier to track. | jacquesm wrote: | Yes, the roller coaster is a great way to put it. One of my | business partners had it so bad that whenever he was out of | sight for longer than an hour or so people would start to | worry if he was ok. We had a major crisis when he dropped off | the radar for a full day, everybody pitched in until we found | him (and not in a coma). Scary stuff, and with large | variations between individuals in terms of severity and speed | of onset of symptoms. | tracker1 wrote: | The worst, is the couple times I've experienced | ketoacidosis... always feels like a cold/flu at first, and | only when I'm coughing up water do I stop to take notice. I | keep a keto mojo in addition to my cgm and glocometer... if | my glucose is elevated at all, and my ketones are as well, | time to start hourly injections until in normal range... I | have my cgm alarm at 70 & 240, only because it will fire | off many times after eating if I don't and takes a while to | settle (few hours). | | Definitely sucks having a broken metabolism. Wish I could | go back to my 15-20yo self and totally stop consuming most | processed food, seed oils and sugars. It's sad that a | glucose tolerance and resting insulin tests aren't | normalized since a1c won't start slipping until years | later. | jacquesm wrote: | It's a huge problem. On the plus side though: there is an | absolute mountain of information about this disease and | there is substantial funding poured into getting it | further under control. The holy grail (and artificial | pancreas like a pace maker) is still a long way off. But | substantial improvements have been made in the last | decade and a half and I expect that trend to continue for | a while. | | What I love about this story is that the DIY community | managed to break the log-jam of the manufacturers and the | regulatory authorities by simply providing them with | proof that it _can_ work and can work reliably enough to | be allowed on the market. That shortcut probably shaved | at least a decade (possibly more) off the progress | charts. Manufacturers were (to some degree rightly so) | antsy about closed loop systems because it would require | them to assume much more liability than they are normally | used to, the symptom- >diagnosis->action loop that you | can engage in by close monitoring and patching together | available systems cuts the human out of the loop: the | system will function autonomously and a software error or | hardware glitch has the potential to kill someone. | | So the manufacturers were effectively all waiting on each | other to show that this can be done safely and that | holding pattern had already lasted for multiple years. In | the meantime, the larger manufacturers had some time to | gain the upper hand over reliability and teething | problems of the newer generation of pumps and those came | together just in time with continuous monitoring to | enable a big step forward in a very hacked (but fully | functional) way. No single manufacturer would have taken | that risk at this point in time without that push. But | now that it is done they can't be left behind either or | they'll lose market share rapidly. | | It's a pity that there are not more diseases (at least, | not that I'm aware of) that would benefit from this | approach, diabetes is unique in that respect. | | Best of luck there. By the way: if you want to stay | current with the developments in this field the best spot | to look for is the announcement of trials, and sometimes | the calls for volunteers for such trials. | bimabet wrote: | Hai | xyzal wrote: | A friend showed me AndroidAPS's automation capabilities and my | jaw dropped. "If this SSID is visible, I am in a gym, so lower | basal rate by 20%". | | edit: docs for the interested> | https://androidaps.readthedocs.io/en/latest/Usage/Automation... | diydsp wrote: | Neat, but GPS is harder to spoof. | Forge36 wrote: | My first thought was this sounded like Tasker. From that link | it looks like a similar concept with workflows focused around | insulin pumps. | lolc wrote: | For me, those features were always very gimmicky. When you | arrive at the gym, you should've set the basal rate lower at | least an hour ago. So it's not going to help unless you stay | for multiple hours. | | The meal detection mentioned is similarly lagging behind. For | people who don't manage to tell their APS when they eat carbs, | yeah it helps, but the outcome is not comparable to dosing | before you eat. | | I also found the calibration features to be too fiddly. Between | sensor noise, sensor offset, and calibration, when they try to | adapt the situation already changed. | | I guess these features work better with a very regular | lifestyle, which I lack :-) And while I don't like having to | micro-manage some aspects, like carbs, I appreciate that | AndroidAPS reduces my mental load quite a bit and enables | living days that are never the same regarding exercise or | meals. | tracker1 wrote: | I'll say, one thing I really appreciate about the fad aspects | of Keto as a diet, is that there are a lot more low carb | options out there. Of course, ymmv with various fiber | varieties and low/no calorie sweeteners in practice. Makes it | a little easier to keep carb load minimal. I still do far | better sticking to eggs, meat and greens, but it's hard to | do. | lolc wrote: | Can relate as I lived borderline keto for a while. That was | nice as my sugar was very stable. Then I decided carbs are | nicer. | | And sure, sweeteners are the better option for drinks. | Still prefer my dessert with some sugar. | DoingIsLearning wrote: | If you have a safety-critical decision maker running on Android | doesn't that raise the criticality of the OS (provided there is | no other fall-back)? | | For the regulatory people out there, how does this align in | terms of risk management in the world of IEC 62304? | iancmceachern wrote: | Many other similar devices use all types of OSS. | | You just need to make sure it fails safe. If the OS or any | software hangs or crashes just make sure the thing turns off | and doesn't dump all the insulin or anything. | DoingIsLearning wrote: | But this is the mitigations I am asking in terms of risk | management. Perhaps people using the app can comment if any | of this is already implemented? | nshepperd wrote: | I have an AndroidAPS. This is how it works. If the phone | loses contact for any reason the device just falls back | to delivering insulin at a fixed rate as normal. | birdman3131 wrote: | I would want a beep or something to let me know it had | disconnected. (Also a low battery alarm as well.) On the | device not on the phone. And the phone should have the same | thing if the device does not respond to a heartbeat signal. | [deleted] | rexreed wrote: | Pancreatic cancer scares the bejeebus out of me. One day I hope | there's some solution because it's almost a death warrant if you | get that diagnosis. | appleflaxen wrote: | This article has nothing to do with cancer, though. | | A bionic pancreas won't help you at all if your native pancreas | developed a malignancy. | rexreed wrote: | Right, my response was more of a hope that continued research | in this area would lead to possibly some solutions for | earlier diagnosis and treatment. Cancer is such a cancer. | paulcole wrote: | The "bionic pancreas" wouldn't help with pancreatic cancer | right? The problem is that nobody notices pancreatic cancer | until the death warrant is signed (to use your metaphor). Using | a bionic pancreas would be like putting out the fire in the | kitchen only when the rest of the house is also in flames. | rexreed wrote: | Definitely what is needed is better early detection but I | know that's a can of worms of its own. I commented on the | bionic pancreas article as I know it's not a solution to | pancreatic cancer, but I'm hoping that continued research in | this direction evolves into better diagnosis and cures. | abraxas wrote: | Not to scare you more but that covers just about any metastatic | cancer. | lemper wrote: | thanks, that's really reassuring. | sgt101 wrote: | well - to be reassuring... we all have a death sentence | imposed by birth. As we get older the cumulative chances of | it having happened increase, eventually hitting 100%. | | Cancer doesn't change that - lots of people with cancer get | killed by car accidents or heart attacks. In fact a friend | of mine recovered 100% from their cancer and then killed | themselves on a motorbike. | NoMoreNicksLeft wrote: | I kept looking for the identity of the minicomputer used, it has | to be either a PDP-11 or a Data General system, I should think, | but they provided no model numbers. | jpitz wrote: | The misuse of that particular term of art should probably be | pointed out to the author. | drgo wrote: | I am a physician, researcher and a programmer. Any one interested | in collaborating to solve similar problems feel free to contact | me: https://drgo.github.io/about/ | nshepperd wrote: | > The DIY community and industry are not in opposition, says | Lewis. | | I would really like to believe that, but given how Medtronic and | every CGM I have used have seemingly intentionally sabotaged open | source loop compatibility with every new product, it doesn't seem | like everyone's on board... | jablongo wrote: | Yeah she's being diplomatic for sure. Dexcom plays ball and is | also the most successful of the CGMs, so you would think that | others would follow their lead and write their data to apple | health. Most companies keep their data thinking its going lead | to some unspecified profits down the line but then never really | do anything with it. | lolc wrote: | Depending on AndroidAPS for my insulin management, I'm very happy | that people are working on getting this into app stores! | | I'm not using most of the advanced features but just having the | device regulate basal rate is life-changing. And I really don't | want to be tied to one supplier here! | cjbgkagh wrote: | I do wonder about the PED aspect of DIY smart insulin, some | bodybuilders already use insulin in this way and I wonder if | elite athletes could use this to boost their performance. | SoftTalker wrote: | Bodybuilders in particular but other elite-level athletes have | always had a propensity to use PED. A thing now is to get on | TRT even if they don't strictly "need" it. | | Medical advances for those who do need them should not be | blocked by fears (real or imagined) of abuse or misuse. | cjbgkagh wrote: | Oh, I'm not suggesting we prevent people from having this | just pointing out that superphysiological results may be | possible. I have ME/CFS and I'm interested in tools like this | that may help me push things a bit harder, I'd prefer if a | bunch of bodybuilders/athletes found the limits before I gave | it a try. | darkclouds wrote: | Much rather increase my manganese intake, which maintains blood | sugar levels, and slows the pancreas from releasing too much | amylase which further increases the blood sugar levels causing | the spike. | | Chromium to make my muscles sensitive to insulin also helps. | liamzebedee wrote: | I posted a thread here in 2019 for anyone curious on the | technical walkthrough for setting one of these up (+ HN | discussions) [1]. | | [1]: https://news.ycombinator.com/item?id=20606230 | logicallee wrote: | I am not quite ready for a pump, but am in the market for half of | the solution, a continuous blood glucose monitor. Any diabetics | here have a recommendation for an affordable out of pocket | continuous blood glucose monitor? (Without insurance). I have an | iPhone 13. | | Which is the best value for money? I am looking for something | affordable. I can pay a reasonable amount monthly for consumables | for it. | jablongo wrote: | The best brand is Dexcom (G6 or G7). The Abbott one is cheaper | but has disadvantages. Either one will be way better than | nothing if you have diabetes. Without insurance dexcom will | cost you like $260 a month via one of these mail order | distributors: | https://rapidrxusa.com/products/dexcom-g6-sensors-3-pack | | Do your part as a consumer and shop around a bit to drive | prices down... good luck! | protomolecule wrote: | Could you elaborate why Abbot's Freestyle Libre is worse? | user_7832 wrote: | As someone using a freestyle Libre 2, I'm also curious. | | From what I know, I think the main reason is that the Libre | needs NFC vs the Dexcom's Bluetooth... except that Abbott | recently updated (!!) the software and now Bluetooth works | at par as the dexcom. | | Some people have better sensitivity with one or the other I | agree, but both are fairly solid. The Libre is smaller | though, so I prefer that. | protomolecule wrote: | I picked Freestyle Libre after asking around a few | endocrinologists (60 euros for a sensor that lasts two weeks), | but curious what others have to say. | [deleted] | epilys wrote: | Note that as with every insulin-pump system, it still has two | major pain points: | | - subcutaneous insulin doesn't act immediately, as it would if it | was injected in the blood directly. it peaks in an hour and then | wanes off at 3-4 hours. | | - it cannot know external factors like how much carbohydrates you | are eating, or if you are planning to work out, etc. Like | conventional pumps you have to enter it manually. | | Buying a sandwich and not having to think about carb grams and | predosing at all sounds like a dream to me. | jablongo wrote: | > - it cannot know external factors like how much carbohydrates | you are eating, or if you are planning to work out, etc. Like | conventional pumps you have to enter it manually. | | Sign up for the waitlist of https://replica.health! It is | designed to make capturing those external factors as painless | as possible. Depending on what setup you have, it will be | available in the next month. | jcims wrote: | My youngest daughter has been on a pump for six years now and | she's completely burned out and apathetic about it all. It just | all blurs together and her diabetes is not well managed at the | moment. My oldest and I had a sort of impromptu intervention | with her and she just broke down crying. It's a lot. | | The pump she has, a t:slim X2 is better than her Medtronic, but | the closed loop aspect (control iq) is impotent and rarely has | a noticeable impact. Hopefully this tech will advance on a good | pace and products will hit the market with more assertive | control algorithms. Obviously there are dangers but we've | already accepted that by hooking her up to a pump with enough | insulin in it to kill her. | heuermh wrote: | Hang in there, lots of folks having similar experience! | | We have been pretty impressed with the closed-ish loop of the | Dexcom and Omnipod, it handles daily fluctuations due to | more/less exercise etc. fairly well. | | Still two separate handheld devices though, and quality | always falls off when the sensor (every 10ish days) and pump | (every 3 days) approach expiration. | cadr wrote: | I love my omnipod/dexcom combo so much. | jacquesm wrote: | Due to NDAs I can't write too much about this but there is a | lot of work being done on this front right now and I expect a | new generation of these devices to be out for trial in the | relatively near future. Pumps are getting smaller, which is | one factor that helps and analysis is getting more accurate. | Reliability and sensors are improving. But the timing aspect | is critical especially without knowledge about environmental | factors and the relatively long hysteresis of the feedback is | a major obstacle to the big leap forward. Key here is that | the body has more data about the situation than an outside | device will ever have and that regulation in the body is a | fairly global affair [1] so it can act faster and with more | precision than you can ever do from a single site. These are | all super tricky problems. But compared to the situation only | a decade ago it is already much better and I fully expect at | least one more round of breakthrough devices. Best of luck | there, it's harsh to be a kid with such a demon on your | shoulders. | | [1] for instance: | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4214828/ | jcims wrote: | That's amazing to hear. Thank you! | mlsu wrote: | Gosh your post really hit a nerve. | | I went through the same struggle with my own Type 1. | | Feeling overwhelmed with responsibility, denying I am any | different than anyone else, denying that I have to | permanently manage a condition to be normal, denying that my | own body would fail me, feeling helpless that even the "best" | I could do would still involve invasive and frustrating | treatments. | | For me, it was a phase. Happened at about the same age | (through my teens, basically) and took about that amount of | time to just get through it. At some point I learned that | with a bit of management, I can thrive and do just as well as | anyone, especially with the new tools that we have now. It | just took that psychological struggle to get there. | | I am really sorry that you have to see your daughter | struggling like that. I know exactly how helpless it feels. | epilys wrote: | I'm on the Medtronic 780g hybrid loop and it's actually | working. If I eat nothing and have no intense physical | activity the CGM curve is a stable straight line. | jcims wrote: | That's the one she had. It's been a few years, maybe they | have fixed it. | jacquesm wrote: | It has indeed been improved substantially in the last | couple of years. If you haven't upgraded the pump in that | time I would definitely recommend you do so. | | One thing about these pumps that doesn't seem to be | advertised widely enough: they don't handle full sun | well, so always keep at least one layer of clothing over | the pump. | mecsred wrote: | I have family with diabetes and I feel some empathy with your | situation. I've felt that second hand anxiety when my cousin | started partying recklessly in uni and not managing it super | well. | | You're helping her manage it and that makes a massive | difference. Those of us without diabetes usually aren't | taking care of ourselves at 100% either. We're lucky to have | access to amazing medical technology, so some scary seeming | situations are pretty recoverable. | | Hopefully a platitude or two helps a small amount :( | photon_lines wrote: | Have you tried putting your daughter on a different diet (low | glycemic-index diet with more natural and keto-friendly | foods)? This will make managing her diabetes a lot simpler | and it'll make her feel better too. | | I'm a type one diabetic and have been one for over 15 years | now. Getting diagnosed is one of the best things that's ever | happened to me. It got me to notice the huge impact diet and | exercise have on the mind and body. I initially had issues | like your daughter too but changing my eating habits and | altering my life-style definitely had a profound effect and | made it much easier to manage. If you need tips / help let me | know and I'll do what I can. My number one tip is to stick to | a more keto-based diet. It will make her blood sugar much | easier to manage and has a lot of health benefits. | jcims wrote: | Thanks for the suggestion! She's 20 and living at school so | I have limited influence over her diet. She's pretty much | raising a middle finger at her diagnosis right now out of | spite and frustration so it's a tricky situation. I've | asked her to try to find a community that caters to | diabetics at school (i know one exists but i tell her to | join it it will not work) to feel less alone about the | whole thing. | | It just sucks all around. | photon_lines wrote: | Ohhh I see and my apology for the misunderstanding!! | Either way - she's still young and she has plenty of time | to figure it out. If not - one other recommendation I | have is getting lab tests done every 3 to 6 months and | going for regular check-ups with a doctor. If you find a | good doctor - they can make a big difference in getting | patients to notice bad HB1C measures and can talk with | her about keeping them in check and why it's so important | to keep blood sugar levels within normal range. Either | way - I wish her a lot of luck and my offer still stands | if she (or you yourself) need any help or advice :) | milesvp wrote: | Second this. Just adding fats and protien to a meal effect | the meal's glycemic index (even though it does nothing to | glycemic load). I did a lot of research both times my wife | was gestational diebetic, and while I already knew that | fats helped to smooth bloodsugar levels, it was still wierd | to see a dataset with toast having one of the highest | glycemic while buttered toast was significantly lower on | the scale. | phil21 wrote: | This is trying to solve the wrong problem. Juvenile | diabetes is almost always a human problem - not one of | optimizing for treatment. | | If you have a kid in their teens or 20's who is not | entirely ignoring it out of spite, you're way ahead of | the game. This problem is _much_ harder to solve than | tracking carbs and insulin doses, or changing diet /etc. | | The person has to be ready to attack it. And for many | young folks (and I assume older as well) this is where | the problem lies. It takes a lot to really accept this is | going to be your entire life, especially at an age where | everyone (seemingly) around you are living these amazing | care-free young adult lives, while you have this constant | monkey on your back being a buzzkill. Very few | individuals have the desire to "do their research" and | start hacking on their health the way the HN community | would tend to approach things. | | Short of commenting on how heartbreaking it is as a | parent to watch your kid go through this, I really have | no good answers. I guess the topic of this discussion is | it - a magic device you can slap on once a week and never | think about again. Short of a device like that, I can't | see this problem turning to technical vs. human any time | soon. | GiorgioG wrote: | My 11/yo has the same pump. Control IQ is great...but it | takes a cautious approach to adjustments of insulin delivery | given that it can only lower blood glucose levels and not | raise them. Hopefully dual-hormone pumps will come out in the | next few years and the algorithms can be more aggressive. | | In the end, our 11 year old ignores his pump much of the | time. We have a bunch of SugarPixels around the house, so if | his sugar is way off we know and can address it ASAP. | sgt101 wrote: | My daughter is on https://camdiab.com/ it really works a | charm, we do have alarms for low glucose (like it can dip | down to 3.1 if she does exercise) and rarely for high | glucose, but these are things you would probably not even see | without the constant monitoring. The data shows that she is | extremely well managed since she started with the closed loop | system. | | Camaps demands that you have a particular model of phone | (about a dozen androids and iphones) which makes it a bit | more expensive I guess. Luckily we are on the NHS in the uk | so my only expense as a parent is that I have to buy the posh | phone, but then I guess that goes with having a teenager | around anyway... | mlyle wrote: | You can build automation with *aps to do a bit better on these | metrics than commercial systems--- e.g. responding to heart | rate, or as someone else pointed out, noticing an SSID from a | gym. | danbruc wrote: | I am aware that I know next to nothing about the topic and that | I am ignorant of countless complications. With that said, your | pancreas also does not know that you plan to work out, at least | I would assume so. So what is the crucial difference between a | pancreas and insulin injections? That the response is delayed | because the injection is not into the blood stream or does the | pancreas also have better sensors to figure out how much | insulin to release, or maybe even release things other than | insulin? If it is the former, what obstacle is there for | injecting into the blood stream? The infection risk of having a | permanently open port into the circulatory system? If so, is | there a similarly effective way to deliver insulin that is not | into the blood stream and with less risks? Or could you have | some kind of membrane in the port that only allows insulin to | pass through but that is impermeable for pathogens? Or would | that get clogged immediately? | photon_lines wrote: | There isn't much of a difference between injecting insulin | (being diabetic) or getting your body to produce it. The main | difference lies in having no automated mechanism for | regulating blood sugar levels. Due to this - you have to | calculate the correct amount of insulin you need for your | meals and measure your blood sugar regularly to make sure it | stays within balance. If your blood sugar levels tend to be | higher than normal (i.e. you aren't injecting enough | insulin), that isn't good. It is OK in the near term - but | can be devastating in the long term due to health | complications (i.e. blindness / nerve damage / etc..). If | your blood sugars are fall too low - you can have severe | consequences in the near term (i.e. die or have a seizure | within 1 hour of injecting insulin). In other words - you | need to always keep your blood sugar in check in order to | survive and to be in good health. Some people find this | extremely hard to do - some people like me embrace it. | epilys wrote: | The difference is the pancreas reacts immediately to changes | and has no practical delay for its effects, same concept as | PID controllers in engineering. | danbruc wrote: | So the limiting factor is the subcutane delivery, i.e. if | the insulin could be delivered into the blood stream, then | continuous glucose monitoring and controlled precise | insulin doses could work as well as the pancreas? | mlsu wrote: | The subcutaneous part is not really solvable, but even if | it were, "real" insulin is much faster than even the | fastest insulins (lispros) that we currently have. So | there is a delay between delivery and action. There is | also a delay on the sensing side; the pancreas always | knows what's up, but even cutting edge CGM technology has | significant delays, mostly related to that subcutaneous | issue from my understanding. | haldujai wrote: | There are faster acting insulins creatively named "faster | aspart" and "ultra rapid lispro" with the latter | beginning to appear in the bloodstream at 2 minutes and | reaching 50% effect around 20 minutes. | | With that said the difference between CGM/pumps and the | human body's mechanisms of blood glucose regulation is | not purely due to pharmacokinetics, regulation of blood | sugar is very complex and we still don't fully understand | them but there are multiple hormones and factors | affecting blood glucose regulation. | | As one example some incretins are released in response to | ingested food content and stimulate insulin secretion | before blood glucose levels rise. We can't replicate that | just by measuring blood glucose (not that we necessarily | have to). | | The homeostatic mechanisms of the human body are | fascinatingly complex. | kaliqt wrote: | CGM circuit systems do auto-handle spikes. The systems are | getting better. | gustavus wrote: | So my wife is a type 1ner. She recently got a pump that also | reads her transmitter and it will change the amount of insulin | being delivered based on what the transmitter is saying. It | isn't perfect she can overwhelm it if she eats a ton of carbs, | but honestly it's gone from her pump/phone yelling at her 7-8 | times a day about being high or low to maybe once a day or once | every other day. | | The biggest thing it has also done is regulate her blood sugar | at night so we don't wake up anymore with the pump screaming at | her that she needs to start shoving fruit snacks down her maw. | GrinningFool wrote: | I have a family member on a similar system. You | might/probably already know this, but I'll put it out there | anyway in case I'm wrong. | | The thing to watch out for is that if the CGM was previously | alerting about frequent nighttime lows, there should probably | be some basal dose adjustment made in the pump. The pump can | cover incorrect basal dosages for a good range with its | automatic adjustments, but it's better to periodically look | at the numbers and see if it's regularly backing off the | basal dose because it's too high. | thereikiway wrote: | Fantastic. Anything to successfully move forward progress, even | with bumps along the way, and not rely on the creaking behemoth | of the useless fda | dankle wrote: | This is fucking amazing!! Love to see it, very interesting future | for folks with t1d now, both re tools like this and new potential | cures in the pipe. | black_13 wrote: | [dead] | myshpa wrote: | I know this article is about Type 1, but I'll post some links | here in the hope that it might help someone. | | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6399621/ | | Calorie restriction for long-term remission of type 2 diabetes | | https://www.nature.com/articles/s41574-019-0186-6/ | | Low-calorie diets in the management of type 2 diabetes mellitus | | https://www.diabetes.org.uk/guide-to-diabetes/enjoy-food/eat... | | A low-calorie diet can be used to treat or manage type 2 diabetes | according to research | | https://www.pcrm.org/news/news-releases/plant-based-diets-be... | | Plant-Based Diets Best for Diabetes Prevention and Treatment, New | Review of Scientific Literature Confirms | | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5466941/ | | A plant-based diet for the prevention and treatment of type 2 | diabetes | | https://www.telegraph.co.uk/science/2016/03/14/type-2-diabet... | | Type 2 diabetes can be cured through weight loss, Newcastle | University finds | | https://trevorklee.substack.com/p/obesitys-relationship-with... | | Obesity's relationship with type 2 diabetes is really weird | | https://www.youtube.com/watch?v=lSwL73evUdA | | Diabetes Reversal and Weight-loss with Neal Barnard, M.D. | | https://www.youtube.com/results?search_query=bernard+diabete... | mlsu wrote: | I assure you: commercial players are working very hard on this. | | The difficult part is actually power management. There are | clearly very sophisticated algorithms that can do no meal | announce closed loop management of t1d (just google scholar | "closed loop type 1" -- it's a very popular problem for control | systems researchers). | | But they take a lot of power. Embedded convex solvers for large | MPC schemes do not come cheap, especially when you want them | running every 5 minutes! I have used this DIY loop system in the | past. It is extremely power hungry and requires recharging daily, | even when plugged in half the day. And I don't even think they | are doing anything exotic like MPC. I stopped using it because of | those battery issues and the implementation is gnarly -- it's | basically a collection of bash scripts and relies on the | operating system (armbian linux) to schedule doses. No RTOS, no | watchdogs... | | Power management is extremely important in a pump. If a pump dies | every <24 hours without being recharged, that impacts both the | patient experience and can be very dangerous. If it dies | overnight you get no insulin and you will be very sick the next | morning. | | That said, I love that this is a thing. It pushes the tech | forward and gets people excited about a machine cure, which is | the only viable solution to "curing" type 1 at the moment. ___________________________________________________________________ (page generated 2023-08-30 23:00 UTC)