Machu Picchu was the most incredible place I’ve seen. Words cannot do it justice but I will try.
I woke at 4:30am to the sound of rain. Damn. I checked my BG – 120. Perfect. Breakfast was 2 bananas, 2 passion fruit, puffed quinoa and a lemongrass tea. 100gms of carbs, 3 units of insulin. As the rain let up I walked to catch the 35 minute bus to the entrance of Machu Picchu.
So much excitement and adrenaline was running through my veins. I could already sense the magic that was about to shine on my 28th birthday. I stepped foot into the sacred grounds of Machu Picchu just after 6am. Not many people had arrived yet and it was perfect!
I walked around the ruins in the lower part of the mountain while the rain fell at a constant pace. I waited for the clouds to clear. As I slowly started to make my way up the mountain, I saw some llamas wandering the grassy areas. I took a moment to take in the incredible Incan ruins. They were built by hand for the purpose of farming and agriculture.
The thought that labor was done on such a large mountain is mind-blowing. The views, even with the clouds, were out of this world. My heart rate was definitely higher than usual as I walked along stony, slippery paths. 2-hours in and its time to test my BG — 90! Yes! I snacked on some dehydrated bananas and figs with no additional insulin (about 40gms) and I continued to climb the mountain and follow the pathway leading to La Puente, which means “The Bridge.”
Along many of the paths I was totally alone. The silence was perfect and added to the magic of the mountains. I made it to the bridge which was on the sheer edge of the cliff! How the Inca’s crossed it, I have no idea!
Another BG test before I walk to the “Gate of the Sun” up the other side of the mountain, and I’m sitting at 127!! Thank you diabetes gods for blessing me on my birthday. I set my pump on a 2-hour reduced temp basal of 50%, throw in some more dried figs and an apple, and set off again!
The 40-minute cliff scaling walk was worth it. To look down upon the Machu Picchu ruins minutes before the clouds blocked my view – I had found heaven!
I take the steep, slippery walk back down and thankfully manage to keep my balance — else I’d be off the edge! The sky had cleared just before I was ready to finish my 4-hour adventure and I got some photos of me with the famous ruins in the background!
As I get back to the entrance to empty my bladder and rehydrate, I’m sitting with a BG of 100 so I eat a banana and some more dried fruit. I decide to run the 5+ miles back down the road to Machu Picchu pueblo!
It felt so good to run at Machu Picchu, with the sun finally shining and the local butterflies putting on a show just for me! Thank you universe!!!
A Meal Fit for a Queen….Or a Tourist
Okay, I made it! Sweaty, exhausted, sore legs and super hungry I’m back in my hotel!
A hot shower was in order followed by a breakfast/lunch combination of banana, quinoa cereal, dried figs, soy milk and a few sneaky vegan gluten-free cookies crumbled on top! With a lot of carbs in my tummy and some relaxation in bed my BGs crept up a little to 250ish….some extra insulin and they shot back down to 120 by the time I was ready to head out to dinner. The only restaurant in this tiny town with decent vegetarian options was a French/Peruvian fusion restaurant. So I headed there for a very tourist priced set menu!
But, it was so so delicious. I skipped the avocado and the oil based dressings and carbed up with the delicious fresh pasta, veggies and fruit and dairy free ice cream for dessert! It was a nice treat meal!
Reflections on T1D & Exercise
Today was an incredible, magical, and quiet start to my 28th year. My diabetes control today reinforced good eating and exercise is the way to get best control and I’m excited to continue my journey of getting better results and continuous stable management, especially when my travel comes to an end. Tomorrow morning I’m back on the tourist train to Cusco! Another week in Cusco to explore the Sacred Valley!
This is a guest post series from Amy McKinnon, a One Drop user and 27-year-old ex-advertising executive who recently swapped her NYC apartment for an oversized backpack to explore the streets of Latin America for six months. Amy has lived with type 1 diabetes for 15 years and tries her best to balance blood glucose levels,marathon training and a high-carb raw vegan diet. Now she has thrown travel into the mix. EDITOR’S NOTE: Amy is a performance athlete and consumes a high-carb diet. At One Drop, we believe that a low-carb approach to food reduces the risk of high and low blood glucose incidents and can effectively reduce blood glucose levels overall. However, we want to share a variety of personal experiences so we can all learn how other people live their lives with diabetes. Always consult your doctor before making changes to a prescribed regimen.
The bus ride from Baños to Cuenca wasn’t too bad for 7-hours. My BGs were in range and I snacked on bananas and low-fat granola. I tried to sip as little water as possible because there were no toilets on the bus and we were taking no stops!
I arrived at Cuenca on a rainy Saturday afternoon and went on an hour-long hunt for some vegetarian food. Starving, I chose a place which wouldn’t have been my first preference but got a basic salad and some rice and beans.
Cuenca was a ghost town on Sunday so my day consisted of yoga, walking, cross training and dinner at the only restaurant open in town. A vegetable curry and salad satisfied my craving for some healthy foods.
On Monday, the rain had stopped and I managed to head out for a 6-mile run along the river.
Back to the Insulin Pump
I had made the decision after 2 months of injections (Novolog and Lantus) to switch back to my insulin pump. I was ready to be reconnected. My main frustration with injections was my lack of BG control during the night: if I didn’t wake up at around 2am and give myself a Novo injection of 2-3 units I’d be waking up with a BG above 250. Lantus wasn’t giving me the flexibility of varying basal rates like my insulin pump could and I really needed to get my night time numbers back in control! Mostly so I could get an uninterrupted good night’s sleep!
Roaming around the City
Reconnected and ready to be a tourist, I took a 2-hour city bus tour of the old town and surrounding areas. My favorite stop was the mirador (viewpoint) overlooking the city of Cuenca.
On the tour I made a friend, Marta from Venezuela. She was traveling on her own and we had a fun conversation in Spanish. A question I get asked frequently in general conversation once people know my age (28) is, “Do you have children?” I laughed as Marta asked me that, and a life I could not imagine at my age flashed before my eyes.
I struggled with some post-exercise lows, potentially due to pump-induced increased sensitivity. I had to snack consistently and reduce my basal until I found a place called The Vegetable Bar – and it lived up to its name. A fresh juice, salad and soup for lunch!
By the end of the day I was exhausted but happy to be reconnected to my pump and my BGs. I just need to refine my doses a little over the next few days to reduce my lows.
Tuesday was the Bus Tour part 2 in which we visited a factory where they made traditional Ecuadorean hats from straw. The hats were quite famous with the likes of Brad Pitt and Johnny Depp wearing custom-made versions during red carpet appearances. My BGs were much better and I wasn’t having to counteract any lows at this stage.
For lunch I found a vegan restaurant with $3.50 Almuerzo consisting of a soup, a rice and salad dish, and fresh fruit for dessert. I was in vegan heaven.
As the afternoon sky started to get cloudy I wanted to head out for some sprints on a local running track I had discovered. My BGs were a little high (270), but with some insulin on board, I think they’ll decrease as I start working out.
Let’s just say that sprinting in altitude is more than a challenge. I managed 2 miles and was dead, so finished my workout with a slow 2-mile jog along the river. By the time I finished, my BG was 55 – Eeek, the power of exercise!!
Selling Live Guinea Pigs — Not as pets!
By Wednesday the rain was back! Rain coat on, I walked 3 miles to a large market called El Arenal Mercado (having to snack along the way – damn those persistent lows). It was full of fruit, vegetables, grains and guinea Pigs (dead AND alive) on sale for people to eat!! My vegan conscience felt very sorry for these poor animals, especially while seeing them in cages and knowing what lies ahead for them.
I stocked up on bananas, dragon fruit, and papaya. I even found my banana baby guarding some huge bunches of bananas fresh off the tree!
Back at my hostel I continue to reduce my basals and increase my insulin to carb ratio – I’m already back to 20:1. Boom! Very happy with that and hopefully it’ll start to get rid of these lows!
Running and Refueling T1D Style
Thursday morning I woke up ready for half marathon # 3 for www.1bloodydrop.com to raise awareness for type 1 diabetes. It was cold, cloudy, and rainy but I didn’t want to back out. My mind and body were ready to run. With a pre-run banana and a BG of 130, I headed out. 2hrs16mins later and I finished the 13.1 miles feeling a little wet and cold from the mud on my legs, yet accomplished. And I finished my run with a BG of 90 – I was on fire.
I re-fueled my body with 3 bananas, 2 passion fruit and a dragonfruit and headed out to get a much needed manicure – for $3!!
As the day continued, the rain got harder so I felt lucky that I ran in the early hours of the morning!
Lunch was at my new favorite restaurant Quinua and I spent the afternoon sipping on a hot chocolate and reading the local Spanish newspaper El Tiempo.
By early evening I was packed and ready to catch my early morning flight back to Quito where I am staying for 2 more weeks (I just can’t get enough of Ecuador) before I head to Lima, Machu Picchu and Cusco!
I’m excited to be back at Quito’s Nike Run Club, run some more and maybe squeeze in a few more touristy adventures in this big city.
Thanks Cuenca for the runs and the rain!
Let’s hope my BGs continue to stay on track with the magic of my insulin pump!
This is a guest post series from Amy McKinnon, a One Drop user and 28-year-old ex-advertising executive who recently swapped her NYC apartment for an oversized backpack to explore the streets of Latin America for six months. Amy has lived with type 1 diabetes for 15 years and tries her best to balance blood glucose levels,marathon training and a high-carb raw vegan diet. Now she has thrown travel into the mix. EDITOR’S NOTE: Amy is a performance athlete and consumes a high-carb diet. At One Drop, we believe that a low-carb approach to food reduces the risk of high and low blood glucose incidents and can effectively reduce blood glucose levels overall. However, we want to share a variety of personal experiences so we can all learn how other people live their lives with diabetes. Always consult your doctor before making changes to a prescribed regimen.
A few months ago, I read a post on blood glucose meter (in)accuracy that was quite alarming. Chris Hannemann, T1D and OpenAPS’er, tested five popular blood glucose meters for accuracy and found major discrepancies. The overall variability between the meters was roughly ±11 %, and two of the meters — both from the same manufacturer — showed major bias. Chris had been using one of those meters to calibrate his CGM and consistently found that his lab-measured A1C would come in a full percentage point higher than his CGM average would predict (e.g., the meter-calibrated CGM data would correspond to an A1C of 6%, but laboratory-measured A1C would actually be 7%).
As someone who wears a CGM and always strives to achieve an A1C of ~6.0% or lower, this post freaked me out. If I’m calibrating my CGM with a meter whose results are always off by that much… how can I be sure about reaching my targets?!?
But I was also skeptical when I saw Chris’ post, because my A1C has always matched my predictions (based on my CGM average). So, I decided to run my own test on 10 popular meters from various manufacturers. Much to my relief, all 10 meters produced very similar results for each blood sample, with an overall between-meter variability of just under 6%. Below I describe the test and discuss the results. And, in another post, I explain some reasons why your average BG on your meter might not always correspond with your A1C results. (Key point: It doesn’t necessarily mean your meter is bad!)
Accu-Chek Aviva Connect
Contour Next EZ
OmniPod PDM FreeStyle Meter
OneTouch Ultra Mini
One Touch Ultra 2
Walgreens True Metrix Air
Walgreens True 2 Go
Wal-Mart ReliOn Confirm
These 10 meters varied in age and wear. Some were old, some were new… one was my own personal meter that I used to calibrate my CGM and make mission-critical decisions each day. All of them passed their respective control solution tests, so it’s safe to assume that they were in good working order. I tried to match the testing method employed by Chris (author of the original post) as closely as possible.
Eight rounds of testing were performed over the course of 24 hours according to the following procedure:
Wash and dry hands
Arrange meters on table in random order
Insert new lancet into lancing device
Remove test strip from each meter’s strip vial and insert strips into meters
Wipe fingertip with alcohol pad & wait for it to dry
Prick fingertip & squeeze out large drop of blood
Apply blood to each test strip in order
Order of meters was randomized for each round.
Tests were performed only when CGM readings were stable (i.e. no insulin on board and CGM showing a slope of ~0 mg/dL/min).
I didn’t do anything special to stabilize my blood glucose — just tested as I went about a normal day.
The test strips used for each meter all came from their own unique vials.
Before and after completing the eight testing rounds, the meters were checked using their respective control solutions. They all passed the control solution tests.
BG Results For Each Round, Compared
Unlike Chris, I didn’t have an alarming spread in my results for any round. The overall between-meter variability (“% Error”, or “%CV” for you stats folks) was only 6%.
In plain English: My treatment decisions wouldn’t have varied much at all, regardless of the meter I was using.
One unit of rapid-acting insulin brings my BG down by ~80 mg/dL, and I correct whenever I’m over 100 mg/dL. I’ll usually correct down to 70-110 mg/dL, depending on my plans for the next couple hours (big meal = correct to 70; workout = correct to 110).
I was relieved to see that even if I took a correction bolus for the maximum BG of each round, I still would have been brought down to a desirable blood glucose level.
For example, take Round 1. The highest reading I saw was 182 md/dL, and I’d take 1 unit for that. Even if we assume the true glucose was the lowest value from that round, 149 mg/dL, I’m still in good shape taking 1 unit because I’d only go down to ~70 mg/dL.
What does this mean for A1C?
To figure out what this means for A1C estimates, let’s take a look at how each meter’s average value over the 24 hours of testing compares with the overall average across all meters. (NOTE: I realize that the average across all meters may not accurately represent true A1C, but this comparison is useful to show that, no matter what meter you use, you’re getting roughly the same results for averages and, thus, roughly the same estimated A1C.)
Looking below at the deviation from the mean — i.e, how much each meter’s average value (solid gray line) differed from the overall average value (dotted gray line down the center) — I like what I see!
The average BG for each meter (solid gray line) was pretty close to the overall average (dotted line down the center), with the greatest deviation at around 6% (FreeStyle Lite & Walgreens True 2 Go). (Compare Chris’ results, where max deviation was 14%.)
This means an estimated A1C calculated based on the average value from any of these meters would be roughly the same.
For example: If your average blood glucose on your meter were 154 mg/dL, that would translate to an estimated A1C of 7.0%.
If you arrived at that average using a Walgreens True 2 Go, which appears to consistently report lower values, your actual A1C might be closer to 7.3%.*
If you arrived at that result using a FreeStyle Lite, which appears to consistently report higher values, you may be pleasantly surprised by an actual A1C of 6.7%.*
I think most of us would agree that this is an acceptable degree of variation between estimated and actual A1Cs.
* Important note: This is just based on the data I collected for the specific meters I had in my possession. I can’t say whether these trends would be true for all meters of any particular brand that I tested.
My Own Experience With Self-Measured BG Averages & A1C
My CGM averages have always been spot-on when it comes to predicting A1C.
Last Summer & Fall, I was using the Omnipod PDM FreeStyle meter (same one tested here) to measure my blood glucose values & calibrate my Dexcom CGM. For September, my Dexcom showed a 30-day average of 132 mg/dl, which correlates to an A1C of 6.2%. And that’s exactly what my lab-measured A1C was back in September — 6.2%.
For the past 3 months, I’ve been on MDI and using a Freestyle Lite to calibrate my CGM. Right before my latest A1C (~1 week ago) Dexcom’s 30-day average showed 117 mg/dl, which correlates to an A1C of 5.7%. My lab-measured A1C was 5.8%.
And this is pretty much how it’s always been for me. Not the A1Cs — I wish! — but the match between estimates and actuals. 😉 I’ve never had any reason not to trust my BG meter readings, because the results always lined up. BUT I do want to take some time now to explain that even if the numbers don’t line up, it doesn’t necessarily mean your meter is to blame…
What about the post that started all this? Why were those results so off?
Well, the truth is, I don’t know. I actually own the meter that Chris uses, OneTouch UltraLink — I used it for ~4 years back when I was on a Minimed pump. Unfortunately, I didn’t have it with me at the time of this experiment, but I’ve tested with it a bit recently, just to see…
And the results are generally within 10 mg/dL of my FreeStyle Lite readings!
So, I’m not sure why Chris’ results were so different. He’s been using his OneTouch UltraLink for about 7 years, and mine only got about 4 years of use before being carefully stored at my parents place with all my other diabetes “antiques.” I wouldn’t be surprised if after a significant amount of wear, these things just don’t work as well. However, that doesn’t explain why some of the other meters also deviated significantly from the mean glucose value…
It may be the test strips…
The FDA requires that all new meters meet particular standards (shown here in Table 7), but once a meter is approved, the FDA does nothing to monitor accuracy. This is significant because, although the meters may have functioned perfectly when approved by the FDA, that was with a particular set of test strips.
Test strips can vary from batch to batch.
Test strips contain an enzyme that converts glucose into an electrical current that runs through the test strip and is read and displayed on your meter as a glucose concentration. Enzymes are proteins and can breakdown due to humidity, temperature, and many other factors.
So, differences in the environment in which the test strips are manufactured, stored, and used can lead to differences in the blood glucose measurements they provide. Those differences may be OK — the blood glucose values provided by these strips may still fall within the FDA’s standards — but, when we are comparing one batch of strips to another, things can get hairy…
For example, suppose one batch of test strips yields BG readings that are 10% too high, and another batch (for a different meter, by a different manufacturer, or even for the same meter by the same manufacturer) yields readings are 10% too low. Even though each of these batches of strips might have an acceptable difference from the true BG value, there is a 20% discrepancy (bias) between them. The differences could be clinically significant, especially when combined with a 7% random error on top of the 10% systemic bias.
So, where does this leave us?
More testing should be done! I feel pretty good about meter accuracy based on my own experiment and personal experience, but I’d feel even better if more people conducted similar experiments and got similar results.
Results like Chris’ are scary — they make us feel like no matter how hard we try we may still be missing the mark. And the consequences go beyond the emotional toll — meter and test strip inaccuracy may lead to results that fool us into thinking everything is A-OK, when it’s really not.
Bottom line: we need to be able to trust the devices we use to make critical decisions about our health every day. If meter accuracy really is an issue, it needs to be addressed right away.
A few weeks ago, I decided to get back into running after a 5-year hiatus, and I discovered Spring: an app that allows you to walk, run, or bike to the beat of your favorite music. It was love at first run.
Getting started was super simple: choose your workout, pick your favorite music genres, and get moving! Spring takes less than a minute to figure out your cadence, then starts playing music to match your moves. Here are my favorite Spring features after using the app for 2 weeks:
Rhythm Based Movement.Studies have shown that running to the rhythm of music — meaning matching your SPM (steps per minute) to the music’s BPM (beats per minute) — increases performance, endurance, and pleasure derived from working out.
In my brief time using Spring, this has held true for me too. On my first two runs, I wanted to stop so badly at the 2-mile point, but — like magic — a great song would come on, make me smile, and keep me going. I’m now five 3-mile runs into using Spring and it hasn’t let me down yet! And if you happen to not like a song, no problem. Spring works a bit like Pandora: love a song, hear more like it; hate a song, never hear it again. I love that it’s immediately responsive to my feedback.
Maps of Every Run.Spring uses GPS to map out your outdoor runs and tell you exactly how far you went.
I only run outdoors, so I use this feature for every run. It’s so nice to go back and see exactly where you ran, your total distance, and how long it took you on any given day. Bonus: The map shows you what song was playing at every point along your path!
Simple Training Plans.Spring provides a bunch of training plans to guide you in preparing for almost any type of race.
I really loved the fact that the training plans ranged from “Beginner to Half in 12 weeks” to “Master the Marathon.” I just started the “Five Weeks to 5K” program and I am pumped! Once I committed to training, Spring automatically filled in my calendar for the next five weeks — I’ve got an “assignment” every day (some days are just “Rest”) to help me prepare for a 5K I’m running at the end of June. As a born-again runner who needs help staying motivated, I really appreciate this type of guidance and structure.
HealthKit Integration.Spring writes all activity data to the Health app!
This is particularly important to me because I like to track my activity info (along with all of my other health data) in One Drop, and my running data from Spring automagically appears in my One Drop timeline via the Health app. Free and open data sharing!
Would I recommend Spring?
Definitely! I’m a huge fan of Spring Moves and the Spring app. I would highly recommend Spring to anyone trying to start a workout program, whether it’s walking, running, or any other sort of cardio. Music that moves with you might be just the motivation you need to keep you going. So far, it’s worked for me!
NOTE: We write these reviews to highlight products we like that help support a healthy lifestyle. We do this as service to our users. We are not paid for any reviews, nor do we accept payment for any products we review.
The Spring app is a music service and exercise tracker. Spring uses music and rhythm to make runners go faster and farther – with less effort. Whether you’re logging your first miles or running marathons, Spring‘s playlists cater to all runners looking to improve cadence, form and performance. Start your 30-Day Free trial today.
First, what’s the status of the race towards an artificial pancreas?
I’ve been quietly watching from the sidelines for nearly the past two years as work on artificial pancreas algorithms and hardware has gotten much closer to becoming reality. Excitingly, we are now just under two years from having a wide selection of artificial pancreas options on the market! (pending FDA approval of course)
Tandem, Insulet (of OmniPod fame and the only tubeless artificial pancreas trial device I’m aware of), Bigfoot Biomedical and Beta Bionics are all aiming for pivotal trials in 2017 and would therefore potentially launch in 2018.
Short of a cure, the release of these products is something I’ve dreamed about for years. No longer having to check my blood sugar 8 to 12 times per day. No longer having to precisely measure the carbohydrate content of my food. No longer having to painstakingly calculate the correct carb:insulin ratio. And no longer having to worry as much about what I eat in general and constantly have to think about diabetes.
I was lucky to hear about a study going on at Stanford for the artificial pancreas about 6 months ago and ended up taking part in a trial for the Beta Bionics version. That’s the same Beta Bionics, led by Ed Damiano, which just secured $5M for the planned 2017 pivotal trial to take their iLet Bionic Pancreas to market. If you don’t know the Beta Bionics story, Ed gave an excellent TED talk that also serves a good intro to the concept of an artificial pancreas:
3 Weeks on a Bionic Pancreas
The Stanford based study that I participated in used the trial hardware from Beta Bionics — an iPhone 4 based system that is the predecessor for the improved iLet that will end up being the final product. The iPhone based system was clunky, oversized and as a result of integrating an old Dexcom G4 receiver and Tandem pump faced a number of connectivity challenges. However, what’s really important is the algorithm underlying the hardware that is the brains of the entire bionic pancreas.
Each of the implementations of the artificial pancreas leverage different algorithms and each has its own set of assumptions and input mechanisms. The Beta Bionics bionic pancreas system is one of the simplest, requiring only your weight and then, on a meal by meal basis, the type of meal (breakfast, lunch, dinner or snack) and size of meal (ranging from small bite through normal to extra large). Over time, the system learns what a “normal” meal is to you for each type and how to bolus insulin correctly to cover your needs. Other algorithms, such as the Medtronic 670G, will still require you to put in a carbohydrate amount to bolus whereas that is not needed with the Beta Bionics system.
The system is constantly learning from what you tell it. You never need to estimate exact carbs — only compare and answer “is this a normal amount of carbs for this meal for me? less than normal? more than normal?” Based on what the system learns about you and what it observes after meals through the CGM data coming in every 5 minutes, it will adjust future meals of that type and size accordingly.
It is worth noting that there is a limitation in that the system only learns when given four uninterrupted hours after a meal. If you eat again or inject again within four hours it won’t be able to learn from that meal. In today’s world of frequent snacking this sometimes meant extended periods where the bionic pancreas never properly learned how to manage certain meals for me.
The bionic pancreas smartly compensates for any trends it observes. If you start to trend high, it will start injecting tiny boluses to bring you back down into range. And conversely, if you start to trend low, it will suspend insulin delivery so that your blood sugar can rise. Note that the iLet is fully capable from a hardware perspective of being a dual-hormonal system and releasing glucagon to raise blood sugar as well. However, glucagon is not yet FDA approved for small, consistent doses and also current glucagon mixes can’t remain stable for more than 24 hours. Until both those problems are solved (lots of work is being done as you read this), all artificial pancreas systems on the market systems will be insulin only.
The upside and the downside to the simplicity of the Beta Bionics system is the lack of any control over more specific settings. This means that when the system gets it right it is magical and incredibly relaxing. It’s not possible to fully put into words the burden the system took away when I no longer had to constantly keep a portion of my brain dedicated to thinking about my blood sugar and tweaks I needed to make. Going into a meeting and trending high? I know the bionic pancreas will handle it, so not a problem! Forgot to bolus for that little snack? My blood sugar will run a bit high a bit longer since I didn’t give the system any heads up, but ultimately it handled that well too!
That said however, especially for someone who, like me, keeps a close eye on blood sugar levels and is constantly tweaking and correcting, it can be frustrating to watch while the system reacts more slowly than I would have to correct a high blood sugar.
The thing you’ve got to understand is that even if the system were perfect, with today’s technology blood sugars wouldn’t be perfect.
The first issue is that CGM sensors are inserted just under the skin, in the interstitial fluid. While you can get accurate blood sugar readings from the interstitial fluid, the readings are about 15 minutes delayed when compared directly to the blood. Accuracy is rapidly improving in CGMs but this lag issue is going to remain and means that any system relying on CGM data will be slightly behind.
The second issue is that today’s most advanced synthetic insulins peak in 30 to 90 minutes. This means that after the system sees the CGM reading and injects insulin it will take at least 15 minutes for the insulin to start impacting high blood sugar and bringing it down and even longer for it to take full effect.
Even with those considerations, magic is still the only way to describe the fact that I could go to sleep at 180 mg/dL and reliably know that the bionic pancreas would take care of me and I’d wake up at around 120 mg/dL. Across the entire study this was the most universal benefit that resounded with everyone in my study group. Too often sleep is interrupted by hypoglycemia or hyperglycemia and knowing that you had a friend who was watching every 5 minutes and ensuring your blood sugar was in range was incredible!
So would I use it long term?
If the Beta Bionics insulin-only system were on the market today in its final iLet form would I use it? The short answer is in some cases but not always.
I would use the system in a heartbeat for nighttime. Knowing that I can go to sleep and have a friend maintaining my blood sugar perfectly over the course of the night is well worth it for that alone. Waking up within range gives you a perfect start to the day — not only do you feel better but you don’t have to be frustrated dealing with any rollercoaster of blood sugars.
That said, I’m currently using Insulet’s Omnipod, which is tubeless. Aside from the trial I’ve never been on an insulin pump that uses tubing to connect the pump to your body. Between the worry about the tubing catching on things, the hassle of routing the tubing and the fact that the system is not waterproof and has to be removed to swim, it is a no-go for me personally during the daytime.
Additionally, I already aggressively manage my blood sugars and as a result have an A1C that hovers around 6 percent. For me I would love a system that maintained my basal and had the benefits of keeping my blood sugar steady during the day and at night but would still give me the added control of handling meals. This would provide the benefit of the friend who’s always monitoring and helping, but with you still at the reigns.
Due to the insulin-only approach with current systems, the target blood sugars on artificial pancreas systems is going to be between ~120–150, which translates into a slightly higher average A1C given the slower reaction times. For someone who wants a more hands off approach, doesn’t mind tubes, and whose A1C is anywhere higher, however, the system is a complete no brainer. The risk of diabetic complications increases significantly as A1C increases.
Looking to the future
Overall, using the bionic pancreas was a glimpse into the future of diabetes technology. It is incredible to have an independent system that, every 5 minutes, makes decisions about how to better manage my blood sugar. Even today, using the Dexcom G5 I look at my blood sugar maybe every 30 minutes, and often much less frequently. That’s a sample rate increase of at least 6X! That alone provides an incredible amount of room for improvement in control over what I do today.
These next two years are going to be exciting as we watch these systems come to market and immediately start impacting the lives of diabetics everywhere. The impact of bringing someone down from an A1C of 9% or even in some cases 10%+ to the 6–7.5% range these look like they will achieve is the difference between a healthy and long life and one filled with diabetic complications.
Throughout the course of the study there were three key takeaways for me that have led me to better control in the short term:
First, was the fact that CGM data, and blood sugar in general is and always will be a lagging indicator. The only way to keep blood sugars under ideal control is to know in advance what you’re going to eat and what exercise you are going to do and adjust accordingly. I’ve become more mindful of planning my meals and injecting insulin in advance to flatten out spikes in blood sugar.
Second, is the incredible value in the slope of one’s blood sugar. The iPhone trial device displayed the current slope of blood sugar as an actual number e.g. +2mg/dL or -3mg/dL. While the Dexcom G5 shows you arrows, having the actual number is far more actionable. If I’m at 90mg/dL and dropping at -5mg/dL (measured every 5 minutes) and I know I still have insulin onboard then I know I’ll be low (less than 60mg/dL) in 30 minutes and can therefore eat something to avoid that. It’s simple math but it was something I’d never thought of before — having that number gives you predictive knowledge as a leading indicator. For now there is no on-the-market system that displays actual slope values and therefore time before you go low and or high that I’m aware of unfortunately.
Third, with my pump I’d never suspended basal rates entirely. However, watching the system do it regularly to help me avoid lows and maintain my blood sugar made me realize how great a tool that is. Now, when I’m trending low I’ll simply suspend insulin delivery from my pump and avoid or at least lessen the impact of many lows.
Lastly, I was reminded during the study just how incredible the community around diabetes truly is. Ed Damiano flew out to meet our study group and eat dinner with us in person and it was inspiring to hear first-hand why he’s working on this system and his vision for the future. All of the other study participants as well as the team which was running the Stanford study were amazing as well. Dr. Bruce Buckingham, who was running the study, is one of the leading researchers on artificial pancreas systems and his knowledge was enlightening. Everyone helped everyone else and lasting friendships formed that have already far outlasted the conclusion of the study. I’ve written about this before, but it’s always good to get a reminder of the power of the community and the inspiring people within it who are working so hard to bring about change.
Apple CareKit has officially launched, and we just released One Drop v2.2 — our first implementation of the CareKit framework. We are honored to be among the 6 apps selected as Apple’s CareKit partners, and we are so excited to share our new features with you!
What is CareKit?
CareKit is a new software framework designed by Apple to help developers empower people to take active roles in their health care.
One Drop’s new CareKit-enabled features will help you become even more proactive about your health.
Now you can:
set diabetes management goals for blood glucose, carbs per meal, and daily activity
track your daily progress by swiping left on your timeline
share your data with your care team — family, friends, health care providers — instantly
track stress, energy, happiness, and confidence with every moment
One Drop + CareKit =
This is just the beginning…
We are at the leading edge of a major transformation in healthcare: data-driven self care. This is not just about diabetes; this is about all of us. This is about empowering everyone to take their health into their own hands.
[David Rodbard MD is an endocrinologist who started developing computer programs for analyzing glucose data in the mid-1980’s. He’s worked with multiple companies developing glucose meters and CGMs, and has developed a dozen new methods to display blood glucose and insulin data. Currently, he is working on artificial intelligence systems to interpret blood glucose, insulin, medication, food, and activity data – similar to the analysis and data used in One Drop.]
I was really excited when asked to speak at this year’s Advanced Technologies and Treatments for Diabetes (ATTD) conference in Milan. The topic? What I believe to be the most serious issue for people living with diabetes: low blood glucose. How do we get organizations like the FDA to give hypoglycemia the attention it deserves?
Would you choose a drug that was guaranteed to lower your A1C, but also caused lots of nighttime lows? Wouldn’t you prefer a drug that achieved the same decrease in A1C with a much lower risk of lows?
The FDA is charged with ensuring the safety and effectiveness of new drugs and devices. But, for some reason, they have focused almost exclusively on effectiveness when it comes to new diabetes treatments. Simply put, FDA’s primary focus has been on reducing A1C. Now, A1C is definitely an important consideration — we all know that the lower your A1C, the lower your risk of long term complications. So, as far as evaluating the effectiveness of new medications, A1C works fine.
But you can’t just keep increasing your insulin dose in order to lower your A1C. Anyone who does this will quickly run into a major short-term, immediate complication: hypoglycemia. Hypoglycemia is annoying, frightening, and can even be life-threatening. It is the problem that causes people with diabetes, their families and loved ones, the greatest fear and dread. And, it is not safe.
Things have changed a lot over the past 20 years. We’ve now got plenty of tools to lower blood glucose levels and A1C. The major advantage of many new and upcoming diabetes treatments is not that they lower A1C, but that they lower A1C without increasing the risk of dangerous lows.
New Basal Insulins: a recent example of the FDA’s excessive focus on A1C
Until recently, the only long-acting “basal” insulins on the market were Lantus™ (glargine), Levemir™ (detemir). Though they are both much better than their predecessors (e.g., NPH), Lantus and Levemir only last for 16-22 hours, so many people need to take two shots of these insulins each day.
Fortunately, two new forms of basal insulin became available last year: Toujeo™ (glargine U-300) and Tresiba™ (degludec). After injection, these insulins are fully effective for 20-24 hours and 30-40 hours, respectively. This alone is great news — now more people will be able to get by on just one shot of basal insulin per day.
But there’s more! Toujeo and Tresiba affect blood sugar more predictably and consistently than older types of long-acting insulin, with less variability from day to day and from person to person. This predictability, consistency, and reduced variability significantly reduce the risk of hypoglycemia compared to Lantus and Levemir.
Unfortunately, the FDA did not permit the Toujeo or Tresiba manufacturer to inform anyone of their lower risk of hypoglycemia, even though these findings were clearly demonstrated in various clinical trials from investigators throughout the world and published in several leading medical/scientific journals. So, what gives? Why would the FDA hide a critical piece of safety information from the people who need a predictable long-acting insulin?
Moving toward a more holistic approach
Fortunately, lots of attention was brought to this issue during this year’s ATTD conference. I participated in session titled, “Is It Time to Move to Time in Range as the Main Glycemic Control Measure?” Answer: Yes, it is.
Dr. Aaron Kowalski, Chief Mission Officer and VP of R&D of the Juvenile Diabetes Research Foundation (JDRF) made a proposal that we should use “ % Time in Range” – the percentage of time that glucose levels are in a desired target range — as the principal criterion for evaluation of new medications and technologies like the artificial pancreas. Closed loop systems like the artificial pancreas dramatically reduce the burden on the user while minimizing risks of hypoglycemia more than ever before.
I proposed that, in addition to the % Time in Range, we should also consider the percentage of time that blood glucose is low and the percentage of time that blood glucose is high. There are many scoring systems that give a positive result when glucose levels fall in the target range, and a penalty for glucose values that fall outside of that range. The further outside the desired range, the greater the penalty. I also proposed using a graph of the risk of hypoglycemia versus the A1C achieved by a group of subjects receiving any particular form of therapy. This kind of approach will sort out the medications both in terms of effectiveness and safety.
Other speakers also endorsed analysis of A1C and risk of hypoglycemia at the same time, as well as other factors like associated weight gain or weight loss.
So, we’re in agreement! A1C and risk of hypoglycemia should be evaluated at the same time. New diabetes treatments would be evaluated more fairly, and people with diabetes would have the information they need to make better decisions about their health.
It’s the FDA’s responsibility to protect the public health by ensuring the safety and effectiveness of all drugs and devices. In diabetes, it’s time to move toward a safer, more holistic approach that examines hypoglycemia risk and A1C, and we feel confident that the FDA will rise to the occasion.
Happy Birthday to us! 365 days ago, One Drop launched at LAUNCH Festival 2015.
Today, at this year’s #LAUNCHfestival, One Drop founder Jeff Dachis updated the crowd on the road travelled over the past year, including the recent rollout of the One Drop Food Library, and a preview of diabetes coaching services and the bluetooth glucometer and meter subscription service to be launched later in 2016.
It’s been an amazing journey, with much more to come!
[Here’s a guest post series from Amy McKinnon, a One Drop user and 27-year-old ex-advertising executive who recently swapped her NYC apartment for an oversized backpack to explore the streets of Latin America for six months. Amy has lived with type 1 diabetes for 15 years and tries her best to balance blood glucose levels, marathon training and a high-carb raw vegan diet. Now she has thrown travel into the mix. EDITOR’S NOTE: Amy is a performance athlete and consumes a high-carb diet. At One Drop, we believe that a low-carb approach to food reduces the risk of high and low blood glucose incidents and can effectively reduce blood glucose levels overall. However, we want to share a variety of personal experiences so we can all learn how other people live their lives with diabetes. Always consult your doctor before making changes to a prescribed regimen.]
Getting back into my rhythm
I now wanted to get into the rhythm of my exercise and running regime so started my morning off with a 6 mile run in Cana Hueca – the only park big enough to run with a 1-mile loop (quaint, but has nothing on Central Park!).
A bucket shower later and feeling fresh and hungry I’m back at the vegetarian cafe for a strange breakfast – lettuce, tomato, avocado, tortillas and a slab of soy protein. Clearly I need to improve my Spanish translation skills. Mexico also needs some veggie education stat! I have a call with my friend Cyrus Khambatta and discussed the perils of the obesity epidemic and eating habits of most Mexicans. He consoles and reassures me that it’s a grassroots movement to educate one person at a time on healthy eating and things will slowly change. I’m still overwhelmed by the incredulous amount of refined sugar, saturated fat and processed foods consumed in this country. It felt good to share my concerns with someone who understood and was trying to confront this issue rapidly killing a country.
After my processed breakfast my blood glucose is back in the high 200s, but I know some outdoor exercise is around the corner so give a modest correction dose.
Waterfalls, Snacks, and Temp Basals
Aldo and I meet up with his friend Brenda and catch a 2-hour bus to a waterfall. To reach this waterfall, it really was quite a trek, off road in a part of Mexico that had chickens on the streets, tiny tiny houses with tin roofs held down by bricks and plenty of stray dogs. We walked approximately 3 miles to reach the descent to the bottom of the waterfall! I also put on a reduced temp basal of 50% so I wouldn’t have to continue shoveling food into my mouth the whole afternoon. But it was worth every one of them, and every raisin I ate on the way down to keep my blood glucose in range.
We walked through the freezing water to capture the best view of the waterfall, sat down in the sand and had some snacks as we absorbed the grand nature surrounding us. When we had captured every angle of the waterfall,gotten wet up to our knees and put our shoes back on our wet feet, we started the ascent back up the stairs and the 3-mile walk back to the main road.
How do we get back to town to catch the bus to Tuxtla? Hitchhike, of course! Which my friends reassured me was totally safe…
For the trip I had bought along 2 apples, 2 bananas and some raisins and with all the walking I had to gobble them all down to keep my blood glucose around 112, even with a temp basal. The benefits of exercise! When I have healthy snacks on me I don’t mind eating frequently as it wards off hunger and lows.
T1D, no cake for me
Late in the evening we arrive back in Tuxtla, my friend and his mom head to the supermarket to buy a cake, which I learn is a Mexican tradition to share and eat with family and friends at this time of the year. I manage to squeeze in a call to my Dad to wish him happy birthday while I have 5 minutes of alone time! While I gobbled down a salad, the family ate a cake for dinner, which would also be a staple food consumed over the next few days.
After a 7-mile morning run in Cana Hueca, I return home to rice and beans cooked in salt and oil for breakfast (imagine my face when I get back and this is waiting for me). I’m torn between feeling grateful for the generosity of having food made for me and trying to explain the reasons I cannot eat these foods, where there is no understanding of diabetes and the affects of food on it.
I needed some me time, which I normally have in abundance and really really appreciate and love, so I headed to a cafe to send some emails and work on these blog posts.
In need of fresh fruit and veggies — I can never have enough — I head to the Mercardo.
A little Pre-Spanish History and some Exercise
Late in the afternoon I decide to visit one of the limited tourist attractions here in Tuxtla: Instituto de Antropolgia y Historia. I am intrigued by the history of the indigenous Mexicans – Mayans, Zapotecs, Chiapencas, before the Spanish invaded. It was interesting to learn about this and spend some time learning about the history of a country I’d grown to love.
A morning of high-intensity exercise and some intermittent walking throughout the day keeps me blood glucose between 90-130ish. It’s been a good day all around.
Over the past few days more innocently funny questions have been asked, as I respond and giggle inside my head with a smile on my face I know they are coming from a good place, but they are still amusing, at least for me. Here they are:
Do you know who Bob Marley is?
Why don’t you eat fast food when it tastes so good?
Every day: What do you eat? Me: Fruits and vegetables. Every day: Yes, but what else do you eat?
Next on the agenda is La Fiesta Chiapa De Corzo, where men dress as women in bright traditional clothes. Check out my next blog post for photos!