Diabetes Deep Dives: DIY Automated Insulin Delivery

0:00 foreign0:06 Candice and I am from diabetes Canada if0:09 you are new to our video series thank0:11 you for joining us if you have been0:13 enjoying this series welcome back0:15 this video series is designed to go0:17 beyond the surface of General diabetes0:19 information we are diving deeper into0:22 different areas of diabetes management0:23 by featuring Dynamic and engaging guests0:27 with knowledge or live experience on the0:29 topic we hope to spark continued0:31 interest and learning and leave you with0:33 practical tips and tools that you can0:35 easily use0:36 a new video is shared every month so0:39 subscribe to our YouTube channel and0:41 click on the notification Bell to be0:42 notified about new content you can also0:45 check us out on social media to find out0:47 when the next one will be posted on our0:48 YouTube channel0:50 thanks to those who have subscribed and0:52 for your support of our video series0:54 in this episode we are going to shine a0:56 light into the world of automated0:58 insulin delivery also known as aid for1:01 short specifically the conversation will1:03 focus on a Hot Topic in the world of Aid1:05 better known as doing it yourself or DIY1:08 Aid you will hear from Dr Ayanna1:11 Halperin who will take us through an1:13 explanation of Aid what devices are1:16 involved and what it means to do it1:18 yourself1:19 she will share some highlights from an1:21 upcoming diabetes Canada position1:22 statement on DIY Aid as well as the1:25 research that has informed the position1:27 statement1:29 after watching this video we hope that1:31 you will understand what Aid is and1:34 recognize what devices are involved1:36 understand the differences between1:38 commercial Aid systems and DIY Aid1:43 know the benefits and risks of1:45 commercial and DIY Aid systems1:48 feel comfortable with approaching your1:50 healthcare provider with questions about1:52 DIY Aid and know where to find more1:56 information about DIY Aid1:59 while this is a very interesting and2:01 emerging topic we recognize that the2:03 content in this video may not be2:04 relevant for everyone and will depend on2:07 what your experience with diabetes is2:09 and what devices are available to you2:11 where you live if you have specific2:13 questions about Aid please reach out to2:16 your Healthcare team2:18 these videos are for educational2:19 purposes only the content discussed in2:22 this video is not intended to be medical2:24 advice and to the extent that medical2:26 advice is required you should consult2:28 with a qualified medical professional2:30 the information discussed in this video2:32 cannot replace consultations with a2:35 qualified health care professional to2:37 meet your individual medical needs2:39 the views and opinions expressed in this2:41 video are those of the speakers that do2:43 not necessarily reflect the views or2:45 positions of diabetes Canada2:48 Dr Halperin is a staff physician at2:50 Sunnybrook hospital and an assistant2:52 professor at the University of Toronto2:55 as the quality and Innovation lead for2:57 the division of Endocrinology she leads3:00 a group of Physicians committed to3:01 improving quality and safety for3:03 inpatients and outpatients with diabetes3:05 and other endocrine diseases Dr Halperin3:09 has a large type 1 diabetes practice and3:12 believes strongly in the potential for3:14 continuous glucose monitoring to improve3:16 diabetes related outcomes and the3:18 experience of living with diabetes3:21 as always we hope that this video Sparks3:23 your interest in learning more about3:25 diabetes management and now over to Dr3:27 HalperinWhat is Automated Insulin Delivery3:29 hey I'm Dr Lana Halpern and I'm really3:31 excited to be here today to talk about3:33 our new do-it-yourself automated insulin3:36 delivery position statement that will be3:37 out in the July 2023 issue of the3:40 Canadian Journal of diabetes3:44 so let's start by talking about what is3:46 automated insulin delivery3:48 automated insulin delivery utilizes two3:51 Advanced diabetes Technologies3:52 continuous glucose monitoring and an3:55 insulin pump and then a control3:57 algorithm which can be embedded within3:59 the pump itself or on an app on a4:01 smartphone is used to have the insulin4:05 modulated based on the glucose sensor4:08 and it's different from using regular4:10 injections or just the pump and open4:12 loop because if you live with diabetes4:14 you know that no two days are the same4:16 and as much as you can fine tune your4:18 settings there's still days where your4:19 glucose are going to go high and low4:21 because of all the variability in your4:22 day-to-day activities but when you have4:25 a control algorithm modulating their4:27 insulin delivery you can stay in range4:30 more often4:31 and long before we had commercial4:34 systems available there was a community4:36 of individuals living with diabetes or4:39 caring for people living with type 14:40 diabetes who decided to not wait and4:44 they got together and did it themselves4:46 and that's what DIY automated insulin4:49 delivery is using a commercially4:51 available insulin pump and continuous4:53 glucose monitor but a open source4:56 control algorithm which is available on4:58 the internet to help modulate your5:00 insulin delivery5:02 this is a screenshot from one of my5:05 patients using a commercial automated5:07 insulin delivery system5:09 and so I'll Orient you because I think5:11 it's very illustrative to what I'm5:13 talking about this is the target range5:15 of glucose between 4 and 10 and this is5:17 the sensor glucose you can appreciate5:19 that this person is spending over 905:21 percent of their day in the green zone5:24 where we want to be not too high not too5:27 low5:28 in order to do that the insulin pump is5:31 continually adjusting the basal insulin5:34 and when it looks like the person's5:36 glucose is going to drop below our5:37 desired range the pump suspends that's5:40 what these pink lines are5:41 and then in order to as the glucose5:44 levels start to climb the basal insulin5:46 delivery goes back up then the person5:48 wakes up and decides to eat breakfast5:49 and this is where a person living with5:51 diabetes still has to interact with the5:52 pump and say I'm going to eat5:54 approximately 30 grams of carbs it tells5:57 the pump it's eating carbs and the pump5:59 delivers a bolus of insulin but that6:00 wasn't quite right maybe the person6:02 underestimated their insulin or took it6:04 a little too late and so the pump6:06 delivers small correction doses without6:08 the person having to do anything and the6:10 glucose comes back into range then lunch6:13 time the next time a person living with6:14 diabetes should have to think about6:16 their diabetes bolus again this time the6:18 bolus is bang on and the glucose barely6:20 Rises until about four in the afternoon6:22 when maybe you had a stressful event at6:24 work or you grabbed a cookie with your6:26 coffee and forgot to bolus no big deal6:28 the pump delivers a correction bolus and6:30 you're back in range dinner goes well6:33 but as you get closer to bedtime the6:34 glucose starts to drop maybe there was6:36 an after dinner walk or are you over6:38 bullish for dinner either way the pump6:40 suspends and keeps the person living6:42 with diabetes in range6:43 and we know that diabetes Canada wants6:46 most adults living with type 1 diabetes6:48 to spend about 70 percent of their time6:50 in that target range of 3.9 to 106:52 millimoles per liter but with automated6:54 insulin delivery it's very possible to6:56 achieve goals above this with greater6:59 than 70 time and range and much less7:01 than four percent hypoglycemiaDIY Systems7:05 so when we talk about DIY systems7:08 they're part of a larger way of thinking7:10 about insulin delivery options we have7:13 multiple daily injections continuous7:15 subcutaneous insulin otherwise known as7:18 insulin pumps and automated insulin7:20 delivery7:21 and automated insulin delivery comes in7:23 different forms commercial and DIY and7:26 we should be thinking that our patients7:28 should have choices along this various7:30 Spectrum from the yellow to the blue to7:31 the teal here and that whatever makes7:33 sense for you and how you want to manage7:35 your diabetes your team should be7:37 supporting you in7:40 so what automated insulin Delivery7:42 Systems are available in Canada today7:45 the first is the Medtronic 670g system7:48 which we're going to see less and less7:49 of because now the Medtronic 780g system7:52 has been approved and this system is7:55 used with a Medtronic sensor and allows7:59 for individualized targets between 5.68:01 and 6.7 millimoles per liter there's8:04 also the control IQ system which allows8:07 people to use a Dexcom and a tandem pump8:10 and has a control algorithm that adjusts8:13 to a range between 6.2 and 8.9 but then8:17 we have the do-it-yourself automated8:19 insulin Delivery Systems and these8:21 systems are meant to8:23 be a little bit more flexible8:26 people have different options in terms8:28 of which pump and CGM they want to use8:31 and they can build the system right off8:33 of their phone and of course8:36 um the uh targets are also much more8:39 personalized8:40 um of course there is no licensing8:44 so as I mentioned before there's at8:46 least three different DIY automated8:48 insulin delivery options out there for8:50 you today and these are the ones that we8:51 discuss in detail in the position8:53 statement8:55 so why are people with diabetes choosing8:58 to use DIY this is a survey from a9:00 colleague of mine named Kate Farnsworth9:02 who surveyed people using DIY automated9:06 insulin Delivery Systems across Canada9:08 and what she found was that people9:10 choose to use these systems because of9:12 transparency and interoperability they9:14 like the idea of Open Source software9:16 that can be quickly iterated without9:19 having to wait for regulators9:22 in addition it for many people it's the9:25 only kind of automated insulin delivery9:26 available where they live due to9:28 barriers related to insurance coverage9:30 and some people believe it's safer than9:33 other systems because it's built by9:34 people living with diabetes who really9:36 understand what it's like to experience9:38 hypoglycemia and for many it's an issue9:41 of affordability9:44 so although people are choosing to do it9:46 themselves they're rarely doing it alone9:48 because the DIY Community is quite9:50 established and when I recommend these9:53 systems to my patients I direct them to9:56 trusted online resources like the DIY9:58 Facebook groups called Loop and10:02 um I know that they will get good10:03 information there because the Facebook10:04 group is moderated by somebody I know10:06 and trust and that will help them on10:09 their journey to starting to use their10:11 own insulin automated insulin Delivery10:14 Systems10:16 so what about evidence there is evidence10:18 supporting DIY Aid use and this was an10:23 article published in the New England of10:24 Journal about a New England Journal of10:26 Medicine back in the fall of 2022 which10:29 was showed that people were randomized10:32 to either using just an insulin pump and10:34 a CGM or the open source automated10:37 insulin delivery system10:39 and what happened was not surprisingly10:41 the people using the automated insulin10:43 delivery system spent about 10 percent10:45 time more in range across the study10:47 compared to the control group which had10:49 no improvements in their time and range10:51 that resulted in more three hours and 2110:54 minutes a day in the optimal range which10:57 means more time doing other things and11:00 less time worrying about your diabetes11:04 so where can I find more information as11:07 I mentioned I often direct patients to11:09 trusted online resources like the looped11:12 Facebook group or if you're more11:14 interested in understanding11:16 um things about the Android APS system11:18 because perhaps that's the type of11:19 smartphone you use you can find11:21 information about their systems as well11:23 here and all of this will be available11:25 in the publication that's coming out11:28 um in the in the next month11:32 so another thing you might be wondering11:34 is what should I ask my Healthcare team11:37 so we know that one of the reasons11:38 people don't use DIY Aid is because11:41 they're worried their Healthcare team11:42 doesn't support them11:43 are diabetes Canada position paper makes11:46 a strong statement that for diabetes11:49 professionals who support aid meaning11:51 they're comfortable enough with insulin11:53 pumps and continuous glucose monitors11:55 and so they're ready to prescribe11:58 commercial systems they should also be12:01 supporting patients using DIY they're12:03 actually quite similar and we should12:05 support our patients autonomy and their12:09 ability to choose the system that's best12:11 for them in managing their complex12:12 chronic disease12:14 but if your Healthcare professional does12:16 not support DIY Aid maybe they can make12:19 a referral to a team that does12:21 perhaps they haven't had a patient12:24 before but they're willing to learn with12:25 you certainly I learned the most from my12:29 patients who are using DIY Aid even12:32 before there were commercial systems12:33 available such that once the commercial12:35 systems came along and became available12:37 in Canada I was able to take some of my12:39 early learnings and apply those to my12:41 patients using commercial systems and12:43 there's more similarities and12:44 differences between these different12:46 control algorithms so usually a12:49 practitioner who's comfortable with the12:50 general automated delivery system will12:53 be comfortable you can also let them12:55 know because maybe they don't know that12:56 the diabetes Canada position paper and12:58 Healthcare users guide has been12:59 published in cjd and that they can get13:02 lots of useful tips and tricks to help13:04 support you13:07 it's important to recognize that it's13:09 not the job of the health care13:10 professional to build the app for you13:12 that is why it's called DIY13:16 if you're using a commercial system you13:18 can call a 1-800 number if you're having13:20 technical support if you're using a DIY13:22 system the technical support is your13:24 online community however these online13:26 communities have grown so significantly13:28 that sometimes you can get better13:29 support at three in the morning because13:31 there's someone from Australia who13:32 happens to be on Facebook then you can13:34 from the 1-800 numbers I'm not13:37 recommending one system over the other13:38 I'm just recommending that our patients13:40 with living with type 1 diabetes should13:42 have the choice to choose between the13:44 DIY and the commercial systems13:46 it is really important that the13:48 healthcare team continue to support you13:49 in optimizing your settings to help meet13:51 your personal goals and decrease the13:53 diabetes burdenEducation13:55 so education remains an important part13:58 of all Aid systems and having an aid14:01 system doesn't mean you don't need to14:03 know the basics because technology fails14:05 whether it's commercial or the DIY14:07 systems insulin pump sites can fail and14:10 you need to know how to go back how do14:12 you troubleshoot for ketones how do you14:14 calculate the doses that you need if14:16 your pump has failed and you need to go14:18 back to manual injections those are14:20 important learning points that are14:21 Universal and should be reviewed14:22 regularly with your Healthcare team14:25 so when it comes to navigating DIY Aid14:28 to optimize settings there's tons out14:31 there and way outside the scope of this14:34 short video but it's important to know14:36 that there are lots of growing resources14:38 there's a full hour and 20 minute14:40 webinar that I put together for our14:43 Healthcare practitioners to learn more14:45 about this but we talk in general about14:48 understanding how the system calculates14:51 insulin how the system adjusts insulin14:53 what to do when the system stops working14:56 educating on essential management points14:59 like I already mentioned and how to15:00 share the data and that's actually15:02 really important point for you if you're15:04 somebody living with type 1 or a family15:06 member of someone living with type 1 is15:08 your Healthcare team does want to have a15:09 look at the data so figure out what15:11 system works for them there's more than15:13 one but that way when you get back15:15 together in clinic if you've started15:17 using one of these systems they can15:18 review how the insulin Delivery Systems15:20 are working for you and help you to make15:22 changes to your settings to optimize15:23 your glucose outcomes15:26 as with all insulin Delivery Systems15:29 whether they be injections or automated15:32 insulin delivery there's a risk we know15:35 that insulin is a high alert medication15:36 and when given in excess can result in15:38 hypoglycemia but with DIY there's less15:42 parameters than with the commercially15:44 available systems so it is important to15:46 work with your Healthcare team to set15:49 the right Max bazel maximum bolus and15:52 suspend threshold15:54 these are detailed settings that you15:56 will learn more about if you want to15:58 watch our longer webinar and or if you16:00 want to dive into Loop docs and start16:02 building the system for yourself16:04 in general however continuous glucose16:06 monitoring which is recommended by16:08 diabetes Canada for all adults living16:10 with type where all people actually16:11 children and adults living with type 116:13 diabetes16:14 are very helpful to prevent significant16:18 hypoglycemia because alerts and alarms16:20 will prompt you before you've gone too16:22 low16:25 so in summary there are four key16:27 messages I'd like to leave you with16:29 we feel that DIY Aid can be effective to16:33 help individuals with t1d improve16:35 glycemic outcomes while reducing the16:37 burden of day-to-day diabetes16:38 self-management16:40 we also feel strongly that diabetes16:42 Healthcare team has an obligation to16:44 discuss all available treatment options16:46 that have evidence of benefits and that16:48 includes DIY Aid16:51 Healthcare practitioners should connect16:53 interested people with diabetes to16:55 trusted online social media and16:57 in-person resources but they're not16:59 obligated to build the systems for the17:01 patients in fact it's best when patients17:03 build these systems on their own or17:05 using the support of the online17:06 committee uh community so they know how17:09 to troubleshoot it when things go wrong17:12 Healthcare practitioners should continue17:14 to provide ongoing support and education17:16 to people with diabetes who choose to17:18 use the DIY Aid systems including17:21 assisting with optimizing pump settings17:23 and coaching on the behaviors that are17:25 linked to decreasing glucose variability17:27 all of this is so that people with17:29 diabetes can live full and enjoyable17:32 lives and minimize the burden of17:34 managing t1d17:36 thanks so much for joining me on this17:37 deep dive video today17:40 thank you so much for joining us to dive17:42 deeper into the world of DIY automated17:44 insulin delivery and how it can support17:46 diabetes management17:48 again this topic may not be relevant to17:50 everyone living with diabetes but we do17:52 hope that you found it interesting and17:54 learned something new17:56 please take the opportunity to let us17:57 know what you learned what you liked and18:00 how we can do it better18:01 you can do that by posting a comment in18:03 the comments section below or by18:05 clicking the link to the feedback survey18:07 in the description box18:09 if you have other ideas for other topics18:11 you'd like to learn more about you can18:13 include that in the comments or feedback18:15 survey as well18:16 Dr Halperin mentioned that other18:18 educational resources will be available18:20 soon if you are interested in the18:22 upcoming position statement and webinar18:24 please stay tuned to the diabetes Canada18:27 website and the description box on18:29 YouTube for this video as we will post18:31 links to those resources when they are18:33 available18:34 in the meantime you can check out some18:36 additional helpful resources related to18:38 this topic from diabetes Canada18:41 if you are looking for more resources18:42 about diabetes management please visit18:45 our website at diabetes.ca you can also18:48 email us at info diabetes.ca or call our18:51 info line at 1-800-banting that's18:57 1-800-226-8464 and speak to one of our18:59 information and support Specialists who19:01 can address your needs thanks again for19:04 joining us and see you next time19:07 [Music]