September 20, 2023 Diabetes Open Hours: Making Technology Work for You

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Hello and welcome to Diabetes Open Hours, your live Q&A opportunity with experts in diabetes management and care. My name is Kayla Runka and I'll be your moderator for today.

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I would like to start by acknowledging that I'm calling in from Toronto and that I'm located on the traditional Indigenous territory of the Wendat, Holden, Ashtoni, Anishinaabeg and the Mississaugas of the Credit, and that Toronto is now home to many diverse First Nations, Inuit and Matty peoples.

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As a health focused organization, Diabetes Canada recognizes that there is systemic racism within and throughout our institutions and that we all have the responsibility and power to create culturally safe and appropriate environments of care.

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Today's topic is making technology work for you and while we have an expert on the call today, this webinar is for educational purposes only. The content discussed in this webinar is not intended to be medical advice and to the extent that medical advice is required, you should consult with a qualified medical professional. The information discussed in this webinar cannot replace consultations with a qualified healthcare professional to meet your individual medical needs. And lastly, the views and opinions expressed in this webinar are those of the speaker and do not necessarily reflect the views

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or positions of Diabetes Canada.

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Having said all of that, today we're very lucky to have Alana Chambers with us. Alana is a registered dietitian and certified diabetes educator from Kelowna, BC Since completing her training at McGill University, she's focused her career on type one diabetes and technology. She has experience working in the insulin pump industry and her local diabetes program. She is now focused on insulin pump and CGM training and education. She's a dynamic speaker known nationwide for blending current evidence with practical pearls of knowledge. Having lived with type one diabetes

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his childhood, she understands that daily management takes just as much creativity and art as science. Her goal is to help life with diabetes feel just a little bit better when she's not in the diabetes space. She loves to spend time outdoors with her husband and three girls. And before we get started, just a few more housekeeping things. Please note this event is being recorded and will be shared on our website and YouTube channel for on-demand viewing. Any questions or comments that you submit via the chat function will be visible to other participants during this event, but we will not share any names or record of the chat.

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In the recording,

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we ask that any comments or reactions you share be affirming and positive, and we encourage you to discuss your learnings with your regular healthcare provider prior to making any changes to your current routine. And with that, Are you ready to get started, Alana?

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Of course, I had myself muted. Yes, now I'm ready. Kayla, thanks for having me today. Very excited to be here and and talk tech for the next hour with everyone. Amazing. Thank you. It's always good to start with though. Perhaps while we're waiting for our first questions to come in, maybe we can chat a bit about some basics. And I know you and I have discussed the lingo and there's a lot of it in the technology space. So why don't we start maybe by reviewing some of the key terms in technology and diabetes management? Yeah, great question. I think that's a very fair starting point.

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There's acronyms for everything right now is CG. What, right. So let's talk about what these key pieces of technology are that I think we're probably going to be diving into throughout this next hour. So first is some people refer to it as BGM or blood glucose monitoring that we are talking about traditional finger sticking. So you poke your finger and we put it in a blood glucose meter and we get that single number blood glucose monitoring, finger prick. And then we're going to be talking about continuous glucose monitoring. There's a lot of buzz out there about this right now. So that is the acronym is CGM,

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continuous glucose monitoring. And that is where we're wearing our glucose sensors. And those either you scan or it sends automatically to either receiver or a smartphone app or an insulin pump. So that's our continuous glucose monitoring. Let me talk about insulin pump therapy. So those are insulin pumps that we use to deliver insulin. And then I'm really excited towards the end here hopefully to get into some things on automated insulin delivery, closed loop therapy, hybrid closed loop therapy, those are all different terms. We used to talk about that, but I think I'll refer to it today as automated insulin delivery just for simplicity.

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Wow, that's a lot in a short period of time. I'm glad we're recording this so we can go back and review that again. OK, great. Let's start with what are the main technology types available for diabetes management.

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So those are kind of the ones that I explained there. So we do see our, our old standard of care was to use blood glucose monitoring, right? That was when I first got diagnosed with diabetes. I was given a blood glucose meter and insulin syringes, right. And that has now evolved. So now we are seeing the highly rec. If you have type one diabetes. We do recommend the use of a continuous glucose monitor because we see those health benefits. So those are those glucose sensors that will get in a little bit more. And then we have all of our insulin pumps and we have insulin pumps that are connected to CGM's. We have insulin pumps that are

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are just standalone insulin pump systems where you do the, the manual controlling of it. And then we have our automated insulin delivery systems where we have some automation happening in the background.

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Wow. Yeah. I can imagine since you were diagnosed, there's been a lot of changes within the technology world and a lot smarter recently as well. So what start with continuous glucose monitors, sort of what are they, how they work and I guess maybe just the benefits to diabetes management. Yeah. So a continuous glucose monitor, it's really cool because you actually see these now out in the public. We're now wearing our diabetes. And you know, there was a time where we thought it would be really wanted to show people that we have diabetes. And yes, you sometimes want to be discreet,

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but to me, nothing makes me smile more than going to the beach or the swimming pool or just being out in a lineup at a store and and seeing somebody else wearing a glucose sensor. And we kind of feel do like a fist pump or something. I remember having a little girl come up to me at my daughter's track meet and she was smiling so big until I realized she was looking at my glucose sensor on my arm and showing me, hey, me too. So it's kind of a cool way for us to identify each other out there. I see that as a big positive. So. So what do we see when we see somebody wearing a glucose sensor on their arm? If this is new to you,

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underneath that, that transmitter that you see on the outside or that sticker that you see on the outside, there's a glucose sensor that's inserted below the skin and it's a tiny little hair like filament. Many people when they take it off for the first time, they're very surprised by how fine that little, like a little wire that's underneath of your skin and that is measuring the glucose in your interstitial fluid, which is just below your skin. It is not inserted into a bloodstream. It's not reading blood glucose, it's reading interstitial fluid. For that reason, some people

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really expect that meter or that glucose or sorry, expect that CGM to be exactly the same blood glucose reading as their meter. But they're never going to be exactly the same because they're measuring a different substance. But the accuracy of this has come a long, long, long ways. So you're going to wear this glucose sensor for anywhere from 7 to 10 to 14 days, depending on which system you're using. And how you get those readings depends on which type of system you're using. So the first category would be a scan or flash glucose monitor and that would be the Freestyle Libre,

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the Freestyle Libre One and the Freestyle Libre Two, which we have here in Canada. And with those, what you do is you take either your smartphone or your reader and you're going to scan it over your sensor to retrieve your data

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with a real time continuous glucose monitor. And this would be the Medtronic and the Dexcom systems that we have here in Canada. There is a Bluetooth capability on that sensor. So there's a transmitter attached on the outside and it's going to automatically Bluetooth that reading over to either your smartphone to your reader or to your insulin pump. So can be used in many ways and there will be a continuous reading sent that way. The bonus with that continuous delivery of data is that you can set different glucose alarms. And so you can say, hey, my blood sugar is coming up or it's low right now

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or it's high right now and then we can get into some predictive alarms as well, which is hugely beneficial. I don't just want to know that I'm low, I would like to have an advanced warning that I'm going to be low. So that's where we really start to see that therapeutic benefit is when we add that in.

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So when you get your reading, no matter what type of glucose monitoring system you're using for CGM, so whether it's a scan one or real-time CGM, you're getting a lot more information than just a blood glucose meter. Where you get a number you get, hey, I'm 8.9 right now, you're going to get, OK, I'm 8.9 and you'll get an arrow. So it will say OK, you're steady, you have a a straight arrow or you're rising or you're double airing up, you're rising quickly or you're falling or you're falling quickly. And that's incredibly powerful data.

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You think about times when you're about to drive your car, you're about to exercise, you're about to go to sleep at night. To know that you're 8.9 and rising or falling is very drastically, probably going to change what you may do in that situation. So that's a huge, huge piece of power that comes with these systems. The other piece of information that you'll see is you'll be able to look back and see a trend graph. So you'll be able to see over the last several hours what's my glucose been doing. And again, that teaches us a lot about what happened after I ate my last meal. What happened when I

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exercise this afternoon overnight, we can actually see, OK, did I steadily climb overnight or did I climb at one time or did I drop it one time? We see a lot more insights as far as what's going on on a day-to-day basis. And really, all the factors that influence our blood sugars, really, we start to see those in real time.

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Wow, sounds like an incredibly powerful tool. Um, even just from a safety perspective. Absolutely. From that aim, it also sounds like a lot of numbers and a lot of data. So what? Really, what, what? I guess

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is most important in terms of people monitoring the numbers and the data that they can in terms of getting knowledge.

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Absolutely. It is very fair to acknowledge that it can be very overwhelming to go from getting a few blood sugar checks throughout the day to seeing a 24 hour glucose profile and potentially a number every minute or every 5 minutes. And so my best piece of advice at the beginning you're starting C Jam is just stop, take a breath, all right. And we are not wanting to watch minute by minute by minute by minute. Let's just take a deep breath, maybe look at it once an hour, right. We still want to live our lives and and at the beginning, really it's about

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just exploring and learning your patterns. We don't want to fix everything right away. So let's say, OK, I I never used to check my blood sugar 45 minutes after I ate breakfast and today I put on a CGM and I'm seeing it soar up to the sky and I want to fix it. Well, wait a second. Let's take a deep breath. Let's see what happens. I never used to fix it, right. And maybe we see that it comes back down. It's it's very, very normal to see a lot of roller coaster ring when you put on a CGM for the first time. And our goal over time is to learn what's causing those roller coasters and what can we do to smooth it out.

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It is almost never going to be completely flat, OK. Even somebody without diabetes does not have a flat CGM line or very few people would if it is normal to have some peaks and valleys. But we just want it to be a little bit of a smoother ride, OK. So we are going to learn a lot there.

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What we're really looking for as far as a target is we're looking at a new, a new piece of information that we call time in range. And if this is a new term to you, what time and range means is how much time you're spending between 3.9 and 10. OK. So that's kind of where we're aiming to be. And the goal is not to be in that 3.9 to 10 range 100% of the time, not even 90% of the time. This is not going for an A+ in school. The goal is 70% and that is set by

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the Canadian guidelines and also international consensus guidelines. We have seen that that time and range of 70% correlates very nicely with within A1C of 7% which is our goal, A1C and that is where there's been an abundance of research done as far as minimizing the risk of long term care complications and whatnot.

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Now what I'll say though is as much as 70% sounds like it should, well maybe it doesn't sound, but if you're new to see Jimmy, we go, I should be able to get 70%. It is really hard to get 70% time in range. So many, many people will start out on a CGM well below that. So what we also know is that even just an improvement by 10% is going to have a clinically meaningful impact on your overall health. So if you're starting out at 45% and you get up to 55% to start, we're moving in the right direction. OK. We just want to keep moving

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forward overtime. We're continuing to add in more technology. When we get into later automated insulin delivery, I start to see it much more achievable and realistic to get that 70% without all the burden and the work that may come with that. OK. Now as a side note, there are some people who will not use a 70% as a goal. There are certain situations where we do customize that and knowing that you know if there's a risk of hypoglycemia or other health conditions going on, sometimes we will change that. So just be aware of that and talk to your healthcare team about that. The other thing

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that is just as or or even more important actually is we want to pay attention to how much time you're spending in the low range. OK. So those are the two important, we want to be 70% or aiming for 70% in range and we want less than 4% in the low range. And those are unread on all of your CGM reports, all your CGM data and that represents about an hour of the day. We do not want to try to get to that 70% and increase our lows. We want to minimize that and get it as as low as possible. For many people, 4% in the low range even feels like too much. So we do want to,

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to make sure we look at that your healthcare provider can spend time looking through your GM reports with you to figure out kind of what those patterns are. You can log in no matter what system you're using. You can look into care link if you use a Medtronic Libre view, if you're using a Libre or Dexcom clarity. And you can go back and and look kind of day by day and go, OK, where am I? Where am I? Where are things going well? And you know, here's a day where I was in range 70%. What did I do that day and maybe learn from our patterns what worked well and can I do more of those things. And then you can look for periods

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where you tend to run higher and tend to run lower and think about maybe what may have caused some of those and and make some action plans around that.

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I I'm fully intrigued. It sounds complicated, but so useful. Amazing, quite frankly. OK doesn't have to be complicated, Kayla. It sounds like it's just take that deep breath. It's supposed to make life easier

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for sure. And and then you mentioned insulin, so why don't we talk a little bit about insulin pumps.

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So an insulin pump, if you're not familiar, I know we probably have some people in here who are newly diagnosed. So let's just kind of compare how insulin is delivered differently at the pump versus if you're on injections. So if you're on injections and multiple daily injections, you'd be using two types of insulin. So you're using a long acting insulin which is just covering those background insulin needs. We need insulin even when we're sleeping, right. So that's what our long acting insulins are covering and between meals and then we have a rapid acting insulin that we use at a meal time.

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So the one drawback to that is well our long acting insulins have improved significantly over the years. They assume that we need a steady amount of insulin 24 hours a day and what we know is that a lot of people don't necessarily have the same insulin requirements 24 hours a day. So with an insulin pump, what we do is we use rapid acting insulin only and it's given like a little continuous drip, just like somebody's normal healthy pancreas where they getting a continuous amount of insulin all the time. And that allows us to

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fine tune and and give different amounts at different times of day to more closely mimic what your insulin requirements are in the background without food. OK. That insulin is delivered through a an infusion set or through a pod and there's a small little cannula that's inserted underneath the skin, very flexible, very comfortable to wear and there are still some other types of sets out there, but those are the most commonly used ones. So not to be intimidated by that. And so it's giving you that continuous drip for that background insulin requirements. The other beauty of that

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background basal drip is because it's only using that fast acting insulin, we can take some away in certain situations. So you can set something called I I'd like to talk about this right away. We consider it an advanced feature, but a temporary basal rate for something like a more active day. I can turn my pump down if I'm going to go out for a walk or go play tennis or go do something this afternoon. I'm not stuck with that long acting insulin that I gave this morning or last night at bedtime and then I can turn it back up. If I have a time period I'm sick or I'm traveling and I want a little bit more, I can temporarily turn that up

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or dial that back. So that's a really nice advantage of insulin pump therapy.

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So then for our bolus, so for our meal time or our correction insulin, we call that all bolus. We're getting one hit at a time that we go in and you program that into the pump. So typically what we do is we enter in our grams of carbohydrate and it has a bolus calculator. You plunk in your blood sugar and it's going to tell you how much insulin you need for that meal or for that correction. And taking into account a number of other factors as well, it makes it really nice and flexible as far as, hey, you can decide you want a second helping of dinner tonight? I can go and give another bowl

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someone's birthday and there's a dessert. I can give an extra bolus. So we do get a lot of flexibility with our meal time dosing when we use an insulin pump and that is a big draw for a lot of people.

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We kind of we can think about our insulin pumps now into into two main categories. So our first one it would be our non connected or our basic insulin pumps and these ones you're completely in the driver seat. So all of our pump, these do not work with our CGM. All of the pumps on the market in Canada today you can use as a basic insulin pump. So just because some of them have all the bells and whistles doesn't mean you can't use it as a bare bones pump. So if you want to be in the driver's seat and you want to be the one programming your basal rates and making all of your

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adjustments and corrections on that fly, then then that's can be a good way to start. So in Canada, we have a Medtronic system, we have the tandem system, we have the Omni pod, which is the patch pump, and then we have the Yips Ahmed insulin pump as well. So those can all be used as a basic insulin pump.

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The newer option or the second option is if you want your insulin pump to work with your continuous glucose monitor. Now we have a connected insulin pump and we can have different levels of automation with that. And right now in Canada, we see that with the Medtronic and the Tandem systems where we have some level of automation or some options for that.

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So is what you just described what is known as a closed loop system exactly. Yeah. So I want to dive into that now.

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Yeah, leaping, leaping the hot word. Yes, we're layering on the text. So those last two options I talked about and actually I I just talked about too. So with both Medtronic and with Tandem, we do have this ability to use a closed loop or automated insulin delivery. And I will say right off the bat, this is not yet completely closed loop. There still are some things we have to do. OK. So I'm going to explain this also. There is 1/3 option out there as well, which I think we're going to, I'm going to save for another question here, but we do have people using do it yourself.

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Automated insulin delivery system. So we'll get into that. But there are some, there's some core similarities between all of these systems. They use their own unique algorithms. So we are going to see some, some, definitely some differences in the way you program it and the way you manage with it. But as a core, let's talk about how they deliver basal and bolus insulin.

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So that basal insulin, that background insulin that I was talking about on an insulin pump, we program a basal rate to be to be set. So this is your insulin needs at this time of day, it's going to be here at this time of day here and it's going to, it's going to do that just on its own. So now if we add in automated insulin delivery, it's looking at the algorithm is looking at your continuous glucose monitoring readings and it's saying, oh, Alana, your blood sugar is running a little bit on the higher range right now. It's rising quickly. I'm going to give you a little bit more

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right now or oh, now you're starting to drop. I'm going to dial back your basal insulin delivery right now or oh, it looks like you're about to be low. I'm going to stop your insulin delivery right now. So it's kind of got this ebb and flow going that's being adjusted continuously throughout the day and throughout the night. And that is incredibly powerful. Does it get rid of all of the lows and all of the highs? No. Diabetes is still difficult, but we see incredible results with people more than I ever could have imagined, usually from night

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one. Almost everybody that I have started on an automated insulin delivery system sees that blood glucose comes room into range overnight. That overnight glucose profile flattens beautifully across the board no matter what system you're using. And we see that in all of the research studies that are done on this. Will there be the odd person who maybe doesn't see that effect? Yes, we do see that happen sometimes, but it's very rare. So that overnight glucose becomes very consistent very quickly. And then during the daytime, things do get a little bit more challenging

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because guess what, we eat, we exercise, we move, we get stressed out some days. And those things, you know, can throw our glucose in different directions. And this system is going to do its best to try to manage that and it certainly will do better than us having to try and stay on top of that all day long. But we do see sometimes a little bit more variability happening during the daytime,

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OK. So that's that's that basal adjustment that's going on all the time

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for bolus, we do still need to to tell the insulin pump systems that we're eating right now. Unfortunately, we are still stuck with rapid acting insulin that is still a little bit too slow. If you've ever worn A continuous glucose monitor and you've eaten and if you dose that insulin a little bit too late, we do see the glucose rise up and there's a lag time between when that insulin action can catch up to our food sometimes. So if we were to allow a system to just dose when it sees our blood sugar go up because our insulin is still not quite fast enough, it's it's going to have a hard time playing catch up.

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So at the moment what we still do need to do is give that pump a heads up, hey, I'm about to eat, I think I'm eating about 30 grams of carbs or whatever it might be. And then you give that bolus and then in that delayed later after the meal, maybe if I made a little bit of a mistake on my carb counting, it's going to be able to to adjust my insulin delivery later and try and help make up for any errors that may have been done there. And we're seeing that as a very positive thing right now.

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What these systems can do though is they can deliver an automatic correction bolus. So like that situation, I just say, let's say at lunch today, I end up under underestimating the carbohydrates I eat and I go a little bit above target after lunchtime. Well, if that system detects that maybe it's been turning out my basil, but it may say Ohana, we need to give you an extra correction bolus and it can go and do that. So we do see that being very beneficial for people and and definitely take some of the weight off of our shoulders for sure.

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All right. I am not sure if you wanted to just jump right into the do-it-yourself system. I know we have a a very in depth deep dive on do it yourself and some new clinical practice guidelines just came out. But would love to hear you give everybody a a sort of an update on that

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the way so do it yourself and diabetes, I mean think about diabetes and we're doing it ourselves pretty much every day, right. It is one of the few conditions where we are in the driver seat having to self manage type one diabetes and type 2 diabetes especially as well. So what what we think about is before the days that we had commercially available automated delivery systems, these are still very new to the market. We had some people saying hey listen, we have insulin pumps on the market and we have continuous glucose monitors on the on the market and it is taking too long

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has to have these two pieces work together. And if you take some of, you know, the most brilliant minds out there in the type one diabetes community, they said let's do something about this and that they did. And you know I will be the first to say when I first heard about this movement, it frightened me a little bit. I went Oh my goodness, like what what is this going to be? But what we've seen is, is really a beautiful thing happened where they've where they've made this work together with some algorithms. You basically will what's missing is, is the algorithm in the middle, right. So they have that openly available online

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with instructions on how you can put this app on your phone. So you have to build an app on your phone which will speak to both your pump and your CGM and doesn't work with all pumps and it doesn't work with every system. So that is something to do some reading on, but and then in some cases we need a connecting device that works to allow these things to speak together. But what I will say about this is that as I said, we were all a little bit nervous about, you know, is this dependable, is this safe? There has actually been an incredible amount of research done by this and we have many, many people

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using these systems and we have seen that indeed it does improve glycemic outcomes incredibly and we have not seen the adverse events. So that has led us to developing a position statement for Canada where we say, yes, this is a viable treatment option for people and as healthcare professionals we need to support people who are willing to use these systems. What I will say is probably the most important take away from this is that if you're using one of these systems or if you want to use one of these systems, yes, you as the user do have to go and and follow those online instructions

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to build your app and to get it up and working. But still definitely involve your healthcare team, especially if you're new to pump therapy, you need help with those initial pump settings and whatnot. And down the road that fine tuning and making some of the adjustments to the settings, you should involve your healthcare team with that for sure as well.

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Really cool stuff though that's for sure very fascinating. Yes. Yeah. I'm just wondering if we can touch for a minute on sort of the risks or challenges associated with this because it does sound very exciting and very powerful in terms of diabetes management. But are there maybe some people that shouldn't be using technology and what are some of the risks associated with it? So the greatest risk with technology is that technology can fail.

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So yes, your CGM could stop working today. Yes, I could leave my phone at home today or I could end up with a power outage and I can't charge my devices. So we absolutely always have to think about what if my technology fails and have a backup plan for that. And so that is where we certainly do say you know, for continuous glucose monitoring you still need to have a blood glucose meter and you know will you need to use it very often. There's there's nowadays with the accuracy there are very few times that you need to confirm a finger stick with a finger

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check, but make sure you have that meter on hand. If you're going out for a day trip, you're going on a holiday, bring a meter with you. For me, I have actually put my blood glucose meter in a neon coloured case right now because I don't use it as often as I used to and I can't find it when I need it. So it's, you know, it lives in a certain spot. It's in a bright pink case so that I can go in and grab that when I need it. Same thing with our insulin pump systems, right, Those if your insulin pump goes down. The manufacturers are incredible at iPhone. That 1800 support line

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in the middle of the night and they get a pump to you as fast as you can. But natural disasters happen. I live in Kelowna. We've just we're in the middle of of this fire season right now and you don't know if you're going to be blocked in somewhere. I've I've heard all sorts of stories of people getting close to being in trouble. So again, you want to have a backup. Keep some insulin pens. I'm a really big fan of keeping some old fashioned insulin syringes. We can always drop insulin and give insulin as we need. So definitely talk with your insulin pump trainer, with your care team. If if you don't know how to replace the insulin manually, you need to have a

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plan for that. And that is incredibly important. Absolutely.

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Now as far as you know, is this too risky to use technology with certain populations? I love that question because for for many years we did, we did wonder about that. And this has been one of the most incredible shifts with the most recent generations of the technology that we have available today is that we do see that people can be successful on an insulin pump or on CGM regardless of your education level, regardless of how long you've had diabetes, regardless of, you know, where you come from,

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what you have access to or where you're where you're where you're starting A1C, is. There are were times we thought, oh, we should probably try and bring things, you know, closer to target before we start you on this. Hang on a second. No, no, no. That is an old way of thinking. We know now that people actually with a higher A1C have a bigger drop and a bigger improvement when they start using some of these devices. So really it's it's, it's open to everyone for sure, as long as you're willing to participate in your care. As I said, none of this is completely plug and play. You do have to engage with it and and be willing to kind of follow

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patterns and whatnot, but I'm certainly accessible. It should be accessible to everyone.

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OK, great. You mentioned, you know some of the more traditional methods like the the syringe and the insulin pens and things like that. So you know, when would it be good for someone to start technology and and how do they know when they're ready? Because it sounds like having that basic foundation upon diagnosis really lasts you throughout your entire sort of diabetes management journey. So can maybe anyone start or is there a sort of a leg time in terms of of of

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kind of a good time to start would be,

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yeah, great question. So you know this really should be a very individual decision. Absolutely. You will. You and you may sometimes think, can I be ready for this? And we may question ourselves, but I think it's worth everyone exploring if they want, if they may be interested in using diabetes technology.

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Especially at diagnosis, things are incredibly overwhelming. You are learning a lot of information and in many cases your world has been completely rocked and it can be like, Oh my gosh, we need to layer on something else. But what? And so our traditional thinking used to be, hey, let's wait, let's teach. As you mentioned, let's teach kind of some of the the basics, the traditional education, let's start slow and we can get to that later.

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What we're seeing now in the research though is that the sooner you start using technology the better. So for example, there was one study done in the US where they took a look at people who started on CGM within the first six months of diagnosis and those who started later or didn't start on it. And they saw that seven years later those people who started on a real time CGM within that first six months had a lower A1C than those who started later or those who didn't start at all. So what we see

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there's this, there's this kind of this theory about the sooner we can get you on track, we get you on this different trajectory over time. And if we can kind of get you on that on that track earlier after diagnosis, it's going to help you stay there. Again, does it mean it's going to be perfect? No, But the sooner the better is what we're starting to see. We're even seeing some research starting to come out where they're looking at even using automated insulin delivery very soon after diagnosis and people doing very well with that and again that having a lasting impact. So we are seeing this start to shift. We are working on updated

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type one diabetes guidelines in Canada right now. So stay tuned for where that official recommendation comes. But that is that is the pattern that we're starting to see. And and it really makes a lot of sense because we get so much power out of learning what our glucose is doing in different situations that why not give us the tool to be able to see that. And the other thing is that we also see a lot of burden left it. It's like, OK, instead of, you know, being newly diagnosed and not being sure, OK, do I feel low? Is this a low or is it not And to be able to just quickly look and go, OK, no, that is what's happening.

33:42
Um, it's it's a really great learning tool as well.

33:47
Perfect. I'm kind of still stuck on the do-it-yourself people building their own app. So on that note, outside of some of the company's, you know, pairing systems with with reading and things, are there other apps and sort of services out there that help to pull it all together or provide education or or help with respect to diabetes management. So there's there's so much available online right now it it can almost become overwhelming, right? So definitely as far as

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information goes, you know all of these technology companies have their own websites. That's a great place to start just to get making sure that you're getting the clear information from the company on what their system does and doesn't do. But it's also nice to look on some third party websites to kind of see a true comparison of some of the less of the marketing messages and more of the what are the actual things that these things do and don't. So Diabetes Canada always has an abundance of information. I as as you mentioned Kayla, there is a another deep dive with Doctor Halpern on the do-it-yourself systems diabetes. wise.org is

34:53
a great resource for going in and looking at different types of systems out there on the market. Many of the health authorities have really great websites with lots of information as well. Another one I'm thinking about good for technology is Waltzing the Dragon out of Alberta. They're very up-to-date and have a lot of information.

35:13
And then as far as third party apps, really what you want to consider is which apps are going to work with the devices that you are using. Not everything is cross compatible. If you're not using any tech at the moment and you're just kind of wanting to explore it, probably a first step for many people is OK, maybe I'm interested in an insulin pump, but I want to start with a bolus calculator. That's what our insulin pumps use. So there's a few systems out there that do that. Diabetes M is a really great little app where you it has a

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goal is calculator. You can start to get a sense of how some of these systems calculate your insulin doses for meal time. So work with the healthcare team to to set that up though because there are some factors you'd have to put in yips amed that insulin pump company. They do have an app that actually works with their pumps that you can use when you're using multiple daily injections. Again to get a sense of kind of how those calculations work. So that could be a starting point. And then there are some apps that do work that can help Mary data together. So usually you will use the apps that work with your system. But what if I'm using, let's say a Medtronic

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Island pump and a Dexcom sensor and I want my reports to feed together. So that would be a system called tide pool. You can actually upload your your pump and your sensor data and it will come together. Many clinics, we use something called Gluco and your diabetes team will use that. So not Google, but Gluco and that does work with many of our insulin pumps and we can get our sensor data in there as well. So lots of information out there, but but definitely talk with your care team about what you choose to use because some clinics are more used to looking at the reports and whatnot on sound systems versus others.

36:52
Thank you for that. So valuable because as you said, there's so much out there, there's so hear from someone like yourself, those are great options for people out there. Just to call out to those people listening in and we'll be taking the last questions now. And before we sort of wrap up to help us learn and grow, we're going to pop an evaluation form into the chat. So if you want to take a minute or two just to fill that out, that would be great. From our end, a few more questions. So I I think we all

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know that people living with type one diabetes obviously take insulin and so this is a very strong conversation for them. But there are some people living with type 2 diabetes that are also taking insulin. So I'm assuming that these technologies work equally well for those people living with type 2 diabetes as well.

37:43
Absolutely. And and this is we're getting, you know, a growing body of evidence to support this. So depending on where you live, your coverage for using these products is likely going to be different. If you live with type 2 diabetes, for example, here in BC, a continuous glucose monitor you have coverage for if you're living with type 2 diabetes and you're using multiple daily injections. So you're not just on long acting insulin, but you're also on rapid acting insulin. Different provinces have different levels of coverage depending on what type of a treatment regimen you're on. So that is something that you're going to want to look at.

38:17
But yes, we're seeing the benefit, especially someone if you're living with type 2 diabetes, that continuous glucose monitoring is incredibly valuable. You're trying to learn how different food impacts your blood sugar. You're trying to minimize those spikes. So we, we can learn so much about what our glucose is doing to facilitate us making some changes to our daily behaviors. And we're going to, we're going to, we see more and more studies coming out on this, but we do see that A1C improvement across the board no matter what type of diabetes you have. So we're just kind of waiting to get that kind of put together

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a little bit more. But you can benefit from that, an insulin pump and getting into those automated insulin delivery systems. Those are going to work. I mean, you could use it in theory, I guess just for that background basal insulin. But really it's if you're using those multiple daily injections, absolutely you can go in and you can bolus through a pump. I've seen many people with type 2 diabetes do incredibly well on insulin pump therapy.

39:13
I thank you for that. Speaking again, still on technology, what about emerging technologies? I think things are changing so rapidly. Is there anything really wonderful on the horizon?

39:26
You know what? I I can't wait to be surprised. I really can't. So you know I think back to you. I was diagnosed as a kid with type one diabetes and I also had an older sister with type 1. So I had the benefit of having someone to banter back and forth with as a kid about our hopes and dreams. And we would talk about, you know, I wish one day I could see my glucose on my watch. Would that be so cool? You wouldn't just have to wonder where you're at. You would actually know. And we have that today. There's smartwatch integration and and things talking to each other. So I was surprised that that

39:58
going to be I I almost can't even imagine what's next but there are some, there's some really cool things that are being looked at it's it's amazing diving into some of this research. I think the biggest race right now is to refine the algorithms that are automated insulin delivery systems are using so that they can tackle our meal time insulin doses.

40:20
Having to figure out how to dose our insulin every time we eat, quite frankly, is not fun for any of us. And so we have this limitation of our slower insulin. But I have listened at some conferences to researchers, you know, battle back and forth on how they're going to tackle this and how these algorithms do it. And I'm very, very excited to see how that comes to a finish in the US. There's a new system out right now that allows you to simply say I'm eating a small meal, a medium meal or a large meal,

40:51
and then it can and then it can figure out that dosing from there and make up for some error in between. And to me that sounds like an incredible weight lifted. We also see a lot of work needing to be done with exercise. And so how do you teach an algorithm how to adjust to me sitting in my office chair during the day to now having a day where I'm going out for a run or I'm going skiing or I'm doing or I'm gardening, You know, all these things that can throw our blood sugars off. And how do we have these systems catch up on that really quick, much more quickly and effectively and take away some of the work that we have to do? So that's

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that. I'm excited to see how that comes.

41:27
I think really what we're going to start to see though is integration with our smart devices. So if you think about if you wear a smartwatch, it can read your heart rate. OK Can that somehow link in and give some information to my insulin pump system? I've seen some things on even it being able to tell you're leaving your home and smart homes and how can we work those things together? 1 researcher in Europe somewhere was doing something where they were trying to figure out how to tell when people are eating or drinking based on their hand movements and can that be synched in to an algorithm. So it's it's incredible

42:00
and I think with artificial intelligence we're going to see some really cool things but it will be slow because they have to make sure that these things are indeed robust, safe and and what are the possibilities of error. So we weren't going to see it immediately tomorrow, but I think we're going to see some pretty exciting things in the future. I I can't wait to be wowed. I love it. And maybe someone can work on making a faster, fast acting insulin.

42:24
Absolutely. We'll hope for that. Alright, so one last question, It's a bit of a personal question. Just any final words of wisdom in terms of, you know, how to make the best use of of the technology?

42:36
Yeah, you know what I think my biggest advice would be, you know, take a deep breath, like I said earlier, give something new a try. If you're hesitant to use technology or you had a past bad experience with technology, I've heard that a lot. You know, I tried one of the old CGM systems that my clinic put on me back, you know, 15 years ago and it was a horrible experience. Well, let's just open our eyes a bit to our technology has vastly improved and you know give it a try but don't expect overnight results.

43:08
Some people do incredibly well as soon as they put technology on and it's boom, it's life changing right away. And for some people it can take, you know, those first few weeks can be a really big learning curve. I often say, you know it's like having a new baby that first month is tough, then you have three months and then you have six months and it's an ongoing learning experience until it really kind of becomes a part of you and and you know it shouldn't be too much work. What we think the biggest change we see now in new technology versus old technology is that now it should be lifting some of the burden. So by putting on tech,

43:41
I should be able to take a deep breath and and have my system help me no matter what that technology is. And if you're feeling like you need to put more work into it and it's more work, that is a red flag and it's time to go and talk to your healthcare team and say, OK, what? What's going on here and how do we make this work better? Or do I need a different system? But it should be able to lift some of the burden for sure.

44:03
Great. Alright, well we've come to the end of our time. Thank you everyone for taking time out of your busy schedule to join us today. Taking time for ourselves and our personal care is never easy, but it's so important and the benefits are always worth it. If you haven't had a chance to fill in the evaluation yet, please consider doing so now. It does help us learn and prepare for our next sessions to meet your needs better. The link is posted in the chat, so please have a look for it there. With that, a very big thank you

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to Alana, our guest expert. Today I am very intrigued and while I always learn during these open hours, I feel like today was a major milestone for me and I hope all of you took something from today as well. Without the generosity of your time, these open hours would not be possible. And thank you to all of you for joining us today. Open Hours runs the last week of every other month with a different topic and guest expert, so be sure to follow us on social or visit the website regularly for updates. To learn more

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can stay up to date on Diabetes Canada work and resources. You can visit our website www.diabetes.ca or check our social media channels. We're on Facebook, Twitter, Instagram and LinkedIn. You can also call our info team at 1800 Banting BANTING or e-mail info@diabetes.ca with questions. Please join us again in October for our next diabetes open hours. The theme will be how to deal with a new diagnosis. Please stay tuned to our social channels and our Diabetes Canada Open Hours website page for news about the date, time

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and guest for our next conversation. And with that, thank you so much again and we'll see you next time.