Author: Dana Lewis

Makers gonna make…a book about diabetes devices? Kids book written by @DanaMLewis

by Dana Lewis

book inspirationLast year after Christmas, I was running around my parents’ backyard with my niece when she spotted my CGM sensor on my arm and asked what it was. I’m always struck when my niece and nephews have noticed my diabetes devices, and am interested to see what “new” humans think about and how they encounter things and what they mean. In this case, I explained the CGM and we went back to running around, but it stuck in my mind for a few days.

I also remember the excitement and attention any time a kids’ book has a character with diabetes in it, or a storyline of diabetes, because there’s just not much out there. I was diagnosed at 14, but I love seeing PWDs in the wild and like the idea of more diabetes inclusion in materials for all ages.

So, I wrote a kids book, with the goal of introducing the concept of diabetes devices and more broadly, how people are different in different ways. I talked my incredible artist aunt into illustrating this book. :)

This book is primarily for me and my niece and nephews, but I know there might be a few other people who like the idea, too (even as there may be a few people who sniff at the idea*). I investigated the publishing options and decided to go with self-publishing, which would allow for:

  • The cheapest copies for me as the author, to be able to give to my various family members who want them.
  • The ability to make it available to other people who want copies.
  • The ability to price said copies so it’s accessible and reasonable to order easily.
  • (It’s actually cheaper for you to order this on Amazon directly to your house, than it is for you to ask me for an author-priced copy and for me to go through the hoopla of getting it to ship.)
  • Every two copies purchased via Amazon yields an author-priced copy that I plan to donate to libraries, hospitals, etc. (If you’d like to sponsor 10+ books for a library system, feel free to ping me about the easiest way to do that.) I’m planning to use any “profits” from the book to pay for copies that I’m donating.

I’ve been working on it off and on for the past few months as my aunt illustrated it, and got to give a copy to my brother and niece as a total surprise to read when we were in Alabama this past weekend. So now that the cat is out of the bag, the book is available online! The book, “Carolyn’s Robot Relative” (that’s me!), is available on Amazon here (note that’s an Amazon affiliate link). (There’s also now a German-translated copy with the title, “Ist Carolyns Tante ein Roboter?” – see the German version on Amazon.de here!)

—

robot illustration @DanaMLewisI also *love* the robot illustration that my aunt made with the CGM as the main body of the robot.  I reached out to someone on Etsy who does custom “stuffies” – and it turns out, she has a diabetes connection, too! So, you can get a stuffed CGM robot if you or your kids like it, for $20. Here is the link to the listing on Etsy. (I don’t make any money from this; I paid $20 for my first one, but had worked with her on pricing so it would be reasonable for people to get if they liked it!)

CGM robot stuffy from Carolyn's Robot Relative by DanaMLewisCGM robot stuffy from Carolyn's Robot Relative by DanaMLewisThe stuffy with the book – it’s an awesome sized stuffy!

And because I have also been playing with code fabric on Spoonflower (see tweet thread here, or this blog post here) and know they do fabric as well as gift wrap…I uploaded the CGM robot there so I could turn it into wrapping paper, too. Here’s the link to see it on Spoonflower.

CGM robot giftwrap preview! available on Spoonflower as fabric, gift wrap/wrapping paper, or wallpaper—

I learned a lot in the research process about self-publishing options and the route I took that I wanted to share here, especially for anyone who sniffs and goes troll on me about putting this out there.

*Tl;dr – self-publishing is easy, and if you don’t like my book, go make a better one yourself! :) The more books, the better!

—

Some background on the publishing process & how I made the book:

I chose self-publishing with CreateSpace on Amazon. They now have this new “Kindle Direct Publishing” (KDP) program that’s similar, but less tested than CreateSpace, and seems to be higher cost for author copies. I never figured out what the benefits are of that, and chose CS.

I generally Google’d a bunch of questions and ended up on the CS forums, too, and read up on different programs to use to create the book, etc.

My process:

  • I wrote the book test in Microsoft Word, then translated it into a Google spreadsheet so I could visualize the left/right layout of the flow of text, as well as start to identify where I had ideas about what images to use.
    Example_storyflow_spreadsheet_Dana_Lewis
  • My aunt began illustrating, and sending me pictures. Fun fact – all of the images in the book are put in via iPhone photos -> AirDrop -> my computer -> inserted! No fancy graphics. (Although I did open a few of the images in Preview and change the white balance, since each photo was taken in different lighting, in a weak attempt to balance the colors of the pictures side by side.)
  • I started dropping them into a Microsoft Word document. The one thing the CS forums warned about was making sure the images were high enough res. The images were…but later in the upload process, it complained about the DPI being low. I switched to Microsoft PowerPoint (doing the same thing I did in Word to create the custom page size to work with bleed, trim, etc.) and dropped the images in the same way, and PPT doesn’t compress the images and it was fine. Word was problematic. It didn’t take much time to switch back and forth, but if I did it again, I’d start with PPT because they generally seem to get that images need to be full sized.
  • (A workaround if you take screenshots and need to insert images – you can use Preview to go in and adjust the size and make it >300 DPI that CS prefers, before inserting the images into PPT).
  • I placed text boxes on top of the images.
  • Once done, I saved as a PDF, and then went to upload to CS. I uploaded and tweaked and viewed the Digital Proofreader tool about a dozen times the first day I did it, as I wanted to move text a tad up or down, and as I resolved the complaints about DPI not being great.
  • (You do the same process for the cover image, and CS is pretty good about telling you how to calculate your spine size for the number of pages in the book, and adding that in to the front/back cover size to calculate what you need. You can also get a sized template from them, and then use images and cover it up so it’s sized perfectly.)
  • Once you’re happy with what’s uploaded to the system, you submit to CS for review (takes 24 hours). You then get to review another digital proof, and a PDF version, and then get the chance to order a physical proof copy!

Tl;dr version 2 – it was actually super easy, even for someone who’s not a graphic designer, to do this. This was a great method to work with an illustrator with simple iPhone photos of awesome illustrations and turn them into a book. You could probably also scan and do all kinds of fancy stuff…but for a basic book, the basic process described above works great. It actually doesn’t take much time in terms of placing text or uploading and tweaking your file.

The hardest part was calculating the size of the pages and deciding on whether to do with bleed or without bleed.

The other hardest part was keeping the topic of the book a secret from my mom for 10 months, because I thought she’d get a bigger kick out of being surprised with the book’s topic and contents when she had a finished copy in her hands. Sorry, Mom! Hopefully you thought it’s worth it. :)

front and back of "Carolyn's Robot Relative" by @DanaMLewis

Why Open Humans is an essential part of my work to change the future of healthcare research

by Dana Lewis

I’ve written about Open Humans before; both in terms of how we’re creating Data Commons there for people using Nightscout and DIY closed loops like OpenAPS to donate data for research, as well as building tools to help other researchers on the Open Humans platform. Madeleine Ball asked me to share some more about the background of the community’s work and interactions with Open Humans, along with how it will play into the Opening Pathways grant work, so here it is! This is also posted on the OpenHumans blog. Thanks, Madeleine, and Open Humans!

—

 

So, what do you like about Open Humans?

Health data is important to individuals, including myself, and I think it’s important that we as a society find ways to allow individuals to be able to chose when and how we share our data. Open Humans makes that very easy, and I love being able to work with the Open Humans team to create tools like the Nightscout Data Transfer uploader tool that further anonymizes data  uploads. As an individual, this makes it easy to upload my own diabetes data (continuous glucose monitoring data, insulin dosing data, food info, and other data) and share it with projects that I trust. As a researcher, and as a partner to other researchers, it makes it easy to build Data Commons projects on Open Humans to leverage data from the DIY artificial pancreas community to further healthcare research overall.

Wait, “artificial pancreas”? What’s that?

I helped build a DIY “artificial pancreas” that is really an “automated insulin delivery system”. That means a small computer & radio device that can get data from an insulin pump & continuous glucose monitor, process the data and decide what needs to be done, and send commands to adjust the insulin dosing that the insulin pump is doing. Read, write, read, rinse, repeat!

I got into this because, as a patient, I rely on my medical equipment. I want my equipment to be better, for me and everyone else. Medical equipment often isn’t perfect. “One size fits all” really doesn’t fit all. In 2013, I built a smarter alarm system for my continuous glucose monitor to make louder alarms. In 2014, with the partnership of others like Ben West who is also a passionate advocate for understanding medical devices, I “closed the loop” and built a hybrid closed loop artificial pancreas system for myself. In early 2015, we open sourced it, launching the OpenAPS movement to make this kind of technology more broadly accessible to those who wanted it.

You must be the only one who’s doing something like this

Actually, no. There are more than 400+ people worldwide using various types of DIY closed loop systems – and that’s a low estimate! It’s neat to live during a time when off the shelf hardware, existing medical devices, and open source software can be paired to improve our lives. There’s also half a dozen (or more) other DIY solutions in the diabetes community, and likely other examples (think 3D-printing prosthetics, etc.) in other types of communities, too. And there should be even more than there are – which is what I’m hoping to work on.

So what exactly is your project that’s being funded?

I created the OpenAPS Data Commons to address a few issues. First, to stop researchers from emailing and asking me for my individual data. I by no means represent all other DIY closed loopers or people with diabetes! Second, the Data Commons approach allows people to donate their data anonymously to research; since it’s anonymized, it is often IRB-exempt. It also makes this data available to people (patient researchers) who aren’t affiliated with an organization and don’t need IRB approval or anything fancy, and just need data to test new algorithm features or investigate theories.

But, not everyone implicitly knows how to do research. Many people learn research skills, but not everyone has the wherewithal and time to do so. Or maybe they don’t want to become a data science expert! For a variety of reasons, that’s why we decided to create an on-call data science and research team, that can provide support around forming research questions and working through the process of scientific discovery, as well as provide data science resources to expedite the research process. This portion of the project does focus on the diabetes community, since we have multiple Data Commons and communities of people donating data for research, as well as dozens of citizen scientists and researchers already in action (with more interested in getting involved).

What else does Open Humans have to do with it?

Since I’ve been administering the Nightscout and OpenAPS Data Commons, I’ve spent a lot of time on the Open Humans site as both a “participant” of research donating my data, as well as a “researcher” who is pulling down and using data for research (and working to get it to other researchers). I’ve been able to work closely with Madeleine and suggest the addition of a few features to make it easier to use for research and downloading large data sets from projects. I’ve also been documenting some tools I’ve created (like a complex json to csv converter; scripts to pull data from multiple OH download files and into a single file for analysis; plus writing up more details about how to work with data files coming from Nightscout into OH), also with the goal of facilitating more researchers to be able to dive in and do research without needing specific tool or technical experience.

It’s also great to work with a platform like Open Humans that allows us to share data or use data for multiple projects simultaneously. There’s no burdensome data collection or study procedures for individuals to be able to contribute to numerous research projects where their data is useful. People consent to share their data with the commons, fill out an optional survey (which will save them from having to repeat basic demographic-type information that every research project is interested in), and are done!

Are you *only* working with the diabetes community?

Not at all. The first part of our project does focus on learning best practices and lessons learned from the DIY diabetes communities, but with an eye toward creating open source toolkit and materials that will be of use to many other patient health communities. My goal is to help as many other patient health communities spark similar #WeAreNotWaiting projects in the areas that are of most use to them, based on their needs.

How can I find out more about this work?
Make sure to read our project announcement blog post if you haven’t already – it’s got some calls to action for people with diabetes; people interested in leading projects in other health communities; as well as other researchers interested in collaborating! Also, follow me on Twitter, for more posts about this work in progress!

Next generation #OpenAPS hardware work in progress – Pi HATs

by Dana Lewis

tl;dr – No, they’re not here yet, but this is coming soon! Yay for new & more hardware options! See here to pre-order an Explorer HAT, eta of April 2018

—

Over the years, people have had a lot of awesome ideas on how

to improve the hardware that can be used with DIY closed looping. One such example, Oskar’s work with mmeowlink, led us to later work on smaller computer boards with built-in radio stick, aka the Edison/Explorer Board rig. We started working on that last fall; they were produced and available around November, and the community has been using those widely ever since.

However, like all things, the Edison/Explorer is not without it’s downsides. One of which is – there’s no screen. You historically have needed to plug in cables, or remote login to the rig, or have connectivity via your phone, to see what it’s doing. Sometimes this is more annoying than others.

Patrick Kelly, who has a daughter with T1D and began experimenting with OpenAPS, was one of the folks who wanted a screen on the rig. He suggested the idea, which Scott and I thought was awesome – but we don’t have the expertise to build that kind of hardware. Luckily, Patrick and his dad Jack Kelly, *do* have that expertise! They began exploring some of the options around creating a rig with a screen.

(This is one of my favorite parts of the OpenAPS community, where people bring in various types of expertise and we’re all able to collaborate to make everything from hardware and software and usability improvements!)

And at the same time…the rumors became reality, and we learned that Intel has decided to discontinue the Edison module. SAD PANDA. (Intel, if you’re reading this, please bring it back! We love the Edison!) That expedited the need to find the next generation hardware. Luckily, Patrick and Jack had been progressing on the screen, focusing on incorporating it into a “HAT” (board) for the Raspberry Pi. So after discussion with others in the community about pros/cons and availability about various other computing options other than the Pi, given the widespread availability of different types of Pi’s, we’ve decided to move forward with the Pi and a HAT (board) being the most usable option for the next round of hardware that we’ll be recommending to the community.

What exactly does a Pi HAT look like?

I’m so glad you asked 😉 Here is the Pi HAT with screen on a “Pi Zero W” (which I sometimes type as “Pi0” or “Pi 0”) and a “Pi 3” (pi three), compared to the Edison/Explorer Board. My trusty Chapstick is my unit of measurement, but given some of my international friends claim to not understand that yardstick, I threw in some Euro coins on the right as another measurement stick .;)

OpenAPS_hardware_development_Oct_2017_DanaMLewis
The Pi 0 is flipped on it’s back like a turtle – but the same Pi HAT can be used for the Pi 0 and the Pi 3. The HAT is bigger than the Pi so the radio stick doesn’t get blocked.

It’s the same radio as the Edison-based Explorer block, so same expected range.

What’s the point of the screen?

With a screen, you can easily see the logs of what the loop is doing: Pi_HAT_screen_OpenAPS_example_DanaMLewis

YOU CAN EASILY ADD AN OPEN WIFI NETWORK ON THE GO! (Yea, that all caps was intentional! :)). You can also see which wifi network it is on, check for IP address, etc.

Pi HAT adding wifi exampleWe’re still working on adding to the menus and playing around with what’s possible and what’s worthwhile for displaying on the menus by default.

You can do all kinds of fun stuff – which Scott found out after asking me one day, “what else should we add to the menu?” and I promptly said “a unicorn”. Scott said, “these don’t have emoji’s, though”.

Five minutes later, we have a DIY diabetes/OpenAPS unicorn built in ASCII, because why not? 😉

Pi_HAT_screen_unicorn_closeup_DanaMLewis

Ahem. Back to technical topics.

How is this board/HAT going to be made and when is it going to be available?

Like the Edison-based Explorer, the Pi’s Explorer HAT is an open source hardware design, and ERD (who sold the Explorer for the Edison) will also be doing the Pi HAT.

Timeline is not 100% nailed down yet, but it will probably be another month or so. (Which is about a year after the Edison Explorer was first ready…crazy how time flies in the open source community!) We’ll of course, as always, shout from the rooftops when it’s ready for ordering & experimenting with. We’ll also be updating the OpenAPS docs to reflect the new gear recommended to buy, the steps for getting it up and running, troubleshooting, etc.

What about Edison/Explorer boards? Will that rig type still be supported by OpenAPS? Should I get any more of those?

Yep. Edison/EB will still be supported & widely used. There are some still left.

  • But – if you already have an Edison/EB rig – I would make your next rig purchase a HAT for one of the Pi’s.
  • If you’re new to the OpenAPS community and supply still exists, I’d still consider grabbing the parts for an Edison/Explorer rig – they’re still great, and we’ll continue to use the ones we have for a long time, and will still be supported in documentation. But you’ll likely want a HAT for a Pi rig of some sort, too, to take advantage of the screen & all the features that go with that for ease of use.

What about battery life for the Pi0/Pi3? How fast does it run? AND YOU HAVEN’T ANSWERED ALL OF MY OTHER QUESTIONS?!?!

One of the downsides of our (Scott/my) approach of getting everything to the community as fast as possible – both hardware and software – means that sometimes (every time) we share things that are works in progress. (And we are testing a whole lot of stuff on software, too.) The new hardware is no different. We don’t have all the answers yet, and we’ll hope you’ll help us figure things out as we go! Here’s some of the pending questions we have:

  • Cost. (Pi’s are cheaper than Edison’s. Explorer HATs with screens are slightly more expensive. However, we’re expecting in sum that the HAT+screen rigs with Pi of choice will likely be cheaper than an Edison/Explorer.)
  • Battery life. We know the Pi0 itself is not as efficient as the Edison, so it’ll likely require a bigger battery for the same run time. (No idea exactly how much bigger because I’m not using these rigs in the real world 100% of time yet, because…)
  • Some Pi optimizations still need to be done. (The current code works just fine on a Pi3, but the Pi0 needs some optimization work done. The Pi 0, as you can see from the picture, is smaller, and will likely be the ‘mobile’ rig for many folks, while the Pi 3 might be a backpack/home rig.)
  • Other options for “HATs” that don’t have a screen. (Eric has also been prototyping another Pi HAT, that doesn’t have a screen, and it’ll be great to test and see how that works as a potential option, too. Hop into the openaps/hardware-dev channel to chat with him if you have questions about his approach. )

As we work on the optimizations (great place to dive in if you’re looking for a place to help out!) and updating the scripts and the docs to reflect the Pi suite of options, I’ll begin carrying this kind of rig and doing my usual break-everything-in-the-real-world-and-fix-all-the-things testing approach.

—

I’m excited. It’s so great to have this kind of collaboration with expertise in so many areas, with everyone centered on the goal of making life with diabetes easier and safer! Shout out to the Kelly family & their colleagues for all the work on the screen & HATs; to Scott for a lot of development work on both hardware and software side; to Morgan & ERD for continuing to be a part of making great open hardware more widely available; and many other people who are working on bits and pieces to make everything possible!

—

January 2018 update: rigs are still evolving! You can pre-order an Explorer HAT, eta of shipping is April 2018.

Showing the size of the Explorer "HAT" board next to chapstick for size comparison

See the openaps-menu software code here; and the Explorer HAT hardware repo is here.

More open innovation coming soon?

by Dana Lewis

This is a big deal: JDRF just announced funding for companies to open up their device protocols, with an explicit mention of projects including OpenAPS.

This is something we’ve been asking companies for over many years, but even the most forward-thinking diabetes device companies are still limiting patients to read-only retrospective access to the patient’s own data. That’s a start, but it isn’t enough.  We need all device makers to take the next step toward full and open interoperability: participating in open-protocol development of pumps and AP systems. If funding from a major organization like JDRF is what will be needed to prioritize this, great: we’re really excited to see them doing so.

Many of us in the diabetes community have chosen to accept the risk of a flawed device, because of the net risk reduction -and quality of life improvements – that come from being able to DIY closed loop. But that doesn’t mean we’re 100% happy with that.

  • We shouldn’t have to bandaid our pumps – literally – with tape.
  • We shouldn’t have to buy them second hand.
  • We should be able to use in-warranty devices that aren’t physically broken.

In order to use our medical devices in the safest and most effective way possible, we need the ability to remotely and safely control our devices – and understand them – as we see fit.  That means the makers of the medical devices we rely on need to openly document the communications protocols their devices use, so that any informed patient, or any company or organization operating on their behalf, can safely interact with the device.

It’s a big deal for JDRF to put resources into helping companies figure out how to do this, and ease liability and regulatory concerns. Thanks to everyone who’s been a vocal advocate in the DIY community; in organizations like JDRF; and individuals advocating at the medical device companies as well.  And props to the FDA, who last month released official guidance encouraging device makers to “design their devices with interoperability as an objective” and “clearly specify the relevant functional, performance, and interface characteristics to the user.”

We all have the same goals – to make life better, and safer, for those of us living with type 1 diabetes. I’m excited to see more efforts like this that further align all of our activities toward these goals.

To the diabetes device companies: we’ve long said we are happy to help if you want to figure out how to do this. Hopefully, you already have ideas about how to do this smartly and safely. But if you need help, let us know – we’re happy to help, because #WeAreNotWaiting and neither should you.

 

How I change pump sites

by Dana Lewis

Last year, I wrote about how I “pre-soak” CGM sensors for better first-day BGs. That’s something I started doing years ago whenever possible.

Similarly, in the last few years, I’ve also changed how I change my pump sites with similar goals of improved outcomes, whenever possible.

What I used to do (i.e. for 12+ years):

  • Pull out pump site
  • Take shower
  • Put in new pump site
  • If the pump site didn’t work, spend all night high, or the next hours high while I debated whether it was just “slow” or if I needed a second new site. Ugh.

What I decided to start doing and have done ever since (unless a site gets pulled out by accident):

  • On day 3 when I decide to change my pump site, I do not take my “old” pump site out before my shower.
  • After my shower, I leave in the old pump site and put the new pump site on. Which means I am wearing TWO pump sites.
  • Put the tubing on the new site etc. as expected. But because I have the old site on, if I start to see BGs creep up, I can do one of two things:
    • 1) Swap tubing back to old site, give a bolus or a prime on the old site, then switch tubing back to new site. (I do this if I think the new site is working but “slow”)
    • 2) Swap tubing back to old site, ditch the new site, and then insert a second “new” site (or wait until the next morning to do so when I feel like it)
  •  Otherwise, if BGs are fine, I pull the “old” site out once I confirm the new site is good to go.

Is this method perfect? Nope. Does it usually help a lot when I have a new site that is kinked or otherwise a dud? Yup.

To me, it’s worth keeping the old site on for a few (or even ~12) hours. I know many people may not like the idea of “wearing two sites”. But it’s not wearing two sites for 3 days. And if you find yourself having a lot of kinked sites – that’s why and when I switched over to this approach.

YDMV, always. But hope this (post-soaking?) of pump sites, like the idea of pre-soaking CGM sensors, is helpful to someone else.

Not bolusing for meals (Fiasp, 0.6.0 algorithm in oref0 dev branch, and more)

by Dana Lewis

I tweeted last week+, “I just realized I’ve now gone about 3 weeks without meal bolusing.” That means just a meal announcement (i.e. carb entry estimate, a la 30 carbs or 60 carbs or whatever, based on my IFTTT buttons). No manual bolus.

Highlighting 3 weeks without meal bolusing, and just doing a carb announcement, with good outcomes thanks to OpenAPS

I kind of keep waiting for the other shoe to drop, because it sounds to good to be true. I’m sure you’re skeptical reading this.

I bet she’s doing SOME bolus.

Well, she must not be eating any carbs.

She must be having worse outcomes, bad post-meal BGs, etc.

Nope, nope, and nope.

  • While I started testing this new set of features with partial boluses and worked my way down (see more below on the testing topic), I’m now literally doing no manual meal bolus. I start eating, and press one button on my watch for a carb estimate entry (that via IFTTT goes to Nightscout and my rig).
  • I eat carbs. I’ve eaten 120 grams of carbs of gluten free biscuits and gravy; 60-90 grams of pasta; dinner followed by a few gluten free cookies, etc.
  • More nuanced details below, but:
    • My 70-180 time in range has stayed the same (93+%) compared to the versions I was testing before with manual meal boluses.
    • My 70-150 and 80-160 time in ranges have decreased slightly compared to manual meal boluses, but…
    • My average blood sugar has actually dropped down (as has my a1c to match).
    • (So this means I’m having a few more spikes above 160, usually topping off in 160-170 whereas before my manual meal boluses would have me top off around 150, when all was well.)

Also note – no eating soon required. No early bolus or pre-bolus. Just single button press as I stick food in my mouth.

Wow.

(See where I said, waiting for the other shoe to drop?)

That’s why I waited a while to even tweet about it. Maybe it’s a fluke. Maybe it won’t work for other people. Maybe, maybe, maybe. Who knows. It’s still fairly early to tell, but as other people are beginning to test the current dev branch of oref0 with 0.6.0-related features, other people are starting to see improvements as well. (And that could be some of the many other features we are adding to 0.6.0, ranging from exponential curves for insulin activity, to allowing SMBs to do more, to carb-ratio-tuned-autosensitivity, to huge autotune improvements, etc.) 

So while I don’t want to over-hype – and never do, what works for me will not work for everyone – I do want to share my cautious excitement over continuing to be able to push the envelope on algorithms and what might be possible outcome-wise for this kind of technology.

Suggesting no meal bolus means we can quit arguing about the name "artificial pancreas"

Here’s what is enabling me to be in the no-bolus zone for now well over a month, with still (to me) great outcomes worth the tradeoffs described above:

  1. Faster insulin. Thanks to our lovely looping friends in Germany/Austria, we came back from Europe with a few vials of Fiasp to try. I was HIGHLY skeptical about this. Some of our European friends saw great results right away, others didn’t. I didn’t get great results on it at first. Some of that may be due to natural changes between insulin types and not knowing exactly how to adjust my manual bolus strategy to the faster insulin action, but until we did some code changes to allow SMB‘s to do more and added some other features to what’s now 0.6.0, I wasn’t thrilled and in fact after about two weeks of it was about to switch off of it. So that brings me to #2.
  2. More improvements to the algorithm, which is now what will become the 0.6.0 release of oref0. There’s a whole lot of stuff packed in there. Exponential curves. Different carb absorption decay calculations. Allowing SMB to do more. Additional safety guards since we ramped SMB up.

How we started testing no-bolus approach:

  • I have always known that about 6u of insulin (thanks to testing dating back to my early DIYPS days, many many many moons ago) is about as much as I should bolus at any time. So, even if I ate 120 carbs, I usually did about a 6u bolus up front, and let the rig pick up the rest as needed over more hours. I started doing ~75% or something like that of boluses, based on wherever I felt like rounding to with my easy bolus buttons.
  • Whether I did 75% or 100%, I didn’t see a ton of difference at first…
  • ..so I took a leap and tried no-bolus with some SMB adjustments to allow it to ramp up faster with carb entry. Behaviorally, I find it a lot easier to do nothing 😀 vs. figure out the right amount of up front bolus. And outcomes wise (see above) it was very similar.

It definitely was an interesting approach to test. Between the Fiasp and the no-bolus up front, in some meals it matched really well and I had practically no rise. Due to incoming netIOB, food type, etc, sometimes I did have a rise – but while it spiked slightly higher (160-170 usually vs my earlier 150s with manual bolus), it was only up there for 2-3 data points and then came sharply down, leveling out smoothly in my preferred post-meal range. So an important lesson I learned was not to over-react to just the BG curve going up, without looking at the predictions to see where I was going to come just back down. (And as I had more than one meal where the spike and drop back to normal happened, it was very easy to adjust to the BG graph and not get that emotional tug to “do more” with a quick short rise like that).

Obviously, starting BG makes a difference. I’m usually starting <130 mg/dL when I see these spikes cap out at 170 or lower. I’ve started higher, and seen higher rises, too. They’re not all perfect: with occasional pump site issues, carb underestimates, unplanned carb stacking, and all the randomness of diabetes and a non-structured lifestyle (including live-testing bleeding edge algorithm changes), I’ve spent 12% of the last month >160 mg/dL, which is about the same as the 3 months before that. But in most cases (I’d say 95%), the no-bolus approach has actually yielded better outcomes than I expected AND has avoided post-meal lows better than I would have achieved with a manual bolus.

This is huge when you think about the QOL aspect of not having to do as much math at a meal; and when you think about all the complicating factors related to food – timing (do you bolus when you order, or when the food arrives, or earlier than that?), and the gluten factor. I have celiac disease, so if I’m eating out (which we do a lot, and especially since I travel frequently), bolusing prior to setting eyes on the food (knowing they didn’t plate it with bread, causing them to have to go back and start all over again) just isn’t smart. That’s why eating soon historically worked so well for me vs. traditional pre-boluses, because I could set the target entering the restaurant, bolus when I laid eyes on my hopefully safe food, and get reasonable (150 topping out) meal outcomes.

It also worked really well in the case where a restaurant cooked my gluten free pasta in the same pasta cooker and water as regular pasta, but didn’t inform me until after I found stray gluten noodles in the bottom of my pasta dish and started asking how that was possible since they (used to) do gluten free well. (Now, I pick up heaps of pasta, and sort pasta noodles one by one to make sure they all match before ever eating gluten free pasta. It makes waiters look at you very worriedly as you wave pasta around in the air, but better safe than glutened (again).) So, I was majorly glutened, and my digestion system was all out of sorts (isn’t that a nice polite way to describe getting glutened?) for many days, which of course impacted BG and insulin right then and for the days afterward. But because I had done carb entry and no-bolus, I was able to edit the carb entry down, and I didn’t have that much insulin stacked, and didn’t end up low after glutening, which is usually what happens.

Is that a super regular situation for most people? No. But it was super nice. And also helped me face pasta again last night, so I could put in a (very low in case of gluten) carb estimate, match my noodles, eat pasta, and let the SMBs ramp up to match absorption. It works very well for me.

Example BG graph from only announcing, not bolusing for, a meal with OpenAPS

Whether you have celiac or not, for many reasons (insert yours here), it’s nice to not to have to commit to the bolus up front. It’s closer to approaching what I think non-PWDs do at mealtimes: just eat.

(I haven’t done much testing (yet? TBD) for no-carb-entry and no-meal-bolus scenario, I expect I would have higher spikes but would be interesting to see if it would still come down reasonably fast. Probably wouldn’t be my go-to strategy because I don’t mind a general meal size estimate one button push, but would be nice to know what that curve shape would look like. If I test that, it’ll start with small snacks and ramp my way up.)

The questions I always get:

  1. Q: HOW DO I GET THIS?
    A: Caution: like all things OpenAPS but especially always true for the development branch, 0.6.0 is NOT released yet to master and is still highly experimental. I wouldn’t install dev unless you want to pay lots of close attention to it, and are willing to update multiple times over the course of the week, because Scott and I are merging features and tweaks almost daily to it.

    Got the disclaimers down? Ok. It’s in the dev branch of oref0. You should read this PR with notes on some more detail of what’s included, but you should also review the code diff to see all that’s changed, because it’s not all documented yet. Also, follow the instructions at the bottom to be able to install it without git. Hop into Gitter if you have questions about it!

    (Big huge thanks to folks like Tim and Matthias for early testing of 0.6.0; and to Tim for writing up about the initial rounds of 0.6.0-dev here (note that we’ve made further changes since this post), and others who’ve been testing & providing feedback and input into the dev branch!)

  2. Q: When will this get “released” to master?
    A: It depends. This is still a highly active dev branch, and we’re making a lot of changes and tweaking and testing things. The more people who test now and provide feedback will enable us to get to the final “prepare for release” testing stage. Lots and lots of testing, and things depend on how much existing needs tweaked, and what else we decide should go with this release. So, there’s never any specific release date.
  3. Q: What is Fiasp?
    A: Faster acting insulin that was only approved in Europe and Canada…until today. Convenient timing. I asked a PR person who messaged me about it, and they said it’s estimated to be available in U.S. pharmacies by late December/earlier Q1. As previously stated, available elsewhere in other parts of the world.

    Fiasp peaks sooner (say, ~45 minutes) with the same tail as everything else. It’s not instantaneous. For your million and one questions about whether it’s approved for your use in a tree, on a plane, at the zoo, and all other extrapolations – please ask Google/your doctor/the manufacturer, and not me. I don’t know. :)

  4. Q: Will any of this work for people NOT on Fiasp?
    A: Nothing is guaranteed (even for other people on Fiasp), but the folks who’ve started testing 0.6.0 even without Fiasp (on Humalog or Novolog/Novorapid, etc.) have been happier on it vs. earlier versions, too.

    I don’t expect Fiasp to work super well forever for me, given what I’ve heard from other people with months of experience on it…and given my first two weeks of Fiasp not being spectacular, I want people to not expect miracles. (Sorry, this blog post does not promise miracles, so sorry if you got super excited at the above. No miracles! This is not a cure! We still have diabetes!) Like all things artificial pancreas, I think it’s better to be cautiously hopeful with realistic expectations that things *might* be a little bit better than before, but as always, YDMV (your diabetes may/will always vary), your body will vary, and life happens, etc. so who knows.

Just 4 months ago, we published a blog post pointing out that the new features had allowed us to achieve 4 out of 5 of: no bolus; not counting carbs, medium/high carb meals, 80%+ time in range; and no hypoglycemia.  With Fiasp and  0.6.0 (currently what’s in the dev branch), we’ve now achieved all 5 simultaneously: I can eat large high-carb meals, enter very vague guesstimates of 60 or 90 carbs (no need for actual carb counting, just general size-based meal announcement), and still achieve 80%+ time in range 70-150 mg/dL without ever going <55 mg/dL.  Does that mean that OpenAPS with Fiasp finally meets the definition of a “real” Artificial Pancreas (step 5 on JDRF’s 6-step AP development pathway)?  We think it does.

So, tl;dr (because long post is long): with Fiasp and 0.6.0-dev branch, I’m able to not bolus for meals, and just enter a very generally sized meal estimate. It’s working well for me, and like all things, we’re working to make it available to other people via OpenAPS for others who want to try similar features/approaches. It may not work well for everyone. If it helps one other person, though, like everything else it’ll be worth it. Big thanks to Scott for LOTS of development in 0.6.0 and partnership in design of these features; too many people to name for testing and providing feedback and helping iterate on these features; and to the entire community for being awesome and helping us to continue to push the envelope on what might be possible for those of us with type 1 diabetes. :)

Why a non-academic (patient) publishes in academic journals

by Dana Lewis

Today I was able to share that my Letter to the Editor was published in the Journal of Diabetes Science and Technology. It’s on why we need to set expectations to help patients successfully adopt hybrid closed loop/artificial pancreas/automated insulin delivery system technology. (You can read it via image copies in the first link.)

JDST_screenshot_LTE_expectationsI’ve published a few times in academic journals. Last year, Scott and I published another Letter to the Editor in JDST with the OpenAPS outcomes study we had presented at the 2016 ADA Scientific Sessions conference.

But, I’m sure people are wondering why I choose to do so – especially as I am 1) a patient and 2) a non-academic. (Although in case you missed it – I’m now the Principal Investigator on a grant-funded study!)

While there are many healthcare providers, researchers, industry employees, FDA staff, etc. who read blogs like this and are up to speed on the bleeding edge of diabetes technology… there are easily 10x the number that do not.

And if they don’t know about the existence of this world, they won’t know about the valuable lessons we’re learning and won’t be able to share those lessons and knowledge with other healthcare providers and the patients that they treat.

So, in my pursuit to find more ways to share knowledge from our community with the rest of the diabetes community, this is why we submit abstracts for posters and presentations to conferences like ADA’s Scientific Sessions. Our abstracts are evaluated just like the abstracts from traditional healthcare providers (as far as they can tell, I’m just another academic, albeit one with fewer credentials ;)), and I’m proud that they’re evaluated and deemed worthy of poster presentations alongside mainstream researchers. Ditto for our written publications, whether they be letters to the editor or other types of articles submitted to journals and publications.

We need to find more ways to share and distribute knowledge with the “traditional” medical and academic research world. And I’d love to do more – so please share ideas if you have them. And if you’re someone who bridges the gap to the traditional world, I appreciate your help sharing these types of articles and conversations with your colleagues.

Opening pathways for discovery, research, and innovation in health and healthcare

by Dana Lewis

How can we get more patients and other communities to leverage the benefits of the #WeAreNotWaiting mindset for research, development, and innovation in health (and healthcare)?

That’s a question I’ve been asking myself for two years, after seeing the diverse efforts and valuable outpourings from the DIY diabetes community (ranging from amazing remote monitoring solutions for CGM to algorithms, hardware, and other software for automated insulin delivery systems).

But, how to scale? In diabetes, we’re perhaps uniquely positioned given our data-driven disease. However, I believe that the data and innovation approach we’ve taken in diabetes can help many other types of patient communities as well. I just didn’t know how to help scale it… until recently.

Last year when a group of us from the OpenAPS community participated in the Quantified Self Public Health Symposium in 2016, it prompted some follow up conversations with various academic researchers, including Eric Hekler from Arizona State University (ASU).

Eric started a conversation, and kept asking me: What could you do if you partnered with academic researchers? How can traditional researchers help the DIY community, OpenAPS or otherwise?

That also sparked a conversation with Paul Tarini, a senior program officer at the Robert Wood Johnson Foundation (RWJF), about potential funding for a project.

(Important to state here: OpenAPS itself is not a funded project. It has not been, and will not be. It is 100% DIY, non-commercial, and it has been built by a community of volunteers.)

What I wanted to talk to RWJF about was funding a collaboration with academic researchers for studying data and innovation coming out of the community; and to ultimately identify needs and build resources to help scale this type of community effort and empower other patient communities as well.

It took over a year, but we were able to work through initial project proposals and were then invited to submit a full proposal. And on Wednesday (September 6, 2017), I found out that we have been awarded the grant, and this project work will be funded by the Robert Wood Johnson Foundation. The project officially begins on September 15 and will run for 18 months.

So what exactly is this project?

Our project is titled “Learning to not wait: Opening pathways for discovery, research, and innovation in health and healthcare.”

It entails a number of things.

    1. We are creating an on-call data science team to support research in the DIY community. More details will be forthcoming, but essentially this team is there to help do research on the myriad of questions bubbling out of the community. For example – how does sensitivity change during growth spurts, during periods of inactivity, or when changing insulin types? What are some of the most successful mealtime insulin dosing strategies? Etc. People will be able to submit ideas, and get help formulating the idea into a researchable question, and get the research done.
    2. Studying the process of research when done by patients, and the barriers they/their research run into when spreading this scientific knowledge. I personally know there are a lot of barriers, but we need to document them and find solutions. (There are a lot of prejudice and perceived stigmas toward patient researchers doing this type of scientific work, around things like quality of research, methods of distributing knowledge, etc.)
    3. Convening a meeting with patients, traditional researchers, legal experts, and others in this innovative research space to discuss and address some of the known and being-found barriers for this type of research. I envision a white paper type publication to come out of this meeting to document the lay of the land as it is.
    4. Creating toolkit-type resources based on what we’ve learned and are learning in this project for helping patients new to DIY and this type of research take on various levels of research or innovation activity. Part of our project’s scope of work, in #WeAreNotWaiting spirit, includes beta testing with 2-3 other patient communities, so we can get feedback and iterate and roll these out as quickly as possible.

Our project has a couple of principles that I feel strongly about, and am also very proud of in approaching this body of work.

  • I am the scientific Principal Investigator of this project. This is unique in the world of grant-funded research, where a patient is driving the scientific discovery process. (I’m proud and very appreciative to have two amazing co-PI’s who are helping with some of the administrative work since the grant is being administered through Arizona State University Foundation, who is being an awesome partner given the uniqueness of this situation*.) My co-PI’s are Eric Hekler and Erik Johnston. The other members of the team include John Harlow, who’s a MacArthur Foundation Postdoctoral Fellow; Sayali Phatak, a PhD student at ASU; and Keren Hirsch from the ASU Decision Theater.
  • #WeAreNotWaiting is the mantra for this project and our entire team. We plan to be as efficient as possible in doing the project work, which includes being as timely as possible with sharing findings back with the community as soon as they’re ready (a given; there’s no reason to wait) as well as finding ways to publish that are faster than the very traditional academic publishing process, and being thoughtful about the right audiences outside the patient community for communicating about this project’s work.
  • Always asking why. As a brand new PI, I have a lot to learn. But as a non-traditional PI, I also am running into a lot of things that are done the way they’d be done if I was traditionally inside an organization. I plan to explore and challenge as many of these, and try to document the decisions I make in this project as I come to those forks in the road. In some cases, I choose the easier paths because for my project/work/focus, it does not matter. In other cases, based on principle, I choose the harder path-blazing approach.

* About the uniqueness of this project and the administrative details

Since I’m an individual patient researcher, not affiliated with the organization, we decided we would make the official grantee financial organization Arizona State University Foundation, since that’s where my co-PI’s were. But true to the nature of this project, I want to document the challenges and opportunities that come with that, so more to come about all the interesting lessons learned about the process of putting together the proposal and the grant approval process once we heard the grant would be awarded. That way, future patient researchers have a leg up on what is coming when taking on this type of project and are aware of what this approach entailed. The short version is I am a subcontractor to ASU for purpose of the grant; but am not employed or otherwise affiliated with ASU. Props to the many people at ASU who learned about me and this project in the approval process and rolled with it / helped make it happen.

So, what’s next? When do you start? What are you waiting on?!

Coming super soon – a project website (now here) with more details about this project.

For my fellow PWDs:

  • Stay tuned for the project website going live, which will also include more details about how individuals in the diabetes community can pitch ideas/get started working with the on-call data science team.

For patients reading this who are members of other patient disease communities:

  • Ping me if you’re SUPER excited and can’t wait to tell me :), or stay tuned for more info about the process for proposing that your patient community be one of the communities with whom we beta test some of the tools/resources developed toward the latter phases of this project.

If you’re someone else who’s interested in this work (such as a legal expert, other researcher, etc.):

  • Also ping me if you’re interested in hearing more about the meeting we plan to convene with a small multidisciplinary group to discuss and address barriers of patient-driven research. Even if we can’t get everyone interested to attend the in-person meeting, I would still love your input and collaboration for the white paper and/or other publications and intersections with this project.

For everyone else:

  • Please do let me know if there’s a particular aspect of this project that you’re curious to learn more about – whether it’s some of what I’m facing and documenting as a patient PI researcher, or otherwise. That’ll help me prioritize some of the blog posts and articles I’m writing about this process!

Thanks to everyone who managed to read this ginormous blog post.

I am incredibly excited about the project, and having resources to focus on how patients and non-traditional actors in healthcare can drive research, development, innovation, and knowledge sharing in non-traditional methods and from the ground up, plus prioritize and change the healthcare research agenda. Like my work in OpenAPS that stands on the shoulders of so many, I’m hoping this project is the first of many and gets to a place for others to leverage this work and take it beyond the scope of what we’ve all imagined is currently possible.

A huge thanks to the team partnering with me on this work; to ASU for being a great partner as an organization; to the Robert Wood Johnson Foundation for supporting this project (and in particular to our program manager, Paul Tarini, for his ongoing support throughout this entire process); and many extra thanks to Scott and all my family and friends for supporting me throughout the proposal process and being the recipients of some VERY excited and !!! filled texts when I found out we had officially been awarded the grant for this project.

What you should know about closed looping (DIY like #OpenAPS or otherwise)

by Dana Lewis

I’ve been wearing a DIY closed loop for something like 979 days..which means something like ~20,000 hours with this technology. Additionally, I’m not the only one. At the time of writing this post (see the latest count here), there are (n=1)*369+ (and that’s an undercount just based on who’s told us they’re looping) other DIYers out there, so the community has an estimated 1,800,000+ hours of cumulative experience, too.

Suffice to say, we’ve all learned a lot about this technology and how hybrid closed loop makes a difference in life with diabetes.

I previously gave a talk almost two years ago to the Sports & Diabetes Group Northwest here in Seattle, talking about #DIYPS, how we closed the loop, and #OpenAPS. (And you can see a recent TEDX talk I gave on OpenAPS here.) That was a springboard for meeting some awesome individuals who became very early DIY loopers in the Seattle area. And one of them (who also wore a pancreas at HIS wedding :)) had suggested we do another talk for SDGNW to update on some of what we have learned since then. But unfortunately, he got called out of town for work and couldn’t join me for presenting, so I went solo (ish, because Scott also came and contributed). I used a new analogy, because I think there’s a lot to think about before choosing and using closed loop technology, whether it’s DIY or commercial, and wanted to write it up for sharing here.

what_to_know_about_looping_danamlewis

First, some reminders for those familiar and some context for those who are not close to this technology. We’re talking about a hybrid closed loop, which is what I’m referring to when I say “artificial pancreas” or “AP” here. This type of technology makes small adjustments every few minutes to provide more or less insulin with the goal of keeping blood glucose (BG) levels in range. It’s complicated by the fact that insulin often peaks at 60-90 minutes…but food hits in ~15 minutes. So there’s often “catch up” being done with insulin to deal with food eaten previously, and also with hormones and other things that impact BGs that aren’t measurable. (This is also why it’s called hybrid, because for best outcomes people will still be doing some kind of meal announcement/bolus to deal with insulin timing.) As a result, even with pumps and CGMs, diabetes is still hard. A closed loop can do the needed math every five minutes, doesn’t go to sleep, and is very precise. It can respond more quickly (because it’s paying attention) than a human will in most situations, because we’re out living our lives/working/sleeping and not paying attention ONLY to diabetes. It’s not a cure, but it helps make living with diabetes better than it used to be.

However, I equate it to being a pilot who has seen technology on planes evolve to include “autopilot”. Even with hybrid closed loop technology, we’re still flying the “plane”.

looping_is_like_flying_plane_danamlewis

Here’s what I mean. There are stages for picking out and deciding to use the technology; preparing to use it/getting in the mode where you CAN use it; using it successfully; getting ready for the times when you can’t use it; and smoothing the way for the next time you use it.

It’s not perfect 24/7, you see, because we’re still using pump sites and continuous glucose monitor (CGM) sensors. The CGM sensor may last for 7 days, but then you have to change it out (or cough restart it cough), and you have a gap in data, which means you can’t loop. So you have this type of cycle regularly, and here’s what you need to know about each of these stages, regardless of whether we’re talking about DIY (like OpenAPS) or a commercial closed loop solution.

Preparing for takeoff

prepare_for_looping_danamlewisWhen you’re getting into the plane, you have a flight plan. You know when you will and won’t use the technology on board. Same for diabetes & closed looping. Make sure to think about the following for your tech of choice:

When will your loop work? When does it not? What happens if it breaks? What are your back up tools? How do you operate it: what happens if your sensor loses data, or you don’t calibrate? How does the algorithm work? What will it target your BG to be? What behaviors will you have to do (meal bolus or announcement, etc.) and how can you alter those to optimize performance? Also, what are the warning signs of failure to let you know when you need to take additional action with corrective insulin or eating carbs?

Taking off and the new technology learning curve

taking_off_learning_curve_danamlewisJust like switching from MDI pump (or even iPhone to Android and vice versa), you have a learning curve. When you go into looping or automated insulin delivery mode, you have to figure things out. You need to be able to figure out what’s happening and why it’s doing what it’s doing, so if you’re not happy with what’s happening, you can make a change. Why are you running high? Why are you running low? Knowing why it’s doing what it’s doing is critical for adjusting – either tweaking the closed loop settings, if you can, or adjusting your own behavior. Especially in the first few cycles of new tech, you’ll have a lot of learning around “I used to do things like X, but now I need to do them like Y.”

Why you might not be taking off and able to loop

blocking_takeoff_danamlewisYou also need to know why you can’t loop. There are three major categories of things that will prevent you from looping:

  1. No sensor, no looping.
  2. In some systems, wonky or missing data, no looping
  3. Communication errors between pieces of a system.

Some of these are obvious fixes (put in a new sensor if one fell out, or decide to put in a new sensor if the old one is bad), but depending on the system may involve some troubleshooting to get things going again.

Also, some of the commercial systems will kick you out of looping for various reasons (including lack of calibration), in addition to preventing you from looping in the first place without them, so knowing what these basic things are required for looping is useful to make sure you CAN automate.

Flying high: maintenance when you’re actually looping

maintenance_when_looping_danamlewisThere are some critical behaviors required for looping. (After all, when flying, there’s always a pilot present in the cockpit..right?!)

Some of these are basic behaviors you’ll be used to if you’ve been wearing a pump and CGM previously: keeping pump sites changed so the insulin works, and changing and calibrating CGM sensors.

HOWEVER – many people who “stretch” their CGM sensors find that they don’t want to stretch their sensors as far, as the data degrades over time. You do you, but keep in mind this might change when you’re looping vs. not, because you’re relying on good data to operate the system.

That being said, in addition to good sensor life, calibration hygiene is critical. You don’t want to loop off of wonky data, but also some commercial systems will kick you out if your calibration is way off and/or if you miss a calibration. (Personal opinion on this is a big ugh, which is why no DIY system that I know of does this.)

But if you keep your sites and sensors in good condition, this is where life is good. You’re looping! It’s microadjusting and helping keep things in range. Yay! This means better sleep, more time in range, and feeling better all around.

However, you still have diabetes, you’re still in the plane, so you still need to keep an eye on things. Monitoring the system is important (to make sure you’re still in autopilot and don’t need to actually fly the plane manually), so make sure you know how you (and your loved ones) can monitor the system’s operation, and know what your backup alarms are in case of system failures.

Note: there are approximately eleventy bajillion ways to remote monitor in DIY systems, but even if you have a commercial system that comes pre-baked without remote monitoring… you can add a DIY solution for that. So don’t feel like if you have a commercial AP that you can never use anything DIY – you can totally mix and match!

Dealing with turbulence

turbulence_danamlewisWhat kind of airplane/flight analogy would this be without including turbulence? :)

Like the things that can prevent looping in the first place, there are things that can throw off your looping. I already mentioned wonky sensor data that may mean either a blip in your looping time, or may kick you off looping. Again, your sensor life and your calibration practices will likely change.

But the other big disturbance, so to speak, is around body sensitivity changes. You know all the ways it can happen: you’re getting sick, recovering from getting sick, getting ready for/or are on/or are right after your period, or have an adrenaline spike, or have hormones surging, or have a growth spurt, or just exercised, etc.

This is what makes diabetes oh so hard so often. But this is where different closed loop systems can help, so this is one area you should ask about when picking a system: how does it adjust and adapt to sensitivity changes, and on what time frame? (In the DIY world, we use a number of techniques with this, ranging from autosensitivity to adapt on a 24 hour rolling scale of sensitivity changes, as well as using autotune to track bigger picture trends and changes needed to underlying settings. Reminder – anyone can use autotune if they’re willing to log bolus & carb data in Nightscout, not just closed loopers, so check that out if you’re interested! All DIY closed loop systems also use dynamic carbohydrate absorption in their respective algorithms, so that if you have slowed digestion for ANY reason, ranging from gastroparesis to getting glutened if you have celiac to merely walking after a meal, the system takes that into account and adjusts accordingly.)

The other things that can help you tough out some turbulence? Setting different modes, like an activity mode for exercise. The two things to know about exercise are:

  1. You don’t want to go into exercise with a bucket of IOB, so set activity mode WELL BEFORE you go out for activity. Depending on how much netIOB you have, that time may vary, but planning ahead with an activity mode makes a big difference for not going low during activity – even with a closed loop.
  2. Your sensitivity may be impacted for hours afterward, into the next day. See above about having a system that can respond to sensitivity changes like that, but also think about having multiple targets you can use temporarily (if your system allows it) so you can give the system a bigger buffer while it sorts out your body’s sensitivity changes.

Preparing for landing and making time between loops more smooth

prepare_for_landing_danamlewisJust like you’ll want to plan to go on the closed loop, you’ll want to plan for how to cycle off and then back on again. Depending on your system, there may be things you can do to smooth things out. One of the things I do is pre-soak a CGM sensor to skip the first day jumpy numbers. That makes a big difference for the first hours back on a “new” looping session. The other thing I do is stagger receiver start times (where I have two receivers that I stop/start at different times, so I’m not stuck for two hours without BG data to loop on).

But even if you can’t do that, you can do some other general planning ahead – like making sure your looping session doesn’t end in the middle of a big meal that’s being digested, or overnight. Those are the times when you’ll want to be looping the most.

Landing and preparing for the next looping session

Landing_danamlewisJust like learning to fly where you take a lot of training flights and review how the flight went, you’ll want to think about how things went and what you might change behavior-wise for your next looping session. Some of the things that may change over time as you learn more about your tech of choice:

  • Timing of meal announcement or boluses
  • Precision (if needed, or otherwise lack thereof) around carb counting
  • Using things like “eating soon” mode to optimize meal-time insulin effectiveness and reduce post-meal spikes
  • Using different activity patterns and targets to get ideal outcomes around exercise
  • Tweaking underlying settings (if you can)

General thoughts on looping

general_looping_reminders_danamlewisSome last thoughts about closed looping in general, regardless of the tech you might choose now or in the future:

  1. Picking one kind of technology does NOT lock you into it forever. If you’re DIYing now, you can choose commercial later. If you start on a commercial system, you can still try a DIY system.
  2. Don’t compare the original iPhone with an iPhone 6. Let’s be blunt: the Dexcom 7plus is a different beast than the Dexcom G4/G5. Similarly, Medtronic’s original “harpoon” sensor is different than their newest sensor tech. The Abbott Navigator is different than their Libre. Don’t be held up by perceptions of the old tech – make sure to check out the new stuff with a somewhat open mind.
  3. (Similarly, hopefully, in the future we’ll get to say the same about first-generation devices and algorithms. These things in commercial systems should change over time in terms of algorithm capabilities, targets, features, and usability. They certainly have in DIY – we’ve gotten smaller pancreases, algorithm improvements, all kinds of interoperability integration, etc.)
  4. All systems (both DIY and commercial) have pros and cons. They also each will have their own learning curves. Some of that learning is generalized, and will translate between systems. But again, iPhone to Android or vice versa – your cheese gets moved and there will be learning to do if you switch systems.
  5. Remember, everyone learns differently – and everyone’s diabetes is different. Figure out what works well for you, and rock it!

 

What I wish CDEs (diabetes educators) and other HCPs knew about DIY and other diabetes tech (#OpenAPS or otherwise)

by Dana Lewis

I had the awesome opportunity to present at #AADE17, the annual education meeting for the American Association of Diabetes Educators, this past weekend. My topic was about OpenAPS and DIY diabetes… which really translates to some broader things I want all educators and HCPs to know about patients and technology, whether it’s DIY or just unknown to them. Unfortunately AADE didn’t record or livestream my session, so I wanted to write up a summary of the content here.

(If you’re new to this blog/me/OpenAPS, you can also watch this June 2017 TEDX talk where I share some of the story of how I ended up with a DIY artificial pancreas and how the OpenAPS community came to be; or this older talk from OSCON 2016 as well. As always, if you’re curious to learn more about OpenAPS or wondering how to build your own DIY artificial pancreas, OpenAPS.org is the first place to learn more!)

—

Diabetes is hard. Even if you are privileged to have access to insulin, education, and technology – it can still be so incredibly hard to get it right. And even if you do everything “right”, the outcomes will still vary. And after all, the devices themselves are not perfect, and we still have diabetes.

The lack of varying alarms and the unchangeable volume is what led me to create DIYPS (my open loop and louder alarm system), and the same frustration with lack of data access and visualization led John Costik, Lane Desborough, Ben West, and so many others to explore creating other DIY tools, such as Nightscout. And thanks to social media, we all didn’t have to create in a vacuum: we can share code (this is what open source means) and insight through social media, and build upon each other’s work. As a result, these collaborations, sharing, and iterative development is how OpenAPS, the open source artificial pancreas system movement, was created.

I tweet and talk and share frequently about how great it is having #OpenAPS in my life. Norovirus? No problem. Changes in sensitivity due to exercise? Not the biggie it used to be.

Showing flat overnight CGM graph representing sleep uninterupted by hypoglycemia thanks to OpenAPS

However, this technology is by no means a cure. It still requires work on the part of the person with diabetes. We still have to:

  • Change pump sites
  • Change CGM sensors
  • Calibrate regularly
  • Deal with bonked pump sites and sensors that fall out

And also, given the speed of insulin, most people are still going to engage with the system for some kind of meal bolus or announcement. This is why it’s called “hybrid” closed loop technology. (However, depending on the sophistication of the technology, you start to get to be able to choose what you want to optimize for and the behaviors you want to choose to do less of, which is great.)

In some cases, we humans know more than the technology: such as when a meal is going to happen/is coming, and when exercise is going to happen. So it’s nice to be able to interoperate your devices and be able to use your phone, watch, computer, etc. to be able to tell the system what to do differently (i.e. set higher targets in the case of activity, or lower targets to achieve “eating soon” mode , or in the case of waking up).

But in a LOT of cases, it’s tiring for the human to have to think about all the things. Such as whether a pump site is slowly dying and causing apparent insulin resistant. Or such as when you’re more sensitive 12-24 hours after exercise. Or during menstrual cycles. Or when sick. Or during a growth spurt. Or during jet lag. Or during a trip where you can’t find anything to eat. Etc. It’s a lot for us PWD’s to track, and this is where computers come in handy. Things like autosensitivity in OpenAPS to automatically detect changes in sensitivity and adjust the variables for calculations automatically; and autotune, to track the data of what’s actually happening and make recommendations for changing your underlying pump settings (ISF, carb ratio, and basal rates).

And how has this technology been developed by patients? Iteratively, as we figure out what’s possible. It’s not about boiling the ocean; it’s about approaching problems bit by bit as we have new tools to solve them, or new people with energy to think about the problem in different ways. It’s like thinking about getting a car – you wouldn’t expect the manufacturer to sell bits and pieces of the car frame, and you don’t really expect medical device manufacturers to sell bits and pieces of a pump or other device. However, patients are closest to the REAL problems in living with diabetes. Instead of a “car”, they’re looking for solutions for getting from point A to point B. And so in the car analogy, that means starting with a skateboard, scooter, or bike – and ending up with a car is great, but the car is not the point.

So no, any piece of technology isn’t going to be a cure or solve all problems or work perfectly for everyone. But that is true whether it’s DIY or a commercial tool: one size certainly does not fit all. And patients are individuals with their own lives and their own challenges with diabetes, with different motivations around what aspects of life with diabetes feel like friction and what they feel equipped to tackle and solve.

So, here’s some of what’s on my list for what I’d like CDE’s and other HCP’s to know as a result of the proliferation of technology around diabetes:

  • Yes, DIY tech is often off label. But that’s ok – it just means it’s off label; it doesn’t prevent you from listening to why patients are using it, what we think it’s doing for us, and it doesn’t prevent you from asking questions, learning more, or still advising patients.
  • Don’t make us switch providers by refusing to discuss it or listen to it, just because it’s new/different/you don’t understand it. (By the way: we don’t expect you to understand all possible technology! You can’t be experts on everything, but that doesn’t mean shunning what you don’t know.)
  • You get to take advantage of the opportunity when someone brings something new into the office – it’s probably the first of many times you’ll see it, and the first patient is often on the bleeding edge and deeply engaged and understands what they’re using, and open to sharing what they’ve learned to help you, so you can also help other patients!
  • You also get to take advantage of the open source community. It’s open, not just for patients to use, but for companies, and for CDEs and other HCPs as well. There are dozens if not hundreds of active people on Twitter, Facebook, blogs, forums, and more who are happy to answer questions and help give perspective and insight into why/how/what things are.
  • Don’t forget – many of the DIY tools provide data and insight that currently don’t exist in any traditional and/or commercially and/or FDA-approved tool. Take autotune for example – there’s nothing else out there that we know of that will tune basal rates, ISF, and carb ratio for people with pumps. And the ability of tools like Nightscout reports to show data from a patient’s disparate devices is also incredibly helpful for healthcare providers and educators to use to help patients.

And one final point specific to hybrid closed loop technology: this technology is going to solve a lot of problems and frustrations. But, it may mean that patients will shift the prioritization of other quality of life factors like ease of use over older, traditionally learned diabetes behaviors. This means things like precise carb counting may go by the wayside for general meal size estimations, because the technology yields similar outcomes. Being aware of this will be important for when CDE’s are working with patients; knowing what the patterns of behaviors are and knowing where a patient has shifted their choices will be helpful for identifying what behaviors can be adapted to yield different outcomes.

—

I think the increase in technology (especially various types of closed loops, DIY and commercial) will yield MORE work for CDE’s and HCP’s, rather than less. This means it’s even more important for them to get up to speed on current and evolving technology – because it’s by no means going away. And the first wave of DIY’ers have a lot we can share and teach not just other patients, but also CDE’s. So again, many thanks to AADE for the opportunity to share some of this perspective at #AADE17, and thanks to everyone for the engagement during and after the session!