What I’ve Learned From 5,000 Pills Of Pancreatic Enzyme Replacement Therapy (PERT) For Exocrine Pancreatic Insufficiency (EPI/PEI)

I recently reached a weird milestone that no one likely cares about, but that I find fascinating: in the first 534 days of exocrine pancreatic insufficiency (EPI / PEI), I’ve taken more than 5,000 pills of pancreatic enzyme replacement therapy (PERT).

That’s an average of 9.41 pills per day!

PERT (enzymes) helps my body successfully digest the food that I eat, because my pancreas is no longer producing enough enzymes. Like insulin treatment for diabetes, PERT will be a lifelong necessity for me: this number of pills consumed is one that only goes up from here.

Here’s a look at what the pills per day intake has looked like over this time:

  • Min: 2 (early days)
  • Max: 72 (hello, outlier of two ultramarathons! One was 62 miles, the other was 82 miles! Other 30-40+ pill days are likely also ultra 🏃🏼‍♀️ training days, e.g. around 50k of running, which is still 8-9 hours of running and fueling every 30 minutes)
  • Median: 8

Analyzing a graph of my daily PERT enzyme pills, there are noticeable spikes, particularly around my ultramarathon training days. Two distinct spikes at 72 pills per day correspond to my 100k (62 mile) and 82-mile ultra runs.

Here is a graph showing my PERT (enzyme) pills per day totals, there are a few noticeable spikes in the 20-40ish range that are likely ultra training days. The two spikes around 72/day are my 100k (62 mile) and 82 mile ultra runs.

Why so many pills?!

Not everyone with EPI takes as many pills as I do. The number is titrated (adjusted) based on what and how often I eat. A typical meal for me requires 2-3 prescription pills of PERT.

In my case, I sometimes use over-the-counter (OTC) enzymes to ‘top off’ a prescription pill.

For hikes and runs, which I do 4-5 times each week, I eat small amounts every 30 minutes if I’m out for more than 2 hours, which is 3+ times a week. For a run of 5 hours, where I consume 10 snacks, I’d use 10 pills if I went the prescription route. In contrast, I usually use 2-4 OTC pills per snack, which combined costs an average of $0.70. That means $7 in enzyme costs for 5 hours compared to $80 if I had taken prescription PERT! Multiply times several times a week, and you can see why I choose this strategy.

Balancing Cost ($) and Convenience (Fewer Pills)

The “cost” for using OTC pills, though, is 20-40 pills ($7) instead of 10 pills ($80). On a day-to-day basis, my choice depends on convenience, how confident I am in my counts/dosing (I’m very confident for hike/run pre-portioned snacks that I’ve tested rigorously), and other factors.

Increasingly, when I’m not pursuing physical activity, I’m more likely to choose fewer pills at the financial cost of prescription PERT. I’d like to choose fewer pills for physical activity, too, which is why I’ve recently shifted to a slightly more expensive OTC pill that has more enzymes in it, in order to take 1 pill for most snacks instead of 2-4. In a typical long run of 4 hours, for example, instead of 7 snacks resulting in 28 pills, those 7 snacks would instead result in 7 pills! (There’s also a challenge with finding these particular OTC pills, as prescription pill shortage has driven more people to try OTCs and now the OTC pills I prefer are regularly out of stock, too. If you’re curious about using OTC pills with EPI, or prior to a diagnosis of EPI, you may be interested in this post where I describe in more detail using over the counter (OTC) enzyme pills for this purpose.)

Long run days are outliers in my pill count per day numbers and graphs. However, even if I skipped those and only took 8 prescription PERT per day, I’d still have consumed over 4,200 enzyme pills at this point.

EPI or PEI leads to a lot of pill-swallowing, regardless of whether you’re using over the counter enzymes or prescription enzymes.

But they work! Oh, do they work. My GI symptoms used to be most days a week and caused me to feel miserable (read about my experience getting diagnosed with EPI here). Now, I rarely have any symptoms, and when they do occur (likely mistiming a dose compared to what I was eating or taking not quite enough to match what I was eating), they are significantly less bothersome. It’s awesome, and I feel back to “normal” for me well before all of my GI symptoms started years ago! So yes, I have to swallow many pills a day for EPI but my symptoms are completely and regularly managed as a result and my quality of life is back to being what it was before.

If you’re curious to read more about my experiences with EPI, or posts about adjusting enzymes to match what you’re eating, check out DIYPS.org/EPI for a list of other EPI related posts.

If you have EPI and have an iOS device, you also might be interested in checking out PERT Pilot, a free iOS app to track food intake and PERT dosing and outcomes.

You’d Be Surprised: Common Causes of Exocrine Pancreatic Insufficiency

Academic and medical literature often is like the game of “telephone”. You can find something commonly cited throughout the literature, but if you dig deep, you can watch the key points change throughout the literature going from a solid, evidence-backed statement to a weaker, more vague statement that is not factually correct but is widely propagated as “fact” as people cite and re-cite the new incorrect statements.

The most obvious one I have seen, after reading hundreds of papers on exocrine pancreatic insufficiency (known as EPI or PEI), is that “chronic pancreatitis is the most common cause of exocrine pancreatic insufficiency”. It’s stated here (“Although chronic pancreatitis is the most common cause of EPI“) and here (“The most frequent causes [of exocrine pancreatic insufficiency] are chronic pancreatitis in adults“) and here (“Besides cystic fibrosis and chronic pancreatitis, the most common etiologies of EPI“) and here (“Numerous conditions account for the etiology of EPI, with the most common being diseases of the pancreatic parenchyma including chronic pancreatitis, cystic fibrosis, and a history of extensive necrotizing acute pancreatitis“) and… you get the picture. I find this statement all over the place.

But guess what? This is not true.

First off, no one has done a study on the overall population of EPI and the breakdown of the most common co-conditions.

Secondly, I did research for my latest article on exocrine pancreatic insufficiency in Type 1 diabetes and Type 2 diabetes and was looking to contextualize the size of the populations. For example, I know overall that diabetes has a ~10% population prevalence, and this review found that there is a median prevalence of EPI of 33% in T1D and 29% in T2D. To put that in absolute numbers, this means that out of 100 people, it’s likely that 3 people have both diabetes and EPI.

How does this compare to the other “most common” causes of EPI?

First, let’s look at the prevalence of EPI in these other conditions:

  • In people with cystic fibrosis, 80-90% of people are estimated to also have EPI
  • In people with chronic pancreatitis, anywhere from 30-90% of people are estimated to also have EPI
  • In people with pancreatic cancer, anywhere from 20-60% of people are estimated to also have EPI

Now let’s look at how common these conditions are in the general population:

  • People with cystic fibrosis are estimated to be 0.04% of the general population.
    • This is 4 in every 10,000 people
  • People with chronic pancreatitis combined with all other types of pancreatitis are also estimated to be 0.04% of the general population, so another 4 out of 10,000.
  • People with pancreatic cancer are estimated to be 0.005% of the general population, or 1 in 20,000.

What happens if you add all of these up: cystic fibrosis, 0.04%, plus all types of pancreatitis, 0.04%, and pancreatic cancer, 0.005%? You get 0.085%, which is less than 1 in 1000 people.

This is quite a bit less than the 10% prevalence of diabetes (1 in 10 people!), or even the 3 in 100 people (3%) with both diabetes and EPI.

Let’s also look at the estimates for EPI prevalence in the general population:

  • General population prevalence of EPI is estimated to be 10-20%, and if we use 10%, that means that 1 in 10 people may have EPI.

Here’s a visual to illustrate the relative size of the populations of people with cystic fibrosis, chronic pancreatitis (visualized as all types of pancreatitis), and pancreatic cancer, relative to the sizes of the general population and the relative amount of people estimated to have EPI:

Gif showing the relative sizes of populations of people with cystic fibrosis, chronic pancreatitis, pancreatic cancer, and the % of those with EPI, contextualized against the prevalence of these in the general population and those with EPI. It's a small number of people because these conditions aren't common, therefore these conditions are not the most common cause of EPI!

What you should take away from this:

  • Yes, EPI is common within conditions such as cystic fibrosis, chronic pancreatitis (and other forms of pancreatitis), and pancreatic cancer
  • However, these conditions are not common: even combined, they add up to less than 1 in 1000!
  • Therefore, it is incorrect to conclude that any of these conditions, individually or even combined, are the most common causes of EPI.

You could say, as I do in this paper, that EPI is likely more common in people with diabetes than all of these conditions combined. You’ll notice that I don’t go so far as to say it’s the MOST common, because I haven’t seen studies to support such a statement, and as I started the post by pointing out, no one has done studies looking at huge populations of EPI and the breakdown of co-conditions at a population level; instead, studies tend to focus on the population of a co-condition and prevalence of EPI within, which is a very different thing than that co-condition’s EPI population as a percentage of the overall population of people with EPI. However, there are some great studies (and I have another systematic review accepted and forthcoming on this topic!) that support the overall prevalence estimates in the general population being in the ballpark of 10+%, so there might be other ‘more common’ causes of EPI that we are currently unaware of, or it may be that most cases of EPI are uncorrelated with any particular co-condition.

(Need a citation? This logic is found in the introduction paragraph of a systematic review found here, of which the DOI is 10.1089/dia.2023.0157. You can also access a full author copy of it and my other papers here.)

New Systematic Review of Exocrine Pancreatic Insufficiency (EPI) In Type 1 Diabetes and Type 2 Diabetes – Focusing on Prevalence and Treatment

I’m thrilled that the research I did evaluating the prevalence and treatment of EPI in both Type 1 diabetes and Type 2 diabetes (also presented as a poster at #ADA2023 – read a summary of the poster here) has now been published as a full systematic review in Diabetes Technology and Therapeutics.

Here is a pre-edited submitted version of my article that you can access if you don’t have journal access; and as a reminder, copies of ALL of my research articles are available on this page: DIYPS.org/research!

And if you don’t want to read the full paper, this is what I think you should take away from it as a person with diabetes or as a healthcare provider:

    1. What is EPI? 

      Exocrine pancreatic insufficiency (known as EPI in some places, and PEI or PI in other places) occurs when the pancreas no longer produces enough enzymes to digest food. People with EPI take pancreatic enzyme replacement therapy (PERT) whenever they eat (or drink anything with fat/protein).

    2. If I have diabetes, or treat people with diabetes, why should I be reading the rest of this about EPI?EPI often occurs in people with cystic fibrosis, pancreatitis, and pancreatic cancer. However, since these diseases are rare (think <0.1% of the general population even when these groups are added up all together), the total number of people with EPI from these causes is quite low. On the other hand, EPI is also common in people with diabetes, but this is less well-studied and understood. The research on other co-conditions is more frequent and often people confuse the prevalence WITHIN those groups with the % of those conditions occurring overall in the EPI community.This paper reviews every paper that includes data on EPI and people with type 1 diabetes or type 2 diabetes to help us better understand what % of people with diabetes are likely to face EPI in their lifetime.
    3. How many people with type 1 diabetes or type 2 diabetes (or diabetes overall) get EPI?TLDR of the paper: EPI prevalence in diabetes varies widely, reported between 5.4% and 77% when the type of diabetes isn’t specified. For Type 1 diabetes, the median EPI prevalence is 33% (range 14-77.5%), and for Type 2 diabetes, the median is 29% (range 16.8-49.2%). In contrast, in non-diabetes control groups, the EPI prevalence ranges from 4.4% to 18% (median 13%). The differences in ranges might be due to geographic variability and different exclusion criteria across studies.Diabetes itself is prevalent in about 10% of the general population. As such, I hypothesize that people with diabetes likely constitute one of the largest sub-groups of individuals with EPI, in contrast to what I described above might be more commonly assumed.
    4. Is pancreatic enzyme replacement therapy (PERT) safe for people with diabetes? 

      Yes. There have been safety and efficacy studies in people with diabetes with EPI, and PERT is effective just like in any other group of people with EPI.

    5. What is the effect of pancreatic enzyme replacement therapy (PERT) on glucose levels in people with diabetes?
      PERT itself does not affect glucose levels, but PERT *d0es* impact the digestion of food, which then changes glucose levels! So, most PERT labels warn to watch for hypoglycemia or hyperglycemia but the medicine itself doesn’t directly cause changes in glucose levels. You can read a previous study I did here using CGM data to show the effect of PERT actually causing improved glucose after meals in someone with Type 1 diabetes. But, in the systematic review, I found only 4 articles that even made note of glucose levels, and only 1 (the paper I linked above) actually included CGM data. Most of the studies are old, so there are no definitive conclusions on whether hypoglycemia or hyperglycemia is more common when a person with diabetes and EPI starts taking PERT. Instead, it’s likely very individual depending on what they’re eating, insulin dosing patterns before, and whether they’re taking enough PERT to match what they’re eating.TLDR here: more studies are needed because there’s no clear single directional effect on glucose levels from PERT in people with diabetes.Note: based on the n=1 study above, and subsequent conversations with other people with diabetes, I hypothesize that high variability and non-optimal post-meal glucose outcomes may be an early ‘symptom’ of EPI in people with diabetes. I’m hoping to eventually generate some studies to evaluate whether we could use this type of data as an input to help increase screening of EPI in people with diabetes.
    6. How common is EPI (PEI / PI) compared to celiac and gastroparesis in Type 1 diabetes and Type 2 diabetes? 

      As a person with (in my case, Type 1) diabetes, I feel like I hear celiac and gastroparesis talked about often in the diabetes community. I had NEVER heard of EPI prior to realizing I had it. Yet, EPI prevalence in Type 1 and Type 2 diabetes is much higher than that of celiac or gastroparesis!The prevalence of EPI is much higher in T1 and T2 than the prevalence of celiac and gastroparesis.Celiac disease is more common in people with diabetes (~5%) than in the general public (0.5-1%). Gastroparesis, when gastric emptying is delayed, is also more common in people with diabetes (5% in PWD).However, the  prevalence of EPI is 14-77.5% (median 33%) in Type 1 diabetes and 16.8-49.2% (median 29%) in Type 2 diabetes (and 5.4-77% prevalence when type of diabetes was not specified). This again is higher than general population prevalence of EPI.

      This data emphasizes that endocrinologists and other diabetes care providers should be more prone to initiate screening (using the non-invasive fecal elastase test) for individuals presenting with gastrointestinal symptoms, as the rates of EPI in diabetes are much higher in both Type 1 and Type 2 diabetes than the rates of celiac and gastroparesis.

    7. What should I do if I think I have EPI?
      Record your symptoms and talk to your doctor and ask for a fecal elastase (FE-1) screening test for EPI. It’s non-invasive. If your results are less than or equal to 200 (μg/g), this means you have EPI and should start on PERT. If you or your doctor feel that your sample may have influenced the results of your test, you can always re-do the test. But if you’re dealing with diarrhea, going on PERT may resolve or improve the diarrhea and improve the quality of the sample for the next test result. PERT doesn’t influence the test result, so you can start PERT and re-run the test any time.Symptoms of EPI can vary. Some people experience diarrhea, while others experience constipation. Steatorrhea or smelly, messy stools that stick to the side of the toilet are also common EPI symptoms, as is bloating, abdominal pain, and generally not feeling well after you eat.

      If you’ve been diagnosed with EPI, you may also want to check out some of my other posts (DIYPS.org/EPI) about my personal experiences with EPI and also this post about the amount of enzymes needed by most people with EPI. You may also want to check out PERT Pilot, a free iOS app, for recording and evaluating your PERT dosing.

If you want to read the full article, you can find copies of all of my research articles at DIYPS.org/research

If you’d like to cite this specific article in your future research, here’s an example citation:

Lewis, D. A Systematic Review of Exocrine Pancreatic Insufficiency Prevalence and Treatment in Type 1 and Type 2 Diabetes. Diabetes Technology & Therapeutics. http://doi.org/10.1089/dia.2023.0157

Why DIY AID in 2023? #ADA2023 Debate

I was asked to participate in a ‘debate’ about AID at #ADA2023 (ADA Scientific Sessions), representing the perspective that DIY systems should be an option for people living with diabetes.

I present this perspective as a person with type 1 diabetes who has been using DIY AID for almost a decade (and as a developer/contributor to the open source AID systems used in DIY) – please note my constant reminder that I am not a medical doctor.

Dr. Gregory P. Forlenza, an Associate Professor from Barbara Davis Center, presented a viewpoint as a medical doctor practicing in the US.

FYI: here are my disclosures and Dr. Forlenza’s disclosures:

On the left is my slide (Dana M. Lewis) showing I have no commercial support or conflicts of interest. My research in the last 3 years has previously been funded by the New Zealand Health Research Council (for the CREATE Trial); JDRF; and DiabetesMine. Dr. Forlenza lists research support from NIH, JDRF, NSF, Helmsley Charitable Trust, Medtronic, Dexcom, Abbott, Insulet, Tandem, Beta Bionics, and Lilly. He also lists Consulting/Speaking/AdBoard: Medtronic, Dexcom, Abbott, Insulet, Tandem, Beta Bionics, and Lilly.

I opened the debate with my initial presentation. I talk about the history of DIY in diabetes going back to the 1970s, when people with diabetes had to “DIY” with blood glucose meters because initially healthcare providers did not want people to fingerstick at home because they might do something with the information. Similarly, even insulin pumps and CGMs have been used in different “DIY” ways over the years – notably, people with diabetes began dosing insulin using CGM data for years prior to them being approved for that purpose. It’s therefore less of a surprise in that context to think about DIY being done for AID. (If you’re reading this you probably also know that DIY AID was done years before commercial AID was even available; and that there are multiple DIY systems with multiple pump and CGM options, algorithms, and phone options).

And, for people with diabetes, using DIY is very similar to how a lot of doctors recommend or prescribe doing things off label. Diabetes has a LOT of these types of recommendations, whether it’s different types of insulins used in pumps that weren’t approved for that type of insulin; medications for Type 2 being used for Type 1 (and vice versa); and other things that aren’t regulatory approved at all but often recommended anyway. For example, GLP-1’s that are approved for weight management and not glycemic control, but are often prescribed for glycemic control reasons. Or things like Vitamin D, which are widely prescribed or recommended as a supplement even though it is not regulatory-approved as a pharmaceutical agent.

I always like to emphasize that although open source AID is not necessarily regulated (but can be: one open source system has received regulatory clearance recently), that’s not a synonym for ‘no evidence’. There’s plenty of high quality scientific evidence on DIY use and non-DIY use of open source AID. There’s even a recent RCT in the New England Journal of Medicine, not to mention several other RCTs (see here and here, plus another pending publication forthcoming). In addition to those gold-standard RCTs, there are also reviews of large-scale big data datasets from people with diabetes using AID, such as this one where we reviewed 122 people’s glucose data representing 46,070 days’ worth of data; or another forthcoming publication where we analyzed the n=75 unique (distinct from the previous dataset) DIY AID users with 36,827 days’ of data (average of 491 days per participant) and also found above goal TIR outcomes (e.g. mean TIR 70-180 mg/dL of 82.08%).

Yet, people often choose to DIY with AID not just for the glucose outcomes. Yes, commercial AID systems (especially now second-generation) can similarly reach the goal of 70+% TIR on average. DIY helps provide more choices about the type and amount of work that people with diabetes have to put IN to these systems in order to get these above-goal OUTcomes. They can choose, overall or situationally, whether to bolus, count carbs precisely, announce meals at all, or only announce relative meal size while still achieving >80% TIR, no or little hypoglycemia, and less hyperglycemia. Many people using DIY AID for years have been doing no-bolus and/or no meal announcements at all, bringing this closer to a full closed loop, or at least, an AID system with very, very little user input required on a daily basis if they so choose. I presented data back in 2018(!) showing how this was being done in DIY AID, and it was recently confirmed in a randomized control trial (hello, gold standard!) showing that between traditional use (with meal announcements and meal boluses); meal announcement only (no boluses); and no announcement nor bolusing, that they all got similar outcomes in terms of TIR (all above-goal). There was also no difference in those modes of total daily insulin dose (TDD) or amount of carb intake. There was a small difference in time below range being slightly higher in the first mode (where people were counting carbs and bolusing) as compared to the other two modes – which suggests that MORE user input may actually be limiting the capabilities of the system!

The TLDR here is that people with diabetes can do less work/provide less input into AID and still achieve the same level of ideal, above-goal outcomes – and ongoing studies are showing the increased QOL and other patient-reported outcomes that also improve as a result.

Again, people may be predisposed to think that the main difference between commercial and DIY is whether or not it is regulatory approved (and therefore prescribable by doctors and able to be supported by a company under warranty); the bigger differences are instead around interoperability across devices, data access, and transparency of how the system works.

There’s even an international consensus statement on open source AID, created by an international group of 48 medical and legal experts, endorsed by 9 national and international diabetes organizations, supporting that open source AID used in DIY AID is a safe and effective treatment option, confirming that the scientific evidence exists and it has the potential to help people with diabetes and reduce the burden of diabetes. They emphasize that doctors should support patient (and caregiver) autonomy and choice of DIY AID, and state that doctors have a responsibility to learn about all options that exist including DIY. The consensus statement is focused on open source AID but also, in my opinion, applies to all AID: they say that AID systems should fully disclose how they operate to enable informed decisions and that all users should have real-time and open access to their own data. Yes, please! (This is true of DIY but not true of all commercial systems.)

The elephant in the room that I always bring up is cost, insurance coverage, and therefore access and accessibility of AID. Many places have government or insurance that won’t cover AID. For example, the proposed NICE guidelines in the UK wouldn’t provide AID to everyone who wants one. In other places, some people can get their pump covered but not CGM, or vice versa, and must pay out of pocket. Therefore in some cases, DIY has out of pocket costs (because it’s not covered by insurance), but is still cheaper than AID with insurance coverage (if it’s even covered).

I also want to remind everyone that choosing to DIY – or not – is not a once-in-a-lifetime decision. People who use DIY choose every day to use it and continue to use it; at any time, they could and some do choose to switch to a commercial system. Others try commercial, switch back to DIY, and switch back and forth over time for various reasons. It’s not a single or permanent decision to DIY!

The key point is: DIY AID provides safety and efficacy *and* user choice for people with diabetes.

Dr. Forlenza followed my presentation, talking about commercial AID systems and how they’ve moved through development more quickly recently. He points to the RCTs for each approved commercial system that exist, saying commercial AID systems work, and describing different feature sets and variety across commercial systems. He shared his thoughts on advantages of commercial systems including integration between components by the companies; regulatory approval meaning these systems can be prescribed by healthcare providers; company-provided warranties; and company provided training and support of healthcare providers and patients.

He makes a big point about a perceived reporting bias in social media, which is a valid point, and talks about people who cherry pick (my words) data to share online about their TIR.

He puts an observational study and the CREATE Trial RCT data up next to the commercial AID systems RCT data, showing how the second generation commercial AID reach similar TIR outcomes.

He then says “what are you #notwaiting for?”, pointing out in the US that there are 4 commercial systems FDA approved for type 1 diabetes. He says “Data from the DIY trials themselves demonstrate that DIY users, even with extreme selection bias, do not achieve better glycemic control than is seen with commercial systems.” He concludes that commercial AID has a wide variety of options; commercial systems achieve target-level outcomes; a perception that both glucose outcomes and QOL are being addressed by the commercial market, and that “we do not need Unapproved DIY solutions in this space”.

After Dr. Forlenza’s presentation, I began my rebuttal, starting with pointing out that he is incorrectly conflating perceived biases/self-reporting of social media posts with gold-standard, rigorously performed scientific trials evaluating DIY. Data from DIY AID trials do not suffer from ‘selection bias’ any more than commercial AID trials do. (In fact, all clinical trials have their own aspects of selection bias, although that isn’t the point here.) I reminded the audience of the not one but multiple RCTs available as well as dozens of other prospective and retrospective clinical trials. Plus, we have 82,000+ data points analyzed showing above-goal outcomes, and many studies that evaluate this data and adjust for starting outcomes still show that people with diabetes who use DIY AID benefit from doing so, regardless of their starting A1c/TIR or demographics. This isn’t cherry-picked social media anecdata.

When studies are done rigorously, as they have been done in DIY, we agree that now second-generation commercial AID systems reach (or exceed, depending on the system) ADA standard of care outcomes. For example, Dr. Forlenza cited the OP5 study with 73.9% TIR which is similar to the CREATE Trial 74.5% TIR.

My point is not that commercial systems don’t work; my point is that DIY systems *do* work and that the fact that commercial systems work doesn’t then override the fact that DIY systems have been shown to work, also! It’s a “yes, and”! Yes, commercial AID systems work; and yes, DIY AID systems work.

The bigger point, which Dr. Forlenza does not address, is that the person with diabetes should get to CHOOSE what is best for them, which is not ONLY about glucose outcomes. Yes, a commercial system- like DIY AID – may help someone get to goal TIR (or above goal), but DIY provides more choice in terms of the input behaviors required to achieve those outcomes! There’s also possible choice of systems with different pumps or CGMs, different (often lower) cost, increased data access and interoperability of data displays, different mobile device options, and more.

Also, supporting user choice of DIY is in fact A STANDARD OF CARE!

It’s in the ADA’s Standards of Care, in fact, as I wrote about here when observing that it’s in the 2023 Standards of Care…as well as in 2022, 2021, 2020, and 2019!

I wouldn’t be surprised if there are people attending the debate who think they don’t have any – or many – patients using DIY AID. For those who think that (or are reading this thinking the same), I ask a question: how many patients have you asked if they are using DIY AID?

There’s a bunch of reasons why it may not come up, if you haven’t asked:

  • They may use the same consumables (sites, reservoirs) with a different or previous pump in a DIY AID system.
  • Their prescribed pump (particularly in Europe and non-US places that have Bluetooth-enabled pumps) may be usable in a DIY AID.
  • They may not be getting their supplies through insurance, so their prescription doesn’t match what they are currently using.
  • Or, they have more urgent priorities to discuss at appointments, so it doesn’t come up.
  • Or, it’s also possible that it hasn’t come up because they don’t need any assistance or support from their healthcare provider.

Speaking of learning and support, it’s worth noting that in DIY AID, because it is open source and the documentation is freely available, users typically begin learning more about the system prior to initiating their start of closed loop (automated insulin delivery). As a result, the process of understanding and developing trust in the system begins prior to closed loop start as well. In contrast, much of the time there is limited available education prior to receiving the prescription for a commercial AID; it often aligns more closely with the timeline of starting the device. Additionally, because it is a “black box” with fewer available details about exactly how it works (and why), the process of developing trust can be a slower process that occurs only after a user begins to use a commercial device.

With DIY AID, because it is open source and the documentation is freely available, users typically begin learning more about the system prior to initiating their start of closed loop (automated insulin delivery). As a result, the process of understanding and developing trust in the system begins prior to closed loop start as well. In contrast, much of the time there is limited available education prior to receiving the prescription for a commercial AID; it often aligns more closely with the timeline of starting the device. Additionally, because it is a black box with less available details about exactly how it works (and why), the process of developing trust can be a slower process that occurs only after a user begins to use a commercial device. The learning & trust in AID timelines is something that needs more attention in commercial AID moving forward.

I closed my rebuttal section by asking a few questions out loud:

I wonder how healthcare providers feel when patients learn something before they do – which is often what happens with DIY AID. Does it make you uncomfortable, excited, curious, or some other feeling? Why?

I encouraged healthcare providers to consider when they are comfortable with off-label prescriptions (or recommending things that aren’t approved, such as Vitamin D), and reflect on how that differs from understanding patients’ choices to DIY.

I also prompted everyone to consider whether they’ve actually evaluated (all of) the safety and efficacy data, of which many studies exist. And to consider who benefits from each type of system, not only commercial/DIY but individual systems within those buckets. And to consider who gets offered/prescribed AID systems (of any sort) and whether subconscious biases around tech literacy, previous glucose outcomes, and other factors (race, gender, other demographic variables) result in particular groups of people being excluded from accessing AID. I also remind everyone to think about what financial incentives influence access and available of AID education, and where the education comes from.

Although Dr. Forlenza’s  rebuttal followed mine, I’ll summarize it here before finishing a recap of my rebuttal: he talks about individual selection bias/cherry picked data, acknowledging it can occur in anecdotes with commercial systems as well; talks about the distinction of regulatory approval vs. off label and unapproved; legal concerns for healthcare providers; and closes pointing out that many PWD see primary care providers, he doesn’t believe it is reasonable to expect PCPs to become familiar with DIY since there are no paid device representatives to support their learning, and that growth of AID requires industry support.

People probably wanted to walk out of this debate with a black and white, clear answer on what is the ‘right’ type of AID system: DIY or commercial. The answer to that question isn’t straightforward, because it depends.

It depends on whether a system is even AVAILABLE. Not all countries have regulatory-approved systems available, meaning commercial AID is not available everywhere. Some places and people are also limited by ACCESSIBILITY, because their healthcare providers won’t prescribe an AID system to them; or insurance won’t cover it. AFFORDABILITY, even with insurance coverage, also plays a role: commercial AID systems (and even pump and CGM components without AID) are expensive and not everyone can afford them. Finally, ADAPTABILITY matters for some people, and not all systems work well for everyone.

When these factors align – they are available, accessible, affordable, and adaptable – that means for some people in some places in some situations, there are commercial systems that meet those needs. But for other people in other places in other situations, DIY systems instead or also can meet that need.

The point is, though, that we need a bigger overlap of these criteria! We need MORE AID systems to be available, accessible, affordable, and adaptable. Those can either be commercial or DIY AID systems.

The point that Dr. Forlenza and I readily agree on is that we need MORE AID – not less.

This is why I support user choice for people with diabetes and for people who want – for any variety of reasons – to use a DIY system to be able to do so.

People probably want a black and white, clear answer on what is the ‘right’ type of AID system: DIY or commercial. It depends on whether a system is even AVAILABLE. Not all countries have regulatory-approved systems available, meaning commercial AID is not available everywhere. Some places and people are also limited by ACCESSIBILITY, because their healthcare providers won’t prescribe an AID system to them; or insurance won’t cover it. AFFORDABILITY, even if insurance coverage, also plays a role: commercial AID systems (and even pump and CGM components without AID) are expensive and not everyone can afford them. Finally, ADAPTABILITY matters for some people, and not all systems work well for everyone. The point is that we need a bigger overlap of these criteria! We need more alignment of these factors - more AID (DIY and commercial) available, accessible, affordable, and adaptable for people with diabetes. I support user choice for people with diabetes, which includes DIY AID systems

PS – I also presented a poster at #ADA2023 about the high prevalence rates of exocrine pancreatic insufficiency (EPI / PEI / PI) in Type 1 and Type 2 diabetes – you can find the poster and a summary of it here.

Exocrine Pancreatic Insufficiency (EPI/PEI) In Type 1 and Type 2 Diabetes – Poster at #ADA2023

When I was invited to contribute to a debate on AID at #ADA2023 (read my debate recap here), I decided to also submit an abstract related to some of my recent work in researching and understanding the prevalence and treatment of exocrine pancreatic insufficiency (known as EPI or PEI or PI) in people with diabetes.

I have a personal interest in this topic, for those who aren’t aware – I was diagnosed with EPI last year (read more about my experience here) and now take pancreatic enzyme replacement therapy (PERT) pills with everything that I eat.

I was surprised that it took personal advocacy to get a diagnosis, and despite having 2+ known risk factors for EPI (diabetes, celiac disease), that when I presented to a gastroenterologist with GI symptoms, EPI never came up as a possibility. I looked deeper into the research to try to understand what the correlation was in diabetes and EPI and perhaps understand why awareness is low compared to gastroparesis and celiac.

Here’s what I found, and what my poster (and a forthcoming full publication in a peer-reviewed journal!) is about (you can view my poster as a PDF here):

1304-P at #ADA2023, “Exocrine Pancreatic Insufficiency (EPI / PEI)  Likely Overlooked in Diabetes as Common Cause of Gastrointestinal-Related Symptoms”

Exocrine Pancreatic Insufficiency (EPI / PEI / PI) occurs when the pancreas no longer makes enough enzymes to support digestion, and is treated with pancreatic enzyme replacement therapy (PERT). Awareness among diabetes care providers of EPI does not seem to match the likely rates of prevalence and contributes to underscreening, underdiagnosis, and undertreatment of EPI among people with diabetes.

Methods:

I performed a broader systematic review on EPI, classifying all articles based on co-condition. I then did a second specific diabetes-specific EPI search, and de-duplicated and combined the results. (See PRISMA figure).

A PRISMA diagram showing that I performed two separate literature searches - one broadly on EPI before classifying and filtering for diabetes, and one just on EPI and diabetes. After filtering out irrelevant, animal, and off topic papers, I ended up with 41

I ended up with 41 articles specifically about EPI and diabetes, and screened them for diabetes type, prevalence rates (by type of diabetes, if it was segmented), and whether there were any analyses related to glycemic outcomes. I also performed an additional literature review on gastrointestinal conditions in diabetes.

Results:

From the broader systematic review on EPI in general, I found 9.6% of the articles on specific co-conditions to be about diabetes. Most of the articles on diabetes and EPI are simply about prevalence and/or diagnostic methods. Very few (4/41) specified any glycemic metrics or outcomes for people with diabetes and EPI. Only one recent paper (disclosure – I’m a co-author, and you can see the full paper here) evaluated glycemic variability and glycemic outcomes before and after PERT using CGM.

There is a LOT of work to be done in the future to do studies with properly recording type of diabetes; using CGM and modern insulin delivery therapies; and evaluating glycemic outcomes and variabilities to actually understand the impact of PERT on glucose levels in people with diabetes.

In terms of other gastrointestinal conditions, healthcare providers typically perceive the prevalence of celiac disease and gastroparesis to be high in people with diabetes. Reviewing the data, I found that celiac has around ~5% prevalence (range 3-16%) in people with type 1 diabetes and ~1.6% prevalence in Type 2 diabetes, in contrast to the general population prevalence of 0.5-1%. For gastroparesis, the rates in Type 1 diabetes were around ~5% and in Type 2 diabetes around 1.3%, in contrast to the general population prevalence of 0.2-0.9%.

Speaking of contrasts, let’s compare this to the prevalence of EPI in Type 1 and Type 2 diabetes.

  • The prevalence of EPI in Type 1 diabetes in the studies I reviewed had a median of 33% (range 14-77.5%).
  • The prevalence of EPI in Type 2 diabetes in the studies I reviewed had a median of 29% (16.8-49.2%).

You can see this relative prevalence difference in this chart I used on my poster:

The prevalence of EPI is much higher in T1 and T2 than the prevalence of celiac and gastroparesis.

Key Findings and Takeaways:

Gastroparesis and celiac are often top of mind for diabetes care providers, yet EPI may be up to 10 times more common among people with diabetes! EPI is likely significantly underdiagnosed in people with diabetes.

Healthcare providers who see people with diabetes should increase the screening of fecal elastase (FE-1/FEL-1) for people with diabetes who mention gastrointestinal symptoms.

With FE-1 testing, results <=200 μg/g are indicative of EPI and people with diabetes should be prescribed PERT. The quality-of-life burden and long-term clinical implications of undiagnosed EPI are significant enough, and the risks are low enough (aside from cost) that PERT should be initiated more frequently for people with diabetes who present with EPI-related symptoms.

EPI symptoms aren’t just diarrhea and/or weight loss: they can include painful bloating, excessive gas, changed stools (“messy”, “oily”, “sticking to the toilet bowl”), or increased bowel movements. People with diabetes may subconsciously adjust their food choices in response to symptoms for years prior to diagnosis.

Many people with diabetes and existing EPI diagnoses may be undertreated, even years after diagnosis. Diabetes providers should periodically discuss PERT dosing and encourage self-adjustment of dosing (similar to insulin, matching food intake) for people with diabetes and EPI who have ongoing GI symptoms. This also means aiding in updating prescriptions as needed. (PERT has been studied and found to be safe and effective for people with diabetes.)

Non-optimal PERT dosing may result in seemingly unpredictable post-meal glucose outcomes. Non-optimal postprandial glycemic excursions may be a ‘symptom’ of EPI because poor digestion of fat/protein may mean carbs are digested more quickly even in a ’mixed meal’ and result in larger post-meal glucose spikes.

As I mentioned, I have a full publication with this systematic review undergoing peer review and I’ll share it once it’s published. In the meantime, if you’re looking for more personal experiences about living with EPI, check out DIYPS.org/EPI, and also for people with EPI looking to improve their dosing with pancreatic enzyme replacement therapy – you may want to check out PERT Pilot (a free iOS app to record enzyme dosing).

Researchers, if you’re interested in collaborating on studies in EPI (in diabetes, or more broadly on EPI), please reach out! My email is Dana@OpenAPS.org

Air Quality, CO2 monitoring, and Situational Masking

I do a lot of things most people don’t want to do themselves – and I get that. (For example, recording macronutrients while running? Running for up to 16 or 25 hours? Let alone other choices like building DIY and making open source automated insulin delivery systems not only for myself but more widely available for other people.) I’ve also talked before about functional self-tracking and how I don’t track things for the sake of tracking, I track when the data/information is actionable either retrospectively or in real-time.

I’ve spent enough time now collecting real-time data on air quality (via a proxy of CO2 levels) that I think it would be useful to share for other people to consider the retrospective data for THEIR decision making.

You may not want (or be able to afford) a CO2 monitor, and you may not want to mask inside all the time, but the below outlines the general scenarios in which air quality tends to be better or worse and when you would get the most benefit from situational masking in response to those situations.

(Think about situational masking indoors like you think about situational masking for smoke and poor air quality outside. Most of the time, you likely don’t mask outside. But if you’re on the east coast right now or have lived through a previous west coast US summer with a “smoke season”, you’ve probably experienced multi-day air quality outside that was so poor that you considered or did wear a high-quality (N95/K95) mask outside or limit your time exposed to that outdoor air.)

Air quality assessment via CO2 monitoring

In the last few years, Scott and I acquired two different CO2 monitors. The first was cheap, required to be plugged into a battery pack to run it, and was simply viewable on the device display. It was useful to start to get a sense for what the CO2 levels were in indoor spaces as compared to outdoor air.

Later, we decided to invest in an Aranet CO2 monitor, which runs on two AA batteries and lasts months on a single pair of batteries. You can view the data on the device display AND see a retrospective and realtime graph of the data in your phone, because it connects via Bluetooth. You can see not only CO2 but also temperature, humidity, and air pressure.

We have found this useful because CO2 is something that we all produce when we breathe out. The more we breathe out, and the more people that are breathing out, the higher the CO2 levels. The more of that air that is replaced with low-CO2 outside air, the lower the CO2 levels. Measuring the CO2 then helps us understand the ventilation (how much air is flowing through the space and how often it is being cleared out) and the risks of being in that space. A higher CO2 level means more people and/or less air being cleared out of the space, meaning  you are more likely to be breathing in what someone else is breathing out.

How we evaluate CO2 levels

An outdoor CO2 level would be around ~450 ppm in urban areas, or as low as 400 ppm out in nature. Since a perfectly-ventilated space would be 100% outside air, we want to compare any indoor air CO2 reading to outdoor air.

For example, at home in our enclosed apartment with 2 people (and 2 cats), we typically run around 700 ppm, which means ~250 ppm above outdoor air levels. When we open our door or a window, it drops to ~500 ppm, or only ~50 ppm above outdoor air levels. Given that we have confirmed our air intake into our HVAC system for our apartment is outdoor air, this means the ~250 ppm we are sharing between the two of us is just our (and the cats) exhalations, rather than anyone outside our household. So those levels are acceptable to us, but our choice of interventions would change if we were sharing air with other people, especially random strangers. (Stranger danger is one way to think about air, further contextualized below with data.)

In a shared space with random strangers, your risk of COVID aerosol-based transmission is proportional to how elevated the CO2 level is above that of outside air, and the amount of time spent in that space. So a CO2 reading of 650 ppm, which is ~200 ppm over outside air, would be half as risky as a reading of 850 ppm, or ~400 ppm over outside air. And timing matters, so a 1 hour bus ride or the hour you spend boarding and waiting for takeoff on your plane when CO2 levels are highest and the air filtration (see below) is off will be of greater risk than short exposure to the same levels.

Now, we’ve also used our CO2 monitors in many other places, such as in airports and on planes and other public transportation, and other indoor shared spaces like grocery stores etc.

Here’s what we’ve learned about where CO2 levels trend (based on our repeated but n=1 testing).

Trains, buses, and rideshare (e.g. Uber, Lyft, etc) = BAD NEWS BEAR AIR

Public transportation, in every location and every country we have been in, has much higher CO2 levels.

What do I mean by much higher? Often 1000-1500 ppm easily (and sometimes >2000 ppm), which is anywhere from 500-1500 ppm above outdoor air quality.

Trains/metros/light rail where the doors are constantly opening and closing to outdoor air would seem like they would be better, but sometimes they still have (due to the density of riders) >1500 ppm.

Buses where you can’t open the window can be as high of CO2 levels as planes, without the benefit of air exchange or HEPA filtration of the air. Our recent 20 minute bus ride was up to >2500 ppm on a full bus.

Watch out for rideshares, too. Often times we get in a rideshare and the driver intentionally or accidentally has “recirc” or “recirculating air” on, meaning the air isn’t exchanged outside and the driver and riders are re-breathing each other’s air over and over and over and over again..yikes. Specifically looking at the console when you get in the car is useful: if you see the recirc button lit up, ask the driver to turn it off. If they don’t understand or refuse, or you don’t want to try to explain it, opening a window helps immensely to reduce the CO2 levels and the amount of re-breathing air. (The recirc icon usually looks like a car with a U-shaped arrow on it).

Planes (including airports, during boarding, in flight, and during landing/deplaning) = ALSO BAD NEWS BEAR AIR

Airports sometimes have better-ventilated spaces: you can often find less crowded corners of a terminal and see CO2 readings of <900 ppm. However, it’s still pretty common to be in the airport and see >1000 ppm, meaning that the CO2 is >500 ppm above outdoor air quality, and it is air from a whole assortment of random strangers coming and going, so it’s less safe than the air you’d be breathing in at home or in private spaces.

When boarding, both standing close in line with other people but also on the jet bridge and while you are on the plane, is usually even HIGHER CO2 levels than the airport. The typical air for a plane (that they tout with HEPA filters and high air exchange rates) is not turned on until you start to take off, and then it takes some time to exchange all of the air. This means there is a MUCH higher rate of re-breathing other people’s air while boarding and until you are in the air.

Now, we have measured CO2 levels during all of these times. If indoor airport air is around 900 ppm, it usually jumps to 1100-1300 on the jetbridge (if you’ve got a backed up line) and when you’re sitting on the plane watching other people board, it can go up to 2500+. And then it continues to go up as you have a full flight of people breathing in this enclosed space. During flight, we’ve seen CO2 levels hover between 1700-3000 ppm, and in some cases have gone up to ~4000 ppm. This is a lot of CO2! However, there are HEPA filters cleaning the ~half of the air that is recirculated instead of replaced. So, it’s harder to say when the airplane air systems ARE running (during most of the flight) whether the risk is as high (for infectious disease transmission) as it is in other environments that aren’t studiously exchanging and HEPA-filtering any recirculated air.

Note that when they spin down the engines after landing and all the way through taxiing, deplaning, and getting back into the airport – the CO2 level again tends to rise because they again change the air flow when they’re on the ground. So like standing in line to get on or waiting for other people to board, standing in line to get off/waiting for everyone to get off produces high CO2 levels *without the benefit of in-flight air exchange*, so it’s likely higher risk during those times than in the air during the middle of the flight, even if CO2 levels are equally high during flight.

Indoor spaces like grocery stores or conference rooms/meeting halls

Indoor spaces can vary quite a bit, and often by country or venue.

For example, most indoor spaces in the US we’ve found to often have a fairly high (e.g. 900+ ppm) indoor CO2 level, even without a huge density of people. For example, we quickly went into a grocery store the other day and the CO2 was high-800s without being around many people in the aisles, across the entire store. For not having people actively occupying the space, this is fairly high and less optimal.

In contrast, we recently were in Sweden for a conference and were honestly gobsmacked when we got off the plane and found the CO2 levels to be <600 ppm in the airport! And in the hotel lobby! And in the hotel elevator! And at the local grocery store!

(Seriously, it shocked us, because we’ve also recently been in the UK with our CO2 monitor and found US-like CO2 levels typically around 900-1000 ppm or higher, and also in Spain last year where we similarly found it to be >900 ppm even when not densely occupied. The exception to optimal air quality in Sweden was our ~20 minute bus ride where CO2 levels were >2500 ppm).

So, the CO2 levels may vary quite a bit and this is why measuring is helpful. Because you can’t assume that one country/one room means that all of the rooms in that country or even that venue will be the same.

Case in point? Conference rooms/halls or meeting rooms.

In Barcelona, Spain in April 2022, I spoke at a conference. The CO2 levels in the hallways and in the meeting room before the session started were around 800-900 ppm when not occupied. Again, a little high for not having people actively in the spaces. Then, when the conference started, Scott watched the CO2 monitor and saw it rise..and rise…and rise. Within 45 minutes, the CO2 levels were around 2000 ppm (>1500 ppm over outdoor air quality)! He went to the back of the room and opened the doors to try to get some air circulating in the room, although it didn’t make a big difference. That room did not have a high number of air exchanges per hour and was not successfully clearing out the air people were breathing out.

In Sweden (May 2023, where the CO2 was <600 in a lot of public indoor spaces), we found the same challenge in a high ceiling, large meeting hall. With 300 people, the start of the session had about 950 ppm (as opposed to the <600 ppm of less occupied hallways). Not too bad given 300 people in the space. However, by the end of the session, the CO2 level had risen to ~1350! And it continued to rise even as people had exited the room; we didn’t see a drop in CO2 levels until we went out in the hallway to continue talking to people, and it took another ~25 minutes before CO2 levels in the hallway were back down <600 ppm.

Again, we were surprised, because this venue (the hallways, lobby, elevator, etc) all had really great otherwise indoor air quality with CO2 <600 ppm!

But the challenge is the space (and the infrastructure for filtration and air exchanges); the number of people filling the space; and the amount of time, in terms of what happens to the CO2 levels.

The takeaway from this? Conference halls, meeting rooms, and anywhere where you are sitting with a group of people over a period of time is going to have a much higher CO2 level and it will increase in proportion to the time that you are occupying that space (e.g. a 30 minute or 1 hour session is going to have a much higher CO2 buildup than a 10 minute talk where the audience is turning over and leaving the room and it clears out some before the next session).

So what should you do about this information? Consider situational masking.

I really have found a CO2 monitor helpful, because even my best guesses about air quality (e.g. thinking Sweden’s conference hall would have good air quality given the size of the room and ceilings) aren’t always accurate. But if you don’t want to invest in a CO2 monitor, here’s where you can get the biggest bang for your buck with situational masking.

What do I mean by situational masking? Maybe you don’t think you’re at very high risk for COVID or other infectious illnesses, but you are interested in reducing the likelihood that you spread anything you get to other people (thanks!). But you don’t want to have to think about it, and maybe you’ve chosen previously to drop masking so you don’t have to think about it. Here’s a set of easy rules/situations in which, like learning to dump your liquids out before going through airport security, you can get into a habit of doing and not have to think about it much.

  • Public/shared transportation.

    Riding a bus, train, metro, or a car with a stranger and especially with multiple strangers – these have high CO2 levels.

  • Airports, boarding a plane and during takeoff, and during descent/landing/deboarding the plane.

    This is when the CO2 levels are highest and the air exchanges/HEPA filtration is not running.

    Think of it like the seatbelt sign. You board the plane and put your seatbelt on, then eventually once you’ve reached cruising altitude the seatbelt sign goes off. If you’re standing in a line of people (to board or deplane) OR if the seatbelt sign is ON, that’s a huge ROI for wearing a high-quality (N95 or KN95) mask. When the seatbelt sign first turns off during the flight (or you hear the 10k-feet chime) and you want to take and leave it off, or take it off a while to eat or drink – that’s less risky during those times due to the HEPA filtration and air exchanges during flight. But when the seatbelt sign goes on for the plane’s final descent? The air quality is going down, too, so putting your seatbelt AND your mask back on is a higher ROI thing to do.

    (You do you inside the airport, too, but see below about density of people and temperature as a guide for whether you might want to consider situational masking in airports when you’re not eating/drinking.)

 

  • Conferences or meetings where you are sitting for more than a few minutes and there are many people in the room.

    Even with super big rooms and super high ceilings, so far every conference space I’ve presented in during the last several years has high CO2 levels even before the talk starts, and is even higher (>500-1000 ppm added) by the end of the session). If you’re not presenting or eating and drinking and are just sitting there listening and engaging in the session…it’s a low hassle opportunity to pop a high-quality mask on so you’re not breathing so much of the air around you from everyone else. When you’re done with the session and head out and want to socialize? Like leaving the plane, you’ll be around fewer people, and the CO2 levels (and risk) goes down. But sitting there quietly is a great time to wear a good mask and reduce your intake of other people’s exhalations.

 

You might find yourself in situations where the room feels hot and stuffy, or in the case of conferences and meetings, the air feels FREEZING cold. It runs freezing cold because the room gets hot and stuffy with so many people, indicating this space is not well ventilated, so they pump the AC to change the temperature. But that is a compensation for a too-low rate of air exchanges, and pre-cooling doesn’t prevent CO2 and aerosol buildup, so a room that either gets freezing cold or hot and stuffy should be a signal that the air quality likely isn’t ideal.

So a good rule of thumb is, if you’re in a space that feels hot and stuffy OR freezing cold, that’s an indicator that the air quality might be non-optimal. Consider masking in those situations even if you don’t have a CO2 monitor to evaluate the air.

It would be great if we could get 10x people to consider situational masking like this. Avoid the worst of the bad-news-bear-air of public and shared transportation and indoor spaces, which would cut down on a lot of transmission, even if people otherwise are still socializing and eating in indoor spaces and doing whatever it is they want to do. The choice to situationally mask might occasionally protect them but would also protect everyone around them in those situations when their exhalations have the greatest risk of doing the most damage.

A good way to think about it is at a conference. You might be willing to go to bars and socialize, but someone who is higher risk may be choosing not to attend those indoor dining scenarios. That’s fine: you each get to make your own choices! But when you go and sit down next to that person in a conference session, your choices then influence that person by every breath you take in that conference session.

That’s why situational masking – knowing that a situation is low-hassle to wear a high-quality mask (sitting quietly in a session) but high-risk (due to the poor air quality) means you have a high ROI to pull a mask out of your pocket/bag and throw it on – can help the people around you very effectively with little hassle and thought on your part.

You can get in the habit of masking in the bad-news-bear-air situations/locations, and you don’t have to think much about it. You’ll make things a bit safer for yourself and for the people around you, for far less hassle than avoiding buying a drink before you go through airport security because you know you need to dump liquids out.

Data-driven situational masking based on indoor air quality

How To Talk To Your Doctor About Your Enzyme (PERT) Dosing If You Have Exocrine Pancreatic Insufficiency (EPI or PEI or PI)

In exocrine pancreatic insufficiency (EPI/PEI/PI), people are responsible for self-dosing their medication every time they eat something.

Doctors prescribe a starting dose, but a person with EPI determines each and every time they eat or drink something how many enzyme pills (of pancreatic enzyme replacement therapy, known as PERT) to take. Doctors often prescribe a low starting dose, and people have to try experimenting with multiple pills of the small size, and eventually work with their doctors to change their prescription to get a bigger pill size (so they can take fewer pills per meal) and the correct number of pills per day to match their needs.

For example, often people are prescribed one 10,000 unit pill per meal. The 10,000 units represents the amount of lipase (to help digest fat). There are also two other enzymes (protease, for protein digestion, and amylase, for carbohydrate digestion). They may be prescribed 1 pill per meal, which means 10,000 units of lipase per meal. But most dosing guidelines recommend starting at a dose of 40,000-50,000 units of lipase per meal (and people often need more), so it wouldn’t be surprising that someone prescribed one 10,000 pill per meal would need 4-5 pills of the 10,000 size pill PER MEAL, and times three meals per day (let alone any snacks), to get acceptable GI outcomes.

Mathematically, this means the initial prescription wouldn’t last long. The initial prescription for 1 pill per meal, with 3 meals a day, means 3 pills per day. 3 pills per day across a 30 day month is 90 pills. But when the pills per meal increase, that means the prescription won’t cover the entire month.

In fact, it would last a lot less than a month; closer to one week!

Showing that based on the number of pills and 3 meals per day, an intitial RX of 10,000 size pills may last more like a week rather than a full 30 days when the doctor is unaware of prescribing guidlines that typically suggest 40,000-50,000 per meal is needed as the starting meal dose.

Let’s repeat: with a too-small prescription pill size (e.g. 10,000 starting dose size) and count (e.g. 3 pills per day to cover 1 per meal) and with a person with EPI titrating themselves up to the starting dose guidelines in all of the medical literature, they would run out of their prescription WITHIN ONE WEEK. 

So. If you have EPI, you need to be prepared to adjust your dosing yourself; but you also need to be ready to reach out to your doctor and talk about your need for more enzymes and a changed prescription.

PERT (enzymes) come in different sizes, so one option is to ask for a bigger pill size and/or a different amount (count) per meal/day. Depending on the brand and the number of pills you need per meal, it could be simply going up to a bigger pill size. For example, if you need 3 pills of the 10,000 PERT size, you could move to a 36,000 pill size and take one per meal. If you find yourself taking 5 pills of the 10,000 PERT size, that might mean 2 pills of the 25,000 size. (Brands differ slightly, e.g. one might be 24,000 instead of 25,000, so the math may work out slightly differently depending on which brand you’re taking.)

Don’t be surprised if you need to do this within a week or two of starting PERT. In fact, based on the math above, especially if you’re on a much lower dose than starting guidelines (e.g. 40,000-50,000 units of lipase per meal), you should expect within a few days to need an updated prescription to make sure that you don’t run out of PERT.

If you do find yourself running out of PERT before you can get your prescription updated, there is an alternative you can consider: either substituting or adding on over the counter enzymes. The downsides include the fact that insurance doesn’t cover them so you would be paying out of pocket; plus there are no studies with these so you can’t (shouldn’t) rely on these as full 1:1 substitutes for prescription PERT without careful personal testing that you can do so. That being said, there is anecdotal evidence (from me, as well as hundreds of other people I’ve seen in community groups) that it is possible to use OTC enzymes if you can’t afford or can’t get a PERT prescription; or if you need to “top off”/supplement/add to your PERT because your prescription won’t last a full month and you can’t get a hold of your doctor or they won’t update your prescription.

For me, I generally evaluate the units of lipase (e.g. this kind is 17,000 units of lipase per pill) but then factor in for the lack of reliability for OTC and really treat it like it contains 13-15,000 units of lipase when choosing to take it. Similarly for another lipase-only OTC option (that has ~6,000 units per pill), I assume it acts like it only has ~5,000 units. Unlike insulin, there is little downside to taking a little too much of enzymes; but there is a LOT of downside to not taking enough, so my personal approach is that if in doubt, or on the fence, to round up (especially with OTC pills, which cost somewhere between $0.08/pill (lipase-only) to $0.34/pill (for the larger and multiple enzyme pill)).

So how do you talk to your doctor about needing more PERT?

It helps if you bring data and evidence to the conversation, especially if your doctor thinks by default that you don’t need more than what they initially prescribed. You can bring your personal data (more on that below and how to collect and present that), but you can also cite relevant medical literature to show if your dose is below standard starting guidelines.

Below I’ve shared a series of citations that show that the typical starting dose for people with EPI should be around 40,000-50,000 units of lipase per meal.

Important note that this is the STARTING DOSE SIZE, and most of these recommend further increasing of dose to 2-3 times this amount as needed. Depending on the starting dose size, you can see the chart I built below that illustrates with examples exactly how much this means one might need to increase to. Not everyone will need the upper end of the numbers, but if a doctor starts someone on 10,000 and doesn’t want to get them up to 40,000 (the lower end of starting doses) or go beyond 40,000 because it’s the starting dose, I’ve found this chart useful to show that numerically the range is a lot larger than we might assume.

Example of Titrating According to Common Dose Guidelines, Before Adding PPI

Examples of PERT starting doses of 25,000, 40,000, and 50,000 (plus half that for snacks) and what the dose would be if increased according to guidelines to 2x and 3x, plus the sum of the total daily dose needed at those levels.

Here are some citations that back up my point about 40,000-50,000 units of lipase being the typically recommended starting dose, including across different conditions (e.g. regardless of whether you have EPI + any of (chronic pancreatitis, diabetes, celiac, etc)).

  • Shandro et al, 2020, the median starting dose of 50,000 units per lipase “is an appropriate starting dose”, also citing UEG 2017 guidelines.
  • Forsmark et al, 2020, defined appropriate dose of PERT as >=120,000 units of lipase per day (e.g. 40,000 units of lipase per meal).
  • Whitcomb et al, 2022, in a joint American Gastroenterology Association and PancreasFest symposium paper, concur on 40,000 units as a starting dose and that “This dose should be titrated up as needed to reduce steatorrhea or gastrointestinal symptoms of maldigestion “
  • 2021 UK guidelines for EPI management suggest 50,000 units as the starting dose and emphasize that “all guidelines endorse dose escalation if the initial dose is not effective”

There are also many guidelines and research specific for EPI and different co-conditions supporting the ballpark of 40-50,000 units of lipase starting dose:

It is also worth noting that these guidelines also point out that after titrating 2-3x above the starting dose, PPI (proton pump inhibitors, to suppress acid) should be added if gastrointestinal symptoms are still not resolved. Anecdotally, it seems a lot of doctors are not aware that PPIs should be added if 3x the starting dose is not effective, so make sure to bring this up as well.

How to Share Your Personal PERT Data To Show How Much You Need

In addition to pointing out the guidelines (based on the above), it’s useful to share your data to show what you’ve been taking (dosing) and how it’s been working. I’ve written a lot about how you can do this manually, but I also recently created an iOS based app to make it easier to track what you’re eating, what you’re dosing in terms of PERT/enzymes, and what the outcome is. This app, PERT Pilot, is free to use, and it also enables you to visualize on a graph the relationship between what you’re eating and dosing.

PERT Pilot lets you track how many grams of fat each pill of your current prescription has been used for, so you can see with red and green coloring the relationship between meals that you’ve had symptoms after (in red) vs. when you recorded no symptoms (green). If you have a “convergence zone” of green and red in the same area, that may help you decide to change your ratio (e.g. dose more) around that amount, until you can comfortably and repeatedly get green results (no symptoms when you eat).

How you might use this to talk to your doctor

You can take a screenshot of your PERT Pilot graph and share it with your doctor to show them how many grams of fat your prescription size (e.g. pill size) effectively “covers” for you, and how many meals that you’ve tested it with.

Meals based on the ratio of fat:lipase and protein:protease mapped with color coded dots where green means no symptoms, orange means not sure if symptoms, and red means symptoms occurred and the dose likely didn't work at that ratio.For example, I was initially prescribed an enzyme dose that was one pill per meal (and no snacks), so I had 3 pills per day. But I quickly found myself needing two pills per meal, based on what I was typically eating. I summarized my data to my doctor, saying that I found one pill typically covered up to ~30 grams of fat per meal, but most of my meals were >30 grams of fat, so that I wanted to update my prescription to have an average of 2 pills per meal of this prescription size. I also wanted to be able to eat snacks, so I asked for 2 pills per meal, 1 per snack, which meant that my prescription increased to 8 pills per day (of the same size), to cover 2 pills x 3 meals a day (=6) plus up to 2 snacks (=2). I also had weeks of data to show that my average meal was >30 grams of fat to confirm that I need more than the amount of lipase I was originally prescribed. My doctor was happy to increase my prescription as a result, and this is what I’ve been using successfully for over a year ever since.

So in summary, the data that would be useful to share is:

  • How much one pill ‘covers’ (which is where the PERT Pilot graph can be used)
  • How many pills per meal you’ve been taking and how big your meals typically are
  • Whether you are struggling with the number of pills per meal: if so, ask whether there’s a larger pill size in your current brand that you could increase to, in order to reduce the number of pills per meal (and/or snack) you need to take every time

If you are told that you shouldn’t need “that much”, remember the above section and have those resources ready to discuss that the starting dose is often 40,000-50,000 per meal and that the guidelines say to titrate up to 3x that before adding PPI. Therefore, it would be expected for some people to need upwards of 600,000 units of lipase per day (50,000 starting dose, increased 3x per meal and half of the dose used per snack). Depending on what people eat, this could be even higher (because not everyone eats the same size meal and snack and many of us adjust dose based on what we eat).

Also, it is worth noting that the dosing guidelines never mention the elastase levels or severity of EPI: so PERT prescriptions should not be based on whether you have “moderate” or “severe” EPI and what your elastase level is (e.g. whether it’s 45 or 102 or 146 or even 200, right on the line of EPI – all of those elastase levels would still get the same starting dose of PERT, based on the clinical guidelines for EPI).

It is common and you are not alone if you’ve not been giving the starting dose of PERT that the guidelines recommend.

There are numerous studies showing most people with EPI are initially underdosed/underprescribed PERT. For example, in 2020 Forsmark et al reported that only 8.5% of people with chronic pancreatitis and EPI received an adequate prescription for PERT: and only 5.5% of people with pancreatic cancer and EPI received an adequate prescription dose of PERT. Other studies in chronic pancreatitis and EPI from 2014, 2016, and 2020 report that undertreatment often occurs in EPI and CP; and I’ve found studies in other conditions as well showing undertreatment compared to guidelines, although it’s most studied in CP and cancer (which is true of all types of EPI-related research, despite the prevalence in many other conditions like diabetes, celiac, etc.).

You may need to advocate for yourself, but know that you’re not alone. Again, feel free to comment or email privately (Dana@OpenAPS.org) if you need help finding research for another co-condition and EPI that I haven’t mentioned here.

PS – if you haven’t seen it, I have other posts about EPI at DIYPS.org/EPI

How I Built An AI Meal Estimation App – AI Meal Estimates in “PERT Pilot” and Announcing A New App “Carb Pilot”

As I have been working on adding additional features to PERT Pilot, the app I built (now available on the App Store for iOS!) for people like me who are living with exocrine pancreatic insufficiency, I’ve been thinking about all the things that have been challenging with managing pancreatic enzyme replacement therapy (PERT). One of those things was estimating the macronutrients – meaning grams of fat and protein and carb – in what I was eating.

I have 20+ years practice on estimating carbs, but when I was diagnosed with EPI, estimating fat and protein was challenging! I figured out methods that worked for me, but part of my PERT Pilot work has included re-thinking some of my assumptions about what is “fine” and what would be a lot better if I could improve things. And honestly, food estimation is still one of those things I wanted to improve! Not so much the accuracy (for me, after a year+ of practice I feel as though I have the hang of it), but the BURDEN of work it takes to develop those estimates. It’s a lot of work and part of the reason it feels hard to titrate PERT every single time I want to eat something.

So I thought to myself, wouldn’t it be nice if we could use AI tools to get back quick estimates of fat, protein, and carbs automatically in the app? Then we could edit them or otherwise use those estimates.

And so after getting the initial version of PERT Pilot approved and in the App Store for users to start using, I submitted another update – this time with meal estimation! It’s now been live for over a week.

Here’s how it works:

  • Give your meal a short title (which is not used by the AI but is used at a glance by us humans to see the meal in your list of saved meals).
  • Write a simple description of what you’re planning to eat. It can be short (e.g. “hot dogs”) or with a bit more detail (e.g. “two hot dogs with gluten free buns and lots of shredded cheddar cheese”). A little more detail will get you a somewhat more accurate estimates.
  • Hit submit, and then review the generated list of estimated counts. You can edit them if you think they’re not quite right, and then save them.

Here’s a preview of the feature as a video. I also asked friends for examples of what they’d serve if they had friends or family coming over to dinner – check out the meal descriptions and the counts the app generated for them. (This is exactly how I have been using the app when traveling and eating takeout or eating at someone’s house.)

Showing screenshots of PERT Pilot with the meal description input and the output of the estimated macronutrient counts for grams of fat, protein, and carb Showing more screenshots of PERT Pilot with the meal description input and the output of the estimated macronutrient counts for grams of fat, protein, and carb Showing even more screenshots of PERT Pilot with the meal description input and the output of the estimated macronutrient counts for grams of fat, protein, and carb

The original intent of this was to aid people with EPI (PEI/PI) in estimating what they’re eating so they can better match the needed enzyme dosing to it. But I realized…there’s probably a lot of other people who might like a meal estimation app, too. Particularly those of us who are using carb counts to dose insulin several times a day!

I pulled the AI meal estimation idea out into a second, separate app called Carb Pilot, which is also now available on the App Store.

Carb Pilot is designed to make carb counting easier and to save a bunch of clicks for getting an estimate for what you’re eating.

The Carb Pilot logo, which has pieces of fruit on the letters of the word "Carb". Pilot is written in italic script in purple font.

What does Carb Pilot do?

  • Like PERT Pilot, Carb Pilot has the AI meal estimation feature. You can click the button, type your meal description (and a meal title) and get back AI-generated estimates.
  • You can also use voice entry and quickly, verbally describe your meal.
  • You can also enter/save a meal manually, if you know what the counts are, or want to make your own estimates.

Carb Pilot integrates with HealthKit, so if you want, you can enable that and save any/all of your macronutrients there. HealthKit is a great tool for then porting your data to other apps where you might want to see this data along with, say, your favorite diabetes app that contains CGM/glucose data (or for any other reason/combination).

Speaking of “any/all”, Carb Pilot is designed to be different from other food tracking apps.

As a person with diabetes, historically I *just* wanted carb counts. I didn’t want to have to sift through a zillion other numbers when I just needed ONE piece of information. If that’s true for you – whether it’s carbs, protein, calories, or fat – during onboarding you can choose which of these macronutrients you want to display.

Just want to see carbs? That’s the default, and then in the saved meals you’ll ONLY see the carb info! If you change your mind, you can always change this in the Settings menu, and then the additional macronutrients will be displayed again.

Carb Pilot enables you to toggle the display of different nutrients. This shows what it looks like if only carbs are displaying or what happens if you ask the app to display all nutrients for each recorded food item.

It’s been really fun to build out Carb Pilot. Scott has been my tester for it, and interestingly, he’s turned into a super user of Carb Pilot because, in his words, “it’s so easy to use” and to generate macronutrient estimates for what he’s eating. (His use case isn’t for dosing medicine but matching what he’s eating against his energy expenditure for how much exercise/activity he’s been doing.) He’s been using it and giving me feedback and feature requests – I ended up building the voice-entry feature much more quickly than I expected because he was very interested in using it, which has been great! He also requested the ability to display meals in reverse chronological order and to be able to copy a previous meal to repeat it on another day (swipe on a meal and you can copy the description if you want to tweak and use it again, or simply repeat the meal as-is). We also discovered that it supports multiple languages as input for the AI meal estimation feature. How? Well, we were eating outside at a restaurant in Sweden and Scott copied and pasted the entree description from the menu – in Swedish – into Carb Pilot. It returned the counts for the meal, exactly as if he had entered them in English (our default language)!

I’m pointing this out because if you give Carb Pilot a try and have an idea for a feature/wish you could change the app in some way, I would LOVE for you to email me and tell me about it. I have a few other improvements I’m already planning to add but I’d love to make this as useful to as many people who would find this type of app helpful.

Why (was) there a subscription for ongoing AI use?

For both PERT Pilot and Carb Pilot, there is a cost (expense) to using the AI meal estimation. I have to pay OpenAI (which hosts the AI I’m using for the app) to use the AI for each meal estimation, and I have to host a web server to communicate between the app and the AI, which also costs a bit for every time we send a meal estimation request from the app. That’s why I decided to make Carb Pilot free to download and try. I originally played with $1.99 a month for unlimited AI meal estimations, but temporarily have turned that off to see what that does to the server load and cost, so right now it’s free to use the AI features as well.

TLDR:

– PERT Pilot has been updated to include the new meal estimation feature!

– People without EPI can use Carb Pilot for carb, protein, fat, and/or calorie tracking (of just one or any selection of those) tracking, also using the new AI meal estimation features!

You can find PERT Pilot here or Carb Pilot here on the App Store.

PERT Pilot – the first iOS app for Exocrine Pancreatic Insufficiency (EPI or PEI) and Pancreatic Enzyme Replacement Therapy (PERT)

Introducing PERT Pilot, the first iOS app designed for people with exocrine pancreatic insufficiency (EPI / PEI) and the only iOS app for specifically recording pancreatic enzyme replacement therapy (PERT) dosing!

*Available to download for FREE on the iOS App Store *
The PERT Pilot logo - PERT is in all caps and bold purple font, the word "Pilot" is in a script font in black placed below PERT.

After originally developing GI symptoms, then working through the long journey to diagnosis with exocrine pancreatic insufficiency (known as EPI or PEI), I’ve had to come up methods to figure out the right dosing of PERT for my EPI. I realized that the methods that I’ve made work for me – logging what I was eating in a spreadsheet and using it to determine the ratios I needed to use to dose my pancreatic enzyme replacement therapy (PERT) – weren’t methods that other people were as comfortable using. I have been thinking about this for the last year or more, and in my pursuit for wanting to encourage others to improve their outcomes with EPI (and realize that it IS possible to get to few symptoms, based on increasing/titrating the enzymes we take based on what we eat), I wrote a very long blog post explaining these methods and also sharing a free web-based calculator to help others to calculate their ratios.

But, that still isn’t the most user-friendly way to enable people to do this.

What else could I do, though? I wasn’t sure.

More recently, though, I have been experimenting with various projects and using ‘large language model’ (LLM) tools like GPT-4 to work on various projects. And a few weeks ago I realized that maybe I could *try* to build an iOS app version of my idea. I wanted something to help people log what they are eating, record their PERT dosing, and more easily see the relationship in what they are eating and what enzymes they are dosing. This would enable them to use that information to more easily adjust what they are dosing for future meals if they’re not (yet) satisfied with their outcomes.

And thus, PERT Pilot was born!

Screenshots from the PERT Pilot app which show the home screen, the calculator where you enter what PERT you're taking and a typical meal, plus the resulting ratios screen that show you the relationship between what you ate and how many enzymes you dosed.

What does PERT Pilot do?

PERT Pilot is designed to help people living with Exocrine Pancreatic Insufficiency (EPI or PEI) more easily deal with pancreatic enzyme replacement therapy (PERT). Aka, “taking enzymes”.

The PERT Pilot calculator enables you log the PERT that you are taking along with a meal, how many pills you take for it, and whether this dosing seems to work for you or not.

PERT Pilot then shows you the relationship between how much PERT you have been taking and what you are eating, supporting you as you fine-tune your enzyme intake.

PERT Pilot also enables you to share what’s working – and what might not be working – with your healthcare provider. PERT Pilot not only lists every meal you’ve entered, but also has a visual graph so you can see each meal and how much fat and protein from each meal were dosed by one pill – and it’s color coded by the outcome you assigned that meal! Green means you said that meal’s dosing “worked”; orange means you were “unsure”, and red matches the meals you said “didn’t work” for that level of dosing.

You can press on any meal and edit it, and you can swipe to delete a meal.

PERT Pilot also has is an education section so you can learn more about EPI and why you need PERT, and how this approach to ratios may help you more effectively dose your PERT in the future.

Why use PERT Pilot if you have EPI or PEI or PI?

PERT Pilot is the first and only specific app for those of us living with EPI (PEI or PI). People who use the approach in PERT Pilot of adapting their PERT dosing to what they are eating for each meal or snack often report fewer symptoms. PERT Pilot was designed and built by someone with exocrine pancreatic insufficiency, just like you!

With PERT Pilot you can:

  • Log your meals and PERT dosing. No other app specifically is designed for PERT dosing.
  • Edit or adjust your meal entry at any time – including if you wake up the next morning and realize your last dose from the day before ‘didn’t work’.
  • Review your dosing and see all of your meals, dosing, and outcomes – including a visual graph that shows you, for each meal, what one pill ‘covered’ so you can see where there are clusters of dosing that worked and if there are any clear patterns in what didn’t work for you.
  • You can also export your data, as a PDF list of all meals or a CSV file (which you can open in tools like Excel or other spreadsheet tools) if you want to analyze your data elsewhere!
  • Your data is your data, period. No one has access to your dosing data, meal data, or outcome data, and nothing you enter into PERT Pilot leaves your device – unless you decide to export your data. (See more in the PERT Pilot Privacy Policy.)

Note: this app was not funded by nor has any relationship to any pharmaceutical or medical-related companies. It’s simply built by a person with EPI for other people with EPI.

Here is a quick demonstration of PERT Pilot in action:

An animated gif of PERT Pilot in action

You can share your feedback about PERT Pilot:

Feel free to email me (Dana+PERTPilot@OpenAPS.org) any time.

I’d love to hear what works or is helpful, but also if something in the app isn’t yet working as expected.

Or, if you use another approved brand of PERT that’s not currently listed, let me know and I can add it in.

And, you can share your feature requests! I’m planning to build more features soon (see below).

What’s coming next for PERT Pilot:

I’m not done improving the functionality! I plan to add an AI meal estimation feature (UPDATE: now available!), so if you don’t know what’s in what you’re eating at a restaurant or someone else’s home cooked meal you can simply enter a description of the meal and have macronutrient estimates generated for you to use or modify.

Download PERT Pilot today! It’s free to download, so go ahead and download it and check it out! If you find it useful, please also leave a rating or review on the App Store to help other people find it in the future. You can also share it via social media, and give people a link to download it: https://bit.ly/PERT-Pilot-iOS

A Crouton In Your Salad (Or COVID In The Air)

Look, I get it: you don’t care about a crouton in your salad.

If you don’t like croutons, you simply pick them out of your salad and nudge them to the side of your plate. No harm done.

But for me, a crouton in my salad IS harm done. Even if I were (or the restaurant were) to pick off the croutons, the harm is done. There are specks and crumbs of gluten remaining in my food, and since I have celiac disease, my body is going to overreact to microscopic flecks of gluten and cause damage to my intestines and actively block absorbing the nutrients in the other food that I’m eating.

You might scoff at this concept, but one of the reasons celiac is so risky is because there are both the short term effects (days of abdominal pain, for example) and the long-term risk of causing holes in my intestine and drastically increasing the risk of stomach cancer, if I were to continue consuming gluten.

Some people with celiac aren’t symptomatic, meaning, they could eat the specks (or heck, chunks) of gluten and not feel what I feel.

When I eat specks of gluten? Bad news bears. Literally. It feels like bears clawing at my insides for hours, then days of abdominal soreness, headaches, and feeling unwell. That’s from a SPECK of gluten. I have a strong symptomatic response, so that makes it easier – perhaps – for me than for those with celiac without symptomatic response to choose to be very, very careful and avoiding cross-contamination in my food, and lower my long-term risk of things like stomach cancer that is linked to celiac long-term.

But knowing what I know about how my brain works and the rest of what I’m dealing with, I can imagine the alternative that if I was asymptomatic but lucky enough to discover that I did have celiac disease (through routine screening), I would probably still go to 99% of the same lengths that I do now to avoid gluten and cross-contamination of gluten, because of the long-term risks being so high.

I also don’t have celiac in a silo. I also have type 1 diabetes, which raises my risk of other things…and now I also have exocrine pancreatic insufficiency (EPI) which means every meal I am fighting to supply the right amount of enzymes to successfully digest my food, too. Oh, and now I also have Graves’ disease, so while my thyroid levels are nicely in range and always have been, I’m fighting battles with invisible ghosts in my body (thyroid-related antibodies) that are causing intermittent swelling of my eyelids and messing with my heart rate to tell me that there’s something going on in my body that I have no direct control over.

My plate is already full. (Or my dance card is already full, if you prefer that analogy). I don’t want, and can’t mentally envision right now, handling another thing. I work really hard every day to keep myself in good health. That involves managing my glucose levels and insulin delivery (for Type 1 diabetes), taking my thyroid-related medication that might be helping bring my antibody levels down and monitoring for symptoms to better provided feedback to the 6-week loop of data I get from blood testing to decide how we should be treating my Graves’, to thinking about EVERY SINGLE THING I put in my mouth so that I can take the right amount of enzymes for it, to making sure EVERY SINGLE THING I put in my mouth is gluten-free and is safe from cross-contamination.

Every meal. Every snack. Every drink. Every day.

Probably for the rest of my life: I can’t stop thinking about or doing those things.

Perhaps, then, if you could imagine being in this situation (and I’m so glad most of you are not!), you can imagine that I work really hard to make things easier and better for myself. Both with the plate that I’ve been given, but also in doing my best to lower the risk of more things being added to my already over-loaded plate.

(Preface for this next section: this is about ME not about YOU.)

COVID is one such example. I have worked very hard to avoid COVID, and I am still working very hard to avoid COVID. Like celiac and EPI, if I were to get COVID or other viral illnesses (like the flu), there is the risk of feeling very bad for a short period of time (e.g. 5-7 days). (I’m vaccinated, so the risk of short-term illness being severe (e.g. hospitalization, death) is lowered, and is probably at the same risk as being hospitalized for flu. Even when vaccinated for flu, I’ve been sick enough to almost be hospitalized, which is also why I don’t discount this risk, albeit recognizing it is lower with vaccination).

But like celiac and EPI, if I were to get COVID etc, that increases health risks for the long-term. This is true of most viral illnesses. And when you have an autoimmune condition which indicates your body is a super-star at overreacting to things (which causes other autoimmune conditions), you can imagine that poking the bear is going to make the bear (over)react, whether it is in the short-term or long-term.

It’s not so much if, but when, I would get handed my FIFTH chronic condition if I do get COVID. I went from two (type 1 diabetes and celiac) to four (adding EPI and Graves’) within the course of the same year. This is without having COVID. Given the data showing the increased risk in the long-term of developing many other conditions following COVID, even in people who don’t have superstar overreactive immune systems, it is easy to draw a dotted line to predict the future post-COVID infection to imagine it is not if, but when, my fifth thing would develop and get added to my plate.

So this is why I choose to do things differently than perhaps you do. I mask in indoor spaces. I am currently still choosing to avoid indoor dining. I don’t mind if you choose to do differently; I similarly don’t begrudge you eating croutons. But just like I wouldn’t expect you to pelt me with croutons and yell at me for not eating croutons when you can, I also prefer people not to propel possibly-infectious air at me at short-range when I am unmasked, which is why I prefer to be masked in indoor public spaces. The air is lava (or crouton dust) to me in terms of COVID.

Again, the point here is not to convince you to act any differently than you are acting. You do you! Eat your croutons, do what you like in regard to breathing the air however you like.

But like most folks are 100% fantastic about respecting that I’m not going to eat flecks of croutons, I wish folks would be more understanding of all the background situations behind my (and others’) choices regarding masking or avoiding indoor dining. What I do is not hurting someone else, whether it is not eating croutons or choosing to be masked in an indoor space.

Why would someone want to force me to eat a crouton, knowing it would cause immense harm in the short-term and contribute to long-term damage to my body and increase the risk of life-ending harm?

This is the direction in which I wish we could shift thinking about individual behaviors. Me wearing a mask is like me not eating croutons. Also, I don’t usually ask people to not eat croutons, but many of my friends and family will be happy to agree to eat at a 100% gluten free place if that’s the best option, because it doesn’t harm them not to eat gluten on occasion. Sometimes we do eat at a place that serves gluten, and they eat their croutons without thinking about it. I’m fine with that, too, as long as I am not asked or put at risk of having my mouth be stuffed with crouton dust. That’s how, maybe, I wish people would think about masking. Even if you don’t typically wear masks because you don’t feel you need to, you might choose to occasionally mask indoors when you’re around others who are masking to protect themselves. Like eating at a gluten free restaurant with your friends on occasion, it probably won’t be a big deal for you. You get plenty of gluten at other times. Then you can go back to eating your usual dietary choices (croutons all day, not masking).

COVID is interesting because it is something that potentially impacts all of us, which is why I think maybe the dynamics are changed. Someone might say “oh sure, I wouldn’t throw croutons at you or yell at you for choosing not to eat gluten”. But some people might also think they have the right to judge me regarding my choices around showing up somewhere masked, because they are ‘in the same situation’ and are choosing differently than I.

But my point is: this is not the same situation, the risks to me are not the same, which is why I may choose differently.

TLDR – I guess the point is, what looks like the ‘same’ situation on the outside is not the same for everyone; these differences influence our individual choices and needs; and I wish this is the way more people saw things.

A Crouton In Your Salad (or COVID in the air) by Dana M. Lewis on DIYPS.org