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Comment by epilys | Hacker News Reader

Note that as with every insulin-pump system, it still has two major pain points:

- subcutaneous insulin doesn't act immediately, as it would if it was injected in the blood directly. it peaks in an hour and then wanes off at 3-4 hours.

- it cannot know external factors like how much carbohydrates you are eating, or if you are planning to work out, etc. Like conventional pumps you have to enter it manually.

Buying a sandwich and not having to think about carb grams and predosing at all sounds like a dream to me.

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My youngest daughter has been on a pump for six years now and she's completely burned out and apathetic about it all. It just all blurs together and her diabetes is not well managed at the moment. My oldest and I had a sort of impromptu intervention with her and she just broke down crying. It's a lot.

The pump she has, a t:slim X2 is better than her Medtronic, but the closed loop aspect (control iq) is impotent and rarely has a noticeable impact. Hopefully this tech will advance on a good pace and products will hit the market with more assertive control algorithms. Obviously there are dangers but we've already accepted that by hooking her up to a pump with enough insulin in it to kill her.

Due to NDAs I can't write too much about this but there is a lot of work being done on this front right now and I expect a new generation of these devices to be out for trial in the relatively near future. Pumps are getting smaller, which is one factor that helps and analysis is getting more accurate. Reliability and sensors are improving. But the timing aspect is critical especially without knowledge about environmental factors and the relatively long hysteresis of the feedback is a major obstacle to the big leap forward. Key here is that the body has more data about the situation than an outside device will ever have and that regulation in the body is a fairly global affair [1] so it can act faster and with more precision than you can ever do from a single site. These are all super tricky problems. But compared to the situation only a decade ago it is already much better and I fully expect at least one more round of breakthrough devices. Best of luck there, it's harsh to be a kid with such a demon on your shoulders.

[1] for instance: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4214828/

That's amazing to hear. Thank you!

Gosh your post really hit a nerve.

I went through the same struggle with my own Type 1.

Feeling overwhelmed with responsibility, denying I am any different than anyone else, denying that I have to permanently manage a condition to be normal, denying that my own body would fail me, feeling helpless that even the "best" I could do would still involve invasive and frustrating treatments.

For me, it was a phase. Happened at about the same age (through my teens, basically) and took about that amount of time to just get through it. At some point I learned that with a bit of management, I can thrive and do just as well as anyone, especially with the new tools that we have now. It just took that psychological struggle to get there.

I am really sorry that you have to see your daughter struggling like that. I know exactly how helpless it feels.

Thank you, I really needed to hear this.

Hang in there, lots of folks having similar experience!

We have been pretty impressed with the closed-ish loop of the Dexcom and Omnipod, it handles daily fluctuations due to more/less exercise etc. fairly well.

Still two separate handheld devices though, and quality always falls off when the sensor (every 10ish days) and pump (every 3 days) approach expiration.

I love my omnipod/dexcom combo so much.

I have family with diabetes and I feel some empathy with your situation. I've felt that second hand anxiety when my cousin started partying recklessly in uni and not managing it super well.

You're helping her manage it and that makes a massive difference. Those of us without diabetes usually aren't taking care of ourselves at 100% either. We're lucky to have access to amazing medical technology, so some scary seeming situations are pretty recoverable.

Hopefully a platitude or two helps a small amount :(

My 11/yo has the same pump. Control IQ is great...but it takes a cautious approach to adjustments of insulin delivery given that it can only lower blood glucose levels and not raise them. Hopefully dual-hormone pumps will come out in the next few years and the algorithms can be more aggressive.

In the end, our 11 year old ignores his pump much of the time. We have a bunch of SugarPixels around the house, so if his sugar is way off we know and can address it ASAP.

Have you tried putting your daughter on a different diet (low glycemic-index diet with more natural and keto-friendly foods)? This will make managing her diabetes a lot simpler and it'll make her feel better too.

I'm a type one diabetic and have been one for over 15 years now. Getting diagnosed is one of the best things that's ever happened to me. It got me to notice the huge impact diet and exercise have on the mind and body. I initially had issues like your daughter too but changing my eating habits and altering my life-style definitely had a profound effect and made it much easier to manage. If you need tips / help let me know and I'll do what I can. My number one tip is to stick to a more keto-based diet. It will make her blood sugar much easier to manage and has a lot of health benefits.

Thanks for the suggestion! She's 20 and living at school so I have limited influence over her diet. She's pretty much raising a middle finger at her diagnosis right now out of spite and frustration so it's a tricky situation. I've asked her to try to find a community that caters to diabetics at school (i know one exists but i tell her to join it it will not work) to feel less alone about the whole thing.

It just sucks all around.

Ohhh I see and my apology for the misunderstanding!! Either way - she's still young and she has plenty of time to figure it out. If not - one other recommendation I have is getting lab tests done every 3 to 6 months and going for regular check-ups with a doctor. If you find a good doctor - they can make a big difference in getting patients to notice bad HB1C measures and can talk with her about keeping them in check and why it's so important to keep blood sugar levels within normal range. Either way - I wish her a lot of luck and my offer still stands if she (or you yourself) need any help or advice :)

Second this. Just adding fats and protien to a meal effect the meal’s glycemic index (even though it does nothing to glycemic load). I did a lot of research both times my wife was gestational diebetic, and while I already knew that fats helped to smooth bloodsugar levels, it was still wierd to see a dataset with toast having one of the highest glycemic while buttered toast was significantly lower on the scale.

This is trying to solve the wrong problem. Juvenile diabetes is almost always a human problem - not one of optimizing for treatment.

If you have a kid in their teens or 20's who is not entirely ignoring it out of spite, you're way ahead of the game. This problem is much harder to solve than tracking carbs and insulin doses, or changing diet/etc.

The person has to be ready to attack it. And for many young folks (and I assume older as well) this is where the problem lies. It takes a lot to really accept this is going to be your entire life, especially at an age where everyone (seemingly) around you are living these amazing care-free young adult lives, while you have this constant monkey on your back being a buzzkill. Very few individuals have the desire to "do their research" and start hacking on their health the way the HN community would tend to approach things.

Short of commenting on how heartbreaking it is as a parent to watch your kid go through this, I really have no good answers. I guess the topic of this discussion is it - a magic device you can slap on once a week and never think about again. Short of a device like that, I can't see this problem turning to technical vs. human any time soon.

You nailed it.

If you think of our brains as a complex electrochemical reaction, the concept of activation energy is in play. And I just think that for some people in some situations their mind doesn’t have the wiring to generate sufficient potential gradient to achieve the activation energy required to motivate action. They can’t just will a thing, they need to rewire their brain first.

Fortunately this is possible, but not easy.

My daughter is on https://camdiab.com/ it really works a charm, we do have alarms for low glucose (like it can dip down to 3.1 if she does exercise) and rarely for high glucose, but these are things you would probably not even see without the constant monitoring. The data shows that she is extremely well managed since she started with the closed loop system.

Camaps demands that you have a particular model of phone (about a dozen androids and iphones) which makes it a bit more expensive I guess. Luckily we are on the NHS in the uk so my only expense as a parent is that I have to buy the posh phone, but then I guess that goes with having a teenager around anyway...

Nice!!! Do you mind if I ask which pump you’re using? We’re already using the G6 cgm which she seems to like.

G6-cgm and Dana Diabecare-rs. We started with the Dana-i but it was glitchy and so we got the rs instead, which works a charm so far. We also use a setter device that talks to the Dana pump when you are filling it up and tells it how much insulin you are loading (this can be done manually also I think).

She has a samsung s-20 phone, previously we had a pixel 3 which bricked itself on Christmas Eve. I had a LG G7 which we tried to use, but although this is claimed to be compatible it turned out not to work. So we had injections over Christmas which was not great, but when the new phone turned up on 27th all was well again. Google replaced the Pixel, so I now have the replacement handset and it is ready to go as a fail over.

I'm on the Medtronic 780g hybrid loop and it's actually working. If I eat nothing and have no intense physical activity the CGM curve is a stable straight line.

That's the one she had. It's been a few years, maybe they have fixed it.

It has indeed been improved substantially in the last couple of years. If you haven't upgraded the pump in that time I would definitely recommend you do so.

One thing about these pumps that doesn't seem to be advertised widely enough: they don't handle full sun well, so always keep at least one layer of clothing over the pump.

I am aware that I know next to nothing about the topic and that I am ignorant of countless complications. With that said, your pancreas also does not know that you plan to work out, at least I would assume so. So what is the crucial difference between a pancreas and insulin injections? That the response is delayed because the injection is not into the blood stream or does the pancreas also have better sensors to figure out how much insulin to release, or maybe even release things other than insulin? If it is the former, what obstacle is there for injecting into the blood stream? The infection risk of having a permanently open port into the circulatory system? If so, is there a similarly effective way to deliver insulin that is not into the blood stream and with less risks? Or could you have some kind of membrane in the port that only allows insulin to pass through but that is impermeable for pathogens? Or would that get clogged immediately?

The difference is the pancreas reacts immediately to changes and has no practical delay for its effects, same concept as PID controllers in engineering.

So the limiting factor is the subcutane delivery, i.e. if the insulin could be delivered into the blood stream, then continuous glucose monitoring and controlled precise insulin doses could work as well as the pancreas?

The subcutaneous part is not really solvable, but even if it were, "real" insulin is much faster than even the fastest insulins (lispros) that we currently have. So there is a delay between delivery and action. There is also a delay on the sensing side; the pancreas always knows what's up, but even cutting edge CGM technology has significant delays, mostly related to that subcutaneous issue from my understanding.

There are faster acting insulins creatively named "faster aspart" and "ultra rapid lispro" with the latter beginning to appear in the bloodstream at 2 minutes and reaching 50% effect around 20 minutes.

With that said the difference between CGM/pumps and the human body's mechanisms of blood glucose regulation is not purely due to pharmacokinetics, regulation of blood sugar is very complex and we still don't fully understand them but there are multiple hormones and factors affecting blood glucose regulation.

As one example some incretins are released in response to ingested food content and stimulate insulin secretion before blood glucose levels rise. We can't replicate that just by measuring blood glucose (not that we necessarily have to).

The homeostatic mechanisms of the human body are fascinatingly complex.

It's a huge oversimplification, but essentially yes.

The current external artificial pancreas solutions operate subcutaneously, and your pancreas gets to work more directly with your blood. Subcutaneous blood sugar readings lag about 20 minutes compared to actual blood (finger pricks), and subcutaneous insulin delivery lags behind a healthy pancreas by even longer.

There isn't much of a difference between injecting insulin (being diabetic) or getting your body to produce it. The main difference lies in having no automated mechanism for regulating blood sugar levels. Due to this - you have to calculate the correct amount of insulin you need for your meals and measure your blood sugar regularly to make sure it stays within balance. If your blood sugar levels tend to be higher than normal (i.e. you aren't injecting enough insulin), that isn't good. It is OK in the near term - but can be devastating in the long term due to health complications (i.e. blindness / nerve damage / etc..). If your blood sugars are fall too low - you can have severe consequences in the near term (i.e. die or have a seizure within 1 hour of injecting insulin). In other words - you need to always keep your blood sugar in check in order to survive and to be in good health. Some people find this extremely hard to do - some people like me embrace it.

Your pancreas actually does know things like that you've ingested a lot of carbohydrates before they enter the bloodstream, etc. Certainly there is also a response to exercise that occurs before you coiod easily detect it with a CGM. There are very complex brain-gut-pancreas interactions mediated by a variety of molecules/hormones.

So my wife is a type 1ner. She recently got a pump that also reads her transmitter and it will change the amount of insulin being delivered based on what the transmitter is saying. It isn't perfect she can overwhelm it if she eats a ton of carbs, but honestly it's gone from her pump/phone yelling at her 7-8 times a day about being high or low to maybe once a day or once every other day.

The biggest thing it has also done is regulate her blood sugar at night so we don't wake up anymore with the pump screaming at her that she needs to start shoving fruit snacks down her maw.

I have a family member on a similar system. You might/probably already know this, but I'll put it out there anyway in case I'm wrong.

The thing to watch out for is that if the CGM was previously alerting about frequent nighttime lows, there should probably be some basal dose adjustment made in the pump. The pump can cover incorrect basal dosages for a good range with its automatic adjustments, but it's better to periodically look at the numbers and see if it's regularly backing off the basal dose because it's too high.

You can build automation with *aps to do a bit better on these metrics than commercial systems—- e.g. responding to heart rate, or as someone else pointed out, noticing an SSID from a gym.

> - it cannot know external factors like how much carbohydrates you are eating, or if you are planning to work out, etc. Like conventional pumps you have to enter it manually.

Sign up for the waitlist of https://replica.health! It is designed to make capturing those external factors as painless as possible. Depending on what setup you have, it will be available in the next month.

CGM circuit systems do auto-handle spikes. The systems are getting better.

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