April 1, 2025 • 40 mins
In episode 28 of Think Like a Pancreas--The Podcast, host, Gary Scheiner and his guest, Melissa Holloway discuss the highlights from the Advanced Technologies and Treatments for Diabetes (ATTD) Conference held in Amsterdam.
They delve into emerging technologies for diabetes management, innovative medications, and new application software that can enhance the daily lives of those living with diabetes.
Key Takeaways- Melissa feels that the Dexcom 15-day sensor and its improved accuracy is a game-changer.
- There is value in continuous ketone monitoring.
- Updates on the latest insulin delivery systems and extended wear infusion sets.
- Information about dual hormone infusion systems and their potential benefits.
- Advancements in CGM, insulin pumps, and AID algorithms.
- Introduction to innovative apps like 'Diabetes Cockpit' and their practical applications.
- 00:00 - Introduction and Welcome
- 01:43 - Hello to Melissa Holloway
- 05:43 - Game Changing Technology
- 09:43 - Finger Stick Monitoring Developments
- 10:30 - Continuous Ketone Monitoring Thoughts
- 13:23 - GLP-1 Use in Type 1 Diabetes
- 17:43 - Advances in Screening For Prevention of Type 1 Diabetes
- 20:00 - Innovations in Insulin Delivery Systems
- 25:11 - Advances in Infusion Set Technology.
- 27:16 - Dual Hormone Infusion Systems
- 29:30 - Medtronic's Simplera Sensor
- 30:18 - Diabetes Apps of Interest
- 34:19 - Smart Start Software
- 39:34 - Conference Highlights and Reflections
- Advanced Technologies and Treatments for Diabetes (ATTD) Conference in Amsterdam.
- The use of AID around physical activity and exercise in type 1 diabetes.
- https://syntactiq.ai
- Diatech Diabetes
- Smart Start Health
The information contained in this program is based on the experience and opinions of the Integrated Diabetes Services clinical team. Please discuss any changes to your treatment plan with your personal healthcare provider before implementing.
If you enjoyed today's episode, don't forget to like, follow or subscribe on your favorite podcast app.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:30):
Welcome to Think Like a Pancreas,the podcast where our goal is to keep
you informed, inspired, and a littleentertained on all things diabetes.
The information contained in thisprogram is based on the experience
and opinions of the IntegratedDiabetes Services clinical team.
Please discuss any changes to yourtreatment plan with your personal
(00:50):
healthcare provider before implementing.
Welcome to Think Like a Pancreas.
The podcast, uh, we're gonna be talkingtoday, uh, about the advanced Technologies
and treatments for diabetes conferencethat just took place in Amsterdam.
And if anyone out there knowsexactly where Amsterdam is, call in.
(01:10):
We'd love to hear.
No, we, we looked it up on the map.
I did not get to go to thisconference this year, and I love
this conference because it appliesso well to people on insulin and
intensive insulin therapy, more sothan any other conference I know of.
However, my good friend and colleague,Melissa Holloway was there and she is
(01:31):
gonna be giving us the lowdown on some ofthe stuff that she discovered in person.
So Melissa, hey, welcometo the, the program.
Uh, why don't you tell the folksat home a little about yourself.
Thank you Gary.
It's always a pleasure to speakwith you and also always a
pleasure to talk about ATTD.
It is my favorite meeting when I was ina job that I had to request holiday to
(01:53):
go places for, I took my vacation daysto go to ATTD because I love it so much.
So, um, I can't wait to tellyou all the things I picked up.
One of the things that drives me tokeep going is that since I'm now working
on Smart Start, I get to hear all thebuzz about what's happening in CGM and
what are the latest, greatest tools,techniques, approaches to helping people
(02:14):
get the most out of their diabetes data.
And I mean, that's whatgets me up in the morning.
So I didn't sleep very much at ATTD.
Yeah.
And you have a personal connection too.
How long have you had that?
Oh yeah.
Uh oh.
I've just, I'm about to reach my31st dia-versary at the end of this
week, um, and I've been using CGMsince 2006, um, on, on a pump since
(02:36):
1996, and I've been a DIY Looper.
Since June, 2018.
So, um, I've got the t-shirts.
You know, I think for dia-versaries itshould be like anniversaries where every
year has an item associated with it.
You know, you got your gold andyour diamond and all that stuff.
What would be a good first year marker?
(02:56):
Right?
That could be the glucose tablet year.
Or we could throw it back to likeBaskin Robbins and say, you should
go get yourself an ice cream.
Even better.
I love it.
One.
Yeah, as an American, that I could makethat joke, but as you know, I live in
London, so the sunlight that you'reseeing streaming in is our afternoon.
Yeah.
How many years haveyou been in the UK now?
Actually more than half my life now.
(03:18):
I added it up the other day andI moved in 2001 for post grad.
When I thought I was gonna be a PEMAhistorian, and then by 2004 I was working
in diabetes and then moved back to theUS for a couple of years and then made my
way in on a final basis to the UK in 2007.
So the years are ticking upcloser to 20 than to 15 now.
(03:39):
Yeah.
I will tell you, you arestarting to sound a little more
like a UK person all the time.
Every time we get together,I hear a little more of that.
That accent in you.
You know why?
It's because my husband corrects the kidswhenever they say something like I do.
Hmm.
And so now I have to overpronounce my Ts or else the kids
start mocking the way I speak.
(03:59):
Yep.
So anyway, Amsterdam islocated in the Netherlands.
Of course that helps nobody knowingthat it's in the Netherlands,
but I, I saw we've got this, thisworld map on our shower curtain.
I'm, I learned so muchgeography when I shower.
The Netherlands is just alittle bit west of Germany.
It's a little bit north of Belgiumand a little south of Denmark.
(04:22):
So it's sort of nestled in that.
Part of kind of Northern Europe, right?
What was Amsterdam like?
I've never been there.
It's a lovely city.
I got to go a couple years ago andsaw much more of it when I went to a
big exhibition of Vermeer paintings.
There's loads and loads of canals.
It's very much a city on the water andin fact it's got more canals in Venice.
Um, so that's one of their fun facts.
(04:43):
And they're really good at fries.
Fries are a local specialty, um, and
Not chips, but fries.
Fries.
Yeah.
They, they consider themto be more like frites.
If you've been to Belgium and everybodyspeaks English pretty much makes
it a very accessible city for lotsof people from around the world.
So it, it's got a lot of tourists allthe time because it's a fun place to go.
(05:04):
And then of course, some people areattracted by the coffee shop culture.
And in a coffee shopyou don't drink coffee.
It's not about the coffee.
Yeah.
I love how you say water, becausehere in Philly we say water.
Everyone's got their ownpronunciation for it.
Yeah.
Well this is because ofmy husband and the kids.
They make me say water.
If I go to the US for a week,I come back saying, water.
(05:25):
There you go.
Or water.
All right, so if there is one thing, justone thing that stands out in your mind
as you got to this conference, ATTD in,in Amsterdam, and it just blew you away.
You're like, wow, this is a game changer.
What would it be?
Well, I think the data I was mostexcited to see is the Dexcom 15 day and
(05:48):
for G7, and the reason I got so excitedis that they've changed the algorithm
as well and it shows such accuracy.
And even the first day of wear comparedto the previous generations, the product
that Dexcom had come out with, and I'vebeen using Dexcom since 2006, like just
to declare my interest when there wasa corporate symposium and Jake Leach
(06:08):
stood up in front of a timeline of allthe different Dexcom devices there have
ever been, I thought I've got 'em all.
You know, like I've, I've beenthrough all of those generations of
product and today somebody would sayDexcom, pft, that three day sensor!
Gosh, you know, who evenwould've wanted to use that?
And, and I can reflect on how when it wasavailable, it made things better for me.
(06:29):
It was better than 12fingers sticks a day, and I.
I still got my hbA1c down withno more hypos in those days.
So when I think about how far thetechnology has come, I think we're
getting now into these really incrementaladvances in terms of what's possible.
But the idea that the 15 day sensoris still going to have a grace
period attached made me think,gosh, only two sensors a month.
(06:52):
Like for me, having used Dexcom forsuch a long time, going from a sensor
every few days to a sensor every sevendays, to a sensor every 10 days, but
then going to a sensor every, like15 and a half days, I'm gonna have
more room under my bed for shoes.
My husband's not gonna like that partwhen I say there's more room for shoes.
But I like the data.
I thought it looked really strong.
The real benefit is more shoe space.
(07:14):
That's the real advantagethat the 15 day sensor offers
because I was thinking about it.
I, I, it's
The MARD.
I, I like the MARD too.
Every 10 days.
To me, it's not that big a deal.
I'm going to go from changing it threetimes a month to two times a month.
Do you think that reallymakes a big difference?
Not a huge difference, but I dofind myself checking how many days
I have left on my sensor because 10days isn't like an kind of an even
(07:37):
increment of time in comparison tothe other tasks I do for my diabetes.
And I, I did get a chance a few years agowhen I was on a Medtronic ancient pump
with my DIY system to try the seven dayinfusion set and that extended wear set.
Actually meant I spent a littleless time thinking about how
prepared I was for going out withmy diabetes and did I have an extra.
(07:59):
And, um, I mean I could take one extraof, instead of having to take two or three
extras if I were going away for a couplenights and I thought, you know, that's
actually a little bit of an advantage.
And not having to think aboutrewinding the pump and refilling
it as frequently actually did giveme a bit more time in my week.
Um.
And I could feel the difference when Iwent back to using the three-day set.
(08:20):
Yep.
The improved accuracy overallis clearly an a benefit to
anyone who's going to use it.
Um, you know, if you travel,you won't have to carry quite as
many supplies if you're travelingfor a long period of time.
I looked at the accuracy data thatwas reported and they broke it
out into like, three day chunks.
They had the first three days,the middle, the near the end, and
(08:42):
then the end of the 15 day cycle.
And what I saw was that the accuracy inthe middle is still the best you get.
Today's like three to 12 or so.
The accuracy's really good.
It's good at the beginning andthe end, but not as quite as, as
accurate as it is in the middle.
And the last three days.
And the first three days, you'restill looking at a, a MARD in the
(09:04):
eight, you know, in the eights beingthat on average, the, the values the
sensor gives are within about 8% ofa lab value taken at the same time.
And that's, that's tremendous.
It, it is good.
That whole, in the first 24hours, it might not work so hot.
When you're on an AID system,it, it makes people nervous.
Mm-hmm.
(09:24):
I feel like for AID particularly,we're gonna see people feeling
more confident with the firstday's performance, which I will.
I still advise all my patientsto do at least one finger stick
on day one of a new sensor justto verify that it's performing.
Okay.
Was there anything new in the area offinger stick monitoring glucose meters or.
(09:46):
What did you see?
Not much, honestly.
ATTD is much more a meeting about thesensing and the delivery devices, but
in terms of what could be beneficialfor people who aren't on an AID, there
was a lot more focus on pens that couldwork well with sensors, with algorithms.
We had, Medtronic was showing theInPen and Dexcom described how
(10:08):
they're integrating with the NovoPenproducts that are available in Europe.
On the similar basis to how theFreestyle Libre has been integrated
with the NovoPen products, and that'sgonna open up more choices for people
and how they manage their diabetes.
Something I did read about was thatAbbott is, is developing, um, a meter
or a sensor that will not just measureglucose, but also track ketone levels.
(10:30):
Did you guys see anythingabout that at the conference?
Yeah, there's actually quite a lotof debate about what will we do with
continuous ketone data, and there'sa Chinese company that already is
selling a continuous ketone meter as alifestyle product in Europe, and there's
a lot of interest in the, the idea.
Personally, I look at how we've seen datatell us over the years that people who are
(10:51):
on a CGM are less likely to end up in DKA.
So I think, well, okay, we're lesslikely to end up in DKA, where's
the value gonna come from for.
Continuous ketone sensing.
But then I think about how when wehave an AID and we see that there's
a lot of insulin on board, we maythink of this high glucose level.
It'll sort itself out.
(11:11):
It'll come down eventually, butmaybe we have a cannula problem.
Maybe we're getting illand we don't know it yet.
Maybe there's some other issue at playand perhaps having something that comes
up on the screen of whatever device we'relooking at, to get our data that says,
actually, your ketones are going up now.
Whatever your glucose levelis, something's going on here,
(11:31):
Right?
Could add value.
But I do think we need,
It helps you to differentiatebetween, you know, what's caused
by maybe an illness versus what'scaused by a, a pump malfunction.
Or if you're on injections, maybe havingforgotten to take your long-acting
insulin or that insulin has spoiled.
So yeah, I mean there's, thereis some value in, in knowing when
ketones are present or when they'rerising and it's certainly better
(11:54):
than, than the urine testing.
'cause it takes several hours forketones in the bloodstream to.
Appear in the urine so we can catchthese kind of issues a lot earlier.
Mm-hmm.
Um, so that's, and if wecompare to Yeah, go ahead.
I was gonna say, and if we compare tofinger stick ketone testing, which is of
course something that's available, butthose strips are often not as easy to
access, and I know I keep some under mybed with a ketone meter on the principle
(12:19):
that if I'm sick enough that I think abouttesting for ketones, I'm probably sick
enough that I'm at home, but that mightnot be the only time I would benefit from
knowing what's going on with ketones.
Interestingly, there was some debateand you know, speaking of that
Chinese company, it's um, Ionix.
They hosted a symposium and they weretalking about what they think they
could do with continuous ketone sensing,and there was some real pushback from
(12:42):
the audience and the discussion aboutwhat the threshold should be for it
forming the user who has diabetes about.
Their ketone level.
Then if you think about how so many postson social media when someone does do
a finger stick, glucose level will saysomething like, this is the situation,
just did a finger stick ketone test.
The number was X. What do I do about it?
(13:04):
It's not a number that we reallyfeel like we understand the first
time we look at it in the moment.
Yeah, it's gonna take some education,uh, to let users know how to respond.
I think one of the other reasonsthe ketone monitoring might become
more prominent is with the driveto use SGLT two inhibitors in
patients with type one diabetes.
(13:25):
This is that drug that helpsthe body excrete sugars
through the urine all the time.
But there's the, an increasedrisk of ketoacidosis and type
ones who use these medications.
So the pharma industry mightstand to benefit if we can monitor
ketones and mitigate that risk.
And more people with type one couldstart to access those drugs if
(13:46):
that's the case and benefit from them
Potentially.
Although, you know, just to point, youknow, just to put the devil's advocate hat
on, I wonder if we're actually going tosee an indication for GLP1 RAs and type
one before we see a regulatory agencyreally enthusiastic about the use of SGLT.
(14:06):
What did they, what did they, uh, shareat the conference about GLP one use?
There were a few posters and talks andthere was a rumor going round, and I, this
is where I haven't had enough time sinceI've been home to see if there's anything
public about it, but there is a companythat makes a GLP1 that is definitely
doing a decent sized study in typeones, and there were a few investigator
(14:28):
initiated studies going on as well.
So those of us that are using aGLP one off-label are feeling a bit
like we are, you know, exploring newterritory and getting benefit in a way
in a WhatsApp group I'm a member of.
In case people are wondering, GLP onesare the, these are the Mounjaro, the
Ozempic, the The Trulicity, the, theseare the medications that type twos use to
(14:50):
help with weight management, but they canalso be pretty beneficial in type ones
for slowing digestion, blunting appetite.
Also keeping glucagonproduction to a minimum.
So insulin requirements go down everystudy that's been done, and these are
usually small scale studies, have shownthe GLP ones to be safe and effective.
But there haven't been the largecontrolled trials, randomized controlled
(15:13):
trials with them to satisfy the, theFDA's uh, requirements here in the states.
In Europe, they're actually moreprogressive and these medications
are available to more people.
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(16:00):
4 and select option three.
And now back to our program.
Any other medications that youcame across and, and anything
new in the insulin field?
'cause a year or two ago, you know,once weekly insulin icodec was a big
deal and that, that's been slowed downby some research issues that came up.
So anything new in the insulin space?
(16:21):
Well, there was actually a symposium onicodec because in Europe, the regulators
took a somewhat different perspectivethan they did in the US, so there's a
bit more freedom to talk about it here.
One thing that really surprised me wasthat Mannkind was a major sponsor of
ATTD with their inhaled insulin, whichhasn't been commercialized in Europe.
So that was really cool to see.
(16:41):
And I've seen a few people, um,since ATTD who were catching up on
the coverage who are based in Europesaying, this is the first time that
I've heard about inhaled insulin.
So it, it'll be interesting to seewhat their approach is when they start.
Talking to more companies andcountries outside Europe about
what the potential is, 'cause wejust haven't had the opportunity
to have inhaled insulin here yet.
(17:02):
Have you ever tried it yourself?
I think interesting.
Yes.
I had the opportunityafter ATTD in Berlin.
A good friend who does get Afrezza,bought me a big lunch, sat me
down and said, pass some Afrezza.
Did you pass it around the table?
Actually.
In that case, it was thespotlight on me for his video.
Um, but All right.
One inhaler per person.
(17:24):
Well, no, he did have to share his device.
He was like, trust me, I've washed.
Um, but yeah.
Um, he was very excited to seeMannkind as a big sponsor of at TTD,
and it'll be good to see what theyhave in store and where they go next.
Uh, another big drug focus was actually,uh, with screening for type one towards
(17:44):
the prevention of type one with to,and Sanofi is making big investments
in getting more people aware ofscreening for type one because, well,
that's the only way people are gonnabe on the list to be able to access.
And so that was good to see as well,that there was a lot of interest and,
and people were talking about screeningand our own attitudes as people who
(18:06):
live with type one to who else in ourlife are we encouraging to get screened?
And I thought that was good.
Yeah, I think we're gonna be, we're gonnado a podcast on that specifically in
the very short term, but I, I speak forSanofi about, about screening and about
the preventive measures and I, I feel itreally puts the power in people's hands.
A lot of folks are saying like, if I'm athigh risk and I don't wanna know because
(18:29):
it's inevitable, but it's not anymore.
I. There's so many things wecan do besides medications.
There are other approaches we can use toslow down the progression of type one.
Did you ever have your kids screened?
I did.
Actually.
The National Health Service here in theUK has a study called Elsa for people with
type one or want or even didn't have typeone who wanted to have their kids screened
(18:51):
and I should probably get my daughterRescreened because she wasn't quite for.
When she had her finger stick forit, and now she's five and a half.
But at that time, both my kids came backnegative, which was really lovely to see.
Yeah.
On the other hand.
It's a relief, isn't it?
It's like a weight off your shoulders.
It does feel that way, and yet I wasspeaking with someone the other day
who told me that as a parent of achild with type one or one child was
(19:15):
diagnosed at age three and is now 15.
And then her second child was justdiagnosed at age 14 last year, but
the second child had been negativefor antibodies only two years prior.
Mm-hmm.
So that was interesting.
She said something about theinterval for rescreening here.
You know, there's, we don't exactly knowif you get the all clear when you should
(19:36):
be rescreening or perhaps that firsttest that was negative for antibodies.
Maybe that wasn't the most accurate.
Instance, yeah.
I really felt for her becauseI hadn't heard about the second
child having been diagnosed.
I only knew about the first oneuntil we had that conversation.
For those of us who are diagnosed andhave had it for as long as we have,
you know, the technology has evolvedso much in the last several years,
(20:00):
particularly with automated, or Icall semi-automated insulin delivery.
I still feel that, you know,we're, we're in charge of the
vast majority of the decisions.
It's only a, some slight adjustmentsthat these systems can make.
So what can you share with me that'snew with either the pumps, algorithms,
and what features are available withinthe systems and what's coming up?
(20:22):
It was great to hear that Control IQPlus is coming through from Tandem, that
they're introducing some auto boluses.
I need to get my head around alittle bit more about the system to
understand exactly how it's gonna differfrom the control IQ that's already
been out, but they were certainlytalking about it on the booth, and
I thought that was nice to hear.
Yeah, I mean we've got ControlIQ Plus here and we've had
(20:44):
it in play for a while now.
There there's only ahandful of new things.
You know, one is that you can settemporary basal rates while control
IQ is running, which I think isactually a very helpful feature.
If we knew we were gonna need moreor less insulin for a while, we used
to have to create a whole new profileof, of insulin delivery parameters,
(21:04):
turn it on, and then remember toturn it off when we're done using it.
A temp rate, you just go in and say,all right, for the next six hours, bump
my delivery up 40% or lower at 30%.
That's all you have to do.
So the temp basal feels a nicefeature that reintroduce, and
you know it was available prior,but now it's being reintroduced.
(21:25):
And the extended boluses, which arealso a very helpful feature with.
You know, the, you know, thetypical American diet, lots of
fat and slow digesting food.
Being able to slow down thebolus deliveries is very useful.
Tandem used to allowit for up to two hours.
Now it goes up to eight.
I can't imagine something thatwould take that long to digest,
but I suppose it's possible.
(21:46):
They're having a, a Spanishlanguage capability.
What else?
And those are the major things.
Um, it's all that comes to mind.
Those are the, you know, more significantchanges that are being incorporated.
But I've also learned a lot about.
Their insulin on board out calculation,something called dynamic IOB.
So it doesn't always use theinsulin on board at face value.
(22:07):
It doesn't just deduct thatamount from boluses anymore.
If your glucose is trending upor it's high, it's gonna deduct.
Less.
And if it's low or or dropping,it'll deduct a little bit more.
And also if you've eaten recently, itconsiders some of the food offsetting the
IOB, so it'll deduct a little bit less.
So it's an intelligent kind ofinsulin on board adjustment.
(22:30):
So even though you still can't adjustthe duration of insulin action,
it's a little smarter approach.
It feels a little bitlike how we can use loop.
Yeah, the way you described it.
The DIY systems do that for us already.
You're right.
Yeah.
Were there any presentations fromOpen Source DIY platform developers?
(22:50):
Yes.
And now before we move on toOpen Source, just a couple other
highlights in terms of devices.
So we saw SQL present with theTypool Loop system with Twist.
They need Chubby Checkeras their spokesperson.
I don't know if he's still around.
Do the twist.
Um, yeah, so it wasnice to see them there.
They're not necessarily comingto Europe immediately in the very
(23:14):
near future, but, um, it was goodto see them on the horizon here.
And then Kaleido, a pump company that'sactually based in the Netherlands was
back on the scene with a launch party.
For their new pump, which will beavailable around Europe hopefully
in the next several months.
And I've been aware of the developmentbehind it for several years and
it really looked like the companymight not make it to a full scale
(23:36):
commercial launch several years ago.
So it was great to seethem really doing well.
What do you like about it?
It's really quite cute and it comesin some colors and if you compare
the size of their new on body part,'cause it's a patch pump style.
It's similar to Omnipod, but ithas a little tiny bit of tubing.
Their unit comes up just a littlebit smaller than an Omnipod pod and.
(23:59):
I can see it being very wearable.
Yeah.
I, I, I had to say whenI saw it, I thought, Hmm.
How much, how in insulin did it hold?
Do you remember?
Uh, my recollection is thatit's 200 units, but we might
have to fact check that.
Is there anything new from Insulet?
Nope.
Omnipod five is Omnipod five.
And actually you're asking,that brings up a good point.
I, there was a real vibe around theconference of "there's not too much,
(24:22):
that seems completely revolutionaryin automated insulin delivery
here this year." And, I said tomy friends who had very, well, you
know, sorry, who observed at that.
I said, yeah, you know, for so manyyears, every year that we came to ATTD,
there was more research into algorithms.
There was more research into physiology.
There was more on the drawing boardto try to consider and trying to
(24:43):
make these systems functional.
Now, we've reached a point where it'sactually about implementation and
rollout, and a lot of the incrementaladvances that we're gonna see are
gonna feel like kind of small stepsforward because now these systems are
really getting into people's hands.
The upgrades are going to be more steadyand slow in terms of how they hit.
(25:05):
Yeah.
Speaking of the application of thetech, you know, in infusion devices
are something that we've been lookingfor improvements in for a long time.
You know, Medtronic launchedtheir extended wear set a couple
years ago, as you pointed out.
You know, Tandem is, is developingsomething called steady set.
It's their, their versionof an extended wear.
Any news about infusion set developments?
(25:25):
Well, more around how canwe detect occlusions better.
Um, and in fact, there was a spotlighton DiaTech Diabetes in the yearbook
session because of their technologythat can help detect occlusions faster
than a lot of the current tech can.
So that was good to see.
That's one of the things thatSQL is, is riding on with the
launch of Twist is very, uh,early detection of, of occlusions.
(25:48):
You feel that, that, that, do you thinkthat's gonna make a, a big difference?
Is that gonna move the needle,so to speak, in how we manage
glucose with pump therapy?
Well, back to ourconversation about ketones.
I think if you can detect occlusionsfaster, you're not looking for ketones
to be how you know, and I feel likethat's, you know, a bit of a push pull.
I'd rather have a system that couldtell me, "Hey, you have an occlusion",
(26:11):
before I feel sick because I gotan occlusion, if that's possible.
Now, it won't necessarily know if thecannula got dislodged and I'm just wearing
some insulin on the top of my skin, butI might smell it or I might notice a
spike in my glucose that lets me knowthat somehow that insulin didn't hit so.
Those are things that I feelmight be quite interesting
to watch the development of.
(26:32):
There were a couple other insulindelivery systems on the show in the tech
fair that have some novelty to them.
Pharma Sense has what they call theNEA pump, and their NEA signature
pump has both a cannula and aninfusion set attached to it.
It's a single unit.
It does the, what we used to callthe snake bite, where it's two
(26:52):
prongs in terms of form factor.
I do look at it and think, are we goingfrom being afraid of catching tubing
on a doorknob to wearing the doorknob?
It's not the smallest, lightestthing there, but um, but it's
interesting as an approach, and theyhaven't been very public about what
CGM technology it's integrating.
So I look forward to hearing more on that.
(27:13):
Where do we stand with, uh, dualhormone insulin and glucagon
infusion from the same system?
Another good question.
Um, there's a small company that'sbased in the Netherlands called EN Rita.
Which has shown up at European conferencesfor a while with a dual hormone product.
They do seem still to be stuck withthe fact that the glucagon isn't
stable for very long after you mixit up and put it into the system.
(27:36):
And that of course creates complexitieswith cost as well as function.
I. Even with like, like Zeis and uh,Zeins formulations that are stable at
liquid form for years at are in temp.They can't use those in these systems.
I think it's all about the commercialcollaboration that it would take
to get them there, and so far wehaven't seen them in the space.
(27:57):
Doing it, and maybe that's somethingthat the community can start to
say we'd like to see more of.
Yeah, I mean, that was what iLet wasoriginally supposed to be, uh, Beta
Biotics was a dual hormone pump initially.
They ran into so many issues withthe glucagon that they had a, it
really slowed down their researchand that's picking up again.
And all, all the re studies I've seenis that when you have both glucagon
(28:21):
and insulin infusion taking place, youcan achieve much tighter control being
range more often with less hypoglycemia.
It might make exercise much moremanageable 'cause that's still one
of the biggest challenges we faceis dropping with physical activity.
We've got, basically, we've got agas pedal, we can push the blood
sugar down, but we don't have brakes.
(28:42):
You know, you drive in a car withno brakes, without glucagon in the
equation, but then you gotta wear twodifferent infusion sites, have two tubes.
You all know how much, uh, the generalpublic loves tubing to begin with.
Like you said, doorknobs,drawer handles, et cetera.
We'll make things more complex.
Yeah, true.
Although I, I do wanna, um, point outthat the more we have app control for
(29:03):
systems, the more we could wear thepump in the tubing all under clothes.
That was one of the things that madeit work for me when I was on a DIY
system with the Medtronic pump, wasthat having the app control meant
that I didn't miss that experienceof feeling a bit too, being free.
I didn't have to pull outmy pump and handle it.
Every time I needed to take a bolus.
(29:24):
It is nice.
Did Medtronic have, uh, anything to sayabout their upcoming sensor and, and pump?
There was some discussion of Simpleraand they were giving out little,
you know, you can have an experienceof what it's like to wear it.
Not real sensors, just a sticky patch.
And there wasn't a lot being said aboutfuture changes to the current indications,
but certainly they're talking about it.
(29:45):
And of course they've said.
Publicly as well that they're goingto have an integration with the
Abbott Libre product in future too,so that, that's gonna be interesting.
Yeah, I, I wonder if that's evergonna actually happen though.
Medtronic's only, you know, theyonly play with their own in their
own sandbox for the most part.
What I've seen about Simplera,it's infinitely easier to insert
(30:05):
and Simplera and smaller and morecomfortable than their existing sensor.
The accuracy data still lagged a bitbehind what we see with Dexcom and Libre.
You mentioned the apps, like thephone apps making life easier.
Were there any other new interestingapps that were on display?
Well, in terms of on display inthe tech fair, again, there was
presence from enhanced there.
(30:26):
An app company that's based inEurope working on an exercise thing.
Are you familiar with enhanced?
I've heard of it.
Yeah, yeah,
Yeah, um, and I think that's gonnabe interesting to see how many people
will take it up and use it regularly,and how many people it can help.
They just signed on as an ambassadorHenry Slate, who's a rugby player
(30:47):
with type one, and they've had a fewother elite sports people who live
with type one could come and, youknow, be on their team, so to speak.
You're an elite sports person.
You do like, you're a, you'rean endurance athlete, Melissa.
I think you're thinking back to that time,that one time that I did a century bike
ride on my first wedding anniversary.
I happened to be approachingmy 15th wedding anniversary.
(31:08):
But no excuse,
But that was a good memory.
Um, yeah, I mean, I go to my exerciseclasses a few days a week and I do,
well, I guess you could call bicyclingin central London as an extreme sport.
I did read, uh, there was apresentation at the conference
about using the AID features tomanage blood sugar during exercise.
(31:29):
I've not found those featuresto be particularly helpful.
I mean, within the DIY apparatus,we can do some more creative things.
I found we still have to go back toour old school management methods
of either eating carbs beforehandor making bolus reductions ahead
of time if it's post-meal workouts.
Anything new you picked up on aboutexercise and blood sugar management?
(31:51):
Well, there was some discussion of someof the guidelines that have come out,
which there was a whole symposium atthe European Association for the Study
of Diabetes meeting back in the autumn.
And you know, there was a bit of recapon those guidelines which are available.
We could put a link in the show notesbecause the guidelines have been
thought up with varying in mind.
Each system, they're not reallygeneric, they're, they're
(32:14):
actually more usable in terms of.
With this system becauseof how the algorithm works.
This is probably good advice ifyou're doing this kind of exercise.
Lots of credit to the people who'veworked on those guidelines, I think.
But it'll take a while to educatethe healthcare professionals and the
people with diabetes who need to know,because there's so much to understand
when you get onto an AID system.
(32:34):
Yeah.
The last category I was thinking aboutis software, either downloading software,
reporting software, data collection,merging activity, lifestyle type
data that you happen to come across.
Anything about that?
Sure.
There's a couple things to highlightin terms of data that we as people
with diabetes can get out and use.
It's available for DIY users, notbroader than that at this point.
(32:57):
And on Apple iPhones cockpit app,do you know Diabetes Cockpit?
No, I haven't.
Oh, it's cool.
So my friend Lucas developed it.
He was working for MySugr and startedthinking as someone who lives with
Type one, actually there's a lotof data that comes from my DIY
looping system and Apple Health.
How can I work these data sets together?
(33:19):
Well, maybe even plug in Nightscoutdata if somebody doesn't have Apple
Health and their DIY system connected.
So yeah, so the Diabetes Cockpit app.
Um, and it is doing correlations so thatyou can see when you have, you know, days
with fewer step counts, is there somethingthat might turn up in your diabetes data?
Now that, that gets me all jazzed up.
(33:40):
I love that.
'cause I'm always trying to figure out,you know, what are the cause and effect
relationships when I'm looking at dataand for the most part, the software.
That we have now does a terrible job.
It doesn't really provideinsights like that there.
There's a few select bits and pieces hereand there, but being able to see cause
and effect relationships, knowing that onTuesday afternoons, if I have an active
(34:01):
day, I go low, or if I have more than Xgrams of carb, that's when I tend to drop.
That kind of information wouldmake my life a lot easier, not
just as a clinician, but my owndiabetes management as well.
Yeah.
Speaking of cool software,you've got one called SmartStart.
Can you tell me a little about that one?
Sure.
Um, and then after I tell you alittle bit about SmartStart, I
(34:23):
might tell you just two more thingsthat I saw in software at ATTD.
Yeah.
So in a nutshell, SmartStartis doing CGM user education.
With adaptive learning paths on yourphone, the proof of concept product, which
you know well is currently available onour website, SmartStart Health, and with
big grant support from the UK governmentand some investors, we're developing
(34:46):
the version that'll be our MVP MinimumViable Products for proper launch, which
will have an adaptive component so thatdepending upon what somebody already knows
about using CGM when they start and whatthey're learning along the way, their
learning journey will adjust dynamically.
So we saw in the proof of concept studythat it took folks between an hour and a
(35:06):
half and up to two hours to get throughthe seven content modules which cover
everything from, what do we call thepieces and parts of a CGM system so that
if something's not working, really, youknow, you know which bit it is that you're
reporting when you talk to somebody oncustomer service, phone line, or when
you have to talk to your team aboutwhat's working for you and what's not.
All the way through to what happenswith the alarms and alert settings, what
(35:29):
things are likely to be changeable basedon your needs and how to look at the
graphs, how to understand what the datacan mean for you and your management.
In the real time moment and when wetalk about things like time in range
and a GP ambulatory glucose profile.
And the UK government supported this?
Yeah.
Um, innovation grant.
What's it like having agovernment that actually supports
(35:52):
quality health initiatives?
'cause we don't, we don'treally have that here anymore.
I, I, I might have to move out there.
So what are the other, uh, softwaresthat you were excited about?
Well, building on the mention ofDiabetes Cockpit, the founder of Diabetes
Cockpit, Lucas and a couple of otherfolks have gotten together and started
a new company syntactic so that theycan take the insights that come from the
(36:15):
diabetes cockpit app and de-identify,anonymize and create a data set that
can be used by researchers to optimizefuture insulin delivery algorithms.
And I think that's really smart.
So I'm impressed with what they're up to.
And another thing we saw is that Dexcom isnow working on population health software.
(36:36):
We got a little glimpse of whata dashboard might look like
in their corporate symposium.
And I found that really interesting'cause looking at how people
are doing in a larger set of.
People under the same clinicis something that healthcare
professionals should be doing.
But it's really hard when youhave individual level data
and you can't aggregate it.
Um, and to be able to put on filtersand think, well, are there some patients
(36:59):
in this clinic or in this healthsystem who are doing really well?
What do they have in common versusthose that maybe are struggling, need
more support, or maybe we just haven'tseen them very much and we can now look
at their data in a remote basis andgo, you know, those are the patients
that we should be phone calling to seehow they're doing, maybe getting them
in if we need to see them in person.
(37:20):
So seeing that Dexcom is lookingat how they can help support health
systems on a different basis.
I thought that was neat to see too.
Very nice.
Yeah, I mean, I, I am just kicking myselffor not being able to go this year.
This sounds like itwas an amazing meeting.
A lot of new stuff to see, new stuffto learn, and it's all focused on the
areas of, of interest for people whoare taking insulin and taking multiple
(37:42):
injections or using pumps so much.
It all applies to us, to our daily lives.
Which it really does.
I can't say about every conference yougotta sift through at other conferences
to find stuff that's really useful.
I will say there was an awful lotabout the use of CGM in people with
type two who aren't necessarily oninsulin as well, and to see that focus
increasing, that's getting us intowhere can diabetes technology make
(38:05):
a bigger difference in the future.
I like to say that ATTD trendsabout seven years ahead of actual.
In terms of how clinicaldecisions are being made today.
So I, I remind myself when I go thatthe rest of the world is not necessarily
thinking about the same topics.
The way the people who are leadingthe presentations at at TTD are, yeah.
(38:27):
But what a vision of theworld does it create?
It, it makes me hopeful.
It makes me feel like there'sa lot to learn, and next
year it's in Barcelona, so...
I, I will be there.
Um, it'll be nice to see you.
Maybe we'll have to go for tea again.
Melissa's the only person who has ever,ever gotten me to go for afternoon tea
(38:47):
as I visited her in London years ago.
So maybe a little, I don't know.
Do they do tea in Barcelona?
Uh, not particularly,but they do great tapas.
I'm good for tapas.
I'm down anytime.
Yeah.
We can do tapas in Barcelona for sure.
And before that we canhave breakfast at a DA.
That's right.
See you in Chicago.
Yeah.
Yeah.
It's a couple months away.
Melissa, thank you so much for joining.
(39:07):
I know it's, it's.
What time is it there?
It's like dinner time for you, isn't it?
Nah, it's almost three in the afternoon.
Okay.
It's not too bad.
It's about, it's alright.
10:00 AM here's, yeah, I stillhave a couple meals to go to catch
up to you, but thank you so much.
I mean, you're just, you're such awealth of information and you, you
put things in a nice perspectivethat, that we can all relate to.
So again, thank ev.
I wanna thank everybody for,uh, joining the podcast and
(39:29):
have a great rest of your week.
And don't forget to think like a pancreas.
2025 ATTD conference inAmsterdam was fantastic.
Even though I wasn't there,it was still fantastic.
We learned from Melissa about a lotof the innovative things that were
displayed and, and discussed newmedications, uh, type two medications
(39:50):
that can be applied in the type onespace management approaches for handling,
exercise and prevention of hypoglycemia.
All the updates that are in the pipelineinvolving continuous glucose monitors,
insulin pumps, and the algorithmsthat drive automated insulin delivery.
There are also a number of innovativeapps that have come out and are in
(40:13):
development and software, and some ofwhich are applying AI technology to make
them even more helpful and resourcefulfor those of us living with diabetes.
Welcome to Think Like a Pancreas,the podcast where our goal is to keep
you informed, inspired, and a littleentertained on all things diabetes.
The information contained in thisprogram is based on the experience
and opinions of the IntegratedDiabetes Services clinical team.
Please discuss any changes to yourtreatment plan with your personal
(00:50):
healthcare provider before implementing.
Welcome to Think Like a Pancreas.
The podcast, uh, we're gonna be talkingtoday, uh, about the advanced Technologies
and treatments for diabetes conferencethat just took place in Amsterdam.
And if anyone out there knowsexactly where Amsterdam is, call in.
(01:10):
We'd love to hear.
No, we, we looked it up on the map.
I did not get to go to thisconference this year, and I love
this conference because it appliesso well to people on insulin and
intensive insulin therapy, more sothan any other conference I know of.
However, my good friend and colleague,Melissa Holloway was there and she is
(01:31):
gonna be giving us the lowdown on some ofthe stuff that she discovered in person.
So Melissa, hey, welcometo the, the program.
Uh, why don't you tell the folksat home a little about yourself.
Thank you Gary.
It's always a pleasure to speakwith you and also always a
pleasure to talk about ATTD.
It is my favorite meeting when I was ina job that I had to request holiday to
(01:53):
go places for, I took my vacation daysto go to ATTD because I love it so much.
So, um, I can't wait to tellyou all the things I picked up.
One of the things that drives me tokeep going is that since I'm now working
on Smart Start, I get to hear all thebuzz about what's happening in CGM and
what are the latest, greatest tools,techniques, approaches to helping people
(02:14):
get the most out of their diabetes data.
And I mean, that's whatgets me up in the morning.
So I didn't sleep very much at ATTD.
Yeah.
And you have a personal connection too.
How long have you had that?
Oh yeah.
Uh oh.
I've just, I'm about to reach my31st dia-versary at the end of this
week, um, and I've been using CGMsince 2006, um, on, on a pump since
(02:36):
1996, and I've been a DIY Looper.
Since June, 2018.
So, um, I've got the t-shirts.
You know, I think for dia-versaries itshould be like anniversaries where every
year has an item associated with it.
You know, you got your gold andyour diamond and all that stuff.
What would be a good first year marker?
(02:56):
Right?
That could be the glucose tablet year.
Or we could throw it back to likeBaskin Robbins and say, you should
go get yourself an ice cream.
Even better.
I love it.
One.
Yeah, as an American, that I could makethat joke, but as you know, I live in
London, so the sunlight that you'reseeing streaming in is our afternoon.
Yeah.
How many years haveyou been in the UK now?
Actually more than half my life now.
(03:18):
I added it up the other day andI moved in 2001 for post grad.
When I thought I was gonna be a PEMAhistorian, and then by 2004 I was working
in diabetes and then moved back to theUS for a couple of years and then made my
way in on a final basis to the UK in 2007.
So the years are ticking upcloser to 20 than to 15 now.
(03:39):
Yeah.
I will tell you, you arestarting to sound a little more
like a UK person all the time.
Every time we get together,I hear a little more of that.
That accent in you.
You know why?
It's because my husband corrects the kidswhenever they say something like I do.
Hmm.
And so now I have to overpronounce my Ts or else the kids
start mocking the way I speak.
(03:59):
Yep.
So anyway, Amsterdam islocated in the Netherlands.
Of course that helps nobody knowingthat it's in the Netherlands,
but I, I saw we've got this, thisworld map on our shower curtain.
I'm, I learned so muchgeography when I shower.
The Netherlands is just alittle bit west of Germany.
It's a little bit north of Belgiumand a little south of Denmark.
(04:22):
So it's sort of nestled in that.
Part of kind of Northern Europe, right?
What was Amsterdam like?
I've never been there.
It's a lovely city.
I got to go a couple years ago andsaw much more of it when I went to a
big exhibition of Vermeer paintings.
There's loads and loads of canals.
It's very much a city on the water andin fact it's got more canals in Venice.
Um, so that's one of their fun facts.
(04:43):
And they're really good at fries.
Fries are a local specialty, um, and
Not chips, but fries.
Fries.
Yeah.
They, they consider themto be more like frites.
If you've been to Belgium and everybodyspeaks English pretty much makes
it a very accessible city for lotsof people from around the world.
So it, it's got a lot of tourists allthe time because it's a fun place to go.
(05:04):
And then of course, some people areattracted by the coffee shop culture.
And in a coffee shopyou don't drink coffee.
It's not about the coffee.
Yeah.
I love how you say water, becausehere in Philly we say water.
Everyone's got their ownpronunciation for it.
Yeah.
Well this is because ofmy husband and the kids.
They make me say water.
If I go to the US for a week,I come back saying, water.
(05:25):
There you go.
Or water.
All right, so if there is one thing, justone thing that stands out in your mind
as you got to this conference, ATTD in,in Amsterdam, and it just blew you away.
You're like, wow, this is a game changer.
What would it be?
Well, I think the data I was mostexcited to see is the Dexcom 15 day and
(05:48):
for G7, and the reason I got so excitedis that they've changed the algorithm
as well and it shows such accuracy.
And even the first day of wear comparedto the previous generations, the product
that Dexcom had come out with, and I'vebeen using Dexcom since 2006, like just
to declare my interest when there wasa corporate symposium and Jake Leach
(06:08):
stood up in front of a timeline of allthe different Dexcom devices there have
ever been, I thought I've got 'em all.
You know, like I've, I've beenthrough all of those generations of
product and today somebody would sayDexcom, pft, that three day sensor!
Gosh, you know, who evenwould've wanted to use that?
And, and I can reflect on how when it wasavailable, it made things better for me.
(06:29):
It was better than 12fingers sticks a day, and I.
I still got my hbA1c down withno more hypos in those days.
So when I think about how far thetechnology has come, I think we're
getting now into these really incrementaladvances in terms of what's possible.
But the idea that the 15 day sensoris still going to have a grace
period attached made me think,gosh, only two sensors a month.
(06:52):
Like for me, having used Dexcom forsuch a long time, going from a sensor
every few days to a sensor every sevendays, to a sensor every 10 days, but
then going to a sensor every, like15 and a half days, I'm gonna have
more room under my bed for shoes.
My husband's not gonna like that partwhen I say there's more room for shoes.
But I like the data.
I thought it looked really strong.
The real benefit is more shoe space.
(07:14):
That's the real advantagethat the 15 day sensor offers
because I was thinking about it.
I, I, it's
The MARD.
I, I like the MARD too.
Every 10 days.
To me, it's not that big a deal.
I'm going to go from changing it threetimes a month to two times a month.
Do you think that reallymakes a big difference?
Not a huge difference, but I dofind myself checking how many days
I have left on my sensor because 10days isn't like an kind of an even
(07:37):
increment of time in comparison tothe other tasks I do for my diabetes.
And I, I did get a chance a few years agowhen I was on a Medtronic ancient pump
with my DIY system to try the seven dayinfusion set and that extended wear set.
Actually meant I spent a littleless time thinking about how
prepared I was for going out withmy diabetes and did I have an extra.
(07:59):
And, um, I mean I could take one extraof, instead of having to take two or three
extras if I were going away for a couplenights and I thought, you know, that's
actually a little bit of an advantage.
And not having to think aboutrewinding the pump and refilling
it as frequently actually did giveme a bit more time in my week.
Um.
And I could feel the difference when Iwent back to using the three-day set.
(08:20):
Yep.
The improved accuracy overallis clearly an a benefit to
anyone who's going to use it.
Um, you know, if you travel,you won't have to carry quite as
many supplies if you're travelingfor a long period of time.
I looked at the accuracy data thatwas reported and they broke it
out into like, three day chunks.
They had the first three days,the middle, the near the end, and
(08:42):
then the end of the 15 day cycle.
And what I saw was that the accuracy inthe middle is still the best you get.
Today's like three to 12 or so.
The accuracy's really good.
It's good at the beginning andthe end, but not as quite as, as
accurate as it is in the middle.
And the last three days.
And the first three days, you'restill looking at a, a MARD in the
(09:04):
eight, you know, in the eights beingthat on average, the, the values the
sensor gives are within about 8% ofa lab value taken at the same time.
And that's, that's tremendous.
It, it is good.
That whole, in the first 24hours, it might not work so hot.
When you're on an AID system,it, it makes people nervous.
Mm-hmm.
(09:24):
I feel like for AID particularly,we're gonna see people feeling
more confident with the firstday's performance, which I will.
I still advise all my patientsto do at least one finger stick
on day one of a new sensor justto verify that it's performing.
Okay.
Was there anything new in the area offinger stick monitoring glucose meters or.
(09:46):
What did you see?
Not much, honestly.
ATTD is much more a meeting about thesensing and the delivery devices, but
in terms of what could be beneficialfor people who aren't on an AID, there
was a lot more focus on pens that couldwork well with sensors, with algorithms.
We had, Medtronic was showing theInPen and Dexcom described how
(10:08):
they're integrating with the NovoPenproducts that are available in Europe.
On the similar basis to how theFreestyle Libre has been integrated
with the NovoPen products, and that'sgonna open up more choices for people
and how they manage their diabetes.
Something I did read about was thatAbbott is, is developing, um, a meter
or a sensor that will not just measureglucose, but also track ketone levels.
(10:30):
Did you guys see anythingabout that at the conference?
Yeah, there's actually quite a lotof debate about what will we do with
continuous ketone data, and there'sa Chinese company that already is
selling a continuous ketone meter as alifestyle product in Europe, and there's
a lot of interest in the, the idea.
Personally, I look at how we've seen datatell us over the years that people who are
(10:51):
on a CGM are less likely to end up in DKA.
So I think, well, okay, we're lesslikely to end up in DKA, where's
the value gonna come from for.
Continuous ketone sensing.
But then I think about how when wehave an AID and we see that there's
a lot of insulin on board, we maythink of this high glucose level.
It'll sort itself out.
(11:11):
It'll come down eventually, butmaybe we have a cannula problem.
Maybe we're getting illand we don't know it yet.
Maybe there's some other issue at playand perhaps having something that comes
up on the screen of whatever device we'relooking at, to get our data that says,
actually, your ketones are going up now.
Whatever your glucose levelis, something's going on here,
(11:31):
Right?
Could add value.
But I do think we need,
It helps you to differentiatebetween, you know, what's caused
by maybe an illness versus what'scaused by a, a pump malfunction.
Or if you're on injections, maybe havingforgotten to take your long-acting
insulin or that insulin has spoiled.
So yeah, I mean there's, thereis some value in, in knowing when
ketones are present or when they'rerising and it's certainly better
(11:54):
than, than the urine testing.
'cause it takes several hours forketones in the bloodstream to.
Appear in the urine so we can catchthese kind of issues a lot earlier.
Mm-hmm.
Um, so that's, and if wecompare to Yeah, go ahead.
I was gonna say, and if we compare tofinger stick ketone testing, which is of
course something that's available, butthose strips are often not as easy to
access, and I know I keep some under mybed with a ketone meter on the principle
(12:19):
that if I'm sick enough that I think abouttesting for ketones, I'm probably sick
enough that I'm at home, but that mightnot be the only time I would benefit from
knowing what's going on with ketones.
Interestingly, there was some debateand you know, speaking of that
Chinese company, it's um, Ionix.
They hosted a symposium and they weretalking about what they think they
could do with continuous ketone sensing,and there was some real pushback from
(12:42):
the audience and the discussion aboutwhat the threshold should be for it
forming the user who has diabetes about.
Their ketone level.
Then if you think about how so many postson social media when someone does do
a finger stick, glucose level will saysomething like, this is the situation,
just did a finger stick ketone test.
The number was X. What do I do about it?
(13:04):
It's not a number that we reallyfeel like we understand the first
time we look at it in the moment.
Yeah, it's gonna take some education,uh, to let users know how to respond.
I think one of the other reasonsthe ketone monitoring might become
more prominent is with the driveto use SGLT two inhibitors in
patients with type one diabetes.
(13:25):
This is that drug that helpsthe body excrete sugars
through the urine all the time.
But there's the, an increasedrisk of ketoacidosis and type
ones who use these medications.
So the pharma industry mightstand to benefit if we can monitor
ketones and mitigate that risk.
And more people with type one couldstart to access those drugs if
(13:46):
that's the case and benefit from them
Potentially.
Although, you know, just to point, youknow, just to put the devil's advocate hat
on, I wonder if we're actually going tosee an indication for GLP1 RAs and type
one before we see a regulatory agencyreally enthusiastic about the use of SGLT.
(14:06):
What did they, what did they, uh, shareat the conference about GLP one use?
There were a few posters and talks andthere was a rumor going round, and I, this
is where I haven't had enough time sinceI've been home to see if there's anything
public about it, but there is a companythat makes a GLP1 that is definitely
doing a decent sized study in typeones, and there were a few investigator
(14:28):
initiated studies going on as well.
So those of us that are using aGLP one off-label are feeling a bit
like we are, you know, exploring newterritory and getting benefit in a way
in a WhatsApp group I'm a member of.
In case people are wondering, GLP onesare the, these are the Mounjaro, the
Ozempic, the The Trulicity, the, theseare the medications that type twos use to
(14:50):
help with weight management, but they canalso be pretty beneficial in type ones
for slowing digestion, blunting appetite.
Also keeping glucagonproduction to a minimum.
So insulin requirements go down everystudy that's been done, and these are
usually small scale studies, have shownthe GLP ones to be safe and effective.
But there haven't been the largecontrolled trials, randomized controlled
(15:13):
trials with them to satisfy the, theFDA's uh, requirements here in the states.
In Europe, they're actually moreprogressive and these medications
are available to more people.
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(16:00):
4 and select option three.
And now back to our program.
Any other medications that youcame across and, and anything
new in the insulin field?
'cause a year or two ago, you know,once weekly insulin icodec was a big
deal and that, that's been slowed downby some research issues that came up.
So anything new in the insulin space?
(16:21):
Well, there was actually a symposium onicodec because in Europe, the regulators
took a somewhat different perspectivethan they did in the US, so there's a
bit more freedom to talk about it here.
One thing that really surprised me wasthat Mannkind was a major sponsor of
ATTD with their inhaled insulin, whichhasn't been commercialized in Europe.
So that was really cool to see.
(16:41):
And I've seen a few people, um,since ATTD who were catching up on
the coverage who are based in Europesaying, this is the first time that
I've heard about inhaled insulin.
So it, it'll be interesting to seewhat their approach is when they start.
Talking to more companies andcountries outside Europe about
what the potential is, 'cause wejust haven't had the opportunity
to have inhaled insulin here yet.
(17:02):
Have you ever tried it yourself?
I think interesting.
Yes.
I had the opportunityafter ATTD in Berlin.
A good friend who does get Afrezza,bought me a big lunch, sat me
down and said, pass some Afrezza.
Did you pass it around the table?
Actually.
In that case, it was thespotlight on me for his video.
Um, but All right.
One inhaler per person.
(17:24):
Well, no, he did have to share his device.
He was like, trust me, I've washed.
Um, but yeah.
Um, he was very excited to seeMannkind as a big sponsor of at TTD,
and it'll be good to see what theyhave in store and where they go next.
Uh, another big drug focus was actually,uh, with screening for type one towards
(17:44):
the prevention of type one with to,and Sanofi is making big investments
in getting more people aware ofscreening for type one because, well,
that's the only way people are gonnabe on the list to be able to access.
And so that was good to see as well,that there was a lot of interest and,
and people were talking about screeningand our own attitudes as people who
(18:06):
live with type one to who else in ourlife are we encouraging to get screened?
And I thought that was good.
Yeah, I think we're gonna be, we're gonnado a podcast on that specifically in
the very short term, but I, I speak forSanofi about, about screening and about
the preventive measures and I, I feel itreally puts the power in people's hands.
A lot of folks are saying like, if I'm athigh risk and I don't wanna know because
(18:29):
it's inevitable, but it's not anymore.
I. There's so many things wecan do besides medications.
There are other approaches we can use toslow down the progression of type one.
Did you ever have your kids screened?
I did.
Actually.
The National Health Service here in theUK has a study called Elsa for people with
type one or want or even didn't have typeone who wanted to have their kids screened
(18:51):
and I should probably get my daughterRescreened because she wasn't quite for.
When she had her finger stick forit, and now she's five and a half.
But at that time, both my kids came backnegative, which was really lovely to see.
Yeah.
On the other hand.
It's a relief, isn't it?
It's like a weight off your shoulders.
It does feel that way, and yet I wasspeaking with someone the other day
who told me that as a parent of achild with type one or one child was
(19:15):
diagnosed at age three and is now 15.
And then her second child was justdiagnosed at age 14 last year, but
the second child had been negativefor antibodies only two years prior.
Mm-hmm.
So that was interesting.
She said something about theinterval for rescreening here.
You know, there's, we don't exactly knowif you get the all clear when you should
(19:36):
be rescreening or perhaps that firsttest that was negative for antibodies.
Maybe that wasn't the most accurate.
Instance, yeah.
I really felt for her becauseI hadn't heard about the second
child having been diagnosed.
I only knew about the first oneuntil we had that conversation.
For those of us who are diagnosed andhave had it for as long as we have,
you know, the technology has evolvedso much in the last several years,
(20:00):
particularly with automated, or Icall semi-automated insulin delivery.
I still feel that, you know,we're, we're in charge of the
vast majority of the decisions.
It's only a, some slight adjustmentsthat these systems can make.
So what can you share with me that'snew with either the pumps, algorithms,
and what features are available withinthe systems and what's coming up?
(20:22):
It was great to hear that Control IQPlus is coming through from Tandem, that
they're introducing some auto boluses.
I need to get my head around alittle bit more about the system to
understand exactly how it's gonna differfrom the control IQ that's already
been out, but they were certainlytalking about it on the booth, and
I thought that was nice to hear.
Yeah, I mean we've got ControlIQ Plus here and we've had
(20:44):
it in play for a while now.
There there's only ahandful of new things.
You know, one is that you can settemporary basal rates while control
IQ is running, which I think isactually a very helpful feature.
If we knew we were gonna need moreor less insulin for a while, we used
to have to create a whole new profileof, of insulin delivery parameters,
(21:04):
turn it on, and then remember toturn it off when we're done using it.
A temp rate, you just go in and say,all right, for the next six hours, bump
my delivery up 40% or lower at 30%.
That's all you have to do.
So the temp basal feels a nicefeature that reintroduce, and
you know it was available prior,but now it's being reintroduced.
(21:25):
And the extended boluses, which arealso a very helpful feature with.
You know, the, you know, thetypical American diet, lots of
fat and slow digesting food.
Being able to slow down thebolus deliveries is very useful.
Tandem used to allowit for up to two hours.
Now it goes up to eight.
I can't imagine something thatwould take that long to digest,
but I suppose it's possible.
(21:46):
They're having a, a Spanishlanguage capability.
What else?
And those are the major things.
Um, it's all that comes to mind.
Those are the, you know, more significantchanges that are being incorporated.
But I've also learned a lot about.
Their insulin on board out calculation,something called dynamic IOB.
So it doesn't always use theinsulin on board at face value.
(22:07):
It doesn't just deduct thatamount from boluses anymore.
If your glucose is trending upor it's high, it's gonna deduct.
Less.
And if it's low or or dropping,it'll deduct a little bit more.
And also if you've eaten recently, itconsiders some of the food offsetting the
IOB, so it'll deduct a little bit less.
So it's an intelligent kind ofinsulin on board adjustment.
(22:30):
So even though you still can't adjustthe duration of insulin action,
it's a little smarter approach.
It feels a little bitlike how we can use loop.
Yeah, the way you described it.
The DIY systems do that for us already.
You're right.
Yeah.
Were there any presentations fromOpen Source DIY platform developers?
(22:50):
Yes.
And now before we move on toOpen Source, just a couple other
highlights in terms of devices.
So we saw SQL present with theTypool Loop system with Twist.
They need Chubby Checkeras their spokesperson.
I don't know if he's still around.
Do the twist.
Um, yeah, so it wasnice to see them there.
They're not necessarily comingto Europe immediately in the very
(23:14):
near future, but, um, it was goodto see them on the horizon here.
And then Kaleido, a pump company that'sactually based in the Netherlands was
back on the scene with a launch party.
For their new pump, which will beavailable around Europe hopefully
in the next several months.
And I've been aware of the developmentbehind it for several years and
it really looked like the companymight not make it to a full scale
(23:36):
commercial launch several years ago.
So it was great to seethem really doing well.
What do you like about it?
It's really quite cute and it comesin some colors and if you compare
the size of their new on body part,'cause it's a patch pump style.
It's similar to Omnipod, but ithas a little tiny bit of tubing.
Their unit comes up just a littlebit smaller than an Omnipod pod and.
(23:59):
I can see it being very wearable.
Yeah.
I, I, I had to say whenI saw it, I thought, Hmm.
How much, how in insulin did it hold?
Do you remember?
Uh, my recollection is thatit's 200 units, but we might
have to fact check that.
Is there anything new from Insulet?
Nope.
Omnipod five is Omnipod five.
And actually you're asking,that brings up a good point.
I, there was a real vibe around theconference of "there's not too much,
(24:22):
that seems completely revolutionaryin automated insulin delivery
here this year." And, I said tomy friends who had very, well, you
know, sorry, who observed at that.
I said, yeah, you know, for so manyyears, every year that we came to ATTD,
there was more research into algorithms.
There was more research into physiology.
There was more on the drawing boardto try to consider and trying to
(24:43):
make these systems functional.
Now, we've reached a point where it'sactually about implementation and
rollout, and a lot of the incrementaladvances that we're gonna see are
gonna feel like kind of small stepsforward because now these systems are
really getting into people's hands.
The upgrades are going to be more steadyand slow in terms of how they hit.
(25:05):
Yeah.
Speaking of the application of thetech, you know, in infusion devices
are something that we've been lookingfor improvements in for a long time.
You know, Medtronic launchedtheir extended wear set a couple
years ago, as you pointed out.
You know, Tandem is, is developingsomething called steady set.
It's their, their versionof an extended wear.
Any news about infusion set developments?
(25:25):
Well, more around how canwe detect occlusions better.
Um, and in fact, there was a spotlighton DiaTech Diabetes in the yearbook
session because of their technologythat can help detect occlusions faster
than a lot of the current tech can.
So that was good to see.
That's one of the things thatSQL is, is riding on with the
launch of Twist is very, uh,early detection of, of occlusions.
(25:48):
You feel that, that, that, do you thinkthat's gonna make a, a big difference?
Is that gonna move the needle,so to speak, in how we manage
glucose with pump therapy?
Well, back to ourconversation about ketones.
I think if you can detect occlusionsfaster, you're not looking for ketones
to be how you know, and I feel likethat's, you know, a bit of a push pull.
I'd rather have a system that couldtell me, "Hey, you have an occlusion",
(26:11):
before I feel sick because I gotan occlusion, if that's possible.
Now, it won't necessarily know if thecannula got dislodged and I'm just wearing
some insulin on the top of my skin, butI might smell it or I might notice a
spike in my glucose that lets me knowthat somehow that insulin didn't hit so.
Those are things that I feelmight be quite interesting
to watch the development of.
(26:32):
There were a couple other insulindelivery systems on the show in the tech
fair that have some novelty to them.
Pharma Sense has what they call theNEA pump, and their NEA signature
pump has both a cannula and aninfusion set attached to it.
It's a single unit.
It does the, what we used to callthe snake bite, where it's two
(26:52):
prongs in terms of form factor.
I do look at it and think, are we goingfrom being afraid of catching tubing
on a doorknob to wearing the doorknob?
It's not the smallest, lightestthing there, but um, but it's
interesting as an approach, and theyhaven't been very public about what
CGM technology it's integrating.
So I look forward to hearing more on that.
(27:13):
Where do we stand with, uh, dualhormone insulin and glucagon
infusion from the same system?
Another good question.
Um, there's a small company that'sbased in the Netherlands called EN Rita.
Which has shown up at European conferencesfor a while with a dual hormone product.
They do seem still to be stuck withthe fact that the glucagon isn't
stable for very long after you mixit up and put it into the system.
(27:36):
And that of course creates complexitieswith cost as well as function.
I. Even with like, like Zeis and uh,Zeins formulations that are stable at
liquid form for years at are in temp.They can't use those in these systems.
I think it's all about the commercialcollaboration that it would take
to get them there, and so far wehaven't seen them in the space.
(27:57):
Doing it, and maybe that's somethingthat the community can start to
say we'd like to see more of.
Yeah, I mean, that was what iLet wasoriginally supposed to be, uh, Beta
Biotics was a dual hormone pump initially.
They ran into so many issues withthe glucagon that they had a, it
really slowed down their researchand that's picking up again.
And all, all the re studies I've seenis that when you have both glucagon
(28:21):
and insulin infusion taking place, youcan achieve much tighter control being
range more often with less hypoglycemia.
It might make exercise much moremanageable 'cause that's still one
of the biggest challenges we faceis dropping with physical activity.
We've got, basically, we've got agas pedal, we can push the blood
sugar down, but we don't have brakes.
(28:42):
You know, you drive in a car withno brakes, without glucagon in the
equation, but then you gotta wear twodifferent infusion sites, have two tubes.
You all know how much, uh, the generalpublic loves tubing to begin with.
Like you said, doorknobs,drawer handles, et cetera.
We'll make things more complex.
Yeah, true.
Although I, I do wanna, um, point outthat the more we have app control for
(29:03):
systems, the more we could wear thepump in the tubing all under clothes.
That was one of the things that madeit work for me when I was on a DIY
system with the Medtronic pump, wasthat having the app control meant
that I didn't miss that experienceof feeling a bit too, being free.
I didn't have to pull outmy pump and handle it.
Every time I needed to take a bolus.
(29:24):
It is nice.
Did Medtronic have, uh, anything to sayabout their upcoming sensor and, and pump?
There was some discussion of Simpleraand they were giving out little,
you know, you can have an experienceof what it's like to wear it.
Not real sensors, just a sticky patch.
And there wasn't a lot being said aboutfuture changes to the current indications,
but certainly they're talking about it.
(29:45):
And of course they've said.
Publicly as well that they're goingto have an integration with the
Abbott Libre product in future too,so that, that's gonna be interesting.
Yeah, I, I wonder if that's evergonna actually happen though.
Medtronic's only, you know, theyonly play with their own in their
own sandbox for the most part.
What I've seen about Simplera,it's infinitely easier to insert
(30:05):
and Simplera and smaller and morecomfortable than their existing sensor.
The accuracy data still lagged a bitbehind what we see with Dexcom and Libre.
You mentioned the apps, like thephone apps making life easier.
Were there any other new interestingapps that were on display?
Well, in terms of on display inthe tech fair, again, there was
presence from enhanced there.
(30:26):
An app company that's based inEurope working on an exercise thing.
Are you familiar with enhanced?
I've heard of it.
Yeah, yeah,
Yeah, um, and I think that's gonnabe interesting to see how many people
will take it up and use it regularly,and how many people it can help.
They just signed on as an ambassadorHenry Slate, who's a rugby player
(30:47):
with type one, and they've had a fewother elite sports people who live
with type one could come and, youknow, be on their team, so to speak.
You're an elite sports person.
You do like, you're a, you'rean endurance athlete, Melissa.
I think you're thinking back to that time,that one time that I did a century bike
ride on my first wedding anniversary.
I happened to be approachingmy 15th wedding anniversary.
(31:08):
But no excuse,
But that was a good memory.
Um, yeah, I mean, I go to my exerciseclasses a few days a week and I do,
well, I guess you could call bicyclingin central London as an extreme sport.
I did read, uh, there was apresentation at the conference
about using the AID features tomanage blood sugar during exercise.
(31:29):
I've not found those featuresto be particularly helpful.
I mean, within the DIY apparatus,we can do some more creative things.
I found we still have to go back toour old school management methods
of either eating carbs beforehandor making bolus reductions ahead
of time if it's post-meal workouts.
Anything new you picked up on aboutexercise and blood sugar management?
(31:51):
Well, there was some discussion of someof the guidelines that have come out,
which there was a whole symposium atthe European Association for the Study
of Diabetes meeting back in the autumn.
And you know, there was a bit of recapon those guidelines which are available.
We could put a link in the show notesbecause the guidelines have been
thought up with varying in mind.
Each system, they're not reallygeneric, they're, they're
(32:14):
actually more usable in terms of.
With this system becauseof how the algorithm works.
This is probably good advice ifyou're doing this kind of exercise.
Lots of credit to the people who'veworked on those guidelines, I think.
But it'll take a while to educatethe healthcare professionals and the
people with diabetes who need to know,because there's so much to understand
when you get onto an AID system.
(32:34):
Yeah.
The last category I was thinking aboutis software, either downloading software,
reporting software, data collection,merging activity, lifestyle type
data that you happen to come across.
Anything about that?
Sure.
There's a couple things to highlightin terms of data that we as people
with diabetes can get out and use.
It's available for DIY users, notbroader than that at this point.
(32:57):
And on Apple iPhones cockpit app,do you know Diabetes Cockpit?
No, I haven't.
Oh, it's cool.
So my friend Lucas developed it.
He was working for MySugr and startedthinking as someone who lives with
Type one, actually there's a lotof data that comes from my DIY
looping system and Apple Health.
How can I work these data sets together?
(33:19):
Well, maybe even plug in Nightscoutdata if somebody doesn't have Apple
Health and their DIY system connected.
So yeah, so the Diabetes Cockpit app.
Um, and it is doing correlations so thatyou can see when you have, you know, days
with fewer step counts, is there somethingthat might turn up in your diabetes data?
Now that, that gets me all jazzed up.
(33:40):
I love that.
'cause I'm always trying to figure out,you know, what are the cause and effect
relationships when I'm looking at dataand for the most part, the software.
That we have now does a terrible job.
It doesn't really provideinsights like that there.
There's a few select bits and pieces hereand there, but being able to see cause
and effect relationships, knowing that onTuesday afternoons, if I have an active
(34:01):
day, I go low, or if I have more than Xgrams of carb, that's when I tend to drop.
That kind of information wouldmake my life a lot easier, not
just as a clinician, but my owndiabetes management as well.
Yeah.
Speaking of cool software,you've got one called SmartStart.
Can you tell me a little about that one?
Sure.
Um, and then after I tell you alittle bit about SmartStart, I
(34:23):
might tell you just two more thingsthat I saw in software at ATTD.
Yeah.
So in a nutshell, SmartStartis doing CGM user education.
With adaptive learning paths on yourphone, the proof of concept product, which
you know well is currently available onour website, SmartStart Health, and with
big grant support from the UK governmentand some investors, we're developing
(34:46):
the version that'll be our MVP MinimumViable Products for proper launch, which
will have an adaptive component so thatdepending upon what somebody already knows
about using CGM when they start and whatthey're learning along the way, their
learning journey will adjust dynamically.
So we saw in the proof of concept studythat it took folks between an hour and a
(35:06):
half and up to two hours to get throughthe seven content modules which cover
everything from, what do we call thepieces and parts of a CGM system so that
if something's not working, really, youknow, you know which bit it is that you're
reporting when you talk to somebody oncustomer service, phone line, or when
you have to talk to your team aboutwhat's working for you and what's not.
All the way through to what happenswith the alarms and alert settings, what
(35:29):
things are likely to be changeable basedon your needs and how to look at the
graphs, how to understand what the datacan mean for you and your management.
In the real time moment and when wetalk about things like time in range
and a GP ambulatory glucose profile.
And the UK government supported this?
Yeah.
Um, innovation grant.
What's it like having agovernment that actually supports
(35:52):
quality health initiatives?
'cause we don't, we don'treally have that here anymore.
I, I, I might have to move out there.
So what are the other, uh, softwaresthat you were excited about?
Well, building on the mention ofDiabetes Cockpit, the founder of Diabetes
Cockpit, Lucas and a couple of otherfolks have gotten together and started
a new company syntactic so that theycan take the insights that come from the
(36:15):
diabetes cockpit app and de-identify,anonymize and create a data set that
can be used by researchers to optimizefuture insulin delivery algorithms.
And I think that's really smart.
So I'm impressed with what they're up to.
And another thing we saw is that Dexcom isnow working on population health software.
(36:36):
We got a little glimpse of whata dashboard might look like
in their corporate symposium.
And I found that really interesting'cause looking at how people
are doing in a larger set of.
People under the same clinicis something that healthcare
professionals should be doing.
But it's really hard when youhave individual level data
and you can't aggregate it.
Um, and to be able to put on filtersand think, well, are there some patients
(36:59):
in this clinic or in this healthsystem who are doing really well?
What do they have in common versusthose that maybe are struggling, need
more support, or maybe we just haven'tseen them very much and we can now look
at their data in a remote basis andgo, you know, those are the patients
that we should be phone calling to seehow they're doing, maybe getting them
in if we need to see them in person.
(37:20):
So seeing that Dexcom is lookingat how they can help support health
systems on a different basis.
I thought that was neat to see too.
Very nice.
Yeah, I mean, I, I am just kicking myselffor not being able to go this year.
This sounds like itwas an amazing meeting.
A lot of new stuff to see, new stuffto learn, and it's all focused on the
areas of, of interest for people whoare taking insulin and taking multiple
(37:42):
injections or using pumps so much.
It all applies to us, to our daily lives.
Which it really does.
I can't say about every conference yougotta sift through at other conferences
to find stuff that's really useful.
I will say there was an awful lotabout the use of CGM in people with
type two who aren't necessarily oninsulin as well, and to see that focus
increasing, that's getting us intowhere can diabetes technology make
(38:05):
a bigger difference in the future.
I like to say that ATTD trendsabout seven years ahead of actual.
In terms of how clinicaldecisions are being made today.
So I, I remind myself when I go thatthe rest of the world is not necessarily
thinking about the same topics.
The way the people who are leadingthe presentations at at TTD are, yeah.
(38:27):
But what a vision of theworld does it create?
It, it makes me hopeful.
It makes me feel like there'sa lot to learn, and next
year it's in Barcelona, so...
I, I will be there.
Um, it'll be nice to see you.
Maybe we'll have to go for tea again.
Melissa's the only person who has ever,ever gotten me to go for afternoon tea
(38:47):
as I visited her in London years ago.
So maybe a little, I don't know.
Do they do tea in Barcelona?
Uh, not particularly,but they do great tapas.
I'm good for tapas.
I'm down anytime.
Yeah.
We can do tapas in Barcelona for sure.
And before that we canhave breakfast at a DA.
That's right.
See you in Chicago.
Yeah.
Yeah.
It's a couple months away.
Melissa, thank you so much for joining.
(39:07):
I know it's, it's.
What time is it there?
It's like dinner time for you, isn't it?
Nah, it's almost three in the afternoon.
Okay.
It's not too bad.
It's about, it's alright.
10:00 AM here's, yeah, I stillhave a couple meals to go to catch
up to you, but thank you so much.
I mean, you're just, you're such awealth of information and you, you
put things in a nice perspectivethat, that we can all relate to.
So again, thank ev.
I wanna thank everybody for,uh, joining the podcast and
(39:29):
have a great rest of your week.
And don't forget to think like a pancreas.
2025 ATTD conference inAmsterdam was fantastic.
Even though I wasn't there,it was still fantastic.
We learned from Melissa about a lotof the innovative things that were
displayed and, and discussed newmedications, uh, type two medications
(39:50):
that can be applied in the type onespace management approaches for handling,
exercise and prevention of hypoglycemia.
All the updates that are in the pipelineinvolving continuous glucose monitors,
insulin pumps, and the algorithmsthat drive automated insulin delivery.
There are also a number of innovativeapps that have come out and are in
(40:13):
development and software, and some ofwhich are applying AI technology to make
them even more helpful and resourcefulfor those of us living with diabetes.
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