December 18, 2024 • 49 mins
In this episode, Gary Scheiner and Alicia Downs discuss the Tandem Mobi insulin pump, sharing their experiences and insights on its features, usability, and the technology behind it.
They explore the pump's form factor, user interface, algorithm, and how it compares to other systems in managing diabetes.
The conversation also touches on the challenges users may face, including the limitations of the app and the importance of user engagement in diabetes management.
Key Takeaways
- The Mobi pump has a user-friendly form factor that enhances wearability.
- Control IQ algorithm provides immediate functionality without a learning curve.
- Users can customize profiles for different insulin needs based on lifestyle changes.
- The app requires multiple confirmations for actions, which can be cumbersome.
- The Mobi pump's charging method can be inconvenient during use.
- Exercise and sleep modes allow for tailored insulin delivery adjustments.
- Tandem's transparency about their algorithm empowers users and clinicians alike.
- The Mobi pump currently supports Dexcom G6 and G7, with plans for Abbott Libre compatibility.
- User feedback is crucial for improving diabetes technology.
- The conversation emphasizes the importance of proactive diabetes management.
Integrated Diabetes Services website: https://integrateddiabetes.com/
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:33):
I'm your host, Gary Scheiner, Owner and Clinical Director of Integrated Diabetes Services.
I'm happy to be joined by my friend, colleague, and fellow geek, if you will, AliciaDowns.
Alicia is the Director of Patient Care and Education here at Integrated Diabetes Services.
(00:54):
Alicia, it's always fun to have you on this program.
I like hanging out with you.
We get a chance today to talk about
the Mobi pump, Tandem's new Mobi insulin pump.
We love picking apart all the new technology and you and I both had a chance to startusing this a couple of weeks ago.
(01:17):
That was a fun experience getting started.
You remember the circumstances?
Yeah, nothing like starting a pump in a race in a poorly lit crowded Chinese restaurantsurrounded by Tandem reps trying to not shock them by our complete disregard for proper
(01:39):
training protocol.
That's right.
Yeah, we went to the, we went with our Tandem reps set us up with systems and we met atthe Chinese restaurant and you
doesn't even have a number next to the
(02:03):
It took me a little bit longer to get my app up and running, so you beat me.
But yeah, it was nice.
We had a good meal, nice conversation, and we walked out of there both on the Mobi.
And one of the things that's really neat with Tandem's Control IQ system, it ain't nolearning curve.
(02:24):
That algorithm kicks in and is fully functional the second you activate it.
So it was it was kicking that pad thai right right away getting getting full auto bolusinggetting all of you get its full feature Right out of box day one.
You don't have to like wait two weeks to see what can this thing really do?
(02:48):
There's no greater challenge to glucose management than pad thai.
It took me, I think, 6 or seven tries to kind of figure it out and it still challenges mesometimes.
That stuff is chock full of hearty carbohydrates, among other things.
Yeah, and was thinking like while we were doing that, I mean, and I think I had like friedrice and a steam bun and like General Tso's chicken.
(03:15):
So I did not go carb-light either.
And I actually thought to myself, could you imagine day one of any of the other hybridclosed loop systems eating this meal?
boy, that would have been, I mean, I'd have been.
plus 220 [mg/dL] for the rest of the night.
Like, it would have been 4 a.m.
(03:35):
before I got that back in range.
You and I have an interesting perspective to share on this.
You are usually a Tandem Control IQ user.
So you were familiar with how Control IQ, the algorithm operates, but the pump itself, theform factor, the physical pump itself was completely new to you.
(03:58):
Yeah.
So let's talk first about the pump.
I want to go through the pump, the user interface, the CGM and the algorithm in thatorder.
Let's talk about just the pump first.
What's your take on the form factor, the physical pump?
The physical pump itself, I really like for wearability, especially for me, because I havenever been able to be a patch pump user.
(04:30):
I can't wear the Omnipod because of a skin condition.
It causes me to get hives.
So I can't even make it two days on an Omnipod.
So it's just not worth it.
Like my blood sugars would always be crazy because I'd be changing pods every day.
So having a pump where I can change where the...
(04:51):
patch placement is so I can move where the pump itself is but leave my insulin alone andjust move that piece around or not even wear the big piece on my skin for a day if I need
to give my skin a break is a deal breaker for me that is what lets me now use patch pumpwhich has always been out of reach I've been a tube pump user since day one and then I
(05:14):
also like that it's not an all throw away
You know that we're not throwing away batteries and microchips every 3 days is reallythoughtful It's pretty comfortable.
I'm usually not a big fan of anything that has a corner or a like a 90 degree edge Indiabetes.
(05:35):
I'm like come on.
We wear these things on our body for 3 days Can we make them round and cozy and comfy thisdoes have more corners on it that I would like?
But in having warn it
I've never felt a corner poke or jab me anywhere.
So I'll take it.
It's and it is, it's tiny.
(05:57):
Like it's it's really unobtrusive.
It's as I think they've made it about as small as they can make it and cram in everythingthey need to cram in.
I and I love the bolus button.
Because the other thing that keeps me from wearing a patch pump is when I have used apatch pump, I lose my phone something chronic.
(06:19):
I am wearing an Apple Watch.
The feature I use the most is not even to look at my blood sugar.
It is the Find My Phone feature.
And so when I get to a restaurant and I can't bowl this because I don't have my phone withme, that will end.
That'll end the pump for me.
Or just walking around the house, like I'm ready to eat dinner and now I'm just marchingaround the house for 10 minutes trying to find my phone.
(06:46):
That's a deal breaker.
There's nothing worse than not being able to eat because you can't locate your phone.
mean, one might ask, well, how are the two connected?
Okay, well, need my phone to give my insulin so I can eat my food.
It's complicated.
And I discovered something about the bolus button,
you can do more than just enter units of insulin with it.
(07:08):
You can switch it to enter grams of carb.
So you can have it enter like 5 or 10 or 15 gram increments and it'll calculate your doseand deliver the right amount based on that.
So if you are out somewhere and you have a pad thai and you've got to enter a hundredgrams of carb, you can do it and it'll calculate an appropriate dose.
(07:31):
So if you don't happen to know your insulin to carb ratio is off the top of your head,
It'll do the math for you.
Isn't that sweet?
And you get your correction dose and everything because it's pulling your blood sugar fromthe Dexcom.
So you're getting all your info.
You're getting a regular bolus just like you would if you had your phone with you.
Yeah, yeah.
(07:51):
So the size of this device is fantastic.
It's similar, very similar in size to the Omnipod in terms of its dimensions.
It's tapered so it doesn't snag on things.
I was more impressed not by the size but the weight.
This thing weighs barely an ounce even when it's filled with insulin.
(08:14):
It is feather light.
And because of that, the adhesive holds it to the skin very nicely.
It doesn't take much because of the weight.
The Omnipod weighs considerably.
more because it has those metal components and batteries and things that that add weightto it.
This thing feels like there can't be much more than just plastic components in here andmaybe one tiny computer chip.
(08:40):
That's really all that it needs.
So the weight to me makes it an enormous difference.
Yeah, and that's where I'm wearing, I, because it's so light, I honestly forget that I'mwearing it or where I'm wearing it.
Where the Omnipod, I do, I kind of feel that little kind of pull down on my skin.
(09:05):
Like I can kind of feel gravity, kind of.
on it.
That might be part of why my skin doesn't get as irritated with the Mobi as it does withthe Omnipod.
But yeah, it's significantly just tiny.
It feels tinier on my body.
Like it's kind of not there.
(09:25):
this type of small form factor gives users the opportunity to wear it directly on theirskin in a little sleeve or using double-sided tape.
And you and I have both tried the tape that comes with the Eversense sensors, because thetransmitter has to stick to the skin.
(09:46):
And we both found this works really nicely.
But Tandem provides these sleeves.
little bit of adhesive on them to keep the pump in place and locked in place.
And I tested it out.
I ran full court basketball two days in a row and you know I sweat anyway and this thingheld on great.
(10:07):
It really stuck well.
I think it's because of the the light weight of the pump.
So users can wear the pump directly on their skin and then use the 5 inch tube and havethe infusion site right next to where the pump adheres.
But you can also use the traditional longer tubing and either put the pump in a pocket,clip it on an undergarment or clip it to your waistband or your belt.
(10:36):
Again, because it's so light, you don't even notice it's there.
and I found the clip is cute, it's this tiny little clip and it's pretty strong as well soit holds onto the belt really nicely.
Aside from those things, having a pump this size, there are some drawbacks to that.
(10:58):
What are some of the issues created by having a pump this small?
For me, it's so...
It's been so weird because everything's so tiny and I can put it anywhere, which meansthat now I don't see my diabetes world.
(11:19):
So I've gotten on one side this amazing thing of like out of sight, out of mind.
Isn't that like amazing?
Like I don't even think about being a person with diabetes.
On the other side, out of sight, out of mind.
I'm not even thinking about my diabetes.
Like I sit down and I'm like 3 bites into a meal and I'm like, my gosh, I have type 1diabetes.
(11:43):
I have to take my insulin.
I have missed more boluses.
My pre-bolusing has gone from like pre-bolusing every meal and pre-bolusing like a champto like...
I'm lucky if I pre-bolus at all.
I finally this week got it into my head.
Like I started using the pump button to pre-bolus because I'm not like cooking dinner withmy phone in my hand.
(12:09):
And without some sort of tactile thing to remind me like, hey doofus, you have to takeinsulin.
I was just forgetting to do it.
It was like being on shots all over again.
It was like it was in another room so I wasn't thinking about it.
I had to start wearing
Apple Watch to remind me to look at my blood sugar because I'm just so used to having mypump on my hip and that reminds me to look down at my blood sugar without that physical
(12:36):
tactile reminder.
So it's a double-edged sword, the convenience and this out of sight, out of mind is a nicething when you got diabetes because we're thinking about blood sugars so much.
But also it is helpful to have those reminders so we don't forget to do our boluses, wedon't forget to check our glucose, et cetera.
(12:58):
The physical size of this has, you one limitation is the size of the insulin reservoir.
It only holds 200 units before priming, which works well for most people, but there'sstill a lot of folks who go through
more than 60, 70 units a day and you're in that category.
(13:19):
I am and so you know I'm a rule breaker by nature.
So, FDA and Tandem, plug your ears.
I use U200 insulin because I'm a high volume insulin user.
I find U200, my insulin just absorbs better in general and it lets me use patch pumps.
Without U200, patch pumps are out of reach for me.
(13:42):
So that's the work around that I immediately reach for.
I as long as people know what they're doing and realize they're using double concentratedinsulin.
Yeah, I've got some patients also doing that and it works fine.
The other issue is with the infusion sets.
If you like the 5 inch tube and want to wear the pump on your skin, you're a bit limitedin terms of which infusion sets you have access to.
(14:07):
So tell us about that.
Yeah, so that's true for me as well.
I'm not a big fan of the 90 degree sets.
I get a lot of set kinks and I find they're just not comfortable a lot of the time.
They'll hit muscle or things like that for me.
So I like the angled sets.
(14:28):
Tandem says, yeah, we're in the works and we're gonna, you know, we're gonna increase.
We always know when a company says it's in the works, that means don't hold your breath.
And they've got their capillary bio extended wear set in development.
So it doesn't take a genius to go, it would be kind of silly of them to develop a wholeline of 5 inch tubing in their current sets and then turn around and then do this whole
(14:54):
development with their new extended wear sets.
That sounds like just
resource waste to me, so we're probably going to be a while.
So what I've been doing is with my angled sets, I mean, I usually use like 43 inch tubingso that I can wrap my tube around and stick it wherever I need to stick the pump to hide
it.
(15:14):
So I take that extra tubing and I just loop it into a little coil and throw a little pieceof tape on it.
And the little pouch you were showing with the pump, I just take that extra tubing and Ituck it in that little pouch.
with the pump and then take that little adhesive tab and tape it all in there so I don'thave my tubing hanging out everywhere.
(15:36):
I am going to MacGyver diabetes.
If I can't, I'm never gonna be able to do diabetes through exercise, proper eating, andbeing a good person.
That's never gonna happen.
So I better just MacGyver this thing together.
Definitely outside the box thinking you got it got to be that way when you live withdiabetes Okay, so and the pump also requires charging unlike the t-slim pump where you
(16:05):
plug in to charge it, you know, know the tube, you know The cable to plug it has differentlengths this you have to sit the pump on a little docking station to charge it So if
you're using the short tube or you're using a MacGyvered short tube
out of long tubing, you've really got to disconnect in order to charge it.
(16:25):
It's just not logistically possible to charge it otherwise, which can be a little bitinconvenient.
It takes about 15-20 minutes to charge up completely.
So during the time it's charging, has to be sitting on that docker that's plugged into anoutlet.
And you found another interesting little issue while it's charging where it may actuallycome to life and start to move.
(16:52):
Tell us about that.
Yeah, so I hate the charging probably.
There are two things I hate about this pump, like a lot, and the charging is one of them.
So there are two ways, if you're gonna take the pump off your body, you have to do one oftwo things.
You either have to suspend insulin.
(17:13):
The current app,
it's kind of a step behind the X2 software right now.
So it doesn't have a timer on the suspend.
So it just after 15 minutes starts buzzing and in my case, vibrating, which is great whenyou're wearing it, but not so great when you've got it on a little docking station that
(17:36):
has no magnet that has no way of attaching it.
So I'm leaving it on the charger and I'm like,
and I'm watching the app to see when it gets up to a good charge and it's not getting past40%.
And I'm like, why?
And I go into the next room and it has vibrated itself off of its little charging dockerbecause of the alerts.
(17:57):
And I also, if you have a low insulin alert or any kind of alert, it's just off.
And I was like, are you?
So I'm like, get back over here.
And I put it back on.
I was like.
You know what that reminds me of?
And I was a kid, this is back in the 70s.
I had this tabletop electronic football game that you plugged in.
Yeah,
(18:18):
the field would vibrate and it would move the players kind of randomly.
So that's what the pump does when it's sitting on the charger.
And I hate that, because I mean you say you like you probably because of tubing you haveto take it off you have to take it off because the I mean if you put that thing on an
uneven shelf the pumps gonna just slide it right off I can't imagine a world I mean maybeif you duct taped them together or something
(18:43):
will come up with a better charging option at some point.
And I give Tandem credit.
They update their systems pretty regularly and pretty rapidly.
With other companies, it usually takes at least a few years for any updates to come out.
And Tandem seems to generate these within the year in most cases.
(19:04):
They're able to move through the process pretty quickly.
Medtronic, are like Toyota.
know, they're actually, more like Honda.
Like they've got a million different models, plus like chainsaws and 4 wheelers andlawnmowers and like whatever else they're making out there.
(19:24):
So when we say, this thing is a pain in my butt, whatever.
It's like me complaining to Toyota about my cup holders.
Shut up, we don't care.
But when we go to Tesla and we're like, hey Tesla, we don't like where you put your cupholders.
They're like, where would you like your cup holders?
And what color would you like them to be?
(19:45):
And how deep should the cup holder be?
Like they're taking notes, because this is all they make.
I am a significant portion of their market share.
So when we go to Tandem and we're like, hey Tandem, change your product.
They're like, really, what's wrong with it?
Because this is their only product.
This is all of their eggs in one basket.
So they are more attentive and they jump on it when they see a flaw.
(20:08):
An area I wish they had been a little more attentive in designing the product is some ofthe user interface features in the app for Mobi.
I'm the type who likes as little inconvenience as possible when I'm programming and usingmy pump.
(20:29):
And I've been a little turned off by the number of button pushes.
There's so many confirmation steps I found with any programming at all.
First off, it requires you to have the unlock feature on your phone turned on.
So you have to enter either a 4 or 6 character code or use your face recognition in orderto unlock your phone.
(20:51):
You have to do the same thing to unlock the programming on the the Mobi app, and again, toconfirm delivery.
There's just so many, I find there's just a lot of button pushes.
And likewise, it has these confirmation beeps or vibrates that the pump provides.
Every single time you activate something, program something, deliver something, I justfind it a little bit annoying.
(21:19):
I know there's a trade off here between convenience and I guess what someone there callssafety.
But what are your thoughts about that?
Do you feel this is really providing an extra layer of safety that we need, or is it justthe FDA sticking their noses where they didn't belong and forcing the company to do this
sort of thing?
(21:40):
Yeah, I think, I mean, the initial opening of the app, I mean, that's already covered byopening your phone.
And then having it again as part of you've already got, I would like the bolus.
Yes, I confirm the amount.
(22:02):
Yes, I confirm the amount.
then.
adding just another 4th confirmation that in your case requires then a multi-digit code.
It's too far.
I can see them requiring that I have the lock feature on my phone.
That makes sense.
I can see them saying like, no, we require that you make sure that your toddler can't justpick it up and do dot, dot, dot, dot, and kill you while you're napping.
(22:30):
okay, that's a logical safety feature to protect the customer.
But to then say, no, we now require that you have a safety feature to deliver insulin orchange your profile or suspend insulin or, well, that's not in any other pump.
That's not in my X2.
That's the security pin feature.
(22:53):
And I should be able to turn that off just like I can on the X2.
So that's a step too far.
All of the vibration, you can't opt out of the vibrate / beep.
like bolus confirmation.
You want to add insult to injury?
When you get a notification, you have to get either a buzz or a beep.
(23:17):
And then when you swipe to acknowledge to turn it off, you get a buzz or a beep that youturned off the buzz or beep like.
Get it again, yeah.
That is that's a kick
also redundancy with the alarms.
I use a Dexcom and it provides me all the alarms and alerts I need and then some.
(23:42):
And with this pump, yes, you can turn off certain high and low alerts, but if thealgorithm
predicts a high or predicts a low, there's no way to prevent those alarms from happening.
So I'm getting redundant alarms from both my Dexcom and from the Mobi app.
(24:02):
So I've got to go into two places to shut them off.
As an X2 user, I had forgotten how annoying the Control IQ High 200 Alert was because theycame out with an update, gosh, 6 - 8 months ago that eliminated that.
And my world has been just a beep- free nirvana since that happened.
(24:26):
Not to humble brag about blood sugar control, but boy, the alert fatigue that eased off mybrain after they did that alert was monumental.
And now it's back.
the the beeps and vibrates aside, it is really nice being able to program everything aboutmy pump through my phone.
(24:47):
It's the screen's big.
You know, can you can get where you want easily.
The layout is pretty well done.
That part I like.
And as someone who used to use the Loop app and I use my phone for everything there, too,it was an easy transition.
It definitely is convenient.
And like you said though, if you wanted a bolus without the phone, you can do it just byentering carbs using the single button on the pump itself.
(25:14):
So that is pretty nice.
You have anything you particularly like or dislike about the app itself, the userinterface on the app?
I really don't like the setting.
I don't like that things don't default to things.
the last time I went into the settings menu, I was doing something with CGM alerts.
(25:40):
So now when I hit settings, it goes straight to CGM alerts.
Yeah.
Which I, as a person who has been playing with the app for a while and am not afraid tojust push buttons until I find what I need, will just go, right, so if I just keep hitting
settings, then I get back to this and I can find...
(26:00):
But like, I think about my mom, who like, when she uses the remote control, if she hits abutton and it doesn't do what she wants to, she's like, help!
Like it's gonna suddenly set off a nuclear warhead, right?
And then now this is attached to insulin.
So she's gotten a screen she doesn't expect.
She's just going to stop pushing buttons immediately.
I've talked to the folks at Tandem about this, anytime the app times out, it should goright back to the dashboard.
(26:25):
You should be right at your, and the dashboard on this thing is nice on the app.
It shows you all kinds of graphs of what adjustments have been made, your sensor data,your boluses, all of the status of everything going on.
It even gives you some stats, quick stats on how you've been doing with your glucosecontrol recently.
It really needs to just default to that and from there you go to your main programmingicons at the bottom.
(26:51):
But instead, like you said, it defaults when you open the app up again.
It defaults to the previous menu you were on, which is often the notifications screenwhere you shut off an alert.
So yeah, that's not what you want to do most of the time.
You want to bolus typically when you're going into your app.
Let's get to the algorithm because this is often what differentiates one AID system fromanother.
(27:18):
I mentioned right from the get-go, I love the fact that there is no learning curve.
The app doesn't need to learn about how much insulin you use and come up with its ownsettings.
It uses your settings, your basal rates, your correction factors, your carb ratios.
(27:38):
That's what it uses as its starting point.
What's the advantage of that as opposed to the app trying to learn your needs and figurethem out on its own?
Me?
Everything.
Absolutely everything.
Because my insulin world changes significantly based on my metabolism.
(28:03):
There are hormones.
I use a significantly larger amount of insulin during PMS.
I know that.
I've tested it.
I've found it to be true.
And with Tandem, I can just set up a profile
with those settings that I know work during that time and I can just say, it's the daythat I'm gonna run higher.
(28:26):
Let me put on that profile.
Boom, immediately I'm getting the insulin that I need.
And those two days, you can't tell are different from my blood sugars.
With any of the other AID systems, FDA approved AID systems, it's going to take them 3days to make at least.
(28:47):
or more to make any adjustment to significantly affect those days.
And by then those days are over.
So my blood sugars are going to run higher.
And then when that's over, well, now guess what?
Now my period's done.
Guess what happens at the end of my period?
I'm significantly more sensitive.
(29:10):
So I need less insulin.
On the Tandem, can bada boom, change that profile again.
And you don't have to program a new profile every time.
You can store them in there.
all stored.
can have, think, nine different profiles stored in the pump ready to go named, you know,each name for what I use them.
Is it?
(29:31):
I thought it I never get above.
I've gotten like 5 at a time and then I'm like, I need to clean houses.
a lot.
Yeah, that even then I've got a clean house.
What am I doing?
I usually I usually recommend 3.
Most people can do the normal- high- low- and that's enough for most people unless they'vegot like shift work or something weird going on in their life or like weekends.
(29:52):
With with any of the other systems, they've cranked up my insulin for those high days andnow they're running on assuming I need more insulin and here comes that low day.
Yeah, and it doesn't respond immediately.
Yeah, I've got a profile I created for days where I'm sitting all day, because if I'm inmeetings, traveling, things like that, I need more insulin because I'm just not moving
(30:14):
around as much.
And I don't want to wait, like you said, days for the system to react to that andrecognize it.
I want to be able to tell it that.
So in a way, the Mobi and the T-Slim, they let the user
use their skill set.
The other systems don't give the user that opportunity.
Now, some people prefer not being involved.
(30:38):
They just want to sit back, not think about their diabetes and let this thing figure itout.
But ultimately, their control can be better if they're involved and engaged in theday-to-day management.
The one aspect I find particularly nice in terms of using the user's settings as thestarting point,
is the basal program.
(30:59):
Is there anybody who has a dawn phenomenon where the glucose starts to rise in the earlymorning?
If they're using another AID system that has a flat 24-hour profile and then adjusts whenyou start to rise or fall, you rise or fall.
if the system uses your basal rates, you can prevent the rise or fall in the first place.
(31:24):
With young people, there's often a growth phenomenon in the evening.
They make growth hormone towards the late evening hours and kids' blood sugars on theseother systems start to shoot up around bedtime and there's nothing you can do about it
unless you bolus in advance, guessing that it's gonna happen.
But with the Tandem option, using your basal rates, you can prevent that rise.
(31:48):
So I just, like being able to use.
A very basal program that you're used to using and no works.
As opposed to a flat background profile that the other systems go with.
Like you said, Gary, you can do something about it.
Just That empowerment of knowing I can do something about it is huge when you're livingwith diabetes.
(32:12):
There's nothing worse than having a problem and not having a tool.
I mean, that's what an insulin pump is.
It's a tool.
It's our highest level tool.
And so for that tool to have an edge ground down so you don't get to use it anymore.
is counterproductive.
Like give me all the edges and then let me decide which ones to use and which ones to notuse.
(32:35):
But don't grind one off.
it takes an educated user and a clinician who can guide them properly to take advantage ofthat.
And that is the other thing that I really like about Tandem Systems over the other FDAapproved AID is that as a clinician, Tandem has so far been the only company to step out
(33:01):
and say everything about your insulin, your data, and how you're getting it is yourinformation.
Their algorithm is public published information.
You want to look it up and go build one in your garage?
Have at it.
You can go for it.
You want to take your data and see on your app in real time exactly how much insulinyou've gotten 24 hours a day.
(33:30):
Go for it.
It's right there at your fingertips as a clinician.
If I want to see what Control IQ is done and use that to retrospectively build your basalmodel, I can do that with all of the other FDA approved systems.
They consider my insulin data, how I'm getting insulin, and what they're doing with mybody, their proprietary data.
(33:59):
And even the algorithm is secret sauce to the other companies.
Tandem, they publish handouts explaining exactly how the algorithm functions.
It's a 30-minute predictive algorithm.
It's looking at where it expects you to be in 30 minutes based on your current glucosevalue and the direction it's headed, the rate of change.
(34:22):
If it thinks you're going to be above 160, it's going to bump up your basal.
If it thinks you're going to be above 180, it'll administer a small correction bolus.
And if it thinks you're going to be below, and I love this number, 112.5, I picture theboardroom when they decided this.
They're arguing 110, no 115.
(34:43):
And they decide, we'll split it down the middle.
So if you're going to be under 112.5.
the pump, it just says 110.
Yeah, well 110 is what it uses for corrections.
If it's doing a correction bolus, it aims for the 110.
The basal algorithm uses 112.5.
So if you're be under that, it starts backing off a little on the basal.
And if it thinks you're gonna be under 70, it shuts it off.
(35:06):
And the automatic correction boluses that it delivers, and it'll do those up to once anhour, those are a little, they're about,
a little more than half of what a normal correction would be because the system is alsoraising basal at the time.
And the magnitude of the adjustments are directly related to the correction factors thatthe user has set.
(35:32):
So that there is complete transparency from Tandem about how their algorithm works.
And it shows on the reports and even on the user's screen, right on the...
right on that homepage, it shows the exact adjustments that are being made.
And as clinicians, what do you look for?
(35:53):
How would you use that kind of information in fine tuning a patient's program?
So with Control IQ, I look for things like, are we seeing suspends after every meal?
Okay, your correction rate or your carb ratio is probably a little over aggressive versusare we seeing autoboluses after every meal?
(36:14):
Okay, then it's a little weak.
We can get in there and we can get the sense of settings doing a little more so the systemdoesn't have to be constantly taking on that burden versus when we are seeing suspending
and we should be seeing kind of 15, 20 minute little blips that are just kind ofself-corrections for the little DEXCOM wobbles and biological wobbles of the day.
(36:37):
We shouldn't be seeing these big half hour to an hour long suspend chunks.
That's a sign that settings are just overly aggressive.
We're just getting too much insulin through our day in those areas.
Likewise ramp ups.
We want to see our system at rest really resting on pretty much programmed basal, which isrepresented by just a solid light blue bar.
(36:59):
If we're seeing those spike ups, the ones that look kind of like a city skyscraper,skyline, we're seeing a lot of those in particular.
if they're pretty large.
Again, the system's doing a lot of work.
And then we look over time.
So if it's got that same pattern over time.
All right, we just need to shift the programming there to make it so that it can just reston what we've programmed and now let the system flourish from there because otherwise the
(37:30):
program is working on just getting Alicia right instead of dealing with like the Chinesefood that she had for lunch and her lack of pre-bolus because she didn't have her phone.
at data in that way.
We can optimize not only the patient's settings, but hone their own skills.
(37:51):
And that helps prevent the rises and falls.
It's not about just wait for the algorithm to fix things, because that's what some systemsand some people prefer, let the algorithm fix it.
But for those who really want to spend as much time in range as possible, we want tooptimize those settings and want their skills as far as carb counting and exercise
(38:13):
adjustment, et cetera, to be in place.
And speaking of exercise adjustment, there are two
I guess we call them overrides that the user can use.
Tell us about those.
Well, we have the activity feature, which has a picture of a little running guy.
I always tell patients, when you look at it, don't see a running guy.
(38:36):
It should really be a picture of somebody like pushing a grocery cart.
Because that's a much more accurate representation of what it's capable of.
I don't know who is capable of actually exercising and staying in range with that activityfeature, because it ain't me.
Unless I'm doing like lifting, if I'm doing anaerobic,
Cool.
That's great.
(38:56):
The system's great for anaerobic workouts.
My martial arts workouts, my lifting workouts are fantastic.
It keeps me in range because I don't have to push any buttons.
But yeah.
no, chasing my son down tanks my blood [sugar] unless I'm angry at him.
If I'm angry, audible is audible is audible.
If there's some stress involved, I'm good.
(39:19):
But yeah, so we've got a few kind of levels of tools.
We've got Control IQ itself, which is pretty good.
It just kind of the recreational day to day.
Like if I'm just kind of off on a little strolly stroll, it's a pretty good, if I'm to geta little bit more than that, like I'm going to be doing, if I'm going to do shopping, if
I'm going to be doing like, like housework around the house, but something that's going tobe kind of focused and a little longer duration in time, that activity feature is pretty
(39:47):
decent.
I always equate it to about maybe a
30 % reduction in basal.
It's going to be kind of like an old school 10 basal reduction of about 30%.
But anything more than that, anything where we're getting up to like a 50 % reduction in10 basal, like a real like aerobic workout, getting it done, doing yard work kind of a
thing.
Yeah, I usually.
(40:09):
for that.
You'll go to a lower profile.
can switch a profile or I can just cut and run.
I just turn Control IQ off, go old school, temp-basal down, do what I know has worked forthe last 15 years and...
Yeah.
Now, I have to tell patients, if you're gonna carb up, turn Control IQ off.
(40:32):
Because if you don't, if you've got Control IQ on and you eat a handful of gummy bearsbecause you're gonna go mow that front acre of lawn,
and your blood sugar starts to jump, Control IQ is gonna go, I can help, and it's gonnathrow insulin at it, and now you're gonna tank in the middle of the front lawn.
So anytime you're gonna push your blood sugar up on purpose, you have to get Control IQout of the way first.
(40:55):
You have to turn that thing off first.
and I think all the systems have some kind of exercise feature, it simply makes thealgorithm less aggressive.
It's accepting higher, little higher readings.
It doesn't fix things unless they're really high.
And even if you're approaching, approaching a low range, it's shutting the basal back.
(41:16):
So it just makes it safer.
from that like 112 to 160 and bumps it up to 140 to 180, which is essentially like a 40point bump in blood sugar.
But I mean, aerobic exercise does not drop my blood sugar 40 points.
It drops it like 120 points.
so, and you also have, you have to set that in advance.
(41:39):
So you have to think ahead.
Especially if you're just doing the online training.
The online training is like, Tim's gonna exercise.
He should turn on his exercise feature.
And the guy's like standing outside the gym and he's like, boop, and then he walks intothe gym.
And it's like, and now Tim dies of hypoglycemia in the gym.
Yeah.
The other override feature, which I make liberal use of is called sleep mode.
(42:06):
Sleep mode does just the opposite of exercise mode.
It makes the algorithm a little more aggressive.
Instead of waiting till you're going to be over 160, it'll start correcting if it thinksyou're going to be over 120.
So it keeps you within a tighter...
narrower range, presumably during your sleep time when there's nothing else affecting yourglucose.
(42:31):
And it does that, but when you're using that sleep mode feature, it will not also givecorrection boluses.
It only makes basal adjustments.
And I think that's a smart move because overnight, a lot of people are more sensitive totheir correction doses than they are during the day.
So that I think is a pretty useful feature.
(42:53):
And I'll be honest with you, I use sleep mode around the clock.
I don't just use it during my sleep hours.
I find it gives me tighter overall control.
A number of our patients do the same thing.
So it's another kind of a MacGyvering approach to management.
Yeah, 24-hour sleep mode is really good for patients who already have good control.
(43:15):
I tell patients, if you're not often projected to spike to a 180, those autoboluses aren'thelping you.
You're not getting them frequently or large enough for them to really do much.
Stay in sleep mode.
But also, if you are kind of erratic or unpredictable in your daily habits, like littlekids, like teenagers,
(43:37):
and you're finding those autoboluses are often making you go low.
Sleep mode is really good.
Toddlers, preschoolers, young school-aged kids who just have that thing of like justjumping up and running off and sleep mode does great.
It's counterintuitive because it's it's keeping them lower.
Won't they go low more?
(43:57):
It's aiming them at a lower target, but it's also getting more hypo protective and notautobolusing them.
So it helps things smooth out a lot.
the CGM options.
With Tandem's Control IQ, you've got the G6, the G7, both Dexcoms, but it also will workwith one of the newer Abbott sensors, Libre 2+.
(44:22):
It's gonna be switching to working with the 3+.
The Mobi right now just works with G6, G7.
It will soon work with the Abbott Libre 3 Plus, so there'll be multiple options.
And I do appreciate the way Tandem allows the user to pick their choice of sensor anddoesn't dictate it for them.
(44:47):
but not their choice of phone.
It's like, come on guys, you're on the right path.
Everybody can come to the party.
Android, like we need Android.
Yeah, right now it only works with the iPhones.
It's interesting when I work with Omnipod users, it's just the opposite.
(45:09):
Omnipod app at this point only works on the Android devices and not the iPhones, butthey're working to integrate it with the iPhones as well.
started their limited release with iPhone.
it's and Omnipod is a baby step ahead.
Tandem is really good.
They lead in these big software rollouts.
(45:30):
You know, they've got a lot of them under their belt and they're really good at them.
So they say they've got one coming in the next.
think it's supposed to be in the next couple of months for Mobi that is supposed to bringtheir features up.
Right now we're lacking the timer on the exercise feature, which I stayed in exercise modefor a solid two days because I didn't have it.
(45:54):
The timer on the suspend, which will stop our pump from vibrating off the docking charger.
And the expanded CGM range, as well as some beat changes and that the 200 high it takesus.
up to like a 220 and you have to be 220 for like an hour, hour and a half, something likethat before it goes off.
(46:15):
So that those things that X2 users have come to expect and enjoy are coming.
Hopefully two months doesn't turn into two quarters like it tends to do sometimes in thisfield.
But.
Between you and me and anyone listening, I am flabbergasted that the companies don't makea more concerted effort to launch with both iPhone and Android compatibility because they
(46:45):
cut their market in half, essentially.
It's like, okay, well, there's one feature here and you're going to lose half your marketif you don't have it.
You'd think they would make that more of a priority.
But, yeah, they seem to launch with just one or the other and make people wait.
I mean, they launch with one infusion set.
(47:06):
Yeah, or one one type of infusion scent.
set.
I'm surprised they don't launch with one insulin and one basal rate at this point.
If they've got it, they throw it out there like the company is on fire.
Yeah.
So I guess you and I are in a similar boat with the Mobi.
It's got a lot of nice qualities.
It's got some tremendous features.
(47:28):
The form factor is fantastic.
I guess there are really little things that could make it more livable, easier to use on aday-to-day basis.
I know the clicks.
It does click as it's delivering.
I know that bothers you.
I don't even notice it, but you notice it.
(47:48):
Gary, I'm gonna talk to your wife.
We'll get you scheduled with an audiologist because the thing is every now and again, it'sa little like wearing one of those like ACME time bombs.
It clicks.
I thought the Omnipod was loud until I wore this pump and I was like.
mini-med pump used to click.
(48:09):
Back in the 90s, those pumps had a solenoid motor that would click with every tenth of aunit delivery.
And it was louder than this.
bought a bunch of used ones and shoved them in the movie because wow, get some WD-40 onthis thing, guys.
Yeah, yeah.
All right.
So anyway, thanks.
(48:30):
We got to wrap it up because we're running out of time here.
But that's a wrap for today's episode of Think Like a Pancreas, the podcast.
Big thank you to Alicia Downs for joining me and sharing her insights about the new TandemMobi pump.
We hope you found today's chat helpful.
Maybe picked up a few creative ways for managing your diabetes a little better.
(48:53):
And as always, if you have questions, comments, or just want to share your ownexperiences, reach out to us at Integrated Diabetes Services.
We'd love to hear from you.
And until next time, remember to keep thinking like a pancreas, because let's face it,your pancreas isn't going to do it for you.
We've got to do the thinking for it.
Have a Great rest of the week.
I'm your host, Gary Scheiner, Owner and Clinical Director of Integrated Diabetes Services.
I'm happy to be joined by my friend, colleague, and fellow geek, if you will, AliciaDowns.
Alicia is the Director of Patient Care and Education here at Integrated Diabetes Services.
(00:54):
Alicia, it's always fun to have you on this program.
I like hanging out with you.
We get a chance today to talk about
the Mobi pump, Tandem's new Mobi insulin pump.
We love picking apart all the new technology and you and I both had a chance to startusing this a couple of weeks ago.
(01:17):
That was a fun experience getting started.
You remember the circumstances?
Yeah, nothing like starting a pump in a race in a poorly lit crowded Chinese restaurantsurrounded by Tandem reps trying to not shock them by our complete disregard for proper
(01:39):
training protocol.
That's right.
Yeah, we went to the, we went with our Tandem reps set us up with systems and we met atthe Chinese restaurant and you
doesn't even have a number next to the
(02:03):
It took me a little bit longer to get my app up and running, so you beat me.
But yeah, it was nice.
We had a good meal, nice conversation, and we walked out of there both on the Mobi.
And one of the things that's really neat with Tandem's Control IQ system, it ain't nolearning curve.
(02:24):
That algorithm kicks in and is fully functional the second you activate it.
So it was it was kicking that pad thai right right away getting getting full auto bolusinggetting all of you get its full feature Right out of box day one.
You don't have to like wait two weeks to see what can this thing really do?
(02:48):
There's no greater challenge to glucose management than pad thai.
It took me, I think, 6 or seven tries to kind of figure it out and it still challenges mesometimes.
That stuff is chock full of hearty carbohydrates, among other things.
Yeah, and was thinking like while we were doing that, I mean, and I think I had like friedrice and a steam bun and like General Tso's chicken.
(03:15):
So I did not go carb-light either.
And I actually thought to myself, could you imagine day one of any of the other hybridclosed loop systems eating this meal?
boy, that would have been, I mean, I'd have been.
plus 220 [mg/dL] for the rest of the night.
Like, it would have been 4 a.m.
(03:35):
before I got that back in range.
You and I have an interesting perspective to share on this.
You are usually a Tandem Control IQ user.
So you were familiar with how Control IQ, the algorithm operates, but the pump itself, theform factor, the physical pump itself was completely new to you.
(03:58):
Yeah.
So let's talk first about the pump.
I want to go through the pump, the user interface, the CGM and the algorithm in thatorder.
Let's talk about just the pump first.
What's your take on the form factor, the physical pump?
The physical pump itself, I really like for wearability, especially for me, because I havenever been able to be a patch pump user.
(04:30):
I can't wear the Omnipod because of a skin condition.
It causes me to get hives.
So I can't even make it two days on an Omnipod.
So it's just not worth it.
Like my blood sugars would always be crazy because I'd be changing pods every day.
So having a pump where I can change where the...
(04:51):
patch placement is so I can move where the pump itself is but leave my insulin alone andjust move that piece around or not even wear the big piece on my skin for a day if I need
to give my skin a break is a deal breaker for me that is what lets me now use patch pumpwhich has always been out of reach I've been a tube pump user since day one and then I
(05:14):
also like that it's not an all throw away
You know that we're not throwing away batteries and microchips every 3 days is reallythoughtful It's pretty comfortable.
I'm usually not a big fan of anything that has a corner or a like a 90 degree edge Indiabetes.
(05:35):
I'm like come on.
We wear these things on our body for 3 days Can we make them round and cozy and comfy thisdoes have more corners on it that I would like?
But in having warn it
I've never felt a corner poke or jab me anywhere.
So I'll take it.
It's and it is, it's tiny.
(05:57):
Like it's it's really unobtrusive.
It's as I think they've made it about as small as they can make it and cram in everythingthey need to cram in.
I and I love the bolus button.
Because the other thing that keeps me from wearing a patch pump is when I have used apatch pump, I lose my phone something chronic.
(06:19):
I am wearing an Apple Watch.
The feature I use the most is not even to look at my blood sugar.
It is the Find My Phone feature.
And so when I get to a restaurant and I can't bowl this because I don't have my phone withme, that will end.
That'll end the pump for me.
Or just walking around the house, like I'm ready to eat dinner and now I'm just marchingaround the house for 10 minutes trying to find my phone.
(06:46):
That's a deal breaker.
There's nothing worse than not being able to eat because you can't locate your phone.
mean, one might ask, well, how are the two connected?
Okay, well, need my phone to give my insulin so I can eat my food.
It's complicated.
And I discovered something about the bolus button,
you can do more than just enter units of insulin with it.
(07:08):
You can switch it to enter grams of carb.
So you can have it enter like 5 or 10 or 15 gram increments and it'll calculate your doseand deliver the right amount based on that.
So if you are out somewhere and you have a pad thai and you've got to enter a hundredgrams of carb, you can do it and it'll calculate an appropriate dose.
(07:31):
So if you don't happen to know your insulin to carb ratio is off the top of your head,
It'll do the math for you.
Isn't that sweet?
And you get your correction dose and everything because it's pulling your blood sugar fromthe Dexcom.
So you're getting all your info.
You're getting a regular bolus just like you would if you had your phone with you.
Yeah, yeah.
(07:51):
So the size of this device is fantastic.
It's similar, very similar in size to the Omnipod in terms of its dimensions.
It's tapered so it doesn't snag on things.
I was more impressed not by the size but the weight.
This thing weighs barely an ounce even when it's filled with insulin.
(08:14):
It is feather light.
And because of that, the adhesive holds it to the skin very nicely.
It doesn't take much because of the weight.
The Omnipod weighs considerably.
more because it has those metal components and batteries and things that that add weightto it.
This thing feels like there can't be much more than just plastic components in here andmaybe one tiny computer chip.
(08:40):
That's really all that it needs.
So the weight to me makes it an enormous difference.
Yeah, and that's where I'm wearing, I, because it's so light, I honestly forget that I'mwearing it or where I'm wearing it.
Where the Omnipod, I do, I kind of feel that little kind of pull down on my skin.
(09:05):
Like I can kind of feel gravity, kind of.
on it.
That might be part of why my skin doesn't get as irritated with the Mobi as it does withthe Omnipod.
But yeah, it's significantly just tiny.
It feels tinier on my body.
Like it's kind of not there.
(09:25):
this type of small form factor gives users the opportunity to wear it directly on theirskin in a little sleeve or using double-sided tape.
And you and I have both tried the tape that comes with the Eversense sensors, because thetransmitter has to stick to the skin.
(09:46):
And we both found this works really nicely.
But Tandem provides these sleeves.
little bit of adhesive on them to keep the pump in place and locked in place.
And I tested it out.
I ran full court basketball two days in a row and you know I sweat anyway and this thingheld on great.
(10:07):
It really stuck well.
I think it's because of the the light weight of the pump.
So users can wear the pump directly on their skin and then use the 5 inch tube and havethe infusion site right next to where the pump adheres.
But you can also use the traditional longer tubing and either put the pump in a pocket,clip it on an undergarment or clip it to your waistband or your belt.
(10:36):
Again, because it's so light, you don't even notice it's there.
and I found the clip is cute, it's this tiny little clip and it's pretty strong as well soit holds onto the belt really nicely.
Aside from those things, having a pump this size, there are some drawbacks to that.
(10:58):
What are some of the issues created by having a pump this small?
For me, it's so...
It's been so weird because everything's so tiny and I can put it anywhere, which meansthat now I don't see my diabetes world.
(11:19):
So I've gotten on one side this amazing thing of like out of sight, out of mind.
Isn't that like amazing?
Like I don't even think about being a person with diabetes.
On the other side, out of sight, out of mind.
I'm not even thinking about my diabetes.
Like I sit down and I'm like 3 bites into a meal and I'm like, my gosh, I have type 1diabetes.
(11:43):
I have to take my insulin.
I have missed more boluses.
My pre-bolusing has gone from like pre-bolusing every meal and pre-bolusing like a champto like...
I'm lucky if I pre-bolus at all.
I finally this week got it into my head.
Like I started using the pump button to pre-bolus because I'm not like cooking dinner withmy phone in my hand.
(12:09):
And without some sort of tactile thing to remind me like, hey doofus, you have to takeinsulin.
I was just forgetting to do it.
It was like being on shots all over again.
It was like it was in another room so I wasn't thinking about it.
I had to start wearing
Apple Watch to remind me to look at my blood sugar because I'm just so used to having mypump on my hip and that reminds me to look down at my blood sugar without that physical
(12:36):
tactile reminder.
So it's a double-edged sword, the convenience and this out of sight, out of mind is a nicething when you got diabetes because we're thinking about blood sugars so much.
But also it is helpful to have those reminders so we don't forget to do our boluses, wedon't forget to check our glucose, et cetera.
(12:58):
The physical size of this has, you one limitation is the size of the insulin reservoir.
It only holds 200 units before priming, which works well for most people, but there'sstill a lot of folks who go through
more than 60, 70 units a day and you're in that category.
(13:19):
I am and so you know I'm a rule breaker by nature.
So, FDA and Tandem, plug your ears.
I use U200 insulin because I'm a high volume insulin user.
I find U200, my insulin just absorbs better in general and it lets me use patch pumps.
Without U200, patch pumps are out of reach for me.
(13:42):
So that's the work around that I immediately reach for.
I as long as people know what they're doing and realize they're using double concentratedinsulin.
Yeah, I've got some patients also doing that and it works fine.
The other issue is with the infusion sets.
If you like the 5 inch tube and want to wear the pump on your skin, you're a bit limitedin terms of which infusion sets you have access to.
(14:07):
So tell us about that.
Yeah, so that's true for me as well.
I'm not a big fan of the 90 degree sets.
I get a lot of set kinks and I find they're just not comfortable a lot of the time.
They'll hit muscle or things like that for me.
So I like the angled sets.
(14:28):
Tandem says, yeah, we're in the works and we're gonna, you know, we're gonna increase.
We always know when a company says it's in the works, that means don't hold your breath.
And they've got their capillary bio extended wear set in development.
So it doesn't take a genius to go, it would be kind of silly of them to develop a wholeline of 5 inch tubing in their current sets and then turn around and then do this whole
(14:54):
development with their new extended wear sets.
That sounds like just
resource waste to me, so we're probably going to be a while.
So what I've been doing is with my angled sets, I mean, I usually use like 43 inch tubingso that I can wrap my tube around and stick it wherever I need to stick the pump to hide
it.
(15:14):
So I take that extra tubing and I just loop it into a little coil and throw a little pieceof tape on it.
And the little pouch you were showing with the pump, I just take that extra tubing and Ituck it in that little pouch.
with the pump and then take that little adhesive tab and tape it all in there so I don'thave my tubing hanging out everywhere.
(15:36):
I am going to MacGyver diabetes.
If I can't, I'm never gonna be able to do diabetes through exercise, proper eating, andbeing a good person.
That's never gonna happen.
So I better just MacGyver this thing together.
Definitely outside the box thinking you got it got to be that way when you live withdiabetes Okay, so and the pump also requires charging unlike the t-slim pump where you
(16:05):
plug in to charge it, you know, know the tube, you know The cable to plug it has differentlengths this you have to sit the pump on a little docking station to charge it So if
you're using the short tube or you're using a MacGyvered short tube
out of long tubing, you've really got to disconnect in order to charge it.
(16:25):
It's just not logistically possible to charge it otherwise, which can be a little bitinconvenient.
It takes about 15-20 minutes to charge up completely.
So during the time it's charging, has to be sitting on that docker that's plugged into anoutlet.
And you found another interesting little issue while it's charging where it may actuallycome to life and start to move.
(16:52):
Tell us about that.
Yeah, so I hate the charging probably.
There are two things I hate about this pump, like a lot, and the charging is one of them.
So there are two ways, if you're gonna take the pump off your body, you have to do one oftwo things.
You either have to suspend insulin.
(17:13):
The current app,
it's kind of a step behind the X2 software right now.
So it doesn't have a timer on the suspend.
So it just after 15 minutes starts buzzing and in my case, vibrating, which is great whenyou're wearing it, but not so great when you've got it on a little docking station that
(17:36):
has no magnet that has no way of attaching it.
So I'm leaving it on the charger and I'm like,
and I'm watching the app to see when it gets up to a good charge and it's not getting past40%.
And I'm like, why?
And I go into the next room and it has vibrated itself off of its little charging dockerbecause of the alerts.
(17:57):
And I also, if you have a low insulin alert or any kind of alert, it's just off.
And I was like, are you?
So I'm like, get back over here.
And I put it back on.
I was like.
You know what that reminds me of?
And I was a kid, this is back in the 70s.
I had this tabletop electronic football game that you plugged in.
Yeah,
(18:18):
the field would vibrate and it would move the players kind of randomly.
So that's what the pump does when it's sitting on the charger.
And I hate that, because I mean you say you like you probably because of tubing you haveto take it off you have to take it off because the I mean if you put that thing on an
uneven shelf the pumps gonna just slide it right off I can't imagine a world I mean maybeif you duct taped them together or something
(18:43):
will come up with a better charging option at some point.
And I give Tandem credit.
They update their systems pretty regularly and pretty rapidly.
With other companies, it usually takes at least a few years for any updates to come out.
And Tandem seems to generate these within the year in most cases.
(19:04):
They're able to move through the process pretty quickly.
Medtronic, are like Toyota.
know, they're actually, more like Honda.
Like they've got a million different models, plus like chainsaws and 4 wheelers andlawnmowers and like whatever else they're making out there.
(19:24):
So when we say, this thing is a pain in my butt, whatever.
It's like me complaining to Toyota about my cup holders.
Shut up, we don't care.
But when we go to Tesla and we're like, hey Tesla, we don't like where you put your cupholders.
They're like, where would you like your cup holders?
And what color would you like them to be?
(19:45):
And how deep should the cup holder be?
Like they're taking notes, because this is all they make.
I am a significant portion of their market share.
So when we go to Tandem and we're like, hey Tandem, change your product.
They're like, really, what's wrong with it?
Because this is their only product.
This is all of their eggs in one basket.
So they are more attentive and they jump on it when they see a flaw.
(20:08):
An area I wish they had been a little more attentive in designing the product is some ofthe user interface features in the app for Mobi.
I'm the type who likes as little inconvenience as possible when I'm programming and usingmy pump.
(20:29):
And I've been a little turned off by the number of button pushes.
There's so many confirmation steps I found with any programming at all.
First off, it requires you to have the unlock feature on your phone turned on.
So you have to enter either a 4 or 6 character code or use your face recognition in orderto unlock your phone.
(20:51):
You have to do the same thing to unlock the programming on the the Mobi app, and again, toconfirm delivery.
There's just so many, I find there's just a lot of button pushes.
And likewise, it has these confirmation beeps or vibrates that the pump provides.
Every single time you activate something, program something, deliver something, I justfind it a little bit annoying.
(21:19):
I know there's a trade off here between convenience and I guess what someone there callssafety.
But what are your thoughts about that?
Do you feel this is really providing an extra layer of safety that we need, or is it justthe FDA sticking their noses where they didn't belong and forcing the company to do this
sort of thing?
(21:40):
Yeah, I think, I mean, the initial opening of the app, I mean, that's already covered byopening your phone.
And then having it again as part of you've already got, I would like the bolus.
Yes, I confirm the amount.
(22:02):
Yes, I confirm the amount.
then.
adding just another 4th confirmation that in your case requires then a multi-digit code.
It's too far.
I can see them requiring that I have the lock feature on my phone.
That makes sense.
I can see them saying like, no, we require that you make sure that your toddler can't justpick it up and do dot, dot, dot, dot, and kill you while you're napping.
(22:30):
okay, that's a logical safety feature to protect the customer.
But to then say, no, we now require that you have a safety feature to deliver insulin orchange your profile or suspend insulin or, well, that's not in any other pump.
That's not in my X2.
That's the security pin feature.
(22:53):
And I should be able to turn that off just like I can on the X2.
So that's a step too far.
All of the vibration, you can't opt out of the vibrate / beep.
like bolus confirmation.
You want to add insult to injury?
When you get a notification, you have to get either a buzz or a beep.
(23:17):
And then when you swipe to acknowledge to turn it off, you get a buzz or a beep that youturned off the buzz or beep like.
Get it again, yeah.
That is that's a kick
also redundancy with the alarms.
I use a Dexcom and it provides me all the alarms and alerts I need and then some.
(23:42):
And with this pump, yes, you can turn off certain high and low alerts, but if thealgorithm
predicts a high or predicts a low, there's no way to prevent those alarms from happening.
So I'm getting redundant alarms from both my Dexcom and from the Mobi app.
(24:02):
So I've got to go into two places to shut them off.
As an X2 user, I had forgotten how annoying the Control IQ High 200 Alert was because theycame out with an update, gosh, 6 - 8 months ago that eliminated that.
And my world has been just a beep- free nirvana since that happened.
(24:26):
Not to humble brag about blood sugar control, but boy, the alert fatigue that eased off mybrain after they did that alert was monumental.
And now it's back.
the the beeps and vibrates aside, it is really nice being able to program everything aboutmy pump through my phone.
(24:47):
It's the screen's big.
You know, can you can get where you want easily.
The layout is pretty well done.
That part I like.
And as someone who used to use the Loop app and I use my phone for everything there, too,it was an easy transition.
It definitely is convenient.
And like you said though, if you wanted a bolus without the phone, you can do it just byentering carbs using the single button on the pump itself.
(25:14):
So that is pretty nice.
You have anything you particularly like or dislike about the app itself, the userinterface on the app?
I really don't like the setting.
I don't like that things don't default to things.
the last time I went into the settings menu, I was doing something with CGM alerts.
(25:40):
So now when I hit settings, it goes straight to CGM alerts.
Yeah.
Which I, as a person who has been playing with the app for a while and am not afraid tojust push buttons until I find what I need, will just go, right, so if I just keep hitting
settings, then I get back to this and I can find...
(26:00):
But like, I think about my mom, who like, when she uses the remote control, if she hits abutton and it doesn't do what she wants to, she's like, help!
Like it's gonna suddenly set off a nuclear warhead, right?
And then now this is attached to insulin.
So she's gotten a screen she doesn't expect.
She's just going to stop pushing buttons immediately.
I've talked to the folks at Tandem about this, anytime the app times out, it should goright back to the dashboard.
(26:25):
You should be right at your, and the dashboard on this thing is nice on the app.
It shows you all kinds of graphs of what adjustments have been made, your sensor data,your boluses, all of the status of everything going on.
It even gives you some stats, quick stats on how you've been doing with your glucosecontrol recently.
It really needs to just default to that and from there you go to your main programmingicons at the bottom.
(26:51):
But instead, like you said, it defaults when you open the app up again.
It defaults to the previous menu you were on, which is often the notifications screenwhere you shut off an alert.
So yeah, that's not what you want to do most of the time.
You want to bolus typically when you're going into your app.
Let's get to the algorithm because this is often what differentiates one AID system fromanother.
(27:18):
I mentioned right from the get-go, I love the fact that there is no learning curve.
The app doesn't need to learn about how much insulin you use and come up with its ownsettings.
It uses your settings, your basal rates, your correction factors, your carb ratios.
(27:38):
That's what it uses as its starting point.
What's the advantage of that as opposed to the app trying to learn your needs and figurethem out on its own?
Me?
Everything.
Absolutely everything.
Because my insulin world changes significantly based on my metabolism.
(28:03):
There are hormones.
I use a significantly larger amount of insulin during PMS.
I know that.
I've tested it.
I've found it to be true.
And with Tandem, I can just set up a profile
with those settings that I know work during that time and I can just say, it's the daythat I'm gonna run higher.
(28:26):
Let me put on that profile.
Boom, immediately I'm getting the insulin that I need.
And those two days, you can't tell are different from my blood sugars.
With any of the other AID systems, FDA approved AID systems, it's going to take them 3days to make at least.
(28:47):
or more to make any adjustment to significantly affect those days.
And by then those days are over.
So my blood sugars are going to run higher.
And then when that's over, well, now guess what?
Now my period's done.
Guess what happens at the end of my period?
I'm significantly more sensitive.
(29:10):
So I need less insulin.
On the Tandem, can bada boom, change that profile again.
And you don't have to program a new profile every time.
You can store them in there.
all stored.
can have, think, nine different profiles stored in the pump ready to go named, you know,each name for what I use them.
Is it?
(29:31):
I thought it I never get above.
I've gotten like 5 at a time and then I'm like, I need to clean houses.
a lot.
Yeah, that even then I've got a clean house.
What am I doing?
I usually I usually recommend 3.
Most people can do the normal- high- low- and that's enough for most people unless they'vegot like shift work or something weird going on in their life or like weekends.
(29:52):
With with any of the other systems, they've cranked up my insulin for those high days andnow they're running on assuming I need more insulin and here comes that low day.
Yeah, and it doesn't respond immediately.
Yeah, I've got a profile I created for days where I'm sitting all day, because if I'm inmeetings, traveling, things like that, I need more insulin because I'm just not moving
(30:14):
around as much.
And I don't want to wait, like you said, days for the system to react to that andrecognize it.
I want to be able to tell it that.
So in a way, the Mobi and the T-Slim, they let the user
use their skill set.
The other systems don't give the user that opportunity.
Now, some people prefer not being involved.
(30:38):
They just want to sit back, not think about their diabetes and let this thing figure itout.
But ultimately, their control can be better if they're involved and engaged in theday-to-day management.
The one aspect I find particularly nice in terms of using the user's settings as thestarting point,
is the basal program.
(30:59):
Is there anybody who has a dawn phenomenon where the glucose starts to rise in the earlymorning?
If they're using another AID system that has a flat 24-hour profile and then adjusts whenyou start to rise or fall, you rise or fall.
if the system uses your basal rates, you can prevent the rise or fall in the first place.
(31:24):
With young people, there's often a growth phenomenon in the evening.
They make growth hormone towards the late evening hours and kids' blood sugars on theseother systems start to shoot up around bedtime and there's nothing you can do about it
unless you bolus in advance, guessing that it's gonna happen.
But with the Tandem option, using your basal rates, you can prevent that rise.
(31:48):
So I just, like being able to use.
A very basal program that you're used to using and no works.
As opposed to a flat background profile that the other systems go with.
Like you said, Gary, you can do something about it.
Just That empowerment of knowing I can do something about it is huge when you're livingwith diabetes.
(32:12):
There's nothing worse than having a problem and not having a tool.
I mean, that's what an insulin pump is.
It's a tool.
It's our highest level tool.
And so for that tool to have an edge ground down so you don't get to use it anymore.
is counterproductive.
Like give me all the edges and then let me decide which ones to use and which ones to notuse.
(32:35):
But don't grind one off.
it takes an educated user and a clinician who can guide them properly to take advantage ofthat.
And that is the other thing that I really like about Tandem Systems over the other FDAapproved AID is that as a clinician, Tandem has so far been the only company to step out
(33:01):
and say everything about your insulin, your data, and how you're getting it is yourinformation.
Their algorithm is public published information.
You want to look it up and go build one in your garage?
Have at it.
You can go for it.
You want to take your data and see on your app in real time exactly how much insulinyou've gotten 24 hours a day.
(33:30):
Go for it.
It's right there at your fingertips as a clinician.
If I want to see what Control IQ is done and use that to retrospectively build your basalmodel, I can do that with all of the other FDA approved systems.
They consider my insulin data, how I'm getting insulin, and what they're doing with mybody, their proprietary data.
(33:59):
And even the algorithm is secret sauce to the other companies.
Tandem, they publish handouts explaining exactly how the algorithm functions.
It's a 30-minute predictive algorithm.
It's looking at where it expects you to be in 30 minutes based on your current glucosevalue and the direction it's headed, the rate of change.
(34:22):
If it thinks you're going to be above 160, it's going to bump up your basal.
If it thinks you're going to be above 180, it'll administer a small correction bolus.
And if it thinks you're going to be below, and I love this number, 112.5, I picture theboardroom when they decided this.
They're arguing 110, no 115.
(34:43):
And they decide, we'll split it down the middle.
So if you're going to be under 112.5.
the pump, it just says 110.
Yeah, well 110 is what it uses for corrections.
If it's doing a correction bolus, it aims for the 110.
The basal algorithm uses 112.5.
So if you're be under that, it starts backing off a little on the basal.
And if it thinks you're gonna be under 70, it shuts it off.
(35:06):
And the automatic correction boluses that it delivers, and it'll do those up to once anhour, those are a little, they're about,
a little more than half of what a normal correction would be because the system is alsoraising basal at the time.
And the magnitude of the adjustments are directly related to the correction factors thatthe user has set.
(35:32):
So that there is complete transparency from Tandem about how their algorithm works.
And it shows on the reports and even on the user's screen, right on the...
right on that homepage, it shows the exact adjustments that are being made.
And as clinicians, what do you look for?
(35:53):
How would you use that kind of information in fine tuning a patient's program?
So with Control IQ, I look for things like, are we seeing suspends after every meal?
Okay, your correction rate or your carb ratio is probably a little over aggressive versusare we seeing autoboluses after every meal?
(36:14):
Okay, then it's a little weak.
We can get in there and we can get the sense of settings doing a little more so the systemdoesn't have to be constantly taking on that burden versus when we are seeing suspending
and we should be seeing kind of 15, 20 minute little blips that are just kind ofself-corrections for the little DEXCOM wobbles and biological wobbles of the day.
(36:37):
We shouldn't be seeing these big half hour to an hour long suspend chunks.
That's a sign that settings are just overly aggressive.
We're just getting too much insulin through our day in those areas.
Likewise ramp ups.
We want to see our system at rest really resting on pretty much programmed basal, which isrepresented by just a solid light blue bar.
(36:59):
If we're seeing those spike ups, the ones that look kind of like a city skyscraper,skyline, we're seeing a lot of those in particular.
if they're pretty large.
Again, the system's doing a lot of work.
And then we look over time.
So if it's got that same pattern over time.
All right, we just need to shift the programming there to make it so that it can just reston what we've programmed and now let the system flourish from there because otherwise the
(37:30):
program is working on just getting Alicia right instead of dealing with like the Chinesefood that she had for lunch and her lack of pre-bolus because she didn't have her phone.
at data in that way.
We can optimize not only the patient's settings, but hone their own skills.
(37:51):
And that helps prevent the rises and falls.
It's not about just wait for the algorithm to fix things, because that's what some systemsand some people prefer, let the algorithm fix it.
But for those who really want to spend as much time in range as possible, we want tooptimize those settings and want their skills as far as carb counting and exercise
(38:13):
adjustment, et cetera, to be in place.
And speaking of exercise adjustment, there are two
I guess we call them overrides that the user can use.
Tell us about those.
Well, we have the activity feature, which has a picture of a little running guy.
I always tell patients, when you look at it, don't see a running guy.
(38:36):
It should really be a picture of somebody like pushing a grocery cart.
Because that's a much more accurate representation of what it's capable of.
I don't know who is capable of actually exercising and staying in range with that activityfeature, because it ain't me.
Unless I'm doing like lifting, if I'm doing anaerobic,
Cool.
That's great.
(38:56):
The system's great for anaerobic workouts.
My martial arts workouts, my lifting workouts are fantastic.
It keeps me in range because I don't have to push any buttons.
But yeah.
no, chasing my son down tanks my blood [sugar] unless I'm angry at him.
If I'm angry, audible is audible is audible.
If there's some stress involved, I'm good.
(39:19):
But yeah, so we've got a few kind of levels of tools.
We've got Control IQ itself, which is pretty good.
It just kind of the recreational day to day.
Like if I'm just kind of off on a little strolly stroll, it's a pretty good, if I'm to geta little bit more than that, like I'm going to be doing, if I'm going to do shopping, if
I'm going to be doing like, like housework around the house, but something that's going tobe kind of focused and a little longer duration in time, that activity feature is pretty
(39:47):
decent.
I always equate it to about maybe a
30 % reduction in basal.
It's going to be kind of like an old school 10 basal reduction of about 30%.
But anything more than that, anything where we're getting up to like a 50 % reduction in10 basal, like a real like aerobic workout, getting it done, doing yard work kind of a
thing.
Yeah, I usually.
(40:09):
for that.
You'll go to a lower profile.
can switch a profile or I can just cut and run.
I just turn Control IQ off, go old school, temp-basal down, do what I know has worked forthe last 15 years and...
Yeah.
Now, I have to tell patients, if you're gonna carb up, turn Control IQ off.
(40:32):
Because if you don't, if you've got Control IQ on and you eat a handful of gummy bearsbecause you're gonna go mow that front acre of lawn,
and your blood sugar starts to jump, Control IQ is gonna go, I can help, and it's gonnathrow insulin at it, and now you're gonna tank in the middle of the front lawn.
So anytime you're gonna push your blood sugar up on purpose, you have to get Control IQout of the way first.
(40:55):
You have to turn that thing off first.
and I think all the systems have some kind of exercise feature, it simply makes thealgorithm less aggressive.
It's accepting higher, little higher readings.
It doesn't fix things unless they're really high.
And even if you're approaching, approaching a low range, it's shutting the basal back.
(41:16):
So it just makes it safer.
from that like 112 to 160 and bumps it up to 140 to 180, which is essentially like a 40point bump in blood sugar.
But I mean, aerobic exercise does not drop my blood sugar 40 points.
It drops it like 120 points.
so, and you also have, you have to set that in advance.
(41:39):
So you have to think ahead.
Especially if you're just doing the online training.
The online training is like, Tim's gonna exercise.
He should turn on his exercise feature.
And the guy's like standing outside the gym and he's like, boop, and then he walks intothe gym.
And it's like, and now Tim dies of hypoglycemia in the gym.
Yeah.
The other override feature, which I make liberal use of is called sleep mode.
(42:06):
Sleep mode does just the opposite of exercise mode.
It makes the algorithm a little more aggressive.
Instead of waiting till you're going to be over 160, it'll start correcting if it thinksyou're going to be over 120.
So it keeps you within a tighter...
narrower range, presumably during your sleep time when there's nothing else affecting yourglucose.
(42:31):
And it does that, but when you're using that sleep mode feature, it will not also givecorrection boluses.
It only makes basal adjustments.
And I think that's a smart move because overnight, a lot of people are more sensitive totheir correction doses than they are during the day.
So that I think is a pretty useful feature.
(42:53):
And I'll be honest with you, I use sleep mode around the clock.
I don't just use it during my sleep hours.
I find it gives me tighter overall control.
A number of our patients do the same thing.
So it's another kind of a MacGyvering approach to management.
Yeah, 24-hour sleep mode is really good for patients who already have good control.
(43:15):
I tell patients, if you're not often projected to spike to a 180, those autoboluses aren'thelping you.
You're not getting them frequently or large enough for them to really do much.
Stay in sleep mode.
But also, if you are kind of erratic or unpredictable in your daily habits, like littlekids, like teenagers,
(43:37):
and you're finding those autoboluses are often making you go low.
Sleep mode is really good.
Toddlers, preschoolers, young school-aged kids who just have that thing of like justjumping up and running off and sleep mode does great.
It's counterintuitive because it's it's keeping them lower.
Won't they go low more?
(43:57):
It's aiming them at a lower target, but it's also getting more hypo protective and notautobolusing them.
So it helps things smooth out a lot.
the CGM options.
With Tandem's Control IQ, you've got the G6, the G7, both Dexcoms, but it also will workwith one of the newer Abbott sensors, Libre 2+.
(44:22):
It's gonna be switching to working with the 3+.
The Mobi right now just works with G6, G7.
It will soon work with the Abbott Libre 3 Plus, so there'll be multiple options.
And I do appreciate the way Tandem allows the user to pick their choice of sensor anddoesn't dictate it for them.
(44:47):
but not their choice of phone.
It's like, come on guys, you're on the right path.
Everybody can come to the party.
Android, like we need Android.
Yeah, right now it only works with the iPhones.
It's interesting when I work with Omnipod users, it's just the opposite.
(45:09):
Omnipod app at this point only works on the Android devices and not the iPhones, butthey're working to integrate it with the iPhones as well.
started their limited release with iPhone.
it's and Omnipod is a baby step ahead.
Tandem is really good.
They lead in these big software rollouts.
(45:30):
You know, they've got a lot of them under their belt and they're really good at them.
So they say they've got one coming in the next.
think it's supposed to be in the next couple of months for Mobi that is supposed to bringtheir features up.
Right now we're lacking the timer on the exercise feature, which I stayed in exercise modefor a solid two days because I didn't have it.
(45:54):
The timer on the suspend, which will stop our pump from vibrating off the docking charger.
And the expanded CGM range, as well as some beat changes and that the 200 high it takesus.
up to like a 220 and you have to be 220 for like an hour, hour and a half, something likethat before it goes off.
(46:15):
So that those things that X2 users have come to expect and enjoy are coming.
Hopefully two months doesn't turn into two quarters like it tends to do sometimes in thisfield.
But.
Between you and me and anyone listening, I am flabbergasted that the companies don't makea more concerted effort to launch with both iPhone and Android compatibility because they
(46:45):
cut their market in half, essentially.
It's like, okay, well, there's one feature here and you're going to lose half your marketif you don't have it.
You'd think they would make that more of a priority.
But, yeah, they seem to launch with just one or the other and make people wait.
I mean, they launch with one infusion set.
(47:06):
Yeah, or one one type of infusion scent.
set.
I'm surprised they don't launch with one insulin and one basal rate at this point.
If they've got it, they throw it out there like the company is on fire.
Yeah.
So I guess you and I are in a similar boat with the Mobi.
It's got a lot of nice qualities.
It's got some tremendous features.
(47:28):
The form factor is fantastic.
I guess there are really little things that could make it more livable, easier to use on aday-to-day basis.
I know the clicks.
It does click as it's delivering.
I know that bothers you.
I don't even notice it, but you notice it.
(47:48):
Gary, I'm gonna talk to your wife.
We'll get you scheduled with an audiologist because the thing is every now and again, it'sa little like wearing one of those like ACME time bombs.
It clicks.
I thought the Omnipod was loud until I wore this pump and I was like.
mini-med pump used to click.
(48:09):
Back in the 90s, those pumps had a solenoid motor that would click with every tenth of aunit delivery.
And it was louder than this.
bought a bunch of used ones and shoved them in the movie because wow, get some WD-40 onthis thing, guys.
Yeah, yeah.
All right.
So anyway, thanks.
(48:30):
We got to wrap it up because we're running out of time here.
But that's a wrap for today's episode of Think Like a Pancreas, the podcast.
Big thank you to Alicia Downs for joining me and sharing her insights about the new TandemMobi pump.
We hope you found today's chat helpful.
Maybe picked up a few creative ways for managing your diabetes a little better.
(48:53):
And as always, if you have questions, comments, or just want to share your ownexperiences, reach out to us at Integrated Diabetes Services.
We'd love to hear from you.
And until next time, remember to keep thinking like a pancreas, because let's face it,your pancreas isn't going to do it for you.
We've got to do the thinking for it.
Have a Great rest of the week.
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