How would diabetes tech help those who face diabetes struggles?

[MeiChanski]

Hello friends,

If we could put NICE guidelines and criterias to one side, what if we could all get those shiny pumps and CGMs, would it help those who are struggling?
I know there are those out there who rarely test, carb count, or inject insulin, do you think it'll help them get back into managing their condition? or not really because they'll face as much struggles on a pump than MDI? or it doesn't solve the core issue of diabetes burn out? or do you think some of us have some misconceptions that a pump and CGM means you won't have to do anything because "it does it all for you"? I know the point of libre sensors, CGMs and pumps is make our lives easier to some extent but we still have to put effort in. However do you think showing them the guidelines and criterias will make them reconsider diabetes teach or could they argue and put a case forward for one?

Let me hear some of your thoughts.

 

[DCUKMod]

Hello friends,

If we could NICE guidelines and criterias to one side, what if we could all get those shiny pumps and CGMs, would it help those who are struggling?
I know there are those out there who rarely test, carb count, or inject insulin, do you think it'll help them get back into managing their condition? or not really because they'll face as much struggles on a pump than MDI? or it doesn't solve the core issue of diabetes burn out? or do you think some of us have some misconceptions that a pump and CGM means you won't have to do anything because "it does it all for you"? I know the point of libre sensors, CGMs and pumps is make our lives easier to some extent but we still have to put effort in. However do you think showing them the guidelines and criterias will make them reconsider diabetes teach or could they argue and put a case forward for one?

Let me hear some of your thoughts.

MeiChanski, obviously as a T2, I have no skin in this specific game, however, my observation of how people embrace or reject their diabetes and all the paraphernalia that goes with it, tells me there is no one size fits all.

Some hate the prospect of being attached to a pump, never mind pump + CGM or whatever. Some love the idea the tech "just does it all", only to find that's not quite the case.

I don't believe it is any HCP's job to be a "salesperson" for physical goods, but they do have a part to play in terms of how tech is introduced, or trialled, and it is certainly their role to manage expectations. For instance, I have heard of several people having a trial of the Libre, with the DSN attaching the sensor and then being told to go and use it for a couple of weeks, without any further explanation than that they wave their reader in order for a reading to be registered.

In my view, a lot of these things come down to education (of those living with diabetes, parents or carers for the young or those needing extra support, but also of the HCPs in specialist clinics) and choice.

Allowing individuals to choose the direction their management takes is likely to be more readily taken up that strictly prescriptive, instructed approaches. If change isn't owned, it tends not to last.

However, as I say, I have no skin in the game.

 

[Diakat]

Surely burn out is a separate issue from the tech? We could all have all the kit and still feel unable to deal with it or act on the info.
If we did live in a magic world where we all had the kit then education and support on what to do with the feedback would be the main thing. What does this graph show me, how can I change things?

 

[ert]

My understanding from DAFNE is that the tech isn't a closed loop, so a pump is just a delivery system. The same as MDI. As for the CGM, you still have to calibrate and check blood sugars daily. If you're in a bad place, you're unlikely to want to do either.

 

[himtoo]

My understanding from DAFNE is that the tech isn't a closed loop, so a pump is just a delivery system. The same as MDI. As for the CGM, you still have to calibrate and check blood sugars daily. If you're in a bad place, you're unlikely to want to do either.

actually there is the Medtronic 670g which combined with CGM is indeed a closed loop system
here is an article on the subject https://www.diabetes.co.uk/news/2019/mar/medtronic's-closed-loop-minimed-670g-now-available-on-nhs-in-some-areas-99233687.html

the user still has to manually bolus for food but the pump adjusts the basal insulin automatically corresponding to what the users BG is doing according to the CGM

 

[porl69]

Technology as good as it is still needs a LOT of effort from the user.
With a pump you have to me more accurate in your carb counting due to the smaller amounts of insulin it can deliver. And also the adjustments to your basal profiles you can set up for differing times of the day and exercise etc.

@himtoo I see a lot of people are turning off Automode on the 670G due to the issues they are having with higher BGs. Trying to find where I actually seen that!!

 

[NicoleC1971]

Great thread!
IMO I think part of the reason that the pump tech is rationed is that whist it is a great tool for motivated patients to tweak their insulin delivery the outcomes (HBA1C) don't show much advantage over MDI and it costs a lot more (will find that research).
However now that we have flash glucose monitoring it is possible that the outcome measures will change from HBA1c plus hypo management only to Time in Range and the fine tuning of a basal rate allowed by the pump would really come into its own with regards to basal rates being adjusted. hour by hour.
As for boluses, if you can't time your bolus and count carbs consistently then the pump is of no benefit; I have a lovely steady graph when I don't eat but it all goes wrong when I eat even low carb!
In short I think the closed loop systems will benefit the burnt out with much less work on their part. It should be noted that those teenagers who are 'non compliant' are in danger of ketoacidosis or uncontrolled hypos but do have a little bit of time to sort themselves out before major damage occurs to their vessels (see Ken Sikaris - Aussie pathologist on this topic)>

 

[MeiChanski]

Hello friends,

It's been on my mind a few times, I'm quite partial when it comes to diabetes tech because there are different flavours of diabetes burn out. But the most common one being - not testing, not attending appointments, not injecting insulin and not carb counting. I know it is a separate issue but I feel some have this idea that the pump and CGM will help them but I feel diabetes burn out is much deeper than that. I feel they wouldn't get the full benefit of the kit if the root cause of diabetes burn out isn't solved. Like your mental state has to be okay in some way before dealing with the frustrations of a pump. If someone is struggling to inject, a pump wouldn't help. If someone is struggling to test, or tests once a day which is better than nothing then they're at a risk of DKA if the pump isn't working properly. However if they're trying to get a better understanding of their condition and they're doing everything from testing to carb counting, then sure let them have at it. I also feel education is again very important, so you don't go off abusing the pump and using the pump properly.
I guess we could say it can go either way - either help them or it can go badly.

 

[EllieM]

I've turned down a pump in the past. For me, periods of good control have always coincided with periods of more frequent blood tests. And I've definitely had times when I struggled. The brief period (8 months) when the libre worked for me was life changing and glorious, it was the easiest control of my life. But in retrospect, I had too many hypos, and risked loss of hypo awareness.

I'm actually going to argue that diabetes education is the most important thing for me. On 49 years of T1, it was only a couple of years ago that an NZ DN told me my carb ratios and correction ratios, I'd winged it (fairly successfully) up to then, though I did carb count (maybe not that accurately ). And my hba1cs are definitely lower now, as low as I can dare to go without losing hypo awareness or getting a cgm that works (libre are sending me a free sensor after the one I'm currently using (after a 6 month break from the last one that also did not work) decided that any blood sugar less than 6 was going to read as LO and its readings up to about 6 can be anything between 2 and 6 under my true level. It's not totally useless, so I'm leaving it on, but I'm not expecting the next sensor to be any better).

I can sort of understand why people get burnt out. You know your levels aren't good, you fear going to the diabetic appointment to be told how bad they are, you fear even doing the blood tests because of how bad you think they may be, and you get into a vicious circle of avoidance and denial. (Funnily enough, I missed going to the dentist for about 4 years in a similar mindset, and the relief when I finally went, and had a whole lot of fillings, was enormous. It was bad, but not as bad as I'd feared.) But I can't see that someone who's struggling to carb count, test or even do injections is going to be a suitable candidate for a pump. Cgms are wonderful and glorious though, (if they work), I think you should give them to many many more T1s.

So flash tech probably isn't going to help if you're in a depressed state and just want it all to go away. (And let's face it, we all want T1 to go away.) I don't think I would ever trust a closed loop system, I would be too afraid of either an insulin overdose or an accidental disconnection and a DKA. But maybe when the tech is more mature? (Yes, I'm too much of a coward to be an early adopter on that.)

New Zealand has some of the cheapest and nastiest blood testing meters known to mankind, but they are liberal with test strip prescription, and the DNs here have been liberal and awesome with their time and expertise, which has been more valuable to me than a lot of fancy tech.

So my vote is : education, education education, and cgms if people want them. Pumps are icing on the cake for those who are ready for them.

 

[MeiChanski]

I understand the fear associated with high numbers and seeing your team. Over the years and especially now, my team have been very supportive and all they want to do is patch you up instead of watching you suffer. At the same time, if you want something, you have to see your diabetes team so again commitment needs to be there. Or at least a build a relationship with your team, so they know you more. I'd give every type 1 access to CGMs if there is some kind of response from them - correcting high BGs instead of leaving yourself to suffer for the entire day. But I know that's very difficult for someone who absolutely refuses to inject. But it's also kind of harsh to tell them they won't benefit from a CGM or a pump? However I've been turned down for certain treatments unless my blood glucose improves which at first felt horrible but as I improved my readings, I felt better and fit enough to go for treatment. I guess we could say the same for access to pumps and CGMs?
I feel pumps are the next level of administrating insulin, you have to be ready for them.

On the other hand, I am quite sceptical about the Medtronic 670G with CGM, I know a few people absolutely disliked auto mode. But I'll let everyone know how the closed loop system is, if I complain, you can slap me on the wrist.
Again as time goes on, I hope to see more improved closed loop systems and possibly more closed loop patch pump systems.

 

[LooperCat]

Tech has totally saved me from diabetes, as you know. Even more so now I’ve built my closed loop system

 

[ert]

actually there is the Medtronic 670g which combined with CGM is indeed a closed loop system
here is an article on the subject https://www.diabetes.co.uk/news/2019/mar/medtronic's-closed-loop-minimed-670g-now-available-on-nhs-in-some-areas-99233687.html

the user still has to manually bolus for food but the pump adjusts the basal insulin automatically corresponding to what the users BG is doing according to the CGM

Pumps only have one type of insulin, short-acting. It's the bolus around mealtimes that most people have issues with, particularly people not coping well with their diabetes. So it's a long way off being an artificial pancreas or closed loop.

 

[EllieM]

And short acting insulin is used for basal on a pump by pumping at different rates depending on body needs.

Just curious, is there an extra short acting insulin used by pumpers? Logically you want it to mimic the insulin produced by non-diabetics, which I'm assuming is very short acting indeed, given that it's continuously produced...

 

[himtoo]

Pumps only have one type of insulin, short-acting. It's the bolus around mealtimes that most people have issues with, particularly people not coping well with their diabetes. So it's a long way off being an artificial pancreas or closed loop.

I think you are confusing peoples inability to run closed loop with the fact that closed loop exists . I know people in real life that are successfully running closed loop .

 

[LooperCat]

I think you are confusing peoples inability to run closed loop with the fact that closed loop exists . I know people in real life that are successfully running closed loop .

Exactly. I’m running a DIY closed loop artificial pancreas.

 

[MeiChanski]

@ert In a nut shell, a pump is just a way of administrating insulin. However there are more options of a closed loop systems coming out or some people are not waiting and have been able to DIY a closed loop system. I've been considered for a closed loop system which is the medtronic 670G. I think the whole idea of it is to mimic the way a healthy pancreas works but it does have flaws according to reviews. I hope it'll improve as time goes on.

 

[Gary61]

If you read my blog which I've just started, it might hopefully give you an insight on how I have found my control
since starting the 670g.

 

[Gary61]

Sorry its https://www.diabetes.co.uk/forum/blog/gary61.146959/

 

[Abigail18]

I think it may depend on the person and the reasons.
In cases where hypos can cause mental health issues then it may help to reduce this but it depends on if they are willing to be attached to something all the time.
In my case I have rather high anxiety when having a hypo due to a number of lows in the past which required help and had the libre trial a couple weeks back and found it gave me peace of mind and helped with the hypos. Maybe in the future I may be considered for a pump but overall it depends on the individuals circumstances if it helps.

 

[Gary61]

I think it may depend on the person and the reasons.
In cases where hypos can cause mental health issues then it may help to reduce this but it depends on if they are willing to be attached to something all the time.
In my case I have rather high anxiety when having a hypo due to a number of lows in the past which required help and had the libre trial a couple weeks back and found it gave me peace of mind and helped with the hypos. Maybe in the future I may be considered for a pump but overall it depends on the individuals circumstances if it helps.