ATTD Discoveries with Melissa Holloway

Welcome to Think Like a Pancreas, the podcast where our goal is to keep you informed, inspired, and a little entertained on all things diabetes. The information contained in this program is based on the experience and opinions of the Integrated Diabetes Services clinical team. Please discuss any changes to your treatment plan with your personal healthcare provider before implementing. Welcome to Think Like a Pancreas.

The podcast, uh, we're gonna be talking today, uh, about the advanced Technologies and treatments for diabetes conference that just took place in Amsterdam. And if anyone out there knows exactly where Amsterdam is, call in. We'd love to hear. No, we, we looked it up on the map. I did not get to go to this conference this year, and I love this conference because it applies so well to people on insulin and intensive insulin therapy, more so than any other conference I know of.

However, my good friend and colleague, Melissa Holloway was there and she is gonna be giving us the lowdown on some of the stuff that she discovered in person. So Melissa, hey, welcome to the, the program. Uh, why don't you tell the folks at home a little about yourself.

Thank you Gary. It's always a pleasure to speak with you and also always a pleasure to talk about ATTD. It is my favorite meeting when I was in a job that I had to request holiday to go places for, I took my vacation days to go to ATTD because I love it so much. So, um, I can't wait to tell you all the things I picked up.

One of the things that drives me to keep going is that since I'm now working on Smart Start, I get to hear all the buzz about what's happening in CGM and what are the latest, greatest tools, techniques, approaches to helping people get the most out of their diabetes data. And I mean, that's what gets me up in the morning. So I didn't sleep very much at ATTD. Yeah. And you have a personal connection too. How long have you had that? Oh yeah. Uh oh.

I've just, I'm about to reach my 31st dia-versary at the end of this week, um, and I've been using CGM since 2006, um, on, on a pump since 1996, and I've been a DIY Looper. Since June, 2018. So, um, I've got the t-shirts. You know, I think for dia-versaries it should be like anniversaries where every year has an item associated with it. You know, you got your gold and your diamond and all that stuff. What would be a good first year marker? Right? That could be the glucose tablet year.

Or we could throw it back to like Baskin Robbins and say, you should go get yourself an ice cream. Even better. I love it. One. Yeah, as an American, that I could make that joke, but as you know, I live in London, so the sunlight that you're seeing streaming in is our afternoon. Yeah. How many years have you been in the UK now? Actually more than half my life now. I added it up the other day and I moved in 2001 for post grad.

When I thought I was gonna be a PEMA historian, and then by 2004 I was working in diabetes and then moved back to the US for a couple of years and then made my way in on a final basis to the UK in 2007. So the years are ticking up closer to 20 than to 15 now. Yeah. I will tell you, you are starting to sound a little more like a UK person all the time. Every time we get together, I hear a little more of that. That accent in you. You know why?

It's because my husband corrects the kids whenever they say something like I do. Hmm. And so now I have to over pronounce my Ts or else the kids start mocking the way I speak. Yep. So anyway, Amsterdam is located in the Netherlands. Of course that helps nobody knowing that it's in the Netherlands, but I, I saw we've got this, this world map on our shower curtain. I'm, I learned so much geography when I shower. The Netherlands is just a little bit west of Germany.

It's a little bit north of Belgium and a little south of Denmark. So it's sort of nestled in that. Part of kind of Northern Europe, right? What was Amsterdam like? I've never been there. It's a lovely city. I got to go a couple years ago and saw much more of it when I went to a big exhibition of Vermeer paintings. There's loads and loads of canals. It's very much a city on the water and in fact it's got more canals in Venice. Um, so that's one of their fun facts.

And they're really good at fries. Fries are a local specialty, um, and Not chips, but fries. Fries. Yeah. They, they consider them to be more like frites. If you've been to Belgium and everybody speaks English pretty much makes it a very accessible city for lots of people from around the world. So it, it's got a lot of tourists all the time because it's a fun place to go. And then of course, some people are attracted by the coffee shop culture. And in a coffee shop you don't drink coffee.

It's not about the coffee. Yeah. I love how you say water, because here in Philly we say water. Everyone's got their own pronunciation for it. Yeah. Well this is because of my husband and the kids. They make me say water. If I go to the US for a week, I come back saying, water. There you go. Or water. All right, so if there is one thing, just one thing that stands out in your mind as you got to this conference, ATTD in, in Amsterdam, and it just blew you away.

You're like, wow, this is a game changer. What would it be?

Well, I think the data I was most excited to see is the Dexcom 15 day and for G7, and the reason I got so excited is that they've changed the algorithm as well and it shows such accuracy.

And even the first day of wear compared to the previous generations, the product that Dexcom had come out with, and I've been using Dexcom since 2006, like just to declare my interest when there was a corporate symposium and Jake Leach stood up in front of a timeline of all the different Dexcom devices there have ever been, I thought I've got 'em all. You know, like I've, I've been through all of those generations of product and today somebody would say Dexcom, pft, that three day sensor!

Gosh, you know, who even would've wanted to use that? And, and I can reflect on how when it was available, it made things better for me. It was better than 12 fingers sticks a day, and I. I still got my hbA1c down with no more hypos in those days. So when I think about how far the technology has come, I think we're getting now into these really incremental advances in terms of what's possible.

But the idea that the 15 day sensor is still going to have a grace period attached made me think, gosh, only two sensors a month. Like for me, having used Dexcom for such a long time, going from a sensor every few days to a sensor every seven days, to a sensor every 10 days, but then going to a sensor every, like 15 and a half days, I'm gonna have more room under my bed for shoes. My husband's not gonna like that part when I say there's more room for shoes. But I like the data.

I thought it looked really strong. The real benefit is more shoe space. That's the real advantage that the 15 day sensor offers because I was thinking about it. I, I, it's The MARD. I, I like the MARD too. Every 10 days. To me, it's not that big a deal. I'm going to go from changing it three times a month to two times a month. Do you think that really makes a big difference?

Not a huge difference, but I do find myself checking how many days I have left on my sensor because 10 days isn't like an kind of an even increment of time in comparison to the other tasks I do for my diabetes. And I, I did get a chance a few years ago when I was on a Medtronic ancient pump with my DIY system to try the seven day infusion set and that extended wear set.

Actually meant I spent a little less time thinking about how prepared I was for going out with my diabetes and did I have an extra. And, um, I mean I could take one extra of, instead of having to take two or three extras if I were going away for a couple nights and I thought, you know, that's actually a little bit of an advantage. And not having to think about rewinding the pump and refilling it as frequently actually did give me a bit more time in my week.

Um. And I could feel the difference when I went back to using the three-day set. Yep. The improved accuracy overall is clearly an a benefit to anyone who's going to use it. Um, you know, if you travel, you won't have to carry quite as many supplies if you're traveling for a long period of time. I looked at the accuracy data that was reported and they broke it out into like, three day chunks. They had the first three days, the middle, the near the end, and then the end of the 15 day cycle.

And what I saw was that the accuracy in the middle is still the best you get. Today's like three to 12 or so. The accuracy's really good. It's good at the beginning and the end, but not as quite as, as accurate as it is in the middle. And the last three days. And the first three days, you're still looking at a, a MARD in the eight, you know, in the eights being that on average, the, the values the sensor gives are within about 8% of a lab value taken at the same time.

And that's, that's tremendous. It, it is good. That whole, in the first 24 hours, it might not work so hot. When you're on an AID system, it, it makes people nervous. Mm-hmm. I feel like for AID particularly, we're gonna see people feeling more confident with the first day's performance, which I will. I still advise all my patients to do at least one finger stick on day one of a new sensor just to verify that it's performing.

Okay. Was there anything new in the area of finger stick monitoring glucose meters or.

What did you see? Not much, honestly. ATTD is much more a meeting about the sensing and the delivery devices, but in terms of what could be beneficial for people who aren't on an AID, there was a lot more focus on pens that could work well with sensors, with algorithms. We had, Medtronic was showing the InPen and Dexcom described how they're integrating with the NovoPen products that are available in Europe.

On the similar basis to how the Freestyle Libre has been integrated with the NovoPen products, and that's gonna open up more choices for people and how they manage their diabetes. Something I did read about was that Abbott is, is developing, um, a meter or a sensor that will not just measure glucose, but also track ketone levels.

Did you guys see anything about that at the conference? Yeah, there's actually quite a lot of debate about what will we do with continuous ketone data, and there's a Chinese company that already is selling a continuous ketone meter as a lifestyle product in Europe, and there's a lot of interest in the, the idea. Personally, I look at how we've seen data tell us over the years that people who are on a CGM are less likely to end up in DKA.

So I think, well, okay, we're less likely to end up in DKA, where's the value gonna come from for. Continuous ketone sensing. But then I think about how when we have an AID and we see that there's a lot of insulin on board, we may think of this high glucose level. It'll sort itself out. It'll come down eventually, but maybe we have a cannula problem. Maybe we're getting ill and we don't know it yet.

Maybe there's some other issue at play and perhaps having something that comes up on the screen of whatever device we're looking at, to get our data that says, actually, your ketones are going up now. Whatever your glucose level is, something's going on here, Right? Could add value. But I do think we need, It helps you to differentiate between, you know, what's caused by maybe an illness versus what's caused by a, a pump malfunction.

Or if you're on injections, maybe having forgotten to take your long-acting insulin or that insulin has spoiled. So yeah, I mean there's, there is some value in, in knowing when ketones are present or when they're rising and it's certainly better than, than the urine testing. 'cause it takes several hours for ketones in the bloodstream to. Appear in the urine so we can catch these kind of issues a lot earlier. Mm-hmm. Um, so that's, and if we compare to Yeah, go ahead.

I was gonna say, and if we compare to finger stick ketone testing, which is of course something that's available, but those strips are often not as easy to access, and I know I keep some under my bed with a ketone meter on the principle that if I'm sick enough that I think about testing for ketones, I'm probably sick enough that I'm at home, but that might not be the only time I would benefit from knowing what's going on with ketones.

Interestingly, there was some debate and you know, speaking of that Chinese company, it's um, Ionix. They hosted a symposium and they were talking about what they think they could do with continuous ketone sensing, and there was some real pushback from the audience and the discussion about what the threshold should be for it forming the user who has diabetes about. Their ketone level.

Then if you think about how so many posts on social media when someone does do a finger stick, glucose level will say something like, this is the situation, just did a finger stick ketone test. The number was X. What do I do about it? It's not a number that we really feel like we understand the first time we look at it in the moment. Yeah, it's gonna take some education, uh, to let users know how to respond.

I think one of the other reasons the ketone monitoring might become more prominent is with the drive to use SGLT two inhibitors in

patients with type one diabetes. This is that drug that helps the body excrete sugars through the urine all the time. But there's the, an increased risk of ketoacidosis and type ones who use these medications. So the pharma industry might stand to benefit if we can monitor ketones and mitigate that risk. And more people with type one could start to access those drugs if that's the case and benefit from them Potentially.

Although, you know, just to point, you know, just to put the devil's advocate hat on, I wonder if we're actually going to see an indication for GLP1 RAs and type one before we see a regulatory agency really enthusiastic about the use of SGLT. What did they, what did they, uh, share at the conference about GLP one use?

There were a few posters and talks and there was a rumor going round, and I, this is where I haven't had enough time since I've been home to see if there's anything public about it, but there is a company that makes a GLP1 that is definitely doing a decent sized study in type ones, and there were a few investigator initiated studies going on as well.

So those of us that are using a GLP one off-label are feeling a bit like we are, you know, exploring new territory and getting benefit in a way in a WhatsApp group I'm a member of. In case people are wondering, GLP ones are the, these are the Mounjaro, the Ozempic, the The Trulicity, the, these are the medications that type twos use to help with weight management, but they can also be pretty beneficial in type ones for slowing digestion, blunting appetite.

Also keeping glucagon production to a minimum. So insulin requirements go down every study that's been done, and these are usually small scale studies, have shown the GLP ones to be safe and effective. But there haven't been the large controlled trials, randomized controlled trials with them to satisfy the, the FDA's uh, requirements here in the states. In Europe, they're actually more progressive and these medications are available to more people. A word from our sponsor.

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Any other medications that you came across and, and anything new in the insulin field? 'cause a year or two ago, you know, once weekly insulin icodec was a big deal and that, that's been slowed down by some research issues that came up. So anything new in the insulin space? Well, there was actually a symposium on icodec because in Europe, the regulators took a somewhat different perspective than they did in the US, so there's a bit more freedom to talk about it here.

One thing that really surprised me was that Mannkind was a major sponsor of ATTD with their inhaled insulin, which hasn't been commercialized in Europe. So that was really cool to see. And I've seen a few people, um, since ATTD who were catching up on the coverage who are based in Europe saying, this is the first time that I've heard about inhaled insulin. So it, it'll be interesting to see what their approach is when they start.

Talking to more companies and countries outside Europe about what the potential is, 'cause we just haven't had the opportunity to have inhaled insulin here yet. Have you ever tried it yourself? I think interesting. Yes. I had the opportunity after ATTD in Berlin. A good friend who does get Afrezza, bought me a big lunch, sat me down and said, pass some Afrezza. Did you pass it around the table? Actually. In that case, it was the spotlight on me for his video. Um, but All right.

One inhaler per person. Well, no, he did have to share his device. He was like, trust me, I've washed. Um, but yeah. Um, he was very excited to see Mannkind as a big sponsor of at TTD, and it'll be good to see what they have in store and where they go next. Uh, another big drug focus was actually, uh, with screening for type one towards

the prevention of type one with to, and Sanofi is making big investments in getting more people aware of screening for type one because, well, that's the only way people are gonna be on the list to be able to access. And so that was good to see as well, that there was a lot of interest and, and people were talking about screening and our own attitudes as people who live with type one to who else in our life are we encouraging to get screened? And I thought that was good.

Yeah, I think we're gonna be, we're gonna do a podcast on that specifically in the very short term, but I, I speak for Sanofi about, about screening and about the preventive measures and I, I feel it really puts the power in people's hands. A lot of folks are saying like, if I'm at high risk and I don't wanna know because it's inevitable, but it's not anymore. I. There's so many things we can do besides medications. There are other approaches we can use to slow down the progression of type one.

Did you ever have your kids screened? I did. Actually. The National Health Service here in the UK has a study called Elsa for people with type one or want or even didn't have type one who wanted to have their kids screened and I should probably get my daughter Rescreened because she wasn't quite for. When she had her finger stick for it, and now she's five and a half. But at that time, both my kids came back negative, which was really lovely to see. Yeah. On the other hand.

It's a relief, isn't it? It's like a weight off your shoulders. It does feel that way, and yet I was speaking with someone the other day who told me that as a parent of a child with type one or one child was diagnosed at age three and is now 15. And then her second child was just diagnosed at age 14 last year, but the second child had been negative for antibodies only two years prior. Mm-hmm. So that was interesting. She said something about the interval for rescreening here.

You know, there's, we don't exactly know if you get the all clear when you should be rescreening or perhaps that first test that was negative for antibodies. Maybe that wasn't the most accurate. Instance, yeah. I really felt for her because I hadn't heard about the second child having been diagnosed. I only knew about the first one until we had that conversation.

For those of us who are diagnosed and have had it for as long as we have, you know, the technology has evolved so much in the last several years, particularly with automated, or I call semi-automated insulin delivery.

I still feel that, you know, we're, we're in charge of the vast majority of the decisions. It's only a, some slight adjustments that these systems can make. So what can you share with me that's new with either the pumps, algorithms, and what features are available within the systems and what's coming up? It was great to hear that Control IQ Plus is coming through from Tandem, that they're introducing some auto boluses.

I need to get my head around a little bit more about the system to understand exactly how it's gonna differ from the control IQ that's already been out, but they were certainly talking about it on the booth, and I thought that was nice to hear. Yeah, I mean we've got Control IQ Plus here and we've had it in play for a while now. There there's only a handful of new things.

You know, one is that you can set temporary basal rates while control IQ is running, which I think is actually a very helpful feature. If we knew we were gonna need more or less insulin for a while, we used to have to create a whole new profile of, of insulin delivery parameters, turn it on, and then remember to turn it off when we're done using it. A temp rate, you just go in and say, all right, for the next six hours, bump my delivery up 40% or lower at 30%. That's all you have to do.

So the temp basal feels a nice feature that reintroduce, and you know it was available prior, but now it's being reintroduced. And the extended boluses, which are also a very helpful feature with. You know, the, you know, the typical American diet, lots of fat and slow digesting food. Being able to slow down the bolus deliveries is very useful. Tandem used to allow it for up to two hours. Now it goes up to eight.

I can't imagine something that would take that long to digest, but I suppose it's possible. They're having a, a Spanish language capability. What else? And those are the major things. Um, it's all that comes to mind. Those are the, you know, more significant changes that are being incorporated. But I've also learned a lot about. Their insulin on board out calculation, something called dynamic IOB. So it doesn't always use the insulin on board at face value.

It doesn't just deduct that amount from boluses anymore. If your glucose is trending up or it's high, it's gonna deduct. Less. And if it's low or or dropping, it'll deduct a little bit more. And also if you've eaten recently, it considers some of the food offsetting the IOB, so it'll deduct a little bit less. So it's an intelligent kind of insulin on board adjustment. So even though you still can't adjust the duration of insulin action, it's a little smarter approach.

It feels a little bit like how we can use loop. Yeah, the way you described it. The DIY systems do that for us already. You're right. Yeah. Were there any presentations from Open Source DIY platform developers? Yes. And now before we move on to Open Source, just a couple other highlights in terms of devices. So we saw SQL present with the Typool Loop system with Twist. They need Chubby Checker as their spokesperson. I don't know if he's still around. Do the twist.

Um, yeah, so it was nice to see them there. They're not necessarily coming to Europe immediately in the very near future, but, um, it was good to see them on the horizon here. And then Kaleido, a pump company that's actually based in the Netherlands was back on the scene with a launch party. For their new pump, which will be available around Europe hopefully in the next several months.

And I've been aware of the development behind it for several years and it really looked like the company might not make it to a full scale commercial launch several years ago. So it was great to see them really doing well. What do you like about it? It's really quite cute and it comes in some colors and if you compare the size of their new on body part, 'cause it's a patch pump style. It's similar to Omnipod, but it has a little tiny bit of tubing.

Their unit comes up just a little bit smaller than an Omnipod pod and. I can see it being very wearable. Yeah. I, I, I had to say when I saw it, I thought, Hmm. How much, how in insulin did it hold? Do you remember? Uh, my recollection is that it's 200 units, but we might have to fact check that. Is there anything new from Insulet? Nope. Omnipod five is Omnipod five. And actually you're asking, that brings up a good point.

I, there was a real vibe around the conference of "there's not too much, that seems completely revolutionary in automated insulin delivery here this year." And, I said to my friends who had very, well, you know, sorry, who observed at that. I said, yeah, you know, for so many years, every year that we came to ATTD, there was more research into algorithms. There was more research into physiology. There was more on the drawing board to try to consider and trying to make these systems functional.

Now, we've reached a point where it's actually about implementation and rollout, and a lot of the incremental advances that we're gonna see are gonna feel like kind of small steps forward because now these systems are really getting into people's hands. The upgrades are going to be more steady and slow in terms of how they hit. Yeah. Speaking of the application of the tech, you know, in infusion devices are something that we've been looking for improvements in for a long time.

You know, Medtronic launched their extended wear set a couple years ago, as you pointed out. You know, Tandem is, is developing something called steady set. It's their, their version of an extended wear. Any news about infusion set developments? Well, more around how can we detect occlusions better. Um, and in fact, there was a spotlight on DiaTech Diabetes in the yearbook session because of their technology that can help detect occlusions faster than a lot of the current tech can.

So that was good to see. That's one of the things that SQL is, is riding on with the launch of Twist is very, uh, early detection of, of occlusions. You feel that, that, that, do you think that's gonna make a, a big difference? Is that gonna move the needle, so to speak, in how we manage glucose with pump therapy? Well, back to our conversation about ketones.

I think if you can detect occlusions faster, you're not looking for ketones to be how you know, and I feel like that's, you know, a bit of a push pull. I'd rather have a system that could tell me, "Hey, you have an occlusion", before I feel sick because I got an occlusion, if that's possible.

Now, it won't necessarily know if the cannula got dislodged and I'm just wearing some insulin on the top of my skin, but I might smell it or I might notice a spike in my glucose that lets me know that somehow that insulin didn't hit so. Those are things that I feel might be quite interesting to watch the development of. There were a couple other insulin delivery systems on the show in the tech fair that have some novelty to them.

Pharma Sense has what they call the NEA pump, and their NEA signature pump has both a cannula and an infusion set attached to it. It's a single unit. It does the, what we used to call the snake bite, where it's two prongs in terms of form factor. I do look at it and think, are we going from being afraid of catching tubing on a doorknob to wearing the doorknob?

It's not the smallest, lightest thing there, but um, but it's interesting as an approach, and they haven't been very public about what CGM technology it's integrating. So I look forward to hearing more on that. Where do we stand with, uh, dual hormone insulin and glucagon

infusion from the same system? Another good question. Um, there's a small company that's based in the Netherlands called EN Rita. Which has shown up at European conferences for a while with a dual hormone product. They do seem still to be stuck with the fact that the glucagon isn't stable for very long after you mix it up and put it into the system. And that of course creates complexities with cost as well as function. I. Even with like, like Zeis and uh, Zeins formulations that are stable at

liquid form for years at are in temp. They can't use those in these systems. I think it's all about the commercial collaboration that it would take to get them there, and so far we haven't seen them in the space. Doing it, and maybe that's something that the community can start to say we'd like to see more of. Yeah, I mean, that was what iLet was originally supposed to be, uh, Beta Biotics was a dual hormone pump initially.

They ran into so many issues with the glucagon that they had a, it really slowed down their research and that's picking up again. And all, all the re studies I've seen is that when you have both glucagon and insulin infusion taking place, you can achieve much tighter control being range more often with less hypoglycemia. It might make exercise much more manageable 'cause that's still one of the biggest challenges we face is dropping with physical activity.

We've got, basically, we've got a gas pedal, we can push the blood sugar down, but we don't have brakes. You know, you drive in a car with no brakes, without glucagon in the equation, but then you gotta wear two different infusion sites, have two tubes. You all know how much, uh, the general public loves tubing to begin with. Like you said, doorknobs, drawer handles, et cetera. We'll make things more complex.

Yeah, true. Although I, I do wanna, um, point out that the more we have app control for systems, the more we could wear the pump in the tubing all under clothes. That was one of the things that made it work for me when I was on a DIY system with the Medtronic pump, was that having the app control meant that I didn't miss that experience of feeling a bit too, being free. I didn't have to pull out my pump and handle it. Every time I needed to take a bolus. It is nice.

Did Medtronic have, uh, anything to say about their upcoming sensor and, and pump?

There was some discussion of Simplera and they were giving out little, you know, you can have an experience of what it's like to wear it. Not real sensors, just a sticky patch. And there wasn't a lot being said about future changes to the current indications, but certainly they're talking about it. And of course they've said. Publicly as well that they're going to have an integration with the Abbott Libre product in future too, so that, that's gonna be interesting.

Yeah, I, I wonder if that's ever gonna actually happen though. Medtronic's only, you know, they only play with their own in their own sandbox for the most part. What I've seen about Simplera, it's infinitely easier to insert and Simplera and smaller and more comfortable than their existing sensor. The accuracy data still lagged a bit behind what we see with Dexcom and Libre. You mentioned the apps, like the phone apps making life easier.

Were there any other new interesting apps that were on display?

Well, in terms of on display in the tech fair, again, there was presence from enhanced there. An app company that's based in Europe working on an exercise thing. Are you familiar with enhanced? I've heard of it. Yeah, yeah, Yeah, um, and I think that's gonna be interesting to see how many people will take it up and use it regularly, and how many people it can help.

They just signed on as an ambassador Henry Slate, who's a rugby player with type one, and they've had a few other elite sports people who live with type one could come and, you know, be on their team, so to speak. You're an elite sports person. You do like, you're a, you're an endurance athlete, Melissa. I think you're thinking back to that time, that one time that I did a century bike ride on my first wedding anniversary. I happened to be approaching my 15th wedding anniversary.

But no excuse, But that was a good memory. Um, yeah, I mean, I go to my exercise classes a few days a week and I do, well, I guess you could call bicycling in central London as an extreme sport. I did read, uh, there was a presentation at the conference about using the AID features to manage blood sugar during exercise. I've not found those features to be particularly helpful. I mean, within the DIY apparatus, we can do some more creative things.

I found we still have to go back to our old school management methods of either eating carbs beforehand or making bolus reductions ahead of time if it's post-meal workouts. Anything new you picked up on about exercise and blood sugar management? Well, there was some discussion of some of the guidelines that have come out, which there was a whole symposium at the European Association for the Study of Diabetes meeting back in the autumn.

And you know, there was a bit of recap on those guidelines which are available. We could put a link in the show notes because the guidelines have been thought up with varying in mind. Each system, they're not really generic, they're, they're actually more usable in terms of. With this system because of how the algorithm works. This is probably good advice if you're doing this kind of exercise. Lots of credit to the people who've worked on those guidelines, I think.

But it'll take a while to educate the healthcare professionals and the people with diabetes who need to know, because there's so much to understand when you get onto an AID system. Yeah. The last category I was thinking about is software, either downloading software, reporting software, data collection, merging activity, lifestyle type data that you happen to come across. Anything about that?

Sure. There's a couple things to highlight in terms of data that we as people with diabetes can get out and use. It's available for DIY users, not broader than that at this point. And on Apple iPhones cockpit app, do you know Diabetes Cockpit? No, I haven't. Oh, it's cool. So my friend Lucas developed it. He was working for MySugr and started thinking as someone who lives with Type one, actually there's a lot of data that comes from my DIY looping system and Apple Health.

How can I work these data sets together? Well, maybe even plug in Nightscout data if somebody doesn't have Apple Health and their DIY system connected. So yeah, so the Diabetes Cockpit app. Um, and it is doing correlations so that you can see when you have, you know, days with fewer step counts, is there something that might turn up in your diabetes data? Now that, that gets me all jazzed up. I love that.

'cause I'm always trying to figure out, you know, what are the cause and effect relationships when I'm looking at data and for the most part, the software. That we have now does a terrible job. It doesn't really provide insights like that there. There's a few select bits and pieces here and there, but being able to see cause and effect relationships, knowing that on Tuesday afternoons, if I have an active day, I go low, or if I have more than X grams of carb, that's when I tend to drop.

That kind of information would make my life a lot easier, not just as a clinician, but my own diabetes management as well. Yeah. Speaking of cool software, you've got one called SmartStart. Can you tell me a little about that one?

Sure. Um, and then after I tell you a little bit about SmartStart, I might tell you just two more things that I saw in software at ATTD. Yeah. So in a nutshell, SmartStart is doing CGM user education.

With adaptive learning paths on your phone, the proof of concept product, which you know well is currently available on our website, SmartStart Health, and with big grant support from the UK government and some investors, we're developing the version that'll be our MVP Minimum Viable Products for proper launch, which will have an adaptive component so that depending upon what somebody already knows about using CGM when they start and what they're learning along the way, their

learning journey will adjust dynamically.

So we saw in the proof of concept study that it took folks between an hour and a half and up to two hours to get through the seven content modules which cover everything from, what do we call the pieces and parts of a CGM system so that if something's not working, really, you know, you know which bit it is that you're reporting when you talk to somebody on customer service, phone line, or when you have to talk to your team about what's working for you and what's not.

All the way through to what happens with the alarms and alert settings, what things are likely to be changeable based on your needs and how to look at the graphs, how to understand what the data can mean for you and your management. In the real time moment and when we talk about things like time in range and a GP ambulatory glucose profile. And the UK government supported this? Yeah. Um, innovation grant. What's it like having a government that actually supports quality health initiatives?

'cause we don't, we don't really have that here anymore. I, I, I might have to move out there. So what are the other, uh, softwares that you were excited about?

Well, building on the mention of Diabetes Cockpit, the founder of Diabetes Cockpit, Lucas and a couple of other folks have gotten together and started a new company syntactic so that they can take the insights that come from the diabetes cockpit app and de-identify, anonymize and create a data set that can be used by researchers to optimize future insulin delivery algorithms. And I think that's really smart. So I'm impressed with what they're up to.

And another thing we saw is that Dexcom is now working on population health software. We got a little glimpse of what a dashboard might look like in their corporate symposium. And I found that really interesting 'cause looking at how people are doing in a larger set of. People under the same clinic is something that healthcare professionals should be doing. But it's really hard when you have individual level data and you can't aggregate it.

Um, and to be able to put on filters and think, well, are there some patients in this clinic or in this health system who are doing really well? What do they have in common versus those that maybe are struggling, need more support, or maybe we just haven't seen them very much and we can now look at their data in a remote basis and go, you know, those are the patients that we should be phone calling to see how they're doing, maybe getting them in if we need to see them in person.

So seeing that Dexcom is looking at how they can help support health systems on a different basis. I thought that was neat to see too. Very nice. Yeah, I mean, I, I am just kicking myself for not being able to go this year. This sounds like it was an amazing meeting. A lot of new stuff to see, new stuff to learn, and it's all focused on the areas of, of interest for people who are taking insulin and taking multiple injections or using pumps so much. It all applies to us, to our daily lives.

Which it really does. I can't say about every conference you gotta sift through at other conferences to find stuff that's really useful. I will say there was an awful lot about the use of CGM in people with type two who aren't necessarily on insulin as well, and to see that focus increasing, that's getting us into where can diabetes technology make a bigger difference in the future. I like to say that ATTD trends about seven years ahead of actual.

In terms of how clinical decisions are being made today. So I, I remind myself when I go that the rest of the world is not necessarily thinking about the same topics. The way the people who are leading the presentations at at TTD are, yeah. But what a vision of the world does it create? It, it makes me hopeful. It makes me feel like there's a lot to learn, and next year it's in Barcelona, so... I, I will be there. Um, it'll be nice to see you. Maybe we'll have to go for tea again.

Melissa's the only person who has ever, ever gotten me to go for afternoon tea as I visited her in London years ago. So maybe a little, I don't know. Do they do tea in Barcelona? Uh, not particularly, but they do great tapas. I'm good for tapas. I'm down anytime. Yeah. We can do tapas in Barcelona for sure. And before that we can have breakfast at a DA. That's right. See you in Chicago. Yeah. Yeah. It's a couple months away. Melissa, thank you so much for joining. I know it's, it's.

What time is it there? It's like dinner time for you, isn't it? Nah, it's almost three in the afternoon. Okay. It's not too bad. It's about, it's alright. 10:00 AM here's, yeah, I still have a couple meals to go to catch up to you, but thank you so much. I mean, you're just, you're such a wealth of information and you, you put things in a nice perspective that, that we can all relate to. So again, thank ev. I wanna thank everybody for, uh, joining the podcast and have a great rest of your week.

And don't forget to think like a pancreas. 2025 ATTD conference in Amsterdam was fantastic.

Even though I wasn't there, it was still fantastic. We learned from Melissa about a lot of the innovative things that were displayed and, and discussed new medications, uh, type two medications that can be applied in the type one space management approaches for handling, exercise and prevention of hypoglycemia. All the updates that are in the pipeline involving continuous glucose monitors, insulin pumps, and the algorithms that drive automated insulin delivery.

There are also a number of innovative apps that have come out and are in development and software, and some of which are applying AI technology to make them even more helpful and resourceful for those of us living with diabetes.