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Closed loop during pregnancy Diabetes

Closing the loop – looping for dummies

Looping is the next big thing in the diabetes world at the moment. But even for me, whilst I work in science and am used to some of this mumbo-jumbo, it was difficult to dive in. You literally get dropped in the deep-end and I missed a looping-for-dummies explanation. Hopefully this article can help out those people looking to grasp some of the basics, written not just with those who want to start looping in mind but also as a potential resource for family members, school nurses, colleagues or anybody interested in learning a little bit more.

To get everyone on the same page let’s start with a couple of sentences on type 1 diabetes mellitus (T1DM). With T1DM the pancreas no longer produces insulin. We need insulin to extract glucose/energy from the foods that we eat. So with T1DM we need to give ourselves insulin for meals, keeping in mind any factors which could influence insulin absorption like hormones, sickness, sports etc. Basically this turns into a huge guessing game, and with all these guestimates we try to keep our blood sugars under control. It is a time intensive process requiring a lot of dedication, energy and hard work. And we never get a moment off. Until loop.

Loop does not cure us, although loop sounds fantastic it is not for everyone! Don’t get me wrong, it makes life so much easier, HOWEVER, you need to understand all of the single components that loop takes into account. More on this later in another post. Let me first explain what loop is.

Interior of a Tesla

Let’s start talking about Tesla. For our wedding vehicle my husband chose a Tesla. At first I didn’t realize how cool it was. Yet once we were driving it was amazing. We were on the freeway and if you put out the blinker to move a lane, the Tesla will do the rest itself. It will check if there are any cars near you or in the lane you want to move to. It will steer itself into the lane. It is crazy to just sit there and watch the car do all the work. You do always have to keep an eye on the car. It can only assess situations where nothing unexpected happens. If all of a sudden a deer crosses the road, or a car in front of you slams onto the brakes with no warning, you need to intervene. It can brake slowly but it cannot make an emergency stop.

Now let’s go back to loop. It works similar to the Tesla in the sense that it can help improve our blood sugars but if unexpected things happen we need to help out. So although it doesn’t mean you don’t have to ever think about your blood sugars again with loop, it does immensely reduce the amount of time you spend on it and it can, if you understand how to change your settings accordingly, greatly improve the amount of time your blood sugars are in range. Now who doesn’t want that?

Here is another example. With the Tesla, or any car with cruise control, you set a speed at which you want to drive. If you go down a hill the car will automatically break a little so the set speed is not passed saving you from paying a ticket. If you drive up a hill the car will add some power to maintain the set speed so you don’t have angry cars honking behind you because you are going too slow. 

Now with loop, there are many variables which it uses to predict future blood glucose. But it all boils down to this; if Loop sees your blood sugars are dropping too fast, it will actually shut down your insulin delivery. It will turn itself back on once you are steady again. If your sugars start to rise, loop can increase your insulin rates to try and prevent you from going high. Most times it will catch a high or low before it happens, as long as it goes relatively steady. Which of course is not always the case with diabetes. In my experience though, even if I have to intervene myself it will at the very least help my lows be less dramatic because the insulin will have been decreased for a while and my highs less high because loop will have been trying to bring me down already. 

Loop screen: green/yellow/red dots are values from a continuous glucose monitor, purple dots are predicted blood glucose. Blue blocks are basal values whereas the circles are carbohydrates and/or bolus insulin.

Once again, Loop is not a cure. Nor does it mean you don’t ever have to think about your diabetes again. Yet for me it has meant that most nights I can sleep through the night because loop keeps me stable. It has given me back so much energy because most days I only need to think about my diabetes at mealtimes or before sports. And I don’t have to check my blood sugars every 10 minutes to see if I need to make adjustments. Loop does this for me! Even if loop would not work during the day, just the fact that I can have some well rested and deep sleep, has made all the difference!

Categories
Closed loop in de zwangerschap Diabetes (NL)

Closed loop voor dummies

Closed loop is momenteel hot in de diabetes wereld. Zelf werk ik in de wetenschap dus ik ben wel wat gewend qua lastige artikelen maar zelfs voor mij was dit onderwerp in het begin overweldigend. Je wordt linea recta in het diepe eind gegooid, eigenlijk niet eens in een overzichtelijk zwembad maar gewoon midden in de zee, zonder dat je enig idee hebt waar je heen moet. Ik hoop met dit artikel wat duidelijkheid te verschaffen voor iedereen die meer informatie over loopen wil in winnen. Of dit nu voor toekomstige loopers is, familie leden, school opvang of collega’s.

Voor we verder gaan met het onderwerp closed loop even een paar zinnen over type 1 diabetes (T1DM) om iedereen op dezelfde lijn te krijgen. Met T1DM produceert de alvleesklier geen insuline meer. Insuline heft het lichaam nodig om glucose/energie uit eten op te kunnen nemen. Met T1DM moeten wij onszelf insuline geven, rekening houdend met alle verschillende factoren die opname van zowel insuline als ook eten kunnen beïnvloeden. Denk hier aan hormonen, sport en beweging, uitslapen, verkoudheid etc. Elke maaltijd is in feite een grote gok ronde; hoeveel zou ik nu weer nodig kunnen hebben? Al dat gokken moet onze bloedsuikers dan onder controle houden… Het is een intensief proces wat veel tijd, energie en werk vergt. Dan te bedenken dat we nooit een pauze moment krijgen. Tot Loop.

Loop is geen genezing! Hoewel het ideaal klinkt en de oplossing voor al onze problemen is het zeker niet voor iedereen. Begrijp me niet verkeerd, als het goed werkt is het hemels, hoe veel makkelijker je leven er van wordt. MAAR, je moet wel alle aspecten van de berekening snappen en zeer goed weten hoe je eigen lichaam werkt.

Het interieur van een Tesla

Om looped te begrijpen ga ik het eerst hebben over zelf besturende auto’s. Voor onze huwelijksauto had mijn man een Tesla uitgezocht. Een mooie bak maar het wonder van Tesla werd mij pas echt duidelijk toen we op de snelweg reden. Mijn echtgenoot gaf met de knipper aan dat hij van baan wilde wisselen en de auto deed de rest. De auto controleerde eerst of er andere auto’s naast ons reden. Als er ruimte is stuurt hij vanzelf naar de volgende rijbaan, bizar om er naast te zitten en de handen van de bestuurder niet eens aan het stuur te zien. Uiteraard moet je de auto wel altijd in de gaten blijven houden. Het werkt alleen in overzichtelijke situaties. Als er plotseling een hert over steekt of de auto voor je op de rem trapt moet je zelf ingrijpen. De auto kan wel rustig af remmen maar geen noodstop maken. 

Terug naar Loop. Het is vergelijkbaar met de Tesla in de zin dat het de bloed suikers kan verbeteren, maar alleen als er geen onverwachte dingen gebeuren. Dus het betekent zeker niet dat een closed loop er voor zorgt dat je nooit meer over je diabetes na hoeft te denken, maar het vermindert wel de tijd die je er mee bezig bent. Als je snapt hoe en welke wijzingen je moet maken kan het zo de tijd die je binnen je streefwaarden zit significant verbeteren. Maar hoe dan?!

Om dat uit te leggen nog een Tesla voorbeeld. Of eigenlijk is dit toepasbaar op elke auto met cruise control. Daar stel je de snelheid mee in die je wilt rijden en de auto probeert zich daar op aan te passen. Als je een heuvel afrijdt zal de auto automatisch wat af remmen zodat je geen boete krijgt als je de flitser onderaan passeert. Vervolgens bij heuvel op zal de auto wat gas bij geven zodat de mensen achter je niet gaan toeteren omdat je te langzaam gaat. 

Bij loop werkt het vergelijkbaar. Er zijn een heleboel verschillende variabelen die loop gebruikt om een bloedsuiker te voorspellen, maar in feite is de basis van het gehele system hetzelfde als een cruise control. Als Loop ziet dat je suikers hard aan het zakken zijn stopt hij de insuline toevoer. Zodra je weer stabiel zit mag de insuline weer aan, terwijl als loop ziet dat de bloed suikers stijgen de insuline toevoer wordt verhoogd. Als het geleidelijk gaat kan Loop zo hoge en lage bloedsuikers voorkomen. Maar geleidelijk en diabetes gaan meestal niet hand-in-hand. Uit eigen ervaring kan ik wel zeggen dat hoewel hoge en lage bloedsuikers niet compleet verdwijnen de extremen wel minder zijn. Doordat loop de insuline al uit zet op het moment dat je gaat zakken kom je minder diep met je bloedsuikers of dus minder hoog omdat je al extra insuline in je lijf hebt zitten.

The green/yellow/red dots display the blood glucose as measured by a continuous glucose monitor, the purple dots are the predicted blood glucose. The blue blocks represent the (adjusted) basal insulin values with the blue dotted lined being baseline levels.

Nogmaals, Loop is geen genezing. Tevens betekent het niet dat je nooit meer over de diabetes hoeft na te denken. Voor mij betekent het wel dat ik tegenwoordig bijna elke nacht door kan slapen omdat loop mij stabiel houdt. Het heeft mij meer energie gegeven doordat ik ‘s nachts opeens slaap en overdag niet meer elke tien minuten zelf hoef te kijken of er meer of minder insuline bij moet, dat doet Loop nu tenslotte! Zelfs als Loop gedurende de dag niet goed zou werken, het feit dat ik opeens diep en rustig kan slapen maakt het al allemaal waard!

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Uncategorized

Nederlands deel van de website niet up to date

Hoewel deze blog in twee talen gevoerd wordt kost het veel tijd om dit zelf te vertalen. Vandaar dat niet alles in het Nederlands te vinden is en de meest recente inhoud alleen in het engels is. Check dus vooral ook de Engelse versie!

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Nederlands

Nederlands deel niet up to date

Lieve Nederlandse lezers,

daar er veel tijd in gaat zitten om mijn berichten zelfstandig te vertalen heb ik besloten om de voertaal van deze blog in het engels te doen. Ik zal proberen om af en toe nog berichten in het Nederlands te zetten omdat het soms gewoon veel fijner is om berichten in je eigen taal te lezen en hoewel ik een google translate vertaal knop onderaan de pagina heb staan dit toch vaak bizarre resultaten geeft.

Mocht je de meest recente blogs en informatie willen hebben raad ik je aan het engelse gedeelte van de site te bekijken!

Categories
Diabetes English Uncategorized

Dexcom: crash and burn

After the first night with dexy I was a little less enthusiastic. During the day I had noticed that the app would crash every time I would open it but since I silenced all alarms on my apple watch I didn’t think too much about it. I was very happy when dexy woke me up to a low relatively in time. I turned off the alarm, or so I thought, and got out my sugar tablets. I had set all alarms to vibrate so was quite shocked when after five minutes my alarm went off again; full volume. Its safe to say my husband was not too pleased…. I tried turning the alarm off again but every time I would open the app it would simply crash. If I would open up the app again the alarm would be gone but nevertheless it would go off after 5 minutes again. I ended up just turning off the alarm, waiting until I was out of the alarm zone and then turning them back on. This was not making me a happy chappy….

Categories
Diabetes

Dexcom: initial excitement

The days before I am getting the Dexcom (G5) I am extremely excited. I simply cannot wait to try it out. Can it really live up to the hype? Is it really as good as others have told me? How will it be to not check my blood sugars on my pump but on my apple watch?!

img_1100.png
Can’t wait to get started!

Friday morning, 09:00 a.m. How happy I am that we made the appointment in the morning because I am bursting with enthusiasm. After all the introduction talks (which feel like forever) Sexy Dexy (aptly named by Bittersweet Diagnosis) is finally installed on my arm. FINALLY! Wohoo!! But now I still have to wait for another 2 hours, *sigh*.

Two hours and two bg checks later sexy dexy is up and running! Yeah for Dexcom! I check my apple watch and…. I CAN SEE MY BG TREND!! So far I have been using Medtronic which for some stupid reason has not caught on yet that people want to see their values on their phone. Although they have the guardian connect in Europe this only works as a standalone cgm. As soon as you want your cgm coupled to your pump you cannot use the connect system anymore. Even worse is that the upload with Medtronic is tedious; not only do you need a computer, and your blood glucose meter to connect your pump to the computer, the website often doesn’t even work.

First of all it’s still Java based. Second of all when you get new updates it takes forever before they incorporate them. I remember when I got a windows 7 laptop it took almost a full year before I could throw my old laptop out of the window because I still needed it to upload my sugars. Two weeks ago I upgraded my macbook to IOS 11. Guess what… I can no longer upload my sugars from my computer anymore. Luckily we have older windows computers at work but it means I cannot upload my sugars whenever I want. Come on Medtronic, keep up!

Oooohh, let me check my apple watch again. Oh how exciting this is. I am in love already. I’m still measuring as I would usually with my Medtronic cgm, before every meal because my enlite simply isn’t accurate enough to bolus without doing a check. But oh my, sexy dexy is soooo sexy! It’s just ALWAYS spot on whenever I measure. Is it possible for me to really only measure every 12 hours?? Medtronic has promised me this but even with cgm I still measure 4-6 times daily. I’m not even 12 hours in and I already don’t ever want to give my Dexcom back!

Read the other post on my experience with Dexcom:
Medtronic vs Dexcom

Categories
Diabetes English Uncategorized

Dexcom: initial excitement

The days before I am getting the Dexcom (G5) I am extremely excited. I simply cannot wait to try it out. Can it really live up to the hype? Is it really as good as others have told me? How will it be to not check my blood sugars on my pump but on my apple watch?!

Categories
Diabetes

Medtronic vs Dexcom

My four years are up. It’s that time I get to choose a ‘new’ pump. A difficult choice since I will rely on this piece of technology to keep me alive every day. Currently I still have the Medtronic Veo (530 in USA) and roughly 0.5-0.75 years after I got this ‘new’ pump the 640G came out.

Now the hybrid closed loop 670G is already out in the states but it most likely won’t come to Europe/Austria until the end of 2018. There are rumors the 670 might not reach Europe at all as the next version supposedly is coming soon. However I do feel that if I choose the 640G now I’ll have outdated software soon. I’m also not buying the iphone 5 anymore when the iphone 8 is already out. On top of that I’ve not been happy with the Medtronic sensors in combination with my veo pump. And then to think that these sensors will determine if my insulin will be shut-off for hypo’s or not.

Currently, by the time I have already solved my hypo, my sensor usually gives me an alert. I have a whole lot of doubts and questions and for the first time in my life am really unsure about my next pump choice and feel a little unsatisfied with the choices. In Austria we currently only have the choice between the Medtronic 640G, omnipod, Ypsopump, Accucheck combo und Accucheck insight. All of these pumps have been on the market for quite some years and I just feel I would be majorly settling. I have heard quite some good reviews from my friends in the Netherlands about the Kaleido pump but so far this is only available in the UK and the Netherlands. I was actually really excited about the t:slim but this still hasn’t reached Europe yet although I’ve read online its coming to Scandinavia soon.

Comparison of medtronic vs dexcom CGM and measured value

After always going for Medtronic without a doubt I feel myself at a loss. I am really sick of the Medtronic sensor inaccuracy and have decided to request a Dexcom trial. If I choose a Dexcom the pump market all of a sudden opens up as well, I feel like although there are a lot of options no matter what I chose I will make the wrong one. I would just really like to have something new, fresh and something that works well! For the next 1,5 weeks I will have a Dexcom at my disposal and a friend of mine has been so kind to lend me his 640G now he is using and old Medtronic pump to close-loop. A chance for me to try my options and see what the pros and cons are before I’m stuck with something for the next 4 years.

Read my other dexcom post here:
Dexcom: initial excitement

Categories
Diabetes English Uncategorized

Medtronic vs Dexcom

My four years are up. It’s that time I get to choose a ‘new’ pump. A difficult choice since I will rely on this piece of technology to keep me alive every day. Currently I still have the Medtronic Veo (530 in USA) and roughly 0.5-0.75 years after I got this ‘new’ pump the 640G came out. Now the hybrid closed loop 670G is already out in the states but it most likely won’t come to Europe/Austria until the end of 2018. There are rumors the 670 might not reach Europe at all as the next version supposedly is coming soon. However I do feel that if I choose the 640G now I’ll have outdated software soon. I’m also not buying the iphone 5 anymore when the iphone 8 is already out. On top of that I’ve not been happy with the Medtronic sensors in combination with my veo pump. And then to think that these sensors will determine if my insulin will be shut-off for hypo’s or not. Currently, by the time I have already solved my hypo, my sensor usually gives me an alert. I have a whole lot of doubts and questions and for the first time in my life am really unsure about my next pump choice and feel a little unsatisfied with the choices. In Austria we currently only have the choice between the Medtronic 640G, omnipod, Ypsopump, Accucheck combo und Accucheck insight. All of these pumps have been on the market for quite some years and I just feel I would be majorly settling. I have heard quite some good reviews from my friends in the Netherlands about the Kaleido pump but so far this is only available in the UK and the Netherlands. I was actually really excited about the t:slim but this still hasn’t reached Europe yet although I’ve read online its coming to Scandinavia soon.

After always going for Medtronic without a doubt I feel myself at a loss. I am really sick of the Medtronic sensor inaccuracy and have decided to request a Dexcom trial. If I chose a Dexcom the pump market all of a sudden opens up as well, I feel like although there are a lot of options no matter what I chose I will make the wrong one. I would just really like to have something new, fresh and something that works well! For the next 1,5 weeks I will have a Dexcom at my disposal and a friend of mine has been so kind to lend me his 640G now he is using and old Medtronic pump to close-loop. A chance for me to try my options and see what the pros and cons are before I’m stuck with something for the next 4 years.

Read my other dexcom/medtronic reviews here:
Dexcom: initial excitement
Dexcom: crash and burn

Categories
Diabetes (NL) Nederlands Uncategorized

Ja ik wil………………………………omlaag !!!!!!!

Origineel in twee delen verschenen op https://www.diabetestype1.nl/blogs/dagelijks-leven/48-ja-ik-wil-omlaag-deel-1-de-combi-trouwjurk-en-insulinepomp

Begin mei was het dan zo ver; mijn meisjesdroom kwam uit. Eindelijk mocht ik mijn fantasie gaan beleven; ik ging trouwen.

Al vrij kort na het moment van verloven begon ik al gekscherend grapjes te maken; zie je het voor je, op het moment dat we ja moeten zeggen ik in een hypo zit en te traag reageer. Of dat net voor ik binnen kom lopen ik een hypo voel, de deuren open gaan en ik suiker in m’n mond sta te proppen? Ik had er een leuke diabetes comedy film over kunnen maken. Hoewel het enigzins overdreven was zat er wel een kern van waarheid in, enigzins zorgen had ik wel over hoe mijn suikers zich zouden houden op de bruiloft. Maar dat duurde nog zo lang; dat zien we dan wel weer.