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New pill can deliver insulin (news.mit.edu)
564 points by theBashShell on Feb 8, 2019 | hide | past | favorite | 249 comments

> Once ingested, water dissolves a disk of sugar, using a spring to release a tiny needle made up almost entirely of freeze-dried insulin. The needle is injected into the stomach — which the patient can’t feel, owing to a lack of pain receptors in the stomach. Once the injection has occurred, the needle can break down in the digestive tract.

That's some pretty impressive ingenuity. Also sounds kinda terrifying if the 1.0 has any kind of edge case that involves tearing holes in your stomach lining.

I'm not diabetic, but I still have vivid memories of sitting with my grandmother while she constantly pricked her finger to test blood sugar and jabbing insulin pens into her abdomen. It's always stuck with me as a particularly unpleasant lifestyle to have to endure. Even still, if I were a diabetic I think I'd still be waiting a year or two after the release of something like this to make sure all the kinks have been ironed out ;)

What doctors and researchers get wrong about diabetes is that pin-pricks and injections are not even remotely bad. I don't know a single diabetic who cares about injections and blood sugar tests. You get used to that within the first week of diagnosis.

No, the unpleasant part of being diabetic is having to live every second of your life as an act of weighing how what you're currently doing is going to affect your blood sugar levels an hour for now:

- Have I been sitting in this chair too long? - Have I not been sitting down enough this morning? - Have I been drinking enough water? - Did I just drink too much water? - I haven't been to the bathroom in two hours; does this mean I'm screwed? - If I eat a piece of toast after dinner, will I be able to have sex with my wife without going hypoglycemic? - I'd like to go hiking, but it's hot outside and my insulin might spoil, so maybe I'll walk around the block instead. - I just plan on going to the grocery store for 20 minutes; do I need to bring insulin in case there's a traffic jam on the way home?

Etc., etc. Pharmaceutical companies can't solve the real lifestyle problems associated with diabetes short of inventing an actual cure.

> I don't know a single diabetic who cares about injections and blood sugar tests.

I'm diabetic and the sole reason I don't check my blood sugar (unless I think something is drastically out of whack) is that it takes me upwards of 30 minutes to do a finger prick for testing. My anxiety skyrockets and nothing I do can tell me that it's not going to be excruciating. Most of the time I end up having my wife do it, which isn't a fun process for either of us.

It's not the worst thing, but it's deeply, deeply unpleasant for me. Come at me with a 10ga needle, I won't flinch; come at me with a 30ga lancet and I'll be a mess. I'm going to be switching to a CGM purely for this reason.

I was on a CGM (Dexcom) for about 3 months until my new insurance would not cover it. Even though it's convenient, it comes with its own set of problems - having to restock every month (with copays) got tiring and somewhat expensive compared to strips. I also had false low reads a number of times. And the amount of wasted plastic (the applicator gun) is concerning if you are environmentally conscious.

As for lancets, you might want to try the AccuCheck fastclix. It's a pen shape device with a cartridge that holds 6 lancets. One cartridge can last me a couple months as I tend to use the same lancet 10 or more times (I know, probably not recommended). It's also the most painless lancet I've ever used and it's easy to carry around.

I second the AccuCheck fastclix. The needles are silicon coated so they don't tear tissues -- so very little pain. I hated using the other brands of lancets. The needles are encased in a cartridge, so you can throw them away in a trash can and don't have to worry about anyone getting a stick or punching through a trash bag.

> I tend to use the same lancet 10 or more times (I know, probably not recommended)

I'm not a diabetic or anything else that needs to use needles regularly, so I can only vaguely imagine the economic downsides of only using a needle once. Especially when your insurance doesn't cover them.

But this picture kind of freaked me out and would me make think twice: https://i.imgur.com/Sh8lteI.jpg

It shows microscope pictures of a needle after 0, 1, 2 and 6 reuses.

Thank you for that. I re-use them myself - I justified it as a harm-reduction technique because I test and inject myself more regularly then. This will make me take the extra effort.

I third the FastClix. My biggest problem is that they charge about 10x the cost of the cheap lancets. I also reuse them to keep the cost down.

I had one of those for a while, and it does say you should only use each lancet once. Realistically, I don't know if there are any real risks to reusing them though?

I reuse them until it becomes mildly discomforting at which time I know the lancet has dulled. Of course AccuChek prefers that you use it once;)

I have been mostly reusing (up to a point) both the lancets and insulin pen needles. I don't go overboard, i.e .weeks, but ... how much contamination is possible? well... i never reused syringes, however. The idea of doing that makes me wary.

Blush. I hardly ever change my lancet. Maybe every other month (about 100 sticks per month).

I'm using Freestyle 14 day and yea the waste for each sensor is pretty amazing. For a tiny sensor the size of a fat nickel I end up with a box of waste that's huge. Reminds of Amazon shipping. 8-)

I've been pretty happy with the accuracy compared to blood sticks - within 10% so far for each reading.

If you were on the G5, you might want to look at the G6 if/when your insurance begins to cover it. I've had both, anf the G6 seems much more accurate. Plus, you never need to poke yourself to calibrate it (I still do sometimes, but you don't _need_ to)

I also have a needle aversion. A couple things that helped me.

1) Playing the guitar helped me build calluses big enough that I can't feel my finger tips anymore on my left hand.

2) I like to put an ice cube on the skin about an inch away from where I give himself a shot in my stomach. For me my brain really focused on the cold sensation from the ice and I notice the needle much less. It's nice too because the ice melts a little and I can use that water on the skin to wipe away any blood that drip out after the injection.

Are you aware of monitors like this https://www.freestylelibre.us/? A friend of mine has it and is really happy about it.

I used Freestyle for awhile and was mostly happy, but then had to deal with a series of them that were so inaccurate, it was a waste of money despite the replacements. The less than ideal accuracy was a bit concerning, but for understanding larger general trends, it was good.

Have you tried alternative test site meters? I test on my forearm and it doesn't hurt and mostly takes a couple of quick lanceting. I use Freestyle lite test meter with a multiclix lancet. No finger damage, no mess, just have to have forearms visible. Easier for your wife to do too since lancet placement is trivial (anywhere on forearms). Hope the CGM works for you ofc

Have you tried using the intermediate segments of the finger instead of the fingertips? It makes a big difference for me in pain perception. Drawing blood is a bit harder sometimes but I still prefer that over having to prick the sensitive tips. (Not that I fret over it. Luckily I lost that within a week of doing regular measurements.)

Hospital staff is surprised when they see where I draw blood but so far none told me to change it. I still let them prick the fingertips so they don't have to change their routine.

The suggestion in the manual of the lancet I used was to use the fingers on the less dexterous hand. It seems logical (but may not actually be correct) that you have more precise/sensitive feeling in the dominant pair.

I used to alternate hands, but I dislike pricking my tips on either hand. Using the other two segments of the finger doubles the amount of available segments so now I only prick the right hand, as I'm somewhat left-handed.

And as we're deep into the nitty-gritty: My device (Accucheck Mobile) shows the count of remaining strips when turning it on. If I take modulo 8 of that number I always know which segment to use, so I automatically distribute wear. Except that the cartridges start at 50, which means my index finger gets more pricks. I should really lobby Accucheck to make a cartridge with 56 checks! :-)

...more sinister hand

The paw further down south.

Just so you know, those days there are ways to monitor glucose levels without finger pricking, google: glucose monitor without needle.


Most (maybe all?) CGMs need to be calibrated regularly with finger pricks. In fact in the case of both the Dexcom G5 (haven't known anyone on the G6) and Medtronic Guardian sensors they can occasionally sort of derp out and ask for multiple calibrations in a row for utterly mysterious reasons. I just asked and my partner says the most times she has had to test to get a Guardian sensor back to normal was seven times in two hours.

Of course this is anecdotal, but the point is that your mileage may vary.

Apparently there's a problem with the Guardian transmitter that causes the multiple calibration requests. Minimed is taking orders for free replacements: https://info.medtronicdiabetes.com/bgcheck

I switched to the Dexcom G6 though. It's amazing. I'm using it with open source closed loop pump software for iOS called Loop. There's also a Linux based solution called OpenAPS.

Freestyle Libre isn't strictly a CGM, but it doesn't need calibration.

Dexcom 6 doesn't need to be calibrated anymore. Well, it still needs the first calibration when you insert it, but none other than that. Lasts for some 2-3 weeks before sensor needs replacing.

The Dexcom G6 system does not require any calibration, insertion is remarkably pain-free, and it lasts for 10 days. I've had it for a few months (after a couple of years of using the G5 system) and I can't imagine living without it.

Yeah I like it too, but it still asks me for the 2 calibrations right after insertion.

To be fair, that could be just xDrip+ that wants calibrations.

Have you talked with a mental health professional about your anxiety? They may be able to help you with techniques to reduce it.

Yeah, I've done a good bit of therapy (which I never found effective) and I'm on a cocktail of meds (which are remarkably effective, but they can only do so much). Anxiety's effect on my life has been drastically reduced over the years, but there are some areas where it's still quite bad; this is one of them.

A few responses have brought up alternate site testing. Have you tried the palm of your hand? The bottom of 1/4 of your palm, below the pinky. It was life-changing for me. Rarely painful (at worst a sting if my palm is sweaty or my skin is dried out), as accurate as a finger prick, and it bleeds as easily as my fingers. I had the same anxiety for years, and now it’s like nothing. You need a special cap (usually clear) for your lancet device. Sometimes it’s included, sometimes you have to call and ask for one.

Although I'm type 2 I just starting use a CGM (Lifestyle 14 day) and it's a revolution in data collection for me. I had no issue with finger sticks but you miss a lot of data. Now I get a full and complete set of blood sugar reading for a full 8 hours even if I don't scan the sensor.

It's really helping me decide how much medication I need and when it's most effective. And it's not economically difficult - if I finger stick 3 times a day then I need about 100 strips which costs me about $30. 2 14 day sensors covers a month which cost about $15 (insurance) and since I can read it with my iPhone the actual meter is optional.

I find the sensors read within 10% of a blood stick which is perfectly fine for me. I don't know if that's acceptable to Type I.

Nicely FreeStyle has an online website to access the data from the sensors and it has full download capabilities of the raw data so one can do all kinds of stuff with it.

I have a strong aversion to needles but I’ve been a type 1 diabetic for many years. I use an older Medtronic pump and want to move to a CGM soon

My checks take about 5-10 seconds but I can see where after a while it can make you hesitant.

Why do diabetics use one of the most sensitive parts of the human body for blood testing? Why not prick your forearm, or your leg, or anywhere else?

Apparently there are accuracy problems when testing other sites (though they can be used).

> "The downside to using alternative test sites is that the readings may not be as accurate under certain circumstances. In particular, if blood glucose levels are changing rapidly — as would be expected after a meal, after an insulin injection, or during exercise — there may be a significant difference in the blood glucose level measured in a fingertip sample and in an alternative site sample. Therefore, using a fingertip sample is recommended if you are monitoring at these times."

(source: https://www.diabetesselfmanagement.com/managing-diabetes/blo...)

Better source, WebMD:

> "When the amount of sugar in the blood was rising or dropping rapidly, only the finger prick testing accurately caught these rapid changes. It took about 30 minutes for the forearm values to catch up to those reported by the finger prick tests."



CGMs are great for this.

Also, try a Freestyle Libre. It’s closer in behaviour to a finger prick but still gives the trend info.

Yeah. I've been T1D since I was 13 (now 30) and I can't even imagine what it's like to live without it. It's literally a constant thread in my mind, every waking moment, and a few times a week while I sleep. I carry glucose tablets and a few granola bars on me, and you're right about carrying insulin. Am I likely to eat on this trip, or can I leave it at home so it doesn't spoil?

I once failed to bring my insulin on an international trip. That was a doozy!

Making injections easier would be nice, sure. Not having to worry about finding a bathroom or bleeding into my pants or whatever. But that's a real minor set of issues compared to the constant attentiveness that managing it well requires.

Also a T1D here. I once had my test meter go bad on an international trip; by the time I realized it wasn't working I was on a deserted island that was an about a 4-hour boat ride away from the nearest pharmacy, which was closed.

Talk about stress levels going through the roof!

> Talk about stress levels going through the roof!

(Which, of course, is EXACTLY what you want to have happen when you have no way of monitoring your BG.) Yikes!

LOL, yeah. Looking back on it now, five years later, it's a bit humorous. I went and found the resort manager and explained the whole situation to her. She didn't know anything about diabetes, so she really wasn't understanding how severe the situation was.

Resort Manager - "Won't you be ok for a week until the boat makes a trip back to the mainland for supplies?"

Me - "No, I'll be dead before then."

Resort Manager - "Is it really that serious? Do you know how much it will cost? It's really going to cost a lot of money; you will have to pay for the gas, the boat crew, and the pharmacy isn't even open on Saturdays. This is really going to cost a LOT of money."

Me - "I don't care how much it costs. I'm a dead man without it. Go wake up the boat crew and call the emergency line for the pharmacy and have someone come in."

I am type 1.5 and disagree with both parts of your post. While learning to use them routinely only takes a few days, needles and lancets do bother people for anxiety reasons, but also for physiological reasons. Lancet areas develop callouses, can have blood flow issues and in more advanced stages of diabetics can risk infections/damage. Injection sites go bad over time or appear to; right now I am dealing with an issue where I think some of my preferred injection sites are becoming less effective, but I can’t really tell, which is preoccupying. I don’t think research into alleviating the need to use needles and lancets is getting anything wrong just because it solves a need not every diabetic has.

Secondly, I think your description of diabetes is overblown. If you’re checking BGL frequently with a CGM, then you have a good understanding of what will happen in routine situations. If you’re not, you aren’t going to sweat 30 minutes in the car or the delta between the carbs from dinner plus toast and physical activity (I do like the humble-brag here, though!) because you don’t know what’s going on anyway. Hypoglycemia has the advantage of being treated with glucose tablets, which don’t spoil and can be stashed everywhere. Moderate activity and water intake are important but not going to swing your BGL wildly like a bottle of soda or an intense workout.

This disease can be a hypochondriac’s dream and I think that teaching other diabetics to be so preoccupied is dangerous to them because it increases the temptation to give up on the daily routines that actually make a difference.

"Hypoglycemia has the advantage of being treated with glucose tablets, which don’t spoil and can be stashed everywhere."

Umm... glucose tablets do in fact spoil. I've never seen an unopened bottle spoil, but once they are opened they can spoil over time mostly from the humidity. I found this out the hard way.

Sure, I replace them periodically. They don’t spoil quickly, though, in the sense that insulin spoils just from being outside too long. You don’t have to curtail your physical activity to avoid hypoglycemia because glucose is portable and durable.

"You don’t have to curtail your physical activity to avoid hypoglycemia because glucose is portable and durable."

Between this and your "humble-brag" on your other post, what I'm led to believe is that you're pretty ignorant on how variable insulin sensitivity and blood sugar management is from individual to individual.

I've maintained an A1C of less than 6.5 for more than a decade so I'm the picture of "perfect" control and I can tell you that physical activity is a pain in the ass. I'm hypersensitive to insulin during physical activity. When I go to the gym I want zero insulin on board because just 10 minutes on the treadmill could drop me from 160+ to 30. Just walking is enough to cause me to have low blood sugars, so I have to reduce or skip insulin with food accordingly. I'm required to elevate my blood sugar to 200 before I can scuba dive and then I can still only dive for a maximum of an hour because there is too much risk I will pass out and drown.

And then you say, "I am dealing with an issue where I think some of my preferred injection sites are becoming less effective". Preferred injection site? WTF dude? Of course it is becoming less effective, that is why they tell you to constantly change the location. Preferred injection sites are a huge no-no.

I'm like you when I do any activity having insulin on board. I'm a T1 using a pump, and I really like the combination of a pump and CGM for staying away from surprises. I use AndroidAPS to monitor my glucose and insulin on board, taking a temporary basal setting of 0% if needed before any activity, so my insulin on board drops to the base level or a bit below.

Soon the insurance replaces my pump to a Dana RS, which supports closed looping with AndroidAPS. Then it's just setting a temporary glucose target to a higher value and the system takes care of the basal rates to keep the glucose from dropping.

The article here is kind of weird. How am I supposed to dose e.g. 0.3 units or 0.75 units of insulin with the pills? The ability for a very fine granularity and the possibility to automate my medication are much more interesting compared to the pills mentioned in the article.

You are spot on.

The temporary reduction or even suspension of insulin depending on my activity are key in preventing lows for me.

The closed loop pumps are the biggest improvement I've seen for living with T1. There's always lots of promises, but this is one of the few things that really improves my life on a day to day basis and it just keeps getting better.

Right now it seems there is official support only to prevent hypos, but not to give you more insulin at night when you ate something too heavy and didn't guess the right TBR.

Only the open source AndroidAPS for Android and Loop for iOS do this. And then you have a very limited set of pumps you can use.

The Medtronic 670g is the only pump that currently will automatically correct highs, but it only works with the Medtronic CGM which is untrustworthy.

The Tandem t slim x2 only has support for hypo prevention today, but it supports at home firmware/software updates and they are pretty far along with the FDA on getting approvals for their auto dosing for highs. They anticipate a release this summer.

I wish that OmniPod was further along on this front. I would love to have a tubeless solution and the convenience of not needing to disconnect every time I'm going to get in the water, but the trade-off just isn't worth it IMHO.

If you can to get the right pump, I highly recommend compiling one of these apps. Just wipes out all the competition from the commercial axis, truly life changing apps if you learn how to use them.



These open source projects, written by people who actually have Type 1 are light years ahead of doing what I want a closed loop system to actually do. The medtronic 670 is so unusable. I can't say enough good things about OpenAPS AAPS (android) and Loop(iphone). For those living in the US, we are forced to use a very old medtronic pump because it's the only way with a programatic means to control the pump's basal and bolus actions.

OmniPod support is coming to AndroidAPS. Development has already started.


Yeah, I noticed that. I went and took a look to see how the project was coming along after you reminded me of it.

I would be seriously interested in a closed loop Omnipod, but it will be awhile before I’m eligible for a new pump under insurance.

I was kind of "lucky" Animas went bankrupt and they will take all the pumps back paying money for the insurance, so I get a new Dana RS earlier in a couple of months.

Yes, I deal with all that besides Scuba diving (interesting!) These routines around everyday exercise are not constant worries as represented in the earlier post. After exercising a few dozen/hundred times you know what to expect and don’t need to think about what to do. I will say that inconsistently performed intense exercise can be challenging; a regular exercise schedule is less effort to manage for diabetics.

I rotate injection spots but have favorites based on convenience, sensation, etc. like anyone else. The variation in effectiveness I’m seeing is small enough that I’m not sure what’s happening yet. It’s not really a big deal because my numbers are fine.

It’s not a disease that varies so much from individual to individual that lessons can’t be learned and shared, and it’s a disservice to misrepresent the mental effort to new diabetics and people potentially lapsing into poor control.

teaching other diabetics to be so preoccupied is dangerous to them because it increases the temptation to give up on the daily routines

^^ Sorry, this makes no sense at all. Maintaining a routine is one way to express a preoccupation with diabetes management!

I mean: there are a few things you need to do each day to manage diabetes. These are important. What you don’t need to do is worry about it between those times. If you convince someone they need to do too much to manage the disease, they’re more likely to give up on the whole thing.

More likely, as measured how? How do you know this? Spending more time thinking about my condition is a great way to improve blood glucose control, at least in my experience.

Of course. I spend plenty of time thinking about diabetes and I stay involved in the data measuring communities (Nightscout, Spike, etc.) I enjoy knowing what’s going on with my body and I try to get like-minded diabetics to look into that. I also help people figure out how to get a CGM prescription and sell them on it by loaning mine out for a few weeks (and just that much data eases worry once they see their actual operating parameters. It’s worth my going without for a bit.)

I know this because I know diabetics who have lapsed out of control, or retreated into a rather small life, because they felt the excessive personal rules they’d either self-imposed or been taught by others were burdensome. When possible, teaching them a lighter set of principles to follow has had a positive effect.

As an aside, you ever see those 'Cash for Strips' signs on the side of the road[0]?

Those are typically a person who's insurance is so lacking that test strips end up as a financial burden. Typically, well insured diabetics will partner with someone who is less well off and share strips. The test strips from a good insurance provider are typically much more than enough to cover the time period that they are prescribed for (exp: you are given 1000/mo, but only use 300/mo).

It's a fascinating side of life, somewhat like the deaf community, that exists in plain sight and yet is invisible to anyone outside of that particular community. Sociologists should investigate that partnering process if they have not already, despite the uproar that insurance companies would make over these kind acts.

[0] https://www.gannett-cdn.com/-mm-/519e70b3dd198a728f9efe74a59...

Completely agree.

Pin-pricks and injections aren't even on my radar; they're nothing at all next to the problems of needing to maintain at least some level of vigilance at near all times. Additionally, needing to constantly have plans for carrying around carbs, insulin, monitoring equipment, ensuring various prescriptions have refills and there will be pharmacies around, that the event you're attending has things you can eat, etc.—and still having periodic interruptions to whatever you're engaged in from lows or highs, or just needing to stop and check because it feels like you might be dropping low—that's the terrible stuff.

I have a hard time imagining how someone could even compare the small bother of injections to the above. I suppose if you're morbidly fearful of needles or something, but otherwise I'd be very confused at how a mild quick pain could match up to having your life dominated by this constant attention sink.

EDIT: I should also add: I got the FreeStyle Libre a couple months ago (it's effectively a CGM—or at least far far closer to the CGM side on a spectrum from finger-prick monitor to CGM), and it does help significantly with the attention problem.

And, I'm guessing how much the attention problem affects you depends on your personal standards for acceptable BG levels. I don't like how I feel when it's above 140 or so, and it's supposed to negatively effect cognitive performance to be too high, so my standards are very high (I've now had two doctors say I had the best A1c scores they'd seen).

Probably also depends on your inclination for analytical introspection / self-monitoring. I would bet I'd have ranked high on that even before the diabetes diagnosis, off-the charts high for several years after, and now, after spending years working on meditation etc.—moderately high.

By happenstance I have spent about half of my life living with people with T1D and this post echos pretty much exactly what I have heard over the past decade or two.

A lot of non-t1d folks seem to fixate on the needle/lancet parts of management because it is visceral, but have difficulty grasping the huge amount of stress and responsibility around managing time, activity, boluses, diet etc.

For example, managing stress can itself be stressful. Some people with t1d have sever anxiety, and a panic attack can trigger a cortisol dump into their bloodstream, which in turn causes a significant spike in blood sugar. I once saw a panic attack spike a person from 80mg/dl to over 400 mg/dl with no eating, no pump/infusion site failure, or incorrect basal rate.

Also, concerns about your ability to engage in sexual activity with regard to blood glucose is the furthest thing from a humble brag. It is an issue for many, many diabetics and is often a point of embarassment. Kudos for mentioning it!

Recently my partner (23yrs with t1d) and I made accounts on the twitter-like site called Beyond Type 1 which has actually been a really great community of diabetics (and diabetic-adjacent people like me) sharing their concerns and advice and we have both loved it.

T1 here. This is a perfect summary. I received my Dexcom G6 yesterday. If you dont have a CGM and insulin pump, I highly recommend both.

One thing I'm worried about WRT switching to a pump is the impact of heat on insulin. I can't have a Humalog pen exposed to 80+ degree heat for more than a few minutes without it losing efficacy. I live in Texas. What will stop the summer heat from cooking all the insulin in my pump's reservoir while I'm walking down the street?

Do you have any thoughts on this? I'd love to have more flexibility.

Insulin efficacy isn't really an issue until you are about 90+ F, anything below 90 and it will take long enough to breakdown the proteins that you would already be due to swap your infusion set (every 3 to 4 days). But being in Texas, you might exceed 90F at which point, yeah it could go bad really fast. Not a big deal though, just get a cooling wallet for your pump; FRIO seems to be the popular choice https://www.frioinsulincoolingcase.com/frio-pump-wallet.html

Thanks for the pointer. I have a FRIO, and love it. I wasn't aware that they made FRIOs for pumps.

Agreed with the other user's assessment of pumps. I've had T1D since 1990; been wearing a pump since 2004. My A1C has averaged 6.3 since 2000 (so I was in control before I started on the pump) - and I lived in Los Angeles from 2000 to 2008 (so I've dealt with the heat).

Personally, I've rarely had an issue with the heat affecting my pump's reservoir - except when I would go skydiving up in the Mojave desert, where temps would reach north of 110 degrees F. Would simply pack it in a bag with a cool pack when I was outdoors, then put it back on once I got to the ground and was back inside.

Since I was in good control, my biggest reason for transitioning to the pump was convenience. I was up to taking 7 injections a day (when I was working from home and couldn't resist the urge to snack). Once I made the switch, I was amazed at the convenience - I could eat almost anything and take the insulin to cover it (of course, moderation is the key here - and knowing how quickly and persistently some foods elevate your blood sugar. For instance, I'd much rather have a snickers bar than Chinese food. The high fat content and the rice carbs wreak havoc on my BG).

Point being, it's well worth looking into it, if you have the means and the desire.

I've been on a Medtronic pump since making the switch, but will likely be jumping over to a Dexcom CGM and compatible pump once my latest pump warranty is up. (I've stopped using the Medtronic CGM due to some hassles with calibration issues; the Dexcom is supposedly more reliable overall).

Regardless, good luck!

Yeah; it's really too bad that the Medtronic CGM is not better. I think Medtronic's pump is slightly ahead of the Tandem pump today on the closed loop, but I'm hoping Tandem catches up this summer if they get their new predictive algorithm approved for automating correction dosing for high BG.

I use the Tandem t:slim X2 pump in conjunction with the Dexcom G6 continuous glucose monitor. The one thing I hate about the pump is that it's always clipped on or in a pocket. Literally, I'm always plugged into this thing. So that part does suck, but otherwise it's just a lot better than manual injections.

It keeps track of my insulin on board so I don't have to worry about stacking and getting a low nearly as much. It's programmed with my carb ratios so I just type in the carbs and it doses accordingly, it will even take your current BG into consideration and increase/lower the insulin dosage to help get you at target BG.

With manual injections, you have to give 1 full unit of insulin; the pump can give doses as small as .04 units of insulin so the dosing is much more precise. You are no longer saying, "Well should I round up or down..."

The pump has a closed loop with the CGM, so the pump knows if my blood sugar is going to be low BEFORE I'M LOW. So it just automatically quits giving insulin to help prevent the low before it ever happens.

Honestly, it's pretty amazing to me how far these things have come from just 10 years ago.

Our 7 year old lays on top of his pump regularly when he sleeps and despite it making the entire pump way hotter than 80 degrees, it’s never caused any efficacy issues. He’s played soccer for 3+ hours in the 95+ degree heat (4 days in a row), no problems with the insulin on board.

From the context of your message, I think I correctly understood you to mean you have had no problems with the insulin that is in the insulin pump's infusion set reservoir?

Trying to help and I don't want to come off as rude, so please forgive me in advance. The term "insulin on board" has a very specific meaning and it refers to the fast acting insulin that is currently in one's body and still active.

So let us say you are using fast-acting insulin, like Humalog, and it stays active in your body for 2.5 hours.

You take 3 units of insulin at Noon

1 hour later you take another 3 units of insulin

1 hour later you take another 4 units of insulin

At 2:00 you have 10 units of insulin on board

At 2:30 you have 7 units of insulin on board

At 4:30 you no longer have any insulin on board

You're right - I'm sorry, I shouldn't have been so careless with my words. What I meant was, we've never had a problem with the insulin in his pump's cartridge/reservoir even in 90+ degree heat for 3+ hours with him running and sweating.

My friend is T1 and uses a Dexcom as well, it seems like a way better solution. He recently got a diabetic alert dog too which seemed to give him a lot more piece of mind, although I realize that's a pretty expensive route and not for everyone.

Grats on the Dexcom. It's a game changer. I don't use a pump myself for a variety of reasons (chiefly, my current routine is working well, no reason to change it), but I dearly miss the Dexcom when I have to go without for some reason.

Ditto for me. I don't mind the insulin pens or the blood tests - it is the constant monitoring / science experiment aspect of all this that is exhausting. Even if I had a phone app that graphed my levels for the past 24 hours, counted carbs for me, and calculated insulin doses, I'd still find it all irritating and would slack off on the 24 hr a day 'mindfulness' it takes.

Even then, I am still going to die earlier than a non-diabetic. So why should I kill myself for 50 years going to the n-th degree when n-1 or n-2 is ok enough? That is my justification for keeping h1bc below 8 or 9, never mind below 7.

All the effort into projects like tech for snorting insulin is just surface stuff, much like all the glitz in the IT world that accomplishes superficial stuff (but takes lots of VC money). I am reminded of the CueCat... 30 years ago, they said there'd be a cure by now. I am still waiting and am going to die before it ever happens. Snortable insulin is sexy, but not that useful in the grand scheme of things.

Type 1 for 30ish years... I wish there was some way to move this comment to the top of this thread. You pretty much hit the nail on the head. Yeah, injections suck, but the real sinister issue is the constant attention it requires, and if you don't pay attention, you can get in trouble (hospital, death) real fast. Longer term, lose limbs, eyesight, etc.

"What doctors and researchers get wrong about diabetes is that pin-pricks and injections are not even remotely bad. I don't know a single diabetic who cares about injections and blood sugar tests. You get used to that within the first week of diagnosis."

Dude, you don't know many diabetics then. Companies spend billions of dollars to solve this problem.

I’m Type 1 and I agree with him. Injections are not a problem worth solving for me. It’s the constant mental grind of tight-rope walking blood sugar through balancing food, insulin, exercise, and random body events (that you never quite figure out) that is the problem.

Blood sugar testing is an annoyance, but the main problem is not the actual test, but the inadequacy if testing your sugars a few times a day as a method of control. There we do have solutions coming out; the latest generation of continuous blood glucose monitors are life-changingly good.

I've been using Dexcom now for two years, and it finally helped me to really understand certain weird things about my blood glucose, after having a type1 diabetes over 20 years.

a) The morning peak is a dawn phenomenon. Solved with a higher basal setting 3 hours before waking up.

b) Going to sleep with a 100 mg/dl and waking up in the middle of the night with a glucose of 300 mg/dl? Usually because eating fatty and heavy food for dinner. Depending on your meal, a 150% temporary basal or if looping, letting the oref1 super multi bolus to take care of it.

c) Having a cold and suddenly there is no way to keep your glucose levels down? I use AndroidAPS's profile multipliers here. Last time I was sick I set the multiplier to 160%, which means more basal, more insulin for carbs and correction.

d) Doing sports? Get the insulin on board settings right in AndroidAPS, and try to do exercise only when the IoB is back to the base level. Use 0% TBR if needed.

And still I have an alarm almost every night for a hypo/hyper. Soon closing my loop and letting the automation take care of the nightly surprises. It used to work great with my Accu-Chek Combo pump until the pump broke. Now hopefully getting a Dana RS soon, so I can automate lots of things for the software to take care of.

I’ve been using Dexcom for about 6 months, and it’s taught me that the situation was utterly hopeless without it. I’ve figured out a few patterns like the huge nighttime sugar spike with fatty dinners, but overall I have unpredictable reactions to food and even moderate activity. Like you, I have usually spikes in the morning without eating, but sometimes dips.

The CGM has allowed me to be more like a reaction machine. Going up? Injection. Heading close to to low? A few sips of juice. I can be more aggressive with my dosing know I can see those lows coming. It’s a huge cognitive load off, and has taking my control from poor to excellent.

But yeah, those night time alarms, huh? I’ll close the loop when it’s all done with my phone.

Oh yeah. More than two beers in the evening: hypos in the morning, either 4am or sometimes when I woke up around noon.

Also instead of taking sugar when going low, try using a system that counts your basal rates to the IoB. Then after a meal you start going down a bit too early, you turn the TBR to 0%. Loop or AndroidAPS helps with this a lot.

Yes, and many of them have failed. Pfizer's inhaled insulin was a flop and MannKind's isn't doing well. They were positioned as "no more needles!" and what they realized is that it's not enough to get people to switch.

I think people who don't need to inject don't realize how benign it really is: I'm not diabetic, but I did need to give myself 3/daily subcut injections (same style as insulin) for a month after an injury. It was absolute agony for the first week or so; often I'd need to psyche myself up for a good 15 minutes before injecting. But by the end of the process it was a 15 second endeavor that I didn't mind in the slightest.

Me and my wife are T1D since childhood. I have started with reusable glass syringe with bovine insulin then Insulin pen and recently switched to pump. Living in developing county and having diabetes is nightmare. Constant mood changes due to sugar imbalance and highly chaotic environment of developing county make the things more difficult. People and even doctors are not able to understand about this decease related situations. Since last 5 years, we are not able to decide whether we should have baby or not.

One of my friend was telling me that I am not participating much in adventure activities I smiled and told that for me, living life itself is far more adventurous.

What doctors and researchers get wrong about diabetes is that pin-pricks and injections are not even remotely bad. I don't know a single diabetic who cares about injections and blood sugar tests. You get used to that within the first week of diagnosis.

My father in law seems fine with the act of injecting itself, but he's very private about his health issues and seems very self conscious about injecting. I've known him about 15 years and he'll always leave the room to inject even in his own home with only family around. I'd imagine this might help someone like him in a small way.

> I don't know a single diabetic who cares about injections and blood sugar tests. You get used to that within the first week of diagnosis.

Tell that to my wife who has had diabetes for 4 years.

I just stopped caring and accept that I have to die sometime. I have good A1C control, test regularly, and am very physically active. But thinking about it constantly just drives me nuts so I go about my life and if it's what kills me, so be it. And if in the (hopefully far) future my physical health is compromised to the point that I don't want to deal with it anymore, I'm at peace with that, too.

Don't feel required to answer, but I'm curious, does that mean you just run high (>150mg/dL) all the time? I find being low (<70mg/dL) or high makes me feel physically poor, and keeping in that narrow range is what I mean when I say it takes constant attention.

No. I rarely go over 150-160. I'm usually around 100 on waking and am between 70-140 for 90+% of the day. Most common lows are during/after a long run or when I overcorrect for a high.

Insulin is pretty temperature stable these days: http://link.springer.com/content/pdf/10.1007%2FBF00277482.pd...

I’m not diabetic but just reading your comment is making me feel queasy and on edge.

This seems like the perfect job for a machine. Is there a reason CGMs and insulin pumps aren't more common? Cost?

Cost seems to be the major factor. I believe the NHS doesn’t supply them for this reason. That said, CGMs cost about £150 a month. Worth sacrificing just about any optional expense for I would say.

From what I've seen with friends, CGMs seemed to be a pretty big lifestyle improvement through technology.

Once ingested, water dissolves a disk of sugar, using a spring to release a tiny needle made up almost entirely of freeze-dried insulin. The needle is injected into the stomach — which the patient can’t feel, owing to a lack of pain receptors in the stomach. Once the injection has occurred, the needle can break down in the digestive tract.

With the right compound in the needle, thst sounds like an incredible way to assassinate someone without leaving any traces which are unlikely to be found. The combination of a tiny needle mark on the inside of the stomach, a lack of dissolved pills in the gut, and a likely delay between administration and onset of effects, it’s sort of perfect.

Sorry, I don't think so. Getting someone to swallow a pill sounds strictly harder then getting them to swallow a liquid.

It’s a sugar pill, if the target eats candy or takes any other pill it would be doable. It would also be easy to slip into food. Liquid is easier, but will leave unavoidable forensic evidence. If making something look like natural causes even under extreme scrutiny is the goal, this is a hell of a way to do it.

How often do you swallow candy without chewing?

Yeah... that’s a good point. Candy is probably out, but with the number of supplements and pills people take, that’s probably easier. Then of course you have the challenge of accessing them at some point, but no one said that attempting an assassination like this would be easy. More of a problem would be that if it didn’t work, and was discovered, it would be very clear that a government or similarly powerful organization was involved.

So good for secrecy, bad for deniability. All told, strangling someone and making it look like a suicide, or “helping” someone make a jump is probably still simpler and safer.

>> With the right compound in the needle, thst sounds like an incredible way to assassinate someone without leaving any traces which are unlikely to be found.

If I recall correctly there was a story about a CIA weapon that shot a needle or dart made of a frozen toxin. It would penetrate the skin, melt, and cause a heart attack. There would be no evidence other than an incredibly hard to find hole in the skin with no physical object to be found.

I don't think that myth would work out although it is a common one. Namely it would show up on a tox screen in some way presumably. Since that is usually how poisonings are found - granted they would need to do an autopsy in the first place.

The interesting thing that isn’t usually an issue with tox screens is the they are limited. You can search whole classes or drugs, but ultimately a truly novel poison would be detectable in principle, but likely to go unnoticed. Now for you and me that’s enough, because we have the resources of individuals, but a large lab and especially a government can afford to engineer toxins that are not tested yet.

Having said that, such a toxin that could also be frozen and the resulting “dart” being strong enough to survive being fired into someone, is not perfect. Like the poison umbrella, you’d expect traces of toxin to be found around the wound, and even small wounds become evident under ALS.

What is ALS? I'm presuming you don't mean amyotrophic lateral sclerosis.

Sorry about that, you’re right too, it’s Alternate Light Source.

Seems like a very complicated and expensive way of administering poison.

The real question here isn't the delivery mechanism, but the properties of this magical compound - whether it leaves any traces in the body, and what symptoms it causes.

Perhaps this is a "peace dividend" of a military project, much like the Hubble Telescope.

I test my insulin willingly with no diabetes. One hard squat hurts way more Than either of those activities. I have actually teared up from hard lifts. Needles are just a nuisance. The real downside to beetus is having to think about it constantly, IMO. (And managing it for kids, who don’t have perspective on blood/needles)

> The real downside to beetus is having to think about it constantly, IMO

Pretty much this. Obviously needles and finger pricks are a bigger deal for some people, but most diabetics get used to it fairly quickly. The hard part is the constant mental drain of having to be your own pancreas. It's like you're constantly flying a plane where you have to manually maintain a certain altitude, because you'll crash and die if you fly too low or too high. It's exhausting.

Do you mean you test your blood glucose levels, or are you really testing your insulin levels somehow? (I don't know if that's a thing?)

Yeah, sorry, blood glucose.

~meditation or similar mental massaging seems to be key at one point. Avoiding the damages of constant stress is important.

Yikes! Just a quick follow up to my original comment... After reading a lot of the replies I realized I have never actually given serious thought to what it would be like to have diabetes. Sure I shared my little anecdote, but I’m currently a reasonably healthy (read: lucky) person who doesn’t have to grapple with any illnesses.

Given that, it was quite improper for me to share my thoughts about how I would respond to an interesting development in medicine like this. So, thanks to all the thoughtful replies to the parent, they were very eye opening.

I can't help but smile at the idea of using sugar to deliver insulin

Less painful but it's hard to see how this would be as reliable as a standard dermal injection. Pumps definitely have reliability issues but they tend to alert in most cases.

I'd have hoped for needle-less operations (lack of pain is not the best of arguments).

That said when MEMS meets medicine there could be a vast change.

"...and you don't have to prick your fingers anymore!"

(Sorry, if you don't get this reference please ignore.)

Type I diabetic here.

The injections are really not a significant problem for me. A lot of people may recoil at the thought of injecting themselves often, as though it's painful. It's either not painful or maybe a little, but I just don't care much.

Much worse things about being diabetic are:

* Danger of low blood sugar

* Trying to get the right dose

* Timing the dose so it is effective at the right time

* Carrying around a bunch of stuff that I need or may need, like insulin and glucose tablets

* Trying to keep the insulin cold enough or fresh enough that it retains its potency

* Keeping my phone on and charged all the time, which has my blood sugar readings, and checking it at times where it might seem like I'm rude. I'd rather use a watch or special device, but the special devices are strangely bulky and don't hold a charge, and watches apparently can't receive blood sugar readings yet (without a phone also present).

None of those things are very terrible. Treatment is much better now. But they are all way worse than the tiny insulin needle injections.

Hey - I assume you're using a CGM - Dexcom?

Check out XDrip. Its an opensource community built collector for CGM data. They have a version that runs on Google Wear so your android watch can act as a collector. You can also still use your phone to collect and just have the data appear on your watch.

Nightscout is another good related resource


xDrip is such a great piece of software that few people know about.

If you’re want to see the future of medical care using smart devices, start there.

Can you give a bit more detail on how you use it? Is extra hardware required?

No extra hardware needed. Only your phone and a CGM if you wish to use one.

xDrip allows you to configure various care settings and then will provide real time blood sugar feedback and dosing suggestions.

There’s (almost) nothing else like it in this space.

I'm confused as to what parakeet does. I have a Medtronic 670g with CGM, and xdrip supports it. Apparently Medtronic already has an app, but xdrip uses data from it. Also not really clear where nighscout fits in. Is that just the service in the cloud to store it, and xdrip is the display?

We have a Dexcom G5 and use Xdrip to read the data directly from the CGM. It has a number of benefits over the OEM provided readers: -no forced replacement times for sensors. -No forced delayed starts on new sensor insertions -predictive algorithms and treatment recommendations. -more integrations into third party systems (like IFTTT) -Opensource community project that keeps evolving much faster than the OEMs

Nightscout is a cloud service to store data reading and treatments. Again its community developed opensource solution which gives you complete ownership over your data. Some of its earlier game changing features are now common in the OEM solutions, but I still like the idea of owning this and it being opensource. Nightscout is a really big help for us managing our son (whos 6) since it makes it really easy to give real time access to his CGM and treatments to anyone anywhere.

Nightscout is also the unofficial hub for the Opensource development in diabetes. They've contributed so much that is now being used by OEMs. Im a big supporter.

just to add to this. There's a similar solution for iOS called Spike, its not in the appstore though https://spike-app.com/

Also check out https://openaps.org/ - its a community developed closed loop solution. Very cool.

Cool! Yes, on the dexcom G6.

Thanks, I will check those out!

And if you want a smart watch able to show your glucose value, get a pebble if you can find one somewhere. The battery lasts 6-7 days and the e-ink screen is easy to read in the sunlight and will not blind you at night.

Works with xDrip.

This! We have these for my sons teacher (hes T1 and in grade 1). Their pretty bullet proof.

I use Spike on iOS https://spike-app.com/ to get it on my apple watch (it does this by creating new meetings in the calendar) works ok.

Its amazing to me that Pebble can allow real time updates to the watch face and apple severally restricts this feature for third party apps.

Maybe better for children? The needle is probably their biggest concern.

I was diagnosed around 12. It was briefly a concern until I actually did it.

The blood checking pokes are much worse, because they have to actually draw blood. Usually fine but sometimes quite painful or difficult. Now I use a continuous glucose monitor (CGM) and it's much better.

Weirdly, it’s not age but an individual perception thing.

Many many people don’t really notice or care about the needles (me included) because as OP parent posted, we have other stuff to deal with that takes up way more mental space.

I guess this isn’t apparent because the needles are the obvious bits but then rest is all the “thinking” that invisibily surrounds the injection.

There are however many people who just can’t wrap their head around needles and can’t do it. The needles themselves are tiny so it’s not that - it’s just how they perceive the world.

Any technology that helps these people and makes their lives easier should be embraced.

I just watched a lecture on diabetes by Dr John McDougall last night. He described type 2 diabetes as the body's natural way to limit weight gain. He points out that morbidly obese people are often not diabetic: lack of insulin resistance is what enabled them to keep growing. Viewed this way, diabetes is a sign that a person has reached maximum weight. Giving a person additional insulin at this point is like trying to override the body's defense mechanism and forcing it to gain even more weight.

McDougall has lots of other interesting insights in the lecture and discusses how he treats diabetics. He goes into some detail about how he decides how to adjust medications and why he recommends his diet.

I'm posting this here because it may be of use to people who may not have heard this information from their own doctors.

The lecture is found here: https://youtu.be/UgE2IdL6tMw?t=1103

The link starts the video at the point where McDougall starts discussing type 2 diabetes specifically. Before this he talks about insulin and type 1 diabetes.

and why he recommends his diet.

...which is the key. McDougall's claim to fame is fad diets and prepackaged food for the same since the 80s, and anything where his bottom line is involved is suspect. He's the vegan equivalent of Robert Atkins, basically.

McDougall is not who I look to for nutritional (or really any) advice. I'm sure he's right sometimes, but his credibility is so compromised by his business that I'd need to hear it from someone else first with their data proving it before I'd ever believe it. If he told me the sky is blue, I'd get a second opinion.

I am mostly familiar with McDougall because of his extensive, high-quality, free youtube lectures. I have exactly the opposite impression of him than you. Instead of advocating a fad diet, he advocates a low fat, whole food, starch-based diet. He justifies it first on the grounds that every successful civilization has had this diet. Pick any civilization, country, or people group that is healthy and you will find that their diet is based on starch. His diet is the opposite of a fad diet: it's the diet that has sustained civilization.

His diet is cheap and accessible. You can follow his diet by eating locally produced wheat, potatoes, oats, rice, corn, millet, beans, etc, in all parts of the world that have an agriculture season. A feature of his diet is that starchy foods store well. Indeed, he says that the reason humans became so successful is because they were able to have a food supply that was high in energy and could be stored.

McDougall does not sell pills or supplements. He specifically counsels against them, saying that they are unnecessary with a good diet and potentially harmful.

In addition to a lot of free educational content, his website (drmcdougall.com) features different programs, including a 10 day live-in program which includes medical care plus meals and education for $6,060 for a single, full participant. You can also buy books, podcasts, and apparel. I didn't see any prepackaged food on the site.

I've considered him a source of high-quality, unbiased advice for several years. His presentations are clear and logical. He's not trying to sell me something. He is conservative in the sense that he prefers cheap, simple solutions before expensive, complex ones. For example, he would recommend that before you try medication and surgery, you should first try to change your diet. If you're not feeling well, make sure you're eating eating a low-fat, whole food, starch-based diet before trying to find a missing miracle vitamin or supplement.

Can't speak to the claims in this comment around type 2 diabetes, but worth noting this article and pill is specifically for type 1 diabetes, which is in no way related to weight or metabolism, but rather an autoimmune disease.

I think there's a lot of confusion/ignorance with Type 1 and Type 2 and most people just lump them both under the same diabetes umbrella. Diet and exercise will never be enough for Type 1's since the disease is an autoimmune disorder where the pancreas is attacked to the point where it makes little or no insulin (thus the need for external insulin). Type 2, as I understand it, is a progressive disease where the cell's insulin receptors become nonreceptive. I think, in some cases, though, Type 2's can become Type 1's due to their pancreas being overworked to the point where they need insulin. And on the flip side, Type 1's can become Type 2's as a result of eating poorly and overusing insulin. But I wish each disease had it's own name to avoid confusion over how each one should be treated.

This is a huge problem. I wish the medical industry would stop using "type" and assign specific names to disease variations. So type 1 would be diabetes but type 2 would be dropped from convention and called insulin resistance (or a new name, I dunno, setebaid). Some other words that have probably cost the world billions of dollars and interfered with public opinion:

* Hepatitis A/B and C (A and B were cured early on so name should be livervirus or whatever, C should remain hepatitis until it's eradicated)

* Herpes types 1 and 2 (1 should be renamed to cold sores since almost everyone has it, 2 should remain herpes until it's cured)

* Nonfatal cancers (especially of the skin) need new names to prevent scaring people, especially if they've been largely cured.

* SSH "private key" and "public key" (should have been called "secret" and "share" so that people would know which to keep secret and which to share.. yes I realize they are symmetric)

I could go on, but you get the drift. I think a problem here is that experts in various fields may have exceptional problem solving skills but be terrible at naming things. I've met many programmers with this affliction!

I think the naming of private/public keys is already pretty clear ...

I know several Type 2 diabetics who are not (and have never been) obese. While obesity is definitely a cause for the disease, it is not the only cause there is.

I googled "diabetes in thin people" and found the term "skinny fat", slim but with a high percentage of body fat. These are people who may appear to their body to have enough fat stored to survive a tough winter. (This was how McDougall describes the onset of diabetes.) Can people with low body fat get diabetes?

Did you mean, can a person with low body fat get Type 2 diabetes?


Dominique Wilkins has type 2 diabetes. I would imagine his body fat is pretty low.

Yep- it's in my family. Nothing to do with bodyfat. A body weight change of +/- 50 pounds makes no difference in fasting blood sugar. Hits later in life though (50s).

This is extremely myopic...

Once you're diabetic, a lot of "bad things" happen. People don't take insulin then just to continue eating...

McDougall points out at one point that it's common for people to gain weight after their doctor tells them to lose weight and puts them on insulin. Insulin promotes weight gain.

It doesn't. Eating too much and exercising too little promotes weight gain.

Right. And the insulin injections allow them to continue their lifestyle of eating too much and exercising too little. Their body is literally rejecting food and that's the problem insulin solves. It does not solve the root issue.

If you spend a lot of time around diabetics you'll met many people who have lost appendages and continue to live an morbidly unhealthy lifestyle.

The insulin injections also allow diabetics to regulate their blood sugar so that they don't have to deal with even bigger problems.

I have spent a lot of time around 4 diabetics in my family, none of which had morbidly unhealthy lifestyles. Sure, they could all use a little more exercise and moderation in their diet, but then again most people can.

> ...described type 2 diabetes as the body's natural way to limit weight gain.

Hogwash. If that were true, I'd be skinny. Aside from the standard low fat calorie restricted diets preferred by nutritionists, I've noticed that there seems to be two prevalent themes with respect to currently marketed dietary advice targeted towards T2 diabetics:

Theory #1. High fat intake or the "wrong" fat intake causes insulin resistance by infiltrating the cells or "clogging up" the insulin receptors on cells. Solution: buy my low fat vegan diet plan.

Theory #2. Eating carbs spikes glucose, which intern spikes insulin. "Insulin resistance is a function of having high insulin levels all the time." Solution: buy my low carb diet plan, or buy my book on intermittent fasting.

How would this be reconciled with significant weight loss often being a symptom of type 2 diabetes?

> How would this be reconciled with significant weight loss often being a symptom of type 2 diabetes?

I don't know, but here is my guess:

At the beginning of the lecture McDougall talks about there being three kinds of diabetes: type 1 (pancreas produces no insulin), type 2 (pancreas produces enough insulin, but it doesn't work because of insulin resistance), type 1.5 (not enough insulin is being produced to cover the body's needs). Significant weight loss seems to fit in the type 1 and type 1.5. McDougall will prescribe insulin if a person is in danger of losing too much weight.

Sadly it's easier to staple stomachs than produce lasting behavior change

Study by Novo Nordisk. one of the fine companies responsible for raising insulin prices by thousands of percent.

Read up on the matter. The culprits are pharmacy benefits managers who push producers to increase list prices while demanding obscene rebates that are never passed on to the consumers. Most producers don’t disclaim the rebates, but Lars Fruegaard (Novos CEO) is on record saying that it increased from 64% to 67% last year. So pharmacy benefits managers are pushing up the list price but less and less is getting through to the producers. The American system is rigged by the middlemen who approach consumers with ownership of “cheap drugs” because of the rebates, while they approach the producers with ownership of the consumers. As an alternative to that system Novo Nordisk is releasing cheaper insulin through a partnership with Walmart where it goes directly to the consumers.

Openness around rebates will be a great first step to help lower prices, but the PBMs have gotten the industry into a reverse price war where everyone is overbidding each other on price in order to provide the larges rebate to PBMs. Something big has to change to revert that cause.

Disclaimer: I work for Novo Nordisk.

Although I appreciate the $25/vial insulin sold at walmart, its unfortunate that its such an old-school version that that it makes it almost dangerous to try and manage diabetes with it *obviously better than nothing though.

I know, before insurance, it costs around $240 a vial, and I know personally I go through roughly 3 vials a month. I would guess I use a lot less insulin than a lot of others too.

So I know the manufacturer isn't the only one to blame, and maybe its unfair to completely blame them, but as much as the manufacturers are donating to politicians I cant imagine they are doing a lot to fight it either.

>Read up on the matter.

Slightly off-topic, but could you talk about what pharmacy benefits managers are supposed to do and actually do, for insulin especially, and their effect on the market?

I Googled this term but can't make of sense of your comment based on what I've read. (The definitions of pharmacy benefits managers that I found have nothing to do with what you wrote.)

There is a paragraph in the wikipedia article on PBM[0] full of sources on this.

[0] https://en.wikipedia.org/wiki/Pharmacy_benefit_management#Co...

Can they just sell direct to consumers? Cut out the pharmacy and the insurance companies. You guys could earn more while the patient pays less.

90% of diabetics are insured. If we stop selling to insurance and try to sell directly to these patients we would end up being more expensive than competitors and lose those customers. I mean you could argue that if they are paying their own insurence they could cancel and perhaps have a net saving on the insulin, but that seem very risky considering potential comorbidities of diabetes, and you’d lose all other coverage.

Each level in the system INCLUDING PHYSICIANS gets a cut.Thein entice is to keep raising prices.

Jesus man. Novo has invented and produced more insulin in the last 30 years than any other company or organization. I get that you're disgruntled about the price of insulin; I am, too. But put the blame where it belongs, not on the people who are producing more and more insulin to accommodate more and more diabetic lifestyles and helping to drive the price down rather than up.

Per a quick google <15% of type 2 diabetics use insulin. I would say this effects more type 1 diabetics than anything. Or are you trying to say peoples lifestyles are leading them to an autoimmune disease?

Also, according to a quick google search only ~5% of diabetics are type 1, so there are still about 3 times as many type 2 diabetics taking insulin.

Regardless, I suspect he meant that more different types of insulin allow diabetics to take insulin in more different ways aka lifestyles. e.g. closed loop CGM vs a daily long acting insulin plus a short acting for meals.

Both T1D and T2D are increasing year-over-year. Also, 90-95% of diabetics in the US have T2D, so the 15% of T2D patients on insulin is still 13.5-14.25% of all diabetics. We already know that 76.5-80.75% of all diabetics aren't using insulin, because they're non-insulin using T2D patients.

In other words, more T2D patients take insulin than exist in all of the T1D population.

I'm saying Novo Nordisk produces insulin, and in doing so causes downward pressure on insulin prices thanks to basic economics. (When the supply of a good increases at the same level of demand, price falls.) This is true for both type 1 and type 2 diabetics.

In Novo's case, they have two kinds of long-acting insulin analogue taken 1-2 times per day for both T1 and T2; they have to my knowledge the only ultra-long-acting insulin on the market, taken once every 2-3 days, most appropriate for T2, but also viable for some T1 lifestyles; they have very-rapid-acting insulin for T1 diabetics only, and they have older kinds of insulins appropriate for older patients.

They offer all of these products in good supplies. I've never seen or heard of a Novo product's being unavailable at the pharmacy. So, as far as I can tell, their only influence on insulin prices is downward pressure, not upward pressure. Every new product they produce lowers the price of insulin despite industry-wide changes.

There are really 2 major makers of insulin Norvo and Elli and another that isnt near as popular, Apidra. Each insurance company has a 'preferred' where you only have 1 choice.

So, with that I dont feel like there really is any competition. A good step forward might be to disallow insurance companies from having 'preferred' brands.

Not a bad idea at all. I'd prefer that insurance companies weren't involved at all, but as a second-best option, I'd prefer if the insurance companies allowed the pharma companies to compete with each other for my business!

Insulin prices have inflated by about 500% over the past two decades in the United States.

Novo Nordisk's profits have seen a similar rise.

Now, im no economitician, but I'd wager a vial of Fiasp® that there's more than just supply and demand going on here.

Here's what an ADA working group[0] had to say about possible causes for Novo Nordisk's insulin price increase:

> Novo Nordisk also published data for two of their insulin products, NovoLog and NovoLog FlexPen. Since the early 2000s, the CAGRs for the list prices for NovoLog and NovoLog FlexPen (Fig. 7) have been in the range of 9.8–9.9% (22). This translated into large total increases in the list prices: 353% (2001–2016) for a NovoLog vial and 270% (2003–2016) for a FlexPen. In contrast, net prices received by the manufacturer increased at a more modest rate (3–36%) with CAGRs of 0.2–2.1%. Novo Nordisk, Eli Lilly, and Sanofi have reported that rebates have grown rapidly in recent years, representing more than 40% of U.S. gross sales in some cases

[0] - http://care.diabetesjournals.org/content/diacare/41/6/1299.f...

Yes, there is more than supply and demand going on here, which explains why one company's pricing policies can't account for a 500% industry-wide increase. Novo is not a monopolist.

A lot has changed in the last 20 years. A lot of regulatory and insurance law changes. When the law mandates that we pay for all our medicine via 3rd party intermediaries, you can expect a corresponding price increase as those 3rd parties add their intermediary markup.

The price of Novo insulin in Denmark has not risen since 2005 for the products I checked.[0] So they haven't followed the price index and have thus become cheaper.

[0] https://www.medicinpriser.dk/?lng=2

You're missing the key part of the story. Yes, Novo's price went up, but so did their rebates. The price of insulin (net price) has actually be increasing less than inflation.

Novo Nordisk has yearly profits of somewhere in the neighborhood of 10b a year.

Those numbers are partially generated by pricing insulin products out of reach of many people who died from not being able to afford it.

Sorry if I don't have a lot of sympathy for them.

25$ at Walmart. I don’t get how people disregard this all the time. I don’t know if any other companies are selling affordable insulin directly to consumers but Novo IS doing just that.

If this is at all attractive to people, it's going to make insulin so damned expensive.

The price of insulin is already rising: there aren't all that many generic manufacturers of it, leaving them in a competition-free market. If this takes off it's going to suck up a good chunk of the marketplace, and probably leave us with maybe one or two generic manufacturers - enough to have an effective monopoly. Insulin prices will spike the same way epi pens did.

Good tech. But sad re. what it's going to do to patients for a while.

> The price of insulin is already rising

That really is a sad state of affair, insulin is cheap to produce and we shouldn't live in a world where such a basic medicine is controlled by for profit organizations.

At least in countries with a proper health system the cost isn't impacting on an individual level.


Generic insulin is available at $25 per vial. Guess what? Nobody wants to use it because the next generation of insulins is better.

As a type 1 diabetic, this isn’t remotely true for me. Novolog and its equivalents made timing impossible for peaks of insulin and food absorption. Also made low carb impossible due to the peak pattern of the insulin compared to digestion of low carb, high protein meals. Insulin pumps with combo boluses resulted in unpredictable absorption due to scar tissue from having low body fat percentage.

Ended up switching back to generic novolin R (regular) as injections which allows me to use different areas of the body, eat low carb, and dropped my a1c down 3 points. Reduced my standard deviation of blood sugars by about 45 as well.

Every diabetic is different though as others have found great success with novolog, insulin pumps, etc.


What I’ve heard from other diabetics is that the older Novolin drugs take a lot more effort to get constant insulin levels than the newer ones.

I guess not true for everyone!!

There isn't a generic insulin available (at least in the US) - that's why there's a movement of biohackers to homebrew insulin.

While not a true generic, Novo Nordisk does sell an old version of their insulin at Walmart for $25 a vial. About as close to a generic as you’re going to get.

Manufacturing insulin isn't under patent or a trade secret is it? If the price of insulin rises, then manufacturing insulin becomes more economically viable, so new players will enter the arena, thus driving the price down.

Is there any reason this wouldn't be subject to the normal laws of supply and demand?


Looks like a patent issue (every new improvement in production methods has its own patent, so the insulins for which patents have expired are lower-quality in one way or another) plus shipping costs (refrigerated bottled liquids with a shelf life <6 months).

You would think so, but the market is dysfunctional because of the regulatory complexity of the US healthcare system: https://health.usnews.com/health-care/for-better/articles/20...

Insulin has been around 90 years. Its gone through several different methods of extraction and manufacturing. They know how to make it high quality and inexpensive.

Breakthrough like this needs to be designed so that people can afford it. It just becomes burdensome (and depressing) for people who may need it and find the cost out of reach.

On the other hand, given that treating diabetes is more costly to the society in general (although more profitable for the pharma companies), shouldn't there be more research to ensure people don't get into the trap of becoming diabetic? One reason people become Type 2 diabetic is that they are completely unaware that their lifestyle and food they are eating are slowly creeping in to make them suffer with this disease. Healthy people only know about them becoming diabetic because the cycle to get your blood sugar measured (A1C Hemoglobin) is too far in between (annual checkups). If a person is more aware of his/her blood sugar levels at shorter intervals, then a proactive approach can be made so that the person can do changes that will help prevent diabetes.

BigPharma is a business and has no incentive to prevent or cure disease but to make sure the patient remains a customer

What's the point of having this be an internal device? Why not use the same technology to make external injection devices easier to use? It seems to me like having the device be internal just increases the number of possible failure modes and makes failures harder to spot/recover from.

Depending on what I eat, I need different ammounts of insulin, and adjust the dose acordingly using my insulin pen and needle.

How does one adjust the dose in a pill? Do I take more or fewer pills?

They mention the insulin is "freeze dried". What does this mean in practice? Do I need to carry around a climate controlled box with my insulin in?

"freeze dried"

"Freeze drying is a water removal process typically used to preserve perishable materials, to extend shelf life or make the material more convenient for transport. Freeze drying works by freezing the material, then reducing the pressure and adding heat to allow the frozen water in the material to sublimate."

You freeze it or shock freeze it and then "distill" the water of in vacuum. The ice goes into the vapor phase, skipping the liquid phase. This process is called sublimation and part of each first year high school chemistry curriculum.

The substance, insulin or other peptides, will be stable after this at room temperature for some time.

Freeze dried foods usually remain stable at room temperature and do not require refrigeration/heating once freeze drying is completed.

People that are pancreatic insufficient take replacement enzymes in capsule form and the dose is based on their size and the amount of fat in the meal that they are eating. There is a learning curve when they start but they get pretty adept at guessing how many capsules to take.

I know we're a little ways off, but this seems like a great platform to combine with automatic blood sugar measurement. Imagine taking one pill in the morning that measures your blood sugar and internally administers insulin as necessary. There are already externally attached pumps that do both (my father, a type 1 diabetic, uses one) but having an electronic device permanently attached to your stomach is a bit of a hassle.

I can see why they're targeting type 2's, as they may need more of a fixed insulin boost than full insulin replacement that I and other type 1's need. Part of the fun being type 1 is figuring out proper adjustments to your insulin dosages based on food, activity level, stress and other factors. It's a clever design, though, and may help some people stay more compliant with their treatment.

I view this is interesting research about medicine that has nearly zero usefulness for actually treating diabetes in humans. Since this is a technical audience, if you're diabetic I can't speak highly enough of the opensource efforts combining a cgms (like a dexcom) with a pump and then software running on android or iphon or raspberry pi to create a "feedback loop" to slowly but usefully bring blood sugar back to desired range. For more see: For an overview https://diyps.org/2017/08/09/what-you-should-know-about-clos... iPhone version call Loop https://loopkit.github.io/loopdocs/ raspberry pi https://openaps.org/

Inhalable insulin was a total failure, even though it worked. I don't expect this to succeed where inhalable insulin failed.

Mannkind is still around, though not growing much. Why do you think it was a total failure?

Oh, really? I thought I read an article about how the product had been discontinued. I stand corrected.

First time I heard about inhalable insulin! Indeed it's unclear what the pills could offer over this.

I would be scared the needle hits hard food or something else and doesn't inject the insulin with me not knowing it.

Hope the price per pill is more reasonable that current prices on insulin which are skyrocketed over 20 years.

I’m hoping Apple will pull out a miracle and able to measure blood sugar with the Apple Watch. With that data, people can make apps to do really cool things to help that person out.

Apple's focus is on "average" people, not people with diabetes.

Also it saddens me to hear "I hope that company X will solve Y" instead of "I hope some university develops a method to solve Y".

Diabetes is becoming more and more common, especially in the US. It also could be used for monitoring healthy people so they don’t fall into T2 diabetes. The problem is, at the current technology level it might not be possible. Johnson&Johnson tried to do that for decades and failed.

I doubt that the apple watch will be able to do this reliably.

But if someone is interested (speak investment interested) in non-invasive blood glucose measurement feel free to inquire. Peer reviewed publications available.

Even if they could, reporting on medical information has very large consequences if the information is wrong. I don't imagine it would be worth it to them to enter that arena.

We already have continuous blood sugar monitors that are good, and work with Apple Watch. The invasiveness of the patch is not a big deal in my opinion given the benefits.

Is diabetes curable with gene therapy? I'm surprised we can cure hemophilia with gene therapy but not diabetes. Is it impossible to get your pancreas to create insulin naturally because it's missing something vital?

[1] https://www.nih.gov/news-events/nih-research-matters/gene-th...

type 1 diabetes is an autoimmune disease where your immune system kills the beta cells that live on the pancreas. you can get donar beta cells that will work but your immune system will just kill them off again. This only works with immunosuppresents which will cause 10x more issues than just taking insulin.

Interesting, I never knew type 1 diabetes is an autoimmune disease. I just thought the body just stopped creating insulin because the pancreas is messed up.

Why would that surprise you? Hemophilia is a genetic disease, while diabetes rarely is. The pancreas has the genes it needs, it's just damaged (in type 1) or ineffective (in type 2)

A potential huge impact of this advance is inspiring further research into peptide-based drugs; this is a whole new paradigm with the potential to be comparable or better than the small-molecule drugs we currently focus on, but the poor marketability of injections has kept most pharmaceutical companies from being very interested in them.

Doesn't this have to work 100% of the time if you rely on it? I mean if it works 99% of the time your odds are low you'll make it thru a year. It seems like a cool idea, but the mechanism does seem like it would work not every time.

Can anyone shed some light on why this can only help type 2 and not type 1 diabetics?

Is it not bad to have tiny needles traveling through your intestines?

There is no metal needle anywhere in the product. The needles are made of freeze-dried insulin. It is injected into the stomach wall where it dissolves into the bloodstream.

Oh I didn’t get that on the first read through.

Probably not worse than having bigger needles traveling through your skin. But public perception of the device will definately be a large obstacle to overcome if it reaches the market.

This still seems dangerous to the stomach lining over time. Why not suppositories?

What's it going to cost, though? A big problem with insulin now is the cost...

And what happens if it gets stuck in your esophagus?

So it's a roughly gömböc-shaped capsule, then?

This seems like a solution looking for a problem.

As a TYPE 1 Diabetic. All I can say is AMEN!

URL should probably be the source press release: http://news.mit.edu/2019/pill-deliver-insulin-orally-0207, since techcrunch is just a less detailed summary of that

Thanks for the link!

Plant based diet can reverse diabetes ( I and II ). For type I milk products need to be stopped. Take 1% of your bodyweight as fruits. Take 1 % of your body weight as Raw ( uncooked ) vegetables. Take 10% of that vegetable quota as green leafy vegetables. Based on China Study by Colin Campbell.

e.g. weight 150 pounds 1.5 pounds fruits before 1 pm 1.5 pounds raw vegetables for the day If you are still hungry you can eat cooked food after completing daily raw fruits vegetable quota. Avoid all animal,milk,processed packaged products and heated oils. Will reverse diabetes in 3 days for newly detected patients. Add 1 day for each year you have diabetes

https://biswaroop.com/ https://www.youtube.com/watch?v=KgxvGu4fuGo&t=561s lookup his youtube videos

We detached this subthread from https://news.ycombinator.com/item?id=19114135 and marked it off-topic.

You mean diabetes type 2.

It's tiring to keep getting suggestions of how to change diet when my body absolutely needs insulin from an external source. Further, while people may be able to reverse type 2, they still need insulin until they actually get there. So research into insulin delivery is relevant to all diabetics.

Also there are many ways of reducing carbohydrate intake. The diet you write about is just one of many ways to do that. Why single it out?

It is not just about carbohydrates.It is the healing by natural minerals vitamins from fruits and vegetables which cannot be replaced by supplements. There is a long science with research papers which cannot be explained here.

Nutrition research is a minefield of easy answers. People who speak in certainties (like you do) can be presumed to not have studied it in depth.

It can't be explained here because it's wrong. People with Type I are born with or later develop an inability to produce insulin. It may be physical (the removal of a pancreas) or an autoimmune condition can destroy the beta cells, or they were born without functioning beta cells. Type II is a disease of poor nutrition, and is absolutely reversible through diet, exercise and/or fasting. Type I is a physical inability to produce insulin. Fruits won't solve that.

T1 can’t be reversed.

Exactly. My sister is type 1 because she doesn't have a pancreas. So no diet is going to change that.

This diet with stopping milk products can. Milk protein with 17 rings similar to beta cells. Body in an attempt to kill milk protein which escapes into blood without breaking down the ring structure also kills beta cells https://www.youtube.com/watch?v=4edofibXOiM watch at 48 mins

This part of the video makes no sense. (I didn't watch the rest.)

From the video:

> If you observe milk protein (casein) under a microscope it will appears as this - there are 17 links in it.

The video says "links", you say "rings". It's a small but important distinction. Proteins are made by linked aminoacids, so sing "link" is a good approximation, but most of them don't look like "rings".

I can't find where the "17" comes from. After a few google searches I found that casein has approximately 210 aminoacids, the number can vary, but it is not 17.

(Also, you can't see a single casein protein under a normal microscope, nor the parts of it. I guess it's only a metaphor, but it makes me suspicious.)

I don't find the part in the video that says that casein escapes to blood. (I didn't try too hard.)

Casein is split in the stomach by the enzymes IIRC they are the regular enzymes that also split the proteins in meat, and other food, not specialized enzymes.

(There is an specialized enzyme for lactose that is an special sugar in milk, but this is not what the video or you say. But if this were dangerous, we'd have a lot of babies with diabetes. Moreover, only some adults produce the enzyme to digest lactose, so it would be easy to test.)

I didn't find a source that says that beta cells have some proteins that are similar to casein. It is posible, but I doubt.

And IIRC most autoinmune diseases, where the body get confused and start to attack some part of it don't go away after you remove the initial agent that causes the reaction. So stopping drinking milk won't stop the reaction.

It would be a sensation if that worked! Just because a guy in a suit says so doesn't make it any truer. Please stop peddling pseudoscience.

To all the type II diabetics here, I'd suggest looking in to iodine. I'm not diabetic, but I started taking it for other reasons and as a side effect I seemed to have better blood sugar regulation. There are also doctors out there that claim it reduces insulin dependence.

I'm not claiming a cure, or even an actual treatment. Just want to point some people to something that most people have never heard of.

For the case of T2D, eating fewer carbs may be more effective than later reducing it with expensive insulin and fancy MIT pills.

I often hear good stuff about these guys: https://www.virtahealth.com/ (no affiliation)

edit: clarify that Virta is treating T2D primarily.

Eating fewer carbs is completely ineffective when your pancreas is not producing insulin in the first place.

I was talking about type 2 diabetes, not type 1. You're of course correct regarding type 1.

Speaking as a T1D, please always specify. It's a shame these two totally unrelated diseases have the same name.

They're not "completely unrelated" — they are an absolute and a relative deficiency of insulin production respectively. They do have significantly different aetiologies though, and the conflation is very unhelpful.

It's a good point too that taking insulin is associated with greater risk of obesity and further worsening of T2D in the long term. So dietary interventions (which are experiencing great success -- both Virta and also the work of Dr. Jason Fung et co at Intensive Dietary Management) -- often produce much better outcomes for type two than insulin (naturally no one should go off insulin without being under the guidance of a doctor of course)

Yeah, eating less carbs is great for T2s like me (I don't take insulin, I control my blood sugar with a keto diet and metformin).

For T1s, eating less carbs might reduce the amount of insulin they need, and make swings in blood sugar less likely, but they're still going to need some insulin.

This is a common but dangerous misconception. The human body needs insulin to function, even without dietary carbohydrate. This is why insulin dosing includes basal (continuous background) as well as mealtime insulin.

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