Pump data reports - what does it all mean?

[JoeC]

I haven’t seen a thread where people discuss the data downloads from pump systems?

If there is an existing thread, we can move this.

I am a newish Type 1.5 LADA , only 2 years since I was diagnosed at age 60

Oct 2015 > (mis)diagnosed type 2? started pills, diet, exercise
Feb 2016 > nighttime insulin
Aug 2020 > failed the GAD test, now Type 1, started on pump and sensor

I am using a Medtronic Mini Med 770G pump with CGM and running in auto mode as much as possible

The system provides a lot of information – but as a newbie I have no baseline to compare it to

Here is just one of at least 10 possible reports Medtronic creates

It is an eye chart for sure
It compares sensor blood sugar over 24 hours for the current two weeks A (blue) to previous 2 weeks B (orange)
Here is what I have learned (or would like to know), would love to hear what you experts also see

1) Overall

Overall, my diabetes clinic nurses say this is pretty good trend, do you agree, is it good enough?
They can’t say much more because of patient confidentiality, but I get the sense most people don’t even look at this information
Would love to know if this is good, bad, or ugly so I can take action as required

2) Default settings

This system is still at system defaults
Low is set at 2.2 to 3! (this is not what I feel as a low!)
Target is set at 3.9 to 10 – even a 3.9 for me feels awful, anything less than 5 and even a rapid drop (two arrows down) is painful for me

Are these reasonable values? Should I be sucking it up and will I get used to it?
I am thinking of changing target to 5 to 10 to capture what I call a low

The lowest I have ever tested was 3.2 and I never want to get anywhere near that ever again
Will I better tolerate lows as the disease progresses – if you folks laugh off less than 3 you are some rock stars

3) Time in range 49 & 50% (too high)

My endocrinologist and clinic nurses say this is the new key measure with a pump, 70% or better is the goal. Do you agree?

Overall the system seems to actually target 10 (dotted black avg line)
If it is set to atime in target of 3.9 to 10 > I would expect to see a lower dotted black average line.
Is this the lawyers keeping me high (and them safe from lawsuits?)
Or me not bolusing enough and auto mode can’t walk me down?

4) Auto mode (per week) 90%

I have always tried to keep auto mode on except for sensor change day
However lately I have been experimenting with suspend before activity lately, temp bolus doesn’t keep me from low

5) GMI 7.8%

GMI is estimated A1C (I think)
My actual A1C is typically a bit lower than this , it has averaged 7.2 since pump started (Aug 20)

Jul-20 6.9
Dec-20 7.1
Jun-21 6.9
Nov-21 6.9
Dec-21 6.8
Apr-22 8.1
Jun-22 7.3

6) Coefficient of variation 34.7%

(I think) this is hi to low range – advice from team is to reduce variation
That makes sense to me but what is good number?

9) Low/High SG Alerts per day 4.4/4.6

System says over 4 lows per day, but note these lows are based a low starting at 3.9 – for me low is 5, so I am going low way more than 5 times a day – is that normal and to be expected?

For me this is the biggest single issue
I can’t get the clinic nurses to tell me what is a normal number of lows to expect
They offer a sunny happy unicorns and rainbows view of diabetes and imply with proper control it will be sunshine and lollipops all day every day

This is not my lived experience

If the reality is I will be going low multiple times every day I just need to hear that

Then I will suck it up, treat, suffer and get back to work

As it stands, I feel I am doing something wrong and should be able to do much better at avoiding lows, just need a dose of truth/reality

10) Total daily dose (per day) 44.6 units

Clinic nurses say I am insulin sensitive, which is why I go low so much
Is this really a low amount?
I believe this is meal bolus as well as what the pump squirted in

11) Auto basal / Basal Amount per day 61%

Auto bolus amount is over half of my daily insulin, I believe this means I did not get meal carbs/bolus correct and the pump had to work too hard to make it up (could not make it up)?

12) Carbs per day 128 +/- 49

To the best of my ability this is a very close and accurate carb count
What is typical (likely no such thing) for a diabetic, is this too much daily variation

A long post - lets see where it goes?

 

[Robin]

Hello, and welcome to the forum. There's a lot in your post to digest,so I will kick off talking about the things I know about, and hope someone else who is looping on their pump will fill in gaps.
Im not on a pump, but I am using a Libre, and the same principles apply, 70% time in range (3.9 to 10) is what we are supposed to aim for, with only 4% below 3.9.

Are you in the U.K.? (I ask because you posts in what is the middle of the night here, and you seem to have started on a pump much more quickly than most people).

With hypos, I think the better warning signals you get, the better. If your body is used to higher levels, it will probably warn you at a higher level (in your 5s, as you are finding) but I certainly wouldn’t want my body to get used to low levels and stop responding. I would certainly worry if I wasn’t getting warning signs when I’m in the high 3s, and I would never want to be less than 3. The margin between feeling the symptoms and having time to treat before you pass out must be very small, for people don’t feel hypos til they are in the 2s. In the U.k., it would also result in you losing your driving licence. As you get nearer the 70% time in range, you may find your body adjusts to warning you when you are around 4.

I don’t think anyone on this forum has ever found that their Diabetes management is all sunshine and lollipops, we all struggle and get fed up from time to time, when it won’t play ball.

Comparing amounts of insulin between people isn’t always helpful, you need what you need. I need less than you, but I'm a 9st woman and quite active. Some members on here use more.

I'll tag @SB2015 and @everydayupsanddowns , both of whom I think have their pumps connected to their CGMs on a looping system, and hope they can fill in the gaps about the pump aspect.

 

[everydayupsanddowns]

Welcome to the forum @JoeC

I am on a different closed loop to you, so I’m not sure which settings you can change on the pump.

Often you can set different alarm/alert values to the settings the algorithm uses to intervene (eg my sensors alert me at 5.2 so that I have time to intervene if the pump’s suspend feature isn’t acting quickly enough.

Similarly, Dexcom Clarity (the graph generating software with my sensors) allows me to set low levels and high levels for the ‘target range’ reporting it provides at levels that suit me.

If your body is more used to high levels, as @Robin says, your body can alert you earlier than would be expected. 5.0 is a little higher than many members would expect strong warning signs to appear. It may be that your ‘glucose thermostat’ resets over the coming months and you begin to get symptoms in the low 4s instead?

Whenever your BG falls below 4.0 your brain changes to try to ‘do better’ at low BG levels - so with repeated exposure to low BGs it is possible for your warning signs to dim a little unfortunately.

 

[SB2015]

Hi @JoeC
i am guessing that you are in the USA since you refer to a 770 pump, whilst weare using the 780 in the UK. I personally used the graphs initially but as I am now in closed loop and I am fairly confident about my carb ratios I tend to let the pump get on with things.

The only things that I can change on my pump when in closed loop are:

My target BG I use5.5 most of the time,but use a higher value in the heat as I find I hypo more. I also use a temp target of 8.6 when I am doing exercise.

The action time of my Novorapid insulin. I had to adjust this, and at that time I did use my graphs in Carelink.

My carb ratios. I check these now and then by looking at the graph which allows you to line up the bolus delivery time for meals and see what happens an hour before and 2 hours after. A ver6 useful tool, as my meals are at different times on any two days.
I hope that that helps.

 

[rebrascora]

I can never decide if clinicians really believe it is as easy as they make believe to manage diabetes or they say it to lift our spirits and motivate us but in reality, it makes us feel bad when we fail to achieve their targets. Diabetes management is really difficult and complicated and we don't have control over all the levers, so even when we give it 100% concentration all the time..... which means we really can't live our lives.... it still doesn't always go according to plan. You have to find some sort of balance between managing it reasonable well and going out and getting on with life.

That said, I believe you are asking for candour in our responses, so I will say that I personally would be very disappointed with those results and with 2 years of insulin usage with the help of Libre I was averaging 90% Time in Range and I am not on a pump, which I would have expected to be giving you better results than I can achieve manually with MDI.
I wonder if you maybe got the pump too early, before you really learned how to manage YOUR DIABETES yourself. I emphasize YOUR DIABETES, because we are all very different in how our bodies respond to insulin (and indeed the different types/brands of insulin), and food and exercise... and stress and illness and heat etc. You do have to learn a lot in those first few months and years but I wonder if perhaps you have not had the opportunity to experiment and learn how your body works and have maybe assumed or been led to believe the pump will just do it for you.

I appreciate that hypos are to be avoided as much as possible but I also think that fear of hypos is extremely debilitating for many people and sometimes a bit more exposure to them alleviates that fear and allows you gain confidence in managing them without the body going into panic and releasing the stress hormones like adrenaline which then cause the sweating and feeling like you are going to pass out. I am very aware that it is a fine balance between fear and being blase about them and I probably err slightly the wrong way on this but being comfortable and confident to deal with hypos allows me to get on with my life without fear of them and I live on my own so I am not relying on anyone for back up.
My Libre has clocked me 11 hypos in the last 7 days. Most of those were not actual hypos because Libre reads about 1 mmol lower than a finger prick, sometimes a bit more, so the majority of those events were actually low 4s and probably just 2 or 3 of those 11 were actual hypos and I think one of the nocturnal ones may have been a 2.9 but the rest would be high 3s. Usually I can just munch a jelly baby of two and carry on with what I was doing (even just dropping back off to sleep) at that mid-high 3s level or quite physical work like mucking out my horses. It always amazes me just how much 1 or 2 Jelly babies can achieve.... Like I can power walk 8 miles on 2 jelly babies if my basal insulin is correct. It is also important to note that non-diabetic people can drop into the mid 3s occasionally without having a panic attack or nearly passing out, or, doing their brain any damage. The key thing for us diabetics is that we need to preserve our awareness of this low level and if we visit this level too often our bodies will get used to it and we will not sense that we are going dangerously low. However when levels are regularly running too high, our sense of what is low is unnaturally raised which is why you feel so bad when you have a hypo, even when you reach 5 let alone below.
I can remember the first few hypos I had when I genuinely thought I might die or at least pass out and couldn't even be bothered to fight the feeling. It was absolutely horrid, so I do understand how you feel when you describe the hypos you are having. My personal experience is that it gets easier with a bit more exposure to them and maintaining your levels more in range. Not that I am advocating you deliberately have more hypos but maybe just lower your levels overall a bit more so that your body doesn't get such a shock when you get down to 5.... which is after all, a good number!
The key thing is to ALWAYS be prepared to treat a hypo. Have hypo treatments in small bundles (I keep little packets of just 2 jelly babies or 3 Glucose tablets), so that you don't over treat them, otherwise levels go straight back up to a high and the body doesn't get used to what should be normal levels. If I can treat a hypo and level out afterwards in the low-mid 5s that is ideal for me. That usually takes one or at most 2 jelly babies (5 or 10g carbs) for me, but you would have to learn what worked for you. If you were feeling bad in the mid 4s, I would suggest just 1 jelly baby or 5g carbs because you want your body to get used to that level. Obviously if your levels are dropping very fast, then you may need more than 1 but it is about taking it steady, eating 1 initially if you are still above 4 and then watching to see what happens and taking another one if necessary.... And chewing your hypo treatment really well because the glucose will absorb faster through your mouth walls whilst you chew it thoroughly than a couple of chews and swallowing it.

Anyway, those are my thoughts. I am apprehensive about hitting the "post" button as I feel that this post isn't as positive and encouraging as I would like and I also feel like it is rather controversial.... but it is how I feel and reflects my experience.
I think your fear of hypos may be keeping your levels a bit too high and making the hypos or false hypos you experience more traumatic for your body than they should be. Once you get confident in dealing with them and know how much hypo treatment works for your body and confident in finger pricking and checking that it has worked (don't rely on Libre to monitor your recovery from a hypo) then you feel much more confident about managing your diabetes in general and then you can get on with enjoying life and just dealing with the diabetes when you have to, whilst obviously doing your best to avoid having hypos, but accepting that occasionally they happen.

 

[PhoebeC]

@JoeC I can’t relay help as I’m on MDi

What I do want to say is I only at 65% time in target and I have had diabetes for 17 years and do my absolute best.

As others have said if you normally or even for a few days running a little high when you do get a low under 5 it can feel horrible, but it’s not a true hypo until lower. If you can manage to settle the higher levels it will help reduce this intense reaction.

What have your team suggested?

 

[JoeC]

Robin

Thanks for confirmation of 70% time in range as a target

I am in Canada, the Canadian and American forums are toxic, happy to find good people here

Everydayupsanddowns

Interesting you guys call it looping (from a closed loop system?)

I am a long way from unawareness as yet, but would be happy to be 5 and not shaky

SB2015

I am in Canada but right on the US border. My local pharmacy gets insulin tourists here since so many can’t afford meds

I have heard we will be getting the 780 funded in the new year, we follow the UK apparently

I have been having better luck with suspend vs temp target. It seems if I have any active insulin onboard, I will be going low with any activity

I think I can do more with carb ratios, have tended to set and forget

rebrascora

I think you are right, the clinicians are afraid I will just give up in the face of the reality so they keep it light and positive. Just the opposite works for me, give me the facts so I can manage

You raise some interesting thoughts, thank you – just what I was looking for

I was at 70% time in range for most of last year and hoped to improve. Went the wrong way. Maybe Covid (it stomped on me hard), maybe age, maybe phases of the moon

I think I agree with getting on a pump too early. I do carb count, and bolus for those carbs. Breakfast is 30 carbs exactly same every day, and every day is a different reaction….

Interesting that you power walk on 2 candies "if basal insulin is OK".
Can I ask what OK means for you?
As I have said before if I have any active insulin during “activity” I am going low (or what I call low)

I use orange juice to treat lows, find it works faster than sugar pills (dry and chalky) or candy (slow)

Your post tone is right on, it was what I was looking for.
No one has said yet that my new life includes lows every day.
Now that I know that is reality, like you said I can treat and carry on.
Again, very helpful.
In fact, today I worked most of the day on my daughter’s basement renovation, suspended before starting, had one low, treated and kept working.
Not ideal but lights are installed and working!

PhoebeC

I will see the clinic nurses in a month (if Covid doesn’t rear up again), we will see what they come up with. I hope I soon get used to a 5!

Thanks all !

 

[rebrascora]

Hi Joe. Pleased you took my response in a positive manner. It is really difficult to assess tone in the written word but I sensed you needed a bit of reality..... although my reality may be very different to some other people's. Diabetes is highly individual.
One thing that struck me in your reply....

I was at 70% time in range for most of last year and hoped to improve. Went the wrong way. Maybe Covid (it stomped on me hard), maybe age, maybe phases of the moon

This is interesting and I think you are probably right. Being LADA you are essentially Type 1 with a long honeymoon period. Your insulin producing beta cells don't all get killed off at once, so when you first started on the pump it was set up and keeping you stable together with the insulin production your own body could manage. Covid will have stimulated/triggered your immune system and it is possible that in that state of alert looking for the virus to attack, it also took out a few more of your viable beta cells..... This appeared to happen to me after the first Covid vaccine. My remaining beta cells had not been able to produce enough insulin to make a difference to my meal requirements, but it was ticking along in the background, helping out my injected basal insulin. It is my belief that after the covid vaccine (over the next 3 months) my basal needs progressively increased by almost 100% and then levelled out and have been static ever since (+/- 2-3 units here and there for exercise etc.)

If you have not learned to adjust your basal rates to what your body actually needs and you haven't had significant input from pump trained experienced Diabetes specialist nurses, then your basal profile is likely not matching what your body needs, which is why your Time in Range has dropped. For me basal insulin is 2 injections a day and with practice I have learned how to adjust it (both the doses and the times of those doses) to get a pretty good match for what my liver churns out day and night. Yes, I get it a bit wrong sometimes but it is more a dark art than a science so I am never going to be spot on all the time. Your basal doses are supplied by the pump in a set rate for probably hourly periods throughout the day and night, so you can fine tune it really quite precisely, but only if you understand how to do that and even when you or an experienced nurse gets it set up right, it will still need tweaking quite regularly. This is the really complex bit about pumps which I think having a basic understanding of using and adjusting basal insulins, helps before going onto a pump.
If basal profiles on your pump don't match what your body needs then it's like building a wall on wonky foundations, it gets progressively more off as you go up. Getting basal right is key to things making any sense. You will never get it perfect but as near as you can get makes diabetes so much less frustrating.... and this was what I was meaning about having my basal insulin right and then being able to power walk 8 miles on 2 jelly babies. Obviously, if there is bolus insulin in your system before you exercise then that will have an impact. I follow a low carb way of eating so often don't have any bolus insulin in my system when I exercise which helps prevent nasty harsh drops which do make u feel particularly rubbish and if my basal is then holding me level my body will just use up the stores in my muscles.... although I will usually have to dial back my evening dose to prevent nocturnal hypos as my muscles replenish their stores.

Anyway, good to hear you had a better day and got stuff done. I would hope that daily hypos are not a habitual problem and as you learn to manage your diabetes a bit better, they should become less and more importantly less debilitating. Suspending the pump when your levels are dropping is one of the great advantages of having it ... Once I have injected my basal insulin I can't take it out again, but suspending the pump or using a temp basal rate, stops or slows the basal rate for the next hour or two I believe, so not immediate benefit but much better than the 12 hours that mine is active for.

Really hope that you can start to feel more positive about it. This forum has been an invaluable resource in improving my understanding of my diabetes and giving me the confidence to experiment in order to find what works for me. I hope you can find what works for you, but I think you probably need someone experienced to go over your basal rate profile and see what needs tweaking as a start so that your foundations are nice and flat. I always know that my basal insulin doses need tweaking when I feel frustrated with my diabetes.

Good luck and keep asking questions. It is a continual learning process. Apologies if I have explained a lot of basic stuff that you already knew. It is difficult to gauge from a few posts.

 

[everydayupsanddowns]

It’s not a report I have (as I am on a different pump), but a couple of things stand out now I’ve zoomed in and looked at the screenshot.

Your average BG is reported as around 12mmol/L (+/- 5), which i think probably helps to explain the strong hypo symptoms you get at 5. Making some changes to try to reduce your average down to 10 or below will help to reset your internal ‘glucose thermostat’ - ideally with a reduced range (the +/- figure) as the level drips to reduce risk of hypos.

There are multiple occasions noted where the algorithm reaches the time limit of it’s intervention and your BGs remain high. So it may be that you need to cautiously manually intervene with additional insulin to try to reduce your time above target. When doing this I tend to take account of insulin/autocorrections already delivered (and any planned exercise or activity), and then aim to reduce BG to 9mmol/L which is the recommended post-meal maximum in the UK.

The report suggests a pattern of high readings, which roughly correspond to post-meal periods. So it looks like you aren’t taking enough insulin to cover your meals. You may also find it helps to take your meal insulin earlier - waiting some time between dosing and eating to allow time for the insulin to get going.

I notice that you are regularly leaving longer than Medtronic recommend between site and reservoir changes. This might mean that some of your infusion sites are becoming less reliable, so that the insulin your pump is providing can’t work properly, or that it is beginning to degrade in the reservoir and is becoming less effectove. It might help to stick to the 3 day changeover recommendations - there’s a reminder you can set in the pump.

 

[JoeC]

Robin & everydayupsanddowns

Thanks for the input, this has been very helpful. Having knowledgeable people look at this really helps

You have good insight into some of my problem, not taking enough insulin to cover my meals and not taking it early enough
I have ADHD so I have always tended to act then think (for 60 years)

It is really, really hard for me to plan 30 minutes ahead. I am already on the roof nailing down shingles before I think to check my level and trends. I eat then remember to bolus – way too late!

I believe us late onset folks need some additional or different coaching to break lifelong habits, I don’t think this is understood enough by the system yet, at least not in Canada anyway. I had to stop the clinic nurses in our first session and ask “wtf is a bolus”. We really are starting at less than zero. A child knows more than us.

And since I have been high for so long, closer to normal feels bad to me

It is really hard for me to get ahead of the curve, high feel normal I carry on as always, low hurts and slows me down immediately

Intellectually I understand that I will get used to normal (my low) as I become stable at a lower level, but I am averse to “lows”

Canada gave the world insulin but also Nurse Wettlaufer and the Montreal CIA funded insulin shock experiments. This stuff hits like a ton of bricks for a newbie

Also good catch on the infusion site change days. You made me look in the books and of course you are right, 3 days.
I was waiting until my reservoir was empty. I will fix this immediately

One big takeaway from this forum is to really understand my active insulin levels before starting any activity

The hard part for me is planning an hour ahead, I will get to work on it

Thanks again for the input