AID Systems Study Day

Structure of the day

The study day is structured into three segments.

1. The AID therapy landscape — evidence base, equitable onboarding, and service-change strategies.
2. A deep dive into four AID systems — MiniMed 780G, Omnipod 5, t:slim X2 with Control-IQ, and CamAPS FX, with case studies.
3. Insider tips and tricks — expert sessions on nutrition, exercise, young children, alcohol, skin problems, and download interpretation.

Active learning is at the heart of this experience. The delegate workbook is the learning companion. Completing the programme as a team helps unify clinical approach. It can be done in one sitting or in bite-size chunks.

Technology and evidence evolve, but the principles from this study day (May 2024) remain relevant. This is not designed to be prescriptive. It is a sharing of one service’s journey and what has worked. Take what is useful, discard the rest.

Four stages of learning

Where are you at before you begin?

1. Unconscious incompetence — In the dark about what is not yet known. Common when AID therapy is new. Some material will take time to sink in. Stick with it.
2. Conscious incompetence — Knowing what is not known and eager to learn. Most will start here and gain a lot from the programme.
3. Conscious competence — The post-study day goal, where application brings knowledge to life. Those already here are well placed to help guide others and to be productively sceptical.
4. Unconscious competence — Mastery through persistent learning and experimentation over many years. Very few sit here. If this describes you, please help others and provide critical feedback.

Section 1: The world of AID therapy and equitable onboarding

Session 1: The three Ws

• Why AID therapy: A dive into the daily variability of insulin requirements and how AID systems meet the challenge.
• Where we were: An honest review of inequitable allocation of AID systems up to 2023.
• Where we are going: Looking ahead to ensure equitable onboarding to meet NICE TA 943 for hybrid closed loop.

Top three learnings from Session 1:

1. The flexibility of AID systems meets highly variable insulin needs, highlighting just how challenging type 1 diabetes is to manage.
2. Self-assessment to determine whether AID onboarding is equitable is the essential first step. Review the data honestly — it might be uncomfortable, but discomfort drives change.
3. NICE TA 943 creates unprecedented potential for access to AID therapy. The rate-limiting step is the onboarding cadence of diabetes teams. Embracing digital technologies can speed up equitable onboarding.

Dr Addala: Type 1 diabetes disparities — awareness, challenge yourself, challenge the systems

Dr Addala fully engages with the issue of inequity and, crucially, offers practical solutions to challenge the status quo.

Top three learnings from this session:

1. Look after your own backyard: Affluent white populations typically have better access to advanced diabetes technology and better glucose outcomes. Start by recognising and addressing disparities in your immediate surroundings. How significant is the inequality in technology provision in your own service?
2. Awareness and action: Inequity is multi-layered. Equity is not the same as equality. Tailor care to individual needs, providing more support to those facing learning and language barriers. From BCH’s experience, families from privileged backgrounds can often manage with virtual support and self-learning, whereas families with language barriers and lower educational attainment may require around four times as much face-to-face contact with interpreters. That may not be equal, but it is equitable.
3. Challenge and advocate: Once disparities within your own sphere have been addressed, broaden your focus. Understand power dynamics and work towards equitable access to technology and services. True progress requires both individual and systemic change.

Session 2: The three Cs

• Capacity creation: Strategies to make room in the service to prioritise AID onboarding.
• Creation of pathways: How the team switched from face-to-face-only onboarding to a versatile virtual model.
• Checking the results: Insights from the audit.

Top three learnings from Session 2:

1. AID therapy is a high-value activity that may require deprioritising other work. A hybrid virtual programme can halve educator time and increase onboarding cadence roughly five-fold.
2. Step-by-step teaching guides, Survive and Thrive guides, and school care plans act as templates that save significant time.
3. Starting settings calculators and AID download assessment tools are tools for guidance, not gospel. They make suggestions based on average insulin sensitivity. Use them with clinical judgement and maintain a continuous audit-and-improve mindset.

Further context is available in the full story of the BCH service transformation, which may be valuable for teams wanting to meet the NICE TA 943 challenge.

Resources from Section 1

Session 3: AID system selection

Thanks to Anne-Marie Frohock from Oxford for helping put these slides together. Note: one slide in an earlier version incorrectly states Control-IQ predicts 10 minutes into the future. The correct figure is 30 minutes.

Top three learnings from Session 3:

1. Each AID system is like a unique supercar. Suitability varies by individual physiology, preferences, and context.
2. Online tools such as Google or Teams forms are practical for system selection and pre-AID education.
3. The clinical team’s role is to guide rather than dictate AID system choice.

For people living with type 1 diabetes: the GNL guide to choosing an AID system may also be helpful.

Section 2: In-depth analysis of four AID systems

Session 1: Control-IQ

You will need the AID tool, the Survive and Thrive guide for t:slim, and the T:Simulator app for Apple or Android.

Now it is your turn. Work through Control-IQ case study 1 with the AID tool for case study 1, then Control-IQ case study 2 with the AID tool for case study 2. Bounce ideas off colleagues first, then compare with the BCH team’s thoughts on the t:slim case studies. You will almost certainly spot things that were missed.

Top three learnings from the Control-IQ session:

1. Keeping basal rates and correction factors updated is critical. A single flat basal can be completely fine for simplicity; use the correction factor to tune the algorithm. Those with clear dawn or dusk phenomena may need different basal rates.
2. The correction factor is the most important setting to optimise in Control-IQ for improving time in range.
3. Control-IQ has huge flexibility, which is powerful but demands responsibility. In children and young people, Control-IQ tends to require relatively frequent updates to basal rates and correction factors.

Session 2: Omnipod 5

You will need the AID tool, the Survive and Thrive guide for Omnipod 5, and the Omnipod 5 simulator for Apple or Android.

Now it is your turn. Work through Omnipod 5 case study 1 with the AID tool for case study 1, then Omnipod 5 case study 2 with the AID tool for case study 2. Do the thinking first, then compare with the BCH team’s thoughts on the Omnipod 5 case studies.

Top three learnings from the Omnipod 5 session:

1. Tailoring target levels at different times of day allows the algorithm to match individual insulin requirements more closely.
2. Maximising connectivity between Pod and sensor — particularly maintaining line of sight — matters, especially for swimmers.
3. Using activity mode for exercise and alcohol is essential, as the algorithm’s aggressiveness is roughly halved in this mode.

Session 3: MiniMed 780G

You will need the AID tool, the Survive and Thrive guide for 780G, and the MiniMed 780G virtual demo pump.

Now it is your turn. Work through 780G case study 1 with the AID tool for case study 1, then 780G case study 2 with the AID tool for case study 2. Do the work first, then check against the 780G case study notes.

Top three learnings from the 780G session:

1. Time in range can be improved by using a short active insulin time (2 to 2.5 hours) and a tight target (5.5 mmol/L). However, for people with frequent or unpredictable activity, aggressive auto-corrections can create significant insulin on board, which can backfire.
2. Managing exercise and alcohol using the Temp Target feature is essential.
3. Manual basal rates and correction factors still matter and should be updated regularly in case manual mode is needed.

Session 4: CamAPS FX

You will need the AID tool, the Survive and Thrive guide for CamAPS FX, and, if you have an Android phone, the Amazon App Store and the CamAPS FX app. Full disclosure: this is the system with least BCH experience at the time of recording.

Now it is your turn. Work through CamAPS FX case study 1 AID tool with the case study 1 graphic, then CamAPS FX case study 2 with the AID tool for case study 2. Do not skip the work. Then compare with the CamAPS FX case study notes.

Top three learnings from the CamAPS FX session:

1. Adapting target levels for varying intra-day insulin requirements is powerful. CamAPS allows targets from 4.4 to 11.0 mmol/L.
2. Using the “Add meal” functionality supports better handling of hypoglycaemia and high-fat meals.
3. Inaccurate carbohydrate counting can blunt algorithm performance. The more accurate the carb count, the better the system behaves.

Section 3: Specialised insights

Session 1: Nutritional wisdom with Francesca Annan

Top three learnings:

1. Major in the major: Children need adequate energy and carbohydrates to grow and thrive. Structured days, balanced meals, and pre-meal bolusing remain the core of good time in range.
2. Minor in the minor: High-fat and high-protein meals with AID systems are important, but do not overcomplicate until a problem appears. As Francesca puts it: find out before you fiddle — the algorithm may cope just fine.
3. The art is individualising advice: meet the person where they are, know the AID system being used, and learn through trial and error.

Session 2: Exercise strategies with Dessi Zaharieva

Dessi combines research, clinical, and educational expertise in a way that is relentlessly practical. This talk on exercise and the four AID systems is all signal.

Top three learnings:

1. Start activity modes 1 to 2 hours before exercise. Consider reducing the carbohydrates entered into the bolus calculator by around 25% if eating 1 to 2 hours pre-exercise.
2. The Omnipod 5 can work underwater if the sensor and Pod remain very close together.
3. After exercise, be ready to replace insulin quickly. Prolonged insulin suspension during activity can lead to significant glucose rises after the next meal. Each AID system has specific ways to manage this.

An additional longer presentation (~40 minutes) covers why exercise is one of the most powerful longevity tools, risk factors for hypoglycaemia during exercise in order of importance, and AID case studies including open-loop use during exercise and managing alcohol after team sports.

Top three learnings from the extended session:

1. AID and exercise may require rethinking traditional strategies. T25/T25 (25% carbohydrate reduction, 25% basal or bolus tweak depending on system) can be a pragmatic starting point, but rapid adaptation is often needed.
2. Large carbohydrate loads immediately before exercise can trigger the algorithm to drive insulin delivery during activity, increasing hypoglycaemia risk. Smaller, frequent doses of fast-acting carbohydrates every 20 to 30 minutes are often safer.
3. Switching to manual or open-loop mode around 90 minutes before planned exercise can standardise insulin conditions and make responses more reproducible. This is mainly relevant for athletes seeking performance and predictability — it is not necessary for everyone, and requires tuned basal settings and a trial-and-error approach.

Session 3: Young children and AID with Elizabeth Jelleryd

Top three learnings:

1. Pre-meal insulin of at least around 30%, and as much as possible, is generally needed to prevent post-meal hyperglycaemia in young children.
2. Managing sporadic activity in young children requires extra carbohydrates, particularly with AID therapy on board.
3. Structured, balanced meals have a double benefit for children with type 1 diabetes: they support both nutrition and more predictable glucose control.

Session 4: Thriving with AID and managing alcohol

Top three learnings:

1. Do not forget the basics. Accurate CGM readings and healthy pump sites are foundational for any algorithm to work properly.
2. Strategic overnight target adjustments can reduce inconsistent post-breakfast spikes after nights out.
3. Activity or similar modes can be used for alcohol management. Above all, safety first: use followers and support when drinking.

Session 5: Overcoming skin problems from diabetes devices — Dr Anna Korsgaard Berg

Top three learnings:

1. Types of skin issues and their causes: Lipodystrophies (rare, likely autoimmune); lipohypertrophy (anabolic effect of insulin, causing poor absorption); contact dermatitis (eczematous reactions to adhesives); infections; and skin injuries from mechanical removal. Itching can be an early warning sign of barrier compromise.
2. Prevention strategies: A structured skin-care programme such as that described by Berg et al. (2023) can minimise wounds and mechanical damage. Choose adhesives carefully, rotate sites, avoid unnecessary extra taping, and use moisturiser after removal. Use adhesive remover and remove devices low and slow.
3. Treatment principles: Avoid affected sites while healing. Use topical steroids for limited periods and lipid-based lotions to restore barrier function. Build and maintain a prevention-focused skin-care plan.

Session 6: Big picture to small picture — interpreting downloads with Dr Julia Ware

Top three learnings:

1. Structure is key: Start with the big picture then move to the small picture, using the CARES framework from the Panther Programme. Use cheat sheets from the CYP diabetes network to ensure systematic coverage.
2. Big picture targets: Less than 4% time below range, at least 70% time in range, coefficient of variation below 36% (ideally below 32%), over 90% time in automode where applicable. Review AGP patterns to identify times of day prone to highs or lows.
3. Small picture focus: Meal boluses, carbohydrate counting, missed meals, suspensions, over-treatment of hypoglycaemia, early set changes, and overuse of manual corrections. Always meet the person where they are and adjust settings in a way that is both physiologically sensible and tolerable in real life.

References

1. Phillip M, Nimri R, Bergenstal RM, et al. Consensus recommendations for the use of automated insulin delivery (AID) technologies in clinical practice. Endocr Rev. 2023;44(2):254–280.
2. Griffin TP, Gallen G, Hartnell S, et al. ABCD-DTN: Best practice guide for hybrid closed-loop therapy. Diabet Med. 2023;40(7):e15078.
3. Adolfsson P, Taplin CE, Zaharieva DP, Pemberton J, et al. ISPAD Clinical Practice Consensus Guidelines 2022: Exercise in children and adolescents with diabetes. Pediatr Diabetes. 2022;23(8):1341–1372.
4. Zaharieva DP, Morrison D, Paldus B, et al. Practical aspects and exercise safety benefits of automated insulin delivery systems in type 1 diabetes. Diabetes Spectr. 2023;36(2):127–136.
5. Pemberton JS, Kershaw M, Dias R, et al. DYNAMIC: structured education programme improves time in range in a socioeconomically deprived cohort with type 1 diabetes. Pediatr Diabetes. 2021;22(2):249–260.
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7. Pemberton JS, Gupta A, Lau GM, et al. Integrating physical activity strategies to lower hyperglycaemia in structured education programmes. Pediatr Diabetes. 2023;2023:1–8.
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9. Sherr JL, Schoelwer M, Dos Santos TJ, et al. ISPAD Clinical Practice Consensus Guidelines 2022: Diabetes technologies: Insulin delivery. Pediatr Diabetes. 2022;23(8):1406–1435.
10. Hanas R, Adolfsson P. Bolus calculator settings in well-controlled prepubertal children. J Diabetes Sci Technol. 2017;11(2):247.