Database Enabled Insulin Pump (DEAP)

David Bowen, dbowen1@umd.edu, 2009

When I think of the challenges of diabetes control, I think of two things:

carbohydrate counting and insulin absorption. Many people live like I do, with rotating
schedules where no two days in their lives are the same. Food comes from many different
sources, and has greatly varying ingredients. Up until now, the best a diabetic could do is
to only look at carbohydrates in food and give insulin accordingly. However, all diabetics
are familiar with the pizza paradox, where the combination of carbohydrates and fat
cause a bifurcated glucose response. This blood sugar roller coaster leaves diabetics
feeling far worse than the rest of the world’s non-diabetic population after eating cheap
pizza.
Insulin pump manufacturers are aware of this problem, and have added a two
peak bolus feature to insulin pumps, giving part of a dose now, and giving part of the
dose later to handle both the carbohydrates and the fat. This is fantastic; pizza can now be
handled. Unfortunately, we live in the real world where all food isn’t as simple as pizza,
and no one should be eating pizza for every meal. Why can’t all foods have customized
glucose responses, like the bifurcated response of the two peak (pizza) bolus?

Figure 1. Generic glucose response curve.

My proposal for an improved diabetes control device is the following. Ipods and
Iphones and all manners of PDA can store gigabytes of data. Why can’t an insulin pump
remember food glucose responses and allow them to be used in a user friendly way?
Consider an insulin pump that looks more like a Blackberry®. Within the memory is a
personal database of food. These foods include commercially available restaurant food as
well as common generic foods. This database is also not static. New foods can be added
by downloading upgrades from the manufacturer’s website, or customized by the user.
Stored along with each different food in the data base will be the data for the glucose
response (See figure 1). At the touch of a menu, the particular food pops up displaying all
nutritional information including the glucose response curve.
Well, simply having the glucose response curve may be informative for a diabetic,
but not particularly useful. To make the database at all useful, the glucose response curve
can be administered by the pump. The pump will not act only to bolus for a few minutes,
but will tailor the dose over many hours to achieve the most stable glycemic response as
indicated by the particular foods glucose response curve stored in the database. Of
course, rarely do people eat just one particular thing, so selecting many foods from the
database will effectively be administered simultaneously. The database enabled insulin
pump (DEAP) will sum the glycemic responses from a bouquet of foods in a single meal
and form the appropriate and complex insulin response.

Figure 2. Example of a database page containing the food info for a Subway tuna sub.
 As stated earlier, the glucose response curves would be available for download
from the pump manufacturer. These glucose response curves can be determined
empirically through non-diabetic trials, or calculated based on the carb-protein-fat
signature of a food. The curve is scaled based on quantity consumed and the diabetic’s
particular carbohydrate ratio and initial blood glucose. In the mid 1980’s, much research
was conducted studying the glycemic response of people after eating “mixed meals”
(meals with identifiable carbohydrate, protein, and fat components). The correlation was
made to a single foods glycemic index, which is defined as the area under the glucose
response curve of the food divided by the area under the glucose response curve of white
bread. The three papers reviewed [1]-[3] indicated a constellation of factors that effect
the real glucose response of a person. This fact makes the approach of bolusing for carbs
and basal for everything else method of diabetic control seem outdated. It was nice to
have instantaneous control after the introduction of lispro to the market, but it has been
over ten years and more sophisticated techniques are needed. Storing the glucose
response of thousands upon thousands of foods into a database enabled insulin pump
(DEAP) that will intelligently combine the glucose responses of each food in a meal is
the next best thing to an operating pancreas.

Figure 3. Glucose response data for mixed meals [3].

The benefits of the DEAP are critical on one external factor: insulin absorption.
Insulin pump infusion sets should be changed every three days in order to maintain a high
rate of insulin absorption. However, three days is an average time, and particular
irritation of the site or the insertion of the cannula into scar tissue could result in poor
absorption long before three days is up, making boluses ineffective and blood sugars
erratic. To further aid diabetics in their control and improve the operation of the DEAP
(or any insulin pump), I propose the following. A micro electro-mechanical (MEM) salt
sensor be placed at the tip of the cannula to monitor the rate of insulin absorption. The
subcutaneous site around the tip of the cannula will have a predictable change in salinate
level from the injection of insulin. This level will dissipate back to an equilibrium
salinate level as the insulin is absorbed. If the insulin is being absorbed below some
threshold rate, the salt level being monitored by the MEM sensor will not return to
equilibrium quickly enough, and the user should be alerted to change infusion sites as
soon as possible. Thus, high insulin absorption will be monitored and maintained.
The concept of the DEAP replaces the function of the pancreas as an insulin
controlling organ. The improved infusion site monitoring will account for the external
nature of the DEAP and the problem of delivery. With the DEAP and near perfect insulin
absorption, unexplained blood sugar spikes will be a thing of the past.

References:
[1] Wolever, Thomas. Jenkins, David. “The use of glycemic index in predicting the blood
glucose response to mixed meals”. American Journal for Clinical Nutrition, 43, 167-172,
1986
[2] Chew, Irene. Brand, Janette. Thorburn, Anne. Truswell, A. “Applcation of glycemic
index to mixed meals”. American Journal for Clinical Nutrition, 47, 53-56, 1988
[3] Gulliford, Martin. Bicknell, E John. Scarpello, John. “Differential effect of protein
and fat ingestion on blood glucose responses to high- and low-glycemic index
carbohydrates in noninsulin-dependent diabetic subjects”. American Journal for Clinical
Nutrition, 50, 773-777, 1989