#1959 Dr. Joanna Mitri from twiist
Dr. Joanna Mitri from twiist
Dr. Joanna Mitri is an endocrinologist and Sequel's chief medical officer. Scott brings her a list of questions from the audience about twiist — coverage, cost, sensors, tubeless, and what's next.
Jump to a moment
- She came to fix diabetes care, and stayed to build the tool. Dr. Mitri trained in endocrinology in Lebanon, where she describes care as fragmented and access difficult, and came to the United States intending to learn integrated care and go back. Instead she spent years overseeing Joslyn affiliates — going into clinics in the US and abroad to repair their diabetes care models.
- Her diagnosis of the real problem: we build the model and make people fit it. Every clinic she visited had a different obstacle — staffing, electronic records, whether they had a diabetes educator at all. Her conclusion was that excellent technology existed and simply wasn't being offered, because it was seen as too complex or didn't fit the workflow. Joining Sequel was, in her framing, a chance to build technology around people instead.
- The number they brought to ADA. She reports that real-world data on people using twiist in daily life — not in a study — showed almost seven out of ten meeting recommended glucose goals. Scott presses on whether that's people who were already doing well; her answer and the surrounding detail are in the episode. These are the company's own reported figures.
- Coverage runs through the pharmacy, not durable medical equipment. twiist is cleared for ages six and up. Her description of the path: see a provider, get a prescription, fill it at the pharmacy — which removes a common barrier. On cost, she says commercial insurance means $0 the first month and no more than $50 a month after, covering the kit, the cassettes and the infusion sets. Medicare depends on the specific Part D plan, and she recommends checking with Sequel directly rather than guessing.
- On tubeless, and on sensors that misbehave. Asked the audience's most common question — will there be a tubeless twiist — she doesn't commit, but says they hear it and want the system to meet people where they are. On unreliable sensors, she notes twiist works with two sensor options, and that because the algorithm re-decides every five minutes rather than learning over time, a bad reading doesn't set a lasting course. Nothing here is medical advice.
- twiist — The twiist AID system from Sequel, powered by Tidepool — targetable to a glucose level as low as 87.
- Diabetes Pro Tip series — Episodes 1000-1025 — settings, insulin timing, and food impact.
- T1D Exchange registry — US residents 18+ with type 1 — take the survey and support research.
Every word of the conversation
Cold open & sponsors0:07
Hello, friends, and welcome back to the juice box podcast. If you don't love today's episode, you can have your money back. You should not, in any way, shape, or form, take anything you hear on the juice box podcast. As medical advice, I'm talking about medical advice, regular advice, any kind of advice. This is a podcast.
Nothing you hear on the juice box podcast should be considered advice, medical or otherwise. Always consult a physician before making any changes to your health care plan. I cannot stress that enough. Spend a few minutes today making the world of type one diabetes a better place by completing the survey at t1dexchange.org/juicebox. They're looking for US residents 18 or older who have type one diabetes.
T1dexchange.org/juicebox. Links are in the show notes. This episode of the podcast is sponsored by the Twist AID system powered by Tidepool that features the Twist loop algorithm, which you can target to a glucose level as low as 87. Wanna learn more? Go to visit .twist.com/juicebox.
That's visit.twist.com/juicebox, and Twist has two i's. Understand? Twiist.com. Visit .twist.com/juicebox.
Hi, Scott. Thanks for having me today. Tell you a little bit about myself. I'm Joanne Amitri, an endocrinologist by training, and I'm the chief medical officer here at Sequel.
Oh, you guys make the twist pump.
We do.
I am excited to talk to you. I have a list of questions sent in by the audience, and I'm sure you have some things you wanna share too. Can can I just ask you a little bit about yourself before we jump into the questions?
Yeah. Of course.
From Lebanon to Joslyn to Sequel1:57
Tell me what happens to you in your early life that makes you want to be a physician, and then once you decide to be a physician, what makes you pick endocrinology?
Yeah. No. It's it's it's a good question. It's actually a long story, but I'll make it short. I really started out with a plan.
At that time, I think it was a clear plan. I and, you know, I was interested actually in food, to be honest, like how food shape, like, our health, how it leads to growth and aging. And that's what really led me to do diabetes and endocrinology in the first place. But where I grew up is in Lebanon. It's a country where, like, diabetes care was is very fragmented
Mhmm.
Scattered. And I'm sure you, Scott, and many people here would would would identify with something like that where, like, access sometimes is difficult. Things are not coordinated. So I came to The US because I wanted to know, like, how, like, integrated care works. So I thought I'd come here, and I'll go back, and I'll build everything in one place.
But that didn't happen. So instead, I actually ended up working here in The United States on care models for diabetes. What kept what I can tell you yeah. Go ahead.
I cut you off. I apologize. But what what kept you? Was it a was it a job that you loved? You meet a boy?
What what what made you not
want? What happened? Great. All of the above, but no. No.
What I say is that, so I it's funny because I really wanted to go back and build that center in Lebanon. Mhmm. But I was lucky because what I couldn't do in Lebanon, I was able to do it here in The US for many places. I was overseeing what we call the Joslyn affiliates, which means we go to centers in The US who needed to help fix their diabetes care model, and we would help them. We also did it internationally in different countries in the world.
Wow. So I felt like I couldn't accomplish my mission in Lebanon, but I I did it here for other people who needed it. And I can tell you that every everywhere I went, whether here it's in The United States or outside, I felt that, we tend to build model or technology and fit people inside and not the other way around. Mhmm. So when SQL, came up and the opportunity came up, I felt like this will be an opportunity for me just to to be part of a technology that actually work in people's life and not the other way around.
So this is how I ended up at Sequel.
It's interesting that you bring this up because I was just having a conversation with a friend of mine who is a CDCS and a a lifelong type type one. And we were talking about how the academic side of diabetes tends to say, oh, this will fix it, but they don't often, do a great job of wondering if that's what people need or finding a way to translate it to regular everyday life. Can you tell me, when you were doing that work, what are a couple of things that still stick out in your head now that you identified when you looked into clinics that needed to be, like, straightened up, fixed, I don't know, collected in a way that could be used over and over again and be valuable?
Why good technology never reaches people5:26
Yeah. This is really great. I mean, honestly, like, this is where I found most of the challenges. First of all, every that's the thing. Every clinic had a different problem.
Not all clinics are the same. It really depend on resources, how much people and staff they had, what electronic health record they used. Do they have diabetes educators? Not all of them had diabetes educators available to teach about new technology all the time. Mhmm.
So I felt like there's a lot of technology out there. There's a lot of new devices, new tools, amazing technology, and but it wasn't being used, because it was felt that it's either too complex, or there wasn't enough enough staff or models to incorporate it into their workflow and to offer it to people with diabetes. So at the end of the day, many people were actually left out. They were not even offered what's existing out there.
I I find that I think of it as the this, like, cycle that keeps everybody trapped. So is the is it's like a chicken or the egg. Right? Do you spend your time educating people so they can make better decisions, or do you put technology on them that will limit their need to make decisions? And then somebody eventually says, oh, well, if they don't know how to use the technology, that might be dangerous.
But they're also in a dangerous situation now. So it's almost like, you almost have to pick one and go with it. And what I found is that there are some people who are eager to be educated, to be able to make better decisions, and they're able to take that that in. But there's also some people where that's not a good fit for them, and that I don't think that means that they should be left out of a healthy lifestyle. So what did you land on?
If you could only if you magic wand people and it had to go over the whole society, you can only decide one thing, would you lean education, or would you lean technology that does it for them?
Yeah. First of all, it's it's it's it's really a great question. And you're talking specifically, Scott, about people with diabetes. Right? Do you educate them or you give them the tool?
Right.
I I think what what in my in my opinion, the ideal thing to do to give people with diabetes is to let them determine the goal they want and then give them the tool that lets them get where they want Mhmm. In my opinion. So I think, yes, you wanna educate them, but you wanna give in my the priority would be give them the tool that will help them get there. Let them decide what goal they want, and the technology will help them get there.
Yeah. I'm with you. I I have to say that if I take a pill that takes care of a thing, I don't care how the pill works. I just know it works. And, you know, as long as I have it, I'm okay.
Because I'll hear people make the argument, well, they need to know how to do it with a with a needle and, you know, and a meter. And I don't I don't disagree that that would be valuable, but some of this technology and I guess we should just jump in and talk about it. Some of this technology is so advanced and just continuing to to advance that I I just think it's sort of a shame not to give it to people. I I that that's my opinion. I wouldn't be I wouldn't be worried, oh, they can't figure it out.
I think they'll figure it out way sooner than they're gonna figure out that a meal with 40 grams of fat in it isn't gonna hit them the same way as a meal with 10 grams of fat in it. That's a that's a heavier lift for a lot of people. So can you start off by telling me what Sequel and Twist talked about at ADA? Like, what was your big, your your big reveal at ADA?
What Sequel brought to ADA8:54
We're a company. We're really focused on improving how, people living with diabetes, improve how we can improve their lives. So we have the Twist system, and, we launched it back in July of last year. And, it it was really great to be at ADA. It was a big moment for us, which happened at in June of this year.
And what I was really most excited about, I would say, is to bring what we were able to bring this year, which is really a big batch of real world data that we've looked at on people using Twist in their everyday lives. Mhmm. And not not really in a study, just like using it on a daily basis. And we shared that data with the diabetes community, with health care providers to to tell them how how really Twist has been performing in real life.
What what was exciting about that data? What did you what did what's your take what should people's takeaways be about using Twist?
Yeah. I think the headline, I would say, for me was that the data we show we shared showed that almost seven out of ten people using Twist were able to hit their recommended glucose goals.
Seven out of ten hitting their goals10:11
And are these people who previously struggled to meet that goal, or they were already doing well and discontinued to do well for them? Who who I guess everybody would benefit if if if the answer is both, but I'm just wondering because sometimes this data gets skewed a little bit. Right? Like, we gave, we we gave, lollipops to 10 people that don't eat lollipops. None of them ate them.
You know, that that kind of thing. Like, what what did you guys do? How did you put this together?
Yeah. And I love this question, and and the answer is quite simple. We actually didn't filter anything out. These are people who made their own decisions to go on Twist, and they come from different backgrounds, from different prior therapies. Some people were on AID systems, and some other people were even using the DIY, and others were coming from injections, multiple injections per day.
So we've had people coming from all those backgrounds, and this is the result compiled for all of them without, like, leaving every filtering or leaving every anybody out.
Filtering mean you didn't take any data that you didn't like and pull it
Gotcha. We just all of them looked at all of them.
Well, what's unique about the algorithm that's running on Twist? Why don't you tell people where you guys got it from and why you think it's it's a good choice?
Yeah. So we got it from the DIY community. I don't know. I can tell you a little bit about that, or I can jump into the algorithm uniqueness.
No. You know what I would say? I would say let's talk about that a little bit because I think that the DIY online, like, the people just listening, not people who are involved in it or really understand it, but I think it had a season. And I don't think it gets talked about as much as it should anymore, that there's a an awesome group of people who have been working on some of these algorithms, you know, privately in their own time for a long time. And Loop, I guess, is, you know, is one of them.
So tell tell me how Loop goes from being a thing that people online are making for themselves and sharing amongst each other, and how does it end up on a on a retail pump?
Yeah. I wanna say awesome is the correct word about this community who developed, this algorithm. So, yes, the twist loop algorithm is actually based on that, diabetes community driven type pull loop. And so I'll tell you a little bit more about it because the people who built it, these are the people who are we call them like, they built a movement called the we are not waiting community movement.
Sure.
And we really value everything they did and they brought to the community because those are people with diabetes who didn't want to wait based on the needs that they felt their their loved ones needed to have.
Why does it well, let me say this before I ask my question. I I just like to share this from my personal perspective. I think not only is the work that has been done over the years by all those people too numerous to mention important, I actually believe it's what drives the space. I think that most companies are out there trying with their algorithms because this thing got started. I think there's an argument to be made that if if the we are not waiting movement didn't happen, then a lot of people would've waited.
So I I I just I wanna applaud everybody. I think I think we're where we are now because of those people. Don't have you don't have to answer if you don't want to, but that that's my opinion.
Well, I have to say that it's because of this community and because at SQL, we share the same values, and we wanted to bring in an algorithm that was built by people who really like I said, rather than designing system and trying to fit people in Mhmm. We wanted to we wanted to include a system that was built by community for people and instead offering that so it can fit in their real lives.
Targeting as low as 8714:14
Yeah. There's a lot of smart people out there. So so okay. So you get this you know? So, I guess, so that people can understand a little bit, Tidepool did the lift, right, of getting looped through the FDA.
And then
We took it and embedded it on we did some we call it mathematical equivalence and embedded it on our pumps.
Could another company could I do that? Could I say, hey. I have an insulin pump. I wanna embed it on there. It's already been cleared.
Would it work that way?
Well, the code is in the is is is in the open source, so people people can access it, obviously. But I think to get it on a pump, there's a lot of work that needs to be happened to integrate it so it can be part of, like, a closed loop system.
Yeah. I I don't worry about I'm not starting a juice box pump. I just want I just want although it's not the worst idea in the world. But, no, I just wondered if it somebody else could pick it up and use it. So okay.
So you guys, you integrated together and start selling them last year. People are having good outcomes on them. Are we seeing, like, measurable a one c drops? Are we seeing more time in range? Do we see there are people reporting less distress, fewer lows?
What's the feedback so far?
We put it out there, like I said, in July, and people decided to go on those who decided to go on twist. We looked at the first batch of data, and we've seen that overall without taking anybody out, those who started high or low or those who had any if anybody had any issue, all of them actually, together achieved a time and range of 74.4. And like I mentioned, almost 70% of those users achieved their targets.
What's is that range fixed for everybody? The the the low high range that you're that you're saying time and range for?
That's so people can achieve their own. Like, they could say what they what they wanna be at. Mhmm. But the American Diabetes Association, there's a consensus on people need to achieve a certain amount of glucose between between the time and range that it's recommended, and that's the one that I'm referring to.
What is that range?
70 to one eighty.
70 to one eighty. Okay. And loop Lupin Twist allows you to target like, what's the lowest blood sugar you can target with it?
And that's one of the uniqueness about Twist. So in most others current existence systems before Twist, like, you could set it up as low as a 100, the lowest. And with Twist, you can you have a range, and you can set it up as low as 87. Mhmm. And you can go as high in one eighty.
So you really have this, vary or this large correction range.
Yeah. A target number that the that the device is shooting for when it's giving you insulin.
Exactly. So it goes as low as 87, and it goes at as high as one eighty. You can select any number in between to meet your own goals.
Mhmm. Was it what's it like doing your job at a company that is you know? I mean, you're sort of a software company. You're sort of a hardware company. Right?
Like, you're you've got a pump now. I have a a question here from people, about your site. When do non Clio sites options arrive? So, like, is there an auto insert coming? They have a lot of questions, I guess, about how the pump goes on to them.
Here's what makes Twist different. It measures the volume of insulin delivered with every dose using Soundwave technology. That gives it the ability to recognize a blockage quickly, allowing you to step in and deal with it before things potentially get out of range. It is also the only automated insulin delivery system that can be controlled from an Apple Watch. So you can discreetly check-in, enter carbs, or deliver insulin right from your wrist.
You can also set your glucose target anywhere from 87 to 180 milligrams per deciliter and adjust it for different times of day. So if mornings, workouts, school work, or bedtime all need a little different approach, Twist can flex with that. And here's a real life example. You enter carbs then something changes and you do not actually eat what you planned. With Twist, you can go back and correct or remove the carb entry and the system adjusts based on the new information because diabetes doesn't always follow the plan and your tech probably should not expect you to either.
If you'd like to learn more, go to visit.twist.com/juicebox. That's visit.twist.com/juicebox. Don't forget, Twist has two i's.
Yeah. First of all, I'll tell them we hear you, and we're we're always trying to improve on things we have. And you're correct. And we have taken some steps to enhance the experience. And now ICU Medical has modified some of that on the inserter adhesive pad to to help maintain the adhesions performance.
And we, on the other hand, we are working at SQL on our proprietary infusion set because we want to be able to give users more options.
K. Do you have a time frame for that? Do you have any idea when it might be available?
I I can't share a timeline, but I can tell you that, we got it cleared, and, we're just right now have to work through some logistics, some testing, and then putting it out there.
Oh, that's exciting. Well, so that's a a hardware question. People also said, why why did temp so temp bazel, did it get removed from your version of loop? It isn't available when loop mode is running, and they wanna know if you're gonna give it back or not.
How the algorithm actually behaves20:07
Yeah. So I can tell you a little bit on the temp bazel just to I do wanna clarify first that we do have temp Basel in two ways. The first way is that if if people wanna use manual mode, they could set a temporary Basel. But when in your in loop mode, which is when you're in a closed loop, the you the system does the adjustment for you. So they it does this what we it it is a temporary basal because it adjusts your basal every five minutes and put it in another state to make sure it it's accounting for the glucose and where you are, where you're going to be, and how much you ate how how your carbs is being absorbed.
So it sets up its own temporary basal to while you're looping. Mhmm. But I think what the community probably wants to hear is that we're there are more features coming up. And I think if there's more features like those, the DIY would call them, like, presets, there's more feature we're continuously evolving, to include, features that exist and people love in the DIY, and those are things we're listening to and try we will be bringing at some point.
I have a question that comes right from me. So I don't know how long ago my daughter started to use Loop, But, god, it feels like it was maybe six years ago, I'm guessing. And when I started, I feel like I started on a version similar to the one that you guys are using now, but then eventually moved to one that instead of trying to address higher blood sugars with, like, a basal increase, it started to do a bolus. They called it auto bolus back then. And I'm wondering how how does this system address higher blood sugars, and do you have an eye on on changing that, or do you like where it sits now?
Yeah. It's it's a good question. But, Scott, I'll I'll tell you. So if your glucose is high, you get insulin. You can get it whether you get it in a bolus or in a basal, insulin at the end is insulin.
Right? So some people gives it different type of names, on how it adjusts for the glucose. And in the current version of the twist, loop, algorithm, the adjustment for when your glucose is predicted to be high happens through what we call basal modulation, which means the basal was will go up so it can adjust for the, predicted high glucose taken into account, obviously, other factors as well.
Mhmm. And do you think yours will ever will you look at the auto bolus version? Do you see a reason to do it, or do you do you think that what you have is is is great and doesn't need to be adjusted? I guess I'm wondering about when you get the algorithm from, you know, the DIY community and it comes into the company, do you start thinking about how to make improvements to it in house, or do you think about going back out to DIY and because then don't you have to then put that back through the FDA if you did that again? Like, I I don't under like, it gets intricate and hard for me to understand right there.
Yeah. I can explain a little bit more. So first of all, we we do listen to people like you, who who express on what they need. So we're listening right now and trying to see if people wants those additional features. Be like I said, we know that there are features that people love and want, and they're feature that some people love but others may not want.
So what we do is that once we hear all the feedback, and this is what we're actually doing, is that we take that and work with Tidepool, to to kind of source those codes and upgrade it on the pump and work with the FDA to, update the next version of the algorithm.
I like that. That's a good answer. Thank you. Is Twist compatible with Dexcom right now?
It is not. But we know that for us, providing people with diabetes with choice is at the core is the core of what we do every day, and that includes CGM choice. So we don't have a public timeline on that, but our work is ongoing. But in the meantime, I'll say, Scott, that, our CGM road map is really actively expanding. We we are integrated with Eversense three sixty five, the Freestyle Libre three, and we are working to finalize the the Libre Duo integration as well.
Awesome. Thank you. How about for Android devices?
So, Android is this, I wanna say, is kind of, on the same page that, we we know that some people have different preferences on what they use. And, and if you're on Android and you're interested in Twist, I could say that you can't use it yet, but I don't I don't wanna brush pass past that. So, it's something our team is actively working on, and it is coming. I just don't have a date on it today.
Okay. That sounds more promising than a Dexcom answer, so that's good. Multiple profiles. People say multiple basal insulin to carb ratio, insulin sensitivity profiles for exercise stress, menstrual cycles, etcetera. They wanna know if those would be available.
So I guess set up a profile that's like, this one's when I'm active. This one's when I'm sedentary. This one's for when I'm sick, that kind of stuff.
Profiles, presets, and variability25:42
I think it's an important things to be able to have like, wanting to to have different profile if that's what works for people because they have variability. But but what I could say is that currently, Twist have tools right now in place to allow to flex for that variability. Mhmm. Because we have things like activity pre exercise preset. But for those who obviously likes to completely change profile for a certain period of time, those are things we're also working on based on feedback, some of the feedback we've heard.
Yeah.
Yeah. But but what I could say, maybe, Scott, just to add is that our algorithm, because it doesn't learn, so, it adapts, which means that if you're right now go through, let's say, exercise or hormonal changes
Yeah. To what's happening now. It's not
Exactly.
I'm jumping around a little bit here, but I'm enjoying the way we're doing this. Are you okay so far? Are you feeling good?
I'm feeling very good.
Awesome. Awesome. So there's a question here from the audience. I have to tell you, a lot of people ask me questions and I generally have answers, but this one I never quite know how to answer. How am I supposed to use, they wanna know, an automated system that relies on the data coming from my CGM when my CGM feels like it's never accurate or sometimes says I'm 400 when I'm 60 or says I'm 60 when I'm 300, like that kind of stuff.
“What if my sensor is never right?”27:14
And and all I can like, you know, when I when I'm asked the question, I say, look. All I know is that Arden has used Omnipod five. She's used Loop. She's used Trio. It's never been a problem.
And I don't but that's also my daughter also does not have a lot of issues with sensors. Right? So her sensors tend to work well, not get choppy, last the entire time. But I I never do know what to say to those people. Do you have you this is a thing you thought about or that you talk about internally?
So first of all, the if they have issues with one sensor, the good thing about our system is that it's compatible with two sensor Mhmm. Right now. And we're we're con like I said, we want to provide people with more choices. So if a sensor doesn't work for them to to select another sensor. But the other thing is that so there are some guidelines.
Right? If the sensor is completely off by a good amount, you're talking here over 50 or, like, really off, then, obviously, you you you're gonna the the the algorithm will make a decision, but to say how much insulin to give. But the uniqueness about Twist is that that decision will change in five minutes if that was if something was wrong and the sensor let's say, you change sensor or you fixed or things don't go in the right direction, the algorithm will reset again every five minutes and make the decision based on new information. Mhmm. Now if the sensor is off the whole time for like, you check and it's not really you're not able to there are sensor you can calibrate, sensor you cannot calibrate, then, you just basically, you can't you have to change the sensor.
Yeah. Okay. Let me ask you a a quick question about access and coverage. So people wanna know about how to get started. Is it covered by private insurance?
Coverage, prescriptions, and the pharmacy29:13
Does Medicare cover it? And then they actually, some of them specifically asked about certain health health care coverage. I'm not gonna ask you names, but I'm I do appreciate everybody sending the questions. And is there any plans for your indication to go under six years old?
Yeah. Right now, we are Twist is cleared for those age six and up. And in terms of access, right now, the path is very clear for us. If somebody wants to go on Twist, they'll speak to health care provider. They get a prescription.
It comes through the pharmacy. There's nothing that go through durable medical equipment, which sometimes may take longer and more things to navigate. So that removes one of the barrier. Now on cost wise, I think the the way it's designed that the first month, it's go if you have an insurance, the cost will be $0, but then it will not be more than $50 a month afterward for for refills. I'll say that when we launched or as we launched, we had a strong commercial coverage.
Now there may be specific plans you have called out maybe. I would say the most reliable way to get a real answer is to reach to your SQL team because, coverage can be different between one one and another, and I don't want to just make a guess here.
Sure. Sure. Of course. Oh, I appreciate that. So I'm I wanna make sure I understood what you said, though.
So if it's covered, it's nothing the first month and then no more than 50 moving forward. That's private insurance?
If you have a commercial insurance, the first month is $0, and then it would be no more than $50 per month, afterward.
Oh, wow. So what do you you're getting the device itself and then infusion sets. Is that right?
You would get the whole kit, the device, the infusion set, and, yes.
Okay. So the 50 a month would be for infusion sets mainly?
Well, the pump has two parts. It has the cassette, nonreusable part, and you have the reusable Okay. So you get in your package.
Yeah. I didn't mean to talk over you. The cassettes are disposable along with the infusion sets. That's the the supplies you're gonna need month to month. I got it.
You would be getting this on a monthly basis.
Zero the first month, fifty after31:37
That's a really fair price, actually. Is that a thing, like, that you guys set out to do? Is that was that part of the the idea when you got going? Like, let's do something that won't cost a bunch of money, or, I mean, is that just how it worked out?
This was really very important to us. It's one of the things that our CEO is very passionate about. Arlen Lodwin is our CEO, and and the first thing that he really told everybody and told us that he wanted to make sure that those system are accessible, and they are at a price that people can afford. Obviously, I know not everybody can afford, but I think we wanted to make sure that that we can work with payers to give it at at a at a rate that may work for many.
Yeah. How about I I did I miss did I not hear? But did you say, is it covered by Medicare?
So right now, it it depends. So we we the the way it works with Medicare, I think, depending on the specific plan that people may have.
Okay. Alright. So they should check with Medicare to see if it's covered?
Well, if they are on Medicare Part d and they have a specific coverage, that's what I meant. They may have coverage through the pharmacy.
I see. I see. Oh, through pharmacy. I'm sorry.
Correct.
I'm gonna ask you for a second a little bit about what you guys are looking into for type two, but I don't wanna I don't wanna make people wait any longer for what I think might have been the biggest question that I got asked when when I went to the community and asked. And here it is. Will Twist ever have a tubeless option?
Will there ever be a tubeless twiist?33:16
So it's very important for us. Like I said, this question and many others, when people we we we want to be able to meet people where they are. We want to listen to what, really matters for them. And, we know that tubeless is something people are asking about. Some people may think that they want tubeless because they want something maybe easy to use.
So we listen to all of that, and the idea for us is to make sure we we make Twist is continue to be able to be personalized to everybody and meet them where they are.
Is there anything I haven't asked you that that I should have stuff that would have led to information you want people to have about the device or the company? Did I leave anything out? I am gonna ask about the type two stuff, but I wanna know, like, did I leave anything out? Because in my listen. Here's how I'll put it.
I feel like I know a lot about loop. And not as much as some, but a a fair amount. And I know how fantastic it is. My daughter used it for years. And I would tell anybody if you wanted to use a DIY loop and you couldn't figure out how to do it, I would a million percent look into Twist.
I would also say this is probably a good time for me to say that you guys are on again, off again advertisers on the podcast. And I think at this at this juncture, we are actually in the middle of a a contract. So just so people know that. But I'm telling you, if if you wanna try Loop, definitely look at Twist, especially if you're afraid to build it yourself. But I wanna make sure that I didn't, like, skip anything or miss anything that you're sitting here thinking, oh, no.
They should really know about this part, and it didn't come out.
Yeah. Maybe if there's, like, one last thing I wanted to leave people with is that that the the belief that we we build around because I've heard few questions and that we believe that technology should adapt to the person, not the other way around. Mhmm. So we listen to feedback, and we're committed as ever to the community that we're serving today, the type one community. And I know you've had questions on others, and we're trying to make sure we're putting a lot of energy to making their their experience better, but also expanding access to others.
Now our Twist algorithm has what is unique about it is that you're you're able to really customize it according to to your target and to your needs, but also the the health care provider who's helping you have some levers to will have some levers to use if they wanna be more aggressive or less aggressive. They have those tools that we are we are teaching them about
Type 2, and who else this could serve36:03
Yeah.
To make sure they're comfortable adjusting their their settings for the patient sitting in front of them.
You're telling me that other systems some other systems work the way they work, and that's that. And you you can actually go into into Twist, into Loop, and make finer adjustments maybe to insulin sensitivity, carb ratios, things like that.
Yeah. So if people I mean, I'm a health care provider, and sometimes it's hard to to know which because there's things that you can't change. And with Loops, you have the option to change things if you want to be, more aggressive or if you want to account for a few things. And and the last thing I would say about our algorithm is that it has also some uniqueness that it does adjust for how your carbohydrate is predicted to be absorbed. You know that not all foods are absorbed in the same way.
Right? So some things may be absorbed quickly. Something may be absorbed more slowly. So the algorithm, when it makes the adjustment for insulin every five minutes, it takes into account the the meals that the patient or the person with diabetes would have entered.
Yeah. Is that still done by touching pictures of food, like lollipop and stuff like that, or did you guys make an adjustment to how that works on on this system?
It is done by selecting an emoji. Yeah. And for those who don't wanna select an emoji, it will select it will default, sorry, to the three to the three hours absorption Mhmm. Which is probably the majority of the meal.
It's a fantastic algorithm. It really is. It's just whoever thought it all up and did it, yeah, kudos to them. And and for you guys for bringing it out into the world, I mean, I've I've always said I'm very candid on the podcast. I've always said, I think the DIY community is fantastic, and the algorithms they build are amazing.
But, I mean, how many people are we really reaching with them? Like, it's people who are comfortable building an algorithm and uploading it onto their own phone, and it's just it's a leap for a lot of people. It's wonderful to bring it to the masses like this. It just it genuinely it's a it's a great thing for people living with diabetes. So notice I didn't say people with type one because you guys did a a trial for type two.
I'm guessing you're just starting to get into it, but what what led to wanting to do this investigational trial for type two, and and what are you guys thinking about over there?
Yeah. So we do want to improve we want to make technology accessible to everybody who would benefit from it. And right now, we are cleared for use in type one only, age six and older, but we want we're doing a lot of work to get us to get this technology cleared for other populations as well.
Yeah. And do you have a timeline for that? Are you something you're hoping for, or is it even too soon? Did you get data back that made you think, okay. That's good.
We'll keep going. This looks like a good idea.
Yeah. I can't share a timeline, but I can tell you that, yes, we completed our, trial, which is an important step, to get us, to get this tool or this technology to people with diabetes.
Mhmm.
And then we shared that data at the American Diabetes Association.
Okay. And, can where can people find it? It's on your website, I imagine.
So we did issue a press release, that tells, that tells about, the completion of the trial and, the data that was shared at the at the ADA.
That's cool. Did you include people, using a GLP in the trial?
We did include people coming from, different backgrounds and different therapies. GLP one, SGLT two, different age groups, different, race and ethnicities, different, insulin regimen coming in.
Joanna, can I share with you this is not a thing I need you to comment on? This is all completely from me. But I think the future of even for type ones is going to be a combination of an algorithm and a low level of GLP to kinda cut into insulin resistance. My daughter does it that way, and the outcomes are just spectacular. So I I think it's gonna be a a couple tools in the toolbox over the next few years.
And then my hope is that you and other people like you continue to work on these algorithms and get us to a point where maybe we don't have to announce meals. I think that would be a really big deal for people with type one diabetes. And then, you know, who knows from there? But in my mind, if you put me in charge, those are the things I'd be that I think I've seen be most valuable for people and that I'd be shooting for. So that's my 2¢.
GLPs, phenotypes, and a time capsule41:02
Of course,
I make a of all.
I make a podcast, you're a doctor. So, you know, you take it with a grain of salt.
No. I've I I wanna thank you for sharing your experience with your daughter. People have different needs. Right? So GLP one may help with, glucose after a certain after a certain meal.
It may help a little bit with the weight, help with insulin resistance. And, if that's what people need, to use with their AID system, then that's that's what they need to get to the goals that they want for themselves.
Yeah. Hey. Listen. I just said it here so that, like, years from now, I can use this as a time capsule and look back and say, yeah. I was right about that.
And and and it doesn't have to be and what I would add to it so we can both look at it back in time, the future Okay. Is that it doesn't have to be one or the other. Right? Sometimes it it it it has so you're right. Like, it may be that it's a combination of things to to get people where they wanna be.
Oh, yeah. No. I don't think it's for everybody. I mean, my just looking at people right now and having conversations, I think there are some type ones that have type one diabetes and have some insulin resistance almost as if if they didn't have type one, they might still have insulin resistance. And I'd also I'd also look out for the the appropriate bodies to start I think they're gonna say that a dual diagnosis is, like, a a legitimate thing in the in the future too.
I would I would imagine that's coming as well.
Anyway, like people working on different phenotypes. Right? Like, the diabetes, not all the same. Not all type one are the same. Yeah.
So you are correct in that regard.
Do you do you know doctor Hamdi?
Yeah. I worked very closely with him. I did work very closely with him, and him and I always get into that discussion. We're both very I would say, personally too, I'm passionate about those different phenotypes in diabetes because I believe that we can't only just think of them as type one or type two. People have different profile, different needs, and and I like different classification too.
I interviewed him last year. He's one of my favorite doctor interviews I've done in a while, and passion was the right the right word. I think he's one of the people who will move it all forward for people. Anyway, let me just say this. If any of this made you guys excited, I'd personally appreciate it if you went to twist.com/juicebox to learn more about it.
Twistwith2i's.com/juicebox. We'll probably put your ads on this episode so people can hear it too. But thank you very much for doing this. This was wonderful. It was great to meet you.
You and I hadn't met pre previous to this, and this was really lovely. It took us a while to get you on here. You canceled on me a bunch of times, I just wanna say.
You must be busy. Thanks so much for having me. I did enjoy. Obviously, I did enjoy. It was a great conversation.
Oh, I'm I'm glad you think so. Well, thanks again for coming. I appreciate it. To learn more and see if you might be able to get Twist from the pharmacy and try it for free, head to visit.twist.com/juicebox. That's visit.twist.com/juicebox, or give them a call at 18774.
That's +1 (877) 489-4478 and tell them Scott sent you. TWIST requires a prescription and is indicated for people with type one diabetes six and older. Let's face it. Diabetes is tough, but it's easier when you have a community around you. So if you're looking for a great community around type one diabetes, check out the juice box podcast private Facebook group.
Juice box podcast type one diabetes, but everyone's welcome. Type one, type two, gestational, loved ones, it doesn't matter to me. If you're impacted by diabetes and you're looking for support, comfort, or community, check out the juice box podcast private Facebook group. Juice box podcast, type one diabetes on Facebook. I promise you it is the most unfacebook like experience that you'll ever ever find.
What a great group of people. I don't like saying this usually because it dates the ad, but right now, there are 86,000 active members. 86,000 people in there who might have your experience, know what to say, or just be a great shoulder to lean on. Don't be too proud to find a community. It really does help, and it's completely free.
Juicebox podcast, type one diabetes on Facebook. I just wanna say thank you so much for listening. I'll be back very soon with another episode of the juice box podcast. If you're not subscribed, please subscribe in a podcast app. It really helps Apple Podcasts, Spotify, or whatever your favorite audio app is.
Like and subscribe. You know what the kids say on the YouTube, like and subscribe. It really does help. If you or a loved one was just diagnosed with type one diabetes and you're looking for some fresh perspective, the bold beginning series from the Juice Box podcast is a terrific place to start. That series is with myself and Jenny Smith.
Jenny is a CDCES, a registered dietitian, and a type one for over thirty five years. And in the bowl beginning series, Jenny and I are gonna answer the questions that most people have after a type one diabetes diagnosis. The series begins at episode six ninety eight in your podcast player, or you can go to juiceboxpodcast.com and click on bold beginnings in the menu. Thank you so much for listening. I'll be back soon with another episode.
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