#189 The Tide is High
Scott Benner
Loop, loop skip to my loop…
Tidepool's own Christopher Snider is here to talk about looping with type 1 diabetes. AP baby!
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DISCLAIMER: This text is the output of AI based transcribing from an audio recording. Although the transcription is largely accurate, in some cases it is incomplete or inaccurate due to inaudible passages or transcription errors and should not be treated as an authoritative record. Nothing that you read here constitutes advice medical or otherwise. Always consult with a healthcare professional before making changes to a healthcare plan.
Unknown Speaker 0:00
Hello everyone, today
Scott Benner 0:00
you're listening to Episode 189 of the Juicebox Podcast. We are sponsored as always by Dexcom on the pod and dancing for diabetes. Now you can go to my omnipod.com Ford slash juice box, you can go to dexcom.com Ford slash juice box, or dancing for diabetes.com. That's the number four. While you're at the dancing for diabetes website, click on their link to Instagram. They're doing something cool for the next 34 days on Instagram. And while we're speaking about Instagram, let me say this dex comes on there. They do a great job there. But you know who's new on Instagram just this week, on the pod there at my on the pod on Instagram now flood them with messages, give them some likes, let them know you came from the podcast. Today's show is ripped from the headlines. That's right. I saw some news happening breaking in the diabetes community. And I went right to my I just picked up my phone really. And I sent a message to somebody I know. Chris Snyder. You know, Christopher, you know, Christopher Snyder, you will soon anyway, I sent a message to Chris because he works for the company who broke the news. And I was like, Hey, Chris, I know you. Can you come on my podcast? And he said, Yeah, sure. And I was like that easier it? I mean, I like to make it sound like it was bigger than it was. Now why do we want to be talking to Christopher Snyder? Well, that's an interesting question. I'm gonna answer for you right now. Chris has had Type One Diabetes a very, very long time. He is married to a lovely woman who also has type one diabetes, he works for a company called tide pool. Chris has done a lot in the diabetes community over the years. I've known him for quite some time. And he's an amazing advocate for people like you. Today, Chris is on the show, because he's here to talk about looping, artificial pancreas tide pool like this kind of a lot of words that you might be like, I don't know those words, Scott. But don't let this feel technical to you don't need to understand the words. Even though by the end, you will just know this. We are all very close to our Dexcom CGM sending data to an algorithm, a little program. Basically, they're probably live on your cell phone. And that will tell your insulin pump more insulin, less insulin, it'll help you stop getting out, it'll stop you from getting high. That's the near future. That's what Chris is here to talk about. Please remember that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise and to always consult a physician before making changes to your insulin plan. I think part of my delightful charm is my ignorance. I know tide pull doesn't mean that you work on a cruise ship helping people learn to surf.
Unknown Speaker 2:35
This is true that
Scott Benner 2:36
that much I understand the rest of it. I've never, I'm not embarrassed, but I'm spread a little thin. I've never really delved too deeply into it, because it hasn't. It hasn't been something I've needed. But it is always one of those things that I think Gosh, I'm pretty sure I should understand this better. Like what tide pool is in general. And then you guys came along and started making this announcement about loop. And I was like, Alright, it's time Scott needs to be informed. So can you tell me first what you do at tide pool and and what time pool is?
Christopher Snider 3:08
Sure. So I'm the community manager at Tide Pool, which means I'm responsible for among other things, social media and email communications. So if you do receive typos emails, it's my smiley face at the bottom was in data. Christopher Snyder. title is a nonprofit organization. We create free software to view data from pump CGM. And why do we use meters all in one place? That I mentioned that it's free, it's free for people diabetes their families and clinicians that I mentioned that it's free. That's the thing that I have found whenever I provide demos of our software to Coalition's they are all most often surprised by whenever they see what all this stuff looks like in motion, which is really, really exciting. But that also means that there's a natural follow up of Wait a second, it's free. How do you stay operational as a nonprofit organization to which I say great question, eager person who's paying attention to my software demo. And I said, We are supported in part by grants from Helmsley Charitable Trust and the jdrf. They've been a big supporter of ours from the beginning of time cool. I say ours even I've been a part of the team for a little over a year and a half. But at this point, ours. And also, there's a whole research component to the title platform. And on that side of things, we do charge money. The type of platform can be used as a data back end for clinical studies. So if you've got an idea and you're conducting research and you need diabetes device data type will can help you with that. Additionally, people with diabetes we're using type will have the choice to opt in to something called the typo Big Data donation project. What that means is that we will anonymize and de identify the device data that you upload to title secure servers. And we will license those data sets out to different partners and people with a grand idea. So when you hear things about machine learning algorithms and things like that, the big data, data sets that are coming out of typos can contribute to that. This This program is entirely opt in that type of we believe people diabetes own their data. First and foremost, we don't do anything without their explicit consent. So it's like maybe it is a checkbox that you would have to check to enable that sort of process to begin. But that money that we make keeps us sustainable as a nonprofit, and it's really useful. To work at this company, we are a growing group now as we're about to get into thanks to this typo loop thing. But almost everybody, I think for the exception of one person, a typo on either has diabetes or has a kid with diabetes, I, myself am living with type one, my wife also has type one for what it's worth. And one person who doesn't have type one diabetes, he just loves devices and that sort of technology thing. And he sort of found his way through his own master's thesis into diabetes tech, and then eventually found a better title. So it's like there's, there is a very earnest and sincere obsession with getting this right, because we know what's at stake, because it's our lives. It's our kids lives. It's our spouses lives that are dealing with this stuff, too. And it makes it really impactful to work with this group. And it's been a really special ride for me to be part of this and to ultimately be one of the voices of this company. So that's the data access side. I know is Arden still rocking it? Omni pod?
Scott Benner 5:53
Yeah, Arden uses Omni pod. And she's using g six. Okay, I've never, I've never looked more into it. Because we're having, we're having so much success already. And I end up being one of those people, Chris, who's I wanted to come out of the box and work and I don't want to understand it. Like, like, that's for pretty much any of my technology. I've never been, I don't know, I don't have that gear. And I have to admit, like, at some point when someone said Raspberry Pi, and I saw electronics champion with Tic Tac box, I was like, I'm out. And, and it doesn't matter. It could have been the easiest thing to do. I saw that. And I was like, I'm done. And I think that I reflect I think I really think my opinion is reflected through most people because it is really it comes down to like compute cycles in my day. I just I don't have any more time for anything else.
Christopher Snider 6:46
So buddy, do you have USB cables hanging around your house, of course. And you have you have a google google chrome on your computer? I do. Okay, then you could use fiable, you could sign up for a free typable account right now connect that PDF, and then connect the Dexcom. And you could see all that data in one place, and also potentially donate it to research if you were so inclined. It's as simple as a USB cable. That's all you need to stifle. Yes, sir. Yes, let's do what
Scott Benner 7:10
the most interesting thing ever happened on any podcast. And that's go to the internet. So you're, you're saying I go to tide? pool.org?
Christopher Snider 7:18
I'm working tightwad org. There's a button at the top that says sign up. I see that. You click on that. That'll get you started on the process.
Scott Benner 7:25
No kidding. And then so what So basically, it's going to let me see everything from art and CGM and everything from ardens pump all in one place. Now, tell me something. Is this not? What is this not what? On the pods telling me I'm going to have soon anyway? Or is how is it different? different from what from like other stuff that everyone else is doing? Like what sets this apart? Like, why is because you guys have risen to the top? And I mean, I think when I look into Thank you mean, no, absolutely. I think there's there's a number of companies all sort of like saying, Hey, we this is what we do. I feel like you guys have have have really kind of ascended. And so why do you think that is? Why do you think people lean towards side pull over other options. Option one is your blood sugar's just doing what it's doing. And you can't say option two is it's doing what it's doing. And you can say it, which sounds better, option one or Option two. Option one, your child's at school, their blood sugar's getting too high, you'd like to do something about it, but they don't go to the nurse for three hours. So it just keeps going up and up.
Unknown Speaker 8:29
Option two,
Scott Benner 8:30
your child's at school. They're wearing their Dexcom g six CGM, their blood sugar goes above the number you've designated. It sends a little message to your phone, beep beep. It says to you, your kids, blood sugar's over. For me, it's 120 instead of three hours of a high blood sugar, what you have is an immediate ability to bump that blood sugar back to where you want it. What sounds better, option one or Option two. Option one, you're out for a run in the park. It's a beautiful day you have type one diabetes, and everything's looking good. You've put in the food you expect to handle things. But what you don't know is that 20 minutes from now, your blood sugar is going to drop pretty quickly, under 50. Now option two is the predictive alert on the Dexcom g six tells you Hey, I expect your blood sugar to be under 50 in about 20 minutes. Maybe now's a good time to do something about that. What sounds better, option one or Option two. I want you to go to dexcom.com forward slash juicebox. Find out more today about the dexcom g six continuous glucose monitor. I'm putting this ad earlier in the show because the rest of what you're going to listen to it all hinges on having a dexcom it's time to get going. If you think of your life with Type One Diabetes is not having options. I'm here to tell you there are a lot of them and they're pretty great. Dexcom is a huge part of that. Today's the day to get started dexcom.com forward slash juice box. The links in your show notes were the links at Juicebox podcast.com. Why do you think people lean towards side pull over other options?
Christopher Snider 10:05
I think the nonprofit angle definitely helps I think the personal connection and the credibility that the type whole team has built across the years the title has been around, like when you hear our CEO Howard talk about this stuff, his daughter has type one. Like he's, it's clear that he gets it. Obviously, he's the CEO of this of this entire venture. But he speaks in a certain way that is so passionate, and so empathetic about it, that it's hard to not want to run through a brick wall for him, and then know that he will be on the beat or on the other side, with some sort of, you know, EMF service to help you out in case for some reason, you actually did try to run through a brick wall. I think from a technical side of things, it what's really exciting is that there is an ease of use to it. But also there's a standardization to what we do, does that mean data comes in on an animist pump on a T slim on an omni pod on a Medtronic 670 g as those from those individualizes. But we visualize it in the exact same format no matter what the device looks like. So if you have sort of artisan or Omni pod right now, if she switches to a Medtronic for reasons, the data is still going to look the same. So there's no new process for trying to understand how to interpret the data, it's just a matter of changing the upload process a little bit, because it's a different device. And I think that that standardization, and what I believe is an ease of use, and a nice opportunity to interpret and understand your data because it is yours or your kids data in this case, I think that Ease of Access provides a lot of opportunity for people that they didn't necessarily think that they need it because there is, as my cat claws at the wall in the background is gonna make for great audio. There is a great opportunity for for that sort of like there's like a lightbulb moment, we sort of internally call it a typo moment of actually seeing all that data together in the first for the first time. Because if you're uploading your Dexcom stuff that clarity, yes, they clearly does a great job of providing Dexcom specific reports, all their trends, your weekly reports of how often your remains and things like that. That's fantastic. But what are you doing on the insulin side of things? declared can tell you that? But if you put it all together with title, for example, then you can then you have the entire context of your diabetes experience. Hey, Arden went low. What happened before that? Oh, wait, there is a Bolus over here. Was that too much? Was that too little? What's happening over there. And then you can sort of connect those dots as it were, and try to make a little better sense to hopefully, you don't necessarily want to say get it right, but have hopefully a better outcome the next time around. Makes
Scott Benner 12:13
sense. And also, I mean, it's funny, as you're talking, I thought that's not interesting. Like say I have a DVR for my television, and I'm used to the on screen, UI. But there's a better DVR that comes up but it's completely different. Like I can't I have I switch I have to switch I get a new DVR, I get a new UI and that's it. But what you're saying is no matter I can go from pump the pump to pump. My data always looks the same. Yes, sir. That's a great idea. And and how is that? So tell me a little bit about that side of like, how is that possible? Like, why?
Unknown Speaker 12:45
Like, what
Scott Benner 12:46
is it just because you're a separate entity, right? Like it you're not attached to a company. And like when when you tell me tide pool works with all these pump companies, is that something they had to agree to or it doesn't matter. But so for all of the devices that we currently support, with the exception of Medtronic, we have signed agreements for them to share their data protocols with us so that it's easier for us to implement across the board. In the case of Medtronic, they had some different perspectives on data ownership, for example.
Christopher Snider 13:14
And we had to do the work ourselves to build our own Medtronic driver. And that's why it took over a year for us to release support for Medtronic six series pumps.
Scott Benner 13:22
Tomic Sonic, I
Christopher Snider 13:24
have a different view of them to it. Well, it's, you know, it's, you know, everybody has their own perspective on it. And, and we've had plenty of conversations with Medtronic, we still have conversations with them to this day. Ultimately, I think even and I can't speak to the specific conversations, but my, my, my sort of assessment of it is that there are plenty of people at Medtronic that get it and that, you know, in that aren't necessarily believe what we believe, but they, they get it. But ultimately, it comes down to you know, certain people making those decisions. And if certain people don't feel a certain way about or they don't want to sign an agreement that that day, then Okay, and then we'll just see what happens next time. We have another conversation. But that hasn't stopped. title from pursuing conversations with different you know, pumping CGM companies across the board, like we want to work with everything with everybody. Because we believe people diabetes on their database should have unfettered access to it. And we're gonna do everything we can to provide that. And it's, you know, so far, it has been so good, but you know, as more stuff comes out, you know, hopefully we can we can stay ahead of the curve and continue to be the go to place for for data access.
Scott Benner 14:27
I think of data as experiences and I couldn't agree more. I think that everything that I accomplished with my daughter herb, I'm looking right now our blood sugar's 106. It's nice and stable. It's been like this for hours while she's at school this morning. And and the things that people hear on the podcast that then they kind of put into process in their own life and hopefully have similar outcomes. It's all just understanding your experiences, having an experience looking at it, and then making adjustments to it next time, a little sooner, a little later, a little more, a little less. That's really what it boils down to. I think that I think that for me, the cool of managing Type One Diabetes is understanding how insulin works in your body. I think that's, that's the first step to the whole thing. And so obviously more data leads you into that space. I think the word data sometimes scares people, which I think is why I say experiences. But that's what I mean. I mean, you got to go back and look and see what happened and make adjustments. Yeah. Interestingly enough, and this is a little behind the curtain, but I think it's important to know, When, when, when you guys made this announcement about loop, which is something we're gonna talk about in a second. The first thing I did out of respect to the relationships I have is I went on the pod and I said, Is it alright, if I interview tide pool about loop? Like, I don't understand the business of it like, is that somehow getting in the way of what you? Do? You know what I mean? Like, is it a direct competitor, and they very quickly got back to me said, No, absolutely talk to tide pool, that's fantastic. Because what they're what they thought was, there's going to be a way, you know, horizon is gonna come out one day, right, and they're gonna have an artificial pancreas system and everything. But if there's another way to do it, and someone can still use an omni pod and use a different algorithm, or whatever, they're, they're excited for that. They're excited for people to have more options to use their product with. And I think that that is an amazing leap, just in general, that a company would say, Hey, you know, sure, we're gonna have software that does that. But if someone else does you like it better, or works better for you, or whatever, go use that one. Like, that's, that's a great moment. For us. For people, I don't have diabetes, I know, I feel like I do sometimes. But for people living with Type One Diabetes, that's spectacular, that's a company not trying to lock you into their idea. And because their idea might not progress as quickly, because they're busy making insulin pumps, you're busy working on software.
Christopher Snider 16:43
Mm hmm. I think the key word in there that you are alluding to is choice, and providing people with diabetes and their families choice in their therapy. So like, with typo you like we don't necessarily title can dictate, you know, what insurance is going to cover. But we want to provide you the choice and the option and the ability to view that data and an unfettered way through our free software. And and that's that's sort of the vision that we have with Hyperloop is that as, as different ICG M's and AI pumps come to market and they we do establish agreements with these companies to to include them in the title loop, you know, sort of process with our AI algorithm or AI control, I'm not sure what it's ultimately going to be. But the key thing at the end of the day is to be able to sort of pick the pieces of your diabetes management that you want, and then just make it and it will all just work. And that's the promise of it. Obviously, like, you know, as we are recording this, we made an announcement about type polio today, three days ago, on Monday, the eighth and I've been losing my mind and Twitter notifications ever since. So like, you know, we haven't announced obviously, which devices The thing is gonna work with just yet. But we the goal, ultimately is to provide choice to the diabetes community.
Scott Benner 17:50
Over the next few weeks dancing for diabetes, we'll be introducing you to 34 incredible and inspiring young individuals on their Instagram account, please go to dancing the number four diabetes.com right now check out what they're doing. And then scroll to the bottom and click on their link for Instagram. And don't forget if you're local in the Orlando area dancing for diabetes is holding their 18th annual extravaganza at the Bob Carr theater. Let me ask you a question that you may or may not have a thought on and and this would require you to speak for someone else but maybe maybe you can have maybe you can Why did it take tide pool to exist? why don't why didn't accompany have like dinner? I mean, like why wouldn't they do this already? That was the thing that I always like, you know, any of the devices I've seen everybody's pumped. And like you said the information you get back is nice, but it doesn't. It doesn't speak to you know, another device, it doesn't do overlays, there's all kinds of problems and I use clarity every you know, not every day, but I use clarity a lot and it does fine for me. But to your point it doesn't I can't see what I'm doing with insulin and I can only see what the blood sugar is doing. I just as you're as you're describing with high blood, as I'm looking here on this website, what I can think is like why didn't one of them do this? Like why? why did why do you make any sense? It doesn't make sense that you needed to do you know what I mean?
Christopher Snider 19:11
Yeah, um, as I was actually in a roundabout way, talking with our CEO about this a couple of days ago, just sort of like why him Why then why now and a little a little about context. I mean, Howard was VP of software at TiVo and Amazon like, he's a big geek. It's it's kind of remarkable. Like, how, how much of a nerd he actually is about all this stuff. And it just like, you know, fate is not a word that we want to throw around too often. But it just, it was the right place right time for for him whenever his daughter was diagnosed, and she was on a pump and CGM. And it's like this technology is great, but why can't I see all this data? Why can't I make any sense of it? Why isn't it working? And then, you know, being in Palo Alto, he has a different level of access and opportunity and he found some very smart people who had a similar idea. And then together they became the foundation of title and it's evolved and grown. And expanded into what it is today. And it's I hate for it to be a matter of right place right time. But and I in Howard even told me himself that he believed that something like this would have come along. If it weren't for him. I mean, somebody else would have had a similar thought they just happened to be him, he happened to be the right person at the right time to, to spearhead this and then take the lead on it. And then Ever since then, we've done what we can to to move the conversation forward about data access, we've been as part of like the title loop thing, like we published our meeting minutes with the FDA. So you can go to tide pool.org slash documents right now and see everything we've told the FDA about this project to date, which is a level of transparency that I quite frankly, I haven't seen anywhere else, when it comes to diabetes stuff when it comes to FDA stuff, like Howard has believed. I've known him on and off. I mean, I guess before working a title, I've known him for about four or five years. From the beginning, he's always said the FDA is not the enemy, you just have to be willing to engage with them early and often. And and that has benefited us tremendously to the point that I feel like we are regularly punching above our weight in the conversations that we're having across the healthcare industry, not just diabetes space, but across the healthcare space, because of how we're approaching data validation, our process our our quality management system, as far as the level of transparency that we're sharing with the rest of the community, anybody who wants to take a look and see what we're doing our code is open source, the Trello boards that we have for the current work that we're doing and work that we've completed are all open to the community, we know, to the extent that we can share something with with everybody we do that. And it's it's pretty remarkable to be part of that process. Whenever, whenever the like I said, like there hasn't been a lot of history supporting that sort of effort. And we'll see what happens five years from now, like that fighter window for these people is always a tenuous thing. But we'll see what happens if more companies sort of take that approach. I hope that they will. I mean, if I hope that we people see us as a standard setter for this. And in seeing this as not just a fluke or an anomaly, but as like a genuine path forward for how you can approach digital health software.
Scott Benner 21:55
My wife works in drug safety, her whole career pretty much. And she always tells me that the biggest problem that pharma companies have is that they're afraid needlessly of the FDA. Yeah. And she's like, if they would just do what you just said, She's like, everything would just and I just clicked on this, like, this is an incredible collection of everything you guys are doing, made public. But he or she would always say that if they just would just not be scared. And I think the first person I saw diabetes, not be scared, right? was when Sanofi opened up, they're coming, they're kind of community arm and they they were reaching out to people with diabetes more, they were the first person who would, to me just said, Well, let me let me do what we think is right here, have good intentions. And if and, and the FDA will tell us if we've gone too far, instead of instead of pulling back doing less than we think would help people, let's do what we think would help people and then and then maybe that won't be a problem. And it turned out wasn't a problem. And my wife says that all the time. She's like, if you just if you just went forward with good intentions, that's what the FDA wants, they want you to do good work for people. They don't they're not in the business of telling you. No, they're in the business of telling you do do good things for people. Yeah. And so that's, that's really spectacular. I can't tell you that that's going to lead to so much success. I mean, it definitely seems like it will to me, and it looks like it is already. Okay, so tide pool starts out, it's a way to aggregate my data together for my pump, some ice jams and all this stuff. But now the world is I don't know how much people listening really understand. But there are plenty of DIY people in the world. You know, I we've had some of them on here making their own artificial pancreas as with all pumps and algorism algorithms that they wrote themselves. And there's a lot of people sort of on the fringes of diabetes doing this work for themselves that you know, they don't want to wait for a company to do it. They're doing it for themselves. And I hear people tell me all the time, oh, we're looping now. We're looping. And I just think of that movie with Bruce Willis. And that handsome boy and then I don't know, I haven't seen that movie yet.
Unknown Speaker 24:03
Is it really good?
Scott Benner 24:04
You know what, Chris? It's worth it. You'd like it. Okay,
Christopher Snider 24:06
you would Yeah, I'm always down for a good sci fi time travel sort of paradox thing and like it's been like on my Amazon with watch lists, but I haven't actually pulled the trigger because I have no time anymore. But thanks to puppy and just barely watching any of the shows that we normally watch is a whole hassle and there's like a half hour shows. So like trying to watch out for a movie is an impossible task at this point.
Scott Benner 24:26
A couple of things that people may or may not care about one I saw you got a puppy on line. I was like that's adorable. Because I love our dogs and so wish I didn't have them some but but I was like oh Chris and his new wife are gonna have this nice house and whether that dog pees on the floor ones anyway um,
Unknown Speaker 24:47
but
Scott Benner 24:48
But no, I get what you're saying. So looper as a movie review. It falls apart a little bit at one point but not in a way that makes you sad that you watched it. Okay. So and and Bruce Willis does his halfway between his diehard fans. And halfway between his Moonrise Kingdom thing. So he's he's writing his Bruce Willis sweet spot in my opinion.
Christopher Snider 25:07
That's that's fine by me. I'm diehard three all day.
Unknown Speaker 25:09
Yeah. So
Scott Benner 25:10
and then there's that other boy with the three names whose name I can't remember right now.
Unknown Speaker 25:13
Joseph, Joseph Gordon Levitt Joseph Gordon
Scott Benner 25:15
Levitt, who's been I don't think been banned. anything I've ever seen. So, okay, so everybody go watch looper that has nothing to do with looping. You're gonna have to talk to me like I'm for for a second. What is loop? Instead of an on the pod ad right here, I'm gonna tell you a little bit about a note I got last night. It's from a person who said that they let's see. Hey, Scott, I want to thank you for the podcast making diabetes management actually seem manageable. I found the show this summer. When I was looking for details about the Omni pod products that were coming up, I found your interview with them dove into the older episodes. And of course, listened to the classic episode number 11. I honestly never looked at diabetes management that way before. But I changed my mindset completely tweaked my basal rates changed, my ratios changed my dexcom alarms started treating high blood sugars more aggressively. And here I am three months later with my a one c down from seven, one to 5.5. And then she uses an expletive here, which I like, I don't know that my once has been that low and 16 years of having diabetes. This is the great part. I'm getting married in December. Thinking about having kids before I found your podcast, I just don't know if I ever would have felt comfortable enough to try to get pregnant with my one season the seventh. Going to the doctor today and seeing that 5.5 was so exciting. And also a relief, I can do this. Thank you for giving me the confidence to do something about it. I included this story here in this ad for Omni pod because three years ago, when I had the idea to start this podcast, and not one download to show for it. I went to Omni pod I said I need you to back this idea I have to help people. And they did before there was any reason to support it. And here we are now three years later, reading a note like that, about a woman who's about to start a family and have children with the help of something she heard on a podcast, something that three years ago didn't exist, that I couldn't afford to start on my own. Something that ami pod heard about and said, Yes, I'm really gonna let you into this conversation. You think things are about money all the time in business, I told them, Look, I don't know if this is ever going to make any money. But I can tell you that I really believe that it's going to help people. And if Omnipod wants to be part of helping the community, I really would appreciate your support. And they did it based on that, before they even knew if I could ever get it, download my omnipod.com forward slash juice box, try the free no obligation demo today. Try the pump on see what you think and support the company that supports this podcast, while just trying to support you. You're gonna have to talk to me like I'm for for a second.
Christopher Snider 27:53
What is loop? Alright, so we had to take a step back, I got Well, first of all context, which is really exciting. Like there are currently nine people a tide pool that are looping or have used open APS, which for that doesn't really mean a lot. But it's just like a fun little number we can throw around. So you have cgms people know about that the Dexcom thing that does every five minutes your blood glucose value in the people have figured out ways through things like nightscout to get that data elsewhere to have that visibility elsewhere. Some very, very smart people figured out that certain old Medtronic pumps can receive commands through very specific radio frequencies translated from very specific devices to alter basal rates and to do other things that has branched off into a couple of exciting new ventures, Android APS open APS, which people might have heard and loop. Ultimately, we're talking about Dexcom data, going into some sort of algorithm based thing and then sending a command to an insulin pump to say, Hey, I'm a little low, a little less Basal please or ham a little high, a little more Basal please. or, in the case of blue, pay about the eat, give a little more insulin, let's go. People figured this out. They're very, very smart. They have shared this code, it is all open source. And in depending on the route, you want to go with it, you can go open APS, which means that you carry around this thing called an Edison board. It's like the size of a of like a post it note ish. But it is a computer in your pocket that handles all the math to adjust your your insulin dosing based off your CGM data and the settings you were put into it as well. The other path is loop. And that is an iPhone app that you have to build yourself. So you have to have an apple developer license, which is apparently you can just sign up for it's like 99 bucks a year or whatever. And then there's another device called a Riley link. It's about the size of a tic tac box. And what happens is your CGM data goes to your iPhone, the phone does the algorithm stuff and then it sends something to the Reilly link and the Reilly link says hey Medtronic pump do this. And so the right link is basically being a translator for that radio frequency to to adjust insulin dosing from that, again, that is all open source. But as you can imagine, there's effort required to make this happen. You'd have to find a very specific old Medtronic pump and as the months and years have gone on, finding those has become more difficult and more expensive. There is time involved in quality In the code and executing the code, and making all that happen, making adjustments, there is some sort of tech savvy required. The community itself has been tremendous at helping people along and providing guidance and assistance and pointing out things whenever people are looking for help. But you still have to do it on your own to DIY system, do it yourself. Also, there's money involved, you have to buy the Edison board, you have to buy the Reilly link, you have to buy the apple developer license there, there's all this investment up front, before you can get this closed loop system, that you're managing yourself. And all of a sudden, you know, as our VP of product of Biz Dev, Brandon arbeiter, he controls his insulin pump from his Apple Watch, which is both wild and crazy. But he's doing all that and it's really, really cool type of loop. I did my own Monday, typos has, we have announced to the world that we are going to take the loop project and turn it into our own thing, and make it an FDA approved application to work with commercially available pumps and CG items. So we're talking about stuff that that insurance will cover that your doctor will write a prescription for, and they will feel comfortable writing a prescription for because it is FDA approved. And we will be supporting that'd be so DIY loop as we're calling it just draw a distinction will still be a thing will still move forward and will still receive updates and things like that that's not going anywhere. But typo loop, the branch of the project that we maintain and monitor, that's going to be our thing, and it's going to work with it and warranty stuff. So you don't have to go to the gray market. For an old Medtronic pump. You don't have to buy additional hardware, beyond the phone that you already need to make all this stuff work. But the future that we envision as you go, you talk to your doctor get a prescription. And then I'm not sure the exact process but also you're gonna get a prescription to go to the App Store and download this thing on your phone without having to do anything else. And then when you boot it up, you say I've got this pump. I've got the CGM. Here are my settings, loot me, I don't know if that actually is going to be the command. But we're just gonna have some fun right now. But ultimately, like I said, Our vision is that we will be supporting multiple pumps in CGM will be compatible with the software. So you pull up, you got your pump, you got your CGM, you configure your system, you're good to go. And then you can control your diabetes from your phone. And it helps me that'll automate stuff in the background. So it'll adjust your basal rates as your blood sugar's high and low. You'll be able to bolster stuff, you can set different targets whenever you are exercising and things like that. All this will be automated. And in theory, and actually not in theory, because I've actually I because I work with these people. And the system is incredible. I'm quite jealous me and my tandem like, we want to talk about basal IQ for a little bit. Hopefully, the pot sponsors won't get mad, but like, I'm rocking baseline IQ, I love this thing. But to see what happens whenever you have control on the highs and the lows, that peace of mind that has been provided, as I was talking with my co workers about it a few months ago, he's like, he doesn't think of it as diabetes nearly as much as he ever did and improves his quality of life and improves this work and improves his personal life for the relationship with his family. Do you spend more time with his kids all the time that you're spent dealing with diabetes, you still care about he so you know, keep a portion of your brain on it. But there's a huge chunk of that you get back. And then like at this point, like just with basal IQ only managing the lows, like I don't know what to do with that extra portion of my brain now,
it's not a lot. It's enough that I'm like, I'm not thinking about my diabetes right now. No, I
Scott Benner 33:06
we spoke about it recently on the podcast because I was like, This is fantastic. But it really is just the low side it's more of the it's more of the you know, the the don't die alarm. It's not the it's not the whole process but the whole process is so who do you you know someone who's you know a number of people that loop so you're telling me that that I if my blood sugar is thinking about getting low in the future and there's no way I can possibly know that the the loop understands that and it cuts my bazel back so that that hopefully low doesn't happen.
Christopher Snider 33:39
Yes, or it's not as severe and not
Unknown Speaker 33:41
as fair
Scott Benner 33:42
or and if I start getting crazy low and something really is going to go wrong. It just shuts my insulin down so that whatever is happening doesn't get worse. And does it come back it comes back on on its own I don't have to tell it Hey, you know you you sent my bazel down but now put it back on I really there's not a lot to do.
Christopher Snider 33:59
It's relying on that CGM data so as long as that's flowing then you're good to go. So a little bit like I get I get I'm on a T slim I have not looped before. So I can't speak to the specific current loop experience. But the thing is as often as is as automated as it can be, and it is remarkable to see it in action. Okay,
Scott Benner 34:16
so this so loop is no different than it well no different in a basic way than what any of your pump companies are off working on right now on the pods working on their, their algorithm, that's their loop for the lack of a better term. And so and so as I'm assuming tandems gonna try to go from base like you do a full system. I'm assuming they
Christopher Snider 34:35
are. It's called control IQ. I believe they're supposed to be working on. Last I heard from one of their reps at the conference I was at they said something about summer 2019. But that's like, super unofficial I have no idea. I'm,
Scott Benner 34:48
I know I know. Omnipod says like, like the end of 2019 or 2020 or something like that. And at the same time, it's interesting it really is now because because look what Luke did for everybody because I'm now Thinking that, that all these companies who have these target dates way off in the future? Why is that different from you? Like, how are you going to get it? Like, do you imagine yours is going to have FDA approval before these other companies?
Christopher Snider 35:15
We have an aggressive timeline in mind internally that I cannot share with you. I think it is a great question, though, and there is some something of a more substantial answer to it. And part of the reason is that DIY loop already exists. And it is a true is a fantastic sort of foundation for what type of loop will become. And there are a couple of pieces that are gonna be coming into play with this one is an observational study that's gonna be taking place, the Jade center metaphor is going to be looking at current loop users to sort of measure like not just the data, but also do some quality of life stuff to just sort of see how it's going. because there hasn't actually been a substantial clinical trial or clinical study, or, in this case, an observational study done on a DIY system before. And as you will see, in our meeting minutes that we published on type.org, slash documents, we're going to use that data to sort of prove the safety and efficacy of the system. And that's part of the thing that we're gonna be using to submit Hyperloop for FDA approval. And also along the way, there's this whole other thing that we didn't even talk about called the FDA, the digital health software pre certification pilot program. Basically, what that means that the FDA realizes that their process for approving digital software is outdated and ancient, and they would need help and they needed help figuring out what the new process should be a bunch of companies applied to be part of that process. typo was one of the nine companies selected along the likes of Apple, and Google barely and Fitbit and Johnson and Johnson and pair therapeutics and two others, I believe, so we are helping to make an FDA policy with Apple and Google and a bunch of other folks to hopefully provide what we are more simply describing as like a TSA precheck. So it's sort of like a fast lane for approval for digital software so that this stuff can get to market sooner. And part like we're actually going through an FDA audit right now to sort of prepare ourselves down the road for our eventual submission of typo loop. So like, there's a tremendous Foundation, from the code side of things, there's going to be clinical study data we're gonna able to use for our submission. And then with this FDA pre cert thing happening, about two different pieces are at play here, that should help us get this thing out in a much more reasonable timeline than I think people may ever imagined. So cool.
Scott Benner 37:23
No, I mean, no, can you can I suppose for a second, is there a world where you can eventually talk pump complex? So let me ask this question before that. So we the way it's set up right now, you described that my phone has an app that then talks to a little board, I have to hold a key I carry around with me to talk to this Medtronic pump. So how do you get past that say, say you guys sign an agreement with Omni pod? Does Omni pod have to put that board in their pump? How does from the How does it get from the app to the pump, when it's not that old Medtronic that somebody found a radio frequency though.
Christopher Snider 38:00
So there's a whole other FDA, there's a lot of FDA talk here, but it's all really exciting because the FDA wants all this stuff to happen, which I think is the most encouraging thing. So Dexcom recently received a classification for their g six called CGM leave if things are interoperable? I think so I, but basically, it means that it can work me it has been approved to work with other health software with other health applications and things like that, which is why tendons basal IQ got approval with dexcom g six, because it was g six was already certified by the FDA to do this stuff. and Canada said, Hey, we're gonna use g six to do something cool. And FDA said, awesome, go have fun with it. So that's the CGM side of things. On the AI pump side of things. There is yet to be an AI pump out in market yet, but the vision is that an AI pump will be able to receive data from an AI CGM, or to interact properly with CGM to do cool stuff. So you have the AI pump, you have the CGM, and then type a loop would be the AI algorithm or the AI controller, and all these interoperable pieces. Again, you get to pick your pieces of the puzzle. Right now it's just bringing the AI algorithm portion, we just be typing a loop. But I mean, hopefully down the road, we you have multiple CGM to pick from multiple pumps to pick from provided insurance covers and blah, blah, blah. But you get to pick the pump that your kid is most comfortable with. And then you just boot up Hyperloop, and you're good to go. And all that stuff will just with it. So I mean, if ami pod were a company that supports that, then that's great to go. And this is all going to happen. Because the different companies that that we are talking with that we haven't actually had a chance to share who we're talking with and what software is compatible yet. But there's something happening over Bluetooth, and they're all going to be compatible with the IPAM protocol. And once they're all on board, and we signed the agreements to make that happen, then they're sharing their data protocol communication agreement or their data communication protocols with us, so that our software can able to can be able to communicate with their devices. Actually,
Scott Benner 39:48
I can't believe I understood but I really did. So as you were talking I was incredibly impressed with myself because I would
Unknown Speaker 39:55
just fall.
Christopher Snider 39:56
For anything. This is good because I haven't had a lot of chance to talk about Too often so I feel okay that I'm being able to hopefully describe this in a reasonable fashion without getting into the weeds about it.
Scott Benner 40:05
No, absolutely, I'm thinking to boil it down is that Dexcom has added something to G six that allows it to make that communication with pumps that are that are set up to handle the communication. And then I extrapolate a little bit of my brain that I think about the companies who already have an agreement with Dexcom are moving forward, I use on the pod because I know it, I know they're developing their horizon, artificial pancreas system with the Dexcom g six. So it makes sense that they that would be for instance, one of the companies you'd be able to, to talk to, and and tandem the same way, if tandems already got their base like you and they're working on the other IQ system, then it makes sense that tide pool would work well with them and anyone else who has this agreement. So I see I do understand, and it takes away their need for me to carry around a small circuit board and a tic tac box. That really was the sticking point for me, in case you're wondering. Actually, it's funny, I mean, the, you know, in my mind, the real sticking point would have been going to a two pump I, when I heard that I stopped. I was like, Okay, I don't want to do that. But, but let me understand the rest of it. And then as I was like, if I did want to go with this to pump, then what would I have to do and then I like you were talking about earlier like, and I'd have to become a developer and it gets beyond my depth. And I've even had people reach out and say we could set it up for you. And I thought, well, that's great. Except that, you know, when my Wi Fi stops working, I like that I know how to get it working again, like I don't want my daughter to be using an insulin pump system that is dry through some lovely person in Montana who set it up for me who I don't want to have to call two in the morning if it doesn't work. And so in plus, I'm in the very, I guess I'm in the good position of, you know, my daughter's agency and her blood sugar stability is all very well regulated right now, just with just with what we're doing. So I didn't feel a pressure. But that didn't stop me from thinking about the other people who may be listened to this podcast and go, it's great that you're doing that I can't figure it out. Right. And I wish I had something else to do I talk all the time about I think the end of this podcast ends up being when looping and artificial pancreas becomes something that everyone can afford, then I don't see a need for this podcast anymore. I'll do a final six months, make sure everybody understands their artificial pancreas, and then I'm riding off into the sunset. But you know, but prior to that, there's there's more people than just me who can afford to get my daughter and in some competent CGM, and has the time to sit around and think about it, right. And so I try to think about all the levels of people living with Type One Diabetes, their access to health care, their access to technology, their ability to understand it, their ability to implement it, those are those are, you know, there are many, many levels of people in all varying situations like that, I am excited for the day when everybody gets to have a piece of this, you know, in a in a in a meaningful way that leaves you not walking around constantly scared of being low, or not looking at a meal and thinking, I don't know how to handle this, you know, so I'm just not going to eat or I'm not going to eat that. Like That to me is. That's that's the next level that I can imagine. I'm sure that I'm sure there's more past that. But I'm gonna be an old man by then Chris, I don't know, I'm gonna care by then what I think.
Christopher Snider 43:20
But I'm glad I can make you a believer is a nice,
Scott Benner 43:22
dude, you I mean, it's it's not that I didn't be clear, it's not that I didn't see the value in it before. It's just there were too many hurdles. And what I'm here, what I've been waiting for is for the companies to take the hurdles away. But what I'm,
Christopher Snider 43:34
but that's what we're here for you, I believe in the type of mission. Our goal here is to make data accessible, meaningful and actionable. We already talked about the accessible and meaningful part with the access regardless of the device and meaning, because it'll look nice and pretty on type of software. Now we're talking about action, but we're gonna put all this data to good use for you because it is your data, but also, you know, we get all these things happening and you start you start that type of loop process. And hopefully, you know, through that action, life gets a little bit easier, you know, in some marginal fashion, like it's, we're talking before we start recording, like all things considered, life is pretty good for me. But I also recognize that privilege and my ability to save that but you know, diabetes is definitely absolutely part of that equation when it comes to how am I doing and if it just like I said, Just seeing what basal IQ was done for me and my and how I feel about my diabetes and how I balance in turn, improve my life. Adding in more pieces to that control process, be it control IQ or Omni pod horizon or typo loop or whatever open APS continues to become like, all these different options are part of that process to try and make life a little bit easier. And diabetes is gonna go away anytime soon. Like I'm not I'm not sure how I really feel about like a proper biological cure, like give me this pill and all sudden I'm good to go. If we can improve the technology, while also continuing to have conversations about affordability for insulin and things like that, like those conversations aren't going to stop anytime soon. And type was absolutely going to be part of that. Anything else we can do to contribute to that in a positive fashion, it's super exciting to share that news with the world.
Scott Benner 45:08
I found these 10 phrases that they say make hypnosis more effective, I'm going to use them right now over the next 30 seconds, just pretend you've gone to dancing the number for diabetes.com. And the more time you spend there, the happier you feel, every time you go back, that happiness swells. This is what it must be like to be in heaven. Suppose you listen to me, and you remember to go to dancing for diabetes.com. Imagine what it would be like, when you get there, you'll be full of warmth and happiness, and find yourself realizing that you've done the right thing. So whether it's sooner or later, you're going to go to dancing for diabetes.com. Look into my eyes, you're getting sleepy. As you're talking, what I realized is this is you know, we're in October already in 2018. So this whole next year, you know, this whole next year is going to be just a run up to this explosion that's going to happen. You know, throughout all these tech companies wrapped around diabetes, like this is going to be the most exciting 12 months of since my daughter's had type one, and we're up on a dozen years now. So it's starting to feel it's starting to feel like a long time, you
Christopher Snider 46:25
know, and you throw in beta bionics and Bigfoot, like there's a lot happening. And it's, you know, him with all the caveats of access, and affordability and insulin pricing, all that other stuff. It's still a really exciting time right now to be to be sort of looped in on this conversation around where this technology can go and hopefully have you know more and more choice and more, more opportunity for people to seek better control so they can get back to posting their they Juicebox Podcast, doing one of the 15 podcasts that I have, or you know, to knitting whatever you want to do go walk your dog did not worry about this stuff. Just the idea of
Scott Benner 46:59
the free time is so exciting. I like Arden's blood sugar was incredibly stable last night, so I slept, you know, I went to bed earlier than I usually do. And I slept longer than I did. And I feel better today than I have felt all week. And I can't imagine how that would be I sometimes I lay in bed and I think I don't even have it. Like Like, what about every adult that's climbing into bed right now who's like, I'm gonna leave my blood sugar high so that I don't get low, or I'm gonna try harder to keep it where I want it. But then it's and then I got low and it's just it's a sleep is supposed to be this just regenitive restful time. And for so many people who use insulin, it's not it's the opposite. It's like this fearful, scary thing. And just to make that go away is amazing. So yeah, dude, it's very, it's incredibly exciting. I'm so happy that I reached out to you and asked you to explain this to me, because yeah, I was I feel like I was right there. But I was never speaking within about any. I didn't have any real confidence when I was talking. I'm like, I would always like parse, I'd be like, I think what it is, is this, it sounds to me like it says, I'll tell you as you were talking, I realized with all these great companies that are doing this work on their different ends. Dexcom really is the center of all this, isn't it?
Unknown Speaker 48:11
Like had they kind of crazy, right? Yeah, yeah,
Scott Benner 48:13
without them, like this doesn't exist at all.
Christopher Snider 48:16
But you think about where Dexcom is right now and how the community has pushed all that forward, like you think about what nightscout did to open up access to that data and visibility. And then all of a sudden, Dexcom share became a much more viable thing. And then, you know, the Apple Watch and all this other stuff, like, you know, I mean, the community absolutely deserves credit for moving all of this forward. And you think about I mean, like I said, like the open APS and DIY loop, like this community is driving the conversation. And to the point that we hired peach while the person who designed the Riley link and Katie de Simone, the person who created loop docs.org, the fantastic documentation site for people that are looking to get started with loop. We hired those two people that are working at type one full time to work on loop and loop docks, and also how about and also work on typo loop. So I mean, like you said to me, like it's like they were doing the stuff part time overnight, like they had they had full time jobs. But then there were also doing this loop stuff. And now because of everything that they've done in the community has done to move this conversation forward to put people in a position to make this happen. We can make this their full time job, their dedication to commit to the community has resulted in a tremendous opportunity, not just for them, but also for them, but for all of us. And it's from that from that tireless effort. That is it's just it's so remarkable.
Unknown Speaker 49:29
It's just it's crazy
Scott Benner 49:29
to think that the efforts of just random people scattered all over the globe, that that foisted a company on its shoulders really moved by the way Dexcom I'm gonna charge more for the ads. Now I didn't realize how valuable this was. And it just it No but seriously, it took this great idea and it helped move them forward. Not that they're not a great company and they're not doing good work there. The way they deal with the FDA is is revolutionary, to be perfectly honest with you like that some of the stuff that they've gotten through so quickly was mind boggling. A couple years ago how quickly they jumped from g4 to share from share to font like it was really something, you know, but but just to see that move forward. And for that to be that data, again, it's the data, the data is the hub, the data, helps the pumps do more the data helps you do less the data is it's everything, the experience and the understanding of how that insulin works, is the whole thing. That's fascinating. Well, it really is, and congratulations to everybody, anybody who's listening, who had any part of just, you know, sharing their experience or pushing a company, because I'm telling you, I found myself saying this a lot recently. But if you go back even to like, when you and I met, you know, a number of years ago, it used to just be exciting if a meter came out, like Oh, look at the meter, and everybody's like, Whoa, you know, like, like, that was the extent of like, the excitement in the diabetes world. You know, maybe this pump company will refresh this pump in a decade if we're lucky. Like, that's how it used to feel. And now I feel like I might wake up every day and hear about some amazing accomplishment, some giant leap forward. And it's a great time to it's a great time to have type one diabetes, that's a T shirt. Yeah,
Christopher Snider 51:09
it kind of is. But also Yeah, you may wake up tomorrow and find out which you know, pumps in CGM will actually be properly compatible for typo loop and that's what's coming tomorrow. But you know, this thing is happening and it's gonna happen. And because I mean, I, for anybody who's been following typo bait, people should know, we like to move quickly. And I can leave it with that sort of generous and probably overly aggressive teas
Scott Benner 51:32
like that. I take that so when you have anything else to say you feel free to reach back out. Chris as as we get ready to say goodbye Chris has alluded to he has a podcast of his own that you should be listening to first you want to tell people
Christopher Snider 51:47
and I got three one of them is kind of collecting dust. The other one just talking is the longer running one which is includes an interview with you from like, probably four years ago, whenever you met one Miss Katie Couric just talking podcast.com mostly talking with patient advocates a lot of people with diabetes and then started to branch out to the Legal Health Network to talk with other people, including somebody who has hyperhidrosis excessive sweating, which is the whole thing. And there's there's a lot to unpack, there was a really remarkable conversation. The other one that I have is called mark all that apply. It's a conversation about race between multiracial siblings, my younger sister, and I talk about race related topics. As you can imagine, there's a lot to get into there. But also, it's a lot of fun, because we view our blackness differently, which creates a lot of interesting conversation, but also she's pursuing her PhD and some something in the realm of multi racial studies and culture. So I personally believe as her big brother that doing this podcast will help her her thesis defense down the road, which is where a lot of fun play out. So that means that that is the personal life. And then of course, I pulled out dog. It's food, folks, go check it out.
Scott Benner 52:51
And there'll be Scott. Yeah, I Well, first of all, I will. And secondly, links in the show notes for all everything Chris just talked about. And I can't thank you enough for doing this. Can we throw this together very quickly. As soon as the as soon I think pretty much hours after I saw what happened. I reached out to Chris and I was like, Hey, I really want you to come on the podcast. One last thing. Can
Christopher Snider 53:11
you tell your son, tell your son that he's got a great crow hop still. We talked about this many, many years ago when you're on the podcast about how I love it. Good crow hopper. And you mentioned how fluid his motion is from the outfield. And I've seen some videos you've been posting really isn't that you got yourself a winner over there.
Scott Benner 53:26
I'll tell you what he's poor kid gets to college about six weeks ago. Now. As soon as he gets there, he's there for four days, he gets sick. And it's this horrible head cold that moves into his chest. And he's just he's so beat up. But baseball started for the fall. And I was like, you gotta you have to rest and he's such a type a kid. He won't not go to class. He won't not do his homework. He won't not go play baseball. There's nothing he won't give anything up to feel better. So he's been feeling pretty beat up but not stopping. And he told me he's like, it's I'm not hitting the way I want. He's like, I just I can't quite get rested. I'm not focused. He's like, I just want to feel better, you know? And I said, Okay, that's great. You know, you will Don't worry. And then a couple weeks into it. He said, Well, we have a scrimmage. You know, it's kind of a whole day the parents come if you want to come so I show up and my wife's there and my daughter's there and we're all watching Cole and he runs out into the outfield and the first ball hit to him. Chris was about a I might have to say roughly 280 feet from home plate. There was one out with a man on third called caught the ball and he promptly threw the kid out trying to run home coming
Christopher Snider 54:32
from third. That makes me so happy.
Scott Benner 54:35
I swear to you, I couldn't even make a noise. Thank you, Chris for coming on the show. Don't forget to go to tide pool.org get your data so much together from your CGM from your pump, make it go together squishy so you can see it and what it's doing. You understand and some goes here. This is what happened next. This is the information you need to make better decisions. Thank you dancing for Diabetes. Thank you Omni pod. Thank you Dexcom for sponsoring the Juicebox Podcast. Go to my omnipod.com Ford slash juice box, go to dexcom.com Ford slash juice box go to dancing the number four diabetes.com there are links to all of this at Juicebox Podcast comm or in the player that you're listening to right now on your phone, Instagram users check out my Omni pod decks calm and dancing for diabetes. They're all on Instagram. Now go listen to some old episodes. And I'll be back next week. Come on, tell a friend about the podcast download Episode 11. You heard her talking about it or Episode 53 or 65 or 92 or 114 137? What about Episode 617 44? Sick? Look how many there are. There's like 190. I could list all the numbers but I mean, you know all the numbers, right? It's 123 and then it gets to 10. Then it starts building then it's like going back to one then so it's 10 then 11 which 10 is really just 10 plus one and then 12 which is 10 plus two and then 10 plus accounting is actually very simple.
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