The Efficacy of Basal Rate and Carbohydrate Ratio Learning Algorithm for Closed-Loop Insulin Delivery (Artificial Pancreas) in Youth with Type 1 Diabetes in a Diabetes Camp

Background: Optimizing programmed basal rates and carbohydrate ratios may improve the performance of the artificial pancreas. We tested, in a diabetes camp, the efficacy of a learning algorithm that updates daily basal rates and carbohydrate ratios in the artificial pancreas. Materials and Methods: We conducted a randomized crossover trial in campers and counselors aged 8-21 years with type 1 diabetes on pump therapy. Participants underwent 2 days of artificial pancreas alone and 6 days of artificial pancreas with learning. During the artificial pancreas with learning, programmed basal rates and carbohydrate ratios were updated daily based on the learning algorithm's recommendations. All algorithm recommendations were reviewed for safety by camp physicians. The primary outcome was the time in target range (3.9-10 mmol/L) of the last 2 days of each intervention. Results: Thirty-four campers (age 13.9 +/- 3.9, hemoglobin A1c 8.3% +/- 0.2%) were included. Ninety-six percent of algorithm recommendations were approved by the camp physicians. Participants were in closed-loop mode 74% of the time. There was no difference between interventions in time in target (55%-55%; P = 0.71) nor in hypoglycemia events (0.8-0.9 events per day; P = 0.63). This was despite changes in programmed basal rate ranging from -21% to +117%, and changes in breakfast, lunch, and supper carbohydrate ratios from -17% to +40%, -36% to +37%, and -35% to +63%, respectively. Morever, postprandial hyperglycemia and hypoglycemia did not decrease in participants whose carbohydrate ratios were decreased (more insulin boluses) and increased (less insulin boluses), respectively. Conclusions: In camp settings, despite adjustments to programmed basal rates and carbohydrate ratios, the learning algorithm did not change glycemia, which may point toward limited effect of these adjustments in environments with large day-to-day variability in insulin needs. Longer randomized studies in real-world settings are required to further assess the efficacy of automatic adjustments of programmed basal rates and carbohydrate ratios.