Persons with diabetes who use insulin crave a sense of certainty or predictability when it comes to the action of their shots or boluses and the effects that follow. Unfortunately there are many reasons why an insulin dose can seem fickle in how it affects your blood sugar levels. Injected insulin (whether by syringe or a pump) enters the body through the tissues under the skin surface. While we know this method of delivery ultimately works to lower sugar levels, it's nevertheless an unnatural route. In the subcutaneous tissues, insulin begins its journey to reach its intended target: the insulin receptors on the surface of insulin response tissues (muscle, liver, fat) throughout the body. P
Sugar Surfer Patti Kasper has been a PWD x 51 years. Patti composed the post below to share some highlights of her journey towards Sugar Surfing. (Steve Ponder MD, CDE) I am among a wonderful group of T1D warriors who have survived our daily battle for over 50 years, despite decades in what I call the “medical dark ages.” Home blood testing was not available until just before I went off to college as a teen. Frankly, I find it a miracle I survived the “static thinking” models of diabetes management so prevalent in my youth. I never attempted to take good control of my disease until college, when I began to see real time results of my choices. I typically have jumped on new T1 technologies
“I’m glad he met you first” This is a small but powerful quote from the last few minutes of the classic movie “ET, The Extraterrestrial”. One of the kinder Scientists, Mr. Keys, asks Elliot what more could be done to help an ailing ET, plus explain the “phone home” device. Keys goes on to acknowledge to Elliot that ET was not left here on purpose, and that Elliot had done the best anybody could do to help him. His closing words to Elliot being “I’m glad he met you first”. If you’ve seen the movie, you appreciate the true depth of that statement. A diabetes diagnosis can make us and our children with diabetes feel like we’ve been dropped into a strange new world too. Lost and afraid. Full of
Is fear a prerequisite to manage a chronic disease well? Over the years I've read many posts in response to questions I've posed regarding closely held attitudes and beliefs about their or their child's diabetes. One theme overshadows all others. Fear, confusion, anxiety and even guilt often rules following a diabetes diagnosis. For some, this is eventually replaced with acceptance, confidence and a firm resolve to succeed. In most cases, quality education (initial and ongoing) about diabetes usually played a role in this evolution. But there seems to be a significant percentage of those in the online community who, even after years of living with diabetes, still seem very fearful of this di
Accomplished Sugar Surfers master the art of 'subtle touch'. They know the circumstances behind a low range BG level and can apply just the correct amount of force to 'correct' the situation. In Sugar Surfing™ , this method is called "micro-carbing". It's the twin sibling of "micro-bolusing" with rapid acting insulin. Both methods are core Sugar Surfing skills. It usually requires less time to raise a low blood sugar level compared to lowering an elevated value with insulin. In both situations, patience is a virtue. The situation (operative conditions) leading up to this action is shown on the left side of the image. After drinking 6 grams of 100% Welch's grape juice (a high glycemic index c
When I starting receiving injected insulin in 1966, this was the syringe I used. I can't show you the thick needles (25 gauge) and measured 5/8 inches long. They were reusable. Unfortunately my parents were not taught to sharpen them. We just used them until they were mostly unbearable to use any more: around 3 weeks. Today's insulin syringe needles are much thinner and considerably shorter. But how short is short enough? Put another way: how long is "long enough"? Read this recent report from The Forum for Injection Technique and Therapy: Expert Recommendations (FITTER) workshop in 2015. It contains lots of great information to update our knowledge of injection and infusion of insulin. It's
True Sugar Surfers understand that they're actually steering a glycemic trend line and not just responding to a single point in time BG value. Rather than watching helplessly as their blood sugar trends chaotically rise and fall, Surfers take charge. The tools of the Sugar Surfer are numerous and well described in the book Sugar Surfing ™ The double tap pivot (i.e., multi-tap pivoting) is a sound method to consider when you are either a) just learning how to pivot, or b) seeking to minimize the risk of taking too large a BG drop from a larger corrective insulin dose. In this example I demonstrate a double tap pivot used to steer a late and slow nighttime BG rise (i..e, delta wave) which cros
As a person with type 1 diabetes for over half a century, I've lived through many technological breakthroughs in how my condition has been cared for and managed. Many examples come to mind. Disposable insulin syringes certainly made the process of preparing an insulin injection much easier than boiling (to sterilize) a glass syringe and reusable needle each morning. Blood glucose meters gave me more specific information about my diabetes control compared to testing my urine in a glass test tube chemistry set or with a plastic dipstick. Insulin pumps changed the way my body received insulin compared to erratic, long acting forms of insulin like NPH and Lente. Like most persons with diabet
"Doc, I (we) tried that once before and it didn't work" For me, that's one of those "if I had a nickel for every time I heard that... I'd be rich" sayings. When working with patients and parents of children with diabetes, I'm constantly attempting to explain, teach, or suggest the adoption of new ideas, devices, or strategies based on my interpretation of what I'm told by them or what I deduce during the encounter. But the "push back" I sometimes hear (or see posted on line in many instances) revolves around the belief that because that suggested change, device, or care strategy didn't work once before, then it won't ever work at all, or is not worth continuing to work on until success is ac
“The Wall” The journey to combat my own for of diabetes-related "learned helplessness" (LH) in some ways began over 25 years ago. I learned an invaluable lesson about living well with type 1 diabetes in a most unconventional way. It has remained with me ever since. It was the early 1990's and I was working at the Texas Lions Camp diabetes sessions in Kerrville as the camp’s Medical Director. That afternoon I was covering camper activities at the high element ropes course. There was a new 75 foot climbing wall that the campers would attempt to scale and ring a small victory bell at the top. After all the campers had their turn to climb up and ring the bell, the adult staff were invited to par
Type 1 diabetes (T1D) is an autoimmune disease which is driven by a subset of white blood cells known as Th1-lymphocytes. Through a complex series of steps, some known and other poorly understood, the insulin producing pancreatic β-cells are slowly destroyed. This results in a life-long dependency on injected (or infused) insulin, daily self-care responsibilities, and significant risks for short and long term health concerns and complications. The way type 1 diabetes develops is complex and nuanced. It involves the activation of both major arms of the immune system, known as the humoral and cellular, and an imbalance between certain classes of white blood cells called effector and regulatory
“A college freshman with type 1 diabetes goes to a college party with her friends on a Friday night. The next morning her dorm roommate can’t wake her up to grab an early lunch. Even shaking her fails to arouse her.” Low blood sugar (hypoglycemia) is the first consideration anytime a person with type 1 diabetes (T1D) experiences an altered level of consciousness and/or seizures. This story highlights a common scenario of underage alcohol consumption. Alcohol is the most widely used substance by young adults, and young adults with T1D are just as likely to drink alcohol and abuse other substances as their peers. Unfortunately, people with T1D are at high risk of developing hypoglycemia both
Here is a quote from a d-parent I know: “Our daughter has had type 1 diabetes for 6 years, her A1C runs as high as 8%. We’ve recently been using the insulin pump but can’t seem to control or balance the blood sugars during activities or after changing the infusion site. Can you advise us on how to adjust the pump?” Ok, reasonable and common concerns I’ve heard for years. And I certainly understand the intent. But the focus might better be placed somewhere else besides primarily on the device. Patients and parents often tell to me they want to get themselves or their child “back in control” of their diabetes. Questions like these are often asked in a way that implies that I’ve got a secret I
Once upon a time I cared for a family with young child with type 1 diabetes who was very well controlled. This family had very much to be thankful for. The child's excellent diabetes control was not due to a prolonged honeymoon phase, but from an invested, hard working family. plus and a child who was just as diligent and attentive. He spent quality time of his own choosing to maintain the best blood sugar control possible. When I complemented them for their hard work and excellent results, the parents told me an fascinating story I am compelled to share. His mom told me she was having a hard time dealing with the general negativity she received from sharing the success of managing her child
While long-acting or basal insulin delivery (insulin degludec [Tresiba], glargine [Lantus], detemir [Levemir], or the basal delivery rate of an insulin pump) is like having a long roof over your glycemic ‘head’. Injections or boluses of rapid acting insulin properties which are more "umbrella"-like. Consider this image: Properties of any insulin preparation include: 1) time to onset of sugar lowering effect; 2) duration of peak sugar lowering activity; 3) an effective duration of action; and, 4) day to day inconsistency, which can wobble or vary a bit. It’s not only helpful, but crucial that a person using insulin have a good working understanding (conceptualization) of these properties of t
History and literature are overrun with examples of conversions: from Saul’s journey on the Road to Damascus in the New Testament, to the overnight transformation of the miserly Ebenezer Scrooge in “A Christmas Carol”. For the first 40 of my 50+ years living with type 1 diabetes I operated under the assumption that if I only had the right combination of insulin doses and carefully measured what I ate, then I would have the best diabetes control possible. I also told thousands of patients to do the same. Boy, was I misinformed! Being a 'Dr. Gadget', I of course purchased a real time continuous glucose monitor as soon as I could get my hands on one. In the early days of cgm I used the Abbott N
To be successful at Sugar Surfing requires us to make a fundamental change in how we visualize or conceptualize blood sugar levels. Since the late-1970's, the concept of blood sugar measurement has been founded upon the collection of a single glucose value or 'level' from a sample of blood. Ironically, the term 'level' tends to promote a sense of stability. And this 'level' is collected at a single point in time, not over a period. Interestingly, prior to the days of self-monitoring of blood glucose (SMBG), we used urine glucose measurements. When blood sugars rose above a certain level (usually 180 mg/dL [10 mmol/L], glucose would begin to ‘spill’ through the kidneys and into the urine. Uri
Dynamic Diabetes Management is better known as Sugar Surfing. The image below describes what this form of diabetes self care is all about. It's the result of 'glances' of the BG trend (done by the Surfer and which vary in their frequency) combined by choices made to 'act' or 'not act'. The power of omission is not to be underestimated. Sugar Surfing is diabetes management in the moment. It transcends static insulin dosing formulas which don't take your BG trending pattern into consideration. In this image, arrows point to measureable actions. They include insulin doses and food (carb) intake. What is NOT shown are the multiple glances (less than 2 seconds each) and the decisions made to NOT
I've followed many children with type 2 diabetes, and it's precursor: the metabolic syndrome. This recent publications raises very serious questions about an organ that we don't routinely think of as a target for complications: the brain. Conclusions: Metabolic syndrome was associated with impaired reading, working memory, and attention among adolescents. To read the full text manuscript as PDF including links: http://online.liebertpub.com/doi/pdfplus/10.1089/met.2016.0015
