"How does diabetes stand by you?" I find metaphors useful in describing diabetes concepts and our approaches to self-care. One I often evoke with patients is "how do you walk with diabetes"? In my experience as a person with diabetes for a half century, and as a Diabetologist, I can say that there are only three ways we "walk" with our condition. We journey through our lives with diabetes always nearby. That is not a choice, but a fact. However, where we position ourselves relative to our condition IS a choice. Read on. A common position is to place our diabetes behind us, out of emotional sight. "Huh? What diabetes"? you might say or think to yourself. In ignoring or denying our disea
“Are Doctors Really Necessary in Diabetes Care?” There is a principle in the computing world called Moore’s Law. Simply stated, computing power doubles every few months to years. At some point this will level off, but for now it’s still increasing. Medical knowledge also doubles every few years and has been expanding at a staggering pace. Yet with this knowledge explosion, the human capacity to absorb and apply it remains relatively static. We are already facing the consequences of this knowledge-action imbalance in medicine. The need for health care providers has never been greater as the number of persons with diabetes explodes. To fill the growing provider gap, health care delivery has t
One of my roles as an endocrinologist and certified diabetes educator (CDE) is to educate and support my patients' diabetes care skills in ways that help them understand how to best problem-solve and troubleshoot daily diabetes dilemmas. It's all about fulfilling my mission of empowering persons with diabetes. We all have a set of values and beliefs we use to interact with our world. There is a phrase (not necessarily a complementary one) called "living in a bubble". It means you see or interpret the world more narrowly than others. Sometimes very narrowly. I'll be first to admit that I have lived in many different "bubbles" over the years. Perhaps my opinions or attitudes on social issues d
In 1975, a famous endocrinologist published a very elegant experiment. He recruited 7 healthy adults with long standing type 1 diabetes. Using a chemical inhibitor called somatostatin, he blocked all glucagon production from their pancreases. Then he withheld their insulin doses to induce diabetic ketoacidosis (DKA). It took 18 hours for DKA to begin, compared to the 10 hours it took for the unblocked type 1 patients to develop DKA. His study was the first to affirm that insulin deficiency alone is not enough to trigger DKA. It took glucagon too. Glucagon is a so-called "stress hormone". In the pre-insulin era, progressive diabetes doctors knew that careful avoidance of stress and a low calo
The key to managing diabetes is a willingness to frequently check blood sugar (including CGM), thinking about the situation (assuming you already have the knowledge), and taking action (sometimes not doing something is the right action). Just do two of three and you'll miss the mark. Sugar Surfing is our attempt to impart the knowledge and to encourage you to check, think and do... repeat. True, we now have mostly reliable CGM. But the key to it all is the appropriate application of personalized knowledge gained through experience. In my opinion, most people, including medical professionals, still have a long way to go and it starts with the motivation to learn new ways of performing old tas
Air travel safety is a great American success story. This wonderful track record is driven not only by high tech avionics, but by a clear, focused and ongoing attention to maintaining the skills of the human element: the pilot. Ironically, our avionics can become a crutch of sorts. We’re now seeing calls by the FAA for pilots to get more involved with actually flying their planes since so much of the process has become so automated after take-off. There is apparently too much reliance on autopilot technology. And when something does goes awry, as it did over the Hudson River in 2011, everyone wants a Captain "Sully" Sullenberger at the controls. There is no question that “easy does it”. But
It's the little things that can really foul us up in our day to day diabetes self-care. Case in point: simply cleaning hands before a BG check. I DID NOT clean my hands when I got the first value of 170 mg/dl [9.4 mmol/L]. I noticed a significant variance compared to my CGM device (lower). Of course I then washed my hands and rechecked. Voila, 102 mg/dl [5.7 mmol/L]. It was a much more "in range" value and consistent with my CGM device at that moment in time. Now think about this. What if I DIDN'T have a CGM to compare with? What if you are a d-kid (or adult) and take any meter value you get at face value? Imagine if you chose to dose rapid acting insulin to lower the higher BG value, when i
"Glancing" is a Sugar Surfing term. It's those quick looks at your CGM data while on the go. I glance often and it takes no more than a couple of seconds. The following tip might make this easier for you. If you Sugar Surf using an iWatch, and assuming you have the latest updates for your iPhone and iWatch, you can put the BG and trend arrow icon at the bottom of most faces of your iWatch. Press the screen until you get the customize button (above). Press customize. Then scroll using the watch stem until you find your Dexcom icon, then press the stem button to finalize your selection. Happy Sugar Surfing!
My day job is as a pediatric endocrinologist ("peds endo" in the diabetes on line community vernacular). In our current health care system, primary care “providers” (doctors, physician’s assistants and nurse practitioners) evaluate and examine patients, determine if their patient needs more assistance or care than what they can provide, and then get referred on to specialists as needed. I am one of those “specialists”. Here is a referral note from a primary care provider I got a few months ago: "Patient needs to be seen by peds endo and [patient] needs new monitor for home and for school. Lectured [patient] regarding health and taking charge and to stop depending on other people to take care
It's exciting when we find Sugar Surfing™ making inroads to the professional community. "...There are different levels of usage of CGM. It can be used retrospectively to learn from previous decisions (what worked well/what didn’t), but can also be used pro-actively to make real-time adjustments. The pro-active approach is quite different from the standard model of diabetes management and can take a lot of confidence and practice. Many healthcare professionals may struggle with this approach, but it is our duty to provide our patients with the information, knowledge and confidence to use this expensive treatment to its fullest. The best example I have come across with this is Sugar Surfing by
Ever since numbers crept into the management of diabetes, all of us have fallen prey to our desire to compare and contrast. Searching for differences and variances in any situation are simply part of being a human being. That would not be much of a problem if we didn’t take the next step: to judge. Whether it’s the A1C, BG meter readings or sensor patterns, our ability to compare and contrast can easily slide down a dark path to judgment, shaming, and even condemnation. Social media allows for easier expression of these emotions. I’ve shared hemoglobin A1C data with tens of thousands of patients and families over the last 35 years. At first, the value was not well understood or appreciated.
One of my core beliefs about diabetes is that quality self-care is derived from an ongoing series of choices we’re constantly making (whether we realize it or not). Action and omission (NOT acting) are both choices. The ups and downs of our blood sugar levels are beholden to many (if not most) of our actions (or lack thereof). The corollary to this is that a health care provider can’t really manage anyone’s diabetes unless they’re at the patient’s side 24-7. From my perspective, the primary task of the health care provider is to serve as a coach, teacher, mentor or even a role model at times. Sadly, in some cases the provider assumes the role of judge, jury, and critic. Take home message: ha
I have the ultimate New Years resolution to make for 2017: let's not miss any more new cases of type 1 diabetes before they can get too far out of control. I'm a member of a consortium of specialist physicians and health care organizations aiming to raise awareness of the signs and symptoms of type 1 diabetes and to get more doctors to screen for this. New cases of type 1 diabetes are on the rise. This has been the case for as long as I can remember. As a pediatric endocrinologist, I've heard the detailed stories of what led up to my patient's formal diagnosis. In my professional experience I have found that the diagnosis is missed early on in at least one third of cases. This includes patie
