Diabetes Tight Control

I have had Type I Diabetes since 1988. I have been pumping Humalog since 1998. My hemaglobin A1C tends to be in the 5.5 – 5.9 range. I have had A1Cs as high as 6.3 and as low as 5.4, not counting my long honeymoon period.

The reasons to maintain tight control and to improve whatever level of control each of us has have to do with the Diabetic Control and Complications Test (DCCT) that was performed years ago. That long term test of varying levels of control proved the intuitively obvious. Better control reduces diabetic complications. It also quantified it. Those in the tight control group saw a 50% reduction in all diabetic complications except one. For retinopathy the reduction was 60%. Tha’s a 60% reduction in the chances of going blind. That’s huge. It also proved that it was not a simple tight control yes or no type question but that improvements in control at all levels reduced risks of complications. So, that’s some serious incentive for maintaining the tightest control we can, whatever that is for each of us.

I am probably not qualified to give much information about type II diabetes, as it is a completely separate disease with similar symptoms. However, some of the information will overlap. And, since exercise years ago dropped my daily intake of insulin from about 75 units a day to about 25 units a day, with my current level at between 20 and 45 depending on food and exercise, I may have something to say about insulin sensitivity as well.

Please feel free to ask questions about any topics listed here or not. I will do my best to answer with any information I have. If I do not have an answer, however, I will NOT make one up.

So, my main topics for control will likely stay limited to testing a lot, guessing food (I do not count carbs, I just eyeball and let my brain recognize patterns, something the human brain is good at), exercising, adjusting for increased food and/or exercise, and temperature (an odd one that I notice because I spend a lot of time outdoors).

Testing a lot is really key to my control. I am not willing to give up and have a highly regimented life. So, for me, whenever I am not in my normal workday routine, I am constantly testing. How much was that large weekend meal with friends? Well, my estimate was almost certainly off. That’s a given. So, I may do a reading as early as an hour later. And, since it’s almost certainly rising at that point (something I can now tell with continuous glucose monitoring, but knew even before that), If it is above what I consider a normal post-meal range, I’ll adjust with a bolus. Pumping makes it easy to adjust often, even by small amounts. Sometimes, I do a reading when my blood sugar is level and adjust by amounts as small as a few tenths of a unit.

When I guess my bolus, I do not count anything. I just try to sum up what I’m eating. I try to guess if it has more or less carb content than normal.. I also pay attention to fat levels, which slow food absorption quite significantly. For higher fat meals, I may take a square or dual wave bolus due to the lower glycemic index. I also tend to take square waves whenever a meal is large. Even if it’s all carbs, it’s going to take a long time to digest a big meal. So, I’ll take a big bolus for a large meal but also take a large square wave bolus.

Exercise has a huge effect. However, I notice that hiking has a much larger effect than paddling a canoe. I expect that part of this is because I typically insert my infusion site in a leg and part is because the activity is genuinely more strenuous. Of the activities in which you participate with any degree of regularity, learn which are more strenuous. Downhill skiing for example, is not particularly strenuous. However, maintaining body temperature when out in the cold is strenuous. It surprised me to actually prove this to myself. However, when I went camping on an ice floe in the arctic, I needed to cut my basal rate in half and bolus less, despite the fact that all of the work was done for us and we rode around in sleds pulled by snowmobiles the whole time.

In fact, by far, the vast majority of the calories that the human body burns in a day are to maintain body temperature. So, when you’re outdoors, pay attention to the temperature. If it’s cold, you may need to cut your insulin intake, either through a lower temporary basal rate, lower boluses or both. And, whenever you depart from your normal daily routine, test a lot.

Exercise is important not only for your overall health and fitness, but also for insulin sensitivity. This is the biggest overlap in care between types 1 and 2 diabetes. Exercise allows your body to absorb sugar with less or no insulin during the time of activity. Regular exercise reduces the need for insulin over the long term. My gut feel, based on nothing, is that it also makes it easier to control blood sugar since the body is more receptive to the insulin.

Also pay attention to weight gain and weight loss. If you are dieting (or gaining weight), your insulin need will change over time. A lighter body needs less insulin. This won’t be sudden, but do pay attention to when you may need to adjust your basal rates.

I also feel the need to point out that although I am lucky and seem to have a relatively easy time maintaining good control and get high marks from my doctor every visit, I do still see blood sugars above 200 and even the rare 300 as well as lows at and even sometimes below 40. I have come to the conclusion that it is not worth beating myself up over these. They happen. It’s part of not having a working pancreas. I do the best I can and that’s all I can do. So take them in stride. If you can find the cause and not repeat it, great. If not, just keep doing your best.

Oh, and doctors are an interesting issue. Personally, I see an endocrinologist specializing in diabetes. In my very humble opinion, it would be very difficult to really stay on the cutting edge of diabetes care and still be good as a regular physician. There may be exceptions to this. When my A1C reached 6.3, which I considered high for me, my doctor was able to help me get back below 6 in ways I would not have thought of on my own. I would personally have to recommend finding a doctor that specializes in diabetes if at all possible.

Again, please feel free to ask me anything that comes to mind with respect to diabetes care. If it is specifically about continuous glucose monitoring, please try to keep that on the thread that I have started solely for that.

If you are new to pumping, I may also be able to give some advice about that. I remember when I started, I almost gave up because I kept pulling my infusion site out by getting it caught on stuff. My minimed trainer said simply, “anyone can pump.” Thanks. What I really needed to hear was, “Stick to it. That may happen for a while. But, in time, your body will develop new reflexes to recognize the first hint of a tug at the site and stop dead in your tracks.” This took about a month and a half for me, during which time, I probably pulled out my infusion site accidentally on average about every day or day and a half. Then suddenly, one day, I felt myself stop in my tracks without thinking about it and it has become a rare occurrence since then.

Nothing else like that stands out in my mind. But, if you ask, I may remember something.

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10 Responses to Diabetes Tight Control

  1. Higghawker says:

    Scott,

    I have a friend who was issued a trial one of these “pumps”. He loved it. Just as he was getting used to it, they took it back saying it hadn’t been certified by the FDA? He was amazed at the unit waking him in the night.
    The one he had was around the size of a matchbox, but, he said they are getting smaller.

  2. Misanthropic Scott says:

    Higghawker,

    Interesting. I wonder what brand he tried. MiniMed (now Medtronic) pumps have been approved for years. When I started using mine in 1998, it had already been on the market for years. I started pumping humalog (insulin analog) when both pump and humalog were approved, but not for use together.

    As for the unit waking your friend, that makes me think it may have been the continuous glucose metering discussed on my other diabetes post. They did combine the functions of monitoring the glucose level into the insulin pump, which may be causing the confusion. The sensor was only recently approved and does not yet have an insurance code.

    The two bits of functionality, though on the same device, are quite different. One monitors glucose levels every 5 minutes and can provide alarms when the level is out of range. The other pumps insulin into the body.

    I suspect that they combined the two features in one device because:

    A) They could.
    B) It saves space on one’s belt.
    C) The original charter of minimed is to create an articificial pancreas. That will need to be one device.

  3. pakipics says:

    Help and Guidance for patients suffering from diabetes can be found here at http://www.reddiabetes.com

    If you are a patient of diabetes or know any patient suffering from diabetes you must refer him to this site http://www.reddiabetes.com

  4. Misanthropic Scott says:

    pakipics,

    The site didn’t look particularly fantastic to me. It did look legit at first glance though, so I won’t call your post spam, despite the resemblance. Better advice though, especially for those relatively new to diabetes and unlikely to have developed complications, don’t suffer with diabetes. Take control of diabetes and enjoy your life. I’ve had diabetes since 1988 am 44 years old, and do not let my diabetes stop me from anything, or at least not much. I did decide not to take up SCUBA diving, which is expensive and more complicated for a diabetic. I also have never taken flying lessons partly because diabetics can’t get licenses and partly because, again, it’s extremely expensive. I do travel around the world in search of wildlife and get to places far more remote than most of the non-diabetics I know. Many think I’m a tad insane. Check my trip list for details. All of these trips have been since I got diabetes.

    http://misanthropicscott.wordpress.com/vote-for-the-next-travel-location-write-up/

  5. Hey Scott,

    You’ve provided some fantastic info about diabetes and the pump/CGM, for which I am grateful. I was hoping to ask you a couple of questions, if you don’t mind using the email link that’s embedded in my comment (couldn’t find a link to email you here). One thing in particular that I’m wondering about is, with the CGM, have you used the sensors past their use-by date? How long past it? Or anyone else who is diabetic and following this conversation, I’d love to know if they really do expire.

  6. Hi Becky,

    I replied to you by email. Let me know if you didn’t receive it.

    For anyone curious about the reply, here’s the main answer.

    I have not watched the expiration dates on the sensors at all. I’ll have to check the dates on my current box. Personally, I would not waste them, especially if you’re paying for any significant portion out of pocket. I doubt that the quantity of chemicals on the sensor, even if they have changed somewhat, would really be seriously harmful. I would use them and see if they track your glucose accurately enough. If you find that they don’t or that you experience pain or swelling, stop using them. Realistically, the most likely thing that would make them expire is that the chemical would react as it does with your glucose, leaving the sensors with too little of the chemical to be effective in tracking your glucose levels.

    Of course, I am neither a doctor nor a chemical engineer nor an employee of Minimed/Medtronic with inside information. So, obviously, this would be at your own risk. I just think that the number of chemicals that can truly hurt you in minuscule quantities is quite small. And, minimed would be unlikely to use a chemical related to something that dangerous on a device inserted into your body.

    So, without advising you what to do, I will say that I would use them until/unless I see them not working or causing pain or swelling or some other minor bad effect.

    Scott

  7. bobbo, the evangelical anti-theist says:

    Scott–I think diet affects us all more than we know AND that our diet has been subtly, covertly, and even unintentionally negatively impacted by Frankenfoods. Not Franken because we are fearful of anything new or “not natural” but Franken because of those things done with good intent that have negative unrecognized consequences. Nutritional depletion of soils is one example.

    I’m fat and have been since getting a desk job 30 years ago. My diet is pretty good by my exercise level is zero. I’ve been expecting to get diabetes but I’m as healthy as a horse except for high blood pressure. Yes, I should exercise. BUT to the issue of DIET:

    While I have never had a recognized allergy or reaction to food, I’ve been lucky in not liking sweet food, or even fatty foods. But I have to admit I like bread and wheat products a lot. My current and foreseeable hobby is baking: wheat, sugar, and fat.

    As a result, I have started to “notice” articles about gluten and even wheat intolerance and my reaction has always been “I’m not sensitive thank goodness” but who knows for real? Maybe thats why I don’t sleep well?

    This is all preamble to one of the most interesting articles I have read to date about gluten and wheat. It makes “sense” and even may be true but I wonder in your opinion are these concerns relevant to the great majority of people, or only those with a proven susceptibility–ie those with or those predisposed or those who really want to avoid diabetes?

    http://www.huffingtonpost.com/dr-mark-hyman/wheat-gluten_b_1274872.html

    Note–I read all the time the brain uses 80% of our energy==you sure its to maintain body temperature?

  8. Hey bobbo,

    I was surprised to see you on this post. Now I see why. First, let me state in no uncertain terms, I am not an expert in type 2 diabetes. I am a type 1 diabetic. The two illnesses have similar symptoms but are completely different in their causes and somewhat different in their treatments.

    Type 1 is caused by an autoimmune problem where the body attacks and kills its own pancreas, kind of like rejecting an organ transplant, except that the organ in my case is the one with which I was born. Diet is important. But, diet and exercise are not the reasons for my illness. Further, in some ways, type 1 is easier to treat. The only drug to take is insulin. When I eat a ton of crap, as I just did this morning, I simply hit the turbo button on my insulin pump to counteract all that food.

    Type 2 is the one you have been expecting. The cause of type 2 is a resistance to insulin. In most type 2 diabetics, the level of insulin in the body is actually very high. It is simply not working to let the cells absorb the glucose. Treatment for type 2 usually begins with some form of drug that helps with insulin sensitivity. Type 2 may also be treated with insulin, but almost always in combination with other drugs, to the best of my limited knowledge. Sometimes, type 2 can even be “cured” by diet and exercise restoring insulin sensitivity to your body.

    Regarding FrankenFoods, I’ve got mixed feelings. I don’t think the food in itself reduces soil. I think that is an issue of how it’s farmed. Organically grown wheat is probably far better from an environmental perspective than that grown with chemical fertilizers (read fossil fuels). But, we’ve been eating FrankenFood for thousands of years. The genetic engineering was done through standard breeding practices rather than in a lab. But, the effect is the same. The wild precursors of wheat and corn are both inedible for humans. You probably wouldn’t even recognize corn’s ancestor as being the same plant.

    Regarding severely modified laboratory FrankenFood, my main concern would be whether they escape and become an invasive species.

    Celiac is a real issue for a great many people, but not most. For those of us who feel no effect from it, it’s probably no worse than the empty calories in corn or rice. The gluten just passes through, as far as I know. Though, this article hints that I may be mistaken. I’ll keep an eye out for further information. But, I’m unlikely to stop eating wheat unless I start getting symptoms of celiac.

    This is, of course, just the opinion of a lay person, not a medical professional. For real information, contact a doctor.

  9. bobbo, the evangelical anti-theist says:

    Thanks Scott. I’ll lie only a little bit and say I knew everything you said, but now, not lying, I’ll say I never “related” the bits I knew as well as you just did. Thanks.

    I did think the article would be relevant to you regarding wheat sensitivity of diabetics (re Cat 1 and I was wrong.) but non-personal health wise the whole issue of this “short wheat” strain which I guess was the basis of the green revolution a while back? To me its “like” Red Delicious Apples. They have been modified to be large and look good and store/ship well but they have become INEDIBLE giving rise to the Fuji which I am sure we are busy screwing up. Same now with Wheat?

    Depleting our soils I thought was a real issue? Not for the big 3 requirements that oil based fertilizers supply but all the micronutrients that are also necessary for health? The plants take them from the soil then are harvested and shipped away. After about 5-6 generations of plants, they no longer are the healthy vegetables all the accumulated wisdom is about.and that we need for health. All a matter of degree?

    As the diseases arise independently, and quite a few get either==how come I have never heard of people having BOTH Type 1 and 2 Diabetes? Talk about the fickle finger of fate just dumping on people?

    As baking is my hobby, I am still going to try some of the various non-wheat flours in 50/50 mixes in my bread/baking products and see what might be acceptable to me? Alternatively–I once had a date in New Orleans with a lady who took me to Panda Express and we had a sandwich there where the bread function of holding the sandwich innards was LETTUCE! It worked quite well. Sandwich was quite tasty and 10X more healthy. I like salads but as a single person I have shied away as the ingredients tend to spoil before getting used up. ….xxxxxxxx….Funny thinking about it now, I’d say half the reason I eat sandwiches is for the cheese and the other half is for the lettuce/spinach. SLAP MY FOREHEAD: who needs bread?

    Hmmmm—thanks again Scott==your excellent knowledge and my dithering may amount to something yet?

    Dithering Footnote of Relevance: trying to regulate the gluten in bread rather than getting rid of bread altogther and use Lettuce: much like bending oneself into a pretzel to regulate debt swap instruments rather than simply outlaw this form of pure gambling? You know pure gambling: no significant economic function other than the transfer of wealth once created by others?

  10. I can’t answer most of the questions in your last post. Sorry.

    Depleting top soil is a huge issue. The one you raise about nutrients in it being depleted may indeed be real. I’ve never heard that before. I’ve heard a lot more about the actual loss of the soil. Our midwest “breadbasket” used to have 24″ of top soil. Now it has 12″. Half is gone already. And, our farming techniques are depleting it at ever faster rates.

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