1.10 practical tips to help make type 1 diabetes work for you! Stephen W. Ponder MD, FAAP, CDE Professor of Pediatrics Pediatric Endocrinologist Scott & White Healthcare Medical Director, Diabetes Camping Sessions Temple, Round Rock, College Station

2. Todays agenda 1. 2.3. 4. 5.Understand what you are really trying to manage with diabetes: FLUX and DRIFT Know how your tools are supposed to be used and how they work (insulin, food, exercise, monitors, pumps) Appreciate the limitations of your tools, technology and yourself or the PWD/CWD Be able to recognize a trend or pattern from randomness or poor technique Understand when and how to make prudent changes to the Dmanagement plan6.Diabetes affects kids but managing it is not childs play: its a team sport 7. Be prepared for common Demergencies and know how to prevent or manage them 8. T1D usually has an entourage: know who the other players are and keep an eye on them 9. Whats new and changing in type 1 diabetes 10. Diabetes self care is a series of never-ending choices; strive for perfection but be satisfied with excellence 3. Appreciate the normal flux of glucose levels in normal individuals first! Trick Question: How would you rate this persons diabetes control? 4. One goal of diabetes care is managing glucoseHint: It takes TIME and PATIENCE! 5. Why do blood sugar levels shift all the time? 6. Postmeal Blood sugars, A1c and CV RiskVascular system 220 glucoseHbA1c1808%1407%1006% 5%Pre-meal 952 hr ?Pre-meal 115Goal: improve post-meal control: BG < 180 mg/dl 7. Before meal sugarAfter meal sugar 8. Inflammation drives d-complications 9. 24 hour glucose plot A1c 5.7% 10. To manage flux Everything becomes a TOOL to understand, use, and master Food Insulin Exercise Timing Devices, etc. 11. 7 6The 3 is the 4th dimension? What dimensions of insulin5 4peak3 2onset1 0duration 12. 7 6 5 4 3And the 4th dimension is: consistency2 1 06h12 h18 h24 h 13. The 2013 insulin arsenal Long (Lantus, Levemir) Intermediate (NPH) Fast (Regular) Rapid (Humalog, Novolog, Apidra) Premixed (75/25 and 70/30) Ultra-rapid? (in development) Ultra-long? (Degludec and others) 14. Comparing insulin actions 15. How does a basal insulin work? Turns off or tones down sugar coming out of the liver Allows a reasonable amount of sugar to enter cells Keeps sugar levels steady or in balance between meals and snacks. 16. Timely insulin facts Rapid insulin cant lower BG any sooner than 20 minutes It peaks on average in about 1 h 15 min Its mostly gone in 2-4 hours Maximum fall in BG is 4 mg/dl/min (rare) 17. TIP: A standing insulin dose (or regimen) is ALWAYS CHANGED LAST When troubleshooting a type 1 diabetes blood sugar problem First consider Food Timing Equipment BEFORE changing an insulin regimen 18. Why is the TDD so important? TDD/24 = basal rateInsulin on Board (IOB) (2-8 hours)500/TDD = carb ratioTotal Daily Dose (TDD)TARGET BG1800/TDD = correction 19. Average TDD insulin ranges by age and weight0.6-0.8 U/kg/d (toddler) 0.8-1.0 U/kg/d (child) 1.0-1.2 U/kg/d (teen) 20. Basal-Bolus: Example Calculations 30 units as glargineGive dose at bedtimeTDD60 units ~ 30 units divided as boluses10 10 10 + snacks OR60 units500 rule8.3 ~ 10Insulin to carbohydrate ratio60 units1800 rule30Correction factor (aka sensitivity factor) 21. Adjust The TDD For A High Avg. BG or A1C Example: someone with a TDD of 35 units and few lows. A1c = 9%, so more insulin is needed: about 3.2 units. 22. Time to reach 100 mg/dl (at ~ 4 mg/dl/min) Blood sugar420 340 260 180minutes 23. Proper meal planning 24. Timing of Bolus Insulin (humalog/novolog/apidra) High GIModerate GILow GIBG Above Target Range30-40 min. prior15-20 min. prior0-5 min. priorBG Within Target Range15-20 min. prior0-5 min. prior15-20 min. afterBG Below Target Range0-5 min. prior15-20 min. after30-40 min. after 25. Timing of Bolus Insulin vs. GI or BG Low BG OK High BG Low G.I. Mod High G.I. -30-150 Minutes from meal1530 26. Why timing matters 200150Pre-Meal Insulin Post-Meal Insulin100Note:4 hrs3-hrs2-hrs1-hr050Carbs estimated w/pre-meal insulin. Carbs known with post-meal insulin.Source: Clinical Therapeutics 2004; 26:1492-7. 27. Why timing matters CGMS data Bolusing with mealCGMS data Bolusing pre-meal 28. Beware of delayed-action foods Pizza Pasta/noodles Mexican foods Fried foodsThat slowly turn to sugar in body 29. Fried-food revenge and correctionBG = 194 6 unit correction @ 7AMFried food earlier in evening @ 8PMBG = 115 in 3 hours 30. If insulin keeps us alive, as does food, then why should one get more attention than the other? 31. Because 1) Most doctors are not nutrition specialists 2) Diagnosing and prescribing are what were trained to do 3) Our health care system downplays the role of RDs by not always paying for those services 4) Plus WE think were all food experts anyway! 32. DONT SHORT CHANGE THE MEAL PLAN Food questions are number one for most parents and patients Dont use the D word. Its a meal plan. Meal plans change often after diagnosis and should be reviewed (at least) yearly or for growth 33. D-teens count carbs POORLY23% 34. New paradigm: Insulin keeps us alive while food helps keep us in control 35. The pancreas has an off switch for insulinand its triggered by exercise 36. Exercise is the wild card since It can occur suddenly or unexpectedly It can last for different periods of time Intensity can shift up or down Its hard to measure Its impact on blood sugar can vary 37. Checking BG to fine tune? Or not? 38. Meters are commodity items a commodity is the generic term for any marketable item produced to satisfy wants or needs The best BG meter is the one youll use $10.41 for 50 strips (Medicare 2013 rate) Lancing devices (avoid the nerves) Ketone meter (get one!) 39. ISO and FDA allowable errorsGlycemic Roulette? Diabetes Spectrum Volume 25, Number 3, 2012 ISO 15197 Standards for SMBG 40. 223 mg/dlOops! 5%114 mg/dl 95 mg/dl95% of the time76 mg/dl52 mg/dlOops! 5% 41. CGM calibration advice A CGMs accuracy is the sum of its variances. Variance is the difference from what is measured and what is real Sominimize variance whenever possible Calibrate (if possible) when things are steady Wash hands; get proper sized blood sample (repeat if needed) If you calibrate when high or low, do some more later when back in your zone You can over-calibrate too. 42. Ponders Pumping Principles 1. An insulin pump is no better or worse than the human being attached to it 2. Master carb counting first BEFORE pumping3. Age does not limit who can pump insulin 4. Garbage in, garbage out: beware of the pump and dump phenomenon5. A good pump doctor behaves like a coach 6. Simple is a good place to start, but pumping skills MUST advance over time 43. Ponders Pumping Principles 7. A good insulin pumper troubleshoots and problem solves daily. Its all about mastering the PROCESS of pumping 8. Technology changes; people dont 9. Self-consistency is a virtue10. Everyones blood sugar fluxes; seek out your own sugar patterns in the chaos 11. Success is always a relative thing12. Dont ever be afraid to start over 44. Why do lows happen at night? Hormonal patterns Lower insulin need Insulin peaks? Post-exercise effect Snacking stacking?Lower overnight insulin/add snack 45. Dont pass up an opportunity to correct a high (or low) BG Choose what you consider actionable? BG above or below chosen thresholds Consider recent and impending actions Check your results with BG levels Repeat as necessary 46. Check your targets often Make sure you hit your target zone sugar ( 30 mg/dl) Rapid-acting insulin results are best examined at 2-3 hours Results should feedback to the next attemptPractice makes better 47. Curb your liver! The liver makes as well as stores sugar A proper insulin level calms down the liver Aim for an in-range sugar level ( 300 If any nausea or vomiting, regardless of BG level During any illness, check ketones periodically Watch: http://db.tt/00PIDcoG Diabetes Sick Day Rules (17 min) 60. Type 1 diabetes can have sidekicks Thyroid disease Screen with antibodies Thyroid blood levels Celiac disease Screen with antibodies Formal Dx by GI doc Gluten-free prevention? 61. Annual responsibilities Eye (retinal) exams Urine microalbumin studies at start of teen years or after 5 years Lipid profile (after 10) Hemoglobin A1C (quarterly) Vitamin D levels(?) 62. Prior to 1980, 50% of people with type 1 diabetes would develop renal failure 10-20 years after onset of diabetes* * Bruce Buckingham, MD 63. Most are now living normal lifespans individuals with type 1 diabetes without renal disease achieve longterm survival comparable to the general population. Diabetologia. 2010 Jul 28. [Epub ahead of print] http://www.ncbi.nlm.nih.gov/pubmed/20665208 64. More from the DCCTWe thus believe the dramatic improvement in life expectancy is likely true for the general population with childhood onset type 1 diabetes and not due to a preferential participation of healthier individuals in the EDC in later years. Furthermore, the improvement in life expectancy is far greater than that seen in the general population. Diabetes, July 30, 2012 - DOI: 10.2337/db11-1625 65. DX'd 1965-1980DX'd 1950-1964Diabetes, July 30, 2012 - DOI: 10.2337/db11-1625; data interpretation 66. The JDRF Closed Loop Pathway 1 Very Low Glucose a Insulin Off Pump START6 Fully Automated Insulin + END Anti-insulin Closed Loop23Hypoglycemia MinimizerHypo/Hyper Minimizer54Fully Automated Insulin Closed LoopAutomated Basal / Hybrid Closed LoopFrom Aaron Kowalski, PhD, JDRF Artificial Pancreas Presentation, 2008 www.jdrf.org/artificialpancreas 67. Insulin Action Even rapid acting analogs are too slow Speed of onset matters to reduce hyperglycemia Duration of action matters to reduce hypoglycemia Many companies working on solutions lets look at one 68. Biodel PharmacokineticsDeveloping a faster insulin 69. Might Need Glucagon Too 70. Time in Range with Bihormonal AP 48 Plasma Glucose Leptin, No DKAhttp://diabetes.diabetesjournals.org/content/60/5/1414.full.pdf 82. Near Normal BGhttp://diabetes.diabetesjournals.org/content/60/5/1414.full.pdf 83. Diabetes self care is a choice 84. Actually its a series of choices 85. I haven't failed. I've just found 10,000 ways that won't work. Thomas Edison 86. Wisdom is not a product of schooling but of the lifelong attempt to acquire it 87. Life is not a matter of holding good cards, but of playing a poor hand well. R.L. Stevenson (1850-1894) 88. we are going to relentlessly chase perfection, knowing full well we will not catch it, because nothing is perfect. But we are going to relentlessly chase it, because in the process we will catch excellence. 89. Is the future already here? Lifespan with type 1 diabetes vs. without 8075DX'd 1980--?? Average American70Type 1 DiabetesDX'd 1965-1980Linear (Average American)65Log. (Type 1 Diabetes)6055DX'd 1950-1964 50 196419801996 90. Take home message Care today is fundamentally different from a generation ago Complications are becoming rare and are not inevitable Lifespan can be essentially normal Science is moving forward on many fronts