Think Like a Pancreas

by Gary Scheiner

  Figure 3-1. Hormonal effects on the liver’s glucose secretion and storage

  Emotional stress (fear, anxiety, anger, excitement, tension) and physiological stress (illness, pain, infection, injury) cause the body to secrete a number of stress hormones into the bloodstream. For those without diabetes, an increase in insulin secretion follows the stress-induced blood sugar rise, so the blood sugar rise is modest and temporary. For those of us with diabetes, however, stress can cause a significant and prolonged increase in the blood sugar level.

  The Little Stuff

  If forgetting to recap the toothpaste or put the toilet seat down can wreck a marriage, imagine what the little things can do to your blood sugar!

  Table 3-6. Secondary factors that can influence blood sugar levels

  Tend to raise blood sugar Tend to lower blood sugar

  growth alcohol

  menstrual hormones heat/humidity

  later stages of pregnancy heavy brain work

  rebounds from hypoglycemia previous intense exercise

  gradual loss of beta cell function (type 2) new/unusual surroundings

  exiting the “honeymoon” period (type 1) socializing

  depression stimulating environments

  weight gain early stages of pregnancy

  excessive sleeping beta blockers

  caffeine mao inhibitors

  steroid medications nicotine patches

  diuretics ritalin

  estrogen stress reduction

  niacin depression treatment

  Little things do mean a lot. There are countless variables that can affect blood sugar levels—some raising it, some lowering it, and some . . . well . . . some seem to have a mind of their own. A number of these situations may occur on a semiregular basis, whereas others may happen once in a lifetime. Table 3-6 (on page 57) lists many such variables. We’ll be spending the next several chapters focusing on ways to cope with and adjust to these variables in everyday life.

  Chapter Highlights___________________________________________

  •There are many forms of diabetes; the major ones are type 1 and type 2.

  •Type 1 occurs when the immune system attacks the pancreas, destroying the insulin-producing cells.

  •Type 2 begins as insulin resistance. If the pancreas can’t produce enough insulin to overcome the insulin resistance, blood sugars rise. Later, the pancreas burns out, and as a result, more aggressive treatment is required.

  •The major factors that raise blood sugar are carbohydrates and stress hormones.

  •The major factors that lower blood sugar are insulin, diabetes medications, and exercise.

  CHAPTER

  4

  The Three Keys to Control

  These days, everyone is talking about control. How’s your control? Is your blood sugar under control? You don’t want to get out of control!

  Maybe it would be a good idea to define what we mean by “control.” First off, I don’t believe that diabetes should control anyone’s life. There is much more to life than diabetes. If you’re spending hours or more each day dealing with your diabetes, there is something wrong. Please, go smell the coffee . . . or the flowers . . . or something. In other words, as soon as diabetes management starts to get in the way of enjoying your life, it’s time to ease up.

  That said, I like to define quality diabetes control as achieving the lowest possible HbA1c without frequent or severe episodes of hypoglycemia and without your diabetes maintenance interfering too much with your daily life. Occasional, mild episodes of hypoglycemia are acceptable and not all that dangerous for most people. However, once low blood sugars become too frequent (more than two or three a week) or severe (causing accidents, seizures, or loss of consciousness), it will be in your best interest to control your blood sugar less intensively.

  For those new to this diabetes management thing, HbA1c (also called a “glycosylated hemoglobin” or simply “A1c”) is a laboratory blood test that provides an overall blood sugar average for the past two to three months (see Table 4-1 below). If you take insulin, getting an A1c test done every three months is a good idea. The A1c provides a more accurate average than you can obtain with typical premeal fingerstick readings because the A1c takes into account glucose levels all the time—before eating, after eating, while sleeping, exercising, watching TV, going to the bathroom, and so forth. An A1c that is much higher than expected (based on your usual premeal meter readings) may be a sign of after-meal or overnight high blood sugars. A lower-than-expected A1c could indicate that low blood sugars are occurring too often, possibly without any symptoms.

  Quality diabetes control means achieving the lowest possible HbA1c without frequent or severe hypoglycemia and without interfering too much with your quality of life.

  Table 4-1. HbA1c and average glucose

  A1c (percent) Avg. glucose (mg/dl) Avg. glucose (mmol/l)

  5 97 5.4

  6 126 7.0

  7 154 8.6

  8 183 10.2

  9 212 11.8

  10 240 13.3

  11 269 14.9

  12 298 16.5

  13 326 18.1

  14 355 19.7

  15+ Don’t bother with numbers. It’s high—real high.

  Technically, the A1c represents the percentage of red blood cells (the cells in our blood that carry oxygen) that have glucose stuck to them. When blood glucose levels are normal, approximately 4 to 6 percent of red blood cells will have glucose attached. Red blood cells live for an average of two to three months before they are broken apart and replaced with new ones. So, an A1c measurement gives us a good estimate of how high the blood glucose has been over the past two to three months. The formula for calculating your average glucose based on the A1c is in Table 4-2.

  Table 4-2. Converting A1c into average glucose, and vice versa

  Avg blood glucose (in mg/dl) = (A1c × 28.7)-46.7

  Avg blood glucose (in mmol/l) = (A1c × 1.59)-2.59

  and in reverse:

  A1c = (avg blood glucose (in mg/dl) × 28.7)-46.7

  A1c = (avg blood glucose (in mmol/l) × 1.59)-2.59

  Why is A1c so important? The Diabetes Control and Complications Trial (DCCT) and United Kingdom Prospective Diabetes Study (UKPDS) showed that A1c is closely linked to the risk of both developing and worsening diabetic complications. Essentially, the higher the A1c, the greater the risk of developing and worsening eye, kidney, nerve, and heart problems. Given these risks, efforts should be made to keep the A1c reasonably close to normal. In most cases, that equates to an A1c in the 6 to 7 percent range. However, those who have hypoglycemia unawareness (don’t receive low blood sugar warning symptoms) or significant heart disease as well as those who work in high-risk professions may seek slightly higher targets. Slightly higher targets are also reasonable for young children who cannot detect or treat hypoglycemia independently. Pregnant women, individuals planning for surgery, and those looking to slow or reverse existing complications may seek lower targets.

  In any case, the goal is not simply the lowest average but also stability. Anyone can lower their A1c by taking too much insulin, but this would cause frequent and perhaps severe hypoglycemia. Instead, aim to achieve a good overall average with a high percentage of readings (or time, if you are using a continuous glucose monitor) within your acceptable target range.

  Which begs the questions: “What should my target range be?” and “How often do I need to hit it?” Obviously, this is something that needs to be individualized and discussed with your health care team. With my clients, I recommend different targets for premeal versus the postmeal peak (one to one and a half hours after finishing eating). For the average person trying to achieve an A1c in the 6–7 percent range, a premeal range of 70–160 mg/dl (4–9 mmol/l) might be considered acceptable. Likewise, aiming to keep the postmeal peak below 180 mg/dl (10 mmol/l) is within reason. See Table 4-3 below for details.

  Table 4-3. Acceptable pre- and postmeal glucose ranges

  This
does not mean that you should expect to hit your premeal and postmeal targets every time you check your blood sugar. That would be like a baseball player getting a hit every time up to bat. What is reasonable is to get a “hit” at least 70 percent of the time, with fewer than 10 percent of your readings below your target range. This represents fairly stable control without excessive glucose swings. The degree of glucose variability can also be assessed by looking at the standard deviation of glucose values. This is a statistic that glucose meter and continuous glucose monitor download software can generate. We’ll discuss this in more detail later in this chapter.

  The Three Keys

  Just as a chain is only as strong as its weakest link, successful diabetes management depends on three interlinked criteria: tools, skills, and attitude. Having one or two just won’t cut it; all three are required. You could have the latest cutting-edge technology at your fingertips, but without the expertise to use it properly, it would go to waste. Likewise, fancy technology and top-notch skills fail to yield desired results without the ambition and desire to apply them properly.

  The Right Tools

  Imagine trying to run the latest software on a computer built five years ago (maybe you don’t have to imagine!). Likewise, trying to apply the latest diabetes management techniques with yesterday’s technology can be equally challenging.

  Below are some of the tools that make taking proper care of your diabetes possible.

  The Latest Insulin

  Today’s insulin formulations are vastly superior to the insulins that were commonplace only ten years ago. (Of course, by the time Think Like Your Entire Digestive System goes to print, today’s insulins may be equally obsolete.)

  Yesterday’s synthetic “human” insulins (regular, NPH, Lente, Ultralente) have been all but replaced by analog and basal insulins. Analog insulins (lispro, brand name Humalog; aspart, brand name Novolog or Novorapid; and glulisine, brand name Apidra) have a slightly different structure than regular insulin. This structural change allows the insulin to absorb much faster into the bloodstream, act more quickly, and match the blood sugar rise caused by carbohydrates better than regular insulin ever could.

  Modern basal insulins (glargine, levemir) have chemical properties that make them activate in the bloodstream in a steady, gradual manner without a major peak—sort of like a time-released medication. This makes them much less likely to cause hypoglycemia than will intermediate-acting insulin (NPH). Not that NPH and regular insulin can’t still play a role in diabetes management, but they certainly should not be the first choice for forming the foundation of your insulin program.

  One other insulin option that is gaining popularity is U-500 regular insulin. As described in Chapter 3, U-500 is five times as concentrated as ordinary regular insulin. In other words, 5 units of U-500 has the blood sugar–lowering power of 25 units of regular insulin; 10 units has the power of 50 units. U-500 has become a popular choice among people who are extremely insulin resistant and require more than 300 units of insulin per day. The concentrated property of U-500 allows a person to take more manageable doses—a definite plus for those using an insulin pump or are limited by the size of standard insulin syringes. However, because U-500 acts even slower than regular insulin (its onset, peak, and duration take on the characteristics of NPH insulin), it should only be used in cases of extreme insulin resistance.

  A Good Insulin Delivery Device

  If you choose to administer insulin via injections, choose a device that permits the greatest accuracy as well as convenience and flexibility.

  Disposable syringes are the traditional method for delivering insulin in the United States. (Most other industrialized countries have moved away from disposable syringes due to the large volume of medical waste they create.) When choosing insulin syringes, select the smallest size possible given your usual dose. This allows for the greatest dosage accuracy. Low-dose syringes are now available that have half-unit markings. If you rarely require more than 20 units in a single injection, choose .3cc (30-unit) syringes with half-unit markings. If you sometimes require more than 20 units but rarely take more than 40 units in a single injection, choose .5cc (50-unit) syringes. If you often require more than 40 units in a single injection, choose 1cc (100-unit) syringes.

  Choose the syringe size that meets your needs and permits the most accurate dosing.

  As far as the syringe needle, thinner is almost always better. Thinness is measured by gauge. And here’s where this gets interesting: The higher the gauge, the thinner the needle (trust me, that wasn’t my idea). Make sure your syringe needles are at least 30-gauge. Depending on your pharmacy or supplier, you may be able to get syringes with needles that are as high as 32-gauge. As discussed earlier, the optimal needle length depends on your body type, although needles longer than eight millimeters are rarely necessary, even if you are very heavy. Using needles that are too thick or too long can cause unnecessary pain, bruising, and accidental injection into muscle.

  Insulin pens are discreet, safe, fast, and simple to use, making them ideal for frequent meal/snacktime injections. Pens permit precise dosing by turning a dial on the top of the pen and then pressing a button to deliver the insulin. In addition to visualizing the dose in the pen’s display window, the user can hear and feel clicks as the dial is turned. Pens containing long-acting/basal insulin deliver in whole-unit increments. Pens that dispense rapid-acting insulin can administer either whole- or half-unit increments. If you are fairly sensitive to insulin (i.e., if you take less than 25 total units per day), consider using a pen that delivers in half-units.

  Durable pens use 300-unit disposable insulin cartridges. Some can deliver in half-unit increments.

  Disposable pens come prefilled with 300 units of insulin and deliver in whole-unit increments.

  If you often require doses of one unit or less, a pen may not be your best option, as dosing accuracy is not as precise at doses that low. With any type of insulin pen, the pen needle must be kept in the skin for five to ten seconds following the injection in order to ensure complete and accurate insulin delivery.

  Pens come either prefilled or with disposable insulin cartridges. The disposable needles used on insulin pens are thinner and sharper than traditional syringe needles, and hence they are more comfortable. Select a pen-needle length that is appropriate for your body type; four- to eight-millimeter needles should suit most people. A list of commonly available pens is located in Chapter 10.

  Injection ports are an option for those with a significant dislike of frequent needlesticks. These devices (also listed in Chapter 10) require just one needlestick every two or three days in order to place a tiny, plastic infusion tube below the skin. Injections are given into a port that sits on the skin surface, so there is no skin puncture or discomfort whatsoever when insulin is injected into the port.

  Needleless air infusers offer another option for those with severe needle phobia or allergies to the materials found in syringe and pen needles. Air infusers use pressurized air to create an insulin mist that travels through the pores of the skin at a high speed. When used properly, these devices can be virtually painless and may help to accelerate the action of mealtime insulin. Used improperly, however, they can cause bruising, scarring, and inaccurate insulin dosing. (See Chapter 10 for a listing of these devices.)

  Injection ports include the iPro and Insuflon.

  Insulin pumps were first developed in the 1970s, as scientists and physicians looked for a way to copy the world’s best blood glucose control device: a healthy pancreas. The insulin pump mimics the pancreas by releasing small amounts of rapid-acting insulin (in tenths or hundredths of a unit) every few minutes. This is called basal insulin. When you eat, you program the pump to deliver a larger quantity of insulin fairly quickly. This is called bolus insulin.

  Today’s insulin pumps are truly marvels of bio-engineering.

  Insulin pumps are the size of beepers and contain a cartridge filled with rapid-acting insulin. They have a s
ensitive motor that turns very gradually to push insulin from the cartridge through a tube and into the body. Some of the newer pumps are referred to as “patch” pumps—the pump itself sticks directly to the skin and has its own built-in canula that infuses the insulin below the skin, so there is no tubing. Patch pumps are programmed via a remote control. It is important to note that insulin pumps do not control blood sugars automatically. It takes a skilled, educated, and motivated user to operate the pump properly and benefit to the fullest.

  Those who use insulin pumps tend to have tighter glucose control with fewer lows and less variability than those using injections. Pump users also enjoy considerable schedule flexibility and report improvements in overall quality of life. That’s because, besides cutting down drastically on the number of needlesticks (usually one every three days), insulin pumps offer a number of unique therapeutic advantages over traditional injection therapy.

  OmniPod and Solo are examples of “patch” pumps.

  When using a pump, basal insulin delivery can vary by time of day to suit each individual’s unique needs. You can make temporary adjustments to the basal rates for situations such as prolonged exercise, stress, and illness. In terms of mealtime and correction insulin (boluses), pumps have built-in bolus calculators that take your usual dosing formulas into account and deduct insulin that is still working from previous boluses. They can deliver with incredible precision—to the nearest tenth, twentieth, or fortieth of a unit. Pumps can also spread out the delivery of boluses over a period of time so that blood sugars don’t drop after you consume slow-digesting foods. All pumps are downloadable and can provide considerable historical information for the user and their clinician.