Think Like a Pancreas

Part 1

Copyright Note: The information in this book is true and complete to the best of our knowledge. This book is intended only as an informative guide for those wishing to know more about health issues. In no way is this book intended to replace, countermand, or conflict with the advice given to you by your own physician. The ultimate decision concerning care should be made between you and your licensed health care provider. We strongly recommend you follow his or her advice. Information in this book is general and is offered with no guarantees on the part of the authors or Hachette Go. The authors and publisher disclaim all liability in connection with the use of this book. The names and identifying details of people associated with events described in this book have been changed. Any similarity to actual persons is coincidental. Copyright © 2004, 2012, 2020 by Gary Scheiner Cover design by Terri Sirma Cover illustration © Sylverarts Vectors/Shutterstock Cover copyright © 2020 Hachette Book Group, Inc. Hachette Book Group supports the right to free expression and the value of copyright. The purpose of copyright is to encourage writers and artists to produce the creative works that enrich our culture. The scanning, uploading, and distribution of this book without permission is a theft of the author’s intellectual property. If you would like permission to use material from the book (other than for review purposes), please contact permissions@hbgusa.com. Thank you for your support of the author’s rights. Hachette Go, an imprint of Hachette Books Hachette Book Group 1290 Avenue of the Americas, New York, NY 10104 HachetteGo.com Facebook.com/HachetteGo Instagram.com/HachetteGo Previously published by Da Capo Lifelong: 2004, 2012 First Hachette Go edition: May 2020 Hachette Books is a division of Hachette Book Group, Inc. The Hachette Go and Hachette Books books name and logos are a trademark of the Hachette Book Group. The Hachette Speakers Bureau provides a wide range of authors for speaking events. To find out more, go to hachettespeakersbureau.com or call (866) 376-6591. The publisher is not responsible for websites (or their content) that are not owned by the publisher. ISBNs: 978-0-7382-4668-0 (trade paperback), 978-0-7382-4669-7 (ebook) E3-20200415-JV-NF-ORIContents Cover Title Page Copyright Dedication Foreword by Nicholas B. Argento, MD, FACE ONE: Time for a Little Transparency TWO: “Glucose. Control, Y’all. What Is It Good For?*” THREE: Beyond the Basics FOUR: The Three Keys to Better Control FIVE: The Basal/Bolus Approach SIX: Basal Insulin Dosing SEVEN: The Art and Science of Bolus Calculations EIGHT: Meeting the Challenges of Daily Living NINE: Taming the Highs and Lows TEN: Resources for Everything and Anything Diabetes Discover More Appendix A Appendix B Appendix C Appendix D Appendix E Appendix FTo Debbodil, My Big Girl, BumbleBee, Awesome-O, and the Princess— you guys are my writing fuelExplore book giveaways, sneak peeks, deals, and more. Tap here to learn more. Foreword For every complex problem there is an answer that is clear, simple, and wrong. —H. L. Mencken To be prepared is half the victory. —Miguel De Cervantes I was diagnosed with type 1 diabetes (T1D) in 1968, at a time when there were no fingersticks. Insulin was impure, of animal source, and still delivered mostly in glass syringes. Injection needles were large, reused many times, and had to be sharpened. No one had heard of a hemoglobin A1c. The tools to manage diabetes were primitive, the prognosis grim. Blindness, limb loss, kidney failure, heart disease, disability, and early death were all too common. Pregnancy for women with diabetes was extremely risky for both mother and fetus. Tight blood glucose control, which was not of proven benefit, was nearly impossible to achieve. Attempting to control blood glucose amounted to hurtling down a twisting mountain road with eyes closed. We in the T1D community were told: “Have faith. Researchers are working on a cure, which might be only five to ten years away.” In 1991, I started practicing as an endocrinologist specializing in diabetes. Tight blood glucose control, which was still not of proven benefit, was then more readily achievable. Progress had been made: human insulin had been bioengineered and purified; injections were delivered in disposable syringes with smaller needles. A test of long-term control, the hemoglobin A1c, had been developed and was in wide use. Most important, self-monitoring of blood glucose was possible—one could finally measure what one was trying to regulate. Insulin pumps had been developed, though at that time they amounted to fancy syringes. Laser treatment for diabetic eye disease could save many eyes from blindness. New medications could forestall diabetic kidney damage and reduce the risk of heart disease, and successful pregnancy with diabetes was achievable and common, though challenging. Gary Scheiner, MS, CDE, much to his surprise, joined the club that no one wants to belong to when he developed T1D in 1985. He soon realized that, despite having dedicated well-meaning health care providers, he was often left to just figure things out on his own. There had to be a better way! Getting low blood sugar with exercise—oh, sorry, that’s just diabetes. Maybe you should just not exercise so much. Low unexpectedly some nights from that bedtime shot of NPH? (Some of us in the T1D club believe NPH really stands for Not Particularly Helpful.) Why, just have a snack before bed. But sometimes my blood sugar is low, and then sometimes it is so high in the morning if I do that! I feel like I am on a roller coaster! Gary, Gary, that’s diabetes. You are probably just not counting your carbs correctly. If you just do that, everything will be fine. And have faith—researchers are working on a cure, which might be only five to ten years away. At that point, the outlook for those with diabetes was undoubtedly brighter. But we were still burdened with insulins that could not duplicate normal pancreatic function, and those fighting to achieve tight blood glucose control risked severe hypoglycemia reactions, especially at night. For those prone to hypoglycemia, it was like being hunted by a relentless predator, one that never slept. We never got a night off. But now, instead of hurtling down a twisting mountain road with eyes closed, we could open our eyes via fingersticks, albeit only periodically. We in the T1D community were told: “Have faith. Researchers are working on a cure, which might be only five to ten years away.” As I write this, we who use insulin and our care providers are in an entirely different world. The current tools to manage diabetes are powerful and proven. The benefit of tight blood glucose control is beyond reasonable doubt. Powerful treatments to prevent and treat the complications of diabetes are in widespread use. Insulins are available that can mimic normal pancreas secretion patterns. Insulin pumps are now sophisticated diabetes management devices, even those used in open-loop mode. Continuous glucose monitors (CGMs) have been game changers: accurate, user-friendly devices that inform those living with diabetes where their glucose is, where it is going, and how fast it is changing. Now that drive on the twisty mountain road can be with eyes wide open, and there are alarms to warn you when you are going off course. Closing the loop with an insulin pump combined with a modern CGM is no longer five to ten years away, and uncertain—it is here, now, and rapidly improving. Management of insulin-requiring diabetes remains challenging. A tool is only useful if you know how to use it, and only used to its full potential if you can become expert in its use. The need for self-management education remains a core need in the diabetes community. There are many experts in the diabetes care community who do not have diabetes themselves but who can and do contribute greatly to the well-being of their diabetes patients. However, those who have diabetes themselves often have a higher level of insight and understanding. There is so much you don’t have to explain to someone who drives that mountain road. Gary is widely recognized as an innovator, motivator, and thought leader in the diabetes space. As a certified diabetes educator, he worked to develop solutions to the challenges that he and his patients all face, with a particular emphasis on the challenges with exercise and pregnancy. Gary founded Integrated Diabetes Services (integrated diabetes.com) in 1995 and serves as its clinical director. He has received many awards and recognitions, but perhaps his most notable and valued achievement—other than four children and a wonderful spouse—was the 2014 Diabetes Educator of the Year award from the American Association of Diabetes Educators. It could not have gone to a more deserving person. Both the first and second editions of Think Like a Pancreas were received with wide acclaim in the diabetes community. This third edition has been updated completely and extensively to reflect this rapidly changing field—new treatments, new insulins, new pumps, CGMs, and efforts to finally “close the loop” with a pump that uses CGMs to guide therapy. Gary offers concrete and tested coping strategies that are generated from his own experience, plus that of countless others he has counseled. While we should have faith—researchers are working on a cure, which might be only five to ten years away—we need to help people with diabetes succeed today so that they can be healthy and thriving. I know those with diabetes, and especially insulin-requiring diabetes, will find this new edition extremely useful, as will all health care providers in the diabetes space. Nicholas B. Argento, MD, FACE September 2019 Dr. Argento would like to thank Elizabeth M. Argento for her expert editorial assistance.ONE Time for a Little Transparency I’d like to get to know you (if I could). —Spanky and Our Gang Nowadays, everyone is looking for transparency. Transparency in business dealings. Transparency in personal relationships. Transparency in tape. So it makes sense to begin the third edition of Think Like a Pancreas with some transparency of my own. Why did I decide to write a third edition? No, it’s not for fame and fortune. One look at my meager checking account should be proof enough of that, and people aren’t exactly lining up to touch the hem of my retro garments. If you read my ramblings in a previous edition, you know I focus on three key elements for successful diabetes management: the Right Tools, the Right Skills, and the Right Attitude. The attitude part hasn’t changed, but the tools and requisite skill sets have evolved dramatically since the second edition came out back in 2010. New additions to our diabetes management war chest include continuous glucose monitors, hybrid closed-loop systems, an array of new types and concentrations of insulin, additional classes of noninsulin medications, smart pens, injection/infusion best practices, apps, software, and a greater understanding of all aspects of nutrition. And that doesn’t even touch on the explosion of social media and web-based resources that are now available within the diabetes community. So obviously, a new edition is needed. One cannot think like a pancreas using outdated tools and know-how. Now let me get up on my soapbox. Despite all the new gadgets, I still find diabetes to be a royal pain in the ass (pain in the bum for those of you in the European Union and Australia; pain in the tuchus for my Jewish friends). Even after working at it diligently year after year, I’m driven batty by the inconsistencies. Why, for instance, should the same bagel from the same bagel shop make glucose go very high one day but not the next? Like you, I have enough to do without all the added responsibilities of taking care of my diabetes. Doctor’s appointments, getting lab work, and waiting on the phone to fight with my insurance company take time away that I’d much rather spend with my wife and kids or riding my bike down the Shore (this is a Philly term for “the beach in South Jersey”). Every meal and snack has to be preceded by a mathematical ritual. And I’d much rather spend my money on new running shoes or tickets to a ballgame than on steep copays for all my diabetes stuff. Face it: managing diabetes is like having another full-time job on top of everything else in our lives—but without weekends off and certainly without the paycheck. You may have also found, as I have, that today’s health care systems simply aren’t equipped to manage diabetes properly. And that goes for more than just the American system. Virtually everyone I’ve worked with around the globe has had the same experience: most health care providers lack the time, expertise, and empathy to help us manage our diabetes properly. This is not from a lack of desire—most physicians are talented, motivated, caring people who wish they had the time and resources to do more for their patients. It’s just that the demands placed on today’s health care providers are so great that precious little time is available for staying on top of the latest developments and teaching us the finer points of diabetes self-management. I hope you’re nodding your head by now, muttering, “Yeah, he gets it.” Well, here’s an updated synopsis of my life with diabetes thus far. See if anything else sounds familiar. My Story It was two o’clock in the afternoon on a typically hot, muggy summer day in Sugarland, Texas. (No, I’m not making this up. The irony is just unbelievable.) Home following my freshman year at college (Washington University in St. Louis), I had spent half the summer sucking down cold drinks and the other half peeing them out. My energy was gone, and there was no way the Houston summer could have caused me to lose so much weight—I had gone from 155 pounds to 117 (70 to 53 kilograms). I couldn’t tighten my belt enough to keep my

Part 2

pants from falling down. Then I saw an episode of M*A*S*H in which a helicopter pilot had diabetes. And guess what: he had many of the same symptoms I was experiencing! So I decided it was time to see the family doctor. The clothes hanger on the left is me, out on a date the night of my diagnosis, almost forty pounds (eighteen kilograms) underweight. The doctor’s office was only a ten-minute drive from our family’s short-term home near Houston (we’re originally from the East Coast), so I was able to make it with just one pit stop to use a gas station restroom. That summer, I learned where all the best public restrooms were along the I-59 corridor in southwest Houston. When I got to the doctor’s office, I put on my glasses (miraculously, I could suddenly see road signs without my glasses for the first time ever as a result of changes in my vision), wiped off the steam created by the 101 percent humidity, and prepared for the worst. After a quick physical exam, blood test, and urinalysis, the doctor came back in to the exam room and said nonchalantly, “Gary, I’ve got bad news, and I’ve got good news. The bad news is that you have diabetes, and you’re going to have it for the rest of your life.” I have no idea what the good news was because I stopped listening at that point. The first syllable from “diabetes” stuck in my head. What the heck is diabetes? About all I knew was that it was making my body wither away and that it wasn’t going to go away. Ever. I remember him telling me that my blood sugar was 600-something (over 30 millimoles per liter), and that this was six times the normal level. I also remember him saying that I would have to take shots and be very careful about what I ate. The thought of giving myself shots was one thing, but limit what I eat? Was he crazy? I was an active eighteen-year-old with the metabolism of a small country. The very thought of not being able to eat whatever I wanted whenever I wanted made me feel totally depressed. So off I went to an endocrinologist at a fancy high-rise in downtown Houston. Keep in mind that the year was 1985, so getting in to see a specialist was as easy as making a phone call. “You are lucky to be diagnosed now,” explained the endocrinologist. “We have come a long way in the treatment of diabetes. I’ll bet that in five or ten years, your diabetes will be cured.” I should have taken that bet. I then met with a nurse, a diabetes educator before they even had the term, who taught me the basics about diabetes. I discovered what insulin is and why it is important. I learned a little bit about how food and exercise affect blood sugar levels and what can happen if I don’t keep mine under control. I also found out why the high blood sugars turned me into a relentless peeing machine. Mean without the lean: Early disposable syringes used half-inch (thirteen-millimeter), 28-gauge needles. Finally, I was instructed on how to inject insulin. Forget about practicing on oranges, pillows, and teddy bears. I gave myself my very first injection right in the stomach. It hurt—probably because I had almost no fat left on my body and the syringe needles were much thicker and longer than they are today. But mostly it hurt because I was tense and overwhelmed at the thought of sticking needles in myself for the rest of my life. I was also given a bottle of test strips and taught about blood sugar testing. No meter, mind you—just test strips. These strips featured a square box that had to be covered with blood, blotted, and then timed before matching the color on the strip to the chart printed on the bottle. Pale blue meant you were 40 milligrams per deciliter (mg/dl) (2.2 millimoles per liter [mmol/l]) to 70 (3.9)—a bit low; light blue, 70 (3.9) to 100 (5.6)—low normal; ocean blue, 100 (5.6) to 125 (6.9)—normal; aqua blue, 125 (6.9) to 150 (8.3)—slightly above normal; just plain aqua, 150 (8.3) to 200 (11.1)—slightly high; aqua green, 200 (11.1) to 250 (13.9)—high; sea green, 250 (13.9) to 350 (19.4)—very high; green, 350 (19.4) to 450 (25)—very, very high; brownish green—you don’t want to know. In other words, determining your blood sugar required an extremely sensitive eye for subtle differences in pastel shades. When I grew up, there were only eight crayons in my box of Crayolas, and none of them were “sea green.” So, this was a little bit challenging. The bottle of test strips came with a medieval torture device called an “Autolet.” The Autolet had a small disposable platform with a hole where you placed the victim—I mean, your finger. A disposable 25-gauge lancet was placed in the firing mechanism, which swung around at a high speed like a pendulum to stab your finger and make it bleed. The lancet didn’t retract out of your finger the way it does with today’s devices; it stayed in until you pulled your finger away. I called it the “Guillotine.” The original Guillotine (I mean Autolet) for performing fingersticks. Then I met with a dietitian—a tiny, middle-aged woman who taught me the fine art of the “exchange” diet. “You really don’t have to change what you eat that much,” she told me. “You just have to be careful not to eat too many concentrated sweets, fats, or very large portions of anything.” Apparently, she had no idea whom she was talking to. I can still remember my “generous” twenty-five-hundred-calorie exchange diet—chock-full of fruits, vegetables, meats, milks, fats, and starches. Oh, how I hated that diet. There’s nothing like telling someone they can’t have something to make them crave it more than ever. I was hungry constantly. The exchange system meant that everything I ate had to be placed in a category and that I could only eat so many things from each category at each meal and snack. Talk about sucking all the fun out of eating! My first exchange diet meal looked so puny on the plate—a sandwich, a piece of fruit, a cup of milk, and a handful of chips. And there were no seconds, thirds, or fourths like I was used to. I felt hungry all the time. The first couple of weeks were tough. Even after starving myself and doing everything I was asked to do, the stupid test strips kept turning aqua blue instead of sea green (or maybe it was the other way around). I cried a lot those first couple of weeks. My mom told me that my dad, normally an unemotional guy (a chemical engineer by trade), had cried too and that he wished it was he and not I who got diabetes. A few weeks after my diagnosis I purchased my first blood glucose meter—a Glucometer, to be exact. It weighed about a pound and was the size of a brick. The testing procedure is still etched in my brain: Guillotine, then squeeze out a big “hanging” drop of blood, dab the big box on the strip, start the counter, wait one minute, blot the strip, insert it in the meter, press the button again, and wait ninety seconds for that 58 (3.2) or 314 (17.4) to appear on the screen. (Just once, wouldn’t you like to see a meter advertisement in which the reading on the screen wasn’t so damn perfect?) That meter lasted about a year. Then Lifescan came out with its first One Touch meter, and I jumped to get one. Imagine—no blotting, a round test area (covering a square box with a round drop of blood is not easy!), and only forty-five seconds from fingerstick to out-of-range number. The new meter didn’t do much for my control, but I did have an extra five minutes a day to spend doing things other than obtaining blood sugar values. My first blood glucose meter, aka “the brick.” Lifescan’s One Touch II meter was a major improvement over earlier models. My early insulin program also presented a challenge: NPH and regular, at breakfast and dinner. NPH was the long-acting insulin in vogue at that time; regular was the stuff used to cover meals. The regular insulin would peak in about two hours and last about six; the NPH would peak in six hours and last about twelve, although every day it seemed to have a mind of its own. Everyone at the endocrinologist’s office kept telling me the same thing: “You can live a normal life as long as you take your insulin.” But that meant that I would have to eat certain things at certain times of day, exercise (with caution) at certain times of day, sleep only at certain times because of the need to take shots at specific times, and test my blood sugar at certain times. What could be more normal than that? Back in 1985, two shots a day was the norm. So was making your life conform to your insulin program. But things did improve over time. I was given a sliding scale for adjusting my regular insulin, which was a good thing because I started to sneak lots of extra “exchanges” into my meals and snacks. With all the exercise I did, I probably had as many lows as I had highs, so my glycosylated hemoglobin (precursor to the A1c) looked pretty decent. However, the low blood sugars were becoming more frequent and more severe, especially during the night. When I returned to college in the fall, my new endocrinologist in St. Louis suggested that I move my dinnertime NPH to bedtime. Although that helped cut down on the nighttime lows, I started having more lows before lunch. Oy vey. My One Touch meter got a lot of use through college. Before dinner my friends would gather to wager on my blood sugar level. Everyone threw a dollar on the table, with the closest guess taking the loot. Some of them became pretty adept at the whole diabetes thing: They would ask questions like, “What did you eat for lunch?” and “Did you work out this afternoon?” Talk about getting by with a little help from my friends! Stuff like that kept me from getting down about my diabetes. Frequent high and low blood sugars plagued me throughout college. Anyone with diabetes knows how those blood sugar swings make you feel: fatigued and frustrated. In addition to the support of my friends, exercise was a key to helping me keep my balance. I had always been into sports, but after being diagnosed with diabetes my passion for staying in shape soared to a whole new level. Every day I managed to find time for some form of exercise. If no one was available to play basketball or racquetball, I would go to the gym to lift weights, ride my bike around the park, or jump rope in the dormitory lounge to the beat of Motown music. Exercising made me feel strong, fit, and in control of my own health despite having diabetes. Unfortunately, low blood sugar often followed the emotional high I got from exercise. A month after starting my first post-college job, I showed up for work in a complete daze. Some days I couldn’t even remember getting dressed or driving to work. It was a miracle that I never crashed, buck naked, into a tree. To make matters worse, I was no longer experiencing symptoms letting me know that a low blood sugar was coming. Gone were the good old days of shakes and cold sweats. Now mental confusion was the first noticeable sign that my blood sugar was dropping, and sometimes it was too late for me to handle it on my own. Thank God for my wife, Debbie, whom I met at college. She’s very good at knowing when to step in and when to let me do my own thing. I knew I would marry her after our first Valentine’s Day together. She learned a few things about diabetes and went out of her way to prepare a huge heart-shaped box filled with popcorn and pistachios. You know what they say: the way to a man’s heart is through his pancreas. Debbie and I left St. Louis and moved to Chicago after we both graduated. While in Chicago I met with a few more endocrinologists and other specialists for my diabetes. By that time, I was growing more and more frustrated with the constant swings between highs and lows. Nobody had any answers—just the same old rhetoric: “This is what your insulin is doing. You just need to adjust to it.” Then I had the most severe low blood sugar of my life. It came in the middle of the night after playing basketball earlier in the evening. Debbie told me that I was pale and completely unresponsive, and my limbs were jerking uncontrollably. She called for paramedics, and according to the reports, I fought them off pretty well while they were trying to put an IV into my arm. When I finally regained consciousness, Debbie was standing next to me with an exhausted, worried look on her face. I looked to the side and saw tubes coming out of my arm. I also saw blood. My blood. On the pillow, on the sheets, on the floor—everywhere. That experience really shook me up. Then I met an exercise physiologist who worked part-time as a consultant at a nearby diabetes clinic. He had diabetes himself and gave me some suggestions about eating extra food at bedtime and self-adjusting my long-acting insulin to prevent the nighttime lows after exercise. Why had nobody ever taught me these types of tricks? That exercise physiologist opened my eyes to more than just how to adjust my insulin doses. He set me on an entirely new career path. I liked his approach so much that I decided to become an exercise physiologist myself and focus on helping others with diabetes. So what if there were no full-time jobs for exercise physiologists at diabetes centers? I loved to exercise. I had diabetes. And I was on a mission to help others who were as frustrated as I was. So I went back to school, earned my master’s degree in exercise physiology, and landed a gig with the Joslin Diabetes Center in Philadelphia. Being a New York/New Jersey native, I felt Philadelphia seemed close enough to home—and it had its own NBA, NFL, and MLB franchises (I don’t think I could live in a city that didn’t have those). So we packed up the car and moved to Philly, where I became the Joslin Center’s full-time exercise guru. I have to admit: my office was pretty cool. It had weights, treadmills, bikes, video equipment, and a great view of the sports complex in south Philly. The only thing better than my office was the clinical team that worked around me. The doctors, nurses, dietitians, and psychologists were heavily into

Part 3

the concept of flexible insulin dosing and self-adjustment. I cross-trained with them at every opportunity and absorbed as much as I could about the many facets and nuances of diabetes care. Perhaps the greatest breakthrough in my own self-care was my decision in 1994 to try an insulin pump. Nobody at our diabetes center had used one, but our patients expressed a mounting interest in pumps. So I was the designated guinea pig. I’ll never forget how nervous I was the day I was trained on how to use that little gray box. There were about twenty doctors and nurses watching my every move. My first infusion set, the apparatus that delivered the insulin from the pump into my body, was a steel needle (the needle stayed in all the time). Soon, a flexible plastic infusion set became available, followed by a set that could be disconnected and reconnected easily. Before that, you had to stay connected to the pump all the time—during showers, sports, sex, and so on. The pump was very simple compared to today’s models. Nevertheless, just having the ability to adjust basal insulin levels and fine-tune mealtime doses really helped to stabilize my blood sugar levels. For the first time in almost ten years I could sleep past 8 a.m. without having my blood sugar skyrocket. I could delay my lunch without crashing. And best of all, I could work out to my heart’s content without going low in the middle of the night. In fact, I haven’t had a single severe low blood sugar episode since starting on the pump twenty-five years ago. My first insulin pump, the MiniMed 506. The very first continuous glucose monitor (aka “the black box”), circa 2003. With pump therapy came a whole new approach to dietary management: carb counting. By counting the grams of carbohydrates in my meals and snacks, I could eat pretty much whatever I chose as long as I covered it with the correct dose of insulin. The introduction of rapid-acting insulin analogs (lispro, then aspart, then glulisine) in the late 1990s and early 2000s also had a positive impact on my diabetes management. Unlike regular insulin, which takes thirty minutes to start working, two to three hours to peak, and five to six hours to fade, the rapid-acting analogs peak in about an hour and only last three to four hours. They do a much better job of covering the rapid blood sugar rise that takes place after meals. Of course, several other important developments came along, such as blood glucose meters that take less than half a microliter of blood and produce very accurate readings in five seconds, adjustable lancing pens with lancets that are micro-thin and virtually painless, at-home kits for testing ketones and A1c, and insulin pumps that can practically do your taxes. I began using a continuous glucose monitor (CGM) back in 2003, when the receiver was connected to your body by way of a cable and the information was kept secret until you removed the sensor (a nasty wire that stayed in your body for three days) and downloaded the device to a computer. Over time, the accuracy of CGMs has improved to the point that they can replace fingersticks; calibration has become optional or minimal; data transmits wirelessly to various pumps, phones, and handheld devices; information displays in real time and is shareable with loved ones; and a variety of customizable alerts can be used to guard against high and low glucose levels. Personally, I’ve found CGMs to be the best thing since sliced sourdough bread (you’ll learn about the magical powers of sourdough bread in Chapter 9). I love the fact that I rarely have to prick my finger, and the alerts have saved me from many highs and lows. Perhaps the best thing about them is that they provide context to glucose values. Knowing that you’re 100 (5.5) is one thing; knowing that you’re 100 (5.5) and dropping or rising is another entirely. I was officially sold on CGMs when I completed my first ten-mile run, the Broad Street Run in Philadelphia. I ran the entire course with my CGM receiver held tightly in my fist, glancing at it as I approached each rest stop to see if I needed to grab water or something with sugar in it. My control was immaculate, and I finished the race without having to stop once. Several years ago I added another injectable medication to my treatment program: pramlintide (Symlin). This hormone, produced by the beta cells of the pancreas (and lacking in those of us with type 1 diabetes) helps to slow down digestion so that blood sugars don’t spike right after eating. The combination of rapid-acting insulin and Symlin worked wonders. Gone were the 300-(17)-plus blood sugars right after eating; instead, the readings stayed remarkably stable between meals. Unfortunately, Symlin had its share of drawbacks for me, including some pretty intense nausea every morning right around 11 a.m. So I switched over to an injectable GLP-1 receptor agonist (don’t sweat it—these medications will all be explained in detail in Chapter 3), which provides modest improvements in after-meal control without all the side effects. More importantly, it produces around-the-clock appetite suppression. Without it, right now I’d either be too busy snacking or too distracted by hunger to finish this story. I’ve also dabbled with a few oral medications intended for type 2s, such as metformin and SGLT-2 inhibitors. The latest innovation that has me dancing in the streets is an off-the-grid technological advancement called Loop. Loop is an app that takes an old insulin pump, mixes in CGM data, and applies an algorithm that automates several aspects of insulin delivery. Commonly referred to as a hybrid closed-loop (HCL) system, Loop has given me the best glucose control I’ve experienced in over thirty years. Granted, there are other HCLs on the market—systems developed by major pump companies that have been tested and deemed safe by government experts—and chances are by the time you read this, there will be newer and even better systems available. But at this point, none is as customizable or downright effective as Loop. You’ll read more about Loop and other HCLs in Chapter 4. But technology aside, the thing that has made the greatest difference in my ability to control my glucose levels is learning how to match my insulin to my needs. No more molding my life to fit my insulin program. No more taking fixed doses and hoping for the best. Now I shape the insulin to fit my lifestyle. And that’s what I try to teach my patients to do—to think like a pancreas! As proud as I am of what we have accomplished in diabetes care and treatment, I can’t help but recall how proud my original endocrinologist was with the state of things back in 1985. Heck, I was pretty proud of the state of things back in 2010 when the second edition of this book came out. But ten years from now, I’ll probably look back to today and think, “Did we really do all that just to manage diabetes? That was totally medieval!” Me and my Loop app, 2019 Research is progressing at a rapid pace. We’re closing in on a cure from multiple angles: Artificial pancreas (full closed-loop) technologies. Islet cell transplants. Novel immunotherapies. Even “smart” insulin that only works when needed. The cure will arrive some day, but we can’t sit around waiting for it to happen. We have to take care of ourselves here and now, because our long-term health and short-term quality of life depend on it. So support research efforts wherever and whenever possible, but think like a pancreas while you’re at it. And maybe, with a little luck, I won’t ever have to work on a fourth edition. CHAPTER HIGHLIGHTS • I, like you, think diabetes is a royal pain. • My diagnosis took place in 1985 in Sugarland, Texas. God’s honest truth. • Diabetes self-management has evolved considerably over the past several decades. • Support diabetes research, but don’t forget to take care of your diabetes today.TWO “Glucose. Control, Y’all. What Is It Good For?*” (*sung to the tune of “War,” by Edwin Starr, 1970) Picture this. You show up for your regularly scheduled appointment with your doctor, credit card in hand, ready to pay for your copay or deductible or whatever. “Hold on,” says the receptionist with a cheerful smile. “That won’t be necessary. Here you go.” She hands you an envelope filled with cash. “This is for all the diabetes management work you’ve put in since your last visit.” That’s when the alarm clock goes off. Dream over. Managing diabetes takes serious work, and at times it may seem like there’s no real point. Every day involves a series of repetitive tasks, decisions, costs, and time we could apply toward other things. So why bother? Why make all the sacrifices? You could do just the bare minimum to keep yourself alive, but that would mean missing out on some major benefits. You could do just the bare minimum to keep yourself alive, but that would mean missing out on some major benefits. What’s in It for Me Now? We’ll get to the long-term benefits of proper diabetes management a bit later on. What motivates most people is immediate gratification. Not next year. Not tomorrow. Right now. Here is just a partial list of ways you can be rewarded immediately for managing your diabetes. Immediate Benefits of Diabetes Control Increased Energy More Restful Sleep Improved Physical Performance Appetite Reduction Brain Power Stable Moods and Emotions Fewer Illnesses Faster Healing Softer Skin, Healthier Gums Personal Safety Predictable Periods Cash in Your Pocket Increased Energy Raise your hand if you like being tired all the time. Okay, raise your hand if you’re too tired to raise your hand. Elevated blood glucose reduces energy levels. High glucose is a sign that you may not be getting enough fuel into your body’s cells to burn for energy. The fuel is there—it’s just stuck in the bloodstream, kind of like gasoline trucks that drive around aimlessly instead of unloading at local gas stations. This shortage of fuel inside the body’s cells causes sleepiness and sluggishness. Even if the glucose is only elevated temporarily, the lack of energy will be noticeable. As soon as the glucose level returns to normal, energy levels usually improve. More Restful Sleep We all know how important a good night’s sleep is for feeling good and being productive the next day. Sleep is necessary for allowing the brain to clear out the clutter from the previous day and prepare for new information and adventures. Getting sufficient sleep is also linked to appetite control. Production of the hunger-controlling hormone leptin is diminished in people who are sleep-deprived. It may interest you to know that poor glucose control reduces the quality of sleep. If your glucose is high enough (typically above 180 mg/dl, or 10 mmol/l), you might wake up during the night to run to the bathroom. This is caused by urine diuresis. When glucose levels are elevated, the kidneys have a hard time keeping all that extra sugar in the bloodstream. Sugar spills over into the urine, and it drags a lot of water along with it. As the bladder fills, the brain becomes stimulated to the point that we can’t enter the deep, restful stages of sleep (this is why we wake up to pee instead of wetting the bed). Spending more time in your target range is associated with more time spent in deep and restful “slow-wave” sleep in children and adults. So, if the thought of a restful, uninterrupted night’s sleep appeals to you, manage your glucose levels! Improved Physical Performance Whether you’re an elite athlete or just hoping to make it up a flight of stairs without gasping for breath, glucose control has an immediate impact on your physical abilities. Elevated glucose can reduce your strength, flexibility, speed, and stamina. Keeping blood sugar near normal will result in improved strength, speed, flexibility, and stamina. Sugar is our muscles’ preferred fuel for making rapid bursts of movement. Limiting access to sugar is a detriment to one’s strength. Extra sugar in the bloodstream also leads to something called glycosylation (sticking of sugar) to connective tissues like tendons and ligaments, thus limiting their ability to stretch properly. Muscle stiffness, strains, and pulls are common in people with chronically elevated glucose levels. Excess sugar can block the connections between muscles and nerves, resulting in slower reaction times and blunted reflexes. Extra sugar in the bloodstream limits our red blood cells’ ability to deliver oxygen to our muscles. This can cause fatigue and limited cardiovascular and aerobic capacity. Dehydration and cramping are also common side effects of hyperglycemia (high blood sugar) as a result of urine diuresis. When glucose levels are near normal, your reaction times will be quicker, and you will recover from injuries more rapidly. Many of my patients have tracked their performance in a variety of sports and have consistently performed best when their glucose is in the 80–140 mg/dl range (4.5–8 mmol/l). One young man received his first MVP trophy in a hockey tournament after he managed for the first time to keep his blood sugar from going high or low throughout the matches. (We’ll discuss details regarding sports and exercise control later on.) Overall, you’re likely to see improved performance in all sorts of activities—from carrying groceries to playing soccer to lovemaking—when your glucose levels remain near normal. Appetite Reduction This might sound totally bass-ackwards, but high glucose can actually make us crave more food—especially carbohydrate-rich foods. Remember, the amount of sugar in the bloodstream is not what counts, but rather how much gets into our cells. And if not enough is getting into our cells, hunger will be increased. So controlling glucose levels is a good way to keep your appetite in check—important for anyone trying to lose weight, maintain their weight, or avoid excessive between-meal snacking. Brain Power High and low glucose limits our ability to foc

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us, recall information, perform complex tasks, and be creative. Research studies have repeatedly and consistently shown that as glucose levels go up, so do mental errors and the time it takes to perform basic tasks. Wide variations in glucose levels, such as postmeal spikes, have also been shown to hinder mental function. Likewise, if glucose levels are too low (typically below 55 mg/dl or 3 mmol/l), the entire nervous system lacks the fuel it needs to operate correctly. So if you want to perform as well as possible at work, in school, or in a friendly game of Fortnite, keep those glucose levels within range. Stable Moods and Emotions Besides intellectual performance, the brain is also responsible for maintaining our emotional balance. Like it or not, our moods often change along with our glucose levels. If you don’t believe me, ask those around you! (My wife didn’t take long to realize that.) High glucose levels can make you impatient, irritable, and generally negative. And low glucose can alter behavior in ways you never expected. People who are normally stoic and conservative can become chatterboxes. And people who are normally outgoing might curl up in a corner. Keeping your glucose levels in a healthy range can go a long way toward improving your mood and emotional stability. I’m not saying that you will become an instant socialite, but the way you interact with your family, friends, coworkers, classmates, and even complete strangers can have an impact on your happiness and success in life. Fewer Illnesses Bacteria and viruses love sugar. They gobble it up and use it to grow and make baby bacteria and baby viruses, which, by the way, love sugar too. When blood glucose levels are up, the amount of sugar in virtually all of our body’s tissues and fluids rises as well. This makes an ideal breeding ground for infection. Think of it as “aiding and abetting the enemy”—supplying extra nutrients to the bad guys. Everything from common colds to sinus infections to flu and urinary tract infections are more common when blood sugars are elevated. And once illnesses and infections set in, they are much harder to fight when the blood sugar is high. People with better blood sugar control spend significantly fewer days absent from work, sick in bed, and restricted from their usual activities. So if you want to keep from getting sick, take better care of your diabetes! Faster Healing Whether you’re recovering from major surgery, a minor scrape, or soreness from a hard workout, tight glucose control helps to facilitate the healing process. In addition to reducing the risk of infection, blood sugar management is essential for keeping the body’s natural defenses and repair mechanisms working properly. Softer Skin, Healthier Gums Two body parts immediately affected by changes in glucose levels are the skin and gums. Skin is influenced greatly by our level of hydration. When blood sugars are high, skin tends to become dry and cracked. Not only can this be uncomfortable and unsightly, but it also sets us up for potential infections since the skin is the first line of defense against harmful bacteria. Keeping glucose levels in control helps prevent dehydration and keep our skin soft and intact. Changes in sugar levels also immediately affect our gums. Bacteria that live below the gum line grow quickly when exposed to high sugar levels in the blood vessels that nourish the gums. These bacteria then produce plaque at an accelerated rate, contributing to bleeding gums and loose teeth (periodontal disease). Controlling your diabetes will help cut back on plaque buildup almost immediately. Personal Safety If you happen to drive a car, operate power equipment, play a sport, or just walk across the street from time to time, having out-of-control blood sugar can put you and those around you at risk. We have already discussed how high glucose can cause sleepiness and slow reaction times (a recipe for disaster when driving), but the opposite extreme—hypoglycemia (low blood sugar)—can be even more dangerous. Hypoglycemia can happen to anyone taking insulin, even if it’s just once daily. It can also occur in those who take diabetes medications that cause the pancreas to produce extra insulin (sulfonylureas and meglitinides). Below-normal glucose levels will almost always cause some degree of cognitive impairment. Decision making and judgment will be off. Coordination suffers, and trembling can occur. To keep yourself and those around you safe, you must manage your blood sugar properly. Predictable Periods Research has shown that women with near-normal HbA1c levels tend to have more consistent, regular menstrual cycles compared to women with an elevated A1c. And with predictability comes power. As you will learn later in this book, the ability to predict events that influence glucose levels, such as menstrual cycles, makes it easier to make effective adjustments. Cash in Your Pocket Health care is getting more expensive all the time. Even if you have good health insurance, the deductibles and copays associated with treating diabetes complications and routine illnesses can really add up. And don’t forget time lost on the job or in school when dealing with avoidable health problems. Sustained reductions in average blood sugar are associated with thousands of dollars in cost savings annually per person. What’s in It for Me Later? We’ve all heard the horror stories. “My aunt had diabetes. She ate everything she wanted, and now she’s on dialysis.” “Someone I work with went blind because of his diabetes.” If the thought of vital organs failing and body parts falling off bothers you, then good. Fear and anger can be powerful motivators. They are what keeps us from doing stupid things like picking fights with people twice our size or telling our bosses off every time they do something that annoys us. Use it as your “management fuel.” Let the fear and anger associated with long-term diabetic complications serve as a positive motivator. Long-Term Benefits of Blood Sugar Control healthy eyes healthy kidneys a strong heart adequate blood flow proper nerve function protective nerve sensation minimal pain healthy feet solid memory flexible joints good mental health successful pregnancies optimal growth Sugar is a good thing. It is an excellent source of energy, and let’s be honest: it tastes pretty good too. But too much of a good thing can cause problems. Glucose levels that are too high over a period of many years cause damage to virtually every major organ and system in the body. But there is good news. Major long-term research studies such as the Diabetes Control and Complications Trial (DCCT) and the United Kingdom Prospective Diabetes Study (UKPDS) have proven beyond a shadow of a doubt that tight glucose control does make a difference. Maintaining a hemoglobin A1c (HbA1c, or simply A1c) as close to normal as possible has been shown to greatly reduce the many long-term health risks associated with diabetes. Likewise, minimizing glucose variability (dramatic swings into high and low glucose ranges) has a stabilizing effect on blood vessels and the bodily tissues they nourish. Of course there are going to be some ups and downs when it comes to blood sugar levels; we’re not yet at the point at which perfection is possible. But over the long term, if you take good care of your diabetes and manage it reasonably well, you stand an excellent chance of avoiding long-term health problems. And who doesn’t want to enjoy all these benefits? Keen Eyesight In the back of the eye is a sensitive layer of cells called the retina. Like the film in a camera, the retina receives light from the outside world and transmits signals to the brain to produce vision. Many small blood vessels (capillaries) provide the cells of the retina with oxygen and nutrients. Elevated blood sugar levels make these capillaries very fragile. They can swell, leak, or close off. When areas of the retina fail to receive adequate oxygen and nutrients, new weak capillaries start to grow in and block light from reaching the retina. This is called diabetic retinopathy. Diabetes is the leading cause of blindness among adults age twenty to seventy-four. Diabetic retinopathy accounts for more than twenty thousand cases of blindness each year. Glaucoma, cataracts, and corneal disease are also more common in people with diabetes, and they contribute to the high rate of blindness. The good news is that tight blood sugar control reduces the risk of retinopathy. The DCCT trial showed a 30 percent reduction in the risk of developing retinopathy for every 1-point reduction in A1c (corresponding with approximately a 30 mg/dl or 1.7 mmol/l reduction in average blood glucose). And for those with existing retinopathy, tightening blood sugar control and reducing glucose variability slows the progression significantly. Fabulous Filters Visit any kidney dialysis center, and check the charts of the people who sit there for hours a day with tubes in their arms so that their blood can be siphoned out, pumped through machines, filtered, and pumped back in. Diabetic. Diabetic. Not Diabetic. Diabetic. Diabetic. You get the idea. Diabetes is the leading cause of kidney failure. More than fifty thousand Americans with diabetes begin treatment for end-stage renal disease each year. Elevated blood sugar does damage to the tiny blood vessels (capillaries) that form and nourish the filters within the kidneys. The good news is that tightening blood sugar control reduces the risk of kidney disease dramatically. As was the case with retinopathy, every 30 mg/dl (1.7 mmol/l) drop in average blood sugar leads to a 30 percent reduction in kidney disease risk. Heart Health Despite the long list of health problems diabetes can cause, heart disease is what ultimately kills the majority of people with diabetes. People with diabetes are two to four times more likely to develop heart disease and five times more likely to die from heart disease compared to people without diabetes. Why? Having excessive amounts of sugar in the bloodstream causes problems. Sugar is a sticky substance (think of the last time you ate cotton candy or spilled some juice). It makes fats and cholesterol stick to the walls of blood vessels, causing the formation of plaques. These plaques make the blood vessels thick and rigid—a condition known as atherosclerosis. When pieces of plaques break off, clots can develop, restricting blood flow to vital organs such as the heart. Sugar also sticks to proteins in the blood, causing them to act abnormally. This contributes to blood vessel problems as well. The good news is that improving blood sugar control reduces the risk of heart disease dramatically. Besides eliminating a great deal of the “cement” that clogs up blood vessels, it allows the proteins in the bloodstream to act normally. And don’t forget: the things we do to control blood sugar, such as exercising, eating healthier, and cutting back on stress, also reduce our risk for heart disease by lowering blood pressure and cholesterol levels. Sound Circulation Besides the heart, a number of other body parts require large amounts of oxygen and nutrients. The brain, for example. When blood vessels leading to the brain become clogged, the brain does not receive enough oxygen, and brain cells begin to die. This is called a stroke. The risk of stroke is two to four times higher among people with diabetes. The muscles in the legs also depend on significant blood flow, particularly during exercise. When blood vessels serving the leg muscles become clogged and oxygen delivery is limited, pain or cramping can occur when exercising, walking, or simply standing. This condition is called claudication. Blood vessel disease in the legs is twenty times more common in people with diabetes. Some degree of claudication occurs in 45 percent of people who have had diabetes for more than twenty years. Again, the good news is that tightening blood sugar control, along with all the other lifestyle improvements that come with managing diabetes, will improve circulation to vital body parts. All Systems Go Our nervous system serves as the “wiring” (for lack of a better phrase) for our bodies. More specifically, the autonomic portion of our nervous system controls behind-the-scenes functions like heart rate, digestion, temperature regulation, balance, and sexual function. Nerves are like any other living tissue in the body: they burn sugar for energy and require a blood supply for oxygen and nutrients. Elevated blood sugar levels seem to cause two problems for nerves: they interfere with the blood supply, and energy metabolism is altered such that the nerves swell and lose the waxy coating that normally provides insulation for the nerve fibers. Damage to the nerves that regulate basic body functions is called autonomic neuropathy. Population-based studies have shown that 60 to 70 percent of people with diabetes will develop some form of nerve damage in their lifetime. Nearly 50 percent of all men with diabetes develop impotency, mainly a result of the malfunction of the nerves that help produce an erection. Women with diabetes are more likely than nondiabetic women to suffer from vaginal dryness. Delayed digestion (gastroparesis) affects nearly 30 percent of people with diabetes. This condition can cause painful bloating, and the altered rate of digestion can make blood sugars even more difficult to control between meals. Postural hypotension (low blood pressure upon sitting or standing) is twice as common in people with diabetes. The good news is that blood sugar control is an effective means for preventing all forms of autonomic neuropathy. And here’s more good news for those who already have neuropathy: although it is not always reversible, the neuropathy may regress slightly or cease to progress further once blood sugar levels move toward normal. Freedom from Pain As mentioned above, 60 to 70 perce

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nt of all people with diabetes develop some form of nerve damage in their lifetime. Most develop a form called peripheral neuropathy—malfunction of the nerves in the extremities such as the feet and lower legs. In its early stages, peripheral neuropathy takes the form of tingling or numbness. But as it progresses and nerve inflammation develops, it can cause constant and sometimes severe pain. Although there are many conventional medical and alternative treatments for painful neuropathy, many people find little or no relief. The good news is that tight blood sugar control can help to minimize the pain, slow the progression of painful neuropathy, and prevent it from developing in the first place. Fit Feet Neuropathy, combined with poor circulation, can lead to foot infections and deformities. When you cannot feel a minor foot injury such as a bruise, burn, cut, or callous and continue to put pressure on that injured part, the injury worsens. Furthermore, if there is inadequate blood flow to the injured area to aid in the healing process, an infection can develop easily. As the infection spreads into the underlying tissue and bone, portions of the foot succumb to cell death—a condition known as gangrene. Sometimes the only way to keep gangrene from spreading is to amputate the infected body part. Foot deformities often develop because the nerves that coordinate complex movements in the feet fail to do their job. We may put pressure on inappropriate (or injured) spots, thus causing further damage that goes unnoticed because of a lack of pain sensation. Each year, more than eighty thousand people with diabetes require lower-limb amputations. Diabetes is the cause of more amputations than all other causes combined, and loss of protective nerve sensation is the most critical factor. Even more disturbing is the fact that most people with diabetes pass away within three years of a toe, foot, or limb amputation. The good news is that tight blood sugar control helps to preserve healthy nerve function and blood flow to the feet. Lowering blood sugar levels also reduces the risk for infection. That’s really good news for those looking to prevent foot problems as well as those recovering from existing foot ailments. A Sound Mind Having diabetes increases the risk of cognitive impairment. Duration of diabetes and poor glucose control are both associated with diminished brain function. Few health problems instill as much fear as Alzheimer’s disease, a progressive and fatal disease that affects brain cells, causing problems with memory, thinking, and behavior. Today, Alzheimer’s is the sixth-leading cause of death in the United States, affecting more than five million Americans. Currently, there is no cure for Alzheimer’s, although research has found ways to slow its progression. It was recently discovered that diabetes is a risk factor for Alzheimer’s. Damaged blood vessels in the brain are believed to play a major role. Uncontrolled diabetes, which contributes to blood vessel damage, greatly increases the risk of the disease. The good news is that tight blood sugar control can reduce the risk of Alzheimer’s to the same level as people without diabetes. Overall, chronic high blood sugar is also associated with slower processing speed and lower verbal intelligence. At the opposite extreme, severe and recurrent hypoglycemia is associated with learning and memory deficits in children with diabetes. Managing glucose levels at all ages can help maximize brain function. Flexible Joints Joint mobility problems, including frozen shoulder, trigger fingers, and clawed hands, affect approximately 20 percent of people with diabetes. At the root of joint mobility problems is high blood sugar. Excess sugar sticks to collagen, a protein found in bones, cartilage, and connective tissue throughout the body. When collagen becomes sugar-coated, it thickens and stiffens, forming adhesions between adjoining muscles. This keeps joints from moving smoothly through the full range of motion. In addition to limiting movement, it can also cause pain in the joint. The good news is that keeping blood sugar levels near normal reduces the risk of joint mobility problems. If you already have limited range of motion in your shoulders, hands, or fingers or any of your joints, lowering your blood sugar levels may help to improve your range of motion and limit the pain associated with stiff joints. A Positive Outlook Blood sugar levels have an effect on mental well-being. People with diabetes commonly feel down when blood sugar levels are up. Depression is three times more common in adults with diabetes than it is in the general population. The mechanism for this increased risk is not entirely understood. It could be related to the extra stress associated with living with a chronic illness. But because depression is often biochemical in nature, elevated sugar levels in the fluid surrounding the brain may also play a role. In addition, developing complications from diabetes can instill a feeling of helplessness, which is known to contribute to the onset of depression. The good news is that improving your blood sugar can, in essence, make you a happier person. Researchers at the Harvard Medical School and the Joslin Diabetes Center studied the effects of blood sugar control on mood and disposition. They found that people with lower blood sugar levels reported a higher overall quality of life. Significantly better ratings were given in the areas of physical, emotional, and general health, as well as vitality. Successful Pregnancy (or Two or Ten) Decades ago, women of child-bearing age who had diabetes were discouraged from trying to have children because of the complications it posed for both the mom (including eye and kidney problems and difficulties with blood pressure and blood sugar control) and the baby (including developmental defects and premature growth). Today people with diabetes can have successful pregnancies and healthy babies. In fact, people who control their diabetes tightly throughout pregnancy face the same risks for themselves as well as their baby as those who do not have diabetes. Optimal Growth Height has its advantages in athletics, in some social settings, and definitely when trying to watch a parade. During one’s growth years, glucose control has a significant influence on growth. Poor glycemic control delays pubertal development and reduces one’s final height. Muscles and bones elongate the most when glucose levels are well-controlled. Optimizing glucose control during childhood and adolescence allows each person to reach their maximum growth potential. So that’s pretty much the situation. Who would have thought that blood sugar levels affect almost every aspect of our physical, mental, and emotional well-being? Improving your blood sugar control will enable you to feel and perform better today as well as enjoy a longer, healthier life. If you need a bit more motivation, there are countless examples of people with diabetes who have achieved tremendous success in life: • professional athletes such as Jay Cutler, Catfish Hunter, Bobby Clarke, Chris Dudley, Michelle McGann, Kris Freeman, Gary Hall Jr., Tony Conigliaro, Joe Frazier, Ryan Reed, Charlie Kimball, Ron Santo, and Cathy Freeman • performers and entertainers such as Mary Tyler Moore, Nick Jonas, David Crosby, Bret Michaels, Zippora Karz, and the late Ella Fitzgerald • political leaders such as Theresa May, Sonia Sotomayor, and Menachem Begin • other celebrities such as Nicole Johnson (former Miss America), Kalilah Allen-Harris (former Miss Black USA), and Doug Burns (former Mr. Universe) Unfortunately, there are also people like my late father-in-law, a great man who succumbed to the complications of diabetes, and my wife’s grandmother, who lost her legs, her eyesight, and eventually her life to poor diabetes control. So here’s another “now” benefit of taking good care of yourself: peace of mind. There is something therapeutic about putting in a solid effort. Just knowing that you are doing your best can be a tremendous source of personal satisfaction. There will be a cure for diabetes some day. It may not come in five years (like my first endocrinologist proclaimed thirty years ago), but when the day finally arrives, let’s be in the best shape possible and not have any regrets. Now let’s get to work. CHAPTER HIGHLIGHTS • Managing diabetes takes work and sacrifice. There is no getting around that. • There are many immediate benefits from managing diabetes, including physical and intellectual performance, emotional stability, safety, energy, and a sense of well-being. • The long-term complications of diabetes can be devastating, affecting virtually every part and system of the body. • Tightening blood sugar control dramatically reduces the risk of developing long-term complications and slows the progression of existing complications.THREE Beyond the Basics If you wanna be in control, ya gotta get yourself in the know. —Janet Jackson, “The Knowledge” Before we dive headfirst into the intricacies of blood glucose regulation, let’s take a deep breath and get acquainted (or reacquainted) with some diabetes fundamentals. Even if you think you know all the basics, read through this section anyway. Our knowledge of diabetes is constantly expanding and changing, and if you don’t have a sound understanding of the basics, everything else is going to be more difficult than it has to be. Diabetes by Any Other Name Is Just as Sweet At the heart of our understanding of diabetes is the hormone insulin. Insulin’s job is to move nutrients—particularly glucose—out of the bloodstream and into the body’s cells, where they can be burned for energy. When not enough insulin is produced or the body’s cells cannot use the insulin properly, blood sugar levels rise above normal, and diabetes develops. If you ask an endocrinologist to describe the different forms of diabetes, you’d better have some snacks handy because you’re in for a long discussion. It’s not just type 1 and type 2 anymore; many other forms of diabetes have been designated: gestational diabetes, LADA (Latent Autoimmune Diabetes of Adulthood), MODY (Maturity Onset Diabetes of the Young), neonatal diabetes, and secondary diabetes. We’ll get to those in a little bit. In the vast majority of cases diabetes can be grouped into two major classes: the kind caused by loss of the ability to produce insulin and the kind caused by insulin resistance (the body’s inability to utilize insulin properly). Now here’s where it gets interesting: people who lose the ability to produce insulin can sometimes develop insulin resistance, and those who have insulin resistance sometimes lose the ability to produce insulin. Confused yet? Don’t worry. You’re not alone. Let’s see if we can sort it all out. All forms of diabetes involve blood sugar levels that are too high. This is called hyperglycemia. Hypoglycemia (low blood sugar) can also occur when insulin or insulin-enhancing medications (sulfonylureas or meglitinides) are used in treatment. All require careful ongoing management, and all can produce a wide range of health problems (complications). However, the similarities stop there. From a physiological standpoint, the various forms of diabetes and their modes of treatment vary like flavors of ice cream. First, let’s look at the vanilla—er, type 1 diabetes. Type 1 Diabetes (Vanilla) Type 1 diabetes involves damage to the pancreas, a slimy organ nestled below the liver. At the base of the pancreas is a cluster of cells called the islets of Langerhans, named after the person who discovered them who, interestingly, had no clue about what they did. Contained within the islets are alpha cells (which make the hormone glucagon), gamma cells (which make the hormone somatostatin), and beta cells. The beta cells constantly measure blood glucose levels and produce insulin, as needed, to keep blood sugar within a normal range. Beta cells also secrete amylin, a hormone that helps regulate the rate at which food digests. In type 1 diabetes the body’s own immune system destroys the beta cells. Normally, the immune system only attacks things that are not part of your own body, like viruses and bacteria. With an autoimmune disease such as diabetes, the immune system fails to recognize a part of your own body and attacks it, thinking that it doesn’t belong. In the case of type 1 diabetes, the beta cells are attacked and gradually destroyed over a period of months or years. When enough beta cells have been destroyed and insulin production reaches a critically low level, the blood sugar level goes up, and the body’s cells are deprived of the sugar they need for energy. In type 1 diabetes, the body’s own immune system destroys the insulin-producing beta cells within the pancreas. There are nearly 1.5 million people with type 1 diabetes in the United States, and several times that number worldwide. Tens of thousands are diagnosed with type 1 diabetes every year. Type 1 diabetes may be diagnosed during childhood and adolescence, but half of all diagnoses are made in young and middle-age adults (this is why we no longer use the term “juvenile diabetes”). Most people with type 1 diabetes were born with a faulty immune system, prone to attacking things it shouldn’t. We now have the ability to test for autoimmune markers—antibodies that increase the risk of a person developing diabetes at some point in their lifetime. However, even in people who have multiple markers, it is impossible to say with certainty when or if diabetes will develop. We simply don’t understand enough about what triggers the immune system to begin attacking the beta cells of the pancreas. Viruses, major stress, environmental toxins, exposure to certain foods at a young age, and genetic tendencies have been proposed as potential triggers. At the time of diagnosis, a person with type 1 diabetes will likely have a very high blood sugar level

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and elevated ketones. Ketones are acids that form from the breakdown of large amounts of fat by cells that are starving for glucose. Blood sugar levels above 180 mg/dl (10 mmol/l) tend to cause excessive urination, as the kidneys pass some of the sugar from the blood into the urine. In essence, high blood sugar causes you to urinate away many of the calories you consume. Consequently, you can lose weight rapidly. Frequent urination also makes you very thirsty. And because you are unable to get sugar into your cells without insulin, your energy level will be quite low, and you will be constantly hungry. Nowadays, physical symptoms are not enough to make a true diagnosis of type 1 diabetes. It is usually also necessary to test for the presence of the autoimmune markers mentioned previously. These include GAD antibodies, insulin antibodies, and islet antibodies. Once type 1 diabetes is diagnosed, insulin treatment begins immediately. Initial treatment with insulin injections can provide a rest period for any beta cells that the immune system has yet to destroy. These remaining cells may be able to produce enough insulin to keep blood sugar levels relatively stable for a period of weeks, months, or even years. We refer to this as the “honeymoon phase” (or, more appropriately, “the calm before the storm”). Eventually, however, beta cell function ceases almost completely, and insulin requirements go up and stay up. The length of the honeymoon phase depends on a number of variables, but research has shown that early diagnosis (before most beta cells have been destroyed) and treatment leads to a prolonged honeymoon, as does a pattern of regular exercise. Without insulin, a person with type 1 diabetes will become severely ketotic (have high levels of acids in the blood) and dehydrated, go into a coma, and die. This is the reason type 1 diabetes is sometimes referred to as “insulin-dependent” diabetes: you depend on insulin to stay alive. However, it is possible to have type 1 diabetes and also become insulin resistant, which, as you will see below, is the underlying cause of type 2 diabetes. Those with type 1 diabetes who are insulin resistant must take insulin and incorporate appropriate lifestyle behaviors to achieve successful management. Type 2 Diabetes (Chocolate) Approximately 90 percent of people with diabetes have type 2 diabetes. Type 2 is very different from type 1 in that there is no autoimmune attack on the beta cells of the pancreas, and insulin production continues. In fact, in the early stages of type 2 diabetes, the pancreas may actually produce more insulin than usual. There are typically three stages to type 2 diabetes: insulin resistance, followed by failure of the pancreas to meet the increased insulin need, followed by a reduction in pancreatic function. Let’s look at these stages one at a time. Stage 1: The Resistance In order to do its job of taking sugar out of the bloodstream and packing it into the body’s cells, insulin attaches to a receptor on the outer surface of the cell. This is similar to the way a key enters a lock in order to open a door. Once insulin attaches to the receptor, a “door” opens, and sugar molecules can enter the cell. So for insulin to work, there have to be sufficient receptors on the cell surface, and the insulin must find and properly fit into the receptors. Insulin resistance occurs when there are not enough receptors or the insulin has a hard time finding or fitting into them. What causes insulin resistance? Typically, it is a combination of genetics (heredity) and lifestyle (the way we live). Having blood relatives (parents, siblings) with type 2 diabetes greatly increases the risk. Certain ethnic groups, including Native Americans and people of African, Hispanic, Asian, and Pacific Island descent, are also at high risk. The aging process plays a role as well. The older we get, the more insulin resistant we tend to become. People who have polycystic ovary syndrome (PCOS) often become insulin resistant as a result of the overproduction of hormones that oppose insulin’s action. Likewise, hormones produced during pregnancy oppose insulin’s action and can lead to gestational diabetes. A lack of physical activity can cause insulin resistance, as can stress. That’s because we tend to produce insulin-resistance-inducing hormones during periods of illness, surgery, excitement, or emotional turmoil. Steroid medications such as prednisone and cortisone also cause insulin resistance. But the most widespread reason people become insulin resistant is weight gain. Too much body fat, particularly around the middle, limits insulin’s ability to function properly. In fact, gaining as little as ten pounds over a fifteen-year period can cause insulin resistance to double. The most common reason for people to become insulin resistant is weight gain, specifically too much fat around the middle. Obese individuals are seven times more likely to develop diabetes than those who maintain a healthy weight. And the problem is not restricted to adults: more than ever before, overweight children and teenagers are developing insulin resistance and type 2 diabetes. Stage 2: The Production Shortfall Insulin resistance affects a significant proportion of people worldwide. Why, then, do only a fraction of those with insulin resistance develop type 2 diabetes? The answer lies in the resiliency of the pancreas. When insulin resistance occurs, the pancreas needs to produce more insulin to keep blood sugar levels in a normal range. This is sort of like a business where one person isn’t doing their job—everyone else has to pick up the slack. In most cases the pancreas can keep up with the added workload. But not everyone’s pancreas has this capacity. If the insulin resistance becomes too much for the pancreas to overcome, blood sugar levels rise above normal. In other words, for type 2 diabetes to develop, you must have both insulin resistance and a pancreas that can’t keep up with the added workload. To understand this concept better, imagine that you are an air conditioner trying to keep your house cool on a hot summer day. If you’re one of those high-powered central air conditioning units that can crank out a bazillion BTUs, you’ll have no problem overcoming the warm outdoor weather and keeping the inside of the house cool. But if you’re one of those rusty window units, you’re probably not going to be able to blow enough cold air to keep the entire house cool on really hot, humid days. In this example, the heat and humidity are like insulin resistance: they present the challenge. The air conditioner is like the pancreas: an efficient system can overcome the challenge, but a lesser system will be unable to meet the challenge. You need both very hot and humid weather and a weak air conditioner to create a truly oppressive situation—backs of legs sticking to the furniture and all that. At this early phase of type 2 diabetes, you can often get blood sugars back into a normal range through exercise (which reduces insulin resistance) and a diet designed to ease the flow of sugar into the bloodstream. Sometimes you can use oral medications or noninsulin injectable medications to help the pancreas (or insulin) work more effectively, and this may be all it takes. But it doesn’t usually stay that way forever. Stage 3: Function Reduction Type 2 diabetes is a progressive illness. That is not a good thing. There is nothing hip, cool, or modern about it. It is progressive because it becomes harder to control as time goes on. After you have diabetes for a number of years, your insulin resistance tends to grow worse, and your pancreas struggles to keep up with the huge demand for insulin. Then a new problem sets in: just like an air conditioner that is forced to run full blast every minute of every day, the pancreas starts to break down. (Heck, if you were asked to work day after day without any breaks and no end in sight, you would break down too—or at least find a new job!) Two things cause the breakdown of the pancreas: overwork and a condition known as glucose toxicity. We can all understand the overwork part: force those poor little beta cells into relentless slave labor, and many of them are going to die off. Glucose toxicity occurs when high sugar levels do direct damage to the pancreas, further reducing its ability to produce insulin. This is why the treatment for type 2 diabetes needs to become more aggressive over time, and it explains why millions of people with type 2 diabetes take insulin. Does this mean that all these people with type 2 who take insulin now have type 1? No, it does not. Remember, the type of diabetes is defined by what caused it, not how it is treated. Type 1 diabetes occurs when the body’s own immune system destroys the pancreas cells that make insulin. Type 2 is caused by insulin resistance, followed by insufficient insulin production, which is followed by a gradual breakdown of the pancreas. The type of diabetes you have is defined by what caused it, not how it is treated. If you don’t currently take insulin for your type 2 diabetes, but your health care professional has encouraged you to do so, there is plenty to get excited about. Insulin is the most potent and effective treatment for elevated blood sugar. It is a more natural substance than pills (today’s insulin formulations are chemically similar to the insulin the body produces) and lacks many of the side effects associated with oral medications and noninsulin injectable medications. The fact is, oral diabetes medications and noninsulin injectables have their limits. Unlike insulin, which lowers blood sugar directly, all of the other medical treatments for diabetes work indirectly. This means that they only work when the pancreas has the capability to produce sufficient amounts of insulin and the body’s cells are reasonably sensitive to the insulin. Once the pancreas is unable to keep up with the workload, no amount of other medication is going to solve the problem. Taking insulin is easier and safer than ever before. The latest insulin formulations are much less likely to cause hypoglycemia (low blood sugar) than older types of insulin. Disposable insulin syringes have short, super-thin needles that you can barely feel. Insulin can also be administered with prefilled pens: simply dial up your dose and inject. There is even an inhaler that lets you take insulin with no injection at all. And best of all: when you begin using insulin and experience an immediate reduction in your blood sugar levels, you’re probably going to feel better than you have in years! The Other Diabeteses Okay, I made that word up. Remember, diabetes comes in more flavors than just vanilla (type 1) and chocolate (type 2). There are a host of exotic flavors to choose from. Secondary diabetes (cookies and cream) is a form of insulin-dependent diabetes caused by something other than the body’s own immune system destroying the beta cells of the pancreas. Potential causes include trauma (accidents and injuries), heavy doses of steroids, pancreatitis, alcoholism, cancer treatment, and infection. Regardless of the cause, the treatment is the same as with type 1: insulin, insulin, and more insulin. Gestational diabetes (strawberry) is a temporary form of diabetes caused by insulin resistance that develops during pregnancy. Pregnant people with gestational diabetes usually require insulin to control their blood sugar levels. This is because most oral medications pass through the placenta and may affect the baby’s development. After delivery, when the mother’s production of insulin-opposing hormones drops off and weight comes down, most new moms stop requiring insulin injections. However, their risk for developing type 2 diabetes later in life is markedly increased. MODY (marshmallow) stands for maturity-onset diabetes of the young. Unlike type 2 diabetes, which is typically caused by insulin resistance, MODY involves a single genetic defect that limits the pancreas’s ability to secrete sufficient amounts of insulin. It actually belongs to a group of conditions known as monogenic diabetes. MODY is not associated with being overweight. It is frequently diagnosed during early puberty, perhaps because of the increased demand for insulin at this age. Depending on how defective the beta cells become, oral medications or insulin may be required to treat MODY. Neonatal diabetes (butter pecan) is a rare form of diabetes that occurs in the first six months of life. Similar to MODY, neonatal diabetes is monogenic: it involves a single genetic mutation that limits the beta cells’ ability to produce insulin. In some cases, neonatal diabetes disappears during infancy but then reappears later in life. In other cases, diabetes persists and remains permanent. Insulin is almost always required to treat neonatal diabetes and promote healthy growth and development. LADA (mint chocolate chip) refers to latent autoimmune diabetes of adulthood. Think of it as an incomplete, slowly developing form of type 1 diabetes that is compounded by mild to moderate insulin resistance. Some people call it “type 1½” because it shares characteristics with both type 1 and type 2 diabetes. With LADA, the immune system attacks the beta cells of the pancreas, but the attack is incomplete. Many beta cells survive and continue to secrete insulin, sometimes for years. Many people with LADA can manage their blood sugar with oral medications or low doses of insulin for an extended period of time, but eventually true insulin dependence develops and treatment requires intensive insulin therapy. Unlike the gazillions of books that explore the many treatment options for type 2 diabetes, this book focuses on the use of insulin, with or without the addition of other diabetes medications. The subject matter applies to everyone with type 1 diabetes, secondary diabetes, and neonatal diabetes, those in the later stages of LADA, as well as mil

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lions who have type 2 diabetes, gestational diabetes, or MODY and require insulin. * The Gold Standard: Nondiabetes To “think like a pancreas” is to come as close as possible to matching a normal, nondiabetic state. Whether you have diabetes or not, blood sugar comes from two sources: internal and external. Internally, sugar is stored and secreted into the bloodstream by the liver and, to a much lesser extent, the muscles. External sources of sugar are the foods we eat—mainly carbohydrates but also protein, particularly for those following low-carbohydrate diets. Whether the sugars come from food or our liver, our bodies convert them into a specific type of sugar called glucose. Glucose is the preferred energy source for most cells of the body. Some cells, such as brain cells and nerve cells, will only burn glucose for energy. Muscles burn mostly glucose during the early stages of exercise. Thus, having a steady supply of glucose is necessary for proper body function and survival. Glucose happens to be a fairly large molecule. It can’t break through the membranes of our body’s cells without a little help. Insulin’s job is to take glucose out of the bloodstream and pack it into the body’s cells so that it can be burned for energy. Insulin has another important job: blocking the release of sugar from the liver and muscles. Instead, insulin packs sugar into the liver and muscles so that it can be stored for use at another time. When a person without diabetes has not eaten for a while, their blood sugar level can begin to drop. This can occur between meals, during sleep, and during exercise. When the blood sugar begins to drop, the pancreas decreases its production of insulin and increases its production of another hormone, glucagon. This reduces the amount of sugar being taken out of the bloodstream and stimulates the liver to release some of its stored-up sugar. As a result, blood sugar levels remain stable. In a way, the pancreas acts like a thermostat that keeps your house comfy-cozy. When the temperature goes up, the thermostat kicks on the fan and air conditioner. When the temperature goes down, the thermostat kicks on the heat. Either way, the temperature stays within a comfortable range. In your body, when the blood sugar level begins to rise, the pancreas secretes extra insulin, which brings the blood sugar level down. When the blood sugar starts to drop, the pancreas eases back on insulin production and begins producing glucagon, which brings the blood sugar back up. This system helps keep the blood sugar within a range that is comfy-cozy for your body—approximately 60–110 mg/dl (3.3–6.1 mmol/l). A better title for this book would probably be Think Like Islet Cells, because it is this select group of pancreatic cells that acts like our blood sugar thermostat. (But who would want to read a book called Think Like Islet Cells? Think Like a Pancreas sounds much cooler!) Truth be known, beta cells do more than just measure glucose levels and secrete insulin. They also secrete a second hormone called amylin. Amylin’s job is to work with insulin, particularly at mealtimes, to keep blood sugar from spiking too high right after eating. We will discuss amylin in more detail later. Let’s turn now to the factors that affect our blood sugar levels on a daily basis. Blood Sugar Balancing: The Major Players There are a few major factors that affect our blood sugar on a regular basis (see Table 3-2) and a number of minor factors that pop up on special occasions (see Table 3-5 later in this chapter). Learning to keep them all in balance is what ultimately maintains the blood sugar within a healthy range. Let’s start with the major factors. * Factor 1: Insulin Insulin lowers blood sugar, plain and simple. However, the action of insulin varies depending on its concentration, the rate at which it is absorbed into the bloodstream, and how sensitive the body is to it. Insulin is measured in units. A unit of insulin should lower the blood sugar the same amount no matter what kind of insulin you use. A unit of fast-acting insulin will lower your blood sugar the same as a unit of long-acting insulin; it just does so in a shorter period of time. An exception is when using any insulin that is not the standard U-100 concentration. U-100 means that there are 100 units of insulin in every cubic centimeter (cc) or milliliter of fluid. In some instances, concentrated insulin such as U-200 (200 units per cc), U-300 (300 units per cc), or U-500 (you get the idea) is used in people requiring very large doses so that they don’t have to take as large a volume when injecting. Some people choose to dilute their insulin to allow dosing in more precise increments with standard insulin syringes. For example, a child who is very sensitive to insulin may have their insulin diluted to U-10 by mixing 90 units of neutral diluent with 10 units of insulin. The resulting mixture would be 10 percent as potent as normal U-100 insulin. One unit (as measured on an insulin syringe) would actually be equivalent to one-tenth of a unit of U-100 insulin. A summary of insulin types is given in Table 3-3. Be aware that the precise action times can vary from person to person. And because insulin is injected (or infused, in the case of an insulin pump) into the fat below the skin, the exact onset, peak, and duration can vary from day to day or even meal to meal. Also note that Technosphere inhaled insulin (brand name Afrezza) acts differently because the insulin is inhaled and absorbed through the lungs rather than going through the fat layer below the skin. Premixed insulins, such as 75/25, 70/30, and 50/50, contain a combination of NPH (intermediate-acting insulin) and either regular or rapid-acting insulin. For example, Humalog Mix 75/25 contains 75 percent NPH and 25 percent Humalog. Novolin 70/30 contains 70 percent NPH and 30 percent regular insulin. The actions of the more modern insulin formulations (lispro, aspart/Fiasp, glulisine, glargine, degludec, and detemir) are not affected much by where on the body they are injected, but older-generation insulins (regular, NPH) can vary considerably depending on where they are injected. Afrezza inhaler and insulin cartridges Table 3-3. Insulin Action Profiles The action of NPH and regular insulin is more rapid in body parts that have greater blood flow. Injecting into the abdomen tends to produce the most rapid absorption, followed by the arms, then the legs, and finally the buttocks. When using these types of older-generation insulins, be consistent about your injection sites. For example, use the abdomen in the morning, thigh at dinner, and buttocks at bedtime. This will minimize the amount of variability in the insulin’s action from day to day. Injecting any insulin into a body part that will be exercising may accelerate the action of the insulin, particularly when the exercise is performed within an hour of the injection. This is due to enhanced blood flow in the area that is being exercised. For example, injecting insulin into the thigh and then going for a jog may cause the insulin to start working faster, peak earlier, and finish working sooner than usual. Injecting insulin into muscle will also accelerate its action. Rapid-acting insulin, which normally takes three to four hours to finish working, can do its full work in two hours or less when injected into muscle. This can cause a very rapid blood sugar drop, and it may produce hypoglycemia when given to cover a meal. Below are a few other tips to help ensure that your insulin works as expected. Rotate your sites: A condition known as lipodystrophy can affect insulin action. Repeated injections or infusions into the same small area of skin can cause the fat below the skin to either swell and harden (lipohypertrophy) or wear away (lipoatrophy). In either case, the absorption of insulin will be altered. For this reason, it is best to rotate your injection and infusion sites over a large area, and avoid repeating the same spots too often. If it helps, imagine that you have a monthly calendar printed on each of the body parts where you inject, and inject into the spot that corresponds with that date of the month. We will cover pump site rotation in greater detail later on. Store properly: Unopened insulin vials, pens, and cartridges should be stored in a refrigerator (but not frozen). This should keep your insulin fresh until the expiration date. Insulin may work fine after the expiration date, but you run the risk of losing some of the insulin’s potency. The butter compartment on the door might make an ideal home for your insulin. Once a vial, pen, or cartridge is opened (that is, the rubber stopper is punctured), it may be kept and used at room temperature for up to the length of time recommended by the manufacturer. This is generally ten days for inhaled insulin, one month for rapid-acting insulin, and six to eight weeks for long-acting insulin. Room-temperature insulin tends to form fewer bubbles in the syringe and is generally more comfortable to inject. Again, you may find that insulin works perfectly fine when used beyond a month, but there is always a chance that the insulin may lose some of its potency. If you choose to use insulin past its expiration date or long after taking it out of the refrigerator, monitor your glucose levels carefully, and switch to fresh insulin at the first signs of elevated blood sugar. Insulin can spoil easily when exposed to high temperatures. Your insulin should be kept out of direct sunlight and away from heating devices. When ordering insulin through the mail, request that it be shipped in a thermally insulated package along with a tag that changes color if the contents are exposed to unsafe temperatures. When traveling, keep your insulin with you, and do not leave it in a warm vehicle for more than a few minutes. Do not use insulin that has an unusual appearance. If it has crystals on the surface or residue at the bottom, is an unusual color, or does not mix uniformly, it should be discarded. Mix correctly: NPH insulin, or any premixed insulin that contains NPH, needs to be rolled between the palms several times to ensure an even, cloudy mixture. This applies to vials as well as pens. NPH may be combined in the same syringe with fast (regular, rapid-acting, or ultra rapid-acting) insulin. To ensure that your fast insulin is not contaminated during the mixing process, be sure to draw up the insulin in order from fastest to slowest. In other words, draw the clear (fast) insulin into your syringe before drawing in the cloudy (NPH) insulin. If a tiny amount of fast-acting insulin gets into the vial of NPH, it usually will not cause any harm. However, if NPH gets into the vial of fast-acting insulin, it may contaminate the entire vial. Glargine and detemir should never be mixed with another insulin in the same syringe. Spare the air: Whether you use syringes, pens, or a pump, eliminating large air bubbles is important. Very small (soda-sized) bubbles are not much of a concern, but larger bubbles can cause your insulin dose to be reduced significantly. Room-temperature insulin is less likely to form bubbles when filling a syringe. If air bubbles appear in your pen or syringe, you should inject them out through the needle (into the air) and then redraw your dose. Find the right depth: Because insulin is meant to be injected into the fatty layer below the skin, selecting a needle that is the proper length is important. A needle that goes too deep may accidentally inject into muscle. Not only does an intramuscular injection tend to sting, but any form of intermediate or long-acting (basal) insulin that is injected into muscle can act much too fast and cause severe hypoglycemia followed by hyperglycemia. Injections that are too shallow (barely breaking the skin surface) can hurt and may cause insulin to “pocket” under the skin, resulting in incomplete or delayed absorption and high blood sugar. Remarkably, skin thickness is similar in children and adults as well as in heavy people and lean people—just a couple of millimeters. It is safe and advisable to use injection needles that are four to six millimeters in length. If all you have are longer needles, try injecting at an angle in order to avoid accidental injection into muscle. For those who are extremely lean, it is reasonable to pinch up the skin when inserting the needle and injecting. And if using a pen, remember to keep the pen needle in for five to ten seconds after pressing the plunger to ensure complete insulin delivery. If leakage occurs after the injection (insulin appears on the skin surface after removing the needle), consider leaving the needle in the skin longer or using a longer needle and injecting at an angle. By the way, if the process of inserting the syringe, pen, or infusion set needle into your skin leaves you in a cold sweat, a number of injection aids are available. A list of such devices can be found in Chapter 10. Factor 2: Other Diabetes Medications Diabetes medications come in two forms: pills and injectables. Obviously, one of the injectables is insulin. But there are other injectables that can be used to help manage blood sugar levels; we’ll get to these later in this chapter. For now, let’s explore the various oral medications. Diabetes Pills 1. Pills that help you make more insulin (only for type 2s, never for type 1s) The original medications used to treat type 2 diabetes cause the pancreas to increase the production of insulin. This class of medications includes sulfonylureas (chlorpropamide, tolazamide, tolbutamide, glyburide, glipizide, and glimepiride) and meglitinides (repaglinide and nateglinide). Sulfonylureas work for twelve to twenty-four hours or more to lower blood sugar, whereas meglitinides work for only a few hours. Both sulfonylureas and meglitinides can cause hypoglycemia (low blood sugar) and weight gain. Cut to the chase: Sulfonylureas and meglitin

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ides are usually effective for lowering blood sugar levels in those who are in the very early stages of type 2 diabetes, before the pancreas has lost the ability to secrete sufficient amounts of insulin. However, by increasing the workload on the beta cells of the pancreas, these drugs may actually accelerate their breakdown. These drugs are of no practical use for people with type 1 diabetes or those with type 2 who produce little insulin on their own and require insulin injections. 2. Pills that reduce the liver’s production of glucose (mainly for type 2s, sometimes for type 1s) The liver (the one in our bodies, not the one in the butcher’s shop) is a major source of sugar that appears in the bloodstream. In most people with type 2 diabetes and many with type 1, the liver overproduces glucose, making blood sugars harder to control. Since being introduced in 1994, the biguanide drug metformin has become the most widely prescribed medication for diabetes and one of the most widely used drugs in the world. Metformin decreases the amount of sugar secreted by the liver into the bloodstream. Secondary benefits may include modest improvements in blood pressure and insulin sensitivity. Metformin is often used in combination with other diabetes drugs, including insulin, and is considered safe to use during pregnancy. However, people with advanced kidney disease should not use it, and those with liver problems must use it with extreme caution. Cut to the chase: Metformin is often a drug of first choice for those with type 2 diabetes, and it may be beneficial to those with type 1 who require unusually large doses of insulin. Because the liver is mainly responsible for causing blood sugar to rise overnight, metformin can be particularly helpful to those with elevated fasting glucose levels. 3. Insulin sensitizers (mostly for type 2s, rarely for type 1s) Thiazolidinediones (TZDs), including pioglitazone and rosiglitazone, are medications that increase the sensitivity of the body’s muscle and fat cells to insulin. TZDs may be used in combination with other diabetes medications, including insulin. There is a risk of liver problems and fluid retention when using TZDs, so people with liver disease, poor heart function, or a history of congestive heart failure should not use them. Pioglitazone use has been linked with a reduction in heart disease risk in people with type 2 diabetes. Cut to the chase: Those who are obese but otherwise healthy can certainly benefit from the insulin-sensitizing effects of TZDs. The risk of fluid retention has discouraged many health care providers from recommending them. And the fact remains that you can gain the same benefits TZDs offer simply by exercising and losing weight. 4. Digestion blockers (mostly for type 2s, rarely for type 1s) Before being absorbed into the bloodstream, carbohydrates must be broken down into simple sugar molecules by enzymes in the small intestine. One of the enzymes involved in breaking down carbohydrates is called alpha glucosidase. By inhibiting this enzyme, carbohydrates are not broken down as efficiently, and glucose absorption is delayed. When taken with meals, alpha-glucosidase inhibitors (acarbose and miglitol) can lower blood sugar levels after meals. However, because of the way they work, up to 75 percent of users experience abdominal pain, diarrhea, and gas. Cut to the chase: Acarbose and miglitol may provide some help for those who experience blood sugar spikes after carbohydrate-rich meals. And because they don’t cause hypoglycemia and may diminish between-meal appetite, they could aid those trying to lose weight. However, the side effects are more than most people are willing to endure. 5. Indirect “pancreas helper” (mostly for type 2s, rarely for type 1s) DPP-4 inhibitors (sitagliptin, saxagliptin, alogliptin, linagliptin) work by blocking an enzyme that breaks down a substance called GLP-1 (glucagon-like peptide 1). By increasing the amount of GLP-1 in circulation, DPP-4 inhibitors can do the following: • make it a little easier for the pancreas to release its stored-up insulin when blood sugars are elevated • decrease glucagon secretion by the pancreas • promote some growth and duplication of pancreatic beta cells • slightly slow the movement of food from the stomach into the intestines • decrease appetite subtly DPP-4 inhibitors can be used in combination with other diabetes medications, but those with poor kidney function must use them very carefully. Although they have been proven effective for improving blood sugar levels without causing hypoglycemia, they have not been shown to reduce weight. Cut to the chase: DPP-4 inhibitors offer multiple ways to improve glucose control with minimal side effects. They are the only oral diabetes medications that promote the growth and function of insulin-producing cells in the pancreas. However, the blood sugar–lowering effects are only modest. A more direct and robust way to increase GLP-1 levels will be presented in the injectables section below. 6. Pills that make you pee sugar away (mostly for type 2s, potentially for type 1s) Anyone who has experienced a very high blood sugar knows the feeling: The cloudy mind. The tiredness. The irrepressible urge to urinate. Blood sugar levels above approximately 180 mg/dl (10 mmol/l) result in the spillage of sugar into the urine, along with extra water, thus increasing urination. Now we have a medication that causes sugar to be excreted at just about any blood sugar level. SGLT-2 inhibitors (canagliflozin, dapagliflozin, empagliflozin, ertugliflozin) essentially “lower the dam” for glucose retention by the kidneys, causing the loss of dozens of grams of carbohydrates (and hundreds of calories) on a daily basis. SGLT-2 inhibitors are associated with significant reductions in blood sugar levels as well as some weight loss and cardiovascular benefits. Unfortunately, they are also associated with increased urination and potential for orthostatic hypotension (dizziness when standing up) and, when used by people with type 1 diabetes, ketoacidosis (a potentially deadly state of acidity in the body). SGLT-2 inhibitors do not cause hypoglycemia when used alone, but they can increase the risk of low blood sugar when used along with insulin, sulfonylureas, or meglitinides. Cut to the chase: SGLT-2 inhibitors use a novel and effective approach to lower glucose levels and promote weight loss in people with type 2 diabetes. They can do the same for type 1s, but they can also increase the risk of hypoglycemia. It is very important to maintain good hydration when using them, and people with type 1 diabetes must continue taking their insulin (albeit with dosage adjustments) and consume reasonable amounts of carbohydrates in order to prevent diabetic ketoacidosis (DKA). SGLT-2 inhibitors tend to be costly, and not all health plans cover them for people with type 1 diabetes. Injectable Noninsulin Treatments for Diabetes Until the year 2005, the only injectable treatment for diabetes was insulin. Now we have several injectable medications, with more on the way. 1. GLP-1 receptor agonists (mostly for type 2s, sometimes for type 1s) As mentioned earlier in our discussion of DPP-4 inhibitors, GLP-1 is a very important substance in the regulation of blood sugar levels. Whenever we eat food that contains carbohydrates (sugar or starch), some of the sugar comes in contact with the inner lining of the small intestine. When this happens, cells of the intestine secrete special chemical messengers. One of these chemical messengers, GLP-1, circulates throughout the body and affects several organs in important ways: (1) in people who can still produce their own insulin, it helps the pancreas to release a rapid burst of insulin; (2) it blocks the release of the blood sugar–raising hormone glucagon by the pancreas; (3) it acts on the stomach to slow the overall rate of digestion; and (4) it acts on the brain to decrease appetite. By itself, GLP-1 does not promote low blood sugar or weight gain. Insulin secretion increases only when blood sugars are high and decreases as blood sugars approach normal levels. Devices for injecting GLP-1 receptor agonists Unlike DPP-4 inhibitors, which increase the amount of GLP-1 indirectly (by blocking an enzyme that breaks down GLP-1), GLP-1 receptor agonists, for all practical purposes, are GLP-1, except that they last much longer in the body than naturally occurring GLP-1. GLP-1 receptor agonists are effective for reducing blood sugar (particularly after meals) and promoting weight loss. Currently, several versions of GLP-1 receptor agonists are available in pen form: exenatide (brand name Byetta) is taken twice daily; liraglutide (brand name Victoza) is taken once daily; and dulaglutide (brand name Trulicity), semaglutide (brand name Ozempic), and extended-release exenatide (brand name Bydureon) are taken once weekly. GLP-1 receptor agonists are intended mainly for people with type 2 diabetes. In fact, GLP-1s are often recommended before insulin in type 2 diabetes treatment. However, research has shown that type 1s can benefit as well, particularly those who struggle with postmeal blood sugar spikes and frequent hunger. Varying degrees of nausea are common during the first few weeks of usage, but this usually subsides over time. Those with gastrointestinal problems or kidney disease are usually not good candidates. Cut to the chase: Despite having to be taken by injection and the short-term nausea that many users experience, GLP-1 receptor agonists have the potential to offset many of the factors that contribute to elevated blood sugar in people with diabetes. And no other diabetes medication matches their ability to facilitate weight loss. 2. Pramlintide (for type 1s and type 2s who take mealtime insulin) Pens for injecting pramlintide (Symlin) As mentioned previously, amylin is a hormone that the beta cells of the pancreas normally secrete along with insulin. People with type 1 diabetes secrete little to no amylin. Those with type 2 usually secrete insufficient amounts. Classified as an incretin hormone because it affects the production of other hormones, amylin acts on the central nervous system to: • slow the emptying of the stomach’s contents into the small intestine • blunt the secretion of glucagon by the pancreas (ironically, people with type 1 diabetes secrete extra glucagon right after meals) • decrease appetite By slowing digestion, reducing food intake, and minimizing glucagon production at mealtimes, amylin minimizes the blood glucose rise that occurs after meals. Postmeal blood sugar can influence one’s energy level, intellect, emotions, and physical abilities (imagine how you feel after consuming a huge turkey/stuffing/sweet potato meal on Thanksgiving and then plopping down on a couch to watch football). There is also growing evidence that postmeal blood sugar spikes can raise the HbA1c and contribute to the development of long-term complications. Pramlintide (brand name Symlin), the medication equivalent of the amylin hormone, is taken by injection via prefilled pen in fixed doses before meals. Because of its acidity, pramlintide in its current form cannot be mixed with insulin, and its effects only last a few hours. Besides improving postmeal blood sugar control, pramlintide can also be a valuable weight-loss tool. Users of pramlintide lose an average of six and a half pounds (three kilograms) over the first six months of use, mainly through consuming smaller portions at meals and snacking less often. Pramlintide is intended for people who take insulin at mealtimes. Although not yet approved by the FDA for use by children, several studies have shown that pramlintide is safe and effective when adolescents use it in a supervised manner. The most common side effect with pramlintide is nausea, typically about half an hour after injection. This usually dissipates entirely after a few weeks as the body becomes reaccustomed to having the amylin hormone present. Use of pramlintide has also been associated with an increased risk of hypoglycemia. Because digestion of carbohydrates is delayed when pramlintide is taken, insulin doses may need to be reduced and/or delayed. Cut to the chase: Use of pramlintide adds work and complexity to diabetes care. It must be taken multiple times daily and requires careful adjustment to one’s usual insulin doses. The nausea, particularly early on, can be a major detriment. However, if controlling after-meal blood sugar levels is an ongoing challenge, nothing is more powerful at limiting the postmeal spikes than pramlintide. Likewise, if you have a tendency to “graze” because of constant hunger, pramlintide can make it a lot easier to avoid all the extra snacking. Factor 3: Food Whoever said that there is no such thing as a free lunch really knew what they were talking about. Almost everything we eat or drink can affect blood sugar levels. The three major nutrients found in food are protein, fat, and carbohydrate. Protein’s effect on blood sugar is minimal, unless very little carbohydrate is consumed along with the protein or very large amounts of protein are consumed. Without dietary carbohydrate to provide glucose for meeting the body’s energy needs, the liver begins to convert some dietary protein to glucose. For example, if you wake up to a breakfast of nothing but eggs and bacon, you may see a noticeable glucose rise a few hours later even though there was virtually no carbohydrate in the meal. However, if toast is included with the breakfast, the protein in the bacon and eggs will have little to no effect on the blood sugar level. Dietary fat’s impact on blood sugar is usually of little significance. However, consumption of large amounts of fat can cause two distinct effects. First, it may slow the digestion of the carbohydrates that were consumed along with the fat, resulting in a slower, more gradual postmeal glucose rise. Second, large a

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mounts of dietary fat can produce an additional rise in the blood sugar level several hours later. Here’s how: Step 1: You eat a high-fat meal or snack (this is the fun part). Step 2: In a few hours the fat begins to digest; this continues for several more hours. Step 3: The level of triglycerides in the bloodstream rises. Step 4: High triglycerides in the bloodstream cause the liver to become resistant to insulin. Step 5: When the liver is not responding well to insulin, it secretes more glucose than usual into the bloodstream. Step 6: The blood glucose rises steadily as the liver’s glucose output goes up. For example, when having a large burger and fries dinner at a restaurant, the carbohydrates may take a few hours to kick in as a result of fat slowing the digestion. Then, after you’ve gone to sleep, the blood sugar may rise again through the night as the liver begins secreting more glucose than usual. Large amounts of fat in a meal or snack may slow the digestion of carbohydrates and produce a secondary blood sugar rise after the carbohydrates have finished exerting their effects. Carbohydrates are the nutrients that have the most noticeable effect on blood sugar levels. Carbohydrates (or carbs, for short) include simple sugars like glucose, sucrose (table sugar), fructose (fruit sugar), and lactose (milk sugar) as well as complex carbohydrates, better known as starches. Think of simple sugars as individual train cars and starch as a whole bunch of those cars linked together to make a train. Now here’s the statement that has most people running to call their aunt who claims to know everything about everything. Whether carbohydrates come in the form of sugar or starch is meaningless when it comes to how much the blood sugar will rise. A cup of rice containing 45 grams of complex carbohydrates (starch) will raise the blood sugar the same amount as a can of regular (nondiet) soda that contains 45 grams of simple carbohydrates (sugar). And both will do it pretty fast. You see, when you eat something that contains starch, the individual sugar molecules become unhooked from each other. This process takes place quickly, beginning the moment food comes in contact with saliva in the mouth. The individual sugar molecules start reaching the bloodstream within minutes—as soon as they pass through the stomach and reach the small intestine. * Also be aware that some “sugar-free” products can raise blood sugar. Having spent my first three years after college working in advertising, I can tell you that marketing people will do just about anything to get you to buy their products—even if that means bending the truth a little. “Sugar-free” can be put on a food label if the food does not contain sucrose (table sugar). However, a sugar-free food can contain complex carbohydrates, fructose (fruit sugar), and a variety of sugar substitutes such as sorbitol, xylitol, mannitol, lactitol, isomalt, and maltodextrin—all of which raise the blood sugar, albeit more slowly and slightly less than ordinary carbohydrates. There are only a few artificial sweeteners that have no significant effect on blood sugar levels. These include saccharin, acesulfame K, sucralose, stevia leaf extract, and aspartame. But once again, be careful. Products that contain these artificial sweeteners may also contain sugar substitutes or other carbohydrates that will raise your blood sugar level. The bottom line is that you should always read the nutrition label to find out the true carbohydrate content of any packaged foods. We’ll talk more about carb counting and proper insulin dosing for carbs in the next chapter. Factor 4: Physical Activity Physical activity is a potent tool for lowering blood sugar. It does this by burning glucose and improving the way insulin works, also known as increasing insulin sensitivity. Think again about our door-and-lock analogy. Insulin is the key that opens up doors on your cells, allowing sugar to scurry inside to be either stored or burned for energy. When you’ve been lying around like a sloth, your muscle cells aren’t burning a lot of energy, so they only have a few doors available to open. Now imagine that you temporarily lose your senses and decide to do your own gardening and landscaping work instead of paying a professional to do it. You. Yourself. With no real outdoor skills whatsoever (okay, I’m speaking from experience). All of a sudden, your muscle cells need lots more energy. As you begin mowing over the flowers that your wife painstakingly planted, the few doors that exist on your muscle cells are insufficient to allow enough sugar to get in fast enough. The solution, as you might have guessed, is for your body’s cells to make more doors and “grease the hinges.” And that’s just what happens. Besides building more doors for the insulin keys to open, the locks are enlarged so that the keys have an easier time opening them. And special “revolving” doors are temporarily created that shuttle glucose into the cell without an insulin key. The net result: you suddenly have the energy you need to clean up the huge mess you created in the yard. Unfortunately, nothing lasts forever. The extra doors on your muscle cells are only temporary. After being sedentary for a few hours, the doors begin to be taken down. Stay inactive for a day or two, and you’re right back to where you were at the beginning. In fact, extended periods of inactivity can reduce your sensitivity to insulin, resulting in a state of insulin resistance. This, as you may recall, is a major contributor to type 2 diabetes. But it can happen to people with type 1 as well. The body burns glucose almost exclusively during the early phases of any form of exercise, and it continues to burn sugar throughout. Depending on your body size and the nature and intensity of your physical activity, you might burn upward of 100 grams of glucose per hour! But what’s that? You’ve heard that blood sugar can go up during exercise? True, it can. But the physical activity is not what causes it. Physical activity always burns glucose and improves insulin sensitivity; it doesn’t create more sugar. But maybe something else is going on at the same time, something we call a “stress response.” This can take place during competitive activities, very high-intensity and short-duration exercises, judged performances, and sports that involve quick bursts of movement. To learn more about the stress response, see Factor 5 below. Factor 5: Stress Hormones Last weekend I decided to stay up late and watch a scary movie. It had something to do with decaying zombies that had an insatiable hankering for human flesh. Unlike most movies, this one left me with zero appetite for snacking. Anyway, after the final gut-wrenching, heart-pumping scene, I decided to check my blood sugar. And I’ll be darned—it had risen about 100 mg/dl (5.5 mmol/l) during the movie. With blood that sweet, I felt like the grand prize for any zombie that might happen to be staggering around my neighborhood. Earlier, I mentioned that the liver serves as a storehouse for glucose, keeping it in a concentrated form called glycogen. The liver breaks down small amounts of glycogen all the time, releasing glucose into the bloodstream to nourish the brain, nerves, heart, and other active organs. The liver’s release of glucose is affected by many hormones. Of all the hormones in the body, only insulin causes the liver to take sugar out of the bloodstream and store it in the body’s cells. Most other hormones—including stress hormones, sex hormones, growth hormones, and glucagon—cause the liver to secrete glucose back into the bloodstream (see Figure 3.1 below). Cortisol and growth hormone are produced in a twenty-four-hour cycle and are responsible for the blood sugar rise that we sometimes see during the night or in the early morning. The other stress hormones, particularly epinephrine (adrenaline), are produced when our body needs a rapid influx of sugar for energy purposes. The glucose rise I experienced during the scary movie was no doubt the work of stress hormones. 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, any stress-induced blood sugar rise is followed almost immediately by an increase in insulin secretion by the pancreas, 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. Figure 3.1: Hormonal effects on the liver’s glucose secretion and storage The Little Stuff If forgetting to recap the toothpaste or put the toilet seat down can wreck a marriage, imagine what “little things” can do to your blood sugar! 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. Table 3-5 below lists many of these factors. We’ll be spending the next several chapters focusing on ways to adjust insulin doses in order to keep blood sugars from rising or falling too much in these situations. * 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, other injectable and oral diabetes medications, and physical activity.FOUR The Three Keys to Better Control I’ve looked under chairs I’ve looked under tables I’ve tried to find the key To fifty million fables They call me The Seeker. —Pete Townshend (The Who), “The Seeker” These days, every research study, regulatory body, insurance plan, clinician, and patient focuses on control. Many measure control by looking at just a single number: the A1c. Others see control as the opposite of chaos (or the mortal enemy of Kaos, if you subscribe to the Maxwell Smart way of thinking). Before we talk about the secrets to better 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 flowers—or pizza—or something. As soon as diabetes management starts to get in the way of enjoying life, it’s time for a different approach. That said, I like to define quality diabetes control as keeping blood glucose levels within an acceptable zone as much as possible without frequent or severe episodes of hypoglycemia and without your diabetes management 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 interests to control your blood sugar less intensively. Quality diabetes control means staying within your target glucose range as much as possible without frequent or severe hypoglycemia and without too much interference with your daily life. You may be asking yourself, “Hey! What about the A1c?” We can’t ignore the A1c because it has been shown to correlate with the risk of long-term health complications such as those described in Chapter 2. For those new to this diabetes management thing, A1c (also called glycosylated hemoglobin) is a blood test that provides an overall blood sugar average for the previous 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 all glucose levels into account—before eating, after eating, and 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. * 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 die off and are 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 standard A1c is in Table 4-2. * 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. Granted, there are multiple factors that go into the development of complications besides blood sugar control (lifestyle, genetics, environment, luck). But given our desire to avoid long-term health problems, 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 hypoglyc

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emia unawareness (don’t receive low blood sugar warning symptoms) or unstable 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 people, individuals planning for surgery, and those looking to slow or reverse existing complications may seek lower targets. Recently, with more widespread use of continuous glucose monitors, a new measure of overall glucose control has arisen: glucose management indicator, or GMI. GMI is similar to the A1c in that it represents average glucose over a period of time. However, GMI is calculated specifically from continuous glucose monitor data and is converted to a value that is on par with an A1c measurement. Here is the formula when measuring glucose in mg/dl: GMI = mean (average) glucose from a CGM x 0.02392 + 3.31 The mmol/l version of this equation is: GMI = mean (average) glucose from a CGM x 4.70587 + 12.71 It is best to take a mean value for at least the past two to four weeks when doing this calculation. For example, with a CGM mean of 177 mg/dl, we get 177 x 0.02392 + 3.31, which equals 7.54. This is comparable to an A1c of 7.54, but we don’t call it an A1c because we didn’t actually do the A1c blood test. In my personal experience, GMI tends to come in a little bit lower than the A1c, likely because CGMs tend to underestimate glucose levels more than they overestimate, and sometimes hang in a low range long after a low has been treated. Whether you use A1c or GMI to evaluate your control, the goal is not simply the lowest average but also stability. Anyone can lower their A1c and GMI by taking too much insulin, but this would cause frequent and perhaps severe hypoglycemia. And those with frequent highs and lows might have a decent A1c and GMI since their overall average isn’t too bad (see example in Figure 4.1). But as we’ll discuss in detail in Chapter 9, glucose variability can cause an assortment of short- and long-term problems. So the goal should be to achieve a good overall average with a high percentage of readings within your target range. Figure 4.1: Mr. Dot and Ms. Dash have the same average (and same A1c and GMI), but Mr. Dot’s glucose levels are much more stable. 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 and postmeal peaks (the high point of one’s blood sugar after eating). For the average person trying to achieve an A1c or GMI in the 6–7 percent range, a target 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 for most people. See Table 4-3 below for details. * This does not mean that you should expect to hit your glucose targets every time you check. That would be like a baseball player getting a hit every time they come 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 fingerstick readings or less than 5 percent of your continuous glucose monitor time 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 the standard deviation later in this chapter, but suffice it to say that a low standard deviation is better than a high one. The Three Keys Just as a chain is only as strong as its weakest link, successful diabetes management depends on three things: the right tools, strong self-management skills, and a proper attitude. Having one or two just won’t cut it; all three are required to keep the chain from breaking. 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 get the job done. Figure 4.2: The right tools, strong self-management skills, and a positive attitude are all necessary for successful diabetes management. 1. 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 challenging. Below are some of the tools that make it possible for you to take the best possible care of your diabetes. Physiologically Appropriate Insulin An Appropriate Insulin Delivery Device Other Medications to Support the Insulin A Kick-Ass Glucose Monitoring System A Way to Download and Analyze Your Data A Supportive Health Care Team A. Physiologically Appropriate Insulin Today’s insulin formulations are vastly superior to the insulins that were commonplace just ten years ago. And the stuff we used ten years ago put my original 1985 beef and pork insulin to shame! Older types of insulin (regular, NPH, Lente, Ultralente) are identical in structure to human insulin, but they all have a major flaw: they don’t work when we need them to. Regular insulin is too slow to offset the rapid blood sugar rise that follows most meals. And the older long-acting insulins have unpredictable peaks and valleys and inconsistent action times. Today’s modern insulins have been engineered to work either as quickly as possible (in the case of rapid-acting mealtime insulin, also called bolus insulin) or over an extended period of time with little to no peak (long-acting insulin, also called basal insulin). Boluses are bunches of relatively fast-acting insulin used to cover carbs or to lower high blood sugar levels. Rapid-acting insulins (lispro—brand names Humalog or biosimilar Admelog; aspart—brand names Novolog or NovoRapid; and glulisine—brand name Apidra) have a slightly different structure than human insulin. This structural change allows the insulin to absorb much faster into the bloodstream than regular insulin. For most people, there is no noticeable difference in the speed or potency of any of the rapid-acting insulins. If you’re looking for something that is a little bit faster, try Fiasp insulin. Fiasp, classified as an ultra-rapid insulin, is essentially aspart with an ingredient that produces even more rapid absorption. Fiasp has been shown to start and peak about eight minutes earlier than the other analogs. This may not seem like much, but it can work wonders for those trying to reduce their postmeal blood sugar spikes. For something truly faster, consider inhaled Technosphere insulin (brand name Afrezza). Afrezza starts, peaks, and finishes working about twice as fast as injected rapid-acting insulin. It should be noted that some mealtime insulins are available in concentrated forms. U-500 regular insulin is five times as concentrated as standard U-100 regular insulin. In other words, one unit of U-500 regular has the same blood sugar–lowering power as five units of ordinary regular insulin. 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 advantage of the concentrated formulation is that it requires a smaller volume when injecting or bolusing with a pump. 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 better mealtime option for those who require very large doses of insulin is U-200 Humalog. As the name suggests, this insulin is twice as potent as ordinary Humalog, so half the usual volume is required. U-200 Humalog is only available in pen form, so those wishing to use it in a pump will need to draw the insulin out of a pen rather than a vial. At the opposite extreme, for those who take their insulin by injection and are extremely sensitive to small doses, it is possible to dilute either regular or rapid-acting insulin using sterile diluent (ordered through a pharmacy). By drawing out 100 units of fluid from the diluent vial and injecting 100 units of insulin into the diluent vial, you have created insulin that is 10 percent of the usual concentration. One unit of the mixture has the strength of 0.1 units of insulin. Seven units has the strength of 0.7 units, and so on. This allows you to dose to the nearest tenth of a unit. Modern long-acting insulins (glargine—brand names Lantus, Toujeo, and Basaglar; detemir—brand name Levemir; and degludec—brand name Tresiba) have chemical properties that make them activate 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 NPH insulin. Not that NPH and regular insulin can’t play a role in diabetes management, but they certainly should not be the first choice for forming the foundation of your insulin program. And since premixed insulins (70/30, 75/25, and 50/50) use NPH as the long-acting component of their formulation, they too should be considered a last option. Of the available long-acting basal insulins, Tresiba and Toujeo are the longest-acting (well beyond twenty-four hours) and are least likely to peak. Research has shown that these insulins are less likely to cause hypoglycemia than other, shorter-acting basal insulins. Lantus and Basaglar last about twenty-four hours and have minimal peaking. Levemir usually lasts less than twenty-four hours and may have a noticeable peak and valley. However, when taken twice daily, Levemir achieves a relatively steady state in the bloodstream. B. An Appropriate Insulin Delivery Device If you choose to administer insulin via injections, choose a device that permits the greatest accuracy as well as convenience, comfort, and flexibility. Disposable syringes remain a common tool for delivering insulin in the United States. Most other industrialized countries have moved completely away from disposable syringes because they’re inefficient and create a large volume of medical waste. When choosing insulin syringes, select the smallest size possible given your usual dose. This allows for the greatest dosage accuracy. If you rarely require more than 20 units in a single injection, choose 0.3 cc (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 0.5 cc (50-unit) syringes. If you often require more than 40 units in a single injection, choose 1 cc (100-unit) syringes. Figure 4.3: Choose the syringe size that permits the most accurate dosing. As far as the size of syringe needle, thinner and shorter is almost always better. Using needles that are too thick or too long can cause unnecessary pain, bruising, and accidental injection into muscle. Thinness is measured by gauge. And here’s where it gets interesting: The higher the gauge, the thinner the needle (trust me—it wasn’t my idea). Make sure your syringe needles are at least 31- or 32-gauge. And select a needle length that is no longer than six millimeters. Four or five millimeter needles are best for lean individuals. Insulin pens are discreet, safe, fast, and simple to use. Pens permit precise dosing by turning a dial on the top of the pen to the desired dose and then pressing a button to deliver the insulin. In addition to seeing the dose measurement 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 mealtime (bolus) insulin can dose in either whole- or half-unit increments. If you are fairly sensitive to insulin (that is, if you take less than 25 total units per day), consider using a pen that delivers in half units. Figure 4.4: Durable pens use 300-unit disposable insulin cartridges. Some can deliver in half-unit increments, and some have memory and data transmission capability. Figure 4.5: Disposable pens come prefilled with 300 units of insulin and deliver in whole- or half-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 needle must be kept in the skin for five to ten seconds after pressing the plunger to ensure complete delivery. Pens either come prefilled or use disposable insulin cartridges. The disposable needles used on insulin pens are thinner and sharper than traditional syringe needles, and hence they are more comfortable. As was the case with insulin syringes, select a pen needle that is short (six millimeters or less) and thin (32-gauge or higher). An exciting development in the insulin pen market is the ability to communicate with a cell phone app. GoCap is a device that attaches to the end of certain types of insulin pens and wirelessly transmits dosage data to an app. The app also provides reminders and logging capability. Novo Nordisk recently developed pens that transmit to a data logging app. Going a step further, InPen is a durable pen that accepts cartridges of various types of insulin and communicates doses via a built-in Bluetooth transmitter. The InPen app assists users with dosage calculations, insulin-on-board adjustments, incorporating data from CGMs and health apps, and producing logbook reports. A list of common pens and associated devices can be found in Chapter 10. Injection ports are an option for those with a significant fear of needle sticks. These devices (also listed in Chapter 10) require just one needlestick every two or three days in order to place a

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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 administered. Figure 4.6: 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 a healthy 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 rapid-acting insulin. This is called bolus insulin. Figure 4.6a: V-Go is an example of a basic mechanical insulin pump. Some insulin pumps are basic mechanical devices that deliver a flat rate of rapid-acting insulin into the body all day and night, with release buttons for delivering fixed amounts of bolus insulin. These devices must be changed on a daily basis. They alleviate the need to administer frequent injections and make it convenient to deliver mealtime insulin. Full-feature pumps are the size of beepers and contain a cartridge filled with rapid-acting insulin. They have a sensitive motor that turns gradually to push insulin from the cartridge through a tube and into the body. Patch pumps stick directly to the skin and have their own built-in tube that infuses the insulin just below the skin. Patch pumps are programmed via a remote control. Some of the newer insulin pumps receive data from a continuous glucose monitor and automatically adjust basal insulin delivery. Nevertheless, it takes a skilled, educated, and motivated user to operate the pump properly and benefit to the fullest. Figure 4.7: Full-feature insulin pumps are marvels of bioengineering. Figure 4.8: OmniPod is an example of a patch pump. 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. Besides cutting down dramatically on the number of needlesticks (once every two to three days to insert an infusion set), insulin pumps offer a number of unique therapeutic advantages over traditional injection therapy. 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. Pumps have built-in calculators to help determine mealtime and correction doses of insulin (boluses), taking into account your usual dosing formulas and deductions for insulin that is still working from previous boluses. Pumps 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 slowly digesting foods. All full-feature pumps are downloadable and can provide considerable historical information for the user and their clinician. The modern generation of insulin pumps are integrated with continuous glucose monitors and a computer program (called an algorithm) to automate some aspects of insulin delivery. These are called hybrid closed-loop systems. Essentially, they raise or lower the basal insulin automatically when glucose levels are starting to veer out of range. The “closed-loop” part refers to the automatic adjustments, alleviating the user from having to make every decision. The “hybrid” part means that not all aspects of insulin delivery are automated. Many decisions, such as bolusing for food and adjusting for exercise, remain the responsibility of the user. By adjusting basal insulin on a minute-to-minute basis, hybrid closed-loop systems can help to improve a user’s time spent in range and can also reduce the frequency, severity, and duration of hypoglycemia. Hybrid closed-loop systems are like Hamburger Helper for insulin users: they take a basic insulin pump program and boost it to produce better results. Selecting a pump is a matter of personal preference. All pumps have a set of basic features that allow safe, precise delivery of basal and bolus insulin. Beyond that, a slew of bells and whistles, including wireless links with blood sugar meters and CGM devices, can be found. Shop around for the pump with the features you need and desire. Besides the list of manufacturers and websites in Chapter 10, check out the thorough pump comparisons found at integrated diabetes.com in the resources section. In general, the features that are most important to consider when selecting a pump are as follows: • Reservoir volume: Does it hold enough insulin to last you three days (the typical cycle for infusion-set changes)? • Compatibility: Does the pump receive data from your preferred CGM and/or blood glucose meter? • Hybrid closed-loop features: Can the pump make automatic adjustments to help keep your glucose in range more often? Are these features customizable and simple to use? Hybrid closed-loop features can be beneficial, but they are not for everyone. See Chapter 5 for more on this topic. • Readability: Is the screen bright and sharp enough for you to read the details easily? • Bolus amounts: Are the bolus increments (largest and smallest) suitable to your usual needs? • Calculation features: Does the pump’s bolus calculator allow you to enter your exact dosing formulas (insulin-to-carb ratios, target blood glucose levels, correction factors, duration of insulin action) without having to round off or compromise? • Alarms: Can you hear or feel the alarms when they go off? • Water resistance: Do you require a pump that is fully waterproof? • Wearability: Is the size of the pump and clip or attachment configured well for you? • Coverage: Check to see if your health insurance will only cover certain pumps or if the choice is yours. • Upfront cost: Patch pumps generally cost much less upfront than traditional tubed pumps, but the disposable costs are usually greater over time. Having a pump with the features you need and desire can certainly make life more convenient, but as is the case with any instrument used to deliver insulin, achieving successful control has more to do with the skills of the user than with the device itself. C. Other Medications to Support the Insulin Many people feel that just because they are taking insulin, they can’t use or benefit from any other diabetes medications. Whether you have type 1 or type 2 diabetes, the various noninsulin injectable and oral medications can make quite a difference. For anyone who takes mealtime insulin and is experiencing after-meal blood sugar spikes, pramlintide (brand name Symlin) can provide significant improvement. As described in Chapter 3, Symlin can also help curb hunger for those trying to lose weight. In addition, GLP-1 receptor agonists can provide some postmeal glucose control benefits. Metformin can also be used along with insulin. Because it blunts the liver’s secretion of glucose into the bloodstream, metformin can improve fasting blood sugar and reduce overall insulin requirements in people with either type 1 or type 2 diabetes, particularly those who are insulin resistant (requiring larger than normal doses). SGLT-2 inhibitors can produce an overall reduction in weight, insulin requirements, and glucose levels. However, users with type 1 diabetes must take special precautions to reduce the risk of ketoacidosis. For those who are highly insulin resistant, insulin sensitizing agents (thiazolidinediones) may provide some relief from having to take very large insulin doses. Just remember: if you have type 1 diabetes, none of these supplementary treatments will eliminate your need for insulin, but they may reduce the doses required to manage your diabetes. D. A Kick-Ass Glucose Monitoring System Diabetes management requires a significant amount of information for both day-to-day decision making and fine-tuning your program. Trying to manage your diabetes without knowing your glucose level is like driving a car with your eyes closed. You might be okay for a few moments, but before too long you’re going to crash and burn. The most valuable tool, by far, for measuring glucose levels is a Continuous Glucose Monitor (CGM). Unlike traditional fingerstick blood glucose meters, which only provide occasional point-in-time information, a CGM provides ongoing data with all-important context. To understand the difference, think of the movie The Godfather. Vito Corleone is an underworld mob boss who oversees and coordinates a variety of criminal activities ranging from theft to murder. But he is also a family man quoted as saying, “A man who does not spend time with his family cannot be a man.” If all you saw was the scene of Vito Corleone playing in the backyard with his three-year-old grandson, you might think the movie was a prequel to On Golden Pond. But seeing the full movie lets you paint a full picture of the complex man that is Vito Corleone. Fingerstick readings are like a ten-second movie clip. A CGM provides the complete story. Everyone who takes insulin should use a CGM on a regular basis. Let me repeat that. EVERYONE WHO TAKES INSULIN SHOULD USE A CGM ON A REGULAR BASIS. CGMs display updated glucose information every couple of minutes. Most provide trend graphs (showing what direction the blood sugar is headed), warning alarms to let the user know if they are headed toward a high or low glucose level, and detailed downloadable reports. Figure 4.9: Continuous glucose monitoring systems feature a sensor, transmitter, and display. Left to right: Medtronic Guardian, Freestyle Libre, Dexcom G6, Senseonics Eversense (implantable) Everyone who takes insulin should use a CGM on a regular basis. Currently available CGM systems utilize a thin filament inserted just below the skin to detect glucose in the interstitial fluid (fluid between fat cells). The Eversense from Senseonics uses an implanted device the size of a small pill to sense glucose levels. The information from the sensor is transmitted wirelessly to a receiver, which can take the form of a handheld device, a smartphone, an insulin pump, or a smart watch. Some CGM systems require occasional entry of fingerstick readings for calibration purposes, while others do not. Even though they are not as precise as the latest blood glucose meters (the sensors are generally within about 10 percent of lab values, while meters are closer to 5 percent), they still offer considerable value to the user. One of the key benefits of CGMs is the ability to detect approaching high or low glucose levels. Although they may not detect every high and low, CGMs provide an early warning for the vast majority—and much earlier than most people can feel them on their own. The trend arrows and graphs give users the ability to forecast where the glucose is headed so that they can make appropriate decisions about food, activity, and insulin or other medication. For example, you would probably act differently if you knew that a bedtime reading was 100 mg/dl (5.5 mmol/l) and falling as opposed to the same value but steady or rising. Or, if your pre-exercise reading was 150 mg/dl (8.3 mmol/l) and rising versus dropping. CGM data can be downloaded to a variety of web-based programs and smartphone apps for analyzing patterns, trends, and statistics. The downloaded data can be used to measure the magnitude of postmeal spikes, test the effectiveness of basal insulin, evaluate postmeal and postexercise patterns, detect nighttime lows or rebounds, and measure the precise action curve for rapid-acting insulin. Research has shown that those who use their CGMs consistently tend to have fewer (and less severe) lows and improvements in their A1c, along with more stable glucose levels. Those who don’t use them on a consistent basis may benefit while wearing them but may not see long-term improvements in glucose control. Why would anyone not use a CGM all the time? Well, they do have a few drawbacks. With some systems, inserting the sensor can be a bit awkward and uncomfortable, and the tape used to hold the sensor (or transmitter) in place bothers some people’s skin. There are periods of inaccuracy and occasional false alarms, and there is lag time in any CGM system (the CGM readings lag about five to ten minutes behind actual blood glucose values). And of course, there are costs. Even with insurance coverage, there are usually copays and deductibles that must be met for the hardware (transmitters and receivers) and disposable sensors (which are changed every seven to fourteen days, depending on the system; three to six months for the implanted sensor). Before dismissing the whole CGM idea, remember this: when home blood glucose meters first came out, many people were skeptical of them as well! Personally, I consider the CGM to be the most important innovation in diabetes care since the development of rapid-acting insulin. Even if you decide to use a CGM on an ongoing basis, a reliable blood glucose meter is still essential. Fingerstick readings will be needed for calibration purposes, during sensor warm-ups, and any time the reliability of the CGM is in question. If you don’t plan to use a CGM regularly, you’re likely to be checking your blood sugar quite often with a meter. Look for a meter that is fast (some take as little as five seconds), simple to use (fewer steps means less chance for user error), downloadable (and with substantial memory), and easy on your blood supply (1 microliter or less is ideal; some require as little as 0.3 microliters). Meters that allow second-chance dosing are also desirable, in case you don’t apply enough blood to the strip with the first application. But above all, look for a meter that provides top-notch accuracy. Every meter is tested by

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both the manufacturer and independent parties for accuracy. The results of these tests are reported in the meter’s product specifications (included in either the user’s guide or the test strip container). Look to see how often the meter readings are found to be within 10 percent of laboratory values. If this occurs less than 95 percent of the time, look for a different meter. Readings that are often more than 10 percent off from the actual value can cause misinterpretation of data or, worse, inaccurate insulin dosing. See Appendix A for an accuracy comparison of many popular meters. Figure 4.10: Modern blood glucose meters are fast, compact, easy to use, and require very little blood. Modern glucose meters are unaffected by most over-the-counter medications. However, if you need to use the meter under extreme temperature or altitude conditions, contact the various manufacturers (listed in Chapter 10) to find one that will meet your needs. Some meters have taken on the look and feel of minicomputers. Personally, I’m not a big fan of meters that allow entry of event markers and data such as insulin doses and carbs consumed because entering this type of information usually takes way too long and the data is displayed (either on screen or through a computer download) in a way that makes proper analysis difficult. However, some meters now link wirelessly with smartphone apps that can produce insightful glucose reports and allow for quick and easy logging of other pertinent data. With the advent of meters that require very small blood samples, virtually painless alternate-site testing (taking blood samples from places other than the sensitive fingertips, such as the arm, leg, or heel of the hand) has become a reality. However, be aware that alternate-site testing rarely works with meters that require more than 0.5 microliters of blood. Also, readings taken from alternate sites may lag several minutes behind readings taken from the fingertips, so if you suspect that your blood sugar is rising or falling quickly, it is best to take your blood sample from a fingertip. Regardless of the meter you choose, having more than one is beneficial. Most meter companies will send you extra meters at no charge, assuming that you will continue to purchase and use their test strips. Personally, I keep a meter in each of the places where I am likely to need one—bedside, kitchen, desk at work, and gym bag. I don’t keep one in the car because test strips can spoil easily at very high and low temperatures. The right lancet and lancing device can also make a difference. Oh, how far we’ve come since the Guillotine days of yesteryear! Obtaining an adequate drop of blood with minimal discomfort is all about the tools and techniques. Lancets, like syringe needles, come in varying gauges. And like needles, the larger the gauge, the thinner (and less painful) the lancet. Look for 33-gauge (or higher) lancets. Whatever you do, don’t just grab the lancet and stab your finger. That virtually guarantees a painful fingerstick and buildup of scar tissue. Use a lancing device that has an adjustable depth setting. Start with the lowest or shallowest depth possible, and see if you can conjure up a sufficient drop of blood with a little bit of “milking.” If that doesn’t work, go to the next setting and so on, until you obtain a sufficient drop. That’s the setting you should go with—and not a speck deeper. For alternate-site testing, it is best to use a lancing pen that has a clear cap (so that you can see when a sufficient drop appears) and a thinner head than those used on the fingertips. And one more thing: use the sides of your fingertips, not the tips themselves. Figure 4.11: Size does matter! Choose thinner lancets (and use an adjustable lancing pen) to minimize the pain of fingersticks. E. A Way to Download and Analyze Your Data Virtually all insulin pumps, blood glucose meters, CGMs, and even some insulin pens are downloadable to web-based or app-based programs. These programs are usually free of charge, but some charge a subscription fee. Regardless, downloading your data is an absolute necessity for evaluating your progress and fine-tuning your program. If you’re lucky enough to work with a health care provider who offers remote consultations, downloading data will provide them with the information they need for insightful analysis. A list of popular downloading programs is included in Chapter 10. F. A Supportive Health Care Team We’ve all heard the saying “A lawyer who defends himself has an idiot for a client.” The same holds true for anyone who neglects to call on the expertise of health care professionals for taking proper care of their diabetes. Surrounding yourself with a quality health care team is like putting together a winning basketball team. Each player has a role, yet all should work collaboratively. Your job is to assemble the team, give them what they need, and hold them accountable for doing their jobs. That means you may have to fire or trade some players from time to time, but that’s okay. Unless you’re winning championships every year, getting a fresh perspective once in a while helps. One approach is to go with a preassembled team of diabetes professionals. The American Diabetes Association (ADA) and American Association of Diabetes Educators (AADE) maintain lists of “recognized diabetes self-management education programs,” most of which feature a multidisciplinary group of diabetes-care specialists. Although there are many quality providers not included on the list, ADA and AADE have ensured that all the programs on their lists meet national standards for diabetes education and treatment. For updated lists, go to professional.diabetes.org/erp_list_zip, call 800-342-2383, or visit diabeteseducator.org/living-with-diabetes/find-an-education-program. Otherwise, create your own team of diabetes health care all-stars: A certified diabetes educator (CDE): A CDE is often a nurse or dietitian, but they can also be a pharmacist, exercise physiologist, physician, mental health counselor, or anyone in the health care field with advanced training in diabetes management. Collectively, prior to obtaining certification, these folks are referred to as Diabetes Care and Education Specialists. Your CDE should be able to coach you through the complexities of living day to day with diabetes. CDEs are expert teachers as well as skilled clinicians. If you can find a CDE (or physician) who also has diabetes, you can tap into a gold mine of both personal and professional experience. To locate a CDE in your area, talk to your doctor or visit ncbde.org/living-with-diabetes/findcde. My practice provides the services of skilled CDEs (all with a direct personal connections to diabetes) via phone and the web as well as in person. Visit integrateddiabetes.com, or call 610-642-6055 for information. A physician: Different physicians have different levels of expertise in treating diabetes. Endocrinologists typically have the most experience and skill in diabetes care. However, some endocrinologists specialize in treating other endocrine disorders (such as pituitary or thyroid problems) or are more adept at treating patients who do not use insulin than those who do. Internal medicine physicians (internists) usually treat a variety of chronic health conditions, diabetes being just one of them. Some internists have a great deal of expertise in treating diabetes; others tend to refer their insulin-using patients elsewhere. General practitioners (family physicians) typically treat many short- and long-term illnesses and usually have only a basic understanding of diabetes management. Look for a physician who is board certified; this ensures that they receive continuing education and are updated on the latest treatment methods. Regardless of the type of physician you hire, they are ultimately responsible for screening for complications, prescribing the necessary tests, medications, and equipment, intervening in case of a crisis, keeping you updated on the latest developments in diabetes care, and making sure that your control is on track. If your physician is not meeting these minimum criteria, fails to answer your questions to your satisfaction, or does not support your pursuit of new technologies, management approaches, or other health care specialists, consider looking for someone else. A registered dietitian (RD): Given the huge role that food choices play in diabetes management, it pays to have a nutrition expert in your corner. An RD can work with you to increase your knowledge and skills in carbohydrate counting, weight control, sports nutrition, special-occasion dining, vegetarian meal planning, alcohol safety, and dietary management of conditions such as hypertension, gluten intolerance, and elevated cholesterol. To find an RD who specializes in diabetes, contact the Academy of Nutrition and Dietetics at 800-877-1600, or visit eatright.org (click on the “Find an Expert” icon). A mental health counselor: With all the pressure placed on people with diabetes to manage blood sugar levels while still taking care of everything else in their lives, a mental health counselor can be a valuable member of your health care team. Mental health professionals—social workers, psychologists, and psychiatrists—can help with issues such as stress, depression, eating disorders, sleep disturbances, obsessive or compulsive behaviors, anxieties, relationship difficulties, financial hardship, and job discrimination. In most cases, psychological issues must be dealt with before you can do an effective job managing your diabetes. So if you are experiencing issues that may be interfering with your ability to take proper care of yourself, don’t hesitate to ask your physician for a referral to a mental health professional. An exercise specialist: Exercise remains a pillar in diabetes management and the prevention of health complications. However, you can also get yourself in hot water if you don’t know what you’re doing. Severe hypoglycemia, acute injuries, and worsening of diabetic complications are among the risks faced by people with diabetes. An exercise physiologist is a health professional who understands the physical, psychological, and metabolic effects of exercise. They can help you design an exercise plan, formulate strategies to prevent hypoglycemia, manage blood sugars during sports and competitive activities, and reduce your risk for injuries and other complications. Look for an exercise physiologist who is also a diabetes educator; many ADA- and AADE-recognized diabetes centers and programs offer the services of exercise physiologists. Other specialists: Given the complexity of diabetes and the various body parts that are affected, it would be wise to add a few other specialists to your health care team. These include: • a podiatrist (for preventive foot care and treatment of foot problems) • an ophthalmologist (for routine eye exams and treatment of eye disorders) • a dentist and dental hygienist (for ongoing tooth and gum care and treatment of periodontal disease) • a nephrologist (for treatment of kidney disease) • a neurologist (for treatment of nerve disorders) • a cardiologist or vascular surgeon (for treatment of large blood vessel diseases) Supporters: Although not officially part of your heath care team, support from friends and family can play a vital role in your ability to manage diabetes successfully. It is wise to educate those around you about diabetes so that they can assist in special situations and know when to step in and when to step back. The book Diabetes: How to Help, published by the American Diabetes Association, would make a nice gift for a loved one (see further suggested reading in Chapter 10). 2. Strong Self-Management Skills Modern technology is useless without the know-how to utilize it properly. For example, I have friends I bike with occasionally. Some of them have invested thousands of dollars in lightweight, aerodynamic racing bikes that look like they were engineered by NASA. They also have all the latest cycling apparel and gear. But some of my friends are—how shall I put this?—not in the best shape. I, on the other hand, ride a cheap, clunky, hybrid bike and don’t wear any special gear. But because I work out year-round, I can literally ride circles around them. Likewise, high-tech diabetes management devices are nice to have, but ultimately, technique always wins out. The following are skills and behaviors that are important for everyone who uses insulin. Self-Monitoring Record Keeping Data Analysis Carb Counting (and a few other food-related things) Insulin Self-Adjustment A. Self-Monitoring People who know their blood sugar throughout the day and are able to use the information tend to have the best overall control. That means either: (a) wearing a CGM on a consistent basis, changing the sensor as recommended by the manufacturer, and looking at the glucose display about once an hour or (b) performing fingersticks six to eight times daily (before meals and snacks, before exercise, at bedtime, and occasionally after meals and during the night). Frequent glucose checks allow you to detect (and fix) high readings so that you don’t go for long stretches above your target range. They also give you a chance to detect (and fix) glucose levels that are trending downward before hypoglycemia develops. However, too much of a good thing may not be so good. Checking obsessively (looking at the CGM every few minutes or performing fingersticks every hour of every day) may get in the way of healthy diabetes control. Besides creating anxiety, it may cause you to overreact before your insulin (or your food or exercise) has a chance to take effect. And remember one of our requirements for quality diabetes control: managing your diabetes should not get in the way of enjoying life. To help ensure the accuracy of your CGM, calibrate it as recommended by the manufactu

Part 13

rer, and do so with an accurate meter and proper technique. For accurate meter readings, be sure to use test strips prior to their expiration date. Keep the strips sealed in their bottle, and be sure to apply enough blood to cover or fill the entire test area. Never expose your strips to extreme hot or cold temperatures—so don’t leave them in your car. A clean finger is also a must. There is no need to wipe your finger with alcohol, but the presence of dirt, grease, food, or other foreign substances on your finger can affect the accuracy of the reading. I’ll never forget the time I tried some of the finest barbecue Kansas City has to offer. After devouring a few ribs, I checked my blood sugar and was very surprised to see a reading of 438 mg/dl (24 mmol/l). After cleaning my finger and rechecking, the reading was 108 (6)—quite a difference. At that point, two thoughts crossed my mind: I’m glad I didn’t take insulin for the high reading, and Man, that’s some powerful sauce! If you ever suspect that your meter reading may be inaccurate, recheck—twice if necessary. If you’re still in doubt, use the control solution that came with your meter to verify its accuracy. The reading obtained with the control solution should fall within the designated range on the test strip package. If the result is outside of the reference range, try a new bottle of strips. If that does not solve the problem, call the meter manufacturer, and ask for a replacement meter. B. Record Keeping It’s a fact: people who log their data have better glucose control than those who don’t. Perhaps it’s the sense of accountability, but you can’t deny that keeping organized records makes for easier analysis, which allows us to catch problems and make necessary adjustments. If you’re sitting there saying, “No need. I can just download my thingamabob to the computer. It keeps all the information for me.” Sorry, bud. Most downloadable devices like meters, pumps, and CGMs fail to capture many of the key events that influence our blood sugar levels. Even pumps, which may contain insulin and carb entries, are lacking many elements of effective record keeping. So at least for the time being, some additional logging is going to be necessary. Do you need to do it forever? Probably not. I find that once the insulin doses have been properly fine-tuned, detailed logging can be performed just now and then—perhaps one week per month or any time blood sugars are starting to fall outside of your desired range. Of course, some people take comfort in keeping ongoing records, feeling that it keeps them on track. If you’re one of those people, keep on loggin’! Any good record-keeping system begins with glucose data. If you’re using a CGM, this data should be readily available in graphic and statistical form. If you don’t use a CGM, you will need to either download your meters or record the information manually on paper or in a logging app (see Chapter 10 for a list of available programs, or visit integrateddiabetes.com/diabetic-logsheets for a variety of downloadable and printable logging systems). Blood sugar readings by themselves are not of much use unless they are all running above or below your desired range. For most of us, that just isn’t the case. When inconsistencies exist, you need to figure out why the readings are going up or down. Were they caused by too much or too little food? Miscounting the carbs? Incorrect insulin doses? Changes in physical activity? Stress or illness? The weather? To figure out why your blood sugar levels vary, your records should include: • amounts of insulin taken (and other diabetes medications, if the doses vary) • food consumed (grams of carbohydrate and anything else noteworthy, like restaurant meals or parties) • physical activity (type and length of exercise as well as other labor-intensive activities such as housework, yard work, shopping, and extended walking) • stress that might affect blood sugars (illness, menstrual cycles, emotional events, and hypoglycemic episodes) • if you’re a pump user, when infusion set changes take place In addition to logging apps, this type of information can be logged electronically as “events” in some CGM receivers, glucose meters, pumps, or apps that link with these devices. Use those features! When generating reports, the information that accompanies the glucose data can be extremely valuable for making wise adjustments. C. Data Analysis Reviewing and interpreting your self-monitoring records is essential. Otherwise, your logbooks and stored data are about as useful as those adorable but lonely characters on the Island of Misfit Toys in the old TV special Rudolph the Red-Nosed Reindeer. For most people, it is best to review your own records on a weekly or every-other-week basis. Keep track of how often your readings (or how much time, if you use a CGM) are above, below, and within your target range for each phase of the day—fasting, morning, afternoon, evening, and overnight. At any phase of the day, if more than 25 percent of your glucose values are above your acceptable range, or more than 10 percent are below, changes to your diabetes management program are probably in order. Because low blood sugars can sometimes produce high readings a few hours later, eliminating the lows before addressing the highs is usually the best course of action. It is necessary to eliminate low blood sugars before addressing highs because of the tendency to rebound from lows. When looking at your own reports, don’t just focus on what’s out of range. Feel good about your successes! This is a tough bugger of a condition to manage day in and day out. After giving yourself a pat on the back, it’s time to play detective. Take a look at areas that need improvement, and see if you can figure out what may be causing the highs and lows. Here are some questions to ask yourself: • Are the patterns different on certain days of the week? Certain phases of the month? • Is physical activity having an immediate or delayed effect? • Do certain types of foods always seem to make your blood sugar rise or fall? • Are you always high after experiencing a low? Or do lows tend to repeat themselves? • Are you often low (or still a bit high) after taking extra insulin to correct elevated readings? • Are emotional situations affecting your control? • Does your glucose level vary based on how long you have used an insulin pen, vial, or pump infusion set? For example, one of my patients, a curbside baggage handler at the airport, discovered that his daytime blood sugar varied based on how much luggage he processed. On the busiest travel days—Fridays and Sundays—his blood sugars were much lower than the rest of the week. A simple reduction in his mealtime insulin on busy days solved the problem. Another client had nice, consistent glucose readings throughout the week except for certain evenings. A look at her data taught us that choir practice usually preceded her elevated blood sugars. It seems that the passion and emotion she felt while singing were causing an adrenaline-induced rise in her blood sugar. A little extra insulin before practice solved the problem nicely. One of our young clients, a second grader using a bright pink insulin pump, had very erratic readings when reporting to the nurse before lunch—some highs, some lows, but rarely in range. Her records revealed that the lows were on days she had gym class in the morning, and the highs were on days she had quizzes in the morning. A slight tweaking of her morning insulin based on her level of activity and quiz schedule put her blood sugars back on track. One more example: a delightful middle-aged woman with generally good control, except a tendency to rise overnight on weekends. The culprit was going out to dinner with her husband. I would have told her to never go out to eat, but I would rather not have to take my food through a straw for the rest of my life. Instead, we discussed carb counting and lower-fat food options at her favorite restaurants, along with basal insulin dosing strategies for preventing an overnight rise when she chooses to indulge. Electronic devices such as blood glucose meters, insulin pumps, and continuous glucose monitors can provide useful information—if you know what to look for. Beautiful pie charts and bar graphs might look delicious, but they don’t always yield useful information. Below are some of the more valuable aspects of the data reports. Statistics When viewing data over the past couple of weeks (or more), focus on the overall average glucose, standard deviation, and percentage of readings that are above, below, and within your target range. The average should correlate well with your HbA1c, although meter reading averages may underestimate if you don’t do much after-meal checking (blood glucose levels [BGs] tend to spike up for a short while after meals and snacks). The standard deviation (SD) reflects the amount of variability in your readings. Lower is better. If the SD is more than half of your average, your readings include too many extreme highs and lows. An SD that is less than one-third of your average means that your readings are fairly consistent, without too many in the extreme ranges. The percent of readings (or time) within your target range is the gold standard for assessing the quality of your diabetes management. Though a couple of extreme highs or lows can greatly influence your average and SD, they won’t necessarily wreck your in-range percentage. In your software, be sure to set your target range (the default setting is often unrealistic). The percent of readings in range (or time spent in range) is the gold standard for assessing the quality of your diabetes control. In some data analysis programs, detailed statistics are available by time of day and day of the week. These can help to pinpoint the source of out-of-range readings. For example, you might discover that you’re experiencing frequent lows only on workout days or highs on days when you sleep in. Modal Day Reports These are my personal favorite reports because they provide a quick visual summary of the quality of blood glucose control at various times of day. (See examples that follow.) Be sure the meal schedule in the software corresponds with your usual schedule; many are preset for the “early bird special” crowd, with meals and bedtime at very early times of day. When looking at a meter modal day report, ask yourself: Are there frequent highs or lows at certain times of day? Are the readings consistent or widely scattered? Are the readings taken at relatively consistent times of day or haphazard? In Figure 4.12, many of the fasting (wake-up) readings are elevated, but this could be an after-effect from the frequent lows seen at bedtime. There are also some very high readings before dinner that may need to be addressed. CGM software can superimpose multiple days of sensor data onto a single report. The overlay report, sometimes referred to as a spaghetti graph, provides unique insight into the ebb and flow of glucose levels on a typical day, helping answer questions such as: • When are most highs and lows occurring? • Are mealtime insulin doses returning glucose to normal following meals? • Are glucose levels peaking very high after meals? • Is there an upward or downward trend overnight? • Do lows trigger rebound highs? • Are lows occurring without warning signs or symptoms? Figure 4.12: Example of a blood glucose meter modal day report Figure 4.13: Example of a sensor overlay report Individual Day Reports Figure 4.14: Example of an individual day report Individual day reports provide more detail than can be seen in other reports because, as the name implies, they just focus on a single day at a time. These are particularly helpful when using a pump and CGM, because they can combine the data from both into a single report. Looking at reports for several individual days can reveal: • how long it takes for bolus insulin to finish working (duration of bolus action) • the immediate and delayed impact of various forms of physical activity • whether correction doses are bringing the blood sugar down too much or too little • glucose patterns that follow meal boluses • if glucose levels are stable between meals (for evaluating basal settings) Figure 4.15: Example of a glucose trend graph from a meter download Glucose Trend Graphs Both CGM and meter software can generate trend graphs that show how glucose values vary over an extended period of time, such as a month or several months. By highlighting periodic peaks and valleys, these graphs can shed light on whether adjustments are needed for things like menstrual cycles, off/vacation days versus work/school days, and seasonal variations in physical activity. Trend graphs are also useful for illustrating control changes over prolonged periods of time. Gradual upward trends often indicate a need to intensify therapy. Downward trends may indicate that your therapy is on the right track as long as you are not experiencing hypoglycemia too often. In Figure 4.15, the trend graph shows that glucose levels are becoming steadily less erratic and more in range. Ambulatory Glucose Profile (AGP) Reports AGP is a standardized report that displays CGM data in a graphic format in order to show typical daily ebb and flow. The report includes a median (similar to an average) line, a dark shaded area that includes the middle 50 percent of readings (25 percent above and 25 percent below the median), and a light shaded area that includes the middle 80 percent of readings (40 percent above and 40 percent below the median). Anything outside of the middle 80 percent range represents the extremes that occurred within that time period. Figure 4.16: Example of a standard AGP Report Figure 4.17: An AGP report showing data from a hybrid closed-loop system The essence of an AGP report is its uniformity and simplicity. When the dark shaded area reaches beyond the target

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range, there is reason for concern since a significant amount of time (more than 25 percent) is spent out of range. It is best to evaluate approximately two weeks of data in order for the AGP report to have validity, since single high or low events can produce significant percentages of out-of-range readings when evaluating only a few days at a time. In addition, a time of day when the dark range is uncharacteristically wide (looking like a pig in a snake) represents extreme glucose variability. This may be due to variation in food intake, stress levels, or physical activity at that time of day. On the downside, it can be hard to draw firm conclusions from AGP reports. Very few people (with or without diabetes) follow a consistent, regimented schedule in terms of meals, snacks, exercise, and sleep. An early morning “dawn phenomenon” glucose rise may not be captured in the AGP report if a person’s sleep schedule changes from day to day. Postmeal glucose peaks may not appear for an individual whose meals start and end at different times throughout the week. And it is often not possible to establish cause-and-effect relationships when looking at summaries of large sums of data. Nevertheless, the AGP report is popular among those with limited time for evaluating glucose data, as it can reveal general patterns of high and low glucose levels. Logbook Report When looking at meter data, summary statistics (averages, percent in range, standard deviation) and modal day reports can be misleading. Suppose you check more than once when your blood glucose is high or low? What if you tend to check more often when you feel that something isn’t quite right? These will skew the data and not provide a fair representation of what is typically happening. Logbook reports permit a more accurate assessment of your blood glucose history, listing readings in chart form according to the time of day. Once again, be sure to set up the software so that the time intervals correspond with your typical schedule. A detailed look at your logbook can answer questions such as: • Do lows tend to occur after highs? (Perhaps you are overdosing for the highs.) • Do highs tend to occur after lows? (Perhaps you are overeating or rebounding.) • Do you tend to run several highs in a row? (Perhaps your correction doses are insufficient.) • Do glucose levels change overnight or between meals? (Perhaps your basal insulin needs adjustment.) • Are there patterns related to when you do—or don’t—exercise? • Are there patterns after you eat restaurant or take-out food? D. Carb Counting (and a Few Other Food-Related Things) Being able to quantify the effect food will have on your blood sugar is essential for matching it with the proper dose and type and timing of insulin. As mentioned in the previous chapter, carbohydrates are the primary blood sugar–raising elements in the diet. All carbohydrates (simple and complex), with the exception of fiber, convert into blood glucose fairly rapidly. Thus, quantifying the carbohydrates in our meals and snacks is of the utmost importance. For those who are attempting to match their mealtime insulin to food intake, it is best to count carbohydrates in grams. This is the most precise and practical way to count carbs. Using carb “choices” or “exchanges” tends to make things more complex and less precise. If you are accustomed to using the exchange or choice system, the transition to grams can be made by using Table 4-4 below. Simply add the amount of carbohydrates you are getting from each exchange, and you have the total grams of carbs for your meal. * In other words, a meal consisting of two breads, two fruits, a milk, and three meats contains (2 x 15) + (2 x 15) + (1 x 12) + (3 x 0), or 72 g carbohydrate. Just make sure you have the right portion sizes for each exchange. For example, one banana may be one, one and a half, or two fruit exchanges, depending on the size of the banana. When counting grams of carbohydrate, it’s best to count all carbs equally. True, there are differences in how quickly different carbohydrates raise the blood sugar, but all carbs (except for fiber) eventually turn into glucose. For example, 12 g of carbohydrate from milk will raise the blood sugar more slowly than 12 g of carbohydrate from bread, but after several hours the total rise will be the same. If you consume a food high in fiber, such as whole grain bread, beans, or bran cereal, you may not see as much of a blood sugar rise as you might expect. Fiber is a carbohydrate that is resistant to digestion and does not raise the blood sugar. When looking at the nutrition information on a food label, subtract the fiber grams from the total carbohydrate. For example, a high-fiber cereal that contains 8 g of fiber and 31 g of total carbohydrate should be counted as 23 g of carb (31 minus 8). The more accurate you are at carb counting, the better you will be able to control your blood sugar. The more accurate you are at carb counting, the better you will be able to control your blood sugar. There are several ways to count carbs. One of the simplest and most effective is label reading. Food manufacturers in the United States (as well as most industrialized countries) are required to list the serving size, total carbohydrate content, and carbohydrate breakdown on their food labels. Note that food labels include the fiber in the total carbohydrate even though fiber does not convert to blood sugar. Sugars (simple carbohydrate) + Starch/other (complex carbohydrate) + Fiber = Total carbohydrate Figure 4.18 shows a sample food label: a serving of Gloopers (a half cup) contains 20 g of total carbohydrate. If you consume a full cup, you would have 40 g of carb. Some manufacturers of “sugar-free,” “reduced sugar,” or “low calorie” products may use sugar alcohols as artificial sweeteners. Sugar alcohols such as sorbitol, mannitol, and xylitol are also included in the total carbohydrates on food labels. Although slow to act, sugar alcohols will raise blood sugar, but less than most other carbohydrates. As a rule, deduct half (50 percent) of the sugar alcohol grams from the total carbohydrate. For example, if a food item contains 25 g carbohydrate and 10 g of that amount is sugar alcohol, deduct 5 g from the 25 g, for a total of 20 g. Figure 4.18: Sample food label Another tool for carbohydrate gram counting is a nutrient guide. There are many pamphlets, books, apps, and websites that list the carbohydrate content of various foods. Some cover specific categories such as restaurant food or certain kinds of ethnic cuisine; others cover a wide range of commonly consumed foods. Several are listed in Chapter 10. A somewhat more sophisticated technique for counting carbs is portion estimation. This method is particularly useful when dining out or enjoying foods that vary in size, such as fresh fruits, starchy vegetables, or baked goods. Portion estimation involves using a common object such as your fist or a deck of cards to determine the approximate size of a particular food item. Then the carb count is determined based on the typical carb content for a given portion of that item. A list of measuring tools and the associated carb amounts for a variety of foods is listed in Appendix B. For example, an average adult woman’s fist is equal to about a one-cup portion. If a cup of cooked rice contains 50 g of carbohydrate and you consume one and a half fist-size portions of rice, you will have eaten about 75 g of carbohydrate. Three large handfuls of chips will contain 3 x 15, or 45 g of carbohydrates. A six-inch-long sandwich will contain 6 x 8, or 48 g of carb. A more precise technique for counting carbs involves using carb factors. By weighing the portion of food that you plan to eat (in grams, not ounces) and multiplying by the food’s carb factor, you will obtain a precise carb count. A carb factor is the percentage of a food’s weight that is carbohydrate. For example, apples have a carb factor of 0.13, which means that 13 percent of an apple’s weight is carbohydrate. If an apple weighs 120 g, the carb content is 120 x 0.13, or 15.6 g. For an abbreviated list of carb factors, see Appendix C. When you’re ready to put your carb counting skills to the test, try taking the Carb Counting Quiz at my website, integrateddiabetes.com /carb-quiz. Feel free to send your answers to info@integrateddiabetes.com for scoring by a member of our clinical team. Dietary Discipline Mastering the fine art of carb counting does not give you free rein to consume everything and anything in sight. It is essential to provide sufficient spacing between meals and snacks—particularly if you take insulin at mealtimes. To understand why this is the case, imagine that you are on a small boat that has just sprung a leak. What do you do? If you let the water keep pouring in and just bail out, you’re never going to get the water completely out of the boat (and you can never stop bailing). But if you seal the leak and then bail out, you should have a dry boat in no time. Eating too frequently without allowing space between meals is like letting the water continue to pour in—but in this case, it is glucose flowing into your bloodstream. After eating, your blood sugar is naturally going to rise for a short while, since most foods digest faster than insulin works. If you eat again before the blood sugar has returned to normal, all you’re doing is prolonging the postmeal high. Waiting a while to eat is like plugging the hole: the mealtime insulin bails the glucose out of your bloodstream, and your blood sugar has a chance to come back down to normal. Spacing meals and snacks at least three hours apart will help you to maximize the time you spend in your target blood sugar range. For most people, it is best to wait at least three hours between meals and snacks. After three hours, rapid-acting insulin has done the majority of its work, so the blood sugar should be close to normal again. The bottom line is: don’t graze. Pay Attention to Protein Most of the time, protein has little or no effect on blood sugar levels. It does not slow down digestion, and it does not raise blood sugar—except in two situations. If your diet is very low in carbohydrates, some of the protein from your food will be converted to glucose. This is necessary, because some vital organs only burn glucose for energy, and if there is not enough glucose coming from the carbs in your diet, protein will be converted to glucose and “sacrificed” for energy purposes. The exact threshold at which this happens varies from person to person, but in general, when having meals with less than 10 to 20 g of carbohydrates, it may be necessary to count protein grams and assume that 50 percent will be converted to glucose. See Table 4-5 on the previous page for a chart showing the protein content for a number of protein-rich foods: * For example, if you have a three-egg omelet and half a piece of toast for breakfast, it will be necessary to add 9 g to the carbs in the toast to account for the eggs (3 x 6 = 18; 50% of 18 = 9). What’s that you’re saying? If you have to count one more thing, you’ll probably have a nervous breakdown? Understandable. If you don’t want to have to worry about counting protein grams, just make sure you have at least 15–20 g of carbohydrates each time you have a meal or snack, and space your carb intake evenly throughout the day. The other situation in which protein might raise blood sugar is when having a HUGE amount. Research has shown that large portions of protein (at least 60 g) will raise the blood sugar as much as about 20 g of carb, even when consuming the protein along with carbs. For example, when having a monster-sized steak and baked potato, you will need to count the carbs in the potato and then add 20 g to account for the protein in the steak. How Fat Figures In As mentioned in Chapter 3, consuming large amounts of fat can cause unusual and perhaps unwanted changes to blood glucose levels. For example, large amounts of fat in a meal can slow digestion to the point that rapid-acting insulin peaks before the food has a chance to digest. This can produce hypoglycemia soon after eating, followed by a blood sugar rise a few hours later. When consuming high-fat meals, bolus insulin may need to be delayed (we’ll discuss this in more detail in Chapter 7). Dietary fat can also cause another blood sugar rise hours after a meal. This is because fat in the diet can create insulin resistance, which forces the liver to secrete more glucose than usual. In Chapter 8, we’ll discuss strategies for preventing this type of rise. But even if you are successful at managing your blood sugar with high-fat meals, don’t forget that fat is very high in calories and tends to contribute to both unwanted weight gain and an increased risk of cardiovascular disease. So go easy on the fat intake—particularly saturated fats. E. Insulin Self-Adjustment By its very nature, diabetes management requires ongoing adjustment of insulin doses. Self-adjustment of insulin throughout the day and over longer periods of time is necessary to balance the factors that raise and lower blood sugar. Matching insulin to your precise needs is what your pancreas would do if it could. Thinking like a pancreas means doing what your pancreas would have done on its own. For starters, rapid-acting insulin doses should be adjusted based on: • premeal and presnack blood sugar levels • anticipated carbohydrate intake • changes to your usual sensitivity to insulin, which can be affected by physical activity stress hormonal changes illness medications • the direction the blood sugar is headed (as seen on a CGM device) In addition, adjustments should be made to your overall insulin plan (including basal insulin doses) in the event of growth, weight gain, lifestyle changes, or recurrent hypoglycemia or hyperglycemia. Insulin dosage adjustment and overall plan changes will be the focal point of the next th

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ree chapters of this book. 3. The Right Attitude Every week I come across someone who has everything they need to manage their diabetes—the latest high-tech toys, a great plan, and all the self-management education, training, and support in the world. Everything except the attitude to make it happen. This is a common situation among adolescents, but it can—and does—occur in people of all ages and with varying levels of diabetes experience. A healthy mental approach to living with diabetes is just as important as the tools and skills outlined above—perhaps even more important. See how you fare in the following areas. Determination Problem Solving Persistence Discipline Acceptance A. Determination Where exactly does diabetes management rank in your personal priorities? Although nobody would expect you to place your diabetes self-care above the immediate well-being of your family, it should hold a prominent place in your life—and with good reason. Managing your diabetes enables you to fulfill all your other obligations and enjoy what life has to offer. Think about it: If your diabetes is not in control, how will it affect you at work? At school? At home? At the gym? In bed? It’s like what they say on an airplane before takeoff (when nobody is listening): “In the event of an emergency, put on your own oxygen mask before assisting others.” You can’t do a very good job of taking care of anyone else unless you take care of yourself. Once you’ve made diabetes management a high priority in your life, your effort will naturally improve. B. Problem Solving There will be obstacles to taking care of your diabetes: time constraints, conflicting activities, access to care and equipment, other health issues, costs, and so on. But, as I like to say, when the going gets tough, the tough get solving. For example, if your health insurance is unwilling to pay for a product or service that you feel you need in order to manage your diabetes, appeal it. Contact your state’s attorney general’s office if you suspect that your insurance company is not complying with regulations. And if necessary, pay out of pocket if you can, or find a reasonable, more affordable alternative. You simply cannot put a price on your health. In other words, don’t just throw your hands up. Be a problem solver. C. Persistence Michael Jordan was one of the greatest basketball players of all time. Correct that. He was the greatest of all time. A prolific scorer, tenacious defender, and fierce competitor, Michael managed to win six NBA championships despite being undersized—he was a mere six-foot-six (small by today’s NBA standards)—and lacking a dominant “big man” in his supporting cast. But did you know that Michael “Air” Jordan, icon of the sports world, was cut from his high school basketball team as a freshman? Had young Michael chosen to throw in the towel and concentrate on baseball or—heaven forbid—his studies, he would have deprived himself and the rest of the world of his amazing talents. Persistence is a valuable trait in many aspects of life. From business to relationships to sports, persistence has a way of paying off in big ways. This is certainly the case when managing diabetes. Given the relentless nature of this disease, managing over the long term takes tremendous persistence. Over the course of your life with diabetes, there will be countless setbacks. When they occur, do not give up. It really helps to live your diabetes life one day at a time. You can’t change the past, so don’t worry about what you did—or didn’t do—yesterday. And you certainly can’t live tomorrow until tomorrow. Every day represents an opportunity for a fresh start. D. Discipline Despite being a general pain in the neck, some good things come from having diabetes. We can get seated in restaurants faster. We may be able to sneak past the long lines at amusement parks. And we also can develop a healthy sense of discipline. Being disciplined does not mean living like a robot. It means sticking to a plan even in the face of distraction and adversity—maybe not all the time, but certainly most of the time. And there is tremendous value to structure and consistency; it eliminates many of the variables that can mess up our diabetes management. Take, for example, avoiding “grazing”—even after Halloween, when there are little chocolate snacks everywhere. The benefits of spacing meals and snacks several hours apart are enormous. Discipline also comes into play with regard to physical activity. As we discussed in Chapter 3, physical activity can amplify the effects of insulin, sometimes for a full day or two. Those who exercise off and on usually have a harder time predicting how well their insulin will work. Those who maintain a consistent pattern of exercise tend to have more predictable insulin action. People who are disciplined about logging their diabetes information, monitoring glucose levels, counting carbohydrates, calculating insulin doses accurately, taking their insulin on time, and seeing health care providers regularly also tend to have more consistent blood sugar control and healthier lives over the long term. E. Acceptance Despite your best efforts, you will not be in perfect control of your diabetes all the time—and that’s okay. If a baseball player went to pieces every time she failed to get a hit, we would have a lot of .300 hitters sitting in the dugout crying. Set your expectations at a realistic level. Using the “acceptable range” Table 4-3 earlier in this chapter might serve as a good starting point. If you are currently in range 20 percent of the time, see if you can get it up to 30 or 40 percent by next month. And remember that even those with outstanding control are still out of range on a semiregular basis. To paraphrase Clint Eastwood’s Dirty Harry, “A person’s gotta know their limitations.” Accept that there are limits to what you can reasonably accomplish. Trying to change too many behaviors all at once usually leads to disappointment and burnout. Consider making a list of all the things you could be doing to improve your control and then prioritize them. Try to implement one at a time. For example, if you are just getting started on a new road to managing your diabetes more intensively, try implementing one key change each week: Week 1: Start checking your blood sugar before each meal and snack, and then write down the results. Don’t worry about what the numbers are—just check and record. Or check into obtaining a continuous glucose monitor. Week 2: Start using a formula to adjust your mealtime insulin doses based on your premeal/presnack blood sugar. Week 3: Begin looking up the carb counts in your foods and writing them down, along with your blood sugars and insulin doses. Week 4: Learn to adjust your insulin doses based on carbohydrate intake. Week 5: Start getting some daily exercise. Week 6: Learn to adjust your insulin doses for different forms of physical activity. Week 7: Try downloading your meter or CGM and evaluating the reports to see if adjustments to your dosing formulas are needed. Week 8: Send a batch of thank-you brownies to the author of your favorite diabetes book. (My address, incidentally, is 333 E. Lancaster Ave., Ste. 204, Wynnewood, PA 19096. Please don’t forget the rest of my staff. Our office manager is especially fond of dark chocolate!) Don’t forget that your diabetes records—including blood sugar levels—are simply pieces of data that you and your health care team can use to make competent decisions and fine-tune your management plan. These records are not for passing judgment on you as a person. As I tell my patients: “Any information is good information—regardless of the numbers.” When you look at your logs and downloaded reports, pretend you’re the health care provider evaluating someone else’s data. Don’t take anything too personally! Finally, memorize the Serenity Prayer. Don’t misunderstand: I am not a particularly religious person, but I know when something makes sense. The Serenity Prayer reminds us that not everything is within our control. To get upset over things beyond our control is a waste of time and effort. Instead, concentrate on the things you can control. We may not have the final say over what each blood sugar reading looks like, but we can improve our odds of a decent reading by doing the right things. A little bit of luck—or help from above—wouldn’t hurt either. THE SERENITY PRAYER God, grant me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference. CHAPTER HIGHLIGHTS • The HbA1c is an important test for assessing overall glycemic control, but not as important as spending lots of time within a healthy glucose range. • Establish target glucose ranges based on your personal goals, and strive to hit the targets as often as possible. • Successful diabetes management requires proper tools, strong self-care skills, and the right attitude. One or two won’t cut it—all three are necessary. • Proper tools include the appropriate insulin, an effective insulin-delivery device, a modern blood glucose monitoring system, and a supportive health care team. • Key self-management skills include appropriate self-monitoring, the ability to organize and analyze your own data, accurate carb counting, and the capacity to self-adjust insulin doses. • Attitude traits that contribute to success in diabetes self-care include determination, persistence, discipline, acceptance, and the ability to solve problems.FIVE The Basal/Bolus Approach We go together Like rama lama lama ka dinga da dinga dong. —Jim Jacobs and Warren Casey, “We Go Together,” from Grease So you’ve got everything in place to take on the diabetes beast. You have an entire closet dedicated to your state-of-the-art diabetes supplies. Your carb-counting skills rival those of the diabetes gods. You’ve even figured out how to download your meter. Now all you need is the right insulin program to make it all pay off. If you want to join the official Think Like a Pancreas Club, your insulin program needs to include the two Bs: basal (medical mumbo-jumbo for “background”) insulin, along with bolus (“bunches”) of insulin at mealtimes. Basal: The Blue-Collar Insulin The liver is a fascinating organ. It does about a hundred different things, but one of its main functions is to store glucose (in a dense, compact form called glycogen) and secrete it steadily into the bloodstream in order to provide your body’s vital organs with a constant source of fuel. This is what keeps your heart beating, brain thinking, lungs breathing, and gall bladder doing whatever it is gall bladders do, pretty much all the time. In order to transfer the liver’s steady supply of glucose into the body’s cells, the pancreas normally secretes a small amount of insulin into the bloodstream every couple minutes. This is called basal insulin (pronounced the same, but not nearly as tasty as the herb basil). Not only does basal insulin ensure a steady source of clean energy for the body’s cells, it also keeps the liver from dumping too much glucose out all at once. Too little basal insulin—or a complete lack of insulin—would result in a sharp rise in blood sugar levels. Basal insulin isn’t flashy. It just works in the background to match the liver’s secretion of glucose throughout the day and night. In the absence of food, exercise, and rapid-acting/mealtime insulin, basal insulin should hold the blood sugar nice and steady. Each person’s basal insulin requirement is unique. Typically, basal insulin needs are highest during the night and early morning, and they are lowest in the middle of the day. This is due to the enhanced insulin sensitivity that comes with daytime activity, along with the production of hormones that tell the liver to secrete extra glucose during the night when we’re not eating. Figure 5.1 illustrates how various hormones play a role in the liver’s glucose output. Two hormones in particular—cortisol and growth hormone—cause the liver’s natural ebb and flow in glucose secretion on a typical day. Figure 5.1: The influence of hormones on the liver’s glucose secretion Figure 5.2 shows typical basal insulin requirements for people with insulin-dependent diabetes. The chart is based on data from several hundred insulin pump users whose basal insulin levels were carefully adjusted and fine-tuned. Figure 5.2: Typical basal insulin levels by age group Although no significant differences were found in the basal insulin requirements for men and women, age does play a significant role. During a person’s growth years (prior to age twenty-one), basal insulin requirements tend to be relatively high throughout the night, drop through the morning hours, and gradually increase from noon to midnight. Most adults (twenty-one and older) tend to need more basal insulin during the early morning hours, followed by a drop-off until midday, a low level in the afternoon, and a gradual increase in the evening. The peak in basal insulin during the early morning hours is commonly referred to as a dawn phenomenon. These basal insulin patterns reflect the amount and timing of cortisol and growth hormone secretion within each age category. The youngest group (younger than ten) requires approximately 40 percent less basal insulin than those eleven to twenty, but the twenty-four-hour pattern of peaks and valleys is remarkably similar. The oldest group (over sixty) requires approximately 33 percent less basal insulin than those in the twenty-one to sixty age group, but they have a similar twenty-four-hour pattern. The reduced need in the older population is related to a reduction in overall hormone levels. Basal insulin patterns are dictated mainly by the production of hormones that increase the liver’s secretion of glucose. Basal insulin can be supplied in a variety of ways. Intermediate-acting insulin (NPH) taken once daily will usually provide background insulin around

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-the-clock, albeit at much higher levels four to eight hours after injection and at much lower levels after sixteen to twenty-four hours. NPH can also be taken twice daily to provide around-the-clock basal insulin, but with significant peaks four to eight hours after each injection. Detemir (Levemir) taken once daily provides background insulin for twenty to twenty-four hours, with a slight peak at six to twelve hours. Glargine (Lantus, basaglar) taken once daily or detemir taken twice daily provides relatively peakless insulin levels for about twenty-four hours. Degludec (Tresiba) and concentrated glargine (Toujeo) taken once daily provide steady levels of basal insulin for twenty-four to thirty-six hours. Insulin pumps deliver rapid-acting insulin in small pulses throughout the day and night. With a pump, the amount of basal insulin can be adjusted by time of day to match the ebb and flow in each person’s basal insulin needs. Combining various forms of long-acting insulin to simulate the body’s normal basal insulin secretion is also possible. The following figures illustrate the action profiles of various types of basal insulin programs. Basal Option A: Bedtime NPH The main advantage of this program is the peak that occurs during the predawn hours—useful to those who require large amounts of basal insulin at this time, but very low levels of basal insulin the rest of the day. The disadvantages include the unpredictable timing of the peak, the potential for hypoglycemia in the middle of the night or early morning, and the likelihood that that late afternoon or evening blood sugar will rise as the NPH from the night before wears off. Figure 5.3: Basal insulin supplied by NPH taken once daily at bedtime Basal Option B: NPH Twice Daily Taking NPH twice daily produces a peak in the middle of the night or early morning hours as well as in the middle of the day (to “cover” the carbs eaten at lunchtime). The drawbacks are the same as those described above for NPH taken once daily, plus the major issue of having to conform to a rigid meal/snack schedule during the day because of the peak of the morning NPH insulin. As Figure 5.4 clearly shows, this type of basal insulin program does a poor job of matching the body’s needs. It rarely produces stable glucose levels, particularly during the daytime. Figure 5.4: Basal insulin supplied by NPH taken twice daily, morning and bedtime Those who use premixed insulin twice daily are, essentially, utilizing this approach for their basal insulin program. Each injection of premixed insulin contains anywhere from 50 to 75 percent NPH insulin, with the remainder being either regular or rapid-acting insulin. Basal Option C: Detemir Once Daily For most people, taking detemir once daily fails to provide stable twenty-four-hour basal insulin coverage (see Figure 5.5). However, some find that detemir’s modest peak can help offset a middle-of-the-night or early-morning dawn effect, if timed properly. Figure 5.5: Basal insulin supplied by detemir (Levemir) taken once daily Basal Option D: Glargine or Degludec Once Daily, or Detemir Twice Daily Detemir can be taken twice daily in order to provide more stable twenty-four-hour basal insulin. When injected twice daily, it is best to split the doses evenly and take them approximately twelve hours apart. Taking more in the evening and less in the morning does not tend to produce a desired ebb/flow to the basal insulin. The main advantage of using detemir twice daily, or glargine or degludec once daily, is the relatively unwavering state of the basal insulin (see Figure 5.6). However, the blood sugar may rise during the night or early morning hours (when the liver tends to secrete extra glucose) or drop in the afternoon, as the basal insulin level may exceed the liver’s production of glucose. Some studies suggest that the longer, flatter profile produced by concentrated degludec (brand name Tresiba) results in less risk of hypoglycemia, particularly overnight. Figure 5.6: Basal insulin supplied by glargine once daily, degludec once daily, or detemir twice daily To overcome some of the pitfalls of only using long-acting or NPH insulin, it is possible to use both. A modest dose of glargine or degludec can provide around-the-clock background insulin (and not enough to cause the blood sugar to drop between meals during the daytime), and a modest dose of NPH in the evening can provide a basal peak to offset a nighttime or early-morning rise (see Figure 5.7). This program offers the unique advantage of allowing day-to-day adjustment of the overnight basal insulin level (by adjusting the NPH dose) without affecting the basal insulin level the following day. The disadvantages include the need for at least two separate injections (you can’t mix NPH and long-acting insulin in the same syringe or pen) and the filling of multiple prescriptions. There is also potential for mixing up doses or taking the wrong insulin at the wrong time because several different types of insulin are being used simultaneously. Figure 5.7: Combining long-acting basal insulin with NPH can provide a better match for those who need a basal peak overnight or in the early morning. Basal Option E: Insulin Pump Therapy Insulin pump therapy allows for the greatest degree of fine-tuning in terms of basal insulin. Because the pump uses pulses of rapid-acting insulin to deliver basal insulin, it is pretty easy to program basal peaks and valleys at various times of day (see Figure 5.8). Pumps also permit temporary changes to basal insulin levels in order to accommodate short-term changes in basal insulin needs (for situations such as illness, high/low activity levels, and stress). Certain patch pumps, such as the V-Go, deliver a constant or flat rate of basal insulin; the delivery rate cannot be altered by time of day, and temporary adjustments to delivery are not possible. Perhaps the greatest drawback to delivering basal insulin with a pump is the risk of ketoacidosis. Any mechanical problem resulting in a lack of basal insulin delivery can result in a severe insulin deficiency in just a few hours. Without any insulin in the body, cells begin burning large amounts of fat (instead of sugar) for energy. As a result, large amounts of acidic ketone molecules—a natural waste product of fat metabolism—build up. This rarely occurs when taking injections of long-acting insulin because there is almost always some insulin working (as long as injections are not missed). Figure 5.8: Basal insulin supplied by an insulin pump can match each person’s basal insulin needs quite closely. Bolus Insulin Basal insulin by itself would work just fine—if we never ate. Needless to say, bolus insulin is also necessary to deal with the blood sugar rise that occurs after eating. As discussed in the previous chapter, all carbohydrates (with the exception of fiber) eventually turn into glucose. Most carbohydrates take about ten to twenty minutes to start raising the blood sugar level and two to four hours to finish digesting. Usually, the blood sugar hits a high point (peak) thirty to ninety minutes after eating. Thus the need for bolus insulin for offsetting the effects of food and for bringing elevated blood sugars down as quickly as possible. Bolus Option A: Rapid Insulin Rapid-acting insulin analogs such as aspart (Novolog/NovoRapid), glulisine (Apidra), and lispro (Humalog, admelog) peak sharply about sixty to ninety minutes after injection. Rapid insulin can be used to cover meals and minimize postmeal blood sugar spikes when taken at the right times (usually ten to fifteen minutes prior to eating). Rapid insulin is particularly effective when consuming sugars and easily digesting starches such as bread, cereal, potato, rice, pastries, juices, and candies. Rapid insulin can also be used to bring elevated blood sugar levels back down to normal in about three to four hours. Bolus Option B: Ultra Rapid Insulin Insulin manufacturers continue to look for ways to make rapid-acting insulin work even faster, in order to eliminate the need for premeal dosing and correct high readings even more quickly. The first ultra-rapid insulin on the market, Fiasp from Novo Nordisk, starts working and peaks an average of eight minutes earlier than traditional aspart insulin. During the first hour after injection, Fiasp works 50 percent harder than traditional aspart, which results in less of a postmeal blood sugar peak. Fiasp is well-tolerated by most users, but some report mild site irritation. Pump users sometimes report inconsistent absorption after using Fiasp for a few months; the problem typically resolves when switching back to traditional aspart. Other companies are using creative approaches to make lispro insulin work faster, by combining it with ingredients that dilate blood vessels near the skin surface or “liquify” the subcutaneous fat layer to help accelerate the insulin’s absorption. With any ultra-rapid insulin, users must pay careful attention to the timing of their boluses—particularly with slowly digesting meals. Bolus timing will be discussed in greater detail in Chapter 7. Bolus Option C: Inhaled Insulin (Afrezza) Technosphere insulin, better known as Afrezza, is insulin in a dry power form. It is inhaled through the mouth and absorbs through the lungs directly into the bloodstream. This route of administration allows the insulin to reach the bloodstream much faster than delivering it into the subcutaneous fat layer. Afrezza starts working just a few minutes after inhalation, peaks in under an hour, and clears in about two hours. It is very effective for preventing postmeal blood sugar spikes, and it brings elevated readings down faster than injected (or pumped) insulin. It can usually be given when food is eaten without the need to predose. In fact, because it works and dissipates so quickly, many people find that their glucose level drops shortly after eating and then rises a few hours later (when food is still digesting but insulin is inactive). Delaying or splitting the dose of Afrezza into two inhalations (half with the meal, half an hour or two later) can eliminate this problem. On the downside, Afrezza inhalation is technique-dependent. Using improper technique or coughing after inhalation (which is common for some people) can result in underdosing. And speaking of dosing, it is next to impossible to dose Afrezza in very small increments. The cartridges used for inhalation are labeled as 4, 8, and 12, but they tend to have the efficacy of approximately 2.5, 5, and 7.5 units of injected or pumped insulin. So essentially, it is feasible to dose in 2.5-unit increments, and more than one inhalation is required for doses in excess of 7.5 units. When converting from injected or pumped units to Afrezza units, it is necessary to multiply by approximately 1.6 (5 units injected would be the same as about 8 units of Afrezza, which would be rounded down to 7.5). Additionally, little is known about the long-term effects of inhaled insulin on the lungs. Lung function has been shown to decline very slightly (almost unnoticeably) with use of Afrezza, so users assume a small amount of risk. A basic lung function test is required before starting Afrezza to rule out underlying lung problems. Bolus Option D: Regular Insulin Regular insulin, which is identical to the insulin produced by the pancreas, usually takes thirty minutes to begin working and peaks two to three hours after injection. Why so slow? Ordinarily, insulin produced by the pancreas is secreted directly into the bloodstream and works almost instantly. Injected regular insulin takes so much longer to work because it gets hung up in the fat layer below the skin. Because of its relatively slow (and inconsistent) peak and long duration of action (up to six hours), regular is not the preferred insulin to use at mealtimes for most people. When regular insulin is used, blood sugars after meals tend to spike very high and then plummet several hours later. Taking regular insulin thirty to sixty minutes before a meal helps to reduce the peak, but this is rarely practical. And the prolonged action curve of regular insulin means that there is almost always overlap of doses (also called “stacking”), which can produce hypoglycemia. However, regular insulin can still play a role at mealtimes, particularly when consuming very slowly digesting foods as well as for people with a form of neuropathy called gastroparesis (which causes abnormally slow digestion). Bolus Option E: NPH Insulin Okay, there is one option worse than regular insulin for covering meals. Intermediate-acting insulin (NPH) is sometimes used to cover a meal or snack that will be consumed four to six hours later. For example, NPH taken at breakfast can be used to cover the carbohydrates eaten at lunch. This may be the only option available to someone who is dependent on a caregiver to administer insulin and the caregiver is not available at lunchtime, such as a young child attending a school with limited nursing resources. However, because of the timing of its action, NPH taken in the morning has a tendency to cause the blood sugar to drop before lunch. And because of its broad peak, the blood sugar after lunch can peak extremely high, particularly when consuming rapidly digesting foods. Figure 5.9 compares the various mealtime insulins to the blood sugar rise that follows typical carbohydrate-containing meals and snacks. As you can see, the rapid and ultra-rapid insulins provide the closest match. Putting Them Together Selecting the best insulin program to meet your needs depends on a number of factors. If you have type 2 diabetes or LADA, or if you are in the honeymoon phase of type 1 diabetes, your pancreas may produce sufficient amounts of insulin to meet either your basal or your bolus needs, but usually not both. A laboratory test called a C-peptide can be performed to see how much insulin your pancreas produces on its own. Figur

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e 5.9: Bolus insulin options If you still produce some of your own insulin, you can determine your general insulin requirements by doing the following: • Check your glucose level at bedtime, have no snack, and then check again first thing in the morning. If your glucose rises more than 30 mg/dl (1.7 mmol/l) while you sleep, your pancreas is not making enough insulin to cover your basal needs; you will require basal insulin. • Check your glucose before a meal and again sixty to ninety minutes after eating. If your glucose rises more than 60 mg/dl (3.3 mmol/l) from premeal to postmeal, you will probably need bolus insulin at that meal. For example, if you were 120 (6.7) before breakfast and 200 (11) after breakfast, bolus insulin is probably needed at that meal. • If your glucose is elevated before and after meals, a combination of both basal and bolus insulin should do the trick. If you have type 1 diabetes or have type 2 and are in need of an aggressive insulin regime, you will need to utilize a program that combines both basal and bolus insulin. To select the basal/bolus insulin program that best meets your needs, it can be helpful to compare the benefits, drawbacks, and features of the various programs side by side. Since different features are important to different people, here is my “Consumer Reports” guide to the available basal/bolus insulin programs. Table 5-1. Gary’s Non-Copyright-Infringing Comparison of Basal and Bolus (B&B) Insulin Programs Note: MDI = multiple daily injections (or inhalations) of bolus insulin * B&B Option 1: (Pre)mixed Insulin Twice Daily Pre-breakfast: NPH and rapid insulin (in premixed formulation or combined manually) Pre-dinner: NPH and rapid insulin (in premixed formulation or combined manually) Figure 5.10: The action profile of NPH and rapid insulin taken twice daily This was a common insulin program back in the 1970s and ’80s, with regular insulin instead of a rapid-acting analog combined with NPH. It can be delivered using premixed insulin (70/30 or 75/25) in pen or vial/syringe form, or the user can combine the two in a syringe manually. The premixed formulations have a major shortcoming in that you cannot change the proportion of intermediate to rapid insulin. If you need more rapid insulin, you must also take more intermediate (NPH) insulin, and vice versa. With the morning NPH insulin peaking in the afternoon, you must consume meals and snacks at specific times and in specific amounts. Changes to your usual schedule can lead to high or low glucose levels. Exercise during the day can also produce lows with this type of insulin schedule, unless you consume extra carbohydrates. The evening NPH insulin peaks around midnight and dissipates as dawn approaches, predisposing most users to low blood sugar in the middle of the night and highs at wake-up. Perhaps the only advantage to this program is the ease of administration. Only two injections per day are required, and premixed formulations eliminate the possibility of accidentally taking the wrong type of insulin. Taking NPH insulin twice daily also virtually guarantees that some basal insulin is always present, thus minimizing the risk of ketoacidosis. Taking two doses of premixed insulin has obvious drawbacks and limitations. However, it may prove practical for those who are unwilling or unable to utilize a more sophisticated program safely and consistently. B&B Option 2: Morning NPH and Bolus, Evening Bolus, Bedtime NPH Morning: NPH and bolus insulin Dinner: bolus insulin Bedtime: NPH insulin Figure 5.11: The action profile of NPH taken morning and bedtime, and bolus insulin taken at breakfast and dinner There are a few differences (and improvements) between this program and Option 1. The user mixes the morning dose manually (rather than using premixed insulin), so you can adjust the bolus dose based on the amount of carbohydrates consumed. Likewise, the dinner bolus insulin is not part of a premixed formulation and can be adjusted as needed. By moving the evening NPH from dinner to bedtime, the peak is shifted to early morning (around the time of the dawn phenomenon), thus improving the chances for stable glucose levels during the night and early morning. Otherwise, disadvantages still abound. You must structure and monitor midmorning, midday, and afternoon food intake and physical activity carefully. You have little schedule flexibility. And you still have morning and evening injections of NPH that you must take on schedule but whose action profiles may vary from day to day. This program may be of some practical use to those who depend on a caregiver to administer insulin injections. If the caregiver is unavailable to administer insulin in the middle of the day (such as during the school day), you can utilize the morning NPH to offset the glucose rise from midday meals and snacks (albeit not very effectively). B&B Option 3: Bedtime NPH plus MDI Breakfast: rapid (or ultra-rapid or inhaled) insulin Lunch: rapid (or ultra-rapid or inhaled) insulin Dinner: rapid (or ultra-rapid or inhaled) insulin Snacks: rapid (or ultra-rapid or inhaled) insulin Bedtime: NPH Figure 5.12: The action profile of NPH taken at bedtime and bolus insulin taken at each meal and snack Now we enter that zone we call multiple daily injection or inhalation (MDI) therapy. People used to go to great lengths to avoid taking more injections, but then reality set in. Insulin injections (or inhalations) are probably the easiest thing about living with diabetes. An MDI program allows for a highly flexible lifestyle with better glucose control, all at the small price of a few extra virtually pain-free boluses each day. Pens or inhalers are a great tool for those needing bolus insulin several times daily. With this type of MDI program, NPH insulin taken at bedtime provides a nighttime/early-morning peak to cover the dawn phenomenon as well as a prolonged tail of action that ensures the presence of at least some basal insulin through most of the day. However, the peak and duration of NPH can vary from day to day, putting the user at risk for unanticipated high or low blood sugar levels in the morning. Furthermore, the tapering action of the insulin in the afternoon and evening may result in a blood sugar rise between meals late in the day. This type of plan requires bolus insulin at every meal and snack, although snacks that are very low in carbohydrates may not require a bolus. What qualifies as a “free” snack (not requiring insulin) varies from person to person. In general, the smaller your body size, the more sensitive you will be to each gram of carbohydrate. For example, someone who weighs 250 pounds (120 kg) might be able to tolerate 10 grams of carb without needing any insulin, but someone who weighs 50 pounds (24 kg) might need insulin for as little as 3 to 5 grams of carb. Taking bolus insulin with each meal and snack restores freedom of choice because the doses can be matched to the amount of carbohydrate being eaten. It also allows adjustments for physical activity as well as timely corrections for glucose readings that are above target. Details about fine-tuning mealtime doses of insulin will be covered in Chapter 7. B&B Option 4: Long-Acting Insulin plus MDI or Basic Mechanical Pump Morning or evening: glargine or degludec or Morning and evening: detemir and Breakfast: rapid (or ultra-rapid or inhaled) insulin Lunch: rapid (or ultra-rapid or inhaled) insulin Dinner: rapid (or ultra-rapid or inhaled) insulin Snacks: rapid (or ultra-rapid or inhaled) insulin or Basic mechanical pump Glargine or degludec once daily, or detemir twice daily, provides a steady level of basal insulin around-the-clock, as does a basic mechanical pump that delivers steady pulses of rapid-acting insulin. Figure 5.13: The action profile of long-acting insulin taken once or twice daily as well as bolus insulin taken at every meal and snack, or a basic mechanical pump Use of injected basal insulin or a basic mechanical pump has its pros and cons. The consistent and predictable insulin absorption and lack of a true peak minimizes the risk of hypoglycemia, although glucose levels may tend to drop gradually between meals during the daytime hours because the dose is usually set to meet the higher basal needs that exist during the night. The lack of an overnight/early-morning peak may not be optimal for those with increased basal needs overnight or a pronounced dawn phenomenon. As with any MDI program, injections or inhalations of bolus insulin are necessary with every meal and snack. And unlike NPH, which can be mixed in the same syringe with rapid-acting insulin, glargine, degludec, and detemir must be injected separately from rapid insulin. Those using a basic mechanical pump must remember to use the pump’s delivery buttons to administer insulin with each meal and snack. B&B Option 5: Long-Acting Insulin and Bedtime NPH plus MDI Morning or evening: glargine or degludec or Morning and evening: detemir and Bedtime: NPH and Breakfast: rapid (or ultra-rapid or inhaled) insulin Lunch: rapid (or ultra-rapid or inhaled) insulin Dinner: rapid (or ultra-rapid or inhaled) insulin Snacks: rapid (or ultra-rapid or inhaled) insulin Figure 5.14: The action profile of basal insulin taken in the morning and/or evening, NPH taken in the evening, and bolus insulin taken at each meal and snack Despite requiring the most injections (two to three shots of basal insulin daily plus rapid-acting insulin at each meal and snack), this program comes about as close as one can get to thinking like a pancreas when using injections instead of a pump. A low dose of injected basal insulin (glargine, degludec, or detemir) maintains relatively steady glucose levels between meals during the day, and a nighttime dose of NPH offsets the dawn phenomenon in the middle of the night and early morning. The dose of NPH can be adjusted based on factors that might influence overnight glucose levels, such as illness, heavy exercise during the day, and high-fat meals late in the day. For those with a pronounced dawn phenomenon and a need for very flexible dosing of both basal and mealtime (bolus) insulin, this program might work quite well. B&B Option 6: Full-Feature Insulin Pump Therapy As described in Chapter 4, full-feature insulin pumps are battery-powered devices that infuse rapid-acting insulin just below the skin. Pumps are programmed to deliver tiny pulses of insulin every few minutes throughout the day and night (the basal insulin) along with larger doses at mealtimes (the bolus insulin). The insulin is delivered by way of a small, flexible plastic tube or a tiny needle called an infusion set. The infusion set must be changed every couple of days in order to prevent clogging and infection as well as to ensure consistent insulin absorption. Figure 5.15: The type of action profile achievable with insulin pump therapy The infusion set is usually worn on the abdomen, buttocks, arm, or thigh. The infusion set adheres securely to the skin. All tubed pumps feature a disconnect mechanism that allows the user to temporarily set the pump and tubing aside for situations such as bathing, contact sports, and intimacy, all while leaving the infusion set portion on the skin. All pumps are either waterproof or water resistant, and they come with clips that let you attach them to a belt or waistband. A variety of cases, pouches, and fashion accessories make the pump easy to wear in almost any situation. (See Chapter 10 for a list of companies that offer pump accessories.) For those who prefer not to spend their spare time doing math, pumps have built-in bolus calculators. Enter your blood sugar level and the grams of carbs you plan to eat, and the pump recommends a precise dose based on the dosing formulas you and your health care team set up in the pump. The calculation includes a deduction for “insulin on board”—insulin that is still working from previous boluses. Each pump keeps a record of all this information in its memory for on-screen recall or downloading to a computer or web-based program. Some insulin pumps receive data via radio transmissions from blood glucose meters, thus eliminating the need to manually enter the reading when performing a bolus calculation. Some also receive and display data from a continuous glucose monitor. One unique aspect of full-feature pump therapy is the ability to fine-tune and adjust basal insulin levels throughout the day and night. For example, if you need more basal insulin in the morning and less in the afternoon or evening, you can program this into the pump. By matching basal insulin to the liver’s normal output of glucose, glucose levels should hold steady between meals and during the night. As a result, you can vary your schedule as much as you like in terms of meals, activities, and sleep (imagine: a more “normal” life!). You can also adjust basal insulin levels on the fly for circumstances such as menstrual cycles, pregnancy, stress, illness, travel, high-fat meals, and extended exercise. One unique aspect of full-feature pump therapy is the ability to fine-tune and adjust basal insulin levels throughout the day and night. With insulin pumps, you can administer mealtime insulin at the touch of a button—actually, a sequence of button presses (accidental bolusing is virtually impossible). The doses are highly precise. Some pumps permit dosing in increments as low as one-fortieth of a unit. All pumps offer the option of delivering mealtime boluses all at once or over an extended period of time—in case you expect your meal to take a while to digest. Benefits of full-feature pump therapy include: 1. Better blood sugars. First and foremost, pump users tend to have lower A1cs and less glucose variability (fewer high-to-low and low-to-high swings) than those on injections. 2. Fewer lows. By using only rapid-acting insulin, there is no long-acting insulin peaking or working too hard at inappropriate times. This

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makes pump therapy a good choice for those who have frequent lows, a history of severe lows, or a hard time detecting low blood sugars. 3. A more flexible lifestyle. Raise your hand if you can eat, sleep, and exercise at the same times every day. The pump lets you choose your own schedule. 4. Dose calculations. Pumps come equipped with a bolus calculator that helps you determine mealtime doses based on carb intake, blood glucose levels, and the amount of insulin still active from previous boluses. Imagine: no math! 5. Precise dosing. Pumps deliver insulin to the nearest 0.1, 0.05, or 0.025 units—ideal for those who are sensitive to very small doses, such as children and lean or active adults. 6. Convenience. There is no need to draw up syringes or inject with a pen every time you need insulin; just reach for your pump and press a few buttons. 7. Data analysis. Insulin pumps store a ton of historical information that can be displayed on the pump’s screen or transmitted to a computer programs for analysis and fine-tuning. Potential drawbacks to pump therapy include: 1. Cost. Although most insurance plans cover insulin pumps and supplies, there are often copays and deductibles that must be met. 2. Learning curve. When starting on an insulin pump, don’t expect good control right away. You may need a few weeks or months to get the basal and bolus doses properly regulated. 3. Inconvenience. Wearing the pump around-the-clock, even during sleep, can be awkward once in a while. Patch pumps take their share of bumps, and tubing seems to love getting caught on doorknobs and drawer handles. 4. Technical difficulties. As mechanical devices, pumps are prone to occasional infusion set clogs, electronic failures, computer glitches, or damage due to typical wear and tear. A backup plan (in the form of a second pump or programmer and a way to revert back to injections) is an absolute necessity. 5. Skin problems. Skin can sometimes become irritated from infusion set adhesive, and infections can occur if infusion sets are worn too long or inserted improperly. Insulin absorption can be hindered if you do not change infusion sets regularly and rotate sites properly. 6. Ketosis. The absence of long-acting insulin with pump use can present a problem if insulin delivery is interrupted for more than a few hours. Blood sugar can rise very quickly, and ketones may appear in the bloodstream and urine if the problem is not detected and corrected in a timely manner. 7. Infusion set changes. Every couple of days you must change your own infusion set. This three-to-five-minute procedure involves numerous steps and can be momentarily uncomfortable or challenging for some pump users. Just about anyone with insulin-dependent diabetes and a decent insurance policy can go on an insulin pump. But to succeed with a pump takes preparation and follow-through. I consider the following to be essential prerequisites for anyone seeking an insulin pump: • motivation and interest in going on a pump, keeping in mind that nobody is 100 percent sure that it is right for them until they give it a try; a bit of hesitancy and anxiety about making the switch to a pump are perfectly normal • a true state of insulin dependence (type 1 or type 2, with little or no internal or pancreatic insulin production) • adequate resources to afford the pump and ongoing supplies (via insurance or cash) • ability to handle basic programming and infusion set changes; a guardian or caregiver can do this if the user is very young or has physical or cognitive disabilities Certain skills are essential for making a successful transition to pump therapy. The following should be mastered prior to starting on the pump: • carbohydrate counting (using grams rather than exchanges) • blood glucose monitoring at least four times a day, or use of a continuous glucose monitor • record keeping in paper or electronic form (including blood sugars, insulin doses, carb intake, and physical activities) • self-adjustment of insulin doses (based on blood sugar levels, carb intake, and physical activity) • an understanding of the basic principles of pump therapy (including the components of a pump and infusion set as well as the role of basal and bolus insulin) Successful pump use will also require adequate follow-up and fine-tuning. This should include: • basal rate testing throughout the day and night • fine-tuning of bolus formulas • troubleshooting and preventing emergencies such as DKA (diabetic ketoacidosis) • using advanced pump features such as extended boluses and temporary basal rates B&B Option 7: Hybrid Closed-Loop (HCL) Systems HCL systems are really an extension of full-feature insulin pump therapy, whereby the pump receives data from a continuous glucose monitor and has a built-in computer program that adjusts basal insulin delivery automatically every few minutes based on: • the current glucose level • the rate of rise or fall in the glucose level • the amount of insulin on board • each individual’s sensitivity to insulin HCLs have the potential to benefit many people with diabetes, but they are not for everyone. While they have the potential to improve glucose control for most people, they can also lead to a worsening of control for those who have managed to achieve very tight management on their own. And some systems add considerable work and disruption to an already demanding health condition, so it is important to weigh the benefits against the drawbacks before deciding whether HCL is right for you or which system is best for you. Think of it this way: What’s the purpose of a diabetes management device? Is it to lower A1c? Prevent hypoglycemia? Spend more time in range? Some combination of all three? Don’t forget to look beyond blood sugar control. After all, quality of life has to count for something. Does it make living with diabetes safer and easier? Since HCLs make adjustments based on data received from the linked glucose sensor, it is important that the sensor perform as well as possible. Accuracy is probably the most important characteristic of a CGM system. Currently, of all CGMs that link with HCLs, Dexcom G6 offers the best accuracy, followed by Medtronic Guardian and then the Freestyle Libre. Ease of use is another key feature. Dexcom and Libre are both highly regarded for their ease of use: neither requires fingerstick calibration, and both are very simple to insert. The computer algorithm is the second key component of an HCL system. Those found in the DIY (do-it-yourself?) systems such as the Loop app and Open APS are highly customizable. Others are very conservative and do not allow the user to customize most of the settings. The frequency of alarms or alerts and fingerstick calibration requirements also vary from system to system, with DIYs generally producing the least amount of disruption. However, before jumping to a DIY system, be aware that “off the grid,” non-government-approved systems are not ideal for everyone. The user must obtain special devices such as old, hackable insulin pumps, carry extra transmission equipment, build their own programming app, and seek out help on their own in the event of technical glitches. For those who can get past these challenges, the DIY systems can produce tighter control with a highly pleasant user experience. The insulin pump is the third component of an HCL. Clearly, not all pumps are ideal for all people. Since the pump is something that you will interact with and have attached to you just about all the time, consider the size, features, and usability of the pump when considering the various HCL systems. The good news is that some companies are moving toward HCL systems with interoperable or modular components. We should soon have the ability to choose a pump from one company, a CGM from another, and a computer algorithm from another, and have them all work together. Any HCL algorithm allows the user to revert back to manual management on demand. In fact, users may see better results in manual mode when advanced pump features such as extended boluses or temporary basal rates are needed (these features may not be available when HCL is running). In addition, any time the system isn’t performing just right, it will dump the user back into manual mode by default. Therefore, it is important that the manual mode settings be optimized before beginning to use an HCL system. Fine-tuning basal and bolus settings will be discussed in detail in the chapters that follow. Overall, HCL systems do a pretty good job of fixing rising and falling blood sugars overnight or any time meals/boluses are spaced many hours apart. The overnight control, in particular, can be a godsend for those in need of a good night’s sleep. It reminds me of a large ocean liner that’s put on autopilot so the captain can catch some Zs. If the ship veers off course slightly, the autopilot system gets the ship back on track so that it reaches its intended destination by morning (see Figure 5.16). Figure 5.16: HCLs are like autopilot on a ship—capable of making subtle adjustments in order to keep things reasonably on course. However, when a big ship is moving at a high speed, a small rudder will not allow it to change directions quickly enough to avoid things like icebergs (this is what happened to the Titanic). Everyone who lives with diabetes knows about the hour-to-hour, minute-to-minute challenges we must contend with. These are the icebergs—the things the system must navigate around in order to prevent extreme highs and lows. Essentially, anything that can cause a rapid, abrupt rise or fall in glucose levels represents an iceberg. Remember, we’re dealing with a huge, fast-moving ship with a small rudder. The pump’s basal adjustment just isn’t powerful or responsive enough to prevent high and low glucose levels when confronted with: food (particularly rapidly digesting carbohydrates) physical activity (particularly heavy exercise) stress (particularly sudden, unexpected crises) sudden hormone changes (resulting from injuries or trauma, rebounds from lows) rapid-acting insulin (administered for food or corrections) Bottom line: even with an HCL system in place, you’ll still need to apply your own self-management skills on a regular basis. Users must still count their carbs, adjust for physical activity and stress, and so on. They must also take precautions to prevent anything that can interfere with normal pump and insulin function, such as absorption issues, air in the tubing, displaced or kinked infusion sets, insulin spoilage, and unintended disconnection. So who is the ideal candidate for an HCL system? To succeed with an HCL, one must: have conservative glucose management goals (unless using a DIY system) put in extra work upfront and be willing to tolerate extra alarms or alerts possess some technical aptitude be willing to delegate some decision making to the system lead a relatively structured life (the fewer “icebergs,” the better HCL performs) Substitution Is Permitted When selecting an insulin program, don’t think of it as a lifetime commitment. Many people switch plans because of changes to their lifestyle or when they come to the realization that their current program is failing to do the job. Several of my clients have tried an MDI program but were unable to achieve the kind of control they wanted, so they made the move to a pump. I have also had pump users switch back to injections, either permanently or temporarily, because of image concerns, convenience, or the desire for more structure in their lives. The one constant in life is change—you are not locked into any particular plan. And what if your physician doesn’t agree with the program you choose? Ask why. Perhaps they have a good argument that will sway your decision. If not, you might want to look for another health care provider. After all, this is your diabetes, and you deserve the right to choose the management approach that suits you best. CHAPTER HIGHLIGHTS • For an insulin program to be successful, it should include both basal and bolus insulin. • Bolus insulin may be supplied in the form of regular, rapid, ultra-rapid, or inhaled insulin. • Basal insulin may be supplied in the form of NPH, glargine/detemir/degludec, or insulin pump therapy. Pump therapy usually provides the best basal insulin coverage. • Hybrid closed-loop systems combine an insulin pump, continuous glucose monitor, and computer program to automatically self-adjust the basal insulin around-the-clock. • Various combinations of basal/bolus therapy are possible, each with its own pros and cons. Choose the one that will best meet your personal needs.SIX Basal Insulin Dosing A kind and steady heart can make a grey sky blue, And a task that seems impossible is quite possible for you. —Peter Gabriel, “That’ll Do” Once you have settled on an insulin program that meets your needs, the next order of business is to determine the right doses. Think of yourself as a giant lump of clay that needs to be molded and sculpted into fine art. (My personal self-sculpture is a cross between Rocky Balboa and Bond, James Bond.) Any artistic creation takes time, so be patient. Make one adjustment at a time, evaluate the results, and then fine-tune before moving on. Another truism about fine art: beauty is in the eye of the beholder. What works for some may not work for others. When looking at dosing patterns and formulas, use them only as starting points. Individual needs may—no, will—vary. Let’s start with the fine-tuning of basal insulin. Basal insulin serves as the foundation for your entire insulin program. With a solid foundation, you can build something great. With a cracked or crooked foundation, you will struggle to get anything to work right. In diabetes terms, it is difficult to know what is causing out-of-range blood sugars unless you have already established the proper basal insulin levels. That’s why Chapter 6 comes before Chapter 7: it’s best to

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fine-tune your basal doses before attempting to regulate the mealtime or bolus doses. It’s best to fine-tune your basal doses before attempting to adjust the mealtime or bolus doses. In the previous chapter, I presented typical basal insulin profiles for people within different age groups. During a person’s growth years (prior to age twenty-one), basal insulin requirements tend to be highest throughout the night. This is due to the production of hormones (primarily growth hormone and cortisol) that stimulate the liver to release extra glucose into the bloodstream. Following one’s growth years, the production of these hormones is limited primarily to the predawn hours, causing the liver to secrete extra glucose just in the early morning—the dawn phenomenon. Initial Basal Doses for Those Injecting Insulin The body’s insulin requirements are affected by a number of factors, including body size, activity level, stage of growth, and the amount of endogenous (internal) insulin production from your pancreas. To find out how much insulin your pancreas is producing, the C-peptide test can be performed. C-peptide is a C-shaped molecule attached to insulin when it is first secreted from the pancreas. The combination of insulin and the C-peptide is called proinsulin. Enzymes in the blood break the C-peptide away from proinsulin, leaving two parts: the active insulin molecule and the C-peptide. By measuring the amount of C-peptide in the blood, you can determine approximately how much insulin the body is making on its own. A C-peptide of less than 0.5 nanogram per milliliter (ng/ml) indicates that the pancreas is producing very little insulin. Many people with type 1 diabetes still produce a tiny, insignificant amount of their own insulin, so the C-peptide is typically low but may not be zero. To determine an initial basal insulin dose, it is necessary to estimate total daily insulin requirements first. For those with type 2 diabetes who are still producing some of their own insulin, the total daily insulin requirement is often less than 0.5 units per kilogram of body weight (0.2 units per pound) on a daily basis. However, this can vary depending on your body’s sensitivity to insulin (or lack thereof). For instance, a person with type 2 diabetes who weighs more than 250 pounds (113 kg) and is very insulin resistant might require more than 100 units of insulin each day, whereas someone who weighs less and is only modestly insulin resistant might require only 10 or 20 units of insulin daily. For individuals who produce virtually no insulin on their own (including people with type 1 diabetes), total daily insulin requirements are more predictable. Table 6-1 provides typical ranges for total daily insulin needs. * For instance, if you are a moderately active adult, you will likely require 0.50 to 1.0 unit of insulin per kilogram of body weight per day. If you weigh 160 pounds, that equals approximately 73 kilograms (lbs x 0.454 = kgs). Your total daily insulin need should be in the range of 37 (73 x 0.50) to 73 (73 x 1.0) units per day. Given that basal insulin usually accounts for 40 to 50 percent of a person’s total daily insulin needs (50 to 60 percent covers food), basal insulin doses typically fall within the ranges shown in Table 6-2. Keep in mind that the proportion of insulin used for basal will be greater for those following low-carb diets and lower for those who eat large amounts of carbohydrates. Basal insulin needs also tend to drop as we pass from middle to older age, as reflected in the table. * Before your head explodes from too much math, let’s look at an example. Debbie is a thirty-eight-year-old teacher who has type 1 diabetes. She weighs 136 pounds, exercises for an hour every day, and is fairly active in her job. First, we must convert her weight into kilograms (lbs x 0.454 = kg). 136 x 0.454 = 62 Because Debbie is an active adult, she requires 0.15 to 0.40 unit of basal insulin for every kilogram she weighs. 62 x 0.15 = 9 units 62 x 0.40 = 25 units Debbie should require somewhere between 9 and 25 units of basal insulin daily. It is generally a good idea to start out toward the low end of the dosing range and adjust upward gradually, so she and her physician opt to start conservatively with 10 units of basal insulin. Let’s take another example. Ben is a teenager with type 1 diabetes who gets a moderate amount of exercise and weighs 105 pounds. According to Table 6-2, he will likely require between 0.30 and 0.70 unit of basal insulin per kilogram of body weight per day. His weight in kilograms: 105 x 0.454 = 48 48 x 0.30 = 14 48 x 0.70 = 34 Ben and his physician elect to start in the middle, with 25 units of basal insulin. One more example: Jackie is sixty-eight years old and has poorly controlled type 2 diabetes. Her physician has recommended that she add basal insulin to her current medication program. She weighs 210 pounds and gets very little exercise. Her weight in kilograms: 210 x 0.454 = 95 According to Table 6-2, she will likely require between 0.20 and 0.50 unit of basal insulin per kilogram of body weight. 95 x 0.20 = 19 95 x 0.50 = 48 Given that Jackie is insulin resistant and has very high blood sugar at present, she and her physician choose to start with a dose of 40 units of basal insulin. Fine-Tuning Injected Basal Insulin When injecting basal insulin, the goal is to find a dose that maintains steady blood sugar levels through the night (or while sleeping, for those who work night shifts). Ideally, the doses of injected long-acting or intermediate-acting insulin should not cause the blood sugar to rise or fall more than 30 mg/dl (1.7 mmol/l) while you sleep—assuming that before you go to sleep you do not eat, take rapid-acting insulin, or perform heavy exercise. The right dose of injected basal insulin should keep the blood sugar steady through the night. A frequent rise or fall of more than 30 mg/dl (1.7 mmol/l) indicates a need to change the basal insulin dosage. To determine whether your basal insulin dose is set correctly, follow this procedure: 1. Take your usual dose(s) of long-acting/basal insulin at the usual time(s). 2. If you take rapid-acting insulin at dinner, take your usual dose, and have a fairly healthy dinner without too much fat. Avoid restaurant and take-out food, since high-fat food will cause a prolonged blood sugar rise and will alter the test results. 3. Do not have any calories or take any more bolus insulin after dinner. Calories of any kind (even those coming from fat or protein) can affect blood sugar, so don’t consume anything other than water or diet beverages after dinner. 4. If you normally exercise after dinner, go ahead and do so, but keep the intensity and duration modest. Very heavy exercise may cause the blood sugar to drop several hours later, which would also influence the test results. 5. If you use a CGM that requires calibration, calibrate within four hours after dinner and then not again until morning. You can use your CGM trend graph to evaluate your overnight pattern. If you do not use a CGM, check your blood sugar with a fingerstick four hours after dinner, once in the middle of the night (or the middle of your sleep time), and first thing in the morning. The middle-of-the-night reading is needed to rule out a potential Somogyi phenomenon (see examples that follow). If your glucose level dips below 80 (4.4) at any time after dinner, eat a snack, and try the test another night. If your glucose is above 250 (13.9) four hours after dinner or at any point during the night, give a correction dose of rapid-acting insulin, and try again another night. If you repeatedly have high or low readings at bedtime that keep you from beginning the test, consider making an adjustment to your dinnertime food choices or insulin dose. Now you can evaluate your data. If your blood sugar rises or falls less than 30 mg/dl (1.7 mmol/l) from bedtime to wake-up time, congratulations! Your basal insulin dose looks good. If it rises more than 30 mg/dl (1.7 mmol/l), increase your basal insulin dose by 10 percent, and repeat the test. If it falls by more than 30 mg/dl (1.7 mmol/l), decrease your basal insulin by 10 percent, and repeat the test. Continue adjusting and repeating the test until your blood sugar holds reasonably steady through the night. For example, let’s say you’re taking 10 units of detemir in the morning and 10 units in the evening. If your bedtime blood sugar reading was 87 mg/dl (4.8 mmol/l), 135 (7.5) at 3 a.m., and then 151 (8.4) at wake-up—a rise of 64 (3.6)—an increase in the basal insulin dose would be necessary. Raise the detemir dose to 11 units (both morning and night), and run the test again. Let’s say your CGM trend graph through the night looks like the one in Figure 6.1. The glucose level dropped from approximately 160 (9.1) at bedtime to around 70 (3.9) by morning—a fall of about 90 (5) points. This would require a 10 percent reduction in the basal insulin dose followed by a repeat of the overnight test. Figure 6.1: Overnight CGM trend graph If your bedtime reading was 95 mg/dl (5.3 mmol/l) and 94 (5.3) at 3 a.m., and you woke up at 77 (4.3), shout, “Woo-hoo!” The current basal insulin doses are good since the blood sugar changed by only 18 mg/dl (1 mmol/l) through the night. Attack of the Killer Somogyi What about that pain-in-the-neck reading you took in the middle of the night? No one likes having their sleep interrupted (unless, of course, your hot partner is looking for some action). So that extra reading had better be worth it. Believe me, it is. Sometimes, a blood sugar drop during the night—particularly to below 70 mg/dl (3.9 mmol/l)—causes the body to secrete hormones that raise the blood sugar by morning, all without your knowledge. In the medical community this is known as the Somogyi phenomenon (named after its discoverer). Gone undetected, it can lead to incorrect basal dosing decisions. Consider the following example, illustrated in Figure 6.2 below. Larry and his two brothers, Daryl and Darryl, all have diabetes (now there’s a gene pool to avoid). They each take glargine for their basal insulin. Each finishes the night with a blood sugar that is higher than what it was at bedtime. Without knowing what happened to their blood sugar in the middle of the night, our first instinct would be to increase the basal insulin for all three. But a closer look at the data in Table 6-3 reveals some very useful information. Figure 6.2: Three routes to high blood sugar in the morning Larry is experiencing a sharp blood sugar rise soon after he goes to sleep. Adding a small dose of regular or rapid insulin at bedtime would probably resolve the problem. An insulin pump might also be a good option for Larry because he could program it to deliver more basal insulin during the early part of the night. * Daryl experiences a steady rise through the night, so an increase in his glargine dose should do the trick. Darryl, however, is experiencing a Somogyi phenomenon. He is dropping into a hypoglycemic range in the middle of the night and rebounding to a higher level by morning. Increasing his basal insulin would make the problem worse, not better. A reduction in his basal insulin dose, or possibly adding a bedtime snack, would make more sense. Figure 6.3: Example of a Somogyi phenomenon For those using a CGM, Figure 6.3 provides a nice example of a Somogyi phenomenon during the night. Note that the drop in the glucose level between 1 a.m. and 2 a.m. is followed by a rise for the next several hours. Initial Basal Doses for Insulin Pump Users Basal insulin delivered by an insulin pump comes in the form of tiny pulses of rapid-acting insulin infused every few minutes throughout the day and night. These constant infusions of rapid insulin produce a relatively low, constant amount of insulin in the bloodstream (see Figure 6.4). Figure 6.4: Tiny pulses of rapid insulin throughout the day and night produce “basal” insulin in the bloodstream. Rapid-acting insulin tends to absorb and work more efficiently than longer-acting insulin. As a result, the average pump user requires about 20 percent less basal insulin than those who take intermediate- or long-acting insulin by injection. Since pumps allow us to program different basal settings at different times of day, should we start out with a peak and valley in the basal program? Well, you know what they say about assuming things. Even if your blood sugar patterns on injections led you to believe that you need a peak or valley at a particular time of day, I recommend starting the pump on one flat rate of basal insulin and then fine-tuning using the methodology described in the section that follows (Fine-Tuning Pump Basal Rates). Of course, one flat rate is not likely to meet the needs of people with type 1 diabetes or long-standing type 2 diabetes. But to make assumptions about when and how much of a basal peak you might need based on prepump patterns could be a big mistake. To determine an initial rate of basal insulin delivery with an insulin pump, two approaches can be used: a formula method (which provides a very rough approximation) and an empirical approach (which provides a slightly less rough approximation). One of the formula methods is based on your current insulin injection program: 1. Add up all the units of insulin you take in an average day, including basal and bolus insulin. 2. Take half of the total (assuming that 50 percent of your insulin is going to be basal and the other half bolus). 3. Multiply by 0.8 (to take away 20 percent, for the reason described above). 4. Divide by 24 (to figure the hourly rate). For example, before starting to use an insulin pump, Marley used an MDI (multiple daily injection) program: Breakfast: 10 glargine and 5 units aspart (on average) Lunch: 7 units aspart (on average) Dinner: 10 units aspart (on average) Evening snack: 10 glargine and 4 units aspart (on average) Marley’s total insulin for

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the day is 46 units. Half that amount is 23 units. Taking away 20 percent leaves 18 units. Dividing by 24, we get 0.75 units per hour. Another way to estimate the starting basal dose is by using a body weight formula. Anyone going directly onto the pump without ever having taken insulin injections should use this method. 1. Take your weight in pounds. To convert kilograms to pounds, multiply by 2.2. 2. Divide by 10 (a magic number—trust me on this). 3. Divide by 24 (to figure the hourly rate). For example, if John weighs 195 pounds (88.5 kg), we divide 195 by 10 to get 19.5, and divide this by 24 to get 0.8 units per hour. A more effective method for determining the starting basal insulin dose for pump use involves taking your current insulin program, breaking it down into basal and bolus components, and then taking the basal total to figure your hourly rate on the pump. I still recommend taking away 20 percent when figuring the initial basal requirements on the pump (because of the increased efficiency of pumped basal insulin). Using Marley’s insulin program as an example (glargine morning and evening, aspart with each meal and snack), I would figure that none of her aspart doses are used as basal insulin, only the glargine. If she used NPH insulin in the morning, I would assume that 50 percent of the morning NPH served as basal insulin and the rest as bolus insulin; if she took NPH at nighttime, I would assume that 75 percent of this dose would serve as basal insulin. Without using NPH, the calculation is much easier: She takes a total of 20 units of basal insulin (glargine). Take 20 percent away to come up with 16, and then divide by 24 to come up with an initial rate of approximately 0.65 units per hour. Fine-Tuning Pump Basal Rates When you start using an insulin pump, don’t just assume that the initial basal settings are correct. This is one of the biggest mistakes you can make, second only to telling your partner that you don’t like their outfit. To be honest, I can’t remember the last time I guessed exactly right on a pump user’s basal settings on the first try. The initial settings are merely a starting point; adjustments will be necessary. If you’re using or planning to use a hybrid closed-loop system, you may be thinking to yourself, “Cool! I don’t need to worry about this! My pump adjusts the basal rates for me, automatically!” Sorry, dude, but you’ve been misinformed. Hybrid closed-loop systems do adjust basal insulin levels in an attempt to fix high (or rising) and low (or falling) glucose levels. But if you want the system to perform as well as possible, your basal settings need to be fine-tuned first. Some hybrid closed-loop systems use your usual basal program as a starting point and adjust from there. If your usual program isn’t set up correctly, the system is going to be doing a lot of chasing. Also, consider all of the situations when you’ll be in manual mode: during sensor change-outs or warm-ups, whenever calibrations are delayed, any time the system isn’t performing properly, or by choice in order to use advanced pump features, just to name a few. In these situations, you’ll need your standard basal settings working correctly for you. Remember, the purpose of basal insulin is to match the amount of glucose secreted into the bloodstream by your liver. The right basal rate is one that keeps your blood sugar at a fairly constant and steady level when you have not eaten or bolused for several hours and are not exercising. Testing, adjusting, and retesting basal rates can be a bit of a nuisance, but it is well worth the effort. To determine whether your basal insulin rates are set properly, you will need to wait approximately four hours after your last bolus and meal or snack and then observe what happens. Four hours is usually enough time to allow the carbs in the previous meal to finish digesting and the bolus to finish working. The conditions that must be met in order to run a successful basal test are listed below. No food should be digesting. • Wait at least four hours after your last meal or snack before beginning the test. • The meal or snack preceding the basal test should be low in fat. (No restaurant food or take-out food; these tend to take many hours to digest, and the extra fat content can influence your blood sugar many hours later.) • Do not consume any calories during the basal test unless your blood sugar drops below 80 (4.4). Even fat and protein can affect blood sugar levels. You may have water or diet beverages during the test. • Avoid caffeinated beverages during the basal test—caffeine can cause blood sugar to rise. • Do not consume alcohol immediately prior to or during the basal test—alcohol can reduce the liver’s normal glucose secretion. No bolus insulin should be working during the basal test. • Wait at least four hours after your last bolus of rapid insulin before beginning the test (six hours if using regular insulin). If you delivered an extended bolus at your previous meal, wait four hours after completion of the bolus delivery. For example, if you programmed an extended (or dual, square, or combo) bolus lasting two hours, you will need to wait six hours after programming the bolus to start your basal test. • Do not bolus during the test unless your blood sugar rises above 250 (13.9). Your body should be producing its normal amount of glucose. • Do not perform the test if you have had a low blood sugar reading within the previous four hours. Hypoglycemic episodes tend to produce a hormonal response that can raise the blood sugar for several hours. • Do not run the test if you are ill or experiencing unusual stress. • Do not run the test if you are taking a steroid medication unless it is a medication that you plan to continue taking indefinitely at a steady dose. • Avoid testing just prior to or at the start of your menstrual cycle. Allow basal insulin to be delivered at its normal rate. • Do not place the pump into suspend mode just before or during the test. • Do not disconnect from the pump just before or during the test. • Do not run a temporary basal rate just before or during the test. • Do not change your infusion set just before or during the test. If your pump has hybrid closed-loop capabilities, turn them off four hours before starting a basal test until the test is complete. Maintain your normal level of physical activity. • Do not exercise during the blood sugar evaluation phase of your basal test (starting four hours after the last meal or bolus). • You may perform light or moderate exercise soon after your pretest meal or snack if you normally do so at that time. • Perform your usual daily activities during the basal test. In terms of order, I usually start by testing and fine-tuning the nighttime basal rates. Once you have matched the overnight rate to your liver’s output of glucose, your blood sugar should hold steady through the night. Waking up near normal will make testing the morning segment easier, followed by the afternoon segment and, finally, the evening segment. To start the test, follow these steps: 1. Check your blood sugar at the start of the test (via fingerstick or CGM). Remember, you should wait at least four hours since the last bolus of rapid-acting insulin before starting a basal test. 2. If the glucose is above 250 (13.9), bolus for the high blood sugar, and cancel the test. If below 80 (4.4), eat to bring your blood sugar up, and cancel the test. If the blood sugar is not too high or too low, proceed with the test. 3. During the basal test, if you’re not using a CGM, check your blood sugar with a fingerstick reading every two hours. Less frequent testing may cause you to miss a rise or fall. If using a CGM to collect your glucose data, be sure to calibrate it (if required) prior to the start of the test, and try not to calibrate again until the test is completed. Basal testing should be set up around the framework of your usual mealtimes and sleep patterns. The schedule shown below in Table 6-4 is an example for someone who uses rapid-acting insulin for their boluses. If your meals tend to be on the late side, it is fine to shift the testing schedule. For example, if you normally have dinner at 8 p.m., you can start the overnight basal test at midnight rather than 10 p.m. You may also run basal tests for longer periods of time if you can tolerate the extended fast. Some people are able to complete the basal tests in only two or three segments. It is also reasonable to break the tests into smaller time intervals and complete the testing in five or six intervals (for example, for very young children). * When evaluating your basal settings, it is always preferable to use a CGM rather than pricking your finger relentlessly. Because CGM data is continuous and great at showing subtle rises and falls in glucose levels, it truly is the ideal source of information. If you don’t currently use a CGM, consider obtaining one for personal use, or ask your health care team if they can provide a temporary loaner. Grounds for Adjustment Whether you use fingerstick or CGM data, if your glucose level falls more than 30 mg/dl (1.7 mmol/l) during the test period, the basal rate is probably too high. If it rises more than 30 mg/dl (1.7 mmol/l), the rate is most likely too low. You should adjust and retest the basal rate (the next day, if possible) to determine whether the adjustment is working. Continue to adjust and retest until you obtain a reasonably steady result. For example, Figure 6.5 provides an example of an evening basal test that indicates a basal setting that may need to be reduced. Nancy had lunch (and bolused) at 12:30, and then fasted until her glucose started to drop low at around 7 p.m. She was stable until 5 p.m., then started to drop, indicating that she has too much basal insulin working between 5 p.m. and 7 p.m. Figure 6.5: Nancy’s basal test showed that she is receiving too much basal insulin in the late afternoon. In the example shown in Figure 6.6, Alicia had an early lunch and bolused at 11 a.m., and then fasted until 8 p.m. Her glucose stayed between 150 and 180 (8.3 and 10) from 3 p.m. until 8 p.m., so her basal insulin is matched to her body’s needs at this time. Figure 6.6: Alicia was stable from 3 to 8 p.m., confirming her basal settings. If the result of a basal test appears to be very erratic (rises, falls, rises, falls), try repeating it the next day to see if a similar pattern appears. Inconsistent readings usually mean that an unforeseen variable is affecting the results. Likewise, if the glucose level rises or falls by a very large amount, the cause may be something other than a discrepancy in the basal insulin. Again, repeat the test to see if the results are similar. Quantity of Adjustment The amount of the change made to basal rates depends on a number of factors, including your sensitivity to insulin, the magnitude of the blood sugar change during the basal test, and the precision of your pump. For someone on relatively large doses of insulin, making tiny basal adjustments is like trying to take down a charging rhino with a water pistol. Likewise, making relatively large changes if you are on very small doses is like shooting a mosquito with a bazooka—there might be some collateral damage. See Table 6-5 for suggested adjustments to basal settings. For example, let’s take Nancy’s basal test results from Figure 6.5. Her current basal rates in the afternoon are 0.5 and 0.6 unit per hour. Given that her glucose declined by a large amount, she should reduce her basal setting by 0.2 unit per hour. * Timing of Adjustment Having diabetes teaches us that we need to plan ahead for just about everything. Increasing (or decreasing) a basal rate at 6 p.m. is not going to affect the blood glucose at 6 p.m. The rapid-acting insulin infused by the pump does its greatest work one to two hours after delivery, so basal rates need to be adjusted one to two hours prior to observed blood sugar changes. I prefer to make changes two hours in advance for most adults and one hour ahead for most children and very lean or active adults. For example, take a look at Jenny’s evening basal test in Figure 6.7. She had lunch (and bolused) at noon, and then fasted until almost 11 p.m. Her glucose was stable from 4 to 7 p.m., then rose at a rapid rate from 7 to 11 p.m. Because Jenny is nine years old, we will consider adjusting her basal settings one hour before the observed rise in her glucose levels. Her basal settings from 3 to 6 p.m. are verified. Since her levels rose from 7 to 11 p.m., we will raise her basal rate from 6 to 10 p.m. And because she is currently using a relatively low basal rate (0.25 unit/hour [u/hr] in the evening), we will increase her basal by 0.10, to 0.35 u/hr, based on the large rise that took place. Figure 6.7: Nine-year-old Jenny experienced a large glucose rise during an evening basal test. Basal rates need to be adjusted one to two hours prior to observed blood sugar changes. Incidentally, even though most pumps allow basal rates to be adjusted on the half hour, it is best to set the start time for basal segments on the hour, rather than on the half hour (for example, 1:00 rather than 1:30). Remember, basal insulin is made up of tiny boluses of rapid-acting insulin every few minutes, and rapid insulin works over a three- to four-hour period. Basal insulin levels in the bloodstream don’t change dramatically all at once, so there is no benefit to making adjustments on the half hour. Quality of Basal Adjustments When setting up a twenty-four-hour basal program, our objective is to mimic normal pancreatic function as closely as possible. A healthy pancreas secretes basal insulin in a pattern that repeats every twenty-four hours, based on the presence of hormones that influence the liver’s glucose output. As a result, the pancreas produces more basal insulin at certain hours, less at others. Normally, there is almost always one peak perio

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d and one valley in the twenty-four-hour period—not multiple peaks and valleys. A basal program that includes multiple peaks and valleys is like a three-eyed fish: not impossible but not exactly normal. In most cases, multiple peaks in the twenty-four-hour basal pattern mean that basal insulin is compensating for some other aspect of the insulin program that is not set up properly. For example, consider the basal pattern in Figure 6.8. Figure 6.8: A “respectable” twenty-four-hour basal pattern This pattern has one peak (between 5 and 8 a.m.) and one valley (1 to 10 p.m.). It has integrity, as far as basal programs go. Now consider the pattern in Figure 6.9. Figure 6.9: A twenty-four-hour basal pattern with multiple peaks This program has two peaks: a big peak from 5 to 10 a.m. and a smaller peak from 4 to 8 p.m. Given that the basal rate is 0.5 continuously from 2 p.m. until 7 a.m. except for those few hours in the late afternoon, there is a good chance that the 4 to 8 p.m. rates are set too high. Perhaps the basal peak in the late afternoon is compensating for an afternoon snack that is not covered with a sufficient bolus. A basal program with multiple peaks is like a three-eyed fish: not impossible but not exactly normal. Now let’s take a look at a couple of examples designed to put your basal fine-tuning skills to the test. Annette is a teenager who hates just about everything—especially having diabetes. The only thing she hates more is having high and low blood sugars that interfere with her life. To test her morning basal rate, she agrees to skip breakfast and check her blood sugars hourly through the morning (her parents promised to increase the data limit on her phone if she followed through). She is currently on a flat basal rate of 1.5 units per hour all day and night. Here are the results. What would you recommend? 7 a.m.: 184 mg/dl (10.2 mmol/l) 8 a.m.: 192 (10.7) 9 a.m.: 177 (9.8) 10 a.m.: 190 (10.6) 11 a.m.: 224 (12.4) 12 p.m.: 259 (14.4) Annette’s blood sugar seems to hold reasonably steady from 7 a.m. to 10 a.m., so the 1.5 u/hr basal setting is verified from 6 to 9 a.m. (since she is a child—in more ways than one—we consider the basal settings one hour before the blood sugar checks). Her blood sugar rose significantly from 10 a.m. to 12 p.m., so she is going to need a fairly large basal increase (0.3 u/hr) between 9 a.m. and 11 a.m. Her new settings look like this: midnight to 9 a.m.: 1.5 9 a.m. to 11 a.m.: 1.8 11 a.m. to 12 p.m.: 1.5 Since a retest is needed to evaluate the new settings, we combined a late-morning test with an early afternoon test; she will have an early breakfast (around 6 a.m.) and then fast until 3 p.m. so that we can evaluate how her basal rates are working from 10 a.m. until 3 p.m. Paul is a real estate novelist who never had time for a wife (borrowed that line from Billy Joel—know which song?). He is fifty-five years old and has been wearing a pump for the past fifteen years but needs some fine-tuning of his settings. Here are his current basal rates: midnight to 7 a.m.: 0.8 u/hr 7 a.m. to 1 p.m.: 0.6 u/hr 1 p.m. to 8 p.m.: 0.5 u/hr 8 p.m. to midnight: 0.6 u/hr The first thing you might notice is that he has one peak (overnight) and one valley (in the middle of the day), so right away, his program passes the quality “sniff test.” Upon our recommendation, he runs an overnight basal test first, with a home-cooked dinner (and bolus) before 8 p.m., then no calories, boluses, or exercise until the following morning. The results can be found in Figure 6.10. What would you recommend? Figure 6.10: Paul’s overnight basal test This basal test features a very important lesson. Even though the wake-up reading is right on target, it does not necessarily mean that the basal setting is correct during the night. The fact is that it is not. Paul’s glucose level is slightly elevated but holds steady from midnight until 2 a.m., proving that his basal settings are correct from 10 p.m. until 12 a.m. (two hours prior to the observed pattern, since he is an adult). The glucose then starts to decline until 6 a.m., when he wakes up and has breakfast. The decline from 2 to 6 a.m. will require a basal reduction from 12 to 4 a.m., by 0.1 u/hr (since it was a modest drop and he is on modest basal settings). This gives us a basal pattern that looks like this: 12 a.m. to 4 a.m.: 0.7 u/hr 4 a.m. to 7 a.m.: 0.8 u/hr 7 a.m. to 1 p.m.: 0.6 u/hr 1 p.m. to 8 p.m.: 0.5 u/hr 8 p.m. to midnight: 0.6 u/hr Uh oh—see the problem? By keeping basal at 0.8 from 4 to 7 a.m., we have created an extra peak in his twenty-four-hour basal pattern. Since we know that he needs less basal insulin during the night and that his needs are even lower in the morning, it is reasonable to extend the 0.7 u/hr rate until 7 a.m., giving us this pattern: midnight to 7 a.m.: 0.7 u/hr 7 a.m. to 1 p.m.: 0.6 u/hr 1 p.m. to 8 p.m.: 0.5 u/hr 8 p.m. to midnight: 0.6 u/hr For Paul’s next test, we can start the testing at 2 a.m. (since he was steady until then on the previous basal test) and continue through the morning. In other words, he may have an evening snack and bolus as late as 10 p.m., and then fast until lunchtime. This will allow him to evaluate his basal rates from 2 a.m. until about noon. Normal fasting blood sugars do not necessarily mean that the overnight basal doses are correct. Idiosyncrasies About Basal Testing Life is never simple when you have diabetes. Basal insulin levels and basal testing don’t always follow textbook rules. There are a few quirks that you should be aware of. For starters, never test your basal rates the first day or night when you start on your pump or new injection program. You need at least twenty-four hours for previously injected long-acting insulin to clear from your body. Anytime the blood glucose level is above 180 mg/dl (10 mmol/l), the kidneys will channel some sugar into the urine. This may produce a slight decrease in the blood sugar concentration. Thus, when performing a basal test with elevated blood sugar, a slight drop-off in the blood sugar is to be expected and does not necessarily mean that the basal setting is too high. In some people, a blood sugar level that is borderline low or dropping quickly will cause a hormonal response that induces a blood sugar rise. Again, this does not necessarily mean that the basal setting is too low. After finishing a fasting test, don’t be surprised to see a significant spike in the blood sugar right after eating again. It is natural for food to digest extra quickly after a prolonged fast. If your family includes multiple blood relatives who require insulin, their basal needs will probably be quite similar. The actual doses may be different, but the timing and magnitude of peaks and valleys will likely match up. We can’t explain why, but this is what we tend to see. In terms of overall basal patterns, people who are still producing some of their own insulin tend to have flatter basal profiles than those who are truly insulin-dependent. For those with type 2 diabetes or LADA as well as type 1s still in a honeymoon phase, the pancreas will adjust its own insulin secretion to offset some of the peaks and valleys in the liver’s glucose secretion. For those who produce little or none of their own insulin, the difference between the peak and valley basal needs can be significant. Beyond Basal Basics For kids, establishing a basal program that works properly is very important. But don’t feel like you have to repeat an entire set of basal tests every time your child grows a little bit. That would be cruel and unusual punishment for both of you. Your child’s pattern (timing and magnitude of peaks and valleys) should stay the same throughout their growth years. When it becomes obvious that they need more basal insulin (because of a persistent overnight rise, for example), it is usually fine to increase all of the basal settings throughout the day and night. However, following the transition from childhood to adulthood, it may be necessary to revisit and retest the basal settings since hormone levels tend to shift in both time and magnitude. An additional note about insulin pumps: all pumps can store settings for more than one complete twenty-four-hour program. Secondary basal programs can be useful during periods of heightened insulin need (such as sick days, travel days, or prior to menstruation) or decreased insulin need (such as the start of your period or days filled with extra physical activity). Use of alternate basal programs will be discussed in more detail in Chapter 8, along with the use of short-term basal rate adjustments called “temporary basal rates.” Obviously, fine-tuning basal insulin levels can be complex. This is a great opportunity to work with members of your health care team who specialize in this sort of thing, such as your CDE or pump trainer. And if you don’t have local access to someone who really knows their stuff, give my office a call! (In North America: 877-735-3648; outside North America: +1-610-642-6055.) We consult with people worldwide via phone and online. We even offer an online class at Type 1 University (type1university.com) that focuses specifically on the ins and outs of fine-tuning basal insulin. Remember, great people surround themselves with other great people. Seek out the advice of experts any time you suspect you might be getting in a little bit over your head. That’s what we’re here for! CHAPTER HIGHLIGHTS • Basal insulin is the foundation of your entire insulin program. • Basal insulin’s job is to match the liver’s output of glucose. It should hold your blood sugar steady in the absence of food, exercise, and bolus insulin. • Basal insulin usually makes up 40 to 50 percent of the total insulin for the day. • For those taking basal insulin by injection, the right dose should keep your blood sugar from rising or falling more than 30 mg/dl (1.7 mmol/l) through the night. • Pump users should test and fine-tune their basal settings at each phase of the day and night. • Basal programs typically feature one peak and one valley.SEVEN The Art and Science of Bolus Calculations Reading, writing and arithmetic Are the branches of the learning tree. But without the roots of love every day, girl, Your education ain’t complete. —The Jackson 5, “ABC” Ahhh, pizza, hot from the oven. The aroma of freshly popped popcorn. Cold Italian ice on a hot summer day. That mysteriously tasty cream center in Oreo cookies. Basal insulin would meet our needs just fine if we never ate. But we do eat (praise the Lord!), and the food we eat makes our blood sugar rise. So for everything from Philly pretzels to Philly cheesesteaks to yes, even Philly cream cheese, we have something called bolus insulin. As we have discussed, boluses are bunches of relatively fast-acting insulin given to cover the blood sugar rise caused by meals and snacks. Boluses are also used to lower blood sugars that are higher than we want. There are many factors that influence bolus requirements; several of these will be discussed in the next chapter. For our purposes here, we will focus on the five primary factors that should be considered when determining bolus doses: 1. the amount of carbohydrates in the meal or snack 2. the blood sugar level at the time of the meal or snack 3. the direction the blood sugar is headed 4. the amount of insulin still remaining from previous boluses 5. the amount of planned (or completed) physical activity For those of you who are into math (you know who you are—your favorite shows are NUMB3RS and The Big Bang Theory), boluses are calculated as follows: Bolus dose = (food dose + correction dose + rate of change adjustment – insulin on board) x activity adjustment Get used to this equation. You’re going to see it a lot throughout this chapter. But don’t worry—we’re going to take it one small step at a time. Later in this chapter we will also discuss the importance of bolus timing in order to keep the blood sugar from rising too high or dropping too low after eating. For now, let’s focus on what makes up the ultimate bolus dose of insulin. Part 1: The Food Dose As is the case with basal insulin, appropriate bolus dosing requires individualization and fine-tuning. Each person’s needs are unique. To match insulin to food, the best approach is to use an insulin-to-carb (I:C) ratio. In other words, we need to determine how many grams of carbohydrate are covered by each unit of rapid-acting insulin. For example, a 1-to-10 (1:10) ratio means that 1 unit of insulin covers 10 grams of carbohydrate, and a ratio of 1-to-20 (1:20) means that each unit covers 20 grams. If you have basic math skills (or a calculator or an electronic dosing guide—see Chapter 10), figuring the food bolus is easy. Simply divide your carbs by your ratio. If each unit covers 10 grams of carb and you consume 65 grams, you will need 6.5 units of insulin (65 divided by 10 = 6.5). An insulin-to-carb ratio tells us how many grams of carbohydrate are covered by each unit of insulin. I:C ratios may seem a bit backward at first. A ratio of 1:10 will produce a larger insulin dose than a ratio of 1:15. A snack containing 30 grams of carb will require 3 units if you’re using a 1:10 ratio, but only 2 units if you’re using 1:15. As the second number in the ratio goes up, the amount of insulin goes down. The beauty of an I:C ratio is that it gives you the flexibility to eat as much or as little carbohydrate as you choose while still maintaining control of your blood sugars. However, spacing meals and snacks at least a few hours apart (three or more hours is optimal) remains important, so that bolus insulin can return the blood sugar to normal before you eat and raise it again. Even if carbs are counted—and bolused for—carefully, controlling blood sugar when grazing is almost impossible. Frequent munching puts you in a perpetual state of an after-eating blood sugar rise, waiting for the bolus to kick in and bring t

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hings back down to normal. Incidentally, it is common to require different I:C ratios at different times of day. This is due to changes in hormone levels and physical activity, which affect insulin sensitivity. Many people find that they need their lowest I:C ratio—and thus their highest bolus dose—at breakfast, and their highest ratio—and lowest bolus dose—in the middle of the day. For example, I personally need 1u:10g carb at breakfast, 1u:16g carb at lunch, and 1u:14g at dinner. If you already take rapid-acting insulin at your meals and your blood sugar levels are close to normal most of the time, figuring your I:C ratio is easy. Simply add up the grams of carb in your usual meals and divide by the units of rapid-acting insulin. For instance, Sam usually devours 45 grams of carb at breakfast and takes 5 units of rapid-acting insulin. His blood sugar readings before breakfast and before lunch are similar, so it appears that each unit of insulin covers 9 grams of carb (45 divided by 5). If you have never used an I:C ratio for calculating your mealtime insulin, don’t worry: there are a number of ways to determine a starting ratio. Whichever method you choose, starting with a conservative dose is best (are you getting tired of hearing that yet?). It is better to run your blood sugar a little high than too low because frequent lows can be dangerous and will make evaluating and fine-tuning your dosing formulas very difficult. Formula 1: The 500 Rule The 500 rule is based on the assumption that the average person consumes (via meals and snacks) and produces (via the liver) approximately 500 grams of carbohydrate daily. Dividing 500 by the average number of units of insulin you take daily (basal plus bolus, also called “total daily dose” or TDD), should give you a reasonable approximation of your I:C ratio: 500/TDD. For example, if you take a total of 25 units of insulin in a typical day, each unit of insulin should cover approximately 20 grams of carbohydrate (500/25 = 20). If you take 60 units daily, your estimated I:C ratio would be 1:8 (500/60 8). * The advantage to this approach is its simplicity: only one nice round number to divide (or one easy chart to look at). The obvious weakness to this approach is that it assumes that all people are equally sensitive to insulin and eat about the same amount of food. Those who eat very little will have a lower than expected TDD and will tend to receive too little mealtime insulin. Those who eat a great deal (and have a higher than expected TDD) will tend to receive too much mealtime insulin. This approach also assumes that the amount of insulin you are currently taking is appropriate for you. If your blood sugar is frequently above or below your target range, the I:C ratio derived from this approach will likely be incorrect. Formula 2: The Weight Approach This approach is based on the fact that insulin sensitivity diminishes as body mass increases. Each unit of insulin will cover less food in a heavier person than in a lighter person. To estimate your I:C ratio, divide 1,800 by your weight in pounds, or 850 by your weight in kilograms: 1800/weight (lbs) or 850/weight (kg). One of the potential problems with the weight method is that it fails to consider body composition. An individual who weighs 250 pounds but is very muscular will be much more sensitive to insulin than a person of similar weight who has a great deal of body fat. Another problem is that this system fails to consider stages of growth and hormone production. A growing, hormone-oozing adolescent will require significantly more mealtime insulin than an older person who weighs the same amount. Likewise, a person who is pregnant will require considerably more insulin than a person of similar weight who is not pregnant. (Insulin patterns during pregnancy will be discussed in detail in Chapter 8.) * Fine-Tuning and Verifying I:C Ratios It is best to establish proper basal insulin levels before attempting to fine-tune I:C ratios. Any basal insulin changes made after fine-tuning your bolus doses will require additional bolus adjustments. Fine-tuning I:C ratios is best done empirically (what my people call “trial and error”), and by evaluating each meal and snack separately, since I:C ratios can vary throughout the day. In general, when glucose levels are often above or below target within three to four hours after a meal, the I:C ratio is usually to blame. This is particularly true if the severity of the high and low readings becomes worse as the size of the meal increases. For instance, if your glucose is slightly high following small breakfasts but very high after large breakfasts, it is a sure bet that the I:C ratio needs to be increased. If glucose levels are often above or below target within three to four hours after a meal, the I:C ratio is usually to blame. For example, consider the data for Ryan in Table 7-3. * Remember, it is best to look at each phase of the day separately and come to conclusions about the dose used at the previous meal. Assuming that Ryan is currently using an I:C ratio of 1:15 at each meal, how would you interpret his data? Here’s my take: 1. Ryan’s pre-breakfast readings are generally elevated following normal readings at bedtime, so if his basal insulin dose is correct, his carb ratio for his bedtime snack needs to be increased. I would try 1u:12g carb at bedtime. 2. His readings at lunchtime look spot-on almost every day, so the 1:15 ratio at breakfast appears to be working fine. 3. He is often low prior to dinner, so his I:C ratio at lunch needs to be reduced. I would recommend trying 1u:20g carb at lunchtime. 4. Similar to lunchtime, Ryan is usually on target at bedtime, so I would stay with 1u:15g at dinnertime. Wednesday is an exception. Ryan’s high reading at bedtime was probably the result of a rebound (or overtreatment) from the very low reading that preceded it at dinner. It’s nice when the mealtime readings are as consistent as Ryan’s, but that rarely happens in the real world. When the patterns vary a great deal, detailed data collection is essential. Specifically, you will need your premeal and presnack glucose levels, grams of carbs, and insulin doses. This information can be collected via downloads or apps or in written form. When analyzing the data, try to eliminate factors other than food that might be affecting your blood sugar levels. For example, do not include data collected during or after strenuous exercise unless you do so every day at the same time. Also, don’t look at information collected during an illness or major emotional stress, at the start of a menstrual cycle, or after a low blood sugar. And ignore meals with very high fat content or unknown carb content (such as restaurant meals). To analyze your data, take a look at your blood sugar level before the meal and then again at least three hours later (to give the insulin a chance to finish working), without consuming additional calories or bolusing in between. Because strange things can happen on any given day, I like to consider one to two weeks of data when coming to a decision regarding the I:C ratio. * For example, consider the data in Table 7-4. *As you can see, the conclusions sometimes contradict each other (remember, this is diabetes—nothing is ever simple!). However, we can still come to a general conclusion based on the results. I would be tempted to assign an I:C ratio of 1 unit per 12 grams of carb. Here’s why: First, I would throw out the data on June 3 because of the low reading prior to breakfast (it most likely led to a rebound high). I would also throw out the data on June 8 because it is inconsistent with every other result, and the meal was much larger than usual (perhaps it was all-you-can-eat pancake day at IHOP). The rest of the data indicates that an I:C ratio greater than 1:12 produces a blood sugar rise; less than 1:12 produces a drop. When used, 1:12 held the blood sugar fairly steady, as the lunch readings were within 30 mg/dl of the breakfast readings. Remember, the point is not to see which I:C ratio produces a normal glucose level three to four hours later but to determine which ratio produces a result similar to the premeal value. Another technique for evaluating I:C ratios is to analyze the data from a continuous glucose monitor. CGM downloading offers the unique opportunity to see distinct patterns following meals. With a quick look at a single chart, we can determine whether mealtime insulin doses are too high, too low, or just right. For example, take a look at Figure 7.1 below. This report shows average data by time of day for a one-month period for Armond, who uses an I:C ratio of 1:15 at breakfast, 1:20 at lunch, and 1:15 at dinner. It appears that 25 percent of Armond’s pre-lunch readings are below his target range prior to lunch, and another 25 percent are above the target range late in the evening. Based on this information, we might suggest that Armond reduce his breakfast dose to 1:18 and increase his dinner dose to 1:12. Figure 7.1: AGP (ambulatory glucose profile) report from LibreView Personally, I find that overlay reports, such as the one shown in Figure 7.2, are better for evaluating meal doses than summary or average reports like Figure 7.1, since the details are easier to see. Figure 7.2: Overlay report from Dexcom Clarity The data in Figure 7.2 shows that the I:C ratio at breakfast is probably fine, since the glucose returns to normal by lunchtime (despite the sharp rise that occurs soon after eating). The lunch dose appears to be insufficient since the glucose rises and remains modestly elevated three to four hours later. If a carb ratio of 1:10 is being used at lunch, I might recommend an increase to 1:9. The dinner dose also appears to be insufficient since the glucose level remains markedly elevated three to four hours after dinner. An increase to 1:8 would be worth trying. Figure 7.3 reveals the after-meal glucose patterns over two weeks for the user of a hybrid closed-loop system whose I:C ratios are all set at 1u:8g carb. All of the meal boluses are lined up nicely, so that we can see how the glucose levels look for the three hours that follow. You may notice that on almost all days, the glucose rises after breakfast and remains slightly elevated three hours later. Increasing the I:C ratio to 1u:7.5g might resolve this issue. The glucose levels three hours after lunch are mostly on target. Don’t be fooled by the dotted line (showing the average), which was affected greatly by one day when the glucose was very high. I would keep the I:C ratio at 1u:8g at lunch. Similarly, the glucose levels are mostly in range after dinner. However, it looks as though the data signal is often lost several hours after dinner, limiting our ability to come to a firm conclusion. Figure 7.3: Meal bolus wizard report from Medtronic Carelink When analyzing your data, the more details, the better. You might discover subtle factors that influence your glucose levels and require dose adjustments. For example, one of my clients, Betty, had blood sugar readings that were above target every Sunday at lunchtime, but normal readings the rest of the week. The reason? Church. Betty is very passionate about Sunday morning services. In addition to sitting still for several hours, the adrenaline rush she gets from prayer and singing was producing a blood sugar rise. The solution: use her usual 1:10 formula at breakfast during the week, and increase to 1:8 on Sundays. Another patient, David, was experiencing very inconsistent blood sugars prior to dinner despite having the same lunch each day and using a 1:15 bolus formula every day at lunchtime. In reviewing his records, we found that most of his dinnertime lows were preceded by morning workouts; most of his dinnertime highs were on nonexercise days. The solution: use a 1:10 formula at lunch after sedentary mornings, but decrease to 1:20 following morning exercise. So is that all there is to the food dose? Just counting the carbs and applying the I:C ratio? Unfortunately, no. As described in Chapter 4, fiber should be deducted from the total carb counts, and dietary protein can also contribute to a rise in the blood sugar level—particularly when there is little to no carbohydrate in a meal. When this occurs, some of the protein from your food will be converted to glucose. When having meals with very little carbohydrate, assume that 50 percent of the protein will be converted to glucose, and dose for this amount as if it were carbohydrate. The other time when dietary protein might raise blood sugar is when having very large portions of protein (at least 60 g). In this case, it is usually necessary to add 20 g to the carb count. Fine-tuning food doses can be a challenging proposition. Given the complexities of determining proper I:C ratios and adjusting for dietary protein, having a second set of eyes look over your records is worthwhile. Don’t hesitate to ask your physician or diabetes educator to review your data just to confirm that your conclusions seem reasonable. Or give my office a call; my team would be happy to work with you on the fine-tuning process. Bolus dose = (food dose + correction dose + rate of change adjustment – insulin on board) x activity adjustment Part 2: The Correction Dose Okay, you’ve counted your carbs and applied your I:C ratio to determine the food dose. What’s next? The second component of the bolus calculation is the “correction dose”: the adjustment to the meal bolus to fix blood sugars that are either above or below your target. This adjustment improves your chances of having a blood sugar reading that is within your target range before the next meal. To fully understand this concept, imagine a world-famous archer (green tights and all) named Sir Gary of Kinwood (it just so happens that I live in a town near Philadelphia called Bala Cynwyd, pronounced “kinwood”). Sir Gary is trying to win the beautiful Maid Marian’s hand

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by winning an archery contest. As Sir Gary focuses on his goal (the target, not Maid Marian), what should he aim for? The bull’s-eye, of course! If he aims toward the sides or edges of the target, his chances of hitting the bull’s-eye are greatly reduced. In fact, he might miss the target completely, resulting in a chorus of laughter from the evil sheriff and his band of cronies in the luxury suite. Remember, blood sugar control is far from an exact science; we’re usually happy just to hit the target somewhere. To do so, we should always aim for the center. If your target range is 60 mg/dl (3.3 mmol/l) to 140 mg/dl (7.8 mmol/l), aim for 100 (5.5). If your range is 70 (3.8) to 160 (8.9), aim for 110 (6.1). If your acceptable range is 80 (4.4) to 200 (11.1), aim for 140 (7.8). By aiming for the center, you increase your chances of landing within your target range. Your target blood sugar should be a single number near the midpoint of your acceptable target range. Here’s how correction boluses work. If you designate your bull’s-eye target blood sugar to be 120 mg/dl (6.7 mmol/l) and your premeal reading is 175 (9.7), you will need to add extra insulin to your meal dose in order to bring the blood sugar down to 120 (6.7). Does this guarantee that you will be on target at your next reading? No, but it increases the odds that your blood sugar will come down at least a little bit and put you within your target range. If you don’t add any correction insulin, it’s like aiming to be 175 (9.7) again next time. In archery terms, it’s like aiming for the outer edge of the target instead of the bull’s-eye. Sometimes correction boluses involve taking insulin away from your usual meal dose. This is sometimes called a reverse correction. If your blood sugar is 80 (4.4) and your bull’s-eye target is 110 (6.1), you will need to deduct some insulin from your meal dose. This increases your chances of raising the blood sugar somewhat and being within the target range by the next meal. If you don’t reduce your meal dose when your blood sugar is below your target, you increase your chances of missing the target completely and experiencing a low blood sugar before the next meal. Incidentally, if your blood sugar is below target and you don’t plan to eat, there is nothing to deduct the correction dose from. A small snack should take you up toward your target blood sugar. To figure out the correction dose of insulin, three pieces of information are needed: 1. Your current blood sugar level. 2. Your bull’s-eye target blood sugar. 3. Your sensitivity factor (sometimes called a “correction factor”). The sensitivity factor has nothing to do with how good a listener you are or your willingness to miss a football game for the sake of going shopping with your partner. Rather, your sensitivity factor is how much each unit of insulin is expected to lower your blood sugar. Each person’s sensitivity to insulin is unique. In general, the heavier you are and the more insulin you take on a daily basis, the less sensitive you will be to each unit of insulin. Certain conditions (growth, pregnancy, pre-menses, illness, stress, surgery, use of steroid medications) also reduce insulin sensitivity, albeit on a temporary basis. Determining your sensitivity factor is similar to determining your I:C ratio. We start with an estimate based on a mathematical formula and then fine-tune based on actual blood sugar results. The formula that I find works best for figuring the daytime sensitivity factor is called the 1,700 (94) rule. Take your total daily insulin, including basal and bolus insulin, and divide into 1,700 (94 if measuring blood sugar in mmol/l). See Table 7-5 for examples. * When choosing an initial sensitivity factor, I recommend leaning toward the higher end of the range. For instance, if you average a total of 80 units of insulin per day, choose 25 (1.4) as your initial sensitivity factor. This reduces the risk of overcorrecting your highs and winding up with low blood sugar. Below are some examples. Amy takes an average of 28 units of insulin daily. Applying the 1,700 rule, we get: 1700 / 28 = 61 (94 / 28 = 3.4) This means that every unit of rapid-acting insulin should lower her blood sugar approximately 61 mg/dl, or 3.4 mmol/l. To simplify the calculation and start off conservatively, we’ll round up to 65 (3.5). Remember, a higher sensitivity factor means that less insulin will be given to fix a high reading. Because Amy’s target blood sugar is 110 (6.1), she should add 1 full unit for every 65 (3.5) points over 110 (6.1) and subtract 1 unit for every 65 (3.5) points below 110 (6.1). Expressed as a formula, her correction dose is: In mg/dl: (current blood sugar–110) / 65 In mmol/l: (current blood sugar–6.1) / 3.5 If Amy’s blood sugar is 210, we get (210–110) / 65, or 1.5 units. She needs 1.5 extra units to correct her blood sugar down to 110. If she needs 3 units for her meal and has a premeal blood sugar of 210, she would increase the dose to 4.5 units. If Amy’s blood sugar before a meal is 76, we get (76–110) / 65, or -0.5 units. She needs to take away 0.5 unit from her meal dose. If she needs 3 units to cover the carbs in her meal and has a blood sugar of 76, she should decrease the dose to 2.5 units. Let’s look at another example. Nalani takes a total of 75 units of insulin daily. Each unit should lower her blood sugar 23 mg/dl (1700 / 75 = 23), so we’ll round up to 25. If Nalani’s target blood sugar is 120, she will add 1 full unit for every 25 points over 120 and subtract 1 unit for every 25 points below 120. Her correction formula is: (current blood sugar–120) / 25 If Nalani’s blood sugar is 171, she will need (171–120) / 25, or 2 units, in addition to the insulin she gives to cover her food. If her blood sugar is 310, she will need (310–120) / 25, or approximately 8 extra units. Sensitivity Factors May Vary You may have noticed the word “daytime” used above when describing the sensitivity factor derived from the 1,700 rule. That’s because sensitivity to correction boluses can vary based on the time of day, just the way I:C ratios often vary from meal to meal. Don’t be surprised if each unit of insulin lowers your blood sugar more at night and in the early morning than it does during the rest of the day. In the evening many people experience a drop-off in hormones that counteract insulin. As a result, each unit of insulin can lower the blood sugar more at bedtime and in the middle of the night. From my experience, sensitivity factors tend to run 30 to 50 percent higher at night than during the day in a majority of people. So if you’re just getting started calculating correction boluses and have determined that your daytime sensitivity factor is 40 mg/dl (2.2 mmol/l), you might consider increasing it to 60 (3.3) at night—at least until you have a chance to try it out a few times to see how it works. Sensitivity factors may also change over time. With weight gain, most people lose some sensitivity to insulin, so the sensitivity factor tends to decrease. Changes in physical activity levels can also affect insulin sensitivity. Prolonged periods of inactivity resulting from illness, injury, travel, or a sedentary occupation may lower insulin sensitivity and require a reduction in the sensitivity factor. In contrast, weight loss and increases in physical activity can produce an increase in insulin sensitivity. Verifying Your Sensitivity Factor You can verify the accuracy of your sensitivity factor by doing the following: 1. Check your blood sugar at least four hours after your most recent bolus of rapid-acting insulin. 2. If the blood sugar is elevated, calculate and give the appropriate dose of insulin. Go about your usual activities, but do not eat or exercise for the next several hours. 3. Check your blood sugar four hours later. 4. Calculate how much your blood sugar came down, and then divide by the number of units you gave yourself. With luck, the calculated result is close to your estimated sensitivity factor from Table 7-5. If it is not, repeat the process a couple of times. If your calculated value is consistent but different from the estimated value, go with the calculated value. For instance, yesterday I checked my blood sugar four hours after lunch, and it was 205 mg/dl (11 mmol/l) (darned undercounted hoagie!). Applying my daytime formula of (BS–100) / 40, I gave myself 2.6 units using my insulin pump. Several hours later, just before dinner, my blood sugar was down to 112. I dropped 93 points (205–112). Dividing by 2.6 units, I come up with a sensitivity factor of 36 points per unit—not exactly 40, but close enough. CGMs can also be used to verify whether your sensitivity factors are set correctly. In Figure 7.4 below, the correction boluses appear to be driving the blood sugar down well below target. This indicates that the sensitivity factor may need to be increased in order to prevent further bouts of hypoglycemia. Figure 7.4: CGM daily report showing overcorrection for high blood sugar levels Bolus dose = (food dose + correction dose + rate of change adjustment – insulin on board) x activity adjustment Part 3: The Rate of Change (Trending) Adjustment We’re about halfway there! Now, I’d like you to imagine that you’re about to sit down to your favorite dinner. Mine happens to be meatloaf prepared oh-so-lovingly by my wife. Mmmmmmmm. Sorry—I was a bit distracted. Back to the business of bolus calculations. Figures 7.5a and 7.5b: Data displays from a couple of old-school CGM systems Now imagine that you take a look at your CGM and see a glucose value of 140 (7.8), but the trend graph is showing a distinct upward rise. Should you take the usual dose to cover your carbs and the blood sugar value? Take more than that? Or wait to see if things eventually level off, keeping in mind that your favorite dinner smells amazing and is about to be served? Trending refers to whether the glucose is stable, rising, or falling. There are two ways to identify trends on a CGM display: direction arrows and trend graphs. The images in Figures 7.5a and 7.5b were taken years ago using some old-school CGM systems, but the point still applies to the latest devices on the market. Both CGMs show identical glucose values at the present time. The difference is the direction the glucose is headed. In the display on the left, the trend graph shows that the glucose is falling. In the display on the right, the up arrow indicates a moderate rise. Each CGM system attaches its own definitions to the trend arrows associated with a recent change in glucose levels (see Table 7-6). Table 7-6. Definitions of Trend Arrows in Various CGMs n/a = does not appear on this system * Several professional groups, including the American Association of Clinical Endocrinologists, recommend adjusting insulin doses based on the rate of change that is taking place. Why? Consider the purpose of bolus insulin: to have the glucose level back into one’s target range by the time the bolus has finished working (typically three to four hours later). The usual bolus dosing formulas take the current glucose level into account and assume that the glucose is stable at the time the bolus is given. However, if the glucose is rising, the blood sugar is likely to be above target when that usual bolus has finished working. And if the glucose is falling, the blood sugar is likely to wind up below target. The presence of up or down trend arrows allows us to predict the magnitude and direction of change over the next thirty to sixty minutes. Based on our experience, a gradual upward or downward trend (1–2 mg/dl per minute, or 0.06–.11 mmol/l per minute) typically produces a change of at least 25 (1.4) points, a modest rise or fall (2–3 or 0.11–0.16) will produce a change of at least 50 points (2.8), while a sharp upward or downward trend (>3 or 0.16) typically produces at change of at least 75 points (4.2). So to give yourself the best chance of achieving an in-target glucose over the next several hours, consider adjusting your bolus doses based on the rate of change taking place at the time the bolus is given. Table 7-7. Adjusting Bolus Doses Based on Trend Arrows * There are two ways to accomplish the adjustment. One option is to add (or subtract) from the blood sugar value that you use to calculate your bolus. For example, if your blood sugar is 180 (10) and rising fast, use 230 (12.8) to calculate your dose. If your blood sugar is 120 (6.7) and falling modestly, use 95 (5.3) to calculate your bolus dose. The only downside to this approach is that you may be entering blood sugar values into your pump or logging device that are not true readings, so the data will be inaccurate when downloading. The other option is to calculate your dose using your actual blood sugar, but add or subtract a specific amount of insulin based on your correction factor. The amount of the bolus adjustment depends on your sensitivity factor. For someone whose insulin sensitivity factor is 50 mg/dL (2.8 mmol/l) per unit of insulin, a gradual downward trend could be offset with a half-unit reduction in the usual bolus amount. For someone whose sensitivity factor is 20 mg/dL (1.1 mmol/l) per unit, a sharp rise could be offset with a bolus increase of 2.5 units. Don’t freak out! If the math is more than you’re comfortable with, I’ve done it all for you in Appendix D (D is for “Don’t wanna do all the math myself”). Note that adjusting the bolus by a fixed number of units is more practical than making a percentage adjustment because we are attempting to offset a specific anticipated rise or fall in the glucose level. Percentage adjustments can vary considerably based on the magnitude of the bolus. For instance, if we were to raise a bolus by 20 percent for a sharp rise, the increase would be 0.2 unit for a 1-unit bolus and 3 units for a 15-unit bolus. It is safer and more effective to adjust by a specific number of units than by a percentage of the orig

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inal dose. Bolus dose = (food dose + correction dose + rate of change adjustment – insulin on board) x activity adjustment Part 4: Bolus Insulin On Board Patience is a virtue. Unfortunately, we all know people who refuse to abide by this simple statement. Consider Veruca Salt, the “I Want It Now“ girl from Willy Wonka and the Chocolate Factory, whose impatience lands her in a nasty pile of rubbish. More often than not, things have a way of working themselves out—if given a chance. Take insulin for instance. The fastest insulin currently available, Afrezza inhaled insulin, takes 90 to 120 minutes to complete its job. And the fastest injected (or pumped) insulin takes about four hours—not ten minutes, not one hour, not even two hours. Blood sugars are not likely to be down to normal an hour or two after taking a bolus because the insulin has not yet finished working. So what should you do? Blast away at the elevated blood sugar with a fully loaded correction bolus (sometimes called a “rage bolus” or “angry bolus”)? Or sit there helplessly, hoping and waiting for it to come down eventually? For those of us who want to manage our blood sugar aggressively without being thrust into hypoglycemic seizures, the truth can be found somewhere in the middle. It involves accounting for the insulin that still remains working from previous boluses. This still-working insulin goes by many different names that all mean the same thing: IOB (Insulin On Board), BOB (Bolus On Board), Active Insulin, Insulin Remaining, and so forth. For now, let’s just call it IOB. Deducting IOB from a bolus you’re about to give is important because it prevents stacking insulin doses. For instance, I—like many of you—don’t like the feeling of being in the 200s (12+). I used to check my blood sugar a few hours after eating, and if it was elevated, I would apply my usual correction bolus to fix it. And sure as sugar, I’d wind up low a few hours later. Just like the latest smart pen apps, insulin pumps calculate IOB from previous boluses that were given and deduct it from the dose you’re about to deliver. You might say that IOB is what puts the “smart” into today’s smart pumps. By taking IOB into account, pumps make it safe to correct high readings at almost any time, even soon after meals. However, different pumps have different ways of calculating IOB as well as applying it to bolus calculations. Should you trust the pump’s IOB estimate? Understanding how your pump handles IOB will help you answer this question. For those who don’t own a smart pump/smart pen or don’t bother to use the bolus calculator features, you will need to make the IOB adjustment on your own. * IOB should be based on the typical absorption and action patterns that you see when you take rapid-acting insulin. Keep in mind that insulin absorption and action can vary from person to person and from situation to situation. In some people, rapid insulin can finish working in less than three hours, and in others it can take as long as five or six hours. Inhaled Afrezza insulin is an exception, with an action curve lasting only two to three hours. Exercising a muscle near the site where insulin was delivered, within an hour of giving the insulin, can shorten its action curve considerably. And injecting insulin into muscle (accidentally or intentionally) will cut its duration of action approximately in half. However, in most cases the action of rapid-acting insulin follows the pattern shown in Figure 7.6 and Table 7-9. Figure 7.6: Typical action profile of rapid-acting insulin * For example, if you gave yourself 6 units of insulin for a 3 p.m. snack and then checked your blood sugar at 5 p.m., you would still have 35 percent of your bolus remaining (6 units x 0.35 2 units). If you gave yourself 12 units at dinner and checked your blood sugar three hours later, you would still have approximately 1.2 units (12 x 0.10) remaining. For the sake of simplicity, some people choose to assume that their insulin lasts a certain number of hours and figure a linear runoff of the insulin. Those who like to be aggressive with their dosing can assume a three-hour action time and figure that one-third of their insulin is used up each hour, as shown in Table 7-10. * A more traditional approach assumes that the bolus takes four hours to finish working and 25 percent is used up each hour. (See Table 7-11.) For those who want to be more conservative with their dosing (in an effort to prevent hypoglycemia), assume that the insulin takes five hours to finish and 20 percent is used up each hour. * * Figuring IOB More Precisely Whether you use a pump to calculate your IOB or figure it out yourself, the calculation hinges on how long you think it takes for your insulin to finish working. This is actually a pretty important thing to figure out. If you underestimate how long your insulin lasts, you will also underestimate how much IOB you have. And when you deduct too little IOB from your boluses, you open yourself up to more bouts of hypoglycemia. Conversely, if you overestimate how long your insulin lasts, you will also overestimate how much IOB you have. This can lead to excessive bolus deductions and more frequent high blood sugars. Underestimating your duration of insulin action increases your risk for hypoglycemia. Overestimating increases your risk for high blood sugars. There are a few ways to figure out how long it really takes for your bolus insulin to finish working. One way is to label your insulin with radioactive dye and see how long it takes for your body to stop glowing. Precise but maybe not all that practical. Another way is to check your blood sugar every thirty minutes after giving a correction bolus and see how long it takes for the blood sugar to stop dropping. Once the correction bolus is given, you should not eat, exercise, or give any more boluses until you reach the point at which the blood sugar flattens out. Here is an example: * It appears that the blood sugar flattened out at 11:30, which was three and a half hours after the bolus was given. So the duration of insulin action is three and a half hours. A better way to measure how long it takes for your boluses to finish working is to watch the trend graph on a continuous glucose monitor after giving a correction bolus. See Figure 7.7 for some examples. Figure 7.7: Using CGM to determine duration of insulin action In the example on the left, the blood sugar stopped falling three hours after a correction bolus was given. In the middle example, the correction bolus took four hours to stop lowering the blood sugar. In the example on the right, a meal bolus was given, and the blood sugar stopped dropping at five hours. What to Do with IOB Taking IOB into account before giving more boluses is very important. Whether you deduct IOB from correction boluses only or meal boluses as well is entirely up to you. Personally, I prefer to deduct IOB from any boluses, whether they are being given to cover food, high blood sugar, or both. However, if you recently had a meal or snack that is expected to digest slowly, some of the IOB will be acting on the undigested portion of the meal. This may occur when you recently had a very large quantity of food, a high-fat meal, or low-glycemic-index foods (these will be discussed later in this chapter, in Part 6: Bolus Timing). In cases like this, it may be best to reduce the amount of calculated IOB or ignore it completely. Otherwise, simply subtract IOB from any bolus you plan to give. This helps to prevent accidental stacking of boluses and potential hypoglycemia. If you would normally take 4 units to cover a meal and/or high reading, but 1 unit is still active from an earlier bolus, it would be wise to take only 3 units. If you would normally take 2 units for an elevated blood sugar, but 2.5 units are still active from a previous bolus, you should not take anything. In fact, if the IOB exceeds your correction bolus by a large amount, you might need to snack in order to prevent a low blood sugar from occurring in the next couple of hours. Bolus dose = (food dose + correction dose + rate of change adjustment – insulin on board) x activity adjustment Part 5: Adjustment for Physical Activity Okay, let’s see what we have so far. Bolus insulin is calculated based on the amount of carbohydrate, the current blood sugar level, the direction the blood sugar is headed, and the amount of insulin still working from previous boluses. So that’s it, right? Close, but no cigar. You see, a unit of insulin is not always a unit of insulin. Let me put that another way. A unit of insulin given in one situation may work more or less effectively than a unit given in another situation. Something called insulin sensitivity determines insulin’s effectiveness. The more sensitive we are to insulin, the more each unit will lower the blood sugar, and the more carbohydrate it will cover. A unit that normally lowers the blood sugar by 50 (2.9) might lower it by 75 (4.4). A unit that usually covers 10 grams of carb might cover 15 or 20. A number of factors can affect our sensitivity to insulin, but the most significant is physical activity. Not just exercise, but any form of physical activity, including cleaning, shopping, playing, yardwork, sex, and anything else that has us using our muscles and breathing more heavily than usual. With increased work, muscle cells become much more sensitive to insulin. This enhanced insulin sensitivity may continue for many hours, depending on the extent of the activity. The more intense and prolonged the activity, the longer and greater the enhancement in insulin sensitivity. With enhanced insulin sensitivity, insulin exerts a greater force than usual. Thus you will need to adjust boluses for upcoming and, in some cases, previous physical activity. Some forms of physical activity, most notably high-intensity/short-duration exercises and competitive sports, can produce a short-term rise in blood sugar levels. This is due primarily to an adrenaline surge. But don’t forget that insulin sensitivity has still been increased. Adjustment for these types of activity will be discussed in the next chapter. After-Meal Exercise Most daily chores and aerobic exercises (performed at a submaximal level over a period of time) will cause blood sugar levels to drop as a result of enhanced insulin sensitivity and increased sugar metabolism. To prevent the blood sugar from dropping too low, you can reduce your insulin, increase your food intake, or both. * When exercise is going to be performed within two hours after a meal, the best approach is usually to reduce the mealtime bolus. Because physical activity influences both aspects of the bolus (the food part and the blood sugar correction part), both need to be reduced. To accomplish this, use an activity multiplier. Calculate your mealtime bolus as usual (based on the food, blood sugar level, direction, and IOB), and then multiply the bolus by a factor that results in a dosage reduction. Exercise multipliers are based primarily on the duration and intensity of the activity. Whereas duration is fairly easy to measure, intensity is, shall we say, in the eye of the beholder. Table 7-14 shows a simple and effective way to assess the intensity of your workout. It takes into account the speed and pace of the activity, your current physical condition, the number and size of muscles used, your skill and familiarity with the activity, and the workout environment. * For example, if Marilyn is planning a leisurely twenty-minute bike ride after dinner (she considers it “fairly light”), she would multiply her dinner bolus by 0.90, which would reduce her dose by 10 percent. If she plans a much more intense sixty-minute ride up and down hills (which she considers “very hard”), she would multiply her dinner dose by 0.50, which would reduce her dose by 50 percent. Over time most of us experience a conditioning effect. This means that we tend to become more efficient at performing the same activity once we have had a chance to practice it. As a result, we burn less fuel and may require less of an insulin reduction. Premeal Exercise In some cases, exercising before a meal will require a modest reduction in the bolus given for food or an elevated blood sugar after exercising. If you notice that your blood sugar drops low after the meal (or correction dose) that follows a workout, go ahead and reduce the bolus modestly (a 20–25 percent reduction is usually sufficient). In general, when exercise is going to be performed before or between meals, reducing the bolus at the previous meal would only drive the preworkout blood sugar very high. A better approach is to take the usual bolus at the previous meal and then snack prior to exercising. I will cover details regarding blood sugar management for premeal exercise in the next chapter, along with adjustments for prolonged and exhaustive forms of exercise. Dealing with Pre-Activity Highs If your blood sugar is elevated prior to a workout, it is best to treat it about thirty minutes before the activity begins. This will give the bolus insulin time to take effect. Because exercise has a tendency to amplify insulin’s effects, start out by taking half the amount you would normally give to correct the high reading (less any IOB). For instance, if your normal sensitivity factor is 40 (2.2), assume that each unit will lower your blood sugar level by 80 (4.4) if you are about to exercise. If possible, test your blood sugar during and after your workout to see how well this works, adjusting as needed the next time around. For high blood sugar prior to exercise, take half the usual correction dose, and drink plenty of water. If you want to bring your blood sugar down as quickly as possible, consider giving the correction bolus by injection into a muscle rather than fat. An intramuscular injection can sting momentarily, but it will usually work twice as fast as an injection given int

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o subcutaneous fat. Each unit given into muscle will have the same potency as a unit given into fat (that is, it lowers blood sugar the same amount), but it does so much faster. Inactivity: Sensitivity in Reverse What goes up must come down. Just as increased physical activity causes an improvement in insulin sensitivity, decreased activity can have the opposite effect. Anyone who has gone from a physical job to a sedentary one or an active lifestyle to prolonged recuperation from an injury knows what this is all about. Any time you are very inactive at a time when you are normally active, your insulin is not going to work as well as usual. For example, this can happen when you spend several hours or more sitting in meetings • sitting in planes, trains, or automobiles • sitting at a show • working at a desk • working in front of the computer • napping • watching TV • playing video games reading Long periods of inactivity create a temporary state of insulin resistance, so more insulin is required to get the same job done. When this happens, consider taking your bolus doses up in small increments—perhaps using a bolus multiplier of 1.1 (a 10 percent increase), 1.2 (20 percent increase), or 1.25 (25 percent increase). For example, let’s say Armond is about to board a three-hour flight to Cleveland to visit the Rock and Roll Hall of Fame. Before giving his usual lunch bolus of 5 units, he multiplies the dose by 1.2 and gives 6 units instead. Rock on, Armond! Bolus dose = (food dose + correction dose + rate of change adjustment – insulin on board) x activity adjustment Part 6: Bolus Timing So far we’ve learned all the elements that go into calculating an optimal bolus: the part that covers food, the part that covers the blood sugar, and adjustments for rate of change, insulin on board, and physical activity. These dimensions should just about do the job, unless you live in the real world, where the fourth dimension—time—is of the essence. The timing of your boluses can make or break their effectiveness. To understand this concept, imagine yourself as a tennis player facing a very clever opponent who changes the speed of her serves randomly. When your opponent is serving the ball, not only do you have to swing the racket at the level where the ball is, but you also have to swing it at just the right time—when the ball is bouncing toward you. If you swing just a little bit too early or too late, the ball is likely to hit people on the sidelines. Likewise, boluses must be timed properly. Even if the amount of the bolus is correct, giving it too early will cause the blood sugar to drop low after the meal and then rise high several hours later. Boluses given too late will produce huge blood sugar spikes right after eating. A properly timed bolus in the proper quantity: now there’s a thing of beauty. (Excuse me, I’m getting all misty just thinking about it—sniff!) For this section, we will assume that you are using a rapid-acting analog (aspart, glulisine, or lispro) for your boluses. If you are using an ultra-rapid insulin, take all of the advice given below and take the insulin five to ten minutes later. If you are using an inhaled insulin, delay everything by ten to fifteen minutes. And if you are still using regular insulin (or a premixed formulation that contains regular insulin), back it up twenty to thirty minutes. In order to achieve optimal control of your blood sugar after eating, the timing of your boluses should be based on a few key variables: the type of food you will be eating, your premeal blood sugar level, and the presence or absence of impaired digestion. Glycemic Index and Bolus Timing The glycemic index (GI) tells us how rapidly food raises the blood sugar level. Although virtually all carbohydrates convert into blood glucose eventually, some do so much faster than others. Pure glucose is given a GI score of 100; everything else is compared to the digestion or absorption rate of glucose. See Appendix C for GI listings for many common foods. Many starchy foods have a relatively high GI; this means that they digest easily and turn into blood sugar quickly. Some starches, such as legumes (beans, nuts) and pasta, digest quite slowly. Foods containing dextrose tend to have a very high GI. Table sugar (sucrose) has a moderate GI, whereas fructose (fruit sugar) and lactose (milk sugar) are somewhat slower at raising blood sugar. Foods that contain fiber or large amounts of fat tend to have lower GIs than comparable foods that do not. For example, French fries tend to raise the blood sugar more slowly than baked potatoes, and apples tend to be a bit slower than apple juice. See Figure 7.8 for a summary of how glycemic index affects the timing and magnitude of the postmeal blood sugar rise. Foods with a high GI (greater than 70) tend to raise blood sugar the fastest, with a significant peak occurring in about thirty to forty-five minutes. Examples include bread, potatoes, cereal, rice, and sugary candies. For these types of foods, when using rapid-acting insulin, plan to bolus twenty to thirty minutes prior to eating. Doing so will allow the insulin peak to coincide as closely as possible with the blood sugar peak. And that, of course, will produce the best after-meal control. Bolusing for high-GI foods just before, during, or after eating is not ideal. The food will raise the blood sugar long before the insulin kicks in, thereby producing a significant after-meal blood sugar spike followed by a pronounced drop. If you are not sure of how much you are going to eat, bolus for an amount that you are confident you will have (the “down payment”), and then give the rest when the meal is over (paying “the balance”). That way most of your bolus insulin will be working hardest when you need it most. Figure 7.8: Glucose responses to high, medium, and low glycemic-index foods Foods with a moderate GI (approximately 45–69) digest a bit slower, resulting in a more modest blood sugar peak approximately sixty to ninety minutes after eating. Examples include ice cream, orange juice, cake, and carrots. Bolusing twenty to thirty minutes before eating these types of foods could produce a low blood sugar soon after eating. Plan to bolus five to ten minutes prior to eating moderate-GI foods. Foods with a low GI (below 45) tend to produce a slow, gradual blood sugar rise. The blood sugar peak is usually modest and may take several hours to appear. Examples include whole-grain pasta, milk, yogurt, beans, and chocolate. The same slow, gradual blood sugar rise occurs when consuming meals or snacks over an extended period of time (such as holiday meals, popcorn, or party food), high-fat foods, or very large portions. In these situations bolusing prior to eating may cause hypoglycemia, followed by a significant rise a few hours later as the bolus wears off and the food has its greatest effect. Instead, try these options when having slow-digesting foods: • Bolus soon after eating. This usually gives the food enough of a head start before the insulin kicks in. • Split the bolus into two parts: half given with the meal and the remainder given one to two hours later. Plugging an alarm into your phone can help remind you to give the second half of the bolus. • Take regular insulin with the meal rather than rapid-acting insulin. With its delayed peak and prolonged action, regular insulin does a better job of matching the blood sugar rise from low-GI foods. • If you use an insulin pump, use a combination or dual-wave bolus, with 25 to 33 percent of the bolus delivered just prior to the meal and the remainder delivered gradually over two hours. For a summary of bolus timing based on glycemic index, see Table 7-15. * Blood Sugar and Bolus Timing The second major variable to consider when determining the optimal timing of your boluses is the premeal blood sugar level. To avoid high or low blood sugar after meals, consider giving the bolus earlier when the blood sugar is elevated and later when the blood sugar is below your target range. Table 7-16 summarizes optimal bolus timing based on glycemic index and premeal blood sugar. * Digestive Issues and Bolus Timing Another factor that may influence the timing of your boluses is the rate at which your digestive system operates. Gastroparesis is a form of neuropathy (nerve disease) that affects tens of thousands of people with diabetes. Those who suffer from gastroparesis tend to digest food very slowly, as the stomach is sluggish to empty food into the intestines, where it can then be absorbed into the bloodstream. People with gastroparesis may benefit from using regular insulin rather than a rapid-acting analog, an extended bolus (if using an insulin pump), or simply bolusing fifteen to thirty minutes after eating whenever symptoms are present. Nausea can also affect digestion. Anyone who is prone to vomiting after meals, including those with flu-like symptoms, pregnant people with morning sickness, and cancer patients receiving chemo or radiation therapy, should wait a reasonable length of time after eating to make sure their food will stay down before giving a bolus. Those suffering from nausea related to an acute illness such as the flu should also delay their boluses until after eating. What If I’m Still Spiking After Meals? If you are timing your boluses properly but your after-meal blood sugar is still above acceptable levels, don’t give up. There are a number of very effective strategies that you can use to “strike the spike.” I will present these in detail in Chapter 9. Put It All Together The right dose: (food dose + correction dose + rate of change adjustment – insulin on board) x activity adjustment, timed properly, = THE ULTIMATE BOLUS! Congratulations! CHAPTER HIGHLIGHTS • Bolus doses should be based on five factors: carbs, the current blood sugar, the blood sugar trend, insulin on board, and physical activity. • Insulin-to-carb ratios allow you to adjust your dose to match your exact food intake. • Correction doses are based on your precise target blood sugar and your sensitivity to each unit of insulin. • Bolus doses should be adjusted based on the direction the blood sugar is headed. • Deducting insulin on board (insulin still working from recent boluses) from your boluses will help prevent hypoglycemia. • Increased physical activity will usually require a percentage reduction in your usual bolus dose. Decreased activity may require a modest dosage increase. • Proper timing of boluses is necessary to obtain the best after-meal control.EIGHT Meeting the Challenges of Daily Living Welcome to the real world, she said to me, condescendingly. Take a seat, take your life. Plot it out in black and white. —John Mayer, “No Such Thing” So there you are. Armed with a physiologically perfect basal insulin program and a set of bolus equations that would impress your old, crotchety high school algebra teacher. Off you go to conquer your favorite Italian restaurant. There’s going to be a half-hour wait for a table. No problem, you say to yourself. My basal insulin should take care of that. Well, thanks to a huge party that just won’t leave, that thirty-minute wait turns into sixty minutes. Irritated, you start walking past the table, clearing your throat as loudly as possible. No movement. Time to hit the bar. As time ticks away, the Diet Cokes turn into rum and Diet Cokes. Finally, the hostess calls out your name (mispronounced, but close enough). Elation quickly turns to frustration as she brings your party of four to a table for two. “I asked for a table for four,” you tell her. “Are you sure? We have you down for two.” The veins in your head start to swell. Fifteen minutes later your group finds its way to a table for four. Your frustration grows once again as you check your blood sugar to find that it has risen a great deal since you left home. You think to yourself, “I haven’t eaten a *!%#*ing thing! How could this happen?” Oh well, nothing a little extra insulin can’t fix. Your meal features the usual array of breadsticks, salad with rich dressing, pasta with creamy alfredo sauce, and cheesecake for dessert. Counting your carbs as carefully as possible, you bolus the exact amount your bolus formulas dictate. You even give the insulin after your meal because it contains a lot of slow-digesting foods—something you remembered reading about in Chapter 7. This is a plan that can’t possibly fail, right? Wrong. On the way out of the restaurant, your CGM starts beeping, and you start feeling a bit woozy. How could you possibly be low after a meal like that? No matter, grab a handful of mints from the hostess stand (it’s the least they could do after making you wait so long!) and let someone else drive home. Hopefully, all is not lost. You did count your carbs and bolus the right amount, so your bedtime reading should be decent. In fact, it is only slightly above target, but given all you had to eat, that’s not so bad. A minor insulin touch-up, and it’s off to sleep. That night, you have a nightmare about a giant lasagna chasing you with a fork and a spatula. To make matters worse, you have to get up several times during the night to pee. Upon waking the next morning, you discover that your blood sugar isn’t just up—it’s way up. That’s it, you tell yourself. I’m never going to that restaurant again. From now on, nothing but home cookin’. Welcome to the real world, where things hardly ever go as planned, and blood sugars don’t always turn out as expected. In Chapter 3, we concentrated on the major factors that influence blood sugar: insulin and other diabetes medications, food (specifically carbohydrates), physical activity, and the liver’s secretion of glucose. We spent the next several chapters focusing on how to set up the insulin program and adjust doses to match those factors. Now it’s time to pay homage to the secondary factors: those pesky day-to-day oddities that love to mess with our blood sugar control. The Ot

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her Stuff That Can Raise Blood Sugar Levels Anxiety and Stress Anxious moments and nerve-racking situations happen to all of us. From speaking in public to taking an exam to a simple visit to the doctor or dentist, many events elicit a stress hormone response that causes, among other things, a sharp blood sugar rise. Figure 8.1 is a CGM readout showing a dramatic blood sugar rise I experienced in 2000, when I was late for an important meeting, hit a pothole and got a flat tire, and then discovered that the spare tire was also flat. Without the slightest bit of food, my blood sugar rose almost 300 mg/dl (17 mmol/l)! Figure 8.1: CGM readout showing a stress response Of course, different events cause different responses in different people. What causes a great deal of anxiety for you might have no effect on someone else. The key is to learn your patterns. Is there something that causes a consistent blood sugar response for you? It can be helpful to keep a list of the causes of your high blood sugars to see if certain ones happen on a recurring basis. One of my patients did this and found that high blood sugars were occurring every time she watched a horror movie. Apparently, the sudden appearances of the knife-wielding maniac was causing a major stress response. If you can predict it, you can usually prevent it. The Adjustment: Many stressful situations occur spontaneously. However, some can be predicted—and if you can predict it, you can prevent it. If you notice a consistent pattern of high blood sugars with certain events, consider giving yourself a small dose of rapid-acting insulin an hour prior to the event. If you use an insulin pump, consider raising your basal rate by using the temporary basal feature. A 60 to 80 percent increase for three hours, starting one to two hours prior to the event, can work nicely. The first time you try the adjustment, check your blood sugar frequently to see how well the extra insulin is working. Case in point: A student I work with tends to run very high blood sugars when taking standardized tests in school. Her parents agreed to give her extra insulin at breakfast on the mornings of standardized testing, and her blood sugar stayed pretty close to her target range right through the morning. Caffeine A natural stimulant, caffeine tends to cause a rise in blood sugar levels in approximately thirty to sixty minutes. It does this by promoting the breakdown of fat (rather than sugar) for energy and stimulating the liver’s breakdown of glycogen. Granted, the amount of caffeine found in most foods is insignificant. However, consumption of large amounts of caffeine can produce a noticeable blood sugar rise. Below is a list of some major sources of caffeine: Jolt energy drink: 280 mg stay-awake pills: 100–200 mg Monster energy drink (16-ounce [oz] can): 160 mg 5-Hour energy drink: 100 mg brewed coffee (8 oz): 100–120 mg espresso: 100 mg latte: 100 mg Red Bull: 80 mg instant coffee (8 oz): 60–80 mg regular tea (8 oz): 30–50 mg cola (12 oz): 30–45 mg cold tablets: 30 mg chocolate bar: 20–30 mg chocolate milk (12 oz): 10 mg The Adjustment: If you suspect that caffeine may be causing your blood sugar to rise, either look for a lower-caffeine substitute, or take a little extra rapid-acting insulin when consuming high-caffeine foods and beverages. To determine the amount of insulin you need, test your blood sugar, and then consume the caffeinated item with no other food (bolus only for the carbs in the caffeinated item, if there are any). Check your blood sugar again in three hours, and then divide the rise by your correction factor. For example, if a sixteen-ounce coffee makes your blood sugar rise by about 80 mg/dl (4.4 mmol/l) and your sensitivity factor is 40 mg/dl (2.2 mmol/l), you need to take 2 units of insulin just to offset the effects of the caffeine in the coffee. Disease Progression Most people with type 1 diabetes as well as LADA go through a honeymoon phase soon after diagnosis. For several weeks, months, or even years, the pancreas continues to produce some insulin. This results in blood glucose levels that are stable and relatively easy to control. Usually the pancreas first loses the ability to secrete sufficient amounts of bolus insulin at mealtimes, resulting in after-meal highs. Then the ability to produce basal insulin begins to fade. As a result, blood sugars become higher overall, particularly upon waking in the morning. Likewise, type 2 diabetes becomes progressively more difficult to manage as the body becomes more insulin resistant and the pancreas loses the ability to produce sufficient amounts of insulin. The Adjustment: For those with type 1 diabetes or LADA who are exiting the honeymoon, fasting (or morning) blood sugars will tend to be elevated—perhaps for the first time ever. You will need increases in basal insulin in order to manage overnight blood sugar levels. You may also need increases in bolus doses as the pancreas loses its ability to produce basal insulin throughout the day. For those with type 2 diabetes, the gradual loss of insulin-producing beta cells means that insulin dosage requirements will gradually increase. If you experience blood sugars that are above target for three days in a row, it is time to increase the insulin dose at the preceding meal (or the basal insulin dose, if the high readings occurred first thing in the morning). Protein For many years, nutrition experts professed that protein has no impact on blood sugar levels. So you went ahead and enjoyed a nice cheese omelet with no bolus insulin and learned otherwise. Protein does, in fact, raise blood sugar, but only when consumed with very little carbohydrate. Roughly 50 percent of protein can be converted to glucose if there is no other source of glucose in a meal. Carbohydrates have a “sparing” effect on this process. This means that when carbs are eaten, protein is used for purposes other than supplying blood sugar, such as bodily growth, repair, and creating hormones and enzymes. But without carbs (or very little carb), protein becomes a source of glucose for nourishing the body’s cells. The Adjustment: If you have little to no carbs in a meal or snack, count up the grams of protein that you are consuming. (See Table 8-1 below.) Take half that amount and bolus for it as if it were carbohydrate. Of course, if the protein amount is very modest (such as a single slice of cheese), the effect on the blood sugar will hardly be noticeable, so you will not need to bolus. * Fatty Foods Consuming large amounts of fat in a meal or snack can cause blood sugar levels to rise in a delayed manner over many hours. This rise is in addition to the immediate rise caused by carbohydrates. The mechanism by which fat causes a delayed rise in the blood sugar is believed to be the result of insulin resistance. When you consume a high-fat meal, the level of triglycerides in your bloodstream rises. This sends your liver into a temporary state of insulin resistance, resulting in greater secretion of glucose into the bloodstream. Although there is no specific amount of fat that causes a delayed blood sugar rise in everybody, having more than 20 grams of fat certainly increases the likelihood that a delayed rise will occur. Some common foods that are high in fat are listed below. • Restaurant foods: Meals prepared at restaurants usually have a great deal of fat added during preparation. • Take-out food: pizza usually contains 10–20 g fat per slice; hot wings 2–3 g each; Chinese food: egg roll 15 g, fried rice 13 g per cup, sweet and sour pork 25 g per cup. • Fast food: small cheeseburger 15 g fat; Big Mac 30 g; taco 11 g; sausage/egg/cheese sandwich 40 g. • Fried foods: oils used in preparing fried food contain 10–15 g fat per tablespoon; fried fish sandwich 23 g; fried chicken patty 14 g; small order of French fries 15 g. • High-fat meats: most cuts of beef, lamb, pork, dark meat chicken and turkey, and sardines contain approximately 8–15 g fat per 3-oz serving (about the size of a deck of cards); ground round or hamburger 20 g; ribs and sausage 25 g; most lunch meats 10 g per slice; hot dog 15 g. • Cheesy dishes: approximately 70 percent of cheese is pure fat; American/cheddar/Swiss cheese 8–10 g per ounce (or slice); mozzarella/parmesan 6–7 g per ounce. • Dessert items: an average slice of chocolate cake contains 15 g fat; ice cream 10–15 g per half cup; a cinnamon bun 25 g; 1 doughnut, muffin, slice of cake, or chocolate bar 10–20 g; 1 slice apple pie or cheesecake 20 g. • Salty snacks: chips contain about 10 g fat per handful; peanuts 10–15 g per small handful; a medium movie theater popcorn 60 g fat (without butter topping); nachos with cheese 20–30 g. You will have to determine how much fat you need to consume in order to produce a delayed blood sugar rise. For example, I find that a single slice of pizza rarely causes my blood sugar to rise after the first couple of hours. However, after eating two or more slices, I usually see a significant rise over the next six to eight hours. The Adjustment: As was the case with stress responses, if you can predict it, you can prevent it. When a delayed rise in blood sugar is anticipated, two options are available. For those taking insulin by injection, a small dose of intermediate-acting insulin (NPH) taken soon after the meal tends to do a nice job of offsetting the effects of fat. A dose of NPH equal to 5 to 10 percent of your total daily insulin should serve as a safe starting point. For example, if you take a total of about 50 units of insulin for the day (basal + bolus combined), give yourself 2.5 to 5 units of NPH after a high-fat meal. If you are using an insulin pump, the adjustment is much simpler. Try a temporary basal increase of 50 to 60 percent lasting approximately eight hours, starting after you finish your meal. Check your blood sugar frequently the first time you do this to see how well the adjustment is working. If you use an automated hybrid closed-loop system, you can wait to see if the system raises your basal enough on its own to offset the delayed effects of fat. If not, you can switch back to manual mode after a high-fat meal and set a temporary basal increase on your own. Growth and Weight Gain During a young person’s growth years, insulin needs rise steadily. This is due to increases in body size as well as hormones that counteract insulin and stimulate the liver to produce additional glucose. The accumulation of body fat also increases insulin requirements because fat contributes to insulin resistance. The Adjustment: All aspects of the insulin program will need to increase with significant growth and weight gain. Adjustments should be made in proportion to the amount of weight gained or lost. With a 10 percent change in body mass, changes are usually needed in basal insulin levels, insulin-to-carb ratios, and the sensitivity factor. For example, a person who goes from 120 to 130 pounds (57 to 62 kg) and has blood sugars that are consistently above their target range should consider increasing basal, bolus, and correction insulin by approximately 10 percent. Infection Infections are more common in people with diabetes, particularly when blood sugar levels are chronically high. Infection-fighting white blood cells do not work well when the blood sugar is elevated. Extra glucose in the bloodstream also provides nourishment for viruses and bacteria (aiding and abetting the enemy!). Infections, in turn, cause the body to produce stress hormones that drive the blood sugar even higher and make insulin less effective. Infections commonly affect the sinuses, respiratory system, urinary and vaginal tract, gums, and skin. Symptoms of infection include: • chronically high blood sugars • fever • dehydration • enlarged glands • thick yellow, green, or milky secretions Ketones may be present in the blood and urine during an illness and are caused by severe insulin resistance (as a result of all the stress hormones being produced). It is important to check your blood sugar and ketones frequently during an illness and stay in close contact with your health care team. The Adjustment: Even if you are not eating as much as usual, be sure to keep taking your basal insulin during an illness. Without basal insulin, your blood sugar may become dangerously high, and you will put yourself at risk of diabetic ketoacidosis. When in DKA, your blood becomes so acidic that you will likely vomit and feel extremely achy. Your breathing will become very deep and labored, and your breath will take on a characteristic spoiled-fruit smell as your lungs attempt to rid your body of acid when you exhale. Treatment for DKA requires an immediate visit to the nearest emergency room. In most cases, extra basal insulin is required during an illness. If your blood sugars are repeatedly high and you are not ketotic, consider increasing your basal insulin dose by 25 to 50 percent. If you are ketotic (small or more on the urine ketostick, or >0.5 on a blood meter that measures ketones), you may need to increase the basal insulin 50 to 100 percent. The basal insulin increase is in addition to your usual bolus doses, including correction doses to cover high blood sugars. Keep in mind that insulin will not absorb properly into the bloodstream if you are not adequately hydrated. Drinking plenty of fluids during an illness is essential—preferably clear, caffeine-free fluids. Most adults should consume one cup per hour while awake; small children should consume a half cup per hour. If you suspect that your insulin is not working after you inject or bolus, consider giving an injection directly into muscle, or ask to be taken to a hospital so that insulin and fluids may be administered intravenously. “Couch Potato” Syndrome Sitting or lying down for long periods of time when you are normally active can produce a gradual rise in the blood sugar level. Because your usual insulin doses are based on a standard le

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vel of physical activity, withdrawing that activity can result in less glucose burning and a temporary decrease in insulin sensitivity. The Adjustment: The next time you plan to be completely sedentary for more than a few hours, consider raising your insulin dose slightly. If you use a pump, a temporary basal increase of 20 to 40 percent is a good place to start. If you take injections, adding 20 or 30 percent to your boluses can do the job nicely. Try this the next time you take a long car trip or plane, train, or bus ride as well as any time you plan to veg out in front of the TV, the computer, or a good book for several hours. It can also be used when an injury keeps you from engaging in regular exercise. I find this adjustment helpful when sitting in long, boring meetings (are there any other kind?). Rebounds from Lows Rising blood sugars can occur after hypoglycemia. This is called a ”rebound.” The symptoms that accompany low blood sugar (shaking, sweating, rapid heartbeat) are caused by the production of adrenaline. Adrenaline can raise the blood sugar by stimulating the release of glucose by the liver. It can also inhibit insulin’s action for several hours. As a result, the blood sugar can be unusually high several hours following a low, and treatment with correction doses may not work as well as usual. When low blood sugars occur during sleep, the body’s own natural hormonal responses commonly kick in and produce high readings upon waking. A rebound that occurs overnight is called a Somogyi phenomenon (see Chapter 6 for more details). Many people sleep through these lows and are surprised to see the high readings when they wake up. Of course, taking more insulin at night to fix the morning highs would only make the problem worse! The following symptoms may indicate that you are going low and rebounding during the night. • nighttime sweating • cool body temperature • restlessness • headache or hangover-like symptoms • rapid heartbeat upon waking • strange dreams not feeling well rested in the morning It is a good idea to check your blood sugar at the midpoint of your sleep cycle to verify that your blood sugar is not dropping while you sleep. Use of a continuous glucose monitor, even for just a few nights, will also provide the information you need. For example, the chart in Figure 8.2 indicates consistent blood sugar drops in the middle of the night, followed by a rise in the early morning. Figure 8.2: CGM showing a rise in the morning blood sugar following lows in the middle of the night The Adjustment: When morning highs are preceded by lows in the middle of the night, there are a number of possible solutions. 1. If the lows are usually preceded by highs at bedtime, increase your sensitivity factor starting after dinner. That way you will receive less insulin to cover bedtime highs. 2. If the lows are more common following large bedtime snacks, reduce your insulin-to-carb ratio for food eaten after dinner. 3. If the lows take place when no bolus was given at bedtime, reduce the basal insulin from bedtime to morning (if using a pump) or the dose of long-acting insulin (if taking injections). Unfortunately, predicting when—or if—a rebound is going to occur after typical garden-variety low blood sugars is difficult. Some people find that they only experience a rebound following symptomatic lows—complete with the shakes, sweats, and so on. If you detect a pattern and know when to expect a rebound to occur, give yourself a small dose of rapid-acting insulin once you’ve recovered from the low. If you use an insulin pump, consider raising your basal insulin by 50 percent for the next three to four hours. For example, if your blood sugar always rebounds to the 300s (17–22) following readings below 50 (3), you might benefit from a basal increase once your blood sugar has returned to normal. Speaking of treatment, another way to prevent a significant rebound is to refrain from overtreating the low. Eating excessive amounts of food when you are low is like throwing gasoline on a fire. We will discuss proper treatment of lows in the next chapter. Steroids Steroid medications such as cortisone and prednisone are used to treat asthma, arthritis, emphysema, and muscle and joint inflammation. These drugs create significant insulin resistance and raise blood sugar levels—sometimes dramatically. Inhalers (containing albuterol) and topical steroids (in cream or ointment form) can also raise blood sugar levels. The Adjustment: For those using a steroid medication on a temporary basis, an increase in the usual insulin doses will almost certainly be necessary. Likewise, if you use a steroid medication on a regular basis but have your dosage increased, an insulin dose increase will also be needed. Some steroids are more potent than others, and their onset and duration of action can vary. Ask your physician about the specific medication that you plan to use. Oral steroids tend to have relatively short courses of action, having maximum effect several hours after taking them and less effect twelve to twenty-four hours later. Increasing the basal insulin dose by 50 percent to 100 percent for twelve hours usually works nicely. Injected steroids, such as cortisone (for knee, shoulder, or elbow inflammation, for example) will raise the blood sugar starting a few hours after the injection and last as long as four to eight days. The peak insulin resistance usually takes place two to three days after the injection. The following basal insulin adjustment has worked well for many of our patients: Day 1: 1.5 times the usual basal dose Day 2: 2–3 times the usual basal dose* Day 3: 2–3 times the usual basal dose* Day 4: 1.5–2 times the usual basal dose Day 5: 1.5 times the usual basal dose * Note that many pumps will not allow a basal increase of more than 200 percent (double) the usual settings. It may be necessary to set up a secondary basal profile with the necessary basal increase.

Those who use a hybrid closed-loop system that automates the basal insulin delivery often benefit from switching back to manual mode until the effects of the steroid wear off. If your system takes the past several days of total insulin delivery into account in determining your needs, it might overdeliver following a period of steroid use. It’s best to keep the system in manual mode for several days following a return to your usual basal settings. AWOL Thyroid Having diabetes means that we’re at risk for a host of other health problems. One of them is low production of thyroid hormone (hypothyroidism), also called Hashimoto’s thyroiditis. This condition is caused by the same autoimmune defect that attacks the beta cells of the pancreas and causes type 1 diabetes. In this case, the attack is on the thyroid gland and causes inflammation and stress to occur to the cells that produce thyroid hormone. Approximately one out of six women and one out of eighteen men with type 1 diabetes have hypothyroidism, as do one out of twenty people with type 2 diabetes. When insufficient amounts of thyroid hormone are produced, the body’s metabolism slows down, and blood sugar levels tend to go up. The Adjustment: Treatment for hypothyroidism involves taking a pill to provide extra thyroid hormone. The dose is usually very low to start and is increased gradually until normal thyroid levels are achieved. Until this happens, both basal and bolus doses will likely need to be increased. Take the basal settings, insulin-to-carb ratios, and correction doses up by 10 percent every couple of days until satisfactory fasting and premeal blood sugar levels are achieved. Other Medications Diuretics, Dilantin, estrogen, testosterone, epinephrine, cough and cold remedies that contain epinephrine, certain antibiotics (fluoroquinolone versions), lithium, and many beta blockers can cause a short-term rise in blood sugar levels. See Appendix E for a more complete list of drugs that can cause a rise in blood sugar levels. The Adjustment: If you have been taking any of these medications over an extended period of time, no insulin dosage adjustments should be necessary. However, if you are starting or increasing a dose, you may need to increase your bolus or basal insulin or both. It’s best to wait several days after starting any of these medications to see how your blood sugar patterns are affected, and ask your prescribing physician for advice on the proper course of action. Surgery Medical procedures, ranging from oral surgery to a tummy tuck to cardiac bypass, have certain physiological and psychological consequences. Among these is a stress response by the body (in response to an invasion by “foreign fingers”) as well as the mind (in anticipation of the event). There is also a recovery period that involves bed rest and, in all likelihood, a certain degree of discomfort. What’s it all mean for your diabetes? Yep, high blood sugars—and at the worst possible time. A speedy recovery hinges on good blood sugar control. The body’s tissues heal better and with less risk of infection when the blood sugar is near normal. The Adjustment: If your surgeon offers to control your blood sugars for you during and after the procedure, take her up on it. The medical team will monitor your blood sugar frequently and infuse insulin directly into your bloodstream via an IV to keep your blood sugar as close to normal as possible. For outpatient procedures your doctor will probably ask you to manage your own diabetes. That’s okay—it’s not as complicated as it may seem. Because most procedures require you to fast beforehand, surgeons will typically schedule their patients with diabetes first thing in the morning. (Take advantage of it! We might as well get something for having this disease!) Even though you won’t be eating beforehand, you may need extra basal insulin to offset the effects of stress hormones prior to and during the procedure as well as lack of activity (and discomfort) after the procedure. You should give bolus insulin if or when your blood sugar is elevated. Here’s a quick guide to help you manage. 1. If you use an insulin pump, stay connected to the pump before, during, and after the procedure. Make sure your infusion set and tubing will not get in the surgeon’s way. Keep your basal insulin at the normal level. Reducing your basal will almost certainly cause your blood sugar to run quite high. If your blood sugar is elevated prior to the procedure, cover with a standard correction bolus, and bolus as usual for your after-surgery meals and snacks. If you find that your blood sugar remains elevated for more than a few hours after the procedure, consider raising your basal by 50 percent by using the pump’s temporary basal feature. 2. If you inject long-acting insulin in the morning or at night, or NPH at night, take your usual dose. An hour or two prior to the procedure, check your blood sugar, and administer a correction bolus as needed. After the procedure, check again, and bolus as needed. If your blood sugar remains elevated for several hours following the surgery, talk with your physician about increasing your dose of long-acting or NPH insulin by 25 percent until you have fully recovered and resume your usual activities. 3. If you take NPH in the morning, give 50 percent of your usual dose of NPH the morning of the procedure. Include a dose of rapid-acting insulin if you wake up with high blood sugar. Cover all meals during the day (including lunch) with rapid insulin. If you are unable to eat, check your blood sugar every two to three hours, and administer correction insulin as needed. The Other Stuff That Can Lower Blood Sugar Levels Prior Exercise Have you ever finished a workout with a terrific blood sugar only to go low, out of the blue, hours later? Delayed-onset hypoglycemia (or D’OH, as Homer Simpson likes to call it) is a blood sugar drop that occurs several hours after a high-intensity, long-duration, or exhaustive workout. It typically occurs six to twelve hours afterward, but it can take place up to twenty-four to forty-eight hours later. The timing of the drop varies from person to person and sport to sport. In my own case, playing full-court basketball in the evening usually results in a blood sugar drop the next morning before lunch. There are two reasons why delayed blood sugar drops take place. Heavy exercise makes muscle cells very sensitive to insulin, so every unit of insulin will cover a greater amount of carbohydrate and have a greater blood sugar–lowering effect following hard workouts. Exhaustive exercise can also deplete the glycogen (sugar energy stores) in the muscles and liver, and as muscle and liver cells replenish their glycogen stores, blood sugar levels tend to drop. The Adjustment: If you use a hybrid closed-loop system, it should work nicely to help prevent most episodes of D’OH. If not, here’s a phrase you’ve seen before: If you can predict it, you can prevent it. Keeping detailed records of your workouts should allow you to figure out which types of activities induce a delayed drop and when. For example, since discovering that nighttime basketball makes my blood sugar drop the next day at midmorning, I started reducing my breakfast bolus the morning after full-court hoops. Options for preventing D’OH include: • reducing your pump’s basal insulin leading up to the time of the expected blood sugar drop • lowering the bolus at the meal preceding the expected drop • reducing the long-acting insulin that will be active at the time of the expected drop • having a slow-digesting snack prior to the time of the expected drop (without any bolus or with a reduced bolus) Weight Loss Just as weight gain increases insulin needs, weight loss reduces it. Losing as little as five pounds (2.4 kg) can enhance your insulin sensitivity and improve the overall effectiveness of your insulin. The Adjustment: All aspects of the insulin program will need to be adjusted with weight loss: basal insulin, i

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nsulin-to-carb ratios, and the sensitivity factor. For those trying to lose weight, reducing insulin doses is absolutely necessary, as repeated bouts of hypoglycemia will hinder weight loss efforts. For example, someone who goes from 240 to 230 pounds (114 to 109 kg) and begins to experience below-target blood sugars should reduce their doses by 5 to 10 percent across the board. Aging The older I get, the harder it is to define what is meant by “advanced age.” My kids think people in their thirties are old and those in their fifties (like me) are older than dirt. As we age, our bodies start to produce fewer hormones that raise blood sugar (such as growth hormone). This is rarely seen in middle age. It usually starts to rear its ugly head after age sixty-five and can result in falling blood sugars during the night and between meals. The Adjustment: Be prepared to cut back on basal insulin levels after age sixty. Hypoglycemia is particularly dangerous in the elderly because of impaired counter-regulation—the body’s hormones do little to help raise the blood sugar back toward normal in the event of a low—as well as the risk of falls and heart attacks when hypoglycemia strikes. Brain Work My dad used to tease me by saying that my brain was the hardest working muscle in my body. In fact, the central nervous system is one of the body’s major consumers of glucose. Brain cells rely almost exclusively on glucose for energy. Whenever the brain is working hard, blood sugar levels may drop. This can occur during periods of intense concentration (studying, multitasking), adjustment to new surroundings (new job, new home), and complex social situations (hosting a party, business networking, “working the floor”). Simply being in an environment that features lots of mental stimulation, such as a shopping center, supermarket, arcade, or casino, can make blood sugars drop. The Adjustment: Predicting when extra brain activity is going to induce a blood sugar drop can be difficult. However, if you detect a pattern of blood sugar drops in certain situations, either reducing your insulin or increasing your food intake in anticipation of such events makes sense. For example, I have a tendency to “drop while I shop” at the grocery store. In response, I try to go grocery shopping after lunch and reduce my lunch bolus by about a third to prevent hypoglycemia. If I forget to make the adjustment, I’ll just graze on pretzel sticks while I shop. Alcohol Alcoholic beverages that contain carbohydrates, such as beer, table and dessert wine, wine coolers, hard lemonade, and frozen and mixed drinks, will raise blood sugar in the short term. Beer—regular beer and craft beer—is like liquid bread: it raises blood sugar pretty quickly. However, alcohol has a tendency to lower blood sugar levels several hours later by keeping the liver from secreting its normal amount of glucose into the bloodstream. As a result, hypoglycemia can occur a while after drinking. The fact that intoxication often masks the symptoms of hypoglycemia and keeps glucagon from working properly makes the risk of severe hypoglycemia even worse. Neither the person with diabetes nor people around them are aware of the low blood sugar because the hypoglycemic symptoms take on the look, sound, and feel of being drunk. Consequently, preventing hypoglycemia is of paramount importance when drinking. The Adjustment: When drinking, it is usually advisable to bolus to cover the carbohydrates in your beverages. However, it is also necessary to make adjustments to prevent a delayed blood sugar drop from the alcohol. If you use an insulin pump, a temporary basal reduction of 30 to 50 percent for two hours per drink can work quite well, since each alcoholic beverage takes about two hours (on average) to be processed by the liver (the bigger you are, the less time it takes; the smaller you are, the longer it takes). In other words, if you have three drinks, lower the basal for six hours. Five drinks? Ten hours. If you take NPH at bedtime, consider lowering the dose by 10 percent for each drink you had that evening, up to an 80 percent reduction. If you take glargine or detemir, take the usual dose, but have a modest-sized slowly digesting snack (without bolusing) before going to bed. Examples include nuts, yogurt, chocolate, and carrots. Climate Warm temperatures and humidity have a tendency to cause blood sugar levels to drop. This is due to dilation of blood vessels near the skin surface, resulting in accelerated absorption of insulin from below the skin. Exposure to very cold temperatures can also cause blood sugar levels to decline as the body’s energy expenditure increases in order to produce heat. The Adjustment: Seasonal changes may require modest (10 to 20 percent) changes in basal as well as bolus insulin doses. You may need short-term dosage adjustments when traveling to a climate that is much colder, warmer, or more humid than what you are used to. When you move exercise from indoors to outdoors, you may require a more significant preworkout bolus reduction than usual, particularly when the weather outside is very hot or humid. High Altitude Traveling to altitudes that are much higher than you are accustomed to can cause blood sugar levels to drop. At high altitudes the metabolism (heart rate, respiration) increases in order to deliver enough oxygen to the body’s cells. Luckily, the body usually adjusts to high altitudes within a few days, and metabolism returns to normal. Also, be careful when using your blood glucose meter at very high altitudes. Some meters do not give accurate readings above ten thousand feet (check your owner’s manual, or call the meter manufacturer to see if your meter may be affected). Most CGM systems perform normally even at high altitude. The Adjustment: Be prepared to reduce your basal insulin by 20 to 40 percent for the first couple of days when traveling to high altitudes. This will keep your blood sugar from dropping between meals and while you sleep. Exercising at high altitudes may require a greater dosage reduction than you are used to, as the body has to work extra hard to supply enough oxygen to your muscles. Nausea Any time your stomach is upset, there is a good chance that food you have eaten recently will either digest much more slowly than usual or not absorb completely. If vomiting occurs, food you may have bolused for fails to ever reach the bloodstream. This, of course, puts you at risk for hypoglycemia. The Adjustment: If nausea is common or predictable (such as during chemotherapy or early stages of pregnancy), consider taking your bolus insulin an hour or two after eating, once you are certain that your food will stay down. Likewise, if your stomach is upset at the time of a meal or snack, consider delaying the bolus until after you have eaten just to make sure you have only covered carbs that you actually consumed. If your blood sugar is dropping and you are unable to tolerate ordinary food or beverages, there are a few ways to keep your blood sugar from bottoming out. First, try placing glucose tablets or dextrose-containing candy under your tongue or in your cheek. Even without swallowing, some of the sugar can be absorbed through the lining of the mouth. An upset stomach can sometimes tolerate low-sugar (but not sugar-free) beverages, such as sports drinks or diluted juice. Another option, if you use an insulin pump, is to turn the basal rate on your pump down by 80 to 90 percent for a few hours (something that might occur automatically if you use an automated hybrid closed-loop system). You may also give yourself a small injection of glucagon, using an insulin syringe to inject the glucagon just below the skin. Ten to twenty units of glucagon are usually sufficient to reverse a downward trend in the blood sugar fairly quickly. This type of micro-dosing is possible with the older glucagon kits and the new prefilled glucagon syringes, but not with the nasal version. Other Medications Starting or adding any diabetes medication to your management program can reduce your need for insulin. Other medications, including antidepressants (including MAO inhibitors), nicotine patches, and some antibacterial agents, may result in a temporary reduction in blood sugar levels. The Adjustment: Speak to the physician who prescribed the medication to determine whether the dosage warrants any up-front changes in your insulin doses. Otherwise, take a wait-and-see approach. If you notice lower than usual blood sugar levels around-the-clock after starting (or increasing) the medication, cut back on your basal insulin in 10 percent increments until the problem is resolved. If the lower readings take place at a consistent time of day, reduce your bolus insulin prior to that time. For example, if you have been going low in the afternoon since starting on a nicotine patch, reduce your lunchtime bolus. Stuff That Can Make Your Blood Sugar Rise or Fall Just when you think you have it all figured out, along comes something that can cause blood sugars to rise or fall, depending on the situation. But don’t freak out—we can handle these. Impaired Digestion Gastroparesis is a form of diabetic neuropathy in which the stomach is slow to empty its contents into the intestines. Food digests much slower than usual, so the blood sugar has a tendency to rise several hours after eating rather than right after the meal. Those who take rapid-acting insulin at mealtimes sometimes see a drop in their blood sugar soon after eating, as the insulin begins working but the food doesn’t, followed by a rise as the food kicks in around the time the insulin is wearing off. The Adjustment: Gastroparesis can be treated in a variety of ways. Facilitating the movement of food into the intestines is possible with oral medications, electrical stimulation, or modifications to the diet. If these prove to be ineffective, you will need to make adjustments to the timing or type of mealtime insulin. Switching from rapid-acting insulin to regular insulin works well for many people with gastroparesis. Regular insulin’s delayed peak (two to three hours after injection) and prolonged duration of action (five to six hours) often matches the absorption of sugars into the bloodstream for those with slow digestion. Another option is to delay the mealtime bolus until thirty to sixty minutes after the meal. Those who use insulin pumps can extend their bolus over a couple of hours to delay or blunt the peak and prolong the action curve of the insulin. Menstruation During various phases of the menstrual cycle, the body produces hormones that can raise or lower blood sugar levels. Many find that their blood sugar levels are significantly higher for several days before the onset of their period and then lower for a day or two after menses begins. To determine whether you have a pattern of glucose ups and downs related to your menstrual cycles, note the onset of your period for a few months, and then take a look at the daily or long-term trend report from your meter or CGM. In Figure 8.3, a period that started on January 28 was preceded by three days of elevated glucose levels. Figure 8.3: Average glucose levels went up starting three days before the start of menses. Note that the average values are in mmol/l (multiply by 18 for equivalent mg/dl averages). The Adjustment: If you find a consistent pattern of elevated readings before your period or lower than normal glucose levels after your period starts, it makes sense to adjust your basal insulin dose proactively. As soon as premenstrual symptoms and elevated glucose levels appear, raise your dose of injected basal insulin (or the basal delivered by your pump) by 20 percent to 40 percent. Pump users also have the option of setting up a secondary basal program just to use during the premenstrual phase of the month. Don’t forget to return to your usual settings once your period begins! To prevent lows after your period, reduce your basal insulin by a similar amount for a day or two. Travel Travel can present special challenges for people with diabetes. With changes in meals, activity, and sleep schedules, blood sugars may vary quite a bit when you travel. Time zone changes can wreak havoc on control because your normal basal insulin patterns may not match your sleep/wake schedule at your destination. When in transit, your blood sugar levels may run higher than usual. This is caused by a combination of factors, including the stress associated with travel, consumption of restaurant meals, and prolonged periods of sitting. However, the pattern can change dramatically when you arrive at your destination. The sudden decrease in stress, extra walking, new surroundings to absorb mentally, and (perhaps) warmer temperatures can lead to an overall drop in blood sugar levels. The Adjustment: Plan to take a little extra basal insulin on travel days but a little less once you arrive and settle in at your destination. Incidentally, if you need to take an insulin injection on a plane using vials and syringes, only inject half as much air as usual into the vial. Cabin pressure is a bit lower than the air pressure on the ground, so you won’t need to build up as much pressure inside the vial. When traveling across time zones, you may need to make some insulin program adjustments. If you use an insulin pump, simply adjust the clock on the pump to correspond with the local time once you arrive. This will help ensure that the peaks and valleys in your basal insulin program will correspond to your sleep schedule at your destination. Those taking injections of NPH, glargine, or degludec should continue to take the injections on a schedule similar to what is kept at home. This may mean changing the clock time of your injection. For example, if you normally take your glargine at 10 p.m. and travel west across three time zones, you should begin taking it at 7 p.m. (local time) once at your destination. Upon tr

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aveling home, you can resume your usual injection time of 10 p.m. Note that the timing of ultra-long-acting insulins (degludec or concentrated glargine) can vary several hours from day to day, so unless you’re traveling across more than three or four time zones, it is fine to keep to your usual clock schedule at your destination (for example: 10 p.m. at home, 10 p.m. at your destination). And remember, insulin is stable at room temperature for up to a month. There is not usually a need to refrigerate your insulin while traveling. However, if the temperature at your destination is in excess of 90 degrees Fahrenheit (32 degrees Centigrade) and your accommodations are not air conditioned, either store your insulin in a refrigerator, or bring along a temperature-controlled case for your insulin vials and pens. (See Chapter 10 for travel case options.) Irregular Sleep Sleeping isn’t just something we do to pass the time at night and during afternoon history classes. Sleep is also a powerful regulator of appetite, energy use, and weight. Lack of sleep can cause an increase in stress hormone production, which may result in elevated blood sugar levels. It also tends to increase appetite and can lead to insulin resistance and weight gain, particularly when normal sleep hours are spent in a sedentary state (watching TV, and so on). Conversely, if normal sleep hours are spent working or engaging in physical activity, blood sugars can run lower than usual. The Adjustment: Be prepared to increase your basal and bolus insulin doses if you are having difficulty sleeping—particularly if you are sleeping less than six hours per night. However, if you are forced (or choose) to work late into the night, you may need to reduce basal insulin temporarily by 20 to 40 percent or have periodic snacks to prevent hypoglycemia. Just about everyone benefits from maintaining a fairly consistent sleep/wake schedule. If you are having difficulty maintaining a normal sleep pattern, you may benefit from avoiding caffeine, naps, and nighttime exercise (although daytime exercise can be beneficial). Have a comfortable sleep area that you only use for sleeping. Engaging in a relaxing activity thirty minutes prior to bedtime can also help. In some cases, sleep disturbances can be attributed to stress, sleep apnea, or an underlying illness. If this is the case, your physician may be able to prescribe appropriate medication or refer you to a sleep center for counseling. Menopause Natural menopause is caused by reduced estrogen production by the ovaries. Surgical menopause occurs when the ovaries are removed, resulting in a sudden decrease in estrogen. Weight gain often accompanies menopause. Hot flashes, mood swings, and fatigue may occur as levels of estrogen ebb and flow. Because estrogen makes the body more sensitive to insulin, blood sugar control during menopause can become more challenging. The Adjustment: Many report more frequent and severe low blood sugars during early menopause, especially during the night. Most find that in the later stages, as estrogen levels decrease permanently, their bodies are more resistant to insulin and that they require higher insulin doses. However, changes in blood sugar levels during menopause are varied and highly individualized. I would hesitate to make permanent changes to your program until a pattern of high or low readings is established over a period of several consecutive days. Since the effectiveness of both basal and bolus insulin are influenced by estrogen levels, all doses (basal, I:C ratios, correction doses) should be adjusted upward or downward when a pattern of highs or lows is present several days in a row. Sports and Exercise As discussed in the previous chapter, blood sugar levels usually fall during exercise. However, experiencing a blood sugar rise with high-intensity and short-duration exercise and competitive sports is also common. This is caused by a surge of adrenaline that counteracts the effects of insulin and stimulates the liver to release extra glucose into the bloodstream. That’s why a two-hour practice or training session can produce a significant blood sugar drop, while a two-hour competition can produce a rise. Exercises that often produce a short-term blood sugar rise include: • weight lifting, particularly when using high weight and low reps • sports that involve intermittent bursts of activity, like baseball, cricket, or golf • sprints in events such as running, swimming, rowing, or skating • activities that are being judged, such as gymnastics or figure skating • sports where winning is the primary objective • almost any form of exercise performed in the early morning Ironically, the same high-intensity, strenuous sports that produce a short-term blood sugar rise can also produce a delayed blood sugar drop several hours after the activity (as was discussed earlier in this chapter). Adjustments for Sports and Exercise Given that sports performance hinges on having adequate control of one’s blood sugar, it is essential that everyone who exercises or competes in sports makes sound adjustments. We discussed prevention of hypoglycemia through mealtime insulin adjustment in Chapter 7. When you are going to perform aerobic or cardiovascular exercise after a meal, reducing the mealtime rapid-acting insulin is almost always in order. For Long-Duration Activity With prolonged exercise (physical activity lasting more than ninety minutes), reducing your basal insulin can be helpful. This is easy to do with an insulin pump: Simply set a temporary basal rate beginning an hour or two before the activity. Setting the temporary basal rate ahead of time ensures that you will have less basal insulin working at the time your activity begins. If you wait until the activity starts to reduce your basal rate, you will have to wait a couple of hours to see a noticeable reduction in the level of insulin in your bloodstream. The amount of the reduction depends on the nature of the activity. For mild or moderate activity, a 50 percent reduction is a good place to start. For more intense exercise, the basal may need to be reduced by as much as 80 to 90 percent. It is important to note that temporary basal reductions (or suspending the pump or disconnecting) are not of much use for preventing lows with activities lasting an hour or less. Basal changes take an hour or two to start having an effect, and the total amount of insulin reduction in place during the activity will not be nearly enough to ward off hypoglycemia. Temporary basal reductions are not of much use for activities lasting an hour or less. If you take injections, a reduction in your long-acting insulin dose means that you will be lowering your basal insulin level for nearly twenty-four hours—not just while you are exercising. However, this can be useful if your activity is lasting throughout most of the day because you will probably need less basal insulin after the activity (and perhaps through the night) as well. In this case, a 25 percent reduction in your injected basal insulin dose prior to daylong activity is a good starting point. With long, intense forms of exercise, preventing hypoglycemia will almost always require a reduction in basal insulin as well as carbohydrate-containing snacks at regular intervals. Snacking to Prevent Low Blood Sugar With certain forms of exercise, you will need to eat extra food to prevent hypoglycemia. For example, when exercise is going to be performed before or between meals, reducing the insulin at the previous meal would only drive the preworkout blood sugar very high. A better approach is to take the normal insulin dose at the previous meal and then snack prior to exercising. It’s best to eat the snack approximately fifteen minutes before exercise begins. This allows for some glucose absorption to take place before digestion is slowed by the exercise. If you decide to exercise soon after you have already taken your usual insulin or medication, snacking will be your only option for preventing hypoglycemia. Also, during long-duration, high-intensity activities, you’ll need regular snacks to maintain both blood sugar and energy levels. The best types of carbohydrates for preventing hypoglycemia during exercise are ones that digest quickly and easily (high-glycemic-index foods). These include sugared beverages (including juices, nondiet soda, and sports drinks), bread, crackers, cereal, and low-fat candy. The size of the snack depends on the duration and intensity of your workout. The harder and longer your muscles are working, the more carbohydrates you will need. The amount is also based on your body size: the bigger you are, the more fuel you will burn while exercising, and thus the more carbohydrates you will need. Granted, there is no way of knowing exactly how much you will need, but the figures in Table 8-2 should serve as a reasonable starting point. To use the chart, find the column that matches your weight, and then find the row that matches the intensity of the exercise. The grams of carbohydrates represent the amount needed prior to each hour of activity. If you will be exercising for half an hour, take half the amount indicated. If you will be exercising for two hours, take the full amount at the beginning of each hour. Of course, if your blood sugar is elevated prior to exercising, you will need fewer carbs; if you are below target, you will need additional carbs. And if your CGM trend is pointing up, you’ll need fewer carbs. A downward trend will require additional carbohydrates. * For example, if you weigh 150 pounds (68 kg) and plan a moderate-intensity, forty-five-minute workout, and your blood sugar is close to normal and stable, take about 25 grams of carb beforehand. If your preworkout blood sugar is elevated or rising, cut back to 15 grams. If your blood sugar is below target or falling, increase to 35 grams. For those who use insulin pumps and choose to lower the basal insulin prior to and during physical activity, the amount of carbohydrates you will need (or the frequency with which you need to eat) will be reduced. For a more detailed look at the carbohydrate required for a variety of different activities, see the “Carbohydrate Replacement” table in Appendix F. Keeping Blood Sugar from Rising During Sports Exercising with a high blood sugar level is rarely dangerous as long as there is at least some basal insulin in the body. Without any insulin present, exercise will cause the blood sugar to rise further and may induce the production of ketones, acidic by-products of fat metabolism. If ketones build up in large amounts and you become dehydrated, the delicate pH balance in the bloodstream and body’s tissues will become altered, and you can develop life-threatening diabetic ketoacidosis (DKA). If your pre-exercise blood sugar is inexplicably high, there is one way to make sure you have sufficient insulin to allow for a safe exercise session: check your urine (or your blood) for ketones. The presence of small, moderate, or large ketones in the urine, or a reading of greater than 0.5 mmol/l on a meter that measures ketones, usually indicates a severe lack of insulin in the body. Do not exercise if you have ketones. Instead, drink plenty of water, take a correction dose of insulin by injection, and contact your physician immediately. If you do not have ketones, exercising should be safe as long as you address the high reading with insulin and drink plenty of water. However, high blood sugars during exercise can be a problem for anyone who wants to maximize their performance. As noted in Chapter 2, strength, speed, stamina, flexibility, and mental focus all hinge on blood sugar control. If you notice that your blood sugar rises during certain types of activities, now is the perfect time to think like a pancreas! (Say, that would make a cool book title.) When the adrenaline starts flowing and blood sugar starts rising, the pancreas makes just a little bit of insulin to compensate. Consequently, you need to take extra insulin to prevent the rise. Case in point: One of my clients, Marvin, always saw his blood sugar drop during hockey practice, but during competitive games it would rise into the 300s (17–22 mmol/l). When Marvin started taking extra insulin before games, his blood sugar stayed close to normal, and his speed, stamina, and mental focus all went up a notch. In his first tournament trying this approach, Marvin won his first-ever MVP award! To prevent a blood sugar rise during sports activity, think like a pancreas, and take a small dose of insulin beforehand. To determine how much insulin to take before workouts that cause the blood sugar to rise, consider how much of a rise you tend to see. If it rises 200 mg/dl (11 mmol/l) and your sensitivity factor is 50 (2.8) points per unit, you would normally need to give 4 units of insulin, thirty to sixty minutes beforehand, to prevent the rise. Likewise, if you normally rise 70 mg/dl (3.9 mmol/l) and your sensitivity factor is 30, you will need a little more than 2 units beforehand. My advice to you: don’t do it. If you give these full amounts and then start to exercise, you’ll probably wind up sucking down glucose tablets before too long. Instead, take half of the amount you would usually need to offset the expected blood sugar rise. Remember: exercise makes insulin work more efficiently, so a unit might pack the punch of two while you’re physically active. Likewise, if your blood sugar is elevated prior to or just after a workout, give yourself half of your usual correction bolus. For example, consider our hockey player, Marvin. When Marvin has a game, his blood sugar tends to go up about 150 mg/dl (8.3 mmol/l). His correction factor is 30 mg/dl (1.7 mmol/l) per unit. If his blood sugar before heading for the rink is 200 (11 mmol/l), he needs 2.5 units to offset the expected rise (half the 5 units he would normally need) plus 1.5 units to cover his c

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urrent blood sugar (half the 3 units he would normally take), for a total of 4 units. If you are nervous about giving insulin before exercise, check your blood sugar more often than usual (perhaps every half hour) or use a CGM and spot check it regularly, and have glucose tablets or some other form of fast-acting carbohydrate nearby. Pregnancy If you have diabetes, expect your insulin needs to change dramatically throughout the course of your pregnancy. The proportion of basal (background) to bolus (mealtime) insulin does not change much, but the total amount of insulin required goes through a complete metamorphosis. Do the doses simply rise or fall steadily throughout pregnancy? Of course not! This is diabetes we’re talking about—nothing is simple. For most, insulin needs during pregnancy follow a pattern similar to a log flume ride found at an amusement park. No, I haven’t lost my mind. Let me explain. Weeks 0 to 6: Business as usual. You’re just waiting in line to get on the log flume ride, totally oblivious to what you’re in for. You probably don’t even know you’re pregnant, and insulin needs are no different from what they were before you conceived. Weeks 6 to 12: The slight dip. Figure 8.4: Typical insulin requirements through pregnancy In log flume terms, this is like when you first get into the log boat and the added weight makes it sink slightly into the water. This is truly an amazing phase: you’ve just found out that you’re pregnant, and you’re quite excited. As the embryo evolves into a fetus, the autoimmune process that has been attacking your beta cells all these years suddenly becomes more tolerant. This allows your pancreas to start secreting some insulin on its own. The result: a reduction in the need for pumped or injected insulin. Low blood sugar is common during this phase, as many pregnant people are taken by surprise that they are producing some of their own insulin again. Severe hypoglycemia is three times more common during the first trimester of pregnancy than during the four months preceding pregnancy. Weeks 12 to 36: The steady climb. This is the part of the log flume ride when you get on that long, slow conveyer belt up to the top. Your body and the baby go through steady growth, and the placenta produces hormones (including human placental lactogen, progesterone, prolactin, and cortisol), which cause insulin resistance. Total daily insulin needs commonly double or triple during the second and third trimesters of pregnancy. Weeks 36 to delivery: The moment of calm. Once the conveyer belt has brought you to the top, there is always that relaxing, scenic ride before the big plunge. For a few weeks prior to delivery, insulin requirements level off. Things are in a steady state as you make your last-minute preparations. Delivery: The big plunge. This is what made the log flume famous. Whether your delivery is vaginal or via C-section, insulin needs come down quickly. If you deliver naturally, labor involves a great deal of—well, labor. And that means reduced insulin needs, as if you were running a minimarathon. And with any form of delivery, the removal of the placenta means a sharp drop-off in hormones that were causing insulin resistance. 1–2 Days postpartum: The splash. When that log boat comes careening down, it doesn’t ease comfortably into the pool of water at the bottom. Rather, it torpedoes into it with full force, soaking you and any unfortunate onlookers. Insulin needs do the same thing after delivery: requirements may actually drop below where they were at the beginning. Remember the “slight dip” phase during the first trimester, when the pancreas was capable of secreting some insulin on its own? Well, that process continues until shortly after delivery. And when you combine a pancreas that is producing insulin with the sudden elimination of placental hormones and rapid weight loss, the results can be astonishing. For the first twenty-four to forty-eight hours after delivery, don’t be surprised if insulin needs are dramatically reduced. There are even reports of some postpartum people with type 1 diabetes requiring no insulin during this phase! Home again: It was a wild and crazy ride, but well worth it. Just as the log boat makes its way back to the starting point, insulin needs also tend to find their way back to prepregnancy levels. That’s not to say that there won’t be any special adjustments necessary. Nursing usually causes the blood sugar to drop modestly. Retained weight will increase insulin needs. And new sleep patterns may require changes to basal insulin levels. The Adjustments: During weeks six through twelve, reductions to both basal and bolus insulin are usually necessary to prevent frequent bouts of hypoglycemia. A 25 percent reduction in insulin requirements is common during this phase. During weeks twelve through thirty-six, you will need to make steady, gradual increases to both basal and bolus insulin in order to keep up with your body’s increased needs. As mentioned previously, it is common for total insulin requirements to double or triple from prepregnancy to the later stages of the third trimester. During delivery, because of the physical work being performed, most people need to reduce their basal and bolus insulin doses by approximately 50 percent. Elevated blood sugar during delivery can cause oversecretion of insulin and hypoglycemia in your newborn, so you should cover any highs with rapid-acting insulin, using 50 percent of the usual correction doses (because of the impact of physical labor). After delivery, insulin doses tend to return to prepregnancy levels. However, if any low blood sugars occur, don’t hesitate to make additional reductions for a couple days. Nursing (or pumping breast milk) often requires a small snack to prevent a blood sugar drop. Having 3 to 5 grams of carb per nursing session during the first couple of weeks, and 5 to 10 grams thereafter, is usually sufficient to prevent lows while nursing. CHAPTER HIGHLIGHTS • Secondary factors that tend to raise blood sugar include: anxiety and stress caffeine disease progression protein (in the absence of carbs) large amounts of dietary fat growth and weight gain illness and infection reduced physical activity rebounds from lows hypothyroidism steroid medications other medications surgery • Secondary factors that tend to lower blood sugar include: previous heavy exercise advanced age weight loss heavy brain work alcohol heat and humidity nausea other medications high altitude • Factors that can both raise and lower blood sugar include: gastroparesis travel intense and competitive exercise irregular sleep menstrual cycles menopause pregnancyNINE Taming the Highs and Lows Darling, I don’t know why I go to extremes. Too high or too low, there ain’t no in-betweens. —Billy Joel, “I Go to Extremes” Up to this point, we have focused our attention on matching insulin to our precise needs (thinking like a pancreas!). But let’s be realistic: with so many variables and factors influencing blood sugar levels, there are going to be some highs and lows along the way. Even those people who manage their diabetes very meticulously can still spend upward of 25 percent of their time out of their target range. In this chapter we will focus on what happens when the insulin we take is not matched precisely to our body’s needs. If at any time there is too little insulin in the body to meet the body’s needs, high blood sugar (hyperglycemia) occurs. We can correct most garden-variety episodes of hyperglycemia with a bolus dose of insulin. However, a severe lack of insulin in the body can result in a life-threatening condition called diabetic ketoacidosis (DKA). Because death is something we generally try to avoid, I will present strategies for both preventing and treating severe hypoglycemia and DKA in this chapter. I’ll also take a close look at ways to prevent after-meal highs, commonly referred to as “spikes.” The Science Behind Hypoglycemia Hypoglycemia (hereafter referred to as a “low”) is the main limiting factor in intensive diabetes management. Without the risk of lows we could simply load up on insulin and never have another high reading. Current research involving “smart insulin” (insulin that works only when blood sugars are elevated) takes this approach. Low blood sugar affects virtually all systems of the body, but none quite as much as the brain. Brain cells are picky about their fuel source: they prefer to burn glucose for energy. Brain and nerve cells have another special feature: they do not require insulin to absorb sugar. Instead, they have special built-in transporters that shuttle sugar across their cell membranes without the aid of insulin. Low blood sugar is usually defined as a level of less than 70 mg/dl (3.9 mmol/l). Mild lows can interrupt your day and be a source of inconvenience and perhaps embarrassment. They also contribute to poor physical and mental performance, impaired judgment, mood changes, weight gain, and rebound high blood sugars. Severe lows can induce seizures, loss of consciousness, coma, or even death. Repeated or prolonged bouts of severe hypoglycemia have the potential to cause permanent mental impairment, although this is usually seen only in the most extreme cases. The bottom line: lows are something to be avoided. There is no advantage whatsoever to experiencing hypoglycemia. Sure, frequent lows can reduce your A1c and give the appearance of “good management.” But as my wife so eloquently reminds me from time to time, “Any idiot can have a decent A1c if they’re taking too much insulin and going low all the time!” Mild Lows Soon after diabetes is diagnosed, the brain can detect hypoglycemia quickly and easily. In some cases, symptoms can occur even at blood sugars above 70 (3.9). Blood sugars in the 80s or 90s (4s–5s), or a rapid drop from a very high level toward a more normal level, may induce hypoglycemic symptoms. Upon sensing that the blood sugar is low, the brain sends a signal to the adrenal gland, which releases a surge of adrenaline. Adrenaline, in turn, stimulates the liver to secrete extra sugar into the bloodstream and opposes the action of insulin. Adrenaline also causes a number of physical symptoms: rapid heartbeat, perspiration, shaking, hunger, and a generally anxious feeling. (You may recognize these as the same symptoms that occur when you are under intense stress, like when your in-laws call to tell you they’re coming to visit and will be there in an hour.) When experiencing a mild low, most people are capable of thinking rationally and consuming carbohydrates in order to raise their blood sugar level. Moderate Lows If blood sugar levels are allowed to drop into the 50s or 40s (3–2 mmol/l), the brain begins losing the ability to function properly. Confusion usually sets in, accompanied by dizziness and weakness. Your speech may become slurred, your vision blurry. You may exhibit unusual emotions such as irritability or despair. You will have a difficult time thinking clearly and coordinating your movements. At this point you can still consciously take food or drink to treat the low, but you may require some assistance from a friend or family member. Severe Lows An extreme or extended low may cause you to pass out or experience a seizure. Very severe, prolonged lows can result in coma or death. Severe lows, by definition, require outside assistance and are usually treated with an injection of glucagon or an intravenous infusion of dextrose. The Devolution of Symptoms No, it’s not a typo. And it has nothing to do with the band Devo (“Whip It,” circa 1980). The symptoms of hypoglycemia do not evolve: they devolve, or break down, over time. The brain actually becomes more efficient at extracting glucose from the bloodstream after surviving years of low episodes. This is an adaptive response by the brain, something like when people’s lungs adapt to high altitudes after being there for a while. As a result, the brain ceases to detect mild low blood sugars. Little or no adrenaline is produced, and physical symptoms (shaking, sweating, and so forth) fail to take place. Thus, there may be no warning of low blood sugar in its early stages. The first symptoms are those of a moderate low blood sugar (such as confusion), and these may not occur until the blood sugar has reached a dangerously low level. The name given to this phenomenon is “hypoglycemia unawareness.” It affects most people who have had diabetes for several years and tends to become worse over time. The more lows you have, the less likely you are to experience any warning signs the next time a low occurs. Quite a paradox! Research has shown that the early symptoms of low blood sugar can, to some extent, be restored by avoiding going below 80 (4.4) completely over a period of several weeks. Although this may produce a temporary rise in the HbA1c level, it is well worth it to be able to detect lows and prevent severe hypoglycemia. Look for strategies for preventing hypoglycemia later in this chapter. Treatment of Lows Diabetes is a tricky disease. Lows sometimes feel like highs, and highs sometimes feel like lows. If you suspect that your blood sugar is low, take a few seconds to confirm by glancing at your CGM or checking with a meter. I can’t tell you how many times I thought I was low, only to check and get a reading in the 200s or 300s (teens to 20s). High blood sugars can cause symptoms similar to those caused by lows (tiredness, hunger, a jittery feeling). If you are low, getting an exact reading is also helpful for determining how much carb you need to treat the low. CGM users should be aware that most, but not all, CGM systems are reasonably accurate in a hypoglycemic range. Check the performance of your particular system by looking up how often it is within 10 mg/dl (0.6 mmol/l) of the lab value when the glucose is in a normal-to-low range. This information can usually be foun

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d in the technical section of the user guide. If yours is within 10 (0.6) points less than 90 percent of the time, consider doing a fingerstick each time before treating. With premeal blood sugars that are below your target but above 70 mg/dl (3.9 mmol/l), reducing your meal bolus using your correction formula is a sound approach. This is commonly called a “reverse correction” (deducting from the meal dose so that the blood sugar will rise a little bit). For readings below 70, you should treat the low immediately, wait ten to fifteen minutes for the blood sugar to come up, and then have your meal (giving the usual dose for your meal). If you eat to treat the low and reduce your mealtime bolus, you will have double treated and will probably wind up quite high. There is no one-size-fits-all when it comes to treating lows. There is no one-size-fits-all treatment for hypoglycemia. Proper treatment depends on a number of factors, including: 1. Your body size: The bigger you are, the more carbs you will need to raise your blood sugar. Use Table 9-1 as a guide. * 2. The blood sugar level: The lower your blood sugar, the more carbs you will need to get back up to normal. Table 9-2 provides a good starting point. The goal is to raise the blood sugar to about 120 mg/dl (6.7 mmol/l). If your specific blood sugar target is more or less than 120, you can use the following formula to determine the amount of carb needed: Formula for determining carbs needed to treat a low: (target BG–current BG) / amount each gram raises you For example, if your target is 100 (5.6), your current BG is 56 (3.1), and each gram raises you 4 points (0.22), you will need (100–56) / 4, or (5.6–3.1) / 0.22, which comes to 11 g carb. * 3. The rate of change: This is easily seen on a continuous glucose monitor. If your blood sugar is low and dropping quickly (one or more straight down arrows), you may need 50 percent more carb than the standard amount (see example in Figure 9.1). If you are low and dropping gradually or leveling off, the standard amount should work fine (see example in Figure 9.2). Rapid blood sugar drops are most common when you are still in the peak phase of your mealtime bolus insulin or are in the midst of exercising. Figure 9.1: Low and dropping fast Figure 9.2: Low and leveling off For example, if Asher weighs 125 lbs (57 kg) and has a blood sugar of 61 (3.4), he would normally need 14 g carb to bring his glucose up to 120 (6.7). However, if he also has straight down arrows on his CGM, he should take 14 x 1.5, or 21 g carb. A word of advice for those using hybrid closed-loop systems that reduce or turn off basal insulin delivery in an effort to prevent hypoglycemia: you will need less carbohydrate than usual to treat your lows. The reduction in basal insulin will contribute to a blood sugar rise after the low has been treated, so consuming 25 percent less carbohydrate will help to prevent a rebound high. The Food Type Remember, all carbs are not created equal. Some will raise your blood sugar very quickly, whereas others will take their sweet time (excuse the play on words). When your blood sugar is low, choose a food that will raise you as quickly as possible. As long as your basal insulin doses are set up properly, there is no reason to believe that your blood sugar will drop again right after the low has been treated, so there is generally no need to consume fat, protein, or slow-digesting carbs along with the rapidly digesting carbs. Simply refer to the glycemic index and select foods with a score of at least 70. Examples of high-glycemic-index foods that are portable, measurable, and effective for treating hypoglycemia include: dextrose* (GI =102) dry cereal (70–90) pretzels (81) jelly beans (80) Gatorade (sports drink) (78) vanilla wafers (77) graham crackers (74) plain bread or crackers (70–75) LifeSavers (hard candy) (70) * Dextrose-containing foods include glucose tablets and gels, SweeTarts, Smarties, Spree, AirHeads, Runts, Nerds, and Bottle Caps. Foods with lower glycemic index scores such as whole fruit, milk, ice cream, and—hate to say it—chocolate are not the best choices for treating lows. They will take significantly longer to raise your blood sugar. Many people overtreat their lows by continuing to eat until their symptoms disappear. It usually takes ten to fifteen minutes for high glycemic index foods to raise the blood sugar and twenty to sixty minutes for low glycemic index foods. Be patient! If you suspect that your blood sugar has not come up enough, check your blood sugar with a fingerstick to find out. If your blood sugar is still below 70 (3.9) fifteen minutes after treatment, go ahead and eat a little bit more. CGM systems tend to have a prolonged lag time during hypoglycemia, so they may not be trustworthy until at least thirty minutes have passed. Use fingerstick readings to verify that your blood sugar has risen following treatment for a low. Use fingerstick readings (rather than CGM) to verify that your blood sugar has risen following treatment for a low. If you happen to go overboard on the treatment of your low (as we all do on occasion—food tastes damn good when we’re hypoglycemic!), cover the excess carbs with insulin. For example, if you normally take 1 unit for every 10 grams of carb, and you overtreat your low by 40 grams, give yourself 4 units of insulin once your blood sugar has risen to a safe level. Otherwise, your blood sugar will rise well above your target in the next couple of hours. Treating Severe Lows When a person is unwilling or unable to consciously swallow food, you must treat this severe low differently than mild and moderate lows. Putting any kind of food into the mouth of someone having a severe low is dangerous. They could choke on the food and suffocate, or they could instinctively bite down and take the fingers off the person trying to feed them. There are two things—and only two things—you should do to treat someone having a severe low blood sugar: call for emergency help and administer a dose of glucagon. Glucagon is a hormone that raises blood sugar by stimulating the liver to release its stored-up sugar into the bloodstream. It will usually work in ten to twenty minutes. In some parts of the world, glucagon is available in an easy-to-administer nasal spray (Baqsimi, made by Lilly) or a premixed injectable formulation (Gvoke, made by Xeris Pharmaceuticals), which should be available shortly. Traditional glucagon comes in a kit containing a large, fluid-filled syringe, a small vial with the glucagon hormone in powder form, and instructions written in a seemingly foreign language. The kits have an expiration date printed on them, so check them periodically to make sure yours is fresh. Most people find that glucagon still works perfectly fine if used within six to twelve months of the expiration date as long as it was stored properly. If possible, save your expired kits, and allow your partner to practice with them (on a pillow or foam ball—not you!). There are several steps involved in administering traditional glucagon, and it may be difficult to perform them exactly right in a highly stressful situation. But it is certainly worth the effort. The procedure for administering traditional glucagon, in plain English, is as follows: 1. Call 911. Have paramedics on the way in case the glucagon injection fails to work. 2. Pull the cap off the syringe, and flip the cap off the vial. 3. Inject all of the fluid into the vial. 4. Keep pressure on the plunger to make sure air does not escape from the vial back into the syringe. Remove the needle from the vial. 5. Shake or swirl the vial gently until the fluid is evenly mixed (no clumps) and mostly clear. 6. With the vial held upside down, reinsert half of the needle into the vial. If you put the whole needle in, you will draw in air. 7. Draw the fluid into the syringe. For small children, draw in approximately half of the solution. For teens and adults, draw in most of the solution. There is no exact dose of glucagon required, so estimating is fine. 8. Insert the needle straight (not at an angle) into a muscle such as the thigh, buttocks, or shoulder. Inject the full contents of the syringe. 9. Remove the needle from the skin, and apply a tissue to suppress any bleeding. 10. Turn the victim onto their side to prevent choking (in case vomiting occurs). The victim should regain consciousness in ten to twenty minutes. If they do not, wait for paramedics to arrive. Contact your health care team to troubleshoot and work on a plan for preventing the severe low from happening again. In some instances, glucagon may be used for treating nonsevere bouts of hypoglycemia. For example, if food will not digest easily because of nausea or vomiting or the use of amylin (Symlin); if no food is available (the “desert island” scenario where all you have is a glucagon kit); or even if you’re trying super-hard to lose weight and don’t want to consume extra calories. In these cases, it is possible to inject a low dose of glucagon (10 to 20 units) into the fat layer below the skin using a standard insulin syringe. Note: Everyone who takes insulin is at risk for severe hypoglycemia. It is important to wear or carry medical identification at all times. Wallet cards, bracelets, and necklaces are recommended because these are the first things paramedics are trained to look for when they arrive. See Chapter 10 for a list of companies that supply various types of medical identification. Preventing Lows Minimizing the incidence of low blood sugar can go a long way toward protecting your personal safety and keeping blood sugar levels from bouncing around too much as a result of rebounds. Minimizing the incidence of lows is also the best way to ensure that you will experience early symptoms when your blood sugar is dropping and thus be able to treat the low before it becomes severe. Experiencing a couple of mild low blood sugars per week is usually acceptable. However, if they are occurring more often or if they are of a severe nature, try applying these strategies. Use a Continuous Glucose Monitor—Correctly In the first edition of this book, the CGM did not exist. In the second edition, it was mentioned briefly as a tool for those trying to avoid lows. In this edition, it is ranked numero uno for hypo prevention. CGMs provide alerts when glucose levels dip below a specified threshold. Some CGM systems also provide rate of change alerts that let you know if your blood sugar is dropping very quickly—even if it is still in a normal range—so that you can decide whether you need a snack to prevent hypoglycemia. As mentioned previously, most insulin users have hypoglycemia unawareness and do a poor job of detecting lows on their own. CGM provides an effective early warning system so that lows can be treated early or prevented altogether. But proper use of the system is necessary. First, the low alerts need to be turned on. Research has shown that the average length of low blood sugar episodes is cut in half when the low alerts are in use. This is very important because the length of a low, and not necessarily the severity of the low, is what puts us at risk for seizures and loss of consciousness. The alerts should be set in a way that draws the attention of the user (using vibrations or audible alerts). Second, the alert threshold must be set above the point of hypoglycemia. Because of the lag time that exists in CGM systems, a falling glucose level will generate data on the CGM that is higher than the actual blood sugar. So if you want to catch a low before it hits 70 (3.9), you’ll need to set the alert at 80 (4.4) or 90 (5). Third, every low alert should be addressed quickly and consistently. Treat with an appropriate amount of rapid-acting carbohydrate immediately. And remember, CGM readings may be misleadingly low when you’re recovering from hypoglycemia, so use your meter to measure your blood sugar for the next thirty to sixty minutes. CGMs are very effective for preventing low blood sugar if the alerts are set properly and responded to in a timely way. Use a Hybrid Closed-Loop (HCL) System Taking CGM to the next level, HCLs make automated adjustments to basal insulin delivery in order to help prevent hypoglycemia. Use of HCLs has been shown to reduce the incidence of hypoglycemia as well as the severity and duration of lows by up to 50 percent. But don’t be complacent: HCL systems cannot prevent hypoglycemia entirely. You must maintain all components of the system and remain vigilant with self-care practices. Match Your Insulin to Your Needs The first step in preventing lows is the same as the first step in preventing highs: mimic the action of a healthy pancreas as closely as possible. Daytime doses of NPH (or premixed insulin), in particular, do not match the basal/bolus insulin secretion of the pancreas. NPH insulin can peak at inconsistent and inappropriate times, thereby increasing the odds of low blood sugar. Switching to a flat basal insulin (glargine, detemir, basaglar) or an insulin pump will greatly reduce your risk for hypoglycemia. Use Rapid-Acting Insulin Regular insulin may cost less than rapid-acting insulin, but regular’s prolonged duration of action can be a cause of hypoglycemia—particularly four to eight hours after meals. Rapid-acting insulin usually clears within four hours, so there is less risk of the blood sugar declining long after food has finished digesting. Dose Properly Accidental overdosing of insulin is a common cause of hypoglycemia. If you are on relatively low doses (less than 5 units per injection), look for syringes or pens that offer half-unit markings so that you can dose more precisely. You may also consider diluting your insulin for more precise dosing, as described in Chapter 4. If you have difficulty seeing your syringes, use an insulin pen or injection aid (see Chapter 10). If necessary, have someone else draw up your syringes.

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And pay attention to your math! A single incorrect calculation can send your blood sugar spiraling downward. If you accidentally take too much insulin, drink or eat enough carbs to offset the extra dose, and check your blood sugar hourly until the insulin wears off. Give Your Insulin Time to Work As discussed in Chapter 7, boluses of rapid-acting insulin do not stop working after just an hour or two. They typically take three to five hours to finish working. When figuring the amount of correction insulin needed to bring a high blood sugar down to normal, taking the unused portion of your previous boluses into account is important. Likewise, when evaluating data to fine-tune your meal dosing formulas, base it on the blood sugar three to four hours after the meal. If you set your doses so that your blood sugar is down to normal two hours after eating, you are likely to experience hypoglycemia within the next couple of hours. Time Your Boluses Properly Very large portions, prolonged meals, high-fat foods, and foods with low glycemic index values tend to take several hours to raise the blood sugar level. Giving a bolus of rapid insulin before these types of meals can cause low blood sugar soon after eating. Instead, give your boluses after eating, or if you use an insulin pump, program the bolus to be delivered over an extended period of time. Regular insulin may also be used in place of your usual rapid insulin. These strategies are helpful for those with gastroparesis or who use a medication that slows gastric emptying such as a GLP-1 receptor agonist or amylin hormone replacement. Set Appropriate Targets The lower your target blood sugar, the greater your chances for hypoglycemia—plain and simple. Target blood sugars of 80 or 90 (4.4–5.0) leave little margin for error. Even the slightest bit of extra exercise or a minor overestimate of carbohydrates will probably result in a low. A target of 100 (5.6) or more allows a bit more breathing room. Some people change their target BG from day to day based on their risk for lows. If you’re coming off a day when a low occurred, your BG was very erratic, or you exercised heavily, your risk for hypoglycemia is increased. Raising your target modestly can save you from lows on those particular days. Time Meals and Snacks Appropriately When using any type of intermediate- or long-acting insulin, consuming your meals and snacks on a consistent schedule is necessary. A delay of as little as half an hour (when using daytime NPH) or a couple of hours (when using glargine, detemir, or basaglar) can cause a significant drop in blood sugar. If you anticipate a meal delay, consume part of your usual meal in the form of a carbohydrate-containing snack close to your usual mealtime. Deduct Fiber Grams Fiber is included in the total carbohydrate listings on food labels, but it does not raise blood sugar levels. Any time you are consuming a food item that contains fiber, subtract the grams of fiber from the total carbohydrate before calculating your meal bolus. Adjust for Exercise and Daily Activity Whether you’re running laps or running a vacuum, physical activity will increase muscle cells’ uptake of glucose and enhance insulin sensitivity. In people without diabetes, insulin secretion drops to accommodate these changes. For those who take insulin, adjustments must be made to prevent low blood sugar during and after physical activity. For activity performed after a meal, a reduction should be made to the mealtime bolus insulin. Activity before or between meals will require extra carbohydrates beforehand. Prolonged or very strenuous activity may require reductions in both basal and bolus insulin, along with periodic snacks. Following exhaustive forms of exercise, extra snacks or reductions in basal insulin may be needed to prevent a delayed blood sugar drop. When using a hybrid closed-loop system, raise your target glucose at least an hour before engaging in exercise. Adjust for Alcohol In Chapter 8, we discussed how alcohol can cause a delayed drop in blood sugar by suppressing the liver’s secretion of glucose. After drinking, be sure to either lower your basal insulin level or consume extra snacks. Check, Check, Check—and Evaluate Very few of us are good at guessing our blood sugar levels with much precision, especially when the readings are not extremely high or low. If you don’t have access to a CGM, frequent blood sugar checks will allow you to catch many below-target readings before they turn into hypoglycemia. For instance, a bedtime reading of 82 (4.6) may seem innocuous, but even a slight drop during the night would result in a low blood sugar. Knowing that the reading is close to low allows you the opportunity to have a small snack, thus reducing the likelihood of hypoglycemia during the night. Also, take a look at your blood sugar data from time to time. Patterns of lows don’t just fix themselves! If you detect a pattern of lows, work with your health care team to diagnose the cause and come up with an effective solution. Dealing with Postmeal Spikes Although high blood sugars are not as dangerous as lows in the short term, their long-term effects can be devastating. An almost unlimited number of factors can cause highs, but you can usually prevent (and fix) them with additional insulin. One type of high that infuriates many people is the one that occurs soon after eating. We call this a “postmeal spike.” Postmeal spikes are temporary high blood sugars that occur approximately one to two hours after eating. It is normal for the blood sugar to rise a small amount after eating, even in people who do not have diabetes. However, if the spike is too high, it can affect your quality of life today and contribute to serious health problems down the road. The reason blood sugars spike very high after eating for many people with diabetes is a simple matter of timing. In a person without diabetes, consumption of carbohydrates results in two important reactions: the immediate release of insulin into the bloodstream and the production of the hormone amylin. Insulin produced by the pancreas starts working almost immediately and finishes its job in a matter of minutes. Amylin keeps food from reaching the intestines too quickly (where the nutrients are absorbed into the bloodstream). As a result, the moment blood sugar starts to rise, insulin is there to sweep the extra sugar into the body’s cells. In most cases, the after-meal blood sugar rise is barely noticeable. The reason blood sugars spike after meals in people with diabetes is that food digests faster than it should and insulin works much too slowly. However, people with diabetes are like baseball players with very slow reflexes. We’re in the batter’s box facing a pitcher who throws ninety-eight-mile-per-hour fastballs; by the time we swing, the ball is already in the catcher’s mitt. Rapid-acting insulin that is injected (or infused by a pump) takes approximately fifteen minutes to start working, sixty to ninety minutes to peak, and three to five hours to finish working. And don’t forget about the lack (or deficiency) of amylin: food digests even faster than usual. When food hits the bloodstream long before the insulin, blood sugars spike very high and then come crashing down later when the insulin finally kicks in. Why Are Spikes a Problem? Even though the spike is temporary, multiple spikes throughout the day can raise your A1c. Maintaining an A1c below 7 percent without paying attention to after-meal blood sugar levels is difficult. Scientists and doctors have studied the long-term effects of postmeal highs extensively. Significant postmeal spikes have been shown to produce earlier onset of kidney disease and accelerate the progression of existing eye problems (retinopathy). Glucose variability (lots of peaks and valleys) is associated with long-term cognitive impairment and increases the risk for dementia. And postmeal hyperglycemia is an independent risk factor for cardiovascular problems for people with type 2 diabetes. But the problems are not limited to the long term. Any time blood sugars rise particularly high—even temporarily—our quality of life suffers. Energy decreases, brain function falters, physical and athletic abilities become diminished, and moods become altered. During pregnancy, even mild rises in blood sugar after meals have been associated with excessive and unhealthy growth of the baby. Measurement and Goals The exact timing of blood sugar spikes can vary from person to person and meal to meal. On average, the postmeal peak tends to occur about one hour and fifteen minutes after starting a meal. So checking your blood sugar (using a fingerstick) about an hour after finishing a meal should provide a good indication of how much of a spike is taking place. Continuous glucose monitors that update every couple of minutes and produce trend graphs make it easy to see exactly what is happening after meals. See the example in Figure 9.3. Figure 9.3: CGM report showing postmeal peaks, primarily after breakfast Another way to assess after-meal blood sugar control is through a blood test called GlycoMark. Just as an HbA1c measures average blood sugar for the past few months, GlycoMark measures the degree to which blood sugars are spiking over the past couple of weeks. GlycoMark measures the level of a specific protein molecule that becomes depleted whenever the kidneys are spilling sugar into the urine—typically when BG exceeds 180 (10). A high GlycoMark result (>10) indicates little after-meal spiking. A low GlycoMark result (<10) indicates postmeal spikes. Ask your physician if this test would be helpful in evaluating your glucose control. The American Diabetes Association recommends keeping blood sugar below 180 (10) one to two hours after eating. The American Association of Clinical Endocrinologists and International Diabetes Federation suggest keeping it below 140 (7.8). No specific guidelines are provided for type 1 versus type 2 diabetes, insulin users versus noninsulin users, or children versus adults. My recommendations for postmeal glucose are listed in Table 9-3. * Spike Control If your doctor’s only answer for controlling the after-meal spikes is “Just take more insulin,” think again. Increasing the amount of insulin does little to reduce the immediate postmeal spike but may cause hypoglycemia before the next meal. To reduce the spike, you can use a number of strategies designed to make either insulin work earlier or food appear in the bloodstream later. Let’s first look at ways to get insulin to kick in sooner. 1. Choose the Right Insulin (or Medication) The right insulin or medication program can make or break your ability to control those after-meal spikes. In general, insulin and medications that work quickly and for a short period of time will work better than those that work slowly over a prolonged period of time. If you are still using regular insulin at mealtimes (or daytime NPH to cover your midday meal), switch to a rapid-acting insulin analog (Humalog, Novolog/NovoRapid, or Apidra) or, better yet, an ultra-rapid insulin (Fiasp). Switching to inhaled insulin (Afrezza) can be very effective for combating postmeal spikes. Afrezza starts working, peaks, and finishes working much faster than injected insulin. In fact, Afrezza works so much faster that it may need to be taken during or after meals in order to avoid a postmeal drop in blood sugar. If you have type 2 diabetes and take a sulfonylurea (glyburide, glipizide, glimepiride), ask your physician about switching to a rapid (and shorter)-acting meglitinide (repaglinide, nateglinide). 2. Back Up Your Bolus As discussed in Chapter 7, the timing of mealtime insulin can make a huge difference in postmeal control. Boluses given too late to match the digestion of food can cause major blood sugar spikes, whereas a properly timed bolus can result in excellent after-meal control. In general, giving rapid-acting insulin fifteen to twenty minutes before eating should result in less of a spike than bolusing just before or during your meals. 3. Bolus for the Basal In order to have more insulin working right after eating and less working several hours later, a pump user can set a temporary basal reduction for three hours starting just before eating a meal and give a bolus equal to the basal insulin that would have been delivered. For example, if your basal rate in the morning is 0.7 units per hour, you could bolus 2 units before breakfast and then set a temporary basal of 10 percent (90 percent reduction) for the next three hours. 4. Inject into Muscle Injecting insulin into muscle (rather than the fat layer below the skin) results in faster insulin absorption and action. Overall, it takes about half as long for rapid-acting insulin to peak and finish working when injected into muscle rather than fat. Potential injection sites include the forearm, tricep, bicep, and calf. Be aware that intramuscular injections can sting and cause bruising, since eight- to twelve-millimeter syringes or pen needles may need to be used. 5. Warm the Site Warming the injection or infusion site can facilitate more rapid insulin absorption. This can be accomplished by rubbing or massaging the site for several minutes, placing a warm cloth over the site, or taking a hot shower or bath soon after a bolus is delivered. 6. Get Moving Being physically active soon after a bolus enhances blood flow and helps the insulin absorb and act more quickly. How much activity is required to experience these benefits? Not much. Ten or fifteen minutes (or more) of mild activity will usually get the job done. The key is to avoid sitting for extended periods of time after eating. Instead of reading, watching TV, or working on the computer, go for a walk, shoot some hoops, or do some chores. Try to schedule your active tasks (housework, yardwork, shopping, walking pets) for after meals. 7. Don’t Smoke (or Vape) Nicotine causes blo

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od vessels to constrict. When the blood vessels near the skin constrict, they become slower than usual at absorbing insulin that has been delivered below the skin.

Now let’s consider some strategies for making food digest more slowly. 1. Think Lower GI As we discussed in Chapter 7, glycemic index (GI) refers to the speed with which food raises the blood sugar level. Although all carbohydrates (except for fiber) convert into blood sugar eventually, some carbs do so much faster than others do. As a general rule, switching to lower-GI foods will help reduce after-meal blood sugar spikes. Table 9-4 shows some examples. * 2. Add Some Acidity Acidity in food slows the rate of digestion. This is why sourdough bread has a much lower GI value than regular bread. Research has shown that adding acidity in the form of vinegar (straight or in dressing or condiment form) can reduce the one-hour postmeal blood sugar rise by as much as 50 percent. 3. Split Your Meal If you are having a meal and don’t want your blood sugar to rise all at once, consider saving a portion of your meal for a snack one or two hours later. Still give the full mealtime bolus before eating any of the meal; just don’t eat all of the food right away. For example, if you have a bowl of cereal and juice for breakfast, bolus for the full meal before eating anything. Then have the cereal at breakfast time, and postpone the juice until mid-morning. 4. Sequence Properly Research has shown that consuming the vegetable and protein portions of a mixed meal before consuming the starchy portion results in a slower blood sugar rise postmeal. 5. Use an Add-On Medication Several injectable diabetes medications have effects on gastric emptying. Symlin (pramlintide) is the most powerful. Taken before a meal, Symlin delays the digestion of food by an average of sixty to ninety minutes and produces much flatter postmeal blood sugar patterns. GLP-1 receptor agonists such as Byetta, Victoza, Bydureon, Trulicity, and Ozempic have more subtle effects on gastric emptying but still can help reduce postmeal spikes. Although less potent than Symlin, GLP-1 receptor agonists are usually associated with fewer side effects—particularly nausea. Another class of diabetes medication that can improve after-meal control is called alpha-glucosidase inhibitors. These medications work by partially blocking the transport of sugars across the intestines and into the bloodstream, thus blunting and delaying the appearance of glucose. However, be aware that this class of medications can cause gastrointestinal upset, gas, and bloating. 6. Get Moving Being physically active after eating can reduce postmeal spikes in a number of ways. In addition to helping insulin absorb and act more quickly, muscle activity diverts blood flow away from the intestines, resulting in slower absorption of sugars into the bloodstream. 7. Prevent Hypoglycemia Low blood sugar is problematic in many ways. One of the body’s responses to hypoglycemia is accelerated gastric emptying: food digests and raises blood sugar even more quickly than usual. Although this is a desirable effect for anyone experiencing hypoglycemia, when it occurs soon before meals, it can contribute to excessive postmeal spikes. Preventing hypoglycemia prior to meals and snacks is yet another strategy to “strike the spike.” Troubleshooting Routine Highs Everyone with diabetes experiences blood sugars that are above target from time to time. Individual, out-of-the-blue highs can be caused by any number of factors. Before assuming that your basal doses or bolus calculation formulas require permanent adjustment, consider these common culprits—many of which were described in detail in Chapter 8: • undercounted carbs • accidental underdosing of insulin • intentional underdosing of insulin (diabulimia) or hypoglycemia anxiety • anxiety or stress • caffeine • disease progression • binge eating • protein (in the absence of carbs) • large amounts of dietary fat • growth and weight gain • illness or infection • reduced physical activity • rebounds from lows • hypothyroidism • steroid medications • surgery • gastroparesis • travel • intense or competitive exercise • irregular sleep • premenstrual hormones • menopause • latter stages of pregnancy And if none of these seem to be the answer, it is very possible that the Diabetes Gods, at this particular point in time, are just out to smite you. Hey, it happens. When unexplained above-target blood sugars occur back-to-back, there are certain troubleshooting questions that you should ask: Is my insulin spoiled? Did I forget to take my insulin? Is my insulin absorbing properly? Is there a gap in my insulin coverage? For pump users: Has my pump or infusion set malfunctioned? Let’s take a look at these one at a time. Spoiled Insulin Using spoiled insulin can lead to high blood sugar and ketone production. Insulin that has been frozen or exposed to extreme heat can denature, or break down so that the insulin molecules no longer work. Using the same vial or cartridge of insulin for many months or using it well past its expiration date can also cause serious problems. Prevention: Try not to use insulin vials and cartridges past their expiration date. Once a vial or cartridge is put into use, discard it after a couple of months (the insulin makers recommend starting new insulin vials and pens monthly). Store your unopened insulin in the refrigerator in an area that is not likely to freeze, such as the door. Before using a new insulin vial or cartridge, look for clumps, crystals on the glass, or discoloration. If you suspect that the insulin has gone bad, it probably has. When ordering insulin by mail, ask that it be shipped in a temperature-controlled container, and ask for a temperature-sensitive tag in the shipment. Keep your insulin in your carry-on when you travel, as luggage may be exposed to extreme temperatures. If your insulin has been exposed to high temperatures (above 86 degrees Fahrenheit or 30 degrees Celsius) for more than a few hours, discard it, and start using fresh insulin. If it has been exposed to temperatures above 100 degrees Fahrenheit (38 degrees Celsius) at all, discard it immediately. This applies to pens, vials, and pump cartridges. When exposing an insulin pump to warm weather, keep it out of direct sunlight, and place the pump and tubing in a cooling pouch if possible. Change the insulin cartridge and tubing more frequently when exposing the pump to prolonged warm temperatures. Keep the pump and tubing out of whirlpools, hot tubs, and saunas. Missed Bolus Doses Forgetting or neglecting to bolus for meals and snacks is a far too common problem. Given the dramatic blood sugar rise that can occur with even modest amounts of carbohydrates, missed boluses can result in extremely high blood sugar levels. Research has shown that for every two missed boluses per week, the A1c generally rises by a full percentage point. Prevention: Some pumps, CGMs, pen apps, and blood glucose meters can be programmed with scheduled reminders to take a bolus. Users of the latest insulin pumps can avoid missing boluses by programming missed-bolus reminders at key times of day. Those who take injections might have an easier time remembering to bolus if they take blood sugars at each meal and snack time and keep written records. Those who consistently bolus before eating are less likely to forget compared to those who bolus during or after meals. Some CGM users use the rise alert as a signal that they may have forgotten to dose for something they ate. Let’s say you realize that you missed a bolus some time after you ate a meal or snack. Perhaps you received a reminder alert, or maybe you can hear your partner’s voice echoing in your ears: “Did you take your bolus?!” What should you do? Cover the blood sugar that is now probably elevated and rocketing upward? Dose for the food your forgot to cover previously? Both? If you do both, you will double treat—dose for both the food and the blood sugar rise caused by the food—and will surely wind up low. Your best option is to ignore the blood sugar and dose for the food you ate previously but forgot to cover with a bolus. However, if you use a hybrid closed loop, the system may have already started increasing your basal insulin delivery, so you might need to take a bit less than your normal bolus for the carbs you missed. Missed Basal Injections Skipped basal injections are another potential cause of high blood sugar. Missing a meal dose is problematic in the short term. But missing a dose of basal insulin can lead to both high blood sugar over an extended period of time as well as the possibility of ketoacidosis. Prevention: Plan to take your basal insulin at about the same time each day. If possible, combine it with another activity, such as brushing your teeth, taking oral medication, or eating a certain meal. Getting into a routine is the best way to ensure that you will not miss critical basal insulin injections. Consider setting alarms on your phone or using an app that provides reminders so that you never miss your basal insulin doses. Poor Absorption Poor absorption at the injection or infusion site can cause an insulin deficiency and elevated blood sugar. Remember, once insulin is injected or infused under the skin, it must absorb into the bloodstream in order to take effect. If the insulin pockets under the skin, it may never work. In some cases, the insulin may absorb much later than expected, resulting in a high blood sugar, followed by an unanticipated low. Site irritation or infection can also impair proper absorption. Prevention: Be aware of the possible signs of site irritation and infection: redness, swelling, heat, itching, pain, and milky discharge (gross, I know). Avoid injecting sites that have any of these characteristics, and see a physician for treatment right away. Just as you should rotate your tires to prevent uneven tread wear, you must rotate your injection and infusion (pump) sites to prevent uneven insulin absorption. Injecting or infusing the same spots repeatedly can cause lipodystrophy—a breakdown or inflammation of the fat tissue below the skin. When this happens, the skin can either dimple or become unusually hard and lumpy. One of my patients calls these “happy spots” because they don’t hurt at all when giving a shot or inserting an infusion set. The problem with happy spots is that they have much less blood flow than healthy tissue, and insulin does not absorb properly—if at all. Avoid giving insulin into these areas. Spreading your injection and infusion sites over a large area of skin should help prevent the development of lipodystrophy. It’s best to not use the same exact injection or infusion sites twice in the same month. And in the case of infusion sets, avoid prolonged use: two days is best, and three days is the maximum. Try rotating injection and infusion sites in an organized fashion. Simply going from right side to left side repeatedly may result in the overuse of two specific sites. Instead, stay on one side of your body for several injections or site changes, moving just an inch or two (four to six centimeters) each time. Here is an example: Left Side: 1 2 3 Right Side: 12 11 10 Left Side: 6 5 4 Right Side: 13 14 15 Left Side: 7 8 9 Right Side: 18 17 16

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Once all of these sites are used, consider following a similar pattern on another body part, or start again on the same body part at site number 1. Gaps in Coverage An insulin program that has gaps in basal insulin coverage can lead to rising blood sugars, even in the absence of food. This applies to injected basal insulin (if the dose wears off before the next injection is taken) or pumped insulin (if the pump is suspended or disconnected for prolonged intervals). Prevention: It is essential to understand the action profile of your injected insulin. If it lasts less than twenty-four hours, it will usually be necessary to take it more than once per day. If it lasts twenty-four hours, it is best to take it on a consistent schedule. Delaying it by more than a few hours can cause a major dip in the basal insulin level in your body. When using an insulin pump, suspending is rarely necessary, unless you’re using a hybrid closed-loop system that suspends the pump automatically to help prevent hypoglycemia. But if you do suspend manually, try not to leave the pump in suspend mode for more than an hour. Similarly, when disconnecting at the infusion site (for exercise, bathing, water activities, physical intimacy), try to limit periods of disconnection to no more than an hour. In fact, it is best to replace the missed basal insulin with a small bolus after reconnecting. For example, if your basal rate is 0.6 units per hour and you disconnect for thirty minutes to go swimming, give a bolus of 0.3 units after reconnecting. If you need to disconnect for longer than an hour, reconnect hourly and bolus to replace the basal insulin missed during the previous hour. It is also reasonable to transition back to injection therapy for the day if you will need (or prefer) to spend large amounts of time disconnected. A single dose of glargine, for example, can be given in the morning to replace most of the pump’s basal insulin for the next twenty-four hours. The dose of glargine should be about 20 percent more than your pump’s total basal insulin for the day. Insulin Pump Malfunction Insulin pump therapy opens the door to elevated blood sugar in the event of a problem with insulin delivery, absorption, or action. With no intermediate- or long-acting insulin in the body, pumpers rely on the delivery of basal insulin in the form of tiny pulses of rapid-acting insulin. Any interruption in insulin delivery can result in a sharp rise in blood sugar and ketone production (described below) in as few as three hours after the last bit of insulin was infused. This can be caused by any of the following: • tubing or infusion set clogs • leaks where the cartridge connects to the tubing • air pockets in the tubing • dislodgement of the cannula or infusion set tube from the skin • not connecting the tube completely at the infusion site • improper or insufficient priming • lack of insulin absorption or leakage at the infusion site Prevention: Pump-related issues can be minimized by following correct infusion site-change, priming, and troubleshooting procedures. Check your infusion site and tubing at least once daily. If the infusion set tape is peeling loose or if you spot any redness or swelling around the infusion site or blood in the tubing, move and replace the infusion set immediately. Make sure there are no significant air bubbles in the cartridge before priming the tubing. If you spot air pockets in the tubing, disconnect and prime until the air has been purged completely out. And be sure to rotate infusion sites so as not to repeat the same spot twice in a month. If you smell insulin or detect moisture around any of the tubing joints or at the infusion site, replace the set and tubing immediately. If insulin tends to seep out at the site when you bolus, extend the bolus delivery time or switch to a longer cannula. If your pump alerts you of an occlusion, replace your cartridge, tubing, and infusion set immediately. Change your insulin cartridge as soon as possible after you receive your “low cartridge” warning. This minimizes the risk that your cartridge will run out completely. Ketoacidosis: Hypo’s Evil Twin DKA (diabetic ketoacidosis) is a condition in which the blood becomes highly acidic as a result of dehydration and excessive ketone (acid) production. In a state of acidity, some of the body’s vital systems stop functioning properly. It is a serious condition that will make you ill and very uncomfortable, and it can kill you. Anyone who produces little to no insulin on their own (including just about everyone with type 1 diabetes) is at risk of DKA. The underlying cause of DKA is a lack of working insulin in the body. Let me explain. The primary cause of DKA is a serious lack of insulin in the body. Normal Fuel Metabolism Most of the body’s cells burn sugar (glucose) as a primary energy source. Many cells also burn fat but in much smaller amounts. Glucose happens to be a very clean form of energy—there are virtually no waste products left over when cells burn it for energy. Fat, however, is a “dirty” source of energy. When fat is burned, the cells produce waste products, which are called ketones. Ketones are acid molecules that can pollute the bloodstream and affect the body’s delicate pH balance if produced in large quantities. Luckily, we don’t tend to burn huge amounts of fat at one time, and the ketones that are produced can be broken down during the process of glucose metabolism; glucose and ketones can “jump into the fire” together. (See Figure 9.4.) Figure 9.4: Normal fuel metabolism Obviously, having an ample supply of glucose inside the body’s cells is important. That requires two things: sugar (glucose) in the bloodstream and insulin to shuttle the sugar into the cells. Abnormal Fuel Metabolism What would happen if you had no insulin? I’m not talking about a minor underdosage; I’m talking about having none whatsoever. A number of things would start to go wrong. Without insulin, glucose couldn’t get into the body’s cells. As a result, the cells would begin to burn large amounts of fat for energy. This would lead to the production of large amounts of ketones. Although some of the ketones would eventually spill over into the urine, the body would be unable to eliminate sufficient amounts to restore a healthy pH balance in the bloodstream. (See Figure 9.5.) Figure 9.5: Fuel metabolism in the absence of insulin Dehydration further complicates the problem. Without sufficient insulin to inhibit the liver’s secretion of sugar, large amounts of glucose would be released into the bloodstream. Because high blood sugar causes excessive urination, dehydration would ensue. Without glucose metabolism to help break down the ketones and without ample fluids to help neutralize the ketones, the bloodstream and tissues of the body would become very acidic. This is a state of ketoacidosis. Causes and Prevention of Ketoacidosis What can cause a sudden lack of insulin in the body? There are a number of potential culprits, several of which were described above: • using spoiled insulin • missed injections, or gaps in basal insulin delivery • failure of insulin to absorb once it is injected or infused • insulin pump (or infusion site) malfunction • improper use of SGLT-2 inhibitors A lack of insulin is not the only thing that can cause production of ketones and, potentially, DKA. Illness, infection, dehydration, and major stress can cause the production of large quantities of stress hormones, which counteract insulin. In other words, you could have insulin in your body, but it is rendered almost useless because stress hormones are blocking its action. A lack of carbohydrates in the diet can also induce ketone production. During periods of starvation, prolonged fasting, or severely restricted carbohydrate intake, the body’s cells must resort to burning alternative sources of fuel, namely fat. With increased fat metabolism and limited glucose metabolism, ketone production may exceed the body’s ability to eliminate them. Nutritional ketosis is different from diabetic ketoacidosis in that the ketone level does not become dangerously high, dehydration should not occur, and the pH of the body’s fluids remains close to normal. However, nutritional ketosis has its drawbacks, particularly for the first couple of weeks after starting a ketogenic diet. These include headaches, mild nausea, and a general lack of energy (what many describe as no “get up and go”). Maintaining at least a modest level of carbohydrate intake throughout the day should prevent ketosis. If you must fast for short periods of time, talk with your doctor to ensure that it will not interfere with any other health conditions or medications that you may be taking. You can usually fast safely by taking only basal insulin, with rapid-acting insulin as touch-ups for high blood sugars. If you take intermediate-acting insulin (NPH) in the morning, take half of your usual dose. Be sure to check your blood sugar level regularly during a fast. If your blood sugar drops below 70 (3.9), you must eat carbohydrates to bring the blood sugar back up. Use of SGLT-2 inhibitors can also induce DKA in people with type 1 diabetes. This is due to the way SGLT-2 inhibitors work: they cause loss of glucose through the urine, which produces extra urination and a reduction in insulin requirements. Those who become dehydrated, consume insufficient carbohydrates, and reduce their insulin doses too much put themselves at risk of DKA. However, this risk can be virtually eliminated by consuming ample carbs, drinking plenty of water, and making sure insulin doses are not missed or decreased any more than is necessary to maintain healthy blood sugar levels. It is also beneficial to monitor ketone levels routinely (preferably with a blood meter that measures ketones) and report any elevations to your prescribing physician. The first and most important step in preventing ketoacidosis is early detection of a problem. This starts with frequent glucose monitoring (via CGM or fingersticks), followed by ketone checks with unusually high blood sugar levels. The absence of ketones indicates that the high reading is probably due to insufficient insulin coverage for food eaten recently. The presence of ketones indicates either severe insulin resistance (caused by illness, infection, or stress) or a severe lack of insulin in the body (caused by spoiled insulin, missed doses, malabsorption, or a pump malfunction). Assuming you’re not unusually stressed or ill, the troubleshooting process is shown in Figure 9.6. Figure 9.6: A simple process for early detection and prevention of DKA Three steps should reverse the problem if ketones are present. 1. Give an injection of rapid-acting insulin from a fresh vial, based on your usual correction dose. Injecting into muscle will help bring your blood sugar down faster and ensure that it absorbs completely. 2. Drink several glasses of water. 3. If you use an insulin pump, change your pump’s cartridge, tubing, and infusion set, using a fresh vial of insulin. Failure to correct the problem could result in ketoacidosis in just a few hours. Symptoms and Treatment of DKA Everyone with diabetes who uses insulin should have a way to test for ketones. You can perform ketone testing by way of a urine dipstick or a fingerstick blood sample. (See Chapter 10 for ketone testing supply options.) Positive ketones are indicated by either urine testing that indicates small or more ketones (>15 mg/dl) or blood testing that indicates the presence of ß-Hydroxybutyrate (>0.5 mmol/l). Be sure to have fresh ketone testing supplies on hand at all times—including when you travel. The presence of ketones in the blood is referred to as ketosis; the presence of ketones in the urine is ketonuria. Ketosis and ketonuria are usually—but not always—accompanied by elevated blood sugar, thirst, and excessive urination. This is a precursor to the more severe state of DKA. Symptoms of DKA are more pronounced. With DKA, you are likely to be nauseated or vomiting. Your breathing may be very deep, and you could have a fruity odor on your breath as your lungs try to eliminate ketones when you exhale. You will likely be dehydrated from all the urination, which is a result of the very high blood sugars. This will give you dry skin, intense thirst, and a dry mouth. Your vision may also be blurry; headache and muscle aches are common. Call your doctor immediately if you have ketones in your blood or urine or if you are experiencing these types of symptoms. Although fluids and insulin are the preferred form of treatment for ketosis, DKA is not something that you can treat on your own. The severe dehydration that accompanies DKA usually keeps insulin from absorbing properly from below the skin, and vomiting may limit your ability to consume and absorb fluids. Treatment of DKA almost always requires a visit to a hospital emergency department for intravenous administration of insulin, water, and electrolytes. The acidity of your blood will have to be monitored very carefully at the hospital to prevent coma or death. The length of your hospital stay will vary depending on the severity of the DKA, but expect to be there for at least a day or two. There are a few things that you can do on your own prior to hospitalization. Try to eat light, easy-to-digest carbohydrates and drink at least eight ounces of liquid per hour. Diluted orange juice is a good choice because it replaces fluids as well as potassium that is lost with excess urination. Check your blood sugar and ketones every couple hours, and report the information to your doctor. Remember: they don’t call it “insulin-dependent” diabetes for nothing. We depend on insulin to stay alive. DKA causes more than 80 percent of hospital inpatient admissions for people with type 1 diabetes. Practice the preventive measures described above, and stay in close contact with your health care team at the first signs of trouble.

Part 35

Diabetes management is truly a team effort! LOSING WEIGHT SAFELY WHEN YOU TAKE INSULIN There are good ways and not so good ways to accomplish just about anything. Anyone with diabetes can lose weight if they stop taking their insulin (or take less than they should), but that would only lead to serious health problems that are far worse than anything caused by carrying a few unwanted pounds. Diabulimia, a form of bulimia in which a person takes less than prescribed doses of insulin in order to lose weight, is extremely dangerous and usually requires intervention by a skilled mental health professional. Also, there is nothing magical about very-low-carb diets when it comes to weight loss. Very-low-carb diets are challenging to follow over the long term and come with downsides as well: lack of energy, reduced stamina, potential for unhealthy cholesterol levels, and blood sugar increases from protein intake, just to name a few. Research has shown that just about any reasonable diet plan can result in some weight loss if you pay closer attention to what you eat and strike a favorable caloric balance. The key is to find a plan that you can follow long term. For those taking insulin, there is another caveat: you must find a way to lower your insulin doses without sacrificing blood sugar control if you want to lose weight and keep it off. Remember: insulin promotes the uptake of fuel by the body’s cells, including fat cells. Less insulin means less fat storage. Ways to Cut Back on Basal Insulin • reduce overall stress levels • minimize high-fat foods • increase daily walking or other physical activity • increase muscle mass • take metformin • take an SGLT-2 inhibitor Ways to Cut Back on Bolus Insulin • reduce carb portions • increase fiber intake • exercise after meals • reduce snack frequency • use Symlin or a GLP-1 receptor agonist Hypoglycemia can stand in the way of your weight-loss efforts. Lows are a sign that you have taken more insulin than you need. Most lows force us to consume calories we would not have had otherwise, and overtreatment of lows can really jack up caloric intake. If you are working to lose weight and experience more than one low blood sugar per week at about the same time of day, cut back on the insulin dose that is working at that time. CHAPTER HIGHLIGHTS • Hypoglycemia is a major limiting factor in intensive diabetes control. • Mild and moderate lows should be self-treatable. Severe hypoglycemia requires glucagon or intravenous dextrose. • Proper treatment of lows should be customized to the individual and the situation. • Loss of hypoglycemia symptoms (hypoglycemia unawareness) can be reversed by preventing lows for several weeks. • Implement strategies to prevent hypoglycemia if you are experiencing more than a few lows per week. • Taking bolus insulin earlier and/or applying strategies to slow the digestion of your meals can help minimize after-meal blood sugar spikes. • A complete lack of insulin in the body can lead to diabetic ketoacidosis (DKA). • Checking for ketones at the first sign of unexplained high blood sugar, and administering insulin and fluids if ketones are present can help prevent DKA.TEN Resources for Everything and Anything Diabetes It takes every kind of people To make what life’s about. Every kind of people To make the world go ’round. —Robert Palmer, “Every Kinda People” Giving Support, Getting Support Feeling the ups and downs of blood sugar swings. Handling the incessant responsibilities of managing a chronic disease. Trying to make sense out of a highly imperfect science. And facing the grim reality that, despite all your best efforts, serious health problems may be in your future. Living with diabetes can be a frustrating, frightening, and sometimes lonely experience. If you have ever felt the need to reach out to someone who understands how you feel (someone who has been there), support networks may be just the answer. Even if you don’t feel the need to receive support yourself, the act of giving support to others is worth its weight in gold. Nothing will make you feel better and enrich your life more than helping others. Opportunities for giving and getting support are widespread: both in person and online. And the beauty of it is that you can find groups that are general and diverse or highly specialized and tailored to your particular interests. For an in-person type of support group, a good place to start is at your local hospital or diabetes treatment center. If there is a diabetes association office near you, they probably have a list of support groups in your area. If nothing exists near you, or if what exists fails to meet your needs, consider starting a group of your own. If face-to-face groups are not feasible because of space, distance, or your desire for confidentiality, consider joining or starting an online chat room or group. It truly takes a village to manage diabetes, so don’t hesitate to create one! Resources are not limited to mutual support programs. There is also an assortment of clinical networks, apps, associations, websites, blogs, and product manufacturers ready to serve you. Below is a list of some of the resources we’ve found to be highly useful. They are organized in the following categories: Associations and Organizations Awesome Apps Clinical Diabetes Experts Financial Resources Kick-Ass Products Suggested Facebook Groups Websites and Blogs Recommended Books (Note: All phone numbers are in North America unless otherwise indicated.) Associations and Organizations Academy of Nutrition and Dietetics 800-877-1600; eatright.org American Association of Diabetes Educators (AADE) 800-338-3633; diabeteseducator.org/living-with-diabetes American Association of Kidney Patients 800-749-2257; aakp.org American Chronic Pain Association 800 533-3231; theacpa.org American Diabetes Association 800-342-2383; diabetes.org American Foundation for the Blind 800-232-5463; afb.org American Heart Association 800-242-8721; heart.org Amputee Coalition of America 888-267-5669; amputee-coalition.org Assistance Dogs International assistancedogsinternational.org Bolus and Barbells (for people with diabetes interested in strength training) bolusandbarbells.org Celiac Society celiacsociety.com National Celiac Association 888-423-5422; nationalceliac.org Children with Diabetes (regional and national programs and support services for children, young adults, and caregivers) childrenwithdiabetes.com College Diabetes Network collegediabetesnetwork.org Diabetes Canada 416-363-3373; diabetes.ca Diabetes Education and Camping Association (DECA) 239-984-3554; diabetescamps.org Diabetes Sisters (programs and support services for women affected by diabetes) diabetessisters.org Diabetes Training Camps (athletic training and diabetes management for teens and adults) diabetestrainingcamp.com Friends with Diabetes (Jewish programs and support services) 845-352-7532; friendswithdiabetes.org Gluten Intolerance Group of North America 253-833-6675; gluten.org International Association for Medical Assistance to Travellers (IAMAT) 716-754-4883; iamat.org Jewish Diabetes Association 718-303-5955; jewishdiabetes.org Juvenile Diabetes Research Foundation 800-533-2873; jdrf.org National Diabetes Education Program 800-860-8747; niddk.nih.gov/health-information/communication-programs/ndep National Federation of the Blind 410-659-9314; nfb.org National Institute of Diabetes and Digestive and Kidney Diseases 301-496-3583; niddk.nih.gov National Kidney Foundation 800-622-9010; kidney.org National Library Service for the Blind and Print Disabled 800-424-8567; loc.gov/nls Riding on Insulin (action sports for the type 1 community) 406-214-3266; ridingoninsulin.org Taking Control of Your Diabetes (nationwide conferences and education for people with diabetes) 800-998-2693; tcoyd.org TrialNet (diabetes risk screening and research supporting those at risk for diabetes) 800-425-8361; trialnet.org We Are Diabetes (support for people with type 1 diabetes and eating disorders) wearediabetes.org #WeAreNotWaiting (the Nightscout Project) nightscout.info We Are One (connecting healthcare professionals with diabetes all over the world) 858-755-5683; weareonediabetes.org Local Type 1 Diabetes Support Networks Cincinnati, Ohio: T1D Journey Inc., t1diabetesjourney.org Maine: P-Pods, maineppods.org Maryland and Delaware: Diabetes Destiny, diabetesdestiny.org North and South Carolina: The Diabetes Family Connection, thedfc.org Northern California: CarbDM, carbdm.org Seattle, Washington: ConnecT1D, connect1d.org Awesome Apps Data Download and Reporting • Accu-Chek Connect • Contour Diabetes App • Dario • Dexcom Clarity • Glooko • OneTouch Reveal • Tidepool Mobile Data Logging and Sharing • Blue Loop • Diabetes Pal • MyNetDiary • MySugr • OneDrop • SugarMate Fitness • FitBit • My Fitness Pal • Strong Health Insurance Reimbursement • Better Mealtime Bolus Calculator • iBolusCalc • RapidCalc Nutrition • CalorieKing • Calorie Mama AI • MyFitnessPal Stress Relief and Mental Health • Breethe • Headspace • ThinkUp Supply Sharing and Trading • HelpAround Clinical Diabetes Experts Barbara Davis Center for Childhood Diabetes (Aurora, CO) Recognized as a top research and care program for children with diabetes; 303-724-2323; barbaradaviscenter.org. Behavioral Diabetes Institute Clinic focusing on the psychosocial aspects of diabetes, led by Dr. William Polonsky; 858-336-8693; behavioraldiabetes.org. Cecelia Health (formerly Fit4D) Diabetes education and goal setting and motivation from a team of certified diabetes educators; 866-411-0254; ceceliahealth.com. Diabetes Education Program locator Accredited diabetes education programs, diabeteseducator.org/living-with-diabetes/find-an-education-program. Diabetes Educator Locator The American Association of Diabetes Educators’ search tool; diabeteseducator.org/DiabetesEducation/Find.html. Diabulimia Helpline Professional and peer support for people with diabetes suffering from eating disorders; 425-985-3635; facebook.com/groups/DiabulimiaSupport. Dietitian Locator Contact the Academy of Nutrition and Dietetics at 800-877-1600 or visit eatright.org (click on the “Find an Expert” icon). GlucoseZone by Fitscript Fitness coaching for people with diabetes; glucosezone.com. Integrated Diabetes Services (Philadelphia, PA) My practice, Integrated Diabetes Services, provides diabetes coaching services worldwide via phone and online for children and adults; our clinicians, all of whom live with type 1 diabetes, focus on improving blood sugar control, teach advanced self-management skills, and work with you to reach your individual goals; 610-642-6055; integrateddiabetes.com. International Diabetes Center (Minneapolis, MN) A leader in diabetes care and treatment with multiple locations; 888-825-6315; international: 1-952-993-3393; internationaldiabetescenter.com. Dr. Jody Stanislaw’s T1D Academy Learn how to live your best life with diabetes—videos, courses, retreats, and more; drjodynd.com. Joslin Diabetes Center (Boston, MA) A worldwide leader in diabetes care, with affiliates throughout the United States; 800-567-5461; 617-309-2400; joslin.org. Type 1 University Online courses in various aspects of advanced diabetes management for insulin users and parents and caregivers of insulin users; type1university.com Financial Resources Government Programs to Help Offset the Cost of Diabetes Care Medicaid is a health assistance program sponsored by each individual state. For information, contact your state’s Department of Human Services (look in the government pages of your phone book, if you still have one!). Medicare is a government-sponsored program for people over age sixty-five as well as younger people with serious health problems such as kidney failure. For eligibility information, call the Centers for Medicare & Medicaid Services at 1-800-633-4227, or visit medicare.gov. CHIP is the Children’s Health Insurance Program provided by each state. It is for children whose families earn too much to qualify for Medicaid but too little to afford private health insurance. For information, call 877-543-7669, or visit insurekidsnow.gov. The Department of Veteran Affairs (VA) runs hospitals and clinics for veterans who need treatment for service-related ailments and those who need financial assistance. To find out more about VA health benefits, call 800-827-1000, or visit va.gov. WIC (Women, Infants, and Children) is a federally funded cash assistance program. Women with preexisting diabetes who become pregnant, as well as those who develop gestational diabetes, may be eligible for assistance with grocery costs if certain criteria are met. For more information, call WIC at 703-305-2746, or visit fns.usda.gov/wic. Insulin Manufacturer Financial Assistance Programs Lilly Cares is a patient assistance program for users of Eli Lilly insulin and other medications. For more information, call 800-545-6962, or visit lillycares.com/assistanceprograms.aspx. Also check the Blink Health mobile app for discounts on Lilly insulin. Novo Nordisk offers a patient assistance program that provides insulin and other medications at no cost to those who qualify. For more information, call 866-310-7549, or visit novocare.com/psp/PAP.html. SanofiPatient Connection can provide insulin at no cost if you meet program eligibility requirements. This component of the program is made possible through Sanofi Cares North America. Call 888-VISITSPC (888-847-4877), or visit sanofipatientconnection.com/patient-assistance-connection. Other Pharmaceutical Company Assistance Programs Glucose test strip manufacturers often provide copay cards for users of their blood glucose meters. The copay cards either reduce or eliminate copays associated with test strip purchases. There are usually no income or insurance eligibility limits. For details, call the toll-free number on the back of your glucose meter, or ask your diabetes health care provider. AstraZeneca AZ&

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Me Prescription Savings Programs; 800-AZandMe (800-292-6363); astrazeneca-us.com Becton, Dickinson & Company The BD Insulin Syringe Assist Program; 866-818-6906; bd.com Bristol-Myers Squibb Company Bristol-Myers Squibb Patient Assistance Foundation, Inc.; 800-736-0003; bmspaf.org GlaxoSmithKline GSK for You; 866-728-4368; gskforyou.com Merck and Co., Inc. The Merck Patient Assistance Program; 800-727-5400; merck.com Novartis Novartis Patient Assistance Foundation, Inc.; 800-245-5356; patientassistancenow.com Pfizer Pfizer Friends; 866-706-2400; phahelps.com Takeda Pharmaceuticals North America Help At Hand; 800-830-9159; takeda.us Kick-Ass Products Adaptive Devices • BD (Magni-Guide): 888-232-2737; bddiabetes.com • Diagnostic Devices (Prodigy talking meters): 800-243-2636; prodigymeter.com • LS&S Group (catalog of products for those with visual, hearing, or dexterity limitations): 800-468-4789; lssproducts.com Continuous Glucose Monitors • Abbott (Freestyle Libre): 855-632-8658; diabetescare.abbott • /products.html • Dexcom (G5, G6): 877-339-2664; dexcom.com • Medtronic (Enlite, Guardian, iPro): 800-646-4633; medtronicdiabetes.com/treatments/continuous-glucose-monitoring • Senseonics (Eversense): 301-515-7260; senseonics.com Downloading Software • Abbott Freestyle AutoAssist and LibreView: myfreestyle.com • /data-management • Dexcom Clarity: clarity.dexcom.com • Diasend: diasend.com/us • Glooko: glooko.com • Lifescan One Touch Reveal: onetouch.com/OneTouchReveal • Medtronic Carelink: carelink.minimed.com • Roche Accu-Chek Connect: accu-chek.com/apps-and-software/connect-online-portal • Tandem t:Connect: tandemdiabetes.com/products/t-connect-application • Tidepool: tidepool.org Glucose Meters • Abbott Diabetes Care (Freestyle and Precision meters): 888-522-5226; abbottdiabetescare.com • AgaMatrix (Wavesense meters): 866-906-4197; agamatrix.com • Ascensia (Contour Next meters): 800-348-8100; contournext.com • Dario (Dario meters): 800-895-5921; mydario.com • LifeScan (OneTouch meters): 800-227-8862; onetouch.com • Nova Biomedical (Nova Max meters): 800-681-7390; novacares.com • Prodigy Diabetes Care (Prodigy meters): 800-243-2636; prodigymeter.com • Roche (Accu-Chek meters): 800-858-8072; accu-chek.com Injection Ports • Insuflon (IntraPump Infusion Systems): 866-211-7867; intrapump.com/product/insuflon • i-Port Advance (Medtronic): 800-646-4633; medtronicdiabetes.com/products/i-port-advance Insulin and Other Injectables • Eli Lilly and Company: 800-545-5979; lillydiabetes.com • Novo Nordisk: 800-727-6500; novonordisk-us.com/products/diabetes.html • Sanofi: 800-981-2491; sanofi.com/en • Xeris Pharmaceuticals: 844-445-5704; www.xerispharma.com Insulin Pens and Accessories • BD (Ultra-Fine pen needles): 888-232-2737; bddiabetes.com • Common Sensing (Gocap): 855-310-3377; gocap.me • Companion Medical (InPen smart pen and app): 844-843-7903; companionmedical.com • Owen Mumford (Autopen Classic): 770-977-2226; owen • mumford.com/us/patients/diabetes-care • Timesulin (injection timer cap): +44-0200-333-1879; timesulin.com Insulin Pumps and Infusion Sets • ConvaTec (infusion sets): 800-422-8811; convatec.com/infusion-care/infusion-care-diabetes • Insulet Corp. (OmniPod): 800-591-3455; myomnipod.com • Medtronic Diabetes (Medtronic pumps): 800-646-4633; medtronicdiabetes.com/home • Roche/Disetronic (Accu-Chek and Solo pumps): 800-688-4578; accu-chek.com/support/insulin-pumps • Tandem Diabetes (t:slim pumps): 877-801-6901; tandemdiabetes.com • Valeritas (V-Go): 908-927-9920; valeritas.com/Home/default.aspx • Ypsomed: +41 (0)34 424 41 11; www.ypsomed.com Ketone Testing • Abbott Diabetes Care (Precision Xtra blood ketone meter): 888-522-5226; abbottdiabetescare.com • Nova Biomedical (Nova Max Plus blood ketone meter): 800-681-7390; novacares.com Lancing Devices • Genteel: 503-621-2887; mygenteel.com Medical Identification • Fifty50 Medical (SPORTKids ID): 800-746-7505; fifty50pharmacy.com/product-category/medical-id • Lauren’s Hope (medical ID bracelets): 800-360-8680; lauren shope.com • MedicAlert Foundation: 800-432-5378; medicalert.org Pump and CGM Accessories • Funky Pumpers (United Kingdom): 020-8859-1507; funky pumpers.com • GrifGrips: grifgrips.com • hipS-sister waist bands: 855-934-4777; hipssister.com • SPIBelt: 866-966-4440; spibelt.com • Unique Accessories: 303-618-3152; uniaccs.com Supply Cases • Cooler Concept (Frio cooling wallets): 866-690-3746; cooler concept.com • Medicool (insulated storage/travel cases): 800-433-2469; medicool.com/pages/diabetes-products • Myabetic (designer-look pouches and cases): 213-493-4305; myabetic.com DANA (Diabetes Advanced Network Access) is the brainchild of the American Association of Diabetes Educators. It is a free resource for patients and health care providers. Although some aspects of the website are for AADE members only, others are open to anyone. Look for expert insight on diabetes devices, apps, software, web-based programs, and much more. danatech.org Websites and Blogs ardensday.com/juicebox-podcast Literally hundreds of podcasts covering various topics on life with type 1 diabetes. asweetlife.org Diabetes viewed as a lifestyle rather than a disease. bd.com/us/diabetes/page. aspx?cat=7001 Becton Dickinson’s Diabetes Learning Center. beyondtype1.org A philanthropic group that unites a variety of platforms, programs, and resources serving the global diabetes community. childrenwithdiabetes.com Unlimited resources for kids, parents, and caregivers. diabetesaliciousness.blogspot.com Kelly Kunik tackles diabetes through humor, diabetes ownership, and advocacy. diabetesattorney.net Kriss Halpern is an attorney who specializes in diabetes-related cases. diabetesdad.org Why should moms have all the fun? Follow Tom Karlya as he navigates life with two kids with diabetes. diabetesdaily.com Diabetes news, tools, and community links. diabetesincontrol.com Free weekly news and information for diabetes health professionals. diabetesnet.com Diabetes information, research findings, and discounted diabetes products. diabetesselfmanagement.com Magazine and website featuring in-depth articles on hot topics in diabetes. diabetessisters.org Focused on women with diabetes and women’s issues. diabetesstopshere.org News, updates, and guest posts from the American Diabetes Association. diabetesstories.com Author Riva Greenberg shares her thoughts and experiences on living with diabetes. diabetesstrong.com Christel Oerum’s repository for diabetes and physical fitness. diabeticfoodie.com Shelby Kinnaird covers everything food-related. diabeticinvestor.com David Kliff’s business and investor report on the diabetes industry (pay site). diabeticmommy.com For expectant and recent moms. diatribe.org Making sense of diabetes through news, stories, and insights. d-mom.com Leighann Calentin explores life from the perspective of the mom of a child with diabetes. foodinsession.com Your nutrition education starts here! healthcentral.com/diabeteens The latest stories, news, and expert advice for teens. healthline.com/diabetesmine Amy Tenderich’s blog features humor, straight talk, and a sense of community. insulinnation.com The latest news on type 1 diabetes care and research. integrateddiabetes.com My company; features several free self-management tools. integrateddiabetes.com/blog The world of diabetes from my unique perspective and that of the clinical team at Integrated Diabetes Services. integrateddiabetes.com/mealtime-dosage-calculator Create your own bolus dosing charts based on blood sugar, carbs consumed, and physical activity. integrateddiabetes.com/updated-insulin-pump-comparisons-and-reviews Insulin pump comparisons and reviews. jdrf.org/community/typeonenation/ A network hub of type 1 diabetes communities, created by the Juvenile Diabetes Research Foundation. myglu.org Online type 1 diabetes community sharing wisdom and support. rxlist.com/pill-identification-tool/article.htm Excellent reference for medication actions, side effects, interactions, and so forth. safesittings.org Diabetes babysitting service for sitters and families looking for a sitter who knows type 1 diabetes. scottsdiabetes.com Scott Johnson’s struggles, successes, and everything in between. sixuntilme.com/wp Kerri Sparling takes a humorous approach with her blog; the tagline is “Diabetes doesn’t define me, but it helps explain me.” stitcher.com/podcast/diabetesdailygrind/real-life-diabetes Cutting-edge and sometimes controversial podcasts. thegirlsguidetodiabetes.com Sysy Morales encourages women with diabetes to live their best life. typeonerun.org Global network of type 1 runners. type1university.com The online school of higher learning for insulin users. Suggested Facebook Groups • CGM in the Cloud • Looped • Type 1 Diabetes and Pregnancy • Type 1 Diabetes Memes Recommended Books Note: Books are listed alphabetically by title. General Diabetes Management Bright Spots & Landmines: The Diabetes Guide I Wish Someone Had Handed Me. Brown, Adam. San Francisco: diaTribe Foundation, 2017. The Discovery of Insulin. Bliss, Michael. Chicago: University of Chicago Press, 2007. A First Book for Understanding Diabetes. 13th ed. (aka The Pink Panther Book.) Chase, H. Peter, and David M. Maahs. Denver: Children’s Diabetes Foundation, 2014. Insulin Pump Therapy Demystified: An Essential Guide for Everyone Pumping Insulin. Kaplan-Mayer, Gabrielle. New York: Marlowe & Company, 2003. The Joslin Guide to Diabetes: A Program for Managing Your Treatment. Beaser, Richard S., and Amy P. Campbell. New York: Simon & Schuster, 2005. Not Dead Yet: My Race Against Disease—From Diagnosis to Dominance. Southerland, Phil, and John Hanc. New York: Thomas Dunne, 2011. Practical CGM: A Guide to Improving Outcomes Through Continuous Glucose Monitoring. Scheiner, Gary. Alexandria, VA: American Diabetes Association, 2015. Pumping Insulin: Everything Success on a Pump and CGM. 6th ed. Walsh, John, and Ruth Roberts. San Diego: Torrey Pines, 2016. The Savvy Diabetic: A Survival Guide. Milo, Joanne. Corona Del Mar, CA: 3DogArt, 2013. Sugar Surfing: How to Manage Type 1 Diabetes in a Modern World. Ponder, Stephen W., and Kevin L. McMahon. Sausalito, CA: Mediself, 2015. Training Your Diabetic Alert Dog. Martinez, Rita, and Susan M. Barns. Self-published, 2013. Understanding Insulin Pumps, Continuous Glucose Monitors and the Artificial Pancreas. 3rd ed. Chase, H. Peter, and Laurel Messer. Denver: Children’s Diabetes Foundation, 2016. A Woman’s Guide to Diabetes: A Path to Wellness. Barnes, Brandy, and Natalie Strand. Alexandria, VA: American Diabetes Association, 2015. Women and Diabetes: Staying Healthy in Body, Mind, and Spirit. 2nd ed. Poirier, Laurinda M., and Katharine M. Coburn. Alexandria, VA: American Diabetes Association, 2000. Your Diabetes Science Experiment: Live Your Life with Diabetes Instead of Letting Diabetes Live Your Life! Vieira, Ginger. CreateSpace, 2012. Mental Health The Complete Diabetes Organizer: Your Guide to a Less Stressful and More Manageable Diabetes Life. Weiner, Susan, and Leslie Josel. Ann Arbor, MI: Spry Publishing, 2013. Diabetes Burnout: What to Do When You Can’t Take It Anymore. Polonsky, William H. Alexandria, VA: American Diabetes Association, 1999. Nutrition and Fitness The Athlete’s Guide to Diabetes. Colberg, Sheri R. Champaign, IL: Human Kinetics, 2020. CalorieKing Calorie, Fat & Carbohydrate Counter. Burushek, Allan. N.p.: Family Health Publications, 2018. Diabetes Meal Planning Made Easy. 5th ed. Warshaw, Hope. Alexandria, VA: American Diabetes Association, 2016. Eating Mindfully: How to End Mindless Eating & Enjoy a Balanced Relationship with Food. 2nd ed. Albers, Susan. Oakland, CA: New Harbinger Publications, 2012. Guide to Healthy Restaurant Eating. Warshaw, Hope. Alexandria, VA: American Diabetes Association, 2009. The Ketogenic Diet for Type 1 Diabetes: Reduce Your HbA1c and Avoid Diabetic Complications. Davis, Ellen, and Keith Runyan. Cheyenne, WY: Gutsy Badger Publishing, 2017. The Low GI Handbook: The New Glucose Revolution Guide to the Long-Term Health Benefits of Low GI Eating. Brand-Miller, Jennie. Philadelphia: DaCapo Lifelong, 2010. The Ultimate Guide to Accurate Carb Counting. Scheiner, Gary. The Marlowe Diabetes Library. Boulder: Da Capo Lifelong, 2006. Pregnancy Balancing Pregnancy with Pre-Existing Diabetes: Healthy Mom, Healthy Baby. Alkon, Cheryl. New York: DemosHealth, 2010. Pregnancy with Type 1 Diabetes: Your Month-to-Month Guide to Blood Sugar Management. Vieira, Ginger, and Jennifer Smith. CreateSpace, 2017. Supporting Others Appendix A Diabetes—How to Help: Your Complete Guide to Caring for a Loved One with Diabetes. Scheiner, Gary, and Diane Herbert. Arlington, VA: American Diabetes Association, 2018. Guide to Raising a Child with Diabetes. 3rd ed. Roemer, Jean Betschart. Alexandria, VA: American Diabetes Association, 2011. Parenting Children With Diabetes: A Guide to Understanding and Managing the Issues. Lebow, Eliot. Lanham, Maryland: Rowman & Littlefield, 2019. Raising Teens with Diabetes: A Survival Guide for Parents. McCarthy, Moira. Ann Arbor, MI: Spry Publishing, 2013. The Ten Keys to Helping Your Child Grow Up with Diabetes. 2nd ed. Wysocki, Tim. Alexandria, VA: American Diabetes Association, 2004. Type 1 Diabetes Caregiver Confidence: A Guide for Caregivers of Children Living with Type 1 Diabetes. Markovitz, Samantha. Vancouver, BC: Prominence Publishing, 2017. When Diabetes Hits Home: The Whole Family’s Guide to Emotional Health. Rapaport, Wendy. Alexandria, VA: American Diabetes Association, 1998.Discover Your Next Great Read Get sneak peeks, book recommendations, and news about your favorite authors. Tap here to learn more. Appendix A Blood Glucose Meters The meters in the table below are ranked according to accuracy: within 10 percent of lab values when blood glucose (BG)>75 mg/dl (4.2 mmol/l). * n/a = data not available *Source: Package insert, user guide, and/or company website. **Source: Freckmann

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, G., C. Schmid, A. Baumstark, S. Pleus, et al., “System Accuracy Evaluation of 43 Blood Glucose Monitoring Systems for Self-Monitoring of Blood Glucose According to DIN EN ISO 15197,” Journal of Diabetes Science and Technology 6, no. 5 (Sept. 2012): 1060–1071.Appendix B Measuring Devices and Carb Counts Common Measuring Devices • adult’s fist = approx. 1 cup • adult’s palm = approx. 4 inches diameter • adult’s spread hand = approx. 8 inches diameter • child’s fist = approx. ½ cup • cupped hand = approx. ½ cup • large handful = approx. 1 cup • soda can = 1½ cups • tennis ball = approx. ½ cup • tip of thumb = approx. 1 inch across Approximate Carb Counts for Standard Portion Sizes • cake/muffin/pie ≈ 45 g/cup • cereal ≈ 25 g/cup • chips ≈ 15 g/cup • cooked vegetables ≈ 10 g/cup • cookie ≈ 20 g/4-inch diameter • dense bread (bagel/soft pretzel) ≈ 50 g/cup • fruit ≈ 20 g/cup • ice cream ≈ 35 g/cup • juice, soda ≈ 30 g/cup • milk ≈ 12 g/cup • pancake ≈ 15 g/4-inch diameter • pasta (w/sauce) ≈ 35 g/cup • pizza ≈ 30 g/closed hand (slice) • pizza ≈ 40 g/8-inch diameter (round) • popcorn ≈ 5 g/cup • potato ≈ 30 g/cup • pretzels ≈ 25 g/cup • rice (boiled) ≈ 50 g/cup • rolls ≈ 25 g/cup • salad/raw vegetables ≈ 5 g/cup • sport drink ≈ 15 g/cup • sticky rice ≈ 75 g/cup • sub sandwich rolls ≈ 8 g/inch • tortilla ≈ 15 g/8-inch diameterAppendix C Glycemic Index of Common Foods Bread/Crackers bagel 72 crispbread 81 croissant 67 French baguette 95 graham crackers 74 hamburger bun 61 kaiser roll 73 melba toast 70 pita bread 57 pumpernickel 51 rye, dark 76 saltines 74 sourdough 52 Stoned Wheat Thins 67 wheat bread, high fiber 68 white bread 71 Cakes/Cookies/Muffins angel food cake 67 banana bread 47 blueberry muffin 59 chocolate cake 38 corn muffin 102 cupcake with icing 73 donut 76 oat bran muffin 60 oatmeal cookies 55 pound cake 54 shortbread cookies 64 vanilla wafers 77 Candy chocolate 49 jelly beans 80 LifeSavers 70 M & M, peanut 33 Nestle Crunch 42 Skittles 69 Snickers 40 Twix 43 Cereals/Breakfast All-Bran 42 Bran Chex 58 Cheerios 74 Corn Flakes 83 Cream of Wheat 70 Crispix 87 Golden Grahams 71 Grape Nuts 67 oatmeal 49 pancakes 67 Pop-Tarts 70 Puffed Wheat 67 Raisin Bran 73 Rice Krispies 82 Shredded Wheat 69 Special K 66 Total 6 waffles 76 Combination Foods chicken nuggets 46 fish fingers 38 macaroni and cheese 64 pizza (cheese) 60 sausages 28 stuffing 74 taco shells 68 Dairy chocolate milk 34 custard 43 ice cream, chocolate 68 ice cream, vanilla 62 milk, skim 32 milk, whole 27 pudding 43 yogurt, low fat 33 Fruits and Juices apple 38 apple juice 41 apricots 57 banana 55 cantaloupe 65 cherries 22 cranberry juice 68 fruit cocktail 55 grapefruit 25 grapefruit juice 48 grapes 46 kiwi 53 mango 56 orange 44 orange juice 52 peach 42 pear 37 plum 39 raisins 64 watermelon 72 Legumes baked beans 48 black beans 30 black-eyed peas 42 butter beans 30 chickpeas 33 lentils, red 25 lima beans 32 pinto beans 45 red kidney beans 19 Pasta capellini 45 fettuccini 32 linguini 55 macaroni 45 spaghetti, wheat 37 spaghetti, white 41 tortellini 50 Rice/Grains brown rice 55 couscous 65 instant rice 87 long grain rice 56 risotto 69 Snack Foods corn chips 74 granola bars 61 NutriGrain bars 66 peanuts 15 popcorn 55 potato chips 54 pretzels 81 rice cakes 77 Soups black bean 64 green pea 66 lentil 44 minestrone 39 split pea 60 tomato 38 Sports Bars/Drinks Gatorade 78 Power Bar 58 Sugars and Spreads glucose tablets 102 high fructose corn syrup (regular soda) 62 honey 58 strawberry jam 51 syrup 66 table sugar (sucrose) 64 Vegetables French fries 75 potato, baked 85 potato, boiled 88 potato, instant 83 potato, mashed 91 carrots, boiled 49 carrots, raw 47 corn 46 sweet potato 44 tomato juice 38Appendix D * Key: MM = Medtronic Guardian DEX = Dexcom G4, G5, G6 LIB = Freestyle Libre EVER = Senseonics EversenseAppendix E Medications That May Raise Blood Sugar Levels Generic Name (Brand Name) Abacavir (Ziagen) Abacavir + lamivudine, zidovudine (Trizivir) Acetazolamide (Diamox) Acitretin (Soriatane) Albuterol (Ventolin, Proventil) Albuterol + ipratropium (Combivent) Ammonium chloride Amphotericin B (Amphocin, Fungizone) Amphotericin B lipid formulations IV (Abelcet) Amprenavir (Agenerase) Anidulafungin (Eraxis) Aripiprazole (Abilify) Arsenic trioxide (Trisenox) Asparaginase (Elspar) Atazanavir (Reyataz) Atenolol + chlorthalidone (Tenoretic) Atorvastatin (Lipitor) Atovaquone (Mepron) Baclofen (Lioresal) Benazepril + hydrochlorothiazide (Lotension) Betamethasone topical (Alphatrex, Betatrex, Beta-Val, Diprolene, Diprolene AF, Diprolene Lotion, Luxiq, Maxivate) Betamethasone + clotrimazole (Lotrisone topical) Betaxolol Betoptic eyedrops (Kerlone oral) Bexarotene (Targretin) Bicalutamide (Casodex) Bisoprolol + hydrochlorothiazide (Ziac) Bumetanide (Bumex) Candesartan + hydrochlorothiazide (Atacand HCT) Captopril + hydrochlorothiazide (Capozide) Carteolol (Cartrol oral, Occupresseyedrops) Carvedilol (Coreg) Chlorothiazide (Diuril) Chlorthalidone (Chlorthalidone Tablets, Clorpres, Tenoretic, Thalitone) Choline salicylate (numerous trade names of aspirin formulations—check label) Choline salicylate + magnesium salicylate (CMT, Tricosal, Trilisate) Clobetasol (Clobevate, Cormax, Cormax Scalp Application, Embeline E, Olux, Temovate, Temovate E, Temovate Scalp Application) Clozapine (Clozaril, FazaClo) Conjugated estrogens (Estrace, Estring, Femring, Premarin, Vagifem, Cenestin, Enjuvia, Estrace, Femtrace, Gynodiol, Menest, Ogen) Conjugated estrogens + medroxyprogesterone (Premphase, Prempro) Corticosteroids (numerous trade names—check label) Corticotropin Cortisone (numerous trade names—check label) Cyclosporine (Sandimmune, Neoral, Gengraf) Daclizumab (Zenapax) Decitabine (Dacogen) Desonide (DesOwen, Tridesilon) Desoximetasone (Topicort, Adrenocot, Dalalone, Decadron, Decaject, Dekasol, Dexacort, Dexasone, Dexim, Dexone, Hexadrol, Medidex, Primethasone, Solurex, Dexamethasone Intensol) Dextromethorphan + promethazine (Phenergan with Dextromethorphan, Phen-Tuss DM) Diazoxide (Proglycem) Enalapril + hydrochlorothiazide (Vaseretic) Encainide (Enkaid) Ephedrine and Guaifenesin (Primatene tablets, OTC—this medication includes ephedrine and guaifenesin) Epinephrine (EpiPen, EpiPen Jr, Primatene Mist, OTC) Esterified estrogens, estrone, estropipate Esterified estrogens + methyltestosterone (Estratest) Estradiol, ethinyl estradiol (Alora, Climara, Congest, Delestrogen, Depo-Estradiol, Depogen, Estinyl, Estrace, Estraderm, Estragyn 5, Estragyn LA 5, Estrasorb, EstroGel, Estro-L.A., Gynodiol, Kestrone-5, Neo-Estrone, Menest, Menostar, Ogen.625, Ogen, Ortho-Est, remarin, Valergen, Vivelle, Vivelle-Dot) Estradiol + norethindrone (Activella) Estradiol + norgestimate (Prefest) Estramustine (Emcyt) Ethacrynic acid (Edecrin, Sodium Edecrin) Everolimus (Afinitor) Everolimus (Zortress) Fluoxetine (Prozac, Sarafem) Flurandrenolide (Cordran, Cordran SP, Cordran Tape) Formoterol (Foradil Aerolizer Inhaler) Fosamprenavir (Lexiva) Fosinopril + hydrochlorothiazide (Monopril HCT) Furosemide (Lasix) Gemtuzumab ozogamicin (Mylotarg) Glucosamine Hydrochlorothiazide (Aldactazide, Aldoril, Capozide, Dyazide, HydroDIURIL, Inderide, Lopressor HCT, Maxzide, Microzide, Moduretic, Timolide, Vaseretic) Hydrochlorothiazide + irbesartan (Avalide) Hydrochlorothiazide + lisinopril (Prinzide, Zestoretic) Hydrochlorothiazide + losartan (Hyzaar) Hydrochlorothiazide + metoprolol (Lopressor HCT) Hydrochlorothiazide + moexipril (Uniretic) Hydrochlorothiazide + quinapril (Accuretic, Quinaretic) Hydrochlorothiazide + telmisartan (Micardis HCT) Hydrochlorothiazide + valsartan (Diovan HCT) Hydrocortisone (numerous trade names of topical hydrocortisone formulations—check label) Indapamide (Lozol) Indinavir (Crixivan) Interferon alfa-n1 (Alferon-N) Interferon alfa-2a (Roferon-A) Interferon alfa-2b (Intron-A) Interferon alfa-2b + ribavirin (Rebetron) Irinotecan (Camptosar) Isoniazid (Laniazid, Nydrazid) Isotretinoin (Accutane) Lamivudine (Epivir, Epivir-HBV) Levalbuterol (Xoponex, Xopenex HFA) Levonorgestrel (Plan B, Norplant System) Levothyroxine (Synthroid, Levoxyl) Lopinavir + ritonavir (Kaletra) Magnesium salicylate (Bayer Select Backache Pain Formula, Doans Pills, Mobidin, Nuprin Backache Caplet) Medroxyprogesterone (Provera, Depo-Provera) Megestrol (Megace) Methylprednisolone (A-methaPred, ADDVantage, Depo-Medrol, Medrol, Medrol Dosepak, Meprolone Unipak, Solu-Medrol) Metolazone (Zaroxolyn, Mykrox) Metoprolol (Lopressor, Lopressor HCT, Toprol XL) Modafinil (Provigil) Moxifloxacin (Avelox, Avelox I.V.) Mycophenolate (CellCept) Nadolol (Corgard) Nelfinavir (Viracept) Niacin, niacinamide (Niacor, Niaspan, Nicolar, Nicotinex, Slo-Niacin) Nilotinib (Tasigna) Nilutamide (Nilandron) Nitric oxide (INOmax) Norethindrone (Aygestin, Nor-QD, Micronor) Norgestrel (Orvette) Nystatin (Mycostatin, Nystat-Rx, Nystop, Pedi-Dri) Nystatin + triamcinolone (Dermacomb, Myco II, Mycobiotic II, Mycogen II, Mycolog II, Myco-Triacet II, Mykacet, Mykacet II, Mytrex, Tristatin II) Octreotide (Sandostatin, Sandostatin LAR) Olanzapine (Zyprexa) Pantoprazole (Protonix, Protonix I.V.) Pegaspargase (Oncaspar) Peginterferon alfa-2b (PEG-Intron) Pentamidine (Pentam 300) Phenylephrine (Sudafed PE and others) Phenytoin (Dilantin, Dilantin-125, Dilantin Infatabs, Dilantin Kapseals, Phenytek) Prednisolone (AK-Pred, Blephamide, Blephamide, Liquifilm, EconopredPlus, Inflamase Forte, Inflamase Mild, Poly-Pred Liquifilm, PredForte, Pred Mild, Pred-G, Pred-G Liquifilm, Delta Cortef, Pediapred, Prelone) Prednisone (Prednisone Intensol, Sterapred, Sterapred DS) Progesterone (Prometrium) Pseudoephedrine (Claritin D, Sudafed) Quetiapine (Seroquel) Risperidone (Risperdal, Risperdal MTAB) Ritodrine (Yutopar) Ritonavir (Norvir) Rituximab (Rituxan) Salmeterol (Serevent, Serevent Diskus) Salsalate (Argesic-SA, Disalcid, Mono-Gesic, Salflex, Salsitab) Saquinavir (Invirase) Sodium oxybate (Xyrem) Somatropin (Genotropin, Genotropin Miniquick, Humatrope, Norditropin cartridges, Norditropin NordiFlex, Nutropin, Nutropin AQ, Saizen, Serostim, Zorbtive) Sotalol (Betapace, Betapace AF, Sorine) Streptozocin (Zanosar) Tacrolimus (Prograf, Protopic) Temsirolimus (Torisel) Tipranavir (Aptivus) Tolvaptan (Samsca) Torsemide (Demadex, Demadex Oral) Triamcinolone (Aristocort, Aristospan, Asthmacort, Flutex, Kenalog, Tac, Triacet) Ursodeoxycholic acid, ursodiol (Actigall, Urso) Valproic acid, divalproex sodium (Depacon, Depakene, Depakene Syrup, Depakote, Depakote ER, Depakote Sprinkle) Vitamin C (Ascorbic acid, Ascorbate) Vitamin E (Tocopherol, Tocotrienol) Ziprasidone (Geodone) Source: “Drugs That May Cause Hyperglycemia (High Blood Sugar),” Diabetes in Control: News and Information for Medical Professionals, www.diabetesincontrol.com/drugs-that-can-affect-blood-glucose-levels/#causehyper.Appendix F **Table 3-1. Meet the Diabeteses Diabetes Type: Type 1 Cause(s): autoimmune attack on beta cells of the pancreas Treatment Options: • insulin Diabetes Type: Type 2 Cause(s): insulin resistance and progressive beta cell insufficiency Treatment Options: • lifestyle changes Treatment Options: • oral medications Treatment Options: • noninsulin injectables Treatment Options: • insulin Diabetes Type: Gestational Cause(s): temporary insulin resistance Treatment Options: • lifestyle changes Treatment Options: • insulin Diabetes Type: LADA Cause(s): partial autoimmune attack on beta cells and some insulin resistance Treatment Options: • insulin Treatment Options: • possibly noninsulin diabetes medications in the early stages Diabetes Type: Neonatal Cause(s): monogenic defect limiting beta cells’ ability to make insulin Treatment Options: • insulin Diabetes Type: MODY Cause(s): monogenic defect limiting beta cells’ ability to make insulin Treatment Options: • lifestyle changes Treatment Options: • oral medications Treatment Options: • noninsulin injectables Treatment Options: • insulin *Table 3-2. Major Factors Affecting Blood Sugar Raise Blood Sugar: Food Lower Blood Sugar: Physical Activity Raise Blood Sugar: The Liver Lower Blood Sugar: Insulin Raise Blood Sugar: Stress Hormones Lower Blood Sugar: Other Diabetes Medications *Table 3-4. Simple Versus Complex Carbohydrates Foods Rich in Sugar (Simple Carbohydrates) fruit fruit juice raisins/dried fruit regular soda sports drinks candy chocolate cookies and cakes pies and pastries muffins milk ice cream yogurt smoothies table sugar honey syrup jelly corn syrup Foods Rich in Starch (Complex Carbohydrates) potatoes rice noodles/pasta cereal oatmeal bread crackers bagels pizza tortillas pancakes waffles beans peas corn pretzels chips popcorn matzah *Table 3-5. Secondary Factors That Can Influence Blood Sugar Levels Tend to Raise Blood Sugar (vertical) growth pubertal hormones menstrual hormones later stages of pregnancy “rebounds” from hypoglycemia gradual loss of beta cell function (type 2) exiting the “honeymoon” period (type 1) polycystic ovary syndrome (PCOS) depression weight gain premenstrual hormones excessive sleeping caffeine steroid medications anti-psychotic medications diuretics estrogen niacin Tend to Lower Blood Sugar alcohol heat/humidity intense brain work previous intense exercise new/unusual surroundings socializing stimulating environments early stages of pregnancy beta blockers MAO inhibitors nicotine patches Ritalin high altitude depression treatment postmenstrual hormone changes *Table 4-1. HbA1c and Average Glucose A1c (Standard): 5% A1c (mmol/mol): 31 Average Glucose (mg/dl): 97 Average Glucose (mmol/l): 5.4 A1c (Standard): 5% A1c (mmol/mol): 31 Average Glucose (mg/dl): 97 Average Glucose (mmol/l): 5.4 A1c (Standard): 6% A1c (mmol/mol): 42 Average Glucose (mg/dl): 126 Average Glucose (mmol/l): 7.0 A1c (Standard): 7% A1c (mmol/mol): 53 Average Glucose (mg/dl): 154 Average Glucose (mmol/l): 8.6 A1c (Standard): 8% A1c (mmol/mol): 64 Average Glucose (mg/dl): 183 Average Glucose (mmol/l): 10.2 A1c (Standard): 9% A1c (mmol/mol): 75 Average Glucos

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e (mg/dl): 212 Average Glucose (mmol/l): 11.8 A1c (Standard): 10% A1c (mmol/mol): 86 Average Glucose (mg/dl): 240 Average Glucose (mmol/l): 13.3 A1c (Standard): 11% A1c (mmol/mol): 97 Average Glucose (mg/dl): 269 Average Glucose (mmol/l): 14.9 A1c (Standard): 12% A1c (mmol/mol): 108 Average Glucose (mg/dl): 298 Average Glucose (mmol/l): 16.5 A1c (Standard): 13% A1c (mmol/mol): 119 Average Glucose (mg/dl): 326 Average Glucose (mmol/l): 18.1 A1c (Standard): 14% A1c (mmol/mol): 130 Average Glucose (mg/dl): 355 Average Glucose (mmol/l): 19.7 A1c (Standard): 15%+ A1c (mmol/mol):141 Average Glucose (mg/dl): Trust me. It’s high. Real high. Average Glucose (mmol/l): *Table 4-2. Converting A1c into Average Glucose and Vice Versa Average blood glucose (in mg/dl) = (A1c x 28.7) − 46.7 Average blood glucose (in mmol/l) = (A1c x 1.59) − 2.59 and in reverse: A1c = (average blood glucose [in mg/dl]) + 46.7) / 28.7 A1c = (average blood glucose [in mmol/l] + 2.59) / 1.59 *Table 4-3. Common Glucose Targets Level of Control: very tight Often Applies to: • pregnant people Often Applies to: • tech-savvy people using all the latest tools A1c: 5–6% Acceptable Target Range mg/dl (mmol/l): 60–120 (3.5–8) Postmeal Acceptable Peak mg/dl (mmol/l): <140 (<7.8) Level of Control: tight Often Applies to: • people planning to get pregnant Often Applies to: • most adults A1c: 6–7% Acceptable Target Range mg/dl (mmol/l): 70–160 (4–9) Postmeal Acceptable Peak mg/dl (mmol/l): <180 (<10) Level of Control: average Often Applies to: • children and teens Often Applies to: • adults in high-risk professions A1c: 7–8% Acceptable Target Range mg/dl (mmol/l): 70–180 (4–10) Postmeal Acceptable Peak mg/dl (mmol/l): <200 (<11) Level of Control: loose Often Applies to: • people with severe hypoglycemia unawareness Often Applies to: • people with a history of frequent/severe lows Often Applies to: • elderly/frail individuals Often Applies to: • people with unstable heart disease A1c: 8–9% Acceptable Target Range mg/dl (mmol/l): 80–200 (4.5–11) Postmeal Acceptable Peak mg/dl (mmol/l): <220 (<12) *Table 4-4. Converting Exchanges into Grams (g) of Carbohydrate bread exchange = 15 g carb 1 fruit exchange = 15 g carb 1 milk exchange = 12 g carb 1 vegetable exchange = 5 g carb 1 meat exchange = 0 g carb 1 fat exchange = 0 g carb *Table 4-5. Counting Protein Grams Protein Source: sirloin steak Serving Size: 4 oz Protein Content (grams): 34 g protein Protein Source: chicken breast Serving Size: 3 oz Protein Content (grams): 26 g protein Protein Source: cooked ground turkey Serving Size: 3 oz Protein Content (grams): 22 g protein Protein Source: cooked ground beef Serving Size: 3 oz Protein Content (grams): 22 g protein Protein Source: tuna (drained) Serving Size: 3 oz Protein Content (grams): 22 g protein Protein Source: salmon Serving Size: 3 oz Protein Content (grams): 19 g protein Protein Source: cottage cheese Serving Size: 4 oz Protein Content (grams): 14 g protein Protein Source: tofu Serving Size: 3 oz Protein Content (grams): 13 g protein Protein Source: skim or 1% milk Serving Size: 8 oz Protein Content (grams): 9 g protein Protein Source: lima/kidney beans Serving Size: 1/2 cup Protein Content (grams): 7 g protein Protein Source: cheese Serving Size: 1 oz Protein Content (grams): 7 g protein Protein Source: 1 whole egg Serving Size: large Protein Content (grams):6 g protein Protein Source: low fat yogurt Serving Size: 4 oz Protein Content (grams): 5 g protein Protein Source: Greek yogurt Serving Size: 8 oz Protein Content (grams): 20 g protein Protein Source: nut butter Serving Size:2 Tbsp Protein Content (grams):8 g protein Source: US Department of Agriculture * 1. (Pre)mixed insulin twice daily 2. Morning NPH and bolus, evening bolus, bedtime NPH 3. Bedtime NPH plus MDI 4. Long-acting insulin plus MDI or basic mechanical pump 5. Long-acting insulin and bedtime NPH plus MDI 6. Full-feature insulin pump therapy 7. Hybrid closed-loop systems *Table 6-1 Total Daily Insulin Requirements (Units per Kilogram* Body Weight) * to convert pounds to kilograms, multiply pounds by 0.454 Age Activity Level : Inactive Young Children: 0.60−1.2 Adolescents: 0.80−2.0 Adults: 0.60−1.2 Older Adults: 0.40−1.0 Age Activity Level : Moderately Active Young Children: 0.50−1.0 Adolescents: 0.75−1.50 Adults: 0.50−1.0 Older Adults: 0.35−0.80 Age Activity Level : Very Active Young Children: 0.40−0.80 Adolescents: 0.60−1.2 Adults: 0.40−0.80 Older Adults: 0.30−0.70 *Table 6-2 Daily BASAL Insulin Requirements (Units per Kilogram Body Weight) * * to convert pounds to kilograms, multiply pounds by 0.454 Age Activity Level : Inactive Young Children: 0.25−0.60 Adolescents: 0.30−1.0 Adults: 0.25−0.60 Older Adults: 0.20−0.50 Age Activity Level : Moderately Active Young Children: 0.20−0.50 Adolescents: 0.30−0.70 Adults: 0.20−0.50 Older Adults: 0.15−0.40 Age Activity Level : Very Active Young Children: 0.15−0.40 Adolescents: 0.25−0.60 Adults: 0.15−0.40 Older Adults: 0.10−0.35 *Table 6-3 Larry: Bedtime: 130 mg/dl (7.2 mmol/l) Mid-Sleep: 190 mg/dl (11.1 mmol/l) Wake-Up: 200 mg/dl (11.1 mmol/l) Larry’s Brother Dary| Bedtime: 130 mg/dl (7.2 mmol/l) Mid-Sleep: 160 mg/dl (8.9 mmol/l) Wake-Up: 200 mg/dl (11.1 mmol/l) Larry’s Other Brother Darry| Bedtime: 130 mg/dl (7.2 mmol/l) Mid-Sleep: 65 mg/dl (3.6 mmol/l) Wake-Up: 200 mg/dl (11.1 mmol/l) *Table 6-4. Example of a Basal Testing Schedule Test: Overnight Eat and bolus no later than: 7 p.m. (eat dinner, then skip evening snacks) If using fingersticks, check blood sugar at: 11 p.m., 1 a.m., 3 a.m., 5 a.m., 7 a.m. If using CGM, evaluate data from: 11 p.m. to 7 a.m. Okay to eat and bolus again after: 7 a.m. Test: Morning Eat and bolus no later than: 3 a.m. (have a bedtime snack, then skip breakfast) If using fingersticks, check blood sugar at: 7 a.m., 9 a.m., 11 a.m., 1 p.m. If using CGM, evaluate data from: 7 a.m. to 1 p.m. Okay to eat and bolus again after: 12 noon Test: Afternoon Eat and bolus no later than: 9 a.m. (have breakfast, then skip lunch and afternoon snacks) If using fingersticks, check blood sugar at: 1 p.m., 3 p.m., 5 p.m., 6 p.m. If using CGM, evaluate data from: 1 p.m. to 6 p.m. Okay to eat and bolus again after: 6 p.m. Test: Evening Eat and bolus no later than: 2 p.m. (have a late lunch, then skip afternoon snacks and have a late dinner) If using fingersticks, check blood sugar at: 6 p.m., 8 p.m., 10 p.m., 11 p.m. If using CGM, evaluate data from: 6 p.m. to 11 p.m. Okay to eat and bolus again after: 11 p.m. *Table 6-5. Suggested Magnitude of Basal Insulin Adjustments Current Basal Level (units/hour): Blood Sugar Change During Test:: Modest (30–60 mg/dl; 1.7–3.4 mmol/l): 0.0–0.35: 0.025 or 0.05 Blood Sugar Change During Test:: Modest (30–60 mg/dl; 1.7–3.4 mmol/l): 0.4–1.0: 0.10 Blood Sugar Change During Test:: Modest (30–60 mg/dl; 1.7–3.4 mmol/l): >1.0: 0.2 Blood Sugar Change During Test:: Large (>60 mg/dl; >3.4 mmol/l): 0.0–0.35: 0.05 or 0.10 Blood Sugar Change During Test:: Large (>60 mg/dl; >3.4 mmol/l): 0.4–1.0: 0.20 Blood Sugar Change During Test:: Large (>60 mg/dl; >3.4 mmol/l): >1.0: 0.3 or 0.4 *Table 7-1. Estimating Your I:C Ratio from Total Daily Insulin Total Daily Units of Insulin (Basal + Bolus): 8−11 Estimated I:C Ratio: 1:50 Total Daily Units of Insulin (Basal + Bolus): 12-14 Estimated I:C Ratio: 1:40 Total Daily Units of Insulin (Basal + Bolus): 15-18 Estimated I:C Ratio: 1:30 Total Daily Units of Insulin (Basal + Bolus): 19-21 Estimated I:C Ratio: 1:25 Total Daily Units of Insulin (Basal + Bolus): 22-27 Estimated I:C Ratio: 1:20 Total Daily Units of Insulin (Basal + Bolus): 28-35 Estimated I:C Ratio: 1:15 Total Daily Units of Insulin (Basal + Bolus): 36-45 Estimated I:C Ratio: 1:12 Total Daily Units of Insulin (Basal + Bolus): 46-55 Estimated I:C Ratio: 1:10 Total Daily Units of Insulin (Basal + Bolus): 56-65 Estimated I:C Ratio: 1:8 Total Daily Units of Insulin (Basal + Bolus): 66-80 Estimated I:C Ratio: 1:7 Total Daily Units of Insulin (Basal + Bolus): 81-120 Estimated I:C Ratio: 1:5 Total Daily Units of Insulin (Basal + Bolus): 121-160 Estimated I:C Ratio: 1:4 Total Daily Units of Insulin (Basal + Bolus): >160 Estimated I:C Ratio: 1:3 *Table 7-2. Determining I:C Ratio from Weight Weight (lbs): <40 Weight (kg): <18 Estimated I:C Ratio: 1:50 Weight (lbs): 41−60 Weight (kg): 18−26 Estimated I:C Ratio: 1:35 Weight (lbs): 61−80 Weight (kg): 27−36 Estimated I:C Ratio: 1:25 Weight (lbs): 81−100 Weight (kg): 37−45 Estimated I:C Ratio: 1:20 Weight (lbs): 101−120 Weight (kg): 46−54 Estimated I:C Ratio: 1:17 Weight (lbs): 121−140 Weight (kg): 55−64 Estimated I:C Ratio: 1:14 Weight (lbs): 141−170 Weight (kg): 65−77 Estimated I:C Ratio: 1:12 Weight (lbs): 171−200 Weight (kg): 78−91 Estimated I:C Ratio: 1:10 Weight (lbs): 201−230 Weight (kg): 92−104 Estimated I:C Ratio: 1:8 Weight (lbs): 231−270 Weight (kg): 105−123 Estimated I:C Ratio: 1:7 Weight (lbs): 271−320 Weight (kg): 124−145 Estimated I:C Ratio: 1:6 Weight (lbs): >320 Weight (kg): >145 Estimated I:C Ratio: 1:5 *Table 7-3 Sunday Pre-Breakfast Blood Sugar in mg/dl (mmol/l): 145 (8.1) Pre-Lunch Blood Sugar in mg/dl (mmol/l): 97 (5.4) Pre-Dinner Blood Sugar in mg/dl (mmol/l): 67 (3.7) Pre-Bedtime Snack Blood Sugar in mg/ dl (mmol/l): 113 (6.3) Monday Pre-Breakfast Blood Sugar in mg/dl (mmol/l): 188 (10.5) Pre-Lunch Blood Sugar in mg/dl (mmol/l): 115 (6.4) Pre-Dinner Blood Sugar in mg/dl (mmol/l): 104 (5.8) Pre-Bedtime Snack Blood Sugar in mg/ dl (mmol/l): 109 (6.1) Tuesday Pre-Breakfast Blood Sugar in mg/dl (mmol/l): 205 (11.4) Pre-Lunch Blood Sugar in mg/dl (mmol/l): 89 (4.9) Pre-Dinner Blood Sugar in mg/dl (mmol/l): 58 (3.2) Pre-Bedtime Snack Blood Sugar in mg/ dl (mmol/l): 88 (4.8) Wednesday Pre-Breakfast Blood Sugar in mg/dl (mmol/l): 175 (9.7) Pre-Lunch Blood Sugar in mg/dl (mmol/l): 73 (4.1) Pre-Dinner Blood Sugar in mg/dl (mmol/l): 42 (2.3) Pre-Bedtime Snack Blood Sugar in mg/ dl (mmol/l): 255 (14.2) Thursday Pre-Breakfast Blood Sugar in mg/dl (mmol/l): 169 (9.4) Pre-Lunch Blood Sugar in mg/dl (mmol/l): 146 (8.1) Pre-Dinner Blood Sugar in mg/dl (mmol/l): 117 (6.5) Pre-Bedtime Snack Blood Sugar in mg/ dl (mmol/l): 122 (6.8) Friday Pre-Breakfast Blood Sugar in mg/dl (mmol/l): 222 (12.3) Pre-Lunch Blood Sugar in mg/dl (mmol/l): 128 (7.1) Pre-Dinner Blood Sugar in mg/dl (mmol/l): (forgot) Pre-Bedtime Snack Blood Sugar in mg/ dl (mmol/l): 202 (11.2) Saturday Pre-Breakfast Blood Sugar in mg/dl (mmol/l): 190 (10.6) Pre-Lunch Blood Sugar in mg/dl (mmol/l): 105 (5.8) Pre-Dinner Blood Sugar in mg/dl (mmol/l): 61 (3.3) Pre-Bedtime Snack Blood Sugar in mg/ dl (mmol/l): 136 (7.6) *Table 7-4. Data Log Date: 6/1 Pre-Breakfast Blood Sugar in mg/dl (mmol/l): 175 (9.7) Carbs (grams): 50 Bolus Insulin (units): 6.5 Pre-Lunch Blood Sugar in mg/dl (mmol/l): 101 (5.6) Conclusion About I:C Ratio: 1:8 makes BG drop Date: 6/2 Pre-Breakfast Blood Sugar in mg/dl (mmol/l): 83 (4.6) Carbs (grams): 50 Bolus Insulin (units): 4.0 Pre-Lunch Blood Sugar in mg/dl (mmol/l): 78 (4.3) Conclusion About I:C Ratio: 1:12 held BG steady Date: 6/3 Pre-Breakfast Blood Sugar in mg/dl (mmol/l): 62 (3.4) Carbs (grams): 75 Bolus Insulin (units): 5.0 Pre-Lunch Blood Sugar in mg/dl (mmol/l): 226 (12.5) Conclusion About I:C Ratio: Don’t count—low to start Date: 6/4 Pre-Breakfast Blood Sugar in mg/dl (mmol/l): 151 (8.4) Carbs (grams): 50 Bolus Insulin (units): 6.0 Pre-Lunch Blood Sugar in mg/dl (mmol/l): 93 (5.2) Conclusion About I:C Ratio: 1:8 makes BG drop Date: 6/5 Pre-Breakfast Blood Sugar in mg/dl (mmol/l): 210 (11.6) Carbs (grams): 40 Bolus Insulin (units): 6.0 Pre-Lunch Blood Sugar in mg/dl (mmol/l): 113 (6.3) Conclusion About I:C Ratio: 1:7 makes BG drop a lot Date: 6/6 Pre-Breakfast Blood Sugar in mg/dl (mmol/l): 75 (4.2) Carbs (grams): 75 Bolus Insulin (units): 5.0 Pre-Lunch Blood Sugar in mg/dl (mmol/l): 180 (10.0) Conclusion About I:C Ratio: 1:15 makes BG rise Date: 6/7 Pre-Breakfast Blood Sugar in mg/dl (mmol/l): 123 (6.8) Carbs (grams): 50 Bolus Insulin (units): 5.0 Pre-Lunch Blood Sugar in mg/dl (mmol/l): 86 (4.7) Conclusion About I:C Ratio: 1:10 makes BG drop a bit Date: 6/8 Pre-Breakfast Blood Sugar in mg/dl (mmol/l): 99 (5.5) Carbs (grams): 90 Bolus Insulin (units): 7.0 Pre-Lunch Blood Sugar in mg/dl (mmol/l): 52 (2.8) Conclusion About I:C Ratio: 1:14 makes BG drop* Date: 6/9 Pre-Breakfast Blood Sugar in mg/dl (mmol/l): 97 (5.4) Carbs (grams): 30 Bolus Insulin (units): 2.5 Pre-Lunch Blood Sugar in mg/dl (mmol/l): 114 (6.3) Conclusion About I:C Ratio: 1:12 held BG steady Date: 6/10 Pre-Breakfast Blood Sugar in mg/dl (mmol/l): 154 (8.5) Carbs (grams): 65 Bolus Insulin (units): 3.0 Pre-Lunch Blood Sugar in mg/dl (mmol/l): 274 (15.2) Conclusion About I:C Ratio: 1:20 makes BG rise a lot *Table 7-5. Estimating the Daytime Sensitivity Factor Based on Total Daily Insulin Average Total Daily Insulin (Basal + Bolus units): 5 Approximate Sensitivity Factor (mg/dl): 320–360 Approximate Sensitivity Factor (mmol/l): 18–20 Average Total Daily Insulin (Basal + Bolus units): 7 Approximate Sensitivity Factor (mg/dl): 220–260 Approximate Sensitivity Factor (mmol/l): 12–14 Average Total Daily Insulin (Basal + Bolus units): 10 Approximate Sensitivity Factor (mg/dl): 155–185 Approximate Sensitivity Factor (mmol/l): 8.6–10.3 Average Total Daily Insulin (Basal + Bolus units): 12 Approximate Sensitivity Factor (mg/dl): 125–155 Approximate Sensitivity Factor (mmol/l): 6.9–8.6 Average Total Daily Insulin (Basal + Bolus units): 15 Approximate Sensitivity Factor (mg/dl): 95–125 Approximate Sensitivity Factor (mmol/l): 5.3–6.9 Average Total Daily Insulin (Basal + Bolus units): 18 Approximate Sensitivity Factor (mg/dl): 80–110 Approximate Sensitivity Factor (mmol/l): 4.4–6.1 Average Total Daily Insulin (Basal + Bolus units): 20 Approximate Sensitivity Factor (mg/dl): 70–100 Approximate Sensitivity Factor (mmol/l): 3.9–5.5 Average Total Daily Insulin (Basal + Bolus units): 25 Approximate Sensitivity Factor (mg/dl): 60–80 Approximate Sensitivity Fac

Part 39

tor (mmol/l): 3.3–4.4 Average Total Daily Insulin (Basal + Bolus units): 30 Approximate Sensitivity Factor (mg/dl): 50–70 Approximate Sensitivity Factor (mmol/l): 2.8–3.9 Average Total Daily Insulin (Basal + Bolus units): 35 Approximate Sensitivity Factor (mg/dl): 40–60 Approximate Sensitivity Factor (mmol/l): 2.2–3.3 Average Total Daily Insulin (Basal + Bolus units): 40 Approximate Sensitivity Factor (mg/dl): 35–50 Approximate Sensitivity Factor (mmol/l): 2.0–2.8 Average Total Daily Insulin (Basal + Bolus units): 45 Approximate Sensitivity Factor (mg/dl): 30–45 Approximate Sensitivity Factor (mmol/l): 1.7–2.5 Average Total Daily Insulin (Basal + Bolus units): 50 Approximate Sensitivity Factor (mg/dl): 30–40 Approximate Sensitivity Factor (mmol/l): 1.7–2.2 Average Total Daily Insulin (Basal + Bolus units): 60 Approximate Sensitivity Factor (mg/dl): 25–35 Approximate Sensitivity Factor (mmol/l): 1.4–2.0 Average Total Daily Insulin (Basal + Bolus units): 70 Approximate Sensitivity Factor (mg/dl): 20–30 Approximate Sensitivity Factor (mmol/l): 1.1–1.7 Average Total Daily Insulin (Basal + Bolus units): 80 Approximate Sensitivity Factor (mg/dl): 20–25 Approximate Sensitivity Factor (mmol/l): 1.1–1.4 Average Total Daily Insulin (Basal + Bolus units): 100 Approximate Sensitivity Factor (mg/dl): 15–20 Approximate Sensitivity Factor (mmol/l): 0.8–1.1 Average Total Daily Insulin (Basal + Bolus units): 120 Approximate Sensitivity Factor (mg/dl): 13–17 Approximate Sensitivity Factor (mmol/l): 0.7–1.0 Average Total Daily Insulin (Basal + Bolus units): 140 Approximate Sensitivity Factor (mg/dl): 11–15 Approximate Sensitivity Factor (mmol/l): 0.6–0.8 Average Total Daily Insulin (Basal + Bolus units): 160 Approximate Sensitivity Factor (mg/dl): 10–12 Approximate Sensitivity Factor (mmol/l): 0.5–0.7 Average Total Daily Insulin (Basal + Bolus units): 180 Approximate Sensitivity Factor (mg/dl): 9–11 Approximate Sensitivity Factor (mmol/l): 0.5–0.6 Average Total Daily Insulin (Basal + Bolus units): 200 Approximate Sensitivity Factor (mg/dl): 8–10 Approximate Sensitivity Factor (mmol/l): 0.4–0.6 * Medtronic In the Past 20 Minutes: Rising <3 mg/dL/min [0.17 mmol/L] Rising 2-3 mg/dL/min [0.11-0.17 mmol/L] Rising 1-2 mg/dL/min [0.06-0.11 mmol/L] n/a n/a n/a Falling 1-2 mg/dL/min Falling 2-3 mg/dL/min [0.11-0.17 mmol/L] Falling 2-3 mg/dL/min [0.11-0.17 mmol/L] Falling <3 mg/dL/min [0.17 mmol/L] Dexcom In the Past 15 Minutes: n/a Rising <3 mg/dL/min [0.17 mmol/L] Rising 2-3 mg/dL/min [0.11-0.17 mmol/L] Rising 1-2 mg/dL/min [0.06-0.11 mmol/L] Changing <1 mg/dL/min [0.06 mmol/L] Falling 1-2 mg/dL/min [0.06-0.11 mmol/L]

Falling <2 mg/dl/min [0.11-0.16 mmol/l] Rising <3 mg/dL/min [0.17 mmol/L] n/a Libre n/a n/a Rising <2 mg/dl/min [0.11-0.16 mmol/l] Rising 1-2 mg/dL/min [0.06-0.11 mmol/L] Changing <1 mg/dL/min [0.06 mmol/L] Falling 1-2 mg/dL/min [0.06-0.11 mmol/L]

Falling <2 mg/dl/min [0.11-0.16 mmol/l] n/a n/a Eversense In the Past 20 Minutes: n/a n/a Rising <2 mg/dl/min [0.11-0.16 mmol/l] Rising 1-2 mg/dL/min [0.06-0.11 mmol/L] Changing <1 mg/dL/min [0.06 mmol/L] Falling 1-2 mg/dL/min [0.06-0.11 mmol/L] n/a n/a * Current Trend Rising Very Fast Rising Fast Rising Modestly Falling Modestly Falling Fast Falling Very Fast CGM Arrow Designation Medtronic: Dexcom: Libre: (n/a) Eversense: (n/a) Medtronic: Dexcom: Libre: Eversense: Medtronic: Dexcom: Libre: Eversense: Medtronic: Dexcom: Libre: Eversense: Medtronic: Dexcom: Libre: Eversense: Medtronic: Dexcom: Libre: (n/a) Eversense: (n/a) Adjust Usual Dose to Offset Add enough to usual bolus to offset 75 mg/dL [4.2 mmol/L] rise Add enough to usual bolus to offset 50 mg/dL [2.8 mmol/L] rise Add enough to usual bolus to offset 25 mg/dL [1.4 mmol/L] rise Subtract enough from usual bolus to offset 25 mg/dL [1.4 mmol/L] fall Subtract enough from usual bolus to offset 50 mg/dL [2.8 mmol/L] fall Subtract enough from usual bolus to offset 75 mg/dL [4.2 mmol/L] fall *Table 7-8. How Different Systems Handle IOB Device: Accu-Chek/Roche What It Does with IOB: Calculates the correction bolus required to reach predicted or desirable glucose level given the amount of time since the last bolus was given. Device: Insulet/OmniPod What It Does with IOB: Deducts IOB from total meal + correction dose. Device: Medtronic What It Does with IOB: Deducts IOB from correction bolus only. Meal portion of the bolus is never reduced by IOB. Device: Tandem What It Does with IOB: If the glucose entry is above the target blood sugar, the IOB is deducted from the correction bolus only; the meal portion of the bolus will not be reduced by IOB. If the glucose entry is below the target blood sugar, the meal dose will be reduced by IOB. Device: Ypsomed What It Does with IOB: Deducts IOB from total meal + correction bolus. IOB is calculated based on a linear insulin action profile rather than the usual curvilinear action. Device: InPen What It Does with IOB: If it has been ≤ 2hrs since last food bolus and BG >180 (10), IOB deducted from correction dose only. If >2hrs and BG is above target, IOB deducted from total food + correction dose. If BG is below target, IOB will be deducted from the food dose. *Table 7-9. IOB Based on Time Since Bolus Was Given Time Since Bolus Was Given: 0.5 hr Insulin Used Up: 10% Insulin Still Working (IOB): 90% Time Since Bolus Was Given: 1 hr Insulin Used Up: 30% Insulin Still Working (IOB): 70% Time Since Bolus Was Given: 1.5 hrs Insulin Used Up: 50% Insulin Still Working (IOB): 50% Time Since Bolus Was Given: 2 hrs Insulin Used Up: 65% Insulin Still Working (IOB): 35% Time Since Bolus Was Given: 2.5 hrs Insulin Used Up: 80% Insulin Still Working (IOB): 20% Time Since Bolus Was Given: 3 hrs Insulin Used Up: 90% Insulin Still Working (IOB): 10% Time Since Bolus Was Given: 3.5 hrs Insulin Used Up: 95% Insulin Still Working (IOB): 5% Time Since Bolus Was Given: 4 hrs Insulin Used Up: 100% Insulin Still Working (IOB): 0% *Table 7-10. Simplified IOB Calculation Based on a Three-Hour Duration of Insulin Action Time Since Bolus Was Given: 1 hr Insulin Used Up: 33% Insulin Still Working (IOB): 67% Time Since Bolus Was Given: 2 hrs Insulin Used Up: 67% Insulin Still Working (IOB): 33% Time Since Bolus Was Given: 3 hrs Insulin Used Up: 100% Insulin Still Working (IOB): 0% *Table 7-11. Simplified IOB Calculation Based on a Four-Hour Duration of Insulin Action Time Since Bolus Was Given: 1 hr Insulin Used Up: 25% Insulin Still Working (IOB): 75% Time Since Bolus Was Given: 2 hrs Insulin Used Up: 50% Insulin Still Working (IOB): 50% Time Since Bolus Was Given: 3 hrs Insulin Used Up: 75% Insulin Still Working (IOB): 25% Time Since Bolus Was Given: 4 hrs Insulin Used Up: 100% Insulin Still Working (IOB): 0% *Table 7-12. Simplified IOB Calculation Based on a Five-Hour Duration of Insulin Action Time Since Bolus Was Given: 1 hr Insulin Used Up: 20% Insulin Still Working (IOB): 80% Time Since Bolus Was Given: 2 hrs Insulin Used Up: 40% Insulin Still Working (IOB): 60% Time Since Bolus Was Given: 3 hrs Insulin Used Up: 60% Insulin Still Working (IOB): 40% Time Since Bolus Was Given: 4 hrs Insulin Used Up: 80% Insulin Still Working (IOB): 20% Time Since Bolus Was Given: 5 hrs Insulin Used Up: 100% Insulin Still Working (IOB): 0% * Time: 8:00 a.m. Blood Sugar: 238 mg/dl (13.2 mmol/l) Correction bolus given Time: 8:30 Blood Sugar: 235 (13.1) Time: 9:00 Blood Sugar: 222 (12.3) Time: 9:30 Blood Sugar: 174 (9.8) Time: 10:00 Blood Sugar: 141 (7.8) Time: 10:30 Blood Sugar: 125 (6.9) Time: 11:00 Blood Sugar: 118 (6.6) Time: 11:30 Blood Sugar: 111 (6.2) Time: 12:00 p.m. Blood Sugar: 112 (6.2) *Table 7-13. Bolus Multipliers for Physical Activity Activity Multipliers : Low Intensity (RPE 8–11) Short Duration (15–30 Minutes): 0.90 (10% reduction) Moderate Duration (40–60 Minutes) 0.80 (20% reduction) Long Duration (<60 Minutes): 0.70 (30% reduction) Activity Multipliers : Moderate Intensity (RPE 12–15) Short Duration (15–30 Minutes): 0.75 (25% reduction) Moderate Duration (40–60 Minutes) 0.67 (33% reduction) Long Duration (<60 Minutes): 0.50 (50% reduction) Activity Multipliers : High Intensity (RPE 16–18) Short Duration (15–30 Minutes): 0.67 (33% reduction) Moderate Duration (40–60 Minutes) 0.50 (50% reduction) Long Duration (<60 Minutes): 0.33 (67% reduction) *Table 7-14. Rating of Perceived Exertion 6 7 Very, very light* 8 9 Very light 10 11 Fairly light 12 13 Somewhat hard 14 15 Hard 16 17 Very hard 18 19 Very, very hard * 20 *Note: Very, very light activities constitute little more than resting and typically do not require any insulin adjustments. Very, very hard activities (maximal intensity) are usually “anaerobic,” meaning they cannot be performed for more than a few minutes and often cause a short-term rise in blood sugar levels. *Table 7-15. Optimal Bolus Timing Based on Glycemic Index of Food High-GI food Bolus well before eating Moderate-GI food Bolus soon before eating Low-GI food, prolonged or very large meals Bolus after eating, or spread out delivery *Table 7-16. Bolus Timing Based on GI and Premeal Blood Sugar Bolus Timing in Relation to Meal: BG above target High GI: 35-45 minutes prior Moderate GI: 20-25 minutes prior Low GI, Prolonged or Large Meal: 0-10 minutes prior Bolus Timing in Relation to Meal: BG on target High GI: 20-30 minutes prior Moderate GI: 5-10 minutes prior Low GI, Prolonged or Large Meal: 5-15 minutes after Bolus Timing in Relation to Meal: BG below target High GI: 0-15 minutes prior Moderate GI: 5-10 minutes after Low GI, Prolonged or Large Meal: 20-30 minutes after *Table 8-1. Protein Content of Protein-Rich Foods Protein Source: sirloin steak Serving Size: 4 oz Protein Content (grams): 34 g protein Protein Source:chicken breast Serving Size: 3 oz Protein Content (grams): 26 g protein Protein Source:cooked ground turkey Serving Size: 3 oz Protein Content (grams): 22 g protein Protein Source:cooked ground beef Serving Size: 3 oz Protein Content (grams): 22 g protein Protein Source:tuna (drained) Serving Size: 3 oz Protein Content (grams): 22 g protein Protein Source:salmon Serving Size: 3 oz Protein Content (grams): 19 g protein Protein Source:cottage cheese Serving Size: 4 oz Protein Content (grams): 14 g protein Protein Source: tofu Serving Size: 3 oz Protein Content (grams): 13 g protein Protein Source:skim or 1% milk Serving Size: 8 oz Protein Content (grams): 9 g protein Protein Source: lima / kidney beans Serving Size: half cup Protein Content (grams): 7 g protein Protein Source:cheese Serving Size: 1 oz Protein Content (grams): 7 g protein Protein Source: 1 whole egg Serving Size: large Protein Content (grams): 6 g protein Protein Source:low fat yogurt Serving Size: 4 oz Protein Content (grams): 5 g protein Protein Source:Greek yogurt Serving Size: 8 oz Protein Content (grams): 20 g protein Protein Source:nut butter Serving Size: 2 Tbsp Protein Content (grams): 8 g protein *Table 8-2. Carbs to Maintain Blood Sugar During Typical Cardiovascular Exercise Carbohydrate Needed (grams) per Sixty Minutes of Physical Activity Low Intensity 50 lbs (23 kg): 5-8 g 100 lbs (45 kg): 10-16 g 150 lbs (68 kg): 15-25 g 200 lbs (91 kg): 20-32 g 250 lbs (114kg): 25-40 g 300 lbs. (135 kg): 30-48 g Moderate Intensity 50 lbs (23 kg): 10-13 g 100 lbs (45 kg): 20-26 g 150 lbs (68 kg): 30-39 g 200 lbs (91 kg): 40-52 g 250 lbs (114kg): 50-65 g 300 lbs. (135 kg): 60-78 g High Intensity: 50 lbs (23 kg): 15-18 g 100 lbs (45 kg): 30-36 g 150 lbs (68 kg): 45-55 g 200 lbs (91 kg): 60-72 g 250 lbs (114kg): 75-90 g 300 lbs. (135 kg): 90-118 g *Table 9-1 Weight in lbs (kg): <60 (<28) Amount Each Gram of Carb Should Raise Your BG in mg/dl (mmol/l): 6-10 (0.33-0.55) Weight in lbs (kg): 60-100 (29-47) Amount Each Gram of Carb Should Raise Your BG in mg/dl (mmol/l): 5 (0.28) Weight in lbs (kg): 101-160 (48-76) Amount Each Gram of Carb Should Raise Your BG in mg/dl (mmol/l): 4 (0.22) Weight in lbs (kg): 161-220 (77-105) Amount Each Gram of Carb Should Raise Your BG in mg/dl (mmol/l): 3 (0.17) Weight in lbs (kg): <220 (<105) Amount Each Gram of Carb Should Raise Your BG in mg/dl (mmol/l): 2 (0.11) *Table 9-2. Proper Treatment for Low Blood Sugar (Based on Body Weight and Blood Sugar Level), with a Target BG of 120 (6.7) Blood Sugar mg/dl (mmol/l) Weight : <60 lbs (<28 kg) 80s (4.4–5): 4 g 70s (3.9–4.3): 5 g 60s (3.3–3.8): 7 g 50s (2.8–3.2): 8 g 40s (2.2–2.7): 10 g <40 (<2.2): 12 g Blood Sugar mg/dl (mmol/l) Weight : 60-100 (28-47) 80s (4.4–5): 7 g 70s (3.9–4.3): 9 g 60s (3.3–3.8): 11 g 50s (2.8–3.2): 13 g 40s (2.2–2.7): 15 g <40 (<2.2): 17 g Blood Sugar mg/dl (mmol/l) Weight : 101-160 (48-76) 80s (4.4–5): 9 g 70s (3.9–4.3): 11 g 60s (3.3–3.8): 14 g 50s (2.8–3.2): 16 g 40s (2.2–2.7): 19 g <40 (<2.2): 21 g Blood Sugar mg/dl (mmol/l) Weight : 161-220 (77-105) 80s (4.4–5): 12 g 70s (3.9–4.3): 15 g 60s (3.3–3.8): 18 g 50s (2.8–3.2): 22 g 40s (2.2–2.7): 25 g <40 (<2.2): 28 g Blood Sugar mg/dl (mmol/l) Weight : >220 (>105) 80s (4.4–5): 18 g 70s (3.9–4.3): 22 g 60s (3.3–3.8): 28 g 50s (2.8–3.2): 32 g 40s (2.2–2.7): 38 g <40 (<2.2): 42 g *Table 9-3. Summary of After-Meal Blood Sugar Targets Group/Age: Adults taking mealtime insulin Postmeal Goal: <180 mg/dl (10 mmol/l) Group/Age: Adolescents with type 1 Postmeal Goal: <200 mg/dl (11 mmol/l) Group/Age: School-age children with type 1 Postmeal Goal: <225 mg/dl (12.5 mmol/l) Group/Age: Preschoolers and toddlers with type 1 Postmeal Goal: <250 mg/dl (14 mmol/l) Group/Age: During pregnancy Postmeal Goal: <140 mg/dl (8 mmol/l) Group/Age: Type 2s taking basal insulin only Postmeal Goal: <160 mg/dl (9 mmol/l) *Table 9-4. Examples of Ways to Substitute Low-GI for High-GI Foods Meal: Breakfast High-GI Choices: • typical cereal High-GI Choices: • bagel High-GI Choices: • toast High-GI Choices: • waffles High-GI Choices: • pancakes High-GI Choices: • corn muffins High-GI Choices: • juice High-GI Choices: • breakfast bars Lower-GI Choices: • high-fiber cereal Lower-GI Choices: • oatmeal Low

Part 40

er-GI Choices: • yogurt Lower-GI Choices: • whole fruit Lower-GI Choices: • milk Lower-GI Choices: • bran muffin Lower-GI Choices: • full-fat granola Lower-GI Choices: • nuts Meal: Lunch High-GI Choices: • sandwiches on white bread High-GI Choices: • or rolls High-GI Choices: • French fries High-GI Choices: • tortillas High-GI Choices: • canned pasta High-GI Choices: • most microwave meals Lower-GI Choices: • chili Lower-GI Choices: • rye, pumpernickel, or sourdough bread Lower-GI Choices: • corn Lower-GI Choices: • carrots Lower-GI Choices: • salad vegetables Meal: Dinner High-GI Choices: • rice High-GI Choices: • couscous High-GI Choices: • rolls High-GI Choices: • white potato High-GI Choices: • canned vegetables Lower-GI Choices: • sweet potato Lower-GI Choices: • pasta Lower-GI Choices: • beans Lower-GI Choices: • peas or lentils Lower-GI Choices: • fresh steamed vegetables Meal: Snacks High-GI Choices: • pretzels High-GI Choices: • chips High-GI Choices: • crackers High-GI Choices: • cake High-GI Choices: • cookies Lower-GI Choices: • popcorn Lower-GI Choices: • fruit Lower-GI Choices: • chocolate Lower-GI Choices: • ice cream Lower-GI Choices: • nuts * Manufacturer Ascensia Ascensia Labstyle Innovations Roche Ascensia Ascensia Ascensia Abbott Roche Roche Livongo Health Abbott AgaMatrix AgaMatrix Abbott Roche Arkray Lifescan Arkray Roche Acon Labs AgaMatrix Arkray Nova Biomedical AgaMatrix Lifescan Lifescan Bayer/Ascensia Alternate Site (Arm) Checking Abbott Roche Roche AgaMatrix Talking Meters Omnis Health Prodigy Diabetes Care Diabetic Supply of Suncoast Meter Brand(s) Contour Next Link* Contour Next* Dario* Accu-Chek Mobile** Contour Next One* Contour Next EZ* Freestyle Lite* Accu-Chek Guide* Accu-Chek Nano* Livongo* Freestyle Freedom Lite* Wavesense Presto, Target Up & Up, Kroger Basic, CVS Basic* iBG Star* Freestyle Insulinx* Accu-Chek Compact Plus* Reli-On Prime* One Touch Verio, Verio Flex* Reli-On Micro* Accu-Chek Aviva Plus* Accu-Chek Connect* Accu-Chek Expert * On Call Express* BG Star** Reli-On Confirm* Nova Max, NovaMax Plus, Nova Max Link* Wavesense Jazz, GoodSense Premium, Kroger Premium, Target Premium** One Touch Verio Pro** One Touch Ultra, One Touch Ultra Mini* Contour** Freestyle Lite* Accu-Chek Guide* Accu-Chek Aviva Plus* iBG Star* Embrace* Prodigy AutoCode* Advocate Redi-Code BG <75 mg/dl (4.2 mmol/l) How Often Within 15 mg/dl of Lab Value? 100% 100% 100% 98% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 93% 100% 100% n/a 100% 100% 100% 100% 100% n/a How Often Within 10 mg/dl of Lab Value? 100% 99% 100% 98% 94% 100% 100% 100% 100% 100% 100% 100% 96% 100% 92% 100% n/a 90% 100% 100% 100% 93% 67% 75% 75% 63% 85% 84% n/a 100% 83% 100% 89% 85% n/a How Often Within 5 mg/dl of Lab Value? 100% 95% 81% 75% 82% 100% 86% 73% 67% 90% 67% 67% 64% 65% 85% 84% n/a 51% 100% 85% 73% 83% 33% 11% 39% 20% 49% 61% n/a 70% 50% 57% 68% 48% n/a BG 75 mg/dl (4.2 mmol/l) How Often Within 20% of Lab Value? 100% 100% 99% 100% 100% 99% 100% 99% 100% 100% 100% 100% 100% 100% 98% 100% 99% 100% 100% 99% 100% 99% 100% 98% 99% 98% 96% 96% 95% 99% 99% 96% 100% 99% n/a How Often Within 15% of Lab Value? 99% 99% 99% 100% 100% 98% 99% 99% 99% 100% 99% 99% 97% 99% 98% 97% 96% 98% 98% 98% 99% 96% 97% 95% 94% 90% 88% 88% 91% 95% 91% 86% 99% 96% n/a How Often Within 10% of Lab Value? 99% 98% 97% 97% 96% 96% 96% 95% 95% 95% 94% 94% 93% 92% 90% 90% 90% 89% 88% 88% 88% 87% 86% 79% 78% 70% 68% 63% 79% 79% 70% 69% 90% 74% n/a How Often Within 5% of Lab Value? 80% 75% 86% 67% 81% 78% 77% 68% 58% 70% 73% 68% 57% 68% 54% 57% 57% 62% 53% 58% 54% 62% 56% 44% 45% 38% 38% 31% 51% 44% 43% 42% 56% 40% n/a * If Rising Very Fast <3 <0.17 MM: Dex: LIB: n/a EVER: n/a Add This .25 u .30 u .40 u .40 u .45 u .50 u .55 u .60 u .65 u .70 u .75 u .85 u .95 u 1.00 u 1.10 u 1.15 u 1.25 u 1.35 u 1.50 u 1.65 u 1.85 u 2.15 u 2.50 u 3.00 u 3.40 u 3.75 u 4.15 u 4.70 u 5.00 u 5.35 u 5.75 u 6.25 u 6.80 u 7.50 u 8.35 u 9.40 u 10.70 u 12.50 u 15.00 u If Rising Fast 2-3 0.11-0.17 MM: Dex: LIB: EVER: Add This .15 u .20 u .25 u .30 u .30 u .30 u .35 u .40 u .40 u .55 u .50 u .55 u .65 u .70 u .70 u .75 u .85 u .90 u 1.00 u 1.10 u 1.25 u 1.45 u 1.65 u 2.00 u 2.25 u 2.50 u 2.80 u 3.15 u 3.35 u 3.55 u 3.85 u 4.15 u 4.55 u 5.00 u 5.55 u 6.25 u 7.15 u 8.35 u 10.00 u If Rising Moderately 1-2 0.06-0.11 MM: Dex: LIB: EVER: Add This .10 u .10 u .15 u .15 u .15 u .15 u .20 u .20 u .20 u .25 u .25 u .30 u .30 u .35 u .35 u .40 u .40 u .45 u .50 u .55 u .60 u .70 u .85 u 1.00 u 1.15 u 1.25 u 1.40 u 1.55 u 1.65 u 1.80 u 1.90 u 2.10 u 2.25 u 2.50 u 2.80 u 3.10 u 3.60 u 4.15 u 5.00 u If Stable < 1 <0.06 MM: Dex: LIB: EVER: No Adjustment

If Falling Moderately 1-2 0.06-0.11 MM: Dex: LIB: EVER: Subtract This .10 u .10 u .15 u .15 u .15 u .15 u .20 u .20 u .20 u .25 u .25 u .30 u .30 u .35 u .35 u .40 u .40 u .45 u .50 u .55 u .60 u .70 u .85 u 1.00 u 1.15 u 1.25 u 1.40 u 1.55 u 1.65 u 1.80 u 1.90 u 2.10 u 2.25 u 2.50 u 2.80 u 3.10 u 3.60 u 4.15 u 5.00 u If Falling Fast 2-3 0.11-0.17 MM: Dex: LIB: EVER: Subtract This .15 u .20 u .25 u .30 u .30 u .30 u .35 u .40 u .40 u .55 u .50 u .55 u .65 u .70 u .70 u .75 u .85 u .90 u 1.00 u 1.10 u 1.25 u 1.45 u 1.65 u 2.00 u 2.25 u 2.50 u 2.80 u 3.15 u 3.35 u 3.55 u 3.85 u 4.15 u 4.55 u 5.00 u 5.55 u 6.25 u 7.15 u 8.35 u 10.00 u If Falling Very Fast <3 <0.17 MM: Dex: LIB: n/a EVER: n/a Add This .25 u .30 u .40 u .40 u .45 u .50 u .55 u .60 u .65 u .70 u .75 u .85 u .95 u 1.00 u 1.10 u 1.15 u 1.25 u 1.35 u 1.50 u 1.65 u 1.85 u 2.15 u 2.50 u 3.00 u 3.40 u 3.75 u 4.15 u 4.70 u 5.00 u 5.35 u 5.75 u 6.25 u 6.80 u 7.50 u 8.35 u 9.40 u 10.70 u 12.50 u 15.00 u * Football Gardening Golf Grocery Shopping Gymnastics Handball Hiking (with Pack) Horse Riding (Gallop) Horse Riding (Trot) Horse Riding (Walk) Housework Jogging (3–5 Miles per Hour) Judo/Karate Machine-Tooling Mowing (Push Mower) Painting (Walls) Racquetball Raking Rowing Running (12-Minute Miles) Running (10-Minute Miles) Running (8-Minute Miles) Running (6-Minute Miles) Skating (Intense) Skating (Leisurely) Skiing (Cross-Country) Skiing (Downhill) Soccer Squash Swimming (Fast) Swimming (Slow) Tennis (Doubles) Tennis (Singles) Volleyball Walking (20-Minute Miles) Walking (14-Minute Miles) Weeding Weight Training (Circuit) Carbohydrate Replacement (grams) Per 60 Minutes of Physical Activity 50 lbs (23 kg) 7-10 12-15 7-10 18-22 5-8 7-10 12-15 25-28 5-8 8-12 15-18 2-5 17-20 17-20 7-10 7-10 5-8 8-12 15-18 10-13 2-5 3-7 12-15 23-27 5-8 13-17 7-10 15-18 5-8 13-17 20-23 28-32 38-42 18-22 7-10 18-22 8-12 13-17 18-22 22-25 12-15 8-12 18-22 8-12 3-7 8-12 5-8 10-13 100 lbs (45 kg) 14-20 24-30 14-20 37-43 10-16 14-20 24-30 50-56 10-16 17-23 30-36 4-10 34-40 34-40 14-20 14-20 10-16 17-23 30-36 20-26 27-33 20-26 4-10 7-13 24-30 47-53 10-16 27-33 14-20 30-36 10-16 27-33 40-46 57-63 77-83 37-43 14-20 37-43 17-23 27-33 37-43 44-50 24-30 17-23 37-43 17-23 7-13 17-23 10-16 20-26 150 lbs (68 kg) 20-30 35-45 20-30 55-65 15-25 20-30 35-45 75-85 15-25 25-35 45-55 5-15 50-60 50-60 20-30 20-30 15-25 25-35 45-55 30-40 40-50 30-40 5-15 10-20 35-45 70-80 15-25 40-50 20-30 45-55 15-25 40-50 40-50 60-70 85-95 115-125 55-65 20-30 55-65 25-35 10-20 25-35 15-25 30-40 200 lbs (kg) 28-40 48-60 28-40 74-86 20-32 28-40 48-60 100-112 20-32 34-46 60-72 8-20 68-80 68-80 28-40 28-40 20-32 34-46 60-72 40-52 54-66 40-52 8-20 14-26 48-60 94-106 20-32 54-66 28-40 60-72 20-32 54-66 54-66 80-92 104-116 154-166 74-86 28-40 74-86 34-46 54-66 74-86 88-100 48-60 34-46 74-86 34-46 14-26 34-46 20-32 40-52 250 lbs (114 kg) 35-50 60-75 35-50 92-107 25-40 35-50 60-75 125-140 25-40 42-57 75-90 10-25 85-100 85-100 35-50 35-50 25-40 42-57 75-90 50-65 67-82 50-65 10-25 17-32 60-75 117-132 25-40 67-82 100-115 125-140 192-207 92-107 35-50 92-107 42-57 67-82 92-107 110-125 60-75 42-57 92-107 42-57 17-32 42-57 25-40 50-65

About This Text: This is a historic medical text available on Archive.org . It provides important historical perspective on how medical understanding has evolved over centuries. The medical theories presented reflect knowledge available at the time of publication and may contain outdated or incorrect information by modern standards.

Modern Disclaimer: This historic text is presented for educational and historical purposes. Modern diabetes treatment relies on insulin therapy and other evidence-based medications. If you have diabetes, please consult with a qualified healthcare provider for current, evidence-based treatment recommendations.