, 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.
Think Like a Pancreas
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
S o 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-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