What’s Your Diabetes Gap?

I recently read an inspirational article about The Gap. The author says that everyone has gaps in their life, which he defines as “the difference between what you say you want in your life versus the results you’re actually producing.” And seriously, who can’t relate to that on some level (or many)?

What’s your diabetes gap? Does it have to do with food? Or exercise? Or daily management tasks? Or complaining? Overtreating lows? Fear? Or is your gap completely unrelated to diabetes?

Todd says that we tend to fill our gaps with blame, justification, rationalization, and excuses. Yikes! But he goes on to say that we can close the gap with four things: effort, courage, love and presence. Ok, maybe not easy, but doable, right?

I discussed many of my gaps in my book, and I am still working on some of them (and I’m sure there are new ones). One of the most important gaps I have pretty much closed in my diabetes life is giving myself a break when I don’t meet my goals or expectations in diabetes care. By doing that I am able to keep getting back up and starting again and being successful more of the time.

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Diabetes Innovation Opportunity

diabetesmineCheck this out! DiabetesMine is hosting their 2015 Patient Voices Contest. You could be the lucky winner of a scholarship to attend the Diabetes Innovations Summit at Stanford University in November.

What a fabulous opportunity – why not give it a try?

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Diabetes Alert Day

MF1639Today is Diabetes Alert Day. But any day is a good day to lower your risk for diabetes (if you don’t already have it) and to take good care of your diabetes (if you do have it).

The American Diabetes Association has lots of resources available for people at risk for and living with diabetes. And they’ve been around for 75 years!

My favorites include

Plus tons and tons of other resources for just about any diabetes-related topic you can think of. Check them out!

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High Fat Low Glucose

54f954bed9fda_-_shamrock-shake-mcdonalds-del-blogLately I’ve talked to and read about people who’ve eaten fast food and then experienced low blood glucose. This can be confusing and/or frustrating, but it actually makes sense.

Fat takes longer to break down in our bodies and doesn’t turn into glucose the same way carbohydrate does. Most items in a fast food restaurant are high in fat (burgers, fries, milkshakes, etc.). Even the foods that have a lot of carb still have a lot of fat, which slows down the effect of the carb on blood glucose.

So if we take our insulin for all the carb, but don’t take into consideration all the fat, we can end up low pretty soon after eating. The timing of the food and insulin hitting the blood stream doesn’t match up; the insulin hits at its usual time (Humalog, Novolog and Apidra start working in about 15 minutes and peak in about 90 minutes) but the food hits much later (while carbohyrate, on its own, starts working in about 20 minutes, the fat slows that way down and the timing will vary up to hours).

It takes practice and observation, but luckily there are ways to deal with this. Those of us who use injections (syringe & vial or insulin pens) can take a little bit of insulin up front and the rest after the meal. Or we can take all of it after the meal if we are low beforehand. Those of us who use insulin pumps can take advantage of the extended, square wave, or dual wave bolus (which delivers the meal bolus over time or some right away and the rest over time).

Next time you find yourself at a fast food place, a little extra planning could prevent an unwanted and unnecessary low blood glucose afterward.

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Low Blood Glucose

Question_mark_(black_on_white)Has this ever happened to you? You feel symptoms of a low blood glucose (hypoglycemia), you check, and it’s actually not low? This can happen if you are nervous/excited and are experiencing the affects of adrenaline, which can be the same as low symptoms. This can happen if your blood glucose is dropping quickly. Perhaps when you check it isn’t low yet, but will be shortly. It can also happen if your blood glucose has been running consistently high and now it is lower than it has been (even if it isn’t technically “low”).

I think of that last scenario as your body’s way of saying, “Hey, we were used to all that glucose and now there’s not as much – what’s going on??” And I talk to a lot of people who have experienced this.

Health care professionals usually define low blood glucose (BG) as any number below 70 mg/dL (3.9 mmol/L). That means we don’t usually worry about the dangers of low blood glucose until we reach 70 or below.

But if you feel low at a higher number, you’re not crazy. I read about a blogger who had this experience while in the endocrinologist’s office. This person felt low, checked their BG and found it was in the 170s. The endocrinologist proceeded to roll his/her eyes at the person who felt low but was not (according to the BG).

Dear health care professionals: if you didn’t learn this in school, please take note – NEVER roll your eyes at a patient!

Dear people with diabetes who feel low when the number says they aren’t: don’t worry about it. The way you feel is legit and it could be any number of things going on (see above).

I have found that I tend to feel low when my blood glucose is either rising or falling through the 180 mg/dL range. I honestly don’t know why that is, but my personal suspicion is that it has to do with the renal threshold. The renal threshold is when the blood glucose level surpasses 180 and the kidneys start spilling glucose into the urine. Maybe someone will study this one day (and maybe they already have) and I’ll get an answer, but in the meantime I try to check before treating when I feel low – just in case I’m in the 170s or 180s like the person I read about!

One other thing…if you are feeling symptoms of low blood glucose when your BG is not actually low, keep working on managing your diabetes and bringing your average down and eventually you will feel low when you are closer to or below 70.

 

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Needle Length for Insulin Injection

syringes 002Once upon a time we only had long insulin needles. Of course they weren’t called long; they were simply called needles. But over the past several years the needles for injecting insulin (by syringe or pen) have gotten shorter and finer.

I remember counseling patients who were bigger to use longer needles and patients who were smaller to use shorter ones (if they wanted to). Then one day I was at a conference exhibit and saw a demonstration on skin thickness, which basically showed that shorter needles work for anyone.

Now even I use “short” needles, but I admit I haven’t gone to the shortest ones yet. The options start with 12.7 mm and move down to 8 mm, then 6 mm, 5 mm, and now even 4 mm (in other countries there may be other options).

Back in the day we used to teach people to pinch up their skin (fatty tissue, we called it). It turns out this was necessary in order to avoid injecting into muscle, which can lead to unpredictable insulin action times (usually too fast). We even told people who were extremely thin to inject at a 45-degree angle.

But now we have short needles (and shorter ones), so we no longer need to pinch the skin. In fact, pinching the skin with super short needles could lead to injecting into the dermis (skin) and not the subcutaneous tissue (fat). That would also affect the ability of insulin to do its job properly.

Here are some other interesting tidbits about needle length: men probably would benefit from needle lengths shorter than 8 mm; there tends to be more bruising with longer needles; and studies have shown absolutely no difference in blood glucose levels between the various length needles.

So enjoy your short needles!

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Timing of Insulin

DSCN2322Back in the days of Regular insulin, taking injections at least 30 minutes before a meal was important because it took quite a while for the insulin start working. Nowadays most people use rapid-acting insulin (Humalog, Novolog, or Apidra), which we think of as starting to work in 10 to 15 minutes. But how many people actually take it 10 to 15 minutes before eating? When we first had rapid-acting insulin available one of its claims to fame was that it started working rapidly and we could take it right before the first bite of a meal, or even right after eating.

What we know now is that taking rapid-acting insulin 10 to 15 minutes prior to eating really can lower the A1C. Of course, that requires some planning and knowing how much we’re going to eat. It still makes sense to wait when someone who does not know what or how much they are going to eat, or when eating away from home. It’s always safer to know the food is ready and available before injecting rapid-acting insulin.

Some guidelines for when to take rapid-acting insulin are as follows: if the blood glucose is below 100 take insulin right before eating a meal, if the blood glucose level is in the 100s wait ten minutes, and if the blood glucose is in the 200s wait 20 minutes.

As far as long-acting insulin goes, Lantus can be given any time during the day/evening as long as it is consistent from day to day. For those who take Lantus or Levemir twice a day, taking it consistently about 12 hours apart is a good plan, although personally I take Lantus at 7 am and 10 pm and that works well for me. The point is to be consistent so your background insulin coverage is consistent. I once worked with a teen-ager who could only remember to take her Lantus if she took it at noon – and that’s fine!

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Write Down Your Insulin Pump Settings

Here’s an important tip for those who wear an insulin pump:

Write down your pump settings and put them in a safe place. Literally, write them on a piece of paper or an index card and put the paper/card somewhere you’ll remember (the safe, the “pump” file, the butter compartment, your jewelry box, your safe deposit box…you get the idea).

Feel free to also put your pump settings in your phone (in your “notes,” or whatever), but also write them on a piece of paper and here’s why: when your pump malfunctions (and there’s no guarantee that it will, but there’s also no guarantee that it won’t), your phone may not be available. You may have lost it, left it behind, upgraded to a new one, or your phone, too, could malfunction (timing is everything).

Just play it safe and keep an old-fashioned, hand-written copy of your pump settings around somewhere. Who knows, taking this extra precaution may protect you from ever needing it!

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The first question

While I mean in no way to diminish the seriousness of the problem of poverty, I saw – in this story – many parallels to how we work with people and kids who have diabetes. We diabetes professionals can start by using “compassion, not punishment” and asking simple questions such as “how are you?” and “what do you want to talk about today?” rather than imposing our own agenda. Even the general public can use these principles in how they think about and interact with those who live with diabetes. It is so important that we never assume we know what someone’s experience is. And even more important that we don’t judge based on our assumptions. All we have to do is ask.

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Protecting Ourselves from Sitting

When I first read this article I started getting pretty fired up. Actually, it was after I read the title of the article. Really? It doesn’t take a rocket scientist to figure out that sitting for long periods of time (aka “sedentary lifestyle”) would lead to things like diabetes. But then I read further and discovered that even those of us who exercise regularly and sit for long periods of time (work at a computer, anyone?) are at risk for negative health outcomes.

So I started thinking about how I can make my completely inactive (computer-based) job more active. Here’s what I came up with:

1) fidget

2) walk around whenever I’m on the phone

3) go for a walk after lunch

4) take stretch breaks

5) run/walk up and down the stairs several times a day

6) perform breathing exercises while working

Ok. That’s what popped into my head. Any other ideas?

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