While we wait for the functional cure we have management with injected insulin. I have been managing my own type 1 diabetes for over thirty years through many changes in the tools available. I have developed a few rules. So here, especially for my T1D readers, are tips on the things that get me through.
A Low is Followed by a High
A serious low is treated with oral glucose. To be safe often I end up taking more sugar than strictly needed, and I go high. Even when I get the oral glucose just right, at the next meal the regular dose won’t be enough and I’ll go high. You might think that, after a low, one should take extra insulin with the next meal. The lesson I have learned is don’t fight the high; let it happen, then use the next 2-3 meals to bring it down with reduced calories. A high dose of insulin after a low glucose just delays the high glucose which will pop up anyway.
Test When Suspicious…or When You are Told to
If any part of your mind feels something is wrong, test right away; don’t wait for the next convenient opportunity. You can’t afford not to.
If you work with, live with or sleep with some one, always check your sugar when they tell you to.
I have heard that you should even listen to your dog’s advice. Too bad I have a cat.
When Sick Raise Your Long-acting Insulin As Well As Your Short-acting Insulin
Illness makes the body insensitive to insulin. When you’re sick, and you check your blood sugar, it will be too high. So you take more insulin for the next meal. But your basal insulin need goes up too. Raise both! Your glucose will be easier to control.
If You Want to Lose Weight Cut Your Insulin
…and control your sugars with diet. I cut insulin by 5% and reduce bread, potatoes, rice and pasta to get on track to lose weight in a week.
Never Leave Your Meter and Sugar Behind
Any venture into the unknown that takes you more than five minutes from your supplies is dangerous. Only do it if you are personally aware of the whole situation. If someone tells you, “It’s a short, easy walk,” and it turns out it is 5 miles and a 500 foot climb (which actually happened to me), you might die (and I nearly did). Don’t take the risk.
Always forgive yourself
A bad blood sugar, especially one you did not earn, is depressing, and you feel like chucking the whole thing. Forgive yourself, especially if you made a mistake. Look at the BG, think about how you got there, then plan your next step. Manage it.
I want you alive and healthy until the Islet Sheet is ready.
The foundational, and thus typically unstated, premise of all scientific inference is that the future will be like the past, and since this is seldom the case in diabetes management, blood sugar control is difficult or impossible. I find that if I eat the same meal each night, with each component carefully weighed, and take the same amount of insulin, then eight hours later when I wake up the glucose level will vary according to the theory of errors, being 120 mg/% +/- 60 for 80% of the time. 10% of the time I will wake up about three hours after eating with a catastrophically low blood sugar of 30, and 10% of the time I will wake about eight hours after eating with a catastrophically high blood sugar of 360. I can reliably take no measures the following night to correct for the morning 360 level, since for all I know, the next night will be one of those when the blood sugar mysteriously falls to 30 three hours postprandially, nor can I correct for the extreme lows, since the following day may well prove to be a 360 rather than a 30 day. In fact, normal spontaneous blood sugar variation in type 1 diabetics is so extreme that some researchers are now modelling it by resort to chaos theory. (M. Kroll, “Biological Variation of Glucose and Insulin Includes a Deterministic Chaotic Component,” Biosystems, vol. 50, no. 3, p. 189 (1999))
The standard rule presented to patients used to be, ‘Achieve excellent blood sugar control while avoiding hypoglycemic episodes,’ but recently it has been demonstrated that occurrences of the most severe form of hypoglycemia, requiring the intervention of others to bring the patient out of it, are tripled by strict control, so there is in principle no way to approach normalization of blood sugar while avoiding hypoglycemia. (L. Perlmutter, et al, “Glycemic Control and Hypoglycemia,” Diabetes Care, vol. 31, p. 2072 (2008)) What makes matters worse is that the majority of diabetics cannot accurately estimate their blood glucose levels, and the better the blood sugar control, the greater the risk of hypoglycemia unawareness. (S. Frankum and J. Ogden, “Estimation of Blood Glucose Levels by People with Diabetes,” British Medical Journal of General Practice, vol. 55, no. 521, p. 944 (2005))
With respect to hypoglycemia, diabetics suffer from two diseases: not just a metabolic abnormality requiring a highly approximate control of blood sugar by insulin injections, but also a delayed mobilization of glycogen to release hepatic stores of glucose in response to hypoglycemic crises. Instead of the body providing glucose as quickly as it is required by hypoglycemia, the diabetic body is maddenly slow in responding, and typically releases massive amounts to correct hypoglycemia six or seven hours late. This creates an interesting paradox that the effort to achieve improved glucose control increases the number and severity of hypoglycemic episodes, which then in turn elevate blood sugar later at an unpredictable time and in an unpredictable amount, thus worsening blood sugar control.
Clinicians who are not themselves diabetics often blame their patients for overtreating hypoglycemic episodes, but since I have never found myself facing a team of worried paramedics at home or waking up in the hospital emergency ward without grasping some half-eaten candy in my hand, my motivation to restrict my treatment of hypoglycemia is limited. Since the patient cannot know exactly how low the blood sugar level is trending during a hypoglycemic attack, it is impossible in such an emergency to judge what constitutes overtreating the problem. Ironically, anyone who has ever suffered severe hypoglycemia in a hospital setting will know that the response of hospital staff to such an emergency is a massive overtreatment of the problem with enough glucose to raise the blood sugar above 400 for the rest of the day.
Although patients are taught the comforting oversimplification that their blood sugar levels are a function of external, easily measured and controlled factors, such as the food consumed, its glycemic index, the insulin injected, and the exercise performed, in fact there are numerous internal processes within the body which the patient can neither know nor measure which exert a profound influence on blood sugar variation. High activity of the renin-angiotensin system has been linked to severe hypoglycemia in type 1 diabetics. (P. Kristensen, et al, “Vascular Endothilial Growth Factor During Hypoglycemia,” Metabolism, vol. 58, no. 10, p. 1430 (2009)) The metabolism of subcutaneously injected insulin is so slow and unpredictable that there can be a daily variation in the quantity absorbed and processed amounting to 50%. (D. Warrell, et al, ‘Oxford Textbook of Medicine’ (Oxford: Oxford University Press, 2005), vol. 2, p. 332) Changing levels of thyroid hormone, adrenal output, growth hormone, and pituitary function all have a profound action on blood sugar levels and insulin requirements. (A. Dutour, et al, “Hormonal Response to Stress in Brittle Diabetes,” Psychoneurology, vol. 21, no. 6, p. 525 (1996); J. Unger, “A 62 Year Old Man with Brittle Type 1 Diabetes,” Clinical Diabetes, vol. 20, no. 1, p. 37 (2002); K. Naing, et al, “Recurrent Hypoglycemia in a Patient with Brittle Diabetes,” Practical Diabetes International, vol. 18, no. 1, p. 13 (2001)) I find in my own case that lecturing can increase my blood sugar by an amount varying from 10 to 180 points, depending on how stressful it turns out to be, but there can be nothing like ‘carb counting’ in anticipation of the highly variable effect of stressful situations. Taking insulin after the fact is useless for controlling the hyperglycemic effect of stress, given the extremely slow response of injected insulin to blood sugar.
In all of this, it is important not to lose sight of the ultimate goal of all medical treatment, which is to provide patients with a better net quality of life by any interventions undertaken. While many clinicians today focus exclusively on strict blood sugar control as identical to improved quality of life for the patient, in fact the very high cost of this regimen in relation to patient lifestyle has to be taken into account. If perfect glucose normalization is in principle impossible with presently available treatments, then the effort to achieve normalization can consume the patient’s entire life, thus utterly negating the quality of life which is what medicine exists to improve. Significantly, one study has determined that diabetics rate their loss of quality of life from intensive glucose management to be equivalent to their loss of quality of life from an intermediate level of diabetic complications. (E. Huang, et al, “Patient Perception of Quality of Life with Diabetes Related Complications and Treatments,” Diabetes Care, vol. 30, no. 10, p. 2478 (2007))
“I want you alive and healthy until the Islet Sheet is ready.”
Simple but very encouraging words and all the best in your endeavour. But please, do it fast, and safe!