Thursday, September 29, 2016

Life Before Bolus Wizard

It's hard to imagine life before bolus wizard, isn't it?  Before bolus wizards, before insulin pumps, before Lanuts and Trujeo, and Apidra there was NPH, Regular, Ultra Lente.  Diabetes management consisted of an exchange diet and a sliding scale for insulin.  The exchange diet was basically an allotment from the food pyramid per meal:  for breakfast you might get 1 milk, 2 starch, 1 fat, and 1 fruit.  The sliding scale for insulin delivery consisted of something along the lines of: if your blood sugar was between 80-120 you'd take 4 units of short acting insulin and 10 units of long acting.  And that in a nutshell was diabetes management in the 1980s. (and way before that was urine testing and a shot of mixed beef/pork insulin).

Fast forward a bit to 2000 when I decided to pursue insulin pump therapy, for more flexibility with managing my disease.  In 2000 there were two companies in this space. Medtronic Diabetes, and Disetronic Medical Systems.   I chose Medtronic Diabetes because I was aware of the company, and their history, and felt it was the right option for me.  Before starting on the pump, as a patient at the Joslin Diabetes Center in Boston I had to meet with a social worker and diabetes educator to ensure I was going on a pump for the right reason.  To them "I want to go on a pump so I can eat donuts all day" wasn't a good reason, but wanting more flexibility in my life was.

Between 2000 and today I have used several  MiniMed pumps.  Each new pump included the addition of more innovate technology than the previous:

  • 2000:  MiniMed 508 This pump came out in 1999 and I started on it in the spring of 2000.   It featured bolus and basal, and a temporary basal option, and came with a remote control to deliver a bolus! 
    • This pump operated on 3 watch size batteries, which made me a frequent customer at Radio Shack.

  • 2004: Paradigm 512:  This pump came to market in 2003, and  my best guess is I started on it sometime in 2004.  This pump introduced us to bolus wizard, and the blood glucose meter transmitting readings directly to the pump.  
    • Bolus wizard calculates the amount of insulin a person should take based on input from the insulin pump user including active insulin, blood glucose level, and number of carbohydrates in a given meal.
      • I use this feature daily - to determine if a correction is needed for high blood sugar, and to help figure out insulin dosing for food.  
  • 2011: Revel: This pump came to market around 2010/2011, and I most likely started using it around that same time. The Revel introduced us to the continuous glucose monitor (CGM), and SofSensor. 
    • I was an early adopter of this pump due to the continuous glucose monitor.  
    • The SofSensor worked well for me, but I was a chicken when it came to the insertion process and insurance didn't cover CGM back then so I didn't use it frequently.

  • 2014: 530G with Enlite  This system was approved by the FDA in 2013 and I started on it in 2014.  This system introduced the Enlite sensor and threshold suspend, and an easier  CGM sensor insertion process.
    • Threshold suspend (also known as Smart Guard) was a turning point for me with my diabetes management.
      • As a person with a history of overnight low blood sugar, the idea of the pump stopping delivering insulin once the cgm readings  reached a set low number (that I worked on with my doctor), was a game changer.
      • The Enlite sensor/cgm system has worked great for me.  My cgm readings and blood glucose readings are often within a few points from each other. 
  • 2016: 630G system with smart guard technology:  This pump came to market in August 2016 and I have been using it since October.  This system introduced us to a new platform, a vertical pump layout, waterproofing, and large color screen.
    • I wasn't initially sure about this one.  On paper it seemed like a shinier version of my beloved 530G.  But, I'm glad I made the switch. 
    • Some of my favorite features:
      • The screen which shows everything I need to know about my diabetes management at a glance.  
      • The Guardian transmitter: this transmitter has a stronger signal, and as such I haven't had any connection issues since starting the pump.  With the 530G I received weak signal errors on a weekly basis. 
      • Alarms:  The alarm chimes have changed, and there are more volume options which have been great.
We've come a long way in 16 years.  From a basic insulin pump, to an insulin pump that can stop insulin delivery based on a low blood sugar reading from a continuous glucose monitor, and for that I am grateful.  And this is only the beginning.  I look forward to seeing and hopefully being able to use the hybrid closed loop system, which eventually become (I hope) a fully closed loop system where the pump does most of the work.  I look forward to one day having less decisions to make about my diabetes management.

Tuesday, September 6, 2016

You Can't Eat That...or can you?

What really gets my goat is when people say “You shouldn’t eat that.” (because you have diabetes)

In my opinion, and that of my health care team, unless the food contains poison I can eat *almost anything, with some exceptions:
  • *Celiac Disease:  being gluten free  places s a lot of restrictions on what I can eat and where I can eat.
  • Type 1 Diabetes:  places restrictions on when I can eat, depending on my blood sugar and insulin dosing.
    • high blood sugar usually isn’t the best time to eat a donut, or sometimes anything at all depending on how high it is.  
    • low blood sugar mandates I eat something as soon as possible to bring blood glucose levels back in range.
Several years ago after a spout of diabetes burnout, I was at a diabetes clinical appointment and the diabetes educator suggested, after a chat about snacks, that I shouldn’t eat popcorn since it can spike blood sugar.  Popcorn has always been a staple in my snacking arsenal and I wasn't going to give it up. Not without a fight. Instead I told her point blank that I was not going to give it up and instead asked her to help me come up with a plan to avoid  possible post-snack-spikes. And she did

Carbs are not my enemy.  Food is not my enemy.  Diabetes is my enemy. My personality has always been that if I really want something, I will figure out how to do it.  My relationship with food is the same way.

I eat cereal. I eat Chinese food, and pizza, and donuts, and Tater Tots, and grapes, and so on.  The only things I don’t eat are foods containing gluten, bananas, and peppers.
How do I do it? I’d like to say the answer is simple, but it really isn’t.   I watch, observe, and learn. I watch and observe how my body reacts to different foods, by testing my blood sugar frequently and with the use of continuous glucose monitoring (CGM) technology.

What I've learned:
  • I've learned with the help of my MiniMed530G with Enlite (insulin pump and continuous glucose monitor) that bolusing at least 20 minutes before a meal with carbs helps. A lot. 
  • I've learned that when my blood sugar is over 160, it often takes a bit more time for my insulin to start working.  
  • I’ve learned how helpful the dual wave bolus feature on my insulin pump can be:
    • The dual wave bolus allows you to split the total amount of insulin delivering some as soon as you start it, and the rest at a time frame you've set. How much you do, and how long you set the dual wave basal is trial and error. I started with 50% up front, then 50% an hour later then tweaked it from there.  
  • I've learned to pay attention to portion size also plays into this, as well as reading labels.  I've learned that by paying attention to these portion size (and ingredients) when at home in a controlled setting it's a good starting point when I'm out.
It takes time and practice and isn’t an exact science but it is possible.
  • If you don’t have a CGM, it might mean more finger sticks than without CGM but it is possible.
  • If you aren't on an insulin pump, or your's doesn't have a dual wave bolus option you can still do this manually - perhaps with the help of a timer so you don't forget to do the second bolus.
As always, before starting anything new you may want to check in with your health care team to determine what is the best approach for you.

Bon appetite!

This picture is my blood sugar reading 2 hours after Chinese food for dinner.