Managing the BG Extremes PDF

7/16/2013
Managing the extremes in BG’s:
highs, lows and in-between
Opening thoughts
Stephen W. Ponder MD, FAAP, CDE
Type One Family Network
July 16, 2013
“Life is not a matter of holding good cards, but of playing a poor hand well.”
R.L. Stevenson (1850-1894)
Knowledge alone does not imply understanding
Diabetes care must be customized
Diabetes self care is more process than outcome
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Diabetes care is about choices
24 hour glucose plot – A1c 5.7%
No two days are the same…
8 versus 1440 “decision points”
Diabetes control exists largely in the moment
7:03
115
9:33
129 *
95
12:15
3:34
6:12
9:49
11:53
3:05
Forgotten diabetes tool #1: Timing is everything!
*
*
131 *
168 *
107 *
114 *
132 *
Forgotten diabetes tool #2: Consistency!
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“Chance favors the prepared mind” Louis Pasteur
Managing “d” well requires understanding…
A system with a set of defined rules
and principles
With changing or shifting
conditions
Requiring constant assessments
and adjustments
Driving a car
Flying an airplane
Stock investing
Walking a tightrope
7
6
The
What
“3 dimensions”
is the 4th dimension?
of insulin
5
4
peak
3
2
onset
1
Five things to remember about T1D
1.
Diabetes care isn’t a contest. It’s overrun with numbers. Don’t judge.
2.
Let any remaining guilt (if any) go! NO one is perfect.
3.
Diabetes care is not an action, it is a SKILL SET. It can be practiced and
improved upon.
4.
Control is the end result of your decisions and choices. This applies to
minute to minute control as well as long term control.
5.
NO health care provider manages anyone’s diabetes. They never can and
never will. It’s a self managed condition.
0
duration
Question
A) Any tips on how to keep my preteen’s blood sugars under control during hormonal
changes that are occurring?
B) Teen hormones & Type 1 :)
Now on to your submitted questions…
Answer
Medical: overnight hormone surges usually raise morning sugars. Work to “fix the
fasting first” through fine tuning the over night basal insulin delivery rate(s)(if a
pumper) or with long acting insulin dose (Lantus or Levemir) by injection
Nutritional: Appetite increases at puberty. Adjust meal plan and follow suit with
insulin changes as needed. Be aware of “surreptitious snacking”
Activity: Exercise might play a larger role now than before. Post-exercise
hypoglycemia might become a challenge
Behavioral: don’t back away too soon from sharing diabetes care duties. Stay engaged
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Question
Does the earlier you’re diagnosed affect long-term management?
Answer
Medical: Yes, you might have a longer partial remission phase aka “honeymoon” and
need less overall insulin for a longer period of time
Nutritional: Because you might make more insulin, your sugar levels may be easier to
control in the first couple of years
Activity: No changes
Behavioral: A long honeymoon can delay development of quality self care traits and
behaviors. Sets up problems later on as this phase starts to pass
You CAN influence how fast it goes away
Question
Nighttime nosebleeds...any extra concern??
Answer
Medical: Keep fingernails trimmed. All kids pick their noses, especially at night. Saline
nasal sprays are helpful in dry climates. Don’t use as an alternate site for BG checks.
Nutritional: “boogers” are low-carb, so no worries
Activity: Nosebleeds during exercise, or if recurrent should be brought to doc’s
attention
Behavioral: Ask them to use a tissue or pick nose in their room if they must.
Question
EXTREME FLUCTUATIONS - FROM 30S TO 400 + IN A FEW HOURS (OR VICE VERSA).
DAUGHTER IS 12 AND BEGINNING PUBERTY, Diagnosed JULY 2008
Answer
Medical: She is well out of the honeymoon phase at 5 years. Internal glucagon
response is lower now. Puberty hormones can be raise blood sugars and increase
appetite.
Nutritional: Appetite increases at puberty. Adjust meal plan and follow suit with
insulin changes as needed. Be aware of “surreptitious snacking” (boys) or omitted
food or insulin (girls)
Activity: Exercise might play a larger role now than before. Post-exercise
hypoglycemia might become a challenge
Behavioral: May be active with peer group behaviors. Less attentive to self care.
Wants to just be like everyone else. Parent should stay engaged
Question
How to control breakfast spikes without crashing hours later?
Answer
Medical: “Fix the fasting first”. Take insulin before eating, based on 30 minute prebreakfast BG level; or glycemic real time “trend” (if using CGM). Consider applying a
“superbolus” if a pumper.
Nutritional: Know the breakfast foods most commonly eaten. Study their glucose
raising effect (with frequent BG checks or CGM) and work to preempt them. Use
measuring cups at first so you can be consistent from day to day.
Activity: Exercise AFTER a meal can blunt the rise in sugar levels. It might require
some balancing (reducing) of the insulin dose.
Behavioral: Breakfast is an important meal. Don’t skip it
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Reactive vs. Proactive
Question
How to effectively manage pre meal bolus for toddlers
Answer
Medical: Toddlers are well known to be exquisitely insulin-sensitive. If using shots,
measure food eaten and inject after eating. If high before the meal, apply a correction
only, then a meal dose afterwards (requires second shot; easier with a pump)
Nutritional: Toddlers are picky eaters and most importantly: INCONSISTENT. Unless
you have a high level of confidence that he/she will eat the meal, wait.
Activity: Toddlers are go, go, go or napping and playing with toys. Like with food, hard
to predict. You can try to let them “run down” a high so long as you check them often
Behavioral: Toddler management should not be carried on into later childhood (esp
after meal insulin dosing). It’s a set up for after meal spikes.
Includes consistency as a factor
Includes consistency as a factor
Looks at where you’ve been
Looks at where you are going
Ignores time as a factor
Includes time as a factor
Is the result of prior actions or
omissions
Actions are based on an
understanding of where you’ve
been and where you are going
Involves (re-)acting without
thinking
Requires thinking before acting
Question
Managing type 1 diabetes and Hashimoto’s disease?
Answer
Medical: Thyroid problems are relatively common in persons with type 1 diabetes,
but also in the general population. Hypothyroidism is fairly straightforward to
manage.
Nutritional: Excessive replacement dose of thyroid could increase food intake. Too
little might cause a minor weight gain/swelling.
Activity: If low (hypothyroid) and not treated, exercise tolerance might be lower. If
too high (hyperthyroid) and not treated, excess activity might happen.
Behavioral: If hypothyroid, not much difference. If hyperthyroid, many behavioral
changes, including poor attention span and irritability.
Question
My son is 13 and doesn't like for us to ask him anything about his diabetes in public
settings. Is this typical at his age?
Answer
Medical: Hormones are kicking in and he may want to be one of the guys and not
viewed as “weak”. He might try to prove this to himself or others through risk-taking
Nutritional: He might want to eat the same things as everyone else. This can be done
with some planning and compromise. Try to discuss in advance and in the privacy of
the home.
Activity: As with food, develop an action plan that he can live with. There are some
hard-line responsibilities he must follow. Be flexible!
Behavioral: Absolutely! Respect his privacy and don’t “out” him in public. But
continue to share duties with him even if quietly.
Concrete thinkers* can’t…
1. Consider a hypothesis
2. Consider multiple possibilities in a
scenario
3. Systematically solve a problem
4. Use combinatorial logic
*Lasts until 15-17 years of age
*25% of adults are concrete thinkers.
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Question
Question
Keeping BG in the "non-D healthy person" range for a 3 year old?
I follow your FB posts, are the results you achieve attainable, or desirable, in a young
child?
Answer
Medical: Due to the need for patient involvement in self care, 3 year olds are limited
and should be given a wide berth in regards to glycemic control. It’s important to
prevent repeated severe lows and DKA. Targets BG’s aim for between 100-200 mg/dl.
Nutritional: As said previously, this age group is inconsistent. Most care must be
reactive in nature (as opposed to proactive).
Activity: Erratic and unpredictable: normal for the age.
Behavioral: Approach diabetes in a matter of fact way, avoid use of judgmental terms
like “good” or “bad” with BG data. This is not a curse and there is no room for guilt
with any family member.
Answer
Medical: No, but the principles ARE helpful. I just take it to an extreme to make a
point.
Nutritional: Learn your child’s “top 10” foods and how they impact his/her BG levels.
You don’t have to master the entire grocery store. Practice, practice, practice.
Activity: You might be able from time to time to use activity to lower a higher range
BG (make sure no ketones are present though)
Behavioral: I practice a non-judgmental can-do approach to diabetes. I use a CGM as
part of my armamentarium, but I also use my wits and my experience. Develop yours!
Question
lies inand
the person,
not the tools
Tiger Woods, InsulinSuccess
Pumps,
Common
sense
A) We have trouble with high sugars all the time. My son is active and his sugar rises with adrenaline,
then crashes hours later, sometimes up to 8-10hrs later.
B) Sports and dealing with lows during workout and night time.
+
+
C) Puberty.... Long hours of exercise in a 14 year old and avoiding lows! Son joining marching band and
plays tuba!
=
=
Answer
x
Question
Is apple juice appropriate for lows below 55 mg/dl; it's glycemic index is approx. 44?
Answer
Medical: Glucose tabs or Quick sticks are faster. But juices still work. It’s all about the
time to ingest it, absorb it, convert it and sense it. That can take 15-20 minutes
Nutritional: Make your house/car/purse/pockets/work space “d-friendly” with stable
sources of rapid acting carbs within easy reach. Keep glucagon emergency kit in all
homes.
Activity: When treating a low BG…stop what you are doing and give it time to work!
Behavioral: How fast a carb you need depends on how fast you are falling and how
long you want the BG rise to last. Know your favorite BG raising carbs well.
Medical: Glucagon and adrenaline are involved with exercise induced changes to
sugar. Some kids are more adrenaline driven it seems. Stress hormones like cortisol
and even growth hormone cause later sugar rises. Post-exercise hypoglycemia can
also be present.
Nutritional: Discuss preemptive complex carb snacks at the expected time of these
lows, assuming they are predictable enough.
Activity: Snacking during the activity, if allowed, is one way to preserve internal stores
of glucose. Rule of thumb to start with is 15 grams for 30 minutes. Adjust to response
Behavioral: Check BG more often before during and after activity to determine his
unique response pattern. Once you can start to predict it, you can control it.
Question
Are super boluses appropriate for highs?
Answer
Medical: A superbolus is a special insulin pump delivery method that converts basal
insulin delivery (for a period of time) to the bolus to be delivered. The basal rate is
“zeroed out” for a few hours. “Robbing basal to pay bolus”. It’s meant to me used for
foods that create big after meal blood sugar spikes. This is advanced stuff.
Nutritional: Know the foods that might require a superbolus. Cereals are a common
reason.
Activity: Be careful if you exercise following a superbolus. It might increase it’s effect
more than you expect. Having a CGM sensor on would be ideal. If not, check BG often
as you refine your technique.
Behavioral: Best done with parental oversight in children/teens.
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Mealtime Super bolus
Correction dose Super bolus
Question
My 4 years old, seems allergic to the Dexcom CGM, blood sugars seem to always be
going up or down in large swings 100+ points.
Answer
Medical: Rapid BG shifts can happen to anyone, especially toddlers. Blood sugars can
either drift (gradually change over time) or flux (rapidly change over time). This is due
to food, activity, insulin action, stress hormones and illness. Don’t forget sensor error
or even interfering substances (like acetaminophen). Tape allergy can be a problem
Nutritional: Unexpected food intake can contribute to rapid shifts
Activity: Irregular and explosive in this age group.
Behavioral: Calibrating sensors is as much art as science. Look for a steady baseline,
perform some extra checks on day 1, and don’t enter every BG into machine
(confuses it).
Question
A) How do you know when to change basal rates, how many incidences of highs or lows?
B) How frequently can I make changes when adjusting basal rates to manage highs
Answer
Medical: Basal rate(s) should maintain BG in target zone between meals and
mealtime insulin doses. Usually +/- 30 mg/dl. But this is an AVERAGE only. It’s best to
look at many days of basal insulin effects before changing. Start by “fixing the fasting
first”. You can have lots of rates, but rates are usually best 4 or fewer, often 1.
Nutritional: Basal rates are no match for food (carbs). These will increase BG unless
basal already is too strong or if snacks are used to offset lowering effect of exercise
Activity: Basal rate(s) are for a “typical day”. If exercise is sudden, then drops (or
highs) might happen.
Behavioral: Be consistent with your basal rate(s), esp with injected basal insulin(s).
Question
Dealing with gastric delay and post prandial BGs.
Answer
Medical: Stomach is a holding chamber for food. Most digestion happens further
down the GI tract. Some people with D can have a slower rate of stomach emptying.
Some medications might have this as a side effect too. Adjusting insulin delivery via
multiple injections, delayed dosing (after meal) or dual wave/combo bolus via pump
are strategies.
Nutritional: High fat and high carb meals can slow down stomach emptying.
Activity: Exercise can slow down how the stomach empties in anyone, even PWD’s.
Behavioral: Know the foods that are slow for you to digest, even without a stomach
emptying problem. Fried foods, al dente pastas, pizza, Mexican food are examples of
slower digesting carb containing foods.
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Question
Learning from the Line Graph – Insulin Timing
Dinner time seems to be a real challenge for us between having the basal set
correctly and getting the bolus ratio set. Advice?
Answer
Medical: Consider afternoon activities, snacks and insulin doses/rates to discover why
pre-dinner BG is not in desired range. Time the dose and check 2 hours after meal. If
you wear a sensor there are more advanced methods to address the upswing in BG
after dinner.
Nutritional: If you are only looking at before and after meal blood sugars, it is very
important to know the carbs in your meal.
Activity: Remember that exercise after a meal affects the glycemic response to food
and insulin
Behavioral: Don’t try to fix the entire regimen at once. Start on getting the fasting
readings in control then work your way through he rest of the day.
Question
Exercise affects on BG. I have a 10 year old son. His BG should be +150 before
exercise. Sometimes when he’s done, he's +250, sometimes - 70
Answer
Medical: Exercise triggers many chemical changes that effect sugar levels. Other
factors that impact this include intensity, duration, stress, illness, time of the day, time
since last meal or insulin dose, and even climate (temperature). Exercise is really a
“wild card” in its effect.
Nutritional: If snacks are being eaten during the activity, this can exert a significant
influence of course.
Activity: As you say, aim for a BG range of 140-180 during the event. This can be
accomplished by frequent BG checks and prudent snacking (liquid or solid carbs), plus
plenty of water as needed to prevent dehydration.
Behavioral: Exercise has positive effects on well being and should be encouraged.
Question
Microbolusing with pump using sensor technology?
Answer
Medical: Microbolus and microcarbing are terms I use to describe smaller than usual doses of
insulin or food to effect a smaller, more subtle change in blood sugar level.
Nutritional: As little as a few grams of carbs (e.g., 4-5) can affect basal glucose levels. Usually
these are fast acting carbs or even glucose tabs.
Activity: Short periods of exercise can shift blood sugar levels. It is very situationally
dependent.
Behavioral: This concept can only be safely implemented in a persons wearing a CGM device,
willing to check BG often to verify readings, and with the help of others as needed. It requires
a lot of practice and mindful self management. Still, modified to younger patients, smaller
doses of insulin or carbs can be effective strategies.
Yesterday
Today
350
350
280
280
210
210
140
M
70
I
8a
140
70
Insulin bolus:
10a
7:30 AM
Breakfast: 7:30 AM
IM
8a
Insulin bolus:
10a
7:10 AM
Breakfast: 7:30 AM
Question
A) How to do combo boluses and have them work to minimize nightly corrections
B) Square/dual wave bolusing
C) What's the best way to manage insulin for high fat & high carb foods
Answer
Medical: Combo bolus aims to stretch the insulin dose over a different period of time
to better “cover” the insulin needs of a certain type of food or meal. It’s underused.
Applications include slow overnight corrections (sleep bolus) and high fat and high
carb meals/foods.
Nutritional: You must know the food types that slowly increase BG’s or take longer to
completely digest. This can even include large protein meals.
Activity: Can influence the response to a combo bolus and should be factored in
Behavioral: It’s important to consider simple combo bolus situations and do some
safe experimenting with lots of BG checks (or CGM backup), in a controlled setting.
Question
How critical is Glycemic Index in maintaining BGs?
Answer
Medical: This can be a helpful adjunct to achieve tighter control. It’s an indicator of
speed of conversion of carbs into glucose over 2 hours.
Nutritional: Low is under 55, intermediate is 55-70 and high is 70 and higher. I suggest
you focus on knowing the “usual offenders” and master a technique to offset their
effects on BG.
Activity: In theory this could be helpful to know in planning (timing) an activity after a
meal to help minimize/blunt the rise in sugar levels after a meal.
Behavioral: Studies have shown that even the most motivated teens can be weak at
carb counting. Glycemic index is another layer on top of this.
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Question
How to achieve better control using Lantus/Novalog - preventing the scary lows when
you can't even move.
Answer
Medical: Have a good working knowledge of when your insulin doses work best and
the other factors that influence their results (food, activity, timing, consistency). Have
glucagon in the home at all times, plus fast-acting carbs nearby wherever you are.
Nutritional: Insulin and food are best timed relative to each other based on the
premeal insulin dose and food to be eaten. This is not always possible in the real
world.
Activity: Know when not to exercise after a meal time dose unless it is aimed at
lowering an impending high BG after a meal.
Behavioral: Timing and consistency are huge virtues. Mindful management.
Five things you need to know to prevent lows
Five things you need to know to prevent highs
1.
Understand how your insulin works. Onset/peak/duration. Are you under the
insulin umbrella or not? Be “situationally aware”. “Fix the fasting first”!
2.
Learn the glucose action curves of your favorite meals/foods. Make your own
personal “Top 10” list.
3.
Time and adjust your rapid insulin dose to best pair up with your meal/snack
4.
Check your BG 30 minutes before and 2-3 hours after meals, or use a CGM.
5.
Correct all out of range readings, or consider another strategy to blunt spikes.
But leave no high BG behind! Exception to this rule is in the newly diagnosed
or very young.
Five advanced management tips
1.
Know your carbs well.
1.
Set actionable blood sugar levels. High AND low.
2.
Time your insulin doses properly; know your insulin action curves
2.
Apply frequent pattern management (FPM).
3.
Appreciate the effect of exercise on food and insulin.
3.
4.
Check your BG 30 minutes before and 2-3 hours after meals, or use a
CGM.
With a CGM; “while the reading may be deceiving, the trend is your
friend.”
4.
Leave no high or low blood sugar unattended. (left behind).
Treat lows (and highs) to target and monitor overall control at least weekly.
5.
Always keep aiming at your target: be persistent.
5.
Common diabetes self care mistakes
Over treating a low BG
Mis-timed meal time insulin
Handing over responsibility too soon
Applying value judgments to diabetes numbers
Not checking after meal BG’s
Missed opportunities to correct a high BG
Application of poor carb counting skills
Waiting too long to make a management adjustment or call for help
Have we reached the point of diminishing returns?
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I hope you learned something. Thanks!
A round of applause for Alison Zettle, Doug
Harper and the Type One Family Network!
“And thirdly, the correction factor and carb ratio is more
what you’d call ‘guidelines’ than actual rules.”
Questions?
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