Back To School With Diabetes: 600+ Tasks To Stay Alive

Back To School With Diabetes: 600+ Tasks To Stay Alive | The LOOP Blog

Editor’s Note: With school back in session, we know many parents of children with diabetes face the challenge of how to best work with teachers and other school staff to ensure their child’s safety at school and create a positive environment for learning. We happened to see a letter Lane sent to Hayden’s school and asked him to share it with you. This is just one way to communicate with your child’s school. Meri Schumacher from Our Diabetic Life also had some good tips for going back to school in the September News to Infuse newsletter from Medtronic. How do you do it?

I’d like to thank you in advance for all your support for Hayden. Although he struggles with school, perhaps the attached task list by Ron D. Coffen in the article, “The 600-Step Program for Type 1 Diabetes Self-Management In Youth: The Magnitude of the Self-Stick Management Task” will put things in perspective (see appendix). People with diabetes (and their families!) involuntarily take on hundreds of physical and cognitive tasks just to stay alive and lead a happy, healthy life. We didn’t sign up for these tasks, and our ability to perform them has life and death implications. I am incredibly proud of Hayden’s acceptance and mastery of these tasks. It’s a lot to expect of an adult, let alone a 12 year old.

In addition to being Hayden’s father, I am the product strategist for Medtronic Diabetes, maker of insulin pumps and continuous glucose monitoring sensors. Amongst other things, I’m leading the technical aspects of our next steps towards an artificial pancreas so that I can help Hayden and millions of other people with diabetes.

As part of my job, I have had the privilege of meeting hundreds of people with type 1 diabetes. I find that they fall into two camps: the small minority who “blame” diabetes and live an unfulfilled life as victims, and the majority who rise to the occasion and attain incredible levels of achievement in the face of adversity. I’m delighted to say that far more people with diabetes “learn from it” than “run from it”.

My point in sharing this is to ask you to help put Hayden on the latter path. I believe he has the potential for great, incredible, world-changing achievements. They may not manifest immediately, and he may struggle scholastically while he’s busy mastering the ~600 tasks required just to stay alive. Lisa, Hayden, myself, and our other two children work every hour of every day to tame diabetes. Please give him the emotional support to keep him on the path to greatness.

Tasks for Managing Type 1 Diabetes
Etiology

– Knows that nothing s/he did resulted in diabetes
– States that diabetes may result from viral infections
– Can explain what diabetes is (functionally)
– Knows that diabetes is not contagious
– Can explain the difference between type 1 and type 2 diabetes
– Can explain the function and need for insulin
– Can explain the result of a lack of insulin
– Can explain how diabetes develops
– Knows that the pancreas produces and secretes insulin
– Understands that diabetes is a permanent condition

Pharmacology / Insulin

– Follows an established method for acute insulin adjustment
– Knows s/he must take insulin injections to provide insulin not made by the pancreas
– Knows that diabetes is caused by a lack of insulin production
– Knows that insulin is required every day
– Knows basic difference between beef, pork, and human insulins
– Knows the advantages of using human vs. beef/pork insulin
– Can name the three classes of insulin (short/rapid, intermediate, and long)
– -Can name one insulin of each class of insulins
– If insulin is not refrigerated it is kept between 59 and 68 F
– Extreme temperatures (<36 or >86 F) are avoided
– Excess agitation is avoided
– Knows temperature extremes and agitation can cause loss of usual insulin action
– Insulin is discarded one month after opening
– Vials are dated when opened
– Keeps a spare bottle of each type of insulin used
– Cold insulin is not injected to reduce local irritation
– Insulin is not subjected to temperature variations:
– Not left in a car
– Taken as a carry-on; not checked through in airline baggage
– Knows signs of deteriorated insulin:
– Clear insulins appear cloudy or discolored
– Suspended insulins appear clumpy or frosted
– Discontinues use of deteriorated insulins
– Knows that absorption rate differs for various injection sites
– Knows relative rates of absorption for various injection sites (from most to least rapid: abdomen, arm, leg, hip/buttocks)
– Mixes insulin properly:
– The time delay after mixing is standardized
– Knows Lente and Untalented can contaminate Regular insulin
– Knows that Lente begins to bind with Regular immediately
– Draws up regular insulin prior to suspended insulin
– Knows that normalization of BG can be achieved only via a small amount of insulin working continuously (e.g., Lente/Ultralente) with boluses (e.g., Humalog/Regular) at meals
– Does not change insulin species without physician consult
– Knows that insulin effectiveness varies as a function of exercise, stress, food absorption rates, insulin mix, and hormonal changes
– Knows what kinds of insulin s/he takes
– Knows the physical characteristics of the various types of insulin
– Knows the functional characteristics of the various types of insulin
– Knows that injections must be given at about the same time daily
– Understands why insulin should be given at same times daily
– Knows where insulin may be purchased
– Purchases insulin and syringes
– Knows that at puberty, insulin requirements may change
– Knows pre-pubertal children usually require .6-.9 U of insulin /kg/day
– Knows that pubertal children may require up to 1.5 U/kg/day
– Knows that post-pubertal patients usually require <1U/kg/day
– Knows that too much insulin can lead to unstable control
– Knows that doses above 1 U/kg/day can cause rebound hyperglycemia and weight gain

Insulin Technique

– States the prescribed amount of each insulin type prescribed
– Chooses the correct insulin bottle
– Removes needle cover properly
– Turns insulin bottle upside down with the syringe inserted
– Pulls plunger back to draw insulin
– Draws insulin to the correct unit mark
– Pushes plunger all the way down when injecting (gives full dose)
– Cleans the injection site after injection
– Records amount of insulin dose on record sheet
– Organizes all necessary materials prior to injection (limits errors)
– Cleans hands prior to injection
– Cleans the injection site prior to injection
– Waits for topical alcohol, if used on site, to dry before injecting
– Cleans the top of the insulin vial with 70% isopropyl alcohol
– Gently rolls (does not shake) all but short-acting insulin before drawing up insulin
– Injects air equal to the insulin dose into the vial (not the insulin) prior to drawing up insulin to avoid creating a vacuum
– For mixed doses, injects a volume of air into both vials before drawing up any insulin
– Short-acting insulin are drawn before intermediate-/long-acting
– Syringe is checked for bubbles after dose is drawn
– Flicks syringe until bubbles escape
– An appropriate injection site is selected:
– Upper arm
– Anterior and lateral aspects of the thigh
– Buttocks
– Abdomen (but not within 2 in. of the navel)
– Knows why it is important to rotate injection sites
– Injection sites are rotated to prevent local irritation
– Injection sites are rotated within 1 area type for consistent absorption
– Avoids injections into body areas likely to be exercised
– Insulin is injected subcutaneously (no intramuscular/venous)
– An appropriate injection angle is used (45 angle for a child or thin person, else 90 )
– A fold of skin is grasped or pinched up for injection
– Keeps muscles in injection area relaxed while injecting
– Penetrates the skin quickly
– Does not change the direction of the needle during insertion/withdrawal
– Checks injection site for blood or fluid after injection
– Increases BG monitoring if site is wet after injection
– Safely handles syringes
– Safely disposes of used syringes
– Never shares a used syringe with another person
– Alcohol is not used directly on the needle (it removes the silicon coating)
– Increases BG monitoring if length of needle is changed

Blood Glucose (BG) and Ketone Monitoring

– Knows schedule for testing BG
– Knows that ketones come from the breakdown of fat for energy
– Knows that ketones result when the body can’t use glucose for energy
– Knows that ketones may indicate too little insulin
– Explains how to check for ketones
– Demonstrates how to test urine for ketones
– Explains the steps to check BG using his/her glucose system
– Demonstrates the finger stick for BG monitoring
– Demonstrates how to record results of BG test
– Knows which end of BG strip to insert into meter
– Does not touch strip on electrical contacts
– Cleans target lancet site before obtaining drop of blood
– Cleans target site after blood is used-prevents infection
– Uses a new lancet for each blood draw
– Disposes of lancet safely
– Re-seals bottle of test strips to prevent extended exposure
– Disposes of used test strip safely/hygienically
– Remembers to take BG monitor with him/her when leaving home
– Remembers to take enough strips with him/her when leaving home
– Remembers to take enough lancets with him/her when leaving hm
– Uses an electronic glucose monitor
– Uses BG trends to adjust insulin dosage
– Knows when to give rapid acting insulin supplements
– Indicates quantity and frequency of insulin supplements when needed
– Uses results to adjust caloric intake
– Uses results to adjust physical activity
– Uses results to learn about individual response to food items
– Uses results to learn about how stress affects BG
– Uses results to diagnose and treat hypoglycemia
– Monitors every 4-6 hours for glucose and ketones when sick
– Increases monitoring when traveling across time zones
– Monitors to determine basal and bolus doses if on an insulin pump
– Uses results to evaluate the effect of self management changes
– Obtains a drop of blood sufficient for accurate result
– Maintains temperature stability of meter and strips (<86 F)
– Calibrates the meter with each new lot number (if required)
– Does not use urine tests for glucose monitoring
– Records results in a log (even if the monitor has memory)
– Appropriately tests for dawn phenomenon (takes BG at 3-4 a.m.)
– Monitors at least before meals and at bedtime
– Monitors more if there has been hypo-/hyperglycemia/ketosis
– Checks for ketones when BG is consistently >240mg/dL
– Knows target BG levels:
– Children > 6 yrs: 80-120 mg/dL at fasting
– Children > 6 yrs: 80-180 mg/dL at other times of day
– Children < 6 yrs: 90-130 mg/dL at fasting
– Children < 6 yrs: 90-200 mg/dL at other times of the day
– Identifies things that influence BG levels (e.g., exercise, stress, etc.)
– Can define glycosylated hemoglobin or hemoglobin A1c
– Knows that A1c measures identify average BG levels during the last 1-3 months)
– Can identify hemoglobin results indicating good control Coffen p. 25
– Knows that a good A1c will be deceptive if there have been multiple lows when there have also been many highs
– Knows that BG levels can vary even when there is no deviation from the regimen

Diet

– Knows that all CHO becomes sugar when digested
– Knows that sugar is CHO
– Knows that generally, simple CHOs are absorbed rapidly
– Knows that generally, simple CHOs produce rapid BG elevations
– Can name several foods with simple CHOs
– States that generally, complex CHOs are absorbed more slowly than simple CHOs
– Can name several foods with complex CHOs
– Knows that there are exceptions to the way simple and complex CHOs affect BG
– Knows that exceptions are related to a food’s Glycemic Index (GI) and Glycemic Load (GL)
– Knows that foods with a low GI number raise BG slowly and foods with a high GI raise BG rapidly
– Can name at least one simple carbohydrate with a low GI
– Can name at least one complex carbohydrate with a high GI
– Can define GL in relation to BG
– Demonstrates the ability to interpret labels on sugar free products appropriately
– Describes how sugar gets into the body
– States that blood sugar levels are caused by food for the most part
– States that some sugar can be made from protein
– Knows that everyone has glucose in their blood
– Eats at consistent times
– Knows that skipping a meal or snack can significantly affect BG
– Meals are synchronized with time-actions of insulin
– Knows that about the same amount and types of food must be eaten from day to day
– Knows that food from one meal cannot be substituted at another
– Knows CHO, protein, and fat must be balanced for good health
– Gets 55-60% (adults: 45-55%)b of calories from CHO
– Limits concentrated sweets (i.e., sucrose), including sugar-free products, because they do not contain an appropriate balance of CHO, protein, fat, nutrients, and fiber
– Gets <30% of daily calories from fat
– Gets <7% of daily calories from saturated fat
– Gets <200 mg of cholesterol daily
– Knows that excessive fat can cause significant health problems
– Gets 12-15% of calories from protein (adults: .8- 1.2g/kg)
– Can evaluate food labels for nutritive (caloric) sweeteners
– Gets <3000 mg of sodium per day (1000 mg/1000kcal)
– Selects appropriate foods from a menu
– Reads labels on packaged foods
– Knows that diet is an essential element of diabetes control
– Follows precautions regarding alcohol use:
– Eats before drinking any alcohol
– 2 alcoholic equivalents used 1-2 times / wk (ideally, none)
– Food is not omitted when alcohol is consumed
– Knows that fruit juice or mixers with sugar added to alcohol can significantly affect BG
– Knows that drinking alcohol that contains carbohydrate can significantly affect BG
– Knows that drinking may cause him/her to forget shots, eat too much, etc., and takes precautions against this
– Eats bedtime snack even if BG is high after alcohol consumption
– Follows guidelines for handling nausea and vomiting:
– 15g of carbohydrate consumed over 1-2 hours in small quantities or, 50g consumed every 3-4 hours to prevent starvation ketosis
– Drinks small sips of fluids every hour or so
– Replaces electrolytes via small amounts of salty foods/liquids
– Sips 15g of CHO over 1-2 hrs if foods/liquid cannot be tolerated
– Follows a meal plan (which itself will have multiple tasks)
– If patient is on an exchange system:
– Knows that a Starch/Bread exchange contains 15 grams of CHO
– Knows that a Fruit exchange contains 15 grams of CHO
– Knows that a Milk exchange contains 12 grams of CHO
– Follows caloric guidelines for age/weight/activity
– Does not deviate >1hr. from scheduled snacks
– Sees a Registered Dietitian every 3-6 mos. (6-12 mos. for adult)
– Knows high-fiber diets improve CHO metabolism, lowers total cholesterol and LDL cholesterol
– Gets 35-50g of fiber/day (25 g/1000 kcal, but not >50g)
– Eats at least 3 regular meals, a bedtime snack, and one or more between-meal snacks (may differ if on intensive insulin therapy)
– Knows that children/teens may need 1-2 snacks to maintain growth

Exercise

– Knows that people with diabetes are not restricted in amount of exercise
– Knows how much CHO is needed acutely per hour of exercise (generally is 10-15g / hr)
– Decreases insulin when appropriate
– Increases daily food intake when necessary
– Eats CHO after exercise to avoid post-exercise hypoglycemia
– Knows how long glucose will decline after exercise(can continue to decline 12-24 hrs)
– Avoids insulin injections close in time to exercise
– Monitors glucose before, during, and after exercise
– Adjusts insulin/eats considering relevant factors:
– The time of exercise in relation to type and quantity of insulin
– Body part exercised relative to location of insulin injection and time since injection
– Type, intensity, and duration of exercise
– The previous meal time and type
– Pre-exercise blood glucose level
– Adjusts insulin/eats appropriate quantities
– Knows that exercise usually requires additional food intake
– Waits 60-90 minutes after a meal to exercise
– Avoids exercising during insulin’s peak effect
– Exercises only if BG is between 100-200 mg/dL and no ketones
– Carries a fast-acting carbohydrate
– Wears ID/medic alert at all times, but especially while exercising
– Exercises with someone familiar with his/her diabetes
– Has properly fitting and protective exercise shoes
– Exercise is stopped when feeling faint
– Exercise is stopped when pain is experienced
– Exercise is stopped when unusually short of breath
– Exercise is stopped when hypoglycemic
– Knows that low-intensity exercise (<50% of maximum heart-rate reserve) has less effect on BG than high intensity exercise
– Can calculate maximum heart-rate (HR) reserve and target HRh
– Works with health professionals to develop an individualized exercise program [for diabetics with no complications present]
– Works with health professionals to develop an exercise program in light of concurrent diabetic complications
– Knows that regular exercise is an important part of diabetes control
– Consistently participates in an appropriate exercise program
– Knows that exercise increases sensitivity to insulin
– Knows that exercise increases glucose utilization
– Can indicate diabetes-specific benefits of exercise
– Knows that glucose production by the liver is inhibited by exercise
– Knows exercise depletes glycogen stores which must be replenished and can lead to prolonged glucose lowering effects
– Uses proper footwear
– Avoids exercising in extreme heat or cold
– Inspects feet after exercising
– Avoids exercise during periods of poor metabolism
– Identifies an appropriate pre-exercise snack
– Does not exercise if ketones are positive
– Eats 10-15g (or individualized amount) of rapid-acting CHO every 30-60 minutes of exercise
– Knows that exercising when BG is already high can increase BG even more
– Reduces insulin dose for respective period by about 20% after strenuous activity lasting more than 45-60 minutes
– Knows that high BG after exercise may be temporary due to adrenaline and so waits 60 minutes before bolusing

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