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Back to School with Diabetes: 600+ Tasks To Stay Alive

By Lane Desborough

Product Strategist

Posted:  10/27/2011 12:00 AM

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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?

Hello,

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.

Thanks,

Lane

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 59º and 68ºF
•    Extreme temperatures (<36º or >86ºF) 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 (45º angle for a child or thin person, else 90º)
•    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 (<86º 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

Hypoglycemia


•    Defines hypoglycemia as low blood sugar
•    Tests glucose before, during, and after treatment of hypoglycemia
•    Knows that treating hypoglycemic symptoms will terminate them
•    Knows that hypoglycemia gets worse if not treated
•    Knows that treatment of hypoglycemia consists of eating sugar
•    Begins treating with 10-15g of CHO (5-10 for younger children)
•    Knows that it takes 10-15 minutes for treatment to terminate symptoms of hypoglycemia
•    Glucose is tested 15 minutes after treating
•    Additional 15g CHO taken after 10-15 minutes if symptomatic or glucose <70 mg/dL
•    Does not treat hypoglycemia with chocolate or ice cream (fat reduces rate of CHO availability)
•    The scheduled snack or meal is eaten following treatment
•    The food used to treat is in addition to regular meal plan
•    Knows that symptoms are usually felt when BG is low
•    Knows that BG<70 mg/dL indicates impending hypoglycemia
•    Can describe typical symptoms
•    Can describe idiosyncratic symptoms
•    Recognizes their own hypoglycemia
•    Knows that hypoglycemic symptoms can occur with rapid BG declines even if measured BG is greater than 70 mg/dL
•    Treats symptoms of hypoglycemia even if BG cannot be tested
•    Knows the typical causes of hypoglycemia, such as:
•    Excessive insulin
•    Skipped or inadequate meals
•    Immediate effects of exercise
•    Long-term effects of exercise
•    Ingestion of ethanol without food
•    Onset of monthly menstrual cycle
•    Autonomic neuropathy leading to delayed gastric emptying
•    Decreases insulin or increases food intake appropriately in response to patterned hypoglycemia
•    Notifies health professional following severe (e.g, unconsciousness) hypoglycemic episodes
•    Knows insulin needs are lower between midnight and 3 am
•    Knows that nighttime hypoglycemia can occur without waking the person
•    Checks 3 am BG at least once a week
•    Checks 3 am BG following a day of unusual activity
•    Checks 3 am BG following a day of unusual food consumption Coffen p. 27
•    Checks 3 am BG when insulin doses are being adjusted
•    Always measures bedtime BG to prevent nocturnal hypoglycemia
•    Has a bedtime protein+CHO snack if bedtime BG<120 mg/dL
•    Moves dinner intermediate-/long-acting insulin to bedtime if a reduction in short-term dose at dinner is made to prevent nocturnal hypoglycemia and if this results in fasting hyperglycemia
•    Avoids delaying a meal more than 30 to 60 minutes
•    Carries a source (or sources) of CHO (10g-15g) at all times
•    Knows how to inform family and friends how to treat hypoglycemia
•    Knows what glucagon is
•    Glucagon is kept available
•    Knows glucagon takes 10-15 minutes to work
•    Makes sure family/friends know when and how to administer glucagon
•    Adjusts treatment plan in response to repeated daily hypoglycemia
•    Knows that insulin may need to be reduced if weight is lost
•    Knows small ketones in the morning may indicate nocturnal hypoglycemia
•    Treats hypoglycemia as soon as symptoms are noticed
•    Knows hypoglycemia can lead to unconsciousness or seizure
•    Takes safety precautions when experiencing hypoglycemia (e.g., stops driving, etc.)
•    Knows glucagon is available only by prescription
•    Keeps glucagon at home and at work/school
•    Has informed family/friends/co-worker/teacher:
•    To give glucagon if s/he passes out
•    To call for emergency help
•    Not to give him/her insulin
•    Not to give him/her food or fluids
•    Not to put their hands in his/her mouth
•    Knows that things other than hypoglycemia can cause symptoms (anxiety, fatigue, etc.)
•    Knows types of food/drinks that effectively treat hypoglycemia
•    Knows that there is a possibility for a rebound hyperglycemia after hypoglycemia
•    Knows that the rebound may be due to the action of counter-regulatory hormones
•    Knows counter-regulatory hormones may also produce ketonuria
•    Knows rebound can occur without hypoglycemic symptoms
•    Knows hypoglycemia is most likely when insulin effects are peaking
•    Knows that one incident of severe hypoglycemia is frequently followed by another hypoglycemia incident
•    Knows how to decrease the potential of a second hypoglycemic incident following an earlier hypoglycemic incident

Hyperglycemia


•    Knows typical symptoms
•    Knows idiosyncratic symptoms
•    Discusses appropriate treatment of hyperglycemia with doctor
•    Applies prescribed treatment when hyperglycemic
•    Knows that some types of neuropathy are related to the duration and severity of hyperglycemia

Ketoacidosis (KA)

•    Knows that KA means dangerously high levels of ketones
•    Knows that KA means the body is burning fat (instead of glucose) for energy and this results in ketones as a by-product
•    Knows ketones are acids that build up in the blood
•    Knows that ketones are found in the urine if there is an insulin deficiency
•    Knows ketones poison the body
•    Knows KA can lead to coma and death (i.e., is life threatening)
•    Knows ketones can indicate the onset or presence of illness
•    Knows ketones can indicate the diabetes is “out of control”
•    Knows KA usually results in hospitalization
•    Knows KA usually develops slowly
•    Knows KA can develop within a few hours when vomiting occurs
•    Knows initial symptoms of KA:
•    Thirst and/or a very dry mouth
•    Excessive urination
•    High BG levels
•    “Moderate” quantities of ketones as measured by urine samples
•    Knows subsequent symptoms of KA:
•    Constantly feeling tired
•    Dry or flushed skin
•    Nausea, vomiting, or abdominal pain
•    Difficulty breathing
•    Fruity odor on breath
•    Difficulty concentrating or confusion
•    Calls physician or goes to ER immediately if any of the symptoms are present
•    Has test strips available to test for ketones
•    Tests for ketones every 4-6 hours when ill
•    Tests for ketones every 4-6 hours when BG >240
•    Tests for ketones when any symptoms of KA are present (e.g., nausea, vomiting, abdominal pain)
•    Knows ketones can result from lack of insulin, lack of food, or an untreated insulin reaction (e.g., nocturnal hypoglycemia)
•    Knows to drink lots of water when ketones are present

Illness/Stress

•    Knows that illness/stress can raise BG levels
•    Knows that illness/stress increases chance of KA
•    Knows that during illness insulin needs may increase in spite of decreased food intake
•    Knows that insulin action is diminished during illness/stress Coffen p. 28
•    Knows that glucose is released by the liver during illness/stress
•    Drinks 8 oz. of water/hr while awake to prevent dehydration
•    Avoids caffeinated drinks (which are diuretics)
•    Increases BG monitoring frequency during illness/stress
•    Knows that symptoms of illness/stress can mask and/or mimic usual symptoms of hypo-/hyperglycemia
•    Is able to test ketones
•    Tests ketones every 4-6 hours during illness/stress
•    Checks BG before adjusting insulin dose
•    Knows that insulin must be given even when unable to eat
•    When unable to eat:
•    Gives full dose of intermediate/long-acting insulin
•    Supplements with 10% of routine dose of short acting insulin
•    Supplements with 20% if BG>300 mg/dL and ketones are large
•    Knows that supplements of short-acting insulin may be needed
•    Knows or inquires about the effects of medications on BG
•    Uses sugar-free over-the-counter medications (OTCs) if possible
•    Increases BG monitoring when using OTCs that advise against use by persons with diabetes and calls health professional if necessary
•    Knows whom to call in case of illness
•    Calls a health professional if:
•    Vomiting occurs more than once
•    Diarrhea lasts >24 hrs or occurs >5 times
•    Breathing is difficult
•    BG>300 mg/dL on two consecutive measurements
•    Urine ketones are moderate or large
•    Has developed a plan of action with his/her physician:
•    When to call the physician
•    When to increase BG and ketone monitoring
•    Types of foods and fluids to take during illness
•    How to adjust medication during illness
•    Calls physician if:
•    The illness does not improve after 1-2 days
•    Diarrhea or vomiting persists for >6 hours
•    Ketones in urine measure moderate to large
•    Abnormal sleepiness
•    Any doubt about what to do for the illness
•    Any symptoms of KA
•    Checks with physician or pharmacist regarding the effect of a drug on diabetes control
•    Participates in a regular exercise program to combat stress
•    Knows idiosyncratic response to stress
•    Uses appropriate stress management techniques

Traveling

•    Takes appropriate supplies and phone numbers
•    Appropriately stores and keeps accessible supplies during travel
•    Keeps meal and snack times as consistent as possible
•    Monitors glucose before driving
•    Keeps extra source of carbohydrate in car to treat hypoglycemia
•    Prevents freezing of insulin, meters, and strips

Continuous Subcutaneous Insulin Infusion (CSII; Insulin Pump)

•    Knows primary purpose for CSII is improved control and reduced diabetic complications
•    Has realistic expectations for CSII
•    Knows major risks of CSII ( ketoacidosis, hypoglycemia, site infection)
•    Counts CHO when available on food packages
•    Counts CHO when available from restaurant printed materials
•    Estimates CHO as accurately as possible when info not available
•    Knows that "basal" refers to the amount of 24-hr continuously delivered insulin in units per hr (usually .4 - 1.6)
•    Knows that "bolus" refers to a rapidly delivered dose of insulin
•    Knows that 45-60% of total amount of insulin needed per day is usually delivered as basal
•    Knows that 40-55% of total amount of insulin needed per day is usually delivered as boluses to cover meals (CHO)
•    Knows that basal is too high if BG drops when a meal is skipped
•    Knows that basal is too high if BG is often low early A.M. or before breakfast
•    Knows that basal is too high if BG is repeatedly low during day
•    Knows that basal is too low if BG rises when a meal is skipped
•    Knows that basal is too low when BG is repeatedly high during day
•    Knows to change basal rates in small increments well before (~6 hrs) the time when the problem BG is noticed
•    Knows to use different basal rates on weekends if weekend activities are quite different
•    Tests BG at least 4-6 times per day (ideally, pre- and post-prandial, before bed, and at night)
•    Tests BG before driving
•    Records BG readings
•    Records basal
•    Records boluses
•    Records hypoglycemia
•    Records hypoglycemia treatments
•    Records carbohydrate intake
•    Records exercise duration and intensity
•    Records time and date for each item recorded (BG, basal, bolus…)
•    Matches basal and boluses to insulin need by problem-solving blood sugar patterns
•    Knows how to program and change basal and boluses
•    Overnight basal is stable (bedtime BG 80-120 mg/dl with normal morning BG)
•    Daytime basal is stable (can skip a meal if preprandial BG 100-120 mg/dl without BG dropping >30 over 5 hours)
•    Accurately boluses for CHO (if pre-prandial BG is normal, can bolus insulin so BG is normal 4 hrs later)
•    High BG bolus (can bolus insulin to normalize BG 4 hrs later)
•    Prevents "stacking" (if 2 boluses ≤ 3.5 hrs apart, determines unused insulin from 1st bolus; typically 30% of bolus is used / hr)
•    Recognizes hypoglycemic reactions
•    Handles hypoglycemic reactions without BG rising ≥ 150 mg/dl
•    Knows likely causes of hypoglycemia with CSII
•    Infrequent SMBG
•    Improper timing of bolus
•    Using too large a bolus or too many (e.g., “stacking”)
•    Too few CHO in meal
•    Increased activity
•    Has non-expired Glucagon emergency kit at home for use
•    Home support person is trained to use Glucagon
•    Has non-expired Glucagon emergency kit at school for use
•    School support person is trained to use Glucagon
•    Can keep BG between 70-150 mg/dl when exercising
•    Can insert/change pump batteries
•    Always has spare batteries available
•    Programs pump to deliver correct basal rate
•    Uses the pump to deliver correct bolus
•    Inserts insulin reservoir into pump
•    Attaches infusion set to reservoir
•    Inserts infusion set needle/catheter at insertion site
•    Identifies pump alarms
•    Knows how to stop or suspend pump
•    Knows how to review pump memory for basal, boluses, alarms, etc.
•    Knows how to wear the pump
•    Can analyze BG patterns
•    Knows how to correct problematic BG patterns
•    Does not skip or delay a meal after a bolus of rapid acting insulin
•    Does not suspend pump to treat low BGs
•    If BG ≥ 300 mg/dl, takes bolus by syringe
•    Has set schedule for days to change infusion site
•    Changes infusion site within 72 hrs
•    Ensures O-rings (where present) are lubricated regularly
•    Can transfer insulin into reservoir
•    Eliminates bubbles from reservoir
•    Can detach reservoir needle and replace it with infusion set hub
•    Prevents leaks from hub by firmly tightening hub to reservoir
•    Primes infusion line with insulin before inserting into pump, or, uses pump to prime infusion line
•    Uses pump bolus operation to fill infusion set to tip
•    Washes hands prior to preparing infusion site
•    Does not touch parts that will indirectly or directly contact infusion site
•    Does not breathe on or blow on parts that will indirectly or directly contact infusion site
•    Disinfects 2-inch diameter area of skin around infusion site
•    Allows disinfected infusion area to dry before proceeding
•    Places medical adhesive on infusion site
•    Positions infusion set needle parallel to beltline but not underneath belt
•    Properly boluses if using Teflon infusion set
•    Loops infusion line and tapes it to skin 1-inch from infusion site
•    Checks infusion site daily
•    Changes infusion site immediately when red, swollen or bleeding
•    Never primes infusion set when it is still attached to body
•    Never attempts to unclog infusion line when it is attached to body
•    Changes infusion sets in mornings, not evenings
•    Knows his/her insulin to CHO ratio (ICR) for CHO counting / bolusing
•    Measures servings of foods eaten carefully (measuring cups, scales, etc.) to accurately count CHO
•    Knows by heart how many mg/dl 1g of CHO raises his/her BG
•    Knows by heart how many mg/dl 1U of insulin lowers his/her BG
•    Knows by heart how many mg/dl a certain degree and length of exercise lowers his/her BG
•    Has contact information for 24-hour help with pump
•    Knows that insulin reactions are less dramatic on CSII and requires more frequent BG monitoring
•    Handles pump properly when bathing (detaches, hangs, etc.)
•    Handles pump properly when sleeping (free under pillow, clamped to PJs, etc.)
•    Does not expose pump to heat (e.g., hot tubs or saunas)
•    Knows how to detach pump during exercise or showering, etc.
•    Prevents water exposure if pump is not waterproof
•    Has preparations in place in case of pump problems
•    Knows glycemic index information for foods
•    Can adjust bolus for glycemic index of foods
•    Can insert infusion set subcutaneously
•    Determines his/her total amount of insulin needed per day
•    Adjusts her total amount of insulin needed per day for premenstrual rises in blood sugars
•    Adjusts basal when stress leads to increased BG
•    Adjusts basal when illness results in increased BG
•    Establishes stable basal rates before adjusting bolus ratios
•    Knows that kids often need additional basal in early A.M. when surges of growth hormone can occur
•    Ensures school has backup necessities (batteries, infusion set, reservoir, insulin, etc.) Coffen p. 30
•    Knows how to troubleshoot pump issues for high BGs:
•    Ensures insertion set is properly placed under skin
•    Ensures insertion site is free of physical problems (scarring, etc.)
•    Considers use of a different site that provides better absorption
•    Ensures that cannula is not crimped
•    Ensures line is free of blood
•    Ensures line is free of air
•    Ensures line is not clogged:
•    Removes insertion set from body
•    Has pump deliver a ~5U bolus
•    Insulin should come out of infusion set needle
•    Ensures infusion set is securely connected to pump
•    Ensures infusion line is not damaged/does not leak
•    Ensures hub is not loose
•    Ensures O-ring does not have a leak
•    Ensures basal settings are correct
•    Ensures bolus dose was correct
•    Ensures bolus was given at correct time
•    Ensures pump is not in suspend mode
•    Ensures that reservoir has insulin
•    Ensures potency of insulin (typically by discarding current insulin and replacing with new insulin)
•    Knows circumstances leading to "insulin tunneling" (insulin leaks out around skin at insertion set site)
•    Acts on pump alarms by troubleshooting or planning
•    Knows what foods or products are rapid acting CHOs
•    Always carries rapid acting CHOs
•    Knows what a square-wave bolus is vs. dual-wave bolus
•    Knows when to use square-wave vs. dual-wave bolus


Complications

•    Knows possible acute and long-term complications of diabetes mismanagement:
•    Hypoglycemia
•    Ketoacidosis
•    Hyperglycemia
•    Knows that most acute complications can be avoided with proper care
•    Knows potential complications of diabetes:
•    Hypoglycemia
•    Hyperglycemia
•    Periodontal disease (gum infection):
•    Knows diabetics are at increased risk for gum disease
•    Brushes teeth at least twice/day
•    Uses dental floss once a day to remove bacteria from between teeth
•    Brushes where the teeth meet the gums
•    Sees the dentist every 6 months
•    Sees the dentist if gums bleed while eating or brushing teeth
•    Diabetic KA
•    Hypertension:
•    Arterial blockage can cause impotence
•    Retinopathy (eye disease):
•    Knows that nearly all patients with diabetes develop some degree of  retinopathy after 20years
•    Knows that hyperglycemia is associated with retinopathy
•    Knows that hypertension is associated with retinopathy
•    Knows vision-threatening retinopathy may be asymptomatic
•    Knows that laser photocoagulation therapy can prevent vision loss in many patients with retinopathy
•    Knows that many eye problems are minor and easily treated
•    Knows that some eye problems are serious and may cause blindness
•    Knows diabetes is the leading cause of blindness for adults in U.S.
•    Knows 80% of diabetics will develop at least some background retinopathy after 15 years of diabetes
•    Receives a comprehensive ophthalmologic exam once/yr after having diabetes for 5 years
•    Reports any change in vision to the physician
•    Nephropathy (kidney disease):
•    Knows that high BG levels may cause blood vessel changes over time that prevent the
•    Kidneys from filtering out waste
•    Knows that swelling of feet and ankles, feeling tired, and pale skin can indicate kidney damage
•    Knows that kidney damage may necessitate hemodialysis
•    Knows that high blood pressure and frequent urinary tract infections can affect kidney function
•    Occurs in about 30% of people with diabetes
•    Occurs, on average, 20 years after diagnosis
•    Knows symptoms are not readily detectable by the patient
•    Cardiovascular disease
•    Neuropathy:
•    Can lead to impotence
•    Knows that peripheral neuropathy is the most common long-term  complication of diabetes
•    Knows that some types of neuropathy are related to the duration and severity of hyperglycemia
•    Knows 50% of diabetics will develop some sort of neuropathy
•    Foot problems:
•    Knows foot problems are a major cause of morbidity, mortality, and disability in diabetics
•    Knows problems in the presence of neuropathy/ischemia can result in lower-extremity amputations
•    Knows daily foot inspection is preventative of amputations
•    Knows patients with neuropathy are at high risk for foot ulcers
•    Knows patients with vascular disease are at high risk for foot ulcers
•    Knows hyperglycemia can increase risk of foot problems
•    Knows that foot problems can develop quickly Coffen p. 31
•    Knows symptoms of poor circulation related to foot problems:
•    Cold feet
•    Leg cramps
•    Shiny or dry skin
•    Loss of hair on the toes, feet, or legs
•    Slow healing of foot and leg injuries
•    Knows symptoms of nerve damage related to foot problems:
•    Pain, numbness, burning, and/or tingling in the legs/feet
•    Very little feeling in the feet
•    Knows feet may become very dry and skin may crack
•    Applies lotion to feet after bathing
•    Does not apply lotion between toes
•    Has physician examine feet at each visit
•    Washes feet every day with mild soap
•    Never uses very hot water to wash feet
•    Dries feet carefully, especially between the toes
•    Checks feet and between toes every day
•    Reports foot infections to physician
•    Checks inside shoes for pebbles/objects before putting them on
•    Checks water temperature with finger/elbow (not feet) before bathing
•    Avoids hot water bottles, heating pads, or electric blankets which can cause burns without feeling them if neuropathy is present
•    Never walks barefoot
•    Has physician cut corns and calluses (does not self-treat)
•    Wears shoes that fit and are comfortable
•    Changes socks/nylons every day and wears socks/nylons that are even and smooth and keeps them from wrinkling while wearing
•    Does not soak feet
•    Toenails are cut slightly curved to the contour of the toe
•    Does not use chemicals on feet (e.g., to remove corns, etc.)
•    Maintains proper circulation (i.e., avoids sitting with legs crossed, tight garments, etc.)
•    Assesses feet for redness, swelling, cuts, blisters, calluses, dryness, cracks, corns, and any change in appearance
•    Seeks care within 48 hours for even “small” problems
•    Neurogenic bladder (damage to bladder nerve fibers):
•    Diminished urination frequency
•    Difficult/incomplete bladder emptying
•    Frequent urinary infections
•    Sexual dysfunction (due to nerve damage):
•    Males: 75% experience difficulties
•    Males: retrograde ejaculation
•    Males: impotence; loss of erectile capacity
•    Females: reduction in arousal
•    Females: diminished vaginal lubrication
•    Females: decreased frequency of orgasm
•    Gastroparesis (due to nerve damage):
•    Early satiety
•    Feeling full after meals
•    Heartburn, reflux
•    Reduced appetite
•    Hypoglycemia after meals (delayed stomach emptying)
•    Intestinal disorders (due to nerve damage):
•    Constipation (in up to 60% of diabetics)
•    Nocturnal diarrhea
•    Incontinence
•    Cardiovascular disorders (due to nerve damage):
•    Postural hypotension (systolic drop when moving to stand)
•    Painless heart attack and sudden death
•    Fixed heart rate
•    Pupillary (abnormalities due to nerve damage):
•    Reduced responsiveness to light
•    Decreased pupil size
•    Coronary artery disease:
•    Knows this is the greatest cause of mortality in diabetes
•    Mortality is 2-4 (possibly 8) times that of no diabetic populations
•    Extremity amputation
•    Knows appropriate standards of care that health providers should provide
•    Seeks medical attention in response to symptoms of complications
•    Knows that complications are multifactor but that diabetes control is one factor

General Knowledge

•    Knows why insulin cannot be taken as a pill
•    Knows the function and need for glucose metabolism
•    Knows that cells need glucose inside of them to work
•    Knows that glucose is the major fuel for cells
•    Knows that sugars are used by the body for energy
•    Knows that insulin is necessary for glucose to be used
•    Knows what the dawn phenomenon is
•    Aware that smoking causes insulin resistance
•    Knows that intensive insulin and dietary therapy that maintains glycemic control can delay diabetic vascular complications
•    Knows that smoking is especially dangerous for people with diabetes because it increases the already high risk for blood-vessel disease
•    Knows caffeine can raise BG and make recognizing symptoms of low BG difficult

Miscellaneous


•    Uses mild soap to clean skin
•    Uses warm (not hot) water to clean skin
•    Uses a non-oil-based moisturizing lotion for skin
•    Uses sunscreen when in the sun
•    Has a clearly visible medic alert indicating s/he has diabetes
•    Knows how to get help when needed
•    Informs gym teachers and coaches of diabetes
•    Informs gym teachers and coaches of need for exercise snacks
•    Gym teacher and coaches are prepared to treat hypoglycemia
•    Visits physician at least quarterly
•    Knows that puberty/menses may be delayed in diabetics, especially in poorly controlled diabetics
•    Knows that menstrual irregularities are more common in poorly controlled diabetics
•    Knows that diabetes may be more difficult to control while taking birth control pills
•    Knows that pregnancy for women with diabetes requires an unusually disciplined regimen
•    Knows most infants of mothers with diabetes will not have diabetes

Areas Not Covered

•    Interactions with health professionals
•    Social aspects (e.g., sleep-over at friend’s house, parties, etc.)
•    Cultural aspects of care/education
•    Pregnancy (e.g., teen pregnancy)
•    Preoperative situations
•    Dealing with managed health care and insurance coverage

IMPORTANT SAFETY INFORMATION
- Medtronic Diabetes insulin infusion pumps, continuous glucose monitoring systems and associated components are limited to sale by or on the order of a physician and should only be used under the direction of a healthcare professional familiar with the risks associated with the use of these systems.
- Successful operation of the insulin infusion pumps and/or continuous glucose monitoring systems requires adequate vision and hearing to recognize alerts and alarms.

Medtronic Diabetes Insulin Infusion Pumps
- Insulin pump therapy is not recommended for individuals who are unable or unwilling to perform a minimum of four blood glucose tests per day.
- Insulin pumps use rapid-acting insulin. If your insulin delivery is interrupted for any reason, you must be prepared to replace the missed insulin immediately.

Medtronic Diabetes Continuous Glucose Monitoring (CGM) Systems
- The information provided by CGM systems is intended to supplement, not replace, blood glucose information obtained using a home glucose meter. A confirmatory fingerstick is required prior to treatment.
- Insertion of a glucose sensor may cause bleeding or irritation at the insertion site. Consult a physician immediately if you experience significant pain or if you suspect that the site is infected.

Please visit http://www.medtronicdiabetes.com/importantsafetyinformation for complete safety information.

Comments

Anne Fernandes

Posted on Sat Oct 29 11:14:54 GMT 2011

Hi Lane,
This is the first time that I have visited this posting. I have had diabetes since 1966. I was 12! I appreciate the reflecting about what my parents and I had to do then to cope with the disease, versus the coping strategies today. We boiled my urine in a test tube with several drops of another solution to see if I were "spilling" sugar. That's how we decided how much insulin to give me. I had a glass syringe with stainless steel needles that were boiled weekly. I mixed a fast-acting and slow-acting insulin. When I wanted something sweet, I had fruit...no cookies, cakes, or candy. We measured EVERYTHING in a measuring cup.
I have never enumerated the tasks that my family and I do to keep me healthy, but my husband can tell you..it's a full-time job, and we do it well. My pump and my continuous blood glucose system are from heaven, and assist the all day/every day monitoring of the disease. That was not a whine, just a fact, as you well know. While you're working on the artificial pancreas, maybe you could find a cure for celiac disease, too? One in ten diabetics has celiac sprue, too. Still..not a bad life. My husband learned to shop and cook sans wheat, rye, barley, or oats.
I see my endocrinologist every four months, my opthamologist yearly and have NO retinopathy after forty-five years of living with diabetes. Thank you team... God, family, research, and Medtronic. You make my life manageable and....normal! Anne Fernandes

Meri

Posted on Mon Oct 31 02:01:07 GMT 2011

This is brilliant! Thank you!

Karrie

Posted on Tue Nov 01 16:13:52 GMT 2011

@Anne Congrats on doing so well and thanks for sharing with us!

Lane

Posted on Sun Nov 06 00:46:39 GMT 2011

Thank you so much for your comments, Anne. There's been so much progress in diabetes therapy since insulin was first isolated almost 90 years ago by Banting and Best, however the physical and mental task load is still significant. As you point out, people with celiac disease and other factors often have an even higher task load. My son was diagnosed with celiac six months after he was diagnosed with diabetes, so our family understands first hand the complicating effects of celiac on diabetes. Every couple months he'll accidentally get exposed to gluten, and it usually takes us about 12 hours to figure this out and make accomodations. The first time it happened we thought he'd gone into a second honeymoon, because his blood glucose dropped precipitously and eating extra carbs had no effect. - Lane

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