JDFR Holds T1D & Me Symposium (Continued)
Q: My teenager has been using a Medtronic pump for many years. Is there a pump that teens are more successful with?
Dr. Adi: It's really his or her choice. Medtronic works just fine. The Animas is okay. The Tandem t:slim is really cool, but it doesn't have software for downloading data yet [diaTribe Editor's Note: Tandem's web-based t:connect software is currently awaiting FDA approval]. The difference between Medtronic (176 or 300 units) and Animas (200 units) is how much insulin they can hold. If your child uses 100 units a day, then one pump might not last more than a day. These are the things that you will have to consider before you choose a pump.
Q: My child doesn't like changing the infusion set. What happens if he leaves the same one in for more than three days?
Dr. Adi: The reality with these sets is that after three days the insulin doesn't infuse as well. Either the insulin crystallizes at the end of the catheter, or your immune system reacts to the catheter and encapsulates it so that it does not infuse as well. There are some materials that are better than others. For instance, some metal infusion sets are better because they don't cause the same reactions with the immune system as a plastic set.
High and Low Blood Glucose Levels and Their Consequences
Q: We all know that we must avoid low blood glucose levels and we know that over time high glucose levels are bad, but exactly how dangerous are high blood glucose levels? If my daughter goes high a few times a day, is she going to go blind? What are the key things I should pay attention to? Should I look at her A1C?
Dr. Adi: Truthfully, I don't like the A1C at all. When patients come to my practice, that's what they ask about first. But the reality is that the A1C is the average of all the numbers. The A1C was created at a time when people did not have raw data. You can have an A1C of 7.0%, with numbers that are very tight, 100-180 mg/dl, but you can also have that A1c with a range of 40-350 mg/dl. The first thing you need to look at is the raw data.
The complications come from tissues being immersed in high sugar concentrations all the time. The longer you stay in high sugar concentrations, the more protein glycosylation increases, and the more likely it is to have complications. We are finding that if you are at one extreme, either really high or low, it's not really how high or low of blood glucose level that determines the severity of the complication, but the rate of decline or the rate of increase. If you measure 50 mg/dl, you should aim for increasing the blood glucose level to 90 mg/dl, not 300 mg/dl.
Complications in diabetes are related to many things. First, you have to have the genetics that make you predisposed to them. There are people who have an A1C of 11.0%-12.0% and blood sugar levels of 300 mg/dl and 400 mg/dl who have no complications. There are some genes that are protective and there are other genes that make you susceptible.
Many years of having high blood glucose levels will cause complications — over the span of years. However, you should still try to avoid high blood glucose levels. You should not say that it's only a matter of time before complications occur; you should still try.
Q: I have a two-year-old child, and we are extremely worried about nighttime hypoglycemia. How often do you recommend your patients who do not have a CGM get up at night to check their blood glucose?
Dr. Buckingham: Two is a tough age; you should get a CGM so that you can use it remotely. I recommend that you check once a night, at around 2:00 or 3:00 in the morning. If you check and it's not low, then you can back off a little. If there has been a lot of activity, or if you are concerned, then you should check. Remember though that the brain needs sleep. As a parent, you also become dysfunctional when you don't sleep enough and are checking too often.
Dr. Adi: Just because you are not on a pump yet doesn't mean you cannot have a CGM. You can get your CGM before you get your pump. As a rule, you should check around 1:00, 2:00, or 3:00 AM. Whenever you have a low reading during the day, you need to check that night. If you're high before bedtime and you do a correction, then you need to check. If there's some irregular activity during the day, you need to check.
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Consider a world in which everyone's health data is SO private that no individual, no healthcare professional, no medical textbook can be certain about the cause of a person's symptoms, or how best to treat them. Amidst a myriad of expensive, highly-targeted pharmaceuticals and devices, therapy is a hit-or-miss proposition — provided one is wealthy enough to be able to try one, if not all, of them. In many ways, that's the state of diabetes care today. And if...