Transitions in Care. Howard A. Wolpert

of using a pump?” The early adult and college years are often a time when serious relationships (both romantic and platonic) outside of the family first develop, and some people will find the pump a bit too obvious and public. The added responsibility of starting pump therapy can be too much to handle if you have a lot of other commitments in your life. Some find it’s better to deal with the demands of getting settled into a new job or college before trying the pump. Because it is you who lives with and manages your diabetes day-to-day, only you will really know which type of insulin program will suit you best. The decision should be yours—made in consultation with your health care provider.

FIGURE 3 Schematic showing basal insulin (glargine or determir) and mealtime rapid-acting insulin such as aspart, lispro, and glulisine.

FUNDAMENTAL SKILLS IN MANAGING DIABETES

      You have probably already discovered that the key skill in managing your diabetes is in learning how to think like a pancreas—understanding how to match up insulin with the carbohydrates you eat. Therefore, the essential elements in learning how to regulate your diabetes are having an understanding of how insulin acts and knowing the carbohydrate content of your foods.

      A comprehensive review of all the knowledge needed to tighten up glucose control is beyond the scope of this book. However, as you are moving toward the post–high school phase of your life, there are a number of important skills and concepts that you need to master. Look at the list we offer below and see if you feel comfortable in your knowledge of these topics. If not, use this outline as discussion points with your diabetes team when you see them next. This can be a great opportunity to advocate for yourself. Some of the important skills you will need to master include the following:

      

Understanding how the different insulins you take peak and act in your body.

      

Learning about the carbohydrate and fat content of the foods in your diet. This includes learning how to read food labels (and which parts of the food labels are most important) and judge portion sizes. Sometimes keeping a food diary can be helpful.

      Pros and Cons of Pump Therapy

      Pros:

      • Greater lifestyle flexibility and freedom

      • Greater sense of control over diabetes

      • Greater sense of well-being from a reduction in glucose fluctuations

      • Promise of a healthier future

      • Help with the dawn phenomenon (increased release of glucose by the liver during the early morning [“dawn”] period)

      • Improved ability to recognize low blood glucose reactions (see Bumps in the Journey: Intensive Therapy and Hypoglycemia on page 24)

      • Improved control during physical activity

      • Easier weight control (see More Bumps in the Journey: Intensive Therapy and Weight Gain on page 32)

      Cons:

      • Pumps are a visible sign of diabetes

      • Extra time and effort required to get started and use the pump

      • Inconvenient to wear

      • Increased risk for diabetic ketoacidosis

      • Must monitor blood glucose at least four times a day

      • Added responsibility of taking care of the catheter sites and pump

      • Extra troubleshooting skills required

      • Catheter site infection

      • Cost

      For more information to help you decide whether the pump is right for you, see Smart Pumping for People with Diabetes: A Practical Approach to Mastering the Insulin Pump (Wolpert 2002).

      

Using blood glucose monitoring to decide about insulin doses and using the numbers from your logbooks to identify glucose patterns.

      

Learning how to troubleshoot and treat hypoglycemia (low blood glucose reactions).

      

Learning how physical activity affects glucose control and how to regulate your glucose levels during and after exercise (see Getting Physical on page 54).

      

Learning how to manage your diabetes during illness and sick-days.

      

Learning how alcohol affects your glucose control and how to manage your diabetes when you drink (see page 52).

      This learning will be an ongoing lifelong process, and as you progress further, you will find that that there will always be some additional information or insights that can be important to you. For example, the fat in your diet (sometimes hidden in muffins, pizza, and fries) can make your body less responsive (sensitive) to insulin and can also have a big impact on your blood glucose after meals. So this may be something you will also need to pay attention to as you progress in optimizing your glucose control. Figure 4 illustrates some of the factors that affect the delicate balance between high and low glucose levels.

      For more information on intensive insulin and pump therapy, see the Complete Guide to Diabetes (American Diabetes Association 2005). Your state chapter of the American Diabetes Association (ADA) can put you in touch with ADA-recognized education programs that offer guidance and instruction in diabetes self-management.

FIGURE 4 The balance between high and low glucose levels.

KEEPING PERSPECTIVE ABOUT MONITORING AND NUMBERS

      As already mentioned, expanding your knowledge base and developing a sense of mastery of how all of these factors (insulin, food, exercise, etc.) affect your blood glucose level can take years of experience. Remember that despite the recent advances in the development of new insulins, pumps, and monitoring devices, the tools we have to manage type 1 diabetes today are still imperfect. There is no magic formula for getting perfect glucose numbers. No one living with diabetes can always keep their blood glucose numbers between 80 and 120. Having consistently perfect numbers is an unattainable goal—and so is being a Nobel laureate before the age of 30, or running a mile in under 3 minutes, or shooting a 50 in an 18-hole game of golf. Setting goals that are out of reach will likely cause frustration. There may be some periods in life, such as during pregnancy, where one’s energies and priorities are focused on ensuring remarkably tight glucose control. However, it is usually difficult for women to sustain these tight goals once the pregnancy is over and attention is focused on the needs of the newborn and the other demands of life.

      Having realistic goals is the key to living well with diabetes and to living well in all aspects of your life. It is also important to keep in mind that if your personal blood glucose goal is 70–180 mg/dl, you should aim for the average of your blood glucose measurements to be in that range. This does not necessarily mean that all (or even most) of your individual measurements will be in that target range. The object of monitoring is not to “test” your performance; it’s to give you the information you