Q: We are considering an insulin pump for our son. Do HbA1c levels (glucose control) always improve in pump users?
A: That is a good question. Our initial publication (Pediatrics 107:351-356;2001) found that one-third of people improve their HbA1c, one-third stay the same and one-third worsen. The main reason the one-third worsen relates to forgetting to bolus with meals. The "basal" insulin is very flat in activity and does not provide any peaks for meals. Thus a bolus must be taken (including at least part of the dose prior to the meal) or the blood sugar level will go very high. It is our "clinical" impression that if one bolus per week for a meal is missed for 3 months, the HbA1c will be one-half point higher (or 2 boluses per week = a full point higher).
This is discussed in Chapter 26 in the new 11th edition of the Understanding Diabetes book.
Q: My daughter seems to have a “knack” for losing things. With insulin pumps being so expensive is it possible to get insurance to replace it if it gets lost?
A: One of the families has looked into this. They found that many homeowners insurance policies would not insure medical equipment. However, they did find that one policy called “CHUBB” would. They had to change their homeowners policy to the company but they were then able to purchase a “rider” for $23.00 a year to insure their child’s pump.
Q: My daughter is going to college in the Fall. Does she need to get the (menigococal) meningitis vaccine?
A: If she will be living in the dorms where she will be in close proximity to other students then yes, she definitely does need to get the vaccine. If she will be living off-campus in an apartment or house then the vaccine is not required.
Q: Our family does everything by e-mail now. Is there a way I can get the blood glucose fax sheets from Chapter 7 of the 11th edition of the Pink Panther book on my computer?
A: Yes, this can now be easily done. For families wanting to use these forms to e-mail the Barbara Davis Center, you can get them from these links:
Daily Record Sheet 1.
Daily Record Sheet 2.
or alternatively you can navigate directly from Chapter 7 of the Pink Panther Book at:
http://www.uchsc.edu/misc/diabetes/udchap7.html
Please note that, depending on the resolution of your monitor, the lines on the sheets may not appear continuous. They will, however, print out accurately.
You can also download the pump-blood glucose record sheets using this link:
Pump Record Sheet.
or you may go to Chapter 26 and click on the link for Table 5:
http://www.uchsc.edu/misc/diabetes/udchap25.html
You can e-mail these to your nurse or your doctor at the Barbara Davis Center (naming convention: firstname.lastname@uchsc.edu).
It is essential that you include phone numbers and times that are convenient for providers to call.
Q: I read about the new insulin, Lantus(r). How does one decide if they should try it?
A: You should discuss this with your doctor. It is a genetically altered insulin (like Humalog(r)) that is long acting (24 hours). It is a basal insulin (like pump basal insulin) with very little peaking (see Chapter 8 of Understanding Diabetes). Then Humalog insulin must be taken before each meal - necessitating four shots per day. The Humalog disposable pen can be carried in a pocket or purse and works well for the pre-meal injections.
Some people initially complain of a bit more stinging as the Lantus insulin is injected - this complaint seems to last only a few days. It has a more acid pH than the other insulin, so NO OTHER INSULIN CAN BE PUT INTO THE SYRINGE WITH LANTUS. The other insulin as well as the Lantus will be inactivated if this happens. It is more expensive than the NPH and ultralente insulins ($50-$60/bottle) and may not be covered by some insurance plans. Thus, if interested in this new insulin, it is often wise to start by calling your insurance or HMO to see if they will pay for it. Then discuss possible use at the time of your next clinic visit.
Q: My doctor told me I should take an ACE-inhibitor. What is it?
A: In this case "ACE" is an abbreviation for "Angiotensin Converting Enzyme." The ACE-inhibitor blocks the actions of this enzyme, which normally converts Angiotensin I to Angiotensin II in the body. Angiotensin II is the most potent vasoconstrictor (constricts blood vessels) known in the human body. When the ACE-inhibitor is taken, blood vessels will not constrict as much. Thus, the blood pressure may be lower due to the main official use of the ACE-inhibitor.
The ACE-inhibitors were found to have a second feature that may be even more important for people with diabetes. For people with early kidney damage (microalbuminuria), taking the ACE-inhibitor often causes the microalbumin levels to return to normal. It does this by relaxing the outflow vessels of the kidneys. A third feature of ACE-inhibitors is that they may reduce the risk of heart attacks, for reasons not well understood at present.
The most common side effect of taking an ACE-inhibitor is chronic low-grade cough. It is also possible to have a decrease in the white blood count or an increase in the blood potassium level. These should be checked at three to six month intervals in people receiving this medication. There are now approximately 15 ACE-inhibitors on the market. However, to the best of my knowledge only three of these (Captopril(r), Vasotec(r) and Lysinopril(r)) have been adequately studied to show their effect on reversing early diabetic kidney damage. The Captopril has the disadvantage that it must be taken twice daily, whereas other ACE-inhibitors can usually just be taken in the morning.
It is again important to remind families who have someone who is over 12 years of age and who has had diabetes for at least three years, that two overnight urines must be brought to the clinic once yearly for the microalbumin tests. You are welcome to bring these specimens if you fit these criteria without checking with your doctor or nurse. We appreciate your help. The two overnight samples do not have to be done on two consecutive nights (any time within a week). The instructions are in Chapter 22 in Understanding Diabetes and are included below. The important thing is to detect the microalbuminuria before they become excessive (>200 micrograms/min). It may then no longer be reversible using the ACE-inhibitor.
B. IMPORTANT TIDBITS ABOUT YOUR COLLECTIONS
1. Label each container with your name and #1 or #2.
2. You may use any CLEAN container you have at home that will not leak to collect the sample. We do not provide containers.
3. Store urine aliquots in fridge until your visit (samples are good for one week if kept cold).
4. DO NOT mix collections #1 and #2 together in the same container.
5. DO NOT drink caffeinated or alcoholic beverages or use tobacco after 10 p.m. the evening of the collections.
6. DO NOT exercise strenuously for the four hours prior to bedtime.
7. DO NOT collect specimens during a menstrual period.
8. Failure to follow directions exactly may cause incorrect results.
9. If you have any questions, please call your health care provider.
C. DIRECTIONS FOR MEASURING THE VOLUME
1. Have a measuring cup or (better) a cylinder-preferably marked in cc (mL). One cup is 240cc. Urine is sterile and it is ok to use cooking measuring cups (just wash prior to next use for cooking).
2. Measure the total cc of each overnight sample and put the amounts in the blanks for step 4 for collections #1 and #2.
3. Put a sample of each urine collection in a clean tube. Any clean red top tube from a doctor's office, clinic, or hospital lab will work. Label which sample (#1 or #2) it is, put your name on the tube, and put the tube in a cup in the refrigerator until you get to your clinic. Bring this sheet with the times and total volumes with you.
Q: Is there any way to know if the pop received at fast food restaurants, theaters, and other places is truly "sugar-free" or the regular sugar-containing pop?
A: This question is asked frequently and the answer is "yes." Probably the cheapest way to test is by using the Test-Tape, a roll of yellow tape which can be dipped into the pop. It turns green if there is sugar in the pop. The Diastix, the sugar-only part of KetoDiastix will also change color if there is sugar present. Unfortunately, it is more common than most people realize for the wrong pop to be served, probably in the range of 20% of the time (one glass in five). As sugar pop is one of the most concentrated sources of sugar (approximately 10 teaspoons per can), it usually raises the blood sugar level to the 200 to 400 mg/dl level. This is especially true if it is consumed without other foods which slow the absorption of the sugar, or at a time when Regular insulin is not taken to allow the sugar to enter the cells.
Q: Why are blood glucose levels given in both mg/dl and in mmol/L in the tenth edition of the Understanding Diabetes book?
A: The United States is possibly the last country in the world to still use mg/dl - much as with miles rather than kilometers! It is not likely that the U.S. will switch prior to the next edition in three to four years. However, many other countries do not have an educational book (as in England where I was on sabbatical when this was redone), and physicians from England and elsewhere have asked that the blood sugar levels be expressed in both forms. This will help to make the book more useful in other countries.
Q: Changes in our daughter's insulin dose have confused my wife and me. Initially she was on a low insulin dose which you increased after reviewing her blood sugars and seeing that her HbA1 was high. She got into good sugar control, but now her dose is coming back down again. This doesn't make sense to us.
A: This is quite common, and follows an old adage that: 'GOOD CONTROL BREEDS GOOD CONTROL; POOR CONTROL BREEDS POOR CONTROL." Thus, for someone in poor sugar control, when the liver is making sugar at a very high rate, it takes very little (stress, infection, etc.) to make even more sugar and it may take a lot of insulin to get the liver's sugar production machinery turned off. However, once the liver's pathways for making sugar are turned off, it may not take as much insulin to keep them turned off. Also, stress and infections will not have as great an effect when the sugar production pathways are "turned off." Thus, good control breeds good control!!
Q: Should my child receive the chicken pox vaccination?
A: Yes, if he or she has not had chicken pox! It is recommended by the American Academy of Pediatrics for all children who have not had prior chicken pox infections, and we support that recommendation.
There is an additional factor for children with diabetes who still produce some insulin. Chicken pox is probably one of the many infections that stimulates white blood cells in the pancreas to make toxic particles which cause further islet destruction. This is not proven, but we have heard many times of children being diagnosed with diabetes in the month or two after having chicken pox.
The chicken pox vaccine, Varivax, is a live attenuated vaccine. The main side effects are a mild rash (approximately 3%) and/or temperature elevation (approximately 15%) or tenderness at the injection site (approximately 19%). Ninety-nine percent of people are immune 14 days after the Varivax injection. The immunizations may be obtained by contacting your pediatrician or family doctor.
Q: We notice that when we give the shot to our daughter in the upper outer arm, she frequently has a low blood sugar at school that morning, but is then very high before dinner. Is this possible?
A: It sounds like you are injecting the shot into muscle. This is common in the deltoid muscle (upper lateral arm) area as there is not much fat in that area. I would guess that you are also going straight in (not at a 45 degree angle) which almost always results in the insulin being given into muscle. When the insulin goes into muscle, it is absorbed more rapidly so that low blood sugars are common and then there is not enough insulin left to have its normal effect six to ten hours later.
Q: We just gave our son his afternoon shot and accidentally gave the morning dose rather than the afternoon dose. What should we do?
A: We hear this question almost every week from an anxious parent. The answer is to set the alarm for every two or three hours and to get up and do a blood sugar and get some extra juice or food in. If the value falls to very low levels (below 70 mg/dl), it is necessary to stay up and keep doing the blood sugars every 20 or 30 minutes until the value is above 120 mg/dl.
This problem can be handled and in our experience has never required hospitalization or resulted in a severe insulin reaction. Some families find that having the AM and PM insulin doses taped to the front of the refrigerator can be a helpful reminder - and may also be a good way to communicate or remember recent dosage changes.
Q: Our daughter's HbA1 hasn't gotten down to the desired level. With all the concern from the DCCT on preventing complications, could you please make any suggestions on ways to achieve better control?
A: I have six suggestions:
(1) Perform an afternoon blood sugar after school and judge the afternoon snack and/or insulin supplement on the value at that time.
(2) Wait at least 30 minutes after taking the insulin shot, whenever possible, before eating the next meal (unless the value is <70 indicating a need to eat immediately). The "time-sliding scale" in Chapter 21 of the Understanding Diabetes book is an even better method. I have seen declines in the HbA1, by two points with use of this time scale.
(3) One of the biggest keys to better control which was reported in the DCCT was more frequent blood glucose monitoring, along with making good use of the results. All subjects did a MINIMUM of four blood glucose levels each day. An unfortunate trend in recent years has been to not record results as they are all recorded in the meter. When this is not done, trends for high and low values are often missed and insulin adjustments may not be made.
(4) Strangely enough, preventing low blood sugars is often important in achieving better control. Low blood sugars often result in excessive eating and sending the blood sugar up to 300 or 400 mg/dl. Although excessive eating is probably the major cause of the subsequent high blood sugars, output of balancing hormones (rebounding) likely plays a secondary role in some people. Because juice (no fiber) routinely raises the blood sugar excessively, the DCCT recommended using milk rather than juice to treat most reactions.
(5) I do think that "turning off" the liver's production of glucose (sugar) in the early morning is important in relation to keeping hepatic glucose production "turned off" all day long. For many people, the human NPH insulin just does not last long enough from pre-dinner to arising the next morning to fulfill this function. It may be necessary to take the evening NPH at bedtime to have it successfully last through the night. An alternative that sometimes works is to use Ultralente insulin at dinner, as this sometimes lasts longer than NPH insulin.
(6) Last but not least, a word must be said about missed insulin shots. One shot missed per week results in upsetting balancing hormone equilibrium and secondary very high glycohemoglobins. It is essential not to miss insulin injections.
Q: My Ultralente insulin at dinner seems to be keeping my sugars down much better than NPH insulin does the next morning. Would I be wise to use Ultralente insulin in the morning too?
A: Two shots a day of Ultralente insulin provides essentially a "flat" line of insulin activity (good for suppression of liver glucose production). It is then essential to take injections of regular insulin 30-60 minutes prior to meals to cover the second source of blood sugar - the food we eat. For someone planning to remain on two shots per day, Ultralente insulin in the morning does not peak adequately to cover daytime meals, and morning NPH insulin usually works better.
Q: 1. When and why do you release new editions of the Understanding Diabetes book?
2. Where do some of the new terms such as "false reaction", "thinking-scales" and "internal" and "external" sugar production come from?
A: 1. The new editions of Understanding Diabetes come out about every three years. When an important clinical advance is made, the foundation staff and I try to get this information into a new edition as soon as possible. With the 8th edition, the Diabetes Control and Complications Trial (DCCT) had been completed, and it was important to make some of the results of this study available to families. In addition, there was a major change in philosophy around diet and diabetes and this needed to be communicated. The basic research had been done on the new insulin derivative, Humalog(R), but it had not yet been approved by the FDA, so the name Humalog(R) could not be published, and the term "new-insulin derivative" was used instead. This is the price one pays for bringing information to the public so quickly. The coloring book about diabetes was off press after the FDA approved Humalog(R), so we were allowed to use the name.
The next edition will contain much more information on Humalog(R), as we have learned more about it since so many people now use it. The next edition will also have initial information on subcutaneous glucose sensors now being clinically tested by several companies. The FDA probably will not have approved the sensors before the new book goes to press.
2. Yes, some new terms have been invented or coined with each edition. You are correct in that "false reactions" and "thinking scales" were two such terms in the 8th edition. The concepts of "internal" and "external" sugar production came as new additions to the 7th edition. One new term, "insulin cocktails" for mixtures of Humalog(R) and Regular insulin and used in our recent article in Diabetes Forecast will definitely be a new term in the next edition. (Sorry, Mr. Webster!)
Q: Our teenage son has had a mildly elevated HbA1c value (9%) over the past year. His physician and his mother and I have warned him about kidney failure and vision problems, but it doesn't seem to do any good. He currently receives Humalog(R) and NPH insulin before breakfast and before dinner. What would you suggest?
A: First, it has long been known that scare tactics do not work with teenagers. This is particularly true in the mid-teen period (15 to 17 years) when they are "invincible," which may in itself lead to risky behavior. If you want your son to change, you and his health care providers might start with "planting seeds." It might be suggested that a third shot each day perhaps of Humalog(R) using the insulin pen would help at lunch, or at the time of the afternoon snack. It is also sometimes helpful to switch the evening long-acting insulin (e.g., NPH) to bedtime and to just use the Humalog(R) at dinner. At first, he may resist. Continue to offer education, but without the scare tactics. Eventually, he may be willing to try the third shot. Then praise him and offer support. Hopefully, this will help him to continue the positive action he has taken. It helps if he is able to feel a benefit (feeling better, less frequent voiding, etc.). However, he may not feel different. If growth picks up with the lower HbA1c value, point this out to him. The lower HbA1c value should also be a plus and give him positive feedback for this. Hopefully the sum total will be such that he will want to continue with the new behavior (the third shot). This model for making change has many potential applications, both in diabetes-related change and in other areas.
Q. What is the significance of the Canadian islet transplant report?
A. The Canadian report in the July, 2000 New England Journal of Medicine described seven people cured of diabetes after each received islets from two donor pancreases. Three immunosuppresants were, and are required, but importantly, steroids were not used. Steroids have been used in the past, but increase blood sugar levels which may be toxic to islets. This research definitely offers hope to all families of a person with type 1 diabetes, just to show that a cure is possible. The down-side is that two of the immunosuppressant medicines are new and the long-term side effects of these medicines are not yet known. In addition, only about 1,000 viable pancreases (enough for 500 of the 1-2 million type 1 diabetic patients) are harvested each year. The Barbara Davis Center does plan to start a program to replicate the Canadian report, but older subjects (not children) will initially be studied.
Q. What is the significance of the federal government's consent to allow funding for stem-cell research?
A. As can be surmised from the question on islet cell transplantation, there are not enough pancreases available to cure all of the people with type 1 diabetes. Thus, other sources of islet cells will be important. Stem cells offer one possible source. Stem cells are immature cells that can develop into specialized cells. In this case, stem cells come from an early (one week) embryo. The embryos have been obtained for in vitro fertilization, and as more are obtained than are used, some are left over (in the frozen state). Rather than discard these, they can now be used for research. It should be noted that stem cells may also be obtained from early therapeutic abortions, or possibly even from adults. At any rate, the trick will be to direct the stem cells into islets. It is known that islets "bud" from pancreatic ductules. Thus, in a developing fetus, this would be the place to look for pre-islet stem cells. In the early embryo, much work will be needed to learn how to direct a very immature cell to develop into an islet. This type of research is still far off.