Live Healthy, Live Well– with Type 1 Diabetes

1. Live Healthy, Live Well– with Type 1 Diabetes Rhonda McDavid, Executive Director Southeastern Diabetes Education Services Special Thanks to: Dennis Pillion, PhD – Professor, Dept. of Pharmacology & Toxicology UAB School of Medicine and Ambika Ashraf, MD – Pediatric Endocrinologist Children’s Hospital of Alabama, Division of Endocrinology

2. HI

3. Objectives • Understand the difference between Type 1 and Type 2 diabetes • Recognize signs and symptoms of diabetes • Understand symptoms and treatment of hyperglycemia and hypoglycemia • Learn a patient/caregiver perspective of living with diabetes • Review resources for children, adults, and families living with diabetes • Provide resource referrals to families living with diabetes • Learn resources and opportunities for CME, career growth, and volunteerism in diabetes

4. Pancreas Muscle and Fat Cells Cannot Produce Enough Insulin Cannot Use Insulin Effectively What is Diabetes? Body lacks insulin (Type 1) or is unable to use insulin effectively (Type 2) Type 1 Type 2

5. When the body lacks insulin, what happens? Type 1 Type 1 Diabetes Facts About T1D Type 1 diabetes (T1D) is an autoimmune disease in which a person’s pancreas stops producing insulin, a hormone that enables people to get energy from food. It occurs when the body’s immune system attacks and destroys the insulin-producing cells in the pancreas, called beta cells. While its causes are not yet entirely understood, scientists believe that both genetic factors and environmental triggers are involved. Its onset has nothing to do with diet or lifestyle. There is nothing you can do to prevent T1D, and—at present—nothing you can do to get rid of it.

6. Whom T1D Affects Type 1 diabetes strikes both children and adults at any age. It comes on suddenly, causes dependence on injected or pumped insulin for life, and carries the constant threat of devastating complications.

7. How T1D Is Managed Living with T1D is a constant challenge. People with the disease must carefully balance insulin doses (either by injections multiple times a day or continuous infusion through a pump) with eating and other activities throughout the day and night. They must also measure their blood-glucose level by pricking their fingers for blood six or more times a day. Despite this constant attention, people with T1D still run the risk of dangerous high or low blood-glucose levels, both of which can be life threatening. People with T1D overcome these challenges on a daily basis.

8. What happens when the body is insulin resistant? Type 2

10. The Miracle of Insulin February 15, 1923 Patient J.L., December 15, 1922

11. The Air Conditioner Analogy: Like a thermostat, your body keeps your blood glucose near 100 mg/dL all the time. It releases insulin to reduce the blood glucose level when it rises. When you eat food, your body does two things: 1) it triggers immediate insulin release from the pancreas by a neural response, and 2) as you digest the food you eat, your blood glucose gets higher. In response to the higher glucose, your pancreas then secretes additional insulin. Insulin lowers glucose by reducing liver glucose output and by increasing glucose transport into fat and muscle cells.

12. Between meals, your blood glucose level will go down. Insulin secretion will then be decreased. If you don’t have diabetes, insulin secretion increases and decreases automatically, much like a central air conditioner, to keep your blood glucose from getting too high or too low.

13. Type 1 Diabetes When an air conditioner breaks suddenly, it tops making cool air. The house gets very hot, very quickly. When a person gets Type 1 diabetes, the pancreas “breaks” and stops making insulin. The blood glucose gets very high, very quickly. The reason it breaks is because the pancreas gets infected with a virus and the body produces antibodies that destroy the infected pancreatic beta cells. It is NOT caused by eating too much sugar. The child and the parent have NOT done anything wrong.

14. Type 2 Diabetes When an air conditioner gets old, after 30-40 years of service, it gradually produces less and less cold air. It runs all the time, but cannot keep the house cool. The house gradually gets warmer. Eventually, the air conditioner stops working. When a person gets Type 2diabetes, the pancreas continues to make insulin, but it cannot keep the blood glucose low enough.Thebloodglucose gradually gets higher. This forces the pancreas to work even harder. Eventually, the pancreas stops making insulin.

15. The story has changed… Diabetes in the 1920’s Diabetes in the 21st century

18. Statistics • As many as three million Americans may have T1D.1Alabama is estimated to have 3,000 children living with Type 1 diabetes. • Each year, more than 15,000 children and 15,000 adults—approximately 80 people per day—are diagnosed with T1D in the U.S.2 • Approximately 85 percent of people living with T1D are adults, and 15 percent of people living with T1D are children.1 • The prevalence of T1D in Americans under age 20 rose by 23 percent between 2001 and 2009.3 • The rate of T1D incidence among children under age 14 is estimated to increase by three percent annually worldwide.4 • T1D accounts for $14.9 billion in healthcare costs in the U.S. each year.5

19. Warning Signs Warning signs of T1D may occur suddenly and can include: • Extreme thirst • Frequent urination • Drowsiness or lethargy • Increased appetite • Sudden weight loss • Sudden vision changes • Sugar in the urine • Fruity odor on the breath • Heavy or labored breathing • Stupor or unconsciousness

20. What Is It Like to Have T1D? Ask people who have T1D, and they will tell you: it’s difficult. It’s upsetting. It’s life threatening. It never goes away. But at the same time, people with T1D serve as an inspiration by facing the disease’s challenges with courage and perseverance, and they don’t let it stand in the way of achieving their goals.

21. “Both children and adults like me who live with type 1 diabetes need to be mathematicians, physicians, personal trainers, and dietitians all rolled into one. We need to be constantly factoring and adjusting, making frequent finger sticks to check blood sugars, and giving ourselves multiple daily insulin injections just to stay alive.”— Mary Tyler Moore “It is a 24/7/365 job. We never get to relax and forget about food, whether we’ve exercised too much or too little, insulin injections, blood-sugar testing, or the impact of stress, a cold, a sunburn, and on and on. So many things make each day a risky venture when you live with T1D.”— Mary Vonnegut, adult, Rhode Island “Unlike other kids, I have to check my blood sugar 8 to 10 times a day; everything I eat is measured and every carbohydrate counted. My kit goes with me everywhere I go … Too much exercise or not eating all my food can be dangerous. I think I’m too young to have to worry about all this stuff.”— Jonathan, age 8

22. First there is that of high blood sugar levels this is the effect of not having working islet cells to produce insulin. Without any insulin the body begins to literally consume itself in a process called diabetic ketoacidosis. The long term damage of high blood sugars results in damage to nerves and blood vessels called complications. • The second is insulin itself, it's effect in a normal person, results in the regulation of glucose levels. When given directly to a person without any natural control of the amount released in the body can cause dangerous lows in blood sugar levels, these can lead to insulin shock, leading to coma, or even death. • Other factors are exercise, diet, hormones and a multitude of other influences that can push a blood sugar levels into one extreme or another.

23. Signs and Symptoms of High Blood Sugar – Hyperglycemia • Excessive Urination • Excessive Hunger and Thirst • Dry Mouth • Nighttime Urination • Lack of Energy or Lethargy • Unexplained Rapid Weight Loss • Eventual Coma

24. What to Do About High Blood Sugar Levels • The following recommendations are general treatments for high blood sugar. Specific actions–such as giving additional insulin–should be determined by the adult with type 1 diabetes (T1D), physician, or parents (for a child). • 1. If blood test results are slightly above normal: • Continue regular activity • Drink water or sugar-free drinks • Monitor blood sugar levels by checking regularly • Chart blood glucose test results • 2. If blood test results are moderately high: • Don’t engage in strenuous exercise • Drink water or sugar-free drinks • Inject additional insulin if instructed by physician or parents • Monitor blood sugar levels by checking regularly • Chart blood glucose test results • 3. If blood test results are very high: • Don’t engage in strenuous exercise • Drink water or sugar-free drinks • Inject additional insulin if instructed by parents or physician • Test ketone levels if advised by parents or physician. If high, contact parent or physician immediately • Monitor blood sugar levels by checking regularly • Chart blood glucose test results

25. Low Blood Sugar – Hypoglycemia Symptoms • Symptoms you may have when your blood sugar gets too low include: • Double vision or blurry vision • Fast or pounding heartbeat • Feeling cranky or acting aggressive • Feeling nervous • Headache • Hunger • Shaking or trembling • Sleeping trouble • Sweating • Tingling or numbness of the skin • Tiredness or weakness • Unclear thinking • Fainting, seizure, coma

26. Treatment of Low Blood Sugar - Hypoglycemia • If you have diabetes, check your blood sugar level whenever you have symptoms of low blood sugar. If your blood sugar is low (70 mg/dL), you need to treat yourself right away. • Eat something that has about 15 grams of carbohydrates. Examples are: • 3 glucose tablets • A 1/2 cup (4 ounces) of fruit juice or regular, non-diet soda • 5 or 6 hard candies • 1 tablespoon sugar, plain or dissolved in water • 1 tablespoon honey or syrup • Wait about 15 minutes before eating anything else. Be careful not to over-treat by eating too much. This can cause high blood sugar and weight gain. • Check your blood sugar again. • If you don't feel better in 15 minutes and your blood sugar is still low (less than 70 mg/dL), eat something that has 15 grams of carbohydrates again. • You may need to eat a snack that has carbohydrates and protein if your blood sugar is in a safer range (over 70 mg/dL) and your next meal is more than an hour away. • If these steps for raising your blood sugar do not work, call your doctor right away. • Persons with severe hypoglycemia are treated with glucose injections or the hormone glucagon. Immediate treatment is needed to prevent serious complications or death.

27. Carbohydrate counting seems very intense? • Can a person with diabetes do a fixed amount of insulin with meal?

28. Carb counting/ Insulin: carb ratio • This estimates the grams of carbohydrates that are covered by a unit of insulin • E.g.: 1 unit for every 20 grams of carbs • Benefit is you can have flexible meals with varying amounts of carbs

29. Sliding scale vs. Correction factor • Refers to how many units of insulin is required to correct a blood glucose value to a desired target level Correction factor = BG – target --------------------- Sensitivity • Sensitivity: The amount of drop in BG that can be achieved by 1 unit of insulin • BG- 150/ 50 means 150 is the target blood sugar and 50 is the sensitivity

30. When to Check and Why Before every meal  can give correction, evaluate lantus/ basal rate dose Two hours after meals  To evaluate insulin to carbohydrate ratio Checking blood sugars • Bedtime  To detect low or high blood sugars before going to sleep • 2 AM  To evaluate lantus dose/ overnight basal rate • If on pump: 2 hours after site change  To evaluate site change • Two hours after a correction bolus  To evaluate correction dosing

31. If pattern - decrease insulin accordingly Keep records and track pattern Check BG before exercise, Q 2 hourly during high risk period and at 3 am Can people with type 1 play Sports?YES!

32. What about ketones and exercise? • If BG >250 prior to exercise, check urine for ketone • No exercise with positive ketone • (if Precision Xtra blood ketone >0.5 mmol/l) • If no ketone and BG>250, use half correction • If on pump do not disconnect >2 hours

33. Challenges in Teens Risk-taking behaviors Pushing the limits of therapy (teens often miss boluses, run out of insulin ignore warning alarms, omit catheter changes) Parents must remain involved throughout childhood and adolescence regardless of the intelligence of the child / teen

34. ADA guidelines 6- 12 years of age • The ADA recommended HbA1c for 6 -12 year old <8% • The ideal blood glucose before meal is 90 -180 mg/dl • Ideal blood glucose at bedtime 100- 180 mg/dl

35. ADA guidelines 13- 19 years of age • The ADA recommended HbA1c goal in general for 13-19 year old <7.5% • The A1c goal for an individual patient is <6%, as close to normal as possible without significant hypoglycemia • The ideal blood glucose before meal is 90 -130mg/dl • Ideal blood glucose at bedtime 90- 150 mg/dl

36. Why ARE younger children allowed higher blood sugars? • In younger children high risk of hypoglycemia • Also relatively low risk of complications prior to puberty

37. What are the labs being checked yearly? • Thyroid function test • Celiac disease • Lipid profile • Urine micro albumin • A1C every 3 months

38. Resources: www.southeasterndiabetes.org www.Childrenwithdiabetes.org www.Myglu.com www.Collegediabetesnetwork.org • Re

39. SDES began in 1949 in Mobile, Alabama, when Dr. Samuel Eichold and his wife, Charlotte, founded the first camp for young people with diabetes east of the Mississippi River and south of the Mason-Dixon Line. • Later known as “Camp Seale Harris,” the camp grew from 14 children to now over 500 children and families each year who benefit from diabetes education at, support, and hope at: • Camp Seale Harris residential camp • Camp Sugar Falls day camp • Community Family Programs • Mentoring • Support Groups • Purpose: Teaching children how to • live with diabetes • Values include quality, service and commitment as seen through our medical staff, educators, volunteers and counselors.

40. SDES serves children ages birth - 17 that have Type I Diabetes. More than 2500 children live with Type I Diabetes in Alabama.

42. Primary Purpose: Education and Independence Fun programs that include education about Living Well With Diabetes. Diabetes skills and attitudes/problem-solving are taught during structured classes. Teachable moments occur constantly.

43. Camp Seale Harris Overnight CampLake Martin in Jackson’s Gap, AL • Family Week, Senior Week, Junior Week, Fall Family Weekend • Mobile, AL – Coastal Camp Seale Harris • Camp Sugar Falls Day Camps • Birmingham, Tuscaloosa, Dothan, Mobile, Pensacola • Community Family Programs • Huntsville, Florence/Shoals, Birmingham, Cullman Tuscaloosa/West AL, Montgomery River Region, Auburn/Opelika, Dothan/Wiregrass Area, Mobile, • NW Florida - Pensacola

44. Invitation to You! • Inform your communities about our programs • Refer adults with diabetes to volunteer with camp • Volunteer at our programs – CME at Camp Seale Harris • Lead on local committees • Lead on SDES Boards • Help needy children • Group and individual sponsorships of campers

45. Questions and answers