THE MEDICAL DIRECTORS CORNER FROM TEXAS LIONS CAMP At the conclusion of parent’s day dinner last Friday night, a mom came up to me and said “after listening to what you said tonight, I didn’t know you could take insulin between meals”. This statement from a motivated, intelligent and caring parent struck me like a ton of bricks. Earlier I had been discussing correction doses of insulin and how they worked and were originally conceived. It was shocking to hear that this parent was not aware of this very important type 1 diabetes care skill. Some background is in order. A human pancreas makes insulin in bursts every few minutes. This fact might surprise some of you. In reality, many glands release their hormone products into the bloodstream in surges or bursts. Their quantities might be very small, but they are still released episodically into the bloodstream. The person carefully measuring blood sugar levels (with a meter or a CGM device) will see a fairly “straight line” effect on their sugar levels in a typical non-d person. But even a non-diabetic has blood sugar levels that wax and wane (up and down) during the day. As I like to say: “the only person with a straight line blood sugar level is a dead person”. Getting back to point; the pancreas can always be considered to be “course-correcting” blood sugar levels with small bursts of insulin that are released based on the changes (shifts or trends) in blood sugar levels. When I teach persons with diabetes how to use insulin as an effective tool to manage their diabetes, the concept of the “correction factor” or “insulin sensitivity factor” is a core element of this effort. Why this is discouraged or not even taught, as that mom explained to me, leaves me incredulous. Multi-dose insulin dosing and insulin pump therapy are both based on the principle that a background level of insulin is always needed to prevent high sugars and ketones (Lantus, Levemir or the basal rate of the pump), and when source of glucose (usually food) is eaten, then a proper, matching amount of insulin is needed to offset the rise in blood sugar that would occur in its absence. Like an NFL cornerback tightly covering a wide receiver, the theoretical goal of insulin therapy is to “cover” the changes in sugar levels created by eating food, as well as the natural ebb and flow of sugar from within the body that happens in all of us. A correction dose of insulin is absolutely necessary if anything other than mediocre control is to be expected. Taking an insulin dose (calculated) and balancing it with the carbs eaten is how persons are taught to do. After getting numbers from a general formula, then carefully counting carbs and taking the insulin before rather than after the meal, then “in theory” this is expected to result in near normal blood sugar levels, right? Frankly, this sounds more like a Rube Goldberg contraption than it does a dynamic diabetes management tool. In fact, what I describe could not be more STATIC. In a way, current MDI or pump therapy performed without a correction dose used at or between meals as needed based on measured sugar levels, is like asking a golfer to hit nothing but holes in one at every tee shot, or each quarterback to execute a football play which results in a touchdown every time. Disallowing the correction dose is a setup to fail, plus it’s a setup for frustration. It holds back a person from attaining the best diabetes control possible in my opinion. Readers may consider this post more of an editorial than anything else, but I’ve been working with diabetes patients for decades, a certified diabetes educator (CDE) for 25 years, and lived with type 1 diabetes for almost 50 years. I am of the firm belief that never teaching or allowing an insulin correction factor to be used between meals is flat out wrong. It’s a setup to fail. At best its a rare exception and should never be a norm. Furthermore, the assumption that most patients and families are somehow incapable of managing this is the height of medical paternalism. Dr. Steve.
Posted on: Mon, 04 Aug 2014 04:25:23 +0000
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