If we had a dollar for every time “What the heck??” was uttered in managing diabetes, we’d probably have enough funds to find the cure ourselves! Luckily, we thrive on the never-ending mysteries of diabetes here at our weekly advice column, Ask D’Mine, hosted by veteran type 1, diabetes author and community educator Wil Dubois. This week, Wil tackles high BGs in a type 2 PWD, and how insulin-on-board is calculated differently in various insulin pumps.
{Need help navigating life with diabetes? Email us at AskDMine@diabetesmine.com}
Jerry from California, type 2, writes: I was diagnosed five years ago and at the time I had an A1c of 11.2. A few months later, I found the Atkins Diet and pretty much adopted it as a way of life. It worked great. My A1c dropped to the 6.5 to 6.2 range and stayed there I stopped testing because the results didn’t vary much, never above 150. A few days ago, I tested before dinner and I was 290. I tested four more times because I couldn’t believe the results and the average was about 280+. Cut to end: I went to the lab for the official results and my A1c is now 10.1. My diet’s the same, I’m not sick and nothing major is happening in the stress department. So my question is this: what could possibly be going on? Is this the natural progression? Am I on the way to insulin injections? Or is it likely that things will return to normal?
Wil@Ask D’Mine answers: This is the natural progression. You are on your way to insulin (eventually). Things won’t ever return to “normal.” Well, actually, that’s a lie, because things already are normal. This is normal. Type 2 diabetes is progressive. And I don’t mean blue-shirt, granola-crunching, left-leaning progressive. I mean like the relentless march of time progressive. Type 2 diabetes gets a little bit worse every day. It grows stronger and meaner over time.
Here’s what happened to you: After your diagnosis you made a major change in your lifestyle. And good for you! That’s hard work. You started a diet that minimizes the types of foods that turn to sugar quickly. You most likely lost weight, too, which for a time reduced your insulin resistance. You got your diabetes under control using shear grit.
But you didn’t cure it.
It was still there. Hidden under the surface.
Still growing. Getting stronger every day.
You took your eye off the ball, and diabetes bit you in the butt. It has a tendency to do that. The lesson here is to never turn your back on diabetes. Don’t trust it. Always keep one eye and a glucose meter on it. Sometimes type 2 grows slowly and steadily, other times it grows in leaps and bounds. But it always grows.
So that’s what happened. But what happens next? You asked if you are on your way to insulin. The fact is, all type 2s are on their way to insulin. If you live long enough, you’ll join our club.
No fear.
This doesn’t mean you need insulin tomorrow, although it should be one of the options on the table for you and your doc to kick around. But there are other options both in pills and in shots that might make more sense in the meantime. One thing is for sure, you’ve adopted a pretty radical lifestyle (and please go get your cholesterol checked, OK?) to control your blood sugar, and your diabetes has outgrown it. I’m not seeing much left that you can do in terms of how you eat, to control your diabetes.
It’s time to open the medicine cabinet.
;
Larry from Virginia, type 3, writes: My daughter has been on the OmniPod for the last two years. As I am sure you are aware, OmniPod calculates on-board insulin differently than the other major pump manufacturers. Basically, OmniPod excludes insulin that was designated for specific carbs from the calculation. I would be curious to know your take on the matter.
Wil@Ask D’Mine answers: For non-insulin shooting folks, an executive summary: Insulin can be used to both lower blood sugar or to attempt to keep blood sugar from going too high in the first place (or so we hope). Modern fast-acting insulins take about 20 minutes to start working, hit their peak at two hours and call it a day after four hours. Damn! Where can I find a job like that? Anyway, anyone shooting insulin is theoretically at risk of stacking up too much insulin if they take more than one dose in a four-hour period, and too much insulin can lead to low blood sugar, which can be dangerous.
All of that said, there are many, many times when you do need to take insulin twice (or more) in a four-hour period. So you have to try and keep track of how much insulin might still be floating around in your body from the last dose when you think about taking your next one. This is one area where an insulin pump can theoretically excel — it can keep track of all the insulin given and when, how long it’s going to last and how strong any remaining insulin on board (IOB).
There’re two broad ways to calculate this insulin still on the job; but you’re misinformed about the non-OmniPod pumps being different – all the major pump choices here in the States go about keeping track of this already-taken insulin in pretty much the same way. All the current pumps assume that insulin given to cover food will get sucked up by the food, and the only spare insulin is the insulin taken for corrections. So they only track insulin from corrections. Oh, the devil is in the details, of course, and there’s quite a bit of difference in the mathematics of how they go about doing that. Über CDE GaryScheiner discusses the finer points in detail here.
But back in the day (several years ago) there was a pump called the Cozmo that was radically different than the current choices. Sadly, like the Triceratops, it’s now extinct. Well, nearly extinct, anyway. A few of us old-timers are still holding on to our aging Cozmos, and the #1 reason for this is the different way the Cozmo pump calculates on-board insulin. It assumes that all insulin matters and it tracks both meal boluses and correction insulin.
“My take” on the matter is pretty strong: I think the current state-of-the-art pump-thinking sucks and is dangerous. Criminally so. And I’m not the only one who thinks that.
Now, I’m a pump vet and a certified pump trainer. My personal, professional, and recreational life is diabetes 24/7/365. You might think I’d be an awesome carb counter, that I always take the right amount of insulin for my food, and would be just fine with any state-of-the-art pumps.
You’d be wrong.
I get my mealtime insulin wrong as often as I get it right.
The idea that my best-guess carb count will always nicely suck up my meal insulin is crazy. I think a good insulin pump needs to recognize the reality in the trenches, and the reality in the trenches is that, like me, most of us PWDs reliably get it wrong a lot of the time. A pump that keeps track of all the insulin on board is safer, more realistic and a better service to its wearer than a pump that ignores more than half the insulin you take.
When your daughter’s OmniPod came on the scene, the OmniPod folks apparently surveyed endos to see if the “Medtronic Way” or the “Cozmo Way” was more popular. Apparently, 51% percent of endos preferred the Med-T system so that’s what OmniPod went with. Why on earth they didn’t just create a way for the user or doctor to choose either is beyond me.
When the Solo pump was first approved there was a lot of excitement as they were trumpeting the fact that the new patch pump would use the Cozmo Way of tracking insulin in the bod. But they’ve since been bought by Roche, and only time will tell if this feature will change by the time the device actually gets to market.
There are a lot of reasons to choose one pump over another, but right now the insulin-tracking feature of the current pumps track insulin still on the job is not one of them.
Disclaimer: This is not a medical advice column. We are PWDs freely and openly sharing the wisdom of our collected experiences — our been-there-done-that knowledge from the trenches. But we are not MDs, RNs, NPs, PAs, CDEs, or partridges in pear trees. Bottom line: we are only a small part of your total prescription. You still need the professional advice, treatment, and care of a licensed medical professional.
 Pump Question)
“All the current pumps assume that insulin given to cover food will get sucked up by the food, and the only spare insulin is the insulin taken for corrections. So they only track insulin from corrections.”
That’s definitely not true for the Minimed–IOB includes food boluses. Gary Scheiner even says so in the link you provided: “With the Medtronic Paradigm pumps, all boluses (meal and correction) are taken into account when IOB is calculated.”
@Arielle, what Wil said was that the IOB for corrections was the only IBO used in calculating corrections. That is exactly what Gar Scheiner states in the link Wil provided.
On the home screen of the Medtronic Revel pump the Active Insulin number does include meal and correction bolus insulin. However, if I decide to eat more and put my new carbs into the bolus wizard, it will calculate the bolus for that food and disregard all the active insulin from my previous meal and correction bolus.
So once you’re aware of the difference, you can take the Active Insulin into account as you determine your bolus and possibly override the Bolus Wizard on the bolus recommendation.
So the information is there, but it’s probably only something that more advanced pumpers understand. It might be nice if there was a prompt somewhere in the Bolus Wizard calculation for the new carbs that would say: “you have .4 units of Active Insulin. Would you like to subtract this from your new bolus?”.
Our DD has used the Medtronic MM pump for five years, now using the Revel. At NO time did the Minimed pump neglect to calculate insulin on board from a meal bolus. All boluses (both correction and meal) are tracked. When you hit the ESCAPE button on the Revel you can immediately track IOB, among other things. The Animas pump also has always tracked all insulin on board. The only difference between the Medtronic and Animas pumps is that Animas will ALSO subtract for a blood sugar slightly below target, i.e., if your blood sugar is 80 and target is 100, Animas will give less insulin for your meal bolus. I was told the Minimed does not do this. Different meals require different boluses, I find. Cereal needs a heftier bolus than her current “correct: ICR would dictate. The ICR is not exact for all foods; not even close. It is the best option. You can easily go low or high, even counting carbs correctly. You can go low or high giving the same bolus and eating the exact same food. Perhaps a slight variation in activity is the cause. ICR is not exact; I find it to be a guestimate of the amount of insulin needed at any given time.
Your reply to Jerry’s question helped me so much. I too was doing what had in the past helped control my type 2 diabetes. Like Jerry, i had stopped monitoring frequently for the same reason. My last doctor visit, my A1C was 8.3, much higher than I expected. So i have radically changed my diet and increased my exercise resulting in weight loss. My doctor and those self help books do not say that diabetes is ever progressive like you so clearly pointed out. At least now I understand that constant and frequent monitoring is part of my life and to expect my diabetes to progress. It makes it easier for me to rise to the challenge. Knowledge is indeed power. Thanks!
Another possibility to consider with Jerry from California is that he does not have Type 2 diabetes, but has slow onset Type 1 diabetes. Don’t always assume that if a doctor has diagnosed a person as having Type 2 diabetes, but they need insulin rather quickly, that the person has Type 2. 10% of “Type 2s” are antibody positive, have Type 1 autoimmune diabetes, and have been misdiagnosed.