So, I am thinking about writing both an orientation training manual and a more extended training manual. My initial thought is to do it on a website and conduct a twice yearly one week training in South Florida that would be experiential. This is my introduction to the orientation.
This Orientation assumes that you are either on Lantus and using a short acting insulin to cover meals or you are on the insulin pump. If you are using another insulin therapy it might be interesting reading but not applicable when it comes to the insulin delivery section. I know that some doctors use a different approach. I have been on most of them. While insulin delivery is just one aspect it is a critical one and it is my opinion that the insulin pump is, by far, the best method for insulin delivery. Lantus combined with short acting insulin is often referred to as “The Poor Man’s Pump” because it attempts to simulate what the pump can do but it offers much less flexibility and certainty.
There is one other assumption that is instilled within this training; You are motivated. Dealing with Type 1 diabetes is an extremely challenging thing. The initial diagnosis is a shock to the person and to the family. It is a crisis that must be dealt with. Everyone reacts to crisis in a different way. In my 31 years of experience with the disease I have been through many periods of time when I just did not want to deal with balancing my blood sugars. I did things that were dangerous and that did not lead to being well. I always took my shot but I did not always test my blood sugars on a regular basis to know what was going on. I really did not want to look at the reading from the meter. I often went off of how I felt or what color my urine was or how much I peed. I did not want to check. I crossed a point where I made a decision that I wanted to feel better and master this thing and it happened. I was lucky and blessed with tremendous support from family and friends and good doctors. Thank you to all of them. I assume you are motivated because you are reading this. However, I will give you a few reasons to become more motivated. First, if you can consistantly receive A1C results below 7 you will significantly reduce your chances of acquiring complications. Complications stem from the detriotion of blood vessel integrity as a result of high blood sugar levels. Good control greatly reduces this from happening. Second, you will feel better and be more productive. Third, you will achieve success in a proactive manner. This fosters a sense of control where control has been absent. And fourth, you will affect others around you. It is very difficult for people who love you to know you have diabetes. They feel for you and wish they could make it better. When they see that you are mastering it you will provide them joy.
If you are motivated then this orientation will provide you with a base level of information that is necessary to achieve success. I do not know everything about the disease but I have lived with it for 31 years and have a profound understaning of what it takes to survive and then to thrive. I want to share that with you. The Extended Training Program is designed to be an intenisve thrust in strategies outlined in this orientation section. If you find the orientation helpful and are not getting the support you need from your health care professionals then it might be of benefit to you.
Insulin delivery is a key component of mastering blood sugar balance in Type 1 diabetes. The Basal Dosage is a component of the insulin delivery system. There are several different types of insulin. These types are identified primarily by the length of time they take in becoming active and by the length of time they are active. There are two two ways of delivering insulin. One is by injection and one is by the insulin pump. They had been working on insulin you can inhale but it recently turned out to be not workable. Whether you are using injections or the pump you must be aware of your basal level. Your basal level is the amount of insulin you need to maintain relatively consistent (between 10 to 30 points) blood sugar readings over a significant period of time without ingesting carbohydrates or fats starting four hours after your last meal. In the Mastering your Diabetes Course that I participated in we fasted for 24 hours in order to test our basal dosages. If during this test blood sugars trend downward then the basal dosage is too high. Conversely, if blood sugar readings trend upwards then the basal dosage is too low. Often times, a person’s basal requirements may be higher or lower during specific times during the day. For example, some people experience what is called the “Dawn Effect.” This is when blood sugar levels rise early in the morning (4am to 6am) and therefore a higher basal dosage is needed during this time. A good and tested basal insulin dosage is needed for achieving mastery in blood sugar balancing. A 24 hour test is the minimum requirement needed to have a chance at getting there. To maintain mastery one should be checking in on basal dosage needs every so often. This is a necessary skill if one is to achieve A1C’s below 7.0.
Basal requirements will also change because of illness, stress, exercise, weight gain/loss, mood, types of food being eaten, eating patterns and probably more reasons that I am currently unable to access at this time. To achieve “tighter” control one should……… Wait a minute. I am going to replace the visual and feeling of the last sentence, “tighter control” with a different one …….”more certainty.’ This a a shift in the way to look at balancing blood sugars. Instead of control one is looking to create certainty. Instead of battling chaos you are focused on doubt as the opponent. This shift in perspective increases awareness and responsibility. The result is more control. The objective is more certainty. So, to achieve more certainty you should test basal with the additional factors included in the equation. For example, I sometimes play poker. I have noticed, through testing often, that my basal requirement when playing poker increases by at least 30%. When I do a 3 mile run I don’t need a basal. Depending on other factors, especially, carbohydrate intake I should probably get my blood sugar level to 165 or higher before going out for that run. I also must be vigilant in 12 hours after running as my basal requirement may be lower. A real interesting example is when I went away to a 10 day meditation course. My activity level was significantly reduced, my diet changed a bit and I was meditating 12 hours/day. My basal level reduced by 40% while at this course. I was amazed. You can read more about it in a previous blog I wrote about the meditation experience.
I believe that to create more certainty one should be always seeking the lowest denominator in terms of the basal dosage. In other words, you should be taking the least amount of insulin you can in the form of basal. Think about it. Someone with a 10 unit per hour basal compared to someone with a 1 unit per hour basal has less certainty. Doctors and others involved with Diabetes education may not agree with me here. But it is true that a .5 of a unit shift is a much more significant change for the person with a lower requirement. I look at insulin like an accelerator in a car. The tighter the accelerator the more confidence you have in what the car will do; the more responsive it is. I am always trying to reduce my basal. I do this by testing a lot in many situations especially 4 hours post meal and forward.