Beyond the Basals – Part 1

by gary scheiner MS, CDE

Gary Scheiner has had type 1 diabetes for over 20 years. He has specialized in intensive blood glucose control and lifestyle intervention for people with diabetes since 1995. A devoted husband and father of four, Gary loves exercising (especially basketball, bicycling and kickboxing) and cheering on his local Philadelphia sports teams. diaTribe asked him to weigh in on pump therapy and he produced some wonderful insights in this two-part insulin pumping series. We recommend this piece for anyone who wears a pump, is considering one, or just wants deeper information about the world of insulin pumping.

As a pumper, you've probably discovered that simply using a pump is not going to solve all of your diabetes control problems. Just as a chain is only as strong as its weakest link, successful diabetes management requires three key elements: Tools, Skills and Attitude (a bit of luck doesn't hurt either!). Having one or two just won't cut it. All three must be in place. If you currently use an insulin pump or aspire to use one, you probably have the tools and the attitude necessary for success. The skills, however, might need a slight upgrade.

critical skills

Successful pumping starts long before you program your first bolus. It is your skill set, not your infusion set, that truly prepares you for success.

There are certain traits and abilities I consider essential:

1. Frequent Blood Glucose Monitoring

People who test their blood sugar levels 4-8 times daily or use continuous glucose monitors have the information necessary to achieve the best overall control. Less frequent testing leaves you open to long periods with high blood sugar levels. It also exposes you to potentially severe lows. With pump use, unusually high blood sugar may be a warning sign of an insulin delivery problem; fixing the problem quickly is necessary to prevent ketoacidosis. So get in the habit of testing frequently: before meals & snacks, prior to exercise, prior to bedtime, and occasionally one hour after meals to assess post-meal control.

2. Decent Carb Counting Skills

Carbohydrate gram counting is so important for people with diabetes. Carbohydrate is the primary nutrient affecting blood sugar levels. Virtually all carbohydrates (except for fiber) convert into blood glucose fairly rapidly. In order to control blood sugar levels, it is necessary to match insulin doses to the amount of carbohydrate being consumed. That's why accurate carb counting is an essential skill. A variety of techniques can be used to count carbohydrates: converting "exchanges" into grams of carb, reading food labels, looking up nutrient listings in books/brochures and online, multiplying foods' weight by their respective carbohydrate factors, and converting portion sizes to carb grams. These techniques are described in detail in my book, The Ultimate Guide to Accurate Carb Counting.

3. Detailed Record-Keeping

By keeping organized/detailed written records and analyzing them on a regular basis, you can gain much better control of your diabetes. Of course, blood sugar readings are important items to record, but blood sugars by themselves are not of much use unless they are always high, always low, or always normal. For most of us, that just isn ‘t the case. To figure out why blood sugar levels vary, record the amount of insulin taken, the grams and type of carbohydrate consumed at each meal and snack, the type and length of exercise and other physical activities performed (e.g. housework, yard work, shopping and extended walking), as well as stresses that tend to affect blood sugars (e.g. illnesses, menstrual cycles, emotional events and hypoglycemic episodes). To get the most from your record keeping, organize the information so that it will be easy to analyze. A variety of effective record-keeping forms can be found at http://www.integrateddiabetes.com/logs.shtml.

4. Dosage Adjustment Capabilities

Self-adjustment of insulin doses is the basis for effective self-management. Rapid-acting insulin doses should be adjusted based on:

• Pre-meal/pre-snack blood sugar levels (a "target" blood sugar should be determined, as well as your "sensitivity" per unit of insulin).

• Carbohydrate intake (insulin:carb ratios should be determined for each mealtime).

• Physical activity (adjusting insulin doses before, and possibly after, activity will be necessary).

Trying to learn all of these adjustments and mathematical formulas the same day you start on your pump would be overwhelming. Learn to adjust your own insulin doses long before starting on the pump. Besides making for an easier learning process, the calculations used prior to the pump start will help in determining the initial doses on the pump.

5. An Understanding of the Basal/Bolus Concept

Bolus insulin is a fairly easy concept to grasp - it’s just insulin given all at once (or over a short period of time) to cover carbohydrates or to counteract a high blood sugar. But basal insulin - that’s another story. It amazes me how few people understand what basal insulin is really meant to do. Heck, most people can’t even spell basal correctly! Basil? Basul? I’ve even seen it spelled with a "z".

Whether given by injection (as long-acting insulin) or by a pump, basal insulin’s job is to help cells take up glucose produced from your liver, and use it immediately or store it for later. When set properly, basal insulin should hold the blood sugar steady in the absence of digesting food, bolus insulin, major stress or exercise. Having a firm understanding of the roles of basal and bolus insulin helps guide our decision-making and the fine-tuning process when using a pump.

Every house painter knows that success stems from the preparation. Having trained and managed more than 2000 people on insulin pumps, I cannot emphasize enough the importance of having the right skills and abilities before making the jump to the pump. Utilize the experts on your health care team to help get you to the right skill/ability level. If you don’t have easy access to pump therapy experts, the diabetes educators at my office (all of whom have Type-1 and wear pumps) can coach you via phone and the internet. Go to Integrated Diabetes for details.)

In the next issue of diaTribe, Gary will provide a step-by-step account of how to perform a basal rate test and make adjustments to your basal dosing regimen accordingly.

Editor’s note: Gary Scheiner MS, CDE is Owner and Clinical Director of Integrated Diabetes Services, a private consulting practice located near Philadelphia, PA for people with diabetes who utilize intensive insulin therapy. He is the author of several books, including Think Like A Pancreas: A Practical Guide to Managing Diabetes With Insulin. He and his team of Certified Diabetes Educators work with people throughout the world via phone and the internet. Gary has had type 1 diabetes for 24 years and has worn & trained on every make & model of insulin pump since 1994. He can be reached at gary@integrateddiabetes.com, or toll-free at 877-735-3648.