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  Think Like a Pancreas

  “Gary Scheiner knows as much about diabetes as most endocrinologists and he has translated his knowledge and experience into a wellwritten, easy-to-read treatise on diabetes. A must-read for anyone with an interest in diabetes—most importantly patients and their families.”

  —STEVEN B. NAGELBERG, MD, CLINICAL ENDOCRINOLOGIST

  “Think Like a Pancreas is delightful, unique, comprehensive, and detail oriented. The writing style is easy to follow. It will enlighten and educate for sure. Great work, Gary.”

  —PAULA HARPER, FOUNDER AND PRESIDENT

  OF THE DIABETES EXERCISE AND SPORTS ASSOCIATION

  “Gary Scheiner offers the missing ‘manual’ designed to benefit every patient with diabetes who wishes not only to optimize his/her self-care, but also to comprehend all the forces that work against easily achieving this lofty goal. He offers guidance, expertise, and a first-hand understanding of what it means to have to ‘think like a pancreas.’”

  —RENEE BERNETT, MOTHER OF A CHILD WITH TYPE I DIABETES

  AND MEMBER OF THE JUVENILE DIABETES RESEARCH

  FOUNDATION’S LAY REVIEW COMMITTEE

  “Think Like a Pancreas is the most helpful guide that I’ve encountered about the intricacies of using insulin. Gary Scheiner speaks as one of us—someone who’s lived with diabetes for nearly twenty years—and is able to translate sophisticated scientific concepts into clear laymen’s terms. His humor is motivational and his understanding of the frustrations that can come with using insulin is truly encouraging. Though I’ve taken insulin on a daily basis for over twenty-three years, Think Like a Pancreas has opened my eyes to many new nuances that will surely help me—and countless other people with diabetes—in my quest for tight blood sugar control.”

  —GABRIELLE KAPLAN-MAYER, AUTHOR OF

  Insulin Pump Therapy Demystified, www.INSULINPUMPBOOK.com

  COMPLETELY REVISED AND UPDATED

  think

  like a

  pancreas

  __________________

  A PRACTICAL GUIDE TO

  MANAGING DIABETES

  WITH INSULIN

  __________________

  Gary Scheiner, MS, CDE

  Foreword by Stanley Schwartz, MD

  Copyright © 2004, 2011 by Gary Scheiner

  Photographs © 2004, 2011 by Gary Scheiner

  Foreword © 2011 by Stanley Schwartz

  All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the publisher. For information, address Da Capo Press, 44 Farnsworth Street, 3rd Floor, Boston, MA 02210.

  Text design by Trish Wilkinson

  Set in 11.5 point Goudy Old Style

  Cataloging-in-Publication data for this book is available from the Library of Congress.

  First Da Capo Press edition 2011

  ISBN: 978-0-7382-1514-3

  Published by Da Capo Press

  A Member of the Perseus Books Group

  www.dacapopress.com

  Note: The information in this book is true and complete to the best of our knowledge. This book is intended only as an informative guide for those wishing to know more about health issues. In no way is this book intended to replace, countermand, or conflict with the advice given to you by your own physician. The ultimate decision concerning care should be made between you and your doctor. We strongly recommend you follow his or her advice. Information in this book is general and is offered with no guarantees on the part of the authors or Da Capo Press. The authors and publisher disclaim all liability in connection with the use of this book. The names and identifying details of people associated with events described in this book have been changed. Any similarity to actual persons is coincidental.

  Da Capo Press books are available at special discounts for bulk purchases in the U.S. by corporations, institutions, and other organizations. For more information, please contact the Special Markets Department at the Perseus Books Group, 2300 Chestnut Street, Suite 200, Philadelphia, PA, 19103, or call (800) 810-4145, ext. 5000, or e-mail [email protected].

  10 9 8 7 6 5 4 3 2 1

  To MJ, Bumble Bee, Awesome Boy,

  Lily Poppins, and The Princess.

  And to my wife, Debbie,

  who let me live long enough to finish this book.

  Contents

  Foreword by Stanley Schwartz, MD

  CHAPTER 1

  Let’s Get Acquainted

  My Story

  CHAPTER 2

  What’s the Dang Diddly Point?

  What’s in It for Me Now?

  What’s in It for Me Later?

  CHAPTER 3

  Basics and Beyond

  Blood Sugar Balancing: The Major Players

  Factor 1: Insulin

  Factor 2: Other Diabetes Medications

  Factor 3: Food

  Factor 4: Physical Activity

  Factor 5: Stress Hormones

  The Little Stuff

  CHAPTER 4

  The Three Keys to Control

  The Three Keys

  The Right Tools

  The Right Skills

  The Right Attitude

  CHAPTER 5

  The Basal/Bolus Approach

  Basal Insulin

  Bolus Insulin

  Putting Them Together

  CHAPTER 6

  Basal Insulin Dosing

  Initial Basal Doses for Those Injecting Insulin

  Fine-Tuning Injected Basal Doses

  Attack of the Killer Somogyi

  Initial Basal Doses for Insulin Pump Users

  Fine-Tuning Pump Basal Rates

  Beyond Basal Basics

  CHAPTER 7

  Bolus Calculations

  Part 1. Insulin to Cover Carbs

  Part 2. Insulin to Correct Blood Sugar

  Part 3. Bolus Insulin On-Board

  Part 4. Adjustment for Physical Activity

  Part 5. Bolus Timing

  CHAPTER 8

  Welcome to the Real World

  The Other Stuff That Can Raise Blood Sugar

  The Other Stuff That Can Lower Blood Sugar.

  Stuff That Can Make Your Blood Sugar Rise or Fall . . . or Both

  Sports and Exercise

  Pregnancy

  CHAPTER 9

  Going to Extremes

  The Science Behind Hypoglycemia

  The DEVOlution of Symptoms

  Preventing Lows

  Dealing with Postmeal Highs

  The Other Extreme: Ketoacidosis

  CHAPTER 10

  Resources for Everything and Anything Diabetes

  Giving Support, Getting Support

  Other Sources of Diabetes Management Consulting

  Associations/Organizations

  Financial Resources

  Media and Publications

  Fab Websites

  Blogs

  Recommended Reading

  Products

  Suppliers

  Appendix A: Logsheets

  Appendix B: Carb Factors

  Appendix C: Glycemic Index of Common Foods

  Appendix D: Carbohydrate Replacement for Exercise

  Index

  Foreword

  No man is an island, entire of itself; every man is a piece of the continent.

  —JOHN DONNE

  The nice thing about teamwork is that you always have others on your side.

  —MARGARET CARTY

  Achieving excellent control of diabetes is a difficult task for any individual. This is because so many factors influe
nce blood glucose levels as well as the potential for adverse outcomes. Diabetes affects many different parts of the body, and there are biologic differences within each individual. Add to that the fact that each person reacts differently to insulin, medication, diet, exercise, emotional states, and physical stresses. Nevertheless, there is no doubt that excellent diabetes control reduces eye, kidney, and nerve disease as well as heart attacks, strokes, and amputations, all while improving the quality of one’s daily life.

  It is impossible for any singular physician to “know” everything about diabetes—one needs metabolism and general medical expertise as well as often, sadly, ophthalmology, cardiovascular, kidney, podiatry, and neurology expertise. Although the endocrinologist with experience in diabetes can be a conductor among the physicians, he frequently needs help.

  Similarly, the individual living with diabetes can’t easily become an expert in nutrition, exercise, stress, technology, and the myriad other topics involved in diabetes self-care. Everyone must recognize that they need some help. Each patient needs nurses, nutritionists, exercise physiologists, mental health counselors, and Certified Diabetes Educators to help achieve the goal of excellent glucose control. Thus, teamwork is key.

  One of most difficult aspects of controlling glucose is the selfadjustment of insulin. One must adapt insulin doses to all aspects of daily life—diet, exercise, stress, and so on. With this in mind, Gary Scheiner has written this book. It is for all team members—from the patient to the diabetes educator to the primary care and specialized physician—who need to master basic principles and advanced techniques in the use of insulin.

  Mr. Scheiner has updated his successful first edition, continuing to emphasize the establishment of an appropriate basal/bolus insulin program and the fine tuning of said doses. This edition also focuses on several new approaches, including the use of continuous glucose monitoring, glucose management during pregnancy, use of newer medications, and all of the latest diabetes self-care technologies.

  He is eminently qualified to do so given his experience with patients of all ages—children, teens, and adults; his training as an exercise physiologist; his publications on pump therapy, continuous glucose monitoring, women’s issues (control during the menstrual cycle and pregnancy), behavioral issues, and nutrition; his awards from the ADA and AADE recognizing his teaching expertise; and his lectures to audiences nationally and internationally. Moreover, as a type 1 patient himself for more than twenty-five years, he has the unique opportunity to translate his personal experience to those fortunate enough to be clients of his practice, members of his audiences, and readers of this book.

  We as physicians who care for these patients are privileged to have Gary write a book such as this and to have him on our team. He is the ultimate team player. And when we work as a team, everyone wins.

  Stanley Schwartz, MD

  Affiliate, Main Line Health System

  Clinical Associate Professor, Emeritus

  University of Pennsylvania,

  Ardmore, Pennsylvania

  June 2011

  CHAPTER

  1

  Let’s Get Acquainted

  Let’s be upfront. Either you forked down good money for this book or somebody is making you read it. Either way, you’ve invested your time and/or money and deserve to get something good in return.

  So how do you know you can trust little, old me to set you on the golden path to better diabetes management? I find that establishing some common ground helps. For starters, I too find diabetes to be a royal pain in the butt (pain in the bum for those of you in EU and AU; pain in the tuchus for my Israeli friends). The whole idea of working at something year after year only so that nothing bad happens just doesn’t sit well with me. And even after working at it, the results aren’t always there. Why, for instance, can the same type of bagel from the same shop make my glucose go very high one day but not the next?

  Like you, I have enough to do without all the added responsibilities of taking care of my diabetes. Doctor’s visits, getting lab work, and treating lows take time away that I’d much rather spend with my wife or kids. Checking blood glucose, counting carbs, and calculating insulin doses are part of the price we all have to pay before eating just about anything. And speaking of price, I’d much rather spend my money on new clothes or tickets to a ballgame than on CGM sensors and pump supplies. Heck, managing diabetes is like having another entire job lopped on top of everything else in our lives—but without weekends off, and certainly without the moolah.

  You may have also found, as I have, that today’s health care system simply isn’t equipped to manage diabetes properly. And that goes for more than just the American system; virtually everyone I’ve consulted across the globe has had the same experience: Health care providers consistently come up short when it comes to time, expertise, and access. This is not from a lack of desire; most physicians are talented, motivated, caring people who wish they had the time and resources to do more for their patients. It’s just that the demands placed on today’s physicians (and their support staff) are so great that precious little time is available for teaching/helping us learn the finer points of living with diabetes. And this is true whether your clinician is part of a government-funded health program, a managed-care organization, or a private group of health care providers.

  Hopefully, you’re nodding your head by now, mumbling “Yea, he gets it.” Well, here’s a synopsis of my life with diabetes thus far. See if anything else sounds familiar.

  My Story

  It was two o’clock in the afternoon on a typically hot, muggy summer day in Sugarland, Texas, a suburb in southwest Houston. (No, I’m not making this up. The irony is just unbelievable.) After spending half the summer sucking down cold drinks and the other half peeing them out, I decided it was time to see the family doctor.

  I hardly knew this doctor, but I had had about all I could take. My energy was gone, and there was no way the Houston summer could have caused me to lose so much weight—I had gone from 155 pounds to 117. I actually couldn’t tighten my belt enough to keep my pants from falling down. Then I saw an episode of M*A*S*H in which a helicopter pilot had diabetes. And guess what: He had many of the same symptoms! So I decided it was time to get checked out.

  The doctor’s office was only a ten-minute drive from my family’s house, so I was able to make it with just one pit stop to use a gas station restroom. (That summer, I learned where all the best public restrooms were along the I-59 corridor in southwest Houston.) When I got to the doctor’s office, I put on my glasses (miraculously, I could suddenly see road signs without my glasses for the first time ever), wiped off the steam created by the 10,000 percent humidity, and prepared myself for the worst.

  The clothes hanger on the left is me, out on a formal date the night of my diagnosis, forty pounds underweight.

  After a quick physical exam, blood test, and urinalysis, the doctor came back in and said nonchalantly, “Gary, I’ve got good news and I’ve got bad news. The bad news is that you have diabetes, and you’re going to have it for the rest of your life.”

  I have no idea what the good news was because I stopped listening at that point. The first syllable from “diabetes” stuck in my head. What the heck is diabetes? About all I knew was that it was making my body wither away and that it wasn’t going to go away until I died.

  I remember him telling me that my blood sugar was 600-something, and that that was six times the normal level. I also remember him saying that I would have to take shots and be very careful about what I ate. The thought of giving myself shots was one thing, but limit what I eat? Was he crazy? I was an active eighteen-year-old with the metabolism of a small country. The very thought of not being able to eat whatever I wanted whenever I wanted made me more depressed than anything else.

  So off I went to an endocrinologist at a fancy high-rise in downtown Houston. Keep in mind that the year was 1985 and there were no HMOs yet, so getting in to see a specialist was as easy a
s making a phone call.

  “You are lucky to be diagnosed now,” explained the endocrinologist. “We have come a long way in the treatment of diabetes. I’ll bet that in five or ten years, your diabetes will be cured.”

  I should have taken that bet.

  I then met with a nurse who taught me the basics about diabetes. I discovered what insulin is and why it is important. I learned a little bit about how food and exercise affect blood sugar levels and what can happen if I don’t keep mine under control. I also found out why the high blood sugars I had been experiencing all summer turned me into a human water fountain.

  Finally, I was instructed on how to inject insulin. Forget about practicing on oranges, pillows, and teddy bears. I gave myself my very first injection, right in the stomach. It hurt, probably because I had almost no fat left on my body and the syringe needles were much thicker and longer than they are today. But mostly it hurt because I was tense and overwhelmed at the thought of sticking needles in myself for the rest of my life.

  I was also given a bottle of test strips and taught about blood sugar testing. No meter, mind you—just test strips. These strips had a big square box at the tip that had to be covered with blood, blotted, and then timed before matching the color on the strip to the color chart on the bottle. Pale blue meant you were 40 to 70 mg/dl (a bit low); light blue, 70 to 100 (low to normal); ocean blue, 100 to 125 (normal); aquablue, 125 to 150 (slightly above normal); just plain aqua, 150 to 200 (a bit too high); aqua-green, 200 to 250 (high); sea green, 250 to 350 (very high); green, 350 to 450 (very, very high); brownish green, look out. In other words, determining your blood sugar required an extremely sensitive eye for subtle differences in pastels. Hey . . . when I grew up, there were only eight crayons in my box of Crayolas, and none of them were “sea green.”

  The bottle of test strips came with a medieval torture device called an “Autolet.” The Autolet had a small disposable platform with a hole where you placed the victim . . . er . . . I mean, your finger. A disposable twenty-five-gauge lancet was placed in the firing mechanism, which swung around at a high speed like a pendulum to stab your finger and make it bleed. I called it “The Guillotine.”