My Thoughts on Closing the Loop



"Closed Loop System"



When I have idle time at work I use it to review any and all information related to Diabetes. Yesterday I stumbled across a site called http://www.diabeteshealth.com/ and was scrolling through the numerous summaries regarding new research, nutrition etc...

I reviewed the topic related to closing the loop, since a cure is too distant at the moment, perhaps the focus should be on designing a complex computer feedback system whereby a Continuous Glucose Sensor communicates with a microscopic mega computer that in turn uses fancy algorithms to communicate with the pump telling it what to do.  Sounds pretty cool, except for a couple of things...

My issue and the researchers mainly in Europe feel the challenge is how the computer program will account for things like, spontaneous activity, stress, and the human bodies biochemistry, aka "Diabetic Curve Balls" that get thrown our way on a daily diabetic basis. I have to say I can't see the system being too successful, just my humble opinion.

I know, I am a natural sceptic.

I think they need to focus on insulin analogues that respond to micro changes in blood glucose, like a non-diabetics where the minute the body senses a micro increase the beta cells send out the first responders. Now I am not a biochemist, nor really that smart, I get by, but this just seems logical   Don't know if its possible and I am sure they are working on it.

When I reflect on such things, I can't help to marvel at how truly amazing the human body is designed, how complex our inner workings really are.

What do you all think about this?

Cheers!

Trev

The Lifespan of a Fly - Seriously!

So as many of you know I "Flip Flop" back and forth between Pump and MDI. 

This past week I have been Pumping.  With nice even sugars to boot.

Until last evening.

Pump infusion sets are like flies they have a very short lifespan.

I head to work yesterday knowing the life expectancy is quickly diminishing as I was supposed to change prior to leaving for work.  I glanced at the site, and made the executive decision to wait until after work or lunch hour.  You'd think I'd learn already.  As I mumble to myself, I'm such a dumb ass.

The site did look OK honest, it did. But looks can be deceiving. My glucose that morning was in range, lunch high normal range, no biggy though, then pre supper was 14 mmol(multiply by 18 = 252) You'd think I'd act at this point, but noooo not I.  I bolus for the high, and head out for some groceries.

Spend the evening watching a contestant on American Idol being evicted off the stage. While I enjoy my snacks etc. 

I go to bed.  I know your thinking, this guys an idiot, he should know better. But sometimes, life just carries on and diabetes is left in the background. In any event.

I wake up with heart burn at 5 AM. I know immediately I'm high. I test and I have now entered the 25 mmol (450) range. I now come to my senses, kinda hard not to now, and yank the site. Take 10 units of rapid, and 13 Levemir, down 2 large glasses of water, let the puppy out to take a leak, and hopefully a poop, and go back to bed.

I woke up feeling like I'd been run over by a truck.  I ask myself WHY do you not do what you tell others to do. 

I equate the day after feeling as a kinda diabetic hang-over, tired, upset tummy, headachey, dehydrated.

AND like any hangover, I say I won't do that again.  Until next time that is. 

I have to remember that Pump Infusion Sets have the Life Expectancy of a Tiny Fly.

Cheers!

Trev

Ever Heard of a Flip-Flopper?

I am sure y'all have figured out by now that I am a bit of a flip-flopper. No it's not a type of fish, or a sandal,  it is this undesirable character trait to try something, decide it ain't working(too quickly), and changing it....again, kinda deal.

I am now back to re-analyzing my numbers again. I am stable one day, high the next, like a flippin roller coaster!  Hence me pulling out the Dr Berntstein's Diabetes Solution  and reading it with a magnifying glass this time.

I flip-flop with my diet. I flip-flop with my insulin. I flip-flop with the way I deliver my insulin. What the hell!  Stop it already-I am yelling at my self.  Don't worry not aloud. 

I flip-flop with blog writing, and ultimately do it anyways.  I am sorry if I am confusing to follow, trust me I am torturing not only to you,  but also to the people that surround me on a daily basis.

Okay, I have stuck to some major decisions in my life; my commitment to my wife, my commitment to my career, although I have had many different type of jobs in the same field, but I am still in the field.

I have always enjoyed Muay Thai, never flip-flopped on that.  Too much fun!

But when it comes to diabetes, I need to pick a plan and trial stick with it. Enough with the rapid cyclical trialing of insulin, pump, MDI, back and forth, variable carbohydrate intake, etc. 

I have written about Pro Carb or Low Carb? in a past post, and I have trialed the low carb approach with amazing results. It is obvious to me what needs to be done, I just need to do it.

Well at least for more then a week.

Please tell me I am not completely mad; are there any other PWD that flip-flop???

Trev

Pump Adjustments - Part 3 (Correction Factors)

I am writing this a few days late.  I have taken the pump off today but here is what I did over the week-end.

Now it is time to fine tune my correction bolus. So to refer back to Dr Conway and Colleagues,  The Professionals Guide to Insulin Pump Therapy  as quoted below:        


          Adjusting the Correction Bolus:

The goal is for the blood glucose to return to within 1.7 mmol/L of the target blood glucose within 4 hours of giving the correction blous.The correction bolus is based on the insulin sensitivity factor: the mmol/L one unit of insulin will lower the blood glucose.

Raise or lower the mmol/L on unit of insulin should drop the blood glucose.  Make small adjustements: .3 - .6 mmol/L for each adjustment. 

For example, if the insulin sensitivity factor is 1 unit for every 2.8 mmol/L above the target and the blood glucose 4 hours later after giving the correction blous is ?? mmol/L lower than target, adjust the insulin sensitivity factor to 1 unit for every 3.1 - 3.4 mmol/L.

If you recall I have set my pump correction factors according to the chart. So for 1 unit of insulin it is theoretically suppose to drop me by 1.5 mmol/L. 

This seemed a little high, or low depending on which way you look at it. I know I normally need 1 unit for 3 mmol/L.  Sure enough, I have changed my pump settings since I was reunited 5 days ago. I have set my Correction Factors as follows.

0000 = 1 unit for 6 mmol
0400 = 1 unit for 1.5 mmol
2300 = 1 unit for 6 mmol

I have used the correction for breakfast --- it worked
I have used the correction factor for lunch --- Needed to change it to 1 unit for 2 mmol
I have also change my dinner CF as I was dropping way to low.  Trial and error.

Now they are:

0000 = 1 for 5
0400 = 1 for 1.5
1100 = 1 for 2
1600 = 1 for 3
2200 = 1 for  5


Now you are probably asking yourself why I took the pump off? 

One - I am impatient and my fasting is really sucking lately. I tweak, I test, I trend and change.  But I, at this point in my life, have limited time and energy to do what`s needed to fix my basals.  I don`t want to wake up every three hours to test right now. 

Two - Money, thats right, we have coverage, but we need to purchase up front, and once again, Rowan is priority.

Three - MDI works for me when I let it, meaning, when I behave in the food department.

She is the priority

My plan:

 Wait until I can take a vacation to focus, trend correctly, and have the resources to buy some glucose sensors to really get the settings correct.

So, back to MDI, Levemir, and Apidra.

Trev

 (I had a comment to take into consideration, that is when adjusting basals make the change 2 hrs before hand, which makes a lot of sense)

Pump Adjustments - Part 2 (Carb Ratios)

"Carb to Insulin Ratios"

First a quick update on the basals.  So I've decided to stay Pump Bound, with Mr Wizard Senior.  All is well thus far.  I set my basals as listed in the last post.

 Day one, my AM reading sucked, so it was a bust, day 2 much better.

Lots of testing, and documenting. Every little detail, Carbohydrate, fat, protein, activity, glucose levels.....I knew it would be a lot of work, but today I 'm already seeing stable before meal numbers.

Tonight I will have an early dinner (easy on the fat and protein) and fast until tomorrow to test my night-time rates which means a 0300 AM check. 

Next on my list to tweak are the carb ratios.

So to refer back to Dr Conway and Colleagues,  The Professionals Guide to Insulin Pump Therapy  as quoted below:

Adjusting The Meal Time Bolus:

The goal is for the blood glucose to rise not more then 2.8mmol/L 2 hours after a meal.  The meal bolus is based on the insulin to carbohydrate ratio: one unit of insulin to a determined number of grams of carbohydrate.

Raise or lower the number of grams of carbohydrate covered by 1 unit of insulin.  Make small adjustments: 1 to 2 grams of carbohydrate for each adjustment.

For example, if the insulin to carbohydrate ratio is 1:15 and the blood glucose two hours after is only 1 mmol/L above the pre-meal blood glucose, adjust the insulin to carbohydrate to 1:16 or 1:17.

Okay, so I have programed the 1:10 ratio into my pump for all meals. We shall await the outcome. As I have pumped for many years I know my variables roughly, but I am pretending to be a newbie.

I know that breakfast requires more then lunch and bedtime snack much less then supper, if you follow me. But I will do the trial and error thing and hopefully refine the regime. 

Better test since it's 2 hours post lunch as I type this.  One second.........

Okay, now. I am surprised it is high (Well technically in target, but I personally shoot for single digits) Based on the recommendation I was 7.4 mmol before lunch  and 10.4 (3 mmol raise) so I guess I am being too hard on my self.

I still ask myself;   Did I count properly? (Carbs that is) I did eat 2 strawberries on steroids, well, I am not changing the rate yet and  I plan to leave it for a couple of days.

If I get the same reading tomorrow post lunch then I will heed the advice above and change the ratio accordingly.  Work, work, work, think, think, think, tis diabetes!

I think I may hit Cosco tonight and get some CGM sensors, but man they are 210 dollars. Ouch.

Once again I know a lot of my readers are well versed in pump management. Hopefully someone finds this review useful, I know I am.

Cheers!

Trev

Pump Adjustments - Part 1 (Basals)

So I have decided to give the pump a serious trial despite the multiple variables listed in my last post.

Question is: Where do I start? 

I have decided to start from scratch, from the beginning, like a Newbie.

Why you ask;  well I've been off my pump more then on it in the last 12 months and I have gained a few pounds.  I think starting with the fundamentals(clean slate), will be good for re-training, sharing, and it will force me to look at all variables effecting my current glucose control. If you want to perfect something, go back to the basics. Otherwise old habits will ensue.

My Last A1C was 8 % so clearly I am not controlling my blood glucose levels adequately.

So I figured I would share my plan and experience with adjusting my basals.

First thing I did was review the recommended ways to adjust basals by reviewing a document written by Dr Robin Conway and Colleagues  based out of Smith Falls, Ontario, Canada. The Professionals Guide to Insulin Pump Therapy

I have used this resource in the past and consider it compulsory reading for any pumper.  This clinic's website The Diabetes Clinic is very patient centred, and easy to navigate. It has everything, and I have found it to be the most useful in managing my pump therapy and others I deal with.  I have no affiliation with them other then finding them on the web.

So I flipped through the first 6 pages and came to page 7.  Titled: "Estimates for Starting Insulin Pump Parameters"  It is a chart giving you an estimation on where to start your basal levels at based on your TDD(Total daily dose of Insulin)  Cool. I scroll down, my TDD using MDI was around 44 units per day.
Based on the chart I should do the following:

Basal: 0.7 units per hour
Meal Bolus 1 unit for 11 grams of CHO(Carbohydrate)
Correction Factor 1 unit for 1.8 mmol(multiply by 18 for US)

Neat, very easy to follow. As I remembered.  I have another hand-out from an Endo that adds another factor to consider. If your A1C is above target, Multiply the TDD by 1.1-1.3 and go from there. I will do that since I am not at target. So 44 times 1.2 =  52.8. SO back to the chart and this is what I get.

Basal: 0.8 units per hour
Meal Bolus 1 unit for 10 grams of CHO(Carbohydrate)
Correction Factor 1 unit for 1.5  mmol(multiply by 18 for US)

Okay. I am now programming my pump based on these new settings. However, I would be unwise, since I know my rhythms. I know I need less insulin from bedtime until 0300 AM. I also know I need more insulin after waking. So what to do?

Keep reading.

On page 8, they list 4 Basal rates, but recommend most people begin with one. I am not most people, I know I said I am going to start from scratch but what I will do is this:

I know from the past I need more in the AM, less in the post sleeping so my plan is this:

Basal Plan # 1:

0000 = 0.04 (1/2 the recommended) 
0300 = 0.8
0800 = 1.6
1000 = 0.8
2300 = 0.4


Trust me this is an increase from my current programing. So we shall see how it goes. I suspect some lows.

How do I test the above:  To quote Dr Conway's recommendation below:

 Adjusting the Basal Rate:
The goal is for the blood glucose to remain within 1.7 mmol/L of the target blood glucose value in the fasting state.
Change the basal rate by .1 to .2  units per hour over the period of time the blood glucose is too high or too low
For example, if the blood glucose rises after 3 AM and drops after 9 AM, raise the basal rate by .1 unit per hour from 3 - 9 AM and evaluate the effect each night.

All right then, this is the plan. The document also has good work-sheets to use for recording and analysing numbers starting on page 13, adjusting the overnight basal. Which is the most important one to start with.

As all PWD and those who care for PWD it is much easier when you start the day out with a good number.

Stay tuned, and I hope these new settings, bring the fasting down a little.

Cheers.

Trev


PS: I know a lot of my readers are well versed in pumping, and I want you to know I am open to new ideas and/or alternate resources.

Pumping vs MDI - A Case for Both

VS

I have just recently reintroduced my "External Pancreas" back into my life. Well,  at least on a more permanent basis then before. We now have 100 coverage for pump supplies. Need I say more.

So, as you all know, my last A1C was, not desirable, at 8% which means my numbers were running in the double digits over the last 3 months(Canadian values eh) 

I really have been a bad diabetic, well, lets just say I needed to improve my record keeping and do some serious analysis. I need to measure more frequently and stop eating crap when ever I feel like it, I feel like a big hypocrite some days when I am telling people to do the opposite of what I am doing or "Do as I say not what I do"

In any event, here I am analyzing my numbers, and now I understand why my A1C sucked!!  Okay, too dramatic, but let's just say I did not meet the recommended target of 7%.

My fastings are above 8 mmol(multiply by 18 for US)---Not good.

So I analyse:  Why are they high? (Glimpse into my mind)

-Too much fatty food for evening snack or meal?
-Not enough insulin to cover the food?
-Inadequate Ratios?
-Inadequate Basal?
-Am I sick? Nope.
-Am I stressed? No more then usual
-Am I exercising? Yup, didn't last night.
-Dawn effect, rebound from a low?  Don't know. 
-Am I due for a site change?  Is the site a good one?

Man, these are a lot of variables to consider. "Pumping is sometimes more work then it's worth" --- to quote my direct thought.

Options:
-Switch back to the MDI(Levemir/Apidra) or Stay on the Pump? This is a Rhetorical question, just typing out loud so to speak?

My argument for the Pump:
-Once I do the work, skip breakfast, test the basals, analyse ratios, eat properly, tweak, test, etc....it works, less lows, more of a match to my physiologic profile.
-On the negative it is a whole lot of work, I am not sure if I am up for it.
-Obtain some CGM sensor sets for my pump and really figure out my basals.
-Freedom from Multiple daily injections, once it's(pumps) settings are accurate it is a major time saver in calculating corrections and ratio's, which is a major plus.

My argument for MDI:
-Don't mind injecting, and you know the amount you inject is the amount you will get, as with the pump you have to consider age of the site, site integrity, is the pump flowing like it should etc.
-Less variables to consider. For example, if my before lunch is high, then I need more Apidra, if my fasting is high, is it food, dawn, rebound, or my bedtime Levemir dose.
-Carrying around my Apidra Pen is a pain, but not really, since I would not have my pancreas clipped to my belt.

Other things to consider:
Daily routine:  My routine is stable, Monday to Friday job, predictable exercise patterns, week-ends are a little unpredictable.  Pumping is good for fluctuating schedules and eating patterns, I am a predictable fellow.

As you can see I can justify both methods to control my blood glucose level.  Which will I choose?

Still thinking about it.

Trev

Riding Shotgun with a Rhino

I suppose I should explain the title.

To say "to ride shotgun" means riding in the passenger seat of a vehicle.

I know what your thinking, he is riding in the front seat of a vehicle with a rhino, what the heck is this guy talking about.

I have come down with the "Common Cold" also known as the Rhino-virus. Catchy eh!

I haven't confirmed it to be the Rhino as there are a few other nasty organisms that can also create a snotty, congested nose, headache, scratchy throat, mild fever, and absolutely crazy blood sugars.

But this isn't an infectious disease blog, I wonder if one exists? This is indeed still a diabetes blog.

Stress in all it's forms can wreak havoc on your blood sugars, as most of you readers can attest.  It really messes up the way our body uses insulin. Once again the body is less sensitive to the insulin on board and this causes a subsequent increase in blood glucose. Unless of course we increase our dose or give regular correction shots/boluses we are "hooped"

Diabetes organizations and researchers have gone to great lengths to educate PWD by providing the so called "Sick Day Rules"

Some tricks I've learned a long my journey:

-If you are getting sick or are sick, test, test, test.
-Taking more insulin is not always necessary as you may not have the appetite to support the increased dose. I prefer to rely on correction doses for the kids as it is safer.
-Pumps are great to have during illness as I have found that increasing the basal rate helps for me
-the most challenging illness are the high fever ones, and the vomiting ones.

The higher the fever the higher the insulin resistance. Vomiting, is tricky for obvious reasons. No food, or inconsistent food/carb intake makes the big D almost impossible to control. Thankfully I don't have either of the above today.

I can't wait until this damn Rhino drops me off!

Trev

School for Type 1 Kids - What's Your take?

This post is directed at Parents caring for school aged Type 1 kids.  In my recent post "To Pump or Not to Pump"  there was a period we took Rowan (our 6 yr old pumper) off her pump. To give her a break. 

Click here to purchase book

The experience of breaking from the pump was a difficult one. Hence the post.

I have to be honest, we were very frightened when sending our little insulin dependent 5 year old pumper to school, who can't feel her lows.  Will they test her often, will they feed her activity, will she be okay? It is very frightening at first. 

Now she is back on her "Mr Wizard" pump and things are running smoother.  However, when we had her off the pump it got me thinking, and that's never a good thing. 
First off, our school have been absolutely amazing! They have been willing to take on the responsibility for Rowan's Diabetes management, they have learned how to problem solve, count carbs, and they know how to communicate with "Mr Wizard"  The communication has been bar none the best I could ask for. 

That was with the pump.  During the pump break I had to inject her at lunch time, for legal purposes further documentation was needed due to the switch in insulin delivery (Pump to Injections) It was easier for me to just spend lunch with the wee one then to track down an endo or GP to sign the 4 page document.

I am curious as to what other parents go through, challenges, difficulties, positives, anything related to having a Child with Type 1 in your particular school system.

My School is great and do everything possible to meet the needs of Rowan, and us as a Family.

How is your school? 

Basically what's your take on Type 1 kids in the school system?

Welcome Back Mr Wizard

Well today's the day Rowan goes back on the pump.  Her tiny arms and hips needed a break from the large cannula.

She has been pump-less for about 4 weeks.  First time since she was 2.  However we desperately need "Mr Wizard" to return to our family.  Mr Wizard is Rowan's pumps name.

What now?  We ready our supplies.

1.  Pump and new battery

Mr Wizard and his fuel

2.  Reservoir and Novorapid

3.  Silhouette infusion set(Rowan's Least favorite component)

4. Clean skin(Bath time!) Just imagine toys, barbies and lots of bubbles!

4. Pep Talk

Rowan, ready to invite Mr Wizard back!

6. Insertion

7.  Connect Mr Wizard and Fix Prime

8.  Glucose Check

Hugs, cuddle, hug, and lots of TLC.

Rowan, Mr Wizard, and I

Welcome back Mr Wizard!  You are a pain but you make our life so much easier, thank-you Medtronic

I remember trying to self manage my own pump therapy and found this site the most useful in terms of actually sharing info for pump adjustments, assessing your rates etc.  It is located in Canada but the principals are universal The Diabetes Clinic