Today’s Diabetes Challenge question of the day is for all parents of children or teens with type 1 diabetes. The role of being a parent of a child with diabetes may range between one of constant supervision to a state of complete detachment. Most parents simply feel they’re only fulfilling the role of parent as best as they know how. However, many teens with diabetes feel that their parents behave like the “Diabetes Police”. So the question today is: Rate yourself on a scale of 1 to 10, with 1 being like a diabetes “mall cop” to 10 like being the Diabetes “KGB”. Explain why your level of involvement in your child’s diabetes care is just right, not enough or perhaps excessive. Give examples.

Reflections on the first day of camp.

The second session of Diabetes Camp is underway. I’ve reviewed the state of the more than 200 campers under our care this week. As with the previous session, I saw lots of pumps and multi-dose insulin schedules. Both are what are referred to as “basal-bolus” insulin schedules. The “basal” is the long-acting insulin (Levemir or Lantus) and the “bolus” is the rapid-acting insulin (e.g., Humalog, Novolog, Apidra) taken before meals, large snacks and for correcting high BG levels.

The other approach, “split-mixed insulin therapy”, is rapidly becoming a relic of the past. Classic split-mixed regimens involved taking “intermediate-acting” insulin (NPH or the now defunct Lente) in the morning and evening, plus mixing in fast-acting insulin at the same times (2 shots a day). The total dose was “split” and “mixed”. Newer versions of split-mixed include NPH at bedtime instead of supper, with the rapid insulin still given before the evening meal. I have used a variant of this schedule quite effectively by substituting Lantus or Levemir for the bedtime dose of NPH. It has the advantage of causing much less middle of the night low blood sugar while avoiding the need for an injection at lunchtime.

Less than 10% of campers use an insulin regimen with NPH insulin at our camps. Analog insulin has trumped the old NPH insulin (which had been around since the 1940’s). And that was not an accident. Not only are most long acting analog insulin preparations much more predictable in their action compared to NPH, but they have had the marketing power of major pharmaceutical companies knocking doctor’s doors down to encourage them to prescribe their new and improved insulin analogs. NPH is also less expensive than insulins like Lantus, Levemir, Novolog and Humalog. That’s good for us, but bad for the insulin companies. In the end, NPH’s fate never had much of a chance.

But has there been a rush to judgment? Are the stories of NPH’s demise overstated? Much of the world still uses NPH insulin and classic split-mixed insulin schedules. If for no other reason than cost. NPH insulin costs a fraction of what a bottle of Lantus or Levemir costs. Here at camp last week, we had children using NPH regimens that had A1c values better than many of the campers on more sophisticated basal-bolus schedules or even pumps. The reason for the success of these simpler insulin schemes is consistency. If a diabetic can maintain a regular activity schedule and carbohydrate intake, then these regimens can be quite effective. Compared to the proven potential for better control with a basal-bolus regimen, we seem to be falling well short of realizing A1c values in the sub 7% range in most kids with type 1 diabetes on basal-bolus.

This fact begs a huge question: have we reached a point of diminishing returns as far as our ability to deliver a high quality injected insulin regimen (i.e., basal-bolus)?

Even a pump infuses insulin in a largely non-physiologic way. Insulin injected under the skin must first pass a gauntlet of tissues intent on destroying its action, starting with the skin and ending with the liver. This is why the amount of insulin injected under the skin is usually 10 times the amount of insulin that would be produced inside the body to produce a similar level of glucose control.

As I examined camper insulin regimens on Sunday, I found example after example of poorly applied basic diabetes insulin management principles. Some basal-bolus schedules were essentially fixed dose regimens with seemingly arbitrary rules for dosing extra insulin. Some had no correction factor or insulin to carbohydrate ratio included and dosing was based solely on glucose level and not carbs to be eaten. These factors are integral to any kind of quality basal-bolus or insulin pump regimen.

The frequency of blood sugar monitoring also fails in many cases to be frequent enough to allow for proper self-dosing calculations. Worse, campers in many cases didn’t know how to apply the proper decision making skills that are so essential for basal-bolus to work as expected. This is where parents must step in during childhood for sure, but also well into adolescence (through age 16 at least).

Don’t get me wrong: basal-bolus schedules are based on solid principles. But in many cases they are applied by people lacking the necessary training, skills, experience and motivation to make them work. As a result, A1c values still remain entrenched in the high 8 and mid-9% range for people on these regimens. Is this the kind of return on investment you want for your child or teen? Would you argue that the alternative is worse?

I think that as we look down the road for the next great hope for diabetes, we often lose sight of the tools we already have now and how well they can still work for us. New is not necessarily best or even better than what we have now. Plus, as I’ve said over and over, diabetes care is a series of informed choices, created by ongoing diabetes education and polished by personal experience.

So think twice about whether or not to be the first on your block to get on the bandwagon for the next great thing in diabetes care (whatever it may be). Beware of snake oil diabetes miracle therapies. They’re everywhere.

Stay in virtual touch with diabetes camp

I am posting daily blogs here about important diabetes issues that directly relate to the camp and posing controversial questions to you as above. I’m also tweeting very frequently from camp. Check out my twitter site: http://twitter.com/Dr_Steve_Ponder . My tweets are real time observations from camp (plus twitpics) as they happen, sent immediately from my mobile phone. I’m discussing how things are going and any special problems or situations that all parents of children with diabetes would benefit from. I’ll also answer questions posted to this blog site as quickly as I can. You can also check out the camp’s website at http://www.lionscamp.com where you can check out daily photographs from the day before. As always, we will be preparing a complementary DVD photo album for all campers to be provided at check out on Friday evening.

Parent’s Webinar on Wednesday Evening

A Parents Day Webinar will be held at 8-9PM CST on Wednesday July 29th 2009. Go to the TLC webinar site now for the details on how to participate. It’s totally free and can be accessed from the comfort of your home PC, laptop or just call in using your telephone. Even if you don’t have a webcam, you can dial in to the conference bridge. I’ll be discussing camper progress at camp to date, key observations about how campers are stacking up compared to each other, and address some major hot button issues in type 1 diabetes care of children in 2009. There are several hot topics I’ll be addressing. Join in and listen, or submit questions on line in the Q&A section of the Live Meeting toolbar during the webinar. See you in cyberspace! Also feel free to suggest topics via comments to the blog posts below. (New comments are approved so if this is your first time it may take an hour or two before you see your comment online).

Last 5 posts by Steve

• Halloween and Diabetes CAN mix! - October 5th, 2009
• Introducing Healthy Families of South Texas - October 5th, 2009
• Complications 101 - About Kidney Failure - August 23rd, 2009
• The Sleep Bolus - August 18th, 2009
• The Dirty Truth Behind DCCT - August 16th, 2009

This entry was posted on Monday, July 27th, 2009 at 4:38 pm and is filed under Behavioral, TLC 2009. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.