1. 10 practical tips to help make
type 1 diabetes work for you!
Stephen W. Ponder MD, FAAP, CDE
Professor of Pediatrics
Pediatric Endocrinologist
Scott & White Healthcare
Medical Director, Diabetes Camping Sessions
Temple, Round Rock, College Station

2. Today’s agenda
1.
2.
3.
4.
5.
Understand what you are really
trying to manage with diabetes:
FLUX and DRIFT
Know how your tools are
supposed to be used and how
they work (insulin, food,
exercise, monitors, pumps)
Appreciate the limitations of
your tools, technology and
yourself or the PWD/CWD
Be able to recognize a trend or
pattern from randomness or
poor technique
Understand when and how to
make prudent changes to the Dmanagement plan
6.
Diabetes affects kids but
managing it is not child’s play:
it’s a team sport
7. Be prepared for common Demergencies and know how to
prevent or manage them
8. T1D usually has an entourage:
know who the other “players”
are and keep an eye on them
9. What’s new and changing in
type 1 diabetes
10. Diabetes self care is a series of
never-ending choices; strive for
perfection but be satisfied with
excellence

3. Appreciate the normal flux of glucose levels in normal
individuals first!
Trick Question: How would you rate this person’s diabetes control?

4. One goal of diabetes care is managing glucose…
Hint: It takes TIME and PATIENCE!

5. Why do blood sugar levels shift all the time?

6. Postmeal Blood sugars, A1c and CV Risk
Vascular system
220
glucose
HbA1c
180
8%
140
7%
100
6%
5%
Pre-meal
95
2 hr
?
Pre-meal
115
Goal: improve post-meal
control: BG < 180 mg/dl

7. Before meal sugar
After meal sugar

8. Inflammation drives d-complications

10. 24 hour glucose plot – A1c 5.7%

11. To manage flux
• Everything becomes a
TOOL to understand,
use, and master
• Food
• Insulin
• Exercise
• Timing
• Devices, etc….

12. 7
6
The “3 is the 4th dimension?
What dimensions” of insulin
5
4
peak
3
2
onset
1
0
duration

13. 7
6
5
4
3
And the 4th dimension is: “consistency”
2
1
0
6h
12 h
18 h
24 h

14. The 2013 “insulin arsenal”
•
•
•
•
•
•
•
Long (Lantus, Levemir)
Intermediate (NPH)
Fast (Regular)
Rapid (Humalog, Novolog, Apidra)
Premixed (75/25 and 70/30)
Ultra-rapid? (in development)
Ultra-long? (Degludec and others)

15. Comparing insulin actions

16. How does a “basal” insulin work?
• Turns off or tones down
sugar coming out of the
liver
• Allows a reasonable
amount of sugar to
enter cells
• Keeps sugar levels
steady or in balance
between meals and
snacks.

17. Timely insulin facts
• Rapid insulin can’t
lower BG any sooner
than 20 minutes
• It peaks on average in
about 1 h 15 min
• It’s mostly gone in 2-4
hours
• Maximum fall in BG is
4 mg/dl/min (rare)

18. TIP: A standing insulin dose (or
regimen) is ALWAYS CHANGED LAST
• When troubleshooting a type 1 diabetes blood
sugar problem
• First consider…
– Food
– Timing
– Equipment
• BEFORE changing an insulin regimen

19. Why is the TDD so important?
½ TDD/24 = basal rate
Insulin on Board (IOB)
(2-8 hours)
500/TDD = carb ratio
Total
Daily
Dose
(TDD)
TARGET BG
1800/TDD = correction

20. Average TDD insulin ranges by age and weight
0.6-0.8 U/kg/d (toddler)
0.8-1.0 U/kg/d (child)
1.0-1.2 U/kg/d (teen)

21. Basal-Bolus: Example Calculations
30 units as glargine
Give dose at bedtime
TDD
60 units
~ 30 units divided as boluses
10 – 10 – 10 + snacks
OR…
60 units
500 rule
8.3 ~ 10
Insulin to
carbohydrate ratio
60 units
1800 rule
30
Correction factor
(aka sensitivity factor)

22. Adjust The TDD For A High Avg. BG or A1C
Example: someone with a TDD of 35 units and few lows.
A1c = 9%, so more insulin is needed: about 3.2 units.

23. Time to reach 100 mg/dl (at ~ 4 mg/dl/min)
Blood sugar
420
340
260
180
minutes

24. Proper meal planning

25. Timing of Bolus Insulin
(humalog/novolog/apidra)
High GI
Moderate GI
Low GI
BG Above
Target Range
30-40 min. prior
15-20 min. prior
0-5 min. prior
BG Within
Target Range
15-20 min. prior
0-5 min. prior
15-20 min. after
BG Below
Target Range
0-5 min. prior
15-20 min. after
30-40 min. after

26. Timing of Bolus Insulin vs. GI or BG
Low BG
OK
High BG
Low G.I.
Mod
High G.I.
-30
-15
0
Minutes from meal
15
30

27. Why timing matters…
200
150
Pre-Meal
Insulin
Post-Meal
Insulin
100
Note:
4 hrs
3-hrs
2-hrs
1-hr
0
50
Carbs estimated w/pre-meal insulin.
Carbs known with post-meal insulin.
Source: Clinical Therapeutics 2004; 26:1492-7.

28. Why timing matters…
CGMS data
 Bolusing with meal
CGMS data
 Bolusing pre-meal

29. Beware of delayed-action foods
•
•
•
•
Pizza
Pasta/noodles
Mexican foods
Fried foods
That slowly turn to sugar in body

30. “Fried-food revenge” and correction
BG = 194
6 unit correction @ 7AM
Fried food earlier
in evening @ 8PM
BG = 115
in 3 hours

32. If insulin keeps us alive, as does
food, then why should one get
more attention than the other?

33. Because…
1) Most doctors are not
nutrition specialists
2) Diagnosing and
prescribing are what
we’re trained to do
3) Our health care system
downplays the role of
RD’s by not always
paying for those
services
4) Plus WE think we’re all
food experts anyway!

34. DON’T SHORT CHANGE THE MEAL PLAN



Food questions are
number one for most
parents and patients
Don’t use the “D” word.
It’s a meal plan.
Meal plans change
often after diagnosis
and should be
reviewed (at least)
yearly or for growth

35. D-teens count carbs POORLY
23%

36. New paradigm: “Insulin keeps us alive
while food helps keep us in control”

37. The pancreas has an “off” switch for insulin
…and it’s triggered by exercise

38. Exercise is the wild card since…
• It can occur suddenly or
unexpectedly
• It can last for different periods
of time
• Intensity can shift up or down
• It’s hard to measure
• It’s impact on blood sugar can
vary

39. Checking BG to fine tune? Or not?

40. Meters are commodity items
“a commodity is the generic term for any marketable item
produced to satisfy wants or needs”
• The best BG meter is
the one you’ll use
• $10.41 for 50 strips
(Medicare 2013 rate)
• Lancing devices (avoid
the nerves)
• Ketone meter (get one!)

41. ISO and FDA allowable errors
“Glycemic Roulette”?
Diabetes Spectrum Volume 25, Number 3, 2012
ISO 15197 Standards for SMBG

42. 223 mg/dl
Oops!
5%
114 mg/dl
95 mg/dl
95% of
the time
76 mg/dl
52 mg/dl
Oops!
5%

43. CGM calibration advice
• A CGM’s accuracy is the sum of it’s variances.
• Variance is the difference from what is
measured and what is real
• So…minimize variance whenever possible
• Calibrate (if possible) when things are steady
• Wash hands; get proper sized blood sample
(repeat if needed)
• If you calibrate when high or low, do some more
later when back in your zone
• You can over-calibrate too.

44. Ponder’s Pumping Principles
1. An insulin pump is no better or worse than the
human being attached to it
2. Master carb counting first BEFORE pumping
3. Age does not limit who can pump insulin
4. Garbage in, garbage out: beware of the “pump
and dump” phenomenon
5. A good pump doctor behaves like a coach
6. Simple is a good place to start, but pumping
skills MUST advance over time

45. Ponder’s Pumping Principles
7. A good insulin pumper troubleshoots and
problem solves daily. It’s all about mastering
the PROCESS of pumping
8. Technology changes; people don’t
9. Self-consistency is a virtue
10. Everyone’s blood sugar fluxes; seek out your
own sugar patterns in the “chaos”
11. Success is always a relative thing
12. Don’t ever be afraid to start over

46. Why do lows happen at night?
•
•
•
•
•
Hormonal patterns
Lower insulin need
Insulin peaks?
Post-exercise effect
Snacking stacking?
Lower overnight insulin/add snack

47. Don’t pass up an opportunity to
correct a high (or low) BG
• Choose what you
consider “actionable”?
• BG above or below
chosen thresholds
• Consider recent and
impending actions
• Check your results
with BG levels
• Repeat as necessary

48. Check your targets often
• Make sure you hit
your target “zone”
sugar ( 30 mg/dl)
• Rapid-acting insulin
results are best
examined at 2-3
hours
• Results should
feedback to the next
attempt
“Practice makes better”

49. Curb your liver!
• The liver makes as
well as stores sugar
• A proper insulin level
“calms down” the
liver
• Aim for an in-range
sugar level (<120 mg/dl)
upon waking up each
day

50. basal insulins are not very precise

51. Levemir variability in 9 subjects

52. Lantus variability in 9 subjects

53. “Chance favors the prepared mind”
Louis Pasteur

54. Do 2 RN’s = 1 kid?
Ok?
Ok to me!
=

55. Concrete thinkers*
can’t…
1. Consider a hypothesis
2. Consider multiple
possibilities in a
scenario
3. Systematically solve a
problem
4. Use combinatorial
logic
*Lasts until 15-17 years of age
*25% of adults are concrete thinkers.

56. ATTITUDE CHECK!

There are no “good” or
“bad” blood sugars



“In range”, “high”, “low”
Replace “testing” with
monitoring or checking
Beware of the “perfect”
record book! If you
EVEN LOOK at blood
sugars!
This whole good-bad thing
is stressing me out

57. TIPS FOR IMPROVING ADHERENCE



Your role is more like a
coach or cheerleader
The goal should be a
“normal” life, not just
“normal” blood sugars
Reward/praise the
EFFORT not the
OUTCOME

58. ISSUES FOR PARENTS AND SIBLINGS

Diabetes in a child will
test any marriage


Parents should best
share diabetes care
duties


Encourage couples time
Discuss early in course
Siblings often suffer in
silence

Fear and
misunderstanding

59. Know common reasons for lows
a)
b)
c)
d)
e)
f)
PROBLEM
Delayed meal/snack
Exercise/food/insulin
mismatch
Incorrect standing doses
or dosing ratios
Stacking insulin
Stress (wild card effect)
Post-exercise nighttime
a)
b)
c)
d)
e)
f)
USUAL FIX
Work on timing/remembering
Reduce insulin and/or increase
carbs, check BG before exercise
Check 2 hour BG patterns for
how well targets are being hit
Use bolus calculator/DIA factor
Keep list of unique responses
Eat snack with activity/less
overnight insulin/bigger
bedtime snack

60. Know common reasons for highs
a)
b)
c)
d)
e)
f)
g)
PROBLEM
Overeating (knowing/unknowingly)
High sugars 2 hrs. after meal
High fasting sugar
Damaged/outdated insulin
Stress (adrenaline response)
Insulin pump malfunction
Insulin omission
a)
b)
c)
d)
e)
f)
g)
USUAL FIX
Improve carb counting
Adjust meal dose/carbs
Check basal insulin/carbs
Toss open vials monthly
Pre-activity dose adjustment
Check site/tubing/program
Share responsibility

61. Master the art of ketone-annihilation
• Check ketones when BG > 300
• If any nausea or vomiting,
regardless of BG level
• During any illness, check
ketones periodically
• Watch: http://db.tt/00PIDcoG
• Diabetes Sick Day Rules (17 min)

62. Type 1 diabetes can
have sidekicks
• Thyroid disease
– Screen with antibodies
– Thyroid blood levels
• Celiac disease
– Screen with antibodies
– Formal Dx by GI doc
– Gluten-free
prevention?

63. Annual responsibilities
• Eye (retinal) exams
• Urine microalbumin
studies at start of teen
years or after 5 years
• Lipid profile (after 10)
• Hemoglobin A1C
(quarterly)
• Vitamin D levels(?)

64. Prior to 1980, 50% of people
with type 1 diabetes would
develop renal failure 10-20
years after onset of diabetes*
* Bruce Buckingham, MD

65. Most are now living normal lifespans
… individuals with type 1 diabetes
without renal disease achieve longterm survival comparable to the
general population.
Diabetologia. 2010 Jul 28. [Epub ahead of print]
http://www.ncbi.nlm.nih.gov/pubmed/20665208

66. More from the DCCT…
“
We thus believe the dramatic
improvement in life expectancy
is likely true for the general
population with childhood onset
type 1 diabetes and not due to a
preferential participation of
healthier individuals in the EDC in
later years. Furthermore, the
improvement in life expectancy
is far greater than that seen in
the general population.
Diabetes, July 30, 2012 - DOI: 10.2337/db11-1625
“

67. DX'd 1965-1980
DX'd 1950-1964
Diabetes, July 30, 2012 - DOI: 10.2337/db11-1625; data interpretation

68. The JDRF Closed Loop Pathway
1
Very Low Glucose a
Insulin Off Pump
START
6
Fully Automated
Insulin +
END
Anti-insulin
Closed Loop
2
3
Hypoglycemia
Minimizer
Hypo/Hyper
Minimizer
5
4
Fully Automated
Insulin
Closed Loop
Automated
Basal / Hybrid
Closed Loop
From Aaron Kowalski, PhD, JDRF Artificial Pancreas Presentation, 2008
www.jdrf.org/artificialpancreas

69. Insulin Action
• Even rapid acting analogs are too slow
• Speed of onset matters to reduce
hyperglycemia
• Duration of action matters to reduce
hypoglycemia
• Many companies working on solutions – let’s
look at one

70. Biodel Pharmacokinetics
Developing a faster insulin

71. Might Need Glucagon Too

72. Time in Range with Bihormonal AP
• 48 Plasma Glucose
• <70 – 0.7%
• 70-120 – 38%
• 70-180 – 68%
• Overnight PG
• <70 – 0.5%
• 70-120 – 62%
• 70-180 – 93%

73. Bihormonal AP
• Two pumps (or dualchambered pump)
• Insulin
• Glucagon
• Hand-held controller
• Under study in US
• Ambulatory studies
soon
• Several groups
studying (this from
Boston University)
Photo courtesy of Ed Damiano, PhD of Boston University

74. Bionic pancreas - 2013

75. Islet Cell Transplantation
• Edmonton Protocol
– Long term, whole body immunosuppression
– Graft longevity a serious issue
– Availability of islets an even more serious issue

76. Encapsulation
• DRI encapsulation chamber
– Thumbnail sized device
– Implanted, vascularized, then human islets added
– Local immunosuppression, not whole body
– Islets easily replaced

77. Xenotransplantation
• Islet availability remains a critical limitation
• PERV free pig herd
• Additional physical protection required to
prevent hyper rejection
• Intraperitoneal alginate-encapsulated
neonatal porcine islet implants
• Bob Elliott, Living Cell Technologies from New
Zealand

78. LCT Example
CONCLUSION: This form of
xenotransplantation treatment has the
potential for sustained benefit in
human type 1 diabetics.
http://www.lctglobal.com/html/popups/popup_publicationView.php?documentcode=2081

79. What if it’s not just about insulin? Glucagon
http://diabetes.diabetesjournals.org/content/60/2/391.full.pdf

80. Without Glucagon Receptors No
Type 1 Metabolic Disorder
(in mice)
Average weekly nonfasting glucose
levels in Gcgr+/+
(solid) and Gcgr-/(open) after STZinduced beta cell
destruction.
Diamonds are fasting
averages for week 6.
http://diabetes.diabetesjournals.org/content/60/2/391.full.pdf

81. Suppressing Glucagon?
Taken together these findings indicate in mice
that type 1 diabetes can be converted into an
asymptomatic, benign, noncatabolic, insulinindependent disorder by elimination of glucagon
action. These studies support the clinical utility
of the development of potent Gcgr antagonists
and/or glucagon suppressors capable of
eliminating the lethal glucagon-dependent
component of type 1 diabetes.

82. Or Perhaps Leptin?
http://diabetes.diabetesjournals.org/content/60/5/1414.full.pdf

83. With >> Leptin, No DKA
http://diabetes.diabetesjournals.org/content/60/5/1414.full.pdf

84. Near Normal BG
http://diabetes.diabetesjournals.org/content/60/5/1414.full.pdf

85. Diabetes self care is a choice

86. Actually it’s a series of choices

87. “I haven't failed. I've just found 10,000
ways that won't work.” Thomas Edison

88. “Wisdom is not a product of schooling but of
the lifelong attempt to acquire it”

89. “Life is not a matter of holding good
cards, but of playing a poor hand well.”
R.L. Stevenson (1850-1894)

90. ” …we are going to
relentlessly chase perfection,
knowing full well we will not
catch it, because nothing is
perfect. But we are going to
relentlessly chase it, because
in the process we will catch
excellence. “

91. Is the future already here?
Lifespan with type 1 diabetes vs. without
80
75
DX'd 1980--??
Average American
70
Type 1 Diabetes
DX'd 1965-1980
Linear (Average American)
65
Log. (Type 1 Diabetes)
60
55
DX'd 1950-1964
50
1964
1980
1996

92. Take home message…
• Care today is fundamentally different from a
generation ago
• Complications are becoming rare and are
not inevitable
• Lifespan can be essentially normal
• Science is moving forward on many fronts