tissue, and, for the most part, it could only be used in the hospital setting. I remember feeling that this was a great advance for my patients, and I appreciated that they benefited from the continuous delivery of basal insulin and from the intermittent boluses that were given to match their food intake and to correct an abnormal blood glucose level when indicated. When I reflect back, I realize we have come a long way over the ensuing 30 years. We have witnessed incredible advances in the understanding of what happens to the cells of the body as the result of the diabetes process. We have seen tremendous breakthroughs in diabetes drug discovery, including the development of insulin analogs, and rapid advances in glucose monitoring technology. We have determined better ways to deliver diabetes education and support, and we continue to combat discrimination against people with diabetes. And most importantly for this book, today we have insulin pumps that are small, fast, and smart, and we have continuous glucose monitors (CGMs). CGMs can give information in real time to help with diabetes management decisions. With some devices, the pump and the CGM work together in a single system.
When I diagnose someone with diabetes, I feel as if I start him or her on a new, different life’s journey. To succeed on that journey, one must effectively manage diabetes so that the maximal amount of time is spent with glucose levels in the target range, and the minimum amount of time in the low or high range. To accomplish this, people with diabetes, and their parents or caregivers, must track glucose levels to be able to deliver insulin in a manner that closely resembles how the body produces and uses its own insulin. Often the best way to achieve this is to use an insulin pump. And this may be accompanied by using a CGM. These technologies—although not really that much more complicated than your smartphone, computer, or DVD—do require basic understanding, training, and follow-up adjustment if they are going to be helpful in improving diabetes outcomes. The purpose of this book is to give you practical tips, including the knowledge and the skills to maximize insulin pump therapy and continuous glucose monitoring, if that is what you and your health care provider decide is best for you or your child. The goal is to enable you to make your journey through life with diabetes as successful as possible.
The goal of section 1 is to review the basic physiology of glucose control and what occurs when someone has diabetes. To understand what you are striving for, you must also be aware of glucose and A1C targets. The central principles of how diabetes is now managed are supported by a series of important research studies. The critical ones, such as the Diabetes Control and Complications Trial (DCCT) and important research studies concerning insulin pump therapy, are reviewed so that you understand the evidence surrounding the recommendations for meticulous diabetes control.
The insulin pump is a small mechanical device worn by someone who has diabetes and who is treated with insulin. The insulin pump helps facilitate diabetes control and lifestyle flexibility. Insulin enters the body from the pump after flowing down the tubing into a small cannula, which is a soft tube, or through a small needle placed under the skin. Newer pumps don’t even use tubing. The insulin regimen used by insulin pumps is called basal-bolus therapy, and the benefits of basal-bolus therapy will be outlined. In addition, you’ll see how you can balance insulin administration, food, and activity with greater ease while using an insulin pump.
Section 2 gets into the practical aspects of insulin pump therapy. The components and features of the pump are described, emphasizing the pump’s bolus calculator. Sections on both basal and bolus insulin delivery cover all aspects: from how to determine your initial pump settings to how to adjust settings over time. Because food is a critical element in diabetes management, there is a detailed discussion of carbohydrates, understanding how to read food labels, and ways to assess your portions. One of the true challenges in diabetes management is adjusting insulin and carbohydrate intake for planned and unplanned physical activity. An in-depth review of principles to manage exercise are given in this section.
To succeed with insulin pump therapy, it is critical to understand infusion sets, know how infusion sets differ, and what you need to consider in making the decision about which set you want to use. Although diabetes management can be challenging when you are at home, feeling well, and following your standard routine, special circumstances can make diabetes management more challenging. Situations like illness, traveling (particularly across time zones), or going off to school or college can affect glucose control. Understanding how to adjust your regimen and what do to with your glucose numbers is reviewed in this section.
SECTION 3: ADJUSTING TO INSULIN PUMP THERAPY
Section 3 covers the developmental capabilities of children with regard to managing pumps. You should have realistic expectations of what your child can do with his or her increasing self-management skills. If you don’t know what is reasonable, then you might push or hold back your child in the quest for independence.
When you begin pump therapy, it is like starting all over again. You have to check glucose levels more often, wake up in the night, assess and adjust, and think about diabetes all of the time. This can cause stress in and of itself. Deciding whom to tell about your pump, what it means to be attached to a device, and how your body image might be affected are critical issues in accepting—and ultimately succeeding with—pump therapy.
SECTION 4: CONTINUOUS GLUCOSE MONITORING AND PUMPS
There is increasing evidence of the benefits of continuous glucose monitoring. Having a glucose value displayed continuously and the ability to see trends in glucose levels can improve glucose control and help you avoid serious highs and lows. However, continuous glucose monitoring involves adding another device to your self-care toolbox and learning how to use the additional information that comes from it.
The goal of this section is to give you the information you need to start and succeed with continuous glucose monitoring. How the devices work, what the graphs and numbers mean, and how to integrate this new tool into your life will be discussed.
SECTION 5: A LOOK INTO THE FUTURE
Section 5 will give you a glimpse into the future. There is no doubt that the companies involved in diabetes technology, the diabetes associations—including the Juvenile Diabetes Research Foundation (JDRF), the Helmsley Trust, and the American Diabetes Association (ADA)—and many diabetes researchers are interested in seeing the “artificial pancreas” developed to benefit people with diabetes. The goal of the artificial pancreas is to deliver insulin automatically, almost minute to minute, in response to the glucose levels obtained in real time by the glucose sensor—just like the human pancreas does. Achieving this, however, requires a series of algorithms—mathematical equations that take into account a number of things, such as the glucose level at the time, the immediately prior glucose levels, and the rate of change of the glucose value, as well as how much insulin has already been delivered, and insulin sensitivity, to name a few. Ideally, the end result is near-perfect control of glucose levels without much human intervention. The dream of the artificial pancreas will become a reality through incremental steps that will make insulin pumps more automatic in their operation. We already have pumps that automatically suspend insulin delivery for actual hypoglycemia. In the near future, we may see pumps suspend insulin for predicted hypoglycemia, give an automatic bolus for sustained high glucose levels, or completely control insulin delivery during sleep. The future is bright, and sharing its promise with you will conclude the book.
The goal of this book is to help you understand why you or your child might want to use an insulin pump and a CGM, to give you the skills to use them, and to help you optimize your or your child’s journey with diabetes. Insulin pumps and CGMs may seem overwhelming at the beginning, but trust me, using them can become second nature in no time at all.
