Type 1 Diabetes
“Type 1 diabetes is an autoimmune disease that causes the insulin producing beta cells in the pancreas to be destroyed, preventing the body from being able to produce enough insulin to adequately regulate blood glucose levels.*“
A Type 1 Diabetes diagnosis is a bewildering experience. Managing Type 1 Diabetes is an invasive, unrelenting, every-second-of-the-day experience where knowledge, skill and vital equipment has to hang together for positive results.
The route we’ve chosen to follow and share is the high-tech approach – relying on pumps, CGMs, expert advice and making regular adjustments to keep glucose levels as close to normal as possible – without falling into the black hole of hypoglycemia. We’re not experts, we’re just parents who believe that no stone should be left unturned when looking for the best solutions to guarantee the best possible outcome for our daughter.
NICE Guidelines (UK): Plasma glucose of 4 – 7 mmol/L (72 – 126 mg/dL), except for the 2 hours after meals where the target is 5–9 mmol/L (90 – 162mg/dL).
BG has to be above 5 mmol/L when driving.
ADA Guidelines (US): Plasma glucose of 80-130 mg/dL (4.4-7.2 mmol/L) and limit postprandial (after meal) rise to no more than <180 mg/dL (<10.0 mmol/L).
First steps in Type 1 Diabetes Management
Step 1: Blood glucose monitoring
Controlling blood glucose begins by knowing what it is to start off with. In the UK, a basic BG monitor is provided at diagnosis and a more advanced model is added later on that is paired with MDI or a particular insulin pump.
Step 2: Insulin therapy
In the UK, MDI (multiple daily injections) of insulin is the first management strategy prescribed after diagnosis. Many remain on MDI indefinitely, but young children and those who meet NICE criteria for an insulin pump, may be moved over to insulin pumps. Insulin is needed in two ways:
(i) Basal insulin
Basal insulin, also called background insulin, is a relative small amount of insulin (usually 30-40% of total insulin) continuously provided. For those on injections, this is done by injecting long-acting insulin usually at bedtime, once a day, that will remain active for 20-24 hours. For those with insulin pumps, short-acting insulin is administered in tiny doses every few minutes 24-hours a day.
One of the main advantages of insulin pumps is that basal insulin can be adjusted at any time to accommodate different factors that affect glucose levels – exercise, stress, illness etc. It’s also possible to set up a basal pattern that matches the body’s circadian rhythm, increasing insulin at times when more is required, such as first thing in the morning.
(ii) Bolus insulin
Fast-acting insulin is used to cover meals. A bolus of insulin is given before meals to cover the glucose content that will make its way into bloodstream in hours following the meal. The dosage is usually calculated by determining a person’s insulin-carbohydrate ratio through trial and error and combining it with the number of carbohydrates in the meal. The dose is usually calculated by the BG monitor or pump.
One of the main advantages of insulin pumps is that bolus insulin can be administered in many ways. It’s possible to do split boluses and extended boluses to match glucose release of different foods as close as possible.
Continuous & Flash Glucose Monitoring
A CGM (Continuous glucose monitorer) is a small, wearable device that measures glucose levels every few minutes and display it on a graph. CGM systems have three parts: a diposable 5-7 day sensor, implanted below the skin, a transmitter that connects to the sensor (with a shelf life of around 12-18 months) and a receiver (which could be a standalone unit, smartphone or insulin pump), which displays the data. Some receivers operate as a standalone unit, whilst others interface with a specific insulin pump to facilitate sensor augmented pump therapy.
There are multiple CGMs on the market, we’ve had some success with Medtronic’s Enlite Sensors tied into the 640G insulin pump, which acts as the receiver (see our full review).
The important thing to grasp about CGMs is that they do not measure blood (plasma) glucose levels, but glucose within the interstitial fluid. The CGM software then converts this data to display it as a blood glucose value. There are two factors to remember – (i) the CGM system isn’t perfect, occasionally, particularly on Day 1 of the Enlite sensors, there can be a vast difference between the BG and sensor value and (ii) glucose, once digested, enter the bloodstream first, then it’s transported around the body and move into the interstitial fluid, so sensor glucose readings lag behind about 15 minutes.
Abbott’s flash monitoring system, the Freestyle Libre, is doing amazingly well. It has a much smaller sensor/transmitter, about the size of a £2 coin and the disposable sensor lasts 14 days, making it a great budget option. The system has two disadvantages – data is only available when the sensor is scanned by the receiver – so it will not alert the user and cannot integrated with a pump. The only way to know if levels are rising or falling is to active scan 24-hours a day, reducing its usefulness, particularly during the night when the user is asleep. The second disadvantage is that it cannot be calibrated, which reduces the sensor’s accuracy.
Flash monitoring is a significant step up from only using blood glucose tests, but it does fall short of the full functionality of CGMs (see our full review).
Insulin pump accessories
Insulin pumps are brilliant, but they’re dropped, exposed to water, undergo heavy use and I’m amazed at their robustness. Pump accessories can be protective, such as the really cool Aquapacs, but also decorative or useful to negate particular niggles. We’ve found the Diabete-Ezy lycra belts awesome for sick days, whilst the SPI Belt is indispensable for strenuous activity, entirely removing the annoying bounce factor.
Diabetes: More information
Life with Type 1 Diabetes
Type 1 Diabetes affects every aspect of life every minute of the day, forever. Living with Type 1 Diabetes daily is different from writing about new gadgets, cool systems and helpful resources. Here’s some more personal posts about life with Type 1 Diabetes – some are all about Diabetes, whilst others share the impact of just how much it underpins every aspect of life on a day-to-day basis.
Read more Type 1 Diabetes related blog posts here.