Getting Started with Insulin if You Have Type 2 Diabetes

This content originally appeared on diaTribe. Republished with permission.

By Frida Velcani

New to insulin? Learn about insulin dosing and timing and how often to test your blood sugar levels if you have type 2 diabetes.

If you have type 2 diabetes, it is likely that your treatment regimen will change over time as your needs change, and at some point, your healthcare professional may suggest that you start taking insulin. While this might feel scary, there are millions of others living with type 2 diabetes and taking insulin, so it’s definitely manageable.

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Why do some people with type 2 diabetes need to take insulin?

Type 2 diabetes can progress with time, which means that it gets more difficult for a person’s body to regulate glucose levels. The body’s many cells become less responsive to insulin (called increased insulin resistance), and the specific cells in the pancreas that produce insulin make less of it (called beta cell insufficiency). This is not necessarily related to a person’s diabetes management, and it is likely not possible to prevent.

For many people, adjusting lifestyle factors such as a reduced calorie diet and increased physical activity are key to keeping blood glucose levels stable and in a target range. Healthcare professionals may also recommend that people with type 2 diabetes take additional medications like metforminDPP-4 inhibitorsSGLT-2 inhibitors, or GLP-1 agonists to their treatment plan to improve glucose management, reduce A1C, lose weight, or support heart and kidney health.

When do people with type 2 diabetes start insulin?

After 10 to 20 years, many people with type 2 diabetes will begin insulin therapy, although every person’s journey with type 2 diabetes is different. This happens when lifestyle changes and medications aren’t keeping your glucose levels in your target range. It is important that you start treatment as early as possible to avoid persistent hyperglycemia (high blood sugar), which can lead to long-term health complications affecting your heart, kidneys, eyes, and other organs.

What are the different types of insulin?

The key to transitioning to insulin is knowing your options. Some people taking insulin need to use both a basal (long-acting) and a prandial (rapid-acting or “mealtime”) insulin each day, while others may only need to use basal insulin. Learn about your options here.

  • Basal (long-acting) insulins are designed to be injected once or twice daily to provide a constant background level of insulin throughout the day. Basal insulins help keep blood sugars at a consistent level when you are not eating and through the night but cannot cover carbohydrates (carbs) eaten for meals or snacks or glucose spikes after meals.
    • Some people use other medications, like GLP-1 agonists, to help cover mealtimes. GLP-1/basal combination treatments for people with type 2 diabetes combine basal insulin with GLP-1 agonist medication in one daily injection. This combination can effectively lower glucose levels while reducing weight gain and risk of hypoglycemia (low blood sugar). Learn more here.
  • Prandial (rapid-acting or “mealtime”) insulins are taken before mealtime and act quickly to cover carbohydrates eaten and bring down high sugar levels following meals. Ultra-rapid-acting prandial insulins can act even more rapidly in the body to bring down glucose levels. Rapid and ultra-rapid insulins are also taken to correct high glucose levels when they occur or are still persistent a few hours after a meal.
  • Basal and prandial insulins are both analog insulins, meaning they are slightly different in structure from the insulin naturally produced in the body. Analog insulins have certain characteristics that can be helpful for people with diabetes. Human insulins, on the other hand, were developed first and are identical to those produced by the human body. Human insulins are classified as regular (short-acting insulin) or NPH (intermediate-acting). These are generally cheaper than analog insulins and can be bought without a prescription at some pharmacies.

Although many people use both basal and prandial insulin – which is called multiple daily injections of insulin (MDI) and consists of one or two injections of basal insulin each day as well as prandial insulin at meals – people with type 2 diabetes who are beginning insulin therapy may only need basal insulin to manage their glucose levels. Basal insulin requires fewer injections and generally causes less hypoglycemia. For these reasons, many healthcare professionals recommend basal insulin when you first start insulin therapy.

How do I take and adjust my insulin doses?

It is important to learn the different methods of taking insulin and what kinds of insulin can be delivered through each method. There are several ways to take insulin – syringe, pen, pump, or inhalation – though injection with a syringe is currently the most common for people with type 2 diabetes. There are many apps that can help you calculate your insulin doses.

  • Insulin pens are considered easier and more convenient to use than a vial and syringe. There are different brands and models of insulin pens available. Smart pens are becoming increasingly common and can help people manage insulin dosing and tracking. They connect to your smartphone and help you remember when you took your last dose, how much insulin you took, and when to take your next one.
  • Insulin pumps are attached to your body and can be programmed to administer rapid-acting insulin throughout the day, to cover both basal and prandial insulin needs. When you need to take insulin for meals or to correct high glucose, calculators inside the pump can help determine the correct dosage after you’ve programmed them with your personal insulin pump settings.
  • Inhaled insulin is ultra-rapid acting insulin and can replace insulin used for mealtime and corrections of high glucose. It is taken through an inhaler and works similarly to injected prandial insulin. People with diabetes who do not want to inject prandial insulin might use this, but it’s not for people who only use basal insulin. The only approved inhaled insulin on the market is the ultra-rapid-acting mealtime insulin Afrezza.

Your insulin regimen should be tailored to fit your needs and lifestyle. Adjusting your basal insulin dosage and timing will require conversations and frequent follow-up with your healthcare team. When initiating insulin therapy, you may be advised to start with a low dose and increase the dose in small amounts once or twice a week, based on your fasting glucose levels. People with diabetes should aim to spend as much time as possible with glucose levels between 70-180 mg/dl. Insulin may be used alone or in combination with oral glucose-lowering medications, such as metformin, SGLT-2 inhibitors, or GLP-1 agonists.

One of the most important things to consider is the characteristics of different insulin types. To learn more, read “Introducing the Many Types of Insulin – Is There a Better Option for You?” and discuss with your healthcare team.

In order to dose insulin to cover meals or snacks, you have to take a few factors into consideration. Your healthcare team should help you determine what to consider when calculating an insulin dose. Prandial insulin doses will usually be adjusted based on:

  • Current blood sugar levels. You’ll aim for a “target” blood sugar, and you should know your “sensitivity” per unit of insulin to correct high blood sugar levels.
    • Insulin sensitivity factor (ISF) or correction factor:  how much one unit of insulin is expected to lower blood sugar. For example, if 1 unit of insulin will drop your blood sugar by 25 mg/dl, then your insulin sensitivity factor is 1:25. Your ISF may change throughout the day – for example, many people are more insulin resistant in the morning, which requires a stronger correction factor.
  • Carbohydrate intake. Insulin to carb ratios represent how many grams of carbohydrates are covered by one unit of insulin. You should calculate your carbohydrate consumptions for each meal.
    • Insulin to carbohydrate ratio:  the number of grams of carbs “covered” by one unit of insulin. For example, a 1:10 insulin to carbohydrate ratio means one unit of insulin will cover every 10 grams of carbohydrates that you eat. For a meal with 30 grams of carbohydrates, a bolus calculator will recommend three units of insulin.
  • Physical activity. Adjust insulin doses before, and possibly after, exercise – learn more about managing glucose levels during exercise here.

Learning to adjust your own insulin doses may be overwhelming at first, especially given the many factors that affect your glucose levels. Identifying patterns in your glucose levels throughout the day may help you optimize the timing and dosing of your insulin. Your healthcare professional, a certified diabetes care and education specialist, or insulin pump trainer (if you use a pump), can help guide you through this process. Do not adjust your insulin doses without first talking to your healthcare team.

How often should I test my blood sugar?

The frequency of testing will depend on your health status and activities during the day. Initially, you may be advised to check your blood glucose three to four times a day. As a starting point, check in with your healthcare team about how often to check your blood sugar. Many people test before meals, exercise, bedtime, and one to two hours after meals to ensure that they bolused their insulin correctly. Over time, your fasting, pre-meal, and post-meal blood glucose levels will help you figure out how to adjust your insulin doses.

Continuous glucose monitors (CGM) are particularly useful for tracking changes in glucose levels throughout the day. Some CGM devices also connect with an insulin pump to automatically adjust insulin delivery. After you start a treatment plan, the goal for most people is to spend as much time as possible in their target range. Talk with your healthcare professional about starting CGM and developing glucose targets.

What else do I need to know about taking insulin?

It’s common to experience minimal discomfort from needle injections or skin changes at the insulin injection site. You may also experience side effects of insulin therapy, which can include some weight gain and hypoglycemia. In some people, insulin increases appetite and stops the loss of glucose (and calories) in the urine, which can lead to weight gain. Hypoglycemia can occur if you are not taking the right amount of insulin to cover your carb intake, over-correcting high glucose levels, exercising, or consuming alcohol. Treating hypoglycemia also adds more calories to your daily intake and can further contribute to weight gain. Contact your healthcare professional to adjust your insulin dose if you are experiencing hypoglycemia, or call 911 if you experience more serious side effects, such as severe low blood sugar levels, serious allergic reactions, swelling, or shortness of breath.

Staying in contact with your healthcare team is the best way to make the transition to insulin therapy. Though the first few days or weeks will be challenging, with the right support, you’ll find a diabetes care plan that works for you.

If you were recently diagnosed with type 2 diabetes, check out more resources here.

Source: diabetesdaily.com

My Type 2 Diabetes Is Forcing Me to Find a New Reason to Live

By Abby Hanna

April 21st, 2021 was when it finally happened. It was around 1:00 am and I was dozing off in bed. With the melatonin in my system and a good day behind me, I had no reason to be up any longer. My nights were usually long and painful due to my anxiety and lively thoughts, but that morning I had a good enough day to let me sleep peacefully. An exceptional day even. I had gotten my blood work from the day before back, and it looked like everything was stellar. My doctor emailed me that afternoon- “Hello Ms. Hanna, your labs look good overall.” I had carelessly overlooked the note she left about my low cholesterol (I’ll just eat more avocado toast or something) and went on with my day proud of how my body was taking care of itself without me ever having to intervene.

And then came that night. That was supposed to be a peaceful night. Me dozing off in bed. Melatonin in my system. And something told me to check my email. I decided why not, noone ever sends anything important at 1:00 am, it’ll be a quick scroll and then right to bed. I noticed another email from my doctor, more blood work results from the other day. I clicked on the message that revealed the results, and it was as if someone had replaced that sleepy pill in my system with Adderall. I’ve never sobered up so fast. I actually had a little bit of research to do from the information that she gave me. What I was looking at wasn’t an email explaining my labs, but the actual labs themselves. With a bit of research and decoding, I had confirmed what I thought was true. A cold chill ran through me as I stared at my labs. I rubbed my eyes to make sure I wasn’t dreaming. No, those labs are correct Abby. You have type 2 diabetes.

It was like finding out that your deepest fears were true. Like looking under the bed and seeing that the boogie man actually was there, or feeling the pain of pinching yourself when you thought that you were dreaming. Or looking behind you and realizing that someone is indeed following you, or getting a test back with a big fat F that you couldn’t afford to fail, or opening your bedroom blinds to reveal a dark figure is watching you, or hearing the sputtering of your car breaking down in the middle of nowhere, or reading your lab results in the middle of the night that say: You. Have. Diabetes. It was the end of my world. My body purged itself of any reason to sleep and immediately filled itself with anxiety and anguish. I did eventually end up going to sleep hours later, after learning every single thing on earth about diabetes.

I actually entered a state of bliss for the next few days. I had found out that my A1c (the number that tracks your blood sugar and how much excess sugar you have in your body) was relatively low when it came to the diabetic range. If your A1c is 6.5 or higher, you have diabetes, and mine was 6.6. I felt great about that, and although I aggressively changed my diet the next couple of days, I held dearly to my truth, which was that I wasn’t that much of a diabetic, only a little diabetic. A diet diabetic, if you will!

I knew that when I had a phone call with my doctor she would reassure me that everyone else’s diabetes was bad and that mine was just fine and that with a couple of smoothies, I’d be diabetes-free and back to normal like everyone else. So I waited a couple of days for my appointment. I set up MyFitnessPal. Ate a couple more vegetables, just for kicks, because I knew that when you have diabetes lite like me, you just have to add an order of apples to your McDonald’s meal instead of throwing it out all together.

Monday came around and we finally had the conversation. She told me everything I already knew about diabetes due to my extensive research days before. I told her that my worst habit is eating once a day. She sent a couple of informational videos about living with diabetes and told me that a nutritionist would be calling me soon. And then I posed the question. “So this is like a short-term thing, right? My A1c is pretty low for diabetes, so I just need to get it even lower and then I won’t have diabetes anymore, right?” And then she told me that this diagnosis was forever.

I started sobbing. And I sobbed through the rest of my conversation with her. I sobbed while telling my mom. I sobbed while on my walk. I sobbed in the grocery store while I picked up the “5 best foods to combat high blood sugar”. I sobbed while sitting in the car thinking about how I couldn’t flip this to be something that it’s not. I realized that this was the first thing that I couldn’t run from. I had successfully coped with everything in my life with the help of food. Food was my sidekick, my refuge, my safe space. And with this, I couldn’t run to food. I actually had to do the opposite. I had to run away from food because if I ran to it, it would be the very thing that kills me one day. It made me think about my relationship with myself and my body on a whole new level.

For as long as I can remember, food has been my safety blanket. It was my hobby. I had always loved cooking and wouldn’t mind taking the extra 20 minutes to turn top ramen into fine cuisine, or slow cooking something in the oven to make the taste richer. I loved the crinkly sounds of a takeout order, the squishy packets of soy sauce and ketchup, the red Thank You’s staring at me with gratitude as I opened the bag to reveal what treasure I ordered for that day. I loved the sizzling sound of a raw egg hitting a hot pan. The bubbling boil of a ripe stew slowly melding its flavors over a low fire. Everything about food was special to me, it was an experience, and I unabashedly leaned into it. Eating was my favorite thing to do and I would eat if I felt sad, if I was happy, to celebrate, to commemorate, to combat boredom. Everyone is supposed to eat, obviously, but I wouldn’t shy away from giving myself my favorite foods whenever I wanted them. These tendencies got a lot worse during the pandemic. I was already fighting my depression with cheeseburgers and my anxiety with brownies. The addition of a global catastrophe was scary, but it was no match for pad thai, mac and cheese, and crab rangoon. I felt justified giving myself whatever I wanted whenever I wanted. And why should I feel bad? I hate my life so I’m gonna enjoy my meals because it’s the only thing keeping me from killing myself!

Oops. Did I just say that?

The thought came tumbling to the forefront of my brain as I sat in the car thinking about this new life I would have to live with diabetes. I realized that the only thing keeping me alive was food. Literally. I hated everything else, my depression had taken everything from me but the sweet taste of lemonade or the spicy kick of kimchi. I realized that I hated my body and thus didn’t care what went into it. Growing up with body dysmorphia has made me distance myself from myself as much as physically possible. And mental illness has made me work towards quieting my brain and running from my problems in any way that I can. So, I don’t do my hair, I wear big chunky outfits to hide my body, I let the root of my fears hide in the crevices of my brain, and I revisit my good pal Caviar because it’s the only thing keeping me from ending it all. And now I am forced to take care of my body.

Learning about all the things that can contribute to high blood sugar was probably one of the wildest parts of the diagnosis. Anxiety, bad sleep habits, and stress are three things that I am too familiar with, and three things that also can raise blood sugar. Not eating enough and not getting enough exercise are also three things that can increase your blood sugar, or put it at alarmingly low rates.

Being diabetic means being confronted with my body’s health and well-being for the first time. It doesn’t just mean having more smoothies but it means sleeping at an appropriate time and making sure that I’m not stressing about all the worries of life. It means drinking enough water because my body deserves water, and it means going on a walk because my body deserves to feel the warmth of the sun and the coolness of the wind. This is hard for me. Because I want to sleep all day and I want to stress eat. I want my first time of the day leaving the house to be when I pick up my Ono Hawaiian from the delivery driver. I don’t want to have to think about loving myself and what that really means. But I have to. I have to make the decision to prioritize myself even though indulgence has felt like prioritizing me this whole time. It clearly wasn’t. Because this is where it got me. I don’t know what self-love is and I’m scared to find out, but I know that my security blanket has been ripped from me, and although it’s cold and painful, I hope there is something worth it on the other side.

 

Editor’s note: If you are struggling with mental health issues and diabetes, we urge you to seek professional help. The American Diabetes Association maintains a registry of mental health providers that have specially trained on caring for patients with diabetes.

Source: diabetesdaily.com

How to Advocate for Yourself: Making Employer-Sponsored Health Plans Work for Your Diabetes Care

This content originally appeared on diaTribe. Republished with permission.

By Julia Kenney

The therapies, devices, and care that people with diabetes need can be expensive without adequate insurance coverage. For those with employer-sponsored health insurance, there are steps you can take to improve your insurance options and advocate for yourself.

Over 45 percent of Americans have diabetes or prediabetes and roughly half of US adults receive health insurance through their employer. Unfortunately, not all employer-sponsored health plans meet the needs of people with diabetes. According to a study of 65,000 people with type 1 diabetes on employer-sponsored health insurance, the average annual out-of-pocket cost of diabetes care was $2,500. Eight percent of study participants had annual costs well over $5,000. Since diabetes is most prevalent in low- and middle-income households, these costs, in addition to paying for premiums and non-diabetes healthcare, are unaffordable for many people.

If your health insurance does not cover a component of your diabetes healthcare, or if your diabetes care is covered but still unaffordable, you can work with your employer to get better coverage. Here is an overview of the different types of health insurance, who to go to for help, and how to advocate for better diabetes health coverage.

What are the different types of health insurance?

You will have expenses no matter what health insurance you have, but some plans can be more affordable for diabetes care. These are the expenses you will typically encounter with your health insurance plan:

  • Premium – Similar to paying rent, a premium is a fixed amount that you pay every month to keep your health insurance active. It’s common for employers to pay about half of your monthly premium, and sometimes more. In 2019, people with employer-sponsored insurance paid an annual average of $1,242 for health insurance premiums.
  • Deductible – The deductible is the amount you pay out-of-pocket before your insurance provider covers expenses. For example, if you have a $1,000 deductible, your insurance coverage will not kick in until you’ve paid $1,000 in healthcare expenses for that year.
  • Copays – Copays are a fixed amount that you pay for a health service or medication, and your insurance provider covers the rest of the cost. Copays are a helpful way to pay for diabetes care because they are fixed, predictable costs that people can plan for.
  • Coinsurance – Unlike fixed-price copays, coinsurance costs are a percentage of the total price of a health service or medication. These expenses are less predictable because medication prices can fluctuate.

There are three main types of health insurance – health maintenance organizations (HMO), preferred provider organizations (PPO), and high deductible health plans (HDHP). Here is an overview of the different types of health plans and what they might cost:

  • HMO – Health maintenance organizations have high premiums and low deductibles. An HMO plan covers healthcare within a network of hospitals and healthcare professionals. Your providers must be in-network in order to get your diabetes care covered. If your diabetes care professionals are in-network, this is often the most cost-effective healthcare option for people with diabetes.
  • PPO – Preferred provider organizations also have high premiums and low deductibles than HDHPs. PPOs are more flexible than HMOs because you are able to see providers out-of-network and you can see specialists without a referral. Because of this, PPOs typically have higher premiums and out-of-pocket costs than HMO plans.
  • HDHP – High deductible health plans typically have low monthly premiums and high deductibles. In 2020, the IRS defined a HDHP as any plan with a deductible of at least $1,400 for an individual and $2,800 for a family. If you have a high deductible health plan, you can open a health savings account where you set aside money to pay for medical expenses tax-free. These health plans are good for people who don’t anticipate needing regular healthcare; paying for diabetes care can be difficult with this type of plan because you will have high out-of-pocket costs upfront before you meet your deductible.
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Keeping these different types of health insurance and related expenses in mind, here are some things people with diabetes should think about when reviewing an employer-sponsored health plan:

  • What are my diabetes-related costs? Make a list of your diabetes healthcare costs including medications, devices, supplies, healthcare visits, and lab tests.
  • What are the health insurance costs? Look at the premium, deductible, and whatever cost sharing method (copay or coinsurance) is used for the health plan.
  • Are my medications and devices covered? Refer to your health plan’s Summary of Benefits and Coverage to see what is included in your insurance coverage. If a therapy or device is not covered, you may have to switch to one that is or submit a request to get it covered. Getting a new medication or device covered under your health plan can be a challenging and time-consuming process.
  • Is insulin covered pre-deductible? Some health plans cover insulin before you reach your deductible because it is considered preventive medicine. This can make insulin considerably more affordable, especially for people on high deductible health plans.
  • Are my healthcare professionals in-network? Accessing in-network healthcare is more affordable than out-of-network care. You should choose a health plan where your current providers are in-network or one that has good in-network options.
  • Can I access a flexible spending account (FSA) or health savings account (HSA) to save money? FSAs and HSAs are used to put aside money that is not taxed to help pay for medical expenses. HSAs are paired with high deductible health plans. FSAs can be used for any kind of health insurance and all FSA funds must be used in the same calendar year. Learn more about FSAs and HSAs here.

If I have a problem with my insurance, who do I go to for help?

Your employer’s human resources (HR) department should be able to address many of your insurance-related questions, since it likely helped select the health plan(s) available to you. Your HR department is your first resource for health insurance questions. If you need help selecting an insurance plan, want to see if your diabetes care is covered, need to file a claim, or are having trouble navigating your plan and understanding the costs, the HR department will support you.

For further questions, your HR department can refer you to a representative with the health insurance company or to a third-party administrator. A third-party administrator will help you understand your health plan, file health insurance claims, and navigate the appeals process if your insurance company denies coverage for a diabetes treatment. You can also apply for an exception to get treatments, medications, and devices covered if recommended by your doctor. A third-party administrator will guide you through these steps for getting important diabetes treatments covered.

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How can I make my employer-sponsored health coverage better for people with diabetes?

People with diabetes typically require expensive medications, devices, and regular visits with healthcare professionals to stay healthy. Robust employer-sponsored health insurance plans should make these expenses affordable and predictable. If you are trying to make permanent changes to your employer-sponsored health plan, your HR department can help you advocate for future health plans that better support diabetes needs. Employers have the power to make changes to their health coverage options every year. Here are some changes you can advocate for:

  • Add insulin and other diabetes care to the preventive medicine list.

In 2019, the IRS ruled that expenses for chronic disease management can be covered before you meet your deductible under a high deductible health plan. HMOs and PPOs also have preventive medicine lists. Diabetes care such as insulin, A1C testing, blood glucose meters, and eye screening – which are all considered preventive medicine – can be added to the preventive medicine list to reduce the copay or coinsurance costs for diabetes care. This saves employees money instead of paying full price before meeting their deductible.

  • Request to get a medication or device covered under your health plan.

If a device or medication you currently use (or want to try) is not covered under your health plan, you can ask for coverage in next year’s health plan. Diabetes devices, such as continuous glucose monitors (CGM) and insulin pumps, can help people with diabetes manage their glucose levels and increase their Time in Range, but are expensive without insurance coverage. Employers can typically negotiate to cover essential diabetes care, so request coverage for your medications and devices. Your diabetes treatment should be determined by your healthcare professional, not by what’s included in your health plan.

  • Share discounts and rebates with employees.

While list prices for diabetes medications may be high, your employer’s pharmacy benefit manager (PBM) can negotiate discounts and rebates on drug prices on behalf of the insurance plan and employer. The list price minus the negotiated discounts is called the net price. Sometimes PBMs and employers will keep the money saved; however, employers can pass discounts on to their employees to lower their out-of-pocket costs.

  • Use copayments for cost sharing instead of unpredictable coinsurance.

Coinsurance costs are unpredictable because they fluctuate as a drug’s net price changes. You can advocate for your employer to choose health plans that use copayments for healthcare cost sharing, instead of coinsurance.

More resources for accessing diabetes healthcare with your employer-sponsored health plan:

Feel free to share this article with your employer or your HR department. All people with diabetes deserve access to affordable, high-quality care. To learn more about health insurance and affording diabetes treatment, visit diaTribe.org/access.

Diabetes Series

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This article is part of a series on access that was made possible by support from Insulet. The diaTribe Foundation retains strict editorial independence for all content. 

Source: diabetesdaily.com

The Top Tips for Your Best A1c Yet

Tip 1: Protein – Including some protein, whether plant or animal-based, at every meal, will help with satiation and with post-meal glucose spikes.

Tip 2: Movement – Consistent physical activity and movement each day will help increase your insulin sensitivity. Any type of exercise or movement is suitable!

Tip 3: Portion Sizes – Knowing what and how much you’re eating will help reduce guesswork with insulin dosing or food tracking.

 

Ben Tzeel a registered dietitian, certified strength and conditioning specialist, joins Diabetes Daily to discuss nutrition, ways of eating, and getting the most out of your diabetes management tools and tactics. He is the owner of Your Diabetes Insider, an online nutrition and fitness coaching business that focuses on individuals living with diabetes. He has lived with type 1 diabetes since he was seven years old.

Source: diabetesdaily.com

Achieving a 6.0% A1c by Eating 40 Grams of Carbs Per Meal

My 6-Month Experiment

“6.0”. I didn’t think I heard him correctly. I asked my endocrinologist to repeat himself. “I said 6.0%. You’re A1c was 6.0%.” My mouth gaped in astonishment. Practically non-diabetic. The lowest A1c I have ever had in my 10+ years of type 1 diabetes.

How Did I Do It?

Over the past ten years since my diagnosis with type 1 diabetes, I would consider myself a “good diabetic”. That means multiple fingersticks a day, remembering to bolus at mealtimes, and an overall idea of what kinds of foods were entering my body. My A1c hovered between 6.8-7.4% — which my doctors thought was just fine. I had a strong desire to lower my A1c, but nothing in the past seemed to significantly work.

About a year ago, I began medical school and became inspired to take better control of my diabetes. I began doing a lot of reading on the subject and started to toy with the idea of lowering my carb intake. There have not been many (if any) conclusive studies on the effects of low-carb diets in type 1 diabetics, yet I had a hunch that something like that could be my long-desired solution. I decided to perform a six-month-long clinical trial testing the effects of a low-carb diet on a particular type 1 diabetic — me.

The Rules

I recognized that diabetes is a lifelong condition and that any new diet I would undertake would have to be sustainable over a long period of time. Many popular diets only allow minuscule portions of daily carbs, and I knew that would not be maintainable long term. I didn’t want my diet to be unbearable and rebound. I, therefore, decided at the start that my diet was not to lose weight, and was not to start eating healthier. I allowed myself to eat cookies, cake, etc. (although I did naturally end up eating more vegetables in order to stick to the rules of the diet).

The diet consists of just one golden rule, plus 2 common sense rules.

The Golden Rule:

  • Maximum 40g of carbs at one sitting (eating to treat/prevent a low doesn’t count)

The Common Sense Rules:

  • Don’t eat any foods that make my blood sugar go wonky (some examples for me are pizza, bagels, and deep-fried foods)
  • Always try to bolus at least 15 minutes before eating

As part of The Golden Rule, each “sitting” is separated into three-hour chunks. For example, let’s say I eat lunch one day consisting of a hamburger (meat is zero carbs, the bun is 25g) and an apple (15g). Two hours later, I find myself hungry. What are my snack options at this point? Well, since I already reached my 40g maximum and it is within three hours of my meal, I must wait one more hour (i.e., three hours from my lunch), at which point the clock resets. I can then eat a snack up to 40g. However, let’s assume my lunch consists of just a tuna sandwich (2 slices of bread=30g). Two hours later, I find myself hungry. What are my options at this point? I can eat up to 10g of carbs because my lunch was 10g shy of the 40g limit.

I also toyed with the idea of imposing a daily maximum on carb intake, but I later nixed it. As mentioned, I wanted this diet to be highly sustainable long term, and I felt that a daily carb maximum might impede that goal. Also, diabetes diets that impose daily carb maximums are somewhat controversial in the medical field. Some medical professionals believe that such diets could even be harmful to people with diabetes, and I wanted to stay clear of that controversy.

Why Did I Think It Might Work?

Most people who start low-carb diets are trying to lose weight. Although I did lose a few pounds since I started this diet, this was not at all my intention in this endeavor (although truthfully, it was nice to finally fit into my wedding suit again). The reason I began doing this is twofold:

Reason #1: The Post Prandial Spike

Following a meal, there is inevitably a spike in blood glucose. The size of the spike is proportionate to many things (the types of carbs eaten, the timing of insulin injection, etc.). However, my personal experience has shown that for me, the spike is most directly related to the number of carbs I eat. Therefore, fewer carbs = smaller spike. (Similarly, giving at least 3 hours between meals allows time for the spike to come down).

Reason #2: The Guessing Hypothesis

Guess how much a single banana would cost you at your local grocery store. Go ahead, guess a price. You may have guessed 15 cents. 25 cents? 50 cents? One dollar? $1.50? The actual price is about a quarter. You may have guessed a quarter (you may have even bought a banana before and this, therefore, was not a guess). Or you may have been off by a bit. You may have even been off by a lot. However, most likely your guess was not off by more than a dollar. Now guess the price of 500-seat Boeing 747. Go ahead, think of a number. A quick Google search priced it at $357 Million. Was your guess off by a couple million? The point here is clear: when dealing with larger values, our estimates tend to have larger ranges of error. By keeping the carbs low, we are giving ourselves a better chance of correctly estimating our carb intake.

Conclusions

My main goal was to achieve better control of my blood sugar and somewhat lower my A1c. Yet, since the start of my diet, I’ve reaped numerous benefits and gained far more than I could have expected. My A1c has dropped a full percent, a stark reduction to a degree I had not anticipated. My day-to-day blood sugar has become much more predictable, and those horrible whacky-blood-sugar days that all people with diabetes experience have become much less common. Additionally, my average daily insulin usage dropped from 50.2U a day to 40.8U – almost a 20% decrease! As a nice fringe benefit, I lost a few pounds and really feel better overall.

One thing that people often ask is if my lower A1c came at the expense of more frequent hypoglycemic episodes. When I started this diet, I did indeed see a slight increase in hypos along with my tighter glucose control (however, I cannot quantify this with an exact number because I don’t have records of my hypo occurrences prior to starting this diet). Once I began noticing that my lows were becoming more frequent, I made a conscious effort to keep an eye on my CGM (Continuous Glucose Monitor) and be more aggressive in preventing them. Following that adjustment, I believe I have been having just as few hypos as I did before I started this diet.

I want to point out that my 40g maximum per meal is a completely arbitrary amount. It’s an amount that is feasible for me and is also fewer carbs than I was normally eating per meal. If you are reading this and thinking that you could never manage on such a meal plan, I would suggest coming up with your own maximum-carb-per-meal formula and giving it a try. Every person with diabetes is different, and this plan may not be the solution for everyone looking to gain better control of their blood sugar. However, this diet has had huge advantages for me, and I believe that there are aspects of it from which every diabetic can gain.

This article is not intended to be a substitute for professional medical advice. Always seek the guidance of your doctor or other qualified health professional with any questions you may have regarding your health or a medical condition.

Source: diabetesdaily.com

Global Survey on Do-it-Yourself Artificial Pancreas System (DIYAPS)

By Saskia Wolf, Communication and Dissemination Manager, OPEN

Please support a research study by and for people with diabetes!

At the moment, OPEN is conducting a GLOBAL SURVEY and needs the support of the Diabetes Online Community; this means we need YOUR support. If you are a person with diabetes or a parent/caregiver of one, please participate, whether you are using a DIYAPS or not! More Information is provided on the OPEN website, as well as FAQs and tutorials: https://open-diabetes.eu/open-survey

We all know that diabetes is difficult to live with. It’s all on you to keep yourself alive, and to avoid the chronic effects that won’t present for many years. And no, it’s not easy to just “be disciplined” and keep your blood glucose in a healthy range!

People with diabetes sometimes need help, but not in a paternalistic sense that interferes with daily life. Besides a supportive healthcare professional team and loving family and friends, what does help look like?

For many years, proprietary medical devices were the only help people with diabetes had to manage their condition. Continuous glucose monitors and insulin pumps took a lot of the burden (and pain) away from managing diabetes, but they had limitations. Devices couldn’t talk to each other and had to be manually set; this “open loop” system lacked automation.

Because of these unmet needs, patients developed their own closed-loop systems. Yes, patients — software developers, engineers and other tech-savvy people as part of the #WeAreNotWaiting movement. They created algorithms, made devices talk to each other, and ended up with an automated insulin delivery system that automatically adjusts insulin delivery based on glucose levels to prevent going too high or low. These systems are free and open-source; despite the challenges in building them, the number of people using a “Do-it-Yourself Artificial Pancreas System” (DIYAPS) is steadily increasing.

Users of these systems report tremendous improvements not only in their HbA1c levels, but also in their quality of life. They can finally get a break from managing their diabetes, as well as sleep through the night without CGM alarms or fear of their glucose levels getting too low. But are these systems as life-changing as they sound? What are the barriers for people to build their own systems?

Some healthcare professionals are skeptical; scientists prefer academic studies to social media posts, and thus far most studies have only had small cohorts. There was a need for a concerted research project, led by scientists, clinicians, and users of a DIYAPS alike. This was the genesis of the OPEN Project EU.

The OPEN Project has received funding from the EU Horizon 2020 RISE program to investigate various aspects of DIYAPS, working directly with patients and healthcare professionals. Please visit our website for further information on the project, our team and our publications, follow us on Twitter and visit our Facebook page (@OPENDiabetesEU) and subscribe to the newsletter.

Thank you very much!

Source: diabetesdaily.com

Diabetes & Smoking: What You Need to Know

Most of us know that smoking is horrible for one’s health. According to the Centers for Disease Control and Prevention (CDC), tobacco use is the leading cause of preventable death in the United States, yet over 34 million Americans still smoke tobacco cigarettes nearly every day.

Unsurprisingly, smoking is even worse for your health if you live with diabetes. This article will outline the reasons why smoking is so bad for people with diabetes and what you can do to stop smoking.

Smoking Is Bad for Everyone

Smoking is the leading cause of lung diseases, including COPD, emphysema, and chronic bronchitis. Smoking also contributes to the growth and development of many types of cancer, including cancers of the mouth and throat, voice box, esophagus, stomach, kidney, pancreas, liver, bladder, cervix, colon and rectum, and acute myeloid leukemia. On average, life expectancy for smokers is at least 10 years shorter than for nonsmokers.

The American people have known for a long time that smoking causes cancer. Nearly 60 years ago, in 1964, the then U.S. Surgeon General Luther Terry issued a definitive report linking smoking cigarettes with lung cancer for the first time. Smoking is even worse for people living with chronic diseases, especially diabetes.

Why Is Smoking Especially Bad for People With Diabetes?

People with diabetes who smoke are more likely to have serious health problems and complications, including heart and kidney disease, poor blood flow to the extremities, increased risk of infections, higher incidence of foot ulcers, increased rates of lower limb amputation, and retinopathy, which increases the likelihood of blindness than people with diabetes who do not smoke.

Why is this so?

People with diabetes are constantly working to manage their blood sugars and prevent complications brought on by the disease that include damage to the nerves, eyes, kidneys, and heart. The tobacco in cigarettes exacerbates these issues and accelerates the rate of decline in a person already suffering from a chronic disease.

There are over 7,000 chemicals in cigarettes, 70 of which are directly linked to the development of cancer, aging, and oxidative stress. For example, some of the chemicals found in cigarettes include toilet cleaner, candle wax, insecticide, arsenic, nicotine, lighter fluid, and carbon monoxide, just to name a few. These addicting, dangerous chemicals cause harm to your body’s cells, interfering with their normal function.

In a person with diabetes, the harm caused by a cigarette’s chemicals and nicotine causes chronic inflammation, resulting in insulin resistance and higher blood sugars, and thus makes it harder to manage one’s diabetes.

All of these issues compound to make diabetes management harder, and complications more likely. For people with diabetes, the health risks of smoking a cigarette is four times greater than for someone without diabetes.

Even more striking, a 2014 study revealed that smokers are 30-40% also more likely to develop type 2 diabetes, making the relationship between cigarette smoking and diabetes a vicious cycle.

quit smoking

Photo credit: Adobe Stock

Reduce Your Risk and Improve Your Health by Quitting Smoking

The best thing to do if you have diabetes and smoke is to quit immediately, and it’s never too late to quit! Quitting smoking before age 40 results in lifespans as long as people who have never smoked, and one’s lungs start to immediately heal the day they stop smoking.

Quitting smoking before the age of 40 reduces the risk of death (associated with continued smoking) by 90%, and quitting before age 30 avoids more than 97% of the risk of death associated with continued smoking into adulthood. The sooner, the better, but there never is a bad time to quit smoking.

Studies have shown that people who have diabetes start to respond to insulin better and their insulin resistance drops within 8 weeks of quitting smoking. 

Quitting smoking may be one of the hardest tasks you ever undertake, but the benefits are worth it: a longer, healthier life, better blood sugars, lower HbA1c levels, and fewer diabetes complications.

How to Stop Smoking

There are many resources available to people who want to quit smoking, including:

If you have diabetes and you’re a smoker, take heart: there is never a bad time to quit smoking, and quitting smoking won’t only improve your overall health, your diabetes management will likely become easier as well.

Quit smoking not only for yourself but for the health of your family as well. Lean on your loved ones for support, and work with your doctor to find a treatment plan that will work for you, minimize withdrawal symptoms, and make the transition to a smoke-free life easier.

Whatever it takes, give yourself grace: a new study reveals that smokers try to quit 30 times before they succeed, and living with the stress of diabetes can make those attempts even more challenging, but definitely more worthwhile for you and your health.

Have you quit smoking or tried to quit smoking in the past? What has worked best for you? Share your story in the comments below.

Source: diabetesdaily.com

Athlete & YouTube Sensation: Elijah

Tandem Diabetes Care Pump

This content originally appeared on Tandem Diabetes Care’s blog. Republished with permission.

Elijah is 11 years old and doesn’t let diabetes slow him down — not while pounding the pavement running cross country, and not while playing basketball, football, baseball, or his favorite, golf.

Having spent most of his life with type 1 diabetes, Elijah is a pro at overcoming challenges and adapting. He started on an Animas pump at four years old, then later switched to a tubeless pump. With support from his family, all of this change was manageable.

What Inspired Elijah to Try a Tandem Diabetes Care Pump?

One day, Shawn, a family friend and Tandem Diabetes Care team member who met Elijah the day he was diagnosed ten and a half years ago, proposed the idea of switching to a Tandem pump, but Elijah was reluctant. Elijah liked his current pump. Plus, he still had lingering worries from when his dog grabbed on to his tubing when he was four years old.

“Elijah did not want to switch,” explained mom, Molly. “And we understood, change is hard. He does a great job, but things were not going in a direction we felt good about… he was doing well, considering diabetes is a tough disease, but he had three consecutive A1c results, each higher than the one before it.”

Elijah wasn’t satisfied either. “My first experience wearing and using a pump was great, but I was always going really high and low. My blood sugars were not controlled well,” he explains. It also made some of his favorite activities more challenging, “My blood sugar, especially during baseball, would go low.”

The innovative Control-IQ® technology available for the t:slim X2™ pump piqued his parents’ interest. Around this time, they also moved in next door to Shawn. This created an opportunity for Elijah to get the feel of a Tandem pump, without an infusion site. He wore one around as a test drive of sorts.

Known by his family as a “numbers guy,” Elijah was really interested in the tech and advancement, and his parents reminded him that his body awareness had improved since he was four. They were optimistic the tubing would be less of a challenge, and it was a perk that the t:slim X2 pump offers a variety of infusion set choices.

It didn’t take long before he told his parents, “OK. Let’s do it.”

In October 2020, Elijah officially made the leap. He adjusted with help from some “diabesties” (friends in the diabetes community) and essential mentor, Shawn. By November, he was enjoying his newfound freedom.

“Everyone needs a Shawn,” exclaims Molly. Having that person, whether it be a diabetes educator or Tandem representative, can be an essential part in bridging the gap in “pump 101.”

Tandem Diabetes Care Pump

What Does the Family Love Most About the t:slim x2 Pump?

Elijah’s pump has settings for activities like Exercise and Sleep that can adjust basal rates and deliver automatic correction boluses, and it’s helping him focus more on his sports. “Putting my pump on the Exercise setting makes a big difference.” Whether he’s up to bat or sinking a hole in one, his blood glucose levels are on his mind a little less often these days.

“I sleep all night now,” says Molly, who loves the Sleep feature. “I can’t remember sleeping through the night before.”

These days, Elijah can go to bed at 200 mg/dl and wake up in the morning at 90 mg/dl–now that he wakes up with better numbers, it sets the tone for the rest of the day. After-breakfast spikes are also less likely. Molly describes the switch to Tandem like many often do, “It’s been a game changer.”

After trying a couple different infusion sets, Elijah has found his favorite, the TruSteel, which is rigid and is inserted manually. “He likes it because he controls it going in,” explains Molly. Elijah found that the automatic insertion of this tubeless pump would cause him anxiety each time it was changed. He counted every click in anticipation and was bothered when the timing differed from insertion to insertion.

“I was a little scared of tubing at first, but I don’t even notice it anymore,” says this active guy.

After a few months of use, it was time to see the endocrinologist. Starting at a 7.6 A1c in October, Elijah had achieved an impressive 6.8 by January. While they wish they would have made the switch to the t:slim X2 pump sooner, Molly wanted to wait until her son felt he was ready.

“As a parent, it changes the diabetes game 100%.” Molly goes on to say she knows that highs and lows are still possible, but are far less extreme with Control-IQ technology. When asked who, in her opinion, is a good candidate for a Tandem pump, she replied, “Anybody with type 1—if I was diagnosed tomorrow I’d go on one.”

Tandem Diabetes Care Pump

What Is Elijah Working on Now?

As for Elijah, his focus is on other things. He is hard at work on his own YouTube channel, Diabetic Dude, which features feel-good content and messages about diabetes awareness. “I mainly started to show people what type 1 diabetes is. It’s a serious disease, but I want to show people I can still do everything normal. I’ve started making more fun and hilarious videos.” He hopes his channel becomes lucrative, so he can donate proceeds to JDRF, a nonprofit 501c organization that funds type 1 diabetes research.

“I feel like he has more freedom, I feel like he can be a kid,” Molly says, excitedly explaining how nice it is that he can just have a popsicle at a friend’s house if he wants one. Elijah and his family have only good things to say about other diabetes devices, but Tandem has brought them to that next level of diabetes achievement. They leave us with this insight about Tandem, “The tech is just better. “

We thank Molly and Elijah for sharing their story and wish Elijah a very happy 1-year anniversary of Diabetic Dude! Check out his channel and be sure to subscribe!

Tandem Diabetes Care Pump


 

Responsible Use of Control-IQ Technology

Even with advanced systems such as the t:slim X2 insulin pump with Control-IQ technology, you are still responsible for actively managing your diabetes. Control-IQ technology does not prevent all high and low blood glucose events. The system is designed to help reduce glucose variability, but it requires your accurate input of information, such as meals and periods of sleep or exercise. Control-IQ technology will not function as intended unless you use all system components, including your CGM, infusion sets and pump cartridges, as instructed. Importantly, the system cannot adjust your insulin dosing if the pump is not receiving CGM readings. Since there are situations and emergencies that the system may not be capable of identifying or addressing, always pay attention to your symptoms and treat according to your healthcare provider’s recommendations.

From time to time, we may pass along suggestions, tips, or information about other Tandem insulin pump user experiences or approaches to the management of diabetes. Please note, however, individual symptoms, situations, circumstances, and results may vary. Please consult your physician or qualified healthcare provider regarding your condition and appropriate medical treatment. Please read the Important Safety Information before using a Tandem Diabetes Care product.

Source: diabetesdaily.com

What if a Pump Could Deliver Both Insulin and Glucagon?

This content originally appeared on Beyond Type 1. Republished with permission.

By Lala Jackson

Diabetes technology like insulin pumps and continuous glucose monitors (CGMs) have created less burdensome care routines for people living with diabetes who are able to get them. For some, this tech has also led to lower A1c, more time in range, and fewer hypoglycemic events. As we work to get better access to diabetes technology and medications for all who need them, we’re also looking forward to what’s next in diabetes tech – dual hormone artificial pancreas systems that keep blood sugar levels in a healthy range using both insulin and glucagon delivery.

Existing artificial pancreas (AP) systems, also known as hybrid closed loop systems, integrate insulin-only pumps and CGMs using a programmed algorithm that allows the insulin pump to “make decisions” in insulin dosing based on the blood sugar number provided by the CGM. In the current systems, the insulin pump can dose insulin in response to high blood sugars, but has no way to directly address a predicted low blood sugar other than lowering or stopping insulin delivery, or suggesting external actions (such as eating carbs) be taken. Even with this limitation, current AP systems are shown to significantly improve daily time in range, a key measure for safety and quality of life in those living with diabetes. But what if we could more closely mimic a fully functioning pancreas?

Enter, the Dual Hormone Artificial Pancreas

Also known as the bihormonal artificial pancreas (BHAP), several companies have been working on these systems over the last decade, but the last few years show promise toward a streamlined, effective, easy-to-use BHAP.

In late 2019, the FDA granted breakthrough device designation to the iLet™ pump system, made by Beta Bionics. Breakthrough device designations create an accelerated regulatory review process for a product or therapy that “has potential to address unmet medical needs.” Essentially, it shows priority for a solution that is believed able to create a large impact on people’s lives, beyond anything currently available.

Beta Bionics’ intentions for their iLet systems are ambitious – they aim to provide their system in insulin-only, glucagon-only, or bihormonal with both insulin and glucagon. Additionally, their algorithm is unique, in that the wearer must only enter their body weight, “with no need to count carbohydrates, set insulin delivery rates, or deliver bolus insulin for meals or corrections.

The iLet system was granted breakthrough designation with the use of insulin analogs that are currently approved for usage in an insulin pump, alongside Zealand Pharma’s dasiglucagon, recently approved by the FDA for use in an autoinjector and prefilled syringe. Dasiglucagon, a glucagon analog (i.e. a synthetic lab made version of the naturally occurring hormone), is stable as a liquid, versus old formats of glucagon in which a powder and liquid had to be mixed immediately before use.

Beta Bionics’ insulin-only AP system is currently in Phase 3 clinical trials, with its BHAP system slated to be one to two years behind, having completed a Phase 2 at-home use trial in 2019. Phase 3 trials of the BHAP system are expected in 2021.

Other insulin and glucagon BHAP systems are also in development, with additional companies looking into a dual-hormone format pump using insulin and pramlintide (commercial brand name Symlin), aimed at better mimicking natural absorption rates of food, leading to better time in range.

The Bottom Line

As we get closer to diabetes technology that more closely mimics a fully functioning pancreas, affordable access to both life-improving diabetes technologies and life-sustaining insulin remains key. Robust diabetes technology has the power to greatly improve quality of life, particularly when coupled with affordable, equitable healthcare.

Source: diabetesdaily.com

Real Stories, Real Data, Real Results – Using Your CGM to Improve Time in Range

This content originally appeared on diaTribe. Republished with permission.

By Matthew Garza

In this video on understanding your ambulatory glucose profile (AGP) report, pediatric endocrinologist, Dr. Amy Criego from the International Diabetes Center, uses real-world AGP examples to show how small steps and manageable goals can lead to more Time in Range. 

Continuous glucose monitors (CGM) are an amazing tool; the data they provide can help you learn more about your diabetes and dramatically improve your diabetes management. You can work with your care team to improve your Time in Range (TIR) based on data from your CGM. The International Diabetes Center’s Ambulatory Glucose Profile (AGP) report is a standardized, single-page report included in your CGM software that is based on your last 14 days of glucose data. It shows key measurements – including TIR, a summary glucose profile, and daily glucose graphs – that can be used to assess your diabetes management and outcomes and inform any changes you should make.

In this video, Dr. Criego shares real-world AGP reports from three people with diabetes:

  • Lee is a 20-year-old who has had type 1 diabetes for seven years. He currently uses a blood glucose monitor and insulin injections and his A1C is usually high. He struggles with consistent monitoring of his glucose levels, especially due to an unpredictable schedule.
  • Joe is a 17-year-old who has had type 1 diabetes for 11 years. He has been using a CGM for a long time and is working to increase his independence with his diabetes management.
  • Jill is a 10-year-old who has lived with type 1 diabetes since the age of two. She uses a CGM, and though her parents currently give her insulin injections, the family is interested in exploring insulin pumps to see how they could help her diabetes management.

Dr. Criego discusses how each individual’s care team used data from their AGP report to set attainable goals that could be achieved by making small adjustments to their diabetes management. Even though these examples focus on people with type 1 diabetes, you can definitely still learn from them if you have type 2 diabetes – and be sure to watch Dr. Anders Carlson’s video which includes examples for people with type 2 diabetes.

To learn more about the AGP, check out “Making the Most of CGM: Uncover the Magic of Your Ambulatory Glucose Profile.

Watch our other videos in the “Shedding Light on the AGP Report” series:


Listen to this video at your leisure or fast forward to the section that most intrigues you!

  • 0:00 Introduction
  • 0:33 Analyze Your Report and Improve Your TIR
  • 0:56 The Different Parts of the AGP Report
  • 2:00 What is Going Well and Where are You Now?
  • 2:37 Learning from Lee – How seeing your glucose data can help improve issues caused by inconsistent monitoring by taking small steps towards achievable goals
  • 7:00 Learning from Joe – How understanding your TIR metrics can help teens gain confidence in independent diabetes management
  • 11:33 Learning from Jill – Looking at your AGP report to see how an insulin pump can help with hypoglycemia unawareness and TIR
  • 15:09 When Should You Call Your Care Team?
  • 16:42 Closing Remarks

This article is part of a series on Time in Range.

The diaTribe Foundation, in concert with the Time in Range Coalition, is committed to helping people with diabetes and their caregivers understand Time in Range to maximize patients’ health. Learn more about the Time in Range Coalition here.

Source: diabetesdaily.com

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