So You Got a CGM – Now What?

This content originally appeared on diaTribe. Republished with permission.

By Katie Mahoney, Hanna Gutow, and Diana Isaacs

If you just got a continuous glucose monitoring system, you may be wondering how to use it most effectively and how to understand your glucose data. Read our tips, tricks, and things to consider.

Congratulations – you got a continuous glucose monitor (CGM), an excellent tool to support diabetes management. Hopefully you’re feeling optimistic and excited that you have the opportunity to use this technology.

It’s most likely that you and your healthcare team decided that using a CGM is the optimal way for you to manage your diabetes. Perhaps you were given a prescription for a personal CGM. Or maybe you’re trying CGM as part of Dexcom’s Hello Dexcom program (a free ten-day trial), through Abbott’s MyFreestyle program (a free 14-day trial), or as part of Medtronic’s CGM Discount Access program. You might also be trying professional CGM, which is owned by your healthcare clinic and worn on a short-term basis.

If you haven’t yet been able to get CGM, ask your healthcare team if you can get a trial device or get a prescription. CGM is recommended for anyone with diabetes who takes mealtime insulin. While many people with diabetes currently don’t have access to CGM, we’re hopeful that more and more individuals will be able to use this technology in the future. Regardless of what brings you to using a CGM, we’ve created a three-part guide to help you get started, including tips, tricks, and considerations.

Click to jump down to a section:

Part 1: Before you apply your CGM

Learn the basics.

Before you start using your CGM, it can be helpful to understand its basic features. Continuous glucose monitors (CGM) measure the body’s glucose (or sugar) levels by sensing the glucose present in tissue fluid (also called interstitial fluid). While a blood glucose meter (BGM) provides a measurement of the blood glucose level at a specific moment in time (when you prick your finger), CGMs provide a new glucose level every one to five minutes – depending on the device, that’s 288 to 1,440 times per day. A CGM provides a constant stream of information on glucose levels, trends, and patterns.

A CGM can either be transcutaneous (it goes through your skin) or implanted (it lies under your skin). CGMs require three basic parts:

  1. A sensor that monitors real-time glucose levels under your skin.
  2. A transmitter that sits on top of the sensor and sends glucose information to a smartphone app, reader, or receiver. In transcutaneous systems, the sensor and transmitter are connected as one small on-body device. Some transmitters are disposable with the sensor while others require an additional step to attach. In implanted systems, the transmitter is attached to the skin and can be removed without harming the sensor below the skin.
  3. A smartphone app, reader, or receiver to collect and display your data.

CGMs have a variety of features that differ by brand and model, including the amount of time the CGM needs to “warm up” before glucose readings are available, how long you can wear a CGM sensor before needing to replace it, and alarms that alert you to highs and lows. You can learn more about CGM devices here. For brand-specific resources and information, click here to jump down.

Personal CGM vs. Professional CGM

The CGMs that we just described are called personal CGMs – they are owned by the person with diabetes and used for a long period of time. They are available as real-time CGMs, where the data can be continuously viewed, or as intermittently-scanned CGMs, where information is recorded all of the time, but you need to scan the sensor to view the data.

Another type of CGM is called “professional CGM.” Professional CGMs are given to someone with diabetes for a short session (usually one to two weeks) to better understand that person’s glucose levels. After the wear period, the person will review the data with their healthcare professional. This can provide insights that inform the person’s diabetes treatment, and it can help healthcare professionals recommend therapy and lifestyle recommendations that lead to better glucose management.

Some professional CGMs have a real-time mode, meaning that the user can see their glucose levels while wearing the device. Other professional CGMs have a “blinded” mode. Blinded CGM means that you cannot look at their glucose values on-demand; instead, all of your glucose data is stored and shared with your healthcare professional. This can help your healthcare team identify hypoglycemia (or low blood sugar levels). If you get a blinded professional CGM, your healthcare team will analyze the data and discuss it with you once your wear period is complete.

While long-term, real-time CGM is most effective for day-to-day diabetes management, especially for insulin users, professional CGM can be an important tool for people who are not using personal CGM. Periodic use of CGM can help people learn the effects of food and physical activity on glucose levels, even for those not taking any diabetes medications.

Reflect on your goals, know your targets, and make a plan to respond to highs and lows.

It can be helpful to reflect on your CGM goals, set your glucose targets, make plans for responding to your glucose readings, and decide with whom you want to share your data:

  • Reflect on your CGM goals. Perhaps you want to use CGM to prevent hypoglycemia using its alert system, or to prevent hyperglycemia and increase your Time in Range, or to manage glucose during exercise. Or, maybe you and your healthcare team are going to use professional CGM for two weeks to explore how your lifestyle habits affects your glucose levels. Regardless, the ultimate goal of CGM is to improve your diabetes management.
  • Know your personal glucose targets and make a plan with your healthcare team for how you’ll respond to hyperglycemia and hypoglycemia. Knowing your target glucose range is important for responding to your real-time glucose values. For most people with diabetes the target range is 70-180mg/dl – learn more about Time in Range goals here. Make a plan that incorporates glucose trend arrows from your CGM to help you prevent big spikes out of range. Here are some prompts for you to discuss with your healthcare team:
    • What is my glucose target when I wake up and before meals?
    • What should my glucose level be two hours after a meal? If it is above that value, what actions should I take to bring my glucose levels down?
    • What is my glucose target before bed?
    • What high glucose level should I try to avoid? What should I do if my glucose gets that high?
    • What low glucose level should I try to avoid? What should I do if my glucose gets that low? What should I do if my glucose levels are trending down?

Part 2: Applying your CGM

Connect the CGM to the app and set the system up.

Download the mobile app associated with your CGM system if available. If you’re using a receiver (Dexcom device) or reader (Libre device), make sure it’s charged daily. The CGM should come with instructions for applying the sensor (every seven, ten, or 14 days) and pairing the app, reader, or receiver with your sensor and transmitter. If you have an implanted CGM, it will be applied by a healthcare professional and can last up to 90 days. To jump to brand-specific instructions and tutorials, click here. To learn about CGM adhesives and tips for keeping your CGM on, check out Adam Brown’s suggestions on the topic.

Once your system is set up, your CGM will need to “warm up” before you can see your data. Different models have different warm-up periods, but this will generally take one to two hours, after which your data will be accessible either directly (Dexcom, Guardian, Eversense) or by scanning your sensor (FreeStyle Libre). The warm up period for the implantable Eversense system is 24 hours.

For many people starting to use a CGM, video tutorials can be quite helpful. If you have the opportunity, it’s good to meet with a diabetes care and education specialist or your local pharmacist (if picking up your CGM from a pharmacy). Here are set-up and application tips and tutorials for your CGM:

Part 3: Understanding your CGM data

Once you’re set up with your CGM and the warm up period is complete, you can access your data. There are two types of data you’ll want to pay attention to: real-time data and past data.

Interpret your real-time data.

Depending on the CGM brand you’re using, you can either access your glucose data at any time by looking at an app on your phone, your smart watch, or your receiver. For those using an intermittently-scanned CGM, you can view your glucose levels by scanning your sensor with your smart phone or reader. Looking at your data can feel overwhelming at first, so we recommend focusing on two aspects of your real-time data:

  • First, look at your CGM glucose value. Is it in your target range? If your glucose level is out of range, which steps of your plan should you follow?

If you’re experiencing hypoglycemia in particular, make sure you act right away to increase your glucose levels.

  • Second, look at the trend arrow. Your CGM provides a “trend arrow,” to tell you the direction and speed with which your glucose values are changing. The trend arrow is helpful for understanding what’s going on and how you can respond. For example, if your glucose value is 90 mg/dl and your trend arrow shows that your glucose levels are going down, you may need to take action to prevent hypoglycemia; if your glucose value is 90 mg/dl and your trend arrow shows your glucose levels are increasing, you are likely not going to develop hypoglycemia.

Trend arrows can help with premeal insulin dosing, before and after exercise, before bed, and to understand where your glucose will be trending in the next 30 minutes. Trend arrows are particularly beneficial when used with insulin on board (short-acting insulin that was recently taken for food or to correct a high glucose level and is still working in the body). For example, if your trend arrows are going down and you have insulin on board from an insulin dose given two hours previously, your risk of hypoglycemia is even greater.

For those not using insulin, trend arrows can help understand how different foods and activities affect glucose levels. For example, if a person sees that the arrow is rising rapidly after a certain meal or snack, they can go for a walk to try to bring it down. It may also signal that next time you should consider a smaller portion size or try to add protein or fat to prevent glucose levels from rising as quickly.

Each CGM has a slightly different interpretation of the arrows, but here’s a general idea of what the trend arrows can tell you.

data

Image source: diaTribe

We recommend working with your healthcare team to decide how often to check your glucose levels. Many people benefit from checking glucose when waking up, before meals, before physical activity, and at bedtime. Some people benefit from checking one to two hours after meals. A person should also check their CGM any time they feel symptoms of high or low glucose. CGM alarms are especially helpful for monitoring glucose levels as they change – more on this below.

Interpret your past data.

Once you’ve used your CGM for a few days, you can see your recent daily trends and the amount of time you’re spending in the target range (70-180 mg/dl). This is also called retrospective data. It is beneficial to review your glucose data regularly to understand how your lifestyle – like the food you eat, your exercise habits, your stress levels, and medications you use – affects your glucose levels. Look at your glucose levels over the past two weeks, one month, and three months; talk with your healthcare team about trends that you are noticing and how they might be addressed. Learn about the many factors that affect glucose here.

During diabetes care appointments, your healthcare team can view this data in an Ambulatory Glucose Profile (AGP) report and use it to talk with you about how your diabetes management is going and any potential adjustments to your care plan. This should be a collaborative discussion between you and your healthcare team about how your diabetes data compares to your management goals and what changes could be made.

Each CGM system offers a standardized one-page report, called an ambulatory glucose profile (AGP). The AGP includes three important components:

  1. CGM key metrics
  2. 24-hour profile
  3. Daily glucose patterns

Although there are many ways to view your glucose data, the AGP report often has all of the information that you need. We’ll explain the three main pieces below. To learn more, read our in-depth piece on understanding your AGP report: “Making the Most of CGM: Uncover the Magic of Your Ambulatory Glucose Profile.”

CGM key metrics

More green, less red.

The time in range bar shows the percentage of time you spend in five glycemic ranges:

  • data

    Image source: diaTribe

    Time in Range: glucose levels between 70-180 mg/dl

  • Time Below Range: glucose levels below 70 mg/dl
  • Time in severe hypoglycemia: glucose levels below 54 mg/dl
  • Time Above Range: glucose levels above 180 mg/dl
  • Time in severe hyperglycemia: glucose levels above 250 mg/dl

Your goal is to grow the green bar and shrink the red bars – in other words, increase Time in Range and decrease time Below Range and time in severe hypoglycemia. See more on Time in Range goals and standard targets.

24-hour profile, also known as Ambulatory Glucose Profile (AGP).

chart

Image source: diaTribe

How do you figure out how to change your diabetes management to increase your Time in Range and decrease your Time Below and Above Range? That’s where the 24-hour profile is helpful, which shows your daily glucose trends across the full 24-hour day.

  • Understanding what the 24-hour profile shows: The black line represents your median glucose level throughout the day based on data from a set period of your CGM use (e.g., the last two weeks). The blue shaded areas help show how much your glucose levels vary at different points in the day.
  • Using the data: Compare different times of day to see what might be influencing your glucose numbers. For example, while the person shown above has glucose readings that vary greatly at 3pm (indicated by a very wide shaded area), their 8am glucose numbers are much more consistent (the shaded area at 8am is narrower), despite being higher. This person also regularly sees a spike in sensor glucose readings at around 9am. What’s causing that increase? Maybe it’s a higher carbohydrate breakfast choice, forgetting to bolus, not bolusing early enough, or not accounting for all the carbs in breakfast. Reflecting on what is causing a spike or valley can help you make behavior changes to reduce fluctuations and increase your Time in Range.
  • chart

    Image source: diaTribe

    The goal: The overall goal is to keep your glucose levels in your target range without big spikes or valleys, sometimes called “flat, narrow, in range” (FNIR). In the AGP above, the green box represents the user’s target sensor glucose range (70-180 mg/dl). While the user stays in range overnight and in the afternoon, they tend to see spikes in the morning and evening. With the goal of FNIR in mind, you can look at your long-term data and ask, what’s making it possible for me to stay in range? What is making my glucose spike or fall?

  • The good news is the goal for most people is to spend 70% or more Time in Range. However, increasing your Time in Range by even 5% (an extra hour per day in range!) can be helpful. You don’t have to reach perfection to improve clinical outcomes.

Daily glucose profiles.

With your trend data, you also can see your daily 24-hour glucose profiles from the last two weeks. The figures show the target range (70-180 mg/dl) in gray, spikes above 180 mg/dl (hyperglycemia) in yellow, and valleys below 70 mg/dl (hypoglycemia) in red. Viewing the data day by day can help you evaluate how specific factors and behaviors impacted your glucose values on a certain day.

data

Image source: diaTribe

To make the most out of your daily glucose profiles, it can be helpful to log your daily food and exercise to compare with your glucose profile and see which behaviors help you stay in range and which ones tend to make you go out of range.

A helpful tool when reviewing your data with your healthcare team is called DATAA. Which stands for:

  • Data – look at your diabetes data together
  • Assess Safety – Look for and try to solve Time Below Range (hypoglycemia) first
  • Time in Range – Discuss what’s working and how to replicate that by looking for the times of day or the days of the week when Time in Range was the highest
  • Areas to Improve – Note when you spent more Time Above Range (hyperglycemia) and discuss ways to reduce this
  • Action Plan – Develop an action plan together

Other Tips, Tricks, and Considerations

1. Exercise & your CGM

To learn about how to use your CGM before, during, and after exercise, check out our article “Exercise Well with Your CGM – Recommendations, Glucose Trends, and Strategies.”

An important note about exercising with a CGM: There can be a difference between CGM glucose measurements and BGM glucose measurements due to what we call a “lag.” Changes in glucose levels in interstitial fluid are not seen as quickly as they are in the blood. At rest, the interstitial glucose lags about five minutes behind the blood glucose; in situations when glucose changes rapidly, such as during exercise, lag time can increase up to 24 minutes. This means that your CGM readings aren’t always going to be accurate during exercise. This lag can also occur outside of exercise, any time your glucose levels are rising or falling quickly.

2. How to make CGM alarms your friend

Adam Brown has written about how it can be helpful to think about your CGM as a partner in your diabetes management, rather than a nag that points out when you’re not in range. Alarms can be useful tools. By alerting you to current or predicted highs and lows, as well as rate of change, you can increase your Time in Range and see your 24-hour glucose profile become flatter, narrower, and more in range. You can personalize your CGM alarm settings to your preferred thresholds or turn them off completely (though some devices won’t let you turn off an urgent low alarm at 55 mg/dl). It’s helpful to work with your diabetes care team to determine your individualized alarm settings.

3. Sharing data with friends, family, and care-partners

The ability to share your real-time glucose data with your care-partners and loved ones is a huge plus of using CGM – your support network can help you track your glucose levels and keep them in range. At the same time, sharing your data with others makes some people nervous and self-conscious. Decide who you want to share your data with and talk with that person about boundaries and how you want to communicate about your data. For more on how to approach these conversations, check out Kerri Sparling’s “To Share or Not to Share: My Approach to Diabetes Data,” and “How to Coach Your Care-Partner on CGM Data.”

4. How to talk to your healthcare team about your CGM

Now that you’re using a CGM, talking with your healthcare team about your CGM data should become a key part of every visit.

Ahead of the visit: To help visits go smoothly, many healthcare professionals will ask you to upload your CGM data before you come into the office (or before your telehealth appointment) so they can review the data and be prepared to talk with you. Learn about uploading your data here. Note: some CGM systems upload automatically once connected to the clinic’s data portal. It’s also helpful to look over your data – like your AGP report – and come up with questions to ask your healthcare professional ahead of the visit. You may have questions about parts of your daily glucose profile that you don’t understand, areas where you’re having a hard time staying in range, or just general questions to help you navigate your data.

During the visit: To make sure that you and your healthcare professional are on the same page, it can be helpful to take a few minutes at the beginning of your appointment to explain your interpretation of your data in your own words. This may be a good time to start a conversation on any questions you may have prepared ahead of your visit. It is also important to take time with your care team to develop an action plan based on your CGM data with a few straightforward priorities for you to focus on before your next visit.

Brand-Specific Resources

While any CGM can help improve your diabetes management, there are some differences between the currently available systems that you may want to consider or talk about with your healthcare team – see our chart comparing different CGMs here. Specifically, we recommend asking your healthcare professional about how alarms may be able to alert you to times of hyperglycemia or hypoglycemia, what it means if you have to calibrate your CGM, and how to use your CGM with smart insulin pens, mobile apps, or even insulin pumps in an automated insulin delivery (AID) system.

To reach out to CGM companies for product support, contact their customer service departments:

  • Abbott: +1-855-632-8658
  • Dexcom: +1-888-738-3646
  • Medtronic: +1-800-646-4633
  • Senseonics: +1-844-736-7348

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

Four Steps to Managing Your Fear When Raising a Child with Type 1 Diabetes

By Bonnie O’Neil

The fall chill in the air deepens as the leaves begin their inevitable eruption into glorious color. Children squeal with delight at the prospect of being frightened by houses decked out with ghosts, witches on broomsticks, and ghoulish creatures. This is October, the month when a little Halloween fear can actually be fun.

But, for most of us, fear is not a matter of child’s play. We can’t easily tuck away our fears like so many Halloween decorations, simply exchanging them for thoughts of thanksgiving because the calendar says we should.

When my son was diagnosed with type 1 diabetes at age five, I thought my greatest fear in managing his type 1 diabetes (T1D) would be injecting him with insulin. I would soon discover there were far greater fears awaiting me as his caregiver.

“What if his blood sugar drops precipitously low while I’m sleeping?”

“What if I can’t control his ketones and blood sugars when he has a stomach virus?”

“What if I don’t manage his blood sugars tightly enough when he’s young? What does that mean for his long-term health?”

These are the fears shared by every T1D parent within our collective community when the world is moving in its proper orbit. But these are not normal days and the world seems to be spinning in ways that leave us feeling particularly out of control. Living with the restrictions of the pandemic for eight long months now, our fears have taken on an additional dimension.

“How can I keep my child safe from getting COVID?”

“What if my child gets COVID? What will that mean for him?”

“When will it be safe for my child to resume her normal activities like school, work, and play?”

I know fear all too well. Despising the consequences of yielding to fear, I nevertheless fall prey to its temptations and cling to it as I would a best friend. I carry fear with me as a fire between my temples, a tornado deep in my gut. Awash with fear, it’s easy to descend from the present into an imagined world of what-ifs.

Fear is a cloaked villain, lurking in the shadowlands of our minds. Catching us by surprise, fear for our child’s safety can overwhelm our thoughts, locking us in repeating mental loops. Once that unseen villain kidnaps our thoughts, how do we escape his suffocating stranglehold? Next time the fear villain shows up unbidden, try these steps to send him packing.

1. Acknowledge Your Fear in Managing Your Child’s T1D

So often we feel the emotion without taking the time to name it. We hope by ignoring it, it will go away, when actually, the opposite is true. The more we ignore fear, the greater influence it has over us. Instead of ignoring fear, face it. Sit with it. Name its source by identifying the roots of your fear. You may be surprised to discover you’ve carried this same type of fear for a long time, even before your child’s diagnosis. Talk about your fears with a trusted friend, a therapist, or a counselor.

2. Lean on Meditation or Prayer When Fear Rises up and Feels Beyond Your Control

When we’re deeply afraid, we naturally experience an accelerated heart rate because our body’s sympathetic nervous system activates its natural defensive mechanisms. Once put into motion, we experience increased pulse and breathing rates, elevated blood pressure, and tensed muscles. Intentionally breathing slowly and deeply activates the parasympathetic nervous system, calming the body by decreasing blood pressure, heart and breathing rates, and relaxing tense muscles. Deep breathing exercises associated with meditation and the slow breath prayers practiced in many faith traditions help calm our body when fear surges.

3. Stay Present

We fear what we suspect might happen in the future. When we stay grounded in the present, it’s harder for our thoughts to slip away into uncharted territory. Practicing centering prayer or mindfulness helps us grow in our ability to stay present and teaches us how to reel our thoughts back in if they begin to stray too far into what-if scenarios. When fear overwhelms you, take some time to focus on the present by repeating the word or phrase you use in mindfulness or centering prayer. Repeated slowly, in the rhythm of a deep in-breath followed by a deep out-breath, our heart rates slow, our minds settle, and we stay grounded in the present.

4. Practice Letting Go of Perfection

No one gets everything “right.” Making any decision involves trade-offs. You have an awesome responsibility in caring for your child’s chronic illness, but you can’t determine and control all outcomes affecting her. Some of us naturally have a higher desire for control than others do. If that’s you, remind yourself frequently that you’re doing the best you can, but ultimately, you’re not in control of all things. Releasing control is not a weakness; it could become your greatest strength. Give yourself permission to release control and then visualize yourself letting go.

And when fear rises up in the middle of the night, take a few deep breaths and allow your centering word to carry you back to the present, away from the fear.

Source: diabetesdaily.com

Zoning in on Sick Day Management: Practical Tips, Strategies, and Advice

By Dr. Francine Kaufman

Pediatric endocrinologist Dr. Fran Kaufman shares tips for managing illness and diabetes: make a sick day plan, have supplies on hand, log your data, modify your insulin doses, and call your healthcare team. 

Everyone with diabetes who takes insulin needs to have a sick day plan. This is something you develop with your healthcare professional to help you manage the high and low sugar levels that can be associated with an illness. The following advice applies to people with type 1 diabetes and people with type 2 diabetes who take insulin – the advice may be different if you have type 2 diabetes and do not take insulin.

Click to jump down to a section:

When you get sick, you are at risk of becoming dehydrated from poor intake or from excessive loss of fluids due to nausea, vomiting, diarrhea, and fever (your body may lose more water when you have a high temperature). In addition, dehydration is common in diabetes because high glucose levels (above 180-200 mg/dL) cause sugar to enter your urine, dragging an excess amount of fluid with it. Illness also puts you at risk of developing ketones, which when coupled with high glucose levels can lead to diabetic ketoacidosis (DKA), a very serious condition. How do you know if you have ketones? Good question, click here!

The purpose of your sick day plan is to try to keep your glucose levels in a safe range – to avoid dehydration and to prevent ketones from rising to a dangerous level. When you get sick, you should contact your healthcare team to describe your symptoms, determine if they want to evaluate you or send you to a lab (for testing), and most important, to share the numbers that you will collect as you fill in your sick day log (more on this below). It is possible that no matter what you do, you might need to go to an emergency department or be hospitalized – but acting quickly, obtaining the right data, and doing your best to manage your glucose and hydration will minimize risks.

So what illnesses are we talking about? It turns out just about any common bacterial or viral infection – such as the flu (influenza), a cold (upper respiratory virus), tonsillitis, strep throat, an ear infection, stomach flu (gastroenteritis), a bladder infection, and even a skin infection, such as an abscess – can interfere with your diabetes management. However, right now, the greatest concern is COVID-19. An infection with COVID-19 can lead to very high glucose and ketone levels, putting someone at risk for DKA. Acting quickly to start your sick day plan, even if you end up needing to be hospitalized, is important.

When you get sick, your body needs energy to fight the infection and repair damaged tissue. The infections listed above, particularly those that lead to vomiting, diarrhea, fever, and dehydration, cause your body to release certain hormones (called stress or counterregulatory hormones) that tell your liver to release stored glucose and tell your fat cells to release free fatty acids that form ketones. In someone without diabetes, the body releases more insulin to control the rise in glucose and ketones; because you have diabetes, you have to take additional insulin to manage the high glucose and ketone levels. You want to get your sugar levels between 100-180 mg/dL. Blood sugars below 180 mg/dL will prevent excess urination that can dehydrate your body. Staying above 100 mg/dL helps keep you from dipping too low and risking severe hypoglycemia.

If your glucose level is above 180 mg/dL, you need to consider increasing basal insulin doses, using an increase in basal insulin with the temp basal feature on your insulin pump, or giving repeated corrections of bolus insulin with a syringe, pen or pump. Usually, correction doses should not be given more often than every two to three hours to avoid “stacking” insulin, which could lead to low blood sugars. By having a plan for illnesses that starts your modified care early and by keeping in touch with your healthcare team, you are more likely to keep your glucose values in the 100-180 mg/dL range.

But you also have to be concerned about hypoglycemia. Low sugar occurs, particularly in children and the elderly, if the illness affects calorie and carbohydrate intake by decreasing appetite or by causing vomiting or diarrhea. Although low glucose is usually considered to be less than 70 mg/dL, during illness there is concern if glucose levels are below 100 mg/dL. If your infection or illness leads to low glucose levels, reducing basal insulin and not taking bolus insulin doses should be considered. If suspension of insulin is required, you should not suspend or delay taking the next dose of basal insulin for more than 60 minutes, because this increases your risk of developing ketones. Start sipping a sugar-containing drink, one tablespoon at a time. If hypoglycemia continues and you cannot make it better by ingesting sugar, consider the administration of low-dose glucagon. Low-dose glucagon can increase glucose level by 50-200 mg/dL in 30 minutes. To learn about whether low-dose glucagon is right for you, and at what dose, talk with your healthcare team.

To follow what is happening in your body, it helps to start a log of your glucose levels, ketones, fluid intake, and insulin doses. This sick log can be shared with your health care team. It should show improvement from one time period to the next (see below). Note: the biggest concern is vomiting; if you vomit more than twice in a time period or across two time periods, call your healthcare team.

The log shows only two days, because you should be better after 24 hours and completely on the mend after 48 hours. If you are not getting better, call your healthcare team.

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Image source: diaTribe

Here’s how to keep track (and why to keep track!) of these important numbers:

1. Glucose Levels: Check glucose levels every 1-2 hours. You may have to change this and check your glucose every 30 minutes if your levels are changing quickly. CGM trend data should be looked at every 10-15 minutes. Watch for rapid changes by looking at numbers and arrows. The goal is to keep your glucose between 100-180 mg/dL and without wide swings in values.

2. Ketone Levels: Urine ketones are often detected using a urine ketone strip. A small patch on the strip changes color depending on your level of ketones, representing negative, small, moderate, large and very large levels of ketones. Moderate, large, and very large levels are of concern. Ketones can also be measured with a fingerstick and a special ketone meter. The readings for blood ketones are more accurate and range from 0.0 to 3.0 mmol/L or greater. Blood ketone levels below 0.6 mmol/L are considered normal. Between 0.6 and 1.5 mmol/L ketones are high and show that your fat has broken down to form excess ketones. This puts you at risk of DKA if glucose levels are also elevated. Ketone levels above 1.5 mmol/L are serious, and you should contact your healthcare professional. Signs of elevated ketones:

  • Nausea and vomiting (which may also be present because of the infection)
  • Shortness of breath and labored breathing (your body is trying to eliminate the ketones through your breath so you can also smell them, they make your breath smell fruity)
  • Weakness
  • Altered level of consciousness and trouble staying awake (this is most concerning; call your healthcare professional immediately if this is happening)

Ketones should be tested at the onset of an illness and then every four hours.  If ketone and glucose levels are both elevated, your healthcare team might advise you to increase correction insulin doses further, by an additional 10-15%. If ketone levels are high and glucose levels are not high (less than 150 mg/dL), oral glucose and some insulin – reduced by about 50% – will help clear your ketones. Drinking water will also help reduce ketones as they are removed in the urine. To learn more about ketones, including what they are and how to measure them, click here.

3. Temperature: High fever can help show the severity of your illness, particularly if it is persistent.  We have learned that COVID-19 is associated with persistent high fever. Use the log sheet to document any medications you take to lower fever so that you can report this to your healthcare team.

4. Fluid Intake, with and without Sugar: Consuming liquids is critical if there is risk of dehydration. Fluids with sugar should be taken if glucose levels are between 100-150 mg/dL, and fluids without sugar should be taken if glucose levels are between 150-180 mg/dL. If you have vomited, wait 30-60 minutes before trying to drink, and then start with teaspoons of water or ice chips, progressing to tablespoons and ounces. The goal is to retain 4-6 ounces of fluids (or 2-4 ounces for young children) every 30-60 minutes until you can drink without risk of vomiting and as your thirst dictates. Food is much less important after vomiting; don’t try to eat food until you are on the mend.

5. Urination: Noting frequency and amount (small, medium, or large) is important to understand the ongoing risk of dehydration. As glucose levels reach the target of 100-180 mg/dL, you should see a decrease in both frequency and amount of urination, as well as less dehydration.

6. Vomiting, Diarrhea and Dehydration:  Vomiting and diarrhea can lead to dehydration. The signs of dehydration include dry mouth, sunken eyes, weakness, loose skin, rapid heart rate, and low blood pressure. Vomiting is also of great concern because it occurs not only from the illness, but as a result of DKA. That’s why vomiting that occurs throughout one time period or spans two time periods in your log means it is time to call your healthcare professional.  However, if you feel weak after vomiting only once or twice, it is always better to call earlier than later.

7.  Insulin, Amount and Time: One of the most important things to remember is that during an illness, you still need to take insulin. Even if you are not eating or drinking at the beginning, you need to have insulin in your body. Insulin allows sugar to enter your body’s cells to be used for energy, and you need more energy to fight off an illness. Insulin also reduces ketone formation and stops excess urination by lowering glucose levels. If you have high glucose, you might need 25-50% more insulin than you usually take, due to insulin resistance created by the extra stress or counterregulatory hormones in your body. If you have low glucose, you might need to take 25-50% less insulin than you usually take, but you still need some basal or background insulin on board.

8. Medications: At the beginning of an illness, you should consider calling your healthcare team to determine if you should avoid taking any of your routine medications while sick. This includes glucose-lowering pills or injections, such as SGLT-2 and GLP-1 drugs, or medications for blood pressure and cholesterol. In addition, it is important to write down any medications you take (name, dosage, time) to treat fever, vomiting, diarrhea, or other symptoms of your illness. Anti-vomiting medications may be helpful but should only be taken after discussing with your healthcare professional.

Key Messages:  

  • Know your sick day plan before you become sick.
  • Have supplies on hand. These include supplies to measure glucose, a way to measure ketones, a thermometer, sugar-containing fluids, glucagon, extra-rapid (or short) acting insulin, and medication to treat fever. Discuss with your healthcare team whether you should have medication for diarrhea and vomiting on hand.
  • Have all the contact information for your healthcare team available, and call them sooner rather than later.
  • Before you call your healthcare team, have the data listed on your log sheet written down, plus your symptoms.
  • Take insulin at modified doses to address both high and low glucose levels. You still need to have some insulin in your body, even if you are not eating.
  • Let someone help you while you are ill. It is too big a job to be done alone.

About Fran

Dr. Fran Kaufman is the Chief Medical Officer of Senseonics, Inc. She is a Distinguished Professor Emerita of Pediatrics and Communications at the Keck School of Medicine and the Annenberg School of Communications at the University of Southern California.

Source: diabetesdaily.com

Parenting, Working, and Diabetes During the Coronavirus Pandemic

This content originally appeared on diaTribe. Republished with permission.

By Cheryl Alkon

For some, school cancelations and working from home have added stress that can make diabetes management even more difficult. Here are the perspectives and strategies of several parents who are navigating this environment

With COVID-19 spreading through the United States, every state in the country has closed public and private elementary, middle and high schools. As a result, many of us are living and working at home full time with our kids.

How are you overseeing your diabetes during this time? Several parents with diabetes shared what they’re doing, how they’re managing, and their best advice.

Go Easy on Yourself

Ellen Sheng, of New Jersey, pulled her 11- and 6-year old sons out of their schools three days before the schools closed on March 13 for at least a month. While the fifth grader had online instruction the day after the schools shut, the younger child had a week off from any school-based learning. Sheng’s husband is also working from home during this period.

“I’ve been trying to come up with lessons and activities while also juggling work deadlines,” says Sheng, a financial journalist. “Between the lack of exercise (I usually go to the gym), and all the stress, my numbers have been trending high. I activated my ‘stress’ basal setting on my insulin pump, which is usually reserved for that time of the month or visits from my mom. I’ve still had to do a lot of corrections. I guess I need a special ‘pandemic’ basal setting.”

Sheng suggests focusing on what you can to help ease into what is admittedly a historical and unprecedented period in time. “It’s only been a few days with everyone home, so we are still figuring things out,” she says. “I’ve been focused on getting enough sleep, meditating, carving out time for exercise such as walks with the kids and doing a short high-intensity interval training workout outdoors with my husband, and watching some comedy. I’m also trying to keep to my usual diet instead of stress eating, which I’m prone to do. It’s starting to help: I went back to my usual basal setting today [after about a week of kids being home].”

Take It One Day at a Time, and Be Realistic

Focus on what you can control, advises Theresa Hastings in Denver, Colorado. Her kids are 9 and 6 and have been home since March 13. Overseeing the stress of the pandemic, unexpected homeschooling for her kids with learning differences (autism and ADHD), stocking the pantry, cancelled vacations, and ensuring she has enough diabetes medications on hand, “has taken me from great diabetes management to less than optimal management,” she said. “The entire thing is stressful from top to bottom.”

For supervising her kids’ online learning, Hastings broke the process down into manageable steps. She took the school’s lessons and divided them into daily checklists. That way, her kids can see exactly what they need to do, and once they finish, “know they can play as if it were the weekend,” she says. To work around her son’s hatred of journal writing, which is expected in school but causes a battle and tears at home (and makes Hastings’ blood sugars skyrocket), “I adapted that into something my son would enjoy, which is writing letters to friends and family on a topic with three things about that topic. I communicated with the teacher to make sure my change met her expectations.” The adaptation has worked both for her son and his teacher, and has helped Hastings keep her glucose levels stable.

Making things reasonable helps lower stress levels and contributes to more manageable blood sugars. “While I’d love to do so many amazing Pinterest learning projects and experiments with them, I know my limitations in this current situation,” she says. “I recognize I don’t have the bandwidth to put the activities together and execute them. I’d rather use my creativity to break their lessons into something they won’t fight me on. I also recognize that letting them watch Bill Nye the Science Guy for their science lesson is OK. We don’t have to build papier-maché volcanoes.”

Develop and Maintain Routines

Melissa Lee lives in the San Francisco Bay Area, where California’s governor said on March 17 that all schools would likely remain closed through fall of 2020. While Lee works from home for a remote/distributed company and while her diabetes management is already part of her routine, her 10- and 8-year old have been home since March 16, “and their rather robust independent study coursework that our schools sent home has been our biggest challenge,” she says. “I find that keeping to our routine has been key: mealtimes, food types, snacking behavior and bedtime. The more we can feel like business as usual, the more predictable my diabetes will be.”

Leaning into the familiar is a way to foster normalcy when things are very much not normal now, says Lee. “Accept that there will be some things that can be controlled, like your routine and behaviors, and some things that can’t, like your stress level and how that may impact your glucose levels.” While having family in close quarters may make it harder to spend time on yourself, she says, “consider how you might use this time to nurture some new habits without the pressures of having to be somewhere.”

We’re All in This Together

Know that everyone is doing the same as you—living with the same pandemic situation, working from home, parenting kids—and even if everyone you know doesn’t have diabetes, just about everyone has something they are concerned about, whether that is another health condition, concern for family or friends with health issues, economic worries, and so on. Do what you can to manage stress.

“Stress is the main contributor to fluctuating glucose levels,” said Shannon Brumley in Boston. At work, she directly oversees a staff of two and indirectly oversees a staff of ten. “To manage stress, I ensure my staff and I are comfortable taking breaks—some to tend to children,” she said. Exercise, particularly for those in sedentary jobs, is also important. “Not getting outside, especially when the weather is crummy, will compound stress levels. Today, when the weather was nicer, I took advantage of the day and my kids and I jumped on our trampoline and took our dogs out for a much-needed walk.”

Overall, know you are likely doing your best. “Everyone is in the same boat and employers should be adjusting expectations and ensuring family comes first,” Brumley said. “I am very fortunate to be able to work from home and still be available to my kids during these trying times.”

About Cheryl

Cheryl Alkon is a seasoned writer and the author of the book Balancing Pregnancy With Pre-Existing Diabetes: Healthy Mom, Healthy Baby. The book has been called “Hands down, the best book on type 1 diabetes and pregnancy, covering all the major issues that women with type 1 face. It provides excellent tips and secrets for achieving the best management” by Gary Scheiner, the author of Think Like A Pancreas. Since 2010, the book has helped countless women around the world conceive, grow and deliver healthy babies while also dealing with diabetes.

Cheryl covers diabetes and other health and medical topics for various print and online clients. She lives in Massachusetts with her family and holds an undergraduate degree from Brandeis University and a graduate degree from the Columbia University Graduate School of Journalism.

She has lived with type 1 diabetes for more than four decades, since being diagnosed in 1977 at age seven.

Source: diabetesdaily.com

Taking the Sting Out of Fingersticks: Lancets, Life Hacks and More

This content originally appeared on diaTribe. Republished with permission.By Marcia Kadanoff with Katie Bowles Tips to reduce the pain and hassle of pricking your finger each time you check your blood sugar levels on a meter When I was first diagnosed with type 2 diabetes two years ago, I struggled quite a bit. I had […]
Source: diabetesdaily.com

Diabetes Best Practice: Top 10 Dos and Don’ts

With so much to think about in terms of doses of medication, restocking supplies, tracking calories, etc., it is easy to overlook the most basic of best practices when it comes to managing our diabetes. Sometimes the simple things are the most effective when it comes to diabetes management. Here are my top 10 dos […]
Source: diabetesdaily.com

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