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Posted by on Jul 24, 2017 in Diabetes Management, Lifestyle, Tips and Tricks

Theme Park Fun, With Diabetes Along for the Ride

Theme Park Fun, With Diabetes Along for the Ride

While so many people compare life with diabetes to a never-ending roller coaster ride, I’m proof that real-life roller coasters can be fun! When I visit my local theme park on a hot summer day, I always remember my sunscreen, water and most importantly, a bag full of supplies.

Upon arriving at the park, it’s standard operating procedure to have to face security, and likely your first line of the day. The staff poke and prod through guests’ bags, tossing food and beverages in the trash and sending owners on their way. In my experience, when going through the security process, it’s easier to announce that you have type 1 diabetes (T1D), so when security digs through your bag they are already aware that they will encounter medical equipment. I let them know they will find things like an insulin vial and extra Pods, and also that there is food and water in my bag and it has to stay with me. I’ve noticed in the past few years that when I tell security (regardless where I am) I have T1D, there are no further questions and I don’t have to explain myself.

A lot of theme parks offer something similar to a line hopper pass free of charge to those who have a medical condition which makes it challenging to stand in long lines. I take full advantage of this offer! The theme park I frequent most often is Six Flags New England, where they offer an Attraction Access Pass which gives me (the person with the disability) and three guests access to the ride through the exit.

Here’s how it works. Upon arriving at the park, I check in and they give me a tri-fold pamphlet in exchange for a doctor’s note stating I have a disability which interferes with my ability to stand in long lines. They then tell me the wait time for the day based on how busy they expect it to be (the last time I went, the wait time was 30 minutes). After picking up the pamphlet, you can head into the park and figure out what you want to ride first. As long as it has been 30 minutes from when I checked in, I can enter through the exit and ride the coaster. Before riding, the attendant signs and notes the time, and after I get off the ride I have to wait 30 minutes from that time to enter another ride through the exit. On busy, hot days, this accommodation definitely comes in handy. On days when the lines aren’t terrible, I often just wait in line like everyone else.

Although most of these passes offered don’t let you just hop to the front of the line without waiting, it’ll make your day much more enjoyable because you don’t have to stand in a stagnant line for what can be close to an hour. It is worth noting that the ride attendant will more than likely be the one to choose your seat, so if you’re adamant about riding in the front of a roller coaster, don’t plan on it when using a disability line hopper pass.

As well as offering the Attraction Access Pass, Six Flags New England offers guests with medical conditions the opportunity to carry their bag with them onto every ride. Normally when I enter the park, I ask the security staff to provide me with a medical bag tag which has the date on it and gets stuck somewhere visible on the bag so upon entering the lines on rides you don’t have to lock away your belongings and can have them with you the entire day.

This works well for me personally in many ways:

1.   I can keep all of my supplies with me at all times, which means I can get at them anytime I need to
2.  I constantly have my food and drinks with me just in case I become low
3.  It’s WAY CHEAPER than renting a locker and better for people like me, who can’t just choose a locker and leave my bag in it all day.

While my experience is specific to Six Flags and I know their policies, I would always suggest calling your theme park beforehand to figure out all of your possible options as a person with diabetes. Some parks may require a doctor’s note or something else proving you have trouble with lines, while others may not. Before I go to a new theme park, I always do this just to see what all my options are because more than likely they have a policy regarding special accommodations for people with disabilities. It never hurts to ask and it might save quite a bit of time and money throughout my day.

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Posted by on Jul 19, 2017 in Diabetes Management, Tips and Tricks

Six Ways to Lower Stress with Diabetes

Six Ways to Lower Stress with Diabetes

Work, family, school, traffic, finances, and relationships are common sources of stress for many of us. Add diabetes management and you may feel totally overwhelmed.

It’s really important to learn and practice wellness coping techniques to stay on a healthy track.  Often stress can lead to overeating, undereating, drinking excessive alcohol or being less active, which, for some with type 1 diabetes can lead to high blood glucose levels and illness.

When I feel the stress levels start to climb (or even before then) just to continue to feel well and positive, I open my healthy coping toolbox. Here are six tools I use to stay healthy and keep stress at bay.

My Support Network. These are my family and friends, the ones I can turn to when I need emotional support, to just talk or listen without judgment. Sometimes it is helpful to have friends who also have diabetes, who understand what it’s like to live with diabetes, every day, 24/7.

Incidentally, I found some interesting research on this topic. The Framingham Heart Study followed participants over the course of 20 years and found that a person’s level of happiness was related to the happiness of their social networks. If a person had a happy friend who lived within a mile, they themselves were 25% more likely to be happy. In addition, it found that a person’s happiness can be related to the happiness of someone separated by up to three degrees (a friend of a friend of a friend).

Alternatively, low levels of social interaction were found to have a negative impact on life span. Nearly equivalent to smoking a pack of cigarettes a day or being an alcoholic and twice as harmful as being obese.

Our body’s chemicals play a role in our social connections. The hormone, oxytocin, influences social behavior by increasing relationship bonds and trust.

Get Moving. When we are active, our brains release chemicals called endorphins that actually make us feel better.  For me, even something as simple as a little walk outside in the fresh air is sometimes just enough to turn a negative feeling into a positive feeling. And activities such as yoga and meditation also provide mental health benefits.

Eat Healthy. I’m sure you’ve heard the expression, “You are what you eat.” It’s true! More and more studies are finding that a nutritious diet, low in sugar and simple carbohydrates is not only good for the body, it’s great for the brain and mental health.  Collectively, these results have given rise to a concept called “nutritional (or food) psychiatry.”

A large body of evidence now exists that suggests diet is as important to mental health as it is to physical health. According to the International Society for Nutritional Psychiatry Research, “a healthy diet is protective and an unhealthy diet is a risk factor for depression and anxiety.”

Drink Water. Our brains depend on proper hydration to function optimally. Brain cells require a delicate balance between water and various elements to operate, and when we lose too much water, that balance is disrupted; our brain cells lose efficiency.

According to an article in Psychology Today, years of research have found that when we’re parched, we have more difficulty keeping focused. Dehydration can impair short-term memory function and the recall of long-term memory. The ability to perform mental arithmetic, like calculating whether or not you’ll be late for work if you hit snooze for another 15 minutes, is compromised when our fluids are low.

So indeed, water makes our minds feel good. More of the “feel good” hormones (that also come from exercise) are able to fire through the brain to improve overall mood. Because mood has a direct impact on how productive we can be throughout the day, people with elevated moods often experience higher levels of productivity in contrast to those with lower moods. It sort of ties into how people suffering from major depression often experience a lack of motivation to do anything commonly seen as enjoyable.

Think Positively. When I feel stressed out, I try to think about and celebrate any successes I’ve had recently in managing my diabetes, even tiny ones like just testing my blood sugar. I focus my thoughts on people who bring a smile to my face, and activities and events that I enjoy that make me feel happy and alive.  Just remembering good times is often enough to get me through more challenging times.

Give Myself a Pat on the Back (or a Hug). I do so much every day to manage my life and my health. I try to be good to myself and to give myself a lot of credit.  I don’t beat myself up if I fall short of achieving perfect control because maybe I am expecting too much of myself. Maybe I’m trying to control things that are truly beyond my control.  I do my best. I review what worked and what didn’t, then let it go and do something that I love!

Living with diabetes, we all have our good days and bad days.  And it’s normal to feel upset or angry about the bad days.  Sometimes, when I try the tools above and the stress still feels overwhelming, I know I can always seek out help from my endocrinologist, diabetes educator, or friends for help coping, getting back to being joyful and enjoying life.

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Posted by on Jul 10, 2017 in Pump Therapy, Technology, Tips and Tricks

High Blood Sugar due to Pump or Site Issues?

High Blood Sugar due to Pump or Site Issues?

Anyone who uses an insulin pump knows there are many benefits in terms of lifestyle and glucose control. However, there’s also a lot that can go wrong. Just the other day, I got one of those annoying “occlusion” alarms for no apparent reason. And last week, one of our patients developed pain at their infusion site and had to move to a different spot. Problems like these can result in high blood glucose (BG) levels. There are a number of “parts” that all have to be working properly for the pump to perform well. The insulin itself has to be at full-strength (unspoiled, and/or not expired), the reservoir and tubing have to be free of air pockets, the infusion set/cannula must be properly seated under the skin, the pump itself needs to be in good working order…you get the idea.

Pumps use rapid-acting insulin, which typically takes 3-4 hours to finish working. If something goes wrong, it is important to identify and fix the problem quickly. This requires good troubleshooting skills.  Otherwise, it is possible to have very high BG levels, produce ketones, become dehydrated, and slide headfirst into Diabetic Ketoacidosis (DKA). If you are on a pump and have unexplained hyperglycemia, you need to act fast.

Unexplained hyperglycemia can occur because of a “mechanical” issue related to the pump and its components. So how do you become an effective problem-solver? A little knowledge goes a long way.  Knowing whether an elevated BG is related to a pump issue or some other cause can help you resolve the problem in a timely and effective manner.

What to Do

If you have had an unusually high BG for several hours, it is important to test for ketones (either in urine or a blood sample). The presence of ketones indicates that your body is lacking insulin. Since the pump and its components may be part of the problem, there are three steps to take to help you figure out the possible problem and get back to a normal BG.

  1. Take an injection of rapid-acting insulin using a syringe or a pen to correct the high BG. That way, you’re absolutely sure that insulin has gotten into your body. If you have a tubed pump, you can disconnect a pump and deliver an equivalent bolus into the trash can (or sink) so that the pump can track the insulin-on board accurately.
  2. Change out everything: open a new vial of insulin, replace your Pod, or fill a new pump reservoir/cartridge and replace the infusion set and tubing.
  3. Drink plenty of water to prevent dehydration and to flush out the ketones through urination.

If ketones are not present, you can bolus with the pump. If your BG doesn’t come down within the next couple of hours, follow the three steps above. If it does come down, now is your chance to play detective and figure out what may have caused the high reading. Here’s a list of what I refer to as the “usual culprits:”

  • High BG can occur because of infection or illness, with hormonal changes such as menstrual cycles and growth spurts, following a low blood sugar treatment, or in relation to a change in some other medication–quite possibly one that is not related to diabetes. Steroids are infamous for raising BG levels. Stress and high fat foods can result in high BG levels, as can being too sedentary.
  • Insulin can “spoil” when exposed to heat or excessive agitation. Insulin needs to be stored properly, and care needs to be taken to keep the pump and tubing (if applicable) out of direct sunlight. Furthermore, rapid-acting insulin needs to be used in an insulin pump, so be sure that the wrong type of insulin wasn’t inadvertently used.
  • A site should not be used for any longer than 72 hours. Doing so invites the development of lipodystrophy, which leads to poor insulin absorption and results in high BG levels and a need for more insulin. Practice good site rotation to decrease change of developing scar tissue.

Identifying the Cause

  1. Check to be sure that the pump is delivering insulin as intended. Is the am/pm on the clock set correctly? Having them flipped can result in incorrect basal and bolus dosing. Has the pump been suspended for a while? Have the batteries died? Do you smell the insulin? If so, this indicates that something is leaking (the pump should be an airtight system). Check the connections to be sure they are tight and secure. It might look like the infusion set is in place, but the cannula could be blocked, kinked, or displaced.
  2. Be sure to take a good look at the infusion set and the insertion site. The adhesive on the infusion set should be well-secured to the skin. If it’s starting to lift up at the edges, it needs to be replaced right away. An adhesive product might need to be applied to the site and allowed to dry before you insert the new infusion set, to help it stick better. An overlay bandage could also be used, cutting a hole in the center so that you can still disconnect at the site. Of course, make sure you are not disconnected. If you have missed basal insulin, deliver a bolus to replace it. If you use a pump with tubing, be certain that any air is purged out. If there is a “window” that allows you to look at the placement of the cannula, check to make sure it looks like it was properly inserted. You should only see several millimeters of cannula in the window. If you see more, put in a new infusion set, being certain to insert the introducer needle all the way. Be sure that there’s no blood in the cannula or the tubing. If the insertion site is red, warm, or tender, insert a new infusion set in a different location.
  3. Check for a blockage. Pumps should alarm when a blockage occurs, but silent occlusions (minor blockages that do not trigger an alarm) can and do occur. However, if you do get an alarm, don’t ignore it. You should immediately change the reservoir/cartridge, tubing (if applicable) and infusion set. If occlusions occur often, try switching to a new site and location on your body or a different type of infusion catheter. A steel needle (as opposed to a flexible Teflon cannula) may do the trick. Or switch from a long cannula to a short one, or from a 90 degree to an angled infusion set, or vice versa. If the problem is due to the insulin crystallizing, a switch to a different brand of insulin may solve the problem.

There are a lot of “points in the pipeline” where a problem can occur with a tubed pump. One nice thing about the Omnipod System is that it eliminates (or minimizes) many of the potential issues. If you don’t have tubing, it reduces the likelihood of  air pockets or insufficient priming. The adhesive on Omnipod System also tends to be quite effective, so having the Pod fall off is less likely. Site evaluation with the viewing window is beneficial as you can see if the cannula has dislodged or if a leak is occurring (the window can become foggy or liquid-filled).

It would be great if technology worked the way it’s designed to 100% of the time, but it doesn’t.  Problems crop up, and being able to effectively troubleshoot lets you get back in range and spend as much time there as possible.

Gary Scheiner, MS, CDE

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Posted by on Jun 26, 2017 in Lifestyle, Pump Therapy, Technology, Tips and Tricks

It’s Good to be STUCK! Strategies for Keeping Your Pump Securely in Place

It’s Good to be STUCK! Strategies for Keeping Your Pump Securely in Place

For those of us who use insulin pumps, we need insulin delivery to be seamless. Interrupted delivery can mean a major change in blood sugar, and it often happens at times when we are not prepared. While there are several reasons for interruptions, such as air bubbles in the tubing, periods of disconnection or insulin delivery suspension, it’s extremely frustrating when it happens because our insulin pump site doesn’t stay stuck to the skin. Shouldn’t that adhesive hold for at least three days?

Unfortunately everyone’s activity level and skin (and the oil it makes naturally) is a bit different. Some people have no issues with a site staying securely attached. In fact, they have to use something to loosen the adhesive in order to take it off! Others fight to keep it stuck even hours after a new site has been attached. Different times of the year such as summer can mean sweaty skin that decreases the adhesive quality of infusion sets or pod adhesive. Different activities (heavy exercise, a day at the beach, time in the pool) can also create adhesive challenges.

Where to Start

Surprisingly, one of the best strategies for keeping you pump site in place is to choose the right body part. Pods and infusion sets placed on the arms, legs (compared to the lower back and buttocks) are more likely to get bumped. The skin on the arms and legs (as well as the abdomen) also tends to perspire more, pull/stretch more, and have greater oil secretion. Likewise, hairless sites tend to hold in place better than hairy sites. So choose your body part wisely!

When placing a Pod or infusion set on your skin, make sure that the site is clean. Things like the natural oil in skin, moisturizers (lotions or moisturizing soap) as well as dirt can decrease the “stick” of the adhesive. Use an alcohol pad or soap and water to clean the site and then ensure that it is entirely dry.

Many options are available to help keep the adhesive in place, and remove it when it’s time.

Skin Preparation and Adhesive Removal Products

Some people use Antiperspirant (solid or spray instead of the cream or gel type). Put it on the skin where the infusion set will be placed and wait until the area is completely dry before attaching the infusion set/Pod.

There are sticky products like IV Prep (which cleans the oil from the skin and makes the skin sticky which helps the site stay attached). There are also products like Mastisol or Skin Tac which are kind of like a rubber cement for skin. When placed on the skin before the infusion set is inserted, they help to make a barrier to prevent the skin’s oils from loosening the adhesive. These are very sticky and usually require a product like Detachol to remove the site from the skin. Another alternative for easy removal is to soak a cotton ball in baby oil, dab it around the adhesive and let sit for a few minutes before pulling off the Pod or infusion set.

Tape

Some tapes are a bit like a thin plastic tape, but will fit over or under the Pod or infusion set adhesive to keep it securely attached.  These thin tapes can be used under the Pod or infusion set and will allow the set to be inserted through the “tape,” create a barrier (which can help those with skin allergy to the Pod or infusion set adhesive as well as keep it stuck), and keep the site intact.  These include:

Hypafix, Opsite Flexifix (by Smith and Nephew), Tegaderm, and IV3000. Another good option if you have skin allergies is ToughPads by Johnson and Johnson.

These types of tape can also be used over the top of the Pod or infusion set adhesive, if needed.  Smith & Nephew’s Infusion Set IV 3000 is popular because it has a pre-cut hole to allow access to the infusion set’s disconnect mechanism.

Other types of tape are a bit more like fabric and some come pre-cut in fancy shapes and designs to make your pump site a bit more fun and less “medical” looking. These include:

  • RockaDex
  • Kinesiology tape or Rocktape (not pre-cut, but available through local pharmacies in a roll with many colors available that you can cut to the size and shape you need for your product).
  • GrifGrips have excellent adhesive quality, stylish designs, and pre-cut holes that are custom-sized for Omnipod, CGM transmitters, or traditional pump infusion sets.

Granted, there are about as many products available for keeping that site stuck as there are skin types. It often takes some trial and error to find the product that works best for you. But keeping yourself connected is well worth it!

-Gary Scheiner MS, CDE and the Clinical Team at Integrated Diabetes Services

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