Airport Security Hypo

If you live with type 1 diabetes and travel, those three words: “Airport Security Hypo” probably strike fear into your heart. Airport security is stressful enough with type 1 diabetes, even when it goes smoothly but if you throw in a hypo it’s nerve wracking.

I traveled to London last Saturday solo and this happened as I was coming home. I was in line at the metal detector, I had put all my stuff on the belt and that’s when my CGM (Continuous Glucose Monitor) alarm went off, telling me that my glucose levels were 4.4 mmols and dropping ⇘.

Emmm, what do I do???

Do I jump the person behind me to grab my bag off the belt and risk the security agents responding as I would expect? Or do I wait and see if a more opportunistic moment presents itself? I knew I was going to have to volunteer for a pat down anyway.

I choose the, “Well, it’s only going to take a few minutes and I feel fine so let’s assume my CGM is telling a bit of a fib for right now” option combined with the "wait and see" approach. 

I went through the metal detector and it beeped. I was directed to the body scanner which I declined because of the manufacturers recommendations about my CGM and opted for the pat down. This airport likes to do theirs in a private room which means two female agents need to be available. 

So I took a seat and waited. And waited. Thankfully the agent directing the other people through the metal detector had my back and kept checking that someone was coming to me. And another thankfully, I was at the airport way too early for my flight so apart from the threatened hypo I was chillaxed. 

Another 5 minutes went by and I could start to feel the heat of my body increase but I was still functioning and calm. By the time the agent came to usher me to the screening room I could feel the heat turn into perspiration. I thought about asking if I could grab my glucose out of my test kit. But I really wanted to get this stress over with so I could relax. And I didn’t know how it would be received. These seemed like really nice, jolly agents but I did not want to push it. 

I want to point out this was a choice that I made and take full responsibility for but I didn’t feel at any point that I could not ask for help. 

The screening was over with in less than ten minutes and I was reunited with my bags. I could feel my hypo symptoms increasing but not at the pace of a hard crash. So I moved away from the checkpoint and gathered myself. I took some glucose and decided that even though it was a little early for dinner I was having it. I could feel the glucose tabs were already starting to work as I ordered but I was starving. So hungry that I "hypo-ordered" the biggest thing on the menu with a side. And I finished it. I was stuffed but I cleaned my plate.

Inject Correct-ly

Approximately 90% of the diabetes community in Ireland use insulin pens to manage their diabetes. A study published in 2013 claims the two thirds of the injecting diabetes population has lipohypertrophy - BD Medical (Becton Dickinson) was involved in this the largest study of its kind.  

Last week, on one of my multiple trips to Dublin I was invited to attend an engagement workshop and factory tour organized by BD Medical (Becton Dickinson) where the word lipohypertrophy came up multiple times.

BD Medical manufactures disposable insulin injection pen needles in their factory in Dun Laoghaire, Dublin. They also used to manufacture our hypodermic disposable syringes for those of you who may be old enough to remember mixing insulins.

There were three people with diabetes in the room of about 30 people and a number of clinicians. I brought my personal experience of living with diabetes and some general experiences I observe of my peers in real life and in the online community. But it was really interesting to hear from a diabetes nurse specialist and what she commonly and uncommonly sees in clinics and how they approach new patients and patients who are struggling with their diabetes management. 

We took a break from “workshopping" to hear from Mike Smith, BD’s Clinical Marketing Manager, who presented an informative talk on lipohypertrophy, which is something BD is very passionate about and BD was instrumental in producing the Forum for Injection Technique (FIT) guidelines to reduce the risk of lipohypertrophy and to make sure you are getting the best out of your insulin delivery. Here is a more PWD friendly version of those guidelines. 

Approximately 90% of the diabetes community in Ireland use insulin pens to manage their diabetes. This might be surprising considering all the chatter on social media relating to insulin pumps.

I have always assumed given how often we might inject ourselves with this potentially lethal drug that being taught to inject correctly would be a high priority with healthcare providers. 

However, the Blanco et AL 2013 study sponsored by BD showed that lipohypertrophy was present in:

• 76.3% of Patients with Type 1 and 
• 56.1% of patients with Type 2

This study determined that the reason for such high number of LH was concerns over injection technique. This was probably the “largest survey (the Injection Technique Questionnaire) ever done concerning insulin injection technique in more than 13,000 insulin-injecting people with diabetes from 42 countries.”

What is lipohypertrophy or LH?

“ Lipohypertrophy is a medical term that refers to a lump under the skin caused by accumulation of extra fat at the site of many subcutaneous injections of insulin. It may be unsightly, mildly painful, and may change the timing or completeness of insulin action.” https://en.wikipedia.org/wiki/Lipohypertrophy

What causes Lipohypertrophy?

 “Repeated insulin injections in the same location can cause fat and scar tissue to accumulate.”  Also caused by reusing the same needle more than once. The more you reuse your needles, the higher your chance of developing this condition. One study found that 46 percent of people who developed lipohypertrophy reused needles." From Healthline.com.

How does LH affects your insulin absorption?

“Areas of lipohypertrophy can cause delays in absorption of medication administered to the affected area, like insulin, which can result in difficulties controlling blood sugar.” From Healthline.com. 

What is the Correct Injection Technique and why?

DiaTribe.org condensed the Mayo Clinic’s “Six Sets of Golden Rules to Assist With Implementation of the New Recommendations” into an easy to read page. 

These Golden Rules include:

• Consider your needle length (4mm for pens, 6mm for syringes). 
• Rotate injection sites
• Do not reuse needles.
• Don’t reuse needles.
• Prime your Pen before injecting. 
  • "Dial two units on your pen and then press the button to shoot some insulin into the air to make sure it works. This is called an “air shot” or “priming” the pen. If you do not see at least two drops of insulin after repeated priming, do not use the pen. This indicates there may be a problem. The cartridge could be empty or the pen may not be assembled correctly." From BD’s Using Insulin Pens and Pen Needle Guide.

DISCLAIMER - BD paid for my travel expenses and accommodation to enable me to attend this workshop and patient engagement event.

The aim of the workshop was to introduce the newly established Irish based research and development team to the world of living with diabetes, specifically type 1 diabetes. What are the challenges that we face every day, what living with diabetes is really like, etc.

 In the grand scheme of my diabetes management preventing LH is not high on my priority list because beyond being aware that it exists and rotating my injection sites there doesn’t seem to be anything else I can do to prevent it. 

The Value of my CGM - Priceless

Last week, on a regular old Wednesday morning, I went about getting my teen and preteen ready for school. It was the usual morning routine. 

Just before I sat to breakfast my Continuous Glucose Monitor CGM alarm beeped - “your blood glucose level is below 4.1 mmols.” I had absolutely no symptoms, so I replied “Sometimesyou such a fibber!" Yes, I have conversations out loud with my CGM. I know I'm not alone! Lots of conversations. I pushed a button to see what my CGM thought my glucose was and it said 3.9 mmols.

I double checked on my meter and sure enough it was 3.6 mmols and just as that number was revealed on my meter my cgm did the big beeeeeeep let me know that I was now 3.1. 

I had breakfast and waited. I had twenty minutes before I needed to get in the car. However, about ten minutes later I checked my CGM again to see where I was at and my glucose levels were no longer dropping but they were not rising… yet. 

So I made the decision to ask hubby to drive the children to school. Never drive under 5 mmols. 

Had this event happened at any other time of day, I may have gotten into my car and drove. How scary is that!

This is the value of my CGM. 

Control the Controlables at Thriveabetes

Thriveabetes is a diabetes conference for people with type 1, organised by people with type 1. 

(Disclaimer; I’m heavily, like up to my neck, involved with it’s organisation.) 

However, as an adult with type 1 diabetes I only attended the presentations that were specific to me. I have more reviews to come but these two presentations really had an impact on me. 

Control the Controlables

The first was “Control the Controlables” by Mark Davies, a Psychologist from Belfast and co-presented by former Team NovoNordisk pro-cyclist, Thomas Raeymaekers. He opened his presentation by asking us:
- How much do you feel responsible for your diabetes?
- Lots of people said 100%

He then asked us: 
- How much control do you feel you have over your blood glucose? 
- Most people said between 60-70%

Why?
What, in addition to carbohydrates and insulin, affects blood glucose?
Yeah, right! The list is endless!

So why do we feel 100% responsible for something that is only possible to “control” between 60-70% of the time?

There are a variety of answers to this question but an element of this is also that we make ourselves feel responsible. Sometimes we believe that it’s my diabetes and no one else should carry my burden.

That feeling of trying to be 100% responsible for something, we can only be in control of between 60-70% can lead to diabetes burnout. 

I first saw Mark Davies talk at the international Diabetes Self Management Support Alliance conference in November 2017. I knew straight away it was a talk we had to have at Thriveabetes.

His original title was "Learning from Sports Psychology" but I thought it was about exercise, duh! How wrong I was!

So what does sports psychology have to do with diabetes?

Mark introduced us to aspects of sports psychology that may be useful to apply to preventing or acknowledging diabetes burnout. And this is where Thomas our type 1 former pro cyclist helped out.

Thomas told us of his coach in his early cycling career who focused on winning. Mark asked Thomas how many cyclists he knew who had won a race? The answer was none. We’ve all seen the Tour de France where there is just one winner. There are usually 22 teams with 9 riders each which makes 198 competitors. That’s 197 losers. 

Thomas said by focusing on winning all of the time, he felt awful and he would be so hard on himself after every race.

Does this sound familiar?

Some sports coaches preach what’s known as the “psychology of winning”. The problem with the psychology of winning is that most athletes loose!

If you never “win” then how do you motivate yourself to even try?

The alternative sports psychology is to focus on “performance based” psychology which is the process rather than the end goal. As an athlete, you would focus on training, eating well, etc.

This ethos comes from American football coach, Bill Walsh, who using this process took a team who always lost to winning its first championship in just two years. 

“The San Francisco 49ers won its first championship just two years after winning only two games. Under Walsh the team rose from the cellar to the top of the NFL in just two seasons.

• Aim for a Standard of Performance (which is absolute) vs winning (which is relative to others). 
• Process͟ of improvement leads to ͞result͟ of victory and not vice-versa. 
• Focus on processes that produces results and not on results. 
• Promotions/wins/sales quotas (and HbA1c) are results, they do not provide information about performance. It’s important to dig into performance to find truth hidden behind these results.

In type 1 diabetes the only elements we have real control over are:

• Monitoring BG
• Taking insulin
• What we eat and estimating carbs

And if we focus on these three things then our goals of reducing our HbA1c and having our glucose levels spend more time in range should improve. 

The lesson I walked away with from this presentation was focus on doing my daily tasks in diabetes, don’t focus on number on a meter or a HbA1c, use them as information to improve with, and above all don’t beat myself up over the things I can’t control.

Diabetes Burnout

This complemented Joe Solowiejczyk’s talk nicely especially when someone asked “I’ve done all I was supposed to do to manage my diabetes but why am I still experiencing diabetic complications?”

This brings up two issues:
There is a difference between reducing you risk of getting complications vs having no risk and
If I’ve done all I was supposed to do and still get complications how do I cope with that diagnosis?

I’m going to end with a quote I read recently from Gary Scheiner’s book, Until there is a cure”. that “Many of the decisions we make on a daily basis are simply to make the odds in our favor"(page 117)

Joe Solo talking us through some Diabetes Burnout

Book Review - Until There is A Cure

I read Gary Scheiner’s book “Until There is a Cure: The Latest and Greatest in Diabetes Self Care” just before Christmas and the night I read the very last page, I started again at the first page again. I’ve never done that before. Ever!

This book is more of a follow up to his other book "Think like a Pancreas", which is a “everything you need to know about diabetes” book. "Until There is a Cure" is more of a  “what things we can focus on” every day.

It had a number of nuggets of information that I wanted to read the book again and commit them to memory. 
 

The Nuggets of Information, for me personally, were:

Post Meal Glucose Spikes

“The inclusion of Postprandial (post meal) glucose targets” and “As research continues to point out the link between post meal glucose spikes and the development of long term and short term complications, stronger emphasis is being placed on glucose stability.” I had not realized that post meal spikes were linked to complications! This made me pay more attention on tweaking my post meal spikes, which were dreadful, even if I pre-bolused. 

Vitamin D Deficiency

“Given that many people with diabetes have a vitamin D deficiency…” What! The book told me that my vitamin D deficiency was actually something common in diabetes, not just indicating another problem that I needed to be solved. I was borderline D deficient at the time so that was useful information. 

The Super Bolus

And gave me more information on a “super Bolus” which has been around for a long time but I just heard about the concept recently and didn't quite fully understand what was meant by it. But I was too distracted at the time by all the other information that was coming at me to focus on asking more. 

Playing the Odds

And then the concept that perfect is an unattainable goal. That “Many of the decisions we make on a daily basis are simply to make the odds in our favor (page 117). This so ties in with a talk I heard at Thriveabetes called "Controlling the Controllables" and how we can't control if we get diabetes complications but we can certainly stack the odds in our favour. 

This book taught me a lot! And most importantly it mentions peer support. See below: "Research presented at the American Diabetes Association's Scientific Sessions in 2012 showed that increase social networking was associated with SIGNIFICANTLY lower HbA1c levels..." 

It's a very quick read and I found it well worth the time.