Making an Insulin-Dependent Life BetterFriday, April 12, 2013
Gary Scheiner, MS, CDE, has written Until There is a Cure: The Latest and Greatest in Diabetes Self-Care, which is a comprehensive book designed to help people with insulin-dependent diabetes become aware of the numerous medication and technology options available today. The book also delves into the various aspects of management and offers counsel on treatment strategies.
By: John Parkinson, Clinical Content Coordinator, DiabetesCare.net
Gary Scheiner has 28 years of personal experience with type 1 diabetes. Diagnosed when he was home from college in a suburban Houston, Texas town aptly named Sugarland, Scheiner has lived through what he affectionately calls the “dark ages” of diabetes management.
He has used everything from medieval finger-prick devices to having limited types of insulin. He was also given the promise of a pending cure from his provider. And despite unkept promises, clunky technology, and a lack of sophisticated disease management guidance, Scheiner survived and has in fact thrived.
Scheiner took what began as an interest in taking care of his diabetes and forged it into a successful career as a certified diabetes educator. After a stint at a Joslin Diabetes Center in Philadelphia, Scheiner started his own practice, Integrated Diabetes Services in Wynnewood, Pa.
Along with his practice where he specializes in helping people with insulin-dependent diabetes, he has an online education initiative, Type 1 University, which allows people to view specific diabetes management webcasts. Scheiner also consults the diabetes industry, does speaking presentations, and writes books on the topic. His most recent book is Until There is a Cure: The Latest and Greatest in Diabetes Self-Care.
One of the main reasons Scheiner wrote this book is because he believes there continues to be a lack of true knowledge of how to manage insulin-dependent diabetes. He sees many patients that are being treated in primary care or by specialists and either the providers or the patients lack the information or awareness of what’s available that could be beneficial to patients.
Seeing the evolution and complexity of diabetes management, Scheiner has taken all his personal experience and clinical knowledge and combined it into this book. Until There is A Cure is truly a hands on book that leaves no part of insulin-dependent diabetes management unturned. From medications to exercise to monitoring to avoiding complications, Scheiner discusses it all.
DiabetesCare.net spoke to Scheiner about his personal diabetes experience, some of the old fashioned diabetes management treatments and technologies, insights into why he wrote the book, and some of the newer diabetes technologies he thinks are helpful.
DiabetesCare.net: Can you explain what your management was like when you first had diabetes?
Scheiner: They sent me to an endocrinologist who told me that in five years my diabetes would probably be cured. Back then, it was a matter of here is your insulin program and you had to really conform your life to it.
They explained to me that I was going to take an intermediate insulin twice a day and regular insulin twice a day, and here’s what and when you have to eat.
Even if you still did everything right, your blood sugars were going to be all over the place because we were dealing with such inferior management tools. I was able to get on a glucose meter pretty soon after I was diagnosed. I started off with blood strips that showed just color change. It seemed like no matter what I did, my sugars were hardly ever in range. And it’s no wonder given the kind of insulin programs given back then.
DiabetesCare.net: What was it like in terms of nutrition?
Scheiner: From a nutritional standpoint, things were very strict. Each meal you had to have a certain amount of bread, fruit, meats, and fat exchanges. You only were supposed to eat certain amounts during certain parts of the day. It didn’t leave a lot of flexibility. I can remember going from eating everything and anything to a very rigid diet and being so hungry all the time. It was almost like you had to starve most of the time. It certainly helps me to empathize today with patients who are struggling to control their appetite and food intake. It somewhat still applies today because most people with type 1 are lacking the amylin hormone, which suppresses appetite.
DiabetesCare.net: Through the years treatment and technology have come a long way. And yet, you have written a new book on the topic. Why the decision to do so?
Scheiner: I still think the majority of people with diabetes today don’t know what’s available in terms of treatment methods and technologies. You would be amazed how many people with type 1 diabetes don’t know you can count carbs and match insulin to it, or that there is a long-acting insulin that might work better than NPH.
There is a real lack of information out there. Some of it is attributable to physicians who may not have the comfort level or don’t have time to teach their patients, and part of it is the patients who are not exposing themselves to the latest treatments and technologies.
I feel the book is a way to convey to people what their options are. If people are well-informed, they can make an intelligent decision about how they want to manage their diabetes.
DiabetesCare.net: Who are the audiences you feel would best benefit from this book?
Scheiner: It is geared for all insulin users—for both people with type 1 diabetes and people with type 2 who are on either a basal insulin or multiple injections.
DiabetesCare.net: There is a section in the book where you mention GLP-1s. Are medical providers coming around to using GLP-1s for insulin-dependent patients?
Scheiner: I think more providers are coming around to it. There are those physicians who only prescribe based on product labeling. They won’t prescribe a GLP-1 for someone with type 1 diabetes because it is not intended for that patient population. The fact is this class of drugs can work extremely well. There is plenty of research documenting its safety and effectiveness. You have to have a medical provider who is willing to think outside the box. It`s hard to mange diabetes if you don’t.
DiabetesCare.net: As an experienced healthcare provider and longtime type 1 veteran yourself, what is the single biggest challenge people with insulin-dependent diabetes have with their management?
Scheiner: I think its finding the balance; it’s walking the tightrope 24/7 between highs and lows. If you consider there is a teaspoon of sugar in the bloodstream at any given time, and we are always pouring tons of it in and out of our bodies, and in addition you have stress hormones and environmental factors affecting that sugar level—it’s not an easy thing to do. The better understanding you have about the tools and techniques you can equip yourself with the better chance you have to manage yourself.
DiabetesCare.net: When seeing new patients who may be on insulin-injection therapy, is your treatment protocol to try and have them transition to a pump? What is your criteria for deciding who are good pump candidates?
Scheiner: Almost anybody is a good pump candidate, the question is, is it a good option for them considering the big picture and what their lifestyle is like. I try to educate people on the advantages and disadvantages of using the pump. I’ m a big pump advocate, but there are disadvantages. For example, for someone who has no health insurance and very little resources, a pump is not going to be a great option because it’s costly.
And if someone is on a basal injected insulin, is doing great, has good overnight blood sugars, then going on a pump might just add complexity to things.
DiabetesCare.net: With the variety of insulins that are available today, does that make it more challenging for you as a medical professional to get your patients on the right insulin?
Scheiner: Not at all. I appreciate that there are a variety. In fact one of the more common programs we are using now for people on injections is to have them use Lantus or Levemir once a day and inject a small dose of NPH at night to provide that peak in their basal insulin that is so important to most people.
The real problem with using Lantus or Levemir is striking the balance. If you use a dose to hold steady overnight, you almost are always getting too much during the daytime. And if you set your needs correctly for the day, you are not likely getting enough at night. The other problem is there are some physicians that don’t like mixing different types of insulin. It frustrates me when that happens because it’s a protocol that can work well, and it can actually reduce a person’s risks for highs and lows.
DiabetesCare.net: Are there any newer pumps, mobile apps, or particular insulins either in trials or newly approved you are excited about?
Scheiner: The thing that excites me the most is the improvement in continuous glucose monitoring. That has come a long way.
The original CGM technology was not all that effective; there were issues with reliability. I don’t think we were able to make very good use of them.
My first continuous monitor was a MiniMed CGMS. It was a black box that stored data and there was a cable that connected to your skin. It was very limited in what you could do with it. The latest system that I’m impressed with is the Dexcom G4. That system is what we have been hoping for in a continuous glucose monitor. It’s accurate, easy to use, and it’s comfortable. Insurance companies are coming around to covering it too. When it’s used properly, it really can make diabetes management easier and better.
I work with healthcare providers in teaching them how to interpret sensor data, and with patients teaching them to use the sensor data to their advantage.
One of the newer apps I really like is the iBG Star. It works with the meter made by Sanofi that plugs into the i-Phone. The iBG Star app is a nice record keeping system.
DiabetesCare.net: In terms of record keeping and analyzing patients’ glucose records do you like to analyze patient data, and if you do, how far back do you like to go to get a true sense of a patient’s control?
Scheiner: The beauty is in the details when it comes to diabetes. If you are only looking at someone’s lab work or a smattering of blood sugars, you might see where problems are but you are not going to find proper solutions. With so many variables affecting blood sugar, you have to have details. You need to find out how much they are eating, what type of exercise they are doing, and the stresses in their lives.
When I’m working with clients, I usually look at 30 days of data to find the true patterns and trends. The more details we have to look at, the easier it is to find the practical solutions. And for other patients, who we are looking at more intensively, we might be looking at their blood sugars on a daily basis. For example, someone who is just starting on a pump, we need to do a lot of fine-tuning. During pregnancy, we tend to evaluate data on a weekly basis.
DiabetesCare.net: What data do you like to know in terms of the information?
Scheiner: The key numbers I’m looking at are premeal and presnack blood sugars. I also like to know how many carbs they are eating and how much insulin they are taking. I like to know what physical activities they are engaged in and some other miscellaneous things that have a direct bearing on glucose levels, like stressful events, restaurant food, etc.
Once we have a good handle on the pre-meal blood sugars, then we focus in on the post-meal timeframe. Keeping the blood sugar from spiking too high after meals is important for preventing complications and improving one’s daily quality of life.
The pumps and the newer meters do a decent job of collecting blood sugar, insulin and carb data, but they don’t do a good job of collecting other information. Exercise and activity in particular hardly ever gets incorporated at all.
For those interested in buying Scheiner’s book, Until There is a Cure: The Latest and Greatest in Diabetes Self-Care, people can go here. Those interested in his practice’s consulting services, which are available worldwide, can visit www.integrateddiabetes.com or call (610)642-6055.