Ideas for a Type 1 Diabetes Support Group

A patient of mine was recently diagnosed with Latent Autoimmune Diabetes of Adulthood (LADA) which is a form of autoimmune diabetes for an adult. She is thin and beautiful with a thriving career as a nurse, and this new diagnosis threw her for a quite a loop. She had a hard time reconciling her healthy lifestyle with the sudden need to take four shots of insulin a day. Each week, she struggled with a different aspect of autoimmune diabetes.

Should she regard insulin as the enemy and avoid carbs altogether to obviate the need for bolus doses? Should she tell her friends and family and risk being treated like a victim? Should she exercise continuously to lower her blood sugars naturally? Out of her grief and frustration, she slowly realized a need to help others who were similarly suffering from the emotional shock of being insulin dependent for the rest of their lives. She is now in the process of developing a support group which she is running out of her home, and she is recruiting many of my newly diagnosed LADA patients to join her.  I wanted to share an amalgamation of our ideas for a successful support group so that my readers might be similarly inspired to start groups in their respective communities. Please forgive the verbosity! There is a lot to say on the subject:

Mission Statement:

This group provides a venue for men and women with new diagnoses of autoimmune diabetes who are facing concerns regarding diabetic management, the acceptance of diabetes, and the inevitable resultant lifestyle challenges.

The group will commit to confidentiality and will give all members the opportunity for equal speaking time.

Week 1:

Introductions:

Name, date and circumstances of diagnosis

Pose the following questions to the group:

What was the hardest aspect of learning that you had diabetes?

What helped you move past your fears?

Review target blood sugars:

Discuss the terms “fasting” and “postprandial”.

The American Diabetes Association has established recommended targets for glucose levels.

Before meals: 70-130 mg/dl

Two hours after the first bite of a meal: less than 180 mg/dl

Emphasize concept that these goals are controversial, and some healthcare providers may have discrepant goals.

Discuss the fact that even if you are adhering perfectly to a limited carbohydrate diet, each person responds differently to different foods. There is a trial and error component to diabetes management which necessitates frequent blood glucose testing.

Explain the concept of a HbA1C test:

Hemoglobin A, a protein found within red blood cells, carries oxygen throughout the body. Excess glucose in the bloodstream sticks (i.e. glycates) to hemoglobin A molecules.

The higher the glucose levels in the bloodstream, the greater the percentage of glycated hemoglobin.

Once the glucose glycates to hemoglobin, it remains stuck for the lifespan of that hemoglobin protein, which is generally 120 days or 3 months.

Therefore, the percentage of glycated hemoglobin reflects the blood sugar level over the past 3 months.

A hemoglobin A1C of 7% simply means that7% of the hemoglobin proteins are glycated.

Target hemoglobin A1C levels are controversial. The ADA suggests an A1C target of than or equal to 7%. The American Association of Clinical Endocrinologists recommends a level of 6.5% or below.

The chart below shows what the A1C means in terms of average blood glucose levels.

A1C

Average Blood Glucose

5

95.5

6

125

6.5

139.75

7

154.5

8

184 

9

213.5

Week 2:

Review Kübler-Ross model, or the five stages of grief

Denial: As the reality of chronic illness is difficult to accept, one of the first reactions to the diagnosis is denial. The patient is trying to shut out the reality or magnitude of his/her situation, and begins to develop a false, preferable reality. For example, the lab must have gotten my labs mixed up, or there must be a way to reverse this if I just enroll in the right clinical trial.

Anger: Once in the second stage, the individual recognizes that denial cannot continue. This stage is usually replete with thoughts such as, "Why me? What have I done to deserve this? It is so unfair!" The patient often becomes difficult to care for because of misplaced rage and envy.

Bargaining: This sort of behavior goes something like this "I'll only eat lettuce for breakfast and lunch then maybe I can have a big plate of pasta for dinner" or "If I walk for an extra 10 minutes maybe it will be okay if I eat these cookies.”

Depression:  This is a very common phase of diabetes. Diabetics are twice as likely to be diagnosed with depression as any other demographic group. Review common signs of depression including frequent bouts of crying, early morning awakenings and encourage professional help if necessary.

Acceptance: Patients learn to accept that diabetes is here to stay and make lifestyle changes to incorporate the necessary modifications into daily lives.

Ask group to validate or refute the Kübler-Ross model insofar as it pertains to type 1 diabetes

Week 3:

Review Nutritional Goals

A discussion of carbohydrate intake is crucial to any support group. Although members should be encouraged to meet with a Registered Dietitian or Certified Diabetes Educator, a brief review of carbohydrate recommendations will help emphasize the importance of lifestyle changes.

Show an example of the balanced plate and describe each component of the plate in detail. Encourage the following:  fill ½ a plate with non-starchy vegetables, a ¼ plate with lean protein and ¼ plate (roughly a fistful) with a high fiber carbohydrate. Review target amounts of carbohydrates per meal, which can vary between 30 and 60g.

Discuss the fact that carbohydrates are found in unsurprising food sources such as the starches (breads, pastas, etc.) and starchy vegetables (potatoes, corn etc.) but also in less obvious foods such as yogurt and beans.  

Encourage group members to begin reading labels and researching the carbohydrate content of favorite foods.  

 No discussion would be complete without delving into hidden carbohydrate sources such as sugar-free foods, fat-free salad dressing, and flavored coffee drinks.

Encourage group members to limit alcohol consumption to 1 daily drink for women and 2 daily drinks for men with avoidance of sugary drinks with juices or syrups. Good choices include wine or vodka with club soda.

Ask the group to keep nutritional logs and report back on what foods led to spikes in blood glucose and which foods kept sugars in check. 

Week 4:

Have group discuss findings from nutritional logs

Review definition/symptoms/treatment of hypoglycemia

Definition: generally defined as blood glucose < 70mg/dl.

Symptoms:  include palpitations, fatigue, pale skin, shakiness, anxiety, sweating, and hunger. More severe symptoms include confusion, blurred vision, seizures and loss of consciousness.

Treatment: Early symptoms can usually be treated by consuming 15 to 20 grams of a fast-acting carbohydrate such as candy, juice, regular soda, or glucose tabs or gels. Blood sugar levels should be rechecked15 minutes after treatment. If blood sugar levels are still under 70 mg/dL, the patient should treat with another 15 to 20 grams of fast-acting carbohydrate, and blood sugar levels should be rechecked in 15 minutes. These steps should be repeated until the blood sugar is above 70 mg/dL. Severe symptoms may require injection of glucagon or intravenous glucose.

Share stories about hypoglycemic episodes and how they were treated

Discuss convenient calorie-controlled snacks that can help prevent hypoglycemic episodes:

Unsalted nuts: effective because they contain unsaturated fats, are low in carbohydrates, and high in fiber and protein. Limit yourself to 1 serving or ¼ cup.

100-calorie popcorn bags

Small pieces of fruit

Snack bars: find bars limited to 50g of carbohydrates with at least 3 grams of fiber, 8 grams of protein and no more than 10g of sugar. Top choices include KIND® Bars (without the yogurt or chocolate covering) and Quest® Bars.

As a homework assignment, ask members to try to find bars that meet criteria (50g of carbs of less, 8grams of protein, 10g of sugar or less) and bring enough for the group to the next meeting.

Week 5:

Hand out snacks and analyze content

Review insulin pen needles:

Pen needles are measured by thickness and length.

Most pen needles range from 4mm-12mm in length and 29-32 gauges in thickness or diameter. The lower the mm, the shorter the needle.

The higher the gauge, the thinner the needle.

Ask the group to take out needles and examine length and gauge. Ask if anyone is experiencing painful insulin injections. If so, suggest that they may want to discuss with the physician the possibility of switching to a shorter, thinner needle. The smallest, thinnest needle is the 4mm, 32 gauge needle.

Explain that studies have shown that glycemic control does not change based on needle length. In addition, contrary to popular belief, obese patients do not require longer needles. 4mm is likely to be effective for the majority of patients.

Review lancets:

Encourage members to choose lancets with the thinnest gauge needles i.e. 33g but warn that these needles must be used with meters requiring, 1.0uL or less blood.

Lancets with 33g needles include:

Nova Max Nova Sureflex Lancing Device

One Touch Delica (available in 30 and 33g) 

BD Ultra Fine 33g lancets

If fear of lancets is an issue, ask members to consider Accu-check® Fastclix lancing device which uses a drum with 6 pre-loaded lancets. As a result of the drum, the patient doesn’t need to see or handle any lancets.

If fingerstick testing is painful, suggest alternate site testing in the palm or forearm (not recommended in the setting of possible hypoglycemia given delayed blood sugar results).

Week 6:

Review most commonly used insulins

Rapid-acting insulin

Examples:

Apidra (insulin glulisine)

Humalog (insulin lispro)

Onset: 5 to 15 minutes

Peak: 30 to 90 minutes

Duration: 3 to 5 hours

Intermediate-acting insulin

Examples:

Humulin N (NPH insulin)

Novolin N (NPH insulin)

Onset: 1 to 3 hours

Peak: 8 hours

Duration: 12 to 16 hours, but can last as long as 24 hours

Long-acting insulin

Examples:

Lantus (insulin glargine)

Levemir (insulin detemir) (duration is actually dose-dependent)

Onset: 1 hour
Peak: no peak
Duration: 20 to 26 hours

Pre-mixed insulin

Mixtures of intermediate-acting insulin and either rapid-acting insulin or short-acting insulin (will not review) are available.

Examples:

Humalog 50/50 (50% intermediate-acting + 50% rapid-acting)

Humalog 75/25 (75% intermediate-acting + 25% rapid-acting)

NovoLog 70/30 (70% intermediate-acting + 30% rapid-acting)

Onset: 5 to 60 minutes

Peak: varies

Duration: 10 to 16 hours

Open floor for discussion of relative merits and flaw of each type of insulin. Why have pre-mixed insulins fallen out of favor? Why might Lantus be preferred over Levemir? 

Week 7:

Review proper use of insulin pens:

Unopened insulin pens should be stored in the refrigerator while those that are in use can be stored at room temperature for about a month.

Insulin can be injected into subcutaneous tissue which includes the back of the arms, the outer thighs, and two inches away from the bellow button. Demonstrate these areas.

Intramuscular injections should be avoided because they increase insulin absorption and therefore the risk of hypoglycemia.

Discuss techniques for site rotation.

Remind members that insulin pens need to be primed with a 2 unit “air shot” before each injection.

Discuss frequent pitfalls of insulin pens: not priming, injecting too forcefully, and reusing needles. Explain that needles should not be reused because they become duller and more painful. In addition, leaving needles attached to pen between doses can precipitate air bubble formation which results in under-dosing of insulin. It also allows for potential leakage of insulin from pens as well as crystallization of insulin.

Have members on pumps discuss their experiences with Minimed vs OmniPod vs t-slim vs. Asante Snap etc if possible. Ask the group to debate whether the fear of pumps is rational or not.

Explain that pumps only use rapid-acting insulin which is delivered continuously through a cannula (hollow tube) which is inserted subcutaneously into the body.

The pump also allows boluses of insulin to be delivered based on the number of carbohydrates consumed.

The pump is programmed with an insulin-to-carbohydrate ratio to determine the specific amount of insulin required for a set number of grams of carbohydrates.

The pump is also programmed with a sensitivity factor which dictates how much insulin should be given to reduce high blood sugar levels back to normal.

Give a quick explanation of continuous glucose monitoring (CGM).

It is a portable device which measures blood sugar approximately every five minutes and sends data from a sensor to a receiver. It can alert patients to rapidly rising or dropping blood sugars.

Encourage use in patients with frequent hypoglycemia with unawareness, hyperglycemia, or recent switch to pump.

Emphasize that CGM is meant to complement rather than replace fingerstick blood glucose testing.

If there is a member of the group with CGM, have that member show group the device.

Week 8:

Hand out the following of items to bring on trip:

  • Blood sugar meter
  • Test strips (check expiration date and make sure they are sealed tightly)
  • Alcohol swipes 
  • Lancing device and needles
  • Glucagon
  • Glucose Tablets or gel to treat a low blood sugar
  • Pens, insulin, needles, syringes, cooling packs for insulin storage (DO NOT PACK IN CHECKED LUGGAGE).
  • Sharps disposal container 
  • Blood sugar log
  • A note from MD for TSA
  • Diabetes medical alert
  • Snacks in case of hypoglycemia

Pumps do not need to be removed at security.

Open discussion to personal experiences with the travel of any type or any other concluding thoughts for the group. 

Continue Reading