Taking Control: Intensive Self-ManagementBy anyone’s standards, Dave Kittleson is a busy guy. He is co-owner of a successful business that designs and installs custom closet organizers, he races sports cars as a hobby and he and his wife are raising two young sons. No small feat – but Kittleson also has to find time in his hectic schedule for intensive self-management of his type 1 diabetes.
of Type 1 Diabetes
Type 1 diabetes is an autoimmune disease that destroys islet cells that produce insulin in the pancreas. When the body is no longer able to regulate blood sugar levels, people like Dave need insulin injections to survive. Although the cause of the disease is unknown, researchers ascribe a strong genetic predisposition, as well as possible environmental factors. The disease, which affects more than 1 million Americans, can cause changes in blood vessels and nerves leading to medical complications, including heart and kidney disease, stroke, blindness and impaired circulation in the limbs.
When Kittleson received his diagnosis almost 20 years ago, he says the news "brought me to my knees. All of a sudden I had to go on this rigid routine of checking my blood and taking shots. I felt I couldn’t move. I was just suffocating." But today, Kittleson claims he lives a normal life, thanks in large measure to treatment he received at the Froedtert & Medical College Diabetes Care Center.
The Diabetes Care Center offers educational programs and classes to help people with diabetes better understand and manage their disease. In 1988, it was the first program in the state of Wisconsin to receive recognition from the American Diabetes Association for meeting national standards of excellence in diabetes education, and it has maintained that recognition every year since. According to Julie Kuenzi, RN, Diabetes Care Center coordinator, "We have three registered dietitians and six registered nurses who are all certified diabetes educators (CDE). Kuenzi is board certified in advanced diabetes management.
Patients are referred to the Diabetes Care Center by their physicians and meet with a CDE who develops a care plan based on individual needs. "Our program is unique," says Kuenzi, “in that we offer a continuum of care to all people with diabetes, whether they’re newly diagnosed or experiencing chronic complications associated with the disease. Many look to the Diabetes Care Center to learn the skills needed for intensive self-management.”
According to Gabriele Sonnenberg, MD, Medical College of Wisconsin endocrinologist and director of the Diabetes Care Center, as well as the General Clinical Research Center, in intensive self-management patients must regularly monitor blood sugar levels and count the carbohydrate content of food they eat. They then develop an insulin injection regimen to match these numbers. They also need to plan ahead and calculate how much less insulin they will need if they exercise or increase activity. "With this intensive approach, patients keep their blood sugar levels near normal at all times. This results in less acute and long-term complications. Plus, patients just feel better," says Dr. Sonnenberg.
The key to successful self-management is developing a regimen to match a patient’s lifestyle, explains Paul Knudson, MD, Medical College of Wisconsin endocrinologist. "Some people with diabetes eat at the same time and eat the same things every day. Their disease is easier to manage. But people with small children or those who have erratic schedules require a more sophisticated approach to keep their sugars under control. We find ways to give them the skills and confidence they need to self-manage according to their needs."
Most patients choose multiple daily insulin injections through self-given shots. However, to match his active schedule, Kittleson uses an insulin pump. The pump, about the size of a pager and worn at the waist, is connected to a catheter inserted under the skin that regularly injects small amounts of insulin 24 hours a day. Before meals or at any other time of the day, pump-users can increase their dose to match or correct blood sugar levels. And the pump can be removed during exercise to stop insulin injection when it is not needed.
"With the pump, I can match what I’m doing at any given time. I can’t always predict if I’m going to be active or stressed or miss a meal, or if I accurately counted my carbohydrates. But as long as I check my blood, I can make a correction. I can’t imagine living without the pump," says Kittleson. Adds Dr. Sonnenberg, "Insulin pump treatment most closely mimics the secretion of insulin by the pancreas, meaning there is regular delivery throughout the day and night. And the pump is much more flexible. You can skip a meal, have a larger meal than you planned or have an in-between meal snack."
All people with diabetes benefit from intensive self-management, but it is especially important that pregnant women monitor their blood sugar levels. "For many years we’ve known that women with diabetes who don’t control their blood sugar during pregnancy have a higher risk of certain malformations in their babies," says Irene O’Shaughnessy, MD, Medical College of Wisconsin endocrinologist. "We realized there was a need toprovide special treatment for these women, so we created a system where they could get obstetric and diabetic care in one place."
At the Froedtert & Medical College Diabetes in Pregnancy Clinic, women have blood sugars monitored and insulin regimens adjusted. They also receive obstetrical check-ups, ultrasound and nutritional counseling. The clinic treats all patients with diabetes, including those with type 1, type 2 and gestational diabetes. It also has endocrinologists (specialists in endocrine gland problems, such as diabetes) and perinatologists (specialists in high risk pregnancy) on staff. "We see patients as early in pregnancy as possible, and ideally, even before they become pregnant. Then we see them every two weeks throughout the pregnancy. Through careful monitoring, we can optimize the health of mother and baby," notes Dr. O’Shaughnessy.
“Although intensive self-management is the most successful method for controlling type 1 diabetes, research continues to look at ways to make it easier for patients to live with the disease,” says Dr. Knudson. Dr. Sonnenberg adds, "It’s not yet available, but someday, we believe we will be able to offer a closed loop system, also known as an artificial pancreas. The wireless transfer of blood sugar numbers from the glucose meterto the pump and the subsequent calculation of an appropriate insulin dose by the pump are the first steps in this direction. David Kittleson and other patients are already using this system successfully.” Dr. Sonnenberg is involved in research to develop the software necessary to allow delivery of appropriate insulin amounts during and after exercise and other activities.