Have you guys seen the Boromir Meme?  I always chuckle when I see it.

According to Know Your Meme:

The phrase “One does not simply walk into Mordor” (no comma needed) originates from a Council of Elrond scene in Peter Jackson’s 2001 film adaption of J.R.R. Tolkien’s Lord of the Rings: The Fellowship of the Ring^[1]. Whilst (sp) discussing how to destroy the ring, Elrond explains that the ring can only be destroyed at Mount Doom and that someone must venture into Mordor to do so. After a silence where no member volunteers, Boromir points out the difficulty of this task by saying “One does not simply walk into Mordor.”

I can’t help but think of diabetes related stuff when I see these.

In General

Exercise

Sleep

Lows

Food

Highs

More food

So many of the simple things in life that many people take for granted.  Eating, sleeping, exercising.  With diabetes, we do, indeed, walk into Mordor every single day.

What others do you guys have?  Has this been done before?

One Does Not Simply… is a post from: Scott's Diabetes

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Numbers and Lines

I had a hunch that I could use some fine-tuning.  But overnight fasting basal rate testing sucks, so I kept putting it off.  My doc finally convinced me to bite the bullet, and I’m actually very glad I did.

The idea behind basal rate testing is to eliminate as many variables as possible, so that any changes you see in your blood sugar are most likely from your basal rate.

Wait – am I getting ahead of things here?  Do you guys know what “basal” is?

You need insulin all the time.  I mean ALL the time.  Even when you’re not eating, you need a bit of insulin in you.  In a person without diabetes, the pancreas has a way of knowing exactly how much is needed for each minute of the day.  In my case, I need to figure out how much my pump should deliver on an hourly basis.  That hourly insulin is called my “basal” insulin.

In theory, if your basal insulin is set right, you should be able to fast indefinitely and your blood sugar should stay relatively stable (without extra influences like exercise or illness).

In order to test your basal rate, the idea, again, is to eliminate as many variables as possible.  The typical variables include food and bolus insulin (boluses are what you take for highs or when you eat).  There are a million other variables involved, but we’re only worried about the ones we can influence.  Get rid of as many of them as possible, and any changes you see in blood sugar are most likely from that basal insulin.

I woke during the night to test every two hours.  There’s nothing nice about doing that.  And every single time my phone alarm buzzed me, my wife popped upright and asked “what was that?!”  Poor thing is so accustomed to listening to any sort of pump or CGM alert coming from my side of the bed…

So we both had a less-than-great night of sleep, and I felt bad about how it disturbed her.  I thought about the torture that is overnight basal rate testing and how it affected more than just me.  It’s not fair that it should mess up her sleep too.

But look what I found!  Nearly 100 point rise between midnight and 8:00 AM!  I had a hunch, but holy smokes!  To be fair, this was only ONE night of information, and there were a couple things that might have skewed the results.  The only real way to know if it’s a fluke, or reliable data would be to do another overnight test.  Which I will, soon…  but not too soon.

I will probably make some adjustments based on this information, even though it may not be exact (what in diabetes is ever exact?), then recover a while before repeating the test.

Basal rate testing is a pain, but once you get your basal rates really dialed in, rumor has it that things with blood sugar management get a lot better.

Wise words from my friend Dan (who impressively maintains a 5.x A1C by the way…):

If you can own the night, you can also own a majority of the day AND the weekend! Keep at it! It sucks, but it will help!

Overnight Basal Rate Testing is a post from: Scott's Diabetes

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Hoping you can join us for the pilot episode of “Diabetic Radio”, on KDWA.com (AM 1460 on the dial in the Twin Cities Metro Area (listen live)), Tuesday, January 17,  at 11:05 AM.

You guys remember Mikey, right?  Mikey makes his living driving race cars and fixing engines.  When the snow flies, and he can’t race cars, he’s all about snowmobiles.  For a long time he has been doing regular talk shows about both at KDWA, a local AM station near his home and not too far from the Twin Cities area.

A while back Mike said that the station owner, Dan, who lives with type 2 diabetes, was interested in doing a show all about diabetes, and asked me if I’d be interested.  ”Of course!” I said!  Who could pass up an opportunity to check out the inside of a radio station?

In the online community we have often talked about reaching those who need help, but maybe don’t know about the online community.  I think this is a great opportunity to spread some real information about diabetes, and hopefully reach an audience that could use some help.

If the show is well received, we’ll do it on a regular basis.  I’ll gladly volunteer a couple hours of my time whenever they need it.

We’ll be doing the show live tomorrow, and then it will be re-broadcast periodically through the month.  I don’t have any details on the rebroadcast schedule.  I’m also not sure if I’ll have access to the recording.  If I do, I’ll gladly get it posted for those who are interested.

We are hoping to cover some of the basics tomorrow, talking about the differences between type 1 diabetes and type 2 diabetes, the guilt and shame stigma that many people feel, that there is no “BAD” diabetes (i.e., one type is worse than the other), and hopefully we’ll have time to talk about the tools used to manage diabetes (meters, diet & exercise, oral meds, insulins (types and delivery methods), CGMs, etc.

If you do listen, I would love your feedback.  I think this is an important opportunity to help people, so any thoughts on how we can make it better will be much appreciated.

Catch you on the air (hehe – that sounds pretty cool)!

**** UPDATE *****

Had a lot of fun on the show this morning!  I hope it was well received by the listeners, and if we’re lucky they’ll invite us back sometime soon.  I should be getting a recording in the near future and will get it online as soon as I can.  Thanks everyone!

Mikey, Dan, and Scott, Live on KDWA.com! is a post from: Scott's Diabetes

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I’ve been playing with a Telcare system for the past few days.

Telcare is the world’s first cellular-enabled blood glucose meter that will automatically upload readings to an online logging portal.

I was excited to try this system because it is such a giant step in the direction many of us have been waiting for.

A meter that automatically sends information to a web-based logging system.

I like automation.  We have automation in many areas of our lives, and for a long time automation in the world of diabetes has been lagging behind.  This system is a small step in the right direction.  Bravo Telcare, bravo!

Pre-Production Version

This is a pre-production version, so I wasn’t able to use it to make therapy related decisions.  But I played with real blood, and did a bunch of play-tests with it.

Being pre-production also meant that some of the features of the suite weren’t quite ready for show.   Specifically some of the two-way communication and custom messages.

Speaking of Messages

According to the website, your provider can set up message triggers.  The example Telcare uses is that if there are three tests greater than 300 mg/dl in a row, the system will send a message to the meter that says “Hi. Dr. Goldman here.  Please check for ketones immediately.”

I think that is pretty cool, and a definite plus for us out there living with diabetes, though it may be a challenge to get healthcare providers to spend the time necessary to really use this to its full potential.

I also think the healthcare professionals will need to be super careful how they word these messages.  The last thing I need is another reason to feel bad about a reading that is not in target.

Hey Scott – Dr. Strange here.  What the hell did you eat to get THAT reading?!

Of course I’m exaggerating here – but I don’t think it’s a stretch to imagine some less-than-supportive messages coming from some clinic offices.  On the upside, if this is done right, I think it’s a huge opportunity to educate.  Can you imagine a personalized message from your doc saying “Dude!  Nice job!”? That would buoy my spirits a little bit.  It’s also a great opportunity for caregivers and patients to connect more closely.

Sounds Fancy – Must Be Expensive

It almost seems too good to be true, but there are no monthly service fees, no fees to access the online portal or mobile app, and the meter itself is, in my opinion, very reasonably priced for all it offers.  Strip cost?  How does cheaper sound to you?

The initial starter kit, without contract, is about $150. A bottle of 50 test strips is listed at $55.95 (compare to a 50 count bottle of OneTouch Ultra strips, $58.99 at drugstore.com).

The contract starter kit, which appears to require a 1-year commitment to buy at least 4 vials of strips per quarter (at a lower, contract rate of $35.95 (!) for a 50-count bottle), is $99.95.

Pockets and Noises

I felt that the meter was a bit large – especially compared to some of the smaller meters on the market today.  But given the capabilities, it’s very reasonable.  A bit too big to realistically live in my pocket with all of my other stuff, but then again I’ve never carried a meter in my pocket (I’m still using the CoZmonitor system that clips onto my pump.  I’m in for a serious lifestyle change when I switch pumps and have to start carrying a “meter kit” around).

The Telcare meter makes phone sounds.  Where a different meter might offer a ‘beep’, the Telcare chooses a touch tone sound – like a phone – get it?  I had to chuckle and grin when I first heard it, and I think it’s sort of cute.  The volume can be adjusted or the sounds turned off if you don’t share my low entertainment value.

Oh!  It should also be noted that there is an “airplane” mode that turns off the radio during flights.  You can still test your blood sugar, but the readings will not be automatically uploaded.  Once on the ground again, you’ll have to manually trigger an upload from the meter history (for now, each individual test has to be uploaded rather than being able to send them in a “batch” – much like a failed text message on an iPhone).

What Good is My Data

Automatically uploading stuff is very cool, but if this thing is going to fly for me, I have to like the system my data is uploaded to.  Telcare has an online web system called “MyTelcare”, as well as a mobile app.  Both are decent, if yet a little rough around the edges.  Certainly better than my clipboard, even right out of the gate, and I have a feeling that both will evolve and add features over time.

Hands On

Click here to view the video on YouTube.

Conclusion

This is cool, and a huge step in the right direction.  Don’t sleep on how big of a step this is.  The FDA has cleared a BG meter with cellular communication technology!  This may open so many doors for us down the road – and that is what excites me.

First Look at Telcare – Cellular Enabled Glucose Meter is a post from: Scott's Diabetes

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Click here to view the video on YouTube.

Clipboard on a Lanyard? is a post from: Scott's Diabetes

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Gary Scheiner is working hard to start the new year off right for as many people living with diabetes as he can.  He has decided to offer all live classes at Type 1 University for absolutely free during the month of January!  Space is limited, and classes are filling up fast.

Some of the classes are things like “Mastering Pump Therapy“, “Advanced Carb Counting“, “Weight Loss for Insulin Users“,  ”Strike the Spike: After-Meal Glucose Control“, and “Blood Glucose Control During Sports & Exercise“.   Full curriculum and course schedule can be found at Type 1 University.

Classes are webinar-style, usually just under an hour long, and you get a PDF copy of the slides used.  You’ll also be able to ask questions during the class.

I’m working with Gary to help promote Type 1 University.  I think it’s a really powerful resource for all of us who use insulin, and would love for everyone to take advantage of this opportunity to try it for free (this is a great thing Gary is doing).

Most of us don’t get enough time with our healthcare providers, and are left to learn so much on our own.  What Gary is doing with Type 1 University is exactly what many of us need.  A chance to dig in deeper with the skills we have in managing our blood sugars.

I would ask that you please let me know how you like it.  If you have positive feedback, please tell everyone you can.  If you have negative feedback – send me an e-mail…

Seriously though – we need feedback to fine tune this thing and make it the best it can be.

Disclosure: I have a business relationship with Gary to help promote Type 1 University

January is TUITION FREE at Type 1 University is a post from: Scott's Diabetes

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Spinning class in action!

I spent Sunday afternoon sweating it out with the local Insulindependence regional group.

Insulindependence is all about helping people, of all ages and fitness levels, be active with diabetes.

It’s a great mission!  Would your life with diabetes be different if you had a group of people around and available that were very educated about diabetes and exercise?

Last month we went for a walk (or run, for those who do that crazy stuff).  This month was spinning at Lifetime Fitness.  I am not a member of Lifetime Fitness, but the people at the front desk knew about the meeting and were very helpful about directing me to where I needed to go (past the salon, the full-service cafe, and next to the TWO indoor running/walking tracks).

Spinning can be pretty intense, but it’s totally relative to your level of fitness.  You control the resistance of the bike and how fast you go, so you can go at your own pace.  The goal is to push yourself past comfortable and make some fitness progress.

Insulindependence is all about just getting active, so you don’t have to be a super athlete in order to get involved.  The other thing that I am enjoying is exposure to different activities.  There are plans to do some strength training, to try snowshoeing, to experience climbing; all with a group of people who know and understand diabetes and exercise.

It was a great time, a great workout, and just plain good to hang with other people living with diabetes.  I’m hooked on Insulindependence events, and will make it to any and every meeting they have nearby.

It would be great to see you there too – or to hear about you attending an event in your area (they do this stuff nationwide).  Let’s get moving!

December Dawn Phenom – Insulindependence is a post from: Scott's Diabetes

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Lane Desborough

I met Lane at the Medtronic Diabetes Advocate Forum last Spring.  He made quite an impression on me.

Have you ever met a person who is so smart that they exude inspiration?  That’s Lane Desborough, Product Strategist at Medtronic Diabetes.  His son, Hayden, was diagnosed with type 1 diabetes in August of 2009.

As Lane did his first presentation, he talked about many parallels between the complicated field of process control chemical engineering in oil refineries and the like, and the complicated field of diabetes management.  It sounds crazy, right?  But no more than six hours into his son’s diagnosis, he started seeing those similarities & parallels.

I wanted to follow up with Lane to learn more, and was able to ask him a few questions via e-mail.

2011 MedT Diabetes Advocates Forum

Scott: Can you briefly describe your role at Medtronic Diabetes?  What exactly does “Product Strategist” mean?

Lane: This role was created specifically for me (not the first time in my career this has happened) with all credit to John Mastrototaro, VP of Pump and Closed Loop R&D.  I met John at the Diabetes Technology Meeting in October 2009 and now have the privilege of working for him.

The role was patterned after that of a chief engineer at Toyota, well described here http://blog.scottbellware.com/2008/12/chief-engineer.html

Qualities of a Chief Engineer at Toyota

• A visceral feel for what the customer wants
• Exceptional engineering skills
• Intuitive yet grounded in facts
• Innovative yet skeptical of unproven technology
• Visionary yet practical
• A hard-driving teacher, motivator, and disciplinarian, yet a patient listener
• A no-compromise attitude to achieving breakthrough targets
• An exceptional communicator
• Always ready to get his or her hands dirty

I am far from having any of these qualities today; but these are my aspirations and I now have the tremendous fortune to apply my skills and experience – such as they are – to a domain which has huge personal and societal impact:  improving the lives of people with diabetes.

What does product strategist mean?  One way of looking at it is that there’s a general tendency to start with product-based businesses “selling a widget / exchanging ownership of a physical good”, then transitioning to service-based businesses “selling an experience”, and ultimately to outcome-based business “selling a result”.   My aspiration is to understand and deliver improved outcomes; outcomes which I broadly classify as “reducing glycemic variability”, “increasing lifestyle flexibility”, and “reducing therapy effort”.  As such, I tend to look at how various products and services can work together as a system to provide these outcomes.

I like to think that the fact that I go home every night and experience glycemic variability, lifestyle constraints, and therapy effort as part of a family with diabetes helps me focus my engineering efforts to improve these outcomes.  I joined Medtronic because today Medtronic has the most comprehenive set of product and service “building blocks” to deliver on these outcomes.  I was also influenced by the fact that through the Stanford trial, my son’s been wearing a Medtronic pump, CGM, and using Carelink since ten days post-diagnosis.  To paraphrase Victor Kiam, “I liked Medtronic devices so much, I joined the company!”.

Hayden & Lane

Scott: How far into your son’s diabetes were you when you joined Medtronic Diabetes?

Lane: Hayden was diagnosed with type 1 diabetes on August 28, 2009 and I joined Medtronic on April 19, 2010 - 234 days or ~ 8 months.  The elapsed time was due to a number of personal and work factors.  John recently admitted to me that he knew from the day he met me that I would one day be working for Medtronic.

Scott: At what point into your life with diabetes (through your son) did you start to see similarities or parallels with your background in previous professional roles? 

Lane: About six hours.  I got a call at 3pm to come to emergency at our small local hospital in rural Nevada.  Hayden was diagnosed with T1DM shortly thereafter and after stabilizing him with insulin we were able to take him to the ICU at a bigger hospital an hour away, arriving at 8pm.  Sitting by his bedside that first night was when I first began to see the similarities.  I formed a mental list that night and when I got home the next day I googled the ideas.  The papers I found on google were authored by people that I knew; fellow process control chemical engineers.  That’s when I knew my prior experiences might be relevant.

This was solidified 7 days later when Hayden was admitted to Stanford University as a part of a clinical trial which used a Medtronic-provided closed loop control system to bring him quickly under tight glycemic control.  My son’s blood glucose was being controlled by a PID controller, a technology I’d first applied in the late ’80s!

Hayden's walk/run team

Scott: What was it like to experience revelations around the tricky job of trying to regulate blood sugars and tackling similar challenges in your professional duties?

Lane: Some have argued that chemical plants are the most complex “systems of systems” ever created by mankind.  I think the human body’s complexity transcends any plant I’ve ever worked in, however many of the techniques are still directly applicable.

My prior domain of chemical plant control had the same four basic ingredients as life with diabetes:  humans, hazards, software, and feedback.  Other domains like aviation have these four elements too.  Software-intensive automation in hazardous complex sociotechnical systems can be approached with the same broad techniques.  There may be different levels of maturity of sensors, final control elements, experimental design techniques, models, control algorithms, regulatory regimes, etc, but the fundamentals remain the same.

I think this can be summarized by a quote attributed to William Gibson which I use almost daily here at Medtronic:  “The future is already here, it just hasn’t been evenly distributed yet”.

I like to say that I’m a fundamentally lazy person; why reinvent the wheel?  An hour in google can save a decade of research.  I like to stand on the shoulders of giants.  I’m not doing anything special or innovative here.  I’m just helping to distribute the future.

I love Hayden's Pancreas!

Scott: I was fascinated to hear about even broad similarities between chemical engineering and diabetes management.  Were you surprised to find similarities?

Lane: I was initially surprised by the similarities, now I’m surprised when I spot the occasional difference. We’re miniature chemical plants at the end of the day. Extremely complex, time-varying, nonlinear chemical plants.

Chemical engineers – and aerospace engineers before them – have developed robust techniques to approach an unknown system, define control objectives, perform experiments, develop models, predict future behavior, and develop safe and effective control, then operate that control for decades.

The first controller I implemented (proportional integral derivative or PID) was at a chemical plant in the late 80′s. It’s still operating today. The last controller I implemented (model predictive control or MPC) was at a very dangerous, very complex plastic plant in 2007.

All I’m doing now is applying the same techniques to the most important chemical plant ever.

Scott: Thanks Lane – I can’t express how much I appreciate all that you do!

Lane says that he sees an approximate 20 year head-start in the development of automation concepts from the chemical engineering world to the biomedical engineering world, and that aviation engineering probably has an additional 20 years on chemical engineering.

I’m personally very intrigued by the idea that so much can be learned, and applied to us, from people like Lane and others in his field.  It also opens my mind to ideas that we may learn more yet from unexpected domains.

There are a couple of great blogs posts with Lane at Medtronic’s “The Loop” site.  I encourage you to go check them out.  A couple of my favorites are “What Control Means to Engineers” and “Living with Diabetes: Meet Lane”

My blog post does not do Lane’s brilliance and inspiration justice.  If you ever have a chance to meet him, hear him speak, read something he’s written, you should jump all over the opportunity.

**Disclosure: The Medtronic Diabetes Advocate Forum was held on April 1, 2011.  Medtronic Diabetes paid for my travel, food, and lodging.

Lane Desborough – Chemical Engineering and Diabetes? is a post from: Scott's Diabetes

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Scott & Dr. Robert Larson

Last weekend I bumped into an old friend.

I don’t even know how to properly convey the gratitude I have for Dr. Robert Larson.  He is the pediatric endocrinologist that took care of me and my diabetes for nearly twenty years as I was growing up.  Starting with me at age six or seven, going into appointments with me and my parents, all the way to me at age twenty-five and having to kick me out of his practice because I was getting too old.

In his defense, it was time to go.  Highlights magazine and those big wire frame toys with colored wooden beads were not quite my speed anymore.

Dr. Larson helped me with so much, and very little of it was the mechanics of diabetes care (after the first couple of years).   It was all about me as a person, growing up and learning about life first.  He helped me know my diabetes well enough that it stayed mostly out of the way.  He viewed me as the strong and motivated young person, rather than the rebellious and failing young diabetic person my inner critical voice had created.

These days Dr. Larson is still helping young people to live well with diabetes.  He’s currently working in Mankato, MN, a city a couple hours south of where I am now.  In 2010 Dr. Larson helped start Camp Sweet Life.  A grassroots effort to connect kids with diabetes in southern Minnesota through a safe outdoor camp setting.

Year one was a single daycamp experience, ending in an all family cookout.  Year two, August 2011, camp expanded to an overnight and two-day camp.  Parents were able to stay for educational sessions, and younger children were offered a day-camp experience.  Activities at camp varied from swimming, archery, arts & crafts, tie-dye, and star gazing with their local planetarium expert guiding the way.

They are expanding to include many activities and year-round events in addition to camp.  This last year activities included fall hayrides, sledding, JDRF walk, and a back to school event at Wow Zone.  Earlier in November, Dr. William Polonsky (one of my favorite people in the world!) and Dr. William Tamborlane (Yale School of Medicine Pediatric Endo & Artificial Pancreas Researcher) came to Mankato, MN for a ‘Living the Sweet Life’ Diabetes Symposium.  I totally wish I would have known about this – I would have been there in a heartbeat.

They have a sledding event coming up on Sunday, January 15, 2012 at the Norseland Boy Scout Camp near Mankato, MN.  Keep an eye on their website (www.campsweetlife.org) and their facebook page for more information.

I’m so excited to watch this grow – I know it will be a huge help to many in the area.  I’m hoping to find some ways to help Dr. Larson and the group working on this.  It would be a fun way for me to show my gratitude and serve others with diabetes at the same time.

Camp Sweet Life – Diabetes Camp in Southern Minnesota is a post from: Scott's Diabetes

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Last weekend I attended a JDRF event called “Reach and Teach U” held in Bloomington, MN (one of the Twin Cities nearby suburbs) near the Mall of America.

This was the third annual event, but it was the first I had heard of and attended.  There was no charge (but pre-registration was required).  It was scheduled to go from 8:00 AM – 2:30 PM, with a number of presentations and educational updates.  They even had JDRF KidKamp for children ages 3+ (there was a magician and some other fun activities for the kids while parents and caregivers attended sessions).

There were only a few exhibitor booths there, and in all honesty, it didn’t seem like there was much time to visit them anyway.  Maybe it was just me, but I felt like I didn’t have much opportunity to check out the booths without missing one of the presentations.  I felt very pressed for time.

The opening keynote was incredible.  Dr. Nat Strand, listed as “Amazing Race Winner, Type 1 Diabetic, Optimist” gave an energetic talk about her experiences navigating diabetes and winning (!!) the ‘Amazing Race’ (Season 17) on CBS.  It was really something else.  The adventure took her around the world in 23 days, and she had to pack everything she would need in a single backpack.  She talked about working closely with her CDE who gave her great tips that helped immensely (such as removing some of her pump supplies from the bulky plastic packaging – sacrificing perfect sterility in order to save space).  She said the producers and support staff were very ‘by the book’ and wouldn’t even hold a spare bottle of insulin for her.  Nothing.

The first thing the producers aired containing anything about her diabetes was a clip of her doing a blood test and it coming back at 337 mg/dl.  She talked about how embarrassed she was – with that being her introduction to the world as a person living with diabetes and not being able to show a good number.  But shortly after that episode aired, she started getting all sorts of letters and e-mails thanking her for showing real-life diabetes.  Anybody with diabetes would probably have crazy blood sugars zipping around the world and enduring crazy stressful challenges and events!

Scott, Leah, & Dr. Nat Strand

I got to sit with Leah, who was super excited about listening to Dr. Strand speak.  After her presentation was done, Leah and I went to talk with her.  Leah told Dr. Strand about how she was a big fan of the show, and was diagnosed with type 1 diabetes just before her season (17) started.  Leah  said it was a HUGE boost for her to watch Dr. Strand go out there, battling highs and lows, and doing all of these crazy things.  It was very emotional, and I could tell it was a big deal for Leah to have this opportunity to talk with Dr. Strand and share her story.

There were a few other sessions that were interesting that afternoon, everything from research updates to radical acceptance to diabetes service dogs.  During lunch I was able to help convince my friend Cynthia to start her own blog, which was very exciting to me.  I also ran into Dr. Robert Larson, the incredible pediatric endocrinologist who took care of me and my diabetes for twenty-some years as I was growing up (more to come with him soon!).

A large portion of the lunch time was spent kicking off the 2012 JDRF Walk.  Honestly,  it felt kind of weird.  Like “Oh, THAT’s why they are doing all of this stuff today…”  Or maybe my expectations were just not in the right place.  I think if it is a walk kickoff event, call it a walk kickoff event.

Either way, it was a day well spent, and I would probably do it again.

JDRF “Reach And Teach U” Event is a post from: Scott's Diabetes

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