The Insulin Express

by Oren Liebermann

  Since my diagnosis, my blood sugar numbers have been great. Not perfect, but well within the healthy range. My HBA1C regularly falls between 5.6 and 5.8. I try to limit myself to dessert once every two weeks—easier said than done—and I generally try to eat healthy far more often than I used to. Diet Coke has become my vice of choice. I know it’s not healthy, but there’s a sweetness to it that keeps my desire for other sweets at bay.

  Even after visiting some thirty countries, Cassie and I still long to travel. Since the official end of our trip, we have visited the Netherlands, Panama, Scotland, and Portugal. Sri Lanka and Cuba are now high on the list of places to visit next. When I was in Nepal, I didn’t have a chance to see Krishna and Bimala or visit the doctors who treated me. For that reason, I know I will return to Nepal for a third time. I owe it to myself and to every-one I met there to see Nepal through healthy eyes, and I owe everyone a thank you. A thousand times over, thank you.

  We miss life on the road. There’s nothing like the freewheeling sense of adventure that comes from setting your own path every morning. But now we have someone else’s path to set too.

  On June 2, 2016, Cassie and I welcomed Noa Lillian into our lives. She weighed nine pounds and eleven ounces, and was easily the biggest baby in the nursery. She came out hungry as hell and ready to take on any other baby in the hospital. In short, she came out a Liebermann.

  Because she was such a big baby, they had to regularly check her blood sugar to make sure she was getting enough food. The first time I saw this happen, I had to choke back tears. I knew she did not have diabetes, but it was still difficult to watch. In the back of my mind is the knowledge that she will have a higher probability of developing diabetes than other children. For that, I can blame no one but myself. I am the first person in my family with diabetes, and it would come from no one but me.

  If that day ever comes, I know it will not be easy for me or Cassie or Noa. I will once again shed tears because of diabetes.

  But I hope that if it does come, Noa will pick up this book and, somewhere within its pages, find inspiration.

  Acknowledgments

  If it takes a village to raise a child, it takes an army to write a book. There is much shouting of instructions, a fair amount of discipline, and sometimes you feel like you need just a few more tanks to complete the mission.

  This book would not have been possible without the endless support of my wife, Cassie, both during our trip and every day since. (This book would also not be possible without my failed pancreas, but that mutinous organ is not getting any of my gratitude.)

  Thank you to my wonderful agent, Joan, who guided me along this strange path since this book was no more than a collection of illegible notes in my trusty notepad. Thank you to Kim, Abigail, Jaidree, and the entire team at Skyhorse Publishing for taking a chance on this book. I cannot tell you how much I appreciate your help and support.

  Of course, a huge thank you to the American Diabetes Association for their support and the work they do to advocate for the millions of us with diabetes and to educate the millions without. Your work will only get more important as the diabetes community grows.

  I will always be indebted to my managers and colleagues at CNN who took a chance on me when I had been out of journalism for more than a year. A special thanks goes out to Sanjay, Elizabeth, Richard, Andrew, Michaela, and Mike for their help with this book.

  Thank you to all of the reviewers who gave me input along the way. Patti, Jess, Richard, and so many others. Each of you made this book better with your critiques.

  Thank you to my entire family for their love and support since long before I ever had the idea to write this book.

  And naturally, thank you to anyone who picked up this book and gave it a shot. You had millions of other options for ways to pass your time, but for some reason, you ended up here. And I cannot express in any words I know how much I appreciate that.

  See you on the road!

  Appendix

  American Diabetes Association

  What is type 1 diabetes?

  A diagnosis of type 1 diabetes means your pancreas is no longer capable of producing insulin. The body breaks down the sugars and starches you eat into a simple sugar called glucose, which it uses to fuel cells and give you the energy you need daily. Insulin is a hormone that the body needs to get glucose from the bloodstream into the cells of your body. Without insulin, glucose cannot enter your cells. Instead, it builds up in your blood system and can lead to potentially serious complications.

  Type 1 diabetes is usually diagnosed in children and young adults, and it was previously known as juvenile diabetes. Approximately 1.25 million Americans have type 1 diabetes, roughly 5 percent of people with diabetes. Each year in the United States, an estimated 40,000 people are newly diagnosed.

  People living with diabetes manage their blood glucose levels through an important balance of food, exercise, and medication. If you have type 1 diabetes, insulin is required. The goal of treatment is to come as close to mimicking the normal action of the pancreas of a person that does not have diabetes. Although this is challenging for the person and, at times, the loved ones whose support is important, a growing number of people are living the fullest of lives with type 1 diabetes. To balance diabetes at more optimal levels, it is necessary to monitor blood glucose levels using a blood glucose monitor several or more times a day and night, or use a continuous glucose monitor (CGM) and administer the right amount of insulin to keep your glucose levels in your target range. You need to work closely with your diabetes healthcare team to determine which insulin or insulins are best for you and your body. With a tailored insulin therapy program, a solid understanding and consumption of healthy foods, and enough exercise and other treatments if needed, even young children do learn to manage their condition and enjoy long, healthy lives.

  The ADA’s diabetes camps and retreats offer unique opportunities for children and their families to gain unique peer support and friendships while working with knowledgeable diabetes professionals and recreation staff who often have diabetes themselves and who serve as influential positive role models that last a lifetime.

  Type 1 Diabetes Symptoms

  The following symptoms of diabetes are typical. Common symptoms include:

  • Urinating often

  • Feeling very thirsty

  • Feeling very hungry—even though you are eating

  • Extreme fatigue

  • Blurry vision

  • Cuts/bruises that are slow to heal

  • Weight loss—even though you are may be eating and drinking more

  I’ve been diagnosed with type 1 diabetes. Now, what do I do?

  You’ve just been told you have type 1 diabetes, now what? Understanding diabetes and its effects, both near term and long term, is very important. Education and emotional support is key for you and your loved ones. Talk with your primary care physician regarding your next steps. She will refer you to an endocrinologist, a specialist in blood and hormone disorders and treatment. He will help you find a good health care team, typically nurses and dietitians who are trained diabetes educators and who will help you understand what you must do on a daily basis to control your type 1 diabetes and maintain a healthy lifestyle.

  We encourage you to seek additional information online at www.diabetes.org/type1 or contact or call us at 1-800-DIABETES (800-342-2383), Monday through Friday, 8:30 a.m. to 8:00 p.m. Eastern Time.

  Who is on my health care team?

  Your health care team should consist of everyone you need to help you understand your type 1 diabetes and what to do on a daily basis. It typically includes your physician who is either an endocrinologist or a primary care physician who has a special understanding of type 1 diabetes. Your diabetes specialist will prescribe the type and amount of insulin(s), any technologies if needed/desired (insulin pens, insulin pumps, and continuous glucose monitors [CGM]), and other medications you might need based on blood sugar, as well as any ot
her needed lab results. Optimally, your diabetes specialty team should include along with your physician: a registered nurse or nurse practitioner, a registered dietitian, a psychologist, and access to someone who understands diabetes and exercise. This team will help you understand your insulin(s); glucose monitoring techniques and how to interpret blood sugar results; how to balance your insulin(s) with food, exercise, and schedules; and how to share relevant information about your diabetes with others and build your support network of family, friends, and peers. Your diabetes team members are available to help you and your loved ones navigate diagnosis and guide you towards your new normal.

  What can I eat now?

  There is no such thing as a “diabetes diet.” Healthy, balanced nutrition is a very important part of managing your type 1 diabetes. Knowing how the foods you eat affect you and your diabetes balance will help you plan your meals and insulin delivery for the day. Living with diabetes requires more planning, and with proper planning you can enjoy life to the fullest.

  Counting Carbs

  The keys to balanced nutrition are understanding carbohydrates and knowing the right portions for you. All foods are made up of carbohydrate, protein, and fat. Carbohydrates have the greatest effect on your blood glucose levels. And, carbohydrates are in most of the foods you eat. So, it is important that you can recognize foods high in carbohydrates and are able to estimate their amount. It’s also helpful to know the best sources of lean protein. All protein contains some fat, but some protein foods, such as salmon, tuna, sardines, and herring, contain beneficial fats. Learning about adjusting insulin for high-fat meals is an individualized but important concept. There are many websites and books that can help you understand meal planning and carbohydrate counting, such as:

  “What Can I Eat,” ADA (http://www.diabetes.org/what-can-i-eat/)What Do I Eat Now?, 2nd edition (ADA Books, ISBN 978-1-58040-558-4)

  Know Your Portions

  It is no secret that all too often portion sizes in the United States are too large for most people. One way to get your bearings and use a visual aid is—the portion plate. Using a standard dinner plate with a nine-inch diameter, divide the plate as follows:

  • Make a quarter of your plate a protein-rich food (for example: a lean meat, chicken, or fish; beans; eggs or cheese)

  • Make another quarter of your plate grains or starchy food (for example: green peas, sweet potato, brown rice, quinoa)

  • Make half of your plate non-starchy vegetables (for example: carrots, broccoli, spinach, or peppers)

  See http://www.diabetes.org/create-your-plate for more information on better portions.

  Lifestyle Changes

  Physical Activity

  Regular activity is a key part of managing diabetes along with meal planning, taking medications as prescribed, and stress management. When you are active, your cells become more sensitive to insulin so it can work more efficiently. So, exercising consistently can help lower blood glucose levels, reduce weight (if this is a goal), and improve your A1C, an average measure of blood glucose levels. When you lower your A1C, you will keep your body healthier today and for your many tomorrows. Physical activity is also important for your overall wellbeing and can help with many other health conditions.

  Benefits of regular physical activity:

  • lowers blood pressure and cholesterol

  • lowers your risk for heart disease and stroke

  • helps you lose or maintain weight

  • increases your energy for daily activities

  • helps you sleep better

  • relieves stress

  • strengthens your heart and improves your blood circulation

  • strengthens your muscles and bones

  • keeps your joints flexible

  • improves your balance to prevent falls

  • reduces symptoms of depression

  • improves quality of life

  You can experience these benefits even if you haven’t been very active before.

  Types of Activity

  Aerobic exercise, strength training, flexibility exercises/stretching, balance exercises, and activity throughout the day are the types of activities we recommend for people with diabetes.

  Visit http://www.diabetes.org/physical-activity for more information and activities.

  Travel

  Learning to manage your type 1 diabetes when traveling can seem daunting, but it is easier than you think. Whether you are traveling by automobile, train, ship, or plane—for business or pleasure—it requires planning and organization.

  Tips for packing

  • Take enough supplies and medication for your trip, plus extras in case you are delayed.

  • Make sure all your diabetes supplies are in a bag you carry with you.

  • Pack extra snacks (and glucose tablets) in your carry-on bag.

  • If traveling by plane, put your insulin in your carry-on bag. The luggage compartments of airplanes can be very cold and your insulin could freeze. Or, your luggage may be left out in the hot sun.

  • If you use an insulin pump, take an alternative source of insulin and insulin delivery (syringes or insulin pens with needles) in case your pump stops working while you are away. The larger pump companies have an emergency number on the back of their pumps that you can call if your pump is not working properly.

  • When traveling overseas, ask your diabetes team if they have a diabetes contact in the country you are going to visit.

  Carry-on bag checklist

  Medications

  • Insulin or other injectable medications or pens

  • Syringes, pen needles, pump supplies, CGM supplies

  • Oral diabetes medications

  • Glucose tablets or another source of quick-acting carbohydrate

  • Snacks, such as dried fruit or crackers

  • Antibiotic ointment

  • Other prescribed medications

  • Glucagon kit

  • Anti-nausea and anti-diarrhea medications

  Blood Monitoring Equipment

  • Enough test strips for your trip and unexpected delays

  • Lancets

  • Blood sampling device and a spare

  • Glucose meter

  • Hand-washing gel or alcohol wipes

  • Spare batteries for glucose meter, continuous glucose monitor (CGM)

  • Cotton or tissues

  General Tips

  • Wear a medical ID bracelet or necklace that says you have diabetes.

  • Keep a prescription for insulin and other medications on hand, just in case.

  • Always pack more diabetes medications and supplies in case of emergencies and delays.

  • Don’t get separated from your supplies.

  Security Checkpoints

  Your diabetes equipment and medications are necessary and permitted through security checkpoints; however, it is wise to check for new rules and requirements issued by security agencies (for example, the US Transportation Security Administration [TSA]) to ensure there are no surprises during your trip. Carry a written prescription signed by your physician that says you may purchase and carry each of your diabetes medications and supplies.

  Visit: http://www.diabetes.org/traveltips.

  Meals While Traveling

  Planning meals is an important part of your trip. If traveling by plane or train, many flights or travel segments do not offer food service. It is critical to bring or purchase a nutritious meal or meals with you to eat on your needed schedule. If you have arranged for a special meal in flight or while riding the train, remember that you may not want to inject your pre-meal insulin until your meal has been served as sometimes there are significant delays.

  Traveling Across Time Zones

  Adjusting insulin injections for time zones can be a major challenge. When traveling from west to east, you lose hours from your day, and you may need less insulin. When traveling from east to west, you will add hours to your day, and you may n
eed extra insulin. If you are uncertain of how to plan your insulin and meals, take a copy of your itinerary and work schedule to your diabetes health care team and get their advice.

  Who is the American Diabetes Association?

  For more than seventy-five years, the American Diabetes Association has created and provided state-of-the-art information about all aspects of diabetes. The moving force behind the work of the Association is a network of more than one million volunteers; a membership of more than 500,000 people with diabetes, their families, and caregivers; and a professional society of nearly 14,000 health care professionals; as well as more than 800 staff members.

  We lead the fight against the deadly consequences of diabetes and fight for those affected by diabetes.

  • We fund research to prevent, cure, and manage diabetes.

  • We deliver services to hundreds of communities.

  • We provide objective and credible information.

  • We give voice to those denied their rights because of diabetes.

  Learn more at: http://www.diabetes.org/.

  American Diabetes Association

  2451 Crystal Drive, Suite 900

  Arlington, VA 22202

  1-800-DIABETES (800-342-2383)

  http://diabetes.org

  http://www.diabetes.org/type1/

  Again, don’t forget to discuss your diabetes needs with your diabetes team. Often, they will be your best advisors.

  (February 15, 2017)