Campamento Diabetes Safari 2006

Innovations facilitating stable normoglycemia in an educational camp for youth with diabetes mellitus, tipo 1 (DM1)

Stan  De Loach, Ph.D.
Diabetes Educator, Clinical Psychologist
CDMX, México

Este mismo artículo en español



Abstract and Abbreviations employed

Abbreviations:
A1c hemoglobin A1c
BG blood glucose
CHO carbohydrate
DCCT Diabetes Control and Complications Trial  (1993)
DM1 diabetes mellitus, type 1
F female gender
M male gender
MAGE mean amplitude of glycemic excursions
SD standard deviation
SMBG self-monitored blood glucose
TDD total daily doses of insulin(s)
Objective: For children and adolescents with recent-onset DM1 to learn during an educational Campamento near México City to quickly and safely establish normoglycemia (71—99 mg/dL) and normal glycemic stability (MAGE score < 96), by using self-directed diabetologic education, insulin replacement therapy with insulin analogues lispro and glargine, limited concentrated carbohydrate (CHO) in their diet, and ad libitum physical activity and SMBG.
Methods: A 5-person international multidisciplinary team, functioning as Staff, managed time, task, territory, technique, and technology boundaries, while responding to the educational and emotional needs of 9 Campers (8—17 years of age [11.8 ± 2.6]), with average diabetes duration of 1.62 years (± .88), during a residential 57-hour (3-day/2-night) educational diabetes camp.  Campers chose foods from meal buffets, calculated lispro insulin doses, both preprandial and corrective, and exercised and monitored BG at will.  SMBG values documented in each Camper's combined glucose/ketone monitor furnished statistical data.
Results: Mean arrival and departure BG was 209 mg/dL (± 101.5) and 87 mg/dL (± 23), respectively [P < .0025].  Mean 3-day BG average (95 mg/dL ± 21) and MAGE score (66 ± 27) validated stable euglycemia.
Conclusions: Integrating self-directed diabetologic education, basal/preprandial insulin therapy with analogues, elective physical activity and SMBG principally self-directed, and reduced concentration of dietary CHO rapidly and safely established routinely normal mean daily glycemic levels and stability in this sample.
Keywords: Diabetes mellitus, typo 1; self-directed diabetologic education; diabetes camp; normoglycemia; euglycemia; México


Campamento Diabetes Safari annually offers experiential diabetologic education to children and adolescents 6 to 18 years of age who have DM1.

The purpose of this 3-day residential camp is to support and ensure the physiological and psychological development of the Campers and boost their learning about self-management strategies and techniques designed to normalize BG levels, so as to prevent diabetic complication in the short and long terms.

Through a "non-directive" model of diabetologic education, whose purpose is to permit the discovery and implementation of personalized proactive solutions to the glycemic disequilibrium that frequently characterizes the historic management and self-management of DM1.

The multidisciplinary team that functions as Staff of the Campamento encourages self-awareness, understanding of the physical needs of the body, competence in the analysis and use of glycemic data and modern technological resources, and autonomy.

The Staff of health care professionals aims to foster creativity through exposure to novel ways of thinking about the treatment and self-management of DM1, with the aim of maintaining healthy, safe and stable glycemic levels as a way of greatly improving the children's and adolescents' quality of life in the years after diagnosis.

The non-directive approach to diabetologic education ensures a low-stress environment in which the young Campers can explore self-directed education and learning with the free availability of professional consultation.

Staff embodies the primary educational task of offering opportunities to learn from personal experience about functional self-management of DM1, including pertinent emotional and psychological facets.

The competencies that the Campers learn during the 3 days are the minimal requirements or components needed for learning to achieve and maintain euglycemia or nomoglycemia with confidence and security.

This report from the Director of Campamento Diabetes Safari describes novel methods of increasing personal knowledge relevant to DM1 self-management through self-directed education rather than traditional didactic professional instruction.

The Staff personifies or embodies the main educational task of the Camp, by creating, recognizing and knowing how to take advantage of opportunities to learn aspects of effective self-management of DM1, in the context of the current and real personal practical experiences of the children and adolescent Campers.

Objectives

The practical objective of this Camp is to help Campers achieve stable normoglycemia through a combination of self-directed diabetes education, insulin therapy with insulin analogs lispro and glargine, reduced concentrated CHO in their diet, and optional physical exercise and SMBG.

The educational objective is to provide opportunities to improve the skills of children and adolescents in the self-treatment of DM1, in a context of low psychological stress and professional consultations freely available on request and designed to address the Campers' own interests and educational and psychological needs.

The clinical goal in 2006 was to minimize glycemic decompensation (hyperglycemia and hypoglycemia) in Campers by their learning to maintain average daily glycemic levels within the target range of 71—99 mg/dL.  Supplementary strategies were directed to limiting the cumulative MAGE value to < 96 mg/dL, while also stressing that physical activity or exercise and SMBG were non-mandatory.

All of these variables were considered relevant to the achievement of target metabolic control.

Methods: Self-directed education rather than that directed by health care professionals or parents of the Camper

The basis of non-directive education is that it is not the teacher or expert but the student who decides what, when, how, how much and where to learn.  Non-directive education allows the Camper with DM1 to express his or her interests through the self-directed selection of activities and behaviors.

As a result, the Camper precisely configures the educational contexts or situations that, due to their personal relevance, increase the precision and usefulness of learning through personal here-and-now experience.

This methodology adapts teaching to the characteristics, externalized preferences and needs of the student designing and sharing the process of learning.

The Staff offers support in the process of learning and shares practical diabetes knowledge hinted at or asked about by the children and adolescents, so that education takes into account their own experiences.  There is continuous analysis shared verbally among Campers and Staff, usually incorporating or keeping in mind the errors and successes that these experimental processes inevitably involve.

The Staff makes relevant educational experiences available to the Camper and offers direction in the shared analysis of the intrinsic and learned lessons.  Self-directed education promotes both the experience and development of freedom as well as a focus on the process of learning through personal experience and shared here-and-now analysis of it.

Self-directed education invites Campers to express and exercise their choice in the pursuit of learning that is personally meaningful.  This active participation in the educational process encourages the Campers to publicly articulate or participate in the articulation of the elements of the diabetes curriculum of interest or immediate need.

To avoid entanglement in the politics of domination and submission, the Staff does not impose non-vital orders or mandates on the collaboration with the Campers.  On the contrary, it adapts to their preferences and actively accompanies them in the process of learning about unavoidable daily clinical decisions in the self-treatment of DM1.

The Staff serves as models for the Campers' personal use of research through the basic scientific method and for their understanding of the usefulness of this ongoing research in achieving every glycemic goal.

The self-directed methodology teaches analysis, flexibility, and innovation as ways to productively relate to the salient complicated data: glycemic variability and regulation, presence of hypoglycemia or hyperglycemia, food choices, insulin pharmacokinetics, scheduling of physical activity.

For the Campers, it is usually important to learn to share and analyze these same data with the members of the multidisciplinary health-care team, in a direct and different way from their customary behavior with their parents, their health-care professionales, and with themselves.

The non-directive method of education avoids excessive formality in the verbal and shared analysis of the experience, allowing learning to happen through the exercise of personal freedom in reviewing the ups and downs of acquiring practical competence in self-management of DM1.

The Staff periodically clarifies how the Campers may incorporate their experiential knowledge in the effective practice of diabetes self-treatment.

By participating in such consultations, Campers become actively, rationally, and intellectually involved in the architecture of their own self-care and lifestyle. The ratio of Staff to Campers, which is 1:1.8, guarantees enough time and personalized attention to evaluate and consolidate the application of the lessons and issues addressed.

Staff roles

The Staff performs two roles simultaneously: that of "manager," to regulate chaos through the essential boundaries of time, task, territory, technique and technology.  Boundaries that are defined, clear, publicly promulgated, and competently respected and managed reduce stress and make learning feasible.

The second role is that of consultant or advisor, with availability 24 hours a day to allow articulation, dialogue and analysis of educational opportunities and topics relevant to the experience of living with type 1 diabetes mellitus.

In the role of managers, Staff members deal with the management of the published schedule and program.  They represent and emphasize the educational task of the Camp, which is the provision of opportunities to learn from personal experience about effective self-management and self-treatment of DM1.

They are responsible for the safe use of the territory rented by the Diabetes Safari Camp and assigned for scheduled and improvised activities.  To the Campers, the Staff teaches the techniques of SMBG, the role of CHO in diet and in diabetic pathology, the production and measurement of ketones, the subcutaneous injection of insulin without pain 18, the calculation of prandial insulin doses and the use of physical activity for immediate glycemic adjustment.

On the other hand, in the role of consultant or advisor, the members of the Staff work in the "here and now" to open productive interaction with the Campers, around the topics that are requested or manifest, even if not verbalized.

Formal authorization of Staff and Campers to "work" during the Camp

At the beginning of the Camp, both the Staff and the children and adolescents are publicly and fully authorized to start a consultation at any time, with any member of the Staff and with any subject matter.

This explicit authorization decreases unexamined passivity and submission and thus favors an awareness of the irrefutable existence and utility of personal authority and responsibility, of adults and children and adolescents, as key factors in the effective self-management of DM1 and in the short- and long-term prevention of complications of inept administration and/or self-administration of the condition.

At all times, Campers are free to learn what they want to learn and are always personally responsible for what they learn.

Professional consultations: Opportunities to collaborate rather than continuation or creation of relationships of  inferiority/superiority

For the Campers, consulting with the Staff is always allowed, but also optional.  Because there are no academic classes or formal presentations in the non-directive methodology employed, children and adolescents learn via self-discovery and self-knowledge rather than through traditional pedagogy.

The topics of the consultations vary, often according to the age and maturity of the Camper.  Some examples from 2006 are:

For verbally competent children and adolescents, DM1 requires chronic self-management as the predominant means of treatment.  The decision as to how to use the updated information provided in the consultations at Camp is left explicitly up to the individual Camper.  Psychological and emotional factors affect both their understanding and use of this information.

The quality of glycemic self-management goes hand in hand with psychological health and adaptation.  During the Camp, the psychological dynamics are dealt with in small and plenary group meetings.  Both the evident interpersonal and group dynamics as well as voluntary presentation and reflection regarding nocturnal dreams play a role in the evaluation and the partial resolution of psychological obstacles.

The Staff considers and treats Campers as persons with diabetes and partners in the health team, not as subordinates, passive novices or vaguely inferior people.

Through diabetes education and prior experience, Campers come to know better than anyone their own body and its metabolic response to diet, physical activity, insulins, and glucose excess or deficiency.  This education affords them significant personal authority and responsibility.

This self-learning or self-knowledge has not always been elaborated or articulated verbally nor previously respected, which prevents its maximum contribution to the optimal management of DM1.  During the Camp, participants begin to learn to recognize and list the multiple factors that structure their unique expression of DM1 and their self-care decisions.

Staff avoids obligation or psychological pressure and comparison with other people in their consultations with the Campers.  In any event, they do not produce the results that the Camp philosophy tries to promote and reaffirm.

As far as possible, the Staff does not allow Campers to encourage expressions of guilt, shame or low self-esteem for "having DM1" or to permit such expressions to go unchallenged in the public forum.  These factors must be challenged because they can strongly influence the possibility or definition of the degree of glycemic control that the Camper contemplates or believes they deserve or are capable of.

Staff have also learned from their previous experiences and ideally continue to learn in the "here-and-now"

Sixty percent of Camp Staff have DM1.  Their self-care activities (SMGB, insulin dose calculations, insulin injections, food selection and serving sizes) are public and perceptible examples of the quality of their self-management of the condition.

Their accuracy and skill are evaluated by the same procedure Campers use: the results of SMBG.  Their personal experience, frequently communicated in "teachable moments," that is, the ideal and natural moments to contextualize education and learning, guides their inquiries and gives them credible authenticity.

If Staff members do not learn, Campers will not learn.  This is how any social system such as Campamento Diabetes Safari, which is a temporary educational institution, works. 

The use of what is possible to learn: Personal authority and  responsibility

Self-directed education focuses on the provision of information that allows Campers to understand the complications of inadequate or inexperienced management of DM1 and the short-term complications of insulin and dietary treatment.

The educational opportunities and emotional support provided to Campers are intended to empower them to fully understand known techniques to prevent or respond promptly to short-term diabetic complications. The Staff can function as an advisor, demonstrating, for example, how a Camper could incorporate their experiential learning into improved or competent self-care practice.

The implementation of what is learned or observed, however, remains the sole responsibility of the individual child or adolescent.

Insulin analogs: Lispro/Humalog and glargine/Lantus

At the beginning of the Camp, with the signed informed consent of the parents, 33% of the children and adolescents who previously used multiple daily injections of NPH insulin for the basal component of their insulin therapy changed to a single daily injection of glargine to supply their basal insulin needs.

Before and during the Camp, all Campers were applying lispro for their prandial insulin doses and for complementary or corrective boluses.  The majority (67%) arrived already managing this combination of basal/bolus therapy with insulin glargine and lispro analogs.

Because of their predictable and consistent action profiles, these insulin analogs, in combination with an appropriate diet, provide largely stable glycemic regulation while facilitating any necessary short-term day-by-day modifications of the insulin regimen.

Complementary or bolus insulin refers to ultra-rapid insulin that reduces extemporaneous hyperglycemia that appears more than 2 hours after the last insulin injection.

All prandial insulin is injected before eating food.  The Campers calculate and adjust the doses of lispro before their injection, be it prandial or corrective.  The professional Staff consults in these calculations, but generally accedes to the experienced judgment of the Camper.

Glycemic values seen 1–2 hours after lispro injection confirm discrepancy or accuracy of optimal dosage, highlight factors influencing individual glycemic excursions, quantify current requirements for optimal insulin replacement and inform subsequent calculations of prandial and basal insulin doses.

That is to say, the process of deciding alone or negotiating doses, using the dose finally agreed or decided, adjusting the food choices to this dose, and evaluating the results in the postprandial BG readings...provide invaluable experience of the "scientific" method to use in future self-management decisions.

Food choices with reduced concentrated CHO intake

Curiously, the American Diabetes Association recommends that between 50–60% of the total daily calories for the person with DM come from dietary CHO, including concentrated CHO sources (rice, fruit, pasta, potatoes, bread, desserts, tortillas).

In reality, for most Campers and Staff with DM1, ingesting a high percentage of these "simple" CHO makes it difficult or impossible to normalize and stabilize blood glucose levels within the safe "normal" or relatively normal range.  This has been learned from their personal experience over and over again.

The food served 1 during the Camp is tasty and nutritionally adequate; it contains little concentrated CHO.  The CHO that is presented is intermixed with other nutrients (eg, nuts, avocado, green vegetables).

Water and calorie-free drinks are always available.  Because Campers select their own food and beverages from an all-you-can-eat buffet, an accurate count of CHO ingested is not kept.  The implied goal is a maximum daily total of 30 grams (120 calories).

Typical menus offer alternatives to CHO:

Breakfast Egg salad
Bacon
Green sauce
Chile slices
¼ light drinkable flavored yoghurt  (60 mL)
Lunch Leek soup
Smoked pork chop
Green salad with Caesar salad dressing
Sugar-free gelatin dessert with whipped cream
Dinner Green vegetable soup
Chicken nuggets, unbreaded
Lettuce, cucumber, avocado salad
Green hot sauce
Cheesecake without added sugar


Physical activity (exercise)

Physical activity can accompany the use of insulin analogs and high-quality food to rapidly facilitate, in the short term, optimal glycemic control.

Physical exercise improves glucose tolerance 2 by temporarily heightening insulin sensitivity, through an increase in the affinity for its peripheral receptors and a consequent reduction in insulin requirement.

The recreational activities offered 3 are meant to provide opportunities for the development, expansion and application of diabetes knowledge, in real, practical and often enjoyable contexts.

At the physical site of the Camp, distances of ~750 meters between dining room, hotel and swimming pools require frequent walking, and the program offers additional possibilities for optional individual and group physical activities.

For most of the participants, the intensity of the exercise performed during the Camp is greater than that of their usual daily physical activity, causing a notable reduction in the size of the insulin lispro doses.  Exercise does not affect the pharmacodynamics, i.e. the rate of absorption, of glargine insulin 4.

The explicit and invariable target glycemic range

The target glycemic range for Campers and Staff is 71—99 mg/dL during both the absorptive and post-absorptive states.  This range, previously communicated to Campers and their parents as an informative and educational strategy, is applied 24 hours a day.

This range is considered the "normal" range because it is seen with very limited variation among people not living with any type of DM.  The same range is used to assess the quality of the global, long-term management of DM1 during the Camp.

A blood glucose level < 71 mg/dL defines therapeutic hypoglycemia; at this level, glucose tablets are used to raise the blood glucose to ~ 90–100 mg/dL.  A documented SMBG value of < 54–51 mg/dL indicates pathological biochemical hypoglycemia 5.

The ultra-rapid insulin lispro analog used during the Camp shortens the time period of risk for acute postprandial hypoglycemia.

The basal insulin analog glargine, in physiological doses, does not produce hypoglycemia, since it has no "peak" of hypoglycemic action.

To reverse hypoglycemia without overcorrection and subsequent hyperglycemia, Campers learn the difference between treating documented or suspected hypoglycemia and treating persistent symptoms of hypoglycemia.  They learn that glucose does NOT affect or eliminate the symptoms of hypoglycemia, but rather only serves to normalize blood glucose.

Because the development of diabetic retinopathy begins at a glycemic level of 126 mg/dL 6, a value of > 126—129 mg/dL represents the lower threshold of hyperglycemia during Camp.  The frequency with which the Campers perform SMBG corresponds to their efforts to initiate timely and sufficient prevention and treatment of glycemic decompensation, whether hypoglycemia or hyperglycemia.

Glycemic variability

Interday glycemic instability is assessed by comparing daily glycemic averages and their standard deviation (SD).  Intraday glycemic instability or variability is reflected in MAGE 7 values.

The MAGE value is independent of the average BG and quantifies glycemic excursions whose amplitude is greater than one SD 8.  In people living with DM1, after successful transplantation of islets of Langerhans, the average MAGE value is 73 mg/dL 9.

MAGE values > 94 mg/dL indicate significant glycemic instability and increased risk of hypoglycemia 7, 10.  The presence of MAGE values of 0—94 mg/dL corroborates normal glycemic stability.

Although glycemic instability produces significant oxidative stress 11, 12, which is related in the long term to the risk of diabetic complications, data from the DCCT 13 show that the intraday variability of BG, which is frequently lower in people without DM than in in people living with DM1 14, it does not significantly influence the development or progression of diabetic retinopathy and nephropathy 15

The SD of daily glycemic levels neither contributes fundamentally to the A1c value, nor is it a predictor of it 16.

However, measures of glycemic variability remain accurate indicators of the potential for hypoglycemia and hypoglycemia without warning symptoms.  When mean BG is reduced without also reducing glycemic instability, the incidence of hypoglycemia is increased (see results for Campers A, B, F in Table 1 below).

By lowering the average daily BG and the daily glycemic variability together, the probability of hypoglycemia 17 is reduced in the pediatric population 10.

Results

The data used for statistical analysis (Table 1) are the BG values documented in the glucose and ketone meter (Optium XCEED) given to each Camper by Abbott Laboratories of Mexico.

In a matter of hours, the synergistic combination of the 4 cornerstones of DM1 treatment (diabetologic education, insulin, diet, physical exercise) facilitated mainly normal BG levels and reduced glycemic variability in this sample of children and adolescents with a recent diagnosis (between .58—2.58 years) of DM1.

Differences between the sexes, regarding the average BG upon arrival at the Camp (M = 214 mg/dL, F = 198 mg/dL), the glycemic average of the 3 days of the Camp (M = 88 mg/dL, F = 108 mg/dL), regarding chronological age and daily insulin requirements...were all insignificant.

The average TDD of both insulins (glargine and lispro) applied was 21 units, of which preprandial insulin represented 18% (3.8 units) and basal insulin constituted 80% (16.8 units).  Supplemental or correction doses amounted to approximately 2% of the TDD, indicating infrequent clinical hyperglycemia.

A preprandial dose of lispro, sufficient to maintain postprandial euglycemia, ranged from 0 to 3 units, with a mean effective dose of 1.4 units.

Compared to reported usual doses at home, Campers needed less mealtime insulin during Camp.  They made independent calculations and decisions on prandial doses; these calculations were rarely sufficiently inaccurate that the Staff needed to suggest altering them up or down.

Daily and cumulative BG profiles were analyzed to determine glycemic variability with respect to daily BG levels, SD, and MAGE values.

The initial glycemic value (upon arrival at the Camp) was included only in the analyses linked to it.  The mean initial BG value was 209 mg/dL (± 101.5); at the end of the Camp, the mean final BG value was 87 mg/dL (± 23), (t = 4.22, P < .0025).

The daily average BG varied between 68—154 mg/dL (94 ± 22); the SD was 9.1—77.6.  The SD of the accumulated glycemic average remained between 12—55.

The daily MAGE value ranged from 0 to 136.5; the global cumulative average was 66 (±27), and ranged from 6-48.  The global MAGE average met the accepted criteria (< 96 mg/dL) to indicate stable glycemic control of DM1.

During the 3 days, the Campers manifested hyperglycemia and hypoglycemia.  Of 288 SMBG values (not including baseline), 17% (49 values) were hyperglycemic and 8% (23 values) hypoglycemic.

Of those same 288 SMBG values, exactly 75% (216 values) were normoglycemic.

The risk of severe hypoglycemia was low.  Applying a definition of therapeutic hypoglycemia as < 71 mg/dL, the mean hypoglycemic value was 58 ± 9 mg/dL.  Applying the biochemical criterion of < 54—51 mg/dL (44 ± 5 hypoglycemic values), the average individual percentage of hypoglycemic values was 7.5%.

No association was observed between the frequency or intensity of physical activity and severe hypoglycemia, with or without seizures or loss of consciousness.  The self-determined frequency of SMBG allowed general avoidance of biochemical hypoglycemia.

Timely use of partial, single, or multiple glucose tablets (each containing 4 grams of glucose), followed in some cases by a combination of CHO, protein, and fat (1—4 tablespoons of peanut butter) rapidly returned the glycemic value to the target range, generally without evidence of overcorrection.

Each gram of oral glucose raised BG by ~ 5 mg/dL 18.  Two cases (Campers A, D) of severe hypoglycemia (~ 36 mg/dL) presented without seizures or loss of consciousness.  To reverse them, it was necessary to administer a greater amount of CHO than was sufficient to reverse hypoglycemias of 70—40 mg/dL

To support ad libitum SMBG, Campers receive an unlimited, unquestioned, uncommented number of blood glucose and ketone test strips.  Total individual daily (6-18 times, 11 ± 4] and cumulative (28-41 times, 33 ± 4.4) ad libitum SMBG varied.  This variation reflected individual judgments and decisions.

The frequency performed possibly confirms the results of studies 19, 20 that showed that the ad libitum provision of test strips, even without other clinical intervention, increased the frequency of SMBG and improved glycemic control, and that these positive effects were not diminished during the subsequent 12 months.

Daily CHO intake was not rigorously measured; the estimated individual daily intake was 12—35 grams, depending on the foods selected.  A BG value of > 240 mg/dL (Campers C, H) occurred only 3 times; in those cases, the results of serum ketone monitoring were negative.  Despite low dietary CHO content, no Campers had abnormal ketonemia (> 3 mg/dL).

Meeting and discussion with parents of the Campers

In the final 1½ hours of the Camp's duration, 89% of the parents met with the Camp Director for an optional dialogue in which the Director commented on the overall experiences of the Campers and answered parents' questions.

He reviewed the value of their role as parents in carrying out the function of adult supervisors and partners of the multidisciplinary team for the health of their sons/daughters.

Ultimately, parents, together with the Camper and health care professionals, ensure the timely transfer of appropriate responsibilities for diabetes self-care to the child or adolescent with DM1, even if the supervision of one or more adults continues until diabetes education is relatively complete.

Due to the chronic and progressive nature of DM1, the need and desire for hands-on diabetes learning and relevant continuing education originate with the affected person and do not cease upon entering adulthood.  The concept of continuing education has not been implemented for persons with DM1 or DM2.


Table 1:  Glycemic values during the 3 days
of Campamento Diabetes Safari 2006 *
  
Camper
A
B
C
D
E
F
G
H
I
Age
Gender
8 years
M
9 years
M
9 years
F
10 years
M
11 years
M
11 years
M
12 years
M
12 years
F
17 years
F
Arriving BG
(209 ± 101.5)
230
296
176
330
66
267
97
315
104
Daily BG values and number of SMBG for the day
FRIDAY
103
46
82
72
60
96
133
66
 

n = 9

FRIDAY
175
47
103
82
89
66
92
85
64

n = 10

FRIDAY
111
54
101
84
63
61
109
82
93

n = 10

FRIDAY
105
51
91
78
52
76
92
70
69
89
56
59
75

n = 14

FRIDAY
55
61
69
59
81
66
67
81
73

n = 10

FRIDAY
74
62
65
75
66
94
141
74
65

n = 10

FRIDAY
86
85
83
58
85
82
72
80

n = 9

FRIDAY
249
113
63
86
191

n = 6

FRIDAY
44
56
59
72
81
99
103
113

n = 9

.
SATURDAY
195
42
143
46
87
96
112
175
69
146
136
99
136
79

n = 14

SATURDAY
58
99
108
162
182
121
40
84
54
52
80
93
92
58
133
57
97

n = 17

SATURDAY
103
98
117
256
150
67
87
80
68
44
47
62
58

n = 13

SATURDAY
67
48
173
82
50
78
68
90
125
93
76
36
84
83
71
52
67
70

n = 18

SATURDAY
78
82
77
68
78
79
74
83
68
75
46
84
60
65
77
71

n = 16

SATURDAY
131
172
215
47
9
94
45
71
111
151
162
145
95
81
89
88
61
95

n = 18

SATURDAY
72
58
164
64
73
78
82
74
95
72
76
88

n = 12

.
SATURDAY
118
232
263
179
167
179
217
165
121
118
170
186
166
58
61
66

n = 16

SATURDAY
106
152
137
113
95
44
95
84
85
79
92

n = 11

.
SUNDAY
33
29
46
217
194
92
100
91
64
60
50
84

n = 12

SUNDAY
63
110
123
116
236
96

n = 6

SUNDAY
86
46
90
90
113
70

n = 6

SUNDAY
84
57
72
59
178
53
85
50
64

n = 9

SUNDAY
64
64
86
90
92
86
76
107

n = 8

SUNDAY
58
113
67
63
110
221
125
45
135

n = 9

SUNDAY
148
48
112
88
99
78
88

n = 7

SUNDAY
124
105
164
169
148
143
156
162
117
69

n = 10

SUNDAY
70
90
94
95
90
100
79
70

n = 8

Departing BG
(87 ± 23)
84
96
70
64
107
135
88
69
70
# of SMBG
(3 days)

(33 ± 4)
35
33
29
41
34
37
28
32
28
Mean daily BG value and SD
(94 ± 22)
82
± 27.7

112
± 45.9

88
± 59.7

89
± 36.4

92
± 39.8

124
± 58.8

84
± 21.2

95
± 56.8

83
± 22.6

74
± 16.9

79
± 30.9

78
± 39.6

68
± 9.1

73
± 9.8

83
± 14.6

80
± 25

108
± 45.9

104
± 54.6

79
± 9.5

83
± 27.3

94
± 30.8

140
± 77.6

154
± 60.1

136
± 31.8

78
± 24.9

98
± 29

86
± 11.6

Mean 3-day BG value and SD
(95 ± 21)
96
± 48.4
97
± 43.4
89
± 41.2
77
± 28.8
74
± 12
100
± 44.6
85
± 24.4
146
± 54.7
89
± 24.5
Mean daily MAGE value and SD
(66 ± 40)
41.5
± 10.34

92.83
± 35.45

136.5
± 48.79

92
± 50.91

59
± 16.77

130
± 14.14

44.75
± 12.66

109.33
± 28.15

43.5
± .71

31.29
± 12.18

57.57
± 36.24

122
± 4.24

15.25
± 4.99

21.33
± 10.95

26.5
± 6.36

47.33
± 19.5

89
± 68.42

86.4
± 20.84

20.67
± 9.29

103
± 4.24

82
± 25.46

120.5
± 21.92

102
± 15.87

50.67
± 7.37

0
± 0

49.32
± 2.89

20.5
± .71

Mean 3-day MAGE value and SD
(66 ± 27)
90.3
± 47.6
93.7
± 35.5
65.9
± 37.7
70.3
± 46.7
21
± 5.6
74.2
± 23.3
68.6
± 42.8
91.1
± 36.2
23.3
± 24.8
# of hypoglycemias 
< 51  mg/dL
(2.6 ± 2)
7
2
3
4
1
3
1
0
2
# of hyperglycemias > 129  mg/dL
(5.4 ± 6)
9
5
2
2
0
9
2
18
2

* BG and MAGE values in mg/dL             Not including arriving BG value


Supplemental BG and insulin data
total # of SMBG 288
total # of hyperglycemias 49  (17% of SMBG)
total # of hypoglycemias 23  (8% of SMBG)
total # of normoglucemias (71 - 99 mg/dL)
216  (75% of SMBG)
Average 3-day BG of all Campers 95 mg/dL
Average dose of basal insulin (glargine) 16.8 unidades ± 3.5
Average mealtime dose of  prandial insulin (lispro)  [excluding corrective doses] 1.4 unidades ± 2.4, before each meal
Average total daily dose of  prandial insulin (lispro)  [excluding corrective doses] 3.8 unidades

* BG values in mg/dL            Not including arriving BG value


Average daily dosage of insulin
Camper
A
B C
D
E
F
G
H
I
Age (years)
8
9
9
10
11
11
12
12
17
Gender
M
M
F
M
M
M
M
F
F
Total units of prandial insulin
3.5
 4
2.5
6.5
1
4
7
8
2.5
Total units of basal insulin
12
20
16
13
21
14
15
20
20
Average BG value *
96
 97
89
77
74
100
85
146
96


Average BG value, by gender *
M
88
.
F
108

*  BG values in mg/dL

Concluding thoughts

In a short time of less than 3 full days, the children and adolescents with DM1 who participated in this diabetes Camp were able to employ the self-directed education paradigm to develop an impressive level of competence in the self-management of their blood glucose levels.

Through consultation with their peers and readily available trained professionals, they used the intellectual and material resources available to engineer and successfully maintain glycemic levels within the normal target range (71—99 mg/dL).

In the self-directed search for unaccustomed stability of euglycemic values, the availability of a non-excessively demanding context, with psychological support and competent professional advice served them well.

This context or environment, in many cases different from their daily life and experience in the family, facilitated the study and use of diabetological tools for practical purposes.

In this sample, the environment favored glycemic normalization and stability precisely because it encompassed opportunities for undirected discovery, optional expert advice directed at the Campers' expressed acute needs and current interests.

The use of insulin analogues with predictable action profiles, the unlimited presence of foods with low concentrated CHO content, free access to test strips in unrestricted amounts, and suitable conditions for performing SMBG and physical exercise ad libitum ...all of these contributed to the success of the Campers' dedication, concentration and learning.

The unique context of the Camp makes possible new methods to carry out the teaching of standard strategies to manage DM1.  However, with few modifications, the procedure and the methodology are flexible and are adaptable to daily self-care at home or at school.

The core elements of the Camp protocol (self-directed diabetes education and brief and/or extended informal professional consultation) may be appropriate for individual or family use.

In any setting, achieving stable normoglycemia or an average BG level in the normal glycemic range carries a degree of risk of hypoglycemia, which is not easily or completely eliminated.

Due to the small doses of insulin common and useful in this population, which follow the Laws of Small Numbers, it is essential that children and adolescents have easy access to insulin syringes marked in multiples of ½ unit.  The syringes used during the Camp had graduations of 1 whole unit, but repeatedly a dose of ½ unit or ¼ unit was justified and suitable.

Some episodes of hypoglycemia reported were due to the technical inability of Staff and Campers to accurately dose and inject minute amounts of insulin lispro U100.

Alternatively, a dilution of U100 insulin lispro with "Sterile Diluent for Humalog, Humulin N, Humulin 50/50, Humulin 70/30, NPH Iletin" (Eli Lilly, Indianapolis, IN) reduces the original concentration to U50 (1:2) or U10 (1:10), thus simplifying exact dosing when giving standard U100 insulin with insulin syringes labeled with a 1-unit scale.

Acknowledgements

I greatly appreciate the technical and material support of Abbott Laboratories, Eli Lilly, Sanofi-Aventis, Becton Dickinson and Danone de México.

Financial support from Kathy Garrett, Barbara and Brian Splan, Nancy and Ken Marks, Estela Garcia, the North Mexico affiliate of the "Soñar Despierto" Foundation, and other donors enables the establishment and administration of Campamento Diabetes Safari.

I am grateful to Dr. Janet McGill for her editorial guidance.

Bibliographic sources

(1) Menús y valores calóricos para Campamento Diabetes Safari 2006.  www.continents.com/diabetes-safariINFORMACION06.htm#Alimentación.  Ya no está en internet.
(2) Rivera-Cisneros A. E. / Sánchez-González J. M. / Gutiérrez-González R. V. / Flores-Aranda B. / Bielma Manríquez J. / Chacón-Gutiérrez L.  Ejercicio en diabetes mellitus tipo 1.  Diab Hoy para el médico y el prof de la salud, 2005, 6(1):1349 – 1351.
(3) Actividades recreativas y horario para Campamento Diabetes Safari 2006.   www.continents.com/diabetes-safariINFORMACION06.htm#ActividadesYa no está en internet.
(4) Rajesh P. / Luzio S.D. / Dunseath G. / Miles A. / Hare B. / Backx, K. / Pauvaday V. / Owens D.R.  Effects of exercise on the absorption of insulin glargine in patients with type 1 diabetes.  Diabetes Care, 2005, 28:560 – 565.
(5) Rizza R.A / Service F.J.  Hypoglycemia/pancreatic islet cell disorders.  En Cecil Textbook of Medicine.  21st ed.  Goldman L, Bennett JC, Eds.  Philadephia, W. B. Saunders, 2000, págs. 1285 – 1292.
(6) Ito C. / Maeda R. / Ishida S. / Harada H. / Inoue N. / Sasaki H.  Importance of OGTT for diagnosing diabetes mellitus based on prevalence and incidence of retinopathy Diabetes Res Clin Pract, 2000, 49:181 – 186.
(7) Service F.J. / Molnar G.D. / Rosevear J.W. / Ackerman E. / Gatewood L.C. / Taylor W.F.  Mean amplitude of glycaemic excursions, a measure of diabetic instability.  Diabetes, 1970, 19:644 – 655. 
(8) Service F.J. / O’Brien P.C. / Rizza R.A.  Measurements of glucose control. Diabetes Care, 1987, 10:225 – 237.
(9) Fung M.  An update from the British Columbia Islet Transplant Program, 2005, www.livewellwithdiabetes.com/issue3.pdf.  Ya no está en internet.
(10) Bolli G.B.  Glucose variability and complications (Editorial).  Diabetes Care, 2006, 29:1707 – 1709.
(11) Monnier L. / Mas E. / Ginet C. / Michel F. / Villon L. / Cristol J-P. / Colette C.  Activation of oxidative stress by acute glucose fluctuations compared with sustained chronic hyperglycemia in patients with type 2 diabetes.  JAMA, 2006, 295:1681 – 1687.
(12) Monnier L. / Mas E. / Ginet C. / Michel F. / Villon L. / Cristol J-P. / Colette C.  Glucose fluctuations and oxidative stress—Reply.  JAMA, 2006, 296:1730 – 1731. 
(13) DCCT Research Group.  The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus.  NEJM, 1993, 329:977 986.
(14) Kessler L. / Passemard R. / Oberholzer J. / Benhamou P.Y. / Bucher P. / Toso C. / Meyer P. / Penfornis A. / Badet L. / Wolf P. / Colin C. / Morel P. / Pinget M.  Reduction of blood glucose variability in type 1 diabetic patients treated by pancreatic islet transplantation.  Diabetes Care, 2002, 25:2256 – 2262.
(15) Kilpatrick E.S. / Rigby A.S. / Atkin S.L.  The effect of glucose variability on the risk of microvascular complications in type 1 diabetes.  Diabetes Care, 2006, 29:1486 – 1490.
(16) McCarter R.J. / Hempe J.M. / Chalew S.A.  Mean blood glucose and biological variation have greater influence on HbA1c levels than glucose instability:  An analysis of data from the Diabetes Control and Complications Trial.  Diabetes Care, 2006, 29:352 – 355.
(17) Saudek C.D.  Pumps:  Hopes and expectations.  En FDA/NIH Joint Symposium on Diabetes:  Targeting safe and effective prevention and treatment, Bethesda, MD, 2004.  Bethesda, MD, National Institutes of Health, 20 – 21.
(18) Bernstein R.K.  Diabetes solution:  The complete guide to achieving normal blood sugars.  Little, Brown: Boston, 2003, pág. 311.
(19) Nyomba B.L.G. / Berard L. / Murphy L.J.  Facilitating access to glucometer reagents increases blood glucose self-monitoring frequency and improves glycaemic control:  A prospective study in insulin-treated diabetic patients.  Diabet Med, 2004, 21:129 – 135.
(20) Nyomba B. L. / Berard L. / Murphy L. J.  The cost of self-monitoring of blood glucose is an important factor limiting glycemic control in diabetic patients. Diabetes Care, 2002, 25(7):1244-1245.



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Dr.  Stan  De Loach

Foto Dr. Stan De Loach
Especialista en Diabetes
Mellitus, tipo 1

Educador en Diabetes

53+ años de experiencia acompañando y capacitando a niños, adolescentes, adultos a normalizar sus niveles de glucosa en sangre, para así prevenir hiperglucemia, hipoglucemia y las demás complicaciones diabéticas

Ciudad  de  México

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