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Past News Articles

What's Going On Next Door?

You may have noticed that there is a big empty space next to Joslin with construction vehicles moving around inside. Several years from now, instead of an empty space there will be a nine-story research building with stores on the first floor. While right now it may look like nothing is being built, the construction crew is actually creating an underground parking garage. The first step is to build walls underground, then the construction crew will dig out the dirt in the middle and build the floors. Normally, a construction crew would build walls underground by hammering sheets of steel into the ground in a process called “sheet piling”. However, sheet piling is very noisy, and since the building site is right next to Joslin, they are using a different method by building “slurry walls”. They dig trenches into the ground where the walls will go, then fill the trenches with a liquid cement called a “slurry,” which keeps the trenches from collapsing while they continue to dig deeper. Then, they lower a pipe into the slurry and pump in concrete starting at the bottom of the trench. As the trench fills with concrete, the slurry spills out the top. The result is a concrete wall in the dirt. Once the garage is finished, the construction crew will start building the floors. Then, sometime in 2015, the Longwood Center building will be completed.
-Georgia Feuer, BA

Translational Center for the Cure of Diabetes

Joslin was recently awarded a grant by the Massachusetts Life Science Center to create the Translational Center for the Cure of Diabetes. The purpose of this facility within Joslin is to encourage more interaction between the clinic and the research labs to further our goal of finding a cure. Laboratory and clinical research space on Joslin’s third and fourth floors will be completely renovated to build new examination and procedure rooms for clinical research, specimen processing labs, and work space for research staff such as nurses, nutritionists, and technicians. Joslin will also build an exercise physiology laboratory, which will be the only exercise physiology laboratory in a diabetes center in the Northeastern United States. Joslin will also be upgrading some equipment and technology. In order to receive this grant, Joslin submitted an application in April of 2011. We were chosen out of 25 applications to apply for further review. Finally, after a third round of explaining how this money would help Joslin’s translational research goals of finding cures for type 1 and type 2 diabetes, Joslin was awarded $5 million dollars to build the center. However, in order for Joslin to receive this money, we had to raise $5 million dollars from donors as well. Thank you to the donors who provided funds to build the Translational Center for the Cure of Diabetes. We hope that the improvements to the research process provided by the new facility will put finding a cure for diabetes within reach.
-Georgia Feuer, BA

Groundbreaking Ceremony

On June 14th, 10-year-old Lilly Branka spoke in front of Governor Deval Patrick, news cameras, and the Joslin Board of Directors as part of the groundbreaking ceremony for the creation of the Translational Center for the Cure of Diabetes. The project is funded by the Massachusetts Life Science Center and by Joslin’s donors and will foster collaborative research on diabetes. “Joslin is the best place for research and they will find a cure one day,” said Lilly in her speech. “I look forward to coming here after they turn this place into a museum and I can show my kids where miracles happened and history was made.”


Lilly, with Gov. Deval Patrick behind her

Over 40 Years of Care Cindy Pasquarello, RN, CDE

On May 17, 2012, Cindy Pasquarello, RN, CDE was honored for forty years of caring for Joslin patients. Cindy started at Camp Joslin in 1971. Since then, she has educated over 18,000 campers and 2,000 camp staff. In 1997, she was given the Lifetime Camper Award. At the Joslin Diabetes Center, she been the Nurse Manager of the Pediatric, Adolescent and Young Adult Section, and previously, the Coordinator of the Pregnancy Clinic and of all the Teaching Nurses. She was the recipient of the 1986 American Association of Diabetes Educators’ Diabetes Educator of the Year award. Throughout the 40 years, her work at Joslin has helped almost 200,000 patients and families. Thank you, Cindy, for all that you do.

Dorms, Dining Halls, and Diabetes

Amy Johnson was the 2010 American Diabetes Association’s National Youth Advocate and she speaks at events across the country to raise awareness of the diabetes epidemic. She is a pre-medical, undergraduate student at the University of Missouri-Kansas City. In the following article, she talks about her experiences as a student living with diabetes in college.
What were the biggest changes from high school and how did you manage them?
In high school, I was cushioned by a constant (though under-appreciated) system of checks and balances in the form of my parents. I had my medical team on speed dial and a school nurse I could always rely on. In college, the lack of a safety net became immediately obvious, and all of a sudden I found myself at the mercy of my own judgment. It was now up to me to find food in the cafeteria, adhere to a set sleep schedule, pick up diabetes supplies on time, and ask for help if I needed it. In high school, because I was seated throughout the day, it was easier to maintain stable blood glucose levels between meals. In college, I am constantly on the move. The cafeteria can be tricky. I take ‘to-go’ meals as much as possible because there are healthier options, such as salads, fruit, water or diet soda. I do eat in the cafeteria at times, but I find I often miscalculate my bolus doses even when the menu is labeled with nutritional information because portion sizes vary a lot.
Is your college supportive of your needs?
At my college, there is an office for disability services, which handles accommodations and 504 plans to aid students with diabetes or other health care needs. I have a new 504 plan for college that ensures my diabetes needs are understood and accepted by the school and all my professors. I also found an adult endocrinologist near my school.
How did you adjust your management plan to account for changes to your lifestyle from high school to college?
I use an insulin pump, which gives me flexibility. I try to follow a routine, even if not exactly the same every day, as this helps me to predict my blood glucose levels. I adjust my basal rate as needed and look for patterns, like a rise in blood glucose after a workout. I’ve also noticed that I am more in tune with my body than I used to be. I can feel a low blood glucose and I stop to check and treat it. Basically, paying more attention to my diabetes has made my life easier.
Do you have any advice for people living with diabetes who are entering college?
After starting college, I had a low blood glucose and I found myself sitting alone on my dorm room floor. I realized then that I needed to take charge. Now, I am always prepared with my glucose tabs, glucagon pen, insulin, and other supplies, and I have no reason to worry. No one else who can be fully responsible for this burden-- and likewise, no one else will reap the benefits of good care!

Amy (3rd from left) at an ADA event

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Spring 2012

Caring for Caregivers

Margie Lawlor, MS, CDE has been the Coordinator of Pediatric Research and Education at Joslin for almost twenty years. The creation of the new class Caring for Children with Diabetes: A class for caregivers of young children is the realization of a dream she has had since before she started working at Joslin: to provide caregivers with education on the care of young children with diabetes. In this interview, she discusses why it is so important to educate day care providers, teachers, neighbors, grandparents, relatives, etc.
Can you talk about your own experience as a caregiver?
I spent 16 years as an early childhood educator. I started working in a preschool in 1974 while I was a student at Purdue. Then, I worked at a vocational high school where I was both a high school and a preschool teacher. I taught the highschoolers about early childhood education in the morning, then the preschoolers would come in the afternoons. In the early 1980’s, we switched to a daycare format, caring for 15-month-olds to 5-year-olds. I became the director in the second year of the daycare program. We had about 35 children enrolled and 4 staff, and we operated from 7am to 6pm. The switch from preschool to daycare reflected what was happening in early childhood at the time. More women were working and needing a place for their children to spend the entire day. So, I learned very early how much care young children need, in general, and, in particular, if they have diabetes.
What are the biggest challenges involved in caring for a child with diabetes in a daycare center?
At a young age, children don’t know how, or aren’t yet able, to do things for themselves. They can’t tell you if they are feeling low. The child-to-staff ratios are already tight, and when you add a child who requires extra attention due to diabetes or another condition, it becomes more difficult. Schools have nurses, but very few daycares do. For many daycare providers, caring for children with diabetes is new, but as the number of young children developing type 1 diabetes is rising, we’re seeing more preschoolers in daycare settings who need help and support.
Why did you want to create a diabetes class specifically for caregivers?
I started asking my friends in the field of early childcare how comfortable they would feel caring for a child with diabetes. They thought I was out of my mind. I realized that daycare providers needed support and education, that they were afraid to care for a child with diabetes. With education, we can reduce the fear and anxiety and make the environment safer for the child.
What topics do you address in the class?
The class looks at management cornerstones, including meal planning, insulin, and physical activity. I wanted a class designed for people without medical backgrounds. The focus is on type 1 diabetes. We’ve also made this class very approachable for grandparents, friends, and family members.
Who do you recommend should take this class?
Anyone who deals with children with diabetes: childcare providers, grandparents, other family members, friends, after-school program providers, etc. Even though the class has a focus on the needs of younger children, the basics of the class are applicable to a child of any age. We will also be offering the class in Spanish. This could be helpful because diabetes presents a new vocabulary and concepts.
What do you hope people will get out of taking this class?
The classes should provide knowledge and offer comfort to those caring for kids with diabetes. Basic definitions of diabetes, an introduction to some of the treatment tools, a diabetes medical management plan, and carb counting are covered. We are also hoping that we will encourage discussion between caregivers and parents about care for the child. Because each child is so unique, we do not teach specific techniques in this class; we recommend that parents show caregivers how to perform diabetes tasks specifically for their child. For some people, attending the class validates what they already know, for others it is their first education on the topic. But from whatever level of previous diabetes education, feedback on this class has been overwhelmingly positive.
-Georgia Feuer, BA

Caring for Diabetes in the Netherlands

My name is Roos Joosten and I am a medical student from the Netherlands doing a research internship at Joslin. Before I came to Boston, I shadowed several pediatric endocrinologists in the Netherlands. In the Netherlands, there are currently about 15,000 children and adolescents who have diabetes. Each year, approximately 560 children aged 0-14 years are diagnosed with type 1 diabetes. Pediatricians estimate that 5% of all children aged 0-14 years with diabetes have type 2 diabetes. In the USA, there are about 215,000 people under the age of 20 years who have type 1 or type 2 diabetes, which is about 14 times higher than the number of children and teens with diabetes in the Netherlands. However, the Netherlands is much smaller than the USA; it would fit inside the USA approximately 250 times.
 Just like in the USA, there are a number of diabetes centers in the Netherlands. Since children and teens with diabetes are spread out all over  the country, not everybody is able to go to these centers. This is why a lot of children/teens and their families go to the pediatric department of hospitals to get support from diabetes medical health care teams.
The Netherlands has a national diabetes association, called de Diabetes Vereniging Nederland (DVN) which is similar to the American Diabetes Association. Since many pediatric departments in the Netherlands have a small number (under 100) of children/teens with diabetes, the DVN has founded a club called Sugarkids. Sugarkids organizes activities, camps, and day trips to help children and teens from different hospitals and centers meet each other. In the USA, there are a lot of large diabetes centers, where children and teens get multidisciplinary medical care and they also see, play, and talk to one another at clinic visits, like at the Joslin Diabetes Center.
Health care for children/teens and their families in the USA is similar to the Netherlands. The Netherlands is much smaller than the USA and therefore there are fewer children and teens with diabetes; still, diabetes exists everywhere around the world.
-Roos Joosten, BS

Scuba Diving and Diabetes

Are you picturing an island vacation? Does it include a view of life under water and the thrill of diving? Can you dive if you have diabetes? In the past, the answer would be “NO”, but more recently, that answer has changed to “YES”.
Diving is a sport, and like any sport, it can increase the chance of hypoglycemia (low blood sugar). Symptoms of hypoglycemia may be more difficult to feel when you are under water. And getting treatment can also be difficult – picture trying to open a package of food and getting the contents to your mouth while floating underwater. Because of the risk of hypoglycemia, dive organizations in the US and abroad have designed guidelines for potential divers to encourage safe, enjoyable tours underwater. The following suggestions come from the published guidelines:
1) Being in good physical condition is recommended for anyone who wishes to dive. For a person with diabetes, this also means satisfactory blood sugar control for a year, with no severe hypoglycemic or hyperglycemic events (events that required the assistance of another person or hospitalization). There should be excellent hypoglycemia awareness, and no tendency to hypoglycemia that impairs judgment, causes seizures, or causes loss of coordination. There should be no diabetes complications (eyes, kidneys, nerves) or other medical conditions such as asthma. Your diabetes doctor will be asked to verify your fitness and diabetes management. You should be wearing medical identification at all times.
2) On the day of the dive, your blood sugar should be checked frequently before the dive to be certain it is not heading down. Ideally, it would be around 150-180mg/dl at the time you enter the water. If the blood sugar is too high (300+) or if there are ketones, you should not dive. After the dive, your blood sugar should be checked frequently. As with other strenuous exercise, there is a chance of “lag,” or late hypoglycemia that may require more than usual food intake.
3) Your diving buddy should not have diabetes, but should know the symptoms and treatment of hypoglycemia and carry an extra tube of glucose gel. You should have worked out a signal ahead of time to let him/her know that you  might be low. You should carry glucose gel in your pocket (and practice ahead of time ways to open and use it under water). Shallow dives to less than 100 feet are recommended to avoid the possibility of nitrogen narcosis (“the bends”). Avoid cold water and prolonged dives, both of which can cause blood sugars to drop.
4) If symptoms of hypoglycemia occur, signal your buddy, and both of you should return to the surface. You should keep glucagon on the dive boat.
Most importantly, plan ahead, get instruction from an expert who has some experience with divers who have diabetes, and keep your blood sugars in good control every day, not just when you are ready to take the plunge.
For more information, check out these websites:
 http://www.diversalertnetwork.org (DAN) Divers’ organization has done research on how people with diabetes tolerate scuba diving.
http://www.ukdiving.co.uk Has published guidelines for diving with diabetes. http://www.scubadiving.com Magazine for divers.
-Alyne Ricker, MD

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Winter 2011-2012

A Day in the (Child) Life

It’s 2pm on a Monday and the playroom is busy. Two kids are at a table drawing pictures, a few are at the play cash register, another is sprawled on the floor building a train track. Micaela Francis, CCLS, one of Joslin’s two Child Life Specialists, holds out green “dollar bills” and some old credit cards. “I’m going shopping,” she says. “Who wants some money so they can come shopping with me?” Several kids run up and take the dollar bills out of her hand. A girl looks shocked: “But they took all your money!” “That’s okay,” responds Micaela, “I have these credit cards, and each one has a million dollars on it.” That gets the attention of the whole room. She picks up a doll baby and a box of diabetes supplies. “I have to buy some things for my baby. What diabetes supplies should I buy to take care of her? “A finger pricker!” one child shouts to Jen Griffin, MS, CCLS, the other Child Life Specialist.

Describe a typical session with a patient.

Micaela Francis: We try to engage patients and siblings in activities that incorporate diabetes education first so we can gain a sense of how they are coping with this complicated illness. We can use the precious time while they are in the playroom to correct any misconceptions, fears, or worries they may have about diabetes through medical, therapeutic, and expressive play.

Jen Griffin: Play allows children to take control over a situation where they don’t have a lot of control.

Can you give an example of how you correct misconceptions?

MF: Sometimes a child will try to put a syringe in a doll’s head. We’ll ask things like, “Do you get your medicine in your head like that or does mom and dad put your medicine in your belly or bum?” What does it feel like?”

JG: We let the kids take the lead, allowing them to play through their understanding. How do you use conversation to educate?

MF: We try to keep it casual. We’ll ask “How’s school? What sports do you play?”

JG: Then we may direct the child to talk about their peers. “What do your friends ask about your diabetes? Do you bring a friend with you to the nurse’s office?”

MF: We want the children to see the playroom as a safe and nonthreatening environment so we do not pressure them- that opens the door for the kids to tell us about their thoughts and feelings.

What made you decide to become a Child Life Specialist?

JG: When I was in high school, a friend of mine was diagnosed with leukemia. I had a hard time figuring out how to interact with him when he was in the hospital. I started bringing games with me to visit him. I studied Psychology in college, and when I went to an info session on what to do with a Psychology major, I learned about child life.

MF: In high school, I volunteered at a summer camp for children with life threatening illnesses and their families. It was there that I learned about the child life profession. I always knew I wanted to work with children, and I loved the medical field. When I found that I could combine my two passions, I knew Child Life was my calling. Everyday I continue to love what I do.

Are there any techniques you’d like to share with families to try at home?

MF: If the child is nervous about pump site changes, have everything ready beforehand and provide the child with some distraction while changing the site– like a stuffed animal, sing a song, or practice saying the ABC’s. Offer the child options and provide the child with some control.

JG: For example, let the child count to five before the insertion, or let the child clean the site area.

MF: Don’t misrepresent diabetes visits or treatment tasks to the child. If he/she asks if he/she’s going to get a blood draw at the appointment, rather than say “no,” mention the doctor or nurse will decide what is needed. And remind the child there are many ways to get help and support at the visit.

JG: Also, we’re always happy to talk to older kids and teens about their worries or concerns. Is there anything in particular that the Joslin playroom needs? MF & JG: Markers, coffee filters, construction paper, glitter, colored pencils, fun Band-Aids™, foam projects/shapes, games (Sorry™, Candyland™, etc.), decks of cards, yarn/ribbon, Amazon gift carts, and of course donations of money to the playroom are always appreciated!

One by one, kids enter the playroom and immediately choose an activity, helping themselves to markers, toy cars, or the play doctor equipment. One little boy plays by himself for awhile, but as soon as the cash register is free, he runs over and sits in front of it, next to Micaela. “What do you want to buy?” he asks. When his parents come to take him home, he gives Micaela a big hug and blows her kisses as he and his family walk away. “He used to never want to come here,” Micaela says. “Now he runs straight to the playroom every time.” For more information on the services that Joslin’s Child Life Specialists can provide, feel free to call the clinic and ask for Jen or Micaela, or visit them in the playroom.
-Georgia Feuer, BA

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What to do if your Child is Sick

  • ALWAYS give insulin – the dose may need to be changed with the help of your diabetes healthcare team
  • Vomiting: always check blood glucose AND ketones (regardless of the blood glucose level)
  • Have your child drink fluids to prevent dehydration
  • Check blood glucose every 2- 3 hours Check blood or urine ketones every 2-3 hours
  • Give additional fast-acting or rapid-acting insulin based on your diabetes healthcare team guidelines
  • Call your diabetes healthcare team for support and guidance

When should I contact my diabetes healthcare team?

  • Your child is ill and you need to review Sick-Day Rules
  • Blood glucose remains elevated and/or ketones are present
  • There is persistent illness for over 4-6 hours: frequent diarrhea, vomiting more than once, refusing fluids
  • Your child has signs of dehydration – dry lips and mouth, sunken eyes, dry skin, and weight loss
  • You need advice on how much insulin to give Hypoglycemia resulting from illness or treatment

-Ashley Atkins, RN, MSN, CPNP

Fall 2011

A Family's Guide to Holiday Eating

As the fall approaches we once again enter the whirlwind of the holiday season. From Halloween to the New Year there are many opportunities to celebrate, and these celebrations usually include all kinds of delectable delights. Indulge with a bit of wisdom. We would like to share a few tips to help keep the holidays healthy as well as happy ones!
Halloween:  Tips for Trick or Treating

  • Trade candy bars for small trinkets (kids aged 3+): key chains, pencils, stickers, markers, crayons, barrettes, costume jewelry, action figures, matchbox cars/trucks.
  • Trade candy for a special, pre-determined treat - a family outing (walk or hike, bike ride, fall foliage picnic, etc.), a toy, video, computer game/DVD, CD or music gift card,  money or gift certificate; a new outfit.
  • Give out small trinkets (ages 3+) or toys instead of candy to the children in your neighborhood.

Healthy Holiday Eating Tips
Be Realistic: 

  • You can have treats in moderation and balance them with healthy choices
  • Instead of trying to lose weight during the holidays set a goal of weight maintenance.

Plan Ahead: 

Try not to arrive hungry/thirsty at a party; eat a light but filling snack (yogurt, fresh fruit, raw veggies with hummus, cheese stick, 1/4 cup of nuts, or ½ sandwich) and a glass of water to stay well hydrated before you leave for the holiday party.

Avoid Overeating: 

  • Stay at least an arm’s length away from the food table before and after eating to prevent nibbling
  • Choose small portions of your favorite foods and eat slowly; savor the flavor!
  • Wait a few minutes before going for seconds.  It takes 15 minutes for the signal to go from belly to brain to say, “hey wait, I’m pretty full!”
  • Keep track of nibbling - put a small portion of crackers or chips or pretzels on a plate and walk away from the bowl
  • If planning on dessert, take less starches at the main meal – fill your plate with salad and vegetables

Food Choices:

  • Try to choose more vegetables, fruits and whole grains
  • Limit fried foods
    Have dessert-but keep it small; and remember it’s nice to share!  You can always split a dessert with your friends or family

Physical Activity
Remember to move!Start a family tradition:

  • Take a walk between dinner and dessert
  • Have a game of flag football
  • Break out the croquet set
  • Toss a ball around
  • Enjoy holiday decorations by foot after a meal

-Heidi Quinn, MS, RD, LDN and
-Laurie Higgins, MS, RD, LDN, CDE

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Summer 2011

Celebrating 50 Years on the Frontline of Diabetes Care

On Thursday, June 2nd, Dr. Donna Younger of the Joslin Clinic Adult Section received an award for the length of time she has worked at the Joslin Diabetes Center. Dr. Younger has been working at Joslin for 50 years. In 1961, she began seeing patients under the guidance of none other than Dr. Elliott P. Joslin himself. I met with Dr. Younger to learn about the Joslin Clinic 50 years ago.
The staff and patients of the Joslin Clinic formed a close-knit community, an “extended family,” as Dr. Younger calls it. “We communicated more because we would see each other in the hallways. There was a staff meeting every morning at 8am, and if you were late to it, Dr. Joslin would page your name throughout the whole building.” The patients were included in the family. In the Diabetes Treatment Unit, they received individualized coaching at family style tables from dieticians, nurses, and from other patients. “Patients had tremendous psychosocial support. Everybody used to be together and learn from each other.”

The approaches to diabetes management at the Joslin Clinic were considered radical at the time. The general thinking among outside diabetes care providers was that “...all you had to do was keep (the patients) out of a coma. Complications were inevitable.” Dr. Joslin was unique in his viewpoint that careful management could make a difference in health outcomes. According to Dr. Younger, this viewpoint is why the Joslin Diabetes Center has survived. “People don’t want to hear that you (the care provider) have done all you can do.” But in the 1960’s, care providers faced challenges that don’t exist today. “If a person with diabetes arrived at the ER in a coma, we didn’t know if it was hypoglycemia or hyperglycemia. Depending on how backed up the lab was, it could take two hours to find out if the blood glucose was high or low. We had to diagnose by asking the family members about the symptoms leading up to it. Sometimes we would just give them glucose intravenously and see if they woke up.”
Dr. Joslin himself was “a gentleman of the times.” He always wore a suit, complete with pocket watch. When it came to caring for patients, “he worked hard, and he worked us hard.” Staff were required to be available by phone 24/7. He had great respect for his staff, and would refer to his younger physicians for the latest research findings. So great was his confidence in their abilities that when Dr. Joslin was hospitalized in 1961 (at the age of 92) he insisted that Dr. Younger be his doctor. His explanation was that “any physician good enough for my staff is good enough to be my physician.” Dr. Younger has proved herself not only “good enough” to be a physician to Dr. Joslin, but also dedicated enough to keep helping patients manage their diabetes ever since.                                                                    
Georgia Feuer, BA
Additional reference: Elliott P. Joslin, MD: A Centennial Portrait, by Donald M. Barnett, MD, copyright 1998

Dr. Donna Younger
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Baseball in the Lab?

Joslin teamed up with students from the Massachusetts College of Art and Design (MassArt), who were looking to perform a community service project, and now the lab is painted with a beautiful mural. The phlebotomy lab can cause a lot of stress and anxiety to children, so we wanted to transform the room to make it look more appealing. For two weeks, students spent many hours creating the illusion of being at a baseball game. Children and their families have loved the change. It has been a great conversation starter and helps distract children when they are in the lab.
-Micaela Francis, CCLS


Here are some tips for managing diabetes in the summer time:

  • Keep hydrated. Dehydration, or the loss of body fluids, can happen on these very hot summer days whether you have diabetes or not. If you have diabetes, dehydration also can occur when blood glucose is not under control. When blood glucose is elevated, this can lead to increased urination. To prevent dehydration, drink plenty of caffeine-free fluids such as water, seltzer or sugar-free lemonade.
  • Watch for signs of heat exhaustion, especially if you are working or exercising outdoors. People with diabetes and other chronic diseases like heart disease are more susceptible to overheating. Symptoms include: feeling dizzy or fainting; sweating excessively; muscle cramps; skin that is cold or clammy; headaches; rapid heartbeat, and/or nausea. If you experience any of these symptoms, move to a cooler environment, drink fluids like water, juice or sports drinks (based on your healthcare provider's instructions) and seek medical attention.
  • Exercise in a cool place such as an air-conditioned gym, or outdoors early in the morning or later in the evening, when temperatures outside may be more moderate.
  • Check blood glucose levels at least four times per day, and more often if you are not feeling well. Remember that heat can cause blood glucose levels to fluctuate. Carry plenty of water and snacks.
    Store your blood glucose meter, strips and insulin in a cool, dry place. Do not store insulin in extreme temperatures. Never store insulin in the freezer, in direct sunlight, or in a car. Do not place insulin directly on ice. Examine your vials of insulin. Clear insulin should remain clear. NPH insulin should not have
    any clumping or "frosting" on the vials.
  • Swimming: Check blood sugar before swimming.  If blood sugar is <150, give 15 grams of carbs without insulin for every 30-60 minutes of activity. 

 Additional Tips For Insulin Pump Users:

  • For insulin pump users, excessive perspiration can be a problem in hot weather or during strenuous activities. This can loosen the adhesive securing the infusion set, the part of the device that attaches to your body. If perspiration is a problem, try using a spray of antiperspirant on the insertion site after your usual skin-preparation routine. Others have success with skin-barrier preparations such as Mastisol, IV prep or Skin-Tac.
  • The pump housing provides some insulation from the heat, but if you are concerned about heat, you can use a protective pouch with a small, cold gel pack placed inside the pouch as a way to protect your insulin from the effects of heat. If you are spending an extended amount of time in the sun, cover the pump with a towel to protect it from prolonged direct sunlight. Disconnecting your pump for up to an hour is another option, but if it is disconnected for a longer time, you will need to talk to your health care provider for dose recommendations.

-Ashley Atkins, RN, MSN, CPNP

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Spring 2011

Joslin Patient Promotes Health in Africa

Geoff Ewart, a long-time patient of Cindy Pasquarello, BSN,RN,CDE, spent his January somewhere warm and sunny: Ethiopia and Uganda. Ewart is a phlebotomist, and he travelled with the Global Nurse Initiative to test children for malaria and HIV.

The Global Nurse Initiative is a volunteer group of doctors, nurses, and medical assistants who provide health education and screenings for children in third world countries. “We went into schools and orphanages and set up stations so children could get blood tests, eye exams, and see a nurse practitioner. We took all this mobile medical equipment with us. Getting through customs was fun!"

Ewart found the people to be friendly and welcoming, and in some ways Ethiopia was not so different from home: “They have everything we have, just 5-10 years behind. Their ‘high-speed’ internet is dial-up. Soap, toothbrushes, basic stuff that we take for granted, is available but difficult for them to get.

The country is beautiful, but at the same time there are dead goats and chickens at the side of the road, and the cars would never pass emissions tests in the US. The air is toxic.” In Ethiopia, the group stayed in the city of Addis Ababa. In Uganda, they spent their time in rural villages.

“Travelling in Uganda, we drove up switch backs, and I looked out the window and saw the edge of the cliff right there. The villages lacked everything. The toilets in the clinic—in the clinic!—were holes in the ground with spiders crawling up the walls.”
The group spent most of their time with the kids, but they also toured local hospitals.

Again, Ewart found that they contained all the necessary medical equipment, but it was a bit outdated. Regardless, since 2005, rates of HIV in these areas have been declining. This is attributed mostly to education. “Kids are fearless about getting their blood drawn. They want to know what’s going on.”

I asked Ewart if he recommends the program to others. “Absolutely. I’m going back myself next year!” To learn more about the Global Nurse Initiative, visit globalnurseinitiative.org.         

-Georgia Feuer, BA


The Art of Covering Challenging Meals

Is there a difference in how different meals affect your blood glucose (BG)? In fact, there is! Carbohydrate (carb), protein, and fat are 3 major nutrients found in the foods you eat. They affect your BG in different ways. Most of the carb that you eat turns into glucose very soon after eating (typically 1-2 hours).

 

Protein and fat slow the digestion and absorption of the meal, so they can delay the time by 2-6 hours for all the glucose to enter your blood. This can cause a high BG level several hours after eating because your rapid insulin peaks 1-2 hours after injection (or infusion). Many meals include a combination of carbs, protein, and fat. Some foods tend to be higher in fat. Though the recommendation for healthy nutrition is to eat these foods sparingly, it is completely normal to include these foods on occasion. What kinds of meals are we talking about?

 

Examples include restaurant foods, pizza, Chinese food, fried foods, and desserts, like an ice cream sundae. These types of meals take longer to digest than meals lower in fat and protein. As mentioned previously, for meals higher in fat some of the carbs are digested quickly, and the rest of the carbs are digested over the next few hours. How long it takes to digest is different for everyone. Digestion can also be affected by the amount of carbs in the meal. If you use an insulin pump, there are different bolus features so that you can more closely match your insulin to the timing and food content of your meals. For the Accu-Check pumps, this is called “multiwave bolus,” for the Animas pumps, this is called “combo bolus,” for the Medtronic pumps, this feature is called “dual wave bolus,” and for the OmniPod, this is called “extended bolus.” A combo or dual wave bolus combines a standard, immediate bolus with a longer square wave bolus of insulin. These bolus options allow you to bolus some insulin before the meal and the remainder slowly over time, in order to cover the carbs in meals that take longer to raise your BG. It usually takes some trial and error to find the right bolus combination. Next time you are eating a high fat and protein meal, set the pump so that 50% of the meal insulin will be bolus delivered immediately and the remaining 50% will be delivered over 2 hours. Individual needs can vary and you might discover that different bolus combinations (like 70% up front and 30% delayed) work better for you or for different types of meals. Also, you may need to vary the duration of the delayed bolus from 2 to even 5 hours. To help figure it out, try keeping detailed food, BG, and insulin dose records to see patterns or discuss with your healthcare team. If you are on injections, you can split the bolus dose of rapid insulin to 1/2 before you eat, 1/2 2 hours afterwards. 
If you are unsure of how to use these boluses and are looking for more information specific to your eating plan, make an appointment with your nutritionist for further education.

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Winter 2010-2011

Advice From 176 Years of Healthful Living with Type 1 Diabetes

The type 1 diabetes medal is awarded to people who have achieved 50 years of living with type 1 diabetes. To learn the secrets of the medalists’ success, we interviewed three type 1 diabetes medalists who, combined, have lived 176 years with type 1 diabetes: Tom Beatson (68 years), Patricia Glass (50 years), and Gilda Harris (58 years) (see photo).

How has diabetes management changed throughout time?

PG: We used to take a set dose of insulin, with no clue what was going on with our blood sugar. I was a member of a club at school where everyone at meetings got treats and they’d give me an apple. Those diagnosed now have so many more options.

GH: We tested our urine sugar with tablets. You would put a tablet in a test tube and add drops of urine and water. The liquid would change color, and you could match it to a scale to approximate your blood sugar.

How do you think public knowledge/opinion of diabetes has changed throughout time?

TB: People, especially teenagers, didn’t talk about having diabetes. This has changed. General knowledge is improving, but there are still big problems. Everyone assumes when you tell them you have diabetes that you have type 2, especially of older people.

GH: People do know more now, but there are still people out there who believe diabetes is caused by eating too much sugar, or that people with diabetes cannot have foods with sugar. We call them the “diabetes police,” those who say “you can’t eat that.”

To what do you attribute your success at managing diabetes?

TB: The training that my mother gave me, how she went about learning so that I could learn. She acquired a Joslin manual and put it on the bookshelf and made sure I knew it was there.

PG: Seeking out doctors who work with me to find the best regimen.  I also attribute my success to a good diabetes healthcare team.

GH: Trying to keep blood glucose within range at all times, checking 6-10 times per day and making corrections when necessary. I also eat very healthfully.

Did you ever suffer from “diabetes burnout”? If so, what advice do you have for getting through it?

PG: At times I would wonder “why me?,” but I have found that listening to other’s experiences has helped me. In the early years, I had to search really hard to find support groups, but now there are lots of them.

What would you say to the family of a child just diagnosed with type 1 diabetes?

PG: Don’t be afraid to ask assistance from others living with diabetes. It’s not a death diagnosis. It will change your life, but it’s something you can do.

GH: Take advantage of all the current diabetes tools and equipment, stay on top of management, and enjoy life. What was once inconceivable has now become achievable.

What advice can you give to others living with type 1 diabetes?

PG: Learn all you can. Learn more, and never stop learning. Having diabetes is not the end of the world. You can make it work.

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Winter Sports Recommendations

When it's snowing up North, many of you will be hitting the slopes on skis and snowboards. As for any skier, you will be sure to wear warm clothing, sox, hats and mittens. Don't forget to use sunscreen. In addition,since you have diabetes, you (or your parents) may have questions about being safe and keeping your blood sugar in a healthy place while you enjoy these cold weather sports.

Q. I know that checking my blood sugar often when I’m active is a good idea. But will my meter work when it’s very cold outside?

A. Checking frequently is a great idea. Because you are exercising and because it is cold you are using more fuel = sugar. And fatigue and low blood sugar can feel the same –shaky legs, tired and hungry. So we recommend that you either a) leave your meter at the base lodge and plan to stop in every 1-2hrs to check; or b) keep the meter with you, under layers of clothes as close to the body as possible. In that case, you may have to warm it up by putting it in your armpit for a few minutes, or by going inside the summit lodge before it will work. The listed operating temperatures for most meters start at 40-50 degree F.

Q. I use an insulin pump. Will the cold affect my insulin?

A. Insulin is stable at temperatures between 40 and 86 degrees F. If it freezes it will not work. So it is recommended that you carry the pump under layers of clothing, close to your body. For those using injected insulin (basal-bolus), it is better to leave your insulin with your supplies at the base lodge, available to you when you stop to eat.

Q. What’s the best way to avoid low blood sugars while I’m on the slope?

A. The approach to preventing low blood glucose levels varies according to how routine your planned activities will be. In other words, if you are usually active on a daily basis, your afternoon on the slopes may require very little change to your usual insulin plan, which already incorporates your activities.

If the day of skiing or snowboarding or sledding will bring more activity than usual, you will need to provide your muscles with additional carbs during the activity and then you will likely need to reduce your insulin doses 7 to 11 hours latter due to the 'lag effect' of exercise. You may have heard before that exercise can drop your blood glucose levels twice, first during the activity when your muscles need extra glucose for energy, and then later when your muscles are replenishing their stored glucose as glycogen.

The amount of extra carbs needed for the exercise, often called EX-CARBS (for exercise carbohydrates) depends on the intensity and duration of the exercise. For exercise that is moderate or intense, a teen may need as much as 1/2 a gram of carbohydrates per minute of activity. So, for an hour of moderate exercise like rigorous snowboarding, you will likely need at least 30 grams of carbohydrates. Speak with your health care team about other approaches involving insulin adjustments that can help to prevent low blood glucose levels during exercise.

After a day or afternoon of substantial activity, you will likely need to reduce your evening insulin. For kids treated with an insulin pump, using a temporary basal rate reduction of 20% for 6 hours has been shown to be effective in preventing overnight low glucose levels in kids with diabetes. For youth treated by injection-based insulin therapy, a 20% decrease in the overnight dose of intermediate (NPH) or long-acting insulin (glargine or determir) will likely reduce risk of overnight lows. Again, speak with your healthcare team and consider meeting with one of our exercise physiologists.

    Page last updated: November 01, 2014