Report from Campamento Diabetes Safari 2006
Methods for achieving stable normoglycemia during an educational camp for youth with type 1 diabetes mellitus (DM1)
Annually, Campamento Diabetes Safari offers experiential diabetologic education to children and adolescents 6 to 18 years of age with DM1 during a 3-day residential camp. A multidisciplinary team of health care professionals functions as Staff and aims to foster self-awareness, comprehension, competence, autonomy, and creativity in the self-management of DM1. Staff members endeavor to allow Campers to discover and implement proactive, personalized solutions to glycemic disequilibrium in order to effectively maintain safe, stable glycemic control and assure physiological and psychological health.
Through a nondirective model of education, the camp provides opportunities for young persons to explore self-directed learning about diabetes self-management in a low-stress context with freely available 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.
This study describes novel, reproducible methods for increasing personal knowledge relevant to diabetes self-management, through self-directed educational opportunities rather than through traditional didactic instruction.
The prime clinical objective is to enable the Campers to safely and confidently minimize hypoglycemia and hyperglycemia by maintaining daily mean BG values within target range (71—99 mg/dL) and by limiting the 3-day MAGE value to <96 mg/dL.
The Staff personifies the camp's principal educational task by offering opportunities to learn about the effective self-management of DM1, including its psychological and emotional facets, in the context of individual, hands-on experience.
To facilitate the self-directed learning and the achievement of tight glycemic control and stability, the camp supplies a diet low in concentrated CHO, provides insulin analogues in a basal/prandial treatment regimen, and advocates ad libitum SMBG and physical activity.
Self-directed or nondirective education
The main feature of self-directed education is that the student, rather than the teacher or expert, decides what, when, how, how much, and where to learn. This active participation invites the expression and exercise of choice in the pursuit of personally meaningful learning, inspiring Campers to express their interests and to articulate elements of the diabetologic curriculum of immediate need for them. To avoid entanglement in the politics of domination and submission, Staff members do not impose unnecessary regimentation on the working relationship with Campers, but instead encourage them to configure the educational contexts or situations that will heighten the precision of their learning from personal experience. Using a nondirective methodology, the Staff adapts to the Campers' characteristics and preferences, accompanying them in the process of learning from daily experience and modeling inquiry and flexibility as ways of relating productively to complex relevant data (variability of glycemic values, treatment options, food choices, insulin pharmacokinetics, and programming of physical activity).
The self-directed learning model avoids excessive formality or restriction in the course of shared, verbal analysis of experience, leaving learning to occur through the exercise of personal freedom in acquiring practical knowledge in diabetes self-management. Staff periodically indicates how Campers may incorporate their experiential knowledge in the competent practice of DM1 self-management. Through such consultation, Campers become actively, rationally, and intellectually involved in constructing the architecture of their own self-care and lifestyle. The ratio of Staff to Campers (1:1.8) ensures sufficient time and personalized attention to consolidate application of lessons learned to the inevitable daily clinical decisions required to maintain normoglycemia.
Staff supports the practical diabetologic education initiated by the children and adolescents, so that learning results from a process of transcendent personal experience and continuous shared analysis that takes into account the errors and successes inherent in experiential learning. Staff members put at the Campers' disposition their own relevant educational experiences and consult in the shared analysis of the lessons learned. Self-directed education promotes the experience and development of autonomy as well as a focus on the personal use of the mechanics of basic scientific research to enable learning from personal experience and from shared contemporaneous analysis of it.
Staff members, as a team, exercise two concurrent roles: the manager role, in order to maintain the time, task, territory, technical, and technological boundaries necessary for controlling stress and making learning feasible, and the consultant role, in order to permit articulation, discussion, and analysis of themes and opportunities for learning.
As managers, they coordinate the published schedule and program and engineer safe use of territories for programmed or improvised activities. They represent and support the educational task of the camp, which is to provide opportunities to learn from personal experience about the effective self-management of DM1. As consultants or advisors, they work in the "here and now," to open productive interaction around solicited or evident but unstated topics, concerns, difficulties, and interests. As consultants, they teach BG monitoring techniques, CHO counting, blood ketone measurement, a painless subcutaneous insulin injection method (18), calculation of prandial insulin doses, and the use of physical activity for near-immediate glycemic adjustments. At the outset, both Staff and the children and adolescents are explicitly and fully authorized to initiate inquiry or consultation at any time, around any theme. This authorization curtails unnecessary dependence and passivity and increases consciousness of the indispensable exercise of their own and others' personal authority and responsibility in the prevention of the long-term and short-term complications of diabetes mismanagement. Campers are at all times free to learn and are responsible for what they learn.
Because there are no academic classes or formal presentations in the self-directed educational method used, the children and adolescents learn through self-discovery rather than through traditional pedagogical techniques. Consultation with the Staff is always optional. Assorted themes, differing according to the Camper's age and maturity, arise to give content to Staff's consultations: Do any musicians have diabetes? Is celery converted to sugar? Don't proteins have calories? Why does everyone say that eating chicken skin bad? What can I do when I want something sweet? Why should I rotate the finger stick site when checking my BG? Does an aspirin a day cause bruises from injections? How do insulin pumps work? Why are symptoms absent when my BG is 313 mg/dL? Will my younger brother also develop diabetes? Can I have a baby? How would a girl feel if her boyfriend had diabetes? What is depression? Will I die from diabetes?
Self-directed inquiry frequently leads to emotional considerations. From verbally competent children, adolescents, and adults, DM1 demands chronic self-management as the predominant approach to treatment. The quality of self-management can parallel the physical and psychological health of the “self.” Decisions about how to employ the updated information transmitted in the consultations with Staff always remain explicitly the individual Camper's charge. Because emotional factors impact both understanding and administration of this information, their dynamics are addressed in small and plenary group settings. Manifest group and interpersonal dynamics and voluntary discussion of nocturnal dreams figure prominently in Staff's evaluation and care of acute emotional conflicts and needs for support.
Staff engages Campers as persons with diabetes and partners in health care, not as subordinates, passive novices, or persons of inferior status. Through prior and current education and experience, each Camper comes to know her or his own body's metabolic responses to physical activity, insulin, and glucose excess or deficit better than any other person. However, valid self-knowledge may not have been previously solicited or articulated, impeding its contribution to optimal diabetes self-care. At Camp, participants grow to recognize and voice factors shaping their distinctive personal expression of DM1.
Staff avoids comparing or coercing Campers or applying psychological pressure, guilt, or shame in exploring and defining the quality of their glycemic control. Sixty percent of Staff has DM1; their own self-care activities (SMBG, insulin dose calculation, insulin injections, food choices and portions) are public, observable examples of adroit diabetes self-management. The Staff's proficiency is evaluated in the same manner by which the Campers judge their own competence: SMBG results. Their first-hand knowledge, often conveyed in "teachable moments," guides consultations and lends them trustworthiness, but most self-treatment decisions rest with the individual Camper.
Self-directed diabetologic education focuses on the provision of information that permits the Campers to understand the long-term complications of DMI that is inadequately or inexpertly managed as well as the short-term acute complications of insulin and nutritional treatment. The self-directed educational opportunities and the emotional support provided at camp aim to permit the Campers to grasp known techniques for avoiding or responding to these complications in a timely fashion.
All insulin therapy during the camp employs glargine and lispro. The majority of Campers (67%) arrived already using the basal/prandial combination of glargine and lispro insulin analogues. Through consistent and time-predictable action profiles, these insulin analogues deliver stable glycemic regulation, while facilitating rapid regimen modification as needed. On beginning the 3-day camp, with the signed informed consent of their parents, the 33% of the children and adolescents who previously applied multiple injections of NPH insulin as the basal component of their insulin therapy changed to a single daily injection of glargine to provide basal insulin coverage. Prior to and during the camp, all Campers applied lispro insulin for prandial and complementary insulin doses. Complementary doses utilize ultrarrapid insulin to reduce extemporaneous hyperglycemia appearing more than 2 hours after the last injection of the same insulin.
All mealtime insulin is preprandial. Campers calculate and adjust doses of lispro before each injection, prandial or complementary. Professional Staff members consult to these calculations. Data obtained from SMBG 1—2 hours after lispro injections verify dose precision or imprecision, highlight factors influencing individual BG levels, quantify currently optimal insulin replacement requirements, and inform subsequent basal and prandial dose adjustments.
Food plan with minimal concentrated CHO
For persons with DM, the American Diabetes Association recommends the provision of 50—60% of total daily calories from CHO, including sources of concentrated CHO (rice, fruit, pasta, potatoes, bread, tortilla). For the majority of the Campers and Staff with DM1, intake of a large percentage of these "simple" CHO makes glycemic normalization and stability difficult, if not impossible.
Camp food (1)
is tasty and nutritionally adequate; it contains scarce concentrated CHO.
The CHO offered is intermixed in nutrient blend or multiple composition
foods (for example, nuts, avocado, beans, reduced sugar yoghurt).
Water and flavored sugar-free drinks are routinely available. Because
Campers freely select their own foods and drinks from a buffet, an exact
measurement of the amount of CHO eaten by each Camper is not feasible.
The implicit goal, nonetheless, is a maximum total daily intake of approximately
30 - 40 grams of CHO (120 - 160 calories). Typical menus offer
Physical activity or exercise is joined with the use of insulin analogues and appropriate food choices to simplify optimal glycemic regulation. Physical exercise improves glucose tolerance (2) by temporarily heightening the body's sensibility to insulin through an increase in the affinity of its peripheral receptors, with a consequent reduction in insulin requirements. Available recreational activities (3) contribute opportunities for development, evolution, and application of practical diabetes management skills in a real-life context.
Distances of ~ 1/8—1/4 mile between venues for programmed events (dining room, swimming pools, hotel) require unavoidable frequent walking, and the camp program provides for additional ad libitum individual and group physical activities (games, hikes, swimming). For most participants, the amount and intensity of physical activity performed during the camp is greater than their at-home routines supply, occasioning a general reduction in the appropriate doses of lispro insulin. Physical exercise does not affect the pharmacodynamics (speed of absorption) of insulin glargine (4).
Target BG range
BG levels of 71—99 mg/dL constitute the Campers’ target glycemic range, during both absorptive and post absorptive states. This range, previously disclosed to participants and their parents as an informational and educational strategy, is used at camp to benchmark overall management of DM1.
BG levels of <71 mg/dL define therapeutic hypoglycemia; at these levels, glucose tablets and/or food are used to raise BG to ~ 100 mg/dL. A documented SMBG of <51 mg/dL reflects pathologic biochemical hypoglycemia (5). The ultrarrapid insulin analogue lispro, used at camp, abbreviates the time period for risk of acute postprandial hypoglycemia, as compared with Regular or NPH insulins. In order to reverse hypoglycemia without overcorrection and subsequent rebound hyperglycemia, Campers receive instruction in the distinction between treating documented or suspected hypoglycemia and treating its lingering symptoms.
Because the development of diabetic retinopathy begins at a glycemic level of 126 mg/dL (6), an arbitrary value of >129 mg/dL represents the lower limit of acknowledged hyperglycemia during the camp. The frequency of Campers’ SMBG corresponds with their efforts to initiate timely and sufficient prevention and treatment of glycemic decompensation.
Interday glycemic instability is assessed by comparing mean daily BG levels and SD. Intraday glycemic instability or variability is appraised by MAGE score (7). The MAGE value, which measures the amplitude of the day's largest BG excursions, is independent of mean BG and quantifies the intraday glycemic excursions whose amplitude is greater than one SD (8). In persons with DM1, after successful islets of Langerhans transplants, the mean MAGE value is 73 mg/dL (9). MAGE values >94 mg/dL indicate significant glycemic instability and risk of hypoglycemia (7, 10). In this study, the presence of MAGE values of 0-94 mg/dL substantiates glycemic stability.
Although glycemic instability produces marked oxidative stress (11, 12), tied to long-term risk of diabetic complications, DCCT (13) data reveal that intraday BG variability, which is lower in persons without DM than in persons with DM1 (14), has insignificant influence on the development or progression of diabetic retinopathy and nephropath (15). The SD of daily BG values likewise is not a fundamental contributor to or predictor of glycated hemoglobin (A1c) levels (16).
However, measures of glycemic variability remain sensitive indicators of potential hypoglycemia. When mean BG is lowered without reducing glycemic instability, the incidence of hypoglycemia increases (Campers A, B, F). Lowering daily mean BG and glycemic variability together moderates the probability of hypoglycemia (17), the major risk factor for hypoglycemic unawareness and severe hypoglycemia in this pediatric population (10).
The data analyzed (Table 1) are the documented SMBG values manually downloaded from the meters (Optium XCEED monitor, Abbott Laboratories, Abbott Park, IL) supplied without charge to each Camper. The meter is designed to measure both BG and serum ketone levels.
In short order, the synergistic combination of the 4 pillars of DM1 treatment (insulin, diet, physical activity, and diabetologic education) eased a rapid and safe transition to largely normal mean glycemic values and variability in this sample of children and adolescents with recent diagnosis (.58—2.58 years) of DM1 and scant previous practical exposure to DM1 self-management principles. Gender differences in mean arrival BG (M = 214 mg/dL, F = 198 mg/dL), 3-day mean glycemic values (M = 88 mg/dL, F = 108 mg/dL), and daily insulin requirements were insignificant.
The average combined TDD of glargine and lispro insulins was 21 units, of which preprandial insulin represented 18% (3.8 units) and basal insulin constituted 80% (16.8 units). Complementary ultrarrapid insulin doses amounted to approximately 2% of the TDD.
Preprandial doses of lispro sufficient to maintain postprandial euglycemia ranged from 0 to 3 units, with a mean dose of 1.4 units. In comparison with reported habitual doses, all Campers required less prandial insulin at camp. They independently calculated and decided upon logical preprandial insulin doses. Their calculations were rarely sufficiently misreckoned as to be altered by the consulting professional Staff.
Daily and cumulative BG profiles were analyzed for glycemic variability as measured by mean daily BG levels, SD, and MAGE scores. Arrival BG values were included only in calculations tied to those initial values. The mean arrival BG of all 9 Campers was 209 mg/dL (± 101.5); at camp's close, their mean BG was 87 mg/dL (± 23), (t =4.22, P < .0025). Participants’ mean daily BG values ranged from 68—154 mg/dL (94 ± 21.9); SD of mean daily BG ranged from 9.1—77.6; SD of mean 3-day cumulative BG ranged from 12—55.
For individual Campers, daily MAGE scores ranged from 0 to 137; the global mean daily MAGE score was 66 (± 27), with individual values varying between 21—94. The 3-day mean MAGE score was 66 (± 27), with a range of 21—94. Cumulative 3-day mean MAGE scores met the study's accepted criterion (<96 mg/dL) for stable glycemic control of DM1.
Campers presented both hyperglycemia and hypoglycemia during the 3 days; of 288 SMBG (not including the 9 arrival BG readings), 17% (49) were hyperglycemic and 8% (23) were hypoglycemic values. Severe hypoglycemic risk was low. Applying a <71 mg/dL definition of therapeutic hypoglycemia, the average hypoglycemic value was 58 ± 9 mg/dL. Applying the study's criterion for biochemical hypoglycemia of <51 mg/dL (44 ± 5.3), mean percentage of individual hypoglycemic values was 7.5%. No association was observed between frequency or intensity of physical activity and severe hypoglycemia, with or without loss of consciousness or seizure. The self-determined frequency of SMBG likely allowed periodic evasion of biochemical hypoglycemia.
The opportune use of partial, single, or several 4-gram glucose tablets, followed by the subsequent addition of combined CHO/protein/fat (250 ml "light" yogurt or 1—4 tablespoons of peanut butter) quickly returned mild and moderate hypoglycemic BG values to the target range, generally without evidence of overcorrection. Each gram of oral glucose raised BG by ~ 5 mg/dL (18). Two instances (Campers A and D) of severe, other-treated hypoglycemia (~ 36 mg/dL) occurred without convulsions or loss of consciousness but required greater CHO intake to revert than hypoglycemia in the 70—40 mg/dL range.
To favor ad libitum SMBG, Campers receive an unquestioned, unlimited number of reactive strips for the measurement of BG and blood ketones. Mean daily (6—18 times, 11 ± 4) and 3-day (28—41 times, 33 ± 4) ad libitum SMBG differed insignificantly. Variability reflected individual judgment and behavioral choice. The resulting frequency may confirm reports (19,20) that furnishing BG reagent strips ad libitum, even without other clinical interventions, boosts SMBG frequency and improves glycemic control and that these positive effects show no attenuation during a subsequent 12-month period.
Campers consciously matched CHO intake to foreseen immediate activity levels. Daily CHO consumption was not rigorously measured; estimated individual intake was 6—30 grams per meal, depending on the foods chosen and planned postprandial activity levels. BG values > 240 mg/dL occurred on 3 occasions (Campers C, H). In those cases, blood ketone measurements were also made; all results were negative. In spite of low levels of dietary CHO, no Camper evidenced abnormal levels of ketonemia (> 2.99 mg/dL).
During the last 1½ hours of the camp, 89% of the Campers' parents attended an optional dialogue with the camp Director, who debriefed them and reviewed the worth and meaning of their roles as adult supervisors and multidisciplinary health care team partners assuring the age-appropriate transfer of diabetes self-care responsibilities to their sons and daughters. Until the adolescent's diabetologic education is relatively complete, continued superintendence by one or more knowledgeable, qualified adults is prudent . The chronic and progressive nature of DM1 and the continuing advances in its treatment ensure the unceasing need and possibly desire for practical diabetologic learning and further relevant education. Recognition of these factors originates in the person affected and does not cease with his or her entry into adulthood.
Within a 3-day period, young persons with DM1, through effective peer and professional consultation encompassed in a self-directed learning context, are able and willing to use the required intellectual and material resources to successfully maintain BG values within a normal 71—99 mg/dL target range. The availability of a non-demanding educational paradigm, of psychological support, and of professional expertise facilitates their self-directed path to normoglycemic stability.
In this sample, the beneficial context for glycemic normalization and stability incorporated opportunities for nondirected discovery, optional expert input addressing the Campers' acute needs and currently operative interests, utilization of insulin analogues with predictable action profiles, availability of foods with reduced concentrated CHO content, free access to blood testing supplies in unrestricted quantities, and conditions conducive to ad libitum physical activity and SMBG.
The unique camp context allowed departure from standard methods of teaching DM1 self-management. Yet in terms of insulin regimen, a diet low in concentrated CHO, and ad libitum SMBG and physical activity, the camp experience is flexible and can be adapted for daily self-care of DM1 at home or school. The main element of the camp protocol, the self-directed learning model, may be safely tailored to individual and family use. Clearly, even with mean euglycemia and elevated glycemic stability, the risk of hypoglycemia is not eliminated.
Due to the tiny doses of insulin frequently accompanying the use of a reduced CHO food plan in this young population, it is indispensable that children and adolescents have access to insulin syringes with ½-unit markings. Syringes with 1-unit markings were used during the camp, but a ½-unit or ¼-unit dose was regularly justified. A percentage of the hypoglycemic episodes reported were due to Staff's and Campers' technical inability to deliver with precision minute doses of prandial or complementary U100 lispro insulin.
Alternatively, a titered mixture of U100 lispro insulin with "Sterile Diluent for Humalog, Humulin N, Humulin 50/50, Humulin 70/30, NPH Iletin" (Eli Lilly, Indianapolis, IN) dilutes the original concentration to U50 (1:2) or U10 (1:10), thereby permitting more exact dosing of diluted concentrations of standard U100 insulin with standard U100 insulin syringes marked in 1-unit increments.
The author thanks Abbott Laboratories, Eli Lilly and Company, sanofi-aventis, Danone de México, and Becton Dickinson de México for their material and technical support for Campamento Diabetes Safari 2006, and Dr. Janet McGill for generous editorial guidance. Financial assistance from Kathy Garrett, Barbara and Brian Splan, Nancy and Kenneth Marks, Estela García, the Soñar Despierto Foundation, and other donors makes possible the operation and administration of the camp.
Se prohibe la reproducción total o parcial del diseño de esta página, sin la autorización correspondiente. Este sitio y todas las páginas que forman parte del mismo forman una guía educativa e informativa, que no pretende sustituir el tratamiento o las indicaciones del médico. Cualquier decisión de autotratarse con un medicamento nuevo o de cambiar de medicamento o de alterar la dosis de su medicamento actual deberá consultarse con el médico. El sitio continents.com no se hace responsable del uso de la información contenida. © 2007 - 2012 Dr. Stan De Loach