Dr. Jonathan Beach is a 35-year-old emergency medicine physician who has had type 1 diabetes for 31 years. He owns and operates Urgicare, a wellness center that includes The Northeast Center for Diabetes Care and Education in Plattsburgh, New York, an isolated rural community that has few other resources for diabetes. This is his story of his life with diabetes and his professional experience with the insulin pump.
When I was four years old, I celebrated Christmas with a viral infection. In early January, my mother noticed changes in my sleep and my eating and drinking patterns, as well as frequent urination. Alarmed that I might have an emotional problem, she had my godfather, a college professor with expertise with disturbed children, take me for the day to see what he thought. We had a glorious time making and frosting cookies. When Mom mentioned to “Uncle Ernie” that if she didn’t know better she would think I had diabetes, he found an expired bottle of test strips. When I went home, I urinated on the strip, and apparently it turned black. Thinking it was because the strips had expired, Mom settled me down for my nap. To be on the safe side she checked with my pediatrician, who advised her to bring me to the medical center immediately, without even taking time to pack a suitcase. My father held the ferry for us, and within two and half hours, I had my first insulin injection.
I loved every minute as a child with diabetes. I had a great relationship with some of the nurses, and I loved my pediatrician. I got to make a few television commercials on diabetes and to go to Joslin Camp in the summers. The medical world was exciting, and diabetes became my way of learning and experiencing more. When I was four, I decided I would be a doctor. Without a doubt, diabetes shaped and directed my life in a positive way. There are certainly down times with the disease, but as I see people with other medical problems, I’m far luckier to have a disease that can be self-managed and affords a healthy active life.
I ski as much as humanly possible, swim, and boat, and I am involved in white water rescue. I have four children who keep me constantly active. I manage my diabetes with the Medtronic Revel insulin pump and their continuous glucose monitoring (CGM) system. I have no doubt that the Medtronic pump is the absolute best pump there is, and the CGM is the icing on the cake. My last A1C was 6.8%, and my best is 5.8%, but I typically stay in the 6.5% to 6.9% range.
Living well with diabetes requires a partnership between patient and doctor. To help our patients successfully meet the challenge of the disease, our Diabetes Center prescribes a significant number of insulin pumps. Over 250 of our 420 patients are successful “pumpers.” About 15 percent of our patients have type 1 diabetes, and almost 100 percent are on pumps. As a physician, I highly recommend the insulin pump to anyone who has diabetes and is taking insulin. Not only is it more convenient, but it is also a delivery system that is closer to the action of the “normal pancreas.”
Patients with type 2 diabetes generally do far better on a pump than one would expect. My suspicion is that this is because the great majority have some residual insulin production of their own, and the pump’s basal rates augment their own pancreas. Type 2 “pumpers” tend to have less fluctuation in blood sugars and can often stabilize change to a 10-point deviation. More often than not, I also witness a significant reduction in the hundreds of units of insulin needed without the pump. Because of the constant infusion, the pump tends to improve insulin sensitivity and break the toxicity created by a high dose of insulin. We always reduce the total daily dose when starting the pump, and often we are able to continue with dose reduction as the patient’s sensitivity and blood sugars improve.
A success story that comes to mind is a local gentleman who prior to his pump was taking four shots of Levemir a day, about 100 units each time, and supplementing with NovoLog to cover his meals. His A1C was in the 9% range. He felt horrible and was a self-described “pin cushion.” We started him on the pump and immediately reduced his total daily dose by about 25 percent. Within a week on the pump, he and his wife called me laughing because they couldn’t keep his sugar above 100. I think his last A1C was 6.9%, and he is a huge insulin pump fan! Although much improved, he still requires a high dose of insulin and is not as sensitive as a type 1 patient.
I find the type 1 and type 2 classifications confusing. I see many patients with type 1 who have superimposed type 2 from weight gain and inactivity. Anyone with diabetes can develop insulin resistance. The biggest issue is, how much insulin do they make and how resistant are they? I feel that diabetes is better classified along a spectrum of insulin production and resistance, and treatment depends on where they fall in this spectrum. Whenever I see type 2 patients, our first few visits are spent trying to figure that out. Are they making a ton of insulin and have a C-peptide level through the roof? If so, it’s all about resistance, which doesn’t give me a lot of treatment choices aside from weight loss, exercise, and a few oral medications. Or is it an issue of inability to produce insulin, in which case the pump is a great option?
Unfortunately, I can’t prescribe as many CGMs as I would like for patients. Frequently, the insurance companies fight it and are very resistant to this type of therapy. I try to work closely with the patient to prove how beneficial the CGM is and get as many approved as humanly possible. At this point, even Medicare does not recognize the benefits of this device. I can easily think of about 25 patients that would love a CGM and benefit greatly, but the various insurance companies refuse coverage.
In general, I feel the benefit of CGM is significantly misunderstood. The actual blood glucose number provided by a standard meter is fairly irrelevant because that number tells you nothing about where your blood sugars have been or what direction they’re going. With the CGM, you have three-, six-, 12-, or 24-hour graphs that demonstrate a trend. In the words of my Medtronic friends, “The trend is your friend.” The trend is the most valuable information that I can give to anybody managing his or her diabetes.
In other words, it is fairly insignificant that my blood sugar is 130 right now. More significant is the direction it is going. If I take five units of insulin to cover my meal when my blood sugar is 130, sometimes I might end up at 200, sometimes at 60, and sometimes at 110. It depends on the direction my sugar is heading when I dose for the meal. The CGM allows me to understand what’s going on and to better estimate my insulin needs. Without a doubt, the insulin pump combined with the CGM is one of the most important tools in the self-management of diabetes.
I have spent over 21 years with diabetes learning to fine tune my own control and working to be able to help others. Now, as a physician with significant diabetes experience, I have been afforded the opportunity to educate and guide patients from my community as they learn to live and succeed with their own diabetes. For this opportunity, I will always have thanks and appreciation for my parents and family for all their love and support.