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March 14, 2004

Honeymoon, Insulin

Question from Pennsylvania:

My son, 14, was diagnosed nine months ago with type 1. I have three quick questions with a few sub-domains in each: Does a person have to be a nurse in order to be a CDE? How can one go about becoming one? A recent post from your team indicated seeing the "honeymoon" stage in type 1 diabetes last, sometimes, up to 4 years. In all your years, have you ever seen: the honeymoon stage last indefinitely? the pancreas "fix" itself? is it not acceptable and appropriate to repeat initial tests done at diagnosis for comparison purposes to confirm the honeymoon stage is in fact over, or does one simply rely on the one to two units of total insulin to each kilogram of body weight formula? If one were to change from Humalog/NPH at breakfast and dinner to Humalog/NPH at breakfast (no change--keep NPH to not have to dose in school) and Humalog/Lantus at dinner (simply replacing the dinner NPH with Lantus), then: How do you figure the initial Lantus dose? How do you figure how much to decrease the breakfast NPH? Do you decrease the insulin to carbohydrate count ration with the Humalog? How does one tell which insulin to reduce/increase when Lantus will now be overlapping the breakfast NPH and Humalog?


Anybody can be a CDE if the requirements are met–education, years of experience working with people who have diabetes, passing certifying exam. Usually, CDEs are nurses and dieticians but there are many physicians and pharmacists as well as some educators, physical or occupational therapists, psychologists and social workers who are CDEs. In some parts of the world, there are positions for teachers who have adapted their learning strategies and skills for health educator roles.

The honeymoon phase is really a clinical diagnosis and there are no hard and fast criteria. Some people use endogenous insulin reserves as measured by c-peptide but this is mostly for cutoff research purposes. The stability of the glucose values on a day to day basis is probably the best clinical guide but this is more art than science. The younger the child, the less likely the honeymoon is to occur and the shorter its duration; the older the child, i.e. late teens, or in adulthood, the longer the duration and more likely to occur. But there is a lot of individual variation.

Exactly how much of the different types of insulin would be required is extremely individualized so there are no hard and fast rules for conversion. Several formulae have been developed as initial guidelines in transition from one to another type but they all should be based on actual frequent blood glucose monitoring rather than dogma. Most compromises with the number of injections really produce compromises either in glucose control, inflexibility with food timing or portions and/or hypoglycemia.

Additional comments from Brenda Hitchcock:

For CDE requirements, see the National Certification Board for Diabetes Educators web site.