Bolusing

I've been meaning to do a post about the mental process I use to determine my insulin doses.  I thought it would be easy.  Heh.

See, there are two primary inputs to use when calculating your bolus size - the amount of carb you're going to eat in the next couple of hours and your current blood sugar.  If it's high, you need to take some extra insulin to bring it down again.  (This is often called a corrective.)

The first two factors are close to determinate, but there's still some variability, especially the exact carb count. There's a little fudge factor there, and there are times when your guesses are off a little.  So that will lead to extra Smarties/Lifesavers/juice (or whatever's handy) or corrections later.

But there's a third component that has to do with intuition more than anything else, and that's the hardest to quantify.  If I'm feeling like I'm trending low, I may hold off on a unit to let myself go up a little.  If I'm trending high, I may take an extra unit to come down.

It's not quite the same as basing the dose on the exact BG reading, it has to do with whether today's results have indicated a little extra resistance, or creeping up.

Historically, I've been very conservative about taking extra when I'm in the 80's or so.  Today marked a little bit of a change in that for me.  I've been worried about about going hypo due to too much insulin.  Sometimes I get low, but I have always had plenty of warning since I am very sensitive those situations still, and it's not hard to find appropriate sugar sources if something comes up.  (Or goes down; you know what I mean.)  Sometimes those highs seem very "sticky" in that they don't respond well to correctives, or a little extra carb has more impact than it seems like it should.

The difference between handling this third factor well or not can mean 10-20 points difference on the machine average in a given day.  (That's different from just blowing it and hitting 328 on the meter and fighting that.)  Time will tell how much difference that makes in the long run.  Of course, I'm looking forward to taking my first official post-diagnosis A1C, and we'll see how closely that correlates with the machine average.

I think this is what people mean when they talk about the "art" of bolusing and carb counting.

Averages, averages...

Lately, I've seen some other DOC bloggers talking about averages.  Mine have been pretty decent, though I've been higher than I'd like the last couple of days.  (When I start the day above 130, I seem to tend to drift up...when I start the day around 100, I tend to stay there.  I like staying there.)

Machine averages are a great feature, but they're certainly not everything.  I've caught myself thinking, "Hey, do you really need to test again?  You may ruin your average."  Bad thought, bad idea.  I'm not exactly being graded on this.

I generally feel "OK" in a pretty wide swath that goes well into the "uh-oh" range.  I normally feel fine up to close to 200, and on the other side, I am usually obviously impaired at 70.  I usually feel bad enough at 85 to want to do something about it.  I've only tested below 70 once so far, and it was an odd feeling...akin to the effects of alcohol.  I feel extremely fortunate to be so sensitive to hypos, and I hope I keep that.

So, there's another side to averages too, that needs some discussion.  On days when I'm running high, and I'm doing correction boluses, I know my "actual" average is lower than what the machine would suggest.  So it would be nice if the machine could reflect that in some way.  I believe that it tends to average out over time.  In any case, it's the A1C that everyone trusts.

I know that there are continuous glucose monitors out there, but I'm not sure if my insurance would cover it, and it seems like it introduces several problems as well.  We'll see how well my next A1C (which I expect to do in February) reflects what my machine is telling me.  The techie side of me sees all kinds of opportunities to have fun with the data provided by a CGMS, but I also think I would obsess over it more than would be good for me.

Type 1 on Supernanny

Tonight's episode of Supernanny featured a five year old boy named Aiden with Type 1.  The show did a pretty good job of describing different aspects of the disease, including showing a list of famous people with Type 1.  It showed several quick clips of an insulin shot and something immediately identifiable as a glucometer.  There was some mention of how serious it was, but no specifics about complications.  They did a cute finger puppet show about the "balancing act" between carbs and insulin.

The very end of the show featured a video message from a professional snowboarder, Sean Busby, who is a proud Type 1 diabetic.  (The video message showed him prominently displaying his insulin pump.)  He had a special message for Aiden, which was very touching.  Sean's website is here; he runs regular snowboarding camps for diabetic kids.


I wish Aiden and his family the best - I couldn't imagine living with this at his age.

The Importance of Averages

There are a number of things I've always enjoyed about Thanksgiving, and now that I've got one in the rear-view mirror (so to speak) I can rest a little easier.

Two of my favorite things about thanksgiving dinner have always been stuffing and potatoes.  I did well with those; I think I've gotten pretty good at counting carbs effectively.  That's surprised me a bit because I've never been good at estimating distance or volume.  Well, now I have to be. :)

It was the cheesecake that spiked me.  Make no mistake, my wife makes the best cheesecake *EVER*.  This time, she made one with cherry topping, and really thick (from scratch!) graham cracker crust.  I love the crust.  I love it a lot.  The crust from scratch is especially good, since she makes it with real butter.

I guessed 64 and bolused 8, but I undershot.  (I told you the crust was good.)  I was on a bit of a rollercoaster for the rest of the night - I had tested 99 before the cheesecake, but tested 175, 146, and 192 that night, and finally 149 before I went to sleep.  Not ideal, but in retrospect I worried about it more than I should have, and that probably helped to keep me up.  I wound up putting in a lot of corrective, and I'm well within normal limits now.

If I had run the averages, I probably would have been a little less worried.

The other big thing was that I worked the program I was taught, and it worked for me, though a bit more slowly than I had hoped.

Though it does seem that the higher I go, the more insulin resistant I get.  I'd love to hear if anyone else has similar experiences that way, or if I'm looking at it incorrectly.

Better Numbers

Well, as we head into Thanksgiving, I am grateful for modern technology.  I am thankful to Banting and Best for their work in isolating insulin, without which my life would certainly be quite a bit more miserable than it is right now.

I am also grateful for modern glucometer technology.  I remember seeing one of the 80's vintage glucometers - my mother had it for some reason that escapes me now.  What we have today is certainly tons better than those used to be.

My numbers have been stellar these last few days.  I don't want to brag about it, and I certainly won't presume to judge anyone else.  I'm just trying to do what my CDE and GP are telling me to do, and it's working very well.

My machine average is now 122 over 7 days.  I'm learning to snack to prevent crazy liver dumping in the early afternoons.  (I seem to do that mid-morning and mid-afternoon.)  I hope things continue this way.  I am fortunate enough to lead a relatively predictable life, and I have a lot of freedom in terms of when and what I eat.  I am certainly thankful for that, too. :)

Some Battles are Worth Fighting

From http://lifeafterdx.blogspot.com/2009/11/victory-at-sea.html

Wil, who is a health care professional, writes the LifeAfterDx blog.  He is also a diabetic, and was one of the first to have a continuous glucose monitoring system.

It seems one of the major health care insurers in New Mexico decided they weren't going to cover pens anymore, so Wil wrote a letter about it.  We will have to see what happens, but I wish him the best, and I encourage you to encourage him as well.

Pens are the modern standard of insulin therapy, and they greatly simplified my own adjustment to the diabetic discipline.  They are easy to carry, easy to use, and surprisingly comfortable as well.  (Speaking as someone who has to put a needle into my body at least 10 times a day, that matters to me.)

Ice Cream and Snacking: Perspective

I have always loved ice cream.

I grew up near a Baskin-Robbins in Michigan, and we would walk down there at least once a week.  I remember being especially fond of chocolate chip and gold medal ribbon (which has a caramel stripe).  I later learned to love cookies and cream, butter pecan, and other flavors.

Ice cream was actually the main indicator of my blood sugar problems.  We usually had some around the house, but we were going through about 3/4 gallon a week, and that was largely me.  In addition, I was having the odd pint for lunch at my work cafeteria.  It was one of the major reasons my wife wanted me to get checked out - I was eating far more than a normal person should, and I was still losing weight.  Well, we know how that turned out.

Ice Cream is a tricky thing for diabetics.  Let's do a quick review of diabetic types.  Type 1 diabetes is insulin deficiency, and is much more rare.  The body doesn't produce enough insulin to process the food we eat, and our blood sugar levels climb because there's not enough insulin to bring it down.  For type 2's, which is much more common (they outnumber us about 9 to 1), they make plenty of insulin, but for some reason their bodies resist that insulin and it doesn't work.  Type 1's are (as far as I know) always treated with insulin; type 2's may or may not be.  In both cases, we have to watch what we eat and count carbs - for type 1's, to dose insulin correctly, and for type 2's, to stay within their tolerances.


This leads to significant differences in the way we handle snacking.  For a type 1, occasional snacking is no big deal - count the carbs, take the insulin, eat the snack.  Maybe an extra blood test, to make sure the levels are OK.  Since most type 2's are not on insulin, that won't work for them - they have to find something that fits within their carb budget, or change other things around.

Snacking is also important because of a process called liver dumping.  When we go for a while without eating, the liver will dump glucose into our bloodstream, counting on the pancreas to release insulin to process it.  This is often done when the body feels "hungry" so ignoring hunger pangs and not eating can actually lead to a higher blood glucose level in diabetics than eating something and not dosing.  One of the primary goals of the oral meds they give type 2's is to block this function of the liver.  Frequently, we'll look for snacks that are low in carbs.  My favorites are peanuts and almonds.  Nuts in general are excellent as low carb snacks, and most diabetics I know swear by peanut butter.

So, we still need to eat, and we still need to snack.  One thing that irritates a lot of us is when people tell us we can't eat something.  I have at least once eaten it on the spot, just to prove the point.  (And then snuck off and dosed - some people are very uncomfortable with needles, but most people have never seen the needles that fit on insulin pens.)  And of course, there's the primarily psychological problem of deprivation.  It's hard to see everyone else eating birthday cake, or drinking cider, or whatever, and feeling like you can't.  So it's important to feel that we can, within limits.

That said, it's kind of dumb to blow lots of insulin on candy and other "empty" snack foods.  For one, it's a sure way to gain weight (and now that I'm back to a healthy weight there's no need for that).  For another, there are the consequences of eating the fat and other stuff.  Blood pressure and other vascular problems a re a major class of diabetes consequences that we would all like to avoid, thank you very much.

I'll post more later on some specifics that I've found about various frozen treat things.

For your amusement

The stylings of Sugasheen, with an absolutely fresh take on Beyonce's "All the Single Ladies".  It's been making the rounds in the DOC (that's Diabetes Online Community):

Ah, The Miracle of Retail Pharmacy...

I had to deal with some extra frustration today when it came time to refill my prescription for test strips.

The first time I filled it, they gave me 100.  OK, I didn't know any better.   (I actually felt pretty good that I was walking around and talking...this was the morning of Oct. 5, immediately after learning "the rules", the date my diagnosis felt real to me.)

The first time I refilled it, they adjusted it so I'd get 200 strips for my copay instead of 100.  Seemed like a good deal to me...

So I called in a refill on Monday, using the Rx number I had.  Unbeknownst to me, it's the wrong number - a new one was generated when they clarified the directions.

Thankfully, they were very good about fixing it, and I'll be good on test strips for another month.

Amazing, the things you get to learn when you're diabetic.

Small Victories: Pizza

Pizza is a tricky food for diabetics to eat.  It has two key attributes that make it tricky for those of us who have to worry about our blood sugar levels:

1)  High carb count due to crust and pizza sauce
2)  High fat content, which can delay digestion of the carbs

The first one means we have to push a lot of insulin to process pizza, the second means that if you push it too early, you could go low.  But I like my pizza, so it's a problem worth solving for me.  Plus, who wants to let a little thing like diabetes get in the way of enjoying one of life's more enjoyable foods?

I learned a neat trick from my CDE for dealing with pizza - push the insulin *after* eating the pizza instead of before it.  That gives your system a little margin, since your sugar will go up a little as the carbs process, which will give the insulin something to work on and hopefully won't take you low in the meantime.

This worked for me today:  Two slices of green pepper/onion/black olive/pepperoni hand-tossed pizza.  Estimated 88g carbs, blood sugar prior: 93, 2 hours later: 124.  Huzzah!

First Low

Well, I had my first certified hypoglycemia event today.

I should have known it was coming on when I went into the break room and saw some sugar someone had spilled on the counter and stared at it just a little too long...

I went back to my desk and felt a little faint.  I tested and...67.

I could tell I was dropping, too.  I was slurring, and having a hard time completing sentences.  I grabbed some lifesavers (I always keep some handy) and ate half a roll.

Then followed a brief walk to a meeting with a friend of mine...I remember he mentioned a movie, mathematics, and some other things but no real details.  I remember he said the movie was Friday, and I remember asking, "What day is it again?"

I started my watch timer when I took the lifesavers.  Just after 15 minutes post-lifesavers, I tested again, but I knew I'd be OK - I felt something almost like a pop at about 10 minutes and I felt normal again.

Strange thing, this disease.

After lunch (which was large, and carb-loaded, but I think I bolused correctly) - 328.

Ketone test - negative.

10 units of insulin - check.

After an hour, I was back down to 107.  And munching on lifesavers again to prevent another low.

It's a good thing I enjoy rollercoasters. :)

Reports!

I've been running a little high the last couple days.  Flu's been running through here, so that may be it.  I've been behaving diet-wise, honest. :)  My numbers are high, but not outrageous.  Averaging closer to 150 than 130, which is what I'm shooting for.  I had a false alarm last weekend, that I think was brought on by eating too many nuts for snacks.  This time, I haven't been snacking, and everyone around me is coughing.

So...I've been making progress in the software.

Any software project is all about compromises, and this is no different.  One approach in uncharted waters is to throw something quick together, and see how you like it.  Keep the parts you like, fix the parts you don't.  Of course, you may wind up having to do that several times.

For most applications, the thing that will control everything is the way you store your data.  I'm using PostgreSQL, which is an incredibly powerful free database system.  For the moment, I'm using a Perl CGI interface to insert data via Web forms.  One nice thing about Postgres is that it is easy to get data out of it with just about any programming language, so when I get to the graphing part, it may be in Perl or Python or even something like R.  (Since those can all interface with the data fairly easily.)

Over the next few days, I'll post some of the data I'm tracking, why I'm tracking it, etc.  (Most of them are straightforward and obvious.)  I'm looking for input about what's important to people, so if you have strong opinions, feel free to leave a comment.

Normalcy? What's that again?

So today was running great.  My 7-day and 14-day averages were creeping below 140 (and man, am I glad about that).  I was hovering in the 85-100 range all morning.

Had lunch with some friends at a local Asian restaurant - things still feeling good, I guessed 95 but clocked in at 109.  Dosed for 64g carbs (I like my rice, what can I say?), which has been successful with that place and approximate dish in the past.

Got involved in a conversation with a vendor, and didn't check my post-prandial on time.  Had grabbed some cocoa-roasted almonds, about two handfuls - should be like 6g.  Finally got to checking my glucose 3 hours after eating abd I was 254.

Yeah, 254.

Sigh.

It was a stressful conversation, a bit.  Not horribly.  I shrug, take some extra insulin, and go on from there.
Ick.

I checked again at hour intervals and last time was still over 200.  Well, I'll get back to where I need to be soon enough.  It's about supper time; I've delayed a bit so I can be a little more aggressive with my insulin.  I always feel more comfortable taking more insulin with food.

I Miss Sonic

One of my priorities after being diagnosed was to eat at all the places I used to eat, to re-establish a feeling of control over my life - to establish that I didn't have to be completely subject to the disease.

The one place I always used to enjoy eating that I haven't been back to since I've been on insulin is Sonic.  I love the strawberry slush there.  I looked right after I was diagnosed - 188g carbs for the 44oz version, which I always preferred.

One of these days, I'll have to go and have a small one, at least.  I just haven't gotten around to it, yet.

Beginnings of Normalcy

Today was remarkable for its lack of anything new or remarkable.

I woke up 172, and took a little extra insulin with my banana oat muffin.  (Yes, I've opened my mind to bananas.  It's amazing what happens when you're a little open-minded.)

Figured I was headed low in the morning, tested, and got an 87.  Three lifesavers later, I'm losing that woozy feeling.  Not four, cause that would take me up more than I need to go.

A week or two weeks ago, either of those events would have been...well, exciting, at least.  Now...not so much.

I'm starting to feel normal again, and it's a good feeling.  A very good feeling.  It reminds me a lot of learning to drive - at first, the whole experience was completely new and different, despite having ridden in cars for 18 years (I was a late bloomer for my first license, I know), all the lights, and signs, and road markings and a new and different appearance to me.  I worried a lot about stuff like when to signal turns, and how fast to try to take them.  And over time, I became less and less aware of those things and they became automatic.

I'm still very aware of my diabetes management efforts, but the results are getting more predictable, and edge of newness is wearing off.  That's part of the feeling of normalcy too, and I welcome it.  That's not at all the same thing as slacking off or not testing.

Software?

I'm a technologist by trade (specifically, a network engineer).  That means I keep the little green lights blinking. :)

I do technology for fun, too, and diabetes has afforded me the opportunity to learn more about databases and graphing.

I've written a quick CGI script that runs on my server at home and stores my carb, glucose, and insulin values in a database.

Once the data is in, the fun begins.  The beauty of a database is that you can have it automatically calculate averages and other formulas over a period of time.  I've got an A1C predictor, for example, that looks at a 90-day window of glucose averages and predicts an A1C result based on that.

Right now it's all very rough.  Build one to throw away, they say. :)  I'm using this as a kind of sandbox to try different things and see what I think works and doesn't work.  The database schema (the data structures and definitions, plus all the stuff that lives inside the database, like formulas) has been through a number of revisions already, and I'm sure it will go through more.

My next step will be to generate some HTML reports for date ranges and stuff like that (exports for spreadsheets, like Excel and OpenOffice.org Calc).  The step after that will be to start rendering graphs on demand.

So here is a question:  what statistics are useful in tracking and predicting how your diabetes needs to be treated?  One obvious thing I'm not modeling in the current schema is the ability to track multiple patients, for example.

Saying Hi to a Friend

One of my best earlier memories of diabetes (pre-diagnosis) came about four years ago when I was working on a project with an occasional collaborator from another team.

During this time, we all wore pagers.  I saw an odd-looking device on his belt that looked like a purple one.  I asked what sort of pager it was since I'd never seen one before.

Turned out it was an insulin pump, as he patiently and nicely explained.

Wow, did I feel like a jerk.

Today I sought him out and talked to him about my diagnosis.  It was a good conversation, and an interesting way to close a loop in a way.  I'd felt a desire to stop by and talk to him ever since I was diagnosed.

Odd how things like that work out.

4400+ steps on the pedometer today, and I have been very pleased with my glucose today.

Control...

Well....after *carefully* reading the nutrition label on my favorite snack food (as of late), peanuts have a few more carbs than I thought...and I've been eating them by the quarter cup.  Just enough to push me up, it seems.

Now realizing that, I'm getting ready to check my post-prandial on what may be my best control day yet, in terms of variance and overall levels.  Which is to say, I've been averaging 140, but that's because I split between 100 and 180.  Make no mistake - it beats heck out of 300+, but that's still not ideal from a control standpoint.

So...175 post-prandial.  Not too bad, within guidelines and < 50 points higher than my pre-prandial (which was 157).  Which should put me in the neighborhood of 140 for bedtime, which is about right.

And I need to read the nutrition labels on my snacks a little better. :)

Coming to Grips

I thought this post would be easier to write.  It was intended to be the second post, but others intruded, and this one...seemed to want to wait.

So my official diagnosis day was 10/2/2009.  That was around noon, when my morning blood work came back.

But I really view the beginning of my life with Diabetes as beginning on the Monday after that, 10/5.  That's when I had the followup with my doctor, and when it all really sunk in.  Also, when I got my glucometer and my first batch of insulin and insulin supplies.

But...I'm dawdling. :)  This is catharsis about my actual discovery.

In retrospect, I think some of my memories of the Friday morning and Monday morning are a bit confused, conflated.

So, on the Friday afternoon, I was told that I was, for certain, diabetic.  I had set up a followup with my physician for Monday morning, as they wanted to start treating me right away.  My test results confirmed that, with a 330 BG and an a1c of around 13.  (Need to find out exactly what it was for my records.)

The Monday appointment was one of the longest hours of my life.  In fact, I don't know exactly how long I was in the office.  Time seems to warp around significant events.

I remember hearing a lot about how to take insulin, and the use of the pen being demonstrated for me.  I got a basic formula for how much to take and how often, how much to take for correctives, the difference between Levemir and Novolog.  Stuff like that.

All I'd been hoping over the weekend (knowing that I was diabetic, but not knowing too much about what that meant) was that I wouldn't have to be on insulin.

So here was my insulin.

The big thing I remember:

Fear.  I remember being so very afraid, afraid of complications, afraid of insulin overdose, afraid of all the things I didn't know.  Which was a lot.  Still is, though I feel like I've learned an awful lot in the month that's gone by since then.

I almost broke down into tears at least three times during the appointment.  I was a mess.  I remember not being able to find my way out of the doctor's office diagnostic area, but I'm pretty sure that's a memory from Friday morning instead of Monday morning.  I've never had a great sense of direction, and it's especially bad when I'm under stress.  Ironic, since I'm a network engineer by profession.

It helped a lot that the nurse told me she was diabetic, and taking shots.  I had taken allergy shots as a kid, so giving myself injections wasn't the worst idea in the world.  Still, I wasn't looking forward to it.  I didn't know how invasive the new treatment regime would be, and I was a little afraid that people wouldn't understand, and would think less of me because of it.

I was still a mess when I left the office.  My next stop was to go to the pharmacy to pick up my first batch of prescriptions.  I waited over 2 hours, while several...discrepancies...were worked out between what my health insurance was willing to cover and what I'd been prescribed.  And the pharmacy was unusually busy.

I also remember picking up a 24-can case of Diet Mt. Dew.  I had never before in my life deliberately bought diet cola for myself, that I can remember.  But I knew that the sugar in regular would do me much more harm than good.  It was one of the first milestones in my acceptance of my condition.

I got a referral to talk to the local CDE on Tuesday afternoon - apparently someone had cancelled.  Lucky me. :)

I did my first glucose test Monday night - and took my first Levemir dose.  More on those later.  The glucose test was especially comical. :)

First Sick Day

Well, the flu's been running around here, and our house is no exception.

Two of our kids have had it so far and now my wife is having her turn.

I can feel some of the classic flu symptoms though I'm not running a temperature.  I seem to be exhibiting more insulin resistance than normal, but my last test (a couple minutes ago) had me at 103, so I'm happy about that.  (174 at wakeup and 184 after 2 hours, 30g carbs and 10 units of Novolog).

Maybe I'll get to break out the ketone test strips today. :)