LifeAfterDx--Diabetes Uncensored

A internet journal from one of the first T1 Diabetics to use continuous glucose monitoring. Copyright 2005, 2006, 2007, 2008, 2009, 2010, 2011, 2012, 2013, 2014

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Location: New Mexico, United States

Hi! I’m William “Lee” Dubois (called either Wil or Lee, depending what part of the internet you’re on). I’m a diabetes columnist and the author of four books about diabetes that have collectively won 16 national and international book awards. (Hey, if you can’t brag about yourself on your own blog, where can you??) I have the great good fortune to pen the edgy Dear Abby-style advice column every Saturday at Diabetes Mine; write the Diabetes Simplified column for dLife; and am one of the ShareCare diabetes experts. My work also appears in Diabetic Living and Diabetes Self-Management magazines. In addition to writing, I’ve spent the last half-dozen years running the diabetes education program for a rural non-profit clinic in the mountains of New Mexico. Don’t worry, I’ll get some rest after the cure. LifeAfterDx is my personal home base, where I get to say what and how I feel about diabetes and… you know… life, free from the red pens of editors (all of whom I adore, of course!).

Tuesday, January 10, 2006

Next time ask for a side salad

I'm getting really good at flipping and scrolling. I slip the girl off my belt about every half and hour, flip the case open and check the current trend. I in traded Click. Giggle. For Click, click, click, click, click. Hmmmmmm....

I probably need to be more clear about that. What I'm saying is that when the girl and I were first together I'd click and look at A reading. I was using her like a finger stick. OK, a fast and painless one; but a finger stick none the less. I was looking at a moment in time. A single piece of information.

Now, I never look at a single reading. I check my NOW number and then quickly scroll back in time using the down arrow button. Five minutes per click. I usually glace at a half an hour. Then, instead of just being pleased with the simplicity, I think about what I'm looking at. Direction? Is the BG going up or down? Or is it fairly stable? Speed? Speed I'm not always so good at, 'cause that takes mental mathematics, which is my weak spot. That said I can get a rough idea of how fast things are moving.

On the way up to Denver we stopped at Denney's in Raton. OK, Denney's isn't the best food in the world, but its pretty good. They also have one of the better kids menus. Very flexible. Choose an entree from the list. Choose a side from the list. Would you like another side? Nice vibrant color photos of all the options. Easy for little ones to study the possibilities. Rio's choice, Mac and Cheese (no surprise) and a firm announcement that he wants the cheese pizza the next time we come. It'll be month from now, but he'll remember.

What I personally like about Denney's is that they have extensively published carb data on their menu items. Not just a few here and there, but everything---even deserts (although I refrained today).

I ordered a Philly Beef & Cheese hogie-type sandwich on chiabatta bread, hold the mushrooms. No fungus for me, thank you very much. Good thing, my waitress informs me, as we are out of mushrooms today. It comes with fries. I hesitate a moment, knowing that fries are likely to give me trouble but my brain locks up and I can't come up with any alternatives. Twelve hours later it occurs to me that they would have subbed a side salad for me with no quibbles. Had I done that my day might have been very different. But that's Monday morning quarterbacking.
By the way, the Printcrafter rating on the sandwich: Five stars. Yum.

Sandwich: 53 carbs
Side of fries: 57 carbs
Diet Coke: 0 carbs

Bolus: 5.5 units of insulin. Let's eat! The damn fries are wonderful and I eat every last one, being careful to use minimal ketchup, the stuff is packed with sugar.

Following the meal I keep an eye on the BG as we snake our way up Raton pass and over the New Mexico / Colorado line. Unlike the terrain we're cruising through, my BG is staying really, really flat. I'm thinking there's gonna be hypo in my future.

Quite the contrary. As we near Colorado city a steep rise kicks in. We're about two hours post bolus at this point. We stop at the Cuerno Verde rest area at Colorado City. Rio has important business here. First we play on the rocks. On the West side of the rest area, between the overflow parking and the restrooms, are eight BIG rocks laid out Zen garden style on a bed of sand. It is our tradition to stop here both coming and going. Rio scrambles to the top of each. Two of them are designated jumping rocks. He always does them in the same order, over and over and over and over and over as many times as I'll let him. Today we have an advanced pact. It is dark, very cold, very windy. One time is the deal. He keeps up his end of the bargain then runs to the bathrooms as fast as his little legs can carry him to see the map.

Inside the building that houses the woman's room, handicapped restroom, and men's room is also a generous lobby with a magnificent two story bank of curving windows. In the center is a large rack of brochures for various sights and things to visit. And on the wall is a giant map of the state, including a wee bit of our home state.

Rio points to the map. This is were we ate lunch. And this is were we are now, and this is Grandma Jean's house. And these are the mountains. And what's this? I bend over and squint at the large purple splotch on the map. Ft. Carson, I tell him. Where the army practices with their tanks.

So while Rio studies the map of our Journey, I study the map of my BG. Rio's looking at were we've been, where we are, and where we are going. Likewise, I can see where I've been, and where I am. Where I'm going is trickier. So I've got a quickly rising BG. In an hour I've jumped from 125 to 237 and I know a correction bolus is in order but I've got a radical new theory to test. Well, radical for me anyway.

To be honest, I can't claim full credit for this idea, but I can't recall either if there is just one person who deserves the credit or if this is something I synthesized from various conversations and readings. So if I stole someone's pet theory, I apologize. But here is my own personal take on it.

Ride the wave. That's right, I'm going to try to let this spike reach it's apex before I do anything about it. Before I tell you why, a quick comment that is important. Most of the time my high BGs are below the mid 250s. High BG is not really where I have trouble. I do spike into the 300's sometimes; and I've clocked a 400 or two in my life, but it is not common. The two times recently that I've spent considerable time in the stratosphere didn't even rate me one tenth of a blood ketone. Not that I'm complaining. I'm just pointing out that riding a high wave to its crest is less dangerous for me than bunging jumping off a bridge. Which I've never done. Why survive something that will scare the hell out of you only to be killed by your wife for doing it?

Obviously, if you are ketone prone you should not try my new approach.

This is why I want to ride the wave: I'm trying to avoid Serial Correction Boluses. (there's a new one for Kerri's diabetic dictionary). SCB's always happen to me. When I get a wild sugar ride I find I'm taking correction insulin every two hours. The reason I now realize is this: I'm taking them on the up-slope. The sugar on board has not run its course. That being the case, the various magic formulas in the pump software can't work.

Third grade math example: let us say that we've got a spike that will top out at 300. If I intercept it at 200 and take insulin, the pump is not going to give me enough juice to knock down a 300. Instead, it will flatten out the curve. I'm still going up, but just not as steeply. When it hits 250 the same thing will happen again. Eventually, four or five boluses later I may end up over correcting and end up in the basement.

On the other hand, if I wait until the spike reaches it's high, where it will stay unless I do something about it, then I have some simple facts to deal with. It takes "X" units of insulin to Lower "Y" points of BG to target level of 115. OK, maybe that is more seventh grade than third grade, but waiting maximizes the efficiently and effectiveness of the correction bolus. In theory at least. This little experiment can also serve to help nail down a precise correction bolus ratio.
Point is, if I let it ride to the peak I should be able to knock it down with one correction not five. And that, again, in theory, should leave me high for a shorter period of time. Minimizing your high time is the name of the game for a A1C that will make your heart glow.

Now determining the peak of a spike with finger sticks would be a pain in the finger tip. But with continuous monitoring, this is very easy indeed. It doesn't even matter that much if the Guardian and the BG are not quite in sync, and they probably won't be with a fast rise. You'll still need the finger stick for the insulin, but you can use the Guardian by herself to tell when you've reached the top and leveled off. At that point you take your finger stick and figure out how much insulin is needed.

I get two readings in a row that are the same before we leave the rest stop. I know the peak is near, but I'm not sure we're really there yet. We drive on and I stop near Pueblo, once I'm sure we've leveled off. My readings show: 273, 277, 279, 279, 279. Looks like the crest of the wave to me. I take a finger stick and get a reading of 348. I don't trust freestyle readings over 300 so I do a second stick and get 327. I diecide to split the difference and correct for 337. Furstratingly, the pump stubbornly refuses to let me over ride the most recent finger stick so I correct for 327. Oh well, that's erring on the side of caution.

We hit the road again. I periodically check to progress of my therapy by balancing the monitor on top of the steering wheel, scrolling with my right thumb, driving with my left hand, and keeping one eye on the road and one eye on the monitor.

Damn, she's going up again. So much for science.

The BG keeps going up until Colorado Springs, then noses over nicely. 294, 291, 286, 278, 270, 265, 262, 260.

When we get to the Colorado Blvd. exit of I-25 in Denver I'm at 252.

Very cool. At this point we stop at Noodles, where we've arranged to meet my mom for a late dinner. So we'll never know if this correction would have been picture perfect, but it sure looked good for the home team. By three hours after the meal I'm below 100.

For me, for now at least, I'm going to ride the waves.

6 Comments:

Anonymous Susie Noe said...

Hi! I am really thankful to have found your post. It is so nice for us in the non-selected US cities to get a little view into the inner workings of the Guardian RT. I am 30 and have had Type I since I was 10. I also have a three year old, but unfortunately mine developed Type I at a year. Can you imagine your little one having to go through everything that you do? Its pretty awful! And the crazy thing is, we check his blood sugar every hour. He can drop from 350 to 150 in 30 minutes! So I have been very anxious for information on the Guardian. Its nice to read your blog and find out ahead of time about the finger stick IF differential, and the callibration problem when your sugars are wacko. I also have lost the ability to "feel" my blood sugars. I can't wait to give the Guardian a try for myself. So...thanks for the posts!

12:55 PM  
Blogger Scott K. Johnson said...

Hey Wil!

I like the theory. I think most of the time it will work very well for you.

I have a terrible time trying to NOT react to every single reading. If I see a high BG, I want to take action! That's not always the best course of action for the precise reason you stated here! Don't you just LOVE the IOB screen on your Cozmo?

I've heard that as your BG's get higher your body gets more resistant to insulin. So much so, that as you get in those mid 300's and 400's you may need as much as 10-20% more insulin to get you back down. The other thing that can play games with the insulin absorption is whether you are well hydrated or dehydrated.

So how long after the meal did you hit that high point?

3:10 PM  
Blogger Wil said...

Susie--Wow. Your comment really moved me. Parents of T-1 children have it the worst! I'm glad you are in the same boat, though. I hope that didn't come out wrong. What I mean to say is that I would think it would be easier for a diabetic parent to have a diabetic child than it would be for a non-diabetic parent. You know what to expect. Does that make sense, or am I crazy?

I get email from lots of parents of young T-1 children. They all report what you do, hourly finger sticks and absolutely terrifying swings in BG. The Guardian can't be approved quickly enough for children, if you ask me. (Side note, apparently Medtronic got blindsided on that one. They had fully expected it to be approved for a broader age range; but the FDA asked for youth-specific data. So it is coming!)

Scott (my most loyal reader!)--The wave crested almost exactly three hours after the meal.

One of the lessons I'm learning using the Guardian is: patience. I tend to jump right in too, but now I'm seeing that a steady approach works better. BG is like a big frickin oil tanker on the high seas. You just can't turn that sucker around quickly, no matter how many ice bergs are off your bow.

IOB screen is a T-1's best friend. Did you have a heart attack when you saw how little insulin I took for the sandwich and fries? Our insulin sensitivities are the exact opposite!

I had not heard about resistance being more at higher BGs, I'll need to research that; but the hydration issue makes sense.

6:26 PM  
Blogger Ellen said...

Just wondering how you calculate for the high fat meals at places like Denny's. My son likes to eat a huge calzone at the local mom & pop pizza place. He takes about 40-50% of the bolus up front and spreads out the rest of the bolus over a few hours.

9:10 PM  
Blogger Wil said...

Ellen--That's a good question. I don't eat many meals like that, so I don't have a fully developed strategy yet. What I'm finding now that I'm on continuous monitoring is that things are not as I suspected in the finger stick world. No great surprise there, I suppose.

For instance, tonight I had a triple meat, triple cheese Lotta Burger (New Mexico chain--five star burgers!) with diced green chili. "Plain and Dry," which means just the bun, the meat, the cheese, and the chili. 35 carbs. Been eating them forever, under the assumption they treat my BG well. Tonight, two hours post I was a 157. Another victory for the home team!

Oops. Wait a minute. Spoke to soon. 159, 161, 162, 163...we're still going up.

On the Cozmo pump I can do Combo and Extended Boluses. Combo gives you a percentage up front and the rest spread out over hours. You can program any percentage and time period. It is good for things like pizza with both fast and slow acting carbs. Extended are good for long meals, like the High Tea at the Brown Palace on Mom's B-day. I highly recommend blueberry scones with white chocolate chips smothered in Devonshire Cream and strawberry jam. Hell on the BG, but very good for the soul.

One of my long term projects, using the Girl, is to develop an "Insulin Bolus Recipe Book" for my favorite foods. Because I can now look at the entire trace of a meal and see exactly what the BG does under various insulin dosing strategies, over time I can get very exact at my favorite haunts.

Still a work in progress, as it is a long term project.

10:18 PM  
Blogger Kerri. said...

Serial Correction Boluses ... no that's one to definitely add to my D-Dictionary. I am actually putting together a post about the terms of endearment that have come up over the past few months. I'll need you as my co-contributor because you assign monikers as readily as I do.

Get ready. I'll send you an email!

Kerri.

11:08 PM  

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