Monday, October 24, 2005

What I've Learned About Diabetes

A little more than twenty-three years. That's how long its been since I was diagnosed with Type 1 diabetes. Since that time, treatment of diabetes has changed a lot. We didn't have blood testing machines. (They wouldn't really become available until the following year.) Everything was urine testing. I even recall learning a song at Camp Midicha (diabetic camp). "Don't take a leak in my test tube, my test tube, my test tube; don't take a leak in my test tube, my test tube's cracked!" (Seriously.)

So, what have I learned since then? Plenty. So, I thought I would share some key lessons for those of you with diabetes, or with children with diabetes, or with friends who have children who have friends that have mothers who have siblings who have children with diabetes.

  1. Don't trust your doctor. Not that I'm saying you should ignore them or anything. But I've learned that despite most endocronologists being an "expert" in the field, they really don't know what it is like to live with diabetes on a daily basis. I've even dealt with a few that had God-complexes, insisting that I consult them for each and every change I make. Sorry, but I don't have time for that. I will add the caveat, however, that in order to really take responsibility for your own diabetes, you need to be well-educated. There is much to make the effort to learn it! Not only will you be able to control your diabetes much better, it will make the workload of your endo significantly less.

  2. Learn your symptoms...but test anyway. I will admit that I can, usually, tell my BGL to within 50 pts (mg/dL) without every poking a finger. I know my symptoms, and I'm keenly aware of them. And I've experienced them all. Blurred vision (low), moodiness (high), frequent urination (high...or, perhaps, the result of that Diet. Mt. Dew I just had), weakness (low), a sticky taste in my mouth (high), inability to concentrate (low), frequent coughing (borderline high), etc. But, no matter how well I can detect my BGL...usually...there are those times I don't. So, test. Take note of how you feel when your BGL is slightly high, slightly low, very high, and very low. Remember how you feel, and next time you feel that again...test!

  3. Analyze, analyze, analyze. This ties to number 1. But it is important to pay attention to all the variables in your life that affect your BGL.

    Number one, of course, is carbs. I spent a long time tweaking my insulin to carb ratios.

    Number two is basal rates (if you are on a pump). Even before I was pumping, I threw traditional therapy to the wind and went to a three-dose-a-day NPH schedule in order to simulate a better basal rate. When I switched to Lantus, I used two shots a day rather than one. My endo thought the idea was odd...but a year later, he ended up finding a colleague who was doing that very thing with his patients with much success. On a pump, you need to spend a lot of time and effort getting your basal rates correct for a fasting diet.

    Number three, correction factors. Take advantage of your highs. Bolus, and check, then check again. Pay attention to how much insulin it takes to bring your high down. If you are 300, and you give 4 units, and three hours later you are at 200, then you know each unit lowered it 25 pts. There are exceptions, however. I have found that if I'm high not long after a meal, or if I'm feeling particularly full (loss of appetite), that I still have more carbs in my system that haven't yet been digested. So, I might give those 4 units, and find that it doesn't do anything. All I'm doing is giving my body enough insulin to keep the BGL from going yet higher. Watch out for over-correcting. Then you start yourself on that roller coaster ride.

    Speaking of roller coaster rides, watch out for "feeding" your lows as well. If I wake up low, I feel ravished. I'll eat everything in the kitchen until my BGL is up. So, at those times, rather than trying to force myself to only eat enough to bring up my BGL, I actually will eat a lot of carbs. But then I bolus. Strange to do, I know, when I'm low. But if I am at 50, and I really only need 10 carbs, but I end up eating 60 carbs...then I need to correct for those 50 extra carbs. (Though, I will generally be careful, and give myself an extra 10 carbs leeway.) So, I bolus for 40 carbs, and allow the other 20 to raise my BGL. This keeps me off the roller coaster.

  4. Watch for the unknowns. This is being mindful of those unexplained highs and lows. Just because you can't explain them doesn't mean there isn't an explanation. For example, I found out that Little Caesar's Deep Dish pizza will cause a huge BGL rise about three hours later. (The dreaded "pizza effect".) Now I know to give myself an extra extended bolus for pizza to counteract this. I might not know the reason, fully, but I can recognize the pattern and prevent it. Also, I know that high-fat foods cause a temporary insulin resistance, which might wreak havoc on your insulin-to-carb ratios. Protein, as well, can eventually turn to carbs in the body if you consume enough. Take note of each time you experience any unknown...and then go back and see if you can figure out any pattern. You might even try reproducing the events. Eat the same meal, for example, a few days later and see what happens.
That's enough for now, I suppose. I could go on and on with this. And by the way, if you own a PalmOS-based PDA, check out my diabetes software Logbook DM (see my link along the side of my blog). I'm not saying this to drum up sales. I'll even give you a registration code for free if you really don't want to register. But I have it there to help diabetics, like myself.

And take a moment to share something you've learned!


RyanBruner said...

Hey, doofus...what are you doing telling people to give insulin when their low.

Hey now. Be nice. I didn't tell them to do any such thing. I was just saying what I do.

Whatever. Listen, you do people are gonna try this and get themselves into trouble.

Hmm. You're right. I should have explained better that I only give myself a correction bolus for extra carbs during a low IF and ONLY IF I know the reason for the low. Because you're right. If my BGL is still dropping, then bolusing might just lead me back to another low.


Okay, okay. I'll be sure to clarify that. I wouldn't want people to do anything rash.

You're such a doofus!

Alright. That's enough.


I said...


Scott K. Johnson said...

Hi Ryan!

Great blog - very enjoyable read. I think you've done a very good roundup of things you've learned.

I will also sometimes bolus when I know I'm overtreating a reaction - but like you said, it's something to do with great care and when you know why you've gone low.

I used your Logbook DM program a while back and just LOVED it. I've since migrated to the Pocket PC platform and greatly miss Logbook DM. It's a great program and I encourage folks to give it a try.

RyanBruner said...

Hey, Scott! (I thought I recognized your name.)

Yes...the PocketPC has grown so much that I wish I had the time and resources to port Logbook DM to it. But, alas, I don't. But if someone here knows anyone who might be willing to do it, I would be willing to work with them.

Sandra Miller said...

Nice post, Ryan.

Treating a low with food AND insulin is an interesting idea... I'm assuming you would bolus after the fast sugar has brought your bg up to normal levels, but before or right after consuming the longer-acting carb/protein-- is that right?

We have definitely experienced the dreaded rollercoaster ride you describe here-- low, treat the low, rebound from low, then high, high, high.... ugh!

RyanBruner said...


I supposed I opened a can of worms here, eh? :-)

I will admit, the whole bolusing while still low is easy for me to deal with partially because of my software. But even without using software, the important part is knowing how much unused insulin is in your system still.

If you are low, it is because you have too much insulin for how many carbs you have/had in your system. But, it is quite possible that while there are no more carbs, you still have insulin that is unused.

If you are low, and trying to treat it with food, that information is important. If you last bolused 4 hours ago, you can pretty safely assume there is no unused insulin (other than normal basal insulin) left. Most analog insulins today (Humalog and Novolog) only stick around for a maximum of 4 hours. For me, it is more like 3 1/2 hours.

And, I know that MOST of that insulin is gone, actually, in 1 1/2 hours, with the remainder lasting beyond that being quite minimal.

So, you must figure out, for yourself (or your child), what the unused insulin curve is. You might play it safe, and just presume a straight formula. Something like 50% of insulin remains after 2 hours, etc.

Taking a practical example. Let's say you are low 3 hours after eating (and bolusing). You are starving again, so you eat 50 carbs. Three hours ago, you bolused 4 units. So, you assume that there is still 1 unit unused in your system, which will bring you lower still. That 1 unit will cover, say, 10 of those carbs (depending on your own ratios). That means 40 of those carbs will raise your BGL. 10 will keep it from dropping further. Now, of those 40, 10 are needed to bring the BGL UP to the level you want it. That leaves 30 carbs you overate to treat. So, you bolus for those 30. (And, as I mentioned, I always give myself an extra 10 carbs, just in case.) So, I bolus for 20 carbs when I eat them.

I suppose if you are new to this, it would be best to wait until your BGLs start to rise before bolusing...but in the middle of the night, and with experience under my belt, I don't. I bolus at the same time as I eat the carbs...or immediately after eating the carbs. I will expect to wake up a LITTLE high (given my extra 10 carbs leeway), but certainly not nearly as high as if I hadn't bolused at all. Also, the bolus doesn't really slow down how quickly I recover. Rather it just prevents the roller coaster!

Did you follow all of that? :-) I wrote Logbook DM to account for all of that for you...but with practice, you can do it in your head as well. (After using Logbook DM for a few years, I no longer need to use it because it is fairly automatic for me.)

ME said...

Just came across your blog. You went to Camp Midicha? I did as well, but probably many years earlier than you did. You see, I too have Type 1 diabetes. I was diagnosed in July, 1963. Yep, for those counting that's 42 years ago.

As far as bolusing for extra carbs when low... the newer insulin pumps factor that info for you. My Animas will estimate my insulin left on board and allow me to make a fairly accurate decision on whether I need to bolus for any extra carbs or not.

I too have a blog you can find it at: Come visit when you've got some time.

RyanBruner said...

Howdy, "ME".

Yep. I went to Camp Midicha in, I guess, 1983. Or maybe 1984. I forget now. Loved it, for the most part...except for the pervert we had as a camp counselor. And I'm not really exaggerating there. He enjoyed flashing the female campers, and would walk around the cabin "playing with himself", if you know what I mean. Openly. Well, I (and my parents) complained. Not sure anything happened to him or not, but I never went back as a result.

ME said...

WOW! No flashers when I was there in 1963, 64 and 65. Was he just a pervert or what? Did anyone report his behavior?