Carb Limits

Since being exposed to so many other Diabetics via the #DOC, I've been surprised by how carb-limited many people are.

To begin with, I'm slim and slightly underweight. Could stand to gain 10 or 15 pounds. Gaining 5 takes constant work and the first time I waver it melts away. So I don't need to limit for weight reasons.

I have a self-imposed per-meal limit of 70g of carbs. I'm pretty good at sticking to it. Sometimes I misestimate. Sometimes I intentionally blow past it. But generally, 70 is my limit and 50-60g is common. That makes my per-day carb limit about 210g. In reality, I come in closer to 170g. So that's just north of half the FDA guidelines.

The only reason for that self-imposed limit is how much harder it becomes to manage blood sugar on larger meals. 70 is hard. 90 is... harder.

But when talk turns to food, I notice people limiting themselves to 70g... a day. Less than half of my common day and fully a third of my upper limit. Some people eat 20-30 a meal. And I ask, how? I can eat a huge steak dinner, but without a couple servings with bread, I'm simply not full.

From my understanding, there isn't a maximum safe dose of insulin. So given controlled numbers, there's no downside to taking the insulin to cover the carbs. And if I need that many carbs to satisfy hunger, then I may as well dose for them.

Largely, then, I wonder two and a half things:

1. Is my understanding about insulin wrong? Do I need to use less? Presently I use about 45U on a good day, up to mid-50s when battling highs.
2. How do you stay satisfied with so few carbs? Do you adapt? Did you never want them?
3. And last, how do you deal with lows, especially when so carb-limited? If it takes 20g to produce a rebound, and you only get 30g for a meal, then you're looking at salad. Right?

Generally what I'm doing is working. But seeing so many people, with so similar a regiment, that is so different than mine, leads to second-guessing my plan.

Pauses

When first diagnosed, I was given three hard, numeric references for insulin. Not fluffy relative terms but absolute. rules. I like those. There's no room for interpretation. They just are what they are.

The first was a carb ratio. I would take 1U for every carb exchange. And one carb exchange = 15 carbs. That ratio quickly proved to be a little off, but it was a hard number I could work with.

The second was correcting. I would take 1U for every 50 points above 100 I was. That number, too, was fairly quickly changed in the real world but there it was.

The third I still struggle with. It was an explanation of how long after correcting I should wait to eat. From memory, it was something like:

BGnow	Dose	Delay
100	0 + Meal	Now
120	0 + Meal	5 minutes
150	1 + Meal	10 Minutes
200	2 + Meal	15 Minutes
250	3 + Meal	20 Minutes
And so on

The source of confusion, especially now, is my blood sugar doesn't change that fast. 20 Minutes after correcting with a blood sugar of 250 isn't going to put me anywhere near normal territory!

Logically, I can reckon that:

1. The extra insulin from the meal will lead to a quicker fall than the correction dose by itself.
2. A meal with fewer carbs will have less of a rebound than a meal with more, so you may be able to fudge and eat a little sooner that way.
3. And last, you don't want to be #bgnow 100 with 12U active (and active without lag)

But Novalog, for me, tends to take 15-20 minutes before anything appreciable happens to my blood sugar. And with a hypothetical 250, an hour is unlikely to put me anywhere near 100.

So instead of dealing with a reasonable 10 minute pause, I tend to follow one of three (including lows) algorithms.

For a blood sugar < 140ish

I dose whatever fractional correction the pump spits out at me and eat.

For higher blood sugars

I rage bolus the high, check sugar every 20 minutes or so and once it's fallen by about half eat bolus the difference between active and what I'm meant to take for the food.

And for low blood sugars

I tend to take a 30 or 60 minute square wave depending how complex the carbs are and eat now - because remembering to bolus at some indeterminate point in the future is not one of my strengths.

Over the years, I've been able to adapt the first two rules from the initial diagnosis rather easily but just haven't ever figured out how to incorporate the delays/lags/etc defined in the third into my regiment. I may have a system but it too often leads to a low or high a couple hours in the future. I'd love to one day figure out a math function to give me an optimal time differential for correcting & eating.

Approaching 24 hours with the Dexcom

The Dexcom was waiting outside the door when I got home last night, a day early. So I opened it up, reviewed the getting start process, plugged the receiver in to charge, and went about dinner and #DSMA. After #DSMA, it was time.

I'd worn a Dexcom for about 10 days a month earlier, in a trial through my CDE. (Note, sometimes I call her an Endo, sometimes a doctor, sometimes CDE. I don't really know. I don't really care. She does everything I need and is generally awesome.) I read the process of sensor insertion about half a dozen times and started. It must have taken 15 or 20 minutes to get it in OK. Getting the needle in went ok. Removing the insertion mechanism took some work. Getting that collar up as high as can be HURT. The entire sensor lifted up towards the middle and there was some blood clearly visible. But I did manage to remove the mechanism, and settle the sensor down closer to my skin. The pain was much more severe than when my doctor did it. I suspect that's just the learning curve, because she also did it much faster than I was able.

It was nearly time for bed once calibration was complete. But around 4AM, my wife woke me up because the Dexcom woke her up. (It had been going off for pushing an hour by then.) It was a 48. Confirmed and it really was low, so grabbed some sugar from the nightstand and went back to sleep. When I woke up for real three hours later, the screen looked like ____/----/`````. It said 140-something, but my meter said 104. But over the course of the morning, I had a stubborn but mild high that just didn't want to go away. In retrospect, I wonder if it really was closer to 140.

And now we're at lunch. I had a slice of pizza and salad. Started a square wave 10 minutes or so before eating, so had a slow descent and was in the high 90s while eating. But an hour later, I was still creaping up, past 150. Small correction and kept climbing. Repeat. Repeat. I managed the arrest it by 175 a half hour agp, so the Dexcom adverted a high. I'm flat or slowly descending at 166.

I can't know how I'll feel in 6 months, but for now, I love seeing this kind of information. Probably check the silly thing every 10 minutes. My immediate goal with the Dexcom is just to tighten the ranges. My A1c is pretty good (Labwork likes to warn me that with an A1c around 5.8, I'm at risk of developing Diabetes: HAH!) but it's only that good because I have far too many lows. If I can go from 60 being an every day occurrence to, say, once a week, and make the corresponding cuts on the high end, I ought to be able to hold an A1c in the high fives or low sixes, but hold that much more safely. It'll be the Dexcom's credit if that happens.

DSMA is the Diabetic Online Community at Large

Tonight was #dsma. (It's every Wednesday @ 9PM EST if you're interested.) And so I got to talk with a number of other diabetics who are outside of my normal #doc feed.

While I don't have an exact number, I'd bet I follow fewer than 50 diabetics on Twitter. There are tons more. There are the celebrities of the community like @diabetic_iz_me or @diabetesalic that I don't follow. Absolutely nothing against them, but I use Twitter for bantering with real-life friends, political posturing and technical issues as well. They and many other core group of DOC members are so followed that the number of tweets in the timeline grows exponentially because not only do I see them, I see the bantering between them and everyone else too. It's part of it being a community but given the tools I have, volume-control is the best way to keep Twitter generally useful.

#dsma is a way around that problem. For once a week, I can forsake all matters non-diabetic and see the spectrum of peoples and their thoughts. One hope from this blog is I can follow more in a less instant manner. Still won't see every thought, but it enables seeing more than I would on Twitter alone. And until I can handle the volume on day-to-day Twitter, #dsma is the outlet to the community at large.

Feeling discouraged

It was early 2007 when I got a pump, the Medtronic Paradigm 522. The first month or two could have gone smoother but that was learning and growing pains. Stuff like dealing with the tubing. Or unlearning to pinch my belly before putting the injection in. Since then, I've dealt with a water-damaged pump, two other mysterious incidents where the pump would consume batteries in a matter of hours (for days at a time) but in general, it's all gone smoothly.

But these last few months have been harder. I've started to notice small scars or marks from the infusion sites that last weeks instead of days. As I've been more active this summer than I typically am, it's been a struggle to find fatty parts of my belly to use. And so, four years after starting pumping, I've been exploring alternative sites.

First was hardly exotic at all. I just went all the way to the edges. The infusion site was at my 3 and 9 o'clocks. The first time was on my left and it worked fine. But then on my right side, it could have gone better. Then I followed around to my back. There's little fat there, just two small spots above my hips. And again, left side worked, but on the right side, I struggled with high blood sugars and the infusion site came out with a bent tip.

Next, I tried using glutes. Pattern continued, left worked OK, right didn't work.

I've never been brave enough to try thighs. It's hard to imagine them working any better plus I'd need to shave. And I've heard of people using their arms but that makes me even more squeamish than trying legs.

So last night, being out of viable sites on my stomach, I tried the left side of my butt again. It went it, it didn't hurt, and I was relieved. My last 2 stomach sites have felt like beatings, so for it to go in relatively peacefully was a relief. Couple hours later, I went to bed with a blood sugar of 90.

I've slept better, waking up around 3AM but getting back to sleep. But at 6AM I felt like death. Checked blood sugar and was up to 414. Can't remember the last time I was that high. 350, but 400? Not in a while. I didn't even try correcting, went right to replacing the infusion site. And found the cannula sitting atop my skin. No wonder it didn't hurt!

The Dexcom should be coming in the next week or so, and hopefully that'll keep me from getting into that bad a place again. But I'm so discouraged about pumping right now. It's convenient and has worked well, but it's been so hard these last couple months to find usable sites and the rash of skewed cannulas isn't helping either.

Gadget Names

This probably puts me in the minority of the DOC: I don't name my gadgets.

I've got a Medtronic pump, a FreeStyle meter and soon, a Dexcom 7 CGMS. And I call them "the pump," "my meter," and "the dexcom." Some people seem to give them funny names, people names, etc, but mine are just descriptors of what they are.

That's all.

The Search for Fat

It was time to put in a new infusion site this morning. I searched, groggily, for fresh torso that I could sink it into but found I was somewhat lacking in usable fat. Every really juicy part of my stomach still has those red marks from sites past. I couldn't find a spot on my back that was assuredly cushioned enough. My butt has been too unpredictable and I've never explored thigh sites or other parts of my body.

So I did find a clean spot on my stomach, and it had a bit of fat, so I went ahead to use that. Did all I could to loosen up before releasing the needle, pushed the button, and POW: It hit me like a metallic fist of fury. It was one of those insertions that makes you want to puke in response. Luckily, it passed quickly and settled into something closer to the typical dull pain that the first few hours of a new site means. But, OW!

Luckily, it seems to be working. Been in for about two hours now and my blood sugar's 82.

People often look at me like I'm crazy when wishing to be fatter. I don't want a beer belly or anything like that, but it's incidents like today's that makes me wish I had a little bit.