The thirst that changed my life

Continuous Glucose Monitoring Part 2

2011-06-12T22:49:00.000+02:00

... This is what happened.

Just before the date I got lazy and then sick. The perfect storm that for me translated into a period of massive insulin resistance change. My insulin requirement more than doubled in three days. My blood glucose was not well controlled during this time. Three days into this perfect storm, I was well enough to start exercising again. How this affected my blood glucose control even surprised me. I almost immediately move into a period of great control.

The experience that I had when using the CGM was completely different when I was well controlled from when I was poorly controlled.

When poorly controlled.

Within the poorly controlled period of three days I experienced every possible reading error you can think of. I.e. The CGM told me that my blood glucose was high when it wasn't. It told me that I was normal when I was high. It told me that I was low when I was normal. It told me that I was normal when I was low.

When well controlled.

Within the well controlled period the CGM reading was extremely accurate. After 12 hours between calibrations (the maximum time between calibrations), the tested reading was often only 0.1 mmol/l out.

It is hard to understand why there is such a discrepancy. I suspect that it is largely due to the calibrations. When you re-calibrate the sensor there is an assumption made by the device that at that time your subcutaneous glucose reading is the same as your blood glucose reading. We know that the readings are not the same because there is a 10 - 20 min lag in the subcutaneous glucose reading. This is the reason why it is recommended that you calibrate the device when your blood glucose is stable and not changing quickly, limiting this error. When poorly controlled it is hard to find a time when your blood glucose is not changing quickly. The sensor has certain calibration requirements that may mean you are forced to calibrate when you would have preferred not to. This would result in inaccurate calibrations which in-turn results in inaccurate readings.

Calibration could not have been the only reason for the inaccurate readings. My blood glucose wasn't changing fast enough at calibration time to account for more than a 1mmol/l error (huge error), but I sometime had errors greater than 5 mmol/l. It could not be the hardware, because the well controlled period followed the poorly controlled period using exactly the same sensor (sensors get worse with time not better).

Whatever the reason, CMG is a much more useful if you are well controlled.

CMG may not be the silver bullet I was hoping for, but it is still an incredibly useful tool. It helps to get the timing of your basal changes correct. You can see exactly when the change needs to be made. It also checks you blood glucose when you normally wouldn't. There are likely to be one or two surprises. There was for me.

Maths, your health depends on it.

2011-03-17T20:32:00.001+02:00

The truth is that a certain amount of maths is required to manage type 1 diabetes well. Another truth is that you don't need to be good at maths to succeed in managing diabetes well. It's a question of balance.

I am on my mountain bike at the bike park. It's a blue route. There are two small technical up and down hills followed by a much larger even more technical steep uphill, down and uphill again. Getting up is a bit of a balancing act similar to how I find managing diabetes. You cannot lean too far forward or the back wheel will slip, nor can you lean to far back or the front wheel lifts. You cannot go too slowly because you need momentum to get up the last part, nor can you go too fast or you won't have enough power for when you do slow. You also need the correct line and balance. Basically everything needs to be perfect to succeed. I have done the route before but it still takes more than one attempt to get up.

Then it's the trail around the edge of the mountain. The ground drops away on my left and I feel that sense of exposure. I love it. This is my fortnightly weekend morning getaway. It's great exercise and great for taking my mind off things. It is not working today though. I am in a deep conversation with my brother in-law who is right behind me. I am panting now because the dip with a hair-pin turn to the left is followed by an up-hill I say, "... but It's not that hard. Why would anyone let percentages and basic addition get in the way of good health?" We are at the top now. It's a fast series of tight massively cambered turns. Mind the rock. "You don't get it Paul. Some people are just terrified of maths!" he says. I am lucky to have been blessed with an aptitude in Maths and this is taking some time to sink in. It's a steep downhill and I pickup speed. I need to concentrate now because of the sharp rocks. They are a bit tricky at speed and you don't want to fall here. Regrouping on the other side I say, "... but it's their health! What can me more important?"

My brother-in-law and I are discussing a topic that has been bothering me ever since I was diagnosed with type 1 diabetes. It started with comments like "Don't take advice from that patient. They didn't have the aptitude to work it out so they are on a different treatment." or "You are so lucky you can work these things out. Most people don't and just suffer." I am using a bit of poetic licence here, but you get the message. Another saying "As jy dom is moet jy hard kak" comes to mind.

Initially I just accepted what I was told. Relieved that I 'got it' I moved on. Now that I have had diabetes for more than 2 years and know what is required to know pretty well, these early comments now haunt me. There is a lot that you need to learn, but the maths that you use daily is very basic. Managing diabetes well is more about understanding and balance than maths. I have never heard someone say "You are just not clever enough to ride a mountain bike". Balance is instinctively learned once the problem is understood. I think the fault lies with either the teacher's ability to teach, or the student's willingness to learn, or access to a good teacher, or just the sheer amount needed to be learned. So either find a good teacher, or change your attitude, or get a good book.

If you are not yet sold by my argument, and are 'terrified of maths' or struggle with your daily maths requirements, I have some other suggestions:

Get the gadget. You can buy a scale that does carb-counting for you. You put the food on the scale, enter the food type and ... it tells you the weight of the carbs.

Phone a friend. If you really struggle with the numbers or just want some confirmation, then ask for help. This is serious stuff and most friends are more than willing to help out.

Do the easy maths before the hard. There is always more than one way to get to an answer. Get someone to help you find the easy way. Another example is to learn to carb-count using exchanges first. This is a lot easier than the gram based carb-counting.

What about mental maths?

Now you should obviously not try this until you are confident doing the calculations on you calculator. However if you have got the hang of it there are many useful tips and tricks you can use that make mental maths easier. I want to share one of these tips that I use quite often when carb counting. I.e. how to calculate percentages in your head? Here is an example.

I am quite hungry and in a rush. I need a decent meal quickly. I grab the loaf of low GI bread. (This loaf is not really low GI, but rather 'lower GI' than normal bread. It is quite safe for me to eat.) I grab four slices and pop it on the scale. The scale reads 166g. Recently I have found that the bread thickness varies too much so I prefer to weigh the food. The nutrition label on the loaf says that there are 38g of carbs in each 100g of bread. I read that as 38%. This means that I need to calculate 38% of 166g to get the total carbs in grams of the four slices that I am about to eat.

The trick to mental maths is to change the problem slightly to make it easy. There is nothing easier than working with tens or a multiple of tens. That's what I look for.

38% = 40% - 2% = 4 * (10%) - 2 * (1%)

Now getting 10% from 166g is easy because you just need to move the decimal place by one.
I.e. 10% of 166 = 16.6g
and similarly 1% of 166 = 1.66g
Let's start the calculation: 40% of 166g = 4 * (16.6)
We don't need an exact result so we can safely round to the nearest half gram.
≈ 4 * 16.5 = 66g

Now just subtract 2 % of 166g = 2 * 1.66 ≈ 2 *1.5 = 3g
Total carbs = 66g – 3g = 63g.
There are 63g of carbs in the meal. (As it turns out in this case the exchanges method would have got us close enough and is a lot easier to calculate.)

Mental maths requires a bit of practice before you get good at it. So try it more than once, and soon you will find this quicker than reaching for a calculator.

Loading on the carbs

2010-09-26T22:32:00.000+02:00

Eating a large carb meal can be tricky for someone who is living with type 1 diabetes. The larger the carb meal the harder it is to avoid hyper or hypoglycaemia and the more likely it is to have a severe hypo. This is because any error in insulin dose gets amplified by the size of the meal. I will explore in more detail the things that can go wrong when eating a large carb meal and how to avoid them.
Since I have started writing my blog, I have become more involved in the diabetic online community. One thing that I have noticed is that many people with type 1 diabetes don't eat large carb meals well. One guy even described the hyper that followed a high carb meal as if it was a punishment that he needed to endure for breaking his diet. I believe this is wrong. A high carb meal doesn't have to be a bad experience.
I love eating carbs and I eat a lot of them. I am practically carbo-loading all the time. This meal choice has a lot to do with the amount of exercise that I do, which is a lot. Because of this I have become quite good at eating large carb meals. I still get the occasional meal wrong, but I get most meals right. This is what I have learned.
Getting the insulin dosage correct is not an exact science so there is always an error. The answer to eating large carb meals well is to keep the errors small.

Carb-counting needs to be more precise. Weigh the carb separately if you can. Start counting the carbs in the parts of the food you normally don't count. E.g. the 2-5grams in the sauce etc...
Any mismatch between the food's GI and your insulin absorption will be amplified. If you are using a rapid acting insulin analogue like Humalog or Nova rapid, then you need to particularly watch out for fatty or low GI meals. Increasing these meals can result in a hypo after the meal.
I think it is not wise to more than double the amount of carbs you normally eat for a meal. The insulin-carb ratio you are using is probably not accurate enough for such a large change.

The above points are not always that obvious to identify. I would like to share two examples where it wasn't. In both examples I detail what happened to me when I had a second helping of a meal that I normally eat well with no ill effect.

Single portion pasta meal

I have a favourite pasta dish that I frequently eat. This pasta dish is a favourite not only because it tastes good, but because I always have a good blood glucose response and I feel good afterwards. One day I felt particularly hungry and had a second helping.

Double portion pasta meal

What I did not realise was that the nutrition label was out by 6% (normally a 3 grams error). I also never bothered counting the carbs in the pasta sauce (normally a 2g error). This is a total undercount of 5g of carbs in my normal portion size. I can tolerate a 5g undercount without any problem so I didn't notice the error (check the graph above). When I doubled the meal size, the 5g undercount became a 10g undercount. The second graph shows my not so great blood glucose response. I had a hyper of more than 10mmol/l after the meal and my blood glucose stayed high until the next meal.
The first time that this happened to me I found it very confusing and it took me a while to work out that there was an error in my carb-counting in both meals.

Single portion slightly fatty meal

Here is another example. This time I ate a double portion of a slightly fatty meal. The first graph shows my blood glucose response when eating the single portion. My blood glucose response took a dip at the 1 ½ hour mark but stayed within the normal range and I didn't notice the insulin – food GI mismatch. When I doubled the meal size then I had a hypo an hour later. The graph below shows what happened.

I now recognise a potentially too low GI meal and prevent any ill effects by using a duel – wave bolus (50%, 50% with a 30 min square wave) on my pump. (If you don't have a pump delay giving the insulin can achieve a similar result.)

Double portion slightly fatty meal

When eating a large carb meal, I am particularly careful when counting carbs. I avoid low GI or fatty large carb meals. I also often use my blood glucose response from a large carb meal to fine tune my insulin-carb ratios. I am continuously working at improving my carb-counting checking my food GI and fine tuning my insulin carb rations.

The opposite is true too.
If increasing the carbs in a meal amplifies any errors, then why not decrease the carbs you eat in times of uncertainty. For me that time is when I am on holiday.
One of the reasons why I go on a holiday is to unwind a bit, but this de-stressing completely throws out my insulin – carb ratios. This can make my holiday unpleasant and stressful in a whole different way. What I have started doing is to reduce the amount of carbs that I eat when I am on holiday. My insulin-carb ratios still change and I need to adjust for these changes, but I suffer from less hypo's and hyper's. My holidays are much more pleasant for everyone.

Continuous Glucose Monitoring

2010-09-20T21:49:00.000+02:00

It's official. I am going try it. If all goes according to plan I will be on continuously monitoring of my blood glucose by the 12^th of October. My plan is to share this experience with you, so this is going to be the first of a series of posts on the subject.
This is what I have found out to date.

The promise!

Continuous Glucose Monitoring or a CGM is potentially the most useful device for a person with type 1 diabetes. Imagine knowing your blood glucose reading all the time. Theoretically that would translate to complete control. No more hypo's and no more hyper's. You would see them coming and correct for them. CGM's have been on the market for a number of years so why don't we all already have one? The reason is that current CMG devices are still far from ideal.

Why the promise falls short?

Current CGM devices:

Are invasive. The testing device needs to be inserted below the skin while still being connected to an external transmitter. This means this it is prone to infection so needs to be discarded after 5 days.
Are expensive and expensive to use. The CGM requires expensive consumables to use. When I found out that the transmitter, a main expensive component of Medtronic's CGM, was also a consumable. The cynic in me started wondering whether the designers were not tasked with increasing the annuity income for the medical suppliers ;)
Require regular calibration. The reading you get is not absolute and needs regular calibration. You still need to perform the normal finger prick testing. You will probably need to test less.
Provide results that are 15 min delayed. The current reading shows you what your blood glucose was 15 minutes ago. With a CGM you have to manage using the trend rather than the absolute value. This is generally a much better idea anyway because looking ahead is better. The 15 min delay means that sudden changes are missed. E.g. eating glucose. It is always a good idea to minimise any sudden changes anyway. You tend to have less sudden changes when you are better controlled. CGM should work better the better your control.

Why do I want to use a CGM?

The promise is very appealing.
I have an immediate need. Recently I have been struggling to get my night basal rate correct. It has taken about a month of disrupted nights; waking to test and treating hypos when I got it wrong. If I had a CGM and knew how to use it correctly I suspect that it would have taken 2 -3 days to achieve the same result. Who doesn't want that?
The price has dropped.
The medical aids are more in favour of financially supporting CGM's.

Getting Started

I already have a Medtronic's Paradigm insulin pump that is compatible. What I still need is a transmitter, a cable so that I can download the data on to my PC, and the sensor. The orders have been placed, and I wait in anticipation ...

Insulin Pump – My story

2010-09-13T22:39:00.001+02:00

I have been using an insulin pump for almost 2 years now. Calling me a fan of insulin pump therapy would be an understatement. I think that it's the greatest things since Canderel Chocolate. I didn't start out being such a big fan. This is my story of how I got there.

Question: Why did I consider using a pump?

Endurance Exercise is the short answer. When using injections it is impossible to change your basal (24hrs) dose for an 8 hour period in the middle of the day. This is what your body needs if you have done exercise for longer than 3 hours. This is ok to manage this once in a while, but if you are training then you are doing this all the time. My diabetes is particularly well controlled in the days following endurance exercise. It's a wicked twist of fate that meant that the exercise helping my control was conflicting with my insulin therapy. I was discussing this with my doctor when he suggested that I try using an Insulin pump.
It felt like I had been kicked in the face.
I hid my surprise well. My doctor went through the pro's and con's of using insulin pump therapy and introduce me the diabetic educator who would guide me through the process. The decision was in my hands now. I wiped the scuff mark off my nose as I walked out of his office.

Question: Why was it such a big shock?

I am not sure. Logic tells me that I should have seen it coming. Knowing what I know now, I practically pushed my doctor into making the suggestion. I guess I had never pictured myself connected to a machine. I had never allowed myself to consider that an option. Being attached to a medical device is a bit like admitting to being sick. I have always thought of managing diabetes as a bit like brushing your teeth. It's another thing you need to do to keep back the rot, but it doesn't need to interfere with your life. The situation is actually the same, but a machine seems to somehow make the situation seem that much more serious and restrictive.

Question: Why did I do it?

The promise of better control, improved life-style, reduced hypos and easy management around exercise had sowed a seed that I would eventually circum to. The battle was set, the emotional against the logical. It was a long drawn out battle that lasted three months. I fought hard but in the end surrendered. Logic won.
I decided that I wanted the best therapy above all else. I was going to try it. I was still very uncomfortable with the idea.

Question: Some practical questions?

How will I sleep? What happens if I rollover and block the tube? What about swimming? How much does it cost? How do I pay for it? Going out?
I phoned my diabetic educator and found that there were simple practical answers to all my questions. We decided on a date.

Question: So when did I become a fan of the insulin pump?

I became a fan the day I stopped the injections and turned on the pump. I felt like a weight had been lifted from my shoulders, except it wasn't a weight it was like a physical tension. I had no idea that I even had this 'physical tension', but with it gone I felt normal.
There are more reasons why it makes me feel normal. The freedom you get from not needing to eat at exactly the same time every day. I no-longer need to feel awkward accepting an invited to a late lunch knowing full well that I will have eaten lunch long before it gets offered to me. It gives you the ability to change your mind about how much you want to eat. You can be more precise and even account for one biscuit. Pizza becomes and enjoyable meal again. Then there is the better control, reduced hypos and easy management around exercise.

I got more that what I was expecting.

I no-longer resist being connected to a machine because of the freedom it gives me.

I can still disconnect from the pump at any time, but I prefer not to.

Homeopathy Explained

2010-08-29T21:27:00.000+02:00

I remember the first time that I heard about homeopathy. I didn't know anything about homeopathy but had started making assumptions about it based on associations.

Natural and health are words often used in the same sentence and if you are not careful you may start assuming that homeopathy is a natural health alternative. I did.
I know of a vet who has studied and practices homeopathy. For me this suggested that there was a scientific basis for homeopathy. I could not have been more wrong.
You can buy homeopathy medication in the chemist and even get your medical aid to pay for it. This has a strong suggestion that it at least does something.

Imagine how shocked and let down I felt when I found out the truth. I had been conned.

So... what is homeopathy?

The short answer is it's a placebo. Don't take my word for it let's hear it from the expert. This is a lecture by James Randi where he explains the fundamentals of homeopathy.

The placebo effect is very powerful and prescribing a placebo for a minor ailment has a reasonable chance of success. However prescribing a placebo for a serious medicine dependant conditions such as diabetes is simply criminal. Don't be a victim.

A Healthy Timeout

2010-08-29T11:39:00.001+02:00

Insulin sensitivity is up; managing Hypos; reducing insulin ratios for meals; reducing insulin basal; a hypo at 3am; blood glucose ok for a few days; watching world cup soccer; adding outlook task; 'read up more on super bolus concept'; the kids are fighting more; need to spend more time with them; need more sleep; stress at work is up; insulin sensitivity is down; managing hypers; increasing insulin ratios for meals; it's time I wrote a new blog post; it looks like I may need more insulin at night; don't really feel like wakening up at 3:am; I guess I am lucky that I am already up at midnight; increasing basal levels; notice the outlook task to read up on super bolus, and add another task to post a question on the diabetes daily forum; Spending a lot of time at work; spending a lot of time at home working; falling asleep in front of the TV watching world cup soccer; waking up at 1:00am; testing and changing basal; Changing meal ratios; I am needing more insulin during the week at lunchtime and for all evening meals; weird?; I need TIMEOUT;

Putting the diabetes books back in the cupboard; Stop downloading test results; Stop worrying about diabetes; Playing it by ear; Managing by instinct; Spending time with family; Spending time with friends; Getting on top of work; Getting on top of the to do list; getting more sleep; Finish reading my novel; Watching the soccer world cup - Laduma;

It is good to have some timeout every now and again. It keeps me sane and helps me to stay refreshed.
My timeout took a bit longer than I thought it would, but I am back. It feels good to be back.

Initial human trial for type 1 diabetes treatment

2010-05-21T23:24:00.000+02:00

I have just come across this article by Harvard Science. Initial human trial for type 1 diabetes treatment

Harvard Scientists have discovered that a vaccine commonly used for treating TB has proven to be very affective in curing type 1 diabetes in mice. They have now started human trial on the vaccine. the first stage trials are there just to test the safety and dosage of the drug and not it's effectiveness. It is likely to pass as the vaccine has been in use by humans for 80 years.

Published in Diabetes lifestyle

2010-04-25T23:50:00.001+02:00

One of my first blog posts "Type 1 diabetes quick start guide" has just been published in Diabetes Lifestyle magazine. This is the first issue of the magazine and is the official magazine of the Centre of Diabetes and Endocrinology.

I am just over the moon and there are two reasons why:

It is the first time I have been published in a magazine.
I have been published alongside some of the real leaders in the fight for better diabetes management in South Africa. People like Vanessa Brown (diabetes educator), Dr Stan Landau, Tracy Johnson (podiatrist), Mandy Marcus (dietitian) and Andrew Heilbrunn (biokinetics- exercise).

If you are living in South Africa and have diabetes or know someone who does, look out for Diabetes Lifestyle and get a copy. This magazine is just packed with really useful information. I have learned a few things going through it and I am sure you will to.

Thanks Michael Brown for making this possible.

Managing severe hypos well

2010-04-25T23:07:00.000+02:00

A skill worth mastering
Managing hypos well is a crucial part of coping with diabetes. This is a skill worth mastering as better managed hypos are less disruptive and less likely to get to the point where you need assistance.

Standard advice doesn't scale to handle sever hypos
The standard advice given for managing hypos is good. It draws that fine line between treating and over-treating a hypo well. However in my opinion it fails in one important aspect. It doesn't scale to handle severe hypos. I have come up with two additional guidelines that I use that extend the standard advice so that it handles sever hypos to.

Disclaimer
These guidelines have been tried and tested by me and I have been using them for years. They work well for me, but if they don't work for you, then you should either adjust the guidelines or stop using them.

The quick acting carb you use is important
The second guideline is completely dependent on the speed of your quick acting carb. If your quick acting carb is not quick enough, this guideline will not work. Chocolates and fructose are not fast enough. (You can get away with using a chocolate when a hypo is mild but you will be completely unequipped if you encounter a severe hypo.) The quick acting carbs that I use that work are Fizzers, Super C's (glucose tablets), Jelly-babies and Coke.

Guideline extensions

If your reading is below 3.0mmol/l (54mg/dl) double the amount of quick acting carb I.e. take 30 g of carbs immediately.
If you take a second reading that is less or the same as your first reading and this reading is at least 3 minutes after the first reading then, treat again.

Explanation
The point here is to identify the normal hypo from the hypos where your blood-glucose trend is rapidly approaching zero as soon as possible.
If your first reading is below 3.0 then your blood glucose is likely to be dropping quickly and will require more carbs to treat. I.e. 15g of carbs is required to slow down the drop, and 15 g of carbs to correct the level.
If you are using a quick acting carb and you have treated the hypo successfully, then you should already start to see an improvement 3 minutes after treating. I.e. you blood glucose will already have started to rise. If this is not the case then your blood glucose level may still be on a fast train to zero and you will need to treat again.

Example of how quickly these guidelines scale
I suddenly feel very shaky. I know it's a hypo and it feels bad. I reach for my test kit and test. My blood glucose is 2.8mmol/l. It's below 3.0mmol/l so I double the carb and take 30g of carbs immediately. Things seem to be ok for about 2min's but then suddenly I feel worse. I test again and this time my blood glucose is 2.7mmol/l. It is 3 min for my previous reading and I ate a significant amount of carbs. My blood glucose should already be showing an improvement. I treat again. Because my blood glucose is still below 3.0, I treat again with 30g of carbs.
I am 4 min into my hypo and I have already consumed 60g carbs. The standard advice suggests that I should at this point only have eaten 15g of carbs. I have just saved a trip to the hospital.

If you have just had one of these severe hypo's and you don't know why, then you should probably contact you diabetes educator/team for advice.

Background
I have a black belt in managing hypos. I achieved this the hard way and that is through lots of experience. For about a year and a half after being diagnosed I had an average of one hypo a day. I could have compromised and managed my diabetes at a higher level where I would get less hypos but I was determined not to. Instead I put all my efforts into managing hypos well and fine tuning my diabetes management. I now no-longer have frequent hypos but the skill I have learned I still find very valuable.

Tomato sauce light

2010-04-16T00:46:00.000+02:00

I have been able to get away from work for a few days. I really needed the break and it was great to get away. But... (there is always seems to be a but) there is nothing like a hotel breakfast buffet to remind you of all the foods you cannot go near. Even the food that I normally would eat with no problem in a hotel buffet you just cannot go near. Everything seems to be laced with sugar or the like. I didn't go hungry as there was plenty of food that I could eat, but there were also large sections that I just needed to avoid.

This actually came as a bit of a shock to me. The reason being that somehow I had managed to convince myself that I could almost eat anything. This is mostly true when you can do the shopping and select the more diabetic friendly brands. Then it occurred to me...

Self censorship
I have been undergoing a certain amount of healthy self censorship. When I walk down the shopping islet there are certain sections that I just don't see clearly any more. The sections with foods and brands that I have learned are not good to eat if you have diabetes. Take the tomato sauce section as an example. As I make my way up the islet and my eyes move over countless rows of sweet tomato sauce; they kind of blur and loose focus a bit. When I get to the rows of mayonnaise everything is back in focus. I hardly notice and I miss nothing; or do I?

It took reading through a recipe on the internet to even know that such a thing exists. I started looking and there is was... Tomato sauce light.

Certain products just make living with diabetes so much easier.

Nanotech vaccine cures type 1 diabetes in mice

2010-04-15T23:25:00.003+02:00

Canadian researches have found a vaccine that cures type 1 diabetes in mice.
Check this link out: JDRF: New Vaccine Safely Stops Beta Cell Attack
and this link: Popsci: Nanotech Vaccine Successfully Cures Type 1 Diabetes Mice

This is not the first time that type 1 diabetes has been cured in mice. The difference here is that this looks like this may become a realistic cure. (Other cures have required permanently taking immune suppressive drugs. One of the common side-affects of these drugs is type 2 diabetes. That is just twisted.)

This cure is a vaccine. I.e. it teaches your immune system to fight the bad immune cells that are attacking the beta pancreas cells. Your body does all the work.

Introducing the catch 22 of type 1 diabetes - hypos

2010-03-29T21:03:00.001+02:00

Hypos the toughest part
Hypoglycemia or a hypo is the toughest part of living with type 1 diabetes. It is scary because it can result in a very real and sudden loss of control. The symptoms of hypoglycemia can sometimes be too severe and sometimes not sever enough. All scenarios are scary and disruptive to our lives.

Fear of hypos
The fear that results from someone experiencing a severe hypoglycemic episode can lead to a looser blood glucose control.

Catch 22
I don't know if you have read "Catch 22". It's one of my favourite books. It is set in World War II and is basically about a group of guys who are stuck in a situation that none of them want to be in. They are forced into the situation and it is extremely dangerous. Simply put they are doomed if they do and they are doomed if they don't. What is interesting about the book is that they all do find a way out one way or another.

So here is the catch 22 of type 1 diabetes:

Tighter control leads to more hypos
The closer that you manage your blood glucose to normal levels, the more hypos you are likely to have. This has a quadratic relationship. I.e. the number of hypos increases a lot more than the improvement of your control.
Looser control leads to less hypos
Some people with type 1 diabetes reduce the number of hypos by managing their blood glucose levels higher.
Looser control increases risk of permanent hypoglycemic unawareness
Permanent hypoglycaemic unawareness is the worst of them all. Looser blood glucose control can result in nerve damage that can cause permanent hypoglycemic unawareness.
Frequent hypos can lead to temporary hypoglycemic unawareness
This can be reversed by managing your blood glucose at a higher level and therefore reduce the frequency of hypos.

There are two ways out:

It is a question of balance.
Managing your blood glucose at a level where you are not getting hypos and also not getting highs. This is the option that the majority of doctors prescribe to and is the option that I follow.
Low Carb diet.
I am no expert here, but here is an interview with someone who is Dr Bernstein. I think that some of his ideas are a bit dated, but he also make some very valid points. He has type 1 diabetes himself and lives by what he preaches. It is worth knowing about. (Please read the comments too as these are very informative.)

Exercising with diabetes links

2010-03-28T20:59:00.000+02:00

It has been a while since I have searched the internet for sites discussing diabetes and exercise. This time I found three great sites. I am impressed and I want to share them with you.

The first and the best is the Australian institute of sport.
I particularly like the page discussing sport nutrition strategies for people with Type 1 diabetes. This page is filled with information. I would like to touch on a few points that I particularly liked.
They mention in detail the high you get on race day because of nervousness. I have experienced these. They are a bit irritating but normal.
Let me explain. The last time I experienced one of these spikes was just before my 94.7 road cycle race. I woke up at 3:00 am before the race to have breakfast. I did this because my start time was at 6:30am and I wanted the insulin bolus to be mostly out of my system before the race. My appetite at 3:00 am isn't the best so I force the food down before climbing back into bed. Later at 6:00 am just before the race, I measure my blood glucose and it is 10.0 mmol/l. It's because of the adrenalin pumping through my veins because I am nervous about the race. I take a corrective bolus. So much for starting my race without insulin in my body.
I digress. Another point I liked was that you shouldn't compromise carbohydrate intake to reduce blood glucose on race day. I.e. you need to eat on race day, so take insulin to get your blood glucose down.
A point I didn't know about is that insulin is a banned drug in competitive sports. It is an anabolic agent and therefore can aid athletes and can be abused. If you have type 1 diabetes you can still compete, but you will need to get approval first.
The second best site is Hypo Active (cool name). They have a very useful tips section that is full of information. I also particularly like their research section. There is a lot of ongoing research about diabetes, and this research often isn't passed to the people who need it most. I.e. the people who are living with diabetes. Its worth taking a visit.
The last site that I found is the DESA - Diabetes Exercise Sports Association I particularly like their list of interview they have with pro athletes. They are both informative and inspiring. Unfortunately the site seems to be new and incomplete as there are many missing links. It is still worth a visit.

Exercising with type 1 diabetes getting started guide

2010-03-17T22:06:00.000+02:00

This guide is intended to empower those starting out so that they can approach exercise with confidence and avoid some of the mistakes that I made.

Some background first
Soon after I was diagnosed with type 1 diabetes I decided to return to my regular exercise routine. I was very nervous about starting out. I suspected that I would not cope and would have to give up endurance sport. I asked everyone for advice but got very little. I got some advice on the internet, but there was a lot less information out there than I had hoped to find.
"Everyone responds differently to exercise. We don't know how you are going to respond. Good luck." This seemed to be the underlying theme in all my research. It didn't install much confidence. Everything up until then seemed to be an experiment with myself as the guinea pig. I was tired of being experimented on and this was going to be the ultimate experiment yet.

Experiment gone wrong
This is what I did:

I figured that I would need about 15g of carbs to supplement the exercise I was about to do.
I measured my blood glucose to make sure that I was in the recommend range. I was.
I ate my 15g of glucose and started exercising.
My plan was to test during the exercise so 15 min into the exercise I stopped to check my blood glucose. My blood glucose had gone sky high from the glucose.

It turns out managing type 1 diabetes with exercise is not as hard as I had first thought. Despite my first attempt not going well I have become quite good at managing my blood glucose with exercise. I got there in incremental steps. I have surpassed my expectations and continually set newer harder goals for myself.

Why exercise?
Regular exercise can make the body more predictable. With regular exercise, stress and mood have less of an effect on your blood glucose. For me regular exercise reduces the unknown / random effects on my blood glucose. In addition you generally feel better and your body functions better with regular exercise. Exercise has a way of keeping things in balance.

There are no limits
The doubts that I had in the beginning were unnecessary. There really are no limits when exercising if you have type 1 diabetes. You can go for that run around the block. You can run a marathon or an ultra marathon. You can cycle a 100km road race. You can do a gruelling 9 day staged mountain bike race. All you need to do is learn how.

You are not at a disadvantage
There are many professional athletes who have type 1 diabetes. Here are some links. You are not at a disadvantage if you have type 1 diabetes.
Personally I am a stronger cyclist after being diagnosed and I think the reason for it is the better disciplined eating. My friends were the first to point it out and my first 94.7 road cycle race (94.7km) after being diagnosed was my best time ever (2hrs 32min).

Getting started guide for exercising with type 1 diabetes

How much exercise?

Exercise must be regular
Exercise affects your insulin resistance. I.e. the amount of insulin your body needs. So if you don't exercise regularly, your insulin resistance changes all the time. This is an impossible situation to keep under control and you are likely to be better off not exercising. For me the least amount of exercise I can do without having my insulin resistance change, is three times a week. I try not to let more that 2 days go by without exercising. This is the lower limit and plans are often cancelled; so what I recommend is for you to plan to exercise 5 times a week. This way when you have a week where everything goes wrong and plans are cancelled, you will still have exercised 3 times a week. This may seem excessive and/or impossible but I can assure you that it is not. The secret is to make exercise part of your life. In my opinion the benefits of exercise far outweigh the effort.
Making exercise part of your life Many people have tried to exercise regularly and failed, yet some haven't. In my opinion there are two ingredients that are necessary to make regular exercise part of your life. This doesn't mean that you need any of them to start, but once you start you should be looking for ways to meet them.
- Exercising needs to be convenient. You need to be doing your exercise very close to home or work and at a time of day that is least disruptive to other activities. For me I exercise 1 min from home and I do it at 5:30 in the morning.
- You need to exercise with someone or a group. If you are exercising with someone, you feel like you have let them down if you don't pitch. Exercise with someone is also more interesting, social, a distraction from the pain and might make you push your limits. Exercising on your own is just harder.
Minimum duration
You may need to have a minimum duration of one of your exercise sessions per week. For me I need to have one exercise session that lasts greater than an hour. If I skip this I find that my insulin resistance changes.

The effect of exercise on blood glucose

During exercise

Exercise will normally cause your blood glucose to drop slowly. The rate at which your blood glucose drops will change depending on the type, intensity or duration of exercise. This is a lot easier than it sounds. Firstly this effect is gradual so you have plenty of time to test and correct. Secondly the different types of exercise are similar so you can base the new type on the old and test and correct accordingly. Thirdly the effect of changing intensity is intuitive. The more intense the exercise the quicker the blood glucose drops.
Sometimes your blood glucose can rise during exercise. This is because of adrenalin release during exercise. This effect usually won't continue for more than an hour after which your blood glucose will start to drop. You can normally ignore this effect in your management plan. If you are getting this and you are concerned, check with your diabetic educator on what precautions you need to take if you are going to take insulin and exercise.
After exercise
Exercise decreases your insulin resistance. Your body is going to need less insulin after exercise. If you are on a pump you can reduce the amount of insulin your body is getting (by adding a temporary basal). If you don't have a pump your blood glucose will drop. The blood glucose will drop faster and for a longer period that it did during the exercise. This is typically the most difficult part of managing your blood glucose with exercise. The rate and duration of this effect changes with different types of exercise, duration and intensity.
Exercise safely
There are times when exercise is not safe for people with type 1 diabetes. The medical profession has a list of guidelines that will ensure that exercise is safe. Follow these guidelines.

Starting out

Start short and gradually increase I recommend that you start small and gradually build up the exercise. You will need to test frequently so that you know what is going on. You must spend time trying to understand what is happening so that you can learn from the results. If need be you may need to modify your plan.
15 minutes of exercise is unlikely to require any management of your blood glucose, so start there. 45 minutes of exercise is a decent amount of exercise and will require management of your blood glucose after exercise but probably not during the exercise. Gradually extend your exercise time from 15 minutes to 45 minutes. All the while you are learning how to manage your blood glucose after exercise. This is the hardest part. You can do a lot of exercise in 45 minutes so stick with this for a long time before extending the duration further. Radical management of your blood glucose is normally only required when you exercise for longer than 45 minutes. Become an expert at the 45 minutes exercise before you take it further.
When to exercise
Choose a time when blood glucose control is good. Personally I will exercise anytime of the day. However if you are staring out or are concerned about your blood glucose during exercise, then you may want to consider the time you exercise more carefully.
Choose a time when you are most confident in your blood glucose control. There are two schools of thought regarding when to exercise.
- The first group say that you should exercise an hour after a meal when your blood glucose is naturally high.
- The second group say that you should exercise when you have the least amount of active insulin in your blood. This means that you would be exercising first thing in the morning, or at least four hours after you last bolus.
I agree with the second group, but you should choose the one that suites you.

Managing blood glucose after exercise

On insulin pump therapy: create a temporary basal
If you have an insulin pump this is easy. Set a temporary basal rate that reduces the insulin and the job is done. Some people may also need to use slightly less insulin than normal when eating a meal after exercising. I am not one of these people.
Using injections: eat small amounts regularly
If you are using the bolus/basal insulin injection therapy, then you should eat small amounts of carbs regularly without taking insulin. You can determine how much you should be eating and how frequently you need to eat by testing regularly.
There are other ways to manage your blood glucose after exercise, but I wouldn't use them when starting out.

Nutrition during exercise

When do you eat?
Nutrition during exercise starts to become important when you increase the duration and/or intensity of your exercise. For me that cut-off is about 1.5 hours for a training ride. Below the cut-off I won't need to eat anything during the exercise nor do I need to do anything else to manage my blood glucose during the exercise. If I am going to do 3 hours of exercise however, I will start eating long before 1.5 hours.
Why do you eat?
For endurance exercise you need to eat. If the duration of your exercise is long enough, your blood glucose will start to drop. If you are on a pump, you could re-adjust your basal rate to compensate for this drop. This actually isn't a good idea as you are likely to prematurely deplete your muscle glycogen reserves. I.e. you will 'hit the wall'. This is a mistake you are likely to only make once. It's bad. Sometimes you will adjust the pumps basal rate, but you should always eat.
What do you eat?
The type of food that you eat is exactly the same as what is recommended for people who don't have diabetes. So if you have recently been diagnosed with type 1 diabetes and you used to exercise before you were diagnosed, then your nutrition plan shouldn't have to change much. The biggest difference is that you need to be more disciplined. This means that you can take nutrition advice from other fellow athletes as the advice is equally applicable to someone with type 1 diabetes.
How much do you eat?
This varies depending on how fast your blood glucose will drop. I.e. it depends on the type, duration and intensity of the exercise and everybody is slightly different. If you are starting out 15 grams for every hour of exercise is a good guideline. You need to first work out how long you are going to exercise for, and then you can work out how much you will need to eat.
For me, I know that if I am doing a 4 hour training ride, I will need to eat 45 grams of carbs. If I am doing a 3 hour high intensity cycle race, I will need to eat 60 grams of carbs. Always take more food than you are planning to eat. (I have been on a few 2.5 hour training rides that ended up taking 5 hours.)
Timing?
The timing is slightly different depending on the type of food you are eating. There are broadly 2 type of food people eat during exercise. The high GI (quick acting or simple carb or sugar), and the medium GI (complex carb, slow acting food). I have tried both types and they both work. (Yes this does mean that on a 3 hour cycle you can slowly make your way though a bar of chocolate without feeling guilty.) The best approach is probably a combination of both types. Personally I prefer roughly one third of a medium GI carb and two thirds of a high GI carb which I drink.
- Reactive management With the high-GI foods you need to eat small amounts regularly. You wait for your blood glucose to drop, and then you top it up with a fast acting carb. The disadvantage with this approach is that if you forget to eat/drink often enough you may have a hypo. Also if you cannot see how much you are drinking (e.g. a Camelback) you may over do it and go high. My plan when I have used a high GI carb has been to wait until I am 45 min into the exercise. I then eat/drink the required amount of carb evenly during the remainder of the exercise.
- Proactive management With the medium-GI foods you need to start eating earlier. You expect your blood glucose to drop, so you eat a medium acting carb to compensate for the drop as it is dropping. You can eat small amounts regularly, but this is not as critical as when eating a high-GI carb. When I am exercising with a medium GI carb, I will start eating 20 min into the exercise, and then eat small amounts regularly and for the remainder of the exercise.

My exercise plans.

I am an insulin pump user and manage my exercise by eating and setting temporary basal rates on the pump. Here are the basic plans that I have put together for managing exercise. I think they may be useful as a guide when putting your plan together. If you are not an insulin pump user you need to read the temp basal rate's duration and percentage as the extent and rate at which the blood glucose drops.

Exercise	Intensity and duration	Blood glucose during exercise	Blood glucose drop rate after exercise
Anything	15 min	BG is stable/unchanged	Small enough not to need a correction
Anything	30 min	BG is stable/unchanged	2 hours, 30% basal rate.
Step / kettle-bells / spinning / weights	45 min medium to high intensity	BG is stable. Basal rate unchanged.	4.5 hours 30% basal rate.
Running	45 min medium intensity	BG drop rate is small. Basal rate unchanged.	4.5 hours 30% basal rate.
Circuit	45 min high intensity	BG rises. I normally choose not to compensate for this rise.	4.5 hours 30% basal rate.
Cycling	1 hour	BG drop rate is small enough not to have to compensate for. Basal rate unchanged.	4 hours, 30% basal rate.
Running	1.5 hours medium intensity	BG drop rate is medium. 75% temp basal rate and require 20 g of carbs.	5 hours 30% temp basal rate.
Cycling	2.5 hours medium - high intensity (training ride)	BG drop rate is small. Require 20 g of carbs during exercise. Basal rate unchanged	5 hours, 30% temp basal rate.
	2.5 - 3 hours high intensity (race day)	BG drop rate is small. Require 60 g carbs during exercise Basal rate unchanged.	8 hours, 30% temp basal rate.
	4 hours medium intensity training ride.	BG drop rate is small. Require 45 g carbs during exercise Basal rate unchanged.	8 hours 30% temp basal rate.

Exercise and insulin resistance

2010-03-07T19:58:00.000+02:00

It is amazing how much exercise affects your insulin resistance.

Because of my recent injury I have been unable to exercise. Normally I exercise regularly which is why I have a low insulin resistance. Stopping exercise has meant that my insulin resistance has changed. It is amazing by how much my insulin resistance has changed.

Every single ratio or basal amount has had to change, however most notable change was my evening bolus carb – ratio. In a period of 2.5 weeks my evening bolus carb-ratio changed from 20 grams / unit insulin to 10 grams / unit insulin. That is double the amount of insulin for the same carb meal. This is quite a scary change.

I have recently started exercising again and my evening carb ratio has changed once again. It is now at 15 grams / unit insulin. I still have some way to go before it is back to 20 grams / unit insulin.

Popcorn’s like eating pizza

2010-03-06T12:01:00.001+02:00

Popcorn has always been one of my favourites.

High in carbs
After I was diagnosed with type 1 diabetes it occurred to me that popcorn would be an idea snack to eat. I was quite surprised when I found out that it is quite high in carbs. I had always assumed that there was almost no nutrition in popcorn.

Low GI: a problem
It turns out that popcorn is not an ideal snack. Popcorn isn't easy to eat and I have made many mistakes trying. I could only get it to work if I ate small portions. I have finally figured it out. Popcorn is like pizza. It has a very low GI and doesn't match the rapid acting insulin's action profile. This is not at all what I expected.

Dual wave bolus
Fortunately I am on an insulin pump so I am able to use the dual wave bolus. 50% upfront and 50% slowly released over an hour and a half does the trick. Now I can eat popcorn again. No limits. It's great.

Old but not wise

2010-02-16T14:36:00.001+02:00

Recognise any of these pictures? The classic over the handlebar wipe. If you are a mountain biker it is likely that you have experienced this in one way or another.
Last week end this happened to me. It is not my first time that I have gone over the handlebars, but it's the first time that I couldn't pickup up my bike afterwards. I really hurt myself this time.

I was going fast and I landed well, but still managed to pull every muscle connected to my shoulder and break a rib in the process. This last week I have been unable to drive, I have been taking very strong pain killers and just generally feeling sorry for myself. It is amazing to me how quickly you can hurt yourself, and how slowly it takes to heal afterwards.

Was I too confident?
Am I just older now so I take longer to heal?
Was I just unlucky?
All of the above?

One thing I have learned is that you should be prepared to bunny hop anytime; even if you know you shouldn't need to.

Red tape

2010-02-05T17:07:00.002+02:00

Oh how I hate red tape. I try and avoid red tape at all costs. This is the reason why my ID book is old and falling apart and I still have not applied for a new one.
Since I have been diagnosed with type 1 diabetes I have been forced to confront this lifelong avoidance. The red-tape I am currently working through is procedural run around you get when you are on chronic medication through a medical aid scheme.

This is what I have learned:

Know the rules.
Find out the rules they never tell you about and work the system.
Sometime you just need to jump though the hoops. There is no point in getting upset as it doesn't change anything. It is just the system. Just put your head down and start jumping. (You are likely to have to jump through the same hoop many times.)

My first taste of the red.
After being diagnosed I wanted to join a diabetic center. To join I had to first be on the medical aid's chronic scheme. To get on the chronic scheme my doctor first had to ensure that my medication was correct. He insisted that I was on the medication for a month before he would fill in the application. So ... I waited a month, then joined the chronic scheme. Once that had gone through I could apply to join the diabetic center. You can see I was an amateur then. This is what I should have done. Fired my doctor and gone to a doctor belonging to the diabetic clinic and got the center to process the chronic medication and application without waiting. Scripts can always be changed once you're on the chronic medication scheme.

My second taste.

I arrived to pickup my chronic medication only to find out that I was too early. I always pickup my medication around that time of the month except for the previous month where I was extremely busy and had to push my resources to the limit. Luckily my pharmacist was kind enough to explain to me how it worked. (The rules they don't tell you about.) Chronic medication is not monthly, but becomes available 25 days after the previous collection. This I did not know. So ... all I had to do was collect my medication 5 days earlier every month until I was collecting at the same time of the month as previously. (Working the system.) One extra trip that month and I was wiser. I felt empowered and ready to handle anything, but nothing could have prepared me for what was to come.

Just keep jumping.

I arrived to pickup my chronic medication only to find that I was expected to pay in a large portion of the medication cost and the pharmacist told me that this was an error on the system of the medical aids new clearing house and that I should contact the medical aid to get the error fixed. I chose to cancel the transaction and speak to the medical aid. Once back at the office I engaged with the medical aid only to find that they couldn't find any error on the system and that I had over spent the yearly limit of the last 14 months none of which made any sense. In order for the medical aid to workout any more they required me to have the transaction opened on the system following which I contacted the pharmacist and asked them to re-open the transaction they agreed to but only for a few hours as this impacted their stock level and consequently the running of their business. I once again engaged the medical aid and asked them to look into the problem and they finally agreed that there was in fact a problem. They logged and enquiry against the open transaction and agreed to refund the pharmacist and the problem would be resolved in a day or two. The pharmacist was not happy with this news as it turns out they cannot accept refunds on their system they were also unwilling to leave the transaction open. So... I decided to travel once again to the pharmacist to pay the outstanding amount so that the transaction can be left open so that the medical aid enquiry could run and the stock levels at the pharmacy were not affected. I felt confident doing this as the medical aid had admitted to making an error. I phoned the medical aid to ask them to refund me and not to refund the pharmacist they told me that it would not be a problem. I then went on holiday thinking that everything had been sorted out. I was wrong.
On returning from holiday I found out that the inquiry had run 5 days after reporting it and the problem had been fixed and they had refunded the pharmacist. I explained that the pharmacist could not handle refunds so the medical aid agreed that they would cancel the payment to the pharmacist but I needed to fax them the proof of payment. A day later it turned out that I had lost my slip and the medical aid could not cancel the transaction, but they informed me that the amount was on the pharmacists statements on statement 05 and that the pharmacist had already received their statements but they could not give me a copy because of confidentiality reasons. Another trip to the pharmacist revealed that the only person who could fix the problem was on leave and the statement number didn't make sense and that they had not received any statements for that time period yet would I return at a later date.

Exhausting isn't it...

I still haven't received my refund. I am preparing myself for the next visit to the pharmacist. I am sure that there are a few more hoops waiting for me to jump through.

GI - Glycemic Index Explained

2010-02-02T22:48:00.004+02:00

There seems to be a lot of confusion regarding GI. I would like to try and add some clarity, and explain why GI is important for people who are living with type 1 diabetes.

In summary

Fatty or oily foods may have a GI that is too low. This will cause a hypo after a meal. This is the most severe effect of GI for a person taking insulin.
Foods that are too finely processed (simple carbs) have a GI that is too high and will cause temporary high blood glucose after the meal.
Slight changes of GI don't have a significant effect. Knowledge of GI is important to avoid hypos after a meal (low GI) or excessive temporary highs after a meal.

Excel model graphs.
To help me do this, I have built an excel model of insulin action, carbohydrate absorption and the calculated blood glucose response. I have calibrated this model to provide a response similar to what I experience with my day to day meals. This model is not perfect but it is sufficient for my purpose.

Why is GI confusing?

GI is complicated and can be difficult to understand. For people who are on insulin, low GI food is 'bad' unlike for everybody else. Food labelled as 'Low GI' may not be low GI, but rather lower GI than the norm for that food group. e. g. Low GI bread is actually closer to medium GI and good for people taking insulin. There also seems to be a lot of incorrect data regarding GI. I think this is a result of GI being hard to measure. I have seen apples referred to as being high GI in one source and low GI in another. For me apples are medium GI. There are also two standards for GI. One normalised against white bread and the other normalised against glucose.

What is GI?
GI or the Glycemic index is the rate at which eaten carbohydrates are converted into glucose in the blood stream. You can immediately see why this is important for people taking insulin. Food with a high GI is quickly converted into blood glucose, and food with a low GI is slowly converted into blood glucose. (High GI causes after meal highs, and low GI causes after meal hypos.)

Why is it important for people on insulin to know about GI?

The insulin that you take has a specific profile that shows how quickly it becomes active in your blood. On the right is the absorption curve for Nova rapid insulin.

What people taking insulin want to do is match the insulin with the release of glucose into the blood. If the insulin released matches the blood glucose released into the blood perfectly, then your blood glucose will in fact remain unchanged after a meal. If the blood glucose released doesn't match the insulin released in the blood, then your blood glucose will either rise or fall depending on whether it is higher or lower GI than the insulin release curve.

In all the examples below I have assumed that the carb counting is perfect and the exact quantity of insulin is given. (This is of coarse the most important part to get right.)

On the left is an example of a good match. i.e. the GI of the food matches the insulin release in the blood.

This is what we want.

On the right is an example of eating food where the GI is much too low. Note the severe hypo that occurs ½ hour after taking the insulin, followed by a high three hours after. This is exactly what happens if you take a balanced insulin dose before you eat pizza or under-cooked pasta. (The blood glucose graph ending high looks like the carb quantity and insulin are not balanced. This is not the case because I have modeled the effects of glycogen produced when the blood glucose is low.)

On the left is an example of eating food where the GI of the food is too high. e.g. too much white bread in the meal.

This results in a temporary blood glucose high after the meal. It is recommended that this does not exceed 10 mmol.

If you are on an insulin pump, then you have the luxury of changing the shape of the insulin release profile. On the right is an example of eating a low GI meal (pizza) and using the dual-bolus function. (50% immediate and 50% release consistently over 90 min.)

Here you are effectively changing the insulin release profile to match the GI of the food you are eating.

What foods affect GI?
The 90% of the carbohydrate absorption occurs just below the stomach. This means that 90% of GI is related to how the stomach works. i.e. How long does the stomach take to digest, and how quickly does the stomach empty out its contents for absorption?

Processed / refined / cut-up / cooked foods.

Finely processed food is higher GI as it is more quickly processed by the stomach. This is because finely processed food requires less mechanical-chemical breaking up by the stomach.

Lower GI	Higher GI
Whole	Fine
Raw	Cooked
Solid	Liquid

Oils/fats, soluble fibre and insoluble fibre lower GI

Oils/fats, soluble fibre and insoluble fibre all interfere with the stomachs ability to mechanically and chemically break the food up. Although none of these foods affect your blood glucose directly, their presence makes the stomach process what else is in the stomach slower. They lower the GI of food eaten with these foods. e.g. Adding bran or olive oil to your meal will lower the GI of that meal.

Liquids increase GI

Liquids make the stomach empty out its contents faster. Liquids effectively higher the GI of the food you are eating. The timing of the liquid is important. e.g. Drinking a drink before your meal will higher the GI compared with drinking the drink after your meal.

How fast you eat

You can lower the GI of any food or drink by just eating or drinking it more slowly. There are practical limits to this. (Try eating a bar of chocolate a nibble every 5 sec over a 3 hour period. This just is not possible.) Jokes aside the basic idea has some merit. e.g. If you are having a glass of sweet wine with your meal and you are particularly concerned with its GI. Drink it slowly over 30-45 min. You have effectively reduced its GI considerably.

Don't confuse GI with GL
GL or glycemic load is not a concept that is useful for people taking insulin. (Strangely this is a useful concept for people who have type 2 diabetes and are not taking insulin.) What is important for people taking insulin is foremost the carb-counting, and secondly the GI.

References

I found a good reference on the subject of GI.

Physiological Effects of Dietary Fibre
Digestion, absorption and energy value of carbohydrates

Accu-Chek dietary guide

Impressed, intimidated and then inspired

2010-01-26T08:14:00.002+02:00

Why did I start this blog?
Living with diabetes is sometimes hard and it feels good to share. I also believe that I have something good to add. I am good at simplifying complicated things and living with diabetes is complicated.

New to blogging
I am new to the blogging scene. This is my first blog and until now I have not actively read any blogs either. After starting my blog, I thought it prudent to look at other blogs like mine.

First impressions
At first I could not believe how many there were. I am definitely not the first to think of starting a blog about living with diabetes.

Impressed
When I looked more closely I was not only impressed but I realised that I too had a lot to learn about living with diabetes. There are some good inspiring blogs out there.

Intimidated
Why should I continue to blog then? There is already a lot of good stuff out there. Would my blog meet the standard that has been set? I was completely intimidated.

Inspired
After some thought I decided to continue with my blog. The standard is high, but I will try to meet it. I also believe that I have a different perspective to offer.

I have been inspired to reach for the stars.

Thanks Jim: Jim Huck's Blog

Type 1 diabetic quick start guide.

2010-01-17T23:23:00.014+02:00

In hospital newly diagnosed with type 1 diabetes quick start guide.

What I would like to have been told:

Some background first:

I am fortunate but unimpressed.

When I was diagnosed with type 1 diabetes, I was treated in a private hospital and had a very experienced doctor. Despite this, however I rate my experience as mediocre. There were some good parts and some bad. My main criticism is that there was a lot missing. A few suggestions / good advice would have made the discovery of how to manage this condition much easier. I can only imagine how hard diabetes must be for those who are not as fortunate.

Information up-front is better.
I got the feeling that some of the health professionals were trying to protect me emotionally by holding back information. I believe this is wrong. Diabetes is a shock and forces you to change you and your family’s lives. Information is empowering. It provides answers when you need them. Limiting information is only going to make the problem worse.

Filling the gaps

The advice I have put together below is not intended to replace any of the advice you are getting from your professional medical team. It is intended to help fill some of the gaps in their advice. Some of it is just common sense but it is nicer to have it spelled out to you rather than to have to figure it out by yourself.

So... here it is. You have just been diagnosed with type 1 diabetes. This is what you need to do:

The type 1 diabetic quick start guide:

Psychological:

Inform your friends immediately (as many as possible). Don’t neglect this as it becomes harder with time.
Be realistic. Without insulin therapy, you will not survive. Without well-managed diabetes, you are unlikely to live for more than 15 years with the last 5 years being most unpleasant.
Be motivated. It is possible to manage this condition effectively and have a normal life. I have done it and there are many others who have done it too.
Take ownership. I initially assumed that because I was in hospital, I would be cared for and the diabetes would be managed for me. Nobody will manage diabetes for you. It is up to you to do it.
Don't delay. The sooner you start to get this condition under control, the sooner you will start to feel better.
You are not alone. Talk to other patients with diabetes. It helps.

Reference:

Read all the brochures. This is the part where my experience was good. Accu-check has an excellent series of brochures. They are also available on-line at https://www.accu-chek.com.
Get a good diabetic reference book. You need a good reference. It is good to reaffirm concepts and to learn about issues that may come up before they do. I recommend 'Type 1 Diabetes: A Guide for Children, Adolescents, Young Adults--and Their Caregivers, Third Edition'.
This really is an amazing book it covers both the big issues and the small. Of all my recommendation this one is the one I rate the most highly. I have yet to meet a diabetes-nurse / educator / doctor who has a few of these books in their bottom draw for their patients. I may have just been unlucky so it is worth asking your diabetic nurse / educator / doctor.
Get a book that shows carb content. The book needs to include the carbohydrate content of local food product brands.

Nutrition:

See a dietician. You are about to become an expert in food. Unless you have some other medical condition, your immediate priority should be to get your blood glucose under control and that requires balancing your carbohydrate intake with insulin. Be clear about what advice is specific for controlling your blood glucose and what advice is just a general health tip. You need to take the blood glucose advice more seriously. In my experience I was told that I should not eat chips and to be careful about drinking fruit juice. I nearly cried. Not eating chips turned out to just be a good health tip as I manage to eat chips quite easily without disrupting my blood glucose. (I do have to restrict the portion size and carb-count the chips to get it right, however). Being careful when drinking fruit juice is good advice.
Start learning to carb-count immediately. You cannot manage diabetes effectively without carb-counting. Insist on this. Find a dietician that will teach you or teach yourself from brochures. I did.
Purchase a good digital food scale and start weighing your carbohydrate proportion of your food. Weigh first learn to estimate later.
Low carb meals. You may want to consider a low carb diet. Personally, I am not a fan of this option because I just love eating carbs too much and I do a lot of exercise. You can control your blood glucose without a low carb meal plan; however, with a low carb diet it is a lot easier. If you are considering this option I recommend that you get advice from your doctor and dietician so that you can do this safely.

Diabetic education

Needles. Make sure you get to see a diabetes educator. They will show you how to inject yourself. I used to think that it was impossible to inject myself. I was wrong. The first injection is hard, but practice makes perfect. In a month, you will have done this more than 100 times. You get really good at it and it becomes a non-issue.
Testing. The basic rule for testing is to test when you least know what your blood glucose is. If you are not feeling 100 %, you should test. There are three standard testing times although you are unlikely to want to test at all of them every day. You should choose a testing time to help with what you are least certain. E.g. if you have just eaten a large carb meal or are uncertain about the amount of carbs in the meal or you are uncertain about your carb ratio for that meal, you will want to do the 2 hour test after the meal and might even do the test before the next meal.
Another important rule is it to know why you are testing and what to do with the result. There is no point in testing for the sake of testing. What you should do with your test results may vary between patients. What I recommend is that you put together a plan with your diabetes educator detailing what to do with each test reading. This is what I do:

Testing before meals.
There are two reasons why I test before meals. The first is so that I can use the reading to help adjust the previous meals bolus (or evening basal for breakfast.) The second reason is so that I can include a correction when I calculate my meal bolus. (Ask your diabetes educator to help calculate this correction and the precautions you need to take when doing so.) The correction insulin amount can be added to your previous meal’s bolus. The correct carb-ratio can then be recalculated accordingly.
Testing 2 hours after a meal
The after-meal blood glucose reading should not be greater than 10 mmol/l. There are three reasons why my blood glucose can be higher than expected.
- I might not have taken enough insulin for the carbohydrates that I ate;
- My meal may have contained too many simple carbohydrates E.g. Too many finely processed foods or sugars.
- I took my insulin too late, relative to when I ate my meal.
It is not always obvious what to do if I get a higher than expected blood glucose reading. Sometimes I take a correction dose, but this can lead to a hypo later. It is often better to leave it and test later before making a correction.

If my blood glucose reading is lower than expected this could be as a result of:
- taking too much insulin relative to my meal time carbohydrate intake;
- eating a meal that may have been too high in fat. This slows down the rate at which my food is absorbed;
- eating my food too late after taking my insulin.
If I suspect I am low because of taking too much insulin, I will correct by eating some carbohydrates. You can eat simple carbohydrates when making this correction. This is a good time to have some chocolate.
Testing before bed
The reason why I test before bedtime is to ensure that it is safe to go to bed. If my blood glucose reading is a bit low, I eat some food to prevent a hypo while I am sleeping. If my blood glucose is very high, I sometimes make an insulin correction. When I do this, I will stay awake for 2-3 hours before going to sleep to test and ensure that I do not go low. You may want to contact your diabetes team for assistance here, as this strategy can be very dangerous if you do not understand the action profile of your insulin.

Putting it all together

Manage what you have control over well. Many variables influence our blood glucose levels. Some of them are under our control and some are not. These unknown elements make managing diabetes hard and sometimes seem impossible. You are going to get it wrong sometimes. The fundamental rule here is to manage what you do have influence over well in order to give yourself the best chance.
- Injecting: Waiting before removing the needle to ensure the correct insulin dose has been delivered, is probably the most important. Site rotation, selection and timing of the injections are also vital.
- Eating: Food is food. But, for a person with diabetes, food is also medicine. Eating food (carbohydrates) needs to be done as carefully as you administer insulin. The type of carbohydrate and the timing of meals are important. Carb-counting and meal-specific insulin:carb ratios are important.
Control first - lifestyle second. The idea here is to give yourself the best start you can by removing the variables of diabetes and sacrificing some life-style. You then add the variables back in one by one as you work them out.

Start by eating the same carbohydrate (same brand and same quantity) at the same time every day. I.e. you eat the same carbohydrate for breakfast everyday at the same time. The same goes for lunch, dinner and snacks (if needed).

By eating the same quantity, you have removed the need to know your insulin:carb ratios.
By eating at the same time, you have removed the need to know how your insulin:carb ratios vary with time of day.
By eating the same carbohydrate, you are removing the need to know how your body responds to different foods, different GI’s and errors in nutrition labels etc.
If you have a small error in your basal dose, you can compensate for the error with your meal bolus. This will only work if you are eating your meals at the same time and you are eating the same amount.

Keep the consistency and change what needs to be changed (food type or amount or insulin) slowly until you have control. Make changes slowly. You should probably wait at least for two consecutive days of bad readings before you change a setting. Start changing the variables when you feel confident. Change only one variable at a time. I.e. either change the food, or change the amount or change the time. Each change may come with an adjustment that needs to be made. Work with your diabetes educator when doing this. They will help you work out the cause and make the corrections (and connections) when things go wrong.

Exercise

Regular exercise can make the body more predictable. With regular exercise, stress and mood have less of an effect on your blood glucose. With regular exercise, there may be less unknown / random effects on your blood glucose. (This is purely anecdotal as I am basing this on my personal experience.) It is not a good idea to start exercising in the first few days after diagnosis, but you may want to consider starting as soon as your blood glucose levels are below 14 mmol/l and you have no ketones in your urine. I did and it helped. I am preparing a post that focuses on how to get started with exercising.

Diabetic always have bad/scary tempers? Why?

2010-01-05T08:21:00.003+02:00

Did you know that people who suffer from diabetes had awful tempers? Sometimes they are just scary to be with. They blow up at the smallest thing and it is probably better that you are not in the way when this happens.

Have you heard of this? I would like to think that this is not true but I have met a few people who not only believe this but actually live by this. This is of great concern to me because as a person ‘newly’ diagnosed with diabetes and living with a young family, I do not want to become ill tempered and unapproachable.

So where does this negative perception of people who have diabetes come from? How is it that their relationships got so bad? What can I do to ensure that I do not become that monster?

I have some ideas.

Element of truth

There is an element of truth to the claims. In my opinion these only account for 20% of the cases. As sufferers of diabetes we suffer from hypos, hypers and stress. Hypers make me feel just generally unwell. Hypos make me unaware and a bit abrupt. Insulin therapy although good, is still far from ideal and puts the body under a certain amount of stress. This can make you feel ill at ease. These can have the effect of making people with diabetes seem irritable and short tempered.

Let me provide an example. I initially suffered from frequent hypos. During a hypo I am undergoing damage control. I am trying to behave as normal as I can. During the hypo I am not aware of subtleties such as tone, body language etc.... The result is that I become a terse insensitive communicator.

Hiding symptoms

I have random bouts of hypers and hypos but I want to be seen as a normal person. So when I am having one of these symptoms I don’t tell anyone and just carry on as ‘normal’. You can get quite good at this. Often people around me are completely unaware of the situation.

The result of this being that others cannot tell whether you are having diabetic related symptoms or not.

Others start assuming that all bad behaviour is related to diabetic symptoms.

I cannot hide the symptoms completely. I am not as good at hiding the symptoms of diabetes as I would like to think, or sometimes the symptoms are too severe to hide. The people we spend time with identify that sometimes you are rude/etc... as a result of diabetic symptoms. They then may incorrectly start assuming that whenever you are rude that this is a result of a diabetic symptom.

Becoming the asshole/monster

Have you ever wondered why road rage can reach such extreme proportions, and why people don’t behave like that normally? One of the reasons for this is because we don’t get feedback when we are in our cars. If you walked up to a stranger and started swearing at them and calling them names they respond back to you in a similar way and if you don’t back down at some point the chances are that you are going to end up in a fight. This doesn’t happen in a car. The natural feedback that keeps these emotions/bad behaviour in check is not there. A similar issue occurs with diabetics.

When others assume that you are behaving badly as a result of diabetic symptoms, they don’t respond normally. They don’t give you that back off look and they aren’t rude back to you. The natural feedback that keeps bad behaviour in check is not there. If you suffer from diabetes you may not even be aware of how rude you are being. Unchecked this bad behavior can reach epic proportions.

Habit /crutch

As a person with diabetes you always have an excuse for behaving badly. We are all sometimes rude. If we are confronted it is easy as a person with diabetes to offer the ‘I wasn’t feeling well’ excuse, even if this was not the case. Behaving badly can become a habit.

I have tried to break this cycle of bad behavior. This is what I have done:

1: I communicate to those around me about my diabetic symptoms. I have explained to those close to me how I feel and what I am going through during each of the symptoms. I also discuss how others perceived me during these episodes. I was surprised by what they told me.

2: I have started letting others know when the symptoms are occurring. I try to let them know how long the symptoms will last.

3: I no longer use the diabetic symptom excuse when I am accused of behaving badly.

Tough festive season

2010-01-03T08:56:00.003+02:00

In December I was feeling very confident about my diabetes. It is one of the reasons why I was inspired to finally start this blog. However a day later and before I could add my first post my body's response to insulin suddenly changed.

I suppose it was not that unexpected as it happens every time I go on holiday. I was hoping that this year would be different if I kept my exercise up. I was wrong. It is surprising how much a change in stress can affect us.

It takes a couple of days to get the carb-ratio's correct. Throw in some irregular meals and a change to your sleeping patterns and exercise routine. It can take almost the whole holiday to get things stable again.

I am pretty much stable again just in time because my holiday is just coming to an end.

The season of holidays and festivities is a tough one for those living with diabetes.

My story

2010-01-03T08:50:00.004+02:00

All people who suffer from diabetes have a story of when they where first diagnosed. It is a traumatic event and it was my first introduction to diabetes. I have told this story many times and it is strange to me how important the story is. I suppose it is a way of saying that I am a normal guy and this was the curve ball that life threw at me.

This is my story
I woke up and I was thirsty. It was an ordinary day except for the stress. Stress! Yes I have probably never been that stressed in my life. I was Sleep deprived (my youngest son was 4 months old and hadn’t started sleeping through yet). I was under extreme pressure at work. Then there are the usual financial and relationship stresses you go through when raising a young family.

It was 5:13am and I was on my way to gym at my friend’s house. In recent years I had taken to doing regular exercise. It started as a healthy life style choice but is now probably bordering on obsession. I cycle mainly but that morning it was going to be circuit.

I was already thirsty at 5:15am. That was unusual for me but ... it was a hot day. I drank some water and went to gym. The thirst didn’t really go away.

Denial
It is strange how hard it is to accept that something is wrong. It took me 9 days before I went for medical advice. I clearly wasn’t feeling right because I started changing things. In those 9 days I gave up coffee. I started drinking Game (an energy drink to replace the electrolytes - How bad are our instincts sometimes?). I started eating breakfast (oats). I started taking magnesium for cramp.

Diagnosis
On day 8 I felt fatigued. I remember clearly feeling so thirsty that I drank water until I felt nauseas and I was still thirsty. Finally my wife said: If you are feeling sick then you need to see a doctor. I will make an appointment. Thank goodness she did.

I had the last appointment of the day, and after spending 45 min fighting peak hour traffic I was in the doctor’s office.

“So how can I help you?” I have been feeling thirsty I reply. “It has been pretty hot lately. You need to drink at least 2 litres every day.” I think back to the previous day. I think I have been drinking enough I reply. The doctor then tested my blood sugar and checked my blood for ketones. The tests seemed to take a long time (more than 15 min). I waited patiently.

“Mr Baker I have some bad news for you. Your blood sugar is very high 23.5 mmol. You also have ketones in your blood. You may have diabetes. You also cannot go home. You need to go to the hospital immediately. I have contacted the nearest hospital and the doctor on duty has agreed to wait for you. He will meet you at reception.”

I cried when I spoke to my wife telling her to meet me at the hospital.

Dealing with the trauma
There are a couple of things I know now. The blood glucose test takes 5 sec the ketone test 15 sec and Blood glucose reading of 23.5 mmol with my weight and build pretty much means that I have type 1 diabetes. The first person to confirm that I had diabetes was the hospital nurse that was admitting me. She insisted that I had to have diabetes because of the treatment that she was administering. I also lost 9kg of weight in those 9 days.

I spent most of the evening and all of my phone’s battery life reading up on www.webmd.com about the disease. I worked out that I had 0 of the risk factors for diabetes. I also convinced myself that I had type 2 diabetes. I cried again in the morning when I found out that I had type 1 diabetes.

Crying for your-self was a very strange emotion. For me in the shock of the events I let go and started feeling very sorry for myself. At the same I felt revulsion for the self-pity I was feeling. Shocked and wallowing in self pity and self revulsion. I am lucky it didn’t last too long. I still occasionally have bouts of this, but they are becoming very infrequent now.