What’s Workin’.

TotalsThere was time when anything over 30 total daily units on my pump meant I’d had a serious carb-heavy day. Like I must have had a bowl of ice cream, or a pasta dinner to warrant something in the upper 30s or GASP: 40 units! In one day! (Keep in mind everyone’s total daily units vary and this is not a commentary on the “right” amount of insulin, simply what I am used to).

Those days, honey, are long gone. The past few weeks, I’m a regular in the high 50s.  Sometimes I have a 60 unit plus day and I don’t bat an eye. I will crank that pump up until steam comes off. But as I hit the home stretch here of the last 10 (-ish? We might deliver early!) weeks it’s amazing to see how things done changed with my management. If I thought I had vigilance before, I’ve taken hawk-like monitoring to a whole new level. Our baby is measuring a bit big, despite me having a normal person’s A1c. And although this can simply be chalked up to the fact that both my husband and I were on the larger side as babies, I’m still trying to keep my blood sugars from having anything to do with it. Which means running through 60 units of insulin a day, occluding a few more pump sites than normal, and aggressively checking CalorieKing.com to make SURE I’ve got that carb ratio right. In the spirit of “I can do this damnit,” I thought I’d share a few practical tips, besides investing in Humalog stock, that are working for me during the last trimester of this pregnancy:

1.) Eating dinner no later than 7:30. This was a BIG change for Jacob and I. He and I work late and tend to eat late. Cooking together is our bonding time so we wait until emails are done and everything is buttoned up before we head to the kitchen to cook, catch up on the day, and dine. It was normal for us to eat dinner at 8:30 or 9pm. But since I struggled with overnight BGs, my doctor suggested eating earlier to 1.) have more time to fix a problem before bed and 2.) actually get to the problem (i.e. latent digestion issue, post-prandial spikes) sooner. It’s been hard for us but we’re consistently eating by 7:30 or earlier and it’s made a huge difference. It’s meant leaving emails to the next day and not always feeling “settled,” but it’s working. By the time I hop into bed (um….more like lumber and fall these days actually), I’m usually recovered from any issues and going into the overnight with steady numbers.

2.) Using my bolus calculator at times when I”m at higher risk for stacking boluses. For me, the mornings are when I stack boluses aggressively. I would get annoyed if my number started to drift up, feeling like it would ruin my day. Then I’d pile to much insulin on top of itself and end up low by lunch. Making sure I stop to actually plug in my BG and carb count prevents me from overdoing it too much, and that’s exactly what bolus calculators are for.

3.) Slashing carbs even more than before. Summer time is the best time for all my favorite fruits. I look forward each year to peaches and nectarines and watermelon. And those things aren’t totally off the list, but I’ve reduced all carbs in general, including fruit. I make sure to get plenty of nutrition for me and baby with tons of veggies, proteins, and dairy, but when I’m already taking this much insulin and still being resistant, I can help myself by downsizing the carbs. And don’t worry, I’ll make up for it after the baby is here!

4.) Walking every morning. I stopped running at 22 weeks (about halfway through the pregnancy) but exercise is key to keeping my BGs low and preventing me from using up an entire bottle of Humalog a day. It’s meant getting up much earlier on work days, and sometimes it takes a colossal effort to get my sneakers on and a leash on the dog but I have to move my butt every single day, no matter what. A brisk walk after a meal has also helped my insulin work harder and prevent post-prandial spikes.

5.) Doing my best to ignore the scale. This is a pretty hard one. I have gained weight! Already more than the recommended amount for pregnancy but I’m doing my best to not give a crap (easier said than done). Per my doctor, it’s more important that I keep my BGs as good as they are right now than worry about the weight that’s piling on due to taking so much more insulin than I’m used to. I don’t love this new body type on myself but guess what? It’s not about me anymore. And that’s totally worth it to me!

Hope you don’t mind sleeping at your doctor’s office….

If you’ve noticed I haven’t been blogging much these days, it’s because I actually now live at my doctor’s office. I have packed an overnight bag and some snacks and I now just literally live inside her office, strapped to one machine or another, giving blood samples for one reason or another, and generally habitating at the clinic. I’m going to start taking conference calls there and maybe set up some sort of kiosk to get more work done. It’s gonna be great! I don’t need a bed when I have this comfy exam table to sit on!

Seriously though…I knew having diabetes would mean a lot more monitoring for my pregnancy but Holy. Cow. Seriously I’ll move back in  to my home when fall comes….I think….

Yeah that’s a photo of all my upcoming appointments. And yeah that’s two pages of size 8 font. 10 weeks to go and already this baby has taken over my life!

 

Appointments

 

Crank it up.

Max BolusEveryone said it would happen this way. The books, the blogs, and all the doctor friends I have in my line of work warned me: starting at about 24 weeks your insulin needs are going to go up. Like way up. And they’re gonna keep going up until you deliver. So why I wasn’t mentally prepared for this change I don’t know but I wasn’t.

I saw my endo the same week I wrote that particularly depressing, down-in-the-dumps blog post about the guilt I was having with high BGs. Watching her well-trained expert eyes scan my CGM and pump download, I was reminded once again that it doesn’t matter how long I’ve had diabetes, it’s always good to have a (smart) medical professional on your team too. She took a look at one particularly ridiculous evening – the night Thai food had sent me soaring and taken twenty effing units to get back under control, and pulled out a calculator.

“I know this sounds crazy, but I’m calculating your insulin to carb ratio right now at 1 unit to 4 carbs.”

Yep. That did indeed sound crazy. Because I’ve been using 1:10 for several years, and 1:12 or less when I’m training for distance race and ramped up on cardio and now she wanted me to more than double down on that ratio? But we checked the math against some other examples and all signs pointed to “crazy” actually being “spot on.” Except that being that agressive made her nervous, so we split the difference at 1:7, essentially coming down halfway. We also slashed my correction factor by more than half, with one unit for every 20 mg/dL I wanted to come down. And to round things out, we bumped up my basals to an even unit per hour around the clock.

All the tweaks have added up to a much, much smoother past few weeks. Numbers are looking so much better but more importantly, I’m feeling much more in control of my diabetes. There were a few weeks there where I felt like I couldn’t win. And yes, the total daily units are climbing on the pump, but I’m trying my best to just be ok with that. Even if I gain more weight because of taking so much insulin, the baby’s weight is dependent on how much he or she has to output for insulin to combat hiighs. So the best way for me to prevent a big baby is to make sure that little munchkin doesn’t have to overproduce insulin because of a high that I caused. So, let the units pile up – as long as it keeps the BGs down. You’ll see the steam coming off my pump pretty soon with that motor in overdrive!

A Perk Up.

ExpectingI realize last week’s post was a bit down in the dumps on the whole pregnancy thing. There are many challenges to being pregnant with T1D, but I don’t want those negative feelings to ever overshadow the overwhelming joy and excitement that I have for this human patiently roosting in my belly. So I think it’s only fair to talk about some of the perks of being pregnant! Ladies and gentlemen, I present: The Top Awesome Things About being Pregnant.

 

 

Guilt for two.

Clock at 4amIt’s 4am, and I can’t sleep. No, it’s not the expanding belly I’m sporting or the crazy workday I have tomorrow that’s keeping me awake. It’s the fact that my blood sugar is still over 200mg/dL despite the fact that I’ve been bolusing every two hours since I went to bed at 10pm the night before. A complicated meal of Thai food was the source of the elevated numbers. Any night with highs is bound to create a poor nights sleep, but this one was worse. It’s worse because all I can think when my blood sugar is high these days is: I’m hurting my baby.

If that sentence reads like a gut a punch, then you’ve got an idea of what the actual feeling is when it’s happening. Pregnancy with diabetes isn’t just complicated because of all the added doctor’s appointments and instructions. It’s complicated because of the added emotions on top of what can only be described as the emotional Mt. Everest that is wrapping you brain around baby/parenting/OMG my future.

My A1c is stupid good right now – normal person numbers. I am exercising regularly. I have cut my coffee, added my vitamins, and never once been late to one of the 14,000 doctor’s appointments I’ve already had. But when my BGs climb, it literally feels like alarm bells going off in my head with a drill sergeant in the background yelling “WHAT THE HELL DID YOU DO – FIX IT! NOW!”

Yes, yes, I am only human. Yes, I am trying to manually control a totally unpredictable beast. But when it’s not just you on the receiving end of your decisions, the guilt burden turns colossal. At 4am, all I could think was what the hell was I doing eating Thai food? I know curry sauces have tons of sugar and fat in them! That was the worst idea! Chicken and salad for dinner for the rest of this pregnancy. Don’t mess up again! You KNOW better.” The issue is that anytime I don’t end up with the numbers I hoped for, the hindsight reads like a Choose Your Own Adventure book that I totally effed up. I could have ordered the veggie dish, not the curry. I could have eaten less. I could have bolused further in advance or used a better temp basal or extended the bolus. But I didn’t, and now I feel like I’ve done my child wrong.

I don’t have a fix for managing this guilt. I am buoyed by the fact that my overall A1c is great, and that my baby is developing normal and healthy. I have a husband who tells me all the time that he is proud of me, that I am doing a great job and that everything is ok. But there is the noise in my own head that I could always be doing more – making better choices or trying harder. I can’t sugar-coat (every pun intended) this issue and I cannot tie up this blog post with a pretty platitude about being grateful for the experience or learning to do better with this issue. It’s just hard and I can’t talk myself down from those feelings. I seek solace in the opportunity the next time to do better but it’s tough to focus on that at 4am lying awake with the click…click of my pump in the background delivering another bolus.

Motherhood will be full of all sorts of feelings I’ve never dealt with before, I know this is just one of them. Some of those feelings will be the best a person can experience. Some of them will just suck. This is one of them.

 

 

CHO with my coffee? Or nah?

carbsI’ve long struggled with my dinner-time bolusing due to the fact that 1.) Jacob and I tend to eat dinner pretty late (8pm is the regular), and 2.) we eat pretty low carb (good in the short term, but can be challenging as higher-fat, higher-protein foods digest hours later). When my endo and I discussed this for the 10th time at my last visit, she said perhaps I should pay a visit to the nutritionist on staff, just to get some fresh ideas and perspective. I gave that a big ‘ole “why not” and booked the appointment.

I had not been to see a nutritionist since I was 18 years old, when a woman who appeared to be in her mid to late 90s peered down her nose at me through her bifocals and told me I was not, under any circumstances, to ever drink any alcohol except for “one light beer with dinner.” Which of course led to me drinking only light beer throughout college in amounts far greater than “one with dinner.” This led to wide swings in my BGs as I let them go up with the carb-heavy beer so I didn’t drop too greatly when they caused a low hours later. If only someone had leveled me at that age about alcohol, carbs, how it affects your body and how to drink safely and smartly with T1, I would have saved myself from four years of weekends that consisted of 250s and 60s. So I had not really had a great experience with a nutritionist before, but in this new chapter of child-bearing I find myself in, I am open to new ideas. So I went.

The nutritionist was friendly and open. We reviewed the food log I had prepared and discussed challenges with my BG. Then I got overly defensive when I saw her reach for a book titled “Gestational Diabetes” and I started down the “I am NOT a gestational diabetic I have had Type 1 for twenty-” before she stopped me and said “Oh I know! I’m just pulling some fun menu ideas from this book, that’s all.” Chill. Out. Lex.

Most of our discussion was helpful, and it gave me a few new recipe/menu ideas. But there was one area I had trouble wrapping my brain around. She really wanted me to increase the number of carbs I was eating. In particular, at breakfast. When I asked her why, she first said it was important to ensure that both the baby and I get adequate nutritional value, which personally, I call total BS on. I eat a ton of veggies and proteins, as well as dairy and some fruit. I am sure we are getting the right nutrition, and isn’t my healthy baby and 5.5.% A1c evidence enough that what I am doing is working? (I kept that to myself, by the way).

But then she offered another reason for me needing more CHO at breakfast, and this is where I’m looking for ya’ll’s opinion. She said that not eating any or enough carbs at breakfast can cause my live to over-release glycogen stores throughout the day, leading to higher blood sugars. That, my friends, was news to me and if true, a compelling reason to add more carbs in the AM. But I’ve also never heard of this, and never had it recommended to me before.

Have any of you heard any truth to this? Here’s my skepticism: glucose release from the liver is one way we get energy – the other way being through the food we eat. In normal folks, once the body starts producing insulin, another hormone, amylin, is sent to the liver to say “Hey SHUT IT DOWN, WE HAVE ENOUGH SUGAR.” In T1 folks, we don’t make the hormone amylin, since it also came from our dead beta cells. So if I eat more carb in the morning, and take my usual artificial insulin bolus, that STILL won’t send any signals to the liver telling it to stop sending glucose, correct? My understanding is that signal is only sent when one produces their own insulin.

Thoughts? Feelings? Permission to have half an English muffin with my eggs tomorrow morning?

The Contraband List.

PIZZAMy A1c right now is 5.5%. Please take a moment to log that, remember it, frame it in your mind and put it up in the Trophy Case because IT WILL NEVER BE THIS LOW AGAIN (unless we eventually have another kid which also, please don’t ask me if we are going to because I seriously don’t know if I’m even ready for one).

When I met with my high-risk OB for a pre-conception meeting, I waltzed in there with a 6.2% smug as can be and boasted to her about my rock-solid A1c. She smiled, paused, and said “that’s great…I really need you below 6% for pregnancy.” This is not every doctor’s opinion, keep in mind. I happen to have an OB who is coming from the perspective that if I have a normal A1c, then I’ve zeroed out my risk in some ways – your doctor’s advice may vary. At any rate, I dialed it in even tighter and got sub 6%, found out we were expecting, and have maintained these crazy low numbers ever since. It has been, in short a $h!t-ton of work. Micro-bolusing, CGMing like a fiend, and cutting out any foods that could send me reeling have been my tactics.

Between the changes in my diet, axing all alcohol, and slashing my coffee consumption, it’s hard not to feel totally deprived some days. I feel like I’m in a constant state of restriction, monitoring, and denying. Parties have a different vibe, as does the innocent question of “where would you like to go to dinner?” Yes, of course it’s worth it, and yes of course I am happy to do it, and yes, I feel incredibly blessed to even be pregnant and that our child so far has been so healthy. But it is not easy and I’m the first to admit that. I am lucky to have an incredibly supportive husband who has made many of these changes right along side me, and the support of friends and family who don’t judge or ask questions but instead accommodate (“can I pour my Stevia-lemonade into a wine glass at your housewarming party so it looks prettier?” Yes, yes you can friend).

That doesn’t mean I’m not pining for some of my favorites. If you were to open my iPhone and check the “lists” section, you would find a list called “Food.” And yes, seriously, this is a list of foods that I will be dining on once I’m able to relax my standards a little bit (that would be September 8th, if this Munchkin arrives on time). Scroll down that list and you’ll find every T1s favorite problem foods: pizza, mac and cheese, sushi, ice cream, and even birthday cake made the list (honestly a box of that gross, fake, Betty Crocker yellow cake mix with chocolate frosting sounds SO FREAKING GOOD I CAN’T EVEN TALK ABOUT IT. Seriously don’t talk about it). The list helps remind me that this is temporary, and in just four and half short months, I’ll wonder what the big deal even was.

All of these will  have to wait until this little one finishes baking though. And truly I am blessed and lucky to have such an important job as to be the nest for a miracle. That doesn’t mean I don’t crave bagels though. Big, doughy, delicious bagels. OMG I have to stop. I wish a bagel store would make me a “one bite to go” bagel situation….

Duly noted.

Doctors these days are plagued with the burden of documenting more than ever. Each chart note must explain in graphic detail what was discussed, how much time was spent face-to-face, and exactly what mitigating strategies will be implemented for any high-risk behaviors or conditions. After 22 years with diabetes, I’ve racked up quite the file. Recently, my doctor’s office has started employing medical scribes to help with the documentation burden.

A medical scribe involves a third person rolling a little stand-up desk into the exam room with you and the doctor and typing literally everything that is said during your appointment, and then summarizing for your chart notes. It’s kind of like a court reporter in scrubs. With the implementation of this service, I’ve noticed some interesting changes in my chart notes. Mainly that there are details in there that I don’t recall being central tenets to our discussion, but somehow make it onto the final chart note. And oh, how I hope I am never judged as a person on my chart notes alone. Because if I was, then I would pretty much be a tired, overweight crankpot who doesn’t work out and eats beans before bed….presumabley to make my husband’s life as uncomfortable as possible?

Ladies and gentelmen, I present to you: Chart Note Highlights From My Latest Endo Appointment. Enjoy. I sure did.

Let us all hope we are never defined by our chart notes alone!

 

 

Product Review: Leaf & Love Organic Lemonade

Leaf and LoveLemme go ahead and tell you about one of the greatest injustices of our modern world: You are a normal person until one day, you take a pregnancy test that comes back positive. It is everything you ever hoped for and simply amazing.

And then you realize that for the next nine months, you will be giving up your two best friends in this entire world: wine and coffee.

Ok, ok sorry, I’m being pretty dramatic about this but it IS a bummer. Here you are, ready to celebrate your new little bundle and simultaneously TOTALLY STRESSED OUT because you will soon have a person that means more to you than anything in the world in your house. And to get that person there in a healthy and happy fashion, YOU Mama-to-be with Type 1 diabetes need to keep those numbers more ship-shape than you ever have before. And guess what? That is stressful. And on stressful days, I like two things: a ton of coffee and a nice, thick glass of red wine with my dinner.

You can have a little coffee while you’re pregnant – up to 200mg per day or about one cup. Which if you’re me, is approximately one one hundredth of my normal intake…ok not that much but it’s a downgrade, for sure. And wine, as with all booze, is totally off limits of course. Double downgrade. Trouble is, there’s not much I can replace these two things with either, given the T1D. Some women have sparkling flavored waters, or ginger ale, or juices and smoothies. All of these things usually have a lot of added sugar that I’m not willing to bolus for and try to manage. And the ones that don’t contain too many chemicals to count – things I don’t love even when I’m not pregnant but are more top of mind than ever. Basically my choices are water, soda water, and milk. I’m bored.

Then a nice person from a company called Leaf & Love emailed me and asked if I’d like to try their lemonade. The lemonade was created by two moms, one of whom has a child with T1D. It’s made with all natural ingredients, and sweetened with Stevia (which is considered safe for pregnant people, BTW). And truly, a look at the ingredients proves its authenticity: filtered water, organic lemon, Stevia, and a touch of Himalayn pink salt. They created this concoction in their own kitchens until it became so popular in the neighborhood that they started their company. They shipped me a box of lemonades…which are now gone.

They are gone because this lemonade is absolutely delicious, and only has two grams of carbs per box. Two grams! I don’t have to bolus for it and it tastes great. It is a life-saving alternative to the boredom of water, and is just the cold drink a pregnant chick needs as the days start to heat up more and more around here. Seriously, I love this stuff. And although not many retailers carry it right now, you can get I on Amazon.com in a 32 –pack case (I just ordered two). To top it all off, they also donate portion of their proceeds to the Insulin for Life campaign – how cool is that?

A wonderful find at just the right time – many thanks to Leaf & Love for the samples. Learn more at their website and order your own here at Amazon. And, because the folks over at Leaf & Love are so generous, they want to give you a special code to save you $3 on your order! Enter code SAVELOVE at checkout!

Hello, Panda. Also thanks.

We’ve all had lows at inopportune times. You’re in the middle of a great workout and you have to choke down glucose tablets while on the treadmill. Or you’re driving somewhere and you’re late only to have to pull over and wait the full 15 minutes for your BG to come back up. And we’ve all had those low moments where you’re so low, you can’t think straight, and you just want SOMETHING WITH SUGAR IN IT DAMNIT. Doesn’t matter if it’s a three-year old packet of honey or half a white-bread hot dog bun, you just need glucose.

Friday evening found me with both annoyances, as I shopped at a local Target for a few essentials. I had found my necessary items and was heading towards the checkout when I felt a little too light in the head, a little too much sway as I walked. I grabbed my CGM – 71mg/dL with a downward slanting arrow. Yes, I had glucose tablets in my pocket but I was at Target for crying out loud – THERE’S CANDY THERE. Especially by the checkout counters.

Trouble was, in the 20 seconds it took me to get up to the check stands to select my Diabetes Prize, I must have dropped a little more. I just felt foggy and crummy and I was starting to get sweaty and really, I just wanted to fix the low. In my haze I grabbed the first thing that said “Chocolate” on it, opened the package and finished the contents by the time I got to the front of the line. I handed the empty box to the cashier and simply said “sorry, I got hungry.” She could not have cared less by the way – I am sure she’s seen countless kiddos tear through far more than that in one Target outing.

It wasn’t until after I paid and started to feel a little better that I looked more closely at the package I had just devoured. Yes, there was chocolate inolved…and yes it did the trick and raised my BG…but um….what the eff  is this snack? And why didn’t I know about these before this moment?!

Hello Panda

 

Hello Panda, indeed. In case you were wondering, Pandas are GREAT at fixing lows.