Heard.

I hear: “Nice job on those box jumps this morning.”

I want to hear:  “I can’t believe you managed to use your temp basal rates to get through a tough workout even though you started class at 65mg/dL.”

I hear: “Enjoy your coffee!”

I want to hear: “I know this might raise your blood sugar a little bit, so go ahead with that half unit bolus right now before you take a sip.”

I hear: “Alexis, thank you for providing such detailed information in your last email.”

I want to hear: “Alexis, I can’t believe you wrote such a coherent email after being up half the night with a bad low and then a rebound high, and you STILL got up at 5am to get your training run in! Wow!”

I hear: “Thanks for bringing lunch to our office today.”

I want to hear: “Thanks for bringing pizza and salad even though I know it will take all of your willpower to not have a slice of this delicious pesto pie and you’ll just be sticking to lettuce since you are trying so damn hard to maintain that low A1c of yours.”

I hear: “Some bread would go great with this salmon/cheese/meat/cruciferous vegetable you’re buying!”

I want to hear: “It must be so hard to not have carbs very often, but I bet it’s paying off! You’re doing great!”

I hear: “Sounds like you had a good day!”

I want to hear: “I know it must be exhausting to do your job, train for this half marathon and be working harder than ever at your diabetes managemet. But you are doing the best you can and that’s good enough. You are good enough.”

 

 

Comfort Zone?

arrow downI meet a lot of patients in my day job, and I’m used to everyone having a different way of managing their diabetes, with individualized targets and goals. This is often reflected when speaking with patients about where they set their low and high thresholds on their CGMs (the thresholds are the low and high numbers that the device will alert them at, meaning that’s the number they want to “take action” at). Patients feel lows and highs at different numbers, and they also have different management goals that make customizing those alerts an important part of using a CGM effectively.

But one patient recently told me he sets his low alerts at 60mg/dL, because he’s perfectly fine working, exercising, talking, walking, and functioning in the 60s. In fact, he considers the 60s to be within his target range, and a zone he wouldn’t treat for a low BG, even though this is considered traditionally “low.”

And because being under 70mg/dL is traditionally considered”low,” this begs the question: if a person is fully functional, comfortable and happy in the 60s, is that ok to stay there? Aren’t we hurting our brain cells and denying glucose to our neediest organ in the 60s? There’s a reason that threshold of “low” is set at anything below 70mg/dL, and it’s my understanding that reason is to protect our brains. However, I know many folks without diabetes who have tested their BG on my meter and been in the 60s – usually pre-meal and hungry – and are feeling just fine. But those folks aren’t getting to that low zone by taking artificial insulin, and they have the proper counter-regulatory hormones in place as well if they continue to dip, so that’s not really a fair comparison.

If you were comfortable and functional under 60mg/dL, do  you think it’s ok let that ride and consider it normal? Or treat it anyways because it’s clinically in the danger zone?

Goes together like peanut butter and…chocolate frosting…

I love a good “diabetes hack” when I hear one – anything that makes this ridiculous disease a teeny tiny bit easier I’m game for. I found myself low on Monday night before bed, standing in front of an open fridge, and I was tempted to shovel 2 to 3 times the appropriate amount of chocolate frosting into my mouth to get out of said low and into my bed quicker. This is a decision driven by being tired and cranky (interestingly those are symptoms of both bed time and being low) , but it’s not a good one. This is the kind of behavior that very quickly gets my BGs going up, making me feel “safe” temporarily, but then lands me over 300mg/dL hours later because I have over-done it. This of course then leads to more problems the next day (see Monday’s post for all that jazz!). But then I remembered something that a diabetes educator who is also Type 1 told me: she uses something with a high fat content to slow down the glucose release of high sugar foods. It was in that minute that I realized the genius that was before me:

The ultimate Combo

 

 

 

 

 

 

 

 

Yes. Oh yes. Chocolate and peanut butter. AT THE SAME TIME. Using this brilliant (and might I add, DELICIOUS) combination of foods allowed me to quickly treat the low and bring things up to a happy-and-safe sleeping level, but also provided sustained control for several hours resulting in a glorious flat-line of euglycemia on the trend line of my CGM the next morning. It was gastronomicaly and diabetically (that’s not a word…yet) the best of both worlds.

I don’t know that this would be the best course of action for all lows because some just need a lot of carb and they need it very quickly to be treated. Other times, you’re simply trending low and you might only need the peanut butter, or something like milk that breaks down slowly. But for this low which was not too acute and still involved some active insulin, this was the perfect fix. And oh so good going down!

The only downside? It’s hard to stop with just one tablespoon of each!

Drop it low, keep it low.

Arrow downOur half marathon is fast approaching in just two short weeks, so Saturday I set out to do my longest training run yet: an 11-miler. I’d had a rough night in the BG department. We had dinner at a friend’s house, and I over-bolused for some dessert which had me crashing in the 40s at bedtime on Friday night. Desperate to get some sleep, I over-treated the low and woke up around 5am with a BG near 300 (after ignoring my CGM for a few hours that is). I finally came to my senses and bolused conservatively, but not conservatively enough apparently, since I was down at 63mg/dL by about 8:30am.

In preparation for the run, I turned by basals down by 50%, and had a slice of whole wheat toast with peanut butter and an apple to give me a boost. As I drove down to the waterfront where I intended to run, I expected to see the arrow uptick on my CGM as the food digested. But it didn’t. Instead it sat at 63mg/dL. Not wanting to delay my run anymore though because the sun was out and only getting stronger, I popped a GU pack and turned my basals down by 90%, figuring I’d just turn them back up shortly into the run when I inevitably creeped back up as adrenaline kicked in and glucose poured out.

Except when it didn’t. Like, ever. I ran the entire 2 hours with a BG in the 50s (according to my CGM). It was by mile three that I had already dropped to 56mg/dL. I popped another GU and kept going, expecting to see my arrows turn around any second. In fact, I expected double arrows up at some point – after all, I’d had a total of 66 grams of CHO so far that morning and hadn’t crested 70mg/dL. After another hour of running, around mile 8 or 9, I STILL hadn’t crept up at all, so I had yet another GU. Still nothing budged on the screen for the duration of my run.

By the time I got back to the car, I was finally up to 75 mg/dL, but barely. I did finally rebound after lunch, but I never went above 180, and even that came down quickly when I bolused a correction dose. I don’t know if it’s the amount of running I’ve been doing these days in prep for this half marathon, or something about the way I’ve been eating but I’ve never taken down over 60 grams of carbs and not had the needle move a centimeter. And I’m pretty sure that I didn’t magically cure myself for half a Saturday either. Which means I have no idea what caused me to stay so low that morning. Latent effect from the previous night’s low? Burning more carbs on an 11-miler than I thought? Diabetes just acting totally weird and unpredictable?

Who knows really – has anyone had a day like that before? Where no matter what you do your BG just wants to stay in one place? And was it directly related to distance training ever? Or is this just diabetes being crazy (as usual?)

Nailed it.

Booklet

Dear Well- Meaning Insurance Company,

I”m writing today to let you know I received your extremely informative and helpful brochure in the mail today about “Taking Charge of Your Diabetes.”  The Grandmother character you have featured on the front looked just like me and I immediately realized that she and I must have a lot in common. We are probably both Type 1s, working a crazy-busy full time job that has us too swamped to even shower on a daily basis while also training for a half marathon coming up in two weeks. We’re practically twins!

I especially enjoyed the synopsis of what I will be enjoying in the enclosed booklet – in particular the first item about “Types of medicines that can help control your blood sugar.” I simply cannot wait to dive in to that chapter because I’m so over this insulin stuff! I’m so glad there are other options for me.

 I’ll definitely also dig in to the piece about “Questions to ask my doctor.” Truth be told, when I last asked my doctor if I should change my insulin correction factor during a rise in BG of 2-3 mg/dL when I’m both post-prandial and post-workout, we didn’t have a whole lot to talk about after she said “It depends” for the 37th time that visit. I’m looking forward to getting some new material to talk to her about!

Realistically though, I should start with the section on “What to do if you have a low or high blood sugar,” because I’m tellin‘ ya, I just take insulin for the highs and eat for the lows. I didn’t know there was more to it! I can’t wait to learn some new tips and tricks because honestly, I’m stuck on the whole “trying to maintain an impossible balance of insulin and food” thing.

That last section though about “Helping to reduce the risk of nerve damage or blindness by taking good care of your feet and eyes”  – THAT should be the real winner. Because quite frankly, I don’t have enough riding on this already. I never really worry about my mild retinopathy or my carpal tunnel, or how much work it will be to start a family one day and how much I’ll worry about that future child and stress over the massive layer of Diabetes Guilt that will pile on to what is already a boat-load. How did you know that for 21 years I’ve been thinking about reducing my risk for complications?! I wonder if that has anything to do with good control? Hmmm. Food for thought.

So helpful. Thanks for not separating out Type 1 and Type 2 management. Thanks for not taking patient history into account with your general mailings about diabetes care. Thanks for letting me know at the end of your letter that “Having diabetes can sometimes be challenging.” I’m so glad you get it, Insurance Plan.

Managing Feelings.

FeelingI’m always rooting for my peeps. If you have diabetes, I’m already a friend of yours because I think that all of us have a seriously sucky job that no one signed up for. And I’m especially a fan of thriving with this this disease, and doing the best we all can to stave off those dark and looming complications.

So when a friend of mine with diabetes posted about her recent eye exam and happily reported that 10 years in to living with diabetes her doctor had found no complications, I was surprised to find myself feeling…something other than happy for her. I mean, I was definably happy for her on one level, but I also felt…jealous? Angry? I’m not really sure what the emotion was.

All I know is that I realized that I too used to be in the “complication-free” category, and I had managed to keep that status for two decades. But it was in my 20th year of living with T1 that a doctor first noticed a speck of retinopathy in the back of one eye. And two years later it was tiny specks in each eye. Seeing her post felt so defeating in a way, because even though I am trying my damnedest to take optimal care of myself with this disease, you don’t get points for trying with diabetes. The truth is that many of us who maintain a good A1c and put in a ton of effort will still wind up with some form of complications. To say that diabetes is a bit unfair would be the understatement of the year. How about unfair, not motivating, un-inspiring, and total bull$&%*?Yeah, I think that sums it up a bit better.

Of course in my heart I am so happy for my friend, and I will always be on Team Kick Diabetes Butt. But as my tenure with this disease grows, it can be hard to reign in my resentment over working so hard and still being punished for it. These are feelings I know I will always have to deal with, and I am certain they will intensify when Jacob and I have children one day and I then layer a whole new slab of Diabetes Guilt on things. It surprised (and horrified) me that I could feel anything but happy for my friend and her complication-free status. Although I know that was the diabetes voice talking and not the real me, I felt ashamed for even letting it cross my mind.

Do you all ever feel jealous when someone seems to be doing better with their diabetes than you are in the moment? And do you let yourself feel it or do you shovel it under the carpet?

More better.

alarm clockIt was another long, hot, summer day in Portland and the neighbors had created an impromptu block party on one of their porches. One of our neighbors offered a fellow from down the street a second beer, but he politely declined.

“Nah buddy, thanks but I’m trying to get healthy. I’ve been focusing on eating better, drinking less, and working out more. I saw the doctor a few weeks ago and he said I’m pre-diabetic. Pre-diabetic! Can you believe that?! I kinda freaked out about it. I mean, I never thought I would ever hear that from a doctor. That really hit me hard. But, I’m really trying man.”

It’s hard to convey the underlying sense of urgency and panic that loaded his words, but it was clear that indeed, this had truly hit him hard. He went on to talk about the fact that he didn’t realize that he had gotten so unhealthy, and that he didn’t realize that a diet of beer and grilled steaks coupled with a sedentary job could be the recipe for Type 2 diabetes at a relatively young age. He had always associated it with those who were very old and very overweight.

I didn’t chime in and let him know that I also have diabetes, but that mine won’t be solved with a healthier diet and more activity. I wasn’t in the mood to explain that mine was caused by an inexplicable and irreversible assault on my beta cells, or to get into specifics in that very moment. I did offer words of support for his healthy lifestyle changes and let him know that just about all of us are capable of doing a little better with the food and exercise thing, and that a wake-up call from a doctor can be a blessing.

What was so refreshing about his comment was that this was a person who truly realized he had a opporuntity to intervene. He had taken to heart that he was in the “pre” stage and that he had time to turn it around for now with lifestyle changes. And interestingly, I also found myself feeling a twinge of jealousy. Why does he get the kind that might not last forever? Diet and exercise only? If that was the case for me, I’d be living on the treadmill with nothing but carrots and chicken breasts for meals. But I also realize that it is because I truly know the burden of insulin-dependent diabetes that I can even feel that kind of jealousy for someone who’s got options.

But mostly, I was stoked for him. Stoked that he had a chance to intervene, stoked that he wanted to intervene. Although it’s not awesome to get that news, it is awesome to actually do something with that news. Too often with both Type 1 and Type 2 diabetes we don’t hear about people taking action until something really bad happens – a hospital visit, a wound that won’t heal, or maybe something even worse. And the bottom line with diabetes – whichever kind you have (they all suck by the way) – is that our only job is to get up every day and try and “do better .” That is, actually, good enough, and all anyone can ask for.

 

An Ode to Opsite.

On those hot, sweaty summer days, your devices might have an extra challenge staying stuck to your body. And on those hot, sweaty summer days where you are CLEARLY suffering from insanity because you said “yes” when your friend asked if you wanted to go to a hot yoga class on a day that’s already over 90 degrees then you really have an adhesive problem heading your way.

That’s exactly what happened on Tuesday night when my friend invited me to a hot yoga class (for those who haven’t heard of it before, hot yoga is regular yoga done in a room heated to 120 degrees. “Sweating profusely” doesn’t begin to cover it. It’s supposed to help you stretch out your muscles more and blah blah blah but I just like it because I think I lose like, four pounds whenever I go. Also, if I don’t go to yoga, I don’t do much stretching on my own which is bad for my now-over-30 body. Ug.) I obliged to attending the class, but I knew both my CGM and my pump would need some extra help staying stuck on me.

photo (6)

I reached for my go-to solution in this case, Opsite Flexifix tape. I love this tape because you can order a huge roll for $20 on Amazon. It goes on and stays on completely clear, but it has grid lines that peel off so you can cut off a straight little piece from the roll. It’s flexible, comfortable, doesn’t irritate my skin and works like a charm even through swimming, surfing, and sweating like a linebacker in hot yoga classes and beyond. One strip across the top of my CGM sensor and two little strips across my pump adhesive were all I needed to power through that class.

With a little Opsite, I can concentrate on holding tree pose for longer than three seconds instead of if my pump and CGM are melting off my body. And trust me, when I go to yoga, I need all the concentration I can get!

Let me simplify this. Wait…

Bag of sugar“So, what if you just eat only meats and green vegetables and no sugar and no carbs? Do you still have to take insulin?”

This is the totally fair, totally logical, but still totally exasperating question I was asked at brunch on Sunday. Not exasperating because of the person who asked it. No,he’s a good friend who is well versed in nutrition, a brilliant medical consultant in his own right, and an endurance athlete who understands physiology quite well.

And guess what? Diabetes is still confusing to someone like him. That’s because this is a confusing disease to explain in general.  Think about it:

So, what is diabetes?

Having diabetes means I don’t make any insulin, which your body needs to break down food into usable energy.

So you take artificial insulin?

Yes.

So can you eat whatever you want?

Technically, yes.

So why are you downing that Coca Cola right now like there’s no tomorrow?

I took too much insulin by accident, so now I have to bring my sugar levels back up.

So sometimes you have to eat sugar?

Yes.

That’s awesome!

No, it’s not.

But wait, you said earlier you didn’t want any cookies, I thought you just said that having diabetes means you have to eat enough sugar?

*SIGH*

If you were naive to diabetes, can you imagine how hard it would be to take away a main, overarching concept from a discussion like that? Too much sugar one moment, too little the next. One minute we’re totally ok with a slice of birthday cake, the next minute we’re throwing out the diabetes excuse to refute mashed potatoes. Who can keep up with all that? I’m the one who has diabetes and it barely makes sense to me some days.

Sure, we all like to think we have a science behind every diabetes management decision we make, but do we really? Or are we just really trying to keep the balance between lows, highs, and having a life in between? Having diabetes means you are trying to recreate something that the body does as automatically as breathing, and we all know the human decision-making process is no match for the work of art that is human physiology. Still we try, and we try to explain it to those around us in a way that makes it easy to understand. But the truth is, living with diabetes is complex and layered, and as confusing as all get out.

Sometimes, I just want to play in to every stereotype I’ve ever heard about diabetes and when someone asks me why I’m eating this or not eating that I can just say:

“I got the sugars.”

‘Nuff said.

Just an average.

Long road aheadI’ve had some great A1cs in my life, and some really crummy ones. And most of the time, when I’m under 6.5%, it’s because of hard work and determination. But there are other ways to get to a low A1c. We can’t ever forget that A1cs are simply an average – meaning a great A1c can easily be composed of some really high highs and some really low lows. One of my best A1c’s in recent memory was from 2009 after I ran my first half marathon – it was at 6.1%, and between all my running and my great low number, I should have been feeling amazing.

The only problem was, I knew I had gotten there from seriously wild swings in my BGs. Training for my first half was one long episode of trial and error, with an emphasis on the “error” part of that equation. While I figured out basal rates and nutrition, I regularly ended runs at over 300 mg/dL because of overdoing my carbs, only to later crash into the 50s because I hadn’t adjusted for the latent effects of my exercise. All in, it got me to a nice low A1c, but the spaghetti-string mess on my CGM download was enough to prove the way I had arrived there hadn’t been pretty.

Fast forward to 2014 and training for my third half marathon. Things are way smoother than five years ago but I still see glimpses of those wide swings. Sunday’s seven miler had me coasting between 80 – 110mg/dL until mile five, when I saw the CGM arrow tilt downwards. I downed a packet of GU and smiled when the arrow righted itself a few minutes later. But an hour later, it was double arrows up, 164 mg/dL, and didn’t quit until I was well over 200. Hours later, I almost crashed, but stopped a low at 100mg/dL thanks to my CGM and a snack of an apple and a handful of blueberries. (Side note: it always feels better when you catch a low early enough to treat it with fruit, not straight sugar from something not-so-good-for-you, right?)

Exercise is by and large great for your diabetes management, but endurance training takes things to the next level. Small doses of insulin can become tidal waves, and food planning can become more confusing than ever. Although I’m still not perfect with my training and ‘betes management, I’m grateful for the tools I have now to guide me. A temp basal rate and a CGM can be the difference between a great day and a day spent on the Glucoaster. And the difference between an A1c made out of 100s instead of one made out of 50s and 300s.