It's Like Landing on an Aircraft Carrier...

That is what the "target" BG range is like - landing on an aircraft carrier... in a storm... at night!

The "target" BG range is so narrow, compared to falling short (and crashing right into the aircraft carrier, sinking the ship in the process) or overshooting the strip (and falling somewhere in the sea of high blood sugars that lay beyond the carrier).

This is a typical graph for blood sugar readings. That tiny green strip is considered the "target" range. That narrow strip goes from approximately 80 - 180. You can see, just looking at the picture, it's a tight area!

The margin for error is very slim, with the penalty of a low blood sugars below the "safe zone" and high blood sugars above. With that in mind, let's talk a bit about the calculations that take place when dosing insulin for correcting high BG's or calculating for grams of carbohydrates.

My insulin to carb ratio is 1 unit for every 7.5 grams of carbohydrates. For a correction factor, 1 unit will drop my BG by 35 points. So, I'm assuming based on those two figures that 7.5 grams will raise my BG by 35 points, or 1 gram by about 4.7 points. All of this is altered slightly by any number of things - exercise, being sick, stress, etc. But for the most part, these are the numbers used for the calculations.

It doesn't take much of a miscalculation to send me out of range, one way or another. If I miscount my grams of carbohydrate by 21 grams (slightly more than 1 piece of bread), I will be off target by 100 points! It is deceptively easy to goof up by a slice of bread one way or another, especially when dealing with food in large quantities (one of my other problems...). And how easy is it to over treat a low by 21 grams or better?!

Now, this is an extreme example, being off 100 points, but you can see how being off by even half that amount (half a slice of bread) means 50 BG points off target one way or the other.

An aircraft carrier is huge, until you see it relative to the ocean it's floating in...

The best we can do is take a shot at it, and hope that if we miss we'll still be close enough to swim home!

Makes you look twice

Very quick post -

I tested my blood sugar at 11:11 am and it was 111.

Fun with numbers anyone? I think I'm going to go out and buy a couple lotto tickets, using my last few blood sugars to pick the winning numbers!

It's that time already?

So I just noticed that my quarterly endo appointment is coming up again.

Damn. It feels like just yesterday when I went in there and was thrown into a tailspin with a higher than expected A1C. I've been trying to get my head on straight ever since. And now I realize that it's been almost three months - that's one quarter of a year.

I know I've been fighting. Up and down, feeling good then bad, frustrated then encouraged, crumbling under pressures then rising to challenges. But I'm shocked to realize that I've spent the whole three months fighting with myself.

Have I learned anything through this process? Yes, I think I have. Most of it due to very caring, thought provoking and encouraging comments to my posts. I can't thank you all enough for taking the time to do that. It does make a difference and it does help a great deal.

Though still I have not won the fight. I feel that I am digging my way out, but it's nipping at my heels. I want to be done with it! I want to be at a place where I'm Ok with how I'm doing, and comfortable with those efforts.

I know, just based on my recent struggles, that this next endo visit will be hard to swallow. I'm really not even sure I want to know what my A1C is (although I can't resist the temptation to have yet another number to beat myself up with). It will probably be lower because I'm expecting it to be higher.

Trust that you will all have an entertaining account of how that appointment goes. It's a couple weeks away yet, but it will be here before you know it.

External vs. Internal

Motivation that would be.

Internal Motivation vs. External Motivation.

I must admit that I am always searching for external motivation, or some external "thing" that will motivate me to get going. Whether it's a new meter, a new pump, some new software, a new endo, a new support group, reading or writing a blog entry, or whatever - something external.

This may work, but only for a while. That's the problem with external motivation - the "newness" wears off after a bit.

There are the BIG external motivators, such as my family and such, but as powerful as they are, they don't keep me going on a task level. I can't explain that. I want nothing more than to live a long and healthy life, growing old with my wife and watching my kids grow up. But it doesn't move me on a daily task level. Maybe they are too big? They're just so big that I don't incorporate them well on a daily task level? Is that possible?

Does it have something to do with an acceptance that I have yet to come to? I can, most of the time, do what I have to do in order to get through the day - but why can't I do it consistently? What is this need for motivation to do the stuff I've been doing forever? Why has it not yet just incorporated itself into my life? Or, rather, why have I not yet incorporated it into my life (it doesn't just do itself does it?)?

It has something to do with frustration and anger. Frustration around having to do all this stuff and keep track of a million things (Kelsey's post comes to mind). Anger around not always being able to pull it off or anger with myself for falling off the wagon sometimes. All this is in addition to the regular stresses and challenges that life presents outside of the diabetes realm, which in and of themselves sometimes feel like a lot (financial struggles, working to do a good job raising the kids, paying some attention to my beautiful wife, striving to be better than average at work and whatever else comes along).

It has been said that managing diabetes is different for each person, and it really is. Some of us have to think more about it, or work harder at it. For others it is second nature unless something unexpected happens, for which they shift attentions for a bit to "fix" it, then get back to their regularly scheduled program. Why is it so different though? And how do I get to be one of those other people who do it so easily? Maybe it's a phase...

I think the key to it is finding the right internal motivation for our life situation. In some cases it's very easy, and in others it's not so clear cut. Is it possible that it's also a moving target? A certain motivation may work well one week (one hour?), but not the next? I think so.

Another tricky variable in the equation is the blood sugar. I've found that I'm so much more susceptible to the grasping claws of depression and the blues when my blood sugars are high. This can be both for a single event or for a longer time period. For the single event it would be things like being high and still wanting to snack, breaking down and snacking even though my rational mind knows it would be best to hold off, or the longer time period being running higher than healthy for a few days and just feeling down overall. Getting a good nights sleep can make or break the deal on most days too. Getting a good solid 8 or 9 (or 10 or 11) hours of sleep makes me feel more resolute in the decisions I make through the following day.

There are a lot of things that can pull me off track. Finding the right recipe of motivation to keep me strong and on the right path is what I'm after.

Always Room For Improvement

It's a matter of perspective, but I have a problem with something for which there is always room for improvement. Specifically speaking diabetes.

When is "good" good enough? Our control is measured by our A1C results, at least from the medical professionals, and through their conditioning that number is often times how we measure ourselves.

My A1C's are terrible, and they have been forever. I was once able to get one down to 7.5, that was in February of 1999. My highest since I've started keeping track was a 10.1 in January of 2004. Since that high reading it has been high 8.x's and low 9.x's.

Some people would be embarrassed to admit to numbers like that. What comes to mind is Kassie's post about conversations around those numbers.

I've gone into my personal struggles and how it's a highly mental game for me. In other words, I feel I have the tools I need, and understand how they work, but struggle with the daily application of those tools, discipline and motivation.

My first goal is to get my A1C's down below the 9's. Once I've achieved that I would imagine that I would work to get down under the 8's and into the 7's. Many people are able to get below the 7's and into the 6's. The elite are able to break the threshold of the 6's and be in the 5's. An A1C in the 5's is pretty damn near what a non-diabetic person would test.

I would be happy with anything lower than where I am now, but knowing that there is room for improvement may eventually get under my skin.

I fight with my weight almost the same way. There's always these "thresholds" that I'm trying to break through. They usually fall on the 10 spot. It's as if there is a bigger deal about going from 265 to 263 vs. 260 to 258. A pound off is a pound off - why does it make me feel better about cracking through the 10 mark??

For the record I found out that there are two types of perfectionist. Normal perfectionism and Neurotic perfectionism.

As defined at http://mentalhelp.net/psyhelp/chap6/chap6p.htm:
(standard internet disclaimer applies here - never ever take anything you read on the internet as 100% verified accurate or true)

Normal perfectionism involves the desire to excel and take pleasure from putting in extraordinary efforts without feeling compelled to be perfect. It is setting high personal standards while accepting one's personal limitations, so one feels good about a job well done.

Neurotic perfectionism involves excessively demanding standards that often cause the actor to feel stressed, unhappy and personally critical. Sometimes perfectionists are actually less effective because they fret about mistakes, worry about slow progress, and try too hard to impress others.

I am definitely more along the Neurotic side of that, but only (mostly) in regards to my diabetes. And yes, I do routinely visit with a counselor.

I will at some point come to a place where I'm happy with my numbers, both weight and A1C's. I do believe that they are related - in that my discipline struggles are particularly with eating too much too often, so when I manage to conquer that, both my blood sugars and weight will come to a natural balance.

Lighten Up Already!

I am far too hard on myself.

I beat myself up over every little thing that doesn't work out perfectly. I get depressed about silly little things and just throw my hands up in desperation. I think about it too much. I analyze every little thing, but when it doesn't add up (or it adds up to something I'm not wanting to deal with), I get frustrated. I get to a point and then start to feel sorry for myself, and just start spiraling downward.

It's all very silly because it's all self imposed.

If I'm so critical with myself regarding things that are not so great, why don't I celebrate every success I have?

Have I conditioned myself, or been conditioned by the general medical population, that every high or low BG is some sort of a failure, and one that I am or will be judged on? Is that why I get nervous as heck waiting for my endo to come into the exam room? Again, how silly is that?!

Have you heard about the "dial tone" analogy? There are a whole lot of folks at the telephone companies that work very hard to supply each and every phone with a dial tone the very instant that the receiver is picked up. We take that dial tone for granted. We don't appreciate the dial tone until one day we pick up the receiver and there is no dial tone - at which time we usually get a little angry, cursing the phone company! Rather than miss it when it's not there, shouldn't we appreciate it every time we pick up the receiver and hear that dial tone?

Are decent blood sugars that much different than the dial tone? Should I not pat myself on the back for each and every time I do well?

I'm much too hard on myself, and that is not mentally supportive. I am going to try to lighten up, take a couple deep breaths, be thankful for the "not so far out of range" numbers, be less judgemental, mentally reward myself for making it through unfamiliar scenarios in one piece, take a few steps back, and take one day at a time.

It Is Not Always Diabetes

I feel that I am pretty tuned in to my body. I have been forced to pay attention to the little signals my body sends, that perhaps others can easily ignore.

Most of the time I can tell when I'm dehydrated. I can tell when I'm a bit low, and I can usually tell when I'm really high.

One of the major clues to myself that I'm high is that I get terribly sleepy. All I can think about is catching a few seconds where I can shut my eyes. I can't focus on any tasks or perform any functions. All I want to do is sleep.

When I notice that I feel this way, I will start to think back on the last two or three hours - to see if there was any potential for miscalculation, unwise food choices, hard to measure foods, recently replaced infusion set. an over treated low or a number of other possible causes for a high blood sugar.

Only to test my blood sugar and come in at a perfect 84. Is it a strange sign that I'm slightly confused by a normal blood sugar when I'm feeling a bit "not normal"? Is there a name for the condition of thinking every bad feeling or ailment is actually related somehow to diabetes?

You know, it is possible for a headache to be simply that - a headache, or feeling sleepy because I didn't get nearly enough sleep last night...

Crazy to think, but it's not always related to diabetes.

Rewards and Punishment

My fight is all mental.

If I can be in a good place psychologically, I can manage my diabetes.
Please note, I chose the word "manage" rather than "control". There is no such thing as "control" with diabetes, in my humble opinion.

I have been slowly working my way through "The Physician Within" by Catherine Feste. Cathy Feste is a type 1 diabetic who happens to live in my area. She is a magnificent motivational speaker, and has a true gift for making you feel good through whatever struggles you are dealing with. I attend events where she will be anytime I get the chance, and always come away with something positive.

Partway through the book I stumbled onto something that struck a chord. In chapter 3 she talks about how we have a "natural feeling that efforts should be rewarded". Please note that I have not finished the chapter yet, so I'm commenting on this only partway through.

A natural feeling that efforts should be rewarded.

Maybe that is what gets my head all screwed up most of the time. It is a lot of work for me to manage my diabetes. I can be very diligent, and do it for a while, but eventually I get tired of it, and start to feel worn down. The little obstacles that life presents will mushroom into impenetrable blockades. It's ridiculous.

Am I subconsciously expecting some reward for my hard work? Should I feel some difference during the periods that I'm managing better than when I'm not? Fighting a condition who's only reward is lack of punishment. Even sometimes being "punished" in spite of all the hard work?

And if I am managing only to avoid potential punishment, is that a good reason? Is the fear of long term complications enough to motivate me to do all the hard work every day?

Sometimes.

This potential punishment sometimes seems like it's so far in the future, that the motivational strength is not very strong! It's as if I sometimes feel that it's so far off that I have the time to turn myself around and "get right" in time to keep the complications at bay, even if I "relax" my willpower for a little while right now. A dangerous game to play.

I just really resent the idea of being diligent in my management out of fear of complications. It makes me angry. How many times have you been told "you'd better control your blood sugars or you'll lose a foot"? We are surrounded by horror stories of people someone knows who has experienced some terrible complication. Why doesn't that "scare me straight"? Because it makes me angry, and that never works for long. Anger is not a healthy long term emotion.

In me it breeds rebellion, which causes wild swings in my management efforts.

Along with that though is this build up of potential guilt. What happens if I start seeing complications? Will I be dealing with a bunch of undeserved guilt? Will it really be undeserved? I mean I can manage my diabetes right? Why is it so hard sometimes? I feel like I have to dedicate every waking second of my day & night to making smart decisions and anticipating events, calculating everything (did I mention I hate math?), dealing with unexpected highs & lows (aren't they all unexpected & inconvenient?), and trying to ward off the potential complications and accompanying guilt.

Now these thoughts and feelings might seem very negative. But I don't see it that way. The way I feel is that I need to work through these feelings and find some positive way to deal with this lifelong struggle, and in a way that helps build me up rather than tear me apart.

How do you do it? Is it out of fear of complications? Is that Ok with you? Do you just incorporate it into your life and not bat an eye about it? What is/was your acceptance like? Was it a one time thing, or do you continue to sway back and forth? Is it possible to maintain your sanity with managing diabetes and all else that life throws your way?

The JDRF Walk

The JDRF Walk to Cure Diabetes for my area was held Saturday at the Mall of America in Bloomington, MN (very near Minneapolis).

Thanks to many generous friends and family I was able to raise a grand total of $1175 in donations. I think that is just wonderful. I never expected that I would be able to generate such a large sum in donations. Thank you to all who donated.

The turnout was very impressive. We arrived at about 7:15 AM, and even driving through the parking lot there were TONS of people making their way inside.

It was a very encouraging experience to see all the people coming together. There were many individuals, but also many teams, groups and companies. Many had matching shirts with nifty slogans on them, some shirts & sweatshirts had pictures on them, and others carried big flags or banners.

As we worked our way through to where we were meeting our team, there was a pretty large team, made up mostly of teenage kids and a sprinking of adults. They appeared to be playing some type of a game or something to pass the time waiting for the walk to start. "Bang Bang Clap", "Bang Bang Clap", "Bang Bang Clap" - it sounded like a battle cry or war chant. It was exciting, and they were excited to be there!

In fact, EVERYONE was excited to be there. It was so great to see soo many people, all affected by diabetes in some way or another, come together for this event.

After the walk was done we got some breakfast and then walked the kids around to some of their favorite attractions at the mall. I was a little surprised with my blood sugar. I woke up this morning at 113 (and yes, I'm proud of that). I didn't have any breakfast because I figured the JDRF would have some stuff there. I ended up not eating anything until our breakfast, which was a good three and a half hours later, AND I had been walking (slowly) around the mall, pushing the stroller with at least one kid in it (sometimes both).

The interesting thing here is that when I tested for breakfast, I was up to 169! So I had gone up quite a bit in that bit of time, but had nothing to eat.

I think my body is just weird in the mornings - it doesn't like when I have to wake up early (neither do I). I think it's pumping a bunch of "get up get moving" hormones out, and it makes me a little insulin resistant.

I corrected for the 169 and SWAG bolused for the unfamiliar breakfast.

Afterwards we took the kids to this place called "Dino Walk", which is a large area of the mall were there is a big dinosaur exhibit. My son had wanted to go in there for a long time, but we never could afford the admission!

We were in the gift shop area when the manager started talking to my wife and it turns out we all went to junior high school together. How on earth he recognized us after over 15 years is beyond me! He got us into the main exhibit, and we hung out in there for at least a couple hours. It was a blast! There were life sized dinos, many TV monitors with informative shows playing, computers and toys for the kids, a large movie theatre playing dino based shows (like what you might see on Discovery or something), and even a place for kids to dig for fossils!

I checked my blood sugar after we had been there for a while (a couple hours after breakfast), and it was 128. That is great, BUT I've still got almost 10units of insulin on board. So..... looks like were stopping to eat again on the way out.

When we were all done we packed up and headed out. The kids were asleep before we left the parking ramp.

I had a lot of fun, and all in all it was a very good day.

I shot myself in the foot - and not with a needle...

...or a gun for that matter. It's just a figure of speech.

I mentioned a little bit about how I planned on doing some better logging to help me with my therapy overhaul. I went out and found a daily planner/journal type of thing that I liked, and started my logging.

I have no idea if this picture will show up clear enough for anyone to see any details, but you can see that it was a very busy day for recording. I had a TON of things to record, partially because this day was a day that I play basketball over lunch (which means lots of extra testing and activity).

I had some problems early in the day because I made some bad food choices for breakfast AND had just changed my infusion set that morning. So I was running really high for a while. Playing basketball seemed to kick my BG back down to normal, and it was very manageable the rest of the day.

As the day went along, I kept on testing and recording, testing and recording, testing and recording. The day was awesome. My range (after the morning problems) was between 186 and 57. That is during a time span from 12:05 through 8:15, so basically all day. It was good.

I had dinner at about 8:15 that night. I diligently recorded my blood sugar and everything I ate. Then I ate it.

I got ready for bed and laid down around 10:30. I felt kind of yucky. All of a sudden it clicked. I tested my blood sugar and it was 300. Guess what I had forgotten to do when I ate dinner...

So how can I spend the entire day paying such close attention to every little thing, and completely forget to take my insulin at dinner?!

Maybe I paid too much attention to everything? It seems I got so completely wrapped up with recording everything that I missed something basic! There are also a couple other things that I'm taking into consideration too. I just got home from work. For me, that is a very tough transition. Going from a fairly orderly work environment to one where my kids are pulling me for my attention (which they should, and which I should give them!) - it can just get a little overwhelming sometimes. The other thing that happened is my low test of the day, 57, happened right then too. So, I was dealing with all that and a low that I was treating.

All in all, I really think I was too focused on trying to record every last little bit of information. Moving forward I will make sure I get the blood sugar tested, food calculated and bolus underway before I worry about the logging. I'm working to find the balance between obsessing over my new logbook and ensuring the basics are covered.

Stay tuned...

Why is "D" so isolating?

I think that the "diabetes blogosphere" (aka the O.C.) has really taken off, and is growing every day. It's great. I can't tell you all how much I enjoy reading all that people share, and there is a connection with almost each and every blog and post.

For me, diabetes can be, for the most part, a very isolating thing to deal with. My family (both immediate and extended) are great, very supportive and understanding. But, there is that special connection that happens when you have a chance to compare stories with another person who has diabetes.

Stories about low blood sugars that are very scary, but for some strange reason we can look back on them and chuckle. Centennial lancet changes, and stories about just how many boxes of lancets we have collected over the years. Stories about "oh shit" scenarios, and how we somehow managed to pull through them. Shared frustrations on how we are doing everything "right" but our numbers just won't cooperate. Battles with depression about the never ending physical, mental and social demands that diabetes forces onto us. The list could go on and on.

I think we can connect with each other because we have ourselves experienced many of the same issues, or issues similar enough that we can easily relate.

Diabetes is isolating to me, and I'm willing to bet that I'm not alone in feeling that way. We each carry one hell of a burden, and no one can help us bear that.

It is a nice feeling though to be able to connect with others that bear a similar load.

Does it start with logging?

When coming to a point where I realize my management needs a complete overhaul, where do I start? Just with logging things as they are today?

I haven't done any logging for a long time, and a pattern has to really jump up and smack me in the face before I'll notice it.

I've got a suspicion that my post meal readings spike up during the first couple hours, but sneak back down around three or four hours. I can't prove that.

I think that I have a harder time managing my BG the first morning after I change out my infusion set every third day. I can't prove that.

I think that those post meal spikes could be smoothed out with better food choices. I can't prove that.

My point here is that I have a lot of areas for which I suspect I need changes or adjustments, but I have no data to back it up. I wonder why my A1C is so high, when I am probably averaging near 200 most of the time. I'm wondering why my weight is what it is, when I'm sure I'm eating more than I need to.

I'm going to go buy a rugged notebook. I want to have space to record not only the data points, but the reasons I behind the decisions made around those data points. I'm not happy with any of the computer or PDA software out there, and I'm not happy with any of the commercial log books that I've seen. Sure, I could adapt to any of them, but I don't want to. I'm thinking just a regular notebook that is rugged enough to survive the daily trials of traveling with me. That will give me enough space to do what I want to do. Maybe I can also journal some thoughts there as well. The biggest obstical I can see is the simple fact of having it with me all the time.

But - I've learned to have my cell phone/PDA with me, and other things like that, so I'm sure I can train myself to do so with my notebook.

Like Dennis Rodman

I controlled that rebound like Dennis Rodman!

Dennis Rodman was perhaps the best rebounder in the NBA while he played (mid-late eighties and most of the nineties). That was his specialty! He was such a good rebounder that he was left on the court for almost that purpose alone! He led the NBA in rebounding (15.0 rpg) in 1997-98 for a record seventh consecutive season.

So what does this have to do with me?

Well, I have been waking up with high blood sugars a lot lately. Many times there would be no real good reason that I could figure out for the high.

I work late at least three nights per week, and that pushes my dinners and bedtimes close together. Typically I am laying down with the kids less than 2 hours after my dinner. I've usually got a bunch of insulin on board, and can't get a good feel of where I'm at due to all the activity (digestion, insulin on board, etc).

So I had a suspicion that I might be going low during the night and not knowing it, and seeing a rebound high. To confirm or dismiss this theory, I have to catch at least one or two points during the night.

I set my alarm for 2:00 AM with the intention of waking up and doing a test. Or at least cracking half an eye halfway open to try to stab my finger and get a sample on the right end of the test strip. On that note, I have a freestyle flash meter on my nightstand. The reason I use that meter there is that it has a light that shines onto the strip and sample area so you can see what you're doing. Brilliant.

At about 2:06 AM my wife is kicking me saying "what's that noise?" (I had set an alarm on my pocket pc, not the regular alarm clock). I cracked half and eye halfway open, felt around and gathered all my stuff together (vial of strips, lancing device, meter, finger). Poked my finger a couple times before I got a sample, got it applied to the right end of the strip (thanks to the light on the flash meter!) and got my result.

68.

Aha! Not feeling low at all, but 68 is not a good number to just roll over and go to sleep on. I got up and found a bottle of glucose tabs that had migrated onto the dresser from the nightstand. I had 3 glucose tablets, worth a grand total of 12 grams of carbohydrates.

I woke up in the morning at about 6:30 AM, and checked my blood sugar. 105. It cannot get much better than that.

Low avoided, rebound controlled - like Dennis Rodman.

Stick with the glucose tabs

What is it about Cap'n Crunch cereal that totally destroys the roof of your mouth?

I love cereal, but I don't eat it too often. This is mostly because I have a heck of a time with portion control and accurately counting the carbs (see, I can't eat just one bowl...).

I woke up low again last night. Seems like it's been happening more often lately, so I've got to keep an eye on that. I think lows in general are hard to deal with, just because of all the physiological things that are happening in your body - emergency signals and instinctual urges to eat more than you need, etc.

So instead of having some glucose tabs (ie, the smart thing to do) I went down and had some Cap'n Crunch with milk. Ok, so maybe "some" is not the right word to use here. I thought I had about 6 servings, and bolused for that amount (letting the cozmo subtract from the dose to treat the low). Based on my blood sugar when I woke up in the morning, it was probably more like 7 or 8.

And my mouth hurts.

In my defense, 6,7 or 8 servings sounds like a lot of servings. It is. But lets also keep in mind that a single serving is 3/4 cup. My point here is that those servings can add up a lot faster than you would think.

Next time, I'll stick with the glucose tabs. Especially because the low that woke me up was only a 68 - which is just below a comfortable number. I probably only needed perhaps two glucose tabs (8 carb grams), instead I went downstairs and had a couple hundred grams.

I think I'll have to start using Kerri's 8 sips plan if I decide not to use glucose tabs. On that note, Kerri & Wil, I would ask you to come up with a term we can add to the diabetes dictionary that describes the urges to eat everything in sight when dealing with a low. This might be hard for you Wil - with the lack of symptoms it's probably much different for you...?

Maybe I'll just stick with the glucose tabs...

But I still feel low!

While I agree that the whole 15/15 rule makes perfect logical sense, but I would like to sit down and have a heart to heart talk with whomever "invented" this concept.

The 15/15 rule is this: When experiencing a low blood sugar (aka reaction, insulin shock or hypoglycemia) you are to eat 15 grams of fast acting carbohydrates, wait 15 minutes, then test your blood sugar again to see if you need additional carbohydrates.

This is all fine. IN A ROBOT!!!!!!!

Anyone who has experienced a low blood sugar can fully appreciate the unyielding urge to eat anything and everything you can get your hands on!! You want to eat. And you want to keep eating until you actually feel better.

Unfortunately, this is usually about 10 minutes of continued eating that is above and beyond what is actually required to bring your blood sugar back to a normal range.

It takes surprisingly few grams of carbohydrates to actually bring your blood sugar back up into a normal range. This depends a lot on whether you have additional insulin still working to lower your blood sugar, or if you are done dropping.

In this post I'm talking about a low where I was pretty much done dropping.

I am fortunate to still have many, if not all, symptoms of lows. There are other folks who have what is called "hypoglycemic unawareness". That basically means that they do not experience any symptoms of low blood sugars. This is a particularly dangerous condition, because if a low is not treated promptly you run the risk of becoming incoherent or even losing consciousness. Scary. My friend Wil talks about some of his experiences and his decision to use the Guardian RT continuous glucose sensor to help him deal with this over at his blog.

I had a low tonight from which I learned something interesting (at least to me). I came back from a walk and sat down feeling very shaky, ravenously hungry and very "jittery". I checked my blood sugar and it was 51.

It had been some time since I had eaten, so I justified some snacks out of the vending machine at work. I got a bag of peanut M&M's and a bag of "Zoo Animals" animal crackers. The M&M's had around 30 grams of carbs and the animal crackers had 50. That's a grand total of 80 grams of carbs. I did remember to open the bags before spasmatically cramming every morsel into my mouth. I didn't even notice the wrappers.

When I was done eating, I still felt low! Well, of course, it does take a little time for that stuff to hit the bloodstream.

The problem is that the instinctive urges to eat are often times much more powerful than your rational thought process. Keep in mind that your brain runs off glucose, of which you are presently running low. See the problem?

Somehow I kept my wits about me and didn't eat anymore.

My first test of 51 was at 5:08. As of 5:25, which is just a little more than 15 minutes later I was up to 124. The thing is, I was still feeling low! When you experience a low blood sugar, one of the things your body does is to dump a nice big dose of adrenaline. See, if you don't get some sugar, your body is afraid you will expire. So it responds with the good old fight or flight response.

While my ravenous hunger had gone away, I still felt very shaky and extremly jittery. I could not focus on anything and basically felt like getting up from my desk and pacing around like some deranged lunatic (or a low blood sugared diabetic).

Another few minutes and I was over that. The next thing that hit me was an overpowering wave of sleepyness. I felt drained.

Some lows feel much worse than others, and I'm not sure why. I have tested lower yet didn't have symptoms as strong or noticeable as higher tests.

I see a continuous glucose sensor very valuable in learning how many carb grams it takes to treat a low, and how long it takes for different items to bring the BG back to normal, AND tracking how long the symptoms last even after the blood sugar has returned to a normal range.

You will all appreciate that an hour later I was at 227 because I totally forgot to bolus for the additional grams I ate when treating that low. Typical. Did I mention the brain is low on glucose during a reaction?

Insulin Duration

So how long does your insulin really affect your blood sugar?

It should be pretty easy to test right? In theory all it requires is a fasting bg a bit higher than target, some time, a correction bolus, a bg meter and something to record results on.

Also a good time to check the correction factor - which for some people is different for different times of the day!

I personally have my Insulin Duration figure on my Cozmo pump set to 5:30. That's five hours and thirty minutes. I want to avoid stacking "tails" (see below), and make sure that all unused insulin is accounted for.

This is a portion of the insert that comes along with each vial of Humalog insulin. It is a graph depicting the blood insulin levels after injection of both Humalog (dashed line) and Regular (solid line).

If you look carefully at the graphic, you can see that most of the insulin peaks and then is out of your system at around the three hour mark. But also notice that there is a very gradual and very long tail, reaching almost five hours before levels are back to the starting point.

It is a very gradual curve, but it is there. One could argue that by this time the insulin no longer has any real blood sugar lowering power, which is probably a pretty valid point. But what happens when you have portions of two or three (or more) tails riding on top of each other? That's right. More insulin than you need.

I first saw this figure (the 5:30 figure) presented in an article by John Walsh, P.A., C.D.E and Ruth Roberts, M.A.

I sometimes would have problems with lows very soon after eating dinner. It made no sense to me at all, especially because I had recently eaten a large meal! Fasting basal rate tests proved that my basal rates were, for the most part, pretty darn good - so I stumbled across this article and wondered if it could be the cause.

Time will tell!

I believe the average figure is about 3:30. What do you all calculate for your insulin duration? I also wonder if your insulin duration changes based on the amount you bolus? Does a large bolus "hang around" longer (or have more affect in the "tail") than a smaller bolus?

Annual Eye Checkup

I had my annual diabetic eye exam recently.

It went great. Nothing to report. After 25+ years of diabetes, and questionable control, "nothing to report" is music to my ears.

I partially feel like I've dodged a bullet - my control has never been that great, but I feel like it's been exceptionally poor lately. I was half expecting to have serious damage that required immediate laser surgery!!

It also partially went as expected, mostly because I've never had even a hint of problems with my eyes.

Can I expect it to be that way forever? Probably not, but one can hope!

So, move on from here with good news, and renewed motivation to get my act together!

How fast is fast?

Have you ever felt a little low, only to check your blood sugar and it is Ok?

I have always thought that this was due to a rapid drop in blood sugar levels. But that started me thinking - exactly how fast is fast? In other words, at what rate must BG levels drop in order to start feeling this way?

Is this feeling really due to a rapid drop in BG's? Or could it be something else, perhaps some intricate balance between blood sugar levels and insulin levels? The body is an amazing "machine" and the mechanisms that manage a non-diabetics blood sugars is astounding. Maybe there's more to it than just the dropping BG.

What do you do when you feel this way?

I'm at 142 about 2.5 hours post meal. That's good. But I feel "funny", like I'm low. But the symptoms are so very slight. 8 minutes later I do another test. 137. Is it really going down, or could that difference just be the variance you will find in any two tests. If it is really going down, how far will it go?

Well, this all depends on how much of that last bolus is still working to lower the blood sugar. I have my insulin duration set to what many people will think is too long. I've got it set to 5:30. Yes, that's right. 5 hours and 30 minutes. I don't want to go too off-topic on this post, so maybe I'll address that subject at another time in another post.

3 hours post meal and I'm at 127. Still the tail of a little less than 3 units on board. However I know that it's mostly the "tail" of that insulin, which has much less of an impact on my blood sugar.

Still feeling a little off, but I notice that it's subsiding a bit. Or maybe I'm just getting used to it? Time will tell.

A point I want to stress is that I am in a situation where I can keep a very close eye on things. If the scenario were a bit different I may choose to just pop a couple glucose tabs and be 100% sure that I won't go low.

4 hours post meal and I'm at 91. It would be good if the BG descent stops here.

4.5 hours post meal and I'm at 74 with 1.07 units of residual lunch bolus (almost all "tail" though).

At this point I'm ending the experiment and having 4 glucose tabs. I'm not comfortable being in the 70's, and I also need to walk up to the service station to pick up my beat up old truck, so I need a little boost for that walk.

But why did I start feeling off with a blood sugar of 142? That is the point. There must be more to the equation than just hitting a key number that kicks off the symptoms of low blood sugar, however slight those symptoms might be.

To summarize my BG's all in one easy to read place:

1:48 - 142 - started feeling slight symptoms of low BG.
1:56 - 137
2:30 - 127
3:30 - 91
4:00 - 74 - end of test - ate glucose tabs.

Is the drop I experienced this afternoon fast enough to be considered "rapid", and could it be that "rapid" change that made my experience the symptoms? But I've had one other experience that might indicate it's not the rapid changes? Was it a fluke? Who knows. That experience is an interesting one, and you can read about it here.

Blood and Absorption

We deliver insulin into our subcutaneous tissue, where it absorbs into our bloodstream, the speed of absorption is determined by the type of insulin being used.

I've been thinking about this a little bit lately, and it stems from an experience I had during a research study at the University of Minnesota.

I had a visit planned for this study where I was to stay there all day hooked up to a couple IV's and basically reading, napping or watching garbage on TV. I was to be fasting when I arrived in the morning.

For some reason, I figured that if I had to fast after a certain time of the evening that I was going to go out with a bang! I had a HUGE bowl of ice cream. Now, for me, ice cream is one of those problem foods that is a bit harder to bolus for. I goofed it up a bit and my blood sugar was in the high 300's when I woke up the next morning. I corrected for it, but when I wake up real high like that, the rest of the day is a bitch and I fight the BG's all day long.

When I checked in for the study, and after getting the IV's hooked up, I was still in the low to mid 300's. The study coordinator needed me to be below 200 before starting the tests. I filled them in on my correction bolus and how much insulin I had on board. They checked with the docs and said that they were going to inject Regular insulin into my bloodstream via the IV.

I thought they were nuts! Regular insulin?! That would take HOURS before anything would happen! They went ahead and put it in the IV. 10 minutes later I was down to target. I just about fell over because I was so surprised. We watched my BG as the rest of my Humalog slowly absorbed it's way into my system from the early correction bolus, but we were far enough out that the effect was very small.

Little did I know that once the insulin is in the bloodstream, it's effect is immediate and it has a half-life of about 9 minutes before it's done and out of the system. Apparently what makes the insulins work faster or slower is the stuff that determines how fast it's absorbed through the subcutaneous tissue.

The other thing I thought strange was the fact that I did not feel any ill effects of a rapid drop of BG. I suspect (contrary to this experience), that our bodies just don't like rapid changes.

Same theory with the implantable pumps that have been talked about in the past - from what I remember the insulin is delivered directly into the bloodstream (the portal vein near the liver?).
Can you imagine having insulin that worked right when you bolused? A high blood sugar that was corrected within minutes rather than hours? A meal bolus that could exactly match your digestion?

On the flip side of that coin is a more immediate risk of low blood sugars - say your digestion is delayed due to higher fat or protein content than you expected - your insulin curve would be ahead of your digestion/BG curve. That sounds scary and very dangerous.

If I'm not mistaken, the non-diabetic body releases insulin into the bloodstream based mostly on blood sugar. Trying to dose directly into the bloodstream based on anticipated digestions rates would be dangerous. But, with something like a CGMS, you could get pretty darn close, keeping a post meal spike under a really tight threshold and immediately correcting high BGs.

For those of us using a pump - imagine being able to adjust basal rates in real time! Or even better, use temporary rates right before you need them! For a basal rate change to actually do anything to my blood sugars, I have to make the adjustment at least an hour before I want to see that change. For example, I have to start a temp rate about 1.5 hours before I start playing basketball. I have often times forgotten to start my temp rate, then I'm hustling to keep up with my blood sugars. It would be much easier to make that change 10 minutes before I start.

I wonder if this is the direction that insulin delivery will move towards as the CGMS's hit the market and start to mature?

Grand Rios Waterpark

My wife & I took the first week of January off for a little rest & relaxation and time with the kids while our son was out of school. We took the kids to the local Grand Rios water park for a few days. It was a blast.

We had lots of fun, but there was lots of eating out and I felt really nervous about being separated from my testing stuff and my glucose tablets for long periods of time - especially in an unfamiliar environment doing unfamiliar activities.

I can say that the Cozmo pump performed great. It was wet off and on for over three days. I had to remove the CoZmonitor, which is the BG meter that clips on the back of the pump - that part is not waterproof. I kept that, some glucose tabs, our room key and some other stuff in a locker nearby. It was the fact that the dang locker cost $1 to re-lock after it had been opened that made me think twice about running to do a quick test.

I didn't have any reactions while there, which was good. I was most nervous the morning after a large and unfamiliar breakfast. I really worried that I had taken too much insulin and was worried that it would haunt me hours later. I checked myself after 2.5 hours and was 133 with about 10 units on board. I took the pump off, had 5 glucose tabs and went back to the water. I did fine for the rest of the afternoon and ended the day at 160. Not too bad.

For the most part we each shadowed one of our kids. I would hang with my son while my wife stayed with our daughter, or vice versa. I did try one of the "big slides". It is called the "Toilet Bowl".

So this is a short and fast tube type waterslide that dumps you into this round basin with a 2-3 foot drop into the pool. Sounds fun! So, I get both the kids with the wife and let them know what I plan. They anxiously position themselves by the pool where I'll exit and wait for me to gracefully swirl down into the exit pool.

I start the climb up what seems like a billion stairs. And I climb, and climb, and climb. A few hours later (not really) I get to the top. There's no one up there, so no line to wait in or anything. At the entrance to the slide is a stoplight - kind of like a freeway entrance ramp meter - making sure that the person before you has had the proper amount of time to exit the slide at the other end.

It flashes green and without any hesitation I slide in feet first. Soon after I entered the slide I realized that it was pitch black dark in there, and I was moving WAY too fast. Almost instinctively I stuck my hands to the top of the tube trying to brace myself and slow my descent with some friction. Well, what goes hand in hand with friction? That's right. Heat.

So now my hands are on fire and I'm screaming down this pitch black dark tube doing mach 3 with water now splashing into my face so I can't breath or see. Suddenly I'm blinded by a bright white light! ... Have I died? Is this Heaven? Nope - it's the toilet bowl!

The theory is that you come out of the tube at high speed and twirl round and round in the bowl until you gracefully exit, feet first, into the pool below. Then there's me. I come out of the tube and go around the bowl maybe a time and a half before I plop out of the bowl, completely sideways and land with a big splash in the pool below.

How appropriate.

:-)

You know what they say about diets...

I can personally vouch for the whole "yo-yo diet" statement. You diet to lose a bunch of weight, but when you stop dieting and go back to your old ways, guess what happens?

That's why they recommend lifestyle changes. These just become part of your daily routine - you just make it your way of life.

This post however is not about dieting.

I often feel like managing my diabetes is a lot of work. Made up of a bunch of little tasks and challenges, events and reactions, planning and counting, counting and calculating.

I often get burned out. I get tired of all the counting and calculating, the planning, the reacting to events that always happen at the wrong time (is there ever a good time for a problem or low BG?). I get frustrated. Why do I have to count out 12 chips or weigh out my 2 ounces of noodles (who came up with these "serving" sizes anyways?). Why do I have to start planning for my lunchtime basketball the night before?! I could go on and on about what frustrates me.

That is the way it is. These are the things I must do to take care of myself. This goes on forever and ever - there is no end in sight.

But you see, my mindset is all wrong. I can't look at these things as "work" or "tasks" or "interruptions". This is my lifestyle. Do you see where I'm going with this?

Part of my inspiration comes from Ryan Bruner. Ryan has a zillion things going on at any given time, and his diabetes management is just part of his lifestyle. I had an e-mail conversation with him many years ago regarding his Logbook DM palm pilot software (which is great by the way).

I'm not exactly sure how it came up, but I asked him how the heck he has "spare" time to work on this project with all the other stuff he has going on? I mentioned that for me, just trying to manage my diabetes felt like a full time job! Part of his reply has really stuck with me since then. It was how his diabetes management was just part of his life - he didn't really give it any additional thought. He does what he needs to, and that's just that! Really no additional thought about it. He works on this other stuff the way anyone else would handle their hobby or project or whatever else they wanted to do.

It is his lifestyle.

That is what I'm working on. First step for me is to identify habits that are not good for me (fast food breakfasts for example), and work to replace them with habits that are beneficial.

Going to Extremes

I have a problem with going to extremes.

On one end is the Obsessive Compulsive record everything (stress, caffeine, amount of sleep, exercise, water intake, calories, carbs, BG's, insulin, phase of the moon, menstrual cycle (er, my wife's of course - see "stress" above), etc.) me.

On the other end is the reckless, record nothing, pay attention to little, just enough to avoid disaster me.

I constantly swing back and forth between these two extremes. This is typically not a fast swing, but rather like a giant pendulum slowly moving back and forth.

This is an interesting scenario because I've figured out what starts the swing from the OCD side to the careless side. It is some obstacle that I inevitably encounter, such as not being able to find an exact carb count for something or not having a good format to record everything (how can I when I try to capture so much?!). The thing is, when obsessing about perfection how can you not run into some type of obstacle?

This is a terribly bad thing. I mean, talk about setting yourself up for failure!

When I'm "in the zone" I can successfully beat back those obstacles, but not for long. It doesn't take long before they wear me down and I've started the swing to the "other side".

The struggle is one of balance. I can do perfectly well right in the middle of those two extremes. There is no real reason I need to be all the way on one side or the other.

I think we all struggle with balance in at least one form or another. I'll start with trying to keep the pendulum from swinging all the way to one end or the other.

Rose Colored Glasses?

I really don't mean for all of my posts to be downers. Really. I'm (mostly) a very positive, upbeat, "cup half full", "silver lining" type of guy. Really.

With that in mind it would seem that I should be posting very motivating, energetic and uplifting messages. And I would really like to. It's just not where I'm at right now.

As I share with my wife some of the feedback and "honorable mentions" from others in the OC, she says "that's great hon, you *should* post more". I think about what I should write about. I struggle with topics and ideas. I struggle because they are just that - struggles.

Would it be fair if I took all of these things and painted them in some pretty picture? Do I need to try to put some artificially positive spin on each and everything I express here? I'm not going to do that.

This journal is as much for me as it is for all of you. I need some outlet to express myself. When I feel good about things you will have the opportunity to share that good feeling with me. When I'm feeling a bit crabby or depressed, guess what, you will have the opportunity to share that feeling with me too. I hereby promise to stay 100% true to myself, and will not try to artificially flavor anything one way or another. Love me or leave me.

I'm pretty sure I'm going through another level or cycle of acceptance, which would explain some of the recent hostility about it. It's really been rubbing at me lately. I'm working through it though, and I can feel that I'm making progress.

"Just enough to avoid a disaster..."

You ever run across those little gems of information that strike a cord in you somewhere?

They seem to stick with you forever - mine tend to come in the form of quotes, music, mother nature (even in the city I often see things I would like to snap a picture of) and peoples stories and experiences.

Many years back I was forwarded an article or story about the year 2000 Grand Master Champion of the Body For Life (BFL) challenge, Rory Palazzo. The BFL challenge is a 12 week program of exercise & diet, and many people have experienced amazing transformations. The program, like any other method of losing weight and getting in shape, takes a tremendous amount of drive and discipline.

What makes Rory's story interesting to me is the fact that he is a type 1 diabetic. The piece of his story that sticks with me is a quote from Rory regarding his diabetic control prior to starting the challenge - "doing just enough to avoid a disaster". I am so in touch with that. For what it's worth, I can't find the original article/story/web page whatever. I really need to start saving those types of things somewhere. 20/20 hindsight as they say. It is inspirational to see him master his diabetes and his body, overcoming the challenges that were presented, and winning the competition.

I have been working to pull myself out of this terrible "rut" that I've been in lately. I've been real sloppy with everything, and basically "doing just enough to avoid a disaster". The thing is, that would be a short term disaster that I'm avoiding. I can't ignore the long term stuff - even if it does seem like the easy way out at the moment.

I'm working real hard to pull up and out of this slump, and I can tell that I'm close. Much of the credit for that goes of course to my family, but also the very supportive comments from all of you out there*. Thank you.
* Special thanks to Violet and Wil

One day in particular jumps out at me in terms of being sloppy. I think I *might* have tested my blood sugar three times the entire day. I was just flying by the seat of my pants the whole day, much of the time out and about, grabbing junk food here and there and using the "touch bolus button" on my Cozmo pump for all my bolusing. That basically means that I was not doing any blood sugar tests and was guestimating (or as Wil would say, I was SWAG bolusing (I love that Wil!)).

I felt "funny". Something just wasn't quite right. I checked my BG and I came in at 117. I thought that was pretty good... until I saw I had about 18 units on board!!! Holy Shit.

Let's step away from this scene for a minute. On average I take about 70 something units of insulin per day, depending on whether it's been a good food day, or not so good. 23.3 of that comes from basal insulin, which is usually about 0.8 units per hour, except for a chunk of time in the early morning to offset the dawn phenomenon thing. What this means for those of us who are not mathematically inclined is that 18 units is basically enough insulin to cover a large meal.

Okay - back to the "Holy Shit" moment. Was I feeling funny because my blood sugar was dropping pretty fast? Maybe. I think that many of us would agree that our bodies don't like rapid changes, and that includes rapid increases or decreases in blood sugar. There's more to this than just crossing a threshold and feeling low - sometimes the body just doesn't like that rapid change.

It was at this moment I got really pissed off at myself. I'm in a sticky situation. I'm full (because I've been eating crap all day), but if I don't consume some serious glucose real soon, I'm going to be out of it!! All because I was being sloppy.

I started eating, and eating, and eating... then more eating. Man, talk about a love/hate relationship with food! To make a long and crabby story a little shorter, I didn't have any serious low, and rebounded a few hours later to 356. Nice.

To some degree, I feel very irresponsible about my (lack of) management. I've been at this for what will be 26 years in April. Shouldn't I be "better" at it by now? What kind of example am I setting for all of you? Don't I have some responsibility to take care of this body that God has blessed me with? How can I just take it all for granted like that? I'm sorry folks, but it doesn't get easier. Just different.

Disaster avoided. If only barely.