Monday, June 20, 2011

9:30 am - At School

Every morning at about 9:30, Leslie and all the other kids at her middle school with diabetes leave class and report to the school nurse’s office to check and then report their blood glucose levels. Today Leslie is a little low and requires some food in order for her to get her blood sugar back in the normal range. She is 65. This is her second blood glucose test of the day.

Knowing that Leslie’s blood sugar will rise 10 mg/dL for every 1 gram of carbohydrate she eats, she and the nurse figure out that she needs to eat something that contains between 6 – 10 grams of carbohydrate in order to get her back into the “zone” which will be both be safe and facilitate learning. She eats some peanut butter crackers and heads back to class.

If her blood sugar had been high instead of low, she would have had to take additional insulin to bring it down into the zone. Since it is still morning, the ratios would be the same as those in place when she awakened.

Friday, June 17, 2011

7:00 am - Breakfast

7:00 am

Leslie arrives at the table to eat breakfast. For some reason, Leslie eats like a bird at breakfast time so the portion sizes are always rather small. With this oatmeal, sausage and fruit breakfast, the carbohydrate count is about 30 grams.

Leslie grumbles, “Oatmeal again? Why don’t you guys sleep in and let me make my own breakfast? I’d like to have cereal.”

By this time, Carl arrives at the table and joins Leslie’s chorus of complaints, “See? We don’t like this healthy stuff. Why don’t we eat Pop Tarts like everyone else?” Carl, who often seems to be a bottomless pit when it comes to food, refuses to eat the oatmeal and proceeds to fix himself a bowl of grits and sausage.
He continues, “Why don’t you buy us some real breakfast food? You know, like pancakes and syrup or waffles?”

This now familiar litany results in an equally familiar response from Carol, “Because we don’t eat junk food. Do you know how highly processed the flour is in boxed waffles? I make French Toast so we don’t need pancakes.” For reference, 2 store-bought waffles may have 26 carbohydrate grams (before syrup) but the flour is so highly processes that it will almost immediately turn into sugar once Leslie eats it. Pop Tarts each contain 37 carbohydrate grams.

As Leslie eats her food and Carl inhales his, Carol and I are busy preparing Leslie’s sack lunch for school. On this day, I prepare her a sandwich made on whole grain bread. (White bread is a carbohydrate disaster. The flour is so highly processed that it almost immediately is turned into sugar once eaten, dumping 15 grams of carbohydrate per slice into her blood.) The slice of whole grain bread may have more carbohydrates, but it also has three times as much fiber. Once the roast beef sandwich is prepared, I place it in a baggie, get out a piece of masking tape and a marker, and write on the tape the total number of carbohydrates in the sandwich (45 grams).

Carol, working beside me in the kitchen, is preparing a snack-sized baggie of veggies – usually carrots, cucumbers and a slice of green pepper. One of us packs a similar baggie filled with grapes or some other fruit. To label this baggie’s carbohydrate count requires a kitchen scale. You see, grapes and other fruits don’t come from a package. So how do we know how many carbohydrates are in a bag of 20 grapes?
We may not know how many carbohydrates there are in each individual grape, but scientists have measured how many carbohydrates there are, on average, in a gram of grapes. We have a very handy reference book called Pumping Insulin by John Walsh and Roth Roberts. In it, near the end, is a table of common fruits and their “Carb Factor.” The Carb Factor is simply the percentage of the total weight comprised of carbohydrate. For example, Concord grapes have a Carb Factor of 0.14 and European grapes a Carb Factor of 0.17. To determine the total amount of carbohydrates in the bag of grapes, you simply multiply its weight by the Carb Factor. The bag of grapes we just packed contains 12 carbohydrate grams.

Finally, we fill a bag with chips. Here too, we must weigh the food in order to get an accurate carbohydrate count. Chip bags don’t provide a carbohydrate count per chip since there is too much variation in chip sizes. Rather, the manufacturer provides a serving size and tells you how many carbohydrates are in each serving. If you divide the carbohydrates grams per serving by the weight of the total serving, then you can derive your own Carb Factor for that particular brand and type of chips. Once you have the Carb Factor, you weigh the chips you want to eat and multiply by the Carb Factor to determine how many carbohydrates you are about to consume. Today’s chip bag contains a total of 22 carbohydrate grams.

We keep three calculators in the kitchen and now you understand why.

We’ve now been up for 1 hour and 15 minutes. Carol has prepared breakfast; I’ve gotten ready for work and helped prepare lunch. For both meals we’ve meticulously determined how many carbohydrates are contained within each food item and, at least for the lunch, labeled them accordingly.

When Leslie finishes her breakfast, we together look at how much food she ate and determine how many carbohydrates were consumed. We can calculate how much insulin to administer based on how many carbohydrates were eaten. On this day she ate everything so the calculation is easy.

I say, “Leslie, you need to take 6 units (of insulin).”

How did I arrive at 6 units? Well, Leslie is now 13 years old. In the mornings, we’ve found through trial and error that she needs 1 unit of insulin for every 5 grams of carbohydrate in order to keep her blood sugar at a reasonably low value. This is up dramatically from just 3 years ago when she would have required only 3 units for the same carbohydrate load. Why? I’m not really sure, but we believe it is because she is older and has more body mass – though, as an appearance-conscious teenage girl she might not like me saying that…

The scary thing is that the 5 grams per 1 unit ratio is just a best guess based on what her body’s reaction has been to food on previous days. And it may work fine again today. But it might not. And that’s the reason for the mid-morning blood sugar check, which I will explain momentarily.

Leslie pulls out her insulin pump, fiddles with the buttons faster than an adult eye can comprehend, and says, “Okay!” The pump is swiftly put away.

I say, “Did you get your Lantus?”

Lantus is a type of insulin that that delivers a low-level basal insulin dose over a 24-hour period. The importance of the basal dose is discussed in a previous chapter and I won’t repeat it here. When it is soccer season, instead of having her pump deliver all of her required basal insulin, we give her a shot of Lantus. This allows here to take off her insulin pump for a few hours during soccer practice, which she has twice per week, without adversely affecting her blood sugar.

Lantus insulin cannot be administered in a pump and she only needs a single shot of it per day. Its time-release formula makes sure she gets the added basal insulin dose continuously for the day – including during soccer practice.

Leslie responds, “Oops. I almost forgot. I’ll get it.” With that, Leslie bounds over to the refrigerator to get the vial of Lantus insulin we keep in its door. While she draws up the shot in the syringe and prepares to jab herself in the arm, I ask her the same set of questions I ask every morning.

“Do you have your supplies?”

“Yes, Dad, I have my supplies.”

“Are you sure?” is my typical response.

“Yes! Why do you have ask so many times?” Leslie’s frustration level begins to rise at this point.

“Because I still remember the day you said you had everything when you didn’t. I got called to bring supplies to the school that day. Do you remember that?

Sheepishly, she replies, “Yes. But I checked and I have everything!”

By “supplies” we mean the following:
1) Her glucometer so she can check her blood sugar

2) Test strips for the glucometer. She will need at least 10 to get through the school day with margin.

3) A fresh needle for the finger pricker. Leslie forgets to change the needle and, as a result, often pokes herself with a dull needle. That has to hurt…

4) A package of glucose tabs. If we miscalculate the insulin dose and she runs low during the bus ride to school, then she must have access to fast-acting sugar to raise her glucose. Even though we are very careful, we sometimes err.

5) A banana, bag of grapes or some other fruit. Eating sugar to bring up your blood sugar can get tedious. Having some fruit that quickly digests allows a child with Type 1 Diabetes to bring up their glucose, when needed, without eating too much processed sugar. Sometimes we substitute a granola bar for the fruit.

6) Her fully charged cell phone. While cell phones are banned at school for most kids, Leslie has permission to carry one in case she needs to contact Carol or me with a diabetes question or concern. Going to school with a dead cell phone battery is not unheard of with Leslie.

At this point she grabs her book bag, her lunch bag, and her purse filled with diabetes supplies and heads for the door, pausing only long enough to get a hugs from Carol and me. This is a departure ritual we do not allow to slip by.

By this time, Carl has eaten and left the room to study. All the “diabetes talk” is usually too much for him and he’d just rather not have to think about it.

I than grab my lunch and head for the car so as to get to work on time. Or at least close.

Thursday, June 16, 2011

A Day in the Life or "I am my daughter's pancreas"

6:00 am

The tinny and inexpensive digital alarm clock perched on top of the bed rail above our heads begins it’s morning routine by clicking on. The announcer from National Public Radio then jolts us awake by filling us in on some major national or international news event. As Carol and bemoan the fact that we once again didn’t get enough sleep, we both realize that we’d better get moving or the daunting morning routine will not be accomplished in time for Leslie to catch the bus to school.
By 6:10 we usually roll out of bed and head to the bathroom. Carol quickly dresses and heads downstairs. I stumble into the bathroom for my morning shave and shower ritual.

Now fully dressed and fully awake, I pass Leslie’s room on my way down the stairs. Her light is usually on by this time and I give her my morning through-the-door greeting, “Good morning Leslie. Did you sleep well?” followed by my must-ask diabetes question, “What was your number this morning?”

Leslie groans and says, “Hi Dad. 185.” Meaning, for those who don’t live with diabetes, that her blood glucose level is 185 milligrams per deciliter (mg/dL). Her target blood sugar is 110 - 120 so her number this morning is a bit high. Unfortunately, she is often high in the mornings. This is her first blood sugar test of the day – the small and sharp needle is jabbed into her fingertip producing a small droplet of blood that is then touched to the disposable test strip in her meter, which then tells her the current glucose level in her blood. (The retail cost of her test strips is $0.58 per strip.)

I ask, “Did you correct?” knowing, with near 100% certainty but afraid to assume so, that she has already given enough insulin with her pump to bring her blood sugar down to the target level.

Her predictable answer is then provided, “Yes.” Even though I know she knows to check and then correct her blood sugar levels, I don’t dare assume so. If I don’t ask and this is one of those mornings that she happens to have an extremely high blood sugar, uncorrected, then the additional rise in her blood sugar from eating breakfast could make her sick. It has happened before – not often, but often enough for me to routinely ask the question.

After hearing her reassuring, “yes,” I bound down our comfortably carpeted stairs, walk down the hallway and turn the corner into the kitchen and nook. The first thing I notice when I walk into our nook is the beautiful view from the bay window. Our house overlooks the woods and the onslaught of the color green is a welcome sight each and every time I pass that particular window.

By this time, now approaching 7:00, Carol has been preparing breakfast for approximately half an hour. Breakfast in a household in which a person with diabetes lives merits some explanation and it is here that I must credit Carol. In the early days after Leslie’s diagnosis, she spent hours researching diabetes-friendly diets and guided the entire family in a transition to much more healthy eating habits. We have all benefited from what she learned, though the changes were not always easy to live with.

First of all, the most common breakfast foods are probably among the worst foods anyone can eat, let alone someone with diabetes. Before I describe what the Johnson family eats for breakfast, I’ll discuss a typical American breakfast and explain why it should be avoided.

Example 1: Orange juice, a bagel with cream cheese, and some fruit.
Orange juice is made by squeezing the juice from oranges, leaving most of the pulp behind. The delicious end product is essentially a sugar drink. Fructose, the sugar found in most fruits, raises blood sugar rapidly and effectively. It is so rapid and effective, that most people with diabetes will use orange juice to bring up their low blood sugars in lieu of eating a glucose (pure sugar) tablet. Why, then, would someone with diabetes want to drink 8 ounces of nearly-pure sugar first thing in the morning, raising their blood sugar must faster than insulin can counteract it? (Note - Today’s fast acting insulin takes about 2 hours to work; orange juice can raise a person’s blood sugar in just a few minutes.) Why would a person with diabetes drink OJ and cause their blood sugar to spike? It tastes good. That’s probably okay for the occasional glass of juice, but it is not okay as a daily ritual because it will perpetuate consistently high blood sugars. (8 ounces of orange juice contains 30 grams of carbohydrate – enough to raise Leslie’s blood sugar 200 mg/dL.)

What about the bagel? Most people assume that a bagel is a better breakfast choice than a donut. And, if you were thinking about the fat intake, your assumption would be correct. But if you were concerned about blood sugar spikes and carbohydrate intake, you would be dead wrong. A Krispe Kreme glazed donut has 22 carbohydrate grams. A Panera Bread Whole Grain Bagel contains 66 grams. I’m not advocating a diet filled with yummy donuts; rather I am advocating that people be aware of what is in the food they eat. Who would have thought?

The cream cheese has only 2 carbohydrate grams, so its effect on blood sugar will be minimal.

Depending upon the choice of fruit, the effects on blood sugar can vary between minimal and significant. A high-fiber apple contains 23 carbohydrate grams but it will only slowly raise blood sugar due to all the fiber it also contains. Fiber slows down the rate at which the body digests the food, thereby slowing down the release of sugar into the blood stream. A cup of grapes has very little fiber and 15 carb grams. Though the carbohydrate count is lower, the grapes will likely cause a faster blood sugar spike due to their low fiber content.
The bottom line: A glass of orange juice with a bagel and some grapes will pump about 110 grams of carbohydrate into you system. If you don’t have diabetes, then your blood sugar will probably only spike marginally before your pancreas produces enough insulin to allow the sugar to be absorbed and used where it is needed. If you have diabetes, your artificial insulin will do the same, but it will likely take it more time. The result will be a significant rise in blood sugar and, as we have discussed, such highs take their toll on your body and your overall health. 110 carbohydrate grams is approximately 1/3 of an average adult’s daily-recommended intake – breakfast is usually a person’s lightest meal of the day.

We usually don’t have juice and bagels for breakfast.

What do we eat? A typical breakfast is oatmeal (steel cut oats – whole grain – to slow the rate at which the carbohydrates are converted by the body into sugar and thereby prevent a large blood sugar spike after the meal); in the oatmeal are some cut-up bits of sausage (no carbohydrates but plenty of protein) and some raisins (for flavor). Served with the oatmeal is almost always some sort fruit (a peach, strawberries, or cantaloupe). The carbohydrate count might be comparable to a cereal breakfast, but it will contain more fiber and some protein to slow the carbohydrate-to-sugar conversion.

Next Post? 7:00 am