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.