What do you make of this? What do you call Low?

I've been listening to Robb Wolf's podcasts about eating Paleo diet and solving health problems. One reader asked about non-diabetic people testing their blood sugars and what he considered "normal". He said that with the non-diabetic athletes he works with it is very common for them to maintain blood glucose values of 60-70 mg/dl, all the time. These are insulin-sensitive, low-carb, ketogenic atheletes. I was fairly incredulous (almost mad?) because I have always considered those numbers to be uncomfortable low blood sugar numbers. Also, I have found Dr. Bernstein's standard of 85 mg/dl to be difficult to achieve, but this  60-70 mg/dl business just sounds uncomfortable!

I guess, if I had no chance of actually going hypo because of all the checks and balances (glucagon, etc) of a normal body working perfectly, I wouldn't be too freaked out to just walk around in the 70s all day. However, I do feel some minor hypo symptoms at that level and always correct to get my level back to 90-110 mg/dl.

So, that has me questioning my bias towards high-ish "normal" numbers, and also had me wondering if Robb was fudging numbers downward to make a point. When it comes to blood glucose numbers, we Type 1s are very aware of what is normal and what's not, so we don't go for exaggeration in the place where we live.

Then I saw this guy's graphs and read about him sleeping and waking up regularly with his glucose in the 60-70s. I just wondered, why would you do that? He says he felt better that way. Is that possible? So many questions... (just corrected my fasting 108 mg/dl down a smidge.)

looks like the slide into athleticism is inevitable

I've been finding very positive results with surges of exercise "turning on" my insulin.

 For instance, today... after a rough night with a heart arrhythmia episode, a hypo and over-treating it with ice cream... I woke up with my glucose in the 200s. After a week of fairly great control, it was pretty bleak. Plus, I was headed into a high-adrenaline day, the first day of a new semester, with very little sleep. Sounds like a bad blood sugar day, right?

Yep, all day I just hung out at 200 or so, and boluses did nothing. I was too busy to really care.

 I came home with tons of work to do, but felt lousy from poor sleep and being high all day. I took a nap, more insulin, everything stayed the same. As I was sitting down to put in my evening of work I decided that it would be a worthwhile experiment to put in 15 min. on the elliptical and see if it would budge my stuck glucose level. Immediate change. In 30 minutes I went from 208 to 78. I have never seen anything like it. It's like my insulin is just sitting there in my tissues waiting for me to give it the green light.

 Then I read this article about a Type 1 ironman who greatly improved his control by exercise and eating Paleo. I'm already eating that way, now I just need to figure out how little I can exercise and get the full benefit. I'd like to keep it to 30 min. a day, and be in the comfort of my warm home.

exercise experiment

Based on my recent breakthrough with physical activity upping my insulin sensitivity so much... I tried something after dinner tonight. After I eating, I was watching my sensor and saw that my glucose was already to 140 mg/dl, 30 minutes post meal. Considering that I took my meal bolus about 20 minutes before dinner and  I don't eat fast acting carbohydrate, it seemed like I was headed in the wrong direction. I decided that I'd get on the elliptical after dinner and go for 20 minutes, to see if I could correct the rise. It worked. I went from 140 to 89 within 40 minutes, with a meal in the works.

Now I just need to see if I can get an elliptical in the office at work. Not really, my trickiest readings all day are after dinner and into the night. Digesting dinner just seems to be a wild card.

This is good information. If my insulin worked faster I'd be fine, but it seems like it's always really slow. I'm almost never afraid it will work too quickly. This exercise deal is speeding it up for me. I'm all about it.

works for him...

I have mentioned that my dad is a Type 1 diabetic. Although he lives far away, in another part of the world, we are able to get together every year or so. The past couple times he's been visiting he has been known to take off on walks for 30-60 minutes to solve a blood sugar problem. He has discovered that when his insulin isn't working, exercise makes it happen. I thought it was an interesting move, but I didn't try it. I've always felt that exercise was a "monkey wrench" that would make things more complicated (when things are already off).

We acquired an elliptical trainer this past summer, which allows for Carol and the kids to get in their physical activity while pursuing their homeschooling. I didn't consider it as much of an option for me, because I haven typically gotten my activity outside, on a bicycle. I guess you always have something to learn. 

Recently, I've noticed that under certain circumstances my glucose levels will wind up high and then just stay there, regardless of boluses and temporary basal increases. With some patience (3-6 hours) I'll see it right itself, but it's much slower than you would expect from analog insulin. 

Last night was a perfect example of how I was able to utilize the elliptical trainer to work out a correction rather quickly. I went out to a nice dinner downtown and we ate for about 3 hours and had all sorts of things. The carb counting was totally guessing. I went off my low-carb list here and there, and had my sugar levels climbing despite plenty of insulin in play. By the time I got home my blood sugar was 300 something and I had perhaps 4 units of insulin "on board". It seemed like it was still going up. 

I decided to do 30 minutes on the elliptical to see if it would increase my insulin sensitivity and get me back where I was supposed to be. Based on my glucose sensor, at 9:05 I was at 318, and by 10:45 I was at 94. The drop shown on my CGMS was so precipitous that I stayed awake for a while to make sure it wouldn't go even further. It didn't. When I hit the 90s my numbers started to flatten out and cruise along at that level for the rest of the night.

I was also testing with my meter and it showed the correction to all happen pretty much during the 30 minutes I was active. I know they say you shouldn't exercise when you are over 250, but in this case it seemed like the perfect solution. I wasn't above 250 long enough to have any symptoms of DKA.

It seems like just getting my muscles moving gave all the circulating insulin a place to set up shop and do the glucose metabolism. I know muscle tissues are much more efficient with using insulin and glucose than other tissues, so this must work for that reason. I'm happy that we have an "in-house" option for fixing blood sugar problems in short order. 30 minutes for me is enjoyable, and it's amazingly gratifying to see quick results. I've had high-ish blood sugars after dinner lately, I am wondering if I can solve the problem just by doing a session on the machine after dinner each night. 

busy days...

I'm in the throes of the end of the term craziness right now. I am going to see how things shape up with grading and all that... but, I'm just going to tell myself to take a break from diablogging for a bit. See you when the dust settles. I have several things to discuss when we return.

Ethically sourced?

 http://www.diabetesmine.com/2012/01/whats-up-with-diabetes-stem-cell-research-firm-viacyte.html

This article is a very interesting read.

I like the idea of an credit card in my back that produces insulin and all the other regulatory hormones... and no immune system suppression needed. 

Embryonic stem cells are controversial for a good reason. These are "ethically sourced", but I'm not sure what that means. Either way... while it's the type of research I'm most interested in hearing about, I'd love it more if there were no sticky questions about the ethics of the process. I guess if the device were made available as an effective cure for diabetes I'd have to do some research and evaluate my biases...

Regardless, it seems like they are tracking down some interesting solutions, especially since cadaver beta cells seem like a dead end for a broad scale treatment.

Glucagon emergency kit?

Stats... and yes, I'm pretty much out of insulin.

In my sugary life, I almost always have erred on the side of not enough insulin, and my excursions "out of range" are 95-100% on the high side rather than low.

As I re-read Dr. Bernstein's book, Diabetes Solution, this year, I came across his list of all the things that every diabetic should have. The Glucagon Kit was high on the list. I was realizing that my wife has probably already forgotten that they exist and we haven't even talked about it as a necessary measure in 10+ years.

I have owned about 3 Glucagon kits in my life, and they seem to expire too quickly to stay in my readiness kit. It's hard for me to keep buying them since I've never actually used one... but, I guess that's like saying why wear a seat-belt if you've never had an accident.

Personally, I think explaining it's use to my colleagues would freak them out a bit. And, I would hope that in the era of CGMS, crazy-stealth-severe-hypos might be less likely. What could make me have to use one? Maybe making a major mistake on an insulin dose. Maybe accidentally bolusing 10 units instead of 1 unit, stuff like that? It's never happened to me, but I suppose it could... When I was doing multiple daily injections I once took a Lantus dose with Novolog (oops!) and had to stay up all night watching for the inevitable hypo...

I am wondering how many Type 1 diabetics keep a Glucagon kit ready for emergencies. Have you ever used one? Do you carry it with you? Do you have one at work and home? Have you ever needed it? Do you think it's irresponsible to not have one ready?

Talking about food with Sysy

I have enjoyed reading The Girls Guide to Diabetes and have had a lively email exchange with one of the authors, Sysy Morales. Despite being outside the target audience (I'm not a girl), I find it to be a great blog. I like how the information is constructive and inclusive. Readers can learn and expand their knowledge about their own diabetes from the info on the site. Hopefully, some day The Girls Guide to Diabetes will be a published book.

I was interviewed by Sysy and talked about the way of eating that has worked best for me and my glucose control.  I'm not getting totally normal numbers yet, but things are getting better with study and practice.

the bermuda triangle for glucose control

I have read a lot about diabetes and glucose control. The one thing that frustrates me about everything that I have read is the lack of specific information about two key factors in blood sugar control.

Experts will all agree that infection and "stress" will impact blood sugar levels and insulin demands. But, how much? It's different for everyone... for me, this becomes a big biological experiment and I spend most of the "off" period of time trying to figure out what the magic formula is for normal control again. It seems like the tighter your control is, the more this factor messes things up in a tangible way.

Adrenaline
Stress is cited as a cause of glucose fluctuations in Type 1 diabetics. I have an issue with the word stress. I have a job I love. When I go back to work in the Fall, teaching high school art, I am super energetic and focused on the new school year. I wouldn't call this "stress" as much as adrenaline. However, I do see changes in my blood sugar profiles and I do have to increase my insulin to counter-act the impact of daily adrenaline derived from managing a room full of teens. It's fun, and tiring, and I feel kind of amped up on caffeine for the first 2-3 weeks of school. Even after many years of paying attention to such things, I still don't have a "beginning of the school year" formula for adjusting to the "stress" of teaching. I wish I could just change my basal rate to something known and move on. Anyone have a formula? Oh, that's right this is an individual thing...

Infection
Even before I feel sick, my blood sugar levels will tell me I'm sick. I'll see an unpredictable rise in my levels for no apparent reason and the next day or so, BAM! I'm sick. I normally will ride out a cold fine, with no change, but as soon as infection starts to kick in, it's obvious in my glucose control.

Lately, I've been sorting out some sort of sinus or dental issue and it has given me erratic blood sugars for about 9 weeks. It hasn't been possible to just up my basal and do corrections as needed. Some days it's mostly normal and other days it's mostly off. Sometimes I'll watch my CGMS data going along flat as can be and then something will switch and I'll see a rapid, unstoppable rise. And this is without food in the last 5 hours. It's like watching a jet take off. What the heck?
I wish there was a formula for that too...
I've used temporary basals to try to slowly hammer away at them. I crank it up to 200% for an hour or two and watch it till I see it start to descend. Sometimes there's a low at the bottom of the descent, so I'm trying to be more conservative with 130-150% temporary basals. Anyone have an infection or sick formula? Seems pretty personal, right?

I think these kinds of personal, biological variables are the things that make the development of a "closed-loop" system even more tricky. How can a machine, managing insulin with slow reaction times in the body respond to rapid, unpredictable biological changes? Kudos to those trying to accomplish this... I can't seem to figure it out.

Plans, goals, dreams.

I'm pretty focused on glucose control right now and I think I have to be. I have all the tools and discipline to get better results and am ready to put it out there. A little bit of public accountability, if you will.
I'm going to try to get my A1C into the 5s. I've never seen a number lower than 6.2 in the past.

I have found the Bayer A1C Now tests to be accurate "at home" measurements. I have done them the same day as my lab work was done and gotten the exact same number.

While I was typing this I was actually running one of the tests to get a baseline... but, 2 of them came up with a QC error. So I've wasted 2 tests today, with no numerical results. I wonder what I did wrong? I've never gotten an error before and today it's 2 for 2. I have one left, should I try it once more? Is there something chemically whacky in my blood that is throwing the whole thing off? I'll call them A1C Maybe Later kits.

Alright, I'll be flexible... I'll go with my average glucose number according to my CGMS, which is also prone to error... at times. My 30 day average is 150 mg/dl. And my meter average agrees. It's been a rough month with infection causing swings all over, mostly up. I think it will be easy to improve on this.

My goal, based on less error prone devices... will be to bring my average BG reading to below 126 mg/dl.  According to my A1C test kit, that's equivalent to 5.9% Right now, according to my numbers I have something equivalent to a 6.9%. While I was in the hospital for my heart arrhythmia they tested it at 6.8%.That was roughly a month ago.

Okay, I'll record my progress here around the beginning of every month.

P.S. I have never been able to get my pump to tell me the average BG in the past. I just found out this weekend while looking at the manual (it took me 4 years to go back and read it) that it was just one more button press away. Now I can quickly see my average sensor glucose and meter glucose anytime. So, my monthly averages won't be a surprise at all, like A1Cs sometimes are...

I survived... a sleep study.

I read a lot about sleep apnea, because of the link to heart arrhythmia, and was about to tell anyone who snores that they should get themselves checked out.

Well, I did the sleep study on Thursday night and I'd say, only do it if you have a real sense that it might be causing you a problem. My experience was interesting, to say the least, but I can't say that it was great. It was SO hard to sleep with the idea that you were being studied. I was aware of every inhale and exhale. It's a wonder that I slept at all. I think I slept for about 4 hours the whole night and I felt like I was awake for about 9. Okay, I was only there for 9 hours total, but it was a long night. The thing that cracked me up was that I got home, crashed on the couch and got the best sleep ever... EVER. Deep, REM sleep. Love it.

I don't know what they will turn up with their results, but either way, I'm glad it's over and I can get back to sleeping at home and waking up early for no reason. I love early morning coffee when no one else is awake.

Maybe sometime I'll give some details on what it's like to be studied while you sleep, but, right now, I'm just glad that it looks like I'm done with it.

Additional info: I started snoring this year. I've always been a back sleeper, like a mummy with no movement and my arms across my chest. My wife, Carol, noticed my snoring and made me roll over on my side, and it stopped. The cardiologist took this information and wanted to make sure that my snoring (lack of breathing) wasn't the cause of my heart arrhythmia. I hoped it was the cause, because that would be an easy solution... sleep on your side. Done.