Marching along...

Since the last time I reported numbers I have taken a small step backwards and am averaging slightly higher.
I just ran some reports and it looks like my sensor average for the month was 133 mg/dl. While I remembered things being really great at the end of February, my actual 30 day average for Feb was 132 mg/dl. So, really, with the good and bad all averaged together, things are roughly the same.

My sensor data says that I have been:
 26% above 110 mg/dl
73% between 70-110 mg/dl
1% below 70 mg/dl

My standard deviation (SD) indicates how much swinging I'm doing and it shows 34.9, meaning that my range of deviation is about 35 points around my target. This is okay, but when I get things as tight as I want, I hope to see my standard deviation in the 20s. Some people think this number is more important than the sensor average.

General observations from March...

• I was thinking and blogging that daily consumption Yerba Mate tea was behind my best days. I'm not totally sure that it was the sole player now. I have drunk it every day for the last 3 weeks and still had some high-ish and unpredictable days. I think the main player might have actually been insulin sensitivity caused by regular exercise. The week that I blogged about it was right at the end of a very consistent 2 weeks of daily exercise, strength training and sprinting. I think my muscles were metabolizing more glucose, and causing my levels to hang lower. More recently, with less exercise, I've been seeing a need for more insulin and numbers averaging higher. Lesson learned.
• During Spring Break I have found that my AM dawn phenomenon is always focused around the time I drink my 2 cups of strong coffee, regardless of wake up time. I have learned that if I bolus .5 units for it, I can keep my AM numbers pretty flat. Before I figured that out, I was trying to do it with a basal change, but it was too slow to do the trick. Now, my basal still accounts for DP, but I'm having less lows later from it being too aggressive. 
• One thing that I think is good... I'm seeing a bit faster response to insulin. When I give a correction bolus I am often seeing change happen within 40 minutes. I also find that when I am closer to the target range, things are more responsive.

• Chicken seems to be the protein that gives the biggest glucose spike. I'm still having a hard time timing my insulin to match different types of protein and their effect on my BG. I have started to use the square bolus and dual wave bolus, but can't say that I have have it worked out perfectly yet. 

Caveat: One thing that may have impacted my numbers is that I realized that the box of sensors I was using were expired and I wasn't getting very accurate data from them. I stuck (pun intended) with 2-3 sensors from that box, but found that they would be pretty far off at times. When I switched to a box with a valid expiration date I started getting fairly predictable results again. I had found that both highs and lows were sometimes undetected because of faulty sensors, but, because I didn't trust them, I usually caught them quickly with meter tests. 

More on Symilin

This article and the others from the series taught me enough about Symilin  (in Type 1 diabetics) to know that I want to try it.

I'm finding that my trickiest event with my blood glucose control is dinner. I am finding that I almost always have a rise after dinner, no matter how much insulin I take, and how much lead time I give it. I'm not eating much in the way of carbohydrate, so it seems to be mostly related to glucagon release and glucose released by the liver. If Symilin can help me tame those effects, I think I will benefit a lot from it. Other times of the day I am getting rather predictable results, but my dinner is often creating overnight problems or rises within an hour after dinner. Sometimes some exercise helps, but it seems like slowing down the hormonal side of things might be the best solution.

I'm looking forward to adding it to my regimen, even if it requires a long period of "tweaking things" to get it right.

Labs, coming soon...

I have an appointment with my primary Doctor coming up next month, so I needed to get some blood drawn for my usual metabolic tests. I took advantage of the spring break schedule and went in for my draw on Tuesday AM. I was able to add a thyroid function and testosterone test to the list.

Last time I was at the phlembotomist, I saw some posters about an app that you can get for your smart phone that allows you to receive your labs on your phone. I used it to get my info last time. It's great because, since the data stays in your device you can easily compare results, visit to visit. Well, so far, I haven't gotten anything, but I think my doctor's office usually gets them within 24 hours. My app says it will take 3-4 days for it to be entered into the system. Maybe I'll get some info by the weekend.

Maybe to pass the time, I will pause to predict my A1C. My sensor average says 131 mg/dl for the past 30 days. I guess since my last "at home" A1C test, a month ago, showed 6.1, then it might logically be about the same, or it could be at 6.2 or thereabouts. Based on what I'm seeing on my CGMS, I don't think I'm going to make it into the 5s this time around.

Recently, I've had a harder time getting desired results... I have found that once I have something go wrong, it throws off the precarious balance of insulin sensitivity and then it becomes difficult to achieve that same control for a while. I had gotten to a point last month where I was using only 25 units a day, and now I'm back to 30 units with numbers running higher overall. I think I know why. I have not been doing my 3 times a week strenuous exercise. I have only been using the elliptical for correcting creeping highs. When I was doing fairly heavy exertion regularly I was finding my insulin sensitivity was going up and I had to keep lowering my total daily insulin. I think I'm going to get back on that schedule of strength training or sprinting about every 2-3 days.

Something interesting about A1C measurements

In this article, health guru Kris Kresser says that A1C isn't an absolute test because of the different lifespans of blood cells in different people of different health. It's still always important for diabetics, overall. But, the closer to normal our blood glucose levels are, the more likely we are going to have extended blood cell lives, longer glycation period, and higher A1Cs. So in healthy people he doesn't always expect to see super low A1Cs (like in the 4s).

Kind of a catch 22, eh?

So, I guess there could be different kinds of people getting A1C measurements of 5.3. We might have those with normal glucose and long lived cells (that have collected more glycation over a longer life), and those with almost normal blood glucose numbers, but shorter lived cells. Might be splitting hairs here, but seems like either way it's accepted that it's healthier to keep them lower, as long as the risk of hypos is managed.

Support for a yerba mate theory...

I don't know about how it scientifically works for a Type 1 eating a low-glycemic diet, but from my short experience it has been one of the most noticeable differences from a supplement or tonic. I don't particularly love the flavor, like I do coffee and black tea. However, the energy, focus, and blood sugar stability (insulin sensitivity?) seems really noticeable. I feel like during the last 2 weeks that I have been drinking Yerba Mate I have noticed my overall metabolism has increased.

Over the weekend, I forgot to bring some home, and didn't have it for 2 days. My blood sugar levels crept upwards during the weekend. Upon returning to work, I started it up again, and by Tuesday I was having lower and more stable glucose numbers. Of course, there are other possible factors... like warm weather, weekend food, stuff like that...

Here is an article that seems to go along with my experience.

I'm going to include some of my data that will explain why I'm so intrigued by this phenomena.

The first day I drank Yerba Mate tea. Perhaps one of the best days of glucose control I've had in a while.

Not only did I use less insulin those days, I also ran lower glucose numbers. Notice the creep up on the weekend. 

While Sunday, 3/18, looks to be a low insulin day, I lowered my basal for a 20 mile bike ride, and my BG was higher overall.

This is pretty hopeful stuff...

I like this info.

Seeing all this data in one place is kind of like finding a $20 bill in your jacket pocket. I get lit up by this kind of stuff. Makes me feel like we are making progress, and we have things to look forward to. I will participate as much as I can.

These experts, they speak the truth.

I've been re-reading Think Like a Pancreas. One of the "new" things that I came across was that Gary Scheiner says that hard effort exercise can show it's effect on your glucose levels much later, sometimes 12 or more hours later.

Yesterday I took some students indoor rock climbing, and I worked pretty hard. During the event my levels were a bit higher than usual... adrenaline, surges of glycogen, etc. Sore forearms and everything. Lots of fun and challenges.

Well, overnight my blood sugars were fine, but this AM I have been running low all day and have had to eat some candy twice to keep myself in the comfortable zone. My glucose has been under 90 all morning and dipping below 70 at times. No bolus at lunch. He described his experience with this almost exactly the way it has gone for me today. If I hadn't read that recently, I would have thought it was witchcraft.

I also had some Yerba Mate tea this morning? Hmmm. Maybe something to that theory too.

Yerba Mate?

I like to brew anything. A few years ago I was enticed by the exotic nature of Yerba Mate, and I bought a pound of it. After tasting it, about twice, I left it alone. It wasn't black tea or coffee, that's for sure.

Yesterday I noticed it in the cabinet at work and for some reason decided to brew some up in the French press. The package states that one serving size is 14 teaspoons. I thought it seemed like a lot, so I dumped about 6 into the carafe for my single mug. I drank it and did feel sufficiently stimulated throughout the day. However, I was also feeling great because I had super stable blood sugar for the rest of the night. No big deal, sometimes you have better days...

Well, today I had Yerba Mate again, and again my blood sugar has been great and maybe just a tad lower than usual. I thought maybe it was a known thing so I looked it up online and found that it does seem to stabilize blood glucose levels as well as positively impact lipid profiles. Hmmm.

I'm going to keep having a mug of it in the middle of the day and see where it goes. If you try it, keep in mind that I'm steeping a lot of the bulk tea, and you might have to use more than a tea bag to get the same effect.

Thinking about trying Symilin

I have been doing some reading lately, and keep coming across mentions of Type 1 diabetics using Symilin to reduce insulin requirements and even out post-meals rises. I like the idea of using less insulin. I'm curious if any of my readers have used it, and whether it worked well for them. Anyone?

As I have read accounts on discussion boards it seems like everyone has different results and I don't know whether the best results are with a high carb diet or low-carb diet. The manufacturer says that you should use it with meals with more than 30 grams of carb, but I also see info from Dr. Bernstein, and he is a proponent of very low carb eating. My daily carb intake is usually under 30 grams. I also wonder whether the greatest benefit is for people who already have decent glucose control, or those who are outside the recommended control parameters.

I will be seeing my Primary doctor next month and I'm compiling some of the things I'd like tested (thyroid function and testosterone) or things I'd like to experiment with. I think I may want to try Humalog because it seems to be more potent and faster acting than Novolog. When you use an insulin pump, you can slow down the deployment as much as you want, but there's nothing you can do to speed it up. I find that many times I'd like a faster action. Not more insulin, just a quicker response. You know, like actual human insulin.

Symilin might be interesting to try too. I like the idea of reducing the amount of glucose secreted by the liver. I feel like my post meal rises in blood sugar might be largely related to a glucose/glucagon release by the the liver. I would only try this while using a pump and CGMS. I think it might get tedious, but seeing what's going on all the time might help work out the proper timing and size of insulin doses with Symilin.

One other "benefit" of Symilin is that is creates a feeling of satiety that diabetics are sometimes lacking because of the missing hormone, Amylin (also made by the pancreas). In other words, you might feel full sooner when eating with Symilin in your system. Some people lose weight while using it. This is might be because of the lowered insulin, raised satiety, or maybe even nausea. Yes, early on, for some users, the "satiety" comes across as nausea.

I do notice that by dinner I get a bit ravenous and eat enough that I'm uncomfortable for the rest of the evening. What can I say? I love dinner at home. Most days I only have trouble with blood sugars after dinner, and sometimes they are out of range all night while I sleep. Some of that effect could be from over-filling my stomach and causing the "Chinese dinner effect" (as coined by Dr. Bernstein) and a release of glucagon from the liver.  If Symilin can help with that, one way or the other, I'd be happy.

Diabetics and Statin Drugs

I recently read this blog post by Michael Aviad about his experience with doctors and the perspective that statins are crucial to reducing cardiac risk in diabetic patients. I commented on it as concisely as I could, but I think I'll expand on it here.

My doctor recommended that I take statins last summer because my Total Cholesterol was above the acceptable range for a diabetic. It was fine for a non-diabetic.
Why do diabetics have a lower ideal number than non-diabetics? Risk factors... Because, generally, diabetics tend to have higher triglycerides and higher A1Cs than normal people, which also carry a greater cardiac risk profile. Abnormal A1Cs typically correlate with high LDL counts.

I did some research about statins and found a couple of facts about the relationship of all these things to each other and came to some conclusions.

• Statins are anti-inflammatory, which can reduce risk for inflammatory health problems, like heart disease. Some experts even say that the benefits of statins might be more from the anti-inflammatory characteristics than the cholesterol lowering effects. 
• High blood sugar is inflammatory, which is a risk factor for inflammatory health problems. 
• Insulin also inflammatory. Insulin resistance is a sign of hormonal imbalance and inflammation.
• Eating low-carb reduces the need for insulin and increases insulin sensitivity. Needing smaller amounts overall helps achieve tighter glucose control (Dr. Bernstein's "rule of small numbers".

You could say that they kind of cancel each other out. But... if you can manage to keep your blood sugar normal... then you have activated an anti-inflammatory change and improved your risk. I chose to aim for that, and skip statins. Plus, research has shown that if you lower your A1C score, your LDL count will often descend with it. I'd rather work with something I've had 26 years practice with. Sounds like good glucose control is the winner all around. I'm not saying it's easy, but, it's possible.

Also, about LDL cholesterol. There is a correlation between LDL cholesterol and triglycerides. If you have high triglycerides (from eating a lot of carbs and sugar) then your LDL particles are likely to be dense and be plaque forming. If your triglycerides are low, then your LDL particles are more likely to be large fluffy particles that resist forming arterial plaques. Your LDL isn't considered dangerous if you also have low triglyceride numbers.

As a low carb eater my triglycerides are very low. My A1C is getting closer and closer to normal, non-diabetic numbers. With these two arguments, I told my doctor that I wasn't going to take the statins and risk their side-effects. He agreed with my choice. Another doctor, on the floor at the hospital in December, tried to put me on statins without even meeting me, and I also refused that offer.

I'm much more interested in discipline and knowledge than in a preventative drug.  I think we have the information to make wise individual decisions for ourselves in this matter. Look at all the facts, and check out all the opinions. I don't consider myself to be the average diabetic or statistic. So the collective opinion of doctors created for the average statistic, isn't necessarily a good fit for me.

Graphing inertia

I've noticed that when I have good results for a stretch, it keeps going that way pretty smoothly until I make a mistake, or get cocky or careless and mess it up. Then, it goes poorly for a few days until I dial it in, stop making mistakes and get it back in line.

It seems like if I let my glucose go high for one event, my average need for insulin, and average glucose level will rise for a day or more afterwards. It's like high glucose creates insulin resistance and prolonged poor control.
When things go well, it feels like my body really gets tuned in and then it will stay that way pretty well, even lowering it's need for insulin progressively, and then if I expose myself to high glucose for a day the effect seems to linger and change my metabolism and insulin demands for a while.

This kind of thing makes it difficult to get good control, because it's a slow process of bringing things back into line, and you can't assume anything about normal basal rates and correction doses. It just doesn't work the same until I get everything ironed out again.

Does anyone else see these types of trends?

Additional note:
15 min. Exercise correction
5:20pm 101mg/dl
6:00 dinner & bolus
7:00pm 141 mg/ dl
8:00pm 169 mg/dl (and rising) elliptical 15 minutes
8:15pm 114 mg/dl
10:45pm 90 mg/dl stable

(exposure to abnormal glucose levels- less than 2 hours)

What's worse?

I don't know what's worse... going around without a sensor and neurotically wondering where my glucose is headed, or having a sensor that is inaccurate for it's entire life. It's kind of like the difference between flying blind, and being teamed up with someone you can't depend on...

This week I've had one that has been wrong the whole time. Normally, I give them a couple days grace to get fully calibrated, and then enjoy 5 days of spot-on, predictable accuracy. So far, this one is a dog. As much as I dislike the harpoon-like nature of putting a new sensor in place, it's probably time to end it early and move on to one that works.

I'm happy for the 8 out of 10 sensors that give me great information. It only makes me more aware of my dependency when one doesn't work right. 

At least my meter is dependable... I think.

Discoveries...

Everything that I have found out about diabetes "on my own", was also told to me by someone else a long time ago, and I just didn't grasp it. As I read through books (that I've read before), I'm finding relevant information that reinforces all the "new" knowledge. I guess, I've probably been exposed to a lot of good stuff, I just need the right moment or a 2nd or 3rd go around to "get it".
Diabetics, if you want to make your lives better, go find the info, it's out there. I can vouch for that.

Non-diabetic glucose levels... also a wild ride.

We were driving home from church today and Carol said she was feeling hungry, and like her blood sugar just dropped. A bad feeling. I offered to check her blood sugar in the car, and she was game. She was 142 mg/dl, and I was kind of alarmed. I tested it again, and made sure there was nothing on her finger (142 also). I know that non-diabetics aren't really supposed to hang out in the 140s. And, it wasn't just after a large, carby meal. She had nibbled a couple pretzels at church and was holding out for real food at home. We had some fun joking with the kids about the implications of having two diabetic parents. I hope you guys enjoyed that pizza last night, because it's over!

When we got home I ran an at home A1C test on Carol she read 5.2 (an average BG of 104). Since I'm not used to thinking about non-diabetic numbers, I wasn't sure if it was totally normal or not. I just knew it was a number I'd love for my own... as it turns out, it's pretty normal. Could be lower, but not considered pre-diabetic or anything.

Next, the kids all wanted to be checked.
Ellie (13), was 111 mg/dl. She had just finished eating some ice cream.
Simon (11) was 85 mg/dl.  Pre-lunch for him. He eats low-carb like me. From what I understand, this is the ultimate "normal" reading.
Penny (7) was 141 mg/dl. Fruit snacks at church. They say that young kids have a higher normal range. She's still young (her first test read 217, but after washing her hands it was more reasonable).

Carol tested again, and it was back down to 93 mg/dl. She had eaten a sandwich and felt better.
Tonight we did another test at about 9pm and she was 94 mg/dl. 

I thought it was funny that Carol's sensation that she had "low" blood sugar had prompted this test fest. It was a bit of a role reversal. I think I was the only one that didn't get tested that hour. I have to say, it was kind of fun to share my pastime with the family.

One more note, while my brother, Dave, was visiting last summer he said that after a large meal and a beer he totally crashes, and he said he thought it was because his blood sugar was going high. I was curious, so we tested after a feast + brew. Surprisingly, his glucose was only 110 mg/dl. It just goes to show that non-diabetics have darn good control, but feel all the icky fluctuations of the sugar and insulin roller coaster. You could say it just never really goes off the rails, just feels like it...

Insulin Action Acceleration

The larger a dose of insulin is, the faster it does it's work. Since I take fairly small doses of insulin, boluses are usually around 2-3 units or less, I hardly ever see my sensor with arrows showing that I'm trending down or up. In general, it's good to have changes in glucose happen more gradually, but when you are really out of range, you want faster change.

The one thing that has allowed me to experience rapid changes in blood glucose lately is exercise. I know I've already talked about it, but having a sensor to look at during every experiment has taught me a lot. If I get on the elliptical for even 10 minutes I will soon see an arrow showing a rapid change in my blood sugar. Often, it will be a double arrow, indicating that I'm dropping faster than 5 mg/dl per 5 min. I know that exercise makes you more sensitive to insulin (needing less), but this is clearly also an accelerated absorption rate. If I have a 2 units of insulin in my system and the rate of change is so slow that my sensor graph is barely showing it... 10 minutes of low-level activity will turn the insulin receptors on and have me in a fast correction. I'm finding that it allows me to spend less time out of range, when I make a mistake.

Here's an example from yesterday:
I was going into lunch feeling hypo and my sensor was reading 80. I decided to eat the baked potato that came with my ribs, as a precaution. Since I'm very sensitive to fast-acting carbs (plus, I generally underestimate them), I ended up at 275 mg/dl later in the day. I took a correction bolus, but didn't see much change. About an hour before dinner I got on the elliptical for 15 minutes. My blood sugar began dropping (double-down arrows) and dropped all the way through dinner. By 7pm I was using glucose tabs to keep myself in range. Overall, I didn't take that much insulin, but with exercise, I could have probably taken half as much for correction (and with dinner), and still gotten it fixed in 2 hours.

 In the future, I'll have to be more conservative with correction doses if I am going to use exercise alongside. And, because of the immediacy... I definitely will.

When I first started really focusing on my glucose control in 2003, I spent most of my energy on managing my food intake and insulin. I felt that exercise was just a monkey wrench that would make things more unpredictable. Now that I am tinkering with this, I feel like I just discovered the other 30% of my toolbox. Ironically, I'm spending less time exercising than ever, a little bit seems to be more effective than an hour, so it's much easier to find time for it.

Just a number... yes, I share.

I am doing at home A1C tests every month to see if it jibes with my sensor average. This month it came in at 6.1, which indicates an average glucose of 128 mg/dl for the past 3 months. It's heavily weighted on the last month, but also shows a longer reaching trend. It's my best (likely valid) result that I've had in my diabetic life. I'm happy about it. During the past year I have tested between 7.8 and 6.7 (which translates to averages of 177-146 mg/dl). My goal this year is to get into the 5s.