Ken’s Type-1 Diabetes Journey: Control Part 2 - When Things Go Amiss
By far, the most valuable knowledge I learned at the beginning of my Type-1 diabetes journey is that my blood-sugar is directly controlled by me. The inability to make my own insulin means that my metabolic system is “open-loop”. Open loop means the automatic control mechanism, insulin production, is broken thus requiring manual control. A side benefit of manual control is the freedom to make my blood-sugar whatever I want. It is entirely up to me. But, it is somewhat like riding a bicycle; it isn’t easy at first, but with practice it becomes second nature.
Blood-sugar is a balance between glucose burn rate and supply rate. These two ends of the control see-saw change minute to minute. The variability is simply too much for a doctor to maintain continuous control for you. The good news is that if you are a Type-1 diabetic struggling with poor blood-sugar control; YOU have to power to make it right. Indeed, no one can make it right better than you. Like Dorothy with her ruby slippers – you have the power.
Tools needed are a log and glucometer. A log is required to track insulin requirements and all the short and long term variables that affect the requirements. Without a log, control is only after the fact. A log provides a “connect-the-dots” understanding of the three core elements of metabolic (blood-sugar) control; activity, food and insulin. It helps teach you what climbing and falling blood-sugars feels like – before it actually become high or low. More importantly, it teaches how to predict what the insulin response curve and thus blood-sugar is going to be in response to activities, foods and insulin. It keeps you ahead of the game.
As mentioned in my previous Control post, my goal is to maintain blood-sugar between 70 mg/dl and 100 mg/dl at all times. Predictions are required in order to match the insulin curves with the activity curves and the calorie intake curves. This is why keeping insulin resistance as low as possible makes aligning all the curves so much more accurate, easier to predict and quicker to correct.
Unfortunately, accidents do occur and things do not always go as planned. As with many things in life, sometimes there are slips and surprises that trip you up. With my goal of 70 mg/dl to 100 mg/dl at all times, immediate action is taken anytime I’m outside this range.
Being outside the range on the low side is the easiest to fix. This is why I like to ride the low side of the range. A dip below 70 mg/dl can be fixed in 5 minutes with an 8 oz bottle of Mott’s Apple juice. Over the years, I have experimented with lots of low fixes and up to this point, I have found apple juice to be the fastest, most available and with the least side-effects. Apple or any juice, however, is for a rapid dip that I call a “crash”. This should be a rare event – a trip-up - as opposed to the intentional downward bias, fine-tuned with whole fresh fruit and low-fat starches.
Being outside the range on the high side is the hardest to fix. To fix it, I take an intentional insulin over-dose to force blood-sugar down into range as quickly as possible, preferably within an hour or less. This action, however, will force blood-sugar down at a rate that will plunge below the 70 mg/dl range limit. This is not only expected, but anticipated. Before it reaches 70 mg/dl, however, I am ready with an apple juice to halt the decent. Double testing reveals the decent rate for precise timing of the apple juice for halting the decent just before 70 mg/dl. The apple juice curve is predicted by the log and experience. I continue 15 - 30 minute double testing until certain the decent rate has tapered into range.
Below is a brief list of some of the most common trip-ups:
Food Contamination is probably the most common trip-up, and the most common contaminate is fat. A film of oil, even too thin to see, or slices of avocado camouflaged in a salad raises insulin resistance enough for a blood-sugar rise the next day or day after (24-48 hours after) and lingers for the following week(s). The long delay from ingestion to effect makes it appear unrelated, but a log review is very revealing. It is definite enough for very reliable prediction.
Food Miscalculation is another common trip-up, however, as long as the miscalculation does not involve allergens or fats, the detriment is short lived. For example, excess sugar or carbohydrates dissipate quickly, depending on your level of insulin resistance. Basically, sugar is only an issue with elevated insulin resistance. However, if a meal does push blood-sugar over range, I take a small dose of insulin to force it down – anticipating a low, as described above. If the meal contains too few carbohydrates for the insulin taken, then I simply anticipate a low. This is generally predictable, so a slower “fill-in” starch is taken. If insulin resistance is low and too many calories were consumed, especially sugar, it can be easily and quickly burned off with some physical activity; a brisk walk or even better, a jog or calisthenics.
Activity Miscalculation, as when an activity is planned and the appropriate insulin and meal taken, but the activity is then canceled can result in going out of range on the high side. This can be corrected by adding the insulin units that would have been taken if not for the planned activity. This, however, will result in a timing error with a peak followed by a low. Since I would rather go low than high, I will make the fill-in dose an over-dose and anticipate the low. A much better fix, however, is to burn it off with some calisthenics and / or aerobics. If “trapped” in a meeting, theatre, etc. you can excuse yourself to the restroom and jog to-from and sneak some calisthenics in the restroom.
Unexpected Activity can result in a dangerous blood-sugar “crash”. I always maintain a “safety-net” for unanticipated activity or surprise “crash” by keeping a stash of apple juices and rice cakes in arms reach at all times. I keep my car and work office stocked. When out or traveling, I keep a stocked back-pack ready to grab.
Missed Insulin Dose sometimes occurs when a high level of distractive activity is taking place at insulin time. Fortunately, this is a rare event, but it happens and by the time the missed insulin is realized, blood-sugar may soar into the 300’s mg/dl. Since this makes me feel awful, not to mention fear of all the damage to my body, I consider this a major emergency and take a large insulin over-dose; something near double what the normal dose would have been if taken on time. I then eagerly anticipate the low and treat it as described above.
An Inflammation or Infection may be the sneakiest of all trip-ups. Infections, inflammations and most illnesses prompt the liver to pump additional glycogen into the blood-stream with the intent of the pancreas to follow suit with insulin. The added glycogen and insulin ramps up metabolism to fight the infection, pathogen or deal with an inflammation, etc. The Type-1 diabetic, however, is missing the insulin part, so blood-sugar soars. This can be quite a surprise when the infection, etc. is too small for any noticeable symptoms. Most of the time, the cause is found later if the condition worsens enough for symptoms to be noticed. The rise in blood-sugar is dealt with the same as any other out of range condition; with the insulin over-dose / low anticipation scheme. After that, insulin is simply adjusted to track as with normal testing and logging management. It is, indeed, much harder, however, while the illness is in progress as it mimics the upward biased blood-sugar symptoms of insulin resistance (Even worse if already insulin resistant!). It is important to test and log often to keep in range as everything is less predictable. Additionally, the excess glycogen often stops abruptly, as soon as the liver decides the fight is over, leaving you with an abrupt blood-sugar “crash”. But, since knowing how to deal with that – it is actually something to look forward too!
A Personal Note: I simply cannot sufficiently express the value of all the testing, injecting, logging, tracking and calculating effort of Type-1 diabetes management. Reading about all of this probably seems very consuming, burdensome and restrictive, but once everything is in balance, at non-diabetic (or better) blood-sugar levels (remember - that’s up to you) and very low insulin resistance (also up to you), it is instead profoundly liberating. With all the cause-and-effect Insight made available with a manually controlled “open-loop” metabolic system, you can enjoy a level of vitality and “feel-good” that few ever experience. Indeed, you may actually become very fond of your Type-1 diabetes.
Disclaimer: Please understand that this writing is not medical advice and that I am not a medical professional in any capacity. Additionally, my Type-1 diabetes management methods are non-traditional and in many ways conflict with traditional diabetes guidelines. This writing is only to share my experience and what I have learned from it.