Daily Management

Highs –

You know, I find it interesting the different situations individuals are confronted with and how they select their responses to them. And I say “how they select their responses” vs. “what they select” intentionally; we would all select the best for ourselves but in many situations there is a lot that takes place between when the decision is made and when the results of our decision are placed upon us. You may like the results and you may not…….but it’s inevitable, you will have bestowed upon you, the results of your decisions made each day.

In some situations the feedback is pretty immediate….you learn very quickly not to stick your hand in a pot of hot water. Where there is an immediate impact, we’re typically pretty practical. But when there is some delay, we often make some very foolish decisions. We don’t look down the road and see the unintended consequences. But they will happen as sure as the sun will come up tomorrow.

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Diabetes is very stealthy, very sinister. The complications are so grave we need to find a different way to motivate ourselves into looking at the consequence of our decisions. We need to envision that high blood glucose (BG) levels have an immediate impact…it WILL cause you to go blind. It WILL cause your kidneys to fail. It WILL cause you to get sores that won’t heal. It WILL cause you to lose a foot or a leg. It WILL cause you to have cardiovascular problems. It WILL prevent you from doing things you love. It WILL cause you to have a long, drawn out, miserable death. It WILL cause you to be a burden on your family. Eating a candy bar doesn’t impact you long term, but a high blood glucose reading does. If you’re low, eating the candy bar can get you normal again. But if your BG is normal or high, eating a candy bar will put you in or keep your BG at a consequential level. High BG levels that span a couple hours or more are what we need to look at as having an immediate impact! If you’re high…get it down! And develop a diet and exercise program that will cause the highs to have a shorter duration and less of an impact. A1C’s are a good way to measure your progress.

There are many things you can do to help minimize high BG levels but a few that should be focused on are:
1. Test frequently.
2. Know your carbohydrates to unit of insulin ratio (see Management Tools).
3. Know the Glycemic Index and Glycemic Load of the foods you eat.
4. And if you’re high…know the “formula” to get it down now - Know the impact of a unit of insulin on your BG.
5. Manage nighttime BG.
Test frequently

I test 5-8 times a day. Testing gives you an understanding of the impact different activities have on your BG. In addition, you will start to develop a body language from the intangibles for a “feeling”, of where your BG is at. This is very, very helpful. It also lets you know flat out where you’re at and how you need to respond.

Know your carbohydrates to unit of insulin ratio

Let’s say just before lunch you tested and your BG was 90 mg/dl. You ate a lunch of the following:
Ham sandwich:
- Thin rye bread: 15 gr of carbohydrate
- Swiss cheese: 2 gr
- Deli ham: 2 gr
- Slice of tomato: 1 gr
- Light mayo (1 Tbsp): 1 gr
Fresh grapes (about 4 oz.): 18 gr
Small banana: 24 gr

Total Carbs: 63 gr

You’ve calculated over the last few weeks (we will teach you how to do this accurately in the Management Tools section) that your carbohydrate to unit of insulin ratio is 12:1 so you shoot up with 5 units of U-100 Humalog insulin (some of my favorite stuff). This will cover what you ate and will bring you right back into the 90 – 110 range. However, at about 2:00 PM you’re feeling high; sluggish, “thick”, warm, you can feel it in your chest where it originates but extends down in to your abdomen. So you decide to test and crud….you’re at 275! What the heck…that’s impossible. Then you remember that retirement carrot cake they had for Mike. You had a piece knowing it was closing in on lunch but forgot to add that into your calculation.

Know the Glycemic Index (GI) and Glycemic Load (GL) of the foods you eat.

For GI: 0-55 is low; 56-69 is moderate; 70-100 is high.
For GL: 0-10 is low; 11-19 is moderate; 20 and up is high.

The Glycemic Index (GI) index is a classification system for carbs based on how high and how quickly they increase your BG – foods that are digested rapidly and cause large increases in BG have a high GI. Foods that are absorbed more slowly into the system, causing a more gradual rise in BG have a low GI^1,2,3. The University of Sydney maintains an updated, searchable database of GI for foods at http://www.glycemicindex.com/index.php.

Glycemic Load (GL) takes into account not only the food’s GI, but also the amount of carbs it contains. You need to know not only the way different types of foods’ carbs affect you, but also the quantity of those carbs you consumed if you’re going to be able to accurately predict how the food will affect your BG^1,2,3. Take a Twix candy bar, for example. This tasty little treat has a low GI of 44, very similar to that of the apple, whose GI comes in at approximately 40¹. Before you start gobbling down Twix bars thinking they won’t impact your BG, remember – the GI is a classification for the way in which this type of carb is absorbed by your body; we haven’t yet considered how many of these carbs you will be consuming when you eat this candy bar. A full package (2 bars) of Twix has 34 g of carbs, giving it a GL of approximately 15 (we’ll show you how to calculate this in a minute). An apple contains approximately 22 g of carbs, giving it a GL of about 8.8. Lo and behold, these foods’ GLs tell you that eating the Twix bar will have about 1.7 times the effect on your BG as the apple.

For this reason, a food’s GL gives you the most accurate prediction of how what you just ate will affect your BG. GL is calculated by multiplying the food’s GI by the amount of carbs contained in the serving you ate, divided by 100¹. For example, that piece of carrot cake has a relatively low GI of 36; however, it contains a whopping 41g of carbs. Its GL can be calculated like this: 36(GI) x 41(carbs) = 1476. Divide that by 100 and you get a GL of 14.76, a moderate ranking on the GL scale, much more indicative of how it will impact your BG than its low GI ranking.

Considering this, I know that both the carrot cake and lunch have been converted into BG. I also know the Humalog has already peaked after 2 hours. So I now need to get my BG down…now.

And if you’re high…know the “formula” to get it down now - Know the impact of a unit of insulin on your BG

If I’m at 275 and want to get it down to around 100, I need to impact 175 mg/dl of BG. From testing I know that 1 unit of insulin will bring my BG down 40 pts so I will need to shoot up with about 4 units of Humalog. See the Management Tools section to learn how to determine the impact of a unit of insulin on BG (also known as insulin sensitivity).

Nighttime

Considering nighttime can represent approximately 1/3 of the 24 hour day, it’s one of the biggest opportunities to positively impact your A1C readings. You need to have your BG normal during the night. You don’t want to get low, obviously, so I like to test about an hour before I go to bed and then right before so I know if it’s going up or going down and compensate accordingly. If my first test at 9:45 PM was 120 and then I test at 11:00 PM and it’s 175, I’ll consider when I last ate and if I think most of my food has been converted to BG, I will shoot up with 2 units to try and bring it back down to 100 during the night (2x40=80 pt reduction)./p>

Lows –

You’re a diabetic…low blood sugar (hypoglycemia) is going to happen and you want to be able to respond immediately and effectively. A few things come to mind:

Test often – it not only gives you an immediate reading of where you’re at, but it also helps you develop a good sense of what your body is telling you. Am I dehydrated or is my blood sugar high? My body feels fine but I’m not clicking mentally. Is it because I’m tired or am I low? Test and learn what all these wonderful indicators are telling you. They give you an advantage!

Know this – when you’re low you will not be hitting on all cylinders mentally. You’ve got to make recovery easy and have a plan rehearsed in advance. Know what you are going to do!

Don’t leave home without it…and I’m not talking about American Express. I’m talking about some form of a relatively high glycemic carbohydrate that can bump you up fast. It has to be easy and accessible. My favorites are Gu, cookies, or orange juice because they’re quick, easy,…and tasty. Glucose tablets work great too.

Don’t be afraid to ask for help – you’re knowledgeable, you’ve planned accordingly but it’s one of those days where, who knows why, you blew through your carbs and you’ve got about 2 miles to go on your long run and whoa baby, your blood sugar is dropping like a rock. There is nothing except an eternity between you and your personally controlled recovery at the car. Can you make it…………get it in your mind now; don’t risk it! Ask for help at the closest house or opportunity.

A couple of scenarios to consider that the above will help with:

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You’re a single person, and you wake up in the middle of the night from a hard, confusing dream. Things don’t seem to make sense. Then you notice the phone just quit ringing…or was it your imagination? You're tired, so in a dazed condition you lay down to go back to sleep. Wait!!! Not a good thing to do. You just realized when things don’t make sense you’re going to act and grab a couple of cookies. You do and then check your blood sugar and find out it’s around 48.

You’re on a 16 mile long run and at about 12 miles you can tell your planned carbohydrates are probably going to be running short or cutting it close at best. You slow down and at 13 miles take the last of your Gu. It’s a country road and houses are few and far between. At mile 15 you are bottoming out - it’s getting into the danger zone. There is one last house before you make it back but you only have 1 mile to go…you can make it. Wait!!!! Not a good thing to do. You just realized your plan is to ask for help. Embarrassed, you go up to the house, they offer a nice glass of orange juice, and you continue.

You're in a meeting at work that is dragging on for longer than you expected. It was supposed to go from 10:00 to 11:00 but it's now close to 11:45. The boss is in there, the boss's boss is in there, there are about 10 other high profile individuals whose time needs to be considered carefully and...you're crashing. As a personal choice, you have elected not to let people know you're diabetic, and now you need to step out while in the thick of things. You're waiting for the perfect opportunity but it doesn't seem to present itself so you decide to lay low and avoid being a role player because you're not thinking clearly. Wait!!!! Not a good thing to do. You realized your plan is to simply get up and excuse yourself for a moment and get the carbohydrates stored in your office. You do, recover quickly and return to the meeting where it continues for another 45 minutes. Good thing you grabbed that pop.

Getting low is a dangerous condition and it WILL happen. Be prepared and know how you are going to act, so when the time comes, you don’t have to think about it.

Check out the Nutrition page for detailed information and tips about how to effectively use carbs to raise low blood sugar.

At Work, School or Anywhere Away From Home –

Home, as should be expected, is your comfort zone and there are many reasons why; you own your schedule, no secrets necessary, and if there are people around you, they are people who understand diabetes. You have the ability to respond to highs and lows at will, you can test, make corrections and eat as needed. When you’re away from home the trick is to have enough knowledge to establish these home advantages wherever you’re at.

Six basic principles stand out:

Insulin Storage: Insulin, with proper storage as required, and testing supplies need to be available.
Carbohydrate Strategy: You need to have an advanced carbohydrate strategy for the entire day to protect against lows without getting too high.
Playing It Safe: If you anticipate it will be a very unpredictable day, establish things very conservatively; do not overestimate your insulin needs, choose foods that you know and are predictable, and take advantage of any opportunity that might present itself to help with corrections.
Testing: You need to know where your blood glucose (BG) is at as you start your day and you need to know what opportunities you can create to test during the day and evening.
Accounting for Physical Activity: Know the impact your day’s physical activities might have on insulin efficiency and…
Glucose: Always, always have a quick, easy source of glucose available…don’t leave home without it.

Let’s create a scenario and see how we might best apply these 6 principles.

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You’re planning a midsummer weekend camping trip with some friends, Friday night and Saturday night, with a 5 hour canoe trip scheduled for Saturday 10:00am – 3:00pm. Weather is expected to be hot and sunny. You will be taking your own canoes and there will be quite a bit of physical exertion preparing for the trip and the canoe run itself. The area you will be camping in will be well shaded most of the day but parking area of the cars will have direct sun.

You aren’t using a pump so you take your Lantus in an insulated and cooled carrying case to support the two injections you will need. You have a cooler for food and drinks that will be located in the camping site (car will get too hot) so you will keep the Lantus stored there for extra protection. You also take multiple injections of Humalog so it will be stored there as well for protection from temperature extremes. Since the canoe trip will span approximately 5 hours and a lunch, your plan is to take your Humalog with you.

You have packed an assortment of different foods for the weekend ranging from fruit, pancakes, eggs, sausage, tortillas, potatoes, hot dogs, chips, etc.

Saturday morning your BG is good…you’re at 95 mg/dl. You have time to prepare a breakfast of pancakes and eggs and pack a small lunch consisting of a ham sandwich, fruit and some just-in-case cookies. From counting your carbs (see Management Tools) you know that 6 units of Humalog would typically be needed to cover the carbohydrates consumed during Saturday’s breakfast. However, you have performed a lot of activity and a canoe trip is no time to get low so you take only 4 units and pack a couple of Gu packets (24 gr of carbs each) for your quick and easy source of glucose.

You start your canoe trip and an hour into the trip you hit some fast water that takes you into a turn with a couple of downed trees and you flip the canoe soaking everything…except the air tight carrying case that has your sandwich and insulin. Planning ahead prevented you from losing your insulin and the food you are going to need halfway through this trip. You stop for lunch, test your BG with the small tester you also had tucked away in the sealed container, and find you’re at 65 mg/dl. You eat a couple of the cookies for 25 gr of carbs (from monitoring you know 10 gr brings you up 40 pts) for a net BG impact of 100 pts. You have your ham sandwich (determined to have 35 gr of carbs) a medium apple (17 gr of carbs) and about 8 oz of Gatorade (15 gr). Total carbs for lunch is 92, 10 of which were part of the cookie correction so 82 gr of carbs needs to be compensated for. You are normally 1 unit for 10-12 gr of carbs so 82 divided by 12 = 6.8 units necessary. You elect to be conservative and take 5 units.

Before heading out for the second half of the trip, you double check to make sure everything is sealed away properly and your quick, easy source of glucose, a couple packets of Gu, are still securely located in an accessible place.

You make it back to the camp, check your BG and it’s right on target at 82. The rest of the camping weekend revolves around eating at a predictable time, testing your BG, keeping glucose accessible at night and keeping your insulin properly protected from temperature extremes. The weekend concludes and you had a great time and are now looking forward to the next outing.

Conclusion

Daily management, regardless of where you might be, needs to always consist of:

Matching carb intake with insulin, (see Management Tools)
Protecting your insulin from temperature extremes and
Having a plan that allows an immediate response to any low BG situations you might encounter.

Knowledge and discipline will give you the ability to live and do the things you’ve aspired for and enjoy. So be adventurous, learn as much as you can about managing your diabetes and the process will continue to enhance every aspect of your life.

References
1. The University of Sydney. (2011). Glycemic Index. Retrieved from http://www.glycemicindex.com/index.php
2. Harvard School of Public Health. (2012). Carbohydrates: Good carbs guide the way. The Nutrition Source. Boston, MA: The President and Fellows of Harvard College. Retrieved from http://www.hsph.harvard.edu/nutritionsource/what-should-you-eat/carbohydrates-full-story/
3. Massachusetts Institute of Technology. (2005). Glycemic index. Retrieved from http://web.mit.edu/athletics/sportsmedicine/wcrglycemicindex.html

Stay Informed, Be Successful