To pump or not to pump: reconsidered

 

Alyssa 1.jpgI heard the refrain from a Classic 1970’s Peter Allen/Carole Bayer song when my friend Alyssa called me last week,

Don’t throw the past away

You might need it some rainy day

Dreams can come true again

When everything old is new again

Because Alyssa, who’s had type 1 diabetes since the age of 10, and been on an insulin pump for the great majority of years, is wondering about switching to MDI (multiple daily injections). The “poor man’s pump” I was told years ago.

I have never used an insulin pump. People are always surprised, I’ve had type 1 46 years, I’m intelligent enough, super responsible, but MDI works for me. I’m accustomed to shots, I feel like I have control taking shots, my syringe won’t get occluded, and I don’t enjoy the idea of being tethered either through a foot or two of plastic tubing or just the weight of an Omnipod on me.

Alyssa’s query whether she should come off the pump and start MDI was a challenging consideration for her. She’s more or less run out of real estate on her slim body, and now, being so muscular from her latest hobby, acrobatics, the infusion sets, in her words, “… pop off and won’t go in,” and the whole device is in the way. Yet, she knows diabetes management from a pumper’s perspective.

So she came to me, the old hand using the old delivery system. Of course, for people who take a step “backward”, or take pump vacations as so many do, it’s not just re-learning injection techniques, it’s learning how to do the mental math a pump does for you every time you dose. It’s calculating carb ratios, carbs in food to consume and insulin on board.

I don’t really count carbs. Being on a low carb diet, most meals require about 1 unit of rapid acting insulin or a bit less, so I just eyeball food. Ah, that needs a half unit, that a quarter. And, since there’s so little rapid acting insulin in my body at any one time, I don’t give much thought to insulin on board. Talking with Alyssa I realized how we live in two different diabetes worlds.

Alyssa will make her choice. I think it’s a good thing if you pump to also have the dexterity to switch between pumping and injections. And she helped me realize just because something’s old, MDI, it doesn’t mean it’s any less or inferior. It’s all about what works for you and what you’re willing to sacrifice and gain.

Now of course I’m thinking this acrobatics looks pretty cool…hmmm…and I wouldn’t have to worry about my insulin pump.

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How doctor’s exam rooms make connecting with patients difficult

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This is one of my primary care physician’s exam rooms. The one I found myself in a week ago, just for an annual check-up. Ignore the book, that was mine. Notice the set up.

The nurse came in to take my weight and blood pressure. Then she sat in that chair with her back to me to take me a zillion questions to fill out a form on that computer.

I had difficulty hearing her, as she was talking to the computer screen. There was no connection between us as she hardly looked at me. Only when I asked her to repeat the question because I couldn’t hear her and then she had to turn around.

How does this make patients feel? I talk when I share the Flourishing Approach with health professionals about the importance of creating connection. It’s really hampered here based on the environment.

An office visit isn’t just about getting looked at and getting a script. It’s also about getting LOOKED at, seeing one another, connecting, collaborating, and feeling like you’ve got a partner there.

My doctor, bless his heart, when sitting in that chair, has me sit in the chair aside the computer. He never has his back to me. I think he knows instinctively the importance of seeing his patients and having them see him. But I can’t tell you how many nurses, physician assistants and lab technicians who never face the patient.

I already told my doctor I could redesign the office for him. He smiled wearily and revealed how much has to be fixed today in healthcare.

 

I must be nuts – almond meal is creeping into every recipe

 

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Pre-cut Biscotti on left, Keto rolls on right. Both made from almond meal.

Really, how did I survive before almond meal? First, let me clear up that it’s not the same as almond flour, but pretty darn close. They’re both finely ground almonds. Almond meal tends to be slightly courser while almond flour is finer and is made from blanched almonds, meaning the skin has been removed. But for recipes that call for almond flour you can substitute almond meal. And I do, it’s cheaper and I like the really nutty flavor. I buy it at Trader Joe.

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I’ve probably posted almond meal recipes before, but now it’s like we can’t get enough of it here in this house. Ever since I started making this Keto bread, the husband has put in an order for another six rolls almost every other day. That, from a man who grew up in the Netherlands which he never fails to tell me is, “bread country.”

And then there’s the almond meal pizette, (below) which substitutes for an incredible pizza and a quick meal when we get home late from somewhere, or I’ve just run out of ideas for dinner. Or I make it as a starter and it’s so satisfying and filling, the main gets put away.

The defining touches on this pizza crust are slathering artichoke antipasto (also from Trader Joe) and just a bit of cheese, your choice, on it after you bake it the first time and before it’s second bake. And when it’s completely done, top it with pesto, which I make myself these days, thank you, or fresh arugula. We also like some chili flakes on top.

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In my formative, fatter years, teens, twenties, thirties, if you told me I would have to give up my scones, croissants and corn muffins I would have cried and then cried some more. Big, salty tears.

Now, granted if I’m in France, I will during the trip have a croissant. If I”m in the U.K., I will have a scone. And I will enjoy the heck out of them. But here at home, nada, never.

I am so content with living in a world of almonds the thought never crosses my mind. Now keto bread with almond butter? To die for, or actually just the opposite. This stuff barely nudges the blood sugar. In fact, I’m more likely to overshoot for it, a lesson in the making, or should I say baking?

Here are three more recipes worth biting into – almond meal biscotti, the flax muffin you make in a mug and life-changing bread.

They’ve all changed my life and made it oh, so delicious.

 

Dawn Phenomenon or coffee? Fasting told me.

 

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For the past few weeks I’ve been doing intermittent fasting on and off – not eating from around 8 PM to lunch the next day. I do it for two or three days then go back to having breakfast. I’ve been doing it just to see if I notice any positive results. I wrote about the benefits of fasting a few posts ago.

As for positive results of intermittent fasting, I will say I’ve lost two pounds, and I realize it’s not a big deal to skip a meal. But in addition to the two pounds I’ve lost, I’ve had a huge “aha.” Even when I fast in the morning, I’ve been watching my blood sugar rise like mad. As much as 40 points.

I always thought my morning cup of coffee raised my blood sugar (even though I know coffee doesn’t do this any other time of day) and that I needed 1 unit to cover the coffee. But, in actuality, it’s not the coffee that’s raising my morning blood sugar, but the strong effects of the Dawn Phenomenon.

The Dawn Phenomenon is the liver spilling glucose into your blood stream in the early morning hours to get you ready for activity. When I was having my coffee and eating breakfast first thing upon rising, I calculated I needed an extra unit for the caffeine from my coffee, but in actuality, that unit was a corrective dose for my liver spilling glucose into my blood stream.

Not eating til noon or 1 PM, I find I have to take 1.5 units of Humalog when I wake up to cover my liver’s sugar-slide, even when I take my 9 AM hour walk. Even when I take my walk to my yoga class and then walk back.

I’ve always said if I used an insulin pump I’d have more elegant control, and for sure, this is one of those areas I could better manage with a pump. But, ah, well…

 

Forgot if you took your dose? InPen remembers

 

 

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This is the face of Companion Medical’s InPen’s app. A couple of weeks ago I was given the InPen to try out. The InPen holds rapid acting insulin, a Humalog or Novolog cartridge, and has multi-functions that help you keep track of your dosing. It works through an app on your smartphone bringing some of the functions of an insulin pump to MDI (multiple daily injections) users.

In addition to providing you the comfort of whether you took your shot, it stores records of your blood sugars for your doctor and family members that you can transfer wirelessly. If you wear a Dexcom CGM, you can see your numbers on the app but they’re on a three hour delay. The company is working on that. But they are stored in the app and get sent to your HCP as part of the records.

The pen also has a built in dose calculator based on the carbs you’re planning to eat, tells you how much insulin you still have onboard and you can set alerts and reminders. Plus the InPen delivers half units.

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The shiny blue pen in the foreground is the InPen. In the background is my Tresiba long acting insulin pen. Actually both pens are the same size, it’s an optical illusion that they seem different sizes. My Tresiba pen is sporting its Timesulin cap, a simple counter that lets me know whether or not I took my dose. I find it invaluable, thus, the reason I wanted to try the InPen.

So, is it worth it? Well, it’s funny because I was asking myself the same question when I learned that it kind of is. A few days ago I was in a hotel breakfast dining room and I was so busy enjoying the buffet, and clearly out of my routine, that after I finished breakfast I couldn’t remember whether or not I’d taken my shot.

A wave of anxiety blanketed me and then I thought – check my InPen. I looked at the app and sure enough saw that I had not taken my dose. Whosh! I took out my InPen, took my insulin and the fear was forgotten.

The InPen is not inexpensive. It costs $799 but many insurance policies cover it. You can check whether your insurance covers the pen here. If your insurance covers it, it’s a no brainer to try it out. If not, Companion Medical offers a $250 off coupon bringing the price down to $549.

As someone who uses very small doses of insulin – .5, 1-2 units due to my low carb diet, I hate to waste two units of insulin priming the pen. I often withdraw my insulin with a syringe (don’t tell) and then log my doses manually.

The InPen lasts one year and requires no charging. It’s a very cool looking pen that comes in blue, pink and grey.  Now that I’ve got two insulin pens, and they’re both blue, I separate them on my kitchen counter in separate mugs so I don’t mix them up. I’ve done that once before years ago and hope to never repeat the experience.

Disclaimer – I was given my InPen by Companion Medical.

Why diets don’t work? Not willpower, but insulin

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I’ve read about this for years and buy it. Yet the traditional thinking is so ingrained – to lose weight we must eat less and exercise more. Even doctors have bought the Kool Aid. It just ain’t so. Our bodies aren’t designed that way.

Simply, when you take in less calories, your body’s metabolism slows to match the loss. And exercise, while healthy for us, does not impact weight loss unless you’re spending more than two hours a day at the gym vigorously sweating.

Our hormonal system, working in concert with our metabolism, is primed to keep our body at our set weight. It is higher for some than others. Why? I’ve not read that far in Dr. Fung’s book yet. But unequivocally, The Obesity Code, explains why the conventional motto of “eat less, move more” doesn’t work and why insulin is the prime culprit.

Take almost anyone with type 2 diabetes who’s been put on insulin and you’ll find their weight goes up. Yet we ignore it and still tell people to lose weight and it’s their fault if they’re not. So, the prime remedy for lowering blood sugar is insulin, yet insulin is a fat storage hormone. If you’re insulin resistant you’ll have higher than normal levels of insulin circulating in your blood stream. What’s it doing? Beside lowering your blood sugar it’s storing your unburned carbohydrates as fat.

The solution I know of is to eat a low carbohydrate diet which requires less insulin. Less insulin, less insulin resistance and less fat storage. But I’m sure I’ll learn more before I finish the book. Just a snippet, page 86:

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Dr. Fung’s last chapter is about his strategy that’s helped his patients overcome insulin resistance: fasting. Periods of not eating let insulin and insulin resistance decrease, and of course it cuts calories. But if there’s one theme throughout this book it’s this: calories don’t make us fat and cause chronic illness, insulin resistance does. I agree.

Keto bread – Where have you been all my life?

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In my last post I talked about watching an online summit on ketogenic (very high fat, very low carb, moderate protein) eating and the benefits of fasting. In my search to learn more about both of these eating strategies I came across a recipe for keto bread (low carb bread). I baked it today. There’s no going back. What you don’t see in the photo above was the third roll I devoured, all but those two bites left.

I don’t eat bread at home and I only eat it at a restaurant when it’s really good. Bread for me raises my blood sugar fast and furious. But this bread has not budget it at all.

I’m thinking maybe I have to make these rolls  before I go out to dinner now and bring them with me. Well, I won’t wax on, you get the idea. These are delicious – sweet, tangy, perfect texture – and there’s no sweeter, flour or oil. What’s the secret? I don’t know, but here’s the recipe. Taste for yourself.

Tips: I made half the recipe which made three rolls. No problem. I used Trader Joe Almond Meal instead of almond flour. No problem. My friend Ginger Vieira told me you can use the whole egg, yolk and white, instead of just the white. I didn’t do that, however, because she told me after the fact. And I didn’t have a hand mixer so I just mixed the ingredients with a wooden spoon and a joyful vigor. It all worked just fine.

Yum…

 

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How circadian rhythm affects our sleep, diabetes and obesity – and the keto diet and fasting

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All week I’ve been watching a 9 episode summit from co-hosts Naomi Whittle and Montel Williams. Naomi is a best selling author and “Wellness Explorer” and Montel, has had Multiple Sclerosis for the past 20 years. Both are into the science of metabolism, health and weight loss.

The summit largely covers the ketogenic diet and fasting. Ketogenic eating is a very high fat very low carb eating style. I do eat low carb but I could never follow a keto eating plan. Fasting, apparently, is the new hot strategy for restoring health. Not a juice fast, horror, all those carbs! A plain water fast or something called a “mimicking fast” where you get to imbibe a few things that don’t let your body know you’re not really fasting. Things like green powders, bone broth and maybe some avocado.

The theory is during a fast the body switches from burning sugar to burning fat because you aren’t feeding it, and it starts chewing up your unhealthy damaged cells and remaking healthier cells. The simplest fast is a 16 hour fast. Don’t eat from after dinner around 8 PM til lunch the next day. It’s called intermittent fasting. You can also do a one day fast or a 3-5 day fast which is supposed to regenerate stem cells. I’m not going to go into more detail here but you can find scads of information googling both ketogenic diet and fasting.

I will, however, give an overview of something we rarely pay any attention to that was also discussed on the summit – and that’s how our natural circadian rhythm significantly affects our sleep, metabolism and insulin resistance.

Dr. Felice Gersh was the expert talking on circadian rhythm. From now on I’m going to shorten circadian rhythm to CR. Dr. Gersh’s main point is every organ and cell in our body has a CR, a clock it goes by to do what it does. When we don’t live in sync with our internal clocks we mess up our hormonal system, metabolism, microbiome, brain, well  pretty much everything.

Here are a few take-aways:

• When your CR is off the body’s melatonin production that occurs naturally at 2 AM  doesn’t happen efficiently. This interferes with a good night’s sleep and prevents the brain from restoring itself. We also know by now a poor night’s sleep raises our hunger hormones the next day and we are ravenous and tend to overeat, especially carbs.

• The liver is key to our metabolic health. When you’re not in sync with your CR, your liver doesn’t function well. This plays havoc with your body’s enzymes and the liver and gut (microbiome) become inflamed. Some fallout from this is the liver starts pouring sugar and fat into the bloodstream and doesn’t signal the pancreas to produce as much insulin as the body needs. Blood sugar rises and insulin resistance increases. Triglycerides also elevate.  Insulin is a fat storage hormone and with too much of it circulating in the bloodstream it begins storing carbs as fat in our cells. Fat clusters in and around our organs. It’s unhealthy. Fat in the liver is literally called “fatty liver” which many people with type 2 diabetes have.

• Too much circulating insulin from insulin resistance puts you in a state of constant growth where your body can’t trigger fat burning or cell rejuvenation. Inflammation in a body set for chronic growth can lead to cancer, due to the overgrowth of abnormal cells. It’s also the perfect environment for chronic diseases like diabetes, obesity and dementia.

Dr. Gersh points out society has set up a perfect storm for us to be out of sync with our CR. How can you disagree? How many of us sleep enough hours, eat healthfully and not too much, push away from our screens and devices hours before going to bed? How many of us spend time in nature on a regular basis, move our bodies every hour from sunup to sleep and eat all our meals on time and relaxed?

So what to do. Here are a few suggested tips. You can research further how to get back on track with your circadian rhythm:

• Go to bed between 10 and 11 pm. Sleep in a very dark room.

• Wake up on the weekends the same as during the week

• Spend more time in nature, go camping and sleep on the ground, watch the sun set

The last tip leads us back to the beginning. Dr. Gersh recommends a four day fast for resetting our inner clocks and putting the body into an overall state of rejuvenation.

As a result of the summit I’ve decided to try intermittent fasting so for the past few days I have stopped eating by 8 PM, except when I have to raise my blood sugar before bed with a prune or teaspoon of honey, and not eat again until 1 PM the next day. Days 1 and 2 were remarkably easy. The trick was keeping myself occupied in the morning.

Day 3 I was so hungry I could have eaten a cardboard box. That’s when my friend and fellow type 1, Ginger Vieira, told me it’s working! I still managed to hold off lunch til  12:30 that day, but this morning I gave in to a smaller than usual breakfast and tonight I’m going to fast again. I make no promises but I am enthralled by seeing what this experiment of fasting may do.

It makes perfect sense to me that fasting is healthy and that we overfeed ourselves. Our ancestors lived not having food much of the time, while today we are constantly eating which causes inflammation in the body which I believe is at the root of most disease.

For further reading on keto and fasting here are a few links Ginger shared with me:

1. https://drhyman.com/blog/2015/12/27/separating-fat-from-fiction-10-fat-facts-you-need-to-know/

2. Cheatsheet: Good fats vs. bad fats
4. Another great podcast/article on saturated fats:
I wonder who decided we should eat breakfast like a King, lunch like a Prince and dinner like a pauper?

Health insurance companies’ strategy – confuse, deny and don’t pay for anything

This was posted on Facebook today. I know Meri, she’s one of the loveliest people I’ve ever met, and she has the good and bad fortune to have three of her four sons have type 1 diabetes. I’m so overwhelmed by what she wrote, I will let you read it yourself –

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In addition to health insurance companies no longer protecting us, their rules and regulations are eating away at our health, our time, our hearts and our sanity.

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Meri’s children above. It is inexcusable.

Medicare’s Donut Hole – Get caught inside and you’ll find nothing sweet

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This is not so much an informative post as one of outrage. Quiet, desperate, stomach-churning dissolution and despair, the smoking embers of what I learned 29 hours ago.

My brilliant stroke of outrage came yesterday sitting in the office of my now Medicare broker when I was told how much my insulin is going to cost me after only four months on my Medicare drug plan. I start Medicare in September. By January I’ll be paying outrageous amounts of money for insulin.

My questions during the meeting were about the workings of Medicare, a four-headed beast – Part A (Hospital), B (Doctors & Tests), Supplemental (Who knows but you need it), D (Drugs), but the questions I left with were societal: Where are we headed as a country that’s making medication unaffordable? Is America a society if it only cares about making rich people richer and providing for those in power?

If you want more in-depth Medicare information as someone with diabetes, please go to Laddie Lindahl’s web blog, Test Guess and Go. Laddie did us all a great service taking us through her learning curve as she approached and signed up for Medicare recently.

This post is about outrage and here’s the bottom line: If you have diabetes and you inject insulin you are going to pay just about as much, maybe more, per year for the cost of your Medicare than a commercial health insurance policy. Why? Because of the unregulated inhumane increase in the cost of insulin over the last decades, particularly the last few years.

For this reason you will get caught, a few months into your Medicare drug plan, in the “Donut Hole” also known as the Coverage Gap. You will be required to pay 35% of the actual cost of insulin each month for the rest of the year once you’re in the Hole. For me, and my insulin doses are low, that calculation is $144/month for my insulin. Contrast the $25 I pay currently on my ACA plan for a three month supply. That’s less than $10/month. For type 2s, who use much more insulin than me, the cost will be much, much higher.

What does this mean beside the fact that Canada is looking pretty good as a stop & shop vacation? That this fight to bring down the twenty-fold increased price of insulin since 1970 is essential. I won’t go into the big pharma, lobbying, middlemen bru ha ha but this is a good article if you’re interested. We on insulin also get caught in the donut hole because there are no generics for insulin. Insulin is a Tier 3 brand name drug, the most costly. Basaglar, which is a biosimilar for Lantus, while not a generic may be lower than a Tier 3 drug, I don’t know.

I wrote “injected insulin” earlier. Now get this – If you are on MDI, Multiple Daily Injections, like me you will get your insulin through Medicare’s Drug plan, Part D. If, however, you use an insulin pump, all the insulin you need for your pump is covered under Medicare Part B – durable goods. Part B pays 80% of the cost of your pump, pump supplies and insulin and your supplemental plan covers the remaining 20%. You pay nothing!

To add to the crazy logic – only tubed pumps are covered in Part B. Omnipod, a tubeless pump, is covered in Part D. But think about it – that means you will still be paying for the insulin just as if you were on MDI. You will still end up in the Donut Hole. Sob, I had a shining hour when I thought well maybe going on Omnipod wouldn’t be so bad, but that dream faded when I learned it was covered in Part D.

I don’t profess to be an expert on this; I told you that up front. I am still reading the plans I selected, and hoarding insulin so I can make it through the first year of Medicare sidestepping the Donut Hole. It’s funny, for years and years people asked me why I don’t use an insulin pump. I always said the truth, I am diligent and disciplined and don’t mind shots, so a pump would offer me more elegant management, but it was not worth the trade off to be tethered to an external device. And now that I use the Dexcom CGM, it would be a second device. Who would have thought Medicare may be the reason I finally go on a pump. It remains to be seen.

While this post has not made you significantly more intelligent about Medicare, maybe you now share a bit of my outrage. Let’s do something. Sign the petition on the American Diabetes Association website to lower the cost of insulin. It takes seconds. Get more informed about what the Diabetes Patient Advocacy Coalition (DPAC) is doing to promote and support public policy initiatives to improve the health of people with diabetes and how you can be part of that.

If you are nowhere near the age of 65 I won’t tell you that by time you get here Medicare will be here to greet you. It may no longer exist. All the more reason for each of us to do something now to make our outrage heard and tell those cyclists up top if they have diabetes and take insulin injections they have little to be smiling about.