blood sugar

This is Type 1 diabetes, high and low blood sugars

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This was on Facebook. This is not my Dexcom, but it could be. What struck me is how so many of us are compelled to put our numbers up and share them looking for comfort, camaraderie and someone else who “gets it.” For when it comes to getting it, I believe much of the health care community is in denial. 

We cannot “control” blood sugars in people with diabetes who use insulin. That’s everyone with type 1 and some with type 2. But that frustrates health professionals; after all their job is to cure us, short of that to fix the problem – our up and down blood sugars. 

But that is the very nature of diabetes – fluctuating blood sugars. And even with 24/7 oversight, no matter how hard I work at it, trying to do what a normal functioning pancreas does, I fail. My brain simply cannot replace a normal functioning pancreas.

I wrote about this recently on The Huffington Post in “Type 1 Diabetes Fully Explained.” It went viral in hours. Hundreds of fellow Type 1s wrote to me saying how I had perfectly captured how impossible it is to perfectly control type 1 diabetes. 

It is time for us to agree that the norm of diabetes, intrinsically, its very nature is up and down blood sugars, especially for T1D and insulin-dependent T2s. 

It is time to accept this and stop trying to fight it and control it. I hate that word control. This doesn’t mean that we shouldn’t work at having blood sugars as often as possible in our target range, but let’s agree it’s hard and let’s agree we can’t be perfect at this and let’s sigh a collective sigh of relief. We deserve it.

Furthermore, creating goals is the wrong way to manage diabetes. Goals reinforce the idea that if we only work harder we can lick this beast. But we can’t. Goals reinforce that there is a perfect standard and we just aren’t working hard enough if we haven’t achieved it. 

Rather, what we should learn is what to do with our numbers in the moment, keep breathing, and have the knowledge and no self-blame to do it – and then smile because we did something good for ourselves.

Funny thing, but given that blood sugars fluctuate all day and all night, we are much better off to befriend our efforts, both strong and weak, and behead the doctor who tells us our numbers “should” be better.

I want people with diabetes to hear from their health professional:

“This is tough. You have a condition that requires a lot of work and vigilance. Some days you’ll do better than others. Don’t beat yourself up, instead do your best as often as you can and know that the very nature of diabetes is up and down blood sugars. You cannot do this perfectly because your body will be doing something unpredictable a good deal of the time. Just know this, accept this and keep breathing. I for one honor what you do living with this everyday.” 

Dr. Robert Lustig says fructose is poison, and I believe him

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Robert Lustig is a pediatric endocrinologist at the University of California, San Francisco who is carrying the charge that fructose kills. I’ve just spent the afternoon listening to a radio interview he gave recently, watching his lecture,“Sugar: The Bitter Truth,” and watching a series of YouTube mini documentaries he gives about obesity. 

In short, Lustig says sugar, specifically fructose, is a toxin given the way our body biochemically metabolizes it. That it actually turns to fat and that obesity is not the cause of metabolic diseases like Type 2 diabetes, hypertension,cardiovascular disease, fatty liver disease, but a marker of these. 20% of obese people will never get one of these diseases.

I agree with Lustig about sugar and refined carbohydrates being our undoing. If you read my new book, Diabetes Do’s & How-To’s, I emphatically say fat is not what makes us fat but sugar, or refined carbohydrate. Carbs cause the body to pump out excess insulin (a fat storage hormone) and carbs we don’t burn get stored as fat. Lustig will tell you the 6.5 ounce Coke that has morphed into the 44 ounce Big Gulp is the devil incarnate.

Twenty five years ago when America went on a low fat diet, people’s diets reduced in fat Lustig says from 40% to 30%. That doesn’t sound like much, but what happened is the carbohydrates we consumed skyrocketed. Take the fat out of food and it tastes like cardboard. Put sugar in and consumers won’t notice. In fact, they’ll like it so much, they’ll eat even more to it! Food manufacturers are not stupid. 

In fact, they are ingenious, and spend millions of dollars perfecting recipes that get us hooked on the sublime combination of sugar, salt and fat. But Lustig’s biochemistry lesson will help you understand why fructose is so especially causing our out of control obesity.

Lustig’s proposition is that we could not have, as a nation, and now as a global society – with American fast food now exported everywhere and the rise in obesity paralleling it – gotten obese merely from eating more and moving less.

No, he will tell you it is about what’s in our food and how the body uses it. “A calories is not a calorie,” says Lustig, yet he says they teach dietitians just the opposite the first day of school.

I am consumed (yes, pun) with this debate: what causes obesity, how are our modern day chronic metabolic diseases impacted by what we eat, obesity and how food is being reengineered and what role our environment plays. Where does personal responsibility figure into this and what responsibility does our government and food manufacturers have? A lot in my opinion, yet everyone’s hand is in someone’s pocket.

Personally, I believe if we cut refined carbs out of our diet, including sugared beverages, and ate real food – not processed or packaged – but things that grow on trees and in the ground, relatively untouched by human hands, and animals that are responsibly raised, we would not have an obesity epidemic.

Dr. Anne Peters reviews new CGMs

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For those of you who use a Continuous Glucose Monitor, or think you’d like to, here’s an excerpt from Dr. Anne Peter’s review of Dexcom’s newly available fourth generation, the G4, and MiniMed’s CGM, Enlite, which will be available in the Spring. Dr. Peters is an extremely respected endocrinologist, well known in the diabetes community, who practices at the Keck School of Medicine of the University of Southern California in Los Angeles.

I love that Peters wears the sensors, although she doesn’t have diabetes, to understand what it’s like for patients. With all their advantages, one thing she finds burdens patients is the devices many alarms. Funny, we think of the benefit, alerting us to low and high blood sugar, but not the annoyance factor – I guess unless you wear one, I do not. 

Excerpt: With Dexcom G4 continuous glucose monitoring, the patient can easily insert the sensor under the skin — …on the abdomen or the back of the arm. A small transmitter is then placed on top of the sensor. The transmitter sends the interstitial glucose value to the device so the patient can see the blood sugar level. It transmits this information wirelessly every 5 minutes, so a patient can get a sense of whether their blood sugars are going up, going down, or staying the same.

…the new Dexcom G4 is somewhat smaller [than the earlier-generation device]. It is not as wide, similar to an iPhone, and is easy to put in your pocket. It has a pretty good range so that you can be moving around in your house and the signal will still reach the device. A blood sugar level that is 100 mg/dL and is going up may require much different treatment from a blood sugar level of 100 mg/dL that is flat and the patient might be just fine. Or, if a blood sugar level is falling fast, it may mean that the patient needs to ingest carbohydrate to avoid a low. The patient can get a lot of information in real time from this device. Then, in my office, I download the device and interpret the data for the patient so I can help the patient analyze the data retrospectively, so that in real time patients can make more reasonable choices.

…we also have the new MiniMed continuous glucose monitor, the Enlite™ sensor, which is supposed to be available in the spring. This is similarly inserted under the skin and taped down. In most cases, this device is talking to the patient’s insulin pump. The insulin pump has the tubing necessary to give the patient insulin, but now this pump also becomes the receiver for the signals from the sensor. The patient can look at the pump and see what the blood sugar levels are doing.

A lot of patients want the pump to automatically give insulin based on their blood sugar levels, but that is not what happens. This is truly a sensor, and the patient then needs to use the Bolus Wizard [calculator] to interact with the pump to calculate the insulin dose. That coupling of the sensor and pump is part of the development of the artificial pancreas. Substantial research is being done to make pumps that can use continuous glucose monitoring data so that the patient does not have to think as much about diabetes management. [Those advances] are in the future. 

For now we have sensors that sense interstitial fluid, giving continuous real-time data, and we have pumps that patients interact with to give themselves insulin. You can couple the MiniMed sensor with the MiniMed pump. The Dexcom device does not interact with a pump, although the manufacturer is working on collaborations with some pump manufacturers.

Peter’s full review appeared in Medscape Diabetes & Endocrinology Jan 25, 2013, “Continuous Glucose Monitoring: Practical Uses in Diabetes.”

What you need to know about checking your blood sugar

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I haven’t posted anything in a while because I’ve been away on vacation, but I did write two articles just before I left that are well worth a look if you haven’t seen them. 

Both articles are about our blood glucose meters, why they give us the numbers they do, and why that’s critical to managing your blood sugar. What you should notice in the picture above is almost all the meters show different numbers on them ranging from 99 mg/dl to 118 mg/dl. I took my blood sugar on all of them at the same time and with the same drop of blood.

You’ll find the post about what other things are just as important as our glucose numbers in managing our blood sugar in the article, “Meter Accuracy Counts More — and Less — Than You Think” on the Huffington Post and information about how meters really work in, “Why Meters Can’t Tell Us Our Blood Sugar Levels” on DiabetesMine.com. Be prepared to be surprised. 

On the vacation note, sad to say, I returned on crutches. While taking a lovely walk through the charming town of Leiden in the Netherlands, I tripped over a cobblestone curb and ended up with a sprained ankle. 

More on that in the next few days.

My CGM sensor report

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The CGM iPro sensor I wore for five days (see post below) came off Monday morning in a hurricane. Not exactly what you think, but I like the drama. My walk from the subway station to the hospital to see my CDE was in a rainstorm at high gale winds we rarely see here in New York – umbrellas discarded on the streets, puddles knee-high. Were it not for the fact that my iPro site was itching like mad for two nights from the sticky tape over it I’m not sure I would have braved the storm at all.

By the time I arrived at the hospital the entire front of my jeans was soaked so that I was wringing water out of the cuffs. I was eternally grateful that not only did I brave the storm, but that my CDE did as well. Moments later the CGM came off, a lot more easily than it went in thank goodness, and we downloaded the results. Luckily the battery lasted for as long as I wore it, just over five days. That’s not always the case, but it was here. Hallelujah!

Then we stared at pages of graphs, charts and numbers of my blood sugar numbers as picked up by the sensor every five minutes and I got to see my patterns throughout the day, and night. 

Since I was doing finger sticks at least four times a day along with wearing the sensor, my daytime numbers were not surprising, and, my daytime numbers are typically understandable to me. When I’m a little high it’s usually because I didn’t calculate the carbs in a meal or snack correctly. When I’m a little low it’s usually for the same reason, or my powerwalk lowered me slightly more than I expected. Being insulin-sensitive, as many type 1s are, a half unit of my rapid-acting insulin has an impact. 

During this five day period I also went high after a birthday lunch for my mom who turned 80 – a poor calculation on the calamari and spring rolls! But mom, you’re worth it. And I discovered just as routine is my savior, so is my experience. Since I was logging my numbers, I used the carb counts on packages more than usual and that led me more astray than the educated guesses I typically make based on years of testing. Perhaps it’s because food manufacturers are allowed a 20% margin on the carb counts listed on their packages, so beware.

But what I really wanted to know from this experiment is what my numbers do overnight, and that was the reveal. Around midnight they start sliding downward hour after hour. Around 5 AM they are at their lowest, in the high 50’s/low 60’s, and then they begin to gradually come up between 5:30 and 6:30 AM and then rise more swiftly. If I wake up and test my blood sugar around 6:30 AM the number’s usually around 75 or 80, a half hour later they’re 90 or 100. A half hour after that they’re climbing over 100. This is without doing anything or eating anything.

“This is perfectly normal,” said my CDE and nothing to worry about. In the morning your liver is pumping out glucose-raising hormones to get you ready for the day (dawn phenomenon). Even if you’re a little over 100 before you take your injection, it’s fine.” O.K., I’m relieved about that since my boundaries are admittedly narrow. 

“Can I prevent the overnight slide or morning rise?,” I asked. “Not really, this is your body and you’re doing fine. The only thing that might reduce the overnight low is cutting back on your Lantus one unit, but I don’t think you need to do that. You don’t go that low at 5 AM and then you come back up. “Would a pump level this out?,” I asked. “Yes, and that’s when most of my patients change to a pump, when multiple injections just can’t do more for them.”

So what I know is I’m working the MDI (multiple daily injections) system as best I can. I keep my blood sugar between 120 and 140 before I go to sleep, on the higher end of that range if I’ve had wine with dinner since that creates a slightly greater drop overnight. Then I blunt the morning rise with one unit of my rapid-acting insulin as soon as I wake up and take the rest of my breakfast dose just before or during my morning meal.

My concern that I drop so low overnight, like to 30 or 40 mg/dl, that my liver shoots out glucagon to save me from dying turned out to be false. That is a relief. Also, while I don’t log my numbers ordinarily, I’m already obsessive enough, if you log your numbers – and for most people this is an invaluable exercise – make sure you also note what you eat and any exercise. Most log books don’t give you space for this. So log your numbers on a simple sheet of paper. A bunch of numbers without these references is an incomplete picture.

I highly recommend if you have access to wearing a trial CGM for a few days to see your pattern that you do so. This kind of information can lead to an important change or modification in your treatment plan. I know I’ll be sleeping better from now on.

Note: Our bodies are different. Don’t base any of your own treatment decisions on my results. Check with your health care provider to be safe.

Just a little bionic

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UnknowniPro sensor – 5-day CGM

Noticing I was becoming a sugar-testing junkie recently, I opted to get hooked up to a CGM for a 5 day trial period, save some finger skin and see if I could learn something. 

My recent addiction to knowing where my numbers are, beside a proclivity to perfection, is largely because my blood sugars rise sooo rapidly in the morning. Can I shut the barn door more quickly so I don’t have to do two boluses before breakfast? The first to merely blunt the rise. 

My new CDE put this on me in her office and what should have been a rather simple affair turned out to be quite a painful one. I wasn’t prepared for the tugging, gripping and sensation of tearing skin when this thing went in. In fact you’ll see quite a bit of redness around it which is my blood. My CDE told me it is not uncommon to bleed and not a problem. OK, but it didn’t exactly lift my spirits and it did make me utter, “Diabetes is not exactly a pain-free disease!”

When I left my CDE’s office, newly bionic, I walked about 20 blocks to meet a friend for lunch. Each footfall, I was overly aware of this gizmo dug into my side and the very fact that my walking was impacting my blood sugar. A weird thing for your brain to be so focused on an automatic body function. When I sat down to lunch I copped the banquette seat feeling vulnerable and exposed to any passer by who might ram into my poor abdomen. Well, it’s not really on my abdomen, but I don’t know what you’d call this side area.

Leaving the restaurant I began to experience my plastic gizmo differently. I felt somehow as though it was now my helpmate. As though I was not in this all alone anymore. I found this quite comforting and recognized it as a wholly new feeling.

Now, two days in, I’m used to my CGM, it doesn’t hurt but the five inches of sticky tape that’s holding it in place grips and pulls as I twist and turn. And while my plastic companion is (hopefully) tracking my numbers, so am I four times a day in a log book, along with carb counts and activities, just in case anything goes awry. 

I will keep you posted next week when gizmo comes off. It would be dandy to have learned something more than which pants slide easily over gizmo and which ones don’t.  

Blood sugar meters may improve

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May 6 5 16 PMMy home test: different meters, different results

Would it surprise you to know that the meter you use to test your blood sugar may be wrong by 20%? And that a 20% margin of error for many patients results in seizures, unconsciousness and coma? 

This past June the international group that sets the standards for meters was pressed to tighten them, and we can only hope it’s happening according to the recent article in the New York Times, “Standards Might Rise on Monitors for Diabetics.” Officials said they would keep pushing until monitor accuracy improves.

But it makes you wonder how those who oversee meter accuracy could be so casual and negligent in the first place. Insulin is a dangerous drug, take too much you could die, take too little and high blood sugars will lead to complications; we’re all depending upon our blood sugar readings to keep us from harm. If my meter shows 100 mg/dl my blood sugar could be 80 or it could be 120. 80 means I’m close to caving and may need to take some extra sugar, however if I’m really 120 extra sugar will push me into high blood sugar. 

Something as simple as Tylenol or Vitamin C may also give false readings. In a world where we can land on the moon and talk into a wireless phone and get your email on a two inch screen, can we not create meters that give accurate blood sugar results? A government study revealed among five popular meters, results varied up to 32%! Two meters, both made by Bayer, differed by 62 points!

Really I find it shocking that with diabetes on the rise and health care costs skyrocketing, we still don’t have meters we can assuredly rely on.