I'll have Two Eggs Poached, Toast and a Scoop of Maturity

How do habits start? Sometimes it's difficult to remember how you got where you are and with each passing day it becomes harder to imagine a life that is different. That sentiment can be applied to so many aspects of of our days, but today it will help me tell a story about breakfast.

Arden was two when she was diagnosed, that was a long time ago. Those beginning years were well before I knew about the glycemic index, before I understood that all carbs weren't created equally. Today I know better but that knowledge still wasn't helping me to break Arden's cereal habit. That girl enjoys a Fruit Loop.

It's strange to some degree because Arden isn't a junk eater, doesn't like candy and other sweets. She's the kid that goes trick-or-treating to dress up and run around, not for the candy. Yet every morning she has one cup of Fruit Loops with fat free milk - and her BG's take a hit because of that choice. It's a choice that I sanctioned many years ago, and one that I regret now but all of the talking in the world wasn't getting Arden any closer to eating something different. At some point I gave up on trying to get her to change and set out to try and defeat her spikes as best as I could. I did that with a combination of pre-bolusing, temp basals and shear will. I learned how to defend against spikes and create boluses that didn't cause a low, all because of my battle with Toucan Sam. I guess that I should be grateful for that lesson, and I am. None of that however could make me feel any less like a drug dealer when I handed Arden her cereal in the morning.

But then something wonderful happened...

Arden got tired of the spikes. She began to pay attention to her health in a way that I found astonishing, I did not expect her to make this leap so soon and it all started at her Endo appointment. Arden's A1c experienced a significant decrease about six months ago. Her NP made such a great celebration of her achievement and gave Arden a huge hug as she told her how happy she was for her. As much as I believe that her encouragement got the ball rolling for us... it wasn't until Arden's next Endo appointment that she decided to take her fate into her own hands. Three month later Arden's A1c decreased again by .01, an accomplishment for sure, but it apparently didn't hold a candle to the previous decrease, at least in Arden's mind. 

As we were driving home Arden asked me how she could get her A1c to go even lower, I could see that she was feeling competitive with that number and also beginning to think about her health in a different, perhaps more mature way. I didn't want to make too big of a deal about our conversation and so I offered a few small suggestions. We spoke about being a bit more patient before eating an unscheduled snack to give a bolus more time to work, (we pre-bolus meals but small unexpected snacks not so much). I suggested that we could exchange a grain for another vegetable at dinner and then I slipped in that making different breakfast choices would definitely help. The conversation turned to her CGM graph and I explained about how the prolonged spikes from the cereal raised her A1c. It all may sound like too much as I explain it here, but this was an easy and quick conversation in our car, nothing heavy.

One week later Arden approached me about finding new options for breakfast and she hasn't had a bowl of Fruit Loops since. She is growing up, understanding more, and I am proud to be able to say that I can see her wanting good things for herself.

I don't remember thinking even once about my health when I was eight.

Basal Adjustments

I was asked on FaceBook to explain how I made the adjustment to Arden's overnight basal rates that resulted in the graph above. I'm sorry that it took me so long to write about my (less than technical) process. Here's how I did it...

Somewhere around the second week of overnight lows it became obvious to me that I was dealing with a trend and not an anomaly. Something had changed about her physiology and I was going to have to adjust - basal adjust.

I'm not going to lie, I didn't do any basal testing. I have the procedure around here somewhere, the page or so of directions from Arden's endo that explains how to do basal testing - but I tried a more, let's say, personal approach. Luckily CGM technology lends a distinct advantage and unless we are averting a low, Arden doesn't eat at this time of night so trend graphs are a perfect way to understand where we have too much basal insulin.

I broke out the stupid PC laptop that we had to buy, because the damn device manufacturers refuse to port their software over to OS X (Apple), then I downloaded Arden's DexCom data. It only took a moment to see what time of night that her blood glucose was drifting lower.

Arden's overnight basal rate was .30 per hour, all I did was dial it back to .20 starting one hour prior to when her BG was beginning to fall, not terribly scientific I know. The possibility that this adjustment would be too little or too much wasn't a huge concern, because let's face it, I'm awake anyway.

As you can see in the image above, the slow drift that was beginning around 4 am leveled off nicely. The picture you see here shows that there was room for a little more basal insulin. I waited two more nights to verify that this graph was accurate and then I moved the basal to .25 an hour. That adjustment caused a slight dip and so the next night I staggered the hourly rates .20, .25, .20, things have been golden since.

The reasons that I like handling basal adjustments myself are simple. Waiting until Arden's next endo appointment to discuss this doesn't feel like an option - too long. Continuing to live with lows would have not only taken the rest of the precious little energy that I have left, but also it would leave Arden in danger - not doing that. People living with diabetes will always need to make adjustments like this. Their bodies, like everyone else's, are constantly going through ebbs and flows. My pancreas doesn't secrete the exact same amount of insulin every hour and it makes sense that Arden's pump shouldn't either. Arden's body has needs, ever changing needs - I have to keep up with them.

We all have to be comfortable making decisions like this autonomously at some point. As parents we don't always have the time to call for an army of help and our children's bodies shouldn't have to wait days or weeks for balanced control. Don't get me wrong, I wouldn't make a grand change to Arden's care without our doctor and I don't chase every night that doesn't go perfectly, but basal adjustments when they obviously are needed... We can do that!

If you are going to make basal adjustments please don't forget to write down your old numbers in case you have to switch back. Actually, if you don't already have that information recorded somewhere, take a moment to do that. Write down basal rates, IC ratios, alarm thresholds and all of the other personally inputted data that your pump and glucose monitors retain, just to be safe.

Later this week I'll be talking about Pre-Bolusing, Arden's latest A1c and more... stop back, like Arden's Day on FaceBook or follow the RSS feed to stay in the loop.

Good luck getting those basal rates where they need to be and then enjoy the huge difference in your BGs!

Why does basketball make Arden's BG rise?

Arden brings the ball down the court, passes and looks for a rebound.

Last week during Arden's quarterly Endo appointment I brought up an issue that I had identified but couldn't figure out. I explained to our nurse practitioner that when Arden exercises her BG falls. Riding a bike, running around, recess at school, really all of the her physical activities decrease her BG... except sports.

I, of course, am aware that activity can cause a decline in BG but our issue didn't seem to be following that "rule". It took me a while to be able to see past the expectation that physical exertion would decrease Arden's blood glucose level. Inexplicably, I was having trouble with her BGs actually going up during basketball games and practices this winter. When I finally thought back, I realized that I saw similar BG trends last summer during softball.

Our NP asked about Arden's level of competitiveness, as she spoke I began to understand what she was getting at...

Arden is a very competitive little girl, when it counts. That is to say that if she goes out back with her brother to shoot baskets her BG falls from the activity as you may expect but when she is in a game, when there is a score being kept and winners and losers are recorded - Arden's BGs go up.

I explained to our NP that Arden entered her last basketball game with a BG of 125 and that by the end of the game, just one hour later with no food or carbs in her system, her BG was 220 and climbing. I was bolusing during the game, which was nerve wracking when you consider that the expectation is that there will be a fall from the activity.

The NP described to me that this is a phenomenon that they generally see with boys, then she turned to Arden and said, "so, you like to win huh?". Apparently it's common for very competitive people to access their flight or flight response (also known as 'the stress response') during a sporting competition. Their desire to win is so strong that they feel the game on a different level. Adrenaline is released and their body prepare to battle as if they are fighting for their lives.

Next week when we arrived at the gym. I am going bolus as if Arden was about to consume a 15 carb juice box (the ones we use for low BGs). I'm confident that the insulin begins to act it will find a rising BG to tussle with, if I'm wrong... we'll just drink the juice. I'll report back and let you know what happens... Never a dull moment with type I diabetes.

Everyone Poops

Link is to Barnes and Noble

The Children's book Everyone Poops takes away the stigma of talking about bowl movements with your children. Both of my kids read this weird little gem when they were potty training and I hope that you did as well, because I got some shit to talk about.

The first time I thought that I was imagining things, the second time it seemed like a coincidence. I ignored the fact that Arden's BG seemed to fall after she, well, pooped. Then one day a few weeks ago Kelly mentioned it to me and last week I saw someone on FaceBook ask the question. Today, we are going to get to the bottom (pun intended and it won't be the last one) of this most vexing, strange, yet natural type I diabetes question.

Everyone poops, but is everyone's BG effected by having one in the chamber?

I'm considering making an addition to the endless questions that I ask when I can't figure out why Arden's blood glucose won't come down. In the past it was, did she eat something I don't know about, maybe I mis-calculated carbs, do we have a bad site and the rest of the usual suspects. I'm getting close to asking, "when was the last time you made a number two" to that list.

My parental detective work can only take me so far. I need help. I need to know the answers to a couple of more scientific questions that I'm hoping you may have some insight about.

• Does our waste material still contain carbohydrates?


• If yes, are the carbs being leached from the intestines?


• If no, what is it about having a belly full that could raise BGs?

This is the only hypothesis that makes sense to me but I am more then willing to believe that I am, you'll excuse me for this but, full of crap. I have witnessed this oddity consistently over a long enough period of time to say that we see higher BGs when it's been awhile since a BM. Moreover, these BGs always seem to drop rapidly after the completion of a belated constitutional.

So that's it. If you've noticed this phenomenon please leave a comment and share your observations. If you haven't, please keep your eyes open and report back with the skinny (thought I was going to say poop didn't you?).

Please Test

I need this post to accomplish two distinct and important goals. The first one will be simple. I want to thank my wife Kelly and my daughter Arden for both being so amazing. You'll see why in just a moment...

Second and maybe more importantly, I want to take this opportunity to remind everyone that while CGM technology is fantastic, it isn't foolproof. Because of that sometimes ignorable fact, we always have to test. Normally when we speak about this topic it's in response to the notion that you shouldn't bolus based on a CGM number. While bolusing without testing is something that we should never do, most of us probably have... but we shouldn't becasue CGM technology is designed to be used in addition to testing, not in place of.

Tonight while I was with my son Cole at his baseball practice (yes I know it's January) Arden's CGM alarmed and reported, "101 arrow straight down". Kelly, being the D-mom rock star that she is, tested.

Please test because sometimes, not often, but sometimes, 101 is actually 36. The DexCom CGM technology is so wonderful that it's easy to forget that it isn't perfect. I've been as guilty as the next person of leaning on it too much when I know that it isn't always spot on. It's difficult not to, especially after the sensor has been on for days and consistently reporting numbers that are so close to our tests. Next time that I'm inclined to think that way, I'm going to remember something that Arden and Kelly told me when I got home and I hope that you will too.

Kelly later said that she tested Arden because Arden said that her eyes "felt funny". Arden told me the next morning that it felt like she had been looking, too long, into a computer screen and then suddenly turned away. "My eyes were getting dark" she told me, with no inclination for how her words were breaking my heart. 

I gave her the bolus a few hours before at dinner that caused this low... and her eyes got dark.

Most moments with type I diabetes are uneventful. Our vigilance gives us the sense that we have the disease under control, but that's a foolish notion. It's only under our control until it decides that it wants to run away. When diabetes decides to run you can't stop it. Your best hope is to chase after and keep it in sight until it gets tired of running. Then you can stand next to it again, pretending that you are partners.

We're vigilant because we can't predict when diabetes will take off running, that's why we test. You aren't taking the test, it isn't you that's being judged. It's a test of diabetes, an indicator for whether diabetes is going to stand next to you and play nice or run away.

Please test.