Insulin to Carb Ratio

It doesn't matter if you infuse insulin with a pump or inject, you probably know how many units of insulin covers one carb. We use multiple Insulin to Carb Ratios (IC Ratio), in the morning Arden's IC is 1 to 16. One unit of insulin, for every sixteen carbs consumed. Her lunch, dinner and evening ratios are all slightly different. 

Two weeks ago Arden began experiencing unusual BG spikes after lunch, I'm happy that this happened, not because I want to see her BG high but because the anomaly caused me to draw a mental line between these new lunch spikes and a similar spike that I see too frequently after dinner. Post dinner spikes have been an ongoing issue for us this year. I was certain that they were happening due to bad carb counting but this new situation jarred something loose in my head and allowed me to see the problem from a different perspective.

I had become lulled into a false sense of calm by consistently good BGs from other times of day. Those triumphs clouded my ability to see simple issues that caused BG spikes, spikes that shouldn't have been difficult to diagnose. I made a mistake, focusing too much on the food in the equation and ignoring the insulin.

Diabetes: "Knock, Knock..."

Me: ("I'm just going to ignore that and see if he leaves")

I wonder now if I didn't subconsciously just need a break, maybe I didn't have enough energy to tackle another diabetes riddle. Whatever the reason, I figured it all out the other day... the answer ended up being so simple that I'm now annoying myself by retelling the story. 

Arden's insulin to carb ratios needed to be changed, one quick adjustment is all it took. I'm still fine tuning the dinner number and the breakfast ratio needs a little help from a temp basal but her BGs haven't been going above about 160 (CGM) after lunch or dinner since I made the adjustments. Everything has been so quiet around here for the last few days. No crazy highs, no panic inducing lows... it's almost too quiet, but I'll happily take that calm for as long as it lasts.

I'll be writing more this week about other simple adjustments that make a huge difference. Don't be afraid to make small changes, you can always put them back if they don't do what you expected. Please remember to record the old numbers before you make any changes in your pump.

Don't forget what the bottom of the site says... Always consult your doctor before making changes to your health care. I am not a doctor.

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!

An Unexpected Conversation

Arden didn't want to see 'The Hobbit: An Unexpected Journey' but the rest of us did. She told us that she would come anyway and, "take a nap if I get bored". It wasn't long after she snacked on some popcorn and chips that Arden shifted herself around in her seat, raised the arm rest and laid her head on Kelly's leg. Arden probably slept through the last ninety minutes of the movie, her BG from the snacking didn't take the same break.

I had Arden's DexCom receiver under my leg and was watching it for a rise in her BG. I rarely seem to cover those movie snacks in a way that completely holds down a spike. I probably checked the CGM once every twenty minutes, setting one temp basal over the first hour.

About thirty minutes before the movie ended Arden's CGM shook, she was going to need another bolus. Before I bolused I wanted to go back through the recent insulin delivery history so that I could make a good decision, I was trying to avoid testing Arden in the theater while she was sleeping. I had a pretty good feel for what I wanted to do but felt like it was important to review the last two hours before I pushed any buttons. I must have gotten engrossed in the data because I unknowingly brought the PDM up to my face to read the numbers. When I did the barrier that my seat and legs were providing against the light was lost, the PDM screen was now visible to others in the theater.

Before I could realize what I had done, an angry female voice emanating from my left spoke, "put that phone away, it's rude".

The instant that her words reached my brain I was enraged. My chest felt as if my heart had turned to molten lava and my mind was begging me to release the mixture and drown her with it. I'm embarrassed to tell you how insanely angry I was. My heart rated doubled, I could feel the adrenaline coursing through me. I instantly had a genuine desire to eviscerate the person that spoke in the dark. I wanted to rip her open and pour the hot pain that was boiling in my chest into hers... so that she would know how terribly misguided her words were.

Except that she was right...

I was that guy holding a bright light in a pitch black movie theater. I was interrupting the people around me. The woman who spoke made a completely reasonable assumption that I was holding my cell phone, I probably would have done the same thing. I knew that intellectually, but I still wanted to scream at her. I had to use breathing exercises to let the anger out of my chest. It took me a long few minutes to ride out the adrenaline. I kept thinking about her words as I waited for my primal response to dissipate, thinking of everything that I wanted to scream at her. I thought about it over and over until I could absorb and believe the truth. I was so blinded by anger and my desiree to defend Arden that I was unable to give my thoughts enough clout to overcome my rage. Eventually, my better judgement won out and I began to allow the truth to rule this moment, I was being unreasonable. When I was finally able to relieve myself of the rage that filled me, I was flooded with the notion that, "If she only knew, her reaction would be so very different... if she just understood that Arden has diabetes".

When the movie ended I checked with my son to make sure that the woman sitting two seats from him was the one who spoke. He told me that it was, I immediately stood up and approached her. "Excuse me, can I just have a few seconds of your time", I said. She wasn't sure what to make of my request and so I sat in the empty seat between her and Cole and began to speak before she could answer. "It wasn't a cell phone... it was my daughter's insulin pump, she has type I diabetes".

She calmly replied with an air of superiority, "You still should have taken it outside"...

Well, that didn't sit well with me as perhaps you can imagine. I politely but sternly asked her if I should have taken my daughter outside to give her the insulin that keeps her alive. My displeasure was on display.

To her credit she rethought her statement and recanted it, making up an only half-believable excuse about not understanding what I initially said. If I'm being honest, she was on her guard as I approached and I understood that her first words were defensive.

I explained again, apologized for not doing a better job of quelling the light and thought that, with that, we would part ways. Except that she seemed hell bent on making her point about rude people and their cell phones. It seemed that she was beginning to feel badly about our misunderstanding and wanted to legitimize her response. She began to defend her self but I cut her off before she could get on her soap box, and said this...

"If I can just have thirty more seconds of your time. There is a piece of writing that I love, it's a speech called 'This Is Water', the author makes a number of points in the text, one of them is this. We all see people everyday who drive like assholes. Chances are that most of them are actually assholes, but one of them must have a good reason for speeding and switching lanes too much, one of them must have an emergency that we could all understand. The author makes the point that you can spend your life assuming that those people are assholes, or you can make the humane choice to believe that they have a really good reason for driving that way. I choose to think the latter and I hope that this experience helps you to make the same decision next time something like this happens to you."

Now I must tell all of you that I am not normally the guy that lends strangers advice that they don't want and didn't ask for. I was driven in this moment by the desire to not just defend Arden but each and every one of you. Maybe I was out of line, I think that I was, but people living with diabetes deserve a little bit of... of what? We deserve a little extra compassion. I know that because I live this life, the same life that you live. As I was speaking to her my own words reminded me that everyone has diabetes sometimes, that we all need a little extra compassion once and a while. That acting with concern instead of contempt is one of the most basic and loving human gifts. Too often we respond to others pain with judgement, and if my experience on this night is any indication, we do so because of the judgment that we perceive has been previously levied upon us.

I apologized to the woman again for impugning her, I insulted her by insinuating that she saw the drivers as assholes. Perhaps she doesn't, maybe she's just been to one too many movies where someone pulled out their phone. Either way, I said my peace, defended my daughter and tried to be an advocate for, not just you, but for everyone that could use a break once and a while. Maybe I thought, maybe next time she'll find the strength to hold her boiling lava inside and approach her next issue as I did. Maybe I started a positive wave that will carry into the future. I hoped that my actions would be the start of more human kindness - but maybe she just thought I was an asshole.

When we got to the car Kelly asked me why I was talking to the people next to Cole. I told her this story and then I told my children this. "When I was young I would have yelled at that woman, I would have embarrassed her the way that she embarrassed me, I would have mocked her and verbally punished her for daring to speak up for herself. I grew up just outside of Philadelphia and I wasn't raised to take shit from people, even if I deserved it... I'm glad that I grew up. I hope that you can control yourself when this happens to you one day, and it will." I told them how difficult that it was for me to maintain my composure and I did my best to describe how angry and defensive of Arden I felt when she spoke. I really hoped that my kids got something more out of this evening then popcorn and a movie (and a nap). I'm sharing my experience with you for the exact same reason.

The woman thanked me for taking the time to explain, we shook hands and wished each other a Happy New Year. I think that she was glad that I spoke to her, I at least hope that she was... I know that I was.

Everyone needs a break sometimes... Do your best to remind yourself of that in 2013. It's not always true that the ignorance you face has understandable beginnings, but it does you far more personal damage to believe the worst in people and the assumption gets us no where, it actually holds us back. When you give others the benefit of the doubt, you may be starting a kindness that will one day find it's way back to you or another person whose life is not that much different from ours.

Happy New Year!

All my best, Scott

DSMA Live: Parents Talk (feat. me) Audio

Apparently I have a lot of thoughts on a multitude of subjects and DSMA Live 'Rents, was a perfect place to share them. I'm confident that you will agree... my appearance is not as entertaining as 'The Avengers' but I can promise this, it is 200 times better, then 80% of ABC's comedy TV lineup. Enough build up, here's DSMA Live: Parents Talk from December 17, 2012.

Listen to internet radio with DiabetesSocMed on Blog Talk Radio

DSMA Live and DSMA Live Parents Talk is also available on iTunes and on the DSMA website. Please consider adding a DSMA Twibbon to your avatar and/or making a donation to help DSMA obtain tax exempt status.

Oh Canada, I have new OmniPod info

Over the weekend I received more then a few queries from fellow OmniPodders that live in Canada. All were wondering when they can expect the smaller OmniPod to arrive north of the border. So I tied a tiny electronic note to a digital sparrow and released him into the Internet. This encouraging bit of news is what came back...

"With U.S. FDA approval now in hand, we can move forward with our regulatory filings in Canada. We hope that we would begin selling the new OmniPod in Canada later in 2013." - Brian Roberts, CFO, Insulet

There you have it Canada, I hope that this was the kind of news that you were all hoping for. It's not concrete but Insulet is willing to tie themselves to a date, however vague, and I think that is worth be optimistic about. I'll let you know more when I do.

Oh, you know what, while you're here. I've been wondering this my entire adult life... What's a Canuck? Seriously, is it a bird, plant, slang or none of the above? I need to know, please. Thanks!