Thanksgiving Dinner (Skip if you read Snuffleupabolus)

Here’s a little tidbit that I’ve literally never told anyone, ever. When I see a turkey, I hear the Sesame Street character Snuffleupagus in my head. He says, “Buuurrrd.” Not a huge revelation perhaps, but it’s weird enough that it shouldn’t be shared. In the past, as the father of a child with type I diabetes, I’ve conjured other words while preparing Thanksgiving dinner. Those words were R rated and not appropriate for this blog post. These inappropriate words would pop into my head as I tried to imagine how many carbohydrates were in a scoop of mashed potatoes, homemade stuffing, dinner rolls, fruit, gravy and all the rest of the seemingly unquantifiable holiday treats that cover every inch of counter top in my kitchen.

I say in the past because I was finally able to get out of my own head last year and find a way to give my daughter Arden insulin on those long, food-heavy holidays without making myself crazy or causing Arden to feel like a science experiment.

I think I will call the result of my revelation, Snuffleupabolus. 

Could I measure everything that Arden eats on Thanksgiving? I could. But I’m cooking and cleaning, while socializing with family, trying to sneak a look at a football score and balancing the preparation times of more dishes than I normally prepare in a week. I’ve tried unsuccessfully in the past to count each morsel, but too often the results were uneven. I found that putting in so much effort and care without achieving the desired result to be defeating, and the end of the day brought blood glucose results that made me wish that we skipped Thanksgiving.

All of the day’s tasks are secondary to keeping my daughter’s blood glucose in range. Too low, too high, too inconstant. Each possibility comes with its own physical punishment for my sweet girl. I bet that you know what I want more than a golden brown buuurrrd, perfect stuffing or a well placed table. I want Arden to enjoy her holiday with minimal diabetes interaction or the unpleasant feelings that come with riding the diabetes roller coaster. The enemy of that desire, especially on Thanksgiving, is the difficult to count mixture of complex and simple carbs that tempt at every turn.

During the day we employ a cadre of slick diabetes moves. Increased temp basal rates to combat snacking, pre boluses to help get ahead of carb-heavy meals, and we lean heavily on Arden’s DexCom CGM for guidance (If you don’t have a CGM, frequent testing can produce similar data). But when that meal plate comes with its potatoes steaming and stuffing so plentiful that covers Arden’s slice of buuurrrd - I Snuffleupabolus. I do my best to guess at the carbs, but honesty, Arden’s belly only holds so much food. So if my estimate doesn't match the insulin amount of the largest meal that I’ve seen her eat in recent history, I increase the bolus to match that number. Likewise, if the suggested amount of insulin is greater than the largest recent meal, I decrease the insulin. The odds that Arden won’t eat much more than on a normal day are pretty good. Thanksgiving or not, that little kid can only eat so much food and I’ve found that historically most of her large meals need a similar amount of insulin. There is nothing scientific about this method and I only whip it out on days like Thanksgiving… but I’m getting good results. 

After the malay, I watch Arden’s CGM closely and test, we aggressively tend to high numbers and treat lows with pie and other desserts. The only real time-sensitive planning that I do around food? I like to pre bolus the main course 15-20 minutes before it’s served (DexCom admittedly makes that easier) and I make sure that dessert is finished and the eating frenzy is over, three hours before bedtime. I want Arden’s active insulin to be finished before bed so that decisions can be made about overnight care from a fresh perspective. This is something that I strive for everyday but is extra important on days that contained high amounts of exercise, stress or eating. Thanksgiving day contains all three of those variables in our house, as I’m sure it does in yours.

I hope that your family has a wonderful Thanksgiving, that your home is warm and full of good friends, loving family and one Snuffleupabolus that allows you to enjoy it all with a light heart.

buuurrrd

This post originally ran as part of a Lauren's Hope/Life Is Short, Laundry Is Eternal giveaway. I liked it so much that I wanted to run it in it's entirety, here on Arden's Day. Thanks to Lauren's Hope for not being weird about reposting! They're good people, please check out thier blog if when you get a chance... blog.laurenshope.com

Snuffleupabolus

The lovely people at Lauren's Hope are giving away two $50 gift certificates to their site along with two autographed copies of my award winning (I know, fancy right!?) parenting memoir, 'Life Is Short, Laundry Is Eternal". Just head over to their blog to read my piece about managing Thanksgiving day BGs, then you can enter to win the contest or do whatever else goes on over there.

Good luck in the giveaway! - Free Stuff Friday with Scott Benner

Pre-Bolus

Original art by Mike Lawson - Check out Mike's YouTube page by clicking on the image

This story begins in 2006 just moments after I asked Arden's nurse practitioner if she was "nuts".

NP: <blank stare>

Me: <incredulous gaze>

Only moments before our staring contest began Arden's NP became the first person to suggest that I give Arden her mealtime insulin before she started to eat. I can't be sure if she referred to the practice as pre-bolusing, probably not as we were MDI, but she definitely wanted me to inject before Arden ate.

"Are you nuts?"

I responded emphatically that I could never give Arden insulin before she ate. Arden was two years old and there was no way to be certain of how much food that she would finish. The NP repeated her very reasonable request but I could not wrap my head around this new idea. Pre-Bolusing, bah, Arden would be safer if I left her alone at the mall with money pinned to her shirt.

I was 100% correct on that day. There was absolutely no way to be sure of Arden's appetite. However the inability to guess how much she would eat wasn't the only reason I didn't want to inject before meals. Arden weighed maybe nineteen pounds at the time and Novolog had a way of peaking intensely in her body. She had already experienced a seizure from an insulin miscalculation that I made. That mistakes lesson was still very fresh in my mind and with that bad memory still looming over me, I just couldn't bring myself to administer insulin that wasn't already covered by food or a high BG.

Of course everything that the NP said made total sense. I wanted to give Arden's insulin a head start, I dreamt of a moment when her food would begin to expel it's carbohydrates just as the insulin was pulling her BG lower. I could picture that perfect image in my mind, a tug-of-war with food on one side and insulin on the other. Both combatants pulling furiously without once moving the rope that is Arden's blood glucose value - the dream of a steady mealtime BG. I wanted very much for that to be our reality and so I promised myself that I would make the adjustment when the time was right.

Fear and poor timing stopped me from taking the NP's advice all those years ago. Eventually the day came when I found my footing with the idea and gave up on being scared... that's the day Arden's A1c began to decrease.

We haven't looked back.

The beginning of our trip down the road to pre-bolus freedom was littered with pot holes. The first bump took some time to traverse, we first had to wait until Arden was old enough to give thoughtful consideration to her hunger. After that hurdle was cleared we took the first step, bolusing ten minutes before a meal. Those next ten minutes were the most tense of my day, I would test and worry so much after the bolus that I barely had time to finish cooking. Initial results were less than stunning so I moved the pre-bolus to fifteen minutes before a meal. The extra five minutes increased the impact of the insulin and lessened Arden's post meal spikes, but I still wasn't seeing a huge return on our efforts. I wanted to take the process to another level but I couldn't, in good conscience, give Arden insulin farther from the beginning of her meal. If only I could see the insulin work, I needed a crystal ball...

... or a DexCom CGM

Arden's CGM turned pre-bolusing into the most valuable weapon in our arsenal. It's one thing to have a good idea of how long it takes insulin to begin working in the body. But when you are able to not only witness the movement of the BG, but also the speed with which your glucose level is rising or falling... it's the difference between rumor and fact... between guessing and knowing with reasonable certainty. The day that my eyes were opened to the benefits of wearing a CGM, that was the day that everything changed.

Arden was 149 before dinner last week. I bolused for the elevated BG and pre-bolused for 50 carbs, it was a significant amount of insulin for her. Before DexCom I would have panicked and served the food in less then ten minutes. Now I take my time finishing dinner while Arden and Cole do their homework and leisurely prepare their plates as I wait for the CGM to tell me when to serve.

I put dinner on the table when the arrow on Arden's DexCom G4 turned south, waiting until her BG was below 110. The amount of time between Arden's bolus and her BG decline can vary most days depending on a number of factors. Glucose monitoring grants the flexibility to wait, providing a level playing field for the insulin and those scrappy carbs to wage their battle on.

At least now it's a fair fight.

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.

More about the art: The art work displayed at the top of this post is an original piece from Mr. Mike Lawson. Mike is a tireless advocate for people with diabetes, a friend and extremely talented artist. You can find him working at TUdiabetes, on Twitter and through his fantastic YouTube channel.