Thursday, July 19, 2012

Adjusting Insulin for a normal day

I had another Diabetic class today - the last one I think. This one was about how to adjust the insulin dose.

The thing about Diabetes and Insulin is this.

Diabetes management is adjusting the Insulin for Reacting and and Preventing at the same time
Always keeping them in balance.

It's like a see-saw (or a teeter-totter) only this one is not just one dimensional.

This see-saw is a long plank of wood on a BALL and the ball goes all over the place and you are standing on the plank of  wood on top of the ball and trying to keep your balance in all directions. That's how I see it.

The  first thing you have to know and remember is how the insulin doses affects your BG numbers.

Breakfast Numbers are affected by the NPH Insulin dose from Bedtime the night before

Lunch Numbers are affected by the Rapid Insulin dose at Breakfast time

Dinner Numbers are affected by NPH Insulin dose at Breakfast time

Bedtime Numbers are affected by Rapid Insulin dose at Dinner time.

Now you need to know the 5 rules.

1 - If you have 3 highs in a row at the same time (3 days in a row) - you must INCREASE the insulin that will affect that time.

So for example, if you have High Blood sugar every day for 3 days at Breakfast time, you must increase the NPH insulin you give at bedtime.

If you have high Blood sugar every day for 3 days  at Lunch time, you must increase the Rapid insulin you give at Breakfast.

2 - If you have 2 Lows in a row at the same time of the day, you must reduce the insulin dose.

For example my son has been having low blood sugars every day at lunch time. And for most of the past 2 weeks, the diabetic nurse and I have been slowly reducing the amount of Rapid insulin he gets at Breakfast time.  

The reason he has lows at lunch time is because of all the activity he does at Day camp in the mornings - and when he is active, that uses up his sugars naturally, so he doesn't need as much insulin.

Remember when I said that exercise and insulin are in competition with each other. We are still looking for the right balance of exercise and insulin.

3 - If you have 3 highs in a row - again always at the same time, (for which you adjusted insulin), had a normal number and then had another high on the 5th day - you must still increase the insulin - same as you do after 3 highs in a row.

4 - Always adjust insulin by no more than 10% - and round up if you can only dose in full units rather than half units. My pens only allow me to adjust by 1 unit at a time. So far we are doing a pretty good job.

If you are giving less than 15 units of insulin, than the adjustment is by 1 unit only.
If you are giving more than 15 units of insulin, then the adjustment is by 2 units only.

5 - Only adjust 1 insulin dose per day. If you adjust 2 doses in the same day - you may cause a low the following day and we don't want that.

Lows are dangerous and need to be fixed up immediately. Highs are less dangerous and usually they come down on their own - unless they are super high then they need an adjustment of insulin.

There is a whole different regime of Insulin management when the diabetic child is SICK and NOT feeling well, but I will leave that for another post. 

Wednesday, July 11, 2012

The Honeymoon Period

Honeymoons are usually associated with weddings, not with Diabetes.

But guess what. There is a honeymoon period in the management of Diabetes.(first a little lecture - my apologies but I have to explain this).

As the pancreas shuts down and stop producing insulin, the beta cells (in the pancreas that produce the insulin) are destroyed. As they are destroyed, the blood sugar in the body rises because the sugar is not getting into the cells and the person because tired, fatigued, thirsty, pees a lot, etc etc - all the symptoms my son had when he was diagnosed almost 4 weeks ago.

So the patient is diagnosed, the insulin is started and the pancreas can take a break, which it does. But within a few weeks, it starts producing insulin again. Not all the beta cells have yet been destroyed at this point - because there are still some beta cells in the pancreas that are working. When the pancreas starts working again, this is called the honeymoon period - and it can start anywhere from 2 to 4 weeks after diagnosis and after the insulin injections start.

The Beta cells are still being destroyed by the body's immune system. But while they are working, they want to help. So they do. As the beta cells in the pancreas die off, the natural insulin that is produced by the body drops and the injected amount has to go up to cover the natural drop off. The pancreas can continue like this for anywhere from 3 months to a year and sometimes it even goes as long as 18 months (but that may be mostly due to less cells destroyed at the time the diagnosis was made). But eventually all the beta cells from the pancreas have been destroyed and the body becomes reliant on injected insulin for the rest of its life.

As to why I wrote all that, it was to explain the inexplicable number of low BG's my son had yesterday.

I wrote earlier that exercise and insulin are in competition - they compete for the same sugars in the blood. Too much insulin takes the blood sugars out of the blood and into the cells. As does exercise. So while I am injecting insulin into my sons body, he appears to also be getting insulin from his pancreas - all of which dumps the sugar from his blood into his cells and his BG level drops or goes low.

He had a total of 4 lows yesterday. The first one was at lunchtime - but that was due to the exercise they do every morning at camp. The other 3 lows were all over a 3 hour period around dinner and bed time.

Everytime he has a low, it must corrected by a Juicebox, or by chewing on Dex4 Glucose tablets.

Last night at home, we were out of juice boxes and Dex4 tablets, but we did have some large Rocket candies as an emergency stash.

When you have to give glucose, it is best to give the equivalent of 1 serving of carbohydrates - which is 15 grams of Carbs - always written as CHO

 The Dex 4 tablets each have 4 grams of CHO so you have to eat 4 of them to get one serving.
125 mls of Juice is one serving of CHO - thats one full junior box or half of a standard 225 ml box (roughly).

On the wrapping of the large rocket candies, it says - 6g CHO per 2 candies.

Now for some reason, I must have been slightly panicking last night because of me doing the maths and not figuring out that if 2 candies are 6 grams, then 1 candy must be 3 grams. Therefore 15 grams of CHO means he needs to eat 5 candies.

I was not giving my son 5 rocket candies as I should have done. I only gave him 2 because I was doing the maths like this - 6g CHO times 2 candies = 12 grams. Good he can have 2 candies and thats close enough to one serving. I must have been panicking to think that 1 rocket candy has 6 grams of carbs in it!!

This first low was around dinner time. I managed to get his BG level back up above 4 and then I gave him his dinner insulin and his dinner.

2 hours later at bedtime, he was shaky again. More pokes and again his BG is low. I could not understand why.  So once again I gave him 2 large rocket candies (still thinking that each candy had 6 grams of CHO).

We got his BG level back up above 4 mmol/L and so he had his bedtime insulin injection and his snack and off to bed.

 45 minutes later after going to bed, he said he was shaky yet again. And once again his BG level was below 4.

I was muttering to myself, I have to get his numbers up, I have to get his numbers up.

By this time my husband had been out and purchased another packet of Dex4 tablets, so this time, I gave my son 3 Dex 4 tablets. Each Dex tab has 4 grams of CHO so 4 grams times 3 tabs is 12 grams. After 15 minutes when his BG was still too low, I broke a granola bar in half and gave him that to eat. Granola bars are what he usually snacks on during the day. They have 22 grams of CHO so half a bar was roughly 11 grams. That plus the Dex4 tabs he has just taken, should put his BG numbers back into a safe range.

Sure they did. My meter reader said 24 mmol/L  WTF? My husband said - numbers would not rise that fast. My son simply said, you better test again mom. So I did.

 This time his BG was 13 - which is higher than his target, but at least it means he wont go too low, too fast. So finally my son got to sleep. It was now almost 10 pm.

I went to bed at 1 am and gave him a prick just to reassure myself. His 1 am number was perfect - 6.6 mmol/L - right in the middle of the target.

So my husband and I now believe that the honeymoon period is kicking in, for our son to have so many lows in the space of just a few hours. 

We need to reduce his insulin that is injected in order to help the body's natural insulin to do its job for the next few months.

When the beta cells in the pancreas eventually die altogether, then we will need to bring the amounts of insulin we inject back up again.

Monday, July 9, 2012

Insulin + Exercise = Low Sugars

Today my son went off to summer camp - it was his first day. The camp runs for the next 6 weeks, so it covers most of the summer.

This camp is an academic camp - which has a mix of academics and sports (mostly soccer and basketball) - as well as other special classes like Tae Kwae Do, Akido and science classes.

The kids will also do excursions to places around Toronto such as the Science Centre, the Museum (mostly to see the dinosaurs) and Centre Island.

I had thought they were going to do academics in the morning and sports in the afternoon, but it turned out to be the other way around. So he had sports in the morning and academics in the afternoon.

Now insulin and exercise do not complement each other - they actually compete. They both do the same thing. If you take insulin, it uses up the sugars and carbohydrates in your blood. If you exercise, it also uses up the sugars and carbohydrates in your blood. And if you have both - you end up with a rather LOW level of sugar in your blood.

So my son had a low blood sugar score before lunch today. A juice box took care of that and he was quickly back up into the target levels. I will have to discuss with the nurse about cutting down on the morning insulin.

There is also an overnight camping trip as part of the summer camp program as well. I am not sure if my son can go on the camping trip due to the insulin that must be injected, and most teachers are not trained to do that. I wonder if I can go on the camp too? I'm not sure if he will want me to come. I will have to discuss this with the staff.

Counting Carbs for Beginners

I had another Diabetic education session last week, and now I am supposed to be counting carbs for my son.Every bite that goes into his mouth has to be accounted for.

It kind of hard to keep to the rules when my husband - who has type 2 Diabetes, doesn't count carbs at all. He eats what he like when he likes and gives himself insulin to cover what he eats. Incredibly enough - 90%  of the time - his blood glucose level is within his target range.

My son cannot do that. We now have a specific amount of carbs he has to eat at each meal and snack so that we can keep the insulin on the same level.

On Saturday things went very well - I counted everything - and my sons numbers stayed in inside the BG target for the entire day.

On Sunday (yesterday) we went to the movies. We went to see The Amazing Spiderman - and my son was most upset to discover that he can no longer eat what he likes when he likes.

 Up until now, he has always had a JUMBO bag of popcorn at the movies. Popcorn has 6 carbs per air-popped cup. And Jumbo bags have at least 8 cups - possibly more.  So 6 x 8 is 48 carbs just in one jumbo bag alone. We have never added butter so that's ok. We always add cheese and cheese is a "free food"  Free foods have no carbs.

Yesterday we discovered that he can now only ever eat a SMALL bag of Popcorn - (and that's still at least 4 cups) but we can manage the 24 carbs. Still his BG went a little high but not too high.

Then after the movie we stopped at MacDonalds, and for the first time EVER, we asked for a nutritional fact sheet and sat down to decide what he could have before we purchased it.

So we settled on a double cheeseburger and small fries. We had to buy a Sprite Zero from another shop since MacD's do not sell Diet pop (other than coke and we never drink coke).

AS usual, my son wanted a MacFlurry - but with over 40 carbs, that's now a no-no!!

Again he was not happy.

"I'll never be allowed to eat at MacDonalds again" he sobbed.

Well that's not true, he can eat cheeseburgers and small fries, and salads, and the chicken nuggets, but he doesnt want to eat a healthy salad and he thinks that chicken nuggets are for babies.

Also at MacDonalds, I had to inject him with his dinner time insulin. Since I knew his BG numbers were a little high after the popcorn, I opted to give one extra unit of insulin to cover the high (of both the Popcorn and the Cheeseburger and Fries). This was the right decision to make because his bedtime BG was back down within the target range.

I am proud of myself for making a small decision that turned out to be correct.

Monday, July 2, 2012

And how to deal with High Blood Glucose levels

Today is July 2nd, 2012. We celebrated Canada Day today.

Canada day is usually celebrated on July 1st - but yesterday (July 1st) was a Sunday so today (Monday) is the statutory holiday.

The School year in Canada ended on Thursday June 28th.I mention this because my sons BG level went really high on Friday (June 29th). He had a meltdown temper tantrum right in front of me because I refused to give him anything more to eat. He stamped his feet and swore at me - using really foul language. When he gets mad like that - it usually means his BG is out of control. So I did a finger prick and sure enough - his BG was through the roof!!!

It was showing as 17.7 mmol/L. I was quite worried and wondering why it was so high. He had eaten one small chocolate bar 5 hours before dinner, and one cheese sandwish just 2 hours earlier. Dinner was due in less than 1 hour. 

Fortunately he gets some Rapide Insulin at dinner time, so that took care of his dinner and any other high sugar levels. By bed time his numbers was back down in the normal range. 

Then at 8.30pm (bed time), right when he was due for his last insulin dose of the day, he finally admitted to me that he had actually eaten 4 fig newton cookies at 5 pm while I was out of the apartment.

Each fig newton cookie has 14 grams of carbohydrates and he had eaten 4 of these within a few minutes. That was a whole extra 56 grams of carbohydrates - 1/3 of all the daily requirements. No wonder his BG went up so high.

 I told my husband to NEVER give our son any treats unless he checks with me first, and I told my son to never eat anything I have not approved of first. I do not want him to have another rude tantrum like that one.

The next 3 days of the long weekend (Saturday through Monday) his BG numbers were perfect.

Tomorrow (Tuesday July 3rd) he starts summer camp. I hope he behaves himself and does not overdo the food.