Be Bold and Pre-Bolus Insulin
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.
Original art by Mike Lawson - Check out Mike's YouTube page by clicking on the image
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 disclaimer 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.
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.
Life Is Short: Amazon
Industrial Steel Saw
An email arrived in my inbox, it was from a guy I worked with at the job I had 13 years ago, back before I became a stay-at-home dad. He was writing to tell me that he pre-ordered my book and wished me success with my writing. His note was wonderful and it opened my eyes to an aspect of the process that I didn't give much thought to, people were going to buy my book and read it. Obviously, that is the hope, but I just imagined that my mom would buy a copy, maybe my brothers. It was difficult to consider any success beyond that.
It felt strange when I read his email. My friend went online, clicked on a few buttons and just like that, bought a book that I wrote. Everything about that thought freaked me out. I felt very responsible all of the sudden because he spent his money on something that I created. I was overwhelmed by his words, they warmed my heart.
Since that day others have ordered, I get really nice tweets, FaceBook messages and other notes from a lot of you saying how excited you are for the book to arrive. The book even charted in the US and Canada as a pre-order a number of times! It's a great feeling that I wish I could share with each of you. You know what? Maybe I can try...
I didn't exactly grow up in a hot bed of creativity. Back then I didn't feel comfortable sharing my desire to write with most of the people in my life. Only ever speaking of my dream with my friend Mike. Today as I sit here writing to you, I find myself wondering what my parents would have said if I announced that I wanted to be a writer. I think that idea would have been so far outside of the norm that they wouldn't have known what to say. When I was sixteen I began working in my Uncle's sheet metal shop, I was okay at performing the work but each day reminded me that I wasn't where I belonged. The teenage me didn't hold out much hope that he would find any success outside of that factory. I wasn't hopeless but it was very difficult to be hopeful.
A lot has happened since then...
I began writing on this blog almost six years ago and that act saved me when I was lost. Then my salvation unexpectedly become my passion. I finally found a place where I "belonged" and I was writing. If you would have asked me two years ago, I would have told you that all of this couldn't get better - but then it did.
So when you reach out to tell me that you can't wait for my book, it feels like a dream coming true - each time. I'm instantly reminded that I was once a a young man cutting steel who would drift away in his head and envision himself sitting at a keyboard, but he could never imagine a path to getting there.
You guys have saved me twice so far, once from the isolation of type I parenting and again from the disappointment of a dream not realized. I can only hope that I've helped you somehow, because I owe you all a serious debt. Thank you.
#DOCLove
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.
Life Is Short: Book Signing Information
Educators Workshop/Book Signing for, 'Life Is Short, Laundry Is Eternal'
April 18, 2013 - 4:30 to 6:30 - Barnes & Noble - 425 Marketplace Boulevard Hamilton, NJ 08691
This is an educators only event. Chapter reading, discussion on school related topics/504 plans, Q&A session and book signing. Teachers who attend will receive two continuing education credits (NJ) as well as 20% off of all their purchases. RSVP - Get Directions
Book Signing for, 'Life Is Short, Laundry Is Eternal'
April 18, 2013 - 6:30 to 7:30 (or until every book is signed) - Barnes & Noble - 425 Marketplace Boulevard Hamilton, NJ 08691
My very first public book signing! RSVP - Get Directions
More locations are in the works... this page will be updated when we have confirmation.