Adjusting the Carb Ratio

Looking at Karl's blood-glucose logs yesterday, we discovered that Karl hadn't had low blood sugar once in two weeks, but he'd had high blood-sugar many times. Since insulin is what brings his blood sugar down to normal, being never low but often high means, "too little insulin."

We use what's called "advanced carb counting," meaning that we figure out the grams of carbohydrates in every meal and divide this number by the "carb ratio" to get the number of units of insulin. 

I'm told that Type 1 diabetics whose bodies no longer produce any insulin have a carb ratio of around 8, meaning they get one unit of insulin for every 8 grams of carbohydrate. For Karl, we've been using a carb ratio of 16, meaning that he gets only half a much insulin as the diabetic with no insulin production of his own. This implies that Karl's pancreas is working at half efficiency.

Frequent high readings means that 16 is the wrong number, so we started using 15. The two numbers don't sound very different, but on a typical meal this happens to give Karl an extra half-unit of insulin. We've only been doing this for 24 hours, so the results aren't definitive, but it did exactly what we wanted: his post-meal ("post-prandial") blood sugar was in the 120 range, and his pre-mail blood sugar was in the 80-100 range -- both very good numbers!

It may also turn out that Karl's poor blood-sugar control with higher-carb meals was a simple "not enough insulin" problem.

One thing I've found frustrating in the literature is the weak, hand-waving descriptions of how to adjust insulin dosage. Come on, guys, this is the Age of Science! Is it possible that the problem is that, if you're clear, you might be sued, but if you're incoherent, you'll be left alone? Because basic information is so often mumbled when it needs to be shouted from the rooftops, and this means I haven't found any good "How to adjust your insulin dose" links for this post.

What we do is look at the trends for the last two weeks or more, especially comparing the frequency of lows compared to highs. Lows are scarier than highs, which is reflected in the normal guidelines, where it's considered okay to have several times more highs than lows. If that's not what we're seeing, then our dosage or our technique are not right. 

If your glucose meter comes with adequate software, as the Bayer Contour USB meter does, then you want the averages to be where they should be, the standard deviations to be as small as possible, and the highs and lows to be under control, biased towards modest highs rather than modest lows.

The standard deviation tells you how tight your control is but not whether it's centered around the right value. Getting tighter control, for us, happens when we:

• Reduce the number of carbs eaten
• Calculate the carbohydrates in each meal accurately
• Use the Novopen Junior for its half-unit dosing (insulin pens that only give insulin in one-unit increments are too imprecise)
• Don't cheat in any way.

Having mealtimes at the same time every day doesn't seem to matter for Karl, and if the portion sizes vary, this doesn't matter either if we've figured out the right carb ratio, so long as he doesn't go crazy on the carbs.

Random diabetes tip: The Swiss Miss sugar-free cocoa is sorta thin and unsatisfying, but adding a tablespoon or two of cream into the mix straightens that right up with only 1-2 grams of added carbs. (Avoid their "No Sugar Added" cocoa, since it's full of sugar.)

Leftover Insulin Drops on Injection

Last night at dinner, I noticed a drop of insulin still on the needle after his Novolog injection, and dampness around the injection site. We keep the needle in until a count of eight after the injection, which is supposed to prevent such things.

This time, though, it clearly wasn't effective, and Karl's blood sugar shot up to over 200, meaning that a whole unit had been lost, at least.

We're using the Novopen Junior insulin pen and BD 4mm nano needles and haven't seen this problem before. The instructions for the nano needles say, "Don't pinch the injection site," but Karl wants us to (it's how we were taught to give injections), so we still do. Arguing with an autistic kid is hard work, so we do things Karl's way when it seems okay to do so.

I wonder if the pinch is actually counter-productive with short needles? I wonder if there's a protocol for dealing with a seemingly messed-up injection like this? Estimating the loss seems like a difficult task.

A one-unit corrective dose got him headed in the right direction, though of course these never have the instant effect you'd like.

Fun? With Advanced Carb Counting

The bad thing about diabetes management is that it isn't perfectly simple. The good thing is that, with glucose test strips, you can measure blood sugar any time and find out if things are working, so you never have to be in the dark if you don't want to be.

If you eat the same meals over and over, which is what Karl prefers to do anyway, you can nudge you insulin doses up and down until you hit your targets. The same meal at the same time of day should require the same insulin time after time. This trial-and-error approach means that the theory behind dose calculation doesn't have to be very precise, which is just as well, because it isn't.

We're using what's called "advanced carb counting," which we use like this:

• Add up all the "net carbs" in the meal
• Divide by Karl's "carb factor" (20 for breakfast and lunch, 16 for dinner)
• Adjust if his blood sugar is high or low
• Inject the indicated amount of insulin

What are Net Carbs?


Net carbs, or net carbohydrates, are "the carbs that matter to you." What these are depend on context. What kind of carbs don't matter?

• Fiber doesn't matter, because it's not digestible and doesn't effect blood sugar.
• Sugar alcohols, artificial sweeteners like sorbitol and xylitol, don't matter for people on the Atkins diet (at least, they don't matter for me), but they matter at least some to diabetics.
• "Slow carbs" are in the same boat as sugar alcohols.

What We Do About Fiber

Fiber is technically a carbohydrate, but it's indigestible and has no effect on blood sugar, so if you give insulin for it, you're giving more insulin than you should, which can result in low blood sugars.

We were told to ignore fiber values under 5 grams, but if there were 5 grams or more, to subtract the entire amount of fiber from the total carbohydrates, and use this smaller number.

Why use two rules? Apparently, most people (a) hate subtraction, (b) have hardly any fiber in their diets anyway, and (c) don't much care about an error of up to 4 grams in their calculations. So the "Ignore fiber amounts under 5 grams" rule allows them to skip the subtraction almost all the time, at the expense of accuracy.

I find the five-gram rule more annoying and confusing than the subtraction, and I don't like the inaccuracy it imposes, so I always subtract the fiber.

What We Do About Sugar Alcohols

Most artificially sweetened candies, ice cream, and so on use sugar alcohols as sweeteners. If you're non-diabetic, sugar alcohols are "slow carbs" that metabolize so much more slowly than other carbs that they're almost like proteins or fats as far as low-carb diets are concerned. If you're diabetic, on the other hand, this doesn't seem to work. Being metabolized slowly is good, but it's not enough.

Apparently, different people react differently to sugar alcohols, and some people can count a gram of these as being equivalent to half a gram of ordinary carbs, but for Karl we have to count them at 100%.  This works fine (and it's what our diabetes team told us would happen), though it makes us wonder, "What's the point of using this stuff at all, if diabetic customers have to use as much insulin as with regular sugar?"

Fortunately, some low-sugar foods, like the no-sugar-added Umpqua ice cream that Karl likes, have zero-calorie artificial sweeteners doing most of the heavy lifting, though they also have sugar alcohols, so the total carbs really are a lot lower than with regular ice cream, with a half-cup serving of vanilla weighing in at only 11 net carbs.

What We Do About Slow Carbs

We like Dreamfields Pasta for low-carb meals. Karl isn't interested in pasta, so we haven't seen what effect it has on him. The word on the Web is that the "unavailable" carbs in this stuff aren't as unavailable as all that, and they get digested slowly over a period of hours, which is great for non-diabetic low-carb dieters, but for insulin-dependent diabetics, their mealtime insulin tends to run out of steam before the digestion is done, causing delayed high blood sugar.

Routine Doctor's Visit

Since there isn't a doctor who specializes in diabetes in our area (an endocrinologist), we're seeing our GP, Shawn Foley, for Karl's checkups. We got a thumbs-up, as we knew we would, and Karl had gained a couple of pounds since last time, which is good, since the bout of diabetic ketoacidosis that resulted in his being hospitalized and diagnosed left him thin. And we got a prescription for more test strips per month, since 200 test strips is only 6.7 per day, and we often go above that. (Especially because the school is very good about testing his blood-sugar levels before and after P.E. to ensure that he doesn't exercise his way to low blood sugar and its attendant problems.)

Is Karl's "honeymoon period" lasting? That's the big question. At the hospital, the doctors claimed that his pancreas' ability to produce insulin was a write-off, and it would vanish soon, in a matter of weeks or months (it's been four months now). This would reveal itself through degraded blood-glucose control and increased insulin requirements. Before this week's doctor's visit, I printed out the trend graphs from Karl's Bayer Contour USB blood-glucose meter, and noticed that his blood-sugar was under slightly better control during the most recent 30 days than it was during the previous 30 days, and his insulin requirements are about the same. That's good!

He might have been doing a little better before that, but it's a little unclear because we didn't start taking after-meal blood-sugar readings in the early weeks, so this revealing piece of the puzzle is largely missing. On the whole, it looks like he's holding steady.

This is good, because, for example, if he comes home from school with a blood sugar of 140, it will be down to a more normal 80-90 by dinnertime without corrective insulin. While we want to keep the load on his pancreas down to a minimum, we're glad it's there to fill in the gaps!

We have been adjusting Karl's insulin dosage on our own, which seems to be standard practice these days. The first several times we did it, we bounced it off someone on our diabetes support team, but since they always agreed with us, we kinda stopped. It's always a matter of tweaking doses up or down by half a unit and keeping a watchful eye on happens, and Karl eats the same meals over and over, so this is not rocket science! What works and what doesn't is revealed quickly.

Does Eating Extra Protein Result in High Blood Sugar?

Even though we're using "advanced carb counting" for Karl's meals, the calculations are incomplete. For example, our diabetes educator and many sources of diabetes information point out that protein will digest partly into glucose, and a "big protein meal, like eating a large steak, will cause a rise in blood sugars," but what to do about this? Most sources are strangely silent.

I've read many times that when diabetics deviate from their normal meal plan -- pizza is often mentioned -- they get high blood sugars even when they do everything "right." So it seems to me that we need a method that's better than "advanced carb counting."

Diabetics on very low-carb diets know that their blood sugars rise more after a meal than the small levels of carbs would indicate, and Dr. Bernstein talks about giving insulin for protein in his book, Dr. Bernstein's Diabetes Solution: The Complete Guide to Achieving Normal Blood Sugars (which has been released in a new edition just this month). He doesn't have as much detail as I'd like, because his approach involves eating the same amounts of protein and carbs with every meal, so his description is a little simplified.


There is whole book about this very topic, or at least I think there is: T.A.G.: A Diabetic Food System, by Mary Joan Oexmann, which covers the effect of protein and fat on blood sugar (in addition to carbs), and what to do about it. Like most interesting books, this one is out of print, but I've ordered a used copy and look forward to reading it.




There's a discussion forum for folks using the TAG system, and I'm starting to absorb the info there: http://www.tudiabetes.org/group/tagers.

As I understand it. the T.A.G. system tells you to consider the carbs, protein and fat in a meal. A gram of protein is considered to be equivalent of 0.6 grams of carbs, and a gram of fat is considered to be equivalent of 0.1 grams of carbs.

In a meal with significant amounts of protein or fat, this gives a number much larger than the grams of carbs alone. For example, Karl's current low-carb peanut-butter sandwiches have only 19 grams of net carbs, but the TAG value is 35. If one unit of insulin is the right amount for this sandwich, then, using carb counting, Karl's carb ratio is around 19, but his TAG ratio is around 35. Or something. I need to read the book!

I'm also looking for research on the subject. No doubt the bibliographies in the two books will be helpful.

Do We Count Grams of Protein as Well as Carbs?

Some people count grams of protein as well as carbs, since digestion converts some of the protein into blood sugar. This is normally ignored in insulin calculations, but the standard diabetes diets are low-protein anyway.

Keeping Karl's carbs down means keeping his protein up, so maybe it's worth doing. Dr. Bernstein, who promotes a very low-carb diet, has his patients track their protein consumption.

Our motivation to look into this is that Karl always has chicken nuggets for dinner (sigh), and this is his highest-protein meal of the day, and it's typically followed by high blood sugar, meaning we didn't give him enough insulin. Maybe if we didn't ignore the protein, the math and the results would align better?

I'm looking into this...

Love-Hate Relationship: the Bayer Contour USB Glucose Meter

How does Bayer manage to prevent their Contour USB blood-glucose meter from getting a five-star rating from me? It wasn't easy! It's easy to use and has a lot of good features, including keeping a record of every blood-sugar reading we've ever taken (over 700 so far). It's easy to use, reliable, and rugged. It has a good display, with color and everything -- and it uses scary colors to get your attention for high and low readings! The user interface with the three on-board buttons works just fine. The battery lasts for weeks and recharges quickly from any USB port.

The USB port is a good feature. The Contour USB looks basically like an oversized USB flash drive, so you can plug it directly into a USB port without a cable. And it comes with a cute little wall charger if you don't habitually charge it on your PC, like I do.

But their software has a clumsy and unfinished feel. The built-in clock doesn't know about daylight savings time. The "Glucofacts" software is supposed to run automatically when you plug the unit into your computer's USB port, and it doesn't. The user interface of the software is hard to figure out for such a simple program. Sigh.

But these are minor annoyances. The reports are pretty cool. Here's a trend from the last month (click the chart to enlarge):

Note that the chart says at the bottom left, "Created on Saturday, November 5, 2011," but the chart has data through November 7. The program hasn't noticed that I launched it two days ago and it isn't November 5 anymore! This is the sort of thing that bothers me about this product. The main features work, but the details are sloppy. Come on, Bayer! Get it right!

The green area is within target (70-140 mg/dl), while orange means low and yellow means high. This graph shows, to my eyes at least, that Karl has a few lows and more highs, but the graph is hard to interpret otherwise.

But check this out, a "Standard Day" graph that overlays all the readings onto a single 24-hour chart (click the chart to enlarge):

Wow, look at how Karl's blood sugar rises in the afternoon and evening! Not all the time, but there are essentially no high readings during the morning, but by the time he gets home from school, between 3:30 and 4:00 PM, we start seeing more and more highs. Not only that, but we see fewer lows later in the day.

To us, this implied that either (a) his bedtime Lantus wasn't lasting 24 hours, or (b) he needs a smaller carb ratio for lunch and dinner (that is, more insulin) than he was getting. So we're trying both twice-a-day Lantus and more insulin at lunch and dinner, and we'll see what happens.

So where do I stand with the Bayer Contour USB product? I've tried three meters, and this is my favorite, hands-down. It's worth it for the display and the easy USB data download so I can put the charts together. I've also used the Bayer Contour, which has a lot fewer features (while taking the same Bayer blood glucose test strips and using the same Glucofacts software). I've also tried the LifeScan OneTouch Ultra Mini, which is okay as a meter, but is bigger than the Contour USB and doesn't have the color display or the built-in USB plug, so I was unimpressed.

My verdict? I love the meter and I'm annoyed at the software, but my advice is, "Buy the Contour USB right now!"

And, Bayer? Do us a favor and hire some software engineers who know what "user experience" means.

We got our Contour USB for free at the hospital (suppliers like Bayer really want your lifetime test-strip business, and a free meter is their best chance to get it). If you don't know anyone with a drawer full of these, they're available cheap almost anywhere. Check out the Amazon link below, for instance.

Check the Obvious When Blood-Sugar is High

Karl's been coming home from school with blood-sugar levels higher than we'd like, and we were mystified. What could explain it?

It turned out that, during the period when we were considered changing Karl's carb ratio from 20 to 25, because of occasional morning lows, we'd actually told the school nurse that this was a definite change! So he was getting 3 units of insulin at lunch, when the right dose was 3.5, and that explains his after-school numbers.

Or so we think. A few more days will tell, but we think that's it because his weekend numbers (where we still use 20 carbs per unit) have been better.

So, when in doubt, go back over the basics with everyone involved.

Keeping Carbs Down and the Ultimate PBJ

If it were me with the diabetes, I'd go straight to Dr. Bernstein's super-low-carb diet, since I've been on a low-carb diet since 2008 anyway. The fewer carbs you eat, the less your blood sugar spikes the less insulin you need, and the fewer health issues and complications you have.

Karl isn't me, though, and he has strong food preferences that don't align very well with a super-low-carb diet, so what do we do?

Karl loves peanut-butter sandwiches. Here's how we game the system to get his carbs down without shorting him on calories.

Step 1: More Peanut Butter!


Peanut butter is a low-carb food that's also rich in fats and proteins, meaning that, while it's low-carb, it's high-calorie. Since the game is to reduce Karl's carbs while keeping his calorie intake high (he was painfully thin after his trip to the hospital), peanut butter is exactly the kind of food we want!

In theory, a "serving" of peanut butter is two tablespoons, but you can get three onto a sandwich without having it drip around the edges. We use tablespoon measures to get this right.

Calories: 270
Carbs: 12 g
Fiber carbs: 3 g
Net carbs: 9 g

Step 2: Dinky Little Diet Bread Slices

Using less bread is the obvious way to cut the carbs way down. Our method is to use bread aimed at dieters, which uses small loaves and thin slices to cut the calories and carbs in half.  We've used Orowheat's 40 calorie per slice bread and Sara Lee's 45 calorie per slice bread. Here's the breakdown for two slices of Sara Lee "45 Calories & Delightful 100% Whole Wheat and Honey" bread:

Calories: 90
Carbs: 14 g
Fiber carbs: 5 g
Net carbs: 9 g

We prefer the Orowheat bread. The Sara Lee is okay, except that it often has big holes in it, which I find annoying at bread that costs over $4.00 what (let's face it) amounts to half a loaf!

Step 3. A Dash of Honey

Karl prefers honey on his sandwiches. We started out with a teaspoon (6 grams of carbs), but when we reduced it to half a teaspoon (3 g), he didn't mind.

Calories: 20
Carbs: 3 g

Step 4: Add It All Up

Calories: 380
Carbs: 29 g
Fiber Carbs: 8 g
Net Carbs: 21 g

We base insulin dosage on net carbs (total carbs minus fiber), which is considered to be "advanced carb counting" for some reason. See http://clinical.diabetesjournals.org/content/23/3/120.full for a discussion on the basic flavors of carb counting.

Variations

Karl prefers to have a peanut-butter sandwich as part of every single meal (sigh), unless we're eating out. He takes one to school with him each day to round out the food he buys in the cafeteria. The school has little in the way of low-carb options, and the sandwich is a key to keeping him well-fed at 75 carbs or less per meal.

Because Karl loves peanut-butter sandwiches so much, it pays for us to spend some energy on getting this optimized for him, and, under the circumstances, we think that a 380-calorie entree with only 21 g of net carbs is pretty good!

A peanut-butter sandwich is the gold standard of kids' meals anyway, so there are worse things.

I've tried substituting calorie-free pancake syrup for the honey, which Karl doesn't mind, but since the honey has only 3 g of carbs and he specifically asks for honey, I don't do this as a regular thing. Using jam instead of honey would be fine for anyone but Karl, who doesn't want jam. Just use an amount that matches your goals.

Tiny BD Nano Needles

Karl uses the tiny little 4mm BD Nano Pen Needles (for insulin pens), which are really short and have worked great for us -- no problems at all, and their reputation is that they're safe and painless -- it's hard to get into trouble with a needle so short! We use them for Karl's disposable Lantus pens and for Novolog in his refillable Novopen Junior insulin pen.

For some reason, our doctors started us on the mini (5mm) needles instead, so we had to get a new prescription for the nano needles. I'm told that some people are using even longer pens -- the original pen needles are three times as long as the nano!

The BD Nano page has a link to a rebate form that will let you try the needles for free.

Let's hear it for pain-free injection!