Karl's recovering from a cold, his first real cold since being hospitalized over a year ago. Man, oh man, did his blood-sugar levels go up! Bedtime readings were above 200 three days in a row.
Illness tends to raise blood-sugar levels in diabetics, and if there's dehydration involved, it gets much worse. Karl doesn't like our tap water, so we made sure the supply of bottled water and sugar-free drinks was unusually ample, using the lure of yumminess to overcome any reluctance brought on by lethargy.
Corrective doses at mealtimes were clearly not enough to bring his blood sugar back to normal, so we started a two-pronged strategy of increasing his long-acting Lantus dosage from 8 units a day to 10, and also added an extra 0.5 units per meal in addition to the calculated value. Both corrections together have gotten him into much better territory.
As things normalize, we'll first abandon the extra 0.5 units per meal and then back the Lantus off to suit. If Karl were to suddenly snap back to normal without warning, we might have to give a couple of small snacks to keep his blood sugar up, but it seems far likelier to me that he'll drift rather than snap back to normal.
I have not reviewed all my diabetes books for corroboration, since it's not rocket science to conclude that "if blood sugars are way too high, give more insulin."
We are also giving plenty of Insulow (alpha lipoic acid), which in some ways mimics the effects of insulin and also tends to reverse some of the damage of high blood sugars. While I suppose it's possible to overdo this, since alpha lipoic acid will lower blood sugars, and this could cause trouble if you're not paying attention, we've never seen any evidence of this. Karl normally gets 200 mg per meal, for 600 mg per day, but in his case giving twice this much has little effect on blood sugars. Apparently it's different for some people.
Karl didn't ask for cold medication. Dr. Bernstein's book paints a scary picture of aspirin, ibuprofen, and similar drugs, which can apparently crater blood sugars unpredictably, and Tylenol, which is hard on the liver if you're dehydrated. Karl's pretty content with sugar-free cough drops as the only treatment.
Tuesday, June 19, 2012
Thursday, May 3, 2012
Dairy Queen for Low-Carb Meals?
Normally, you'd expect a place with as heavy an emphasis on sugar as Dairy Queen to be a non-starter for people like Karl who need to watch their carbohydrates, but they have three different low-carb ice cream bars: my favorite, the vanilla orange bar, with 12 grams of carbs, the fudge bar, with 7 grams, and the no-sugar-added Dilly bar, with 19. So if you're on a low-carb diet, you can have dessert at DQ.
And, oddly enough, they have a very good (and large) grilled chicken salad that's very low in carbs, too.
Not to mention the usual fast-food expedient of bunless burgers, which have very low carbs indeed.
Karl's unwavering preference is for chicken strips, which are higher-carb than the above-mentioned alternatives, and he has a weakness for french fries. Sigh. What this means is that I'm eating a lower-carb diet than he is, though he's diabetic and I'm just losing weight.
But for most meals he eats fewer than 60 grams of carbs, and in our experience it's looks like Dr. Bernstein was right, and eating fewer carbs not only means a Type 1 diabetic needs less insulin, but the blood-sugar levels are more stable.
And Karl has gone from being painfully thin at the time of his illness to putting on weight steadily, so it looks like low-ish carb diets have real promise for weight stabilization. They're not just for weight loss.
See you at DQ!
Monday, April 2, 2012
Basal Insulin: What's the right amount?
The sad thing about doctors is that they aren't engineers, and this is doubly true for lawyers. So when you read about medications, everything's written by people who (a) don't think in terms of getting results out of feedback control systems, though that's what the body's all about, and (b) do think in terms of, "If I say something blatantly wrong, I'll get sued, but if I'm mealy-mouthed, I'm safe." This means that the dosage adjustment (titration) instructions for Karl's long-acting Lantus insulin are vague and simplistic, even by the standards of the intelligent layman: http://www.lantus.com/hcp/titration.aspx. Thanks, health-care industry!
So let's talk about feedback control systems, which is a fancy term for something that everyone already knows a lot about. If you set the cruise control on your car, the car will run at the speed you set, increasing the throttle when you're going uphill, decreasing it when you're going downhill, etc. Going up a really steep hill, you might not have enough horsepower to maintain your speed, so you slow down: "flat out" is all you've got. On a downslope, you might go faster than the speed you selected. So cruise control keeps everything constant under a certain range of conditions, but outside this range, you get what you get.
Karl's pancreas is still making some insulin. The pancreas has a very cool feedback control loop which, like cruise control, puts insulin into Karl's system at the right rate to keep his blood-sugar levels constant, within a certain range. The problem is that his pancreas can't make enough insulin to keep his blood sugar under control under most conditions. His pancreas' accelerator is pressed all the way to the floor and he's still not at cruising speed.
If we get his dosage right, injected insulin acts like a strong tailwind, allowing Karl to get up to speed without making his pancreas run flat-out. To continue the auto analogy, this reduces wear and allows it to cool off, so it will last longer.
Not only that, but by allowing the engine run most of the time at, say, 50% power instead of 100% power, if we get an unexpected hill, we can get over some hills without slowing down, because we have reserve capacity. Turning the analogy back to diabetes, if Karl eats a larger portion than we had calculated, so he receives less insulin than he should, or sneaks a snack without any insulin at all, his body has reserves that will cover it without spiking his blood sugar. Sweet!
Because Karl's pancreas is producing some insulin on its own, he can receive different doses of long-acting insulin and arrive at the same average blood-sugar levels. If he gets a low-ish does, his pancreas will provide more insulin, and if he gets a high-ish does, it will provide less. So within this range, the results will be equivalent -- except to his pancreas!
Since the goal is to keep his pancreas from being overloaded, we're aiming for a dose on the high side of this range. So far, we've determined that a dose of Lantus anywhere between 6 and 8 units per day gives about the same results, and we'll probably test 9 units soon. We're adjusting no more often than once a week, since day-to-day variations are wide enough to obscure the results.
So let's talk about feedback control systems, which is a fancy term for something that everyone already knows a lot about. If you set the cruise control on your car, the car will run at the speed you set, increasing the throttle when you're going uphill, decreasing it when you're going downhill, etc. Going up a really steep hill, you might not have enough horsepower to maintain your speed, so you slow down: "flat out" is all you've got. On a downslope, you might go faster than the speed you selected. So cruise control keeps everything constant under a certain range of conditions, but outside this range, you get what you get.
Karl's pancreas is still making some insulin. The pancreas has a very cool feedback control loop which, like cruise control, puts insulin into Karl's system at the right rate to keep his blood-sugar levels constant, within a certain range. The problem is that his pancreas can't make enough insulin to keep his blood sugar under control under most conditions. His pancreas' accelerator is pressed all the way to the floor and he's still not at cruising speed.
If we get his dosage right, injected insulin acts like a strong tailwind, allowing Karl to get up to speed without making his pancreas run flat-out. To continue the auto analogy, this reduces wear and allows it to cool off, so it will last longer.
Not only that, but by allowing the engine run most of the time at, say, 50% power instead of 100% power, if we get an unexpected hill, we can get over some hills without slowing down, because we have reserve capacity. Turning the analogy back to diabetes, if Karl eats a larger portion than we had calculated, so he receives less insulin than he should, or sneaks a snack without any insulin at all, his body has reserves that will cover it without spiking his blood sugar. Sweet!
Because Karl's pancreas is producing some insulin on its own, he can receive different doses of long-acting insulin and arrive at the same average blood-sugar levels. If he gets a low-ish does, his pancreas will provide more insulin, and if he gets a high-ish does, it will provide less. So within this range, the results will be equivalent -- except to his pancreas!
Since the goal is to keep his pancreas from being overloaded, we're aiming for a dose on the high side of this range. So far, we've determined that a dose of Lantus anywhere between 6 and 8 units per day gives about the same results, and we'll probably test 9 units soon. We're adjusting no more often than once a week, since day-to-day variations are wide enough to obscure the results.
Sunday, March 25, 2012
Holding Steady
Eight months after being diagnosed with diabetes, Karl's holding steady, and, if anything, his blood glucose numbers are getting better.
We partly attribute this to our policy of adjusting his dose of long-acting Lantus insulin from time to time, with a rule of thumb, "If two doses give about the same results, give him the higher one, to take some of the load off his pancreas." The less hard his pancreas has to work, the longer it lasts (our goal is "forever"), and the more it can take up the slack if Karl has more cabs than expected. He was down as low as six units, we're at seven now, and we'll likely inch it back up to eight.
Because Karl's autism means that he likes his routine, he's settled into both a dietary and a daily medical routine very well. Because he doesn't pine for treats or change his mind about what he wants for dinner based on what's going on around him, it's very easy to stick with things that work. He's even very good-natured about going into Dairy Queen and getting one or two of their low-carb ice cream bars (the only things in the store that don't have inconceivable levels of sugar).
Everything would be golden if my employer, Citrix, hadn't shifted from an excellent Blue Cross health-insurance plan to a ghastly Cigna one. I'm thinking I'm going to have to buy supplemental insurance to maintain a decent level of care.
Here's Karl's blood sugar graph from the last month:
We partly attribute this to our policy of adjusting his dose of long-acting Lantus insulin from time to time, with a rule of thumb, "If two doses give about the same results, give him the higher one, to take some of the load off his pancreas." The less hard his pancreas has to work, the longer it lasts (our goal is "forever"), and the more it can take up the slack if Karl has more cabs than expected. He was down as low as six units, we're at seven now, and we'll likely inch it back up to eight.
Because Karl's autism means that he likes his routine, he's settled into both a dietary and a daily medical routine very well. Because he doesn't pine for treats or change his mind about what he wants for dinner based on what's going on around him, it's very easy to stick with things that work. He's even very good-natured about going into Dairy Queen and getting one or two of their low-carb ice cream bars (the only things in the store that don't have inconceivable levels of sugar).
Everything would be golden if my employer, Citrix, hadn't shifted from an excellent Blue Cross health-insurance plan to a ghastly Cigna one. I'm thinking I'm going to have to buy supplemental insurance to maintain a decent level of care.
Here's Karl's blood sugar graph from the last month:
Monday, March 12, 2012
Karl at the Prom
Karl had a good time at the Special Ed Prom, though as usual he wore his headphones to cut down on the loud music. The local paper used a photo of Karl, so he's famous again.
On the diabetes front, he's relentlessly sticking to his routine and to his accustomed diet (peanut butter and honey sandwiches on reduced-calorie bread for every meal, and chicken nuggets for every meal but breakfast). We'd like him to have more variety! This keeps his carbs down, though.
He's starting to look forward to Atkins shakes as a snack, and since these have practically no carbs, they're something he can have without insulin. Most of the other no-carb foods (cheese, hot dogs, meat, etc.) he doesn't like until they're made into something like pizza, which sorta defeats the purpose!
On the diabetes front, he's relentlessly sticking to his routine and to his accustomed diet (peanut butter and honey sandwiches on reduced-calorie bread for every meal, and chicken nuggets for every meal but breakfast). We'd like him to have more variety! This keeps his carbs down, though.
He's starting to look forward to Atkins shakes as a snack, and since these have practically no carbs, they're something he can have without insulin. Most of the other no-carb foods (cheese, hot dogs, meat, etc.) he doesn't like until they're made into something like pizza, which sorta defeats the purpose!
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