|Some advice from newly diagnosed Type 1 Diabetics|
July 3, 2007, 4:40:39 am
A few days ago I got back my latest HbA1C results from my doctor. I've been traveling a lot recently - to America, Canada and back to Australia, but in that time I took to studying my insulin and glocuse readings more carefully and figuring out how it all worked.
The HbA1C is a measure of glucose bonding with your red blood cells over a period of 3 months before they break down. It therefore gives you an average of the glucose in your blood over that three month period. It's a very good indicator as to your sugar levels and therefore one important aspect of health. The normal range is between 4.44mmol/L and 6.66mmol/L. The average is 6mmol/L for healthy people.
The average for Type 1 Diabetics in first world countries however is around 10. Unfortunately, recently studies have shown that anything over 6.66 repeating slowly causes damage to your organs as the sugar acts as an internal corrosive agent. I don't mean to sound alarmist, because there's not much the average diabetic can really do to help that.
There are programs around that teach you how to manage your diabetes better - one called DAFNE or "Dose Adjustment For Normal Eating" teaches you how to figure out how many carbohydrates are in the meal in front of you so you can give yourself an appropriate amount of quick acting insulin to counter the carbs you're about to eat. They have a target HbA1C of 7.5mmol/L and most diabetics who go on the course are able to achieve this target.
My HbA1C as of last week is 6.1mmol/L. I never had a chance to learn Dafne - so how did I do it and how can I help other type 1 diabetics out there in the over 20 age bracket who have just been diagnosed.
It's a traumatic time and you find your life is turned up side down. There are some plus sides though - if you're anything like me, before you started getting sick you really never got sick.. not even much of a cold when you were younger right? Right. Turns out that there's a high probability one of the key factors to Type 1 Diabetes is an exceptionally strong immune system - so strong it can attack your body unfortunately.
So something happens, and by 'something' I mean the scientists researching Type 1 Diabetes still don't really know what happens - but something happens and your immune system decides the Beta Islet cells in your pancreas are the enemy. Slowly they attack and destroy these cells until you cannot produce enough insulin to utilize the glucose you consume in your meals. At this point - you will crash and either self-diagnose like I did or end up in the hospital.
Here's hoping you self diagnose. Things to look for: Constantly thirsty, cramps in legs even though you don't think you're dehydrated (you are!), dizziness, tiredness, famished in the mornings, eating lots of fats and sugars, going to the toilet constantly, vision blurring over time, having 'naps' during the day time, urine is not very yellow colour. Go see your doctor - now. I was drinking between 6 and 8 litres of water a day for those who are interested.
I was shocked, because Type 1 Diabetes is also known as Juvenile Diabetes - so how could I possibly have that? some of the symptoms matched Type 2 Diabetes and my diet was crazily bad due to my bodies craving for raw energy foods.. so I was worried I had Type 2.. but this whole ketoacidosis thing where I was dehydrated and drinking lots of water - that means you have Type 1. Not many people realize that the age for Type 1 Diabetes is between young and 30. There are cases over 30 too.
In fact, it's about 50/50 split between young and over 20.. so if you're reading this and puzzled like I was - you must realize that Type 1 Diabetes is a possibility and you should go and see your doctor.
One thing that puzzled me too was the linking of statistics between Type 1 and Type 2 diabetes. They would say things like "10% of Diabetes diagnosis is type 1".. in fact, the rate of Type 1 diabetes hasn't changed throughout recorded history. It's always been a certain percentage of the population - even back when they knew nothing about it. Measuring against Type 2 makes no sense because Type 2 keeps rising. If you look back to literature in the 1980's, they used to say that "20% of Diabetes diagnosis is Type 1".. so there you have it. In 27 years the rate of Type 2 diagnosis has shot through the roof.
But we all know that - lots of money is pouring in to it, this post isn't about Type 2 Diabetes.. perhaps it's worth explaining though that the two diseases are barely related. The word Diabetes means "Sugar Urine" and was the first diagnosis of the condition way-back-when. It wasn't until the 20th century that they figured out there were three main kinds - Type 1, Type 2 and Pregnancy Diabetes. There are a few more kinds too - but those are three that our medical dollars go in to.
Here's some bad news for you newly diagnosed Type 1 Diabetics. You now have a disease that you will manage until they either find a cure or until you die. Here's the good news - modern treatment regimes and research mean you can live to 80+ years of age without complications. And that comes back to why this HbA1C thing matters so much - the complications.
With all this extra sugar roaming around in your body, your organs start to suffer - from ketoacidosis and other complicating factors, your organs shut down or rot away. Your feet will get ulcers, your liver and kidneys will become damaged, your vision will go, you'll be constantly on the verge of a coma and much much more. The list of potential complications is staggering and depressing.
The good news is you need never have to suffer from any of them. If you can keep excess sugars from building up and sitting around in your body - none of those problems will appear. On the crappiest oldest forms of animal insulins people have successfully lived past the age of 70. They used to give out awards to people who lived that long on insulin - now it's par for the course. Hurray for modern science.
And it gets better - we now know a lot more about how the body works and thanks to generic engineering, we have insulins that closely match the way the body produced insulin. There are two main 'modes' of insulin in your body - the basil and the bolus. These are funky scientific/medical terms that basically mean "background dose" and "extra dose".
A normal healthy body will have a constant stream of basil insulin in your blood stream. Then, when your brain decides food is in front of it, in a spectacular display of computational power, it figures out how much bolus insulin to suddenly create and release as you digest the food. It is a dynamic system that works from the initial look at the food, how hungry you are, then the feedback from your stomach and pancreas and other systems in your body.
Insulin is a hormone. Its job is to open up the walls of your blood to allow glucose to pass through and give energy to your body. There is an opposite hormone called Glucogen which causes your liver to release glucose in to your blood stream to counter the insulin if there's too much of it. The two work in harmony to maintain and manage your glucose levels perfectly.
However, now that you have Type 1 Diabetes, your body does not produce insulin - it cannot. So you must inject it in to your body and try to simulate what your body would have done. The most effective way to do that is to have two kinds of insulin - an insulin to simulate the basil background insulin and an insulin to simulate the bolus insulin.
To correctly administer this insulin you must test your blood to see how much glucose you currently have, combine that with the amount of carbs you're about to eat and with your understanding of how your body reacts to the kinds of insulins you're taking and away you go.
Here are some things I had to learn on my own. The amount of insulin you need per grab of carbs is constant. I use 1 unit of insulin per 5 grams of carbs. So a biscuit - 15g's, will take 3 units of rapid acting insulin. A slice of pizza - 20g's will take 4 units of insulin. A meat pie - 40g's of carbs will take 8 units of insulin. The only exception to this is when you intend to eat too many carbs.
If you decide you want to eat two pizza's, for instance, which for me would take around 64 units of insulin (to take an unbelievably extreme example) then before you've had a chance to eat all the pizza, the insulin will be hard at work on the food. So much so that there won't be enough carbs in your system. The glucogen will activate and add more glucose to your body - ruining the perfect linear application of insulin. In short, you cannot inject that much insulin in one go - for this kind of crazy eating frenzy you'd inject some, then some more later, then some more later.. insulin pumps have a mode to do this for you.
So here's the basics - you inject some long acting insulin in the morning, inject some quick acting insulin for breakfast, inject some quick acting insulin for lunch and inject some quick acting insulin for dinner and some long acting insulin for night. Your mileage may vary on the long acting insulin. I'm using Levemir - I take 7 units at the start of the day and 17 at the end of the day.
How I came up with those dosages I'll take about in a bit. The next thing you need to know is how your body reacts to insulin without any carbohydrates. For this you'll want to eat some cheese (non-plastic cheese has very few carbohydrates - you can eat some vegies instead if you want, so long as it's not potato, sweet potato, etc).
For me, if I want to go down 4mmol/L because I'm at 10mmol/L, then I will take 2 units of fact acting insulin. My ratio is 2mmol/L per 1 unit of fact acting insulin. This is very important to know, it's your baseline. Once you have this figured out, you can figure out how you react to carbohydrates. Then you take something like some chocolate - why chocolate? chocolate is very predictable.
One line of cadburies chocolate is around 15g's of carbs (this number of 15g's will keep popping up in your life - it turns out to be the natural 'unit' of carbohydrates for most foods, fruits in particular). You eat that and you give yourself your regular non-carb insulin. Your non-carb insulin is used to cancel out regular insulin alterations. What you're left with is how much insulin you need per gram of carbs. Take the number you get, say you went up from 6mmol/L to 12mmol/L, if you are me - then that means you needed 3 units of insulin which means you need 1 unit of insulin per 5 grabs of carbs.
And the final hard part is to figure out your long acting insulin. There's only one way to do all of this - trial and error, trial and error. Your long acting insulin dosages have no correlation to the fast acting insulin. Given that you now should know how fast your blood glucose rises without insulin (for me, it's about 3mmol/L per hour) you can start off with a small bit of long acting insulin - be exact with your fast acting insulin and carbs through the day - and test at each interval in the day to see how much you were going up or down. If it's too much, your results will be screwed because you will have had to have given yourself glucose or more fast acting insulin to compensate. The goal is to not need to use fast acting insulin to keep your background glucose from rising.
The daytime and nighttime dosages may vary depending on whether you're using Levemir or Lantis or something else. Keep this in mind - when you sleep, your body does -weird things-. Your glucose levels will go up and down based on other hormones and work your body is doing.
So now the next surprise that awaits you - insulin has profiles. What I mean by that is it takes a while to activate and then when it does active, it has a peak activation period. Short acting insulin can take between 5 minutes and 30 minutes depending on the kind (you want the 5-10 minute variety! such as NovoRapid). It will stay active in strength for about 3 hours and die off over the next hour and a half. I use this information to know how I screwed up with my meal.
If I was at 6mmol/L and I eat some pasta and I decide that I need 12 units of insulin (4 lots of 15g's, so I'm guessing the pasta has 60g's of carbs in it) but I hypo 3 hours afterwards, I was 30g's of carbs off. If I hypo two hours afterwards, I was 45g's of carbs off. If I don't hypo until 4 hours afterwards, I was 15g's of carbs off. I dropped from 6mmol/L down 'some amount' based on what I ate because I'm sure my background insulin wasn't slowly making me go up or down over that 4 hour period. From this, I learn and re-estimate next time I eat pasta.
Conversely, after 4 hours, if I'm higher than 6mmol/L, say, I'm at 12 mmol/L then I underestimated my insulin requirements for the pasta meal. Your diabetic dietition can help you learn how to estimate carbs.
The next two things you need to know - exercise and alcohol will screw up these perfectly calculated amounts of insulin. Exercise burns glucose using a different mechanism. If we didn't have insulin, you could probably stay mostly alive by exercising a crap load and having a very low carb diet. The short of it is, you want to deliberately go high with your sugars before you exercise - or take some sugar right before you do exercise, to counteract the effects and not screw up your long acting insulin or the insulin working on the lunch you just ate.
Alcohol, on the other hand, is a double edged sword that will give you a nice kick in the teeth. If you drink an alcohol with very few carbs in it - say - wine, then you don't need any extra insulin. If you drink beer - be aware that a standard glass of beer has around 10g's of carbs in it. But here's the real kicker - because you've drunk alcohol - your liver is busy digesting and filtering out the alcohol. It will not slowly release glucose in to your blood stream - it's too busy, that function shuts down.
What does this mean? It means that your long acting insulin which combats the slow rise of glucose in your blood will cause you to hypo.. and hypo... and hypo.. ALL DAY LONG. So, take this in to account when you're drinking. You need to learn at what point you've drunk too much and your basil insulin will be wrong. Too little and it makes no difference.
Okay, so lets take a scenario. I've just woken up and I'm going to eat a deluxe brekkie roll for breakfast from maccas and my blood glocuse is at 10mmol/L. The long acting overnight insulin has worn off about an hour ago because I slept in. That means I need to do several things:
Okay, so we have a our long acting insulin dosage - 7 units. Nothing changes there, we put that in to our stomach. Next we go and order the maccas. You never, ever take fast acting insulin without a meal in front of you. if it's going to take too long to get the maccas, then we'll need to inject our adjustment insulin now. So let's say it takes too long to get the maccas.. this morning is going to be three needles unfortunately.
Now I know over the next 3-4 hours I'll need 3 units of insulin to counteract my ~5g's of carb rising per hour. I'll also need to fix up my highness and reduce my blood glucose level from 10mmol/L to 6 mmol/L which will require 2 units to use up 4mmol/L. Now I know this isn't exact, so the 5 units I'll be injecting will probably drop me lower than 6mmol/L.. I'll be fine with that since I know there's no way I'll go low enough to hypo. So I inject 5 units right then and there and jump in the car.
I arrive at maccas to eat the monstrosity that they call food. It's got ~50g's of carbs in it. So let's do the math. 50/15*3 is the same as 50/5 which equals 10. I need 10 units of insulin. Okay, slow down - 50/15*3 ? why? . Well, I know that every 15g's of carbs needs 3 units of insulin. The 15g's thing is neat because that's the "natural unit" of carbs you'll find when you drop something in to your hand - a handful of grapes, an apple that fits in your hand, a handful of rice... so on and so forth. So since 15g/3units = 5g/1unit, I only need to take 50g's / 5g's to get 10 units. I inject 10 units and eat the food.
At lunch time, we check again and we should see that we're hovering quite nicely at 6mmol/L. May be we're somewhere between 5mmol/L and 7mmol/L. If we're much more off than that, low for example, then the food calculations were wrong or the adjustment calculations were wrong. Since I'm confident with the food, I'd guess that my adjustment to get back to 6mmol/L were wrong and I'd go from there. If we're high, I'd guess that the food had more carbs in it than they told me.
Okay, that's a rough guide to using long acting insulin + quick acting insulin. Oh - if your doctor puts you on a 30/70 mix - get off it asap - living your life around insulin profiles sucks. Don't do it. Slap your doctor around for being so draconian and be warned that that kind of insulin regime will -not- get you in the normal HbA1C range.
So, if you follow the general jist and be scientific about your insulin intake, you will quickly feel and find your life liberated once more. You can exercise and eat whatever you want whenever you want and have few hypos and end up with a very well managed HbA1C that will be <7.5 and thus not slowly killing you.
There are nitty gritty details that I found out along the way - but a lot of what i've written here about I had to research on my own. Do not expect your diabetes specialist to help you with this stuff like I did - their job is to help the people who cannot manage their diabetes themselves. To them, if you can look after yourself, any safe range (read, <10) they're happy with. They're ultra happy if you're <=8 and if you get <=7.5 they're ecstatic. You don't want to know what they do when you get back in to the normal range *shudder*.
This is your life-altering chronic disease and you must look after it yourself. No one else is going to be able to help you.
Good luck. Drop me a line if this was helpful. And to the newly diagnosed 20 somethings.. it ain't the end of the world, trust me.
By BetterCell on July 3, 2007, 11:45:49 pm
By Rich Demers on July 4, 2007, 8:14:07 pm