Except for diabetes, of course... that never gives you a day off.
Well almost never.
I was thinking about this the other day, and even tweeted my exasperation and the more-than-usually-fickleness of my diabetes of late.
I had an annual review recently, and since my pump is soon out of warranty I am casting a casual eye over the current crop. I've been very lucky to be able to run sensors with my MM640G more regularly recently and there is no doubt that the semi-automation of SmartGuard helps improve my 'time in range' stats (more on that in another post). But recently, although occasionally Threepio acts autonomously and silently to dodge some hypos, more often than not I am having to use warbling alarms to check that SmartGuard isn't just mangling a carefully judged prebolus timing, or I'm getting a notification of a 'suspend' when I've already set a 0% TBR an hour before to cope with such extreme exertions as 'walking round the corner to the shops'.
I currently seem to be extra sensitive to carbs, very sensitive to 'stacked' insulin (overlapping doses acting together), highly sensitive to any form of activity AT ALL when I have any insulin on board, and generally insulin seems to be delighting in a nothing... nothing... nothing... EVERYTHING activity curve. Or not. Depending on the day.
Without sensors I would have been completely lost.
It reminded me of previous phases in my diabetes life when my diabetes would occasionally give me a week or two off.
Let me explain...
There were times when *all* I had to do was estimate carbs in whatever I was eating and deliver the doseto my insulin:carb ratio alongside my basal pattern (and correction factor). And the doses would work. Reliably. For. A. Whole. Week!!
And if I made a small error of judgement in terms of carbs in a meal I could administer the suggested correction dose... and that would bring me to mid-range within about 3-4 hours.
Bliss!
Of course, there's still quite a lot of effort going on there. Carefully tweaked and tested insulin doses, and dose timings. Meal and activity strategies that have been tested, and food choices that have been tailored to try to reduce the bewildering number of variables that life with type 1 diabetes involves.
But when that effort actually works. For whole days, or a whole week on the trot, it genuinely felt like a holiday.
The carb counting and dosing... the fingersticks and correction factors? For me those are the easy bit. They are absorbed into the rhythm of my life so that I barely notice them any more.
What I DO notice, what I find really tough, is the constant faff of putting in all that effort. Of playing my part as carefully as I can... only to get chaotic and unpredictable results back in return. Constantly feeling like I've got it 'wrong'. That I could (should?) have done better. The silent condemnation of BG readings from doses that didn't absorb properly, misjudged exercise, or insulin requirements that seem to change at the drop of a hat.
The 'that didn't happen yesterday's
The 'what on earth went on there's
If T1D was only a bit more predictable, if it would only stick to its own rules, it would be an awful lot easier to live with.
Happy holidays everyone.
Hi Mike,
ReplyDeleteHave a wonderful summer holiday – what a lovely coastal photo :)
I very much agree about living with the day-to-day variability of Type 1, which can be really frustrating at times.
My day job as a Consultant Anaesthetist involves the precision timing and calculation of drug boluses, using applied physiology and pharmacology, and I’ve come to the realisation (from my personal T1D experience) that our standard T1D bolus dose calculation model is great, but has limits. It doesn’t routinely account for many of the factors causing the variations in insulin sensitivity and effect. Examples include the direction of the BG trend arrow at the time of bolusing, sleep, stress, caffeine, the amount of exercise in the previous 24 hours etc. A lot of these will defy accurate measurement anyway. We simply need to do our best and react appropriately to the variation. There will undoubtedly be a rational explanation in there, but it isn’t always obvious!
So please don’t beat yourself up when you get different results with the same meal and bolus combinations. I do worry that we may be setting patients up to develop ‘diabetes distress’ and burnout if we don’t teach about the inherent variation in the standard bolus calculation model. Many will simply feel that they’ve made a mistake in the carb counting or injection technique, presuming that they haven’t of course.
I think one probably has to live with T1D to genuinely appreciate the variation. I don’t know where I would be now without the CGM either. I would probably be beginning to lose hypo awareness now, or have just accepted running high to minimise hypos, putting myself in line for vascular complications in the years to come.
One thing I’ve found essential for smoothing out the day-to-day ups and downs is simply regular exercise. It really is a ‘magic pill’. I think of the liver as akin to a rechargeable battery, storing glucose instead of electricity. The normal pancreas turbocharges the liver to store glucose after meals, injecting high concentration pulses of insulin directly into the liver’s blood flow in the portal vein. In Type 1 we can’t replicate these high insulin concentrations at the liver. Subcutaneous boluses of even the most rapid acting insulins are absorbed relatively slowly and are then diluted into the whole blood volume before they reach the liver.
Normal physiology with meals is similar to charging a Tesla car at a service station supercharger – it’s really fast. With T1D it’s more like a slow but steady charge over several hours – and meantime a lot of the glucose spills over into the circulation. Muscle is great at mopping it up though :)
Glucose enters muscle cells via GLUT4 gates, and we can make lots more of these through exercise, specifically muscle contraction induced upregulation. I’ve found exercise that uses as many different muscle groups as possible works the best – I use swimming or rowing, but whatever works for you. The upregulation of these GLUT4 gates has been shown to last for up to 36 hours. Muscle can also store glucose for it’s own use later, and regular training increases the local muscle storage capacity too.
Combining pre-bolusing with activity after meals works wonders for time in range. I do think having a CGM with a low alarm is very important to be able to do this safely though.
Thank you again so much for the wonderful blog :)
With very best wishes,
Ian
Hello Mike,
ReplyDeletei totally agree with you. Type 1 Diabetes doesnt gives you or your parents a single day off. As my son Aadam was diagnosed with Type 1 #Diabetes when he was four years old. He has never let his #T1D come in his path. To us he is no less than a #superheroe. As a T1D #parent I would advise you all to help your T1D child to lead a happier, healthier lives by giving them constant encouragement, learn what you can about diabetes, and make sure that your #child eats properly, exercise, and stay on top of his blood sugar control every day. http://bit.ly/2Wyyg8o
Nice post thank you Michael
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