Diabetes Math

Here’s a little math problem for you. Your 13-year-old T1 has been sick with a nasty cold for a couple of days. At 2 AM you wake up to Dexcom alarm and see that your T1’s BG is 275 and trending up. You get up to give her a correction bolus. The pump says you should give 4 units of insulin for correction to bring BG to target of 100. You also notice that there are 17 units of insulin left in the pod. Your T1’s basal rate of insulin is 2 units per hour and you will not be able to change the pod until about 7:30 AM. You have ruled out a site failure, determining that it is working more or less OK. You are able to administer insulin correction via the pump and/or via a shot. How much insulin do you give her? How do you deliver it? For a bonus question, how long will it take you to fall back asleep after you are done?

If you quickly run the numbers in your head, it looks relatively simple. 17 units of insulin in the pod minus 11 units needed to last until 7:30 AM minus 4 units recommended for correction = 2 units left to spare. Administer a 4 unit correction via a pump. Fall back asleep within next 15 minutes.

Nice try. You get an F in diabetes math. If you administer a quick 4-unit correction, you could probably get back to sleep in 15 minutes. However, you will be woken up again very soon because the BG will continue to climb up, the alarms will continue to blare, and you will have to do this all over again. Diabetes math is far more complicated than what it seems.

The remarkable thing about our little math problem is that every bit of information I provided is relevant and changes the equation. So let’s do it together.

Age and sickness are important. Teenage hormones are not kind to T1D and can lead to heightened insulin needs, sometimes unpredictably. Illness also causes BG to go up. Both factors, combined with the fact that due to illness V was sedentary for a couple of days, lead to increased insulin resistance. The pump is not programmed to change its calculations based on these constantly moving targets. It recommends the amount of insulin needed based on preset ratios and estimated active insulin remaining (AKA IOB or Insulin Onboard). So when you see a BG of 275 and trending up, under these circumstances you should think about how much more insulin it’s likely going to take to bring V into a better range. This knowledge only comes with experience and trial and error.

I know from experience that in this scenario 4 units are completely insufficient. I also know from experience that when V’s BG is over 250, insulin resistance kicks in like there’s no tomorrow. And let’s not forget that her illness, hormones and lack of activity are also contributing to insulin resistance. This is time to dose aggressively. Not only will you need to give a much bigger correction, you should also increase basal insulin for a couple of hours. How much? Once again, informed by trial and error data, we need to jack it up to 200%. If you do the math again, you will quickly realize that 17 units left in pump are not enough.

Here is the answer. Give a correction of 7 units via a shot. Not only does it save you insulin in the pod, it delivers it more quickly and bypasses any potential absorption issues with pump site. The extra 3 units over the recommended 4 will account for insulin resistance and for the fact that by the time insulin starts working V’s BG will already be around 300. Then, increase temp basal rate by 100% (to 200% total) for 2.5 hours.  Three hours would be ideal, but there is not enough insulin left in the pod. 4 units for 2.5 hrs, plus 2 units per remaining 3 hrs equals 16 units. V will make it to 7:30 AM with only 1 unit to spare.

Mind you that you do this math in your head at 2 AM because you can do this shit like a boss. Then you go downstairs to get insulin vial and syringe. You go back up and turn on the lights. You are fully awake now, and you better be fully awake because you have to draw the inulin and do the shot. You go back to bed hoping that your math is not off by too much. Experience tells you that in this particular scenario you may not have given enough insulin (believe me!). Forget target BG of 100. Due to illness you haven’t seen it for a few days. Your goal is that 1. BG will start trending down instead of up and 2. at 7 AM V will wake up with BG closer to 200 than 300. But it’s 2 fucking AM and you need to go back to sleep. Which, to answer the bonus question, takes you at least one hour.

When you wake up in the morning, while you may be feeling tired, foggy and grumpy, you are rewarded with an A in diabetes math.

BG peaked at 300 around 3 AM and went down to 182 by 6:45 PM. GOALS MET!

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Unicorn

Unicorn is another important diabetes term of endearment with a couple of meanings. First definition is a BG of 100. Second definition is when the CGM and BG readings match perfectly. Once upon a time we caught an extremely rare double unicorn!

And just because, here is a picture of our dogs wearing a unicorn headband. They were not pleased.

SWAG brag

SWAG is a very important Diabetes term of endearment. It means Scientific Wild Ass Guess and it is used when there is no carb info available and you have to make your best guess.

So, when you take your T1 kiddo for some ice cream that was her promised reward for an outstanding swim meet performance, but then you realize that her BG is not optimal for ice cream…

…you take her anyway because a promise is a promise. And then she orders a milk shake, which is OK because a promise is a promise. So you SWAG the carbs at 100 g. (!) And she needs to give herself a shot because it’s a shit load of insulin and there’s not enough in the pump at the moment. Besides, a shot is more effective because she’s high already.

She does the shot without complaining and enjoys the hell out of her shake. But you still second-guess yourself and wonder if you should have given even more insulin.

Then a couple of hours later you ask her to check BG and BAM 💥

NAILED IT!

Another sleepover story in screencaps

Once upon a time, on a lovely September day, V went to her friend’s house for sleepover. We made sure to put a new Dexcom sensor on a few hrs prior so that it would be working well and give us a peace of mind. V went to a sleepover and everything was perfect and everyone slept soundly and lived happily ever after…

Hahahahahahaha. Right.

Mere couple of hours into the evening, and following some pool time, I get this text

Great. We didn’t pack an extra sensor because it was not supposed to just fall off. No Dexcom, no remote monitoring possible, no easy access to BG data and trends. OK, time for Plan B!

Then it was time to figure out night time strategy. If Dexcom was working, we could rely on it to alert to any issues at night. Alas, no such luxury.

Don’t you love it when you have to ask your 13-year old to wake up at 3 AM to check her BG? I felt that this occasion called for some serious sarcasm.

And back to business…

Seriously, whyyyyyy?

Promptly at 2 AM…

At least things were more or less on track. Luckily no more checks or wake-ups were needed.

When we finally spoke in the morning, it was alright…

The End

This GF part of our life

This is a familiar scene for us: waiting for the doctor. And when you are in the “Buy One Autoimmune Disorder, Get One Free” club, like us, you get to experience this scene more often.

Today was V’s annual GI follow up. Things are OK. The antibodies are still not at normal levels but continuing to trend down. The doctor told us that they may not get to a normal level because adhering to a strict GF diet is hard unless you don’t eat outside of the house and maintain a full GF house. Can’t agree more! We are very careful both at home and outside, but accidental cross contamination happens sometimes. But everything else is looking good, V is not experiencing any other/new/troubling symptoms, so the doctor is not concerned and we are to stay the course. That’s a relief because between endocrinologist, dentist, orthodontist, and allergy and asthma specialist, V has some kind of medical appointment just about every month. We will gladly keep our GI visits to once a year.

Bonus good news: unbeknownst to us, when V got her Celiac panel done last week, they also did her A1C. And it’s pretty darn good, which earned V enthusiastic praise from the GI doc.

Five Years of T1D

5/22/18 marked five years since T1D diagnosis. It’s hard to believe that five years have already done by. In five years, our family turned into T1D (and gluten-free) pros. So this Diaversary was a cause for celebration of living well with and despite T1D and Celiac.

The morning of 5/22/18 started with a breakfast complete with a heart-felt whipped cream message, and V sporting her new awesome T-shirt. Pop quiz: Who can tell me what the T-shirt design means?

V wanted to mark the day by getting a treat from Starbucks. Unfortunately it was thwarted by diabetes…

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The trip had to be postponed until the following morning. But fear not, V got to check off her bucket list wish of showing up to school with a cup of Starbucks in hand.

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Then the following day came V’s quarterly Endocrinology appointment. I was curious about her A1C. Her meter and Dexcom readings were suggesting improvements. I was also curious about some other goals that V was working really hard on. When V’s endocrinologist walked into the exam room, she was practically beaming at us. She was so pleased with everything. As she was gushing praise on V for doing a great job, I tried to peek at the paper in her hand with A1C result scribbled on it. Since I was looking at it sideways and upside down, I decided that I was not seeing it right. I didn’t believe it until the Endo announced it. 6.8! V’s best A1C ever!!!

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Better yet, the Endo was also pleased with the range of V’s numbers, which is a different way of measuring quality of BG rather than only looking at the average. And there has been progress with the other goals V had been working on. In other words, success on all fronts!

The Endo suggested that we really ought to celebrate, and who are we to go against medical advice? A couple of days latter we hit our favorite breakfast joint, where V feasted on amazing gluten-free Cinnamon Roll pancakes. 100% bolus-worthy!

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As V’s Diaversary Fest was wrapping up, we decided to update our T1D and GF family photo, with all four of us wearing our matching amazing T-shirts.

 

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So, FU T1D! Here’s to 5 years of kicking its butt, and may V have her entire lifetime of living well with it!

(P.S. If you still don’t know what the T-shirt means, please guess in comments!)

ROIT1D 3 of 3

Early in the year, I made a commitment to run three half-marathons and fundraise for Riding on Insulin. I wrote about it herehere and here.

On November 12th I fulfilled my racing and fundraising commitments by completing my third half-marathon and reaching my fundraising minimum.

This was one of my favorite races. It was extremely well-organized and the course was absolutely gorgeous. Even though it was mostly downhill, I did not set a PR (Personal Record). Because, well, true to my running hat, I run like the winded. But it meant so much to me to complete it and have my family celebrate with me at the end. This one was for V and for all other T1Ds who live their lives fully and don’t allow diabetes to stop them from doing what they love.

Thank you ROI for providing inspiration for me and our entire family!