When I went through the exercise of carb recording again (described in previous blog entry), I was a little frustrated trying to find quick answers online. So I decided to write my own page to give carb contents of food. Embarking on the exercise, I decided to write a "generic" web page interface to answer questions on any topic, particularly ones that required user input to complete the question. Having this very extensible tool, I was able to add a lot more questions and answers in a very short time, for example carb expenditure for various exercises and so on. All answered on one web page.
I hope you find this link useful: Nutrition Answers
Friday, September 21, 2007
Saturday, September 15, 2007
Moving to an Insulin Pump
This post describes my journey since deciding to go onto an insulin pump. I hope that those of you reading this who are "sitting on the fence" trying to decide whether to commit to an insulin pump will be inspired to take action.
It would be useful to start with a brief history of my insulin experiences but those of you more interested in the pump story, feel free to skip the background.
Background
I was diagnosed with Type 1 diabetes in September 1969, so it is now 38 years that I have been living with the condition. I remember the first regime they put me on was one injection a day (ultralente) - the idea being "let's limit the impact of this unpleasant disease on him". Needless to say, that did not work very successfully although it was pretty hard to gauge one's control. There were no nice digital blood glucose meters in those days - I remember having to rely on Testape to get some indication of my glucose level. Those of you post 1982 may be wondering what Testape is - it was a piece of tape that you dipped in your urine and then tried to compare the color it turned against a chart. Even if you could match the color okay, it still did not tell you what you sugar was at that moment, only what it was roughly sometime in the past.
Anyway, I then moved on to two injections a day which was the norm for that time - a combination of lente and ultralente. Then the Novopen came along (1985) and that was quite a "revolution" in it's time. Suddenly now the idea of mutiple injections a day became the preferred treatment and I embraced it fully, moving on to four injections a day, (Actrapid before each meal and NPH before bed for the basal dose). My control inproved and was what I guess one might call satisfactory. I have always suffered from big swings in sugar levels and frequent hypos but fortunately none that debilitated me or that I could not deal with on my own.
Nothing much changed treatment wise for the next 18 years except perhaps the advent of Humalog which was certainly an improvement over Actrapid/Regular insulin. I would always still try to inject at least fifteen minutes before I ate, something which has been a real bane, especially when eating out at restaurants. Need I say more -:)
The other change was the arrival of Lantus as an alternate basal insulin to NPH (Protophane). I was excited to hear about it as I felt I was not getting a very consistent and 24 hour coverage with Protophane. So I was an early Lantus adopter - in fact I adopted it two years before it became available in Australia (had to source it from the USA and Germany). Lantus definitely improved my control and I would certainly recommend it over previous generation insulins. (I have not tried Levemir but believe it to be similar to Lantus.)
The Decision To Pump
I have always recognized the importance of good diabetes management and have been quite religious about eating well, on time and exercising regularly (I run or cycle every other day).
Despite this, by the end of last year I was becoming increasingly dissatisfied with my control. Very often I would wake up with a reasonable sugar level but by 11 am my sugar would be around 18 (324). This is after a simple breakfast of two slices of toast and a pre breakfast bolus of 10 units. Other days this would not happen, in fact I would sometimes go hypo before lunch. Also, I was waking a few times a week with hypos during the night (the ones we hate). Fortunately I have always woken and been able to deal with it myself - sometimes after much confusion (due to insufficient glucose in the brain). There just was not a consistent enough pattern to be able to make logical insulin dosage adjustments, although I did try. My HBA1C was around 7 (okay) but it was my standard deviation that was getting to me - the big fluctuations in one day.
So I finally made the decision to try the insulin pump. Certainly I was aware of pumps for a few years but always seemed to dismiss the concept quite quickly. The thought of being permanently connected to a device and having to lug it around wherever I went was not appealing. And to have to sleep with it as well... But, I figured, the only way to really know is to try and I could always drop it if I felt it was not improving my control and my life.
Preparing For The Pump
My endo felt that I did not really need the pump as my control was okay (and no complications to date, yeah!), but he was willing to support me in my decision to try it. He explained that I don't just get the pump as soon as my private health fund approved the expense. There is a procedure to follow and I was first to see the diabetes educator and the dietitian at the local hospital. I needed to have my diet reviewed and also to go through the carbo counting education again. What? After 38 years of watching my diet so rigorously?
Well, what a valuable exercise this turned out to be! Not so much to review the carbo contents of food (I was pretty accurate here) but to have two fresh sets of eyes review my diet and insulin doses. The real purpose of this exercise was to work out my carbo to insulin ratio for this is a very important factor to quantify before going on the pump. I had never really paid any attention to this factor before as it was not something taught in my day (or at least in my experience). A couple of things really stood out as non-standard. First, my basal to bolus ratio was odd - 33% basal to 67% bolus. It seems the norm here is roughly 50-50. Secondly, my carbo to insulin ratio was about 5 units per exchange, or 1 unit per 3 grams carbo. Again, this was very unusual as it generally is around 1 unit per 10-15 grams carbo. It was clear that my basal dosage (read Lantus) was too low and this was causing my body to compensate in strange ways. So, with the help of Wendy, the diabetes educator, I started increasing my Lantus at night and reducing my Humalog before each meal. I had tried extra Lantus at night before but getting early morning hypos soon stopped me in my tracks. But this time I persevered through this and after about four weeks of slow adjustments, I increased my Lantus from 16 to 22 units per day and reduced my Humalog from 29 to 22 units per day. At this point, I could not increase my Lantus anymore without consistent early morning hypos. I was now on a 50-50 ratio of basal to bolus. With these changes came much more consistent control. Gone were the crazy high readings in the morning which was an over-reaction of too little basal insulin (pathology I won't go there and don't fully understand it myself). In fact I started having second thoughts about going on the pump. But I now really understood for the first time how important basal insulin is to us Type 1 diabetics and I knew I needed more control over this aspect. That is the real power of the pump in my opinion, for even if the Lantus insulin gave a flat line insulin dose throughout a 24 hour period, this is not necessarily what our bodies require.
Starting The Pump
Finally, four months after I had set the ball in motion, I received my shiny new Minimed Paradigm 522 pump (May 23rd). The first task was to work out my basal profile, ie how much basal insulin do I really require a day and, more specifically, at different times of the day. For those not familiar with insulin pump therapy, the real power it offers is to continuously and automatically dispense minute insulin doses which mimics what a normal pancreas does. Pumps also use short acting insulin only (Humalog, Novolog or Apidra) which is much more predictable in action than insulins like Lantus. Also, you can tell the pump exactly how much to give per half hour period (down to .05 of a unit). I first concentrated on getting the night-time and morning basal rates correct. To accurately know what this is, I would periodically skip breakfast and it's associated bolus (or just have a little protein) and then test every hour to see what was happening to my glucose level. After a few weeks of fiddling I came up with roughly this for my body's basal requirements:
This is still a "work in progress" but currently my total basal dosage is around 24 units per day and my bolus total is around 12 units per day. This means my basal to bolus ratio is now 67% basal to 33% bolus - the exact opposite of what it has been for the last 20 years or so. My carbo to insulin ratio is currently about 1:8 (1 unit per 8 grams of carbo).
There is no doubt that going on the pump initially requires a lot of work to get the profiles and ratios correct and this means frequent blood glucose testing (about 10 times a day).
As for my biggest concern, that is being attached to a device 24 x 7, well it really has not been an issue at all. You get used to it quickly and forget that its there. I have a velcro waist pouch that I sleep with and it works really great - the pump does not get in the way and I can sleep unencumbered and get up in the night without thinking about anything. When I run I simply detach for the 45 minutes or so that I am on the road.
In July I travelled for a month from Australia to the USA and Canada. Dealing with time changes and irregular food/eating times was so much easier.
The Bottom Line
I can go into much more depth about a number of issues related to the pump but this blog is already getting too long so here is the bottom line.
It would be useful to start with a brief history of my insulin experiences but those of you more interested in the pump story, feel free to skip the background.
Background
I was diagnosed with Type 1 diabetes in September 1969, so it is now 38 years that I have been living with the condition. I remember the first regime they put me on was one injection a day (ultralente) - the idea being "let's limit the impact of this unpleasant disease on him". Needless to say, that did not work very successfully although it was pretty hard to gauge one's control. There were no nice digital blood glucose meters in those days - I remember having to rely on Testape to get some indication of my glucose level. Those of you post 1982 may be wondering what Testape is - it was a piece of tape that you dipped in your urine and then tried to compare the color it turned against a chart. Even if you could match the color okay, it still did not tell you what you sugar was at that moment, only what it was roughly sometime in the past.
Anyway, I then moved on to two injections a day which was the norm for that time - a combination of lente and ultralente. Then the Novopen came along (1985) and that was quite a "revolution" in it's time. Suddenly now the idea of mutiple injections a day became the preferred treatment and I embraced it fully, moving on to four injections a day, (Actrapid before each meal and NPH before bed for the basal dose). My control inproved and was what I guess one might call satisfactory. I have always suffered from big swings in sugar levels and frequent hypos but fortunately none that debilitated me or that I could not deal with on my own.
Nothing much changed treatment wise for the next 18 years except perhaps the advent of Humalog which was certainly an improvement over Actrapid/Regular insulin. I would always still try to inject at least fifteen minutes before I ate, something which has been a real bane, especially when eating out at restaurants. Need I say more -:)
The other change was the arrival of Lantus as an alternate basal insulin to NPH (Protophane). I was excited to hear about it as I felt I was not getting a very consistent and 24 hour coverage with Protophane. So I was an early Lantus adopter - in fact I adopted it two years before it became available in Australia (had to source it from the USA and Germany). Lantus definitely improved my control and I would certainly recommend it over previous generation insulins. (I have not tried Levemir but believe it to be similar to Lantus.)
The Decision To Pump
I have always recognized the importance of good diabetes management and have been quite religious about eating well, on time and exercising regularly (I run or cycle every other day).
Despite this, by the end of last year I was becoming increasingly dissatisfied with my control. Very often I would wake up with a reasonable sugar level but by 11 am my sugar would be around 18 (324). This is after a simple breakfast of two slices of toast and a pre breakfast bolus of 10 units. Other days this would not happen, in fact I would sometimes go hypo before lunch. Also, I was waking a few times a week with hypos during the night (the ones we hate). Fortunately I have always woken and been able to deal with it myself - sometimes after much confusion (due to insufficient glucose in the brain). There just was not a consistent enough pattern to be able to make logical insulin dosage adjustments, although I did try. My HBA1C was around 7 (okay) but it was my standard deviation that was getting to me - the big fluctuations in one day.
So I finally made the decision to try the insulin pump. Certainly I was aware of pumps for a few years but always seemed to dismiss the concept quite quickly. The thought of being permanently connected to a device and having to lug it around wherever I went was not appealing. And to have to sleep with it as well... But, I figured, the only way to really know is to try and I could always drop it if I felt it was not improving my control and my life.
Preparing For The Pump
My endo felt that I did not really need the pump as my control was okay (and no complications to date, yeah!), but he was willing to support me in my decision to try it. He explained that I don't just get the pump as soon as my private health fund approved the expense. There is a procedure to follow and I was first to see the diabetes educator and the dietitian at the local hospital. I needed to have my diet reviewed and also to go through the carbo counting education again. What? After 38 years of watching my diet so rigorously?
Well, what a valuable exercise this turned out to be! Not so much to review the carbo contents of food (I was pretty accurate here) but to have two fresh sets of eyes review my diet and insulin doses. The real purpose of this exercise was to work out my carbo to insulin ratio for this is a very important factor to quantify before going on the pump. I had never really paid any attention to this factor before as it was not something taught in my day (or at least in my experience). A couple of things really stood out as non-standard. First, my basal to bolus ratio was odd - 33% basal to 67% bolus. It seems the norm here is roughly 50-50. Secondly, my carbo to insulin ratio was about 5 units per exchange, or 1 unit per 3 grams carbo. Again, this was very unusual as it generally is around 1 unit per 10-15 grams carbo. It was clear that my basal dosage (read Lantus) was too low and this was causing my body to compensate in strange ways. So, with the help of Wendy, the diabetes educator, I started increasing my Lantus at night and reducing my Humalog before each meal. I had tried extra Lantus at night before but getting early morning hypos soon stopped me in my tracks. But this time I persevered through this and after about four weeks of slow adjustments, I increased my Lantus from 16 to 22 units per day and reduced my Humalog from 29 to 22 units per day. At this point, I could not increase my Lantus anymore without consistent early morning hypos. I was now on a 50-50 ratio of basal to bolus. With these changes came much more consistent control. Gone were the crazy high readings in the morning which was an over-reaction of too little basal insulin (pathology I won't go there and don't fully understand it myself). In fact I started having second thoughts about going on the pump. But I now really understood for the first time how important basal insulin is to us Type 1 diabetics and I knew I needed more control over this aspect. That is the real power of the pump in my opinion, for even if the Lantus insulin gave a flat line insulin dose throughout a 24 hour period, this is not necessarily what our bodies require.
Starting The Pump
Finally, four months after I had set the ball in motion, I received my shiny new Minimed Paradigm 522 pump (May 23rd). The first task was to work out my basal profile, ie how much basal insulin do I really require a day and, more specifically, at different times of the day. For those not familiar with insulin pump therapy, the real power it offers is to continuously and automatically dispense minute insulin doses which mimics what a normal pancreas does. Pumps also use short acting insulin only (Humalog, Novolog or Apidra) which is much more predictable in action than insulins like Lantus. Also, you can tell the pump exactly how much to give per half hour period (down to .05 of a unit). I first concentrated on getting the night-time and morning basal rates correct. To accurately know what this is, I would periodically skip breakfast and it's associated bolus (or just have a little protein) and then test every hour to see what was happening to my glucose level. After a few weeks of fiddling I came up with roughly this for my body's basal requirements:
| Time | Units/Hr |
|---|---|
| 12-4 am | 0.75 |
| 4-7 am | 0.8 |
| 7-8 am | 1.1 |
| 8-10 am | 1.25 |
| 10-1 pm | 1.0 |
| 1-7 pm | 1.1 |
| 7-10 pm | 1.3 |
| 10-12 pm | 1.0 |
This is still a "work in progress" but currently my total basal dosage is around 24 units per day and my bolus total is around 12 units per day. This means my basal to bolus ratio is now 67% basal to 33% bolus - the exact opposite of what it has been for the last 20 years or so. My carbo to insulin ratio is currently about 1:8 (1 unit per 8 grams of carbo).
There is no doubt that going on the pump initially requires a lot of work to get the profiles and ratios correct and this means frequent blood glucose testing (about 10 times a day).
As for my biggest concern, that is being attached to a device 24 x 7, well it really has not been an issue at all. You get used to it quickly and forget that its there. I have a velcro waist pouch that I sleep with and it works really great - the pump does not get in the way and I can sleep unencumbered and get up in the night without thinking about anything. When I run I simply detach for the 45 minutes or so that I am on the road.
In July I travelled for a month from Australia to the USA and Canada. Dealing with time changes and irregular food/eating times was so much easier.
The Bottom Line
I can go into much more depth about a number of issues related to the pump but this blog is already getting too long so here is the bottom line.
- My control has definitely improved. My first HBA1C was done a couple of weeks ago (after initial three months on pump) and was 6.6 (last one in February was 7.7). I am still getting a few unexplained readings and post-prandial spikes but far less volatility.
- In the four months since I started the pump, I have only had two hypos during the night. Compare this to roughly three a week before the pump.
- I feel so much more relaxed about when and what I eat. Skipping a meal is no problem as is now getting up late and having brunch at 11 am. Also makes things much more pleasant for the people you live with and around you.
- It is much easier to deal with restaurants and other functions when the meal is spread out - just give little mini boluses by pressing a button or two.
- Being continuously attached to a device is not really a hassle - you quickly adjust and forget its there. My only gripe is that once I am carrying this device all the time, I would like it to also have an integrated phone, MP3 player and glucose monitor -:)
- The pump is GREAT and no one is taking it away from me.
While I recognize that the pump is not suitable for all people, I would strongly recommend you give it serious thought if you are committed to giving yourself the best control. Even if your control does not improve, your lifestyle and freedom may and it's hard to put a price on that.
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