The relationship between people and food is complex enough to begin with, and it can be a little overwhelming if you're diabetic. In this post, after giving an overview of type one diabetes mellitus, I'm going to talk a little bit about the additional complexities that diabetics have with food.
A non-diabetic person has a working endocrine system that responds to natural increases in blood sugar levels by having portions of the pancreas produce insulin, which causes muscles and especially the liver to store the sugar. The liver acts as a buffer or gas tank; when you eat, it is like putting fuel in your body. The hormone glucagon has the opposite effect of insulin. Glucagon causes the liver to release sugar into the blood. A normal person always has trace amounts of glucagon or insulin in his/her blood. There is a good graph at Wikipedia that illustrates how insulin levels in a normal person's body react to sugar levels caused by eating and activity.
Keeping the blood sugar level below a particular value is important for many reasons that I do not fully understand. When the blood sugar goes too high, above about twice the normal value, the kidneys are overworked from removing all the sugar, and kidney damage can result. There are additional problems with blood vessels being weakened by high blood sugar. Keeping the blood sugar above a certain value is important because otherwise your cells would starve (leading to death). The combination of insulin, glucagon, intaking food, and the energy stored in your liver are all critical to keeping the blood sugar levels at a normal value.
A person with insulin-dependent diabetes mellitus (IDDM or type one diabetes) lacks the ability to produce sufficient insulin. A T1 (I will use this as short-hand for a type one diabetic, and it also makes me sound like a terminator) has the problem that his/her blood sugar would naturally go too high after meals, which can (over a period of years) cause kidney and blood vessel damage. T1s have the short-term problem that their energy reserves are too low. If a T1 performs vigorous physical activity and doesn't eat, the blood sugar will plummet, causing problems.
The way T1s normally solve these problems is by injecting insulin. There are two types of insulin: long-acting (basal) and short-acting (bolus). Long-acting insulin works over a period of roughly 18 to 24 hours, counteracting the "background" stream of sugar from the liver. Long-acting insulin is normally taken once or twice a day; in the Netherlands, doctors only prescribe it before sleep, though in America the dose is usually split between the morning and the night.
Short-acting insulin is taken at the same time as food. The short-acting insulin works over a period of roughly 4 hours. The amount of short-acting insulin I take is related to the amount of carbohydrates (sugars) in the food I eat. Right now I use about 4 units of insulin when I have less than 100 grams of carbs at a meal, 5 units when I have 100 - 110 g, and 6 units when I have above 110 g of carbs (I don't eat more than 110 g of carbs at a meal). This amount of insulin will increase over time, as my pancreas shuts down. Right now my body appears to produce enough insulin to cover about 60 grams of carbs; I need to inject insulin to make up the difference.
Unfortunately there are two big drawbacks to using the short-acting insulin. The first drawback is that the "response curve" of the insulin is set. The sugars in different foods take different amounts of time to absorb, but how and when the insulin acts is not variable. For example, when a T1 drinks 100 grams of caramelized dextrose, which the human body digests very efficiently, the blood sugar increases quickly and rapidly. In comparison, if I drink about 130 grams high-fructose corn syrup (which contains about 100 grams of sugar), my blood sugar would take about twice as long to rise. This is because the human body is less efficient at processing fructose than dextrose. How quickly a food is absorbed is known as the glycemic index, though this varies from person to person. The long and short of this is that foods with easily absorbed sugars (high glycemic index foods) will cause spikes in my blood sugar, which are bad. This is actually true for people in general; the South Beach Diet is a diet that partially focuses on eating low glycemic index foods, causing a lower variation in blood sugar. This type of diet is supposed to be better for you (you can also use it to lose weight, but that isn't the primary purpose of that diet).
Anyways, the important point is that if I'm not exercising (a different post entirely), then my doctor recommends eating food with a lower glycemic index, and eating it slowly. Foods that seem similar actually act very differently. Cherries have a lower index than raisins. Prunes are better for me than dates. Grapefruit is better than pineapple (but this is definitely only true from a glycemic index standpoint; in every other way, fresh pineapple is vastly superior to grapefruit). Anything made with processed, white flour is absorbed very quickly, so things like pancakes will cause spiky blood sugar.
The other drawback to the short-acting insulin is that there can be absorption problems long-term. Scar tissue builds up if a particular site is stressed repeatedly, and if a pocket of insulin isn't absorbed because of scar tissue, and the insulin is released quickly, a sudden drop in blood sugar can occur. Scar tissue is prevented by rotating injection sites; I use half of my body for a month, and then switch. During the month I also rotate within the site itself. I prefer to use the tops of my thighs in the mornings and the evenings, since the large surface area makes site rotation easy. However, it is a bit inconvenient at work, so I normally use my belly at work. Massaging the area before the injection (increases blood flow) helps a little bit, but massaging afterwards seems to cause bruising. Insulin can and does leak if the needle isn't held in the site; I normally count to 10 after injection.
Long-term, lowering the intake of insulin also prevents scar tissue problems. I am trying to eat a low-carb diet by using the Idaho Plate Method. In this method, you split your main plate into a half and two quarters; low-starch veggies occupy half, starch-heavy grains and veggies occupy a quarter, and protein sources occupy the other quarter. One piece of fruit can accompany a meal. The food has been a bigger adjustment than the shots or finger pokes. I ate a lot of pasta before learning I was T1, and right now if I tried to eat a meal with 250 grams of pasta and 500 ml of orange juice (both huge sources of carbs)...well, let's just say a meal like this is a bad idea at this moment. I could eat such a meal if I wanted to, but I'd need about two or three times as much insulin as a much healthier meal.
You'll notice there is no "dessert." Fruit is dessert right now. Sometimes I'll have a square of very dark chocolate with a meal or before I exercise, but right now I'm adjusting to eating less sugar. It isn't easy, but it reduces the amount of insulin I require and is going to be better for me long term.
Well, this post turned out a bit longer than I expected, but I hope it clears up how diabetics view food. We care more about the amount of sugar and how it is absorbed, in addition to the standard concerns about vitamin content and caloric content. All in all, the forced examination of my diet has turned out to be a pretty good thing. It wasn't a great idea to be eating a meal that was 300 g of spaghetti with 500 ml of orange juice as my primary source of energy.
In the next few posts I'll probably cover differences in vitamin sources from America to Europe (you'll be surprised, trust me), along with how diabetics approach exercise.
Showing posts with label blood glucose. Show all posts
Showing posts with label blood glucose. Show all posts
2011-02-01
2011-01-15
The Design of Everyday Diabetic Things
I figured I'd talk a little bit of the design of things used to treat insulin-dependent diabetes mellitus (IDDM). The equipment features interesting trade-offs between ease-of-use, safety, cost, effectiveness and comfort. There are two main sets of tools: one for checking glucose and one for injecting insulin.
The Glucose Meter
There are many different glucose meters, but I use a Bayer Contour, because that's what the doctors suggested. The meter requires a disposable strip every time I want to check my blood sugar. I insert the strip into the meter, and then hold a drop of blood to the test strip intake.
The gadget is the meter, the plastic container (above the gadget) holds the test strips, the lancer is used to prick fingers (I guess they didn't want to call it a finger pricker for whatever reaon), the mesh compartment holds microlets (finger prickers), and I have some alcohol swabs in the little compartment.
The meter with a test strip inserted. In order to get a reading I have to hold a drop of blood to the little chamber at the bottom of the strip.
What the meter looks like after a reading. I'm using mmol/L, not mg/dl, which is why the reading is so low. A person with blood glucose levels of 5 mg/dl would be in a coma.
The lancing device (finger pricker) with the cap off, along with an uncapped microlet and a capped microlet. You have to twist the cap off the microlet in order to use it; if a child swallows a capped microlet, the plastic is strong enough that the cap shouldn't come off. I think. I'm not really sure, and I'm not planning on running tests, but if you know a child who would be interested in swallowing one, please feel free to contact me.
The amount the microlet penetrates into your skin is adjustable via screwing the cap on the lancing device. Diabetics who prick their fingers a lot develop callouses, so depending on the thickness of the skin, the needle may need to penetrate farther.
I had initially thought the meter was really nice. They're really inexpensive, have some fancy features like alerts, and it is very easy to use. However, much like printers being cheap and ink being expensive, the meter is cheap but the microlets and test strips are very expensive. The microlets and strips cost about a dollar a piece, and IDDM people are supposed to check their blood sugar at least four times a day. You're also supposed to change the microlet (the needle used to prick your finger), as the microlet gets worn after use. In practice most type 1s I know only change the microlet once per day. Anyways, the $20 meter consumes over $1,000 of test strips per year (my insurance covers the use of about 1,600 test strips per year). Right now I'm checking my blood glucose levels about 7 or 8 times a day, since I'm still getting used to everything, but eventually it should go down to four or five times a day. If my insurance didn't cover the strips, I'd almost certainly use a meter with a strip disk, since they'd be cheaper long term.
Overall I'm pretty happy with the meter. It is a little bulky, so I'll probably pick up a smaller one that I could carry with me, but the fact that it was free and the strips are mostly covered by my insurance makes me happy.
Insulin pens
Once per morning and before every meal I have to give myself insulin. There are two types of insulin I use. Lantus, which acts very slowly over the course of about 20 to 24 hours, is called a basal insulin. I use Lantus once per day in the morning, though eventually I'll probably have to split it into a day and night dose. Apidra, which acts very quickly, is called a bolus insulin. I take Apidra before meals; the exact dose depends on the carbs in my meal, my current blood sugar, and the amount of sugar I expect to burn. The location of injection has an important role in how fast my body absorbs the insulin. Injecting in the thighs makes absorption quite slow, while the belly area absorbs quickly. I normally use my thighs for the slow-acting, and my belly for the fast acting. I have to rotate the exact site location, or else scar tissue builds up which can make absorption difficult.
The biggest danger with the pens is that I accidentally confuse the two types of insulin. While the pens are visually distinct, with different colors, I actually wish they were physically distinct --- in other words, the Lantus pen was larger than the Apidra pen. I'm not too worried about confusing the two, since I keep them in different spots, but it would be nice if they were more difficult to confuse.
I have my two pens with two sealed needles on the kitchen table. The pens are disposable; after the pen runs out of insulin, I throw them away. Before use, the pens have to be stored in a fridge. After use, the pens are good for 28 days. I write the date the pens expire after the first use, so I can easily track when I'm supposed to throw them away. The pens are small enough to fit in my pocket.
This is the dial on one of my pens. I choose the number of units to inject by rotating the dial.
This is where the needle screws onto the pen top, with the number of units of insulin units left in the pen displayed.
This is the needle after the seal is taken off. There are screw threads on the inside that screw onto the top of the pen. The needle is inside the plastic container, so it is quite difficult to prick your finger with this. If the needle falls, it won't jab anything.
The needle has two caps, an outer and an inner. The inner cap is color-coded to the size of the needle. Different injection sites require different needle sizes.
A 8mm and a 4mm needle attached to the pens. Before injection, two units are supposed to be "burned," or injected into garbage. Burning the units insures that no air is in the needle. My Apidra pen always has a small amount of pressure, which is why there is a drop of insulin on the end.
I think the pens have a phenomenal design. First of all, the screw cap allows the use of different needles. This is important because, as I previously mentioned, different sites require different needle sizes, and because the needle wears after use, a new needle is required every time. The screw cap doubles as a safety measure; you have to push and screw the needle at the same time to get the cap on, which kid-proofs the pen to a large extent. With a child, the real danger isn't that a kid plays with the needle; the real danger would be a kid injecting themselves with insulin. The screw dial also kid-proofs the pen to a certain extent. An additional feature is that as you inject, the screw dial resets to zero. This means that the default state of the pen is going to be to inject no insulin.
The injections are almost pain free. Insulin injections are subcutaneous, compared to vaccinations which can require injecting into a muscle. I barely notice them afterwards, which has contributed to how quickly I've gotten used to them. The needles and pens, while expensive, are also (almost completely) covered by my insurance.
As I stated earlier, the devices feature some interesting trade-offs. Overall, I've been very impressed by how little pain I've experienced. While I still wouldn't wish IDDM on anyone, it isn't as difficult to deal with as I had initially envisioned. However, my pancreas is still working at some fraction of capacity, so I'll have to wait and see if I think the devices are effective enough when my pancreas produces no insulin.
The Glucose Meter
There are many different glucose meters, but I use a Bayer Contour, because that's what the doctors suggested. The meter requires a disposable strip every time I want to check my blood sugar. I insert the strip into the meter, and then hold a drop of blood to the test strip intake.
The gadget is the meter, the plastic container (above the gadget) holds the test strips, the lancer is used to prick fingers (I guess they didn't want to call it a finger pricker for whatever reaon), the mesh compartment holds microlets (finger prickers), and I have some alcohol swabs in the little compartment.
The meter with a test strip inserted. In order to get a reading I have to hold a drop of blood to the little chamber at the bottom of the strip.
What the meter looks like after a reading. I'm using mmol/L, not mg/dl, which is why the reading is so low. A person with blood glucose levels of 5 mg/dl would be in a coma.
The lancing device (finger pricker) with the cap off, along with an uncapped microlet and a capped microlet. You have to twist the cap off the microlet in order to use it; if a child swallows a capped microlet, the plastic is strong enough that the cap shouldn't come off. I think. I'm not really sure, and I'm not planning on running tests, but if you know a child who would be interested in swallowing one, please feel free to contact me.
The amount the microlet penetrates into your skin is adjustable via screwing the cap on the lancing device. Diabetics who prick their fingers a lot develop callouses, so depending on the thickness of the skin, the needle may need to penetrate farther.I had initially thought the meter was really nice. They're really inexpensive, have some fancy features like alerts, and it is very easy to use. However, much like printers being cheap and ink being expensive, the meter is cheap but the microlets and test strips are very expensive. The microlets and strips cost about a dollar a piece, and IDDM people are supposed to check their blood sugar at least four times a day. You're also supposed to change the microlet (the needle used to prick your finger), as the microlet gets worn after use. In practice most type 1s I know only change the microlet once per day. Anyways, the $20 meter consumes over $1,000 of test strips per year (my insurance covers the use of about 1,600 test strips per year). Right now I'm checking my blood glucose levels about 7 or 8 times a day, since I'm still getting used to everything, but eventually it should go down to four or five times a day. If my insurance didn't cover the strips, I'd almost certainly use a meter with a strip disk, since they'd be cheaper long term.
Overall I'm pretty happy with the meter. It is a little bulky, so I'll probably pick up a smaller one that I could carry with me, but the fact that it was free and the strips are mostly covered by my insurance makes me happy.
Insulin pens
Once per morning and before every meal I have to give myself insulin. There are two types of insulin I use. Lantus, which acts very slowly over the course of about 20 to 24 hours, is called a basal insulin. I use Lantus once per day in the morning, though eventually I'll probably have to split it into a day and night dose. Apidra, which acts very quickly, is called a bolus insulin. I take Apidra before meals; the exact dose depends on the carbs in my meal, my current blood sugar, and the amount of sugar I expect to burn. The location of injection has an important role in how fast my body absorbs the insulin. Injecting in the thighs makes absorption quite slow, while the belly area absorbs quickly. I normally use my thighs for the slow-acting, and my belly for the fast acting. I have to rotate the exact site location, or else scar tissue builds up which can make absorption difficult.
The biggest danger with the pens is that I accidentally confuse the two types of insulin. While the pens are visually distinct, with different colors, I actually wish they were physically distinct --- in other words, the Lantus pen was larger than the Apidra pen. I'm not too worried about confusing the two, since I keep them in different spots, but it would be nice if they were more difficult to confuse.
I have my two pens with two sealed needles on the kitchen table. The pens are disposable; after the pen runs out of insulin, I throw them away. Before use, the pens have to be stored in a fridge. After use, the pens are good for 28 days. I write the date the pens expire after the first use, so I can easily track when I'm supposed to throw them away. The pens are small enough to fit in my pocket.
This is the dial on one of my pens. I choose the number of units to inject by rotating the dial.
This is where the needle screws onto the pen top, with the number of units of insulin units left in the pen displayed.
This is the needle after the seal is taken off. There are screw threads on the inside that screw onto the top of the pen. The needle is inside the plastic container, so it is quite difficult to prick your finger with this. If the needle falls, it won't jab anything.
The needle has two caps, an outer and an inner. The inner cap is color-coded to the size of the needle. Different injection sites require different needle sizes.
A 8mm and a 4mm needle attached to the pens. Before injection, two units are supposed to be "burned," or injected into garbage. Burning the units insures that no air is in the needle. My Apidra pen always has a small amount of pressure, which is why there is a drop of insulin on the end.I think the pens have a phenomenal design. First of all, the screw cap allows the use of different needles. This is important because, as I previously mentioned, different sites require different needle sizes, and because the needle wears after use, a new needle is required every time. The screw cap doubles as a safety measure; you have to push and screw the needle at the same time to get the cap on, which kid-proofs the pen to a large extent. With a child, the real danger isn't that a kid plays with the needle; the real danger would be a kid injecting themselves with insulin. The screw dial also kid-proofs the pen to a certain extent. An additional feature is that as you inject, the screw dial resets to zero. This means that the default state of the pen is going to be to inject no insulin.
The injections are almost pain free. Insulin injections are subcutaneous, compared to vaccinations which can require injecting into a muscle. I barely notice them afterwards, which has contributed to how quickly I've gotten used to them. The needles and pens, while expensive, are also (almost completely) covered by my insurance.
As I stated earlier, the devices feature some interesting trade-offs. Overall, I've been very impressed by how little pain I've experienced. While I still wouldn't wish IDDM on anyone, it isn't as difficult to deal with as I had initially envisioned. However, my pancreas is still working at some fraction of capacity, so I'll have to wait and see if I think the devices are effective enough when my pancreas produces no insulin.
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