Category: Diabetes-related


Diet Sleuth Main Window

Last Thursday’s lunch

One of the problems in carbohydrate counting is figuring out how many grams of carbohydrate are in any given meal. I explained last week how I weigh my food whenever possible. But to get from that to the number of grams of carbohydrate, protein and fat are in a meal, I use a program called Diet Sleuth. This is a program designed for Mac, though a Windows version is available. There are things that have me screaming at it, but I’d have a much harder time controlling my diabetes without it.

The first figure is the main window, with my lunch for last Wednesday selected. (To enlarge the image, click on it.) Double clicking on a food brings up a window to add the food to a meal, with a variety of

Diet Sleuth Entry Window

Entry window for adding a food not in the database

serving sizes or number of grams. I use grams to enter except for the cherries. Since they are pretty uniform in size and one cherry is one of the portion sizes given, I just fill in the number of cherries (10 in this case) and let the program calculate the grams.

The program comes with a large database of foods, based on the USDA database of nutrients. It also has a number of prepared foods, including frozen dinners, fast foods, and snacks. You can easily add any packaged food with a nutrition label. The second figure shows the window for adding a food, filled in.

You can also add recipes. This is particularly useful when you make a large quantity of something and freeze it in serving-size portions. The cookie recipe shown comes up per cookie, but it’s impossible to make every cookie the same, so I go by grams when I’m actually eating one. The only ingredient not in the

Added recipe for Florentine cookies

Florentine cookies, showing window for adding a recipe.

included food database was the candied orange peel, which I added from the package. (By the way, these cookies store very well in the freezer, and I’ll probably make a larger batch next Christmas when candied orange peel is again available. But I rarely eat more than one at a time.)

Problems? Loss of data when I change versions or upgrade my operating system! This is a real problem with added food items and recipes. (It is also the reason I do not guarantee that the version shown is the latest.) There is also a minor bug that puts the “duplicate” button in the middle of the expanded data entry window instead of at the bottom with the other buttons, but I didn’t even know that one existed until I was trying to capture the windows for this blog.

There is another problem that comes up with using any nutrition database: all fruits of the same kind, for instance, are not equal. Take an apple, for instance. Apples vary enormously in sweetness and carbohydrate content per gram. They also vary a great deal by size, if you want to use the “per apple” option rather than per gram. The sizes given don’t often agree with what’s available in the supermarket. That can be addressed by using grams, but the sweetness cannot. Neither can bones in meat.

All in all I’d recommend it as an excellent meal planning tool. You can even use it to keep track of your weight. Just don’t count on it for saving your recipes!

Meals with Diabetes

It would really be nice just to eat what I want, or even just to eat what was good for me. But when you’re using an insulin pump with carbohydrate counting, things are never that simple.

aspargus being weighed

The scale was tared for the weight of the pan; only the asparagus is weighed. This is only 6 grams of carbohydrate; asparagus is not a high-carbohydrate food.

Carbohydrate counting is a relatively complex way to handle the interplay between food and insulin. The simplest way, which is what the doctors started me on 40 years ago, was a rigid diet (the diabetic exchange diet) and an equally rigid schedule of insulin shots. It worked all right during the honeymoon phase, but few people stick to it, and by 10 years ago it wasn’t working. Even when I tried counting carbohydrates to get a more accurate food intake, the intake being dictated by my doctor, I still had problems. Sometimes I would go into shock at the most unexpected times (including while eating); at other times I would go high for no apparent reason.

It wasn’t until I got an insulin pump that I learned the most important lesson of carbohydrate counting: you adjust your insulin to what you are eating, your measured blood sugar at mealtime, and how your body reacts. Some doctors are still not comfortable with this.

The standard method of carbohydrate counting just counts the grams of carbohydrate in a meal, leaving the fat and protein to themselves except for avoiding too much fat and making sure there is enough protein. This works as long as each meal contains about the same balance of fat, carbohydrate and protein. When this balance varies, it’s better to use a complex formula that includes all three, as all eventually show up as glucose in the blood. One formula I’ve seen is grams of carbohydrate plus half the grams of protein plus one-fourth the grams of fat. I use grams of carbohydrate plus half the grams of protein, unless fat makes up more than 40% of the meal. (Not often.)

But how do you get those grams?

If you’re eating prepared food you read the nutrition label. These are actually available online for many national restaurant chains, though it means going online before you go out to eat, or order it sent. (It may also shock you at the amount of fat present.) If you are eating out other than at a national chain, you have to guess – and check your blood sugar often after eating. If you are cooking with fresh food at home, you need to weigh everything and refer to some kind of list, such as the one put out by the FDA, which has nutritional information for all kinds of foods. (The FDA list is available as an iPhone app, and there are may other food listings of this sort online.) Needless to say, this greatly slows down the process of preparing a meal, which is why I tend to rely rather heavily on frozen meals – reading the nutrition labels before I buy!

As to how to weigh food, the ideal is a gram scale, usually digital and battery-powered. Mine’s almost worn out from use, but it’s an essential part of food preparation for me.

As to getting all those weights into a meal, I use a computer program called Diet Sleuth, though it means running back and forth between the kitchen and the computer room to enter the foods I’m going to eat. Next week I’ll describe how it works.

Weight Gain

“Calories in – calories spent = weight gain.” Sounds simple and rather obvious – conservation of energy, right? But as applied, it makes some rather bad assumptions. And as many will testify, it doesn’t seem to work.

To start with, caloric input is NOT the same as the calories you eat. To some extent this is recognized. Cardboard has calories, but there is no way a human body can use them. While fiber (cellulose or soluble fiber) is often excluded from calorie counts, even digestible calories may not always be digested. The true caloric input is the calories your body is able to turn into glucose and lipids in your blood stream. I suspect that people vary quite a lot in how efficient their digestive systems are, and that may even vary with time for the same person. Certainly variation with time could help explain the “set point” for body weight.

Inefficiency in our digestive system? There are digestible calories in what comes out the other end, and not just in diabetics who lose sugar in the urine. Pigs and dogs scavenge human feces, among other things, if given a chance. It is the difference in calories between what we eat and what comes out that is the important energy input, and there has been very little study of how much that form of energy out might vary.

Then there is energy usage. Certainly exercise, even walking, burns more calories than simply sitting. But it takes energy to keep our body temperature up, our heart beating, our lungs expanding and contracting, and especially to keep those big brains operating. Sitting as quietly as you can in a cool room may burn a good many calories, though I wouldn’t recommend it as a way to lose weight. (It is, however, recognized as one of the reasons people working in the cold may need more calories. If your body is very efficient at all these “housekeeping” tasks (low basal metabolism) you may need fewer calories to maintain constant weight than someone whose basal metabolism is higher.

For that matter, some people may use their bodies in exercising more efficiently than others.

I strongly suspect this is an oversimplification of what seems to be a near-epidemic of excess weight. I certainly wouldn’t argue with the idea that something in our environment (including our food environment) is tinkering with the efficiency of our digestive processes, though I suspect serving size has a lot to do with it. But why don’t we ever consider calories out? It would be simple enough in test animals, if not in humans.

Ever invented a disease?

I did, for my science fiction.

It’s called Kharfun Syndrome, and it plays a large role in the history of the Confederation. It first arose among Humans, for whom it was a flu-like but usually survivable disease. Many children got it, developed immunity, and went on to lead normal lives. But it became endemic in the Human population.

The early symptoms are mild – aches and pains, some muscle twitches – and that was as far as it got with a good functioning immune system. For those whose immune systems could not handle it, the virus gradually attacked the peripheral motor nerves, leading to violent muscle cramps which was followed by paralysis, and eventual death from respiratory paralysis. The peripheral sensory nerves were also involved during the active phase, with pain spreading inward from the fingers and toes.

The Human immune system, which is basically chemical in nature, could handle the virus. I’m not going to go into the full immune system here, and in fact there’s a lot we don’t know about it. But there are times when it goes wrong and attacks something it shouldn’t. Like the Islets of Langerhans in my pancreas (which is why I have type 1 diabetes) or the myelin sheaths of my sister’s nerves (Multiple Sclerosis.) Perhaps because of this the R’il’nai, who have a suite of esper abilities and could actually perceive bacteria and viruses and remove them without even being consciously aware of the process, developed an immune system based on esper, and the old-chemical-based system, while still present, became very inefficient.

The problem with Kharfun was that the virus causing it had evolved an ability to hide from esper perception.

As a result, Kharfun was originally 100% lethal to those whose immune systems relied on esper – all pure R’il’nai, and most of the hybrids with a large fraction of active R’il’nian genes. A method of reactivating the old, chemical-based immune system was developed after the disease spread from Humans to R’il’nai, but by that time a large fraction of the R’il’nai had died.

The disease had another effect on the R’il’nai – it reduced their already low fertility. They didn’t have a high birth rate to start with – R’il’nian females were fertile for a few hours a century. (They were usually receptive, but not fertile.) And the immunization had the same effect as the disease on fertility.

So 10,000 years after the initial epidemic, the R’il’nai are nearly extinct. This was the premise behind Homecoming (where Kharfun Syndrome plays a major role) and the society that led to Tourist Trap and the trilogy I’m working on.

Well, I’ve had a couple of good days. First was the email Thursday that Tourist Trap was a finalist in the Reader Views Literary Awards. Yes, that’s the same one Homecoming received last year.

Then I got a phone call from the clinic saying the box of replacement sets had arrived, and I picked them up Friday, thus ending a very nervous couple of weeks.

Replacement sets?

The other end of that plastic cord feeds into me.

I use an insulin pump. It’s about the size of a small stack of business cards, and it normally lives in my pocket. It contains a reservoir of insulin, which theoretically should be changed every three days. (I normally average about six, because that’s how long a full reservoir lasts me, and I have yet to see any drop in effectiveness after six days at body temperature.) The pump gradually pushes that insulin out very fine tubing a couple of feet long to a set, which is fastened to my body by a piece of adhesive and has a fine Teflon cannula piercing my skin and delivering insulin into the subcutaneous tissue. The set has a needle which is used to insert the cannula under the skin, and is then removed. The set has to be changed every three days – any longer than that in the skin, and scar tissue starts to build up and insulin no longer gets through. These sets are not reusable; in fact they become medical waste.

I’m lucky to have very good supplemental insurance as well as Medicare, and every 3 months I get shipped 30 sets. A couple of weeks ago the shipping company called me to check how many sets I had.

“Two. When are you going to ship them?”

“We did, a couple of weeks ago.”

I have them ship to my doctor’s office, because in my experience mail order pharmacies never adequately package temperature-sensitive medications being shipped to regions where 40-below temperatures are common, and in some shipments I get continuous glucose sensors which must not be frozen. So I called the clinic, which usually calls me when a package arrives for me.

They couldn’t find the box.

By that time the pharmacy was closed, so when I called back the next morning I got the details of the shipment. They insisted it had been signed for at the clinic and gave me the exact time and date of delivery.

I called the clinic back. I think it took about a day before they finally said that yes, they had received the box. The person who signed for it remembered it. So did several staff members. But they couldn’t find it, and they’d looked everywhere. They said they’d call the mail-order pharmacy back and pay for a replacement shipment. (This is stuff no local pharmacy carries.)

The mail order pharmacy said that Medicare rules did not allow them to send out a replacement shipment – never mind that it was the clinic, not me, that verified I had never received the sets that are essential to my life, or that the clinic was willing to pay for the replacement shipment.

The clinic combed the offices of the doctors that treat diabetes, and managed to come up with a few sets to tide me over. They also called the pump (and set) manufacturer. The manufacturer FedExed me a few more sets. Finally, Thursday, the clinic called and said they had the sets from the manufacturer, and I picked them up yesterday.

I realize that Medicare does have a huge fraud problem. But in this case the clinic was offering to pay for the lost shipment, so what kind of fraud did they think was involved? It’s not as if the sets were valuable to anyone else, but they are life or death to me.

There are three ways of approaching less than optimal health: prevention, treatment and cure. All have their strong and weak points; all are political hot cakes at the moment.

I think most individuals and societies would agree that the best solution is to stay in good health. It is also a solution that is not always possible. It is, however, the approach that is responsible for the dramatic drop in childhood death in developed countries.

Prevention measures are generally lumped as public health. Clean drinking water, proper sewage disposal, nutritious food, clean air and immunizations all fall into this category. So do measures intended to reduce accidental injury or death (such as seat belts) and those encouraging a healthier life style. Prevention would also include such highly controversial measures as not passing on genes known to have a deleterious effect on health.

In general prevention measures are good for the population, but affect individual choice. They may also affect the bottom line of corporations with a great influence on public policy, such as the food industry.

Some of what I need for treatment of diabetes. I want a cure!

By treatment I refer to ongoing treatment — the pill (or shot) for everything or treatments such as dialysis which must be repeated regularly for the life of the patient. Certainly it is better to have a treatment than not! I am alive today thanks to insulin. But treatment is generally expensive and is often lifelong. Further, treatment of this sort almost always has undesirable side effects. In my case, insulin can produce hypoglycemia which can kill. It should be noted that some “cures,” such as organ transplants, may then produce a condition in which lifelong treatment (anti-rejection drugs) is needed.

A cure implies a return to normal health. In some cases (such as the common cold) a cure is mainly a matter of time, with supporting treatment to prevent secondary infections or ease symptoms. Some cancers are curable with surgery, especially if caught early. Broken bones or other traumatic injuries can often be cured, especially in the young. A number of conditions, however, have no cure. Research on cures is ongoing, but the profit from a true cure is usually not as great as from lifelong treatment. Given that most health research today is profit-driven, research on cures tends to take a back seat to research on treatments.

I’ll probably return to this in the future, looking at one of the three approaches at a time. For right now, how would you order the importance of the three approaches?

Health

One of the things I blog about is health and health care. Here are links to posts on this topic. This post will be linked from the Index page, and I will add new posts as they go live.

General
A Pain in the Back 8/12/11
Pain Gel 10/1/11
The Cost of Health Care 10/8/22
Cranberry Recipes 11/24/11
Three Approaches to Health Care 1/21/12
Vitamin D 10/4/12

Cancer
Breast Cancer part 1 2/12/11
Breast Cancer Part 2 2/19/11
Breast Cancer 3: Mammograms 2/27/11
Radiation Therapy for Breast Cancer 3/12/11
Chemotherapy and Quilts 8/6/13
A Chemotherapy Fashion Show 8/15/13
Chemo, Hair Loss and Wig 8/22/13
Happy News: CT Scan 9/24/13
A to Z Reflections 5/8/14
Cancer Survivor 6/14/14
More cancer 10/6/14

Diabetes
Insulin Pumps 5/20/10
Cataract Surgery Complications 1/29/11
Diabetes and Blood Sugar 2/5/11
Complications of Diabetes 5/27/11
Diabetes: What’s in a Name 7/15/11
Conversation Piece (fiction) 10/20/11
Measuring Blood Sugar 11/12/11
Your Mileage May Vary 11/26/11
Continuous Glucose Monitors 12/3/11
Award and Medicare 3/3/12
Meals With Diabetes 5/19/12
Diet Sleuth: A Useful Meal Planning Tool 5/26/12

500+ posts is too many for me to keep track of, and quite a few are “reference” posts, such as the ones on planet building or horse coat color genetics. So I’m putting in a new feature, an index page that links to posts linking to the posts on a given topic. (Sound confusing? Try doing it!)

These indexing posts start today (see below) and will appear occasionally until the reference posts are all indexed. After that I’ll just be updating the index posts, which will be accessible from the Index tab above.

With 550 posts as of today, I’ve started to have problems remembering what I’ve already put on here. This is particularly a problem with posting existing content such as poems, short pieces from the Summer Arts Festival, or science explanations originally written for the Alaska Science Forum. I can’t remember which books or DVDs I’ve posted reviews on. It also is starting to be a problem when I want to link to a previous post and can’t remember when it was put up or what the title was. And there are posts on this blog that have permanent information, like the series on planet building and the one on horse color genetics, or the book and DVD reviews. I want to make it easier for my readers as well as myself to find things.

I made a start some time ago by adding an index page, which can be accessed from the menu at the top of any page. Right now, the only links are to index pages on my author site. This takes you out of the site and sometimes back in, which is rather clumsy. The index list is also incomplete.

I’m going to start posting an occasional entry which is strictly an index of past posts on a particular topic. These posts will be linked from the index page, and will link forward to the individual blog posts. As it takes a while to find all the posts that belong together, this will be a slow process—probably extending over the next few months. The first in this series, on DVD reviews, is already queued for January 3. Others will follow, most on Thursdays.

I probably won’t be indexing every post. Some, like those early posts which were simply glossary entries for my books, are on the author site and really belong there. Others, like the regular Monday updates on North Pole weather starting in November 2010, can be found easily enough just by using the calendar on the site. But I hope that by the time I have finished this, older posts of interest will be easier to find.

Continuous Glucose Monitors (CGMs) are a relatively recent development in diabetes control. They are still controversial with many insurance companies, though prevention of even one high-cost ambulance trip to the emergency room should make them cost-effective. But they do have problems.

There are three devices that I am aware of, worldwide, and others in development. The best, according to users, is the Navigator – but it has been withdrawn from the US market. This leaves the Dexcom and the Medtronic sensors. My own experience has been entirely with the Medtronic sensor, but all three work in basically the same way, on interstitial fluid, and all are subject to the same problems of time lag.

Medtronics transmitter (white) and the visible part of the sensor (clear) with a U.S. quarter for scale. I use IV 3000 to hold everything in place.

The sensors available today consist of some kind of reusable transmitter, a receiver, and a disposable needle which injects a small disposable sensor under the skin. The sensor is then connected to the transmitter, which lies against the skin.

The sensors are expensive. The price today at the Medtronic store is $42 a sensor, with an official life of 3 days. (Most people actually manage to use them longer, and in fact I find they are most accurate on days 3-5, though I rarely get one that lasts more than a week.) The big advantage of the Medtronic system is that the Medtronic insulin pump (the kind I have) acts as the receiver, though separate receivers are available. The official life span on the Dexcom sensor is 7 days, though I understand they are correspondingly more expensive. Comments from users of the Dexcom are solicited!

A continuous sensor is extremely useful in that it allows you to see how your blood glucose varies between finger sticks, and also allows you to see whether it is rising, falling or staying reasonably constant. The Medtronic sensor allows you to choose whether to see a 3-hour, a 6-hour, a 12-hour or a 24-hour graph of your blood sugar, or download values about 5 minutes apart to a computer, and I believe the Dexcom sensor is similar. On the negative side, CGM accuracy is highly variable, and it needs regular calibration with a finger-stick meter. There is a further problem (at least with the Medtronic system) with alarms.

I used to eat protein bars for breakfast. They had a good balance of protein, carbohydrate and fat, they took no weighing, and they were consistent day to day. They also produced a considerable spike in blood sugar in the hour after breakfast, easily identified on the CGM graph but missed in finger-stick testing. When I switched to Greek yogurt with fruit, also a good balance of protein and carbohydrate but without the fat, my blood sugar graph leveled out. In fact, the CGM has allowed me to identify many regular meals as causing spikes or delayed rises in blood sugar. (The fat in the bars was not the problem; in fact fat delays the absorption of carbohydrates, but much of the carbohydrate in the bars was fast-absorbing sugars.)

I am not alone in finding trends more useful than absolute numbers. A high blood sugar (within reason) is not really a problem if the blood sugar is decreasing, nor is a moderately low reading with an upward trend. On the other had, a high reading going up or a low reading going lower is cause for immediate finger-stick confirmation and treatment if the reading is confirmed. A low reading at night or if I’m planning to drive is always reason for finger-stick confirmation.

What the sensor actually measures is a slight electrical signal, and this must be calibrated with a finger stick measurement to get the actual blood sugar reading. The calibration constant changes over the life of the sensor, and can drop very fast toward the end of sensor life. Consequently the sensor must be calibrated a minimum of twice a day, preferably when your blood sugar is fairly steady, and may give a lot of false low alarms near the end of its life.

Another problem is that the sensor measures the glucose concentration in the interstitial fluid, that is, the fluid between the cells. While this follows blood glucose, there is a significant time lag. My blood sugar can drop very rapidly, especially during exercise, and as a result CGM measurements during exercise can be much higher than my actual blood sugar. This time lag alone makes me very dubious about using this type of sensor for any closed-loop artificial pancreas.

My biggest complaint with the Medtronic system is the alarms. Ideally, to be most useful the CGM system should wake you up if your blood sugar starts to drop. In fact, the alarm is so low in volume and so high in frequency that I almost never hear it unless I am in a very quiet environment and there is only a layer of cloth between my ears and the pump, not a down comforter. This is partly my hearing, as others will sometimes point out to me that I am beeping. Yes, it does start vibrating eventually if I do not respond, but I feel the vibration only if the pump is tight against my skin. I usually feel it driving (well after I start going low) but often not at night.

Is it worth it? Yes, for me. But it definitely needs some improvements.

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