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.

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.

Battery Woes

My computer screen lit up with a message Tuesday morning. Your Bluetooth mouse could quit at any time — change the batteries. Fine – I’ve finally figured out how to change the mouse batteries with the computer on, though it does require attaching my old USB mouse to re-connect to the Bluetooth mouse with fresh batteries. (If there’s a keyboard command for find Bluetooth mouse I haven’t found it.) The problem is that I had changed the mouse batteries the day before.

I use rechargeables, and I try to keep some plugged in and charging all the time. Now rechargeable batteries eventually reach the point where they won’t hold a charge, and I think mine have reached that point. I checked them out on the battery tester. The two I took out of the mouse, which just came off the charger yesterday, tested as weak, and I added them to the sack of dead batteries. (I’m not sure dead batteries are actually recycled locally, but I do turn them in separately to try to keep them out of the landfill.) Guess I’d better put rechargeable batteries on my shopping list; I’m going to have problems the next time the keyboard needs batteries. (It takes three.)

Battery tester–good, fresh battery, but my insulin pump won’t accept it.

That was not my only battery problem recently. My insulin pump runs on one AAA battery. This powers not only the pump itself, but also the backlight, the warning beeps and the vibrator if I don’t respond to the beeps, which I generally don’t hear. The manufacturer recommends non-rechargeable alkaline Energizers, simply because the pump is programmed to respond to their power loss curve as they slowly wear out, in order to give me a timely warning. Because I go through so many and have to have them on hand, I purchased a couple of large packages recently. (I didn’t need a twenty-pack and a twenty-four-pack, but I put the twenty-four pack away and then couldn’t find it until after I bought the twenty-pack.) Both had manufacture dates of 2010. Both claimed a shelf life of seven years. Last time, when neither of the two I tried from the twenty-four-pack worked, I managed to find one that my health supplier shipped. Recently I was out of the extras, and tried two more from the twenty-four-pack. Then three from the twenty-pack. The third one worked, but I now have six AAA batteries that show up as good on the tester but won’t work in my insulin pump. (They are working just fine in my anti-mosquito clip-on.)

I know the pump is picky, but only one battery out of seven? Shall I call Medtronics, or Energiser?

Are we getting too dependent on batteries?

Your Mileage May Vary

YMMV.

That particular acronym, standing for Your Mileage May Vary, is all too common on the insulin-pumpers’ website.

It applies to those of us with any chronic disease, and one of the main problems with “evidence-based” medicine is that it tends to rely on how the “average patient” reacts. There is no such animal as an “average patient.”

I had first-hand experience of this when a doctor, pre-pump, tried to put me on what he called a sliding scale of insulin, and gave it also to nurses in the local hospital. They insisted on using his scale when I was in the hospital for something else. I looked at the dose of insulin they insisted was necessary when my blood sugar was a little high at bedtime, and said “that’s going to put me into insulin shock.” They insisted on giving me the dose anyway. Luckily insulin shock still woke me up back then, and at 3 am I woke up shocky, hit the call button, and demanded a snack for insulin shock. They insisted on checking my blood sugar first, which only confirmed what I had tried to tell them earlier. I know now that that particular sliding scale, which was probably worked out for the average diabetic of my weight, simply did not work for me. I am very insulin sensitive, and while I absolutely need insulin and will see a very fast and uncontrolled rise of blood sugar without it, I need a very small amount, given my weight.

It isn’t just person-to-person differences, either. It can be time of day, time of month, stress, air bubbles, absorption rate of injected or infused insulin, or just the natural cussedness of the universe. Sometimes it can be how what you eat gets into your bloodstream.

Your blood sugar does not rise the instant you put carbohydrates into your mouth. The food has to be chewed and swallowed, as almost nothing is absorbed directly from the mouth or esophagus. It has to reach the stomach. One of the side affects of diabetes in many people is gastroparesis, which is delayed passage of food through the digestive system. To further confuse the person trying to keep diabetes under control, this delay is highly variable.

As a general rule, food I eat at breakfast time gets into my bloodstream, as glucose, fairly quickly. I’ve taken to eating yogurt for breakfast because most of the carbohydrates are lactose, which absorbs fairly slowly, and because the relatively high protein content also slows absorption. At noon my food absorption is a little slower, and by dinner time it’s slower yet – slow enough I normally spread my insulin out over 4 hours or so.

Changing my eating habits, as I did two days ago for Thanksgiving dinner, can cause an unexpected change in how fast the dinner actually gets into my bloodstream as glucose.

I didn’t have a huge dinner, or an unbalanced one, but I had more than normal, and upped my pre-meal insulin to compensate. I kept to a four-hour dual bolus, but by the time we went to another house for dessert, my blood sugar was running low. We had pie for dessert. I had a small piece, and I was still low, but I did take more insulin to balance the pie.

By the time I got home I was well into insulin shock, with a blood sugar below 50, and over the next two hours I ate enough to bring it up to normal by bedtime.

Four hours later my blood sugar was over 300.

I’m pretty sure that what happened was that the relatively large dinner caused more than the usual delay between swallowing food and the actual rise in blood sugar. As a result the amount of insulin I took, which was reasonable for the amount of food I ate, was enough to put me into insulin shock. Later that night the food caught up with the insulin, but by that time I had eaten enough extra to treat the shock earlier that my blood sugar went high.

The only way a doctor can prevent this is by insisting that you eat exactly the same meals at the same times every day. But we’re people. Most of us can’t keep up that kind of regime. And if we don’t accept that rigid a regime, we have to be intelligent enough to treat ourselves, to a certain extent.

I’ll probably do the same thing for Christmas dinner. But I’ll know to spread the insulin out over more than 4 hours.

Cranberry Recipes

The blade to my food processor. That black is supposed to be all one piece.

Disaster struck as I was preparing to start the salad for Thanksgiving dinner — the chopper blade on my food processor is broken. It was fine when I put it away, but now the plastic that holds the blade to the processor is shattered. Guess I’ll have to use the old mini-chopper for the cranberries and chop the rest of the stuff by hand.

Here’s a photojournal of the process of making the salad without a food processor. Turned out the mini-chopper did help with the oranges, too.

Ingredients and tools for the salad. (The paring knife didn't quite make the picture.)

Chopping celery's not that hard--just make a few cuts lengthwise before you start.

Yes, the whole naval orange is cut up. The mini-chopper took it down to small pieces.

Frozen cranberries and nuts help each other in the mini-chopper. It took three rounds, though.

The mini-chopper could not handle the apple wedges, so I had to chop them by hand. Apples were left to last, when I started heating the apple juice and water for the Jello.

What, all those solids for such a little bit of Jello? (I used orange, as I couldn't find lemon.)

The finished salad, ready for the refrigerator.

Recipes?

It’s anything-goes-day as well as Thanksgiving, so I thought I’d share a couple of my favorites. After all, they go well with turkey leftovers, too.

The first is my mother’s recipe for a Jello salad, modified to avoid added sugar and take advantage of a food processor. Note that while the usual Jello salad is Jello with fruit in it, this one is fruit, nuts and vegetables with a little Jello holding it together.

Cranberry-Orange Salad

2 4-serving or 1 8-serving packages of sugar-free lemon Jello
1 12 oz can frozen apple juice concentrate
1 c water
1 seedless orange, washed but unpeeled, cut into chunks
2 cups celery, cleaned and cut into pieces
2 washed apples (Granny Smith preferred), cores removed and cut in chunks
3 cups raw cranberries, washed and (preferably) frozen This is one 12 oz bag.
1 cup walnuts

Heat the water and apple juice concentrate together to boiling, and dissolve Jello. Meanwhile, use the food processor to chop (coarsely) the remaining ingredients. (It may take several batches.) Place the chopped ingredients in a 9” x 13” pan, level them, and pour the dissolved Jello over them. Mix and level to get all of the chopped ingredients below the liquid, and chill until set.

Makes 24 servings of 82 Calories each. For each 68-gram serving:
13 g carbohydrate
1 g protein
3 g fat (mostly from the nuts.)

Don’t laugh at the gram measurement – when I eat this I weigh the portion, and I use the carbohydrate and and half the protein to figure my insulin dosage. The recipe may have no added sugar, but with all the fruits and the apple juice concentrate, it’s far from sugar-free.

A half recipe would probably fit nicely into an 8” x 8” pan; I’ve just never tried it that way as this is my regular contribution to potlucks and Thanksgiving dinners.

The second recipe isn’t mine and is probably quite familiar to NPR listeners, but here is the link to Mama Stamberg’s cranberry relish. It may sound strange and look like Pepto-Bismol, but it’s yummy. I freeze it in an ice cube tray.

Happy Thanksgiving!

Conversation Piece

This is a bit of flash fiction, written in the Summer Arts Festival. The assignment was to write a conversation between two people who don’t understand each other, one of whom has some kind of dominance over the other. I’d call this a dysfunctional school, but this sort of incident can happen–we’ve had similar accounts on the insulin-pumpers e-group.

The small office was too warm, but Cyril never thought of shedding his coat.  Instead, he straightened his tie, pulled himself up in his chair and glared at the student standing in front of him.  “Well?”

The boy–what was his name?  Jerry?   Jimmy?  Jimmy, that was it–refused to meet his eyes and scuffed his right foot on the floor.  “I ain’t done nothing.  What you want to go pickin’ on me for?”  He shoved his hands in his pockets and turned his head, pretending to study the books on the wall.

“Speak properly, boy, and stand up straight.”  Damn kids today.  No respect.   Snotty twelve-year old, thinking he knew more than an adult.  And his hands were tied.  Couldn’t touch the little bastards, no matter how much a good spanking would straighten them out. “Trying to use a cell phone in class isn’t nothing, boy.  Now hand it here.”

Jimmy backed up a step, and his hand tightened around the phone in his pocket.  “Don’t have a cell phone.”  Sweat began to bead on his forehead.

Cecil stared at the boy, outraged by the lie.  “So what’s that in your pocket?”

“None of your business.”

Cyril stood up, lips compressed.  “Give it here.”

“No!”  Jimmy backed away another step, his eyes flickering to the closed door.

Furious, Cyril lunged toward the boy, grabbing the object the youngster held and pulling it away.  It was tethered by a cord to the pocket, and he jerked it free and threw it down.  He heard it smash as it hit the floor.

Jimmy screamed.  “You bastard.  He ran to the broken plastic case and picked it up, crying openly now.  “My mom’ll kill me.  I made her promise not to tell.  New school–I thought the other kids didn’t need to know.  And since the divorce…”

Cyril took the smashed electronics from the boy’s unresisting hands, and suddenly saw the words in the back of the case.  Insulin pump.

Insulin Pumps

Every cell in your body needs sugar as fuel, but it can’t use that sugar without a hormone called insulin. In a healthy person, an organ called the pancreas pumps out just enough insulin. Sugar in the bloodstream is used by the cells for energy or stored in the liver or as fat. People with Type 1 diabetes, however, cannot make their own insulin. People with Type 2 diabetes may eventually lose the ability to make insulin as well.

It doesn’t do any good to take insulin by mouth; insulin is a protein and the digestive system just breaks it down and uses the amino acids as building blocks. If you can’t make insulin, it has to be delivered to the blood stream. As a practical matter, the insulin is injected into the fat layer just under the skin, and from there diffuses into the blood stream. It has to reach the blood stream at just the right rate—too little insulin in the blood and blood sugar will skyrocket (very bad for you long-term), too much and the blood sugar can go so low that the brain shuts down. (I used this in Homecoming—the esper shock that afflicts those capable of talents like teleportation is simply low blood sugar.)

Unfortunately the rate of diffusion has nothing to do with the body’s need for insulin, either to pull down the blood sugar after eating, or to keep the cells of the heart and brain operating. There are artificial insulins available which diffuse faster or slower, and it is possible to take a very slow diffusing insulin to keep the basal metabolism (the heart, lungs, digestion, brain) going and shots of fast-diffusing insulin at mealtimes to deal with the sudden surge of sugar that digestion puts into the blood. But your metabolism varies with time of day, exercise, stress, hormones and other things, most of which are not well understood and often beyond your control.

Enter the insulin pump. Lots of people think that an insulin pump means your diabetes is really bad. Others think it’s just a convenience to keep from having to take shots, or that it does all the work for you. (It doesn’t.) None of these ideas really explains the advantages of an insulin pump.

It is true that changing the place where the pump injects insulin under your skin every three days is a lot less painful than taking five or six shots a day. And there is no question that it is easier to push a few buttons before eating at a restaurant than finding a rest room where you can load a hypodermic and expose your belly for a shot. But an insulin pump can do more than that—if you are willing to work at it.

First, the dosage with today’s pumps is much more exact than is possible with a conventional shot. With a hypodermic or an insulin pen, you can at best get the dosage to the nearest half unit. That may sound precise, but for some people half a unit of insulin is the difference between normal blood sugar and insulin shock, and a whole unit can drop blood sugar from normal to zero. Luckily even fast-acting insulin does not get into the blood as fast as glucose taken by mouth, so it is generally possible to correct for these rough dosages, but why not take the right dose to start with? Almost all of today’s pumps allow you to select the dose to within a tenth of a unit, and at least two pumps now allow even more exact dosages.

Second the basal insulin, the stuff that is dripped slowly and continuously into your system to balance your basal metabolism, can be adjusted to vary by time of day. This is not important for everyone, but some people need as much as twice the amount of insulin per hour at waking as they do when falling asleep. With long-acting insulin, this means a choice of insulin shock overnight or high blood sugar in the morning. With a properly adjusted pump, the rate of infusion of basal insulin can be adjusted in hourly or even half hourly increments.

The downsides? Insulin pumps do continue to deliver basal insulin even if your blood sugar is too low. The FDA has been worried about this. There is a pump available in Europe which when combined with a continuous glucose monitor will shut down if the wearer does not respond to a low blood glucose alarm. As far as I am concerned this is a fail-safe that increases the safety of insulin pumps, but the FDA still has not approved this feature for the USA market.

Another downside is that you have to learn to use the pump, and adjust its features to suit your own body. You will probably need to test your blood sugar more frequently, up to fifteen times a day. Some people are freaked out by the idea of being continuously connected to a machine, even one smaller than a deck of cards. And if you don’t have a waterproof model swimming and even bathing can cause problems.

Is it worth it? Yes, especially for those who are insulin sensitive or for those whose need for insulin varies quite a lot over the course of a day. But you do have to be prepared for a lot of work to get it working as it can.