“Total Accountability and Total Feedback constitute the minimum and only perpetual motion system.” Buckminster Fuller-Critical Path.
In order to re-create the system that has been damaged due to the onset of T1D we must first determine what it is we have to account for.
Then we have to figure out how to receive and assess the information we need (feedback) in order to make necessary corrections.
It will not ever be perfect.
In this training process our objective is to attain average blood sugar levels of 150 and below over a 3 month period.
We know that normal blood sugar averages below 120.
Want to avoid going low (below 75).
Want to keep our “spikes,” after we eat, below 200.
There are so many component parts and functions to this system.
Let’s focus on the critical ones here.
We need to account for:
1.) Food. We need to eat. Food is the fuel for the system. Traditionally, Diabetics are provided with a low carbohydrate, low fat and high protein diet. We must account for the food we eat. Glucose in the blood comes from the amount of carbohydrate and fat grams we ingest. Therefore, we must measure these. It is my experience that “less is better” here. I try and limit my meals to under 40 grams of carbs and under 5 grams of fat. If I exceed that number I am creating more uncertainty.
2.) Insulin dose; The missing key. There are three “numbers” to establish for your system to work. I want to emphasize here that this is how I understand current insulin dosage strategy and how I have established my my insulin delivery within my system. It may not be the way you understand or have been instructed. You must feel comfortable and confident in making any insulin alterations.
A.) First, basal dose is determined. The basal dose is the amount of insulin a body requires to maintain a relatively level blood sugar with the absence of food. If you are taking injections this is your Lantus injection which is typically administered before bedtime. Lantus works for 24 hours and does not peak. If you are on the insulin pump your basal dose is programmed into the pump when you set it up. Insulin pumps use short acting insulin (lasts for about 3-4 hours). The pump will deliver insulin every 3-5 minutes. The basal dose covers one hour. My basal dose is .775 units. The pump delivers .775 units every hour in 3 minute intervals. There is only one way to check to ensure that your basal is accurate. You must refrain from eating for a period of time and check your blood sugar often. The way I check my basal is to wait 4 hours after eating a meal and giving myself a bolus. I want my blood sugar level to be below 150 and above 110. I refrain from eating and don’t exercise or engage in increased physical exertion. I test my blood sugar at least once every hour. Blood sugar results should not vary more than 25 points in either direction.
When testing basal the longer the better. I try for 4-6 hours and extend it as long as I feel comfortable. If I trend up more than 25 points then I know I must increase my basal dose. If I trend down more than 25 points then I know my basal dose is set too high and I reduce it. Basal requirements may change during different times of the day. So basal testing should vary during different times of the day. Remember, this is a dynamic system and many factors can be influencing blood sugar levels. You can probably begin to see why I believe the insulin pump is far superior than injections. If you are taking Lantus injections then your basal dose is set for 24 hours. You cannot make an adjustment until you take your next injection at bedtime. The insulin pump allows you to set multiple basal doses over a 24 hour period. It also allows you to adjust your basal on the fly. You can program what is called a temporary basal. This allows you to reduce or increase your basal based on what you are doing or how you are feeling. CLICK HERE FOR BASAL TESTING CHART (CREATE TAB FOR CHARTS).
B.) Insulin to Carb Ratio. When we eat carbs we must inject a bolus amount of insulin to “cover” them. How much insulin must you inject to cover the carbs you eat? My number here is 11 grams. For every 11 grams of carbs I eat I must bolus 1 unit of insulin. Do you know your number? You can see how important it is to have a proper basal dose in this system. It is really the foundation or common denominator for all other factors.
I have mentioned fat grams often. Fat grams also affect glucose levels. My experience is that if I am eating more than 8 grams of fat in a meal I must account for it. Below 8 grams I don’t have to worry. Fat reduces the efficiency of insulin. You need more. Fat is tricky. It can affect things for several hours. Also, there are different kinds of carbohydrates. Carbohydrates from orange juice must be dealt with differently than carbohydrates from pasta. One peaks faster than the other. An attitude of a scientist or investigator is required here. Test often and get to know how different foods influence blood sugar. I have also mentioned that when I eat more than 40 grams of carbs things become more uncertain. Watch for this as well. CLICK HERE FOR INSULIN TO CARB CHART.
C.) Insulin Sensitivity Factor (ISF). Your ISF is the number of points your blood sugar will drop with one unit of insulin. It is also called the correction number. You will be course correcting all the time. It is the nature of what we must do. To determine ISF I wait at least 3 -4 hours after a meal with little or no fat. Blood sugar level should be 170 or higher. I take one unit of insulin. Don’t eat. I test my blood sugar at the 2 hour mark, the 3 hour mark and the 4 hour mark. Subtracting the number at the four hour mark from the starting blood sugar yields the ISF. My ISF is 40. My blood sugar will drop 40 points with every one unit of insulin. Note: When you are correcting for a high you must take into consideration the amount of Insulin on Board (IOB). This is the amount of insulin that is still working. Remember, there are many other factors that could influence this number at any given time. CLICK HERE FOR ISF CHART.
3.) Exercise/Physical Exertion. Our bodies use or burn glucose all the time. That is why normal blood sugar is 80 mg/dl – 120 mg/dl. The brain cannot function without glucose present. Exercise or physical exertion will lower blood sugar and make insulin more efficient. Therefore, you must account for your physical exertion. This includes structured exercise routines, cleaning the house, moving things around and increased brain functioning (i.e., working on a project that requires increased concentration or exertion). You must get to know how these different physical activities affect you. You must compensate for them by increasing your carb intake or reducing your insulin. In my opinion, the more exercise the better.
4.) Stress. If you are under stress your body reacts by secreting hormones that may elevate blood sugar levels or reduce the efficiency of insulin. I know people who must increase their insulin when driving or spending time with their mother in law. Be aware that this is a factor that must be accounted for. Investigate it and find creative ways to account for it.
5.) Current Physical Condition. In our flying a plane analogy your body is the plane. You should strive to make your body as sleek and in condition as possible. If you are more than 25lbs. overweight than you may have an issue when it comes to implementing this system. Make it a priority to get in shape. It is critical. You will lower your insulin requirement and metabolize food more efficiently when you are in top physical condition.
These are the primary components of the system that we must account for. Now, what is our feedback? The three goals that we established earlier determine where we will look for our feedback.
1.) Are we engaging in this process with an attitude of acceptance and commitment? If not, why? Are we still feeling sorry for ourselves, in denial, angry, depressed, overly anxious? Are we using diabetes as a way to avoid? You cannot do this if you are not 100% committed. This process is all about you becoming the master of Diabetes. Several years ago I attended a personal development program. The facilitator of the group read a “poem” he wrote.
The Difference Between Leaders and Victims
Leaders make mistakes and say, “I made a mistake,” and make up for it.
Victims make mistakes and say, “I’m sorry,” and do the same thing the next time.
Leaders say “I’m good, but not as good as I can be, yet.”
Victims say “I’m not as bad as a lot of other people.”
Leaders affect others.
Victims are affected by others.
Leaders would rather be admired than liked, and wind up having an abundance of both.
Victims would rather be liked than admired, and wind up having little of either.
Leaders respect others and try to learn something from them.
Victims resent others and try to find their faults.
Leaders stand for something and are willing to to fight for it if necessary.
Victims stand for nothing and either fight about everything, or nothing.
“There are essentially two categories of people in the world…leaders and victims. Leaders are those whose purpose seems to be to inspire and motivate victims until they become leaders. Victims are those whose purpose seems to be to criticize and resist leaders until they become victims.”
It is time to be a Leader.
2.) Are you realizing a decrease in the suffering you are experiencing because of diabetes. If you are working this system you should be. And you will be reducing the suffering of those around you by gaining more control.
3.) The continuous feedback we are receiving are blood sugar results. We have begun testing at least 10x/day. I test before eating. I test 2-3 hours after eating. I test anytime I want to know where I am at. I test more often if I want to see how I am trending. Feedback is good. The better the feedback the more information I have to make decisions and corrections. In my early days I did not want to test. I hated to test. Now, I test all the time. I am the master of my diabetes and I want to know where I am.
This was an intense section with a lot of information. Take time to let this sink in and begin to incubate.
1.) Test your basal rate. What is it? Write it down.
2.) Test your Insulin to Carb Ratio. What is it? Write it down.
3.) Test your ISF. What is it? Write it down.
4.) Ok. This is tough one but it must be done. As you test these things create a chart or log. I could not stand doing this because I did not want the nurses, CDE’s or doctors to see how bad I sucked. No one has to see it except you. Chart your carb and fat intake, insulin dosages, exercise, stress level and blood sugar results. Do this for one week. This is the difficult part of the process. It is a necessary part.
Continue with the current yoga practice everyday as you complete the exercises above. Give yourself 5 days to work on these things before moving on to the next section. Stay positive and committed. You are well on your way to Transforming Diabetes!