Secret handshakes for special groups. Decoder rings to translate hidden messages. Star-bellies and not-star-bellies (for the Dr. Suess fans). I felt like I’d finally been given the membership to the special club when I’d read Think Like A Pancreas. Suddenly, the burden of type 1 diabetes management felt ever so much lighter. Not quite as feel-good as Julie Andrews singing on top of a Swiss mountain, but pretty damn close.
The book lays out how to figure out insulin needs. Basals and boluses. Pumps and multiple daily injections. It has all the information.
I’m an engineer by training, and a numbers geek by birth. I have always felt comfortable with math and this book broke diabetes down into numbers. It finally allowed me to look at all those numbers I was collecting in the log books and make sense of them FOR MYSELF. I didn’t have to call the endo to have her do it for me…I could participate in the management and likely do it better because I simply had more hour-to-hour information than the endo had about what was going into those numbers (exercise, stress, sleep, etc).
The first take-away from the book was basals. That a correct basal should hold you steady throughout the day. This hadn’t been really well explained by any of the medical professionals we’d talked with. All we’d been told is that basals were involved in your keeping your waking number steady, but it’s actually a far more complex system than that. The book discusses the value of doing a good basal testing program periodically to test whether your basal is holding you steady. If you’re seeing drifts in blood sugar trends up or down in the absence of food or rapid insulin, that basal might need adjusting. The book helps define an overnight target of <30 mg/dL change from bedtime to wake. If you’re dropping or raising more than 30 mg/dL, it might be time for a change in basal doses.
The second take-away from the book was insulin action time. The doctors had explained that Anna’s rapid insulin (humalog, at the time) would last 4 hours in her body, with a peak action time at about 1 hour after injection. In other words, her blood sugar would still potentially be dropping up to 4 hours after she bolused for food. Most online sources from diabetes websites to drug manufacturer’s quote an action time of about 4-6 hours, like this one from Diabetesnet.com
This book gave me the knowledge that in practice, insulin action time varies from person to person. When we tested Anna’s insulin action time, it actually showed that rapid insulin only lasts 2 hours in her system. What a difference! This meant we understood a little better what mechanisms were at play (or not at play) when we were looking at how her blood sugars were behaving more than 2 hours after a meal. If we saw rising blood sugars more than 2 hours after a meal or correction, we started to know that maybe her basals weren’t enough (and the opposite for falling blood sugars).
The third take-away from the book was about insulin correction factor. We learned how to test, in the absence of food and exercise, how much one unit of insulin would drop her blood sugar. We did the experiment several times and came up with a consistent result. One unit dropped Anna’s blood sugar by 30 mg/dL, not 50 mg/dL like the doctors had been giving us to work with.
Armed with this new knowledge, I started to fine-tune Anna’s basal and bolus numbers based on the daily numbers we’d been collecting. I made little tweaks to the dosing, timing, and started to try to predict what number she’d be two hours after a meal. When she wasn’t near that prediction, I’d look for possible reasons why…exercise, faulty carb counting…and I’d keep notes to help me see if I could find patterns. After just over a week or so, I’d figured out that Anna needed 12 units of lantus, a carb ratio of 1:8, and a correction factor of 1:30. We stopped calling our numbers into the doctor and were making adjustments as needed. Ourselves. It felt great to finally see some insight into the numbers.
The numbers showed the progress (average blood sugar and the standard deviation):
Week 1: 230 mg/dL ± 75 (hospital and home)
Week 2: 160 mg/dL ± 54 (with endo adjustments)
Week 3: 144 mg/dL ± 49 (Think Like a Pancreas)
Week 4: 144 mg/dL ± 41
Week 5: 120 mg/dL ± 33
But wait until you see what happens in week 6!! The CGM arrives!