I never, ever, ever would have believed that one day I’d be writing about SCIENCE on the internet. And like, medicine. And math. These were my least favorite subjects in school. I am solidly an English/Theater type of girl.
But hey, I also never would have believed that I’d one day post my weight on the internet. Or a picture of me in the ER.
Life is just full of surprises this year. So… to the science!
DIABETES 105: Carb Counting
As a diabetic, I dose insulin based on the carbohydrates I’m about to eat. When I was first discharged from the hospital, I was on something called a “sliding scale”, which was intended to make things as easy as possible for me. Basically, I was told to eat about 50g of carbohydrate per meal, and then given a very specific scale of how much insulin to take based on what my blood sugar read before every meal. The higher my blood sugar was, the more insulin I took. The scale was easy to use, but it required that I eat the same amount of carbs at each meal. Not super flexible.
So, when I graduated to “advanced diabetes”, I moved on to a much more complicated, but more flexible, method of dosing insulin before meals: carb counting and correction. This method allows me to eat as many carbs as I want at each meal, but it takes a lot more math to figure out.
The way it works is this: before each meal, I test my blood sugar, then I calculate how much insulin to take based on my carb-insulin ratio and my insulin sensitivity factor. In essence, I am “dosing” insulin to cover the amount of carbohydrates I am about to eat, and to correct if my blood sugar is running high or low.
Carb Insulin Ratio: Every diabetic has their own carb-insulin ratio. It’s how many grams of carbohydrate each unit of insulin will “cover”. For me, it’s 1:10 (pretty standard). That means each unit of insulin I take will “handle” 10 grams of carbohydrate. So if I’m going to eat a 10 g carb snack, I take one unit of insulin. If I were going to eat a 40 g carbohydrate meal, I’d take 4 units of insulin.
Of course, the challenge with carb-insulin ratios is that they’re not perfect. They’re mutable, and don’t account for the fact that there’s a lot of different types of carbohydrate out there. As I’ve mentioned before, 10 grams of carbs of apple juice is going to “hit” the system very different than 10 grams of carbs of broccoli. The juice will hit the system fast, spike the blood sugar quickly; the broccoli will release slowly, and most likely cause a gradual rise more than a spike. Unfortunately, there’s only one kind of insulin, so we do our best to make it work for all kinds of carbohydrate.
And I haven’t even gotten into complex foods. Most foods are not ALL carbohydrate, or ALL fat, or ALL protein. Most are a combination of the three (take…yogurt!), and unfortunately once you bring fat or protein on board, the way the food hits the system gets even more unpredictable. Especially fat. Fat complicates everything. Essentially, it delays the absorption of glucose into the system. So if you eat a donut, you might not see a huge blood sugar spike right away, even though it has a ton of carbohydrates. All the fat in the donut might cause, say, your blood sugar to stay relatively stable for a few hours, and then spike to 250 three hours later.
But if you took insulin when you ate the donut, the insulin probably worked more quickly than the fat allowed the glucose to hit your system. That can lead to some confusing symptoms – essentially, you may have gotten low blood sugar right off the bat. The insulin went right to work, but the fat in the donut kept the glucose from going “right to work”, too. So the insulin beat the donut to the party, and then, because you have insulin in your system and no glucose, you get the dreaded “low” blood sugar.
When you get a low, aka your blood sugar drops below 70 (really, you get concerned when it drops below 55), there’s only one way to get out of it: glucose. You need to feed your body carbs, and because lows are so dangerous (see Living With Diabetes: The First 2 Months), you need to “treat” them with simple, fast acting carbs – things without fat and protein.
So, you treated your low blood sugar after the donut with fast acting carbohydrate – maybe juice or sugary candy, which worked! Your blood sugar moved out of the danger zone. But then it kept rising – probably because the juice carbs kicked in right as the carbs from the donut were “hitting”, and then it’s 3 hours after you ate that donut and you’re sitting on a blood sugar of 450 and wondering what the heck happened.
Did you follow that so far? I wrote and re-wrote those paragraphs like, 5 times to make it comprehensive, and found that I really couldn’t get to a clarity I was happy with. It’s hard to explain – it took me weeks to figure out. So apologies for my confusing description. I tried, really, I did.
Anyway, assuming you somewhat understand carb: insulin ratio and the challenges therein, moving on: The other factor that goes into dosing insulin before meals is called “correction.” The blood sugar “goal” for most diabetics is between 100 and 120 – but guess what: you’re rarely there. Most often, when you test before meals, your blood sugar is somewhere else. When it is sitting perfectly at 100, you rejoice, but more often than not, you use the insulin you take before a meal to “correct” up or down to the golden “100”.
My insulin sensitivity factor is 1:25. That means, when I do not have food in my system, 1 unit of insulin drops my blood sugar down 25 points. This, too, is a useful but not perfect tool. 1:25 is a pretty low correction – from what I understand, most diabetics move a lot farther on one unit of insulin (maybe 1:50 or even 1:70). However, for me it’s about 1:25, especially during the day. At night, 1 unit of insulin might move me a lot farther than 25 points, when there’s no residual food in my system and I’m not doing anything. But for the most part, I can count on 1:25 as my magic number. (Note: how does one “figure out” these magic numbers? Trial and error. Lots and lots of trial and error).
So, when I test my blood sugar before a meal, I figure out how many units of insulin I need to take for correction and add that to my dose for the food. If my blood sugar is 175, for example, regardless of what food I am about to eat, I would be taking 3 units for “correction” to get me down to the magic 100.
So, if I’m going to eat 30 grams of carbohydrate in my lunch, and my blood sugar is 175, I’m going to take 3 units for the carbs, and 3 units for correction, for a total of 6 units.
Of course, it gets complicated. What if my blood sugar is 140 and I’m eating 44 grams of carb? Or what if it’s 77 and I’m about to eat 6 units of carb? Or 218 and I’m eating 77 units? When you take insulin with needles, you can only dose in whole units, so you have to round and hope for the best.
More importantly, though, how the heck do you know how many carbs are in your meal? When you cook the food, it’s easy – or at least, easier. Things with packages that have nutrition labels are great, but even the food you cook at home doesn’t always allow for that (what about full recipes, sauces, baked goods? – it gets complicated).
The most difficult, though, is eating out. Unless you’re in NYC and going to one of the chain restaurants that have nutrition stats posted, you pretty much have to cross your fingers and, once again, hope for the best. Frankly, even the nutrition stats can often be really wrong.
Oh yeah, and then there’s the fact that the meters we use to test our blood sugar ARENT ACTUALLY 100% ACCURATE. In fact, most are considered “accurate” if they get your blood sugar right WITHIN TWENTY PERCENT. WITHIN TWENTY PERCENT. That means your “actual” blood sugar could be 400 but the meter reads it as 480. So you dose for 480. And without realizing it you have waaaaay overdosed insulin.
Because insulin is a powerful little jerk. And one unit wrong could make the difference between a nasty low and the coveted “100”.
In a way, I got lucky. When I was first being introduced to the world of carb counting, I was given a lot of really rudimentary info about nutrition stats. Finally, at one point, I had to interrupt my nutritionist as she was showing me how to read a food label (“look at serving size!”) to say: “Listen, I’m a 27 year old woman who’s spent my entire life overweight. I know how to do this.”
And I did. I had spent 20 years counting calories – (with a few years “break” to count points AMIRITE LADIES WHO DID WW??) It was pretty easy to switch from calories to carbs. Frankly, I’m not terrible at estimating carb counts in meals at restaurants. Sometimes I’m pretty wrong, but usually I’m close, at least. (Although, as I mentioned: fat complicates things. As does serving size).
However, it is impossible – literally impossible – to be a real person who eats more than food from packets and be right 100% of the time. So mistakes are bound to happen. And so are highs. And lows.
Hence, the first time I ever experienced low blood sugar. It wasn’t right away; as I’ve mentioned, after getting diabetes I battled highs much more than lows, but, as early as the week after I was discharged they began sneaking in to my life the way creepy dolls sneak into bedrooms in really bad horror movies.
So I guess I lied to you guys. I had thought my first low happened like, a month or two in. When I was researching this post I realized it actually happened about a week and a half into having diabetes – an isolated drop in a sea of 200s and 250s. I know exactly the day it occurred (March 9th) because I wrote an email to my endocrinologist that day explaining it to her. I remember I typed the email out with this super weird, messed up sense of pride – like, the way a kid makes his parents look in the toilet the first time after he craps in it.
So here were the fabled “lows” I’d heard so much about! As part of my spotty but overwhelming diabetes education in the hospital, I had be warned, over and over again, about the dangers of lows, and the importance of treating immediately, taking them seriously, and making all good effort to avoid them. I thought of Stacey collapsing prettily on the ground – now I was a part of this exclusive club, too! (Uhm, not The Babysitter’s Club. The “gets lows” club.)
It was a Saturday morning and, for probably the first time since discharge, I had slept in. Until 11. I also hadn’t eaten since dinner the night before at 5 pm (blue plate special!) This really stupid combination (which meant 18 hours without eating) was enough to cut through my fog of highs enough to actually crash my blood sugar. I remember sitting on the couch, thinking about what to eat for breakfast (I NEVER knew what to eat in those first few months), and suddenly noticed that I could hear this weird rapid thump. With a start, I realized it was my heart beating – and I could hear it – moreso than normal, I mean, and it seemed to be going fast. I held my hands in front of my face and noticed that, try as I might, I couldn’t stop them from shaking.
This is happening, I remember thinking – procedure! Procedure! What’s the procedure!?
Rule of 15!
Rule of 15, they’d preached at the hospital – that’s how you treat a low. Test your blood sugar (confirm it’s a low), eat 15 grams of fast-acting carbohydrate, wait 15 minutes, test again. If you’re out of the woods, rejoice. If not, eat 15 more grams of fast-acting carbohydrate.
I tested. Holy crap: 60. I hadn’t seen a number below 100 – well, ever. 60!? I yelled for Stefan – something’s happening! We need to figure this out! I ran to the kitchen (but should I be running??! Or should I sit still so that I don’t pass out?! What if I pass out while I’m running?! I should yell again so he knows and if he hears my body crash to the ground he’ll be able to call 911.) So I yelled/ran my way to the kitchen, grabbed a lone bottle of Gatorade (purchased the day after discharge and promptly ignored), poured myself a glass and drank. Mmm, nothing like Gatorade first thing in the morning after brushing your teeth!
And I sat there for 15 minutes (I think I timed it on my phone for God’s sakes), and then, promptly, tested it again. 115. Out of the woods.
That wasn’t so bad, I thought. I had had the perils and horrors of lows drilled into my head so often that I’d been expecting so much worse, but shaking hands and a temporarily racing heart hadn’t been much to worry about at all. If that was what a low was, bring it on.
You stupid, stupid idiot. Once again, so much I didn’t know then that I know now.
Starting with this: 60 is the poor man’s low. 60? My god, today when I hit sixty I take a nap. Wake me up 15 points from here. (Umm….don’t tell my endocrinologist).
The second thing I know is that all lows feel really different. I don’t know why. I know for some people the symptoms are consistent. And sometimes my symptoms are consistent. And sometimes, initially I have no symptoms at all. Sometimes it’s after the fact, when I’m coming out of the low, that the symptoms really hit. And sometimes they’re really nasty. I remember the first low I got that brought on a brutal, piercing headache. Even after the low was long in the rearview, the headache remained all day.
And then there were all the symptoms that I didn’t feel the first day that I have since felt. The heartrate and the shaking, yes, but also the nausea, that bitchy headache, the complete lack of mental focus, the freezing hands and feet, the dissociation, the blurred vision, the anxiety, the cold sweats, the irritability (fortunately for me, no extreme PERSONALITY CHANGE – and can we talk about what a psychotic symptom that is for a disease?!! Like, are you for real, diabetes?!), the weakness, the lightheadedness, the inability to hear very well.
I remember lying on the floor after exercise, feeling like my brain was seeping out through my skull, wondering whether I was going to wake up or just drift into unconsciousness.
I remember sitting in the back of a car, feeling like I was descending into myself, and realizing with a start that people were talking to me – had been talking to me for probably minutes – but that I couldn’t hear them. I couldn’t hear them.
I remember lying in bed quaking – just quaking, hands and feet chattering like someone shook a bag of bones.
I remember sitting on the couch and realizing that, slowly, I was losing feeling to my hands and feet – they were getting so, so cold! Why were they getting so cold?
Or the night when my blood sugar tanked after a huge meal – and I was so, so full – and realizing with a jolt of horror that I was going to have to put something in my body – in fact, my body was simultaneously screaming for calories as my stomach was rebelling at the thought. I remember sucking down a juice box and praying, praying that I didn’t throw it up, I was so full.
And believe it or not, worse than the ones with those nasty symptoms are the ones with no symptoms at all. It’s called “hypoglycemia unawareness”, and my fear is that I’m headed there. Unfortunately, the more lows you have, the more your body “gets used” to them, and you can get to the point where you don’t feel them at all. That’s bad. Really bad. Because while the symptoms of lows suck, none suck as much as passing out. Or dying.
With the exception of that horrific ride on the subway back before I was diagnosed (and I’ll never know exactly what led to that collapse – it could have been low blood sugar, but honestly it also could have been really, really high blood sugar) I’ve never passed out from low blood sugar. Since being diagnosed with diabetes, I’ve come close, in my estimation, twice. But it’s never happened. However, and this is just anecdotal, I find that when I have a period where I’ve been getting a lot of lows in a short period of time, I start to be less symptomatic. Which scares me. Whereas if I’ve gone a while without a low, when I get my next one I’ll really feel it.
So in a way, the symptoms are a blessing. Because without the symptoms, no warnings. No warnings, bad things happen.
Hmm… this has been kind of a downer of a post. I wish I had something optimistic to end it on, and in the absence of something diabetes-centric that’s optimistic, I will end on an unrelated but adorable note. The other day, when I was walking my dog, he got tangled up in some vines.
And it was pretty effing cute.