I went to the CWD Focus on Technology conference in Seattle last weekend and floated away in a hazy cloud of hope. It’s true – only smart, hilarious, beautiful people live with T1, and meeting so many in one place at one time was incredible.
Three talks hit on the main issues we struggle with most of all right now: meal spikes, sleep, and sanity.
Strike the spike!
This was Gary Scheiner’s session on getting mealtime spikes under control (his Type 1 University offers this course online). It was a great sanity check, and using one of the techniques the next morning made breakfast a lot less grisly.
Causes behind meal spikes (i.e. “We’re pre-bolusing big time, so why the f*#& are BGs still screaming sky-high afterwards?”)
* Synthetic insulin still isn’t rapid enough to keep up with most food digestion, except for really low GI foods.
* Type 1 diabetics digest food faster than people with functioning pancreases – so again, the insulin is too slow to keep up. Kids digest food even faster – hence the nasty spikes.
* How cruel is this? – the pancreas in T1 diabetes produces glucagon when it’s least needed, right after meals, adding to the spike.
* Lows before a meal accelerate emptying of the stomach, which means the meal spike will hit even harder.
* Breakfast spikes are the worst, partly due to not having much insulin in circulation from nighttime basals. At lunch and dinner, basals are higher and there’s usually extra insulin in circulation from earlier snacks or corrections.
Recommended post-meal targets:
* Kids under 5: Under 250
* School age kids: Under 220
* Teens: Under 200
We hit these targets less than 10% of time, and a Yale blind study on peaks found the average after breakfast was 293, after lunch was 291, and after dinner 280 (yay, we’re normal!). Doctors, seeing the spikes, often recommend a lower carb ratio – which just causes a crash after the meal.
What to do?
* For older kids, Symlin (off-label) or amylin.
* Bolus for the entire meal up front, but split it and eat the second half an hour or so later. (This worked on Luke – we held off on milk, the worst offender, until he was in the car for the commute to pre-school, and the spike was very gentle.)
* Use physical activity after the meal to speed up insulin absorption and slow digestion (could be something as gentle as walking the dog).
* If a low before the meal is causing a rebound, use a temp basal for 2-3 hours.
* Protein, fat, and fiber help by slowing digestion (low GI foods), as does vinegar. 2t of vinegar have a fatty acid that slows gastric emptying and can lower spikes by 50 points. Sourdough bread, strangely, is low GI due to the this acidity.
* Consider avoiding pure protein, because protein by itself raises blood sugar (on average, half of protein grams turns into carbs, but hard to predict). Having a few carbs with it prevents conversion.
He wasn’t a fan of pre-loading morning basals to blunt the spike, since you’re then locked into a certain time and # of carbs.
Is it Safe to Sleep at Night? (Bruce Buckingham)
The answer, in short (recent JDRF ad aside), was “yes.” Based on many blind studies, it seems it takes 3-5 hours at or below 50 to cause a siezure. So a sensor lag of 5 minutes is not an issue – hypo minimizer trials at Stanford had proven effective and safe without causing hyperglycemia.
I approached Dr. Buckingham after his talk to ask – is it sane for us to be up as much as we are at night, with a T1D 3-year-old? “Oh,” his face fell. “The little ones are so volatile.” Sigh. Which led me to the keeping-your-sanity session –
It’s Not Just a Numbers Game (Joe Solowiejczyk)
This was the first time I’d heard Joe speak, and I laughed so hard I cried through most of his talk. If you haven’t heard him, check out his presentation on CWD!
He talked about finding balance between giving yourself a break (like scheduling “diabetes depression days”) and making care a non-negotiable with kids.
“What do you say when they say they don’t want to test, because it hurts?” one parent asked. “Of course it hurts!” he bellowed in a thick Long Island accent. “If you enjoy this, you’re sick, and you need help! But they need to do it. They need to test, write down their BGs, and take their boluses.”
“How do you respond to the teenage ‘You just don’t get it?'” another parent asked. “Don’t make the mistake of treating her as a rational human,” Joe shot back, “She is not! You don’t need her good housekeeping seal of approval! You say, you’re right, my darling, I don’t, and I don’t care.”
He wasn’t a complete hard-ass either, though. Other suggestions for helping kids deal included driving over their (back-up) glucose meter in front of them and saying, “Wow, that felt good!”; praising them for having a meltdown about diabetes (feeling safe enough to do so); and the hardest – ff your kid worries, don’t tell him not to worry. Tell him hoe brave he is, and that sometimes you worry, too. Allow kids to have their feelings, but don’t try to fix it. Just be there for them. That’s the hardest and easiest part of parenting a kid with T1D.