Diabetes has a sick sense of humor.

Following my hypoglycemia “incident,” I have been trying to get my medical ducks all lined up for a thorough inspection.  Making doubly sure to scrub behind my ears, floss between my teeth (ironically this broke my permanent retainer requiring an emergency trip to the orthodontist, but hey, it was in the name of hygiene), take my vitamins and do an extra plank or two before bedtime, I went into my May endocrinology appointment with the expectation that I was doing everything that could be done for optimal self-care.  Upon seeing that my HgA1C had dropped from 5.8 to 5.3 over the past three months, however, my doctor concluded that I’m probably doing too much to address my diabetes and that’s likely why I had the “incident” in the first place.

“You’re treating your diabetes like you’re still pregnant,” she says. “Your glucose control is too tight and you need to let your overall numbers rise or you’ll be facing more frequent occurrences of severe hypoglycemia.”

Stressing that my concept of the “ideal glucose range” (70 - 140 mg/dL) is only truly necessary for the conception and gestational development of a healthy fetus, my endocrinologist encouraged me to recalibrate my expectations and sight my blood sugar goals above 100 mg/dL so as to provide a buffer between me and, well, the pavement.  Attempting to introduce the concept of leniency into my daily regimen, she argued that my typically aggressive approach toward glucose management will only create more problems rather than solutions as time goes on.  Explaining that while it would logically follow that I become better at diabetes control the longer that I am a diabetic, she said the opposite is actually true because the disease becomes more erratic and more difficult to pin down the farther you go away from your honeymoon phase (which, if you remember, is the period of time following diagnosis where the dying beta cells in your pancreas still makes a small amount of insulin).

“But, what about the adverse consequences of letting my glucose numbers rise?”  I asked.  “Won’t slacking off on my self-care only result in organ damage down the line?”

Taking a deep breath, she responded with the thoroughly uninspired “maybe.”

Explaining that the technology for HgA1C measurements have only been around a short while and that there hasn’t been long term research done on the correlation of A1C management to complications or the lack there of, she said that doctors don’t really know what glucose range to recommend because there are life threatening consequences if you go too far toward either end of the spectrum.  On one side, tight regulation like I do creates frequent medical emergencies for diabetics due to the severe hypoglycemia it creates; whereas unconstrained hyperglycemia on the other end of the spectrum directly causes organ failure, neuropathy, blindness and a whole host of other issues one would rather avoid.  Thus framing my position (rock-me-hard place) as one requiring a very delicate balance, she indicated that she, at least, would be more comfortable with my HgA1C being between 5.8 and 6.0 by my next appointment in August.

Pulling another rendition of my all too familiar phrase of “yes, but” into the discussion I told her that “the perinatologist said that, were we to get pregnant again I should keep my A1C under 5.2 to prevent the complications we saw with this last pregnancy.”

“Well, that’s ridiculous,” she retorts.  “With an A1C that low, you’re more likely to have a hypo-fall and hurt any future babies than to protect them from macrosomia or polyhydramnios.”

Stating that such “minor” complications were (and likely will be in any future pregnancies) unavoidable due to my lengthening history with the disease, she explained that my “diabetic-age” essentially undermines the effects of tight regulation and probably caused the complications with FG’s pregnancy in spite of my stellar A1C throughout the ten months.  So although my A1C this go around ensured a perfectly formed heart, prevented the development of spina bifida and made all concerns about miscarriage or stillbirth a non-issue, it simply wasn’t enough to safe guard against all of the high-risk nuances of a diabetic pregnancy in the face of my crippled pancreas.  But, in light of the existential dangers more frequent hyperglycemia would cause for a growing baby, I think I can cope with the unpreventable complications of larger babies and excess amniotic fluid so long as my glucose management efforts to avoid the worst continue to pay off.  And, frankly, FG definitely counts as paying off!

So long story short, the rational side of me knows the only action plan from here is to set the longer term question about potential future pregnancies aside in favor of very real, here and now self-care concerns and choices.  The emotional side of me, however, is completely upset and frustrated by the “a’int nothin’ you can do about it” attitude I feel like my pancreas is giving me and no matter how I fight its sass-mouth, it still seems to find a way to breach my defenses and leave me vulnerable to its whim.   It’s completely unfair that my growing knowledge of and comfort with my body on artificial insulin doesn’t easily equate to a well balanced, healthy lifestyle.  In some sense, I am envious of those people who have Type 2 Diabetes as their positive effort to address their condition through diet and exercise directly impacts their overall outcome for the better… whereas I can go run a marathon, cut whole food groups to nurse, monitor my glucose numbers, drink water by the gallon and it won’t matter.  No matter what I do, I’ll still be a diabetic and no matter how much “expertise” this brings, I’ll perpetually be relegated to rookie status thanks to the sick humor of chronic illness. 

Endo Check Up

It seems funny to me how our perception of time changes based on whatever it is that makes up "normal" every day life.   Last fall, when I was pregnant with GV, I had so many doctors appointments that my days, perhaps even my hours, seemed to be measured in trips up and down the I-95 corridor to Fairfax INOVA Hospital.  But now that I'm back to "normal," fireman rain coats and matching wellies accent my routine far more than white coats, which are soooo last season.  Doctors appointments now merely indicate the passing of yet another three months -- either in the form of a well baby visit for GV or a routine endocrinology check up for me.

The latter is what I did today. 

The past couple months have been ROUGH diabetes wise and, to be completely honest, I've been dreading this appointment for fear of the criticism I feel is entirely appropriate for my self care.  It isn't that I have been slacking on the job or purposefully blowing off my blood sugar (although, to be fair, I simply forgot to bolus once... yikes), it's just that I'll be going along just fine and then WHAM! my blood glucose is in the high 200s and there is no simple explanation for it.  My pump will indicate that I have enough active insulin in my system to cover the correction, but my glucose will have shot up like the insulin wasn't even there and, quite similiarly to when I was pregnant, come crashing down an hour or two later.  Without understandable rhyme or logical reason for this, I've just been rage bolusing and enjoying a few extra doses of whatever something sweet I'd happen to be craving at the time (currently pecan pralines).

Thus expecting an abnormal HgA1C, which if you remember is anything above 6.0, I brought my support group along for the telling finger prick that would inevitably quantify the amount of flack I'd justifiably be given.  Dispensing with the "oh what an adorable baby" and "you must be such a good big brother" comments and getting down to it, I held my breath and gritted my teeth as I waited for the results in the same manor I did while checking the mail box for my college acceptance letters...

Doctor Rogacz entered the room.  We exchanged our pleasantries and, with little ado, got down to my diabetic trials and tribulations.  Explaining that some things have changed - I'm running more, I've been under more stress and that I'd been sick without singular cause - but that most of my lifestyle factors remain the same, I blushed in embarrassment as I handed her my blood glucose logs for the last two weeks which included daily ventures into the 200s.

"Hmm, I don't know what to tell you," she said. "The timing of these highs are inconsistent and you've got a number of lows as well.  But your HgA1C is good at 5.8 - so you're doing something right even with these numbers."

SHOCK.

Reading my face and plainly hearing HB's comments of "I told you so" (he relishes those opportunities), she then not only didn't give me a hard time about my hyperglycemic excursions she was incredibly encouraging of my dedication.

"You're never going to have perfect blood sugars, no matter how hard you try, so try to relax.  You're doing a great job!"

Frustrated with the medical recommendation "to relax" I professionally dodged her compliment with a question or three about my marathon training to which she merely said "do what you have to do to not pass out" which, in endurance running and diabetes management, I take as excellent advice.

So without jabs about my continuing lack of CGM, lectures about abnormal blood sugar ranges or prescriptions for whatever else might be ailing me, I felt like I dodged a bullet today as we walked back to the car.  I thoroughly expected my HgA1C to be in the high 7 range and I lost significant amounts of sleep last night because of anxious dread of medical criticism... but I guess all that worrying was for not.   My Nana, may she rest in peace, always said that the things you worry about never come to pass and until now I'd figured that was just her way of recommending I "relax" but, hey, perhaps she was right.

We'll see where I'm at in another three months.

Postprandial Hyperglycemia Continues...

Much to my disappointment, I guess my endocrinologist had a point when she said high glycemic index food is out.   I'd initially hoped such a food restriction would be a fluke suggestion for my recent hyperglycemia, but it is unfortunately turning out to be something I actually need to consider.  Bummer.

As per our usual weekend morning tradition, yesterday before mass HB got up and made the family his famous pancake breakfast with a side of bacon and - hallelujah - coffee.  It's not often that I willingly hand over the reigns to my kitchen, but if he offers I always take him up on making this breakfast because it's just so darn good!  I think the special trick to his recipe is the 50-50 split of white flour to wheat flour and his inclusion of melted butter and cinnamon right in the batter... they are so amazing.

Anyway, after HB finished slaving away at his new griddle, he put the plate of gorgeous golden brown pancakes and our three maple syrup variants on the table and lead us in grace.  I set GW up with two pancakes and once they were cut into toddler sized pieces, I turned back to my own plate for calculation.  Taking three pancakes (20 g each), about 1/4 cup of sugar free maple syrup (10 g) and my coffee (20 g) into account, I bolused 5 units of insulin to cover the 100 grams of carbs in front of me (20 g carb per 1 unit insulin).   Back when I was first diagnosed, I remembered thinking that 100 grams sounded like an embarrassing amount of carbohydrates to eat in one sitting, but now that I have a better idea of the composition of food it really isn't difficult to rack up carbs quickly with a couple pancakes or a simple glass of juice.  So eating just barely more than my 3 year old, I finished breakfast and off we went to Sunday Mass.

Returning home an hour later, I checked my blood sugar at the two hour post breakfast mark: 202 mg/dL.  Requiring only 0.90 units for a correction, HB and I were thoroughly agitated to see I still had 3.4 active units in my system.  Sighing deeply, I waited another two hours before checking again and my glucose at that point was down to 71 mg/dL -- which as I have said before, is slightly on the low side but within the correct range of where I want it.

I'd peaked early, again.  I'd calculated my carbs correctly, I'd eaten what I intended to eat and my glucose was eventually were it ought to have been, but not without a cost.  Going up into the 200s isn't healthy and regardless of the temporary nature of it, I cannot afford to go high if I want my HgA1C to stay under tight control in a "normal" person range.  I need it to be normal -- and not just for me and my sanity, but for any unplanned children we may possibly have. I mean I trust God to be looking out for us and our current & future children, but that doesn't mean I should take his care for granted and disregard my responsibility and role in the process.

It's frustrating that after two years of a steep learning curve with diabetes management that things are changing all over again.  My body is responding entirely different to carbohydrates now at three months postpartum than it ever did before or during the pregnancy and, despite my irritation with the idea of the glycemic index, I capitulate that it is completely necessary.  And while my e-whining about cream of wheat and pancakes may indicate otherwise, I think the fact of the matter is that I am more emotionally attached to the luxury of choice than I am to the specific carbs I'm losing... my world is shrinking even further because of diabetes and the reality of my new condition and its limitations causes me great sadness.

Completely unintended.  You'd think it is smiling because it knows...
sick sense of humor pancake, just sick. 

Farewell, my beloved breakfast.

This past Saturday at just before 9:00 in the morning, two hours after my breakfast, my jaw hit the floor when my blood glucose meter read 312 mg/dL.  Having calculated the carbohydrates in my breakfast precisely and then failed to drink my coffee my blood sugar should have dropped low, but like so many early day meals lately my glucose was off the charts.  I'd adjusted my pump settings last week in an attempt to self-correct my post-breakfast hyperglycemia, but seeing my meter read a clearly unhealthy, wholly intolerable number in the three hundreds (THE THREE HUNDREDS!!) I placed a call to my endocrinologist on Monday morning for some much needed help.

Since my two hour postprandial numbers have been high, but my four hour postprandial numbers have been low/almost low she didn't recommend changing my morning bolus ratio and, because my breakfast isn't always at the same time, she said my basal rates shouldn't be the issue.  I inquired about whether I should go back on the symlin injections, but because I am breast feeding she insisted that I do not since there isn't any information about whether or not artificial amylin is transmitted in breast milk and, if it is, it'd create an unsafe situation for GV.

Removing all the "simple solutions" to the issue and still without a clear path forward, Dr. Rogacz inquired about what I usually eat for breakfast.  Telling her that my everyday (yes, the same thing, everyday) go to breakfast is a bowl of cream of wheat and a cup of coffee, she made an "ah ha" sound and proceeded to break my heart by saying "your problem is probably the cream of wheat."  Citing the high glycemic index of wheat, as we loving call it in this house, she instructed me to drop it and similar "dense" carbs out of my diet in order to keep my sugars under better control.

(Insert mopey, pouty face here)

So what is the glycemic index (GI)?  The GI is a measurement of how much each gram of carbohydrate in a certain type of food raises a person's blood glucose level once it is consumed.  Foods that breakdown quickly in digestion and rapidly release glucose into the bloodstream are "high" (over 70) on the GI scale, where as foods that break down more slowly will gradually release sugar into the bloodstream and therefore are considered to be "low" (under 55).   Here are some examples for you:

High:  Rice, plain white bread, potatoes, breakfast cereal and watermelon.

Medium: Sweet corn, bananas, raw pineapple, raisins, pita bread and regular ice cream.

Low:  Raw carrots, peanuts, raw apple, grapefruit, peas, skim milk, kidney beans and lentils.

Because a lower glycemic response usually means less insulin is required to maintain a healthy HgA1C, foods that are low on the GI tend to improve long-term blood sugar control and cause less spikes in sugar like I am currently seeing at my two hour postprandial.  So, you see, on top of needing to be carbohydrate conscious on the basic this is bread that is pork level, my body has decided for the first time since becoming diabetic that it cares what carbohydrates I am eating and is forcing me to forfeit the lusciously dense carbs I emotionally love.

I know my doctor is right in making this recommendation and I'm only just beginning my research on what this actually means as a lifestyle choice, but my first response is that I am thoroughly peeved.  I am annoyed with my diabetes for messing with me again and on something so indulgent as my favorite breakfast.  I mean at least the doc didn't tell me to give up coffee (Lord knows THAT would have been impossible) so I at least still have that, but what to have with it will take some time.  I expect after an adequate period of mourning that I'll come up with something else to whip together in half sleepy delirium, but for the time being, in a state of melodramatic protest I refuse to replace it with something sub-satisfactory.

Running, sans supervision!

The last couple weeks have been over cast, cold and dreary - more or less the meteorological embodiment of my state of mind and energy levels.  I've avoided leaving the house without HB in an attempt to reduce the overwhelmed feeling I get when GW is melting down, GV is hollering to be fed and Lord knows what else is pulling me in six different directions and making my back seize with stress.  Fortunately when HB is home I've got the backup I need, but, I tell you, when it's just me and those clouds I couldn't feel more unmotivated to complicate my life with a trip to the grocery store or rainy playground outing.  But today things were different.  It was the nicest, warmest weather we've had in Virginia in ages - seriously the sky looked fake it was so blue! The sun was shining and, even though HB wasn't here, I decided to take my chances and get out of the house.

Going through the pre-outing check list, I tested my post-breakfast blood sugar to make sure it'd be stable enough to take the kids out on my own.  My meter beeped and it read 230 mg/dL; way high.  Now, granted, hyperglycemic blood sugars ensure I wont randomly pass out and leave my children unsupervised on a walking trail or vulnerable on the swings, but for someone who takes pride in tight glucose control such high numbers are horrific.  I don't know what's causing them, but I've seen several high readings like this lately - I mean I am not under bolusing, miscounting carbs or over eating... I'm just off.   I'll need to talk to my endocrinologist about this...

So I punch in the bg numbers into my pump to see if a correction dose is necessary; which it isn't.  I've got 2.3 active units of insulin left in my system from my breakfast bolus and I only need a measly 1.3 units to get back down into my ideal blood sugar range.  But not wanting to wait for it to take it's sweet time (haha, get it?) to come back down I decided to throw out the mental debate I'd been having between taking GW for a bike ride or simply going to the playground and opt to go for a run instead. 

Now, I've never done this before... "this" being running with the stroller and "this" also being running by my-diabetic-self because HB always pushes the stroller and HB always runs with me.  You might think this is mean of me for not helping tote the extra weight around (stroller: 34 lbs + GW: 38.5 lbs + GV: 13.3 lbs + GV's car seat: 11.7 lbs = 97.5 extra lbs!) or you might think I'm genius for creating a scenario that "requires" HB to exercise, but the reality is the stroller makes my hands go numb (a sensation I loath) and I am terrified of the worst case outcome when combining diabetes with exercise, passing out.  If I pass out with HB around he knows what to do, but if I pass out without him the what ifs start to pile up and I typically don't find the risks worth running. Literally. 

But with my blood sugar sky high, the weather this nice and my mood more zipp-a-dee-doo-dah than normal, I detach my pump, place it on the night stand, lace up my Asics and we head to the car.  Since exercise works to improve insulin efficiency in the body, I know that by running my glucose levels will drop and by starting with my blood sugar so high, removing my pump and strategically checking my bgs along the way I can get back down into a healthy range sooner and then consume quick acting carbs as necessary to prevent going too low.  So without my babysitter and child-pusher, I put my music on and hit the pavement... within one mile my blood sugar was down to 138 mg/dL and by the end of the three mile loop it'd gotten down to 65.  

Admittedly I failed to keep my sugars in the safe range, but I accomplished everything else.  I'd put a mental block in my head about my ability to push that stroller and run on my own that didn't need to be there.  So what that my hands loose sensation? And, yeah, my diabetes still requires conscientious treatment, but oh well, c'est la vie. The point is I can do it - and not half badly either!  Granted I'm not about to let HB off the hook now and run on my own all the time, I'd still prefer to have him around... it just goes to show that the lesson learned today is that I run with HB because I want to, not because I have to.