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Friday, September 08, 2006

Why Being Square Gets the Best of Me!

The other day, Scott over at Scott's Diabetes Journal wrote some about trying to plan for spontaneous happenings. I'd like to touch a little on the same thing but with an emphasis on how symlin can sometimes make that dealing with spontaneity thing just a little harder!

To start off with, I will say that symlin has helped TREMENDOUSLY with post meal blood sugars. Two hours after every meal with which I also use symlin I have basically flawless blood sugars, but there is a catch! Symlin reduces the speed that your body absorbs the food you eat. That means that 2 hours after you eat, you are still digesting your meal! I find that generally between 3-1/2 to four hours post meal I get a "truer" post meal blood sugar that is representative of how high my blood sugars are going to rise with that meal. This basically forces me to use LONG square wave boluses with each meal.

For breakfast I do a 2 hour square wave bolus and for dinner I wait one hour after eating to bolus, and then do a 1-1/2 hour square wave bolus. That means I am not done with my "insulin on board" for four hours!! for breakfast and FOUR AND A HALF HOURS!!! for dinner.

Imagine trying to go out for a bike ride after dinner. Normally, I would wait at least two hours after dinner to let most of that insulin finish up. With these long square waves Id have to wait until like 10pm to go out for that bike ride using this formula! The other thing to take into consideration is that there is no formula to help you figure out how much food you have left to be absorbed by your body. Ive noticed that most of my blood glucose rise is inbetween 2 to 4 hours after I eat. But say I wait two hours after my dinner to take my bike ride. I have 2 and a half hours left of insulin, my blood sugar is 113, and I also have most of my food left to digest! What do I do? Do I eat before I go just in case? I mean, all that insulin on board is going to make me nervous, but I also know I have food left to digest, but exactly how many carbs are left to digest?

Generally I avoid exercise within 3 hours of a meal with symlin at ALL COSTS. First of all, the food flavored burps during a run, are well, GROSS. Second of all, there are too many unknowns and it is just SCARY to try and figure it all out. I mean, what happens if I guess, and I guess WRONG? I usually err on the high side......Is that always better than the low side?

Another thing with these long squares, is what do you do if you have to disconnect from the pump for any reason? (say a shower, bath, etc...) I have a square wave going! It's gonna screw it all up if I disconnect! What I tend to do in this situation is I'll disconnect, making a mental note of how much of my square I've had delivered at disconnect. When I reconnect, I check to see how much I missed and manual bolus that in.

Symlin has been fabulous in helping me to iron out some of my post meal highs, but there is a humongous learning curve. So many different and new things come into play with this. You learn that your pump's computations concerning correction boluses may not be right if you use symlin and you are high 2 hours pp, because you are going to be absorbing most of your food in the next two hours, and half of your insulin you planned for that meal probably is not going to be enough. So you are back to guessing. That is hard, and you guess wrong, A LOT. But, you can figure it out, and I think for anyone embarking on a symlin journey, there will be people who decide it just isn't worth it. I can't say myself that I am totally sold on symlin. I haven't stopped, but I certainly have considered stopping.

Symlin also can take away some of that "spontaneity" freedom you can enjoy on the pump with faster acting insulin because of the need for longer square wave boluses. This can be a BIG problem. Generally, if I know ahead of time, I just won't take the symlin with the meal that will affect the activity later on. Symlin does make you feel strangely satisfied after a meal, but don't get too excited, this too wears off!

The main benefit of symlin, for me, is the ability it gives me to enjoy higher carb meals without crazy post meal spikes. I used to get really really tired after meals as my blood sugar did the one hour 240 2 hour 160 swoop. Now I keep a steady line after meals. An idea of what would happen with a high carb meal is 130 pre-meal, 85 1-hr pp, 120 2-hr pp, 130 3-hr pp, 143 4-hr pp (assuming I counted carbs right!). Whatever you do though, do NOT try to eat ANYTHING else in that four hour window after injecting symlin and eating your first meal! Its damned near IMPOSSIBLE to figure out which carb ratio to use (symlin carb ratio or no symlin carb ratio?)! Well it isn't, but that post meal snacking leads to most of my highs!


Scott K. Johnson said...

Another great post! And thank you for the call out!

Boy, what a double edged sword that symlin is (or at least sounds like).

I have a long insulin duration in the first place - even on Humalog my BG will continue to drop for almost five and a half hours. As you can imagine, I have terrible post meal spikes - but I can't take more insulin because I'd crash at the 4 or 5 hour mark.

It's terribly frustrating.

And trying to figure out how much more the food I can feel in my gut will raise my bg - talk about an impossible game! And just think - I don't even thing I'm dealing with gastroparesis (sp?)!! Can you imagine?

I also struggle with my basketball times. I play ball usually 3 days a week. I start at about 11:30am and play for a couple hours. The amount of energy I burn is incredible, and I start spilling exercise ketones almost every time. There's just no way I can get enough calories in beforehand to avoid it. I think it's Ok, because I've got plenty of fat to burn.

The thing is, eating a big breakfast, and taking a big bolus (to take the edge off the spike), all adds up to an impossible equation to get right! I'm almost always either battling highs on the court (sucks - feel all slow and lethargic), or hustling to keep my bg's out of the toilet! It's a hard thing either way!

Somehow I manage to make it through - and am still trying to find that right balance.

The other thing that makes it hard, which you also mentioned in your last post, is that my bg's are so sensitive in the mornings. maybe some of your neat breakfast ideas will help me tame that a bit.

Well, I think I've caught up to all the posts you've written so far - and let me say again - it's been a real enjoyable read! I'm almost sad that I've run out of stuff to read tonight!

Looking forward to your next post - and again, I'm so glad you've jumped in with us!

Take care!

Sarah said...

I think sometimes exercise can feel impossible, especially if you don't have the preparation for the exercise down pat. For me and running, the whole starting blood glucose value combined with how long I was able to reduce basals is going to play a huge part in how my blood sugars do during a run. The time of day makes a big difference as well. For me, running in the morning is a whole lot easier and my blood sugars are a heck of a lot more forgiving than the afternoon. Another thing is that if you are compensating with carbs during vigorous cardio, there is no way your body can absorb all those carbs at normal speeds. You will actually only absorb a certain percentage of what you intake until after you are done with your exercise. So post exercise highs can be caused by the final absorption of those carbs combined with the ketones you will have after a longer workout. ICK! One thing you can do is try and have your sports drinks or water that you drink with your carbs to be as cold as possible, because your body will absorb the colder drinks easier and more quickly during intense exercise than the warmer drinks. It is hard to do on a ten mile out and back, or a few hours in the gym, but you can try freezing it the night before or putting ice cubes in before you head out? Anyhow, I completely feel your pain on the exercise front, it is difficult and it seems usually impossible to figure out 100%. It seems like this is more so the case the more intense the workout is. I do FINE on an elliptical for an hour, but make me run for an hour and I've got a whole different set of blood glucose values to deal with!

Anonymous said...

testing 1 2 3

Anonymous said...

Oh mercy, I have created another account..........(this beta deal is driving me nuts)/
But.....I am so happy to have another Minnesotan on board - and if there are any more of you out there, please unveil yourselves now!
I love the St Cloud area. I grew up in a very small town about 40 miles south, and our biggest rebellion was to take my father's old car and sneak away to the Crossroads Mall on Saturday. My friend's brother was then able to turn back the odometer and no one knew the differene.
Did you get the appointment with Dr. Fish? About a year ago I tried to schedule an appt with one of the endos at the International Diabetew Center and they told me she was not taking new patients.
Anyway, she took care of my diabetes when I was at Methodist 8 years ago. My internist had just started me on Lantus and I had "a reaction" and gained 40 pounds of edema in 2 weeks. Not a pretty sight, plus very frghtening as they thought I had heart failure. But, happily, it was just the Lantus. At that time, Dr. Fish seemed to really know her stuff and was very kind and personable. The nurses told me they were all afraid of her bacause she was so fiercely protective of her patients. I had a hypo episode and they treated it with 80 grams of carbohydrate, and she called a meeting and really yelled at them for not following protocol.
I have also been to see the behavioral medicine people at the IDC.
So, whoever you see there should be able to help you - I look forward to hearing about it.
Sarah, I think that you and our other newbie, In Search of Balance, both have fantastic attitudes. And, with db, attitude contributes a big part to the quality of our daily lives.
Also, I did get the tea. I remember it from years ago when there used to be a GE restaurant in my neighborhood. It is a bit intense so I like it diluted with a little extra lemon. My ortho surgeon told me that carbonated beverages, whether diet or not, leech calcium from your bones and it's best to stay away from them if possible.
You have a beautiful family.
Build on the victories!! - Kathy

Sarah said...

Thanks for such a nice comment! Saint Cloud is really really nice. I grew up (went to high school) in Denver so sometimes, this town feels to small, but then I go to the cities and that maybe feels to big! I'm glad you had a good experience with Dr Fish. Im hoping she is going to be the doctor that wants to help me go to the next level and is willing to be aggressive with me! I plan to see her in November and when I do see her I will certainly update on what happens. I've really enjoyed your blog, as well as Scott and In Search of Balance. In search of balance has me trying new foods and craving produce lately! haha! I hope you enjoy the tea, Im thinking about saving the tea bags and reusing them, because the tea is so strong!