The Story of the Insulin Onion

I turn 29 years old in 9 days. But yesterday afternoon I was 30.

30 mg/dl, that is.

The day started out as any other. I woke up early so that I could get in a long run — 7 miles — before I was going to meet some other Minnesota bloggers for brunch. Never met them before, so I was excited. The run started off normally enough, but I started to notice my quads hurting more and more, and more and more. Finally, after about four and a half miles I stopped to stretch. It was only then that I could hear a faint buzzing sound penetrating the music in my headphones. I took off one earbud and immediately was crestfallen. The buzzing was actually the screeching of a dead pod.

I was at least two miles from home and my husband was out at our apartment, so I knew I was on my own. Although my Dexcom still had me firmly at 200 mg/dl, I knew it was a lie. I knew that with the 30 grams of carbs I’d consumed and a no basal for God knows how long, the combination of that and exercise was going to spell disaster for me. My body does not like it when I deprive it of insulin. I attempted to run a bit more, hoping that I might either get home faster or perhaps keep my blood sugars down with whatever basal was still in me. But I pretty much failed and practically hobbled home, my legs burning with ketones. (I don’t know if my legs are really burning from the acid of ketones, but that’s what I assume.)

My husband could hear the screaming pod as I walked into our kitchen and immediately gave me a sad face. He knew what that sound meant.

“It’s been dead since halfway through my run,” I said. I asked him to bring me a bottle of insulin, a new pod, and a glass of water. I tested my blood sugar and I was 385 mg/dl. Like I said, the Dexcom lies when it comes to exercise (which is such an unhelpful time to be inaccurate, btw).

I changed the pod and corrected. Then I gave a little bit more for the missing basal. And then I decided to increase my basal 50% because I, you know, assumed I had ketones and that’s what I always was taught. Take more insulin for ketones.

Although I could barely move, I didn’t want diabetes to ruin a perfectly good social event. At brunch, I pretty much ate what I wanted. Sometimes when my blood sugar is high I sort of shrug my shoulders and indulge because, hey, I’m already high, right? Not like I’m ruining any blood sugars here. They already suck! So I indulged in a cinnamon roll, some biscuits and gravy, and pineapple. There was also copious amounts of bacon involved. I kept bolusing for my food.

But I also made a tragic error.

My Dexcom wasn’t showing a decrease in my blood sugars — I was firmly planted at HIGH for a couple hours at this point — so I tested my blood sugar. 455 mg/dl. And I corrected. Not that reduced correction from the IOB I had from previous boluses, but the whole thing. And that was on top of some pretty liberal doses for my brunch.

About an hour later, I had a down arrow at Target. Finally. Whew. And when I got home I decided to take a nap. I hadn’t had much sleep in our first night in our new house, and between that, the 7 mile run, and the crazy blood sugars, I was wiped out. So I took a nap for about an hour or two. When I woke up, my BG was in the low 100s and looked stable.

Or so I thought.

A little while later, my Dexcom finally alarmed that I was low. But a juice box wasn’t enough. I was tanking. And fast. The low blood sugar symptoms were really started to kick in hard and I felt awful. Low blood sugars, for me, are painful. My legs and hands felt like they were being crushed. I don’t know how explain it, but low blood sugars are agonizing.

Dexcom now said I was in the 40s and dropping, not rising. I told Erik to get me another juice box. I tested my blood sugar while he was gone. When he returned, I flashed him the meter.

30 mg/dl.

Not my lowest blood sugar ever (that was a 29 mg/dl at diabetes camp, of all place), but pretty close.

I drank the juice box. I suspended my insulin pump. Erik brought me some chocolate and a graham cracker with peanut butter. Of course, all this food was not reacting well with my Victoza-induced suppressed appetite and I was getting a horrible stomach ache. On top of that, I started sweating profusely. Apparently it was bad enough that Erik started blotting my arms and legs with a bath towel!

My Dexcom swore my blood sugar was rising, but I knew it was lying again so I tested. I was 51 mg/dl. A little bit of movement over the past hour, but not nearly enough.

This is the part of the story where I tell you that I’m an idiot. Because you’re probably thinking to yourself, “Allison, just take some freaking glucagon!” Well, I don’t have any glucagon. Nope, none. I haven’t owned a glucagon since…. Yeah, exactly. I don’t know if I’ve ever filled the prescription in all the years I’ve been on my own. Anything I tell you will just sound like an excuse, which they are. But it just never felt important. Like it wouldn’t matter if I did or didn’t have it.

Well, yesterday, I wished I’d had a glucagon. I thought about calling one of my many Minneapolis PWD friends, but decided to wait just a little longer to see if a third juice box would do anything.

On top of that, I wasn’t entirely sure what I would do with a glucagon once I had one. I was fully conscious and able to eat. I only knew about giving glucagon when you’re unconscious. I figured I wouldn’t need the entire dose if I was awake. How do you dose glucagon for severe lows? At the ADA Scientific Sessions, Jeff Hitchcock had mentioned his daughter Marissa using mini-doses of glucagon when she had low blood sugars and morning sickness, but he didn’t say anything about how much she actually used.

Earlier this afternoon, I had a call with Jennifer Smith, my CDE at Integrated Diabetes Services and I recapped for her the adventures of the day. I asked her how someone should dose glucagon when they’re awake. When do you decide to use it and how much should you take?

Jenny said that using glucagon when you’re awake can be beneficial when you’re either at a very low blood sugar (such as 30 mg/dl) or when you’re not physically able to eat enough to bring your blood sugar up without getting sick (such as morning sickness or if you had a big meal earlier). Very low blood sugar can take a long time to come up and glucagon just works faster. Jenny said that the recommended dose would be half of the glucagon kit. A whole dose is 1 mg, but taking half that is enough to bring blood sugar up quickly.

The low blood sugar seemed to drag on forever, and I couldn’t understand why my blood sugar was tanking even though it had been so many hours since I’d given insulin. My blood sugar didn’t start to really come up until almost eight hours after my last correction, almost three hours after I started treating my low blood sugar! Shouldn’t the insulin be done working by now? Not so, according to Jenny.

She explained that when you give a huge dose, or a lot of doses close together, the insulin forms a bubble under the skin. Rather than just popping, the bubble slowly breaks down. Jenny described this as being a bubble because insulin is a liquid, but I think of it more like an onion. Layer by layer of insulin starts to work, but the inner layers can work until the outer layers have dissipated. The larger the dose, the bigger the insulin onion.

When you take a huge dose, your duration of insulin action is much longer, and your insulin on board might be a lot more than you think. This is what happened to me and why my blood sugar started dropping so far from my last bolus, and also why it took so long to come up. I had a lot more insulin on board than I thought. Jenny suggests splitting a large correction, taking some by pump and some by injection, or splitting your injection into two separate locations. This prevents a big insulin onions from forming.

Eventually, my blood sugar recovered. It actually recovered a little too well, and I almost hit 400 mg/dl again! But I was more careful with correcting and only needed a couple of small corrections.

My blood sugar when I woke up? 90 mg/dl.


Around These Parts

woman-typing-at-computer2I have a few new freelance pieces were published recently that I want to share!

First: Now on newsstands, my eagerly-awaited article on the relationship between patients and their healthcare professionals is now out in the Fall issue of Diabetic Living magazine! That piece features several members of the DOC who graciously contributed their thoughts. I also have a shorter piece on Polycystic Ovary Syndrome, which features Lizmari Collazo.

Second: I’m now one of the featured bloggers on Insulet’s SuiteD! I’ll be sharing some of my thoughts about diabetes and the journey to being an insulin pumper. I have six posts planned over the next few months. My first post, on celebrating life with diabetes, went up last Friday.

Third: My article on diabulimia was published on Insulin Nation earlier this month. I think it’s such an important topic affecting so many women. I was able to speak to a couple of women who work at a local treatment center specializing in diabetes and eating disorders. It was really interesting to learn about the great work being done here in Minneapolis.

And in case you missed it: I also wrote a recap of the ADA Scientific Sessions last month for Insulin Nation, as well as an article comparing five trendy diets.

Fourth: I wrote an article comparing various sweeteners and artificial sweeteners for Diabetes Health. I know this is quite a controversial topic! I also wrote a piece on e-cigarettes for their pharmacist publication. That was quite an interesting topic to read about. I had no idea e-cigarettes were so unhealthy! I mean, I knew they weren’t healthy, but they are a lot worse than I thought.

Before & After

Do you remember your life before diabetes?

I was thinking about the Bionic Pancreas the other day. What it does and how life is different for the few days that people are on it. How they can eat what they want and do what they want and they don’t have to think about numbers or symptoms or back-up plans. The idea that, for the most part, life on the bionic pancreas means just being. I know that a bionic pancreas is not a cure. But it made me think about what it could be like to have life almost without diabetes.

I thought about what it would be like to eat a meal and not check my blood sugar, count carbs, take insulin, and wonder if what I did would be enough. I thought about it and I realized that I’d never really done it before. Of course, having been diagnosed at eight and half years old, there were plenty of meals where I ate without thinking about what I was doing. Hundreds of meals, actually.

And I don’t remember any of them.

I have only the faintest memories of life before diabetes. I remember playing in the sprinklers at day care. I remember the day my brother was born. I remember throwing up in my elementary school’s hallway when I was six (it was quite traumatic). I remember my second grade teacher reading stories in his funny voices. I remember… There’s not much before diabetes.

But I remember diabetes.

I remember the weeks leading up to my hospitalization. I remember the persistent thirst, waiting in line at school for a drink of water and then going to the end of the line for just one more. I remember my third grade teacher pulling me aside, commenting on my pale skin and dark circles, asking if everything was okay. I remember waking up three, four times a night to pee. I remember my dad sitting in my desk chair in the middle of the night, waiting for me when I got back from the bathroom. I don’t remember what he said, but I remember it scared the shit out of me.

Then there’s the day I was diagnosed. I remember the fluorescent yellow lights of my pediatrician’s bathroom as I peed into a cup. Oddly enough, I remember my reflection in the mirror. I remember waiting for the phone call. I remember my mother telling me I had diabetes. I remember the drive to the hospital. I remember throwing up all over myself. I remember feeling very small in the Intensive Care Unit.

My strongest, most vivid memories begin with diabetes. And I carry diabetes with me through all the memories that came after. Many wonderful things have happened since being diagnosed with diabetes, but the truth is that diabetes was there for all of it. Prom, graduation, learning to drive, moving away, college, moving away again, traveling, getting married. My memories are not only about diabetes, but diabetes was still there.

There is so very little before diabetes. But maybe someday I will have an After.



Womanly Woes

I started my period today.

I know it’s not polite conversation to talk about such things, but diabetes doesn’t really give two hoots about polite conversation, does it? It affects everything, including something that is already painful and annoying enough as it is.

Over the years, I’ve seen a lot of questions pop up in the diabetes community about whether or not women have issues with their blood sugars around their period. And the answer is: hell yes it does.

For the most part, the pre-period hormones, progesterone and estrogen, can cause insulin resistance during the week to 10 days before the period starts. Personally that’s when I noticed my blood sugars going up the most and it’s a fairly consistent pattern. One study at the University of Buffalo positively identified progesterone and estradiol as impacting insulin resistance. However, anecdotally I’ve heard of some women who deal with low blood sugar before and during the period, but I’m not entirely sure what would cause that because biologically, hormones cause insulin resistance (seen most commonly in the dawn phenomenon).

ptrack2One thing I have found helpful is tracking my menstrual cycle using an app called Period Tracker (I use the Lite version). I enter when I start and stop my cycle, and the app predicts based on my previous cycles when I should start the next one. It allows you to track a few things, like your symptoms, as well as your fertility (if you’re trying for a baby). I haven’t spent much time tracking my insulin resistance or other PMS symptoms using the app, but I imagine it could be helpful to see how far in advance you typically start having issues so you can be on the lookout. You can set the app to remind you when your period is about to start, so having the head’s up could be useful.

Right now, my app is set to alert me four days before I’m due to start my period so I can be on the look-out for any suspicious rises in blood sugar. I haven’t really tracked when my insulin resistance typically starts, but observationally I haven’t noticed any consistency. If I notice unusual high blood sugars, then I’ll check the app to see how far out I am. If it’s a week or so before my period, I attribute any strange blood sugars to my cycle. But if it’s more like two or three weeks before, then I know it’s something else. Most of the time my insulin resistance will go away the day or so before my period starts, but typically I noticed things calming back down after my period actually starts.

To deal with the insulin resistance, I’ve tried a combination of things. I’ve used temp basal rates, usually about 30 to 50% more, but I usually end up tanking after awhile. There are a lot of mountains and valleys! Something I’ve noticed more recently is that my insulin-to-carb ratio and my correction factor needs tweaking, as my blood sugar will not come down with a correction or it will go up after a meal and not come down all the way.

Unfortunately, Omnipod doesn’t allow me to have various pre-set insulin-to-carb ratios or correction factors, so I tend to be pretty lazy about this. I don’t think any of the other pump companies do this either, but someone correct me if I’m wrong! I end up just being more aggressive with correcting, taking additional units of insulin even when my pump says I have enough insulin on board.

The Diabetes UK website mentions that some women can notice that this phenomenon varies from month to month, and as I mentioned earlier, I have noticed that my hormone levels do not consistently affect my blood sugars. This is one reason that I find the Period Tracker app so useful. I have occasionally started my period without having dealt with any insulin resistance at all. Because it’s not always predictable, it can be easy to get lazy about tracking what’s going on.

Before I started tracking my cycle, I would have days of insulin resistance that felt like a complete mystery because I couldn’t tell if it was associated with my menstrual cycle or not. Now that I’m tracking, it’s easier for me to spot the correlations between my blood sugar and my cycle. I also know that if my blood sugars are going up from my menstrual cycle it means I can leave my normal basal rate alone. It can seem like there are new patterns in blood sugar that need fixing, but in reality it’s just a temporary blip that doesn’t require a complete basal and bolus overhaul.

Although it’s incredibly frustrating, it’s nice to know that if you think your blood sugars are going up before your period, you are not going crazy. Well, you might be going crazy, but that’s just normal PMS. Nothing to do with diabetes (or so we think…).

Musings On Famous Diabetes Bloggers & Advocates

It’s that time of year again. The summer season features three of the largest diabetes conferences: ADA’s Scientific Sessions, CWD’s Friends For Life, and AADE’s Annual Meeting. Thousands of people converging to share new insights and experiences in living with and / or managing diabetes. It’s also become the time of year when more and more diabetes bloggers get the spotlight for the work they do in the Diabetes Online Community. This isn’t to say that spotlight isn’t on certain people the rest of the year. But with so many in person meetings happening between June and September, it seems that the variations of the phrase “famous diabetes bloggers” pop up more often.

And it drives me up the freaking wall.

I suppose it’s because I have a unique perspective. I started alongside — or even before — many of the well-know famous bloggers that everybody clamors to meet. Some might even say that I am one of those top bloggers, but I don’t personally feel that way. I’m not on any best blogger lists, I don’t get hundreds of emails, and I used to participate in blogger forums. But I’m not writing this to get pity or fish for compliments.

What I want to talk about is this hierarchy that I’ve seen develop in the Diabetes Online Community. I suppose I have the unique perspective because I’ve known the top bloggers that you — and I, of course — adore for many years. I knew them before they were famous. And I know how normal they are. I know how flawed they are. I know that they are simultaneously the nicest people you could ever meet, and I also know how stressed out and strapped for time they are. I know that there are so many diverse personalities in the DOC, I know that not all of us are besties, and I know that we all try very hard to be as inclusive as we can but we are sometimes trapped by the confines and habits of pre-existing friendships.

Did I destroy your illusions of the DOC upper class? Good.

When I hear recaps about people’s experiences at conferences, I always love hearing how people felt connected, how they learned so much for being with others or attending sessions with experts (who are also insanely normal and easy to talk to), and how they felt better and more hopeful about life with diabetes.

But what gets me every time is when people talk about how afraid they are to talk to the “big bloggers” of the DOC. And I just shake my head thinking “Whyyyyyy?” It kills me because I honestly know that each one of them wants to meet you. I know that these guys and gals are just doing their thang. And I also know that having the gift for communicating via the written word, or the time, energy and patience to create an online community of thousands, or the perseverance and strategic know-how to kick the FDA in the ass does not mean you are a better human being.

I know how easy it is to be shy and to think that people don’t want to talk to you. Even me, a quasi-big blogger (medium blogger?), sometimes gets tongue-tied and gun-shy around people. And I know what it’s like to admire people and be completely convinced that you are the tiniest, most insignificant speck in their world. When I was at the DHF fundraiser at the ADA Scientific Sessions, Ed Damiano recognized me. The guy who invented the bionic pancreas knew who I was without me having to tell him. And Aaron Kowalski waved at me too! And I was like “Whaaaa?” These guys meet about a billion people every year. How could they remember little old me? But that’s the whole thing that drives me nuts because then I think to myself, well, why wouldn’t they remember me? I’ve worked with them. I interviewed them. I’ve done stuff. I’m around. Why do I expect that no one remembers me?

When I see comments from some of the newer bloggers who say that they are shocked people know who they are, trust me, I’ve been there. And that’s why I want to reach out and give everyone a little boost of confidence when it comes to being a part of the DOC. Don’t let the idea of “big bloggers” fool you. They might have a larger readership but no one is better than you. We all have our own strengths and weaknesses. We all have areas of our lives that we decide to devote more time to. We all work hard at something that means a great deal to us. And sometimes we get lucky breaks.

While the division between type 1s and type 2s will always reign supreme, I feel like the division between “popular bloggers” and “everyone else” could ruin the fabric that is the Diabetes Online Community. It might seem harmless or unintentional, but I think this kind of “big” versus “small” blogger thinking is unhealthy. It’s not needed! I’m not saying we’re at risk for imminent destruction, but I see these comments pop up every so often and it worries me what people might really be thinking. I don’t want to see the DOC ruled by some artificial hierarchy.

When we elevate people far above what is called for, it’s disturbing. It can be soul-crushing for some people. It’s not fair to either side. While there are many people who deserve respect and admiration for what they do, they should not be idolized like gods. They are not superhuman, even when it seems that way. They are very much human. They are very much lovely people. And you are lovely too.

The Become A Better Blood Sugar Whisperer WINNERS!

6a0120a678c547970b019b0013ae37970d-piWow! What an amazing week! Before I announce the winners, I want to say a huge thank you to everyone who entered the Become A Better Blood Sugar Whisperer giveaway bonanza! I was so happy to see that more than 50 people entered to win some really amazing prizes. I loved reading each comment, learning about how a particular prize might help you become a better blood sugar whisperer.

Of course, none of this would have been possible if it weren’t for my amazing sponsors: Integrated Diabetes Services, Sugar Medical, Tallygear, Demos Health, Spry Publishing, GlucoLift, Diabetic Living, and MySugr. You guys rock!

And now for the moment you’ve all been waiting for… the winners!

As previously explained, the giveaway winners are selected in the order the giveaways were listed. They are also listed by the name with which they left a comment. If you win one giveaway, you are ineligible for any subsequent giveaways you may have entered. If you won a giveaway, you have already received an email.

Giveaway #1
A comprehensive diabetes self-care assessment and tune-up with Gary Scheiner, MS, CDE, 2014 AADE Diabetes Educator of the Year and author of Think Like A Pancreas.
The Winner:
Elena Lien

Giveaway #2
Sugar Bags from Sugar Medical in your choice of color.
The Winner:

Giveaway #3
The Original Tummytote Belt from Tallygear in your choice of color.
The Winner:
Charlotte Beasley

Giveaway #4
GlucoLift prize pack with a bottle, tube and Tandem tin in your choice of flavor.
The Winner:

Giveaway #5
One year subscription to Diabetic Living magazine.
The Winner:

Giveaway #6
The Complete Diabetes Organizer by Susan Weiner, RDN, MS, CDE, and 2015 AADE Diabetes Educator of the Year.
The Winner:
Jeanne Shedore

Giveaway #7
MySugr Companion Pro app
The Winner:

Giveaway #8
An autographed copy of Dealing with Diabetes Burnout by Ginger Vieira
The Winner:

Giveaway #9
An autographed copy of Think Like A Pancreas by Gary Scheiner
The Winner:
Anthony Dellett

Giveaway #10
Diabetes Do’s and How To’s by Riva Greenberg
The Winner:

Congratulations to the winners!! I wish I could give prizes to everyone who entered, but I promise you this is not the last giveaway here at The Blood Sugar Whisperer. There will be many, many more opportunities in the future! Thanks to everyone who participated!