And there was evening, and there was morning...

Just a quick update on the ongoing Lantus experiment... If you've popped by before you may have read that I recently changed the timing of my Lantus injection to combat fairly frequent, low-level morning hypos.

After the initial euphoria of my new-found pre-breakfast bg stability had worn off, I began to notice an unfortunate side effect of the new system. True, I was no longer waking up hypo 3 times a week, but I began to find that after breakfast my blood glucose levels would 'spike' - rising steeply and peaking way higher than I'd like.

When I'd suggested shifting my Lantus dose to the mornings to the DSN at the hospital, she had said that in her experience it merely 'moved the problem'. While this wasn't exactly true in my case (as I wasn't having consistent late afternoon hypos) it did appear that I'd simply swapped one problem for another.

My overall control has always been pretty good. A few swings here and there, but on the whole, fairly respectable HbA1c's (the test that reveals how 'normal' your blood glucose levels have been over the previous 12 weeks or so - below 7% is the guideline). One of the things I'm noticing about my renewed focus on tighter control is that you quickly move your own goalposts. I know for sure that one of the ways I've kept my HbA1c's in check is by having rather too many low-level hypos to counteract the high readings over the same period. Good control is not about constantly swinging from high to hypo, but as with all average-based assessments the HbA1c can hide the true picture.

In short, I was not happy to constantly spike after breakfast especially since I was now missing all those pesky morning hypos that would have kept up the illusion of good control in my HbA1c.

So for the last week or so I've been splitting my Lantus dose, half at about 10pm and the rest at around 7am the following morning. My reasoning was this... Lantus takes a good 3-5 hours to get going (this is why it is often recommended that you take the dose last thing at night). It also lasts around 18-26 hours, depending on the person - I think it's around 20-22 hours for me. What I think was happening with my breakfast time dose was that yesterday's had run out, and today's wasn't kicking in until mid-morning at the earliest. This meant that my breakfast bolus was having to cover basal requirements as well as whatever I was eating. By injecting half and half I now have two activity curves running out of phase so that the onset of one is covered by the activity of the other.

I have to confess that the timings of the doses are based more on convenience and the likelihood that I'll remember them than any complicated graph-based calculation of perfect timings, but for the last week or so both fbg (pre-breakfast blood glucose level) and post breakfast readings have been pretty much bang on target.

Well apart from the day I forgot to inject that is... but that's another story.

Update: Basal driving me bonkers

Worrying

Other ways in which diabetes affects our lives: I worry.

I do worry about stuff, all the usual sort of stuff, the kids, money, pet care while we're on holiday etc.; though I don't think I'm an excessive worrier, but I do worry about Mike.

Maybe all wives worry about their husbands, maybe this is totally normal and nothing to do with diabetes, to be honest I have no idea, because this is all I've ever known.

I worry when he goes away without me. I worry when he goes out for an evening with friends. Basically, I worry when I'm not there to look out for him. Don't get me wrong, I know I'm not needed, he can look after himself. That doesn't stop me worrying. I suppose it's because there have been times when he has needed help and I know that not everyone would know how to spot the signs, why they are happening and what to do. Mike is an adult, and I am not his parent, but I think I probably worry in the same way a parent does. I worry that people may think he's drunk when he's actually hypo. I worry if he's away and wakes up low, that people will just think he's overslept. If he starts talking nonsense, will people realise something is wrong, or just change the subject out of embarrassment? Who will be there to spot it and help him?

My worries are, so far, unfounded. If I could stop worrying I would. I try not to show it, I don't really feel that I have the right to worry in the way a parent does, I have to respect Mike's right to independence, he is my equal.

But I do worry, because I love him.

Jane

Where's your pencil case?

Apart from the odd hypo, and a fairly considered diet, there are a couple of other ways in which diabetes affects our day to day lives as a family. The main one of course, is having to know in advance whether there is food provided at a party, or we are likely to be out long enough to need to remind Mike to take his insulin with him. Mike keeps all his stuff in a pencil case, so "Where's your pencil case?" is the question we ask to ascertain whether or not we will be able to eat while we are out.

These days he's pretty good at remembering, the pencil case is kept in a good place to make it a visual reminder, but there have been plenty of occasions in the past when we have had to turn the car round and come back to collect it, and once or twice Mike has had to manage without by either being very restrained and not eating, or choosing carefully. It does affect us all, not only when we have to wait until we get home, but also if we don't. There is nothing joyful about eating party food in front of someone who can't join in.

It's all about being prepared really, and part of that preparation is communication. It isn't the easiest thing in the world to ask the kind person who has offered the party invitation as to whether or not they will be feeding us, it feels a little cheeky. Mike does not like to be so bold. I find it easier, though maybe that's because I'm finding out on someone else's behalf, it's not really me that's 'making all the fuss', not that it is a fuss, but I think that is how Mike sometimes feels. He's not one to draw attention to himself.

It's easier now the girls are older, they are more able to wait, even if they are hungry. I never went anywhere without snacks to keep them going when they were little, again, all about the preparation. Hungry children don't make life worth living, and I'm just as bad. Mike doesn't tend to get hungry, unless he's hypo, it's a useful signal. But it also means that being out with three hungry women, who can't have lunch until we get home because he hasn't brought his kit, does put him in a quite dangerous position which he doesn't necessarily recognise or understand.

On the whole, it's a good idea to keep asking the question: "Where's your pencil case?"

Jane

Timing is everything

Injecting Lantus first thing in the morning... Just a quick follow up to my recent post about switching my Lantus dose to first thing in the morning. It works!

I've just looked back over some old bg readings for the last few years and they suggest I've been waking up to a low level hypo perhaps 2 or 3 times a week. Since switching the timing of the dose 10 days ago my levels have pretty much all been in the 3.9 - 7.5 mmol/l range with the majority between 4.4 and 6.7 mmol/l.

I got into an email conversation with Matt Jones who said he used to have a similar experience and had pretty much solved it overnight by injecting Lantus in the morning. I'd tried slightly altered doses (having got hold of a 1-unit Autopen) and having a small amount of slow-release carbs last thing at night to beat the morning lows but neither had been particularly effective.

I seems it wouldn't work for everyone - I mentioned switching the dose timing when speaking to my DSN and she had said that in her experience it just 'moved the problem', but for me the difference has been amazing.

Thanks Matt. I owe you one :)

Update: Morning and Evening

Diabetes Blog Week (Day 4) : To carb or not to carb

I came across the Bitter-Sweet Diabetes Blog the other day, written by Karen in Conneticut, US. When we began writing this family blog of living with diabetes we did a bit of looking around and while there were a bunch of active bloggers in the states, and some in Europe, those in the UK were a little harder to find. It would seem that Karen is part of a fairly wide-reaching network of diabetic bloggers both in the US and further afield (the Diabetic Online Community or DOC). Last week, Karen had a moment of inspiration and decided to set up Diabetes Blog Week (May 10-16) to inspire anyone writing about their experience of diabetes with a week's worth of topics. Today is Day 4, and the topic is 'To Carb or Not to Carb'.

Sometimes you look back on your life and think, well that was lucky. And that's just how I feel about my diagnosis. I know that's a slightly odd thing to say, but of all the long-term conditions one could get I think diabetes is a pretty good option. Yes you have to change aspects of your life. Yes sometimes it's incredibly frustrating and gets in the way. Occasionally it's quite scary both for you and those around you. On the whole though it is fairly easy to get along with (or even pretty much ignore for very short periods).

Another reason why I feel lucky is that when I was diagnosed I was introduced to the concept of 'exchanges' so I've been estimating carbs and adjusting doses almost from the beginning. The idea that people have been advised by medical professionals to eat great platefuls of carbs without any measurement of the load and just bung in a standard dose is quite frightening. I can't imagine what my control would have been like if I'd been given that as an approach. The first DSN I saw, way back in 1991, asked me about my general diet and from our conversation suggested a base level of carbohydrate to aim for which would make the whole dose thing easier to begin with. When introduced to basal-bolus, one of the main benefits, it seemed to me, was the ability to change the dose to match your meal. There was no longer any reason to stick to x grams of carbohydrate. My fortuitous timing then gave me this outlook:

• Eat normally
• Eat healthily
• Wholefoods will be easier on the bg
• Watch the fat intake but let's not be silly about it (I'm lucky never to have had a problem with my weight)
• Drink in moderation (and be very careful when you don't)
• Have an occasional treat/pudding/blowout - you're not a monk

Only quite recently I have come into contact with several people (both T1s and T2s) who manage their diabetes with a very low carb diet, some with spectacularly good effects. I don't go very low carb myself, tending towards 150g/day, sometimes much higher. In fact the more I read of the experiences of T2s the luckier I feel with T1. At least if I've got a big celebration blowout I can split a whopping insulin dose into several phased deliveries so that it gets gradually absorbed as my digestive system chugs through it all.

The secret to a happy, healthy diabetic diet I think is best summed up by this: Eat to your meter. Testing just before meals is not enough for me. I also need to check what happens in the hours afterwards. That way I can identify which foods cause spikes (or crashes) in my blood sugars, and then I can either avoid that food, or work around the problem with altered doses, splits and timings. Once the patterns have been spotted I've more chance of knowing what to do. Everyone is different. What works for me may not work for you. If you eat low carb and it works, brilliant. If you eat carbs and you can manage it, great!

The bottom line is keeping your control tight. That way we'll all keep well.