Wednesday, November 25, 2015

A Diabetic, A Pump and Airport Security

Today's Project Blue November Instagram Challenge is to show where you've travelled as a Diabetic.  I've been extremely lucky to vacation all over the world and the two of the highlights for me were:

1.  Scuba Diving in Moorea in 2011.  By coincidence the dive instructor had been part of the team that dove with the first T1 Diabetic to receive her PADI certification.
2:  Hiking La Soufrière in Guadeloupe last winter. It was a very steep and challenging 800m elevation changed and I was thrilled to complete it thanks to my pump and my patient hubby.

Travel can be challenging for the T1 Diabetic, with time changes, strange food, and unplanned exercise, but you plan for it and make it work.  The most challenging thing for me in recent years, has been crossing the Canadian border.  As I've mentioned in the past, I am a type one diabetic who uses an insulin pump. I travel by airplane a few times a year, leaving the country about once a year which requires a little more scrutiny when you go through airport security.  My pump causes the alarm to go off about 80% of the time so I used to remove it and pass it around the security system, where it would be checked using the swiping method.  The security guard uses a of pincer device that holds some reactive fabric, they swipe it over the pump and then run the fabric through a testing device.  Recently, airport security decided that Diabetics should NOT remove the pump because security didn’t want to be liable for anything going wrong with the machine while it was in their possession.  So now, when I go through security and my pump sets off the alarm, I get pulled aside for a more detailed examination.    It is a very unpleasant, public experience, where a female officer moves her hands over all parts of my body, including the intimate parts.

The first time it happened I was shocked.  I deal with stress often by using humour, so I joked with my husband, telling him I got a “free massage with a happy ending”. The security guard used the backs of her hands which is supposed to make it less intimate I guess, but personally I still felt like I was being violated.  Only once have I been given the option of going to a separate room away from the public for this to happen.  Because I didn’t want to leave my husband or slow down the process I decided to just get it over with.  The public part of it was the least of my concerns.

The second time it happened for some reason I felt more traumatized. When I knew it could happen a third time, to be blunt, I decided I didn't want to be molested through my clothing by a stranger and purchased a very heavy sanitary pad to put some space between myself and the examiner.  I put the pad on before going to the airport and when it came time for my “massage” it turned out the security guard was a woman in training.  As a result my experience was overseen by her superior (female) and it was very thorough.  I did feel more protected by the pad, but it still was an unpleasant experience.  I later spoke with a lawyer friend who told me I had no legal recourse and had to go through the process whenever I was asked.  

My last experience makes me wondered just how effective this examination really is.  To put it clearly, I had worn a large bulky object between my legs.  Marijuana, cocaine, heroin, explosives, a pocket knife or even illegal amounts of cash could easily be formed or padded into that shape and worn there.   I had been examined by someone being trained in the proper way to do this exam, in order to catch people smuggling illegal or incendiary items.   I was not questioned about what was surely obvious bulk.  So how is it that the examination of that part of my body, in a fairly intimate manner, could possibly be effective in stopping those illegal items from being smuggled into our country. 

I really don't understand then, why it's necessary to put me through this humiliating and invasive experience.  And what about people who have experienced sexual trauma in their lives?  I wonder how it makes them feel?  If you have any sense of compassion, it’s not difficult to imagine.

Tuesday, November 24, 2015

Diabetes and Exercise: The Real Fun and Games

Saturday’s Project Blue November challenge was to show how you keep fit to help control your diabetes.  We all know that being in good physical shape is beneficial whatever your challenges in life.  But I have to laugh when I read that exercise is essential in “helping to control your diabetes”.  I will not deny exercise is good for you, but for a Type 1 Diabetic, exercise can throw a wrench into your control.

 (My dogs help me get in shape by forcing me to walk them daily.  
This view at the top of Mission Ridge is great motivation.)

Whether diabetic or not, how your body reacts to exercise depends on the type of exercise.  Is it intense but for a short period of time, like sprinting?  Is it moderate for a long period of time like walking a dozen kilometres of Mission Greenway?  Is it a combination of two, like playing hockey or soccer where intense activity is followed by periods of rest?  Or is it a hike over terrain where the intensity changes from walking on a level path to climbing a steep grade and back down again?  If you’re a non-diabetic it’s likely the only difference you’ll notice in these activities is how hard you’ll have to work to perform them.  For a diabetic it’s a matter of juggling food, water, and insulin basals and boluses. I guess I should explain how basal and bolus delivery of insulin works for a pump users.  

My pump allows me to set what is called a basal rate of insulin delivery, where every few minutes I receive a very small dose of insulin, just like my pancreas would if it worked.  Because the amount needed can change over the day, I’m able to set different rates at different times of day.  For example at 8:00 a.m I received .800 units per hour, and at 11:00 I start receiving .850 units per hour.  A bolus dose is insulin that’s taken when you’re about to eat a meal or snack, or when you test and discover your blood glucose (BG) level is higher than your desired goal.  

 Long ago I figured out my personal Insulin Carb Ratio (I:C)  and my Insulin Sensitivity Factor (ISF) and these are programmed into your pump when you first set it up.    Now when I eat some carbs, I test my BG level using my glucometer and input the number of grams of carbs I’m about to consume.  Using my current BG reading, my I:C and ISF, the glucometer then calculates the amount of insulin I need.  The pump requires you to input that number into the pump, press OK and in it goes.  Right now, I have a pump that is connected to my glucometer remotely, so I can just input the number on my glucometer and it transmits the info to the pump, which puts then puts the insulin in my body. (I borrowed the above photo from the blog Active Diabetic, An Ongoing Experiment. My pump is similar, his is the next generation Animas Vibe.  I hope to upgrade to it very soon.) 

There are certain rules to be followed when it comes to setting these basals and boluses and there are certain rules to think about when it comes to exercise, but the reality is that it’s much like “The Pirate Code”.  And they can vary greatly from person to person.  I’m just going to talk about hiking, ‘cause that’s what I like to do.  Near the start of a long hike, glucose supplies 80% of the fuel required.  Your body uses glucose that’s already in your blood, it’s available from the interstistal fluid around your cells and your muscle cells have glycogen stores from which they withdraw glucose.  After three hours, half of the fuel comes from glucose, the other from fat.  After six hours, almost 80% of fuel will be derived from fat.  

So one part of preparing for exercise is to reduce the amount of insulin you take, because if your insulin uses up the glucose, then you’re going to have a hypoglycemic reaction.  You can do this by using the Temp setting on the pump to temporarily lower your basal for a set amount of time, and you can take less insulin when you bolus for eating. Your body does need some insulin to get the glucose into yours cells.  And if you lower it too much, then you can end up with high BG levels, which can make activity challenging and cause problems with lung function. I aim for a BG between 5 and 6.5.   If your BG is over 14, for some reason your body will actually start dumping glucose into your system from your liver if you exercise, so if you hit 14 you need to bolus and wait for your BG to drop.  

In terms of carbs, you need to figure out what kind are the best to take.  You need to have fast acting carbs (dextrose, jelly beans, juice) on hand for sudden drops in BG, and you want to consume some slow acting carbs before you start your hike, and small amounts every hour or so when you’re doing a hike that’s more than a couple of hours (granola bars, power bars, fruit).  

When we hiked the Rim Trail at Cathedral Lakes Park, the info showed us the hike would take 7-8 hours with an elevation change of 500m.   This required a lot of supplies.  In my large back pack, I packed a big lunch with two sandwiches, cookies and fruit.  For low blood sugar I added two drink boxes, two granola bars, and three tubes of dextrose tablets.  I packed extra insulin and pump supplies and batteries in case my pump failed in any way.  And of course I had my cell phone and camera.  We also carried a Spot GPS locator.  Not because we were worried about getting lost, but in the rare instance that I might have some sort of distress that would prevented me from hiking and require a rescue if food or insulin ran out.

After a lot of trial and error you figure out what works best for you in terms of how much to lower your basal and bolus and how much extra carbs to consume.  And here’s the fun part.  The less “trained” you are for a particular activity, the more you need to lower your basal and bolus doses to keep from going low, because your body is working harder when you’re not in prime shape, so it will use more glucose.  Therefore as your activity improves your fitness level, your body won’t have to work as hard.  It will use less glucose and therefore as you get in better shape, so you have to adjust your basal, bolus and carb intake all over again.  Fun!  

To add some more fun, your muscles like to keep their glycogen stores up for future activity, so after  strenuous exercise, they steal glucose from your blood to replenish its depleted stores.  As a result you need to keep a close eye on your BG levels by testing more frequently for a day or two after a particularly strenuous event, like a hike or a marathon.  On the first couple of days following our big hike, I took very little insulin over the next two days and had normal BG levels.  It’s pretty awesome to have great numbers over a long period of time.  

So things went pretty well for me over the 8 ½ hours it took to for our hike.  I let myself run a little high to prevent a low, but not high enough that my activity level was compromised.  I did run into a challenge during the last hour and half of hiking. I felt a bit off and tested, only to discover my BG was 11.  I was frustrated because we’d been working fairly hard, hiking up a slope and by all accounts I shouldn’t have been high.  I adjusted my basal, increasing the flow a little and took a very small bolus.  Within about an hour I was feeling low and did a test and discovered I was 3.6.  We stopped, I took a few dextrose tabs and drank some apple juice.  I may have eaten a cookie as well.  While we were waiting for me to return to normal we were joined by a deer, so the timing was serendipitous.  

After my weekend away, I was reading about exercise in the book Pumping Insulin, by John Walsh and Ruth Roberts.  I discovered a possible reason for what happened at the end of the hike.  Turns out dehydration can affect your BG level. Less water in your blood will concentrate it and make the percentage of glucose seem high.  Though we had two camel backs and two bottles of water with us on the hike, we were running low towards the end and though we hadn’t said anything to each other, we were rationing it.  When I stopped to test my BG and had the 11, I was quite thirsty and did drink a fair bit.  It’s likely that as a result, the insulin I added to the mix was more than I needed over the next hour.  In retrospect, I have noticed when I’m struggling a bit on a steep climb, stopping for a drink of water seems to do wonders for my energy level.  It seems there’s always something to learn about managing your diabetes.  Even after 40 years.

Tuesday, November 17, 2015

Ah Food, how do I eat thee? Let Me Count the Carbs

This morning on Facebook I wrote a post about carbohydrates or "carbs" as many people refer to them.  I mentioned that Type 1 diabetics have to determine how many carbs are in the foods they consume before they take their insulin.  How do you do that, you ask?  Here's where I tell you.

There are actually several different ways to determine how many carbs are in your food.  The Canadian Food Inspection Agency requires that most packaged foods put a nutritional breakdown on the label.

According to this label, there are 29 grams of carbs in 1/4 cup of uncooked oatmeal. When cooked that works out to about a one cup serving which is a much larger serving than I would eat.  I'd probably eat about a half cup (15 carbs), add cinnamon and walnuts (no carbs) and a couple of tbsp of apple sauce (6 carbs) and 1 carb for the almond milk.  This gives me total of 22 carbs for breakfast.

I recently read that the number on the box can be out by as much as 30%.  Some days you just have to make the best of it.

 There's also a handy-dandy book you can purchase.  It's purse size - 11x15 cm and the listings are alphabetical, within the alphabetical listing of type of food.  I find the list of beers and alcohol to be quite handy as well.  Spoiler, most hard liquor contains no carbs. There are also apps you can download, some for free, that have similar information and it's much easy to search an app than this bulky book. Calorie King Calorie Fat and Carbohydrate Counter also has listings of some common fast food restaurants and the carb counts of their meals.

And speaking of restaurants many of the big chains have an online page where you can see the nutritional content of their offerings, including number of carbs, and some nutrition and health websites, like Livestrong have a page where you can search for chain restaurant meals as well.

Sometimes I check things out before I leave the house and sometimes I check on my smart phone at the restaurant.  Once in Boston Pizza I asked the waitress if she they had a copy of their menu's nutritional breakdown, which she brought to the table for me.

As you can see the total carb count of Earl's Hunan Kug Pao chicken is 144 carbs.  That's as much carbs as I normally consume in a day and a half.  That meal would require me to take 12 units of insulin. My average dinner time meal is 50 carbs, requiring about  4 units of insulin.  That's a lot of extra insulin to take all at once.  If I really wanted to eat the Kung Pao Chicken I would only eat half of it, and have the rest put in a doogie bag.  What are the chances of me only eating half?  Not good.  A better idea is to ask the waitress if they could only give me half and box the other half ahead of time.

An extra two units wouldn't be so bad, and it's not a big deal to treat yourself every so often. Or you can treat yourself every day.  No judgement here.

My dietitian (who is also a T1D) calls those treats "insulin worthy".  For her it's Pumpkin Pie,  for me it's Cheesecake.  I never have a full piece though, because I've never sat down to figure out just how many carbs it would contain.  I just don't want to know.  I satisfy my craving with a bite or two of my hubby's dessert. 
The final method is my favourite:  A nutritional scale.  It feels more accurate, but unfortunately it's not very portable. They're relatively inexpensive (I think it was $25) and easy to come by.  This is from the Stupor Store.  Just turn the scale on, put the food on the scale, look up the number that corresponds with the food item, enter those numbers (in this case it was 309) press the carb/glucose button and the digital read out tells you how many carbs by weight -  in this case 8.25.

Once you add up all the numbers and figure out how many carbs are in your meal, there's a handy formula to calculate how many units of insulin to take based on the Carb Ratio you've figured out for yourself (it may vary depending on the time of day), your current blood glucose level and your ISF or Insulin Sensitvity Factor which you've figured out over trial and error over the years (and is subject to change without notice).  If you use an insulin pump your Carb Ratio and ISF are programmed into the pump, so you just put in the number of carbs and it does the calcs for you. Did I mention I love my pump?  I'll talk more about Carb Ratio and ISFs in a future post.

Some days it really feels this way.  As I've said before, a sense of humour helps.

Saturday, November 7, 2015

About That Pump

Those of you on Facebook have been inundated with my posts about Type 1 Diabetes (T1D) for the past week as November is Diabetes Awareness Month.  All of this is an attempt to dispel some of the myths and give a little insight into how our lives are affected  by this challenging chronic disease (effected?  I have no clue.)

I've been on an insulin pump since March 2011. I fought it for a long time.  I've noticed that diabetics are often resistant to changing the way we treat our disease.  I couldn't be happier with this change.  I can't imagine my life without a pump, which I think means the next time a new technology comes along, I'll be resistant to that one too.

For the uninitiated, I thought I'd share some of the details about what goes into using a pump.  First of all you need one of two things:  Lotsa money or a premium drug plan.  I'm extremely lucky my hubby has an incredible extended medical plan that gives me 100% coverage on my pump and supplies, right down to the AA lithium batteries that need replacing about once a month.

My Animas Pump costs just under $7000 and is warrantied for three years.  I have to change the infusion site (where it goes into my body using an "inset") every three days and the insulin is stored in a removable cartridge (which also has to be changed) inside the pump. A month's worth of insets and cartridges is about $525. Then there's the insulin which is actually relatively inexpensive at around $35 a month.

Friday I changed my pump site so I took some photos.  Here's what I do every three days:

First I get all the stuff together.  From left to right:  Vial of fast acting insulin, the cartridge...what's that you say?  Am I going to put that big gross needle into me?  No no, that big gross needle is how I get the insulin from the vial into the cartridge.  To the right of the cartridge is the pump.  The screen tells me that it's "rewinding" at the moment.  It's rewinding the plunger so I can put a filled cartridge into the pump.  I didn't say "full cartridge" because you don't fill it up totally.  After some trial and error you figure out how much insulin you need for three days and put that amount in the cartridge.  The round blue plastic item at the bottom is the inset.  It's a spring loaded device that helps get the cannula (the tiny flexible tube the delivers the insulin into me) under my skin.

Here's a picture of the cannula I just removed.  That clear little stem in front of my index finger is what stays under my skin. The tubing carries the the insulin from the pump to the cannula which is very flexible and so small I can't even feel it. 

Meanwhile back at pump set up, the next step is to attach the tube from the inset to the cartridge.  Then, as in the photo I put the cartridge into the pump.  Once it's in the pump, I'll screw that little black rubber thing over the end of the cartridge.  It holds it in the pump and helps make the pump waterproof.  (Yup, I can go swimming wearing my pump - though not scuba diving.)

Now I need to "prime" the pump.  I hold down a button that makes the insulin go through the tubing and I stop pressing when I see insulin come out of the tube that covers the needle in the middle of the inset.  Sorry you can't really see it in the photo.  See that white tab on the inset?  That's part of the paper covering the sticky fabric that will hold the inset in place on my body at the infusion site.  I'll remove the paper before the next step.

I usually move to the bathroom now as I find it easier to look in the mirror and find the best site on my stomach or upper bottock.  Sometimes I use an upper thigh, but I don't need the mirror for that.

I've pulled back the "spring" on the inset and it's ready to go.  Friday I used a spot on my stomach about two inches from my navel.  I hold the open part against my skin, making sure the tubing is pointed towards my waistband as I'll be clipping the pump to my belt. I squeeze both sides of the inset (you can see the spot where I press on this side under my thumb).  This pushes the needle and cannula into the infusion site with great force.  Next I push the back of the inset with my index finger, just to make sure the sticky part is tight against my skin.

In the top half of this picture you see a clear bandaid type thing and the envelope it came in saying "Bioclusive".  You can put this over the infusion site to keep everything from accidentally coming off your body if you've got it in a spot that is vulnerable to wear or if your tubing gets caught on something like a doorknob or a bicycle handle (been there done that).   If you've had an IV on your hand in the hospital, it's similar to what they use.

The other envelope says "skin tack wipe".  It's a little swab with super sticky stuff on it that you can rub on your body at the infusion site.  It helps things stick better.  I use one or the other, or sometimes neither depending on the spot.  I tend to get a heat rash from the Bioclusive and woe is to you if you get the sticky tack wipe on your fingers.

And here's what it looks like. Ignore that little bit of blood at 2:00.  Can't ignore it?  Ok...Sometimes you forget to do things.  See above where I said "I'll remove the paper before the next step."  Well I lied.  I did not take the paper off the sticky part.  The needle went in, but when I pulled the inset away from my body, everything came back with it because the fabric wasn't stuck to me.  A dumb mistake but sometimes you get distracted, c'est la vie.

Normally you wouldn't put two sites so close together, but it wasn't really a "site" because it was just a quick injection with a micro thin needle.

Here's the needle that went into me.  It looks a bit scary but really it's not. I've used the pump for about 4 1/2 years, changing it every three days. That adds up to...a whole lot of times I've done this.  And then there are the extra times when in comes off accidentally or I change it because my blood sugars are wonky and I suspect the cannula did not go in properly or the sticky has come loose.  So out of the hundreds of times I've done this, I've only felt the needle maybe four times and it only hurt for a millisecond.

When the pump trainer came to the house to show me how to use the pump I was pretty overwhelmed.  Not so much by the pump itself, but more by the amount of waste created by the process.  Luckily the with a little bit of work, the majority of the supplies are recyclable.

 As you can see, the cartridge needle is removable, you can cut that blue thing that helps deliver the insulin to the cannula off the end of the tubing.  Pliers make it easy to remove the needle from the inset.
Then it all goes into the Sharps container, which goes to the pharmacy once it's full. 

 All of this goes into the recycling and the cannula goes into the garbage.  Oops, took the picture before I cut that blue thing off the tubing.  Anyone know what that's called?
So there you have it folks.  In the next few days I'm going to do another post about how the pump, my glucometer and I achieve perfect control of my blood-sugars.  (Inside joke for the other T1D's and their families)