Pump Break: The Good, The Bad and The Ugly

As I enter the fourth week of my pump break, I’m slowly beginning to remember some of the reasons why I abandoned Multiple Daily Injections in the first place. But if there’s one thing that’s keeping me from reconnecting right now, it’s the thought of attachment and doing those daily maintenance tasks once again.

This pump break has definitely made me more disciplined with my insulin dosing. Having to physically inject forces me to be more meticulous with my insulin decisions, rather than just lazily dosing another unit to counteract a rising BG. I am using less insulin on Multiple Daily Injections today compared with recent pump history and my initial six year tenure on Multiple Daily Injections.

RapidCalc, the app I am using as my bolus calculator, is telling me that my average bolus insulin is sitting at 19 units per day. I feel that those 19 units reflect most of my days, rather than being an average of variable numbers. Scrolling through my more recent pump history, boluses have become very variable, with most days ranging between 20 and 30 units.

Thinking back to those first six years on Multiple Daily Injections, I also remember lots of wild guesstimates, corrections and big mealtime insulin doses of 5-10 units at a time. Nothing seemed to be able to get the job done. With a much smoother Lantus regimen and a newfound dedication to carb counting today, I can give those small insulin doses of 1-3 units and actually get the job done.

Then there was Lantus. My number one reason for ditching the shots was Lantus. I could never seem to get the dose right at night, while during the day blood sugars felt unmanageable.

Today, my 66/33% split seems to be giving me the best coverage I could ask for from a basal insulin. Six units keeps me fairly steady overnight, with no significant effects of dawn phenomenon while I sleep. A further three units in the morning helps to combat morning insulin resistance, and makes the remainder of my day much more manageable as my nighttime insulin tapers off.

It’s not perfect. Just this weekend I’ve re-learned that skipping a meal will send me low. I also went low one night last week, after skipping my afternoon coffee and then eating a fairly low carb dinner. So yes, Lantus does like it’s routine. But what I am achieving today is more than I ever expected I could get from Lantus, so I’ll take it as a win.

Some aspects of my diabetes management are exactly the same as when I was pumping. Like the delayed bedtime spikes from afternoon snacking that need a correction at midnight. And the weekend blood sugars that tend to cruise a little higher than their weekday counterparts. As much as I’d like to blame my pen or my pump here, I only have myself to blame!

I really miss having my pump on me to conveniently bolus or correct a high blood sugar when I’m out and about. Just last week, I was interrupted mid-injection at work. Which is frustrating, because I really need to focus while I’m injecting to make sure that it all goes in. Which brings me to my next point.

The drops. Those bloody drops of insulin that manifest on the end of my pen needle when I pull out too quickly after an injection. I’m left wondering whether all of the insulin went in, or whether I need to give another shot. There is a technique, by the way. Gently lift the skin beneath your injection site (don’t pinch), inject your insulin, hold the pen in for 15 seconds post injection, release the skin and then pull the needle out.

I’m also finding it harder to rotate injection sites, as they are less visible than pump sites and I do several of them each day. I find myself continually going back to the usual suspect areas, which i know I shouldn’t be doing.

The most enjoyable thing about my pump break is being able to go for a walk in the afternoons and not worry about rapid acting insulin sending me low. Getting changed without having to accommodate a pump in the process. Laying in bed and not having to feel that chunk in my pocket. In fact, I think that this is the least I’ve thought about diabetes in several weeks.

I still remember some wise words from fellow d-blogger Ginger Viera. She says that both methods of insulin delivery have flaws, and that it’s up to us to choose the flaws that bother us the least.

With the Festive Season well and truly upon us and my first Lantus pen nearing empty, I’m wondering just how much longer this pump break will last me. I guess time will tell…

Review: Extend Nutrition Bars

Earlier this year, I was sent a box of Extend Nutrition Bars from IBD Medical to try. I can’t say that I could muster too much enthusiasm for these, given that nutrition and exercise aren’t really my thing. However the folks at IBD Medical were still happy for me to give them a go and provide my own honest opinions. 

Extend Nutrition bars claim to “control” blood sugars for up to 9 hours when eaten at bedtime. Their blend of carbohydrates convert to glucose extremely slowly and therefore do not need an insulin bolus. They have been proven to reduce overnight hypoglycemia by up to 75% when eaten as a bedtime snack, and are also ideal as a snack inbetween meals.

It’s safe to say that I was pretty skeptical of these claims. I struggled to bring myself to actually put carbs into my mouth before bedtime and not bolus for them. Especially 22 whole grams of them. I rely on my basal rates to keep my blood glucose steady overnight, so I couldn’t really see any value in bedtime snacking.

I will preface my experiments by saying that bedtime blood sugars are extremely tricky to read. Evening meals tend to be the most variable, and can sometimes be difficult to carb count and accurately give insulin for. Often there might be delayed effects of afternoon snacks or evening meals that may require a follow up correction later on. However, I’m fairly confident in these observations.

When eaten before bed, the bars spiked my blood sugars by at least 6mmol within 2-3 hours of going into my mouth. If I hadn’t of set an alarm to check my blood sugar levels post-bars, I would have been in for a rude shock the next morning!

I also tried using one of the bars as a pre-walk snack. Usually walking will send my blood glucose low if I don’t make any adjustments to my basal rates or consume carbs. The yoghurt and berry bar sent me from a starting blood sugar of 7.7mmol to 11.6mmol within an hour of consumption.

I do genuinely believe that my experience with Extend Nutrition won’t be reflective of yours. I have learned from friends in the diabetes community that Malitol and other “non factor” carbs can have an impact on some people’s blood sugar levels. However I have also spoken with other type 1s who have tried these bars and experienced minimal impact on their blood sugars. Tammy over at Diabetes: Forever and Always also didn’t seem to experience a noticeable impact on her blood sugar levels in her review of the bars here.

The bars definitely had a slow effect on my blood glucose levels, meaning that they would be an ideal low glycemic index snack for someone with diabetes. It just wasn’t a 9 hour release of energy for me as the packet stated.

My initial verdict was that these bars would likely be great for people with type 2 diabetes who are still producing some insulin to cover the effect of the bars. However after watching this video explaining the science behind the bars, it seems that they were designed for someone taking insulin. Apparently, the non factor carbs in the bars convert to glucose so slowly that basal insulin would cover them.

I did put to IBD Medical questions about the claims of the bars. I was told that in the US, Extend Nutrition conducted a series of trials to underpin each claim for the bars. Meanwhile in Australia, the claims on the packaging have been registered as a general health claim with the Food Standards Australia and New Zealand.

While I don’t doubt the claims, everyone will respond differently to the ingredients in the bars. In my case, Extend Nutrition bars were unable to live up to their claims and control my blood sugars.

The most important deciding factor for me, however, would be the taste. Unfortunately, I wasn’t a huge fan. They tasted too artificially sweetened and gunky for me to want to buy them again. I’d much rather bolus insulin for a bar with oats, seeds, nuts, or even a drizzle of honey.

Extend Nutrition Bars were sold in Australia by IBD Medical, but since it’s taken me so long to write this blog, the link I was given no longer seems to be working. You can find out more about Extend Nutrition on their US website here. 

Disclosure: IBD Medical sent me a box of Extend Nutrition Bars to try. There was no expectation that I would blog about them, and all opinions expressed here are my own. 

Is Diabetes Normal?

In my latest column for Diabetes Daily, I’m pondering over whether I consider myself ‘normal’ as someone living with diabetes.

Since the day of my diagnosis, the notion of diabetes being “normal” has been drummed into me. I can still remember my father reassuring me that although I would be stuck with diabetes forever, I would still live a completely normal life. “The treatments have come so far, son. There will definitely be a cure in your lifetime.”

I rejected this notion that diabetes made me different. I hated seeing campaigns and stories that shed a light on some of the consequences of diabetes. I wanted so badly to project an empowering, superhero-like image of diabetes to the world, even if there were highs and lows along the way.

You can check out the full column here.

Pump Break II

My current pump break is surprisingly different to the one that I took a year ago.

At the time, I was feeling full of anxiety over all of the lows I was having from physical activity. I was still relatively new to insulin pumping, and felt a little overwhelmed at my failure to get everything right. I wasn’t missing my pump one bit, and if it weren’t for the Christmas smorgasbord around the corner I’m not sure that I would have ended up reconnecting.

This time round I’m feeling purely fatigued from the device that I’m using. I’m fatigued from being connected all of the time, and from staring at basal rates and insulin on board all of the time. I find myself getting a little slack with my management, and not getting the most out of my pump. I’m already missing the convenience after just a week, so I’m not confident how long this break will last.

I was deliberating over whether to start my pump break in the morning or evening. I’d read elsewhere that 1) morning would make it easier to monitor my blood sugar in those initial hours, and 2) the effects of Lantus tapering off at the 18-24 hour mark are felt the least. However, I’ve only ever known giving Lantus in the evening. I was also hesitant to have insulin tapering off in the early hours of the morning while I was experiencing dawn phenomenon. So, I stuck with dinner time.

I started with 10 units, the sum of my total daily basal given by my pump. That night, I had about two helpings of Skittles to ward my way out of lows. Residual rapid acting basal insulin from my pump was also very noticeable in those first few hours before bed, and I’d probably create some lag time between disconnecting my pump and giving Lantus if I were to do this again.

The following morning I woke up with terrible insulin resistance, which carried on through much of the day. In the morning it was obviously dawn phenomenon to blame, while in the afternoon my Lantus was likely tapering off.

On night two, I dialled my Lantus dose back to 9 units and added an injection of 3 units the following morning. The evening lows continued, and boy did those Lantus lows feel different. Heavier? Deeper? More intense? It’s hard to describe.

From there my evening Lantus dose went from 7 units to 5 units to 6 units, while my morning dose has remained at 3. That gives me a total daily dose of 9, which is pretty close to the 9.7 units I was giving via my pump. It seems to be keeping me fairly steady while I sleep, so I’m really pleased with that.

My biggest challenge is the moment I get out of bed in the morning. I’ve doubled my insulin to carb ratios at breakfast to combat the insulin resistance. Just don’t make my mistake of putting off brekky for 2 hours and still using double the insulin dose! For the remainder of the day, my regular carb ratio of 1:8 and correction factor of 1:2.6 seem to do their job as per normal.

I’ve been doing all of this blind, aka without the help of a FreeStyle Libre sensor, which means that I’m really feeling the brunt of the pricks on my fingers. BGs have probably suffered in the first week – Lantus was causing some lows in the beginning, while high blood sugars aren’t as easy to manage without a pump. However, I’m looking forward to seeing how this week treats me now that the dust has settled.

At the moment, I’m absolutely loving the freedom from attachment and not staring at my pump every hour. Bolus insulin also just seems to be “working” better. During those last few weeks on the pump, I definitely felt like I was correcting high blood sugars after meals all the time. Having the same kind of insuin for bolus and basal on the pump felt “blurry” at times, if that makes any sense at all.

When I made my decision to start pumping two years ago, I told myself that injections were too clunky and simply didn’t work for me. But after 18 months on an insulin pump, I know that this is not true. So long as I’m prepared to make the commitment to learn and take responsibility for my decisions, I can make any method of insulin delivery work for me.

How long do I think I will stay off the pump? I am missing it already. But I’d like to think I’ll give it until the end of the month, at least.

Diabetes Before 11am.

01:46 Frank stirs in his sleep. Glancing at the alarm clock, he reaches for his meter so that he can check his blood sugar. 10.1. He grabs his iPhone, opens the RapidCalc app and calculates a 2 unit correction to bring his blood sugar back down to 5.5. He reaches for his insulin pen, primes half a unit, then dials up another 2 units and sticks it into his arm. His diabuddies are starting to rub off on him…

07:21 Frank rouses once again. Morning light is streaming in from behind the closed vertical blinds. Feeling guilty that he slept over opportunities to follow up on that high blood sugar during the night, Frank reaches for his meter once again. He’s not feeling too hopeful. Blood sugar 11.9. Facepalm.

07:30 Frank opens the RapidCalc app on his iPhone, which reminds him that his 3 unit dose of Lantus insulin is overdue. It’s now been a week since Frank disconnected from his insulin pump, and he’s wondering whether it’s time to reconnect. While it’s been a great week, he’s really missing the customised basal rates and ease of correcting high blood sugars. Ah decisions, decisions.

07:43 After much deliberation over what to do, Frank ends up giving his 3 unit morning dose of Lantus. He opens up the RapidCalc app on his iPhone, and works out a five and a half unit dose of insulin. 2 units to cover his morning coffee. Double what he would normally give for 8g of carbohydrate, but necessary to cover morning insulin resistance that’s returned without his pump. The other three and a half units to bring his blood sugar back down to 5.5. Again, he primes half a unit and then injects five and a half units into his arm.

08:00 Frank finishes his morning coffee. Considering the high blood sugar, Frank decides against breakfast until his levels come down a little. Plus, he’s not feeling particularly hungry at this moment.

09:06 Too soon to test? Bugger it. Frank grabs a fresh test strip, sticks the test strip into his meter, pricks his finger with the lancing device and places blood on test strip. Blood sugar 9.4. Phew! Finally heading in the right direction.

10:00 Blood sugar 7.4. RapidCalc tells Frank he has 2 units of rapid acting insulin left to act. Should be okay.

10:34 Blood sugar 6.3. 1.2 units of rapid acting insulin left to act. Stomach rumbles. Oh – that’s right! Frank remembers that he hasn’t eaten breakfast yet. He heads into the kitchen, and opens and closes the fridge and cupboards. A slice of toast? Wait! What about the leftover croissants in his bag from Friday?

10:43 Opens the RapidCalc app on his iPhone, and calculates a 4 unit dose of insulin to cover the croissants. Primes half a unit of insulin from his pen, and then dials up 4 units. Sticks needle into his arm, but ouch! Blunt needle. Frank toughens up and sticks it into his arm once again, injecting the 4 units and carefully holding it there so that all of the insulin goes in.

10:50 With the criossants heating up in the microwave, Frank decides that he needs another coffee. It’s been one of those days. He heads back to his insulin pen and swaps out the blunt needle for a new one. Primes half a unit, dials up another unit to cover the coffee and injects it into his arm.

11:05 Frank is sitting in front of his computer, and satisfactory pre bolus time has elapsed. Frank decides that he needs to be a bit more disciplined with his pre bolusing to avoid stubborn high blood sugars like last night’s, and sticking with injections for another week will probably help him with that.

11:10 Frank decides he had better start eating those croissants before he goes low.

11.25 Frank thinks that this would make for the most boring blog post ever, and then decides that writing it in third person might make it a little less boring.

So many diabetes decisions before 11am! Time for a drink yet?