Making Sense of the Glycaemic Index

Mid October, I went to the DiabetesSisters Weekend for Women conference Alexandria, Virginia. See disclaimer at the end. One of the outstanding presentations I attended was by Thriveabetes 2016 speaker, Gary Scheiner’s presentation on “Making use of the Glycaemic Index”. This should not be a surprise to anyone has read Gary’s book “Think Like a Pancreas”. I will be honest here; when I heard the words “Glycaemic Index” I pretended I didn’t. And the reason is that several years ago, when it became a thing that was relevant to diabetes management, I tried to learn but I found it completely and utterly confusing. So I went to Gary’s talk as a skeptic.

BUT! As always Gary puts the information together well. See his blog posts here.

He started by saying that the glycemic index is the speed glucose enters the blood in the first two hours. It does not measure how fast foods enter the blood as glucose beyond that or how long it takes at all. A-ha! Ok so glycemic index is useful information for first two hours. I feel exonerated now.

This is hugely relevant to my diabetes management because I know that my rapid acting insulin peaks in approx 2 hours and that I might need additional insulin doses after that to cover the glucose released into my blood after the two hours.

The glycemic index is measured from 0 to 100. The closer to 100 a Food is, the higher its glycemic index is and the quicker the glucose hits your blood.

Here is a snapshot of the other things I learned;

• A mixed meal, ie a meal with protein, carbohydrates and or fat gravitates towards the carb. Meaning your body will process that first, albeit slower than if it was just carbs. So I might need to take a post meal dose of insulin in addition to my pre-meal dose.
• If you have a low GI food before your meal it will slow down the follow up starch in your meal. This is really good to know! Bring on the peanuts before the pasta or pizza :-)
• Larger portions take longer to digest. This isn’t new information to me but I suppose I always underestimate just how flippin’ long it takes.
• Time since your last meal affects the glycemic index. If you are still processing your food from the last meal, it’s going to slow down glucose absorption even more.

Some additional pieces of information not related to glycemic index but valuable.

• Don’t trust your CGM when you are recovering from a low. The lag time in full force.
• Insulin on board pump feature doesn’t take into account the food on board. As mentioned in the previous paragraph, if you are still digesting food you may need to override the insulin on board recommendation.
• Insulin resistance can happen if you have a meal with a lot of fat.
• Protein to insulin formula = ½ The total of protein grams and treat as carbs.
• Amylin/Symlin is a hormone that slows gastric emptying. People who don’t have insulin don’t have amylin either so stomachs process food quicker.
• Victoza is a GLP-1 injectable medication and reduces glucagon secretion; slows down the absorption of food.

In summary, glycemic index important to people with diabetes because:

• Satiety. Low glycemic index meals help you feel full for longer.
• Helps with the Timing of insulin. For example, if you know a meal or snack is going to have a high glycemic index then you could take your insulin 15 - 20. Minutes beforehand to give it a head start.
• Helps avoid post meal spikes

So, I’m glad that I learned all of this and I’m glad that I don’t have to waste any more of my time trying to figure it out because it makes more sense to me now. And It may help me to know the glycemic index of a Food I’ve never tried before so that I can figure how to deliver my insulin (pre-meal, at meal or extended Bolus).

Disclaimer: Diabetes Sisters paid for my conference registration and accommodation but also gave me a contribution towards my travel costs. All they asked for in return was that I would write a blog post about the conference which I had to do anyway because I learned so much that needs to be shared;-) And I wrote here about how I was selected.

Diabetes on steroids

Back in October, I had a steroid injection in my hip. And yes, it drove my glucose levels bananas! For those of you who may not be aware of it, steroids are one of the medications that truly mess up glucose numbers for lots and lots of people.  The ultimate craziness only lasted two to three days but the residual crazy lingered a couple of weeks.

Here’s a little of the backstory behind why I got a steroid injection.

I have been complaining about my right hip for some time and I finally did something about it in September 2016. I went to my GP. He referred me to my physiotherapist and we did some “process of elimination” exercises. They didn't work. So then I went for an MRI and was referred to a rheumatologist.

At least now, we think I know what is wrong with my hip! It would seem both my physiotherapist and my rheumatologist agree that I have bursitis. And my rheumatologist injected steroids to reduce the swelling. If you have diabetes and you have steroids that plays absolute havoc with blood glucose.

However, no one could tell me how many days, weeks, months the glucose madness would go on for and how severe it would be.

Here is my experience of what happened to my glucose levels.

Prior to my injection my diabetes management was going fairly well with just the usual ups and downs. I had the shot mid morning and my glucose levels didn’t feel the effect of the injection until after lunch. But after lunch my numbers remained in the high teens until the early hours of the next morning. On day two, I noticed that if I increase my mealtime insulin significantly more than usual it would keep them in check. However, if I forgot to make the increase then I struggled to bring my numbers back down for hours.

Then the effect of the steroid started to wane slowly over the next two weeks and I had the opposite problem: trying to keep my glucose levels above hypo level. I adjusted insulin doses slowly and only making one or two changes at a time to bring them back to my normal diabetes levels (?!?!).

I was grateful that not only was I aware that this would more than likely happen but that both my endocrinologist, rheumatologist and physiotherapist reminded me it would. I'm probably going to have another dose in January but now, at least, I have a good idea of what to expect.

Weather the diabetes havoc-er

One of the factors not included in Diatribe’s 22 factors that influence glucose levels is the weather. Sometimes the weather plays with my diabetes management. And here’s how. Do you remember that really, really wet day we had last week? It seems like a distant memory now and I don’t think it had a name, like a storm name, but most of the country was flooded under a yellow weather warning.

When I got up that morning and look out the window I thought “Nope, I’m not walking, I don’t mind being wet and drippy but not that wet!” I was disappointed because most days I love my walk. It clears my head as I inhale clean fresh energy and exhale stress. I swing my arms vigorously and loosen up my neck and shoulders. I had missed my walk the day before due to a doctor's appointment so I was doubly disappointed.

So, with my daily constitutional off the menu, I took my “no-walk” breakfast insulin dose, which tends to be twice what I take if I am walking and off I drove the kids to school.

However, as I was dropping the teen and preteen to school the rain wasn’t that bad. So,I changed my mind (GASP)…. but how can I avoid a hypo seeing as I’ve taking all this insulin without using calories to prevent the low glucose reaction that will surely follow?

I decided to turn my background/basal insulin down to zero for one hour on my insulin pump. Yes, it was going to take an hour to take effect but it was better than a severe hypo. At least it might soften the blow.

Now, if I was on injection pens there is no way I could have avoided preventing a low without glucose.

So was I successful? Weeelll, kind of. I did have a hypo. A doosy at 2.8mmols but it didn’t feel as bad as it was and I didn’t feel like I had to consume the entire kitchen just about a dozen small jellies.

Compared to most hypos this one rebounded quite quickly and not too high. However, I did spend most of the day with glucose levels that were more elevated than my usual.

And there you have it, diabetes the spontaneity killer and weather the diabetes havoc-er.

My World Diabetes Day

For the last three years, I have used the first fourteen days in November, to give a little insight into my life with diabetes and try to dispel some of the myths around the public perception of diabetes on my Facebook and Twitter profiles with my friends, family and followers. Why the first fourteen days in November?

I do it for only 14 days because I'm only human and just can’t do it for the whole month.

But I also bring it to a close on World Diabetes Day, which is November 14th, if you didn’t already know (because of my blasting it in your face;-D). The reason  World Diabetes Day is November 14 is because that is the birthday of one of the creators of my miracle drug Insulin, Frederick Banting.

I make my posts are public so that anyone who is moved can share them and maybe extend diabetes awareness outside of my bubble.

By the way, the symbol for World Diabetes Day is the blue circle in the photo below.

So, in case you missed it, here’s what I posted for those fourteen days.

Day 1 of Diabetes Awareness - Why do I bang on and on about diabetes awareness?

Because it could happen to you! Diabetes can happen to anyone.

I don't want anyone to be diagnosed with diabetes but I also don't want you to die from a missed diagnosis. I would like if all of my nearest and dearest would know 2 things and share it with their nearest and dearest:

1. The risk factors for type 2 diabetes Because many people don’t get diagnosed until they have developed a life altering diabetes complication that may have been prevented.
2. The symptoms of type 1 diabetes are the 4 T’s (Tired, Thirsty, Toilet, Thin) It may prevent someone from ending up in ICU or even save someone’s life. Mine was.

You can read a more detailed post on why exactly I choose those two topics and who I target here.

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Day 2 of Diabetes Awareness - What is Diabetes?

Diabetes is when you have too much glucose in your blood because it can’t go where it’s suppose to.

- The food you eat is broken down into glucose or sometimes called sugar. - The glucose is then absorbed into your blood. - Then, it should move into each of your body's cells and become the energy we need to live. - Insulin is the key to opening the door to those cells and allowing the glucose to enter.

In diabetes:

• If insulin doesn't work properly all the doors are locked or don’t always open when they should and the glucose is trapped in your blood.
• Type 1 diabetes your body doesn’t make insulin, so the doors are locked.
• Type 2 diabetes your body cannot properly use the insulin it produces and so the doors have faulty hinges.
• If your body can’t get energy from the glucose it looks to the fat stores for energy and when this happens in large amounts it produces a toxin/poison called Ketones.
• Too much ketones cause your organs to shut down.

There are more types of diabetes out there and you can find out more here.

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Day 3 of Diabetes Awareness - Who can get diabetes?

Anyone!!! Any age! Any lifestyle!

The most common diabetes in childhood is type 1 but that does NOT mean adults don't get it too. In fact, 50% of all diagnosis of type 1 diabetes happen to people over the age of 30!!!

The most common diabetes in adults is type 2 but that doesn't mean that children don't get it too. 40% of people who are diagnosed with type 2 diabetes are fit and healthy.

Again please know the risk factors for type 2 and know the symptoms of type 1 diabetes.

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Day 4 of Diabetes Awareness - The diabetes jokes aren’t funny.

They’re insensitive and hurtful.

It’s not that we don’t have a sense of humour. We do! Seriously, We do!!! We joke about pricks all the time... finger pricks. We joke about getting high on Lucozade or Fanta.

Jokes about ""eating cake that gives you diabetes"" show that you have limited knowledge about diabetes. So just don't repeat the joke.

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Day 5 of Diabetes Awareness - Did you know that; ALL types of diabetes are bad!

There is not a "good kind" or a "bad kind": all types of diabetes can make life unbearable and can kill you.

All types can cause diabetes complications. Needles really are not the worst thing about diabetes.

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Day 6 of Diabetes Awareness - Did you know that; Managing diabetes is a lot harder than it looks or that some people would have you believe.

Taking care of my diabetes is a lot of work and it takes up a lot of space in my brain.

Balancing food, medication, activity, hormones, and all the other factors that influence glucose levels is not easy. I can only measure/control some of those factors some of the time which means no two days are going to be the same with diabetes.

And it makes me crazy when healthy foods have a crazy effect on my glucose levels!!! It's enough to drive me to cake:-)

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Day 7 of Diabetes Awareness - Did you know that; There are NO stereotypes for diabetes.

Adults get type 1 diabetes, not just children. In fact 50% of all the type 1 diabetes diagnosis are OVER the age of 30 years.

Young, fit and healthy people get type 2 diabetes. In fact, 30% of people who are diagnosed with type 2 diabetes do not fit the stereotype. Know ALL the risk factors!

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Day 8 of Diabetes Awareness - Did you know that;  Insulin has been available for almost 100 years and people STILL die from diabetes!

WHY?

• People with diabetes die because in some countries they can't afford their medication. #Insulin4All. In some countries, children with type 1 diabetes don't expect to become adults.
• They die because a diagnosis has been missed and thought to be the flu.
• They die because they haven't been taught to manage their condition at all and develop life threatening complications.
• They die from Dead in Bed syndrome.
• They die because they have been ill and developed life threatening DKA while ill.

Insulin is not a cure, it's a treatment that allows me to have a life. But it doesn’t beat having a working pancreas.

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Day 9 of Diabetes Awareness - Diabetes is not something that a person did to themselves.

There are a number of risk factors that play a bigger part than the lifestyle choices you make. Yet, people with diabetes are made to feel that they are to blame. And that should not happen!

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Day 10 of Diabetes Awareness - If someone you know is diagnosed with diabetes, please offer them support not judgement.

Ask us what we need. Don't lecture or nag. It’s not helpful. Don't ask if our glucose numbers are good or bad. It is what it is. Don’t focus on what we are not doing, instead see what we are.

Find more tips on how to support someone with diabetes here.

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Day 11 of Diabetes Awareness - Did you know that; Yes, You can live a normal life with diabetes BUT!!!!!

It requires extra planning and thought.

See image below. Nothing can be spontaneous!

Image source from a book called One Lump or Two - Haidee Soule Merritt is the artist ❤

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Day 12 of Diabetes Awareness - Did you know that; About ⅓ of all people with type 2 diabetes do not know they have it.

And that Type 2 diabetes often does not have any symptoms.

Find out here if you are at risk from this online assessment.

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Day 13 of Diabetes Awareness - A lot of times I eat sweets/candy because I have to.

Not because I want to, or would like to. And a lot of times I hate that I have to!

Sometimes I hate food because the math I have to do to eat is mentally exhausting! Last night, my glucose levels dropped and I knew I would have to eat something sweet. It’s happening a lot lately and I’m still trying to adjust my medication to avoid it. But as a result I am so sick of glucose tabs, skittles, jelly beans and jellies.

It was long after dinner and I was full. I hoped for a delayed rise in glucose from dinner. It didn’t happen. I had to eat the jellies even though my stomach just wanted to spew them back out.

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Day 14 of Diabetes Awareness - IT’S HERE!!!!

Happy birthday Fred!

Today, November 14 is World Diabetes Day. #WorldDiabetesDay.

I have been posting some diabetes information for the last 14 days to spread more awareness about the symptoms, risk factors and living life with diabetes.

And Today I celebrate;

• One of the men who is responsible for me being alive, Frederick Banting, whose birthday falls today.
• Being alive. I celebrate the advances there have been in diabetes technology and care, even since my diagnosis 24 years ago.
• And I remember why I will continue to advocate for better health services for all people with diabetes.
  • In 2016 there were over 500 amputations related to diabetes complications. This is not acceptable and can be prevented with more podiatrists.
  • 50% of all vision loss in Ireland is due to complications of diabetes and the same with kidney disease.

And now I take a nap until December:-)

Living with Diabetes is like Parenting

My life is finally slowing down after a number of weeks of events, diabetes awareness "stuff" and children being off school for mid term break. I have so many blogs posts in my head and no time to write them. But soon... In the meantime, while I was fast asleep, my husband had a moment of inspiration about living life with type 1 diabetes and what common human experience might come close to describing the type 1 diabetes experience? Yes, there are a lot of questions to ask about why I was asleep and he wasn't but not for publishing online ;-)

So here is a guest post from my hubby.

Gráinne was away at a conference recently, presenting the "patient experience" to a group of 100 almost entirely healthcare professionals. She came home the first evening very excited by not only how well her talk was received, but the general tone of the conference in general.

I'm sure she will fill in details about the conference in a separate post, but I wanted to write a quick blurb about something that struck me at 3am (don't ask): how does anybody gain insight into the life of a person with type 1 diabetes in an effort to build empathy?

The intellectual approach of explaining all the things one does to manage type 1 is important but somehow inadequate.  Living with (and sleeping next to) a person with diabetes (PWD) can give you some insights, and loving a PWD to the extent where you have some of the same fears and worries they do at a very emotional level yields a whole new level of insights.

But such experiences are hard-earned and not wholly practical. To start with, I'll take issue with others sleeping next to my wife on anything other than an exceptional basis :)

What struck me is there is a very common human experience that might come close to describing the type 1 diabetes experience: parenthood.  I may not have diabetes, but I live with somebody who does.  And...I am a parent of two pretty amazing kids.

What can parenthood do to help build empathy for those living with type 1?  Let me share a partial list:

1. Say goodbye to a reliable full night of uninterrupted sleep.

Even in her pre-CGM days, Gráinne would wake up in the middle of the night not feeling right. Her sugars could be high or they could be low, or she could just be coming down with something. Regardless she had to check her sugars and then decide how to react to the information.

I wouldn't say it's quite like having a newborn baby, but it's pretty close to having a 6 month old baby who can't reliably settle. But without the option of seeing if the baby will be able to settle herself...and without the possibility that the 6 month old baby will grow out of it.

2. There is no rulebook.

 

A new parent is often desperate for a manual on "how to be a good parent."  What you learn as a parent is that every child is unique and has their own set of needs. You just need to figure out what works best for the child in front of you at the time. And of course what works for a two year old is not what works for a twelve year old: the "rulebook" for parenting is forever changing.

Type 1 seems to work in much the same way. There are so many variables in life that what worked for you last week may not work for you this week. You just take on whatever challenges type 1 throws at you, and deal with them in the best way your sleep-deprived, hypo-affected brain can manage.

3. Frequent guilt.

 

We've all as parents done things that we regretted. Maybe it was giving a punishment that was in retrospect overly harsh. Or maybe we're worried that we're being too lenient, or not helping our child learn lessons the hard way because we're spoon-feeding them the answers.  Or maybe our child is struggling in school, or struggling socially, or trying really hard in a sport that they love but are lacking the skills to be really good at...and we feel somehow responsible for this and guilty that we're failing them as parents.

If you have type 1, guilt about "not managing your diabetes" seems to be there. Always. That bit of extra chocolate you had because it looked nice? Unless you accounted for it perfectly (and see point 2: you probably didn't account for it perfectly because there is no rulebook), you're probably going to see the result of that "indiscretion" in your blood sugars. Not getting the HbA1c result you hoped for?  More guilt and self-loathing.

4. Low-grade worry.

As parents, we often worry about our children's future. Some of these things are those over which we have control (and feel guilty about doing "wrong"). Others are longer-term things over which we have no real control: is the planet going to be habitable by the time my grandchildren are born? And every so often, we think about our own mortality: what would happen to our children if Gráinne and I were to die unexpectedly?

These aren't necessarily things that keep us as parents up at night (those are more the "guilt" topics!), but they are the things that can weigh on the mind of a person with type 1. Mortality is a much more real presence in the life of someone with type 1: the very medication that is needed to keep you alive can also kill you (or worse).

5. Lots of "outside" advice

 

New parents (and experienced parents!) are often awash in advice, both solicited and unsolicited.  It is advice commonly wrapped in "you should" and "never" and "always"...very emotionally charged terms.

 

Have you ever talked to a mother who wants to breastfeed but wasn't able to make it work for whatever reason?  Feeding her baby with a bottle can bring on a whole world of emotions with that simple act of providing nourishment to her child, and that's before the very "helpful" commentary from some well-meaning individual: "breast is best!"

The world of diabetes management is awash in advice, much of it from medical experts and some of it from crackpot experts who read an article about "how cinnamon can cure diabetes" or some other such thing. But much with parenting, what a PWD must do is learn to figure out what advice is helpful to them and use that, whilst figuring out how to deflect and ignore advice that does not.

There are more parallels between "parenting" and "managing type 1 diabetes," but this has hopefully given a taster based on my perspectives as a "diabetes insider-but-outsider."

There's one thing, however, that is DRAMATICALLY DIFFERENT FROM BEING A PARENT.  Parents do not have any sort of scorecard. I mean okay, if you have killed your child violently are severely neglecting them to the point their health is in danger, you've clearly failed as a parent...but beyond that parenting is pretty much a "pass" sort of proposition...our children grow up, leave the home, and succeed (or fail) largely on their own effort, merits and socioeconomic position.

But in the world of diabetes...there are all sorts of numbers. The most notable one has been mentioned here a few times: HbA1c, or the "time-weighted average blood sugar over the past three months." Doctors have historically focused on this number which is about as useful for an individual as the Body Mass Index (which is to say: not terribly useful).

With the advent of CGM and FGM technologies, they're now starting to focus on "time in range" which is arguably a better indicator of overall diabetes management and overall health, but it also somehow fails to account for the fact that there are just so many factors over which a PWD has no control.

That's the thing: most PWD who are armed with the best of knowledge, tools, and medicines will struggle to achieve their target HbA1c or time in range.

Imagine if we were to devise a "parenting index" for each and every parent, as a value between 0 and 100, and we set it up in such a way that it's pretty much impossible to get a 100, or even an 80. Why? Because your children have a mind of their own, you can't control them 100% of the time, there are people other than you influencing their lives, and you're human so will make mistakes.

But you as a parent know that "100" is the best possible score, and so you try really really hard to get 100...you're trying to do everything the experts say you should be doing, you're spending lots of money and time to achieve perfection and love your child like no parent has ever loved their child.  But year in and year out, you struggle to get a score over 60. Your best ever score was a 77.

And now ask yourself: Are you a failure as a parent?