The Forgotten Bolus

My friends and family have always complimented me for having a good memory.

What can I say? I have a knack for remembering names and faces. I’m slightly better than decent at keeping track of birthdays. And I’ve kept journals of some sort for most of my life, so I’m usually able to recall the date on which a certain event took place (or I can at least look it up fairly quickly).

But my memory can fail me sometimes, and it did just that the other day when I forgot to bolus for dinner.

I don’t think I’ve ever forgotten a mealtime bolus in more than 23 years of life with diabetes. I suppose there’s a first time for everything…

To give myself a little credit, I truly thought that I had bolused. I remembered picking up my PDM and entering my blood sugar and carbohydrate information, but I never actually hit the very important “enter” button that would start delivering my insulin.

Imagine my surprise, then, when I saw my blood sugar rapidly rising – I’m talking double “up” arrows here – approximately 20 minutes after I finished my dinner.

And at first, I decided to ignore it! I thought that my insulin just needed a little more time to kick in, so I waited. And waited. And waited. But when I saw that I was rising above 250 mg/dL, I figured I should increase my temp basal…perhaps my body just needed a bit more insulin than I anticipated.

That’s when I picked up my PDM and saw that I had zero units of insulin on board. Extreme confusion turned into extreme panic as I asked my mom if I could check her PDM – what if I had picked hers up instead when I bolused for dinner and mistakenly gave her the insulin that was intended for me?!

Thankfully, that wasn’t the case, and I slowly began to piece together that I simply forgot to hit the bolus delivery button.

Whoops.

Almost one full hour after finishing my meal, I was finally delivering my mealtime bolus and silently fuming over my high blood sugar that ended up lasting several hours. It was a completely avoidable situation that shouldn’t have happened, but at least one good thing came out of it: I don’t think I’ll be forgetting to bolus any time soon.

The Truth About My Carb Counting

One of the many reasons why I love the diabetes community is that I’m constantly learning new information, finding inspiration, and enjoying support from my fellow friends living with T1D. Sharing our stories with one another leads to us finding that it’s more than diabetes that we have in common.

Here’s an example: My friend, Cherise Shockley, recently wrote an article for DiaTribe in which she made a confession to herself regarding how she counts her carbs. I recommend reading the extremely well-written article to get a full sense of what she discovered, but in short, Cherise recently realized that her carb counting is inaccurate because of the “glass ceiling” for entering carbs into her pump for bolus calculations. In other words, Cherise’s personal maximum of carbs that she was comfortable with dosing for using her pump wasn’t aligning with the actual amount of carbs she was consuming. This excerpt explains part of it:

That was my moment of truth. I told Natalie I ate my favorite chocolate chunk cookie that day. She asked me how many carbs the cookie contained, and I told her 68 grams; she wondered why I only bolused for 55 grams. I paused before I replied – I did not know the answer.

Natalie then asked me if I had a glass ceiling for entering carbs in my pump. She explained that this means even though I know I eat 63 carbs, I will only enter 50 carbs in my pump because anything higher than that concerns me. What she said was interesting; I had never heard anyone describe it to me in that way.

-Cherise Shockley

When I read this, I said, “Yes! Finally, someone is able to articulate exactly how I handle carb counting!”

This is the truth about my carb counting: I have limits when it comes to how many carbs I will bolus for at a time, but those limits do not apply to the actual number of carbs that I consume.

In my 23 years of life with type 1 diabetes, I never knew the meaning behind my carbohydrate glass ceiling.

To explain, I am only comfortable with bolusing for a maximum of 60 grams of carbohydrate at a time. I do not know how I came up with this particular number, but I do know that there are situations (e.g., holiday celebrations) in which I am absolutely consuming more than 60 carbs in a sitting, and yet I only bolus for that amount.

Still confused by what I mean? Read the full article to understand, but this excerpt from it helps to explain why this fear of bolusing for more than 60 carbs at a time exists for me:

To learn more about carbohydrate glass ceilings and why some people have one, I talked to Dr. Korey Hood, a professor of pediatric endocrinology and psychiatry and behavioral sciences at Stanford University who has lived with type 1 diabetes for over 20 years. Dr. Hood told me that all parts of diabetes management can be challenging, and carb counting is particularly tough because it is hard to be accurate and precise. He always recommends people with diabetes meet annually with their diabetes educator (CDCES) to get a refresher on different aspects of diabetes management, including carb counting.

Dr. Hood said that the glass ceiling is most likely due to one of two issues – worries about hypoglycemia or the meaning behind taking such a big dose of insulin. Dr. Hood said that “many of us with diabetes, particularly those on insulin, worry about going low. Why wouldn’t we – it is a terrible feeling! We often experience fears of hypoglycemia because we had a terrible low in the past and have a desperate desire to avoid it in the future. When we worry about hypoglycemia, we scale back our insulin dosing. This prevents the low but also likely results in high glucose levels. So, it really is not a good strategy.” 

-Cherise Shockley

This was a major revelation for me because suddenly I realized what my reasoning is for my carbohydrate glass ceiling: I have a hypoglycemia fear. I have experienced scary episodes in the past (fortunately, none of which have required medical attention). I have friends who have experienced severe hypoglycemic episodes, and when a colleague of mine experienced a low episode that was so bad that I had to call 911 for him, it left a mark on me. So on the occasions that I do eat more than 60 carbs in a sitting, I simply don’t take the amount of insulin that I should to account for those carbs, and I wind up going high, exactly as Dr. Hood describes in the quote above.

When it comes to diabetes, there is no such thing as “perfection”. My blood sugars cannot and will not be perfect 100% of the time. But one thing that I do have control over is doing the absolute best that I can with carb counting and bolusing. It’s time I hold myself more accountable to my carbohydrate glass ceiling…in fact, it’s time for me to smash through it.

A ginormous thank you to Cherise for being so open and honest in this piece and for inspiring me to own my carbs, too.

One Night with Diabetes

You settle into bed, ready to fall asleep after another long day.

But first, you check your blood sugar, just like you do multiple times every day.

Your glucometer reads 201.

Suddenly,  you’re a little nervous to drift off to dreamland, because you just changed your insulin pod an hour earlier and you’re not quite sure if it’s the reason behind the high blood sugar.

You wonder: Could my blood sugar be high due to a miscalculation with insulin or carbs at dinner? Is it because of my stress levels? Is it because I’m dehydrated, or because I’m starting to get sick, or because my new pod’s site is on scar tissue, or because…?

Before long, you feel incredibly exhausted because you’re cycling through what seems like an endless list of reasons why you might have an elevated blood sugar and it has zapped you mentally.

You feel your eyelids grow heavy, and just before you go to sleep, you give yourself an insulin dose that should bring your blood sugar back down before long.

You experience a broken night of sleep.

One Night with Diabetes
When you read this, put yourself in the shoes of a person with diabetes…and this is just one night with the damn thing.

Since your Dexcom app is programmed to alert you when you’re over your high threshold for an extended period of time, it goes off, practically every hour, from 10 P.M. to 1 A.M.

Every time it happens, you wake up to the sound of your Dexcom alarm blaring in your ear.

You worry about waking up others in the household before you even begin to worry about your blood sugar.

You’re pretty sure it’s not a pod problem, since your blood sugar would probably be higher if that were the culprit, but you’re too damn tired to care about the cause at this time of night.

You bolus, go back to sleep, hear a high alarm, wake up, and repeat until finally your sleep stops getting interrupted by your Dexcom.

You get a few hours of broken rest.

You wake up at 6 A.M. and realize that, after all that, your blood sugar levels are still slightly elevated.

You’re pissed that your Dexcom was off by 40+ points, as confirmed by a fingerstick check.

You take more insulin, and force yourself to get up and out of bed because it’s time to start the day: Your diabetes is waiting for nothing, least of all you.

Just another night of not enough sleep and too much worry, thanks to diabetes.

The Peanut Butter and Chocolate Punishment

loooooove peanut butter (frequent visitors of this blog are very aware of this fact) and chocolate. It’s the perfect combination of salty and sweet. And Reese’s cups of all shapes and sizes are definitely the most delicious snack in the entire world – though I have a special affinity for Reese’s pumpkins for having the ideal chocolate-to-peanut butter ratio.

Despite my unwavering adoration for peanut butter and chocolate, the dynamic duo doesn’t always love me – or my blood sugars – back…especially when I neglect to bolus accordingly.

It was a lazy Sunday afternoon. I’d just woken up from a brief cat nap on the sofa and felt hunger pangs. I checked my CGM and noticed that my blood sugar was going a little low, so I yawned, stretched, and ambled into the kitchen for a snack.

That’s when I remembered I had a tasty treat in the fridge – crunchy peanut butter chocolate squares I’d whipped up the night before to bring to a friend’s apartment. They were made from, obviously, crunchy peanut butter, but also crushed graham crackers, butter, confectioner’s sugar, and a silky, smooth layer of melted dark chocolate. The squares were chock-full of carbs, but cut small enough and on the thin side…so I naively assumed I could eat a couple without doing any real damage to my blood sugar levels.

The Peanut Butter and Chocolate Punishment.png
The crime? The existence of these peanut butter and chocolate squares. The punishment? High blood sugar for unknown length of time. Cruel.

So I dove in, helping myself to some additional crumbs at the bottom of the bag that had broken off from roughly cut squares. After a couple of minutes of totally pigging out, I made myself stop because I could practically feel my blood sugar begin to rise. I even took a couple of units of insulin (not at all calculated, just two off-the-cuff units) to offset any high blood sugar.

Unfortunately, two units wasn’t exactly enough. Within an hour, I saw my blood sugar go from the 80s to somewhere in the 280s. Not at all what I wanted! I began bolusing and stacking my doses like crazy while I fixed dinner and fretted over how long it might take for my blood sugar levels to come back down so I could eat a real meal. By the time dinner was ready, though, I was still high but confident that the insulin on board would do its job. But it took nearly five hours for everything to stabilize, from when I first gave into the peanut butter and chocolate squares to a couple hours after dinner.

Not my finest moment in life with diabetes since everything could’ve been prevented from the beginning. But maybe it goes to show one of the reasons why people start out each new year with the hopes of eating clean and cutting out sweets – junk food tastes so wonderful when it’s being consumed, but the long-term effects are too much of a punishment to make it worth it.

Now, if you’ll excuse me, time to evacuate the apartment of all carb-y confections…

Is it Possible to Eat Pizza Without Encountering Blood Sugar Problems?

My short answer to that question is YES. Yes, it’s absolutely possible to eat pizza – and just about any food, in my opinion – without experiencing turbulent blood sugars.

It all just comes down to serving size, timing, and method of insulin delivery. Piece of cake, right? (Or should I say, piece of pizza?)

Have a slice!

Well, it really isn’t THAT simple. Other factors include the exact type of pizza (Is it gluten-free? Are there toppings? Is the crust thick or thin?), whether or not other food/drink is being consumed with it, whether exercise or inaction will follow in the hours after eating it…truly, there’s all that (and more) that people with diabetes need to think about when eating any type of food.

But what’s different about pizza is that it has a particular combination of fat and carbohydrates that can make it a tricky food for people with diabetes to figure out how much insulin to take and when to take it. It’s a little easier for those of us who have insulin pumps, because we can utilize the extended bolus (or square wave) feature that allows us to give a certain percentage of a mealtime bolus at once, and select a time later on to receive the rest of the bolus.

If that last sentence didn’t make any sense, here’s an example of what I mean:

It’s dinnertime – 5:30 P.M. I have two slices of pizza that I plan on eating. One’s plain, the other has BBQ chicken on it. I figure that there’s 50 grams total of carbohydrates in the two slices of pizza. My blood sugar before eating the pizza is 130 mg/dL. I put that number into my pump, and also input 50 grams of carbs. My pump wants me to take 8 units of insulin to cover the pizza. Instead of administering the full 8 units at once, I hit the “extend” option and opt to take 75% of the dose now, and the remaining 25% an hour and a half from now. So I get 6 units of insulin at 5:30, and 2 units at 7:00. This extended bolus typically has the power to prevent my blood sugar from crashing and spiking hours after eating said pizza, and in turns, saves me from dealing with a massive headache and questioning why I ever ate pizza in the first place.

Granted, an extended bolus isn’t the end-all, be-all. It relies heavily on me and my ability to count carbs correctly and time my boluses perfectly. But I have had fantastic success using it, particularly in a recent situation in which I ate two large slices of whole wheat pizza, a side salad, and a bit of pita bread without spiking beyond 160. I can’t say whether it was the whole wheat crust that helped me out (maybe it has a lower carb count compared to regular crust?), or if it was just supremely accurate calculations on my end, but it really doesn’t matter to me in the end…because I know that I can eat and enjoy pizza – and again, virtually any food – without my diabetes ruining it for me.