Think Like a Pancreas

by Gary Scheiner

  If you can predict it, you can usually prevent it.

  The Adjustment: Many anxious moments occur spontaneously. However, some can be predicted—and if you can predict it, you can prevent it. If you notice a consistent pattern of high blood sugars with certain events, consider giving yourself a small dose of rapid-acting insulin an hour or two prior to the event. This will help to offset the stress hormones produced in anticipation of the event as well as during the event itself. If you wear an insulin pump, consider raising your basal rate by using the temp basal feature. A 60 to 80 percent increase for three hours, starting one to two hours prior to the event, can work nicely.

  The first time you try the adjustment, be certain to check your blood sugar frequently to see how well the extra insulin is working. A student I work with tends to run very high blood sugars when taking standardized tests in school. Her parents agreed to give her extra insulin at breakfast on the mornings of standardized testing, and her blood sugar turned out to be very close to normal at lunchtime. And who knows? Keeping your blood sugar near normal might enable you to cope better with the stressful situation.

  Caffeine

  A natural stimulant, caffeine tends to cause a rise in blood sugar levels in approximately one hour. It does this by promoting the breakdown of fat (rather than sugar) for energy and stimulating the liver’s breakdown of glycogen. Granted, the amount of caffeine found in most foods is insignificant. However, consumption of large amounts of caffeine can produce a noticeable blood sugar rise. Below is a list of some of the major sources of caffeine:

  Jolt energy drink: 280 mg

  stay-awake pills: 100–200 mg

  Monster energy drink: 160 mg

  5-Hour energy drink: 138 mg

  brewed coffee (8 oz): 100–120 mg

  espresso: 100 mg

  latte: 100 mg

  Red Bull: 80 mg

  instant coffee (8 oz): 60–80 mg

  tea (8 oz): 30–50 mg

  cola (12 oz): 30–45 mg

  cold tablets: 30 mg

  chocolate bar: 20–30 mg

  chocolate milk (12 oz): 10 mg

  The Adjustment: If you suspect that caffeine may be causing your blood sugar to rise, either look for a lower-caffeine substitute or take a little extra rapid-acting insulin when consuming high-caffeine foods/beverages. To determine the amount of insulin you need, test your blood sugar and then consume the caffeinated item with no other food (bolus only for the carbs in the caffeinated item). Check your blood sugar again in three hours and then divide the rise by your sensitivity factor. For example, if a sixteen-ounce coffee makes your blood sugar rise by about 80 mg/dl (4.4 mmol/l) and your sensitivity factor is 40 mg/dl (2.2 mmol/l), you need to take 2 units of insulin just to offset the effects of the caffeine in the coffee.

  Disease Progression

  Most people with type 1 diabetes as well as LADA go through a “honeymoon” phase soon after diagnosis. For several weeks, months, or even years the pancreas continues to produce a small amount of insulin. This results in blood glucose levels that are stable and near normal, particularly overnight and first thing in the morning. Usually, the pancreas first loses the ability to secrete sufficient amounts of bolus insulin. Then the ability to produce basal insulin begins to fade. As a result, blood sugars become higher and more erratic, particularly upon waking in the morning. Likewise, type 2 diabetes becomes progressively more difficult to manage as the body becomes more insulinresistant and the pancreas loses the ability to produce sufficient amounts of insulin.

  The Adjustment: For those with type 1 diabetes or LADA who are exiting the honeymoon, fasting (or morning) blood sugars will tend to be elevated—perhaps for the first time ever. You will need increases in basal insulin in order to manage overnight blood sugar levels. You may also eventually need increases in bolus doses as the pancreas loses its ability to produce basal insulin throughout the day. For those with type 2 diabetes, the gradual loss of insulin-producing beta cells means that insulin dosage requirements will gradually increase. If you experience blood sugars that are above target for three days in a row, it is time to increase the insulin dose at the preceding meal (or the basal insulin dose, if the high readings occurred first thing in the morning).

  Protein

  For many years nutrition experts believed that dietary protein caused blood sugar to rise. Then studies of mixed meals (meals containing carbs, protein, and fat) showed that protein had no effect. So what are we to believe? In cases like this, I prefer to rely on experience. What we see time and again is that protein does, in fact, raise blood sugar, but only when consumed without carbohydrates. Roughly 50 percent of protein can be converted to glucose if there is no other source of sugar in the meal. Carbohydrates have a “sparing” effect on this process. This means that when carbs are eaten, protein is used for purposes other than supplying blood sugar, such as bodily growth, repair, and creating hormones and enzymes, but without carbs protein becomes a source of glucose for nourishing the body’s cells.

  The Adjustment: If you have no carbs in a meal or snack, count up the grams of protein that you are consuming. (See Table 8-1.) Take half that amount and bolus for it as if it was carbohydrate. Of course, if the protein amount is very modest (for example, a slice of cheese), the effect on the blood sugar will hardly be noticeable, so you will not need to bolus.

  Things get a bit trickier, however, if your meal or snack contains protein and only a small amount of carbohydrate. If the carbohydrate is insufficient to meet the body’s need for glucose, some of the protein may be converted to glucose. Having at least a moderate amount of carbohydrate in each meal and snack is usually a good idea. That way, the effects of protein on blood sugar can basically be ignored.

  Table 8-1. Protein content of protein-rich foods

  1 ounce of beef, pork, or fish 7g protein

  1 ounce of poultry 9g protein

  1 large egg 6g protein

  1 cup milk 8g protein

  ½ cup cottage cheese 15g protein

  1 ounce cheese 8g protein

  ½ cup ice cream 3g protein

  ½ cup tofu 20g protein

  ½ cup cooked beans 8g protein

  ¼ cup peanuts 9g protein

  ¼ cup seeds 7g protein

  2 tablespoons peanut butter 8g protein

  Fatty Foods

  Consuming large amounts of fat in a meal or snack can cause blood sugar levels to rise in a gradual manner over a period of six to ten hours or more. This delayed rise is in addition to the immediate rise carbohydrates cause. The mechanism by which fat causes a delayed rise in the blood sugar is not entirely understood, but it is believed to be the result of insulin resistance. When you consume a high-fat meal, the level of triglycerides in your bloodstream rises. This sends your liver into a temporary state of insulin resistance, resulting in greater secretion of glucose into the bloodstream.

  Although there is no specific amount of fat that causes a delayed blood sugar rise in everybody, having more than 20 grams of fat certainly increases the likelihood that a delayed rise will occur. Some foods commonly associated with high fat content and delayed blood sugar rises are listed below.

  •Restaurant foods: Meals prepared at restaurants usually have a great deal of fat added during preparation.

  •Take-out food: pizza = 10–20 g fat per slice; hot wings = 2-3 g each; Chinese food: egg roll = 15 g, fried rice = 13 g/cup, sweet and sour pork = 25 g/cup.

  •Fast food: small cheeseburger = 15 g fat; Big Mac = 30 g; average taco = 11 g; sausage/egg/cheese sandwich = 40 g.

  •Fried foods: oils used in preparing fried food contain 10–15 g fat per tablespoon; fried fish sandwich = 23 g; fried chicken patty = 14 g; small order of French fries = 15 g.

  •High-fat meats: most cuts of beef, lamb, pork, dark meat chicken/turkey, and sardines contain approximately 8–15 g fat per three ounces (a deck of cards–sized serving); ground round/hamburger = 20 g; ribs and sausage = 25 g; most lunch meats = 10 g per slice; a hot do
g = 15 g.

  •Cheesy dishes: approximately 70 percent of cheese is pure fat; American/cheddar/Swiss cheese = 8–10 g per ounce (or slice); mozzarella/parmesan = 6–7 g per ounce.

  •Dessert items: an average slice of chocolate cake = 15 g fat; ice cream = 10–15 g per half-cup; a cinnamon bun = 25 g; 1 doughnut, muffin, slice of cake, or chocolate bar = 10–20 g; 1 slice apple pie or cheesecake = 20 g.

  •Salty snacks: chips = 10 g fat per handful; peanuts = 10–15 g per small handful; a medium movie-theater popcorn = 60 g fat (without butter topping); nachos with cheese = 20–30 g.

  Each person needs to determine based on their own experience how much fat he or she requires to produce a delayed blood sugar rise. For example, I find that a single slice of pizza rarely causes my blood sugar to rise after the first couple of hours. However, after eating two or more slices I usually see a significant rise over the next six to eight hours.

  The Adjustment: As was the case with stress responses, if you can predict it, you can prevent it. When a delayed rise in blood sugar is anticipated, two options are available. For those taking insulin by injection, intermediate-acting insulin (NPH) tends to do a nice job of offsetting the effects of fat. Taking a small dose of intermediate insulin along with your rapid-acting mealtime insulin provides a nice one-two punch: The rapid insulin covers the immediate rise produced by the carbohydrates, and the intermediate insulin covers the delayed rise produced by the fat. A dose of NPH equal to 5 to 10 percent of your total daily insulin should serve as a safe starting point. For example, if you average a total of 50 units of insulin for the day (basal + bolus combined), give yourself 2.5 to 5 units of NPH with a high-fat meal.

  If you are using an insulin pump, the adjustment is much simpler. Try a temporary basal increase of 50 to 60 percent lasting approximately eight hours, starting after you finish your meal. Check your blood sugar frequently the first time you do this to see how well the adjustment is working.

  Growth and Weight Gain

  During a young person’s growth years insulin needs rise steadily. This is due to increases in the production of hormones, which counteract insulin and stimulate the liver to produce additional glucose as well as increases in body size. The accumulation of body fat also increases insulin requirements because fat cells secrete hormones that cause insulin resistance.

  The Adjustment: All aspects of the insulin program will need to increase with significant growth and weight gain. Adjustments should be made in proportion to the amount of weight gained or lost. With a 10 percent change in body mass, changes are usually needed in basal insulin levels, insulin-carb ratios, and the sensitivity factor. For example, a person who goes from 120 to 130 pounds (57 to 62 kg) and has blood sugars that are consistently above his or her target range should consider increasing basal, bolus, and correction insulin by approximately 10 percent.

  Illness/Infection

  Infections are more common in people with diabetes, particularly when blood sugar levels are chronically high. Infection-fighting white blood cells do not work well when the blood sugar is elevated. Extra glucose in the bloodstream also provides nourishment for viruses and bacteria (aiding and abetting the enemy!). Infections, in turn, cause the body to produce stress hormones that drive the blood sugar even higher and make insulin less effective.

  Infections commonly affect the sinuses, respiratory system, urinary and vaginal tract, and skin. Symptoms of infection include:

  •chronically high blood sugars

  •fever

  •dehydration

  •enlarged glands

  •thick yellow, green, or milky secretions

  Ketones may be present in the blood and urine during an illness and this is caused by insulin’s lack of effectiveness (as a result of all the stress hormones that are being produced). It is important to check your blood sugar and ketones frequently during an illness and stay in close contact with your health care team.

  The Adjustment: Even if you are not eating as much as usual, be sure to keep taking your basal insulin during an illness. Without basal insulin, your blood sugar will go dangerously high and you will put yourself at risk of diabetic ketoacidosis (DKA). When in DKA, your blood becomes so acidic that you will likely be vomiting and extremely achy. Your breathing will become very deep and labored, and your breath will take on a characteristic spoiled-fruit smell as your lungs attempt to rid your body of acid when you exhale. Treatment for DKA requires an immediate trip to your nearest emergency room.

  In most cases extra basal insulin is required during an illness. If your blood sugars are repeatedly high and you are not ketotic, consider increasing your basal insulin dose by 25 to 50 percent. If you are ketotic (small or more on a urine ketostick, or >0.5 on a blood meter that measures ketones), increase the basal insulin 50 to 100 percent. The basal insulin increase is in addition to your usual bolus doses, including correction doses to cover high blood sugars.

  Keep in mind that insulin will not absorb properly into the bloodstream if you are not adequately hydrated. Drinking plenty of fluids during an illness is essential—preferably clear, caffeine-free fluids. Most adults should consume one cup per hour while awake; small children should consume a half cup per hour. If you suspect that your insulin is not working after you inject or bolus into the fat below the skin, consider giving an injection directly into muscle or ask to be taken to a hospital so that insulin and fluids may be administered intravenously.

  Couch Potato Syndrome

  Sitting for long periods of time when you are normally active can produce a gradual rise in the blood sugar level. Because your usual insulin doses are based on a standard level of physical activity, withdrawing that activity can result in less glucose burning and a temporary decrease in insulin sensitivity.

  The Adjustment: The next time you plan to be completely sedentary for more than a few hours, consider raising your insulin dose slightly. If you use a pump, a temporary basal increase of 40 percent is a good place to start. If you take injections, adding 20 or 30 percent to your boluses can do the job nicely. Try this the next time you take a long car trip or plane/train/bus ride as well as any time you plan to veg out in front of the TV, the computer, or a good book for several hours.

  Rebounds from Lows/Somogyi Phenomenon

  A “rebound” may cause the high readings that follow hypoglycemic episodes. The symptoms that accompany low blood sugars (especially shaking, sweating, and rapid heartbeat) are caused by the production of adrenaline, and not surprisingly, adrenaline can also raise the blood sugar and inhibit insulin’s action for the next several hours. This can cause the blood sugar level to be unusually high and makes it difficult to bring down with your usual dose of correction insulin.

  When low blood sugars occur during sleep, the body’s own natural hormonal responses commonly kick in and produce high readings upon waking. This is referred to as a Somogyi Phenomenon. Many people sleep through these mild lows and are surprised to see the high readings when they wake up. Many believe that they need more insulin overnight to control the morning highs. Of course, increasing the nighttime insulin would only make the problem worse!

  The following symptoms may indicate that you are going low and rebounding during the night:

  •nighttime sweating

  •cool body temperature

  •restlessness

  •headache/hangover-like symptoms

  •rapid heartbeat upon waking

  •strange dreams

  •not feeling well rested in the morning

  It is a good idea to periodically check your blood sugar at the midpoint of your sleep time to verify that your blood sugar is not dropping while you sleep. If getting up in the middle of the night doesn’t appeal to you, try wearing a continuous glucose monitor and check the trend graphs when you wake up in the morning. For example, the chart in Figure 8-2 indicates consistent blood sugar drops in the middle of the night, followed by a rise in the early morning:

  The Adjustment: When morning
highs are preceded by lows in the middle of the night, there are a number of possible solutions.

  1.If the lows are always preceded by highs at bedtime, increase your sensitivity factor starting after dinner. That way you will receive less insulin to cover bedtime highs.

  Figure 8-2. CGM printout showing nighttime low blood sugars followed by wake-up highs

  2.If the lows are more common after large bedtime snacks, reduce your insulin-to-carb ratio for food eaten after dinner.

  3.If the lows take place when no bolus was given at bedtime, reduce the basal insulin from bedtime to morning (if using a pump) or the dose of long-acting insulin (if taking injections).

  Unfortunately, predicting when—or if—a rebound is going to occur after typical garden-variety hypoglycemic episodes is difficult. If you experience a consistent rebound at a consistent time following lows (or certain types of lows), giving a dose of insulin designed to prevent the rise is reasonable. For example, if your blood sugar always rebounds to the 300s (17–22 mmol/l) in the afternoon following prelunch lows, you might consider taking extra insulin at lunchtime. If you consistently rebound to very high levels two to three hours after readings below 50 (2.2), you might consider taking a small dose of rapid-acting insulin (or raising your basal rate for a few hours if you wear a pump) after you have treated the low.

  Speaking of treatment, another way to prevent a significant rebound is to refrain from overtreating the low. Eating excessive amounts of food when you are low is like throwing gasoline on a fire. I will discuss proper treatment of lows in the next chapter.

  Steroids

  Steroidal medications such as cortisone and prednisone are used to treat asthma, arthritis, emphysema, and muscle/joint inflammation. These drugs create significant insulin resistance and raise blood sugar levels—sometimes dramatically. Inhalers (containing albuterol) and topical steroids (in cream or ointment form) can also raise blood sugar levels. For those using a steroid medication on an ongoing basis, increasing the steroid dose can lead to blood sugars that are higher than usual.