Think Like a Pancreas

by Gary Scheiner

  One to two days postpartum: The splash. When that log boat comes careening down, it doesn’t ease comfortably into the pool of water at the bottom; rather, it torpedoes into it with full force, soaking you and any unfortunate onlookers. Insulin needs do the same thing after delivery: They may actually drop below where they were at the beginning. Remember during the slight-dip phase when we discussed how the pancreas is capable of secreting some insulin on its own? Well, that process continues until shortly after delivery. And when you combine a pancreas that is producing insulin with the sudden elimination of placental hormones along with a sudden decrease in your weight, the results can be astonishing. For the first twenty-four to forty-eight hours postpartum, don’t be surprised if insulin needs are dramatically reduced. A small percentage of women don’t need to take any insulin during this phase!

  Home again. It was a wild and crazy ride, but well worth it. Just as the log boat makes its way back to the starting point, insulin needs also tend to find their way back to prepregnancy levels. That’s not to say that there won’t be any special adjustments necessary. Nursing usually causes the blood sugar to drop modestly. Retained weight will increase insulin needs. And new sleep patterns may require changes to basal insulin levels (as described above).

  The Adjustment: During weeks six through ten, reductions to both basal and bolus insulin are usually necessary to prevent frequent bouts of hypoglycemia. A 25 percent reduction in insulin requirements is not uncommon.

  During weeks ten through thirty-six, you will need to make steady, gradual increases to both basal and bolus insulin in order to keep up with the increased needs. It is not unusual to see total insulin needs double or triple from preconception until near the end of the third trimester. For the last couple weeks before delivery, insulin needs tend to level off.

  During delivery, due to the physical work being performed, women usually need to reduce their basal and bolus insulin doses by approximately 50 percent. Elevated blood sugar during delivery can cause oversecretion of insulin and hypoglycemia in your newborn, so you should cover any highs with rapid-acting insulin, using 50 percent of the usual correction doses, due to the impact of physical labor.

  The circle of life. Immediately after delivery insulin doses tend to return to prepregnancy levels. However, if any low blood sugars occur, don’t hesitate to make additional reductions for a couple days. Nursing (or pumping breast milk) often requires a small snack to prevent a blood sugar drop. I usually recommend 3 to 5 grams of carb per nursing session during the first couple months, and 5 to 10 grams thereafter.

  Chapter Highlights___________________________________________

  •Secondary factors that tend to raise blood sugar include:

  anxiety/stress

  caffeine

  disease progression

  protein (in the absence of carbs)

  large amounts of dietary fat

  growth and weight gain

  illness/infection

  reduced physical activity

  rebounds from lows

  steroid medications

  surgery

  •Secondary factors that tend to lower blood sugar include:

  previous heavy exercise

  advanced age

  weight loss

  heavy brain work

  heat and humidity

  nausea

  high altitude

  •Factors that can both raise and lower blood sugar include:

  alcohol

  travel

  intense exercise

  gastroparesis

  irregular sleep

  symlin (pramlintide)

  menstrual cycles

  menopause

  pregnancy

  CHAPTER

  9

  Going to Extremes

  “Darling, I don’t know why I go to extremes.

  Too high or too low, there ain’t no in-betweens.”

  —BILLY JOEL

  Up to this point, I have focused all attention on matching insulin to our precise needs (thinking like a pancreas!). But let’s be realistic: With so many variables and factors influencing blood sugar levels, you are going to experience your share of both high and low readings. Even the best-managed people with diabetes have readings that are out of range up to 25 percent of the time.

  In this chapter we will focus on what happens when the insulin we take is not matched precisely to our body’s needs. When we take too much insulin, low blood sugar (hypoglycemia) can occur. Mild forms of hypoglycemia are easily self-treated with a reduction in mealtime insulin or a rapidly digesting snack. However, severe forms of hypoglycemia usually require outside assistance and may lead to loss of consciousness, seizures, coma, or even death.

  When we take too little insulin, high blood sugar (hyperglycemia) occurs. We can treat most garden-variety episodes of hyperglycemia with correction insulin. However, a severe lack of insulin in the body can result in a life-threatening condition known as diabetic ketoacidosis (DKA). Because death is something we generally try to avoid, I will present strategies for both preventing and treating severe hypoglycemia and DKA in this chapter. I’ll also take a close look at ways to prevent after-meal highs, commonly referred to as “spikes.”

  The Science Behind Hypoglycemia

  Hypoglycemia (hereafter referred to as a “low”) is the main limiting factor in intensive diabetes management. Without the risk of lows we could simply load up on insulin and never have another high reading. Or, as my wife so eloquently reminds me from time to time, “Any idiot can have a decent A1c if they’re taking too much insulin and going low all the time!”

  Low blood sugar affects virtually all systems of the body, but none quite as much as the brain. Brain cells are picky about their fuel source: They only like to burn sugar for energy. Brain and nerve cells have another special feature: They do not require insulin to absorb sugar. Instead, they have special built-in transporters that shuttle sugar across the cell membrane without the aid of insulin.

  Low blood sugar is usually defined as a level of less than 70 mg/dl (3.9 mmol/l). Mild lows can cause inconvenience, embarrassment, poor physical and mental performance, impaired judgment, mood changes, weight gain, and rebound high blood sugars. Severe lows can induce seizures, loss of consciousness, coma, or even death. Repeated or prolonged bouts of severe hypoglycemia have the potential to cause permanent mental impairment, although this is usually seen only in the most extreme cases.

  Mild Lows

  Soon after diabetes is diagnosed, the central nervous system detects hypoglycemia quickly and easily. In some cases, symptoms can occur even at blood sugars above 70 (3.9). Blood sugars in the 80s or 90s (4s–5s), or a rapid drop from a very high level toward a more normal level, may induce hypoglycemic symptoms.

  Upon sensing that the blood sugar is low, the brain sends a signal to the adrenal gland, which releases a surge of adrenaline. Adrenaline, in turn, stimulates the liver to secrete extra sugar into the bloodstream and partially blocks the action of insulin. Adrenaline also causes a number of physical symptoms: rapid heartbeat, perspiration, shaking, hunger, and a generally anxious feeling. (You may recognize these as the same symptoms that occur when you are under intense stress, like when your mother-in-law calls to tell you she’s coming to move in.) At this point most people are capable of thinking rationally and consuming food in order to raise their blood sugar level.

  Moderate Lows

  If blood sugar levels are allowed to drop into the 50s or 40s (3–2 mmol/l), the brain begins losing the ability to function. Confusion usually sets in, accompanied by dizziness and weakness. Speech may become slurred. You may exhibit unusual emotions such as irritability or despair. Vision may become blurred. You will have a difficult time thinking clearly and coordinating your movements. At this point you may or may not be able to think rationally enough to consume food to raise your blood sugar. In many instances a friend or family member will need to assist you.

  Severe Lows

&nb
sp; An extreme or extended blood sugar drop may cause you to pass out or experience a seizure. Very severe, prolonged lows can result in coma or death. Severe lows, by definition, require outside assistance and are usually treated with an injection of glucagon or an intravenous infusion of dextrose.

  The DEVOlution of Symptoms

  No, it’s not a typo. And it has nothing to do with the band Devo (“Whip It,” circa 1980). The symptoms of hypoglycemia do not evolve: They devolve, or break down, over time. The brain becomes more efficient at extracting glucose from the bloodstream after going years with off-and-on low blood sugars. In other words, the brain will cease to detect mild low blood sugars; it produces little or no adrenaline response, and physical symptoms (shaking, sweating, etc.) fail to take place. Thus, there may be no warning of low blood sugar in its early stages. The first symptoms are those of a moderate low blood sugar (confusion, etc.), and these may not occur until the blood sugar is already at a dangerously low level.

  The name given to this phenomenon is “hypoglycemia unawareness.” It affects most people who have had diabetes for several years and tends to become worse over time. The more lows you have, the less likely you are to experience any warning signs the next time. Quite a paradox!

  Research has shown that the early symptoms of low blood sugar can, to some extent, be restored by avoiding lows over an extended period of time. People with severe cases of hypoglycemia unawareness have been able to reestablish their early warning symptoms by going several weeks without any readings below 80 (4.4). Although this process may require a temporary increase in the HbA1c level, it is well worth it to be able to detect lows and prevent severe hypoglycemia.

  Treatment of Lows

  Diabetes is a tricky disease. Low blood sugars sometimes feel like highs, and highs sometimes feel like lows. If you suspect that your blood sugar is low, take a few seconds to confirm it by checking your blood sugar. I can’t tell you how many times I thought I was low, only to test and get a reading in the 200s or 300s (teens to 20s). High blood sugars can cause symptoms similar to those caused by lows (tiredness, hunger, a jittery feeling). Getting an exact reading will also help to determine how much carb you need to treat the low.

  With premeal blood sugars that are below your target but above 70 mg/dl (3.9 mmol/l), reducing your meal bolus using your correction formula is a sound approach. For readings below 70, you should treat the low immediately, wait ten to fifteen minutes for the blood sugar to come up, and then have your meal (giving the usual dose for your meal). If you feed the low and reduce your mealtime bolus, you will have double treated and will probably wind up quite high.

  There is no one-size-fits-all when it comes to treating lows.

  There is no one-size-fits-all treatment for hypoglycemia. Proper treatment depends on a number of factors, including:

  1. Body size: The bigger you are, the more carbs you will need to raise your blood sugar. If you weigh less than 60 pounds (28 kg), each gram of carbohydrate should raise your blood sugar about 6 to 10 mg/dl (0.33–0.55 mmol/l); if you weigh 60 to 100 pounds (29–47 kg), each gram should raise you about 5 mg/dl (0.28); at 101 to 160 pounds (48–76 kg), the rise is about 4 points (0.22); 161 to 220 pounds (77–105 kg), about 3 points (0.17); over 220 pounds (105 kg), 2 points (0.11).

  2. Blood sugar level: The lower your blood sugar, the more carbs you will need to get back up to normal. Table 9-1 provides a good starting point. The goal on this chart is to raise the blood sugar to about 120 mg/dl (6.7 mmol/l). If your specific blood sugar target is more or less than 120, you will need more or fewer carbs than the amount listed.

  Table 9-1. Proper treatment for low blood sugar (based on body weight and blood sugar level)

  3. The rate of change: This is easily seen on a continuous glucose monitor. If your blood sugar is low and still dropping quickly, you will need more carb than the standard amount. (See Figure 9-1.) If you are low and leveling off, the standard amount should work fine. (See Figure 9-2.) Rapid blood sugar drops are most common when you are still in the peak phase of your mealtime bolus insulin, in the midst of exercising.

  Figure 9-1. Blood glucose low and accelerating downward

  Figure 9-2. Blood glucose low but leveling off

  The following formula can be used to determine your precise carb needs:

  grams of carb needed to treat a low =

  (target BG - actual BG) / rise per gram of carb

  For example, if your target is 100, your blood sugar is 62, and each gram of carb raises you 3 points, you will need (100–62) / 3, or 13 grams of carb.

  Remember, all carbs are not created equal. Some will raise your blood sugar very quickly, whereas others will take their sweet time (excuse the play on words). When your blood sugar is low, choose a food that will raise you as quickly as possible. Refer to the glycemic index and select foods with a score of at least 70. Examples of highglycemic-index foods that are portable and measurable include:

  dextrose* (GI =102)

  dry cereal (70–90)

  pretzels (81)

  jelly beans (80)

  gatorade (78)

  vanilla wafers (77)

  graham crackers (74)

  plain bread/crackers (70–75)

  LifeSavers (70)

  *Dextrose-containing foods include glucose tablets/gels, SweeTarts, Smarties, Spree, AirHeads, Runts, Nerds, and BottleCaps.

  Foods with a lower glycemic index, such as whole fruit, milk, ice cream, and—hate to say it—chocolate, are not the best choices for treating lows. They will take significantly longer to raise your blood sugar. Many people overtreat their lows by continuing to eat until the symptoms disappear. It usually takes ten to fifteen minutes for high glycemic index foods to raise the blood sugar, and twenty to sixty minutes for low glycemic index foods. Be patient! If you suspect that your blood sugar has not come up enough, test it to find out. If your blood sugar is still below 70 (3.9) fifteen minutes after treatment, go ahead and eat a little bit more.

  If you happen to go overboard on the treatment of your low (as we all do on occasion), cover the excess carbs with insulin. For example, if you normally take 1 unit for every 10 grams of carb and you overtreat your low by 40 grams, give yourself 4 units of insulin once your blood sugar has risen back to normal. Otherwise, your blood sugar will rise well above your target in the next couple of hours.

  Treating Severe Lows

  You must treat severe hypoglycemia (when a person is unwilling or unable to consciously swallow food) differently than you would mild and moderate lows. Putting any kind of food into the mouth of someone having a severe low is dangerous. They could choke on the food and suffocate, or they could instinctively bite down and take the fingers off the person trying to feed them.

  There are two things—and only two things—you should do to treat someone having a severe low blood sugar: Call for emergency help and administer an injection of glucagon (or Glucagen).

  Glucagon (or brand name Glucagen) is a hormone (like insulin) that raises blood sugar by stimulating the liver to release its stored-up sugar into the bloodstream. It will usually work in ten to twenty minutes. Glucagon is a prescription item that comes in a kit containing a large, fluid-filled syringe, a small vial with the glucagon hormone in powder form, and instructions written in a seemingly foreign language. The kits have an expiration date (they are usually good for about eighteen months), so check them periodically to make sure yours is fresh. If possible, save your expired kits and allow your partner to practice with them (on a pillow or foam ball—not you!).

  There are several steps involved in administering glucagon, and it may be difficult to perform them exactly right in a highly stressful situation. But it is certainly worth the effort. The good news is that work is under way to develop glucagon in a premixed formulation (no mixing necessary!), so all you would need to do is take the syringe out of the case and inject. The procedure for administering glucagon, in plain English, is as follows:

  1. Call 911. Have p
aramedics on the way in case the glucagon injection fails to work.

  2. Pull the cap off the syringe and flip the cap off the vial.

  3. Inject all of the fluid into the vial.

  4. Remove the syringe from the vial. Keep pressure on the plunger to make sure air does not escape from the vial.

  5. Shake or swirl the vial gently until the fluid is evenly mixed (no clumps) and mostly clear.

  6. With the vial held upside down, reinsert the tip of the needle into the vial. (Do not put the whole needle in; you will draw in air accidentally!)

  7. Draw the fluid into the syringe. For very small children (under age six), draw in ⅓ cc; for children six to twelve, draw in ½ cc; over age twelve, draw in 1 cc.

  8. Insert the needle straight (not at an angle) into a muscle such as the thigh, buttocks, or shoulder. Inject the full contents of the syringe.

  9. Remove the syringe and apply a tissue to suppress any bleeding.

  10. Turn the victim onto his or her side to prevent choking (in case vomiting occurs).

  The victim should regain consciousness in ten to twenty minutes. If he or she does not, wait for paramedics to arrive. Contact your health care team to troubleshoot and work on a plan for preventing the severe low from happening again.

  Note: Everyone who takes insulin is at risk for severe hypoglycemia. It is important to wear medical identification at all times. The Medic Alert Foundation provides more than just medical I.D. jewelry: It maintains a database of medical information that paramedics will have instant access to when they call in. Bracelets and necklaces are recommended because these are the first things paramedics will look for when they arrive at the scene.