Think Like a Pancreas

by Gary Scheiner

  Lunch sandwiches on white bread/rolls, French fries, tortillas, canned pasta, most microwave meals chili, rye/pumpernickel/sourdough bread, corn, carrots, salad vegetables

  Dinner rice, couscous, rolls, white potato, canned vegetables sweet potato, pasta, beans, fresh/steamed vegetables

  Snacks pretzels, chips, crackers, cake, cookies popcorn, fruit, chocolate, ice cream, nuts

  7. Add Some Acidity

  A food property that directly affects the rate of digestion is acidity. This is why sourdough bread has a much lower GI value than regular bread does. Research has shown that adding acidity in the form of vinegar (straight or in dressing/condiment form) can reduce the one-hour postmeal blood sugar rise by as much as 50 percent.

  8. Split Your Meal

  If you are having a meal and don’t want your blood sugar to rise all at once, consider saving a portion of your meal for a snack one or two hours later. Still give the full mealtime insulin before eating any of the meal—just don’t eat all of the food right away. For example, if you have a bowl of cereal and juice for breakfast, bolus for the full meal before eating anything. Then have the cereal at breakfast time and postpone the juice until mid-morning.

  9. Get Moving

  Being physically active after eating can reduce postmeal spikes in a number of ways. The enhanced blood flow helps the insulin absorb and act more quickly. Muscle activity diverts blood flow away from the intestines, resulting in slower absorption of sugars into the bloodstream. Plus, the working muscles consume some of the sugar that enters the bloodstream.

  How much activity is required to experience these benefits? Not much. Ten or fifteen minutes (or more) of mild activity will usually get the job done. The key is to avoid sitting for extended periods of time after eating. Instead of reading, watching TV, or working on the computer, go for a walk, shoot some hoops, or do some chores. Try to schedule your active tasks (housework, yard work, shopping, walking pets) for after meals.

  10. Prevent Hypoglycemia

  Low blood sugar is problematic in many ways. One of the body’s responses to hypoglycemia is accelerated gastric emptying: Food digests and raises blood sugar even more rapidly than usual. Although this is certainly a desirable phenomenon (who wants to wait for food to kick in during a low?), when it occurs before meals it will contribute to an excessive postmeal rise. Preventing hypoglycemia prior to meals and snacks is yet another strategy to “strike the spike.”

  The Other Extreme: Ketoacidosis

  DKA (diabetic ketoacidosis) is a condition in which the blood becomes highly acidic as a result of dehydration and excessive ketone (acid) production. When bodily fluids become acidic, some of the body’s systems stop functioning properly. It is a serious condition that will make you violently ill and can kill you. The primary cause of DKA is a lack of working insulin in the body. Let me explain.

  The primary cause of DKA is a lack of working insulin.

  Normal Fuel Metabolism

  Most of the body’s cells burn primarily sugar (glucose) for energy. Many cells also burn fat, but in much smaller amounts. Glucose happens to be a very “clean” form of energy—there are virtually no waste products left over when cells burn it up. Fat, however, is a “dirty” source of energy. When fat is burned, the cells produce waste products, which are called “ketones.” Ketones are acid molecules that can pollute the bloodstream and affect the body’s delicate pH balance if produced in large quantities. Luckily, we don’t tend to burn huge amounts of fat at one time, and the ketones that are produced can be broken down during the process of glucose metabolism; glucose and ketones can “jump into the fire” together.

  Figure 9-4. Normal fuel metabolism

  As you can tell, having an ample supply of glucose in the body’s cells is important. That requires two things: sugar (glucose) in the bloodstream and insulin to shuttle the sugar into the cells. (See Figure 9-4.)

  Abnormal Fuel Metabolism

  What would happen if you had no insulin? I’m not talking about a minor under-dosage; I’m talking about having none whatsoever. A number of things would start to go wrong. Without insulin glucose cannot get into the body’s cells. As a result, the cells begin burning large amounts of fat for energy. This, of course, leads to the production of large amounts of ketones. Although some of the ketones eventually spill over into the urine, the body is unable to eliminate sufficient amounts to restore a healthy pH balance in the bloodstream. (See Figure 9-5.)

  Figure 9-5. Fuel metabolism in the absence of insulin

  Dehydration further complicates the problem. Without sufficient insulin to inhibit the liver’s secretion of sugar, large amounts of glucose are released into the bloodstream. Because high blood sugar causes excessive urination, dehydration ensues. Without glucose metabolism to help break down the ketones and without ample fluids to help neutralize them, the bloodstream and tissues of the body become very acidic. This is a state of ketoacidosis.

  Causes and Prevention of Ketoacidosis

  What can cause a sudden lack of insulin in the body? There are a number of potential culprits.

  Illness, Infection, and Dehydration

  Illness, infection, and dehydration can cause the production of large quantities of stress hormones, which counteract insulin. In other words, during an illness, you could have insulin in your body, but it is rendered almost useless because stress hormones are blocking its action.

  Prevention: The sick-day strategies presented in Chapter 8 are worth reviewing. During an illness, insulin requirements are usually increased—even if you are not eating as much as usual. Keep taking your basal insulin regardless of your food intake. If your blood sugars are running high or if ketones are present in your urine, you will need to drink lots of water, and you may need to increase your dose of basal insulin by 50 to 100 percent.

  Lack of Carbohydrates

  A lack of carbohydrates in the diet can also induce ketone production. During periods of starvation, prolonged fasting, or restricted carbohydrate intake, the body’s cells must resort to burning alternative sources of fuel, namely fat and protein. With increased fat metabolism and limited carbohydrate metabolism, ketone production may exceed the body’s ability to eliminate them.

  Prevention: Ketone production is unhealthy for anyone, particularly those with diabetes. Maintaining at least a modest level of carbohydrate intake throughout the day should prevent ketosis. If you must fast for short periods of time, talk with your doctor to ensure that it will not interfere with any other health conditions or medications that you may be taking.

  You can usually fast safely by taking only basal insulin, with rapid-acting insulin as touch-ups for high blood sugars. If you take intermediate-acting insulin (NPH) in the morning, take half of your usual dose. Be sure to check your blood sugar level regularly during a fast. If your blood sugar drops below 70 (3.9), you must snack to bring it back up.

  Losing Weight When You Take Insulin

  There is nothing magical about very-low-carb diets when it comes to weight loss. Research has shown that just about any reasonable diet plan that has you paying close attention to what you are eating will result in weight loss.

  Losing weight when you take insulin can be challenging, but there are ways to make it happen. Ultimately, anything that allows you to take less insulin while still maintaining your blood sugar control will promote weight loss.

  Ways to cut back on basal insulin

  •reducing overall stress levels

  •minimizing high-fat foods

  •increasing daily walking/activity

  •increasing muscle mass

  •taking metformin

  Ways to cut back on bolus insulin

  •reducing carb portions

  •increasing fiber intake

  •postmeal exercise

  •reducing snack frequency

  •using Symlin, Byetta, or Victoza

  If you are working to lose weight and experience more than one low blood sugar per week at the sam
e time of day, cut back on the insulin dose that is working prior to that time. Repeated bouts of hypoglycemia will make it very, very difficult to lose weight. Conversely, cutting insulin back will facilitate weight loss.

  Spoiled Insulin

  Using spoiled insulin can lead to high blood sugar and ketone production. Insulin that has been frozen or exposed to extreme heat can “denature,” or break down so that the insulin molecules no longer work. Using the same vial or cartridge of insulin for many months or using it past its expiration date can also cause problems.

  Prevention: You should not use insulin vials and cartridges after their expiration date. Once you begin using a vial or cartridge, discard it after a couple of months (the insulin makers recommend starting new insulin vials/pens monthly). Keep your unopened insulin stored in the refrigerator, in an area that is not likely to freeze, such as the butter compartment. Before using a new insulin vial or cartridge, look for clumps, crystals on the glass, or discoloration. If you suspect that the insulin has gone bad, it probably has. When ordering insulin by mail, ask that it be shipped in a temperature-controlled container. Keep your insulin in your carry-on when you travel, as luggage may be exposed to extreme temperatures.

  Poor Absorption

  Poor absorption at the injection site can also cause an insulin deficiency. Remember, once insulin is injected or infused under the skin, it must absorb into the bloodstream in order to take effect. If the insulin “pockets” under the skin, it may never work. In some cases, the insulin may absorb much later than expected, resulting in a high blood sugar, followed by an unanticipated low.

  Prevention: Just as you rotate your tires to prevent uneven tread wear, you must rotate your injection and infusion (pump) sites to prevent uneven insulin absorption. Injecting the same spots repeatedly can cause lipodystrophy—a breakdown or inflammation of the fat tissue below the skin. When this happens the skin can either dimple or become unusually hard and insensitive. One of my clients calls these “happy spots” because they don’t hurt at all when giving a shot or inserting an infusion set. The problem with happy spots, however, is that they tend to have reduced blood flow, and insulin does not absorb properly—if at all. Avoid giving insulin into these areas. Spreading your injection and infusion sites over a large area of skin should help prevent the development of lipodystrophy. And with the exception of NPH and regular, insulin may be given in a variety of body parts without altering the absorption rate.

  Missed Injections

  Missed or omitted injections are another potential cause of an insulin deficiency. Missing an occasional meal bolus will not typically cause the body to become totally devoid of insulin, but missed basal insulin injections or repeated missed boluses can have serious consequences.

  Prevention: Plan to take your basal insulin at about the same time each day. If possible, combine it with another activity, such as brushing your teeth, taking oral medication, or eating a certain meal. Getting into a routine is the best way to ensure that you will not miss critical basal insulin injections. Some blood glucose meters can be programmed with scheduled reminders to check blood sugar or take a bolus. Users of the latest insulin pumps can avoid missing boluses by programming “missed bolus reminders” at key times of day. Those who take injections might have an easier time remembering to bolus if they take blood sugars at each meal/snack time and keep written records. Those who consistently bolus before eating are less like to forget compared to those who bolus during or after meals.

  Gaps in Coverage

  An insulin program that has gaps in insulin coverage or is grossly deficient in the total amount of insulin could also induce ketone production and ketoacidosis.

  Prevention: Questioning your doctor’s insulin dosage recommendations is reasonable if (1) there is no basal insulin component to your program, or (2) the total amount of insulin for the day is less than 0.5units per kilogram of your body weight if you have type 1 diabetes or less than 0.25 units per kilogram of your body weight if you have type 2 diabetes.

  Insulin Pump Malfunction

  Insulin pump therapy opens the door to ketoacidosis in the event of a problem with insulin delivery, absorption, or action. With no intermediate- or long-acting insulin in the body, pumpers rely on the pump’s delivery of basal insulin in the form of tiny pulses of rapidacting insulin. Any interruption in insulin delivery can result in a sharp rise in blood sugar and ketone production starting as soon as three hours after the last bit of insulin was infused. This can be caused by any of the following:

  •tubing or infusion set clogs

  •leaks where the cartridge connects to the tubing

  •air pockets in the tubing

  •spoilage of the insulin in the pump

  •dislodgement of the canula/infusion set tube from the skin

  •not connecting the tube completely at the infusion site

  •improper or insufficient priming

  •extended pump suspension

  •extended disconnection or forgetting to reconnect

  •lack of insulin absorption or leakage at the infusion site

  Prevention: The first and most important step in preventing ketoacidosis when using an insulin pump is early detection of a problem. This starts with frequent blood sugar checks, followed by ketone checks with any unusually high blood sugar levels. The absence of ketones indicates that the high reading is probably due to insufficient insulin coverage for food eaten recently. The presence of ketones indicates either an illness/infection or, more likely, a problem with the pump’s insulin delivery. The troubleshooting process is shown in Figure 9-6:

  Figure 9-6. Prevention of DKA when using an insulin pump

  Three steps should reverse the problem if ketones are present.

  1. Give an injection of insulin using a syringe, using your normal correction formula to determine the dose. Giving the injection into muscle will help bring your blood sugar down faster and ensure that it absorbs completely.

  2. Drink as much water as possible.

  3. Change your pump’s cartridge, tubing, and infusion set, using a fresh vial of insulin.

  Failure to correct the problem could result in ketoacidosis in just a few hours. To prevent insulin delivery problems with your pump, be sure to do the following:

  •Limit your disconnection and suspension periods to no more than an hour at a time. If you must disconnect for more than an hour, reconnect hourly and bolus an amount equal to the basal insulin that you missed in the previous hour.

  •Check your infusion site and tubing at least once daily. If the infusion set tape is peeling loose or if you spot any blood in the canula or any redness/irritation on your skin, replace the infusion set immediately.

  •Check for air pockets in the tubing. If you spot any, disconnect and prime until the air has been purged completely out.

  •If you smell insulin or detect moisture around any of the joints where the tubing connects to the pump or infusion set, replace them immediately.

  •If your pump alerts you of a tubing/infusion set clog (“no delivery,” “occlusion,” “blockage detected”), replace your cartridge, tubing, and infusion set immediately. Do not just jiggle your infusion set and attempt to bolus again. Pumps only detect clogs after a significant amount of pressure has built up. Jiggling may temporarily help insulin flow through, but the problem is likely to reoccur.

  •Change your cartridge as soon as possible after you receive your “low cartridge” warning. This minimizes the risk that your cartridge will run out completely.

  •Do not wear an infusion set in the same place for more than three days. Site problems occur much more often after three days of set usage.

  •Rotate sites in an organized fashion. Simply going from right side to left side repeatedly may result in the overuse of two sites. Instead, stay on one side of your body for several site changes, moving just a couple of inches (4–6 cm) each time. Here is an example.

  Left side Right side

  1 2 3 12
11 10

  6 5 4 13 14 15

  7 8 9 18 17 16

  Symptoms and Treatment of DKA

  Everyone with diabetes who uses insulin should have a way to test for ketones. You can perform ketone testing by way of a urine dipstick or a fingerstick blood sample. (See Chapter 10 for ketone testing supply options.) Positive ketones are indicated by either urine testing that indicates small or more ketones (>15 mg/dl) or blood testing that indicates the presence of β-Hydroxybutyrate (>0.5 mmol/l).

  Be sure to have fresh ketone testing supplies on hand at all times—including when you travel. Ketostix in vials are only good for six months after you have opened the vial. Individually foil-wrapped ketostix are good until their expiration date. Ketone test strips for blood testing are also foil wrapped, but once again, they are only good until the expiration date stamped on the package.

  The presence of ketones in the blood is referred to as “ketosis”; the presence of ketones in the urine is “ketonuria.” Ketosis and ketonuria are usually—but not always—accompanied by elevated blood sugar, thirst, and excessive urination. This is a precursor to the more severe state of DKA. Symptoms of DKA are more pronounced. With DKA, you are likely to be nauseated or vomiting. Your breathing may be very deep, and you could have a fruity odor on your breath as your lungs try to eliminate ketones when you exhale. You will likely be dehydrated due to all the urination, which is a result of the very high blood sugars. This will give you dry skin, intense thirst, and a dry mouth. Your vision may also be blurry; headache and muscle aches are common.