The Crystal Ball (or Planning Ahead)
This post was inspired by a comment that Bernard made on a post I did back in July. He commented about having to plan ahead:
"For me, the only thing that really bites is having to sort of plan in advance if I want to play with my children. Otherwise I know that even a half-hour with them cycling or kicking a ball around can send my readings down to the 50s. Now that does stink!"
It does stink - and ever since then it's been rolling around my head. The need to always plan ahead, and not always being able to spontaneously do something without running low.
According to the "Pumping Insulin" book (I only have the 3rd edition), the basal rate should be lowered 60 to 90 minutes ahead of the activity for Humalog insulin. I have had good results if I can start it even earlier than that, more like 120 minutes before the activity.
When things come up that are physically demanding, and I didn't have two hours notice OR have a significant amount of insulin on board from a previous meal, I risk running low. This is not the end of the world, and there are a few approaches I can take that involve eating extra stuff and starting the temp rate as soon as I can.
BUT - I would like to point out that doing so is officially a major PITA (Pain In The Ass).
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The Time: 5:56pm, Monday
The Place: Front yard
The Scenario: Arriving home from work about an hour before the rest of the family gets home, I decided, spur of the moment, to do something productive and mow the weeds.
The Problem: Low Blood Sugar, again - even though I started a temporary rate when I decided to do yard work.
Frustrated, sweaty, covered ingrass weed clippings and "blown about" dirt (that gives you a pretty good picture of the condition of my yard, yes?), and trying to figure out what I can grab quickly to treat my low and get back out to finish the yard - and without tracking a bunch of dirt and outside stuff all through the house.
It feels that I run low every time I mow the yard. Every stinking time! Why? Because I stubbornly try to avoid eating to boost my blood sugar high enough, and two hours ago I didn't know I would be mowing the yard. The temp rate I started has not yet had time to have an impact on my blood sugar level.
The Time: 2:43pm, Saturday
The Place: Sunset Park
The Scenario: The kids wanted to walk up to the park and play. The park is a little less than a mile away, and it's a great day to be outside.
The Problem: We've been playing for about 30 minutes, and I can feel my blood sugar dropping too low - even though I started a temporary rate before leaving the house.
I almost always have a tube of about 10 glucose tabs in my pocket, give or take a few depending on whether or not I've used any that day, or neglected to refill it - which does happen from time to time.
In this situation I have plenty of tabs with me, and can treat the low - but that's not exactly the point. It is the interruption. The having to stop what I'm doing to take care of things (test, cram some tabs, wait for them to digest). The feeling of the low, and the exhaustion afterwards.
The Time: 8:10pm, Wednesday
The Place: Halfway down the basement stairs at my in-laws house. Working to steady the top half of a big, heavy, made of much glass & mirror, china cabinet.
The Scenario: On my way home from work. My mother-in-law called because she needed some help moving a couple of big pieces of furniture out of my sister-in-law's house, to make way for some new furniture being delivered bright and early tomorrow morning. My wife's family is the best, and I would not trade them for anything - but they are masters of the last minute arrangement. And I am the only one in the immediate and local family that drives apile of rust & holes, on wheels pickup truck.
The Problem: We're halfway down the basements stairs, moving the second of three big heavy pieces of furniture. I'm on the bottom side. I'm working with my nephew-in-law, who is strong, but he's young. I'm bracing the cabinet, bearing 70% or 80% of the weight, as he works from the top to navigate and make sure we don't break any of the glass or mirrors.
And I'm feeling low - even though I started a temp rate after getting the call. Muscles shaking, partly from the low, partly from the heavy ass piece of furniture. Sweat dripping everywhere, partly from the low, partly from the heavy ass piece of furniture. Feeling the feeling that I need to take a break, partly from the low, partly from the heavy ass piece of furniture. Hoping I can make my body do what I need it to do to get this piece safely down the rest of the stairs so I can deal with this low. Have I mentioned how frickin' heavy this thing is?! OMG.
(Have you ever thought about what happens to the guy at the bottom if a big piece of furniture slips out of controlling hands and starts to descend down the staircase? Not. Pretty. I don't know that from experience - I'm just using my imagination to picture how that series of events might play out. )
Most of the lows I have are not immediately severe. I can recognize that I need to treat the low, thankfully far ahead of when it would require help to do so. Meaning I usually have a little time to figure out what to do before it gets out of hand. HOWEVER, that fact did little to comfort me as I'm trying my best to a) avoid being crushed to death (or seriously injured) and b) keep from shattering glass and/or mirror all over the place.
We manage to get the cabinet down the stairs without any serious injuries or damage. I let them know I need a break, and chow down all 10 of the glucose tabs in my pocket. Take some time to recover, then it's on to pick up the last piece of furniture. And yes, I'm weak and exhausted from the low (and that heavy ass piece of furniture).
------------------------------------
For all of these situations I should have better anticipated the need to do something to avoid the low. Being that I didn't have time to start the temporary rate far enough ahead of the activity, I should have had a little something to give me a boost. I know that.
The point of this post is that with the absorbtion times of the insulins we use, and the amount of time they are actively lowering blood sugars in our system, it is still a very crude system that requires constant diligence and and almost uncanny ability to see into the near future.
Life just doesn't always work that way.
"For me, the only thing that really bites is having to sort of plan in advance if I want to play with my children. Otherwise I know that even a half-hour with them cycling or kicking a ball around can send my readings down to the 50s. Now that does stink!"
It does stink - and ever since then it's been rolling around my head. The need to always plan ahead, and not always being able to spontaneously do something without running low.
According to the "Pumping Insulin" book (I only have the 3rd edition), the basal rate should be lowered 60 to 90 minutes ahead of the activity for Humalog insulin. I have had good results if I can start it even earlier than that, more like 120 minutes before the activity.
When things come up that are physically demanding, and I didn't have two hours notice OR have a significant amount of insulin on board from a previous meal, I risk running low. This is not the end of the world, and there are a few approaches I can take that involve eating extra stuff and starting the temp rate as soon as I can.
BUT - I would like to point out that doing so is officially a major PITA (Pain In The Ass).
------------------------------------
The Time: 5:56pm, Monday
The Place: Front yard
The Scenario: Arriving home from work about an hour before the rest of the family gets home, I decided, spur of the moment, to do something productive and mow the weeds.
The Problem: Low Blood Sugar, again - even though I started a temporary rate when I decided to do yard work.
Frustrated, sweaty, covered in
It feels that I run low every time I mow the yard. Every stinking time! Why? Because I stubbornly try to avoid eating to boost my blood sugar high enough, and two hours ago I didn't know I would be mowing the yard. The temp rate I started has not yet had time to have an impact on my blood sugar level.
The Time: 2:43pm, Saturday
The Place: Sunset Park
The Scenario: The kids wanted to walk up to the park and play. The park is a little less than a mile away, and it's a great day to be outside.
The Problem: We've been playing for about 30 minutes, and I can feel my blood sugar dropping too low - even though I started a temporary rate before leaving the house.
I almost always have a tube of about 10 glucose tabs in my pocket, give or take a few depending on whether or not I've used any that day, or neglected to refill it - which does happen from time to time.
In this situation I have plenty of tabs with me, and can treat the low - but that's not exactly the point. It is the interruption. The having to stop what I'm doing to take care of things (test, cram some tabs, wait for them to digest). The feeling of the low, and the exhaustion afterwards.
The Time: 8:10pm, Wednesday
The Place: Halfway down the basement stairs at my in-laws house. Working to steady the top half of a big, heavy, made of much glass & mirror, china cabinet.
The Scenario: On my way home from work. My mother-in-law called because she needed some help moving a couple of big pieces of furniture out of my sister-in-law's house, to make way for some new furniture being delivered bright and early tomorrow morning. My wife's family is the best, and I would not trade them for anything - but they are masters of the last minute arrangement. And I am the only one in the immediate and local family that drives a
The Problem: We're halfway down the basements stairs, moving the second of three big heavy pieces of furniture. I'm on the bottom side. I'm working with my nephew-in-law, who is strong, but he's young. I'm bracing the cabinet, bearing 70% or 80% of the weight, as he works from the top to navigate and make sure we don't break any of the glass or mirrors.
And I'm feeling low - even though I started a temp rate after getting the call. Muscles shaking, partly from the low, partly from the heavy ass piece of furniture. Sweat dripping everywhere, partly from the low, partly from the heavy ass piece of furniture. Feeling the feeling that I need to take a break, partly from the low, partly from the heavy ass piece of furniture. Hoping I can make my body do what I need it to do to get this piece safely down the rest of the stairs so I can deal with this low. Have I mentioned how frickin' heavy this thing is?! OMG.
(Have you ever thought about what happens to the guy at the bottom if a big piece of furniture slips out of controlling hands and starts to descend down the staircase? Not. Pretty. I don't know that from experience - I'm just using my imagination to picture how that series of events might play out. )
Most of the lows I have are not immediately severe. I can recognize that I need to treat the low, thankfully far ahead of when it would require help to do so. Meaning I usually have a little time to figure out what to do before it gets out of hand. HOWEVER, that fact did little to comfort me as I'm trying my best to a) avoid being crushed to death (or seriously injured) and b) keep from shattering glass and/or mirror all over the place.
We manage to get the cabinet down the stairs without any serious injuries or damage. I let them know I need a break, and chow down all 10 of the glucose tabs in my pocket. Take some time to recover, then it's on to pick up the last piece of furniture. And yes, I'm weak and exhausted from the low (and that heavy ass piece of furniture).
------------------------------------
For all of these situations I should have better anticipated the need to do something to avoid the low. Being that I didn't have time to start the temporary rate far enough ahead of the activity, I should have had a little something to give me a boost. I know that.
The point of this post is that with the absorbtion times of the insulins we use, and the amount of time they are actively lowering blood sugars in our system, it is still a very crude system that requires constant diligence and and almost uncanny ability to see into the near future.
Life just doesn't always work that way.
posted by Scott K. Johnson | 10:45 AM
14 Comments:
I think it is just plain unfair that one of the side effects of diabetes is not the ability to see into the future.
My entire "diabetes life" has been focused on being NORMAL --> but what defines normal? That;s a whole other issue - but I agree going "low" never happens at an oppertune time!
Not sure about others - but the WORST is when a low happens soon after a big meal. Many times (and you think I would learn) I have chosen NOT to duel bolus - and end up low within an hour after a feast...often Christmas Dinner...when the last think on my mind is food! That is the most annoying to me.
I pretty much fly by the seat of my pants with activity. I will check my glucose on the CGMS before an activity....most of the time I make it through ok...but it is a lottery, you never know!
The frustration of being unable to indulge in spontenaity is awful. My least favorite thing is running in an airport to catch a plane, and then using the first 30 minutes of the flight, when most people's body's feel peculiar anyways, to try and get things right again.
I'd send Dr. Parts and his truck to help, but not sure we'd get there in time. Dr. Parts is helping my brother move some stuff this weekend, and next. You write so well about what this [vulgarity] is all about. Thanks for expressing it so well.
So true...................the thing that really irritates me is on those nice summer nights when one of my neighbors spontaneously asks me if I want to walk around Lake Calhoun and I have to go down the list - when did I last eat? when did I last inject? how much food? how much insulin? blah blah blah and usually I decline because I don't want them to have to stop and sit on a bench with me until I come back up. I don't like it and I feel like a freak.
The lows associated with activity are annoying- because even if there is advance planning there is potential for a delayed effect. We're told exercise is good for us, but for me a deterrant is the unpredicatability of whether the low will hit me during, soon after, or almost 10-15 hours after. A couple weeks ago I took a 25 min walk at 630pm, set a temp basal for 5 hrs after (to avoid a pre-bedtime low) and was 250's the whole time. I had a low at 10am the next morning, and was scratching my head until I thought back to the previous night. So I totally understand your frustration. One suggestion I can make is that if you aren't able to plan ahead, you could always have 15gms of carb right before hand to try to head off a more immediate low. Especially if you know you have active insulin in your system (meal bolus within a 2hr time frame) or it's been awhile since your last meal. 15gms should raise it a safe 50mg/dl so that you have that to burn up without a high bloodsugar.
Scott, you wild man! What were you thinking...mowing the yard spur of the moment like that?
Speaking of planning, I ran in a 5K yesterday. After getting up at 4:30 am to allow 3 hours to pass between bolusing for a light breakfast and race time, packing "just in case" snacks, setting and resetting a temp basal, and numerous blood sugar checks, I arrived at the starting line with a BG of 200. Not great, but better too high than too low at this point. Looking around me at the other runners, I wondered just how nice it would be to just show up and run. And despite all my careful planning, BG skyrocketed up to almost 300 after the race, so had a correction bolus instead of post race goodies. Guess my crystal ball needs a little polishing!
You know, sometimes I wish I could go mysteriously low after meals. I seem to always be mysteriously high. (Not that low is REALLY better...)
I've definitely had bouts where vacuuming the apartment for 15 minutes makes me feel low. The same with cleaning the bathroom top to bottom. Maybe the secret to better control is more cleaning for me, and less housework for you?
Ca-ching!
You've hit the nail squarely on the head, again, my friend.
I too have a "lawn" that is more sticks and stones than actual grass and have had to come in the house to down massive amounts of OJ to get 'er done.
And I love the phrase "cram some tabs"!
Scott,
If it helps at all, but I know anything anyone says never really helps, but you made me feel so not alone and now I understand why most endo's and CDE's just nod their heads at me, because now I can tell they have heard all this about exercise a thousand times. Back when I was on two shots a day and did not test because meters did not exist and was shooting NPH, I would ride my bike for hours at a time, but that is because I probably was always high, my body could handle being high better, and I ate constantly. I went on the pump to maintain and understand better bgs and to help with my constant lows of exercise and the constant eating to maintain my exercise. Guess what a pump is not the answer for exercise, unless you truly plan ahead and still continue to test constantly, and remove your dirty gardening shoes to go test, eat, revieve from a low and try again. Thanks for posting as I really felt I was so alone on this issue and thought I was just not getting the concept of a pump.
Type 1 for 40 years pumping for 3.5 of them and still cannot bike, golf, cut the lawn on the spur of the moment.
Karen
Wow, I really liked Karen's comment about not being able to tolerate highs anymore. In my "early" years I could run around high all the time and had lots of energy. And now, 32 years later I feel absolutely awful if I'm high, even for an afternoon - it just wipes me out big time. Plus, I also think it's the wide swings that are very stressful to the "older" body. It makes a lot of sense.
The inability to do something spontaneously without the risk of BG problems annoys me too. It does not stop me from spontaneously deciding to e.g. go for a bike ride, though. Then I will just have to deal with the consequences of my choice later on - and I must admit it would be so nice not to have to worry about that!
While exercise is supposed to be good for us, and experience teach us how to handle it to make it work as good as possible most of the time, it seems like sometimes even though you have done everything right to prepare for exercise, the BG is not working with you. For me this often happens at times when I have a busy schedule, despite not compromising meals and snacks and the timing of these. The other day was such a day for me. I had soccer practice at 5 PM, which means that I usually aim for leaving work at 3:45 PM in order to arrive at home with enough time to change and have a small snack without it being too stressful. Because I have a lot do to at work this week, I wasn't able to leave until 4 PM. There was a strong head wind so I knew that I wouldn't be able to ride as fast as I usually does (I have a 9 km (9.8 miles) bike ride between work and my home), and I figured that a BG of 4.7 (85) with a small bolus in the system would probably not be enough to go on. I had an apple, went home and got ready for practice, not feeling too enthusiastic about it, though. Once I tested I could tell why: 2.3 (41). Damn it! I ate 6 glucose tabs and a handful of raisins before going out to the field. I still felt crummy and knew that I would have to wait until the carbs had raised my BG. I tested again 15 min after: 2.2 (40)! Why? Grrrr!! Why am I not allowed to enjoy practice? A banana and 125 ml of juice down. Now I had consumed something like 40-50 grams of carb in the last 30 min and finally some of them seemed to take their effect. I missed the first half an hour of practice - very annoying - and finished with a good 5.8 (104), and of course had to deal with sugars this level later that evening.
Cool Vic!
Yeah, that program is from Ryan Bruner, who is one of the bloggers in the OC. The software is excellent.
I have a pocket pc, rather than a palm pilot now (it's kind of the same thing as windows vs. mac - where programs for one don't work for the other). Otherwise I would be using logbook dm now.
It will help you out big time!!
Although I've only been on a CGMS (DexCom) for 2 weeks, I can say that the trend data a good part of the time, gives me a line into the future.
I can usually extrapolite the trend data and see that if I extend the line further in time, at the current rate, I'll go below my preset limit of 80, or above my preset limit of 220, at the rate determined by the trend line.
I can then make an adjustment. I've caught lows before they've occured, on a number of occasions.
It's the closest I've come to being able to accurately predict where my BGs are headed, most of the time.
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