The Golden InCA Triangle:
Legend has it that there is a golden triangle buried deep in the rain forests of Peru.... OK, that I made up.
It's not a real "triangle" in the sense that we can go all "Tomb Raider" and chase after it, it's more of a conceptual representation of the relationship between Insulin, Carbohydrates, and Activity.
- Three Sides to the Story (My D club friends can skip to my math rant, you know this part already):
Side 1: Carb Intake - Insulin Demand
The more Carbs taken in, the more insulin that is required to get the resulting glucose from the blood stream to the cells to fuel them.
Side 2: Activity - Insulin Demand (one way or the other)
This can go one of two ways. In most cases activity can lower blood sugar and therefore reduce the amount of insulin needed however, adrenaline can bring blood sugars up. Therefore, either way, activity levels impact insulin demand.
Side 3: Activity Level - Carb Needs
Food to fuel the body is probably the most commonly understood side amongst diabetics and non-diabetics. It's a matter of biology, the body needs fuel to do work - plain and simple.
So, the three points on the InCA Triangle are: Insulin, Carbohydrates, and Activity.
Now this is a fairly watered down version of what really goes on in all of our bodies (yes all of them, regardless of how you get your insulin). There are numerous factors at play, but these are three of the four main areas and they are the ones that we can directly measure and influence. The fourth one, the one we really can't do much about and especially wreaks havoc in kids, is physiology (ex. stress, illness, bodily changes, etc.). There are a staggering number of things happening in the body at any given time, and we don't fully understand it all. Quite simply, we don't know what we don't know. So, we deal with what we do know, and we go through our days with these three things in the forefront of our minds, guiding our plans, and filtering our post analysis.
T1 management styles can vary depending on how the diet is set up, insulin regimen, age, and lifestyle. In our case, we have chosen to maintain a healthy but non-diabetes centered diet. We manage to a prescribed target range of 6-12 mmol/L with injections of a fast-acting insulin at meals determined by carb ratios, a graduated scale for correction of highs with a fast-acting insulin, and a fixed amount of long-lasting/non-peaking insulin for his basil (aka the once a day shot). That last one is a different insulin than the meal time / correction insulin, and furthermore can not be mixed or share recent injection sites with the other. Age is 4 1/2, and lifestyle is, for lack of a better definition, 4 1/2.
The meal ratios and amount of long-lasting insulin have been set up and adjusted over time to achieve the closest to normal glucose patterns possible (still not close to perfect, but pretty good). Monitoring is constant and adjustments are made as needed, but Jonathan's ratios currently are: Breakfast 1:13, Lunch 1:18, and Dinner 1:20 which is 1 unit of insulin for every x grams of carbohydrates minus fibre. It is given to the lower 1/2 unit, meaning if the ratio results in 3.7 units, he will get 3.5 units since his pen is graduated in 1/2 units (this is where some pumpers have an advantage, they have smaller increments). We do have a bit of a trick up our sleeve though.... we usually adjust the amount of carbs slightly to get to a full half unit up or down ;)
For the most part lately (but there are always exceptions), his breakfast and lunch fasting numbers have been in his target range. Dinner, not as consistently, but his afternoons are more variable and we see him come in throughout his range and sometimes above. We often talk with the clinic about increasing his lunch insulin, and we may be doing that soon, but the worry is though that we don't want to put him at too much risk of lows. As a side note - there is always risk, we all know that. Diabetes management is just as much about risk management as anything else, but I digress (as I usually tend to do).
Although his dinner fasting number is not consistent, I'll still use this meal as my example because we have the most post-meal observation time here.
In a perfect world... ok well in a perfect world we wouldn't be having this discussion.... In a diabetics' perfect world, things would add up, X carbs plus Y insulin at known activity would equal in range glucose levels. But sometimes, and sometimes can feel like a lot of the time, 1+2+3=9.
Nine!? Nine you say!? That's higher than it should be! Yep, it shouldn't be that high, yet it is. And so it can be with glucose. In my previous post and attached comment, I made mention of certain foods. There are some foods that seem to be unpredictable. I have yet to find a good way to nail it down to specific cause and effect relationships, but one thing I do know is the more that is unknown about the food, the more likely it is that glucose will go out of whack. The top three offenders I've heard over and over are: Chinese food, pizza, and pasta.
I have yet to order Chinese food and see it arrive with a nutritional label on each item. There are websites and books and pamphlets and such that list the nutritional values of these foods, but if you've ever had sweet and sour chicken balls at more than one place, then you know there is no way a one-size-fits-all exists for the data on those balls. Similarly with pizza, recipes vary from store to store, that's why we have favourites and are picky about who we call, and I don't recall ever seeing a pizza cut into equally divided pieces, 15g/slice? Maybe. Pasta is not much better. If we make it at home it's actually not any more of an issue than any other food, but at a restaurant.... anyone have a dart board? An Italian friend of mine recommended once that to cut a bitter tasting meat sauce, add white sugar until it's right. Pure white sugar! Although I'll admit, I didn't have a concern over that last year.
There are two other food factors that no one seems to have a good handle on how exactly they fit into the equation, fat and glycemic index, so I'm kind of keeping those in the background for now only paying them a little attention.
Variability is one factor and is generally accepted as a truth. The other biggie that I can't shake, is time or rather time-delay. Asking nurses and dieticians, I'm told that food is digested and glucose is in the blood stream within less than 4 hours (more like less than 2 hours). A hard and fast number no, and there will be differences between foods, but 4 hours is the supposed point of stability because not only have the carbs been absorbed, that's also about how long it takes his bolus insulin to fully run it's course. So, the theory is that by the time 4 hours have passed, all of the carbs have been converted to sugar, moved to the blood stream, his insulin has run it's course and carried glucose away to hungry cells.
Then why is it, even when the meal is an established staple in our house and not some wildly random variable, that he can shoot up for checks beyond the 4 hours? I've seen dinners in the single digits, with +2hr and +4hr checks also being in the single digits only to go into the teens at +6 or +8 hours.
My high school math teacher always asked me to show my proofs. They wanted to know how I determined that x=2. Well, it looked good on paper, but sometimes 1+2+3 really does equal 9. This is where the teacher-student argument would ensue, but I'm sure we could come to some sort of compromise. How about 1+2+3x=9? On paper, we could show that x=2, but in D-world, the x is elusive. X is why we scratch our heads and wonder what we did wrong. X is why we grab our calculators and re-add, rice + milk + strawberries + Oreos = C, C/r = ? units... X is why we keep asking why. There is surely more than one X too.
Scary stuff if you dwell on it too long. So many random variables out to thwart our best efforts. As we keep the monster at bay with our tools and knowledge, all we can really do is focus on what we know and what we can control. How much of and what we eat, how much insulin we inject, and how much and what kinds of activities we do. Beyond that, it's in someone God's hands. Fortunately we have three quarters of the game in our pocket, and in my fuzzy math that's about 90-95% of the battle. Those are pretty good odds. Being the control freak that I can be sometimes, I remain unsettled with less than 100%, but that keeps me on my toes and ever vigilant for my child. I just hope that my attention, determination, and focus can help give him the healthy life he deserves.
PS: I've been poking along at this throughout the day, and at the same time catching up on some others blogs too. I feel I should admit that I write today as "calm, cool, collected Dad", and not "frustrated, discouraged Dad". I can definitely appreciate the frustration that comes from beating back the double digits and the disappointment that there is still no cure yet, but my thoughts today are more in the "at peace with it for the time being" vein.