Shoot Up or Put Up

And lo! the scales fell from my eyes

During the summer last year we went round to some friends of ours for a dinner party. Yes, a dinner party – now that I have reached my thirties, I no longer have the desire to frequent sweaty nightclubs of a Saturday night, downing expensive, sticky drinks and being much, much too close to the dripping unwashed masses.

So being unrelenting and incurably middle class, I now spend Saturday nights with friends, supping fine wines and discussing the issues of the day (I say that, but this particular dinner party ended up being somewhat rowdy, with broken glasses and minor chaos – we eventually left our host in the early hours with an uncontrollable bout of booze-induced hiccups).

Anyway, I digress. I bring up the whole dinner-party thing because I noticed on that particular evening that our host had a rather fancy-pants set of scales which gave you the various nutritional values of whatever you happened to be weighing. I saw that it did carbohydrates and duly lodged this diabetic-friendly piece of information away in the recesses of my brain.

So it came to pass that when our crappy set of TESCO scales gave up the ghost (thanks TESCO – that was £12 well spent, I think not) I finally fulfilled my ambition and purchased a set of said fancy-pants scales.

As I think I’ve mentioned before, I religiously carb count. I mean religiously in that I strictly carb count about as frequently as I attend church (once on Christmas Eve and the occasional wedding). Most of the time I fly solo and make an educated guess for carb contents and insulin doses. But every once in a while I properly check and log everything for a week or so – sort of like a diabetes refresher course – to check I’m doing things well.

It’s therefore when I’m doing a periodic refresher that these scales really come into their own. Can’t be bothered to work out the carb content of your glass of breakfast orange juice? Easy – just bung the glass on the fancy scales, hit 878 (the code for orange juice), fill up with orange and hey presto! up comes the carb content for that exact amount of fruity juicy goodness. Yum!

Using the internal memory, you can quickly tot up the total carb content of your entire breakfast (which is usually, for me, a pint of heavy claret and a whole roast pheasant and trimmings) and log and inject accordingly.

So while not entirely world-shattering, my new fancy-pants scales are actually quite good with helping me to carb count. More importantly, they look really cool. So – in summary – they’re probably a worthwhile spend of £36. If you care, my Salter “Nutri-weigh Slim” electronic scale can be found on the John Lewis web site; if you don’t care, what technology-of-the-future do you use to help carb count?

The thills and spills of formulae

In an idle moment and for a bit of fun – I use the term “fun” advisedly here – I decided to knock up a diabetes spreadsheet.

I thought it would be interesting (again the term “interesting” is relative here) to log my insulin doses, carbohydrate intake and resultant blood glucose. By comparing the carb to insulin ratio – over, say, a 14 day period – to the resulting BG target-range hit-rate, I could objectively calculate my ideal ratio at different times of day. From this data I could then create a personalised insulin calculator. I could type in the time of day, my proposed carb intake and from that calculate the correct dose of insulin to stick in – all based on the data I collected earlier.

I don’t need to tell you, it was a dull, rainy weekend.

I know that the minute I publish this, someone will say in the comments below “Ah yes, the ‘Carbotron-XP’ software can already do this for you”. However, despite that inevitability, it was an interesting exercise to work out the formulas, etc., by myself.

This was mainly because I quickly realised how insanely complex it is to note all the relevant factors and come up with objective calculations. Measuring and logging my BG, carb and insulin intake before and after meals is pretty straightforward (if incredibly, incredibly tedious) but then it gets more complex.

What if my BG is high before my breakfast banquet and I stick in a correcting dose – in addition to an amount to cover the roast pheasant and flagon of port I have each morning? If I simply divide the number of carbs by the amount of insulin I’ve put in then that screws up my carb:insulin ratio calculation, as it doesn’t take account of the correction. So corrections have to be recorded separately.

To keep things simple, I’ve also divided the day into eight separate blocks – that is before and after meals and two night-time blocks. But what if I have a mid-morning snack which I might cover with a unit or two? If that’s not recorded then, it too, will screw up my calculations. I’ve therefore had to cheat and lump my elevenses in with my breakfast. While this is probably near enough, it starts to add a margin of error into the equations.

More errors inevitably creep in as the spreadsheet doesn’t take account glycaemic index, exercise, stress, phase of the moon, tide times and everything else that affects my blood glucose.

And so, in the end, my highly objective exercise results in a rough guide to carb:insulin and requires quite a lot of finger-in-the-air guestimating to get it to work. If carefully recorded data and the massive computing power of Microsoft Excel can’t come up with a useful guide to diabetes, then it’s no wonder I manage to completely cock-up my doses from time to time. I suppose what is more interesting is that – apparently against the odds – I manage to get it right quite so often. Go me!

Do I really believe that?

When I was a child my mother used to carry an uncooked baking potato in her handbag. She knew that potato contained 30g of carbs. When my meal arrived in the restaurant she’d get the raw potato out of her bag and compare it with the one on my plate. Ta-da, a very early version of carb guestimating technology.

Now, I will admit that it isn’t practical to carry in your bag a ready weighed version of all the food you intend to eat. I’m the woman who whinges about the amount of diabetes junk I have to take on holiday, a life size specimen of all foods I may encounter certainly isn’t going in my hand luggage.

Over the years lots of people (ok, more than 10, less than 100) have said to me that we should campaign for all restaurants to publish carb counts of their food. Sounds sensible.

However, I’m a big fan of self sufficiency. I don’t want to be dependent on someone else publishing carb counts when I go out. Surely it’s better to learn the skill of guestimating carbs with the help of a good book and some trial and error rather than rely slavishly on companies to publish the data? That way, you can go anywhere.

I’ve already recounted the Chinese dumpling banquet debacle. A label on each dumpling wouldn’t have helped, there’s no way I would have believed they contained so many carbs and I wouldn’t have been brave enough to put in the full bucket of insulin required.

McDonalds do publish carb counts and if I inject according to their carb count I’m on the floor within 2 hours begging for sugar. I’m sure it’s factually correct; it’s just that the fat content is so high it slows the absorption of the carbs. It doesn’t tell you that on the box.

I’m all for a bit of help to make life easier. However, I also like to pick my battles. Getting CGMS funded by the NHS? I’ll fight til I drop. Getting insulin pen needles on prescription when the Govt refused in the early 1990’s? Done it. Campaigning to ensure that all people with diabetes have access to decent patient education and support? Oh yes. Pushing water up hill to get all restaurants to publish carb counts? Nice to have but if I put my efforts into getting decent education and support for people with diabetes, this one almost becomes an irrelevance.

I spent an age yesterday searching for a proper blueberry muffin. I could find a low fat, low sugar version, or one made with bran (I know it’s healthy but it’s not meant to take me 10 minutes to chew through a muffin, hence I like mine without the bran) but not a genuine, full fat, full sugar, tasty, scrumptious, delicious, naughty but nice blueberry muffin.

Back in 1983 when I was diagnosed (or the dark ages as Tim likes to call it) you struggled to get sugar free anything in the UK. Diet drinks were as rare as a very rare thing. More often than not water was the only sugar free option in a cafe or restaurant (or now I think about it, were my parents just telling me that to keep the costs down???).

We went on holiday as a family to Florida in 1989 when I was 10. We must have spent half a day in the supermarket. It was amazing, they had sugar free everything. Sugar free chocolate soda, root beer (how do you drink that, its vile), cream soda, muffins, toffees, mints, strawberry flavoured chewing gum (we must have brought back a hundred packs of this stuff). I was literally a diabetic kid in a sugar free sweet shop.

I wanted to try all of it. Sadly all the canned drinks were in packs of 6 which was a bit big when you only wanted to try one, but the shop assistant said we could split the packs. That was a revelation, in the UK they start removing your limbs if you try and split a six pack in a supermarket. It just isn’t done.

Actually, most of the sugar free drinks were a grave disappointment. It was the last time I ever drank chocolate soda, root beer or cream soda, but it was so good to try them and know that I wasn’t really missing out!

Ironically now that the world is full of sugar free stuff I no longer have such a need for it. The wonders of carb counting and insulin adjusting mean that if I want chocolate I have a bit of proper chocolate rather than the crime against taste and the digestive system that is sugar free chocolate.  It actually feels like things are going a bit too far in favour of the healthy life. If I want a healthy snack I have an apple. If I want a naughty snack, I have a proper blueberry muffin. The hybrid low sugar, low fat versions seem to miss the mark on both counts – they’re still full of carbs so diabetes wise I still need to think about it, and they doesn’t taste as good as the orignial. On that thought, I’ll get back to my muffin.

Tim heading off on his hols got me thinking about my travels with diabetes.

A couple of years ago we spent a month travelling round China. It was brilliant and surprisingly easy from a diabetes point of view. The food was delicious and I ate pretty low carb food for the whole trip which made a real difference to my control.

The exception was the Chinese dumpling banquet in Xian. A meal comprising twenty two courses of dumplings stuffed with everything from fungus to crab to shark! That’s a lot of dumplings. And nowhere in my many years of accumulated diabetes wisdom have I come across the carbohydrate count of a dumpling.

So I did what every good diabetic does when faced with previously unencountered gastronomic delights, I guestimated.

The banquet was interesting, although after the 14th dumpling it did start to feel like a bit of an endurance test. But we passed; we ate all the dumplings and waddled home looking quite dumpling-like ourselves.

Of course, I had wildly under-guestimated the number of carbs in a dumpling and when you multiply that by 22, that’s quite an error. When I woke up in the middle of the night unable to detach my tongue from the roof of my mouth I guessed I’d underdone the insulin. 24.8 on the meter, a gallon of water, a bucket of insulin and back to sleep.

I woke up the next morning with a headache and a tongue not even wet enough to lick a stamp. Still hovering around the 20 mark, I had another bucket of insulin and went off to see the Terracotta Warriors.  Disconcertingly I could also feel at least 21 of the 22 dumplings sitting heavily at the bottom of my stomach.

This went on for 2 days. That’s how long it seems to take to digest 22 Chinese dumplings and get blood sugar levels back down to normal.

A Chinese dumpling banquet was definitely a once in a lifetime experience, I’d never be stupid enough to repeat it.

We’re back from our long weekend in Venice, it was all the things they tell you in the guide books – romantic, beautiful, lots of bridges, water, gondolas etc and one thing they don’t tell you – carb heavy.

I’ve thought for years that as well as eating low GI foods reducing the number of carbs I eat gives me better control. When I got my CGMS the data showed that I had much better readings when I ate fewer carbs. This is of course logical, if you’re trying to cope with a massive plate of pasta the margin for error in insulin dosing is far greater than if you’re eating a small green salad. This isn’t rocket science.

I do keep an eye on how many carbs I eat and reduce them wherever I can and overall I do ok. But it’s not easy. I like food that contains carbs. And I now think it is physically impossible to have a low carb weekend in Italy – all that fresh pasta, risotto, pizza, ice cream, tiramisu (yes I know they do delicious grilled fish and marvellous salads and I tried, believe me, but they really do specialise in scrumptious carbs!).

I find pizza in the UK to be the root of all diabetes evil so I rarely eat it. Its high carb and also high fat so it’s absorbed quite slowly into my system. I need buckets of insulin to deal with the carbs but not straight away because the fat slows down how quickly those carbs get in. Since I’ve got the pump, I’ve mastered the dual wave bolus which allows me to put some insulin in at the start of the meal and stagger the rest of it over the next few hours. Bingo, pizza without the immediate low or hours later high.

Thankfully proper Italian pizzas have an incredibly thin base so middle of the night highs following pizza for dinner weren’t a problem last weekend. The first one did catch me out though after I was a bit gung ho with the insulin guessing and it appears I needed half a bucket less than I’d thought. And that brings me to the final great thing about Italy – there’s a very tasty ice cream stall on every corner just waiting to help you deal with that low.

This post is an extract (actually an entire copy to be honest) of an article from the About Diabetes page over to the right there. Feel free to add your comments, criticism and general bile at the bottom under the comments.

Anyway, there’s a lot of nonsense talked about what you can and can’t eat as a diabetic. This blog focuses on Type One diabetes and those lucky enough to have Type Two might find their experience differs. But probably not much.

When I was first diagnosed with Type One a few years ago, part of my crash course in diabetes was a session or two (easy there!) with a lovely dietician called Debbie.

By the way, it’s worth noting at this point that “dietician” is a protected term in the UK – much like “solicitor” or “architect”. You can’t call yourself a dietician (or a solicitor or architect) unless you are suitably qualified. However, the same is not true for the term “nutritionist” in the UK (it’s different in other countries though).

Essentially any old snake-oil merchant, quack or loony can call themselves a nutritionist in the UK. This is why pretty much anything written or sold by a “nutritionist” in the UK can almost exclusively be discounted as complete rubbish.

Anyway, that aside, Debbie and I had a lovely time and mainly chatted about my homemade Baileys ice cream and spoke about carbohydrate counting and a diet made up of foods with a low glycaemic index. I’ll talk about carb. counting in another post so ignore that for now, but the glycaemic index thing is worthy of mention as I think it’s possibly the most relevant part of the Type One diet.

Glycaemic index

As you probably know when you eat your deep fried mars bar or delicately sautéed fois gras your digestive system breaks down the foody-goo and releases its various constituent parts. Of interest to us diabetics are the carbohydrates or sugars which are released into our blood stream.

All foods are not equal in terms of the rates at which your body can process them and release them into your ruby-red blood. Essentially, and very broadly, the more pre-processed the food the less your body has to do and therefore the quicker it will be broken down and released in to your bloodstream (and so this food is said to have a high glycaemic index). The less processed it is, the longer it will take to be broken down and released (a low glycaemic index).

So why do we diabetics care about this? While it’s not entirely vital to your well-being, the theory is that low GI food makes managing your food / insulin balance easier. Rapid acting manufactured insulin, like humalog, kicks in pretty quickly – but not as quickly as your own stuff. Therefore if you iron out the peaks and troughs life will be easier.

This wonderful diagram shows the sharp Matterhorn-peak of high GI in red and the low rolling hills of low GI in blue.

There are number of GI-related books and web sites which give you the relative GI values of various foods. But a general and quite useful rule-of-thumb is the colourfulness of foods. The more colourful the better (by better I mean lower) in terms of GI. Though this rules does break down when we get into extremes of lime green and violent orange.

For example, wholemeal pasta (generally nice and brown with bits through it) is lower GI than boring, white pasta. A nice green apple is better than processed, clear apple juice.

Okay, the rule isn’t perfect – but you get the idea.

Eating every day

For the purposes of this article I’m going to assume that you too are not some sort of half-wit who doesn’t know how to boil an egg and lives off deep fried pizzas, so I won’t chat about the basics.

Because my wife and I like cooking we’ve got a load of cookbooks – both general cookbooks and those specifically for diabetics. Having cooked from both, I don’t really notice any significant difference in content between the “diabetic” books and the non-diabetic books, so there’s no point in specifically splashing out them.

Books by people like Nigel Slater or Nigella Lawson are great if you want to show off and Madhur Jaffrey is bloomin’ marvellous if you want to cook for large groups in style.

But we’re more interested in every day normal cooking and I like the following because they have quick and easy recipes for the busy young professional and you can knock ‘em up in twenty minutes or so while swilling back a glass of wine and chatting the day over with your loved one:

* Cool Eating by Louise Pickford
* Good Housekeeping – 1001 Recipes
* BBC Good Food – 101 Meals for Two
* BBC Good Food – Low Fat Feasts

Interestingly enough, as the wife and I are both control and organisation freaks, we organise our food by sitting down on a Sunday evening and working out a menu for the week ahead. This is actually quite fun. No, honestly, it is one of the less-onerous household chores.

What it does mean is that throughout the week every night you know you have something healthy and tasty in the cupboard or fridge and you won’t be tempted to pop down to the chippy for another deep-fried pizza, which can only be a good thing.

Anyway, use and abuse the comments section to tell the world about your favourite cookbooks and your slightly-anal domestic arrangements.

http://en.wikipedia.org/wiki/Nutritionist

http://en.wikipedia.org/wiki/Glycemic