Balancing Act

Matt got a chance to chat with Penny's endocrinologist yesterday, which we don't often get to do -- he usually calls while we're at work, and leaves a message suggesting changes to her insulin ratios or basal rate without really explaining his thinking.

But this time, Matt was home when he called, so Matt got a little insight into things, which was helpful.

For instance -- this past weekend was my dad's birthday, and Penny completely carbo-loaded. She had a baked potato and a hunk of garlic bread and ice cream and baked apples with brown sugar, and by the time I'd added it all up, it was over 100 grams of carbohydrates for the meal, more than twice her usual load of carbs, and I gave her a shot with more than twice her usual dose of insulin.

And then that night, she had a frightening low (41), and remained on the low side all night, and then spent the next day floating a little on the high side. I assumed I'd miscalculated (or incorrectly estimated) and given her too much insulin, and that the highs were a remnant of the juice we'd given her to combat the low. But it turns out that's not quite accurate.

The doctor explained to Matt that with really huge meals, it takes the body longer to process the carbs than it does to use up the insulin -- so the insulin to balance 100g of carbs hit and was all used up within about 3 hours, even though only maybe 50-60g of the carbs had made it into her blood by that point. So we had to give her more carbs to keep her from dropping too low, and because her body was already processing carbs as fast as it could, it just took a while for them to absorb -- which is why she hung a little low all night, but then popped up the next day.

The thing to do, the doctor told us, if (when) she has another massive carb load like this, is to deliver a smaller initial dose than the math suggests (probably capping off at about 150% her usual dose), and then to just be aware that she's likely to run high for about the next twenty-four hours, and to stay on top of that with corrective doses.

Which is, finally, a rational explanation for what they told us in the hospital they called the "pizza effect" -- where diabetics eat certain foods and then run high for a day or more afterward. The specific problem foods vary from person to person, though they tend to be foods high in both carbs and fat (like, say, pizza) are the most common culprits, because the fat slows the absorption of the carbs and stretches it out over a longer period.

It's been said before, and I'll say it again: I have no idea how less intelligent people manage this. Because it's not even a matter of being able to operate this moderately complicated formula for figuring out her dosages -- we actually need to understand a whole host of other variables and take them into account on the fly. We've long since abandoned the neat rounding scheme they gave us at the hospital, and started making judgment calls about whether to round up or down based on whether she's had extra exercise, or a particularly heavy meal, or has been in a bad mood, or even just a gut feeling that she could use a little more or a little less at any given time.

The doctor also lowered Penny's bedtime slow-acting insulin dose; she's been waking up on the lower end of her range, and he wants to see her morning numbers in the 100-120 range, rather than 80-100. I appreciate him telling us the goal in addition to just giving us the change. If we know what the goal is, then we can apply our own not-inconsiderable brains to the problem, instead of just blindly shuffling along behind the solution. Because he's the doctor, and he knows far more than we do about exactly how this disease and its treatments work -- but we're the parents who have to try to teach Penny how to manage the tightrope act, and it helps to know where the rope is, how high up it is, and how much tension it's under.