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Monday, February 16, 2009

I Ate Nothing! Why Are My BGs high?

Most of us discover fairly quickly after we start testing after meals that eating carbs leads to a rise in our blood glucose levels. That seems logical, and it is, so managing those carbs and the resulting spikes becomes a cornerstone of home treatment.

But pretty soon we also discover that logic has limitations. We go to bed at night with good numbers and wake with high numbers. But we didn't eat in our sleep. Or we make the mistake of thinking 'food = spike, fasting = no spike' and find that after eating nothing for six hours we might be normal or even high when we expected to be low.

It doesn't seem to make sense, does it? "I Ate Nothing! Why Are My BGs high?".

I am no expert on this, but I am pretty good at looking things up and then testing the things I read against my own results. My body, my science experiment. So I checked this out a long time back when I first came across the term "liver dump". Here is my rough version, based on the best explanation I've seen (or that I could understand at my level:-) . This is the medical-speak version:

"Stores of readily available glucose to supply the tissues with an oxidizable energy source are found principally in the liver, as glycogen. Glycogen is a polymer of glucose residues linked by a-(1,4)- and a-(1,6)-glycosidic bonds. A second major source of stored glucose is the glycogen of skeletal muscle. However, muscle glycogen is not generally available to other tissues, because muscle lacks the enzyme glucose-6-phosphatase.
*snip*
The major site of daily glucose consumption (75%) is the brain via aerobic pathways. Most of the remainder of is utilized by erythrocytes, skeletal muscle, and heart muscle. The body obtains glucose either directly from the diet or from amino acids and lactate via gluconeogenesis. Glucose obtained from these two primary sources either remains soluble in the body fluids or is stored in a polymeric form, glycogen. Glycogen is considered the principal storage form of glucose and is found mainly in liver and muscle, with kidney and intestines adding minor storage sites. With up to 10% of its weight as glycogen, the liver has the highest specific content of any body tissue. Muscle has a much lower amount of glycogen per unit mass of tissue, but since the total mass of muscle is so much greater than that of liver, total glycogen stored in muscle is about twice that of liver. Stores of glycogen in the liver are considered the main buffer of blood glucose levels."

For the really detailed version click on the links.

Below I put that in words that I understand. I am no biochemist, so if any experts are reading this please correct any errors I make or omissions from over-simplification.

Liver Dumps.

We need glucose for energy. When we eat a meal it is usually a mix of carbohydrates, protein and fats. Carbohydrates are an easily converted source which quickly appear as glucose in our blood. We also, more slowly, obtain glucose by gluconeogenesis from protein or even fats and also from the stored energy in our liver and other organs.

When we create more glucose than our immediate needs some is stored. Some is stored as fat, especially if we have excess insulin floating around, and some is converted to glycogen. Glycogen is stored mainly in the liver and the muscles. The muscles are selfish because the glycogen stored in the muscles can usually only be used for the muscles, but the glycogen stored in the liver is our supply for any glucose needed by the rest of the body. When the body needs it the right amount is automatically released to the right places. As a result there is always a steady flow of energy to meet a person's needs, regulated to demand, regardless of when or what they eat.

At least, that is how it works in non-diabetics. It is the body's version of a fuel tank. Unfortunately, for type 2s, the system can be flawed. Type 2s on the internet use the term "liver dump" for the release of excessive glycogen fr0m the liver to become blood glucose at times when it wasn't really needed or wanted.

For example, one cause of the Dawn Phenomenon is thought to be the body sensing our need for energy when we are about to wake, leading to excessive glycogen release until we eat and send the signal to stop the release. That's why a breakfast soon after we wake is an essential meal for many of us. Similarly, fasting, exercise or heavy physical activity can lead to a liver dump if the body senses the reduction in blood glucose levels and over-compensates with excessive glycogen release.

Preventing liver dumps is complex and I know no general solution. For dawn phenomenon the most common treatment is to eat a late night snack; but the reports of successful snacks vary widely so it's best to perform your own experiments until, hopefully, you find the one that works for you. A minority never does, and others find that the only solution for them is basal insulin.

For those who experience liver dumps after fasting the solution is easy. Don't fast for long periods. Eat something every few hours, even if it is only a small snack.

For those who get them during or after exercise, I have seen reports of success from people who spread small carby snacks across the period of exercise, including a snack before starting.

Sorry I can't be more specific with answers on this one, just suggestions. Once again it's your body, your science experiment

Cheers, Alan, T2, Australia.

Everything in Moderation - Except Laughter

Postscript: Another good comment on the "Dawn Phenomenon can be found in the Misc.Health.Diabetes FAQs. Click on the link and scroll down to "Why is my morning bg high? What are dawn phenomenon, rebound, and Somogyi effect?".

Saturday, February 07, 2009

Travelling With Type 2

Air travel

Travel by air has become a bit more complicated since 9/11. I was travelling through the USA on my first rtw trip in March 2003 when the Iraq war started. Security went nuts and within a week we missed a flight from St Louis to Atlanta because we spent two hours in security. TSA took a long time to find a way to secure air travel without grossly inconveniencing passengers. However, after the initial over-reaction things have settled a bit now.

Food

Hypo protection

For the possibility of lows, I just carry jelly beans. Simple and not bulky, which is important these days for carry-ons with many airlines strictly enforcing size limits.

Mid Air Snacks.

Making some snacks up in advance is best because you can choose exactly what they are. You aren't restricted to the over-priced limited range available at the airport. I usually make up a small sealed plastic container of mixed nuts and raisins. It keeps well, can be kept in a pocket or purse for a quick nibble to stave off hunger and gives a good mix of protein, fats and carb. If that is not possible, I seek out something suitable in the air-side shops. Things like beef jerky (check the carb count), nuts, cheese-'n-crackers or similar. Not for meals, but for those times when you need something to nibble on during a long flight. I don't try for very low carb, but a mix of carbs, protein and fat, including about 5-10 gms carb in a snack.

I never go on a flight without sufficient for two or three snacks in my carry-on. It may be scheduled as a one-hour hop. But, after the first time you've waited three hours in the gate lounge and then sat in a delayed plane on the taxi-way for several hours without food, air-conditioning or information you realise that travelling in those conditions without snacks is not wise. It may only ever happen to you once, but that will be too often if you don't have food available every few hours.

In-flight Meals.

This is becoming a hypothetical subject, but there are still a diminishing number of Airlines that provide meals in cattle class.

Never, ever, ring in advance to advise that you have diabetes and wish to have a "diabetic" meal. If you do, be ready to eat a meal that will commence with a bread roll, followed by a main of low-fat starch, with sides of starch, washed down with fruit juice, followed by a piece of fruit and a dessert of low-sugar rice pudding or similar.

Instead, I have a standard procedure. I wait until the initial boarding rush is over and I can catch the attention of the steward. I advise the steward that I have diabetes that I manage with a strict diet. Then I patiently nod and smile through the set "you should have advised us in advance so we could have provided a special diabetic meal for you". I apologise for not doing so and request a look at the menu of the day. I then choose the least bad choice. Failure to do this means you are risking no choice at all when they run out of the beef casserole and you find that pasta and rice is the only choice left. On two notable occasions, when there were no remotely acceptable choices, the senior steward suggested that I might prefer something from the business class menu. You get a different class of service on Qantas and Air New Zealand.

For longer flights I carry a cooler pack with me. This thing wandered around the world twice with me:

cooler

It doubles as my carry-on for medications and other things I need to get at quickly. Most airlines will allow something like that as a second carry-on, but check if your airline has a one-bag limit.

I often prepare a salad the night before, usually with some cold cuts or similar, and pack it in an appropriate small plastic lunch container. The dry food will get through the TSA security, but liquids won't; I haven't tried a freezer brick through security since those rules changed, so I would transfer the food from the fridge to the pack as late as possible. After passing through security buy a cold drink which can also act as a cooler for the insulated section. If you don't want to pre-prepare you can nearly always buy a prepared salad, or jerky or something similar on the "air" side of security.

Don't try to get drinks through airport security - they will probably be confiscated. Buy your cans or bottles after the security check if you need them; I usually have a coffee instead. On board, I have never travelled on an airline that did not provide water or diet soda on demand, sometimes free.

Medications and Diabetes Supplies

When I fly I always carry a letter from my doc listing my ailments and medications. I have only rarely needed that letter, but on those rare occasions it saved me a lot of stress and hassle. For diabetes supplies read the current rules on the TSA web-site - they apply to all US airports and many overseas airports also use them as a general guide. 

This is a copy of the rules as at 26 May 2016:
heck or Carry-on
Please notify the Transportation Security Officer that you have diabetes and are carrying your supplies with you. Insulin pumps and supplies must be accompanied by insulin, and insulin in any form or dispenser must be clearly identified.


TSA allows larger amounts of medically necessary liquids, gels, and aerosols in reasonable quantities for your trip, but you must declare them to security officers at the checkpoint for inspection.
The following diabetes-related supplies and equipment are allowed through the checkpoint once they have been screened:

* Insulin and insulin loaded dispensing products: vials or box of individual vials, jet injectors, biojectors, epipens, infusers, and preloaded syringes.
* Ice or ice packs to keep insulin cool.
* Unlimited number of unused syringes when accompanied by insulin or other injectable medication.
* Lancets, blood glucose meters, blood glucose meter test strips, alcohol swabs, and meter-testing solutions.
* Insulin pump and insulin pump supplies: cleaning agents, batteries, plastic tubing, infusion kit, catheter, and needle.
* Glucagon emergency kit.
* Urine ketone test strips.
* Unlimited number of used syringes when transported in Sharps disposal container or other similar hard-surface container.
* Sharps disposal containers or similar hard-surface disposal container for storing used syringes and test strips.


Even if an item is generally permitted, it may be subject to additional screening or not allowed through the checkpoint if it triggers an alarm during the screening process, appears to have been tampered with, or poses other security concerns. The final decision rests with TSA on whether to allow any items on the plane.
Also, note that the 3-1-1 gels and liquids rule is eased for Medications. They do not need to go in that quart zip-loc bag. For the specific rules scroll down to "Additionally, we are continuing to permit prescription liquid medications and other liquids needed by persons with disabilities and medical conditions." and subsequent paras. That was a very useful tip explained to me by the TSA supervisor at DFW. It helped that I had my letter from my doc, but items not on the doc's list such as mosquito repellent, antiseptic and similar were also allowed.

That notes that drinks for diabetics are now allowed through security based on the doctor's letter. That worked for me when I left Noumea recently, but I would not rely on it.

Road Trips
 

When possible I prepare exactly the same snacks as I do for an air trip and carry the cooler pack on board. That gets a lot of use in the car, because there will always be a bottle or two of diet soft drinks, a bottle of wine and some cheese, crackers or similar. I add a couple of freezer bricks to keep things cold and fresh. Each night I put those in the room fridge, if it has one, or ask the hotel staff to keep them in the restaurant freezer. I've never had that request rejected but I have occasionally forgotten to collect them in the morning. No big deal, they only cost a couple of bucks. I also store small containers of olive oil for salad dressing or cooking oil, vinegar, salt and pepper in the side pockets.

If the accommodation I am using has cooking facilities I always prefer to cook my own simple breakfasts. While on the road it is easy to pick up some eggs, maybe an onion, mushrooms, cheese (or whatever you like) to make a simple omelette or scrambled eggs in the morning.

I look for diners and Mom and Pop restaurants when I'm on the road. The sort of place where I can get bacon and eggs for breakfast, or they will listen when I ask them to hold the fries and double the salad.

Breakfasts

Hotel breakfasts can vary from wonderful buffet choices to disastrous "continental" breakfasts of a tired croissant and grey cold imitation coffee. They can also be incredibly expensive, with minimum prices in the restaurant or high extras and tips on room service. I refuse to pay $20+ for some watery scrambled eggs and a coffee. If the hotel choice is OK or I can cook my own, wonderful. If not I have a standard routine on arrival at a hotel.

I ask at reception where the nearest diners, cafes and restaurants are and for recommendations. At an appropriate time after I check in, usually after dinner, I take a walk around the district. If I arrived by car I will have already been watching for restaurants as I drove in. I use the walk for exercise and also to check out an appropriate place for breakfast. It is rare that there are no diners or similar within a reasonable walk - which also doubles as my morning exercise.

Eating Out

When I am travelling with my wife, eating out is much simpler. On two trips around the world with her we left a reputation behind us as Aussie cheapskates because, wherever we went, we would order one main course and a spare plate for the two of us. It took some cheek, but we didn’t put the weight back on. We also saved some cash, but that was a bonus, not the intention. Where it wasn’t possible because of language or embarrassment of others, we would order a main course and a side salad or starter – just to get the plate – then mix between the two. This allowed me to leave the high carb items for my non-diabetic wife.

We often found that we still left food on the plate, even when we shared. The food is actually the smallest cost in running most restaurants; many chefs provide enormous serves to attract customers.
When I travelled alone, it was more difficult. I, like many, was raised in an environment where waste was frowned upon - waste not, want not. As a post-WWII child I was taught to clean my plate before leaving the table.

It takes discipline to break the habits of a lifetime and leave over half the food on the plate when you know you are paying for it. But if you eat it, you will pay much more eventually. Specify that you absolutely, definitely do NOT want chips/fries. Many restaurants add them automatically.

For dinners, when travelling alone, I found the method I used most often was to order an appetiser and a side salad instead of a main course. If that was too small I would order a second appetiser. That led to some marvellous and delicious meals; often the appetisers are more varied than the main course and aren't accompanied by piles of potato, rice or fries.

My most common lunch when travelling is "Soup of The Day". But be a little careful of thick "cream" soups; they will often be thickened with cornstarch, flour or potato. In 2006 I happened to be wandering through Germany in Spargelsuppe season. Bliss.

I'm sure I'll recall other tips after I post this, so I'll probably return regularly and up-date it.

Bon Voyage
Cheers, Alan
Everything in Moderation - Except Laughter.