Connecting people with diabetes
Often I hear people with diabetes say things like “I just can’t understand why my BGL’s are all over the place”
Lets explore some BGL’s here and discuss the possible reasons for the numbers in the chart/s.
Please comment on what you see here, so we can have a vibrant discussion.
The purpose is to help everybody improve their understanding of what some of the causes of variations in the norm could be.
Regards,
David – Diabetes Educator at Diabetes Counselling Online
So, the Moveable Feast of Eostre, the goddess of spring fertility, is upon us once again. It’s Easter. We have a full moon, rabbits & chickens, chocolate & sweet fruit buns with a cross baked into the top. For some religions, there are other, more sombre & deeply significant symbols associated with this part of our annual calendar. For most of us, there are 4 days off work, at a time of year when the moon is full, when the day & the night are almost of equal length, with the equinox falling just under 4 weeks before Eostre in 2014, on March 20th. The weather is generally pretty ‘liveable’, whatever hemisphere of this bounteous Earth we are living in.
The stage is set for a time of rest & relaxation, of time with family & friends, of contemplation, & of feasting. In our Northern hemisphere heritage & tradition, even though we are now living in the Southern hemisphere, the annual cycle away from the darkness & deprivation of winter means it’s time to make special purchases of foods that we normally reserve for special occasions: weddings, parties, birthdays, anniversaries. Some observe religious abstinence of some food for part of this time; but all spend at least part of this time feasting.
For about 38 years, our Easter has involved spending time with our extended family. In the early days, these Easter gatherings were held at our house in a small inland country town. We actually sent out invitations, & at first our brothers & sisters & our own parents came, bringing children, the occasional great grandparent, & the occasional dog. We needed caravans & tents for everyone to be able to sleep under cover, & occasionally the bathroom & septic tank struggled to cope. Luckily we were only a short walk from the Public utilities. The cousins bonded for life.
Later, once we acquired our scruffy little fibro beach shack, all the growing cousins brought friends; girlfriends, boyfriends. Meals were mostly eaten outside, huddled away from the sea breezes in a cold year, or gloriously somnolent in sunshine in a warm year. That’s the thing about Easter: it’s a Moveable Feast, so the weather can be like the end of summer; or it can be like the beginning of winter; or even both. We still needed a caravan or a tent some years, but bunks, sofa beds, mattresses on the floor, two showers & an outdoor hose, & two toilets helped a great deal. The septic tank needed regular emptying.
I remember a lot of laughter from those years. For most of those 38 years we were at the beach shack, & our time was taken up with sandcastles, swimming, searching rock pools for little crabs, midnight Jetty fishing excursions, sailing, rowing in a kayak or canoe. Food was abundant of course, as were leftovers. We played cards with gum nuts for stakes, Coon can, Pontoon, snap.
Nowadays our eldest daughter brings her family & we spend about 5 days at the shack. This year, because of the school holidays & other plans our family holiday ended on Good Friday. Traffic on the road to Adelaide was building up, & so they left before lunch today.
Our party this year included a full eclipse of the Moon, two red moons in a row, sunsets & dawns that were peacefully beautiful. Oh & the beginnings of a mouse plague. We swam in the sea, laughed, played games, built sandcastles & lego cities. We spotted our resident gecko, still skittering about inside the shack. We put down mouse bait, & threw out one little corpse. We enjoyed the fun of a 5 year old who wakes bursting with energy at 6.30 a.m. & wants to play baby pelicans (learning to fly & land) baby galahs, or baby seagulls. We enjoyed the seriousness of a tall 15 year old, who wants to share his thoughts & opinions about a myriad of topics. Both children are bursting with the joy of life.
Sure, we did enjoy some great, simple, homecooked meals. We didn’t buy takeaway. We didn’t eat chocolate. We didn’t have any chocolate with us. There are 3 people with diabetes in our party, & we aren’t that fussed about chocolate anymore. After the party’s over, what happens? There are the mechanics to be gone through: cleaning up, working out what to do with leftovers, perhaps extra sheets & towels to wash, if you’ve had house guests as we’ve had. But there is no time to waste on regret, guilt, or ‘shouldn’t haves’. The motto of ‘Acceptance‘, ‘going with the flow’, is the mantra that my daughter repeated many times over the past 5 days. ‘Don’t sweat the small stuff’ in life, whether it’s about food, children’s behaviour, TV programmes, the timing of how a day runs on holiday. It’s OK to change your mind, & also to accept that in many cases whatever decision you make is just fine. Managing diabetes is organised, stressful. Reducing stress can be as simple as letting go of the ‘need’ to be the one who manages, who seeks to ensure that everything is covered. It’s actually OK for things on holiday to not be tightly planned & organised.
Technically,our party is over for this year. Last night I was woken from sleep at 1 a.m. by the sound of young girls laughing out the front. Now I hear the sound of other people’s holiday long weekend just starting. People have arrived, having made a long drive from somewhere. My elderly neighbour on one side is from the Adelaide Hills, & he is having a Prawn feast with his extended family, including a new great grandchild. His elderly red dog is resting outside in the shade. On the other side, the young family of the second son is cooking up a Sausage sizzle. Their dog is a middleaged lab, all protective when he needs to be, & all tail waggingly friendly when he doesn’t. Everywhere I hear children playing, birds calling, wind, the sound of the sea on the shore. Out the front, two little boys aged about 9 are walking past, wearing shorts & fleecy jackets.
We have decided to stay on a little. I have been very unwell, & am still moving more slowly than usual.There is a lot to do. We have no need to rush back to the city, where our daily lives are. And it’s still so beautiful here. Our original plan was to head back today, but slowly our plan evolved into a different one. Acceptance includes being flexible, open to what life brings.
carpe diem
Helen
Helen Wilde is a Senior Counsellor with Diabetes Counselling Online. She has been the parent of a person with diabetes since 1979, and has lived with Type 2 diabetes herself since 2001.
All people have the “dawn phenomenon,” if they have diabetes or not.
The dawn phenomenon is a surge of hormones that the body produces daily around 4:00 a.m. to 5:00 a.m.
People with diabetes don’t have normal insulin responses to adjust for this. They may see their fasting glucose levels go up.
The rise in glucose is mostly because the body is making less insulin and more glucagon (a hormone that increases blood glucose) than it needs.
The less insulin made by the pancreas, the more glucagon the pancreas makes as a result.
Glucagon signals the liver to break down glycogen into glucose. This is why high fasting blood glucose levels are common in people with type 2.
Steps that may help:
Eat dinner earlier in the evening
Do something active after dinner (such as going for a walk)
If your fasting glucose continues to be high (over 6mmols), talk to your diabetes health care team
Who Is Somogyi?
In the 1930s, Dr. Michael Somogyi speculated that hypoglycemia during the late evening induced by insulin could cause a counter-regulatory hormone response that produces hyperglycemia in the early morning.
Normal hypoglycemic counter-regulation
This phenomenon is actually less common than the dawn phenomenon, which is an abnormal early morning increase in the blood glucose level because of natural changes in hormone levels.
Debate continues in the scientific community as to the actual presence of this reaction to hypoglycemia. Shanik, for example, suggested that the hyperglycemia attributed to the Somogyi phenomenon actually is caused by an insulin-induced insulin resistance.
The causes of Somogyi phenomenon include excess or ill-timed insulin, missed meals or snacks, and inadvertent insulin administration. Unrecognized post-hypoglycemic hyperglycemia can lead to declining metabolic control and hypoglycemic complications.
Although no data on frequency are available, Somogyi phenomenon is probably rare.
It occurs in diabetes mellitus type 1 and is less common in diabetes mellitus type 2.
With proper identification and management, the prognosis for Somogyi phenomenon is excellent, and there is no evidence of long-term consequence.
If you are able to effectively identify the of symptoms of hypoglycaemia,; be confident about self adjusting your insulin dose; be careful with the timing of meals, you can reduce your risk of problems.
One tool available to day is the CGMS – a System of Continuous Glucose Monitoring. This can be attached to your body and your BGL will be measured continuously for a few days.
The ability to suppress insulin release is an important physiologic response that people with insulin-requiring diabetes cannot carry out, as they have injected a precise dose of insulin, and this canon change one injected.
Mechanisms of insulin secretion.
Defense against hypoglycemia involves counterregulatory hormones, which stimulate gluconeogenesis and glycogenolysis and counteract the anabolic effects of insulin.
This mechanism is dependent on an intact glucose sensor system in the CNS, pancreas, and afferent nerves.
Counterregulatory hormones include the following:
Studies have cast doubt on the importance of counter-regulatory hormones in mediating glycemic rebound. Hypo-insulinemia (waning of the insulin dose), insulin resistance, and hypersensitivity to the effects of the counter-hormones also may play a role.
People with Somogyi phenomenon present with morning hyperglycemia out of proportion to their usual glucose control. Nocturnal hypoglycemia is missed or asymptomatic, and post-hypoglycemic hyperglycemia is not considered or is confused with the dawn phenomenon.
The most common cause of morning hyperglycemia is hypo-insulinemia.
People with diabetes have an increased need for insulin in the early morning primarily due to the release of growth hormone, which antagonizes insulin action. Cortisol may play a supporting role.
People with diabetes may experience falling insulin levels due to absorption or dose issues from the previous evening. This occurs as the insulin requirement is rising (dawn phenomenon) and results in a rapid rise of blood sugar at 4-8 AM. This occurrence is common in people with either type 1 or type 2 diabetes mellitus.
Laboratory studies for identifying Somogyi phenomenon include fasting blood glucose, nocturnal blood glucose, hemoglobin A1C (Hgb A1C), and frequent glucose sampling.
The fasting blood glucose level is expected to be inappropriately elevated due to hormonally induced rebound.
A glucose reading in the middle of the night will disclose hypoglycaemia as a result of insulin therapy. This will establish the diagnosis.
Obtaining an Hgb A1C level may be helpful if it is within the reference range or low despite an elevated fasting glucose level. It supports the concept of a rebound fasting hyperglycemia in the face of normal glucose control.
An elevated Hgb A1C does not rule out Somogyi phenomenon.
Frequent glucose monitoring may be necessary to confirm the diagnosis and look for other periods of hypoglycemia that may lead to rebound hyperglycemia. Frequent hypoglycemia is responsible for hypoglycemic unawareness, which may cause the typical symptoms of hypoglycemia to be missed.
Somogyi phenomenon should be suspected if you are having atypical hyperglycemia in the early morning that resists treatment with increased insulin doses.
If nocturnal blood sugar is confirmatory or if suspicion is high, reduce evening or bedtime insulin.
Clinical signs, including weight gain, normal daytime blood sugar levels, and relatively low HbA1C, suggest overtreatment.
Complex, yes.
For more information, write any questions of comment below, or send an email request for some 1:1 diabetes education.
Kind Regards,
David
Diabetes Educator @ Diabetes Counselling Online
I didn’t get my blogpost written for the group blog this week. Nor last week. In fact, I haven’t had my head up out of the sheets much since dinnertime on April 1st, when I went out to dinner to celebrate my son in laws’ 50th. With frog cakes..
That’s because I’m sick. I don’t mean with a metabolic disorder (Type 2 diabetes); nor an auto immune disease-my asthma; nor chronic pain; nor reflux; nor blood pressure; nor cholesterol; nor neuralgia; nor neuropathy; nor arthritis. I have a virus. A drag me down, unrelenting, constantly mutating virus. First it was probably the odd sneeze, next the extreme sore throat + a crushing, debilitating headache. Sweating of course, a cough. I slept. For 3 days. Because I take panadol constantly anyway, some symptoms were dealt with. What was I to do about my diabetes? I knew I should eat some carbs, I should try to exercise. On two days I staggered around the block, feeling dizzy & unsafe. On the other days I briefly wandered in my back yard, in my nightie. Eating was of no interest. Nor was checking my blood glucose levels. But I did keep taking all of my oral medications as prescribed, at the usual times. I cancelled all appointments. I stopped reading & working. I couldnt scroll on my mobile, as that was dizzying, so no Facebooking either. I couldn’t care for my grandchildren. I couldn’t visit my poor, demented elderly mother.
On the 8th day, the mutation was sudden. By now my sore throat had eased, the sneezing was still intermittent, & I’d developed what medicos call ‘a productive cough’. I’m a grandma, I know the lingo. But on this day, I actually felt a little better. I did 2 hours of paperwork. Then I stood up. The world swam around me. I felt nauseous, faint. I nearly passed out. I had other symptoms too. The worst was the severe vertigo. I tested my bgl. Steady at 6.2. So it wasn’t low blood glucose. I tested my BP. That was pretty ‘normal’. I rang the Dr’s rooms for advice, the Dr said come here straightaway, or go to Hospital. Now I have never been to an Emergency Department for myself. But I have been many times with Family members. I know you do not want to be in a ‘walk in’ situation in Emergency. I couldn’t drive, I couldn’t even open my eyes for the vertigo, I could barely walk. So my husband drove me. I carried a blue bucket, & a green towel. I was in old ‘trackie dacks’, my hair was a mess. The journey was quick, the Dr terrific. I threw up in my bucket, conveniently, she could test it for blood. She gave me an injection, a prescription, instructions to my husband about blood pressure, & a letter for the Hospital, should certain indications occur. Instructions to “Come back to see me on Thursday”. We set off home. The injection helped very quickly. Although I kept my eyes closed in the car, I was able to walk with eyes open to get to the car, & to have a rational discussion about filling the prescription.
I now had a new regime. 2 hourly Blood pressure checks, to particularly note if the pulse rate climbed & the BP dropped. A new medication, 8 hourly, so unfortunately, to start with, alarms & early morning wakings. My vertigo eased, I slept some more, & suddenly it was Thursday. My husband rang to book me in, of course it had to be a ‘double booking’. My husband said I needed to find something ‘decent’ to wear, as he wasn’t going to take me in as ‘disheveled’ as I’d been on Tuesday. That made me laugh. When the Dr saw me, I was neat, tidy, walking steadily, I was wearing earrings. (Diabeadies by Vivi of course). But when the Dr. examined me, she found another ‘mutation’. Now I have a chest infection, I need an antibiotic. Sigh. My chest does hurt. But apparently it’s not asthma. 
Now it’s the next day. The antibiotics are making me nauseous. The metformin is affecting my gut. The stemetil is helping with the vertigo & nausea, but apparently is only ‘masking’ those symptoms, I still have the virus. The family’s long made plans for the School Holidays are ‘on hold’.
Last night my daughter flew from Sydney to Adelaide. Her plane, like most of the traffic to & from the Eastern seaboard yesterday, was delayed by the massive Category 5 cyclone Ita, which is currently approaching North Queensland.
During the delay, she was texting, & suddenly about 40 minutes before boarding, she texted, “I’m low.” A message like that puts my virus into perspective. Managing my type 2 diabetes when I’m sick is not hard, & it’s not life threatening. I might go high, or low. I might have work to do when the virus passes. But when you are insulin dependent, day by day, hour by hour, minute by minute, intensive mathematical calculations have to be worked through, instant decisions made, not always with a fully functioning brain. In either case, systems & plans are crucial in getting through the situation. Knowing that I’d be worried, my daughter texted, “I’m eating lots of glucose, back up to 10 now. Have longer acting carbs on board. Will make sure I’m 14 before boarding”. What a lovely clear, reassuring plan. Mine is to take the medication as prescribed, rest as prescribed, watch for changes as prescribed. Eat when I can, exercise if I can. I have had somewhat of a ‘bonus’. Not eating much other than my obligatory bananas (for the leg & foot cramps, to get the potassium), I have lost around 4kg. So maybe my T2diabetes is cured? Or maybe the chicken soup will cure me. LOL….
Last night I made Chicken soup.
And today, as cyclone Ita bears down upon North Queensland, I am hoping that no lives are lost.
http://www.abc.net.au/news/2014-04-11/cyclone-ita-compared-to-tracy-larry-and-yasi/5383224
Helen Wilde
Helen is a long term Senior Counsellor with Diabetes Counselling Online. She is the parent of someone who has been living with Type 1 diabetes since 1979, & has had Type 2 diabetes herself since 2001.
If you feel you’d like to talk with Helen or another member of our team, please contact us on this link:
http://www.diabetescounselling.com.au/counselling-request/
Or look out for the chatline on the front page of the site, you can chat live when a counsellor is ‘in’, or leave a message for later.
Please feel free to leave a comment after this post!
This is a blog I have wanted to write for some time. As the parent of a now grown up child with diabetes, I feel a ‘special’ bond with other parents. Because of this, I am one of the moderators of the Facebook Closed group Parents of kids with diabetes. Almost every day I read & respond to heroic, wonderful, ordinary, or desperate stories of parents, ordinary people, most of them with no prior knowledge or experience of life with diabetes. Some are the parents of newly diagnosed infants. Those of us diagnosed as adults, no matter what type of diabetes, we know the emotional rollercoaster that diagnosis brings. Imagine that diagnosis being pronounced on your baby or your child.
The journey of acceptance of the diagnosis of diabetes is often described as the journey of loss, a journey through the stages of mourning. Some people diagnosed, or some partners of people who are diagnosed, get ‘stuck’ in one of the very earliest of stages, Disbelief & or Denial. They may delay or refuse the suggested treatment or advice for management. They may hide their diagnosis from those around them. That stage is bypassed in a Blink for the parent whose child is diagnosed. From lasting perhaps years, this stage is reduced to a few moments, a few hours, a day, a couple of days. From then on, ‘Disbelief’ & ‘Denial’ do not exist. We leap straight to fear, panic, guilt; into anger, blame, shame. We also leap straight into fierce Warrior protector mode. For most of us, our fear has to be submerged into Action, Compliance, & Learning, all embedded in a fierce protective mode that overrides everything else. Our own sadness, mourning, self blame must be submerged under the need to be the responsible Parent, the one who will manage the journey of our precious child into adulthood with lifelong chronic disease. I imagine the journey is similar to that of any parent whose child is diagnosed with a chronic disease or condition.
One of the differences lies in the management. Daily, a parent must monitor & restrict or ‘manage’ the food intake of their child. When birthday parties or celebratory occasions come up, the decisions about how to manage party food become an obsession. We handle insulin, a powerful hormone with great responsibilities attached, several times a day. We check glucose levels, ketones. We must ensure that we never run out of any supplies. We make & keep appointments with a range of HCP’s. We keep records, or trust our children to. We learn jargon. We FB, we Tweet, we SoMe. We must budget to afford all this, & although thankfully in Australia parents do receive some government assistance with costs whilst their children are under 16, in some countries this is a crushing, unsustainable burden. Our sleep is interrupted, sometimes many times a night, for the duration of the time our child with diabetes lives under our roof; and in the case of our daughters, possibly again when (if) (joyfully; & scarily) pregnancy occurs. We become master mathematicians & pseudo nurses & endocrinologists, calculating complex equations several times a day, carbs, insulin, bgl ratios. 
Another difference between being diagnosed yourself & having your child diagnosed is the type & level of Guilt & Self Blame that occurs. For ourselves, it becomes tied up in not talking about our diabetes, in hiding it so that we check our bgl’s or inject our insulin or take our oral medication very privately. We may even not do these things at all if a social occasion comes up. When it’s your child, ‘compliance’ is not an issue. We follow our instructions to the letter, to the minute. We advocate, we speak out, we question, we seek knowledge, advice, support. We talk to teachers, schools, principals, classrooms full of children. For many parents, their Guilt & Self Blame becomes lifelong, but is submerged into supporting a search for a cure. This is absolutely normal. It gives Hope, which is so wonderful. However, for some people supporting a cause such as this can become obsessive, preventing Acceptance, & interfering with normal life, & just getting on with managing the diabetes as best as possible.
It can seem impossible to set aside time for managing to care for ourselves. We can feel as though we are too tired, too busy, too responsible to take some time out just to be ourselves, just to breathe & enjoy our lives. We feel driven to Act, to do. The younger the child, & the more young siblings there are, the more difficult this becomes. Many parents are fortunate in having the practical support of a partner, grandparents, their own siblings. Others have friends in the ‘real’ world as well as in the virtual world. You may have access to good Child Care, where people are already trained or are open to be trained in managing your child’s health condition. It is hard to accept that it is not selfish to use such practical help to simply ‘take a sanity break’. However, doing so can actually be a wise management strategy. By allowing someone else to take care of our child with diabetes for a half a day, a day, a ‘sleepover’, a weekend; we are teaching everyone concerned that if for some reason we are unavailable, they can manage, & manage well. We’re teaching our child that there are safe people & places in the world, & as they get older, that they are clever, brave, strong; and normal. They can be away from us, & we can be away from them. We will come back, & we will all be OK. And we’re teaching ourselves that our lives exist outside our Parenting role, a role which changes over time for everyone, regardless of any health condition of their child.
What activities do you currently do that are solely for yourself? Do you walk, run, climb, meet a friend, visit a library, play a sport, go to the gym, sew, go to the cinema, study, paint, garden, play with animals, swim, do yoga, ski, ride a motorbike or bicycle, box, write a diary or blog? What have you stopped doing that you would like to go back to? What have you always wanted to do or try that you have not yet tried? Do you know how to practice relaxation, controlled breathing, or any stress relief practices?
Always remember, you are a Parent of a child, & you are a Person. These roles do not exclude or preclude each other. Your life is yours, you own it. We have a short time on this earth, & our time is Now.
Remain in Light. Talking Heads
carpe diem
Helen Wilde
Helen is a Senior Counsellor with Diabetes Counselling online, a Teacher, & the Parent of a person living with Type 1 diabetes since 1979. She has lived with Type 2 diabetes herself since 2001.