, strength, speed, stamina, flexibility, and mental focus all hinge on blood sugar control.
If you notice that your blood sugar rises during certain types of activities, now is the perfect time to
think like a pancreas ! (Say, that would make a cool book title.) When the adrenaline starts flowing and blood sugar starts rising, the pancreas makes just a little bit of insulin to compensate.
Consequently, you need to take extra insulin to prevent the rise.
Case in point: One of my clients, Marvin, always saw his blood sugar drop during hockey practice, but during competitive games it would rise into the 300s (17, 22 mmol/l).
When Marvin started taking extra insulin before games, his blood sugar stayed close to normal, and his speed, stamina, and mental focus all went up a notch.
In his first tournament trying this approach, Marvin won his first-ever MVP award!
To prevent a blood sugar rise during sports activity, think like a pancreas, and take a small dose of insulin beforehand.
To determine how much insulin to take before workouts that cause the blood sugar to rise, consider how much of a rise you tend to see. If it rises 200 mg/dl (11 mmol/l) and your sensitivity factor is 50 (2.8) points per unit, you would normally need to give 4 units of insulin, thirty to sixty minutes beforehand, to prevent the rise. Likewise, if you normally rise 70 mg/dl (3.9 mmol/l) and your sensitivity factor is 30, you will need a little more than 2 units beforehand. My advice to you:
don’t do it . If you give these full amounts and then start to exercise, you’ll probably wind up sucking down glucose tablets before too long. Instead, take
half of the amount you would usually need to offset the expected blood sugar rise. Remember: exercise makes insulin work more efficiently, so a unit might pack the punch of two while you’re physically active. Likewise, if your blood sugar is elevated prior to or just after a workout, give yourself half of your usual correction bolus.
For example, consider our hockey player, Marvin. When Marvin has a game, his blood sugar tends to go up about 150 mg/dl (8.3 mmol/l). His correction factor is 30 mg/dl (1.7 mmol/l) per unit. If his blood sugar before heading for the rink is 200 (11 mmol/l), he needs 2.5 units to offset the expected rise (half the 5 units he would normally need) plus 1.5 units to cover his current blood sugar (half the 3 units he would normally take), for a total of 4 units.
If you are nervous about giving insulin before exercise, check your blood sugar more often than usual (perhaps every half hour) or use a CGM and spot check it regularly, and have glucose tablets or some other form of fast-acting carbohydrate nearby.
Pregnancy
If you have diabetes, expect your insulin needs to change dramatically throughout the course of your pregnancy. The proportion of basal (background) to bolus (mealtime) insulin does not change much, but the total amount of insulin required goes through a complete metamorphosis. Do the doses simply rise or fall steadily throughout pregnancy? Of course not! This is
diabetes we’re talking about, nothing is simple.
For most, insulin needs during pregnancy follow a pattern similar to a log flume ride found at an amusement park. No, I haven’t lost my mind. Let me explain.
Weeks 0 to 6: Business as usual.
You’re just waiting in line to get on the log flume ride, totally oblivious to what you’re in for. You probably don’t even know you’re pregnant, and insulin needs are no different from what they were before you conceived.
Weeks 6 to 12: The slight dip.
Figure 8.4: Typical insulin requirements through pregnancy
In log flume terms, this is like when you first get into the log boat and the added weight makes it sink slightly into the water.
This is truly an amazing phase: you’ve just found out that you’re pregnant, and you’re quite excited.
As the embryo evolves into a fetus, the autoimmune process that has been attacking your beta cells all these years suddenly becomes more tolerant.
This allows your pancreas to start secreting some insulin on its own.
The result: a reduction in the need for pumped or injected insulin.
Low blood sugar is common during this phase, as many pregnant people are taken by surprise that they are producing some of their own insulin again.
Severe hypoglycemia is three times more common during the first trimester of pregnancy than during the four months preceding pregnancy.
Weeks 12 to 36: The steady climb.
This is the part of the log flume ride when you get on that long, slow conveyer belt up to the top. Your body and the baby go through steady growth, and the placenta produces hormones (including human placental lactogen, progesterone, prolactin, and cortisol), which cause insulin resistance. Total daily insulin needs commonly double or triple during the second and third trimesters of pregnancy.
Weeks 36 to delivery: The moment of calm.
Once the conveyer belt has brought you to the top, there is always that relaxing, scenic ride before the big plunge. For a few weeks prior to delivery, insulin requirements level off. Things are in a steady state as you make your last-minute preparations.
Delivery: The big plunge.
This is what made the log flume famous. Whether your delivery is vaginal or via C-section, insulin needs come down quickly. If you deliver naturally, labor involves a great deal of, well, labor. And that means reduced insulin needs, as if you were running a minimarathon. And with any form of delivery, the removal of the placenta means a sharp drop-off in hormones that were causing insulin resistance.
1, 2 Days postpartum: The splash.
When that log boat comes careening down, it doesn’t ease comfortably into the pool of water at the bottom.
Rather, it torpedoes into it with full force, soaking you and any unfortunate onlookers.
Insulin needs do the same thing after delivery: requirements may actually drop below where they were at the beginning.
Remember the “slight dip” phase during the first trimester, when the pancreas was capable of secreting some insulin on its own?
Well, that process continues until shortly after delivery.
And when you combine a pancreas that is producing insulin with the sudden elimination of placental hormones and rapid weight loss, the results can be astonishing.
For the first twenty-four to forty-eight hours after delivery, don’t be surprised if insulin needs are dramatically reduced.
There are even reports of some postpartum people with type 1 diabetes requiring
no insulin during this phase!
Home again: It was a wild and crazy ride, but well worth it. Just as the log boat makes its way back to the starting point, insulin needs also tend to find their way back to prepregnancy levels. That’s not to say that there won’t be any special adjustments necessary. Nursing usually causes the blood sugar to drop modestly. Retained weight will increase insulin needs. And new sleep patterns may require changes to basal insulin levels.
The Adjustments: During weeks six through twelve, reductions to both basal and bolus insulin are usually necessary to prevent frequent bouts of hypoglycemia. A 25 percent reduction in insulin requirements is common during this phase.
During weeks twelve through thirty-six, you will need to make steady, gradual increases to both basal and bolus insulin in order to keep up with your body’s increased needs. As mentioned previously, it is common for total insulin requirements to double or triple from prepregnancy to the later stages of the third trimester.
During delivery, because of the physical work being performed, most people need to reduce their basal and bolus insulin doses by approximately 50 percent. Elevated blood sugar during delivery can cause oversecretion of insulin and hypoglycemia in your newborn, so you should cover any highs with rapid-acting insulin, using 50 percent of the usual correction doses (because of the impact of physical labor).
After delivery, insulin doses tend to return to prepregnancy levels. However, if any low blood sugars occur, don’t hesitate to make additional reductions for a couple days. Nursing (or pumping breast milk) often requires a small snack to prevent a blood sugar drop. Having 3 to 5 grams of carb per nursing session during the first couple of weeks, and 5 to 10 grams thereafter, is usually sufficient to prevent lows while nursing.
CHAPTER HIGHLIGHTS
• Secondary factors that tend to raise blood sugar include
anxiety and stress
caffeine
disease progression
protein (in the absence of carbs)
large amounts of dietary fat
growth and weight gain
illness and infection
reduced physical activity
rebounds from lows
hypothyroidism
steroid medications
other medications
surgery
• Secondary factors that tend to lower blood sugar include
previous heavy exercise
advanced age
weight loss
heavy brain work
alcohol
heat and humidity
nausea
other medications
high altitude
• Factors that can both raise and lower blood sugar include
gastroparesis
travel
intense and competitive exercise
irregular sleep
menstrual cycles
menopause
pregnancy
Think Like a Pancreas
NINE
Taming the Highs and Lows
Darling, I don’t know why I go to extremes.
Too high or too low, there ain’t no in-betweens.
, Billy Joel, “I Go to Extremes”
U p to this point, we have focused our attention on matching insulin to our precise needs (thinking like a pancreas!). But let’s be realistic: with so many variables and factors influencing blood sugar levels, there are going to be some highs and lows along the way. Even those people who manage their diabetes very meticulously can still spend upward of 25 percent of their time out of their target range.
In this chapter we will focus on what happens when the insulin we take is
not matched precisely to our body’s needs.
If at any time there is too little insulin in the body to meet the body’s needs, high blood sugar (hyperglycemia) occurs.
We can correct most garden-variety episodes of hyperglycemia with a bolus dose of insulin.
However, a severe lack of insulin in the body can result in a life-threatening condition called diabetic ketoacidosis (DKA).
Because death is something we generally try to avoid, I will present strategies for both preventing and treating severe hypoglycemia and DKA in this chapter.
I’ll also take a close look at ways to prevent after-meal highs, commonly referred to as “spikes.”
The Science Behind Hypoglycemia
Hypoglycemia (hereafter referred to as a “low”) is the main limiting factor in intensive diabetes management. Without the risk of lows we could simply load up on insulin and never have another high reading. Current research involving “smart insulin” (insulin that works only when blood sugars are elevated) takes this approach.
Low blood sugar affects virtually all systems of the body, but none quite as much as the brain. Brain cells are picky about their fuel source: they prefer to burn glucose for energy. Brain and nerve cells have another special feature: they do not require insulin to absorb sugar. Instead, they have special built-in transporters that shuttle sugar across their cell membranes without the aid of insulin.
Low blood sugar is usually defined as a level of less than 70 mg/dl (3.9 mmol/l).
Mild lows can interrupt your day and be a source of inconvenience and perhaps embarrassment.
They also contribute to poor physical and mental performance, impaired judgment, mood changes, weight gain, and rebound high blood sugars.
Severe lows can induce seizures, loss of consciousness, coma, or even death.
Repeated or prolonged bouts of severe hypoglycemia have the potential to cause permanent mental impairment, although this is usually seen only in the most extreme cases.