Snack Time

I hear a lot about teenage boys.  They're always hungry.  You can't keep anything in the house.  Buy out the snack aisle before you even consider inviting their friends over.

What nobody every clued me in to was that the same is apparently also true of teenage girls.  Maybe it doesn't last as long, or maybe I'm encountering a particularly hungry bunch.  But these kids are ravenous.

A bunch of friends came over on a recent half day.  Each one had bought a sandwich or a bagel at one of a couple of eateries on the way home from school.  They sat around our dining room table and ate them. Completely.  It wasn't long ago that I'd have 6 girls here for lunch and there'd be half bagels, large portions of sandwiches or the bulk of the pizza I'd ordered leftover.  On this day, there were napkins and crumbs.

Half an hour later my daughter emerged from the basement playroom (hang out room? rec room?  what do we call it now?).  "I'm bringing down the popcorn chips."

Within half an hour she returned with a bowl containing only a hint of popcorn dust and absconded with over a pound of grapes.

Pretzels were next, enough to fill a large sized salad bowl.  Crumbs and salt covered the bottom half an hour later when it was returned for a refill, and again when it was cleaned up as the girls went home.  Presumably they, like my kid, proceeded to eat full dinners and ask for dessert.

The whole experience felt like a cross between feeding cookie monster and a pack of wolves.  Food disappeared instantaneously.   Crumbs and dust were left in the wake.

The diabetes link in this post, you ask?  It's a challenge to bolus for this kind of grazing.  Up to a year or so ago, I just didn't allow it except at the occasional party.  Snack time involved a bowl, careful counting or measuring cups, and a nice solid bolus.  And on a regular basis, that is still the preferred procedure here.

Somehow, though, she managed to count and bolus enough of her snacks to end up with a very good blood sugar by the time her friends went home and she started asking what was for dinner.

Stuck

The Dexcom buzzed incessantly for days.

Friday: High.  High.  High.

All weekend, Monday, Tuesday: High.

It was like we'd swapped out the insulin in the pump cartridge for simple syrup.

We tried every trick in the book:

Site change?  High.

New insulin?  High.

Walk around a museum for 4 hours (which has never failed to result in a low)?  High.

Walk around the mall (also tried and true).  High.

Another site change.  High.

Up the basals.  High.

Rage bolus, repeatedly.  High.

When she wasn't across the alarm line of the Dexcom, she was skirting it and dropped below the mid-100's only twice over several days.

Then suddenly after dinner last night?  120.

All night:  120-150.

This morning:  115.

Why?  I can't be sure but I think perhaps the hormone factory ceased its overtime production.

Since last week, she's been HUNGRY like only a 13 year old can be.  And she's been 13 like only a 13 year old can be.  A scientific explanation of growth hormone and puberty, and of their impact on blood sugars can be found here.

A less scientific description can be found above.

A Teaching Moment

We visited the endocrinologist this week.  As he glanced at my daughter's A1C slip, he was pleased with what he saw.  "This is what I'd call a good A1C."  Then, turning to my daughter, "Do you know what kind of number a good A1C would be?"

"Ummmm..."

The omnipresent chart was on the shelf to her left.  She looked it over.  "6?"

"Six would be very impressive.  Five would be amazing.  But in people with diabetes, particularly kids, five would be almost impossible without some really nasty lows.  What we aim for in kids your age is an A1C around seven, and you've done that very well."

There was much to appreciate about this little exchange.  The teaching. The relationship building.  The gentle passing of the torch of responsibility for understanding the disease to my daughter.  The affirmation of our hard work which, I know from experience, would have happened no matter what number showed up on that A1C slip.

We don't go to the closest pediatric endocrinologist.  Our visits require a sometimes hairy, sometimes traffic-ridden journey.  When we arrive, we look like we're planning to camp out for the duration, with snacks, homework and books in addition to the usual diabetes baggage and the materials we need for the appointment.  Despite these hassles, we never think twice about repeating this expedition.

I hear horror stories all the time about people's relationships with their doctors.  I realize we're fortunate to live in a part of the country with lots of choices, and that we're fortunate to have insurance which allows us to make them.  Some people have neither.  But if you do, and you're not happy, find a great doctor.  It's so very worth it.

Relentless

We're going through a stretch of very active diabetes management here, and it's exhausting.

Don't get me wrong.  We're always managing diabetes; all day, every day.  It's just that sometimes it fades into the background a little bit.  This isn't one of those times.

At February's appointment we were surprised by a creep up in my daughter's A1C.  Nothing dramatic, mind you, but worth working on.

Suggestions to address this problem were discussed at our appointment, and we implemented them right away.  Then she started eating.  Everything.  She's growing noticeably taller by the week.  At every appointment lately, the endocrinologist has reminded us that her total daily dose of insulin is likely to double in the next couple of years.  At this rate it'll double by the time we see him again in May.

Her basal rates and insulin to carb ratios are going up and up. With these changes come increased finger sticks and dexcom alarms, the return of the log sheets, and an extraordinary amount of thinking.

I'm trying to meal plan and grocery shop more carefully too.  Countable carbs and balanced meals are important so that we know if the insulin changes we're making are right.  The fewer variables in that equation the better.  I'm also trying to fill her up, so that she's not looking for a snack an hour after dinner. If she does want a snack, I want to have healthy, filling choices on hand.

I'm hearing from the nurse's office at least once a day for a high or a low.  Then she's at play practice until five or six o'clock most days after school, so we're managing snacks and dance induced lows via text all afternoon. Meanwhile we're spending time figuring out how to include her diabetes equipment in her play costume. But who doesn't love a challenge?

The sedentary lifestyle of winter is giving way to the activity of spring.  Yesterday was the first outdoor recess since November. She's walking home again when she doesn't have play practice.  Schedule changes and field trips are creeping back into the school days.  So are juice boxes.

Factor in what feels like more than our fair share of diabetes flukes like the other night's 2 a.m. site change, and it feels like it's all diabetes, all the time here.

Which it is.

When Is Enough Enough?

After our last endocrinologist appointment at the end of the school year, we decided it was time to look into a continuous glucose monitoring system.  We also decided that we'd wait until fall.  This decision honored my daughter's concerns about having things stuck all over her during bathing suit season as well as my concerns about keeping things adhered to her during the season of water and sand. 

At the end of the summer we visited the orthodontist.  The idea of some kind of braces sometime in the future transformed into definite braces this January.  These won't be just run of the mill braces.  We left the appointment understanding that she will be chewing with only her four back teeth for between eighteen  months and two years, and that she will be wearing head gear, thankfully only at night.

So here she is...about to turn twelve.  She's growing quickly, and at that adorable-only-to-parents awkward, gangly stage. She already has an insulin pump toggled to her at all times.  She already has to carry around a bag full of accouterments everywhere she goes.  Now we're going to fill her mouth with metal, make eating anything coarser than applesauce a challenge and attach head gear to her at night.

Can you see why her enthusiasm about the CGM is waning?  Tacking on another bionic piece and adding another item to her already overloaded purse doesn't sound so appealing, no matter the benefits.  Lets add that it will probably beep at the most humiliating times.

Can you see why, if she knew anything about 70's television, she would be asking why we want to turn her into the bionic woman? 

We'll still proceed with the CGM.  Once those crazy braces go on, it will probably be even more important to keep a closer eye on those blood sugar numbers, at least until she gets used to eating with them. 

But from a psychosocial perspective, I'm reluctant.  Everyone's awkward at 12.  How much equipment can we adhere to her before the balance tips from awkward to crazy robot girl?  When is enough enough?

Needs More Insulin

We visited the endocrinologist this week. 

In the weeks leading up to a visit, I am usually motivated to keep a more detailed log and to scan through the meter's averages and graphs.  I try to identify any major issues we need to discuss.   Sometimes I am able to fix a few things or at least narrow down the issues to a few really tricky ones.  I do this so that we can spend our endocrinologist time on issues I really need help with.

This time I tried to think about it.  I really tried to weed through all of those numbers and find the places we needed to change things.  I didn't know where to begin.  I gave up.  It turns out my confusion was warranted. The doctor's initial impression?

"She needs more insulin...like most of the day."

Her A1C was up, only by .3, but after going down a couple of times in a row it wasn't great news.  It wasn't surprising either.

Many things had changed since winter.  She'd added height.  She'd added weight. Yet she was missing a sufficient quantity of a key ingredient.

So we added insulin to almost every basal rate.  We added insulin to almost every carb ratio.  We added insulin to the correction factor.

We've been doing diabetes for ten and a half years.  I'm able to tweak a basal rate here and there, or recognize when the correction factor is no longer correcting.   I'm a person who, given sufficient knowledge, tries to solve problems on my own before asking for help.

Yet once in a while, particularly with a growing child, the time comes for a major overhaul. In many ways, it was freeing to hand that whole pile of 'undesirable' numbers over to the endo and say, 'please fix this.'   Now we'll watch and see if he did, and hope he at least got close enough that I can trouble-shoot the rest from there.