Food: It's What's for Eating

An 8 year old relative of a friend of mine was recently diagnosed with type 1 diabetes.  A couple of weeks post-diagnosis, my friend e-mailed saying that the family is really struggling with what to feed him.  He was previously very much a junk-food fan.  What ideas and advice did I have?

My initial e-mail response was lengthy and probably a little confusing.  It's such a complicated and loaded question.

My first response was to look for good articles and posts on my favorite blogs and websites.  After twenty minutes of that, I found twenty different ideas of how best to eat with diabetes.  No wonder they and so many other newly-diagnosed families are confused. 

I imagine the hospital team sent them home with a meal planning guide and some hand-outs about carbohydrate counting and the value of consuming protein and carbs together.  He's on injections for now, so limiting the injections is part of meal planning too.  But he's 8.  And everything's different.  And he'd probably really like a big stack of pringles and a snickers bar.

So here's what I said in a nutshell, hopefully more well-thought out this time (I'll be sure to get them the link to this post):

1. If nothing else, count the carbs.  Learn how to read the labels, learn the carb ratio, learn the math and give the insulin.  A snickers bar is not an apple.  French fries aren't steamed brown rice.  But if you give the right amount of insulin for them, his blood sugar won't spike astronomically and you'll be learning and practicing the carb counting skills which will be the basis of diabetes care for the foreseeable future.

2. Rome wasn't built in a day.  Protein plus carbs is great.  The combination streamlines the blood sugar levels.  Vegetables, fruits, whole grains and low-fat proteins are important too.  Foods with fiber affect the blood sugar less than straight white bread.  BUT eating is great too, and sometimes compromise is necessary.  I had a child who ate nothing but cold cereal, milk, chicken nuggets, goldfish crackers, baby carrots, sugar free jello jigglers and animal crackers for several months of her toddlerhood.  She lived to tell the tale.  Not only that, but this weekend she ate Moroccan spiced chicken stew with whole wheat couscous on Saturday night and roast salmon, salad with balsamic dressing and a brown rice medley on Sunday night.  We actively chose (after a few weeks of frustration) not to force the food issue when she was 2.  Now she's a good healthy eater, because that's the way her parents eat and she slowly learned that a variety of foods are delicious. 

3. Dessert is okay.  We never stopped having treats.  One cookie instead of 3?  Yes.  Parsing out the Halloween candy over a couple of weeks.  Absolutely.  She had animal crackers and a glass of milk most nights until she was 5 or so.  Eventually, other cookies, frozen treats and brownies began to be included in the mix.  Holiday pies and birthday cakes have never been forbidden.  As a result, (I think) I have a kid who has rarely snuck extra treats or cried because she was left out of a celebration. 

Should this newly diagnosed kid be eating a scrambled egg wrap for breakfast, bean soup for lunch and a plate with 2 veggies, lean protein and whole grains for dinner?  Probably.  Should his primary treat be roasted almonds?  Yup.  But he's 8.  And his world just turned upside down.  And no kid or adult really eats like that anyway (well- very few, and they're probably not the happiest people). 

In the real world, balance is necessary. This newly diagnosed kid should be eating the healthiest combination of foods he's willing to eat on a daily basis.  He should be learning about good nutrition from his family, his healthcare team, and others who care about him.  He should be learning to read a nutrition label with help from adults, so that he can take the right amount of insulin for whatever he eats.  He should be learning about low carb and carb-free snacks he can eat when he's hungry but doesn't want to take an injection.  Meanwhile, his favorite foods should remain available and he and his family should learn how to cover the carbs in them. And he should have the occasional junk food if he wants it.  Having diabetes is hard enough as it is.

Watching

This summer marks the first when my daughter is sometimes hanging out at the town pool without me. She and her friends gather there in the afternoon after their assorted camps and volunteer activities.  They bring snacks or money for the snack bar.  They play volleyball, swim, and walk in circles around the pool grounds to see and be seen.

For me, it's an exercise in trust.  First, I have to trust that our general routine and a healthy helping of good luck will keep her safe from any diabetes emergencies.  Second, I have to trust her that she will keep an eye on herself and be aware of impending lows so that she can treat them.  Thirdly, I have to trust that she will choose and bolus for her snacks wisely.  And fourth I have to trust that she will 'remember' to reconnect her pump within a reasonable amount of time after swimming.

I still like to go to the pool too.  On a hot day, some time in the lap lanes is my favorite form of exercise. When I can arrange to meet some other moms there in the late afternoon, it's fun to catch up. When I go, my daughter still sits with her friends and does her own thing.  Which is interesting to watch.

One day as I watched, she ate a cookie, and bolused for it.  She reconnected her pump after swimming, clipping it onto her bathing suit.  She checked her dexcom after getting out of the water the second time and grabbed a handful of goldfish crackers, later telling me she was 80 and felt like she was going down.

Another day I watched as her friends waited patiently for her to reconnect her pump and gather her little bag before they headed for the snack bar after a swim. She bought sour patch kids and bolused for them, as evidenced by the blood sugar of 77 when we got home for dinner.

Would I rather she bring a container of grapes or pre-portioned packages of whole grain crackers to snack on?  Of course.  Do I worry about whether she's going to forget to reconnect her pump and end up super high?  Yes.  Do I wonder if she's relying too much on the dexcom and not actually checking with a meter while she's there. Sometimes.

But here's the thing:  She's coming home with nice looking dexcom graphs and excellent pre-dinner blood sugars.  She's obviously responsibly reconnecting her pump and bolusing for the junk food.  She's noticing when she's trending low and grabbing a handful of something to stop the slide.

Really, this is a great opportunity to practice dealing with all kinds of diabetes issues on her own.  She'll make mistakes this summer, I'm sure.  I've made my fair share of them over the past 12 years when I've been in charge.  Nobody's perfect.

But so far so good.

What Did I Miss?

Today, we'll look back 2 years to a pool party for all girl scouts from our area.  As troop leader, I was there, in charge of feeding and keeping track of my group of fifth grade girls. 

This was our first pool visit of the season.  My daughter disconnected her pump and got in with her friends.  They then got out and opened a couple of bags of chips.  "Can I?"  "Just a few."  We'd delivered  a correction bolus for a 200-ish number on the way to the pool.  With the exercise, I figured a couple of chips couldn't be too bad.  Plus, to be honest, it seemed like such a 'normal kid' thing to sit on a circle on beach towels with your 11 year old friends, talking, braiding each other's hair, and muching on chips.

After another swim, the pizza arrived.  I did (to my credit) remind her to plug her pump back in and check.  230.  I juggled the meter-remote, paper plates for all the girls, opening the grapes and watermelon, pointing out the drink cooler and providing napkins.  I bolused for pizza and watermelon.  I might have added the bg.

She ate, unplugged, and headed for the water slide.  An hour later they came back for dessert.  A cupcake and 2 mini girl scout cookies.  She was already partway through the cupcake when I realized she hadn't checked again.  She was reading the box for the cookies (reclaiming a bit of good will).  "4 each, mom."  I had made the cupcakes, so had a number in my head for those.  Still juggling dessert requests and napkins, I bolused.   I glanced over.  She had no pump attached.  She plugged in and we bolused again.

Half an hour later, she found me talking with a mom on the other side of the pool.  A friend's sister's troop and given our troop mini fire cracker pops.  Could she eat hers (which she was holding, open, in her hand)?  From the cobwebs of my brain came the knowledge that these were 'only' 9 carbs.  I gave the o.k.  She was standing there with her friends, on the way to the shuffleboard court.  She bolused for it when she got back to the table.

Once we'd packed up and gotten in the car, her blood sugar was around the 250 mark.  She corrected and had some water when she got home.  An hour later, still 250.   Obviously, the whole evening was riddled with diabetes mis-steps.  Chips with no insulin (probably more than a few), not accounting for missed insulin in the pool, a dinner diet of pizza, chips, watermelon, cupcakes, cookies and popsicles. Everything was bolused for on the fly, often after the food was partially consumed.

Yet, you diabetes detectives out there, there's one more big reason that high number didn't come down. 

Anybody guess it?

I had bolused for dessert while the pump was detached.  Then again when it was.  The pump included all of that insulin in the insulin on board total.  So when we went to correct the 250 after the party, it gave very little, assuming a whole extra cupcake and 2 cookie's worth of insulin was still hanging around.

Any 'party by the pool' event is a challenge, diabetes-wise.  The level of difficulty rises exponentially if I'm in charge of more people than my own kid.  In the end, it was a fun evening and the 250 came down quickly once I'd realized the error of my ways.  But keeping track of diabetes at this kind of event is a full-time job.

Birthday Day and Other Heavy Eating Occasions

My daughter's friend had a birthday last week.  It was on the same day as mine.  The kids have found a way to skirt the school nutrition policy of 'no outside food for celebrations' by bringing in treats to share at lunch. So lunch that day included oreos, hershey kisses, doritos and munchkins.  To her credit, she ate the sandwich and grapes I packed first, but she sampled the rest as well.

For dinner we went to a Thai restaurant and she had an uncountable portion of pineapple fried rice. We came home and had mini cupcakes and cannolis for dessert.

Our household diabetes philosophy (yours may vary) allows sweets, and even junk food.  Birthdays include cake.  S'mores over the fire pit or a trip for italian ice are part of summer fun.  A little bag of chips for the walk home is o.k.  Most days include cookies or a non-dairy frozen treat before bed. Taken one at a time, or even two in one day, we're o.k. with both the questionable nutrition of it and with the diabetes challenges.

'Everything in moderation' is the general idea. But on days when moderation goes out the window, I'm left feeling torn.  Should we ever let her eat this way?

"Yes!  You can eat anything except poison...or cookies made with poison..." is one side of the coin. But she really can't eat anything and maintain the same kind of blood sugar numbers she does when she eats healthy, countable things.  Twenty carbs of oreos and doritos is not the same as twenty grapes. Half a restaurant portion of pineapple fried rice and a bakery cupcake simply can't be counted and dosed for as accurately as portions prepared, weighed and measured at home. Add the 'one more dorito because everyone else is still eating,' or the picking all the pineapple out of the fried rice despite bringing home 'half,' and the challenge increases.

Still, I lean towards letting her learn from her mistakes over outright forbidding her from eating like this. She'll encounter days with heavy eating potential for the rest of her life, so perhaps helping her develop a healthy sense of how to handle them is the answer.  Last week's birthday day was an example of how not to handle it.  And she knew it.  She was upset that her blood sugar was high for hours.  Between that lengthy high and the general junk food overload, she had some lingering indigestion into the next day.

Sometimes she makes better choices.  Last weekend, she said no to lunch out with a friend before an evening birthday party because it would consist of too much uncountable food in one day.  She's come home from parties and told us she was the only one who ate the proffered grapes or salad to balance out the junk. She will report with alarm how many cookies or cupcakes some kids consume in one sitting.

I guess it's like all things diabetes, really.  We do our best.  We try to fit the diabetes stuff into what we consider a normal, healthy lifestyle.  We try not to let it ruin our fun.  We learn from our mistakes.  And we're never quite sure we're doing it right.

The Buffet Table

Personally, I love a good appetizer and snack focused buffet table.  Interesting dips, meatballs, crackers with good cheese and foods encased in puff pastry are a few of my favorite things.  Top it off with a good cookie table and it's perfect.  If I'm there alone.

With my daughter around, a couple of hours of happy grazing turns into a couple of hours of math and negotiating.

When there is a buffet table, one is expected to graze.  You have a mini hot dog, meet the relative in from out of town, try a couple of dips, chat about the school play, make your way to the meatballs where you spend time with the party host; and on it goes.

The first problem with this scenario is that each snack requires a math problem and a bolus.  When every conversation is interrupted with 'I took 4 meatballs, mom,' or 'I just ate 7 corn chips,' it's hard to carry on a conversation. When I'm interrupted to nix the plea for a 4th cookie, my already limited cocktail party-related social skills take a big hit.

The second, but related problem is an extension of the standard regular-people buffet party challenge.  If I have a drink in one hand and a little plate in another, I already must find a third hand to eat.  Add the meter remote to that third hand and I'm out.  Even with the understanding that every mother develops a third hand (a.k.a. the ability to juggle well), this scenario becomes impossible and I remain hungry or thirsty so that my kid doesn't end up high.

So a buffet party turns into me with a drink OR food in one hand, following my kid with the meter remote while trying to make small talk and perform carbohydrate equations in my head at the same time.

Ironically, I suppose, we throw one of these parties every year.  The difference is that I painstakingly create a list of every food with its carbohydrate content and post it on the fridge.  My daughter takes the meter remote and is able to do her own juggling act while I play hostess and eat my fair share of mini quiches.

In a perfect world, we'd be handed a cheat sheet at the start of every party, and one of these cool plates .

Text Guessing

My daughter recently attended a 'dinner and a movie' birthday party.  They first spent an hour at the birthday girl's house, with chips and chatting.  The next stop was the theater, inclusive of popcorn.  The evening concluded at a pizza parlor. 

Below is a transcript of the evening's texts:

Her: 169 bolused all of it w/popcorn (Before the party, we had discussed a carb count for this theater's smallest popcorn.)

Me: Ok. Have fun.

Her: luv u!!!

Me (smiling): Luv u too.  If u feel funny during movie check. If u can't see and need to go out, ask someone to come with you.(2 hours in a dark room where nobody was paying attention to her made me a bit nervous. Her alone in the lobby of the movie theater...ditto.)

Her:  kk (Why does this now mean 'o.k.?')

Her: (2 very long hrs. later) 226 pizza coming soon

Me: Ok 35 per slice unless it seems thin, then 30.  Add bg.  Hope you're having fun. (It was a new-to-us pizza place, but pizza in the web picture appeared avg. not too doughy.)

Her: kk i will bolus soon

Her: how many carbs is a small garlic knot?

Me: (clueless) I'll guess 5 ;-) (disclaimer...this remains a completely random guess and is most likely quite inaccurate.)

Her: luv u (even nicer than 'thank you!')

Her: how many carbs is a piece of ice cream cake?

Me: I don't know how big???  Guess 35? (I knew she was coming straight home, allowing for post-cake damage control.) (Disclaimer: did not see ice cream cake coming as the birthday-girl is a professed brownie-lover and all logic led us to assume brownies would be served.)

Her: kk

By the time she got home, she was 218, tired, and happy. Her ability to participate in social events on her own makes me thankful for the technology we have for communication,  internet research, and diabetes management.  Looking ahead at those dreaded teen years, I hope she continues to realize that her responsible use of these tools allows her to go out and have a safe, fun night with her friends. 

Pizza and Hot Dogs and Ice Cream, Oh My!

It's currently party season in our little neck of the woods.

In the past two weeks there have been exactly three days when my daughter did not eat pizza or ice cream or a hot dog.  With maybe a bagel thrown in for good measure.  Or a piece of cake.

Birthdays, Father's Day, cookouts, end of softball celebrations, end of girl scouts celebrations, end of school celebrations, graduations...it's endless!

These are not diabetes' favorite food groups.  Fat + simple carbs usually = very high blood sugars for my child.  We try some tricks with the pump which sometimes help, but her body would be happier with grilled chicken, a nice salad and some brown rice.

Yet somehow, maybe because she's been going at break-neck speed at all of these events, there have been few blood sugar disasters in this mix.  Perhaps it's a phenomenon similar to the 'vacation mystery' we encounter.  We're being precise and proactive about counting the carbs.  Then she runs around the party they're served at at a much more active pace than usual.  So it somehow balances out.

Once the end of the school year pace slows down, the eating will follow suit.  We'll resume a healthier and more diverse menu with the occasional fun diversions.  Unfortunately when the pizza is combined with a sedentary summer afternoon at home, those unpleasant high blood sugars will once again accompany it.

As always, we'll try our best to keep the high blood sugars at by. But really, I'd do anything at this point for a sedentary afternoon at home!

Rolling the Dice

Last night we attended the community pool party for all of the baseball and softball teams in town.  This event, as with most of the activities at this time of year, is a food-fest.

My daughter began the party with an undesirable blood sugar of about 260.  With that corrected, she promptly unplugged her pump and got in the pool.  Half an hour later she emerged to air which was colder than the water. She was chilled, and I envisioned her blood sugar creeping even higher as a result.

Dinner was served, consisting of pizza, some fritos, some doritos, and a token portion of raw veggies with dip. My bolus calculation involved thoughts like, 'the pizza crust seems thin-ish,' and 'eh...those chips look like about 12 carbs I guess.'

Ordinarily at this point, I would have insisted on a somewhat 'countable' dessert.  But a team-mate brought a big tub of italian ice from a great local ice cream shop.  It was too fun to resist. 

Fortunately, I'd overheard talk of this plan at a weekend game, so had looked up a generic italian ice carb count.  Eyeballing my child's enormous portion of frozen goodness, and mushing it around in my mind's eye to fit into an imaginary measuring cup, I crossed my fingers and bolused an enormous amount of insulin.

An hour of running around on the playground brought her back to the table claiming she was 'starving.' Once the team awards were handed out, a handful of fritos was taken for the road. We headed to the car, two hours after the initial 260 blood sugar mark.

With much trepidation, I handed her the glucometer.  "Let's see what happened," I said.

"Ninety-eight."

I made her repeat it, thinking I'd perhaps  missed the first number which surely should be a two or a three.

"NINETY-EIGHT, MOMMY."

I'm certain that no diabetes expert would suggest the preceding course of events as the best way to lower one's glucose level 162 points. While I'm happy when a moment like this comes our way, I'm convinced that much of it is just a lucky roll of the dice.