Setting Goals

With Thanksgiving, school, volunteering, doctor visits, and so on, things have been a little cray-cray around these parts. Christmas is coming up now, providing a host of other things to think about. I had a checkup with the endo last week and I’m supposed to get some labs done soon. She seemed to think I’m still doing pretty well, which is good, but without my A1C results to look at it was hard to say for sure. Note to self: get labs done before next doc visit. What I want to write about today though is setting goals, which is tough to do when you’re busy…but so, so important for diabetes management.

I’ve had the wonderful opportunity to help start a diabetes self-management pilot group for one of the free health clinics where I volunteer. The six-week program is for patients that have already been through an intensive diabetes management program that focused on education, blood sugar monitoring, diet and exercise. Unfortunately, many of the patients that go through the first program make great strides in bringing their blood sugars down during the program, but fall off the bandwagon almost as soon as it’s over. It’s as if the lack of accountability, support and encouragement really affects patients’ ability to keep up their good blood sugar control.

The PhD student that is in charge of this organizing the new group believes the mental/emotional component of diabetes management is just as important as educating patients on how to control their blood sugars. It may seem sort of self-evident, but this component of diabetes management is sadly not emphasized in healthcare as perhaps it should be. There’s good evidence in the existing research on this topic that supports her hypothesis. The group, then, focuses mainly on the psycho-social barriers to behavior management.

I bring up this group not to analyze its progress thus far or anything like that, but to try and apply some of its principles to my own life. Although I am a group leader, by virtue of the fact that I also have diabetes like our patients, I too could benefit from “walking the walk.” One of the first things the patients do is learn how to set and manage realistic, achievable goals. So, what is my goal? To be more on top of blood sugar monitoring.

I am pretty good at checking my sugars, but recording and analyzing the data I get from them is something I do only in fits and starts. I feel it’s important to improve my blood sugar monitoring because it’ll be a) easier to identify what causes my sugars to spike and drop, b) provide a resource I can refer to in the future when in doubt. My ultimate goal is to record my blood sugars every day and analyze them once a week to make adjustments. I’m not going to run before I crawl with this one, though, because that’s been my problem in the past. When I set a goal to do something every day right off the bat, things get in the way, I get disappointed, and ultimately I drop off completely. My big goal needs to be broken down into smaller, more realistic parts:

1. Log blood sugars, carbs consumed, exercise, etc. three days a week.

I have a handy spreadsheet provided by Rhodes over at The Diabetes Support Group which I’ll plug my sugars from Monday, Thursday and Saturday into every week (probably the morning after since I’m always foggy at the end of the day). I like having a sample of the different days of the week because my schedule varies from day to day and from weekday to weekend.

2. Pick one day to dedicate to carb counting every meal and snack religiously.

My goal is to do this tomorrow, Monday 12/10. I’ll need to plan ahead as much as possible what to eat, but even those little random things that I tend not to record (like a Christmas cookie here or there…) need to be tracked.

3. Spend 30 minutes reviewing each week’s sugars on Sundays.

This is another thing that I have trouble sticking to. If I set aside a block of time on my calendar and I’ve actually been diligent about recording my sugars for the week, I shouldn’t have trouble with this. This is such an important piece though…what good is doing all the work of collecting data if you’re not going to use it!

To get even more specific, I’ve identified some of the when/what/how/with whom details that will hopefully make it harder for me to slip up:

When: Monday, Thursday, Saturday – record; Sunday – review.

What: Test first thing in the morning, before each meal, before and after exercise, and before bed. Count carbs, not calories right now, at meals and snacks. Record all data on spreadsheet.

Who: The hubby will be helping me by reminding me to log and looking over my shoulder a bit more at what I’m eating. He’ll also review with me on Sundays so he knows as much as I do about my management.

It looks like a lot of information, but I feel like the more specifics the better when it comes to setting and managing health goals. Having a plan (and a backup plan) for a variety of situations is essential to diabetes care, but the elements of that plan have to be realistic for one’s lifestyle. Building in [healthy] rewards for good behavior is also important. My typical M.O. is to reward myself with food or a day of laziness, but that’s not a healthy reward system. I think if I do well for the next month or so my reward will be to spend a girly day pampering myself. I haven’t had a massage in months. A mani/pedi could be nice too… 😉

My Eternal Frustration with Exercise

Exercise and I have a love-hate relationship. It’s hard enough to work up the motivation to do it, but I muster up the willpower about three or four times a week by reminding myself that it’s good for me. Or it’s supposed to be anyway. But what if my diabetes were complicating the positive effects of my exercise routine? What if it could actually be making it harder for me to be healthy? Everyone pretty much assumes that exercise helps with diabetes management…but is that actually true for type 1 diabetics? Let me explain.

This fall I have had the opportunity to use the gym facilities at VCU since my husband is taking grad school courses there. When I found out  I could get a “plus one” membership to the school’s MASSIVE, fabulously-equipped, state-of-the-art gym, I was thrilled. This place is an exercise fanatic’s dream (not that I am myself an exercise fanatic). Admittedly, however, I haven’t gotten much use out of my access to this dream facility since I signed up in September…except for the lap pool. Growing up I swam on my neighborhood swim team every summer from age 6ish to age 18. I was never very competitive — I just loved to swim. Part of the benefit of the VCU gym membership is access to a gazillion different types of fun classes, including the Fitness Swim class I enrolled in back in September. I paid an additional $20 to get to swim with a group for an hour three days a week, working primarily on endurance.

I have been trying to stick to this swimming schedule now for about three months and so far I’m very satisfied with the class itself. I feel stronger and I definitely have more stamina than I did in the beginning. However, this swimming program has resurfaced one of my [many] frustrations with diabetes: the challenge of keeping blood sugars controlled during exercise.

In my personal experience, I’ve noticed that cardio exercises like walking, jogging, using the elliptical machine, etc. tend to make my blood sugar drop fairly quickly. Take for example, these blood sugar readings before and after 20 minutes of walking just over a week ago (pay no attention to the time and date on the purple meter…it wasn’t calibrated correctly):

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Before walk: 232 mg/dl. After 20 mins of walking: 104 mg/dl.

I achieved this reading without taking any insulin during the meal right before our walk. That just goes to show how much more effective my natural insulin production becomes during exercise — but don’t ask me to explain how the physiology of that works!

Swimming, however…well, that’s a different story. My first week of the Fitness Swim class turned out to be an experiment in glycemic control that I hadn’t anticipated. Going into my first session, I prepared by having a light breakfast (I find that if I eat nothing before working out early in the morning it actually makes my sugar go up). I didn’t take any insulin with my meal for fear that I might go too low during the workout. I got to the gym about half an hour after breakfast at 7 am and proceeded to swim. It was very strenuous since I was really out of shape. I decided to do a quick sugar check in the middle of the workout and to my surprise, discovered I was in the mid 200s. What?! I had been working out so hard…how could my sugar be high? I continued with the workout hoping that it might drop. My 2-hour post-breakfast blood sugar check showed I had only a minimal decrease: my sugar was still hovering around 200.

I never have really understood what category of exercise swimming falls into. Is it cardio? Is it strength? Is it both? Is the fact that it’s not-quite-totally-cardio the reason why I’m having trouble keeping my sugars in check? Wanting a fellow diabetic’s perspective, I posed a question in a diabetes forum on MyGlu.org to see if other T1 diabetics had experienced this problem and could explain to me (in layman’s terms) why this was happening. The best answer I received was this:

what I have been told is that “anaerobic exercise” like weight lifting because of the muscle constrictions back and forth raises it because of the hormones going through your body and aerobic lowers it…but that is just what my doc says. I used to always go low running or swimming before starting to weight lift so now I do lifting first at the gym and then cardio…it helps =)

Posted by “Banana”

Anaerobic versus aerobic exercise…hmm. Funnily enough, I’ve been studying aerobic versus anaerobic cellular respiration in humans in my biology class this semester. I decided to do some more investigation on this topic and found a great article which helped me understand the differences between anaerobic and aerobic exercise and their effects on people with type 1 diabetes. Although the article is focused on the benefits of continuous glucose monitoring (CGM) technology, its explanation of the anaerobic vs. aerobic issue is very thorough. Basically, the article confirms Banana’s simplistic explanation:

Control of glucose homeostasis [in non-diabetics] during exercise is dictated by a complex interaction between multiple hormonal regulators (e.g., insulin, glucagon, catecholamines, and glucocorticoids), the nervous system, and various molecular regulators within skeletal muscle and liver, allowing for precise control of glucose concentration during most activities. In persons with type 1 diabetes, however, control of glucose homeostasis during exercise is extremely challenging, as insulin levels cannot change rapidly in response to exercise, and there may be deficiencies or exaggerations in other hormonal responses.8 As a result of a variety of unpredictable factors, exercise may cause either hypoglycemia or hyperglycemia in persons with type 1 diabetes… The wide ranging glycemic responses among individuals appears to be related to differences in pre-exercise blood glucose concentrations, the level of circulating counterregulatory hormones and the type/duration of the activity.

J Diabetes Sci Technol. 2009 July; 3(4): 914–923.

Not only are the effects of exercise on blood sugar dependent on the type of exercise, but also the impaired hormones which respond (or don’t respond) to the stress on your body; the starting blood glucose level; stores of sugars in muscles and the liver; and the duration of activity. Jesus. All I wanna do is swim for one hour every other day. Is that so much to ask?

Of course, I refuse to let my biological inadequacies prevent me from doing an activity I love. My method for preventing hyperglycemia (high blood sugar) after swimming thus far has been to: a) eat a snack before working out…usually a Luna protein bar which has about 19 g of carb, and b) increase my normal insulin to carb ratio to account for the rise in my blood sugar during the swimming. Thankfully, that seems to be working fairly well. This morning I didn’t test my pre-exercise sugar (whoops!), but I ate my Luna bar and took three units of Humalog (fast-acting insulin) and my sugar was 117 mg/dl two hours later. I do notice that when I do this, however, I sometimes have hypoglycemia (low blood sugar) a couple of hours after I exercise, forcing me to eat another mid-morning snack and my sugars tend to be lower throughout the entire day afterward. This phenomenon, called “late-onset postexercise hypoglycemia” in that article I cited, “may last for at least 24 hours” after exercise!

As if the hyperglycemia wasn’t bad enough, now I have to worry about going low for potentially an entire day after exercising. No wonder I can’t lose any weight…I’m always starving and trying to compensate for my low blood sugar by eating every couple of hours! Diabetes presents a huge challenge when it comes to exercise. On the one hand, it almost feels like I’m sacrificing my diet to get exercise because I’m constantly hungry. On the other hand, I’m always playing a guessing game about how much insulin I need to take before exercise and how it will affect me. Will I go high? Will I go low? I’m exhausted just thinking about it.

November

Fall is my second favorite season. It only loses out to spring because of that pesky daylight savings time thing. Today has been an exemplary fall day. Cool, sunny, autumn leaves ablaze. Perfect day for a walk with the hubby.

We set out after breakfast with my blood sugar running high around 232 mg/dl. I wasn’t worried, however, because walking normally causes my blood sugar to drop quite fast. As predicted, I checked my blood sugar again about 25 minutes in and it had reduced to 104 mg/dl. I brought my glucose tabs with me just in case it continued to drop for the remainder of the walk, but I was lucky today! It must be a sign. Someone up there wants me to keep up the good work.

I’ve been getting some nudges lately to return to blogging from friends (ahem…Laura from Get Clean, Girls) and a nagging internal voice. Boy, have I accumulated quite a lot of fodder for blog posts recently. But today, since I’ve been on hiatus, I mostly wanted to pause and reflect a bit on the significance of this exact moment in time which is pulling me back into writing about my diabetes journey. Apart from being one of my favorite months of fall, this particular November is also important for a few other reasons…

OBAMA WON Y’ALL. Hooray for at least four more years of universal healthcare! The Affordable Care Act deserves an entire blog post to itself (see the fodder?!), but given this election season I wanted to give it some due recognition as one of the primary reasons why I voted to re-elect President Obama. One of Mitt Romney’s goals was to repeal “Obamacare.” His alternative? Uhh…he didn’t offer one. If this legislation is repealed, it’s quite likely I will be denied healthcare coverage on the basis of my “pre-existing condition.” My prescriptions (including the insulin I need to live, mmkay?) cost a lot even with health insurance. Without it…I don’t even want to think about it. Let’s just say that this November, I’m more than a little grateful that my right to affordable healthcare is ensured.

National Diabetes Awareness Month. I didn’t realize November was Diabetes Awareness Month until I saw Facebook posts from the American Diabetes Association about a week ago. I guess I’m a little out of the loop for a former ADA intern, eh? (Fodder alert.) I’m definitely feeling a bit of diabetes solidarity with my 26 million brothers and sisters out there going through this. What better time to get back into blogging to do my diabetic duty and raise some awareness. And maybe some money for a cure.

One-year wedding anniversary. This past week my hubs and I celebrated one wonderful year of marriage. I tried to ignore the 265 mg/dl blood sugar I had after eating the top tier of wedding cake that we saved from last year. But I couldn’t. Just another reminder that diabetes, like marriage, requires daily commitment. Sometimes occasions like anniversaries (my diabetes anniversary is April 27, by the way) serve as a good reminder to renew that commitment.

I’m hoping I can keep this up this time.

“D” is for “denial”

Whoa. Took a bit of a hiatus there, didn’t I? It was [mostly] unintentional, actually. Lately I have been hard-pressed to find the time to write as I’m in the midst of a job transition, family birthday season (yes, I consider it a season like the winter holidays), and other spring happenings. I have a lot of catching up to do. Since I find myself trapped in a run-down motel in Middle-of-Nowhere, PA for a wedding all weekend, this seems as good a time as any to do hunker down and write without distraction. I’m also in the process of dredging up lots of material for a future post on eating out and traveling with diabetes. Throw wedding cake in the mix and you’ve got the recipe for a blood sugar roller coaster. So I’m sorry for being absent, but life is what it is. That’s what I’d like to talk about today.

I have to be honest. I created this blog to hold myself accountable to my own health goals and to force myself to “make friends” with this disease I have been begrudgingly living with for three years. My mission felt a lot less complicated when I started out: I wanted to write a few posts about my day-to-day management, research, fun recipes. Ya know, light-hearted stuff to take my mind off how much it really sucks to be a diabetic. I’d hoped this would be project centered around a “diabetes happy” theme. Debbie Downer, no more. Only sunshine and rainbows and unicorns for this lady.

C’mon, now. Let’s not sugar-coat reality (pun intended). I’m slowly discovering that the most difficult parts of managing diabetes are almost always psychological. Sometimes having a blood sugar of 291 post-meal (normal should be no more than 140) makes you feel angry and incredibly frustrated. And the bruises all over my torso from repeated needle stabbings are just plain unattractive. Simply looking at them sometimes is enough to make me queasy thinking of the intense sting when you poke yourself in exactly the wrong place. Diabetes hurts. Physically, emotionally and spiritually. As much as I’d like to suck it up and make the best of it, sometimes I just can’t.

It goes a lot deeper than that, but being a private person, I won’t share all my struggles on the internet. Blogging is a great way to vent, but it’s also creepy and voyeuristic. I think that’s the other reason I’ve been on a hiatus. As an introvert, I have a hard time sharing my thoughts with an audience – especially one as vast and anonymous as the internet. I have no idea who reads this (with the exception of a few friends), and the idea of sharing anything more than the facts about disease makes me more than a little anxious. But, at the same time, I feel like I would be remiss if I didn’t at least acknowledge that perhaps the greatest challenge of dealing with any chronic illness is all in your head. The hardest part of dealing with diabetes – for me, anyway – is dealing with depression and anxiety.

Again, I don’t know who reads this. I fear how much people will judge me for pouring out my heart on a silly blog, but frankly, I think you’re an asshole if you took the time to read this and judge me for writing personal stuff. Diabetes is personal. Hell, I can’t think of many other conditions that hinge quite so much on personal responsibility in day-to-day management. Every choice you make – whether it’s eating, exercising, or even managing stress – affects your health and wellbeing on a very tangible level. People who have never dealt with a disease like diabetes or Crohn’s or something similar which requires constant attention have no idea how hard it is. You can never have a break from being diabetic. There is no cure, no remission. Ever.

It doesn’t help that there is so much misinformation out there. From media portrayals and my own encounters with non-diabetics, it would appear most people think (incorrectly) that it’s a fat people disease and it’s your own damn fault if you get it and you’re a plague on the medical system and all the rest of that bullshit. I don’t mean to generalize. There are a lot of empathetic people out there who do their research and really care. But misconceptions still prevail. My work with the American Diabetes Association has reaffirmed this opinion. Day-in and day-out I am constantly reminded of how appallingly uninformed people are. Even some people with diabetes don’t understand the basics! It can be very depressing and it has made sitting down to write in this blog just once a week even more of a challenge. When I am confronted with ignorance every day, it gets so overwhelming that it makes me want to go bury my own head in the sand and try to forget that diabetes exists.

Although I love having a job that allows me to raise awareness about diabetes, sometimes having to face the hard truths about it are exhausting. It almost makes me feel more frustrated and guilty when I fail and have to accept that I should know better. Ignorant people might be misinformed. I have no excuses. Checking my blood sugar regularly is the litmus test of my dedication in my diabetes management; I dread doing it from the moment I wake up in the morning. I’ve even slacked off for weeks at a time, checking my sugars once a day at most, because I was so afraid of confronting my lack of real control. I know that I take my relative health for granted every day. And I angst because I know one day the little natural insulin production I still have will go away. It’s only a matter of time before I have to be completely dependent on man-made insulin. Why is it so hard to snap out of it and start doing something about it? Why is it embarrassing to acknowledge that diabetes carries with it serious emotional repercussions? Why is there so much stigma? Why is it wrong for people to use a variety of mediums (blogging is like cheap therapy) to deal with it?

I didn’t want this to be a depressing return to my blog, but alas. Life is what it is. Sometimes I get the blues, and that’s just part of the ride. Pile on family drama, career changes and all the rest of it and some days it’s hard to just get out of bed. This is reality, folks. This is life as a diabetic. It’s waking up feeling horrible because you ate the wrong thing the night before and now your blood sugar is 160 and it’s not even 8 am yet. It’s having to pull your car off to the side of the road because you took too much insulin and now your blood sugar is plummeting and you’re scrambling desperately to find something, anything with sugar in it to keep from passing out at the wheel and killing someone. It’s feeling like crying for no reason. It’s worrying constantly about the future and feeling tethered by an invisible line called diabetes which keeps you from being daring and taking good risks. It’s holing yourself up and not letting anyone in because the world expects you be a stoic and “roll with the punches.” Well, sometimes those punches hurt like shit and it takes you a long ass time to get back up. That’s where I’m at.

This is “DHappy” though. I believe “DHappy” really does exist. But how do I get there? How do I face challenges head on without succumbing? I may be down, but I’m not out. Every day is a new day. All hope is not lost. I have an amazing husband and wonderful support network of family and friends. I’m only 24 with plenty of life ahead of me. That is what keeps me going, keeps me from sinking into an abyssal depression. Sorry for the long-winded spiel, people, but it’s been a long two months of ups and downs. Hell, a long three years of ups and downs. After a breakfast of blueberry pancakes my blood sugar is 241. Bad? Yes. But also an opportunity to learn, to correct, to resolve to do better next time. There’s always next time. Diabetes sucks, but living in denial sucks more.