Dry January with Diabetes

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I have completed 15 days of Dry January 2023. Dry January began in 2013 as a campaign sponsored by Alcohol Change UK to encourage people to abstain from alcohol for the month of January. Ten years later the number of participants has grown exponentially and people all over the world are supporting each other for 31 days of avoiding drinking and examining their relationship with alcohol.

Dry January is not really related to my diabetes but like with everything else in my life, diabetes always comes along for the ride. 

There are many criteria for determining alcoholism or at least alcohol abuse. An online search for those terms will give you lots of info–maybe more than you want to know. I don’t think that many others look at me and see a problem drinker and I don’t drink enough to get visibly drunk. But I know that I have been drinking more than the weekly wine allowance for women (7 servings @ 5 oz) and it is a fallacy to pretend otherwise.

I can’t really say that I am currently experiencing many negative consequences from my nightly wine. But there is no doubt that alcohol increases my risk for liver disease, breast cancer, pancreatitis, and all sorts of bad things. I have gained unwanted weight in recent years with the empty calories of wine on top of a slowing senior metabolism. Diabetes-wise, I suspect that my problem with overnight high blood sugars is related to the interplay of alcohol and food. For sure I live with self recrimination. 

My drinking history is unremarkable. I drank a little beer in college but not much. My husband and I rarely drank in the early years of our marriage and definitely not at home. When my youngest son played hockey in high school (circa 2000) we started going to bars after games with other parents. That must have been my introduction to wine because I don’t like beer very much. Hard liquor has never been part of my life and because of my Type 1 diabetes, I have rarely ordered anything with mixers. 

So here I am in 2023 drinking too much wine. What happened?

Things changed gradually and daily drinking wasn’t part of my life until 6-7 years ago. Boxed wine likely skewed my quantity control as the spigot of these boxes dispenses a seemingly never-ending supply of delight with no keeping count. I slowly incorporated a glass of wine into my late afternoon regimen. It was so obvious that when I poured a glass of wine at 5:00, the dog knew that it was time for her dinner. But 5:00 often became 4:00 and occasionally earlier. Ironically my blog became a trigger because it’s quite nice to sip wine while writing about diabetes and my journey into seniorhood. Boredom has also been a factor with alcohol being a nice change from a day filled with water and diet soda. The pandemic definitely magnified my boredom with a lot more time at home and sometimes not much to do. And I like the taste of wine. 

Where does diabetes fit into this?

I’ve had Type 1 (autoimmune, insulin-dependent) diabetes for over 46 years. I am relatively healthy with none of the dreaded nerve, eye, kidney, or cardiac complications. But diabetes is not easy and I spend a lot of time not eating things that I would like to eat. Yes, supposedly I can eat whatever I want, but it is a PITA to balance insulin with large quantities of bread, pasta, cereal, rice, sweets, and other higher carb foods. It rarely turns out well. I can drink white wine with at most a minor impact on my blood sugar. One could argue that a glass or two of wine in the late afternoon is better than a bunch of crackers. Ah, sounds like self-delusion.

The biggest physical effect of Dry January on my diabetes has been that my total daily dose of insulin has gone down dramatically. On most days my basal insulin has been reduced by over 25%. My overall blood glucose numbers are improved but I am unsure whether that is because of no wine or just eating less.

The biggest psychological effect of Dry January on my diabetes is that the discipline of alcohol abstinence is making it easier for me to be disciplined with my eating. Frankly I expected that it might go the other direction and that I would eat junk to replace wine  One of my goals this month is to lose a couple of pounds and I hope that the combo of no wine and less food/fewer carbs will make that possible.

A month ago I purchased the Streaks app in anticipation of Dry January. There is nothing better than a phone icon patting you on the head for a job well done. My first task was eating no junk food after dinner. Apple slices and string cheese are okay, but no cookies, candy, or ice cream. That coupled with no alcohol has eliminated blood sugar spikes overnight. Fortunately I haven’t struggled much with reducing food or alcohol this month and that has been a surprise.

I probably sound like a goody two-shoes saying this is easy and that is easy. What Dry January and restricting junk food after dinner emphasize is that I am good at none and terrible at one. The potato chip commercial that says “Bet you can’t eat just one” is directed at me. I don’t stop at one cookie. I don’t stop at one piece of candy. I don’t stop at one glass of wine. But I can do none.

Why do Dry January? Why not just take a vacation from drinking? I do well with structured goals and get support from nitty-gritty scorekeeping. I go to the calendar in the Try Dry app every evening and after my report of no drinking, I get a bright confetti-laced congratulation. The Streaks app displays how many days I’ve succeeded with my goals. Silly but motivating rewards. Dry January gives me accountability. I said I would do it; therefore I will. For myself and for everyone else participating in the program. 

Another positive with Dry January is that there is a predefined goal and an endpoint. The success of Dry January 2023 will not be determined by what I do on February 1. The challenge is to avoid alcohol from January 1-31 and I am confident that I can do that. But I am already concerned about February 1. Can I move from the structure of Dry January to continue not drinking in February? If I choose to return to wine, can I moderate my quantities? Things that were easy for 31 days will probably become difficult if they turn into forever tasks.

At the beginning of the month I did not have the goal of avoiding alcohol for longer than a month. Two weeks later I like not drinking. I feel good. I am sleeping better. My blood sugars are slightly better. I think I am losing weight. I have one less thing to feel guilty about.

On February 1, maybe I can keep this up for a while longer. I don’t know if I will want to or if I can. But if I do, it will be by avoiding one and staying with none. Not exactly moderation but a good start.

TBD….

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Resources:

Dry January Info:   https://alcoholchange.org.uk/help-and-support/managing-your-drinking/dry-january

NIH Drinking Levels Defined:  https://www.niaaa.nih.gov/alcohol-health/overview-alcohol-consumption/moderate-binge-drinking

National Institute of Alcohol Abuse and Alcoholism:   https://www.niaaa.nih.gov/

Alcohol’s Effect on Health:  https://www.niaaa.nih.gov/alcohols-effects-health/alcohols-effects-body

The Huberman Lab podcast What Alcohol Does to Your Body, Brain & Health:   https://hubermanlab.com/what-alcohol-does-to-your-body-brain-health/

CDC Alcohol Fact Sheets:   https://www.cdc.gov/alcohol/fact-sheets/alcohol-use.htm

Outside the Box: Silencing Tandem Dexcom Alarms

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If you’re like me, sometimes you want to silence all Dexcom alarms.

Maybe you’re at church, a wedding, or a funeral. Possibly a job interview or an important meeting. Maybe you just want to sleep. Maybe it is the first 24 hours of a sensor with erratic readings and nosediving lows.

All Dexcom alerts except for the 55-Low alarm can be turned off on both your phone and Tandem pump. But you can’t turn off the 55-Low critical alarm or even pause it for a certain period of time. Some people think that is a great safety feature and have no problems with the limitation. Me, I struggle with it. Although Dexcom is a great tool and I appreciate that it regularly gives me notifications of highs and lows, I don’t believe that it saves my life every day. I am confident that if I can silence all Dexcom alarms at certain times, I am going to be okay. Sometimes my diabetes mental health requires that. I don’t want my medical device to siren at my niece’s wedding or during an important business meeting. (Actually I am retired and don’t have important business meetings. But you know what I mean.)

In August I wrote about my frustrations with Day 1 Dexcom sensors. Many or most of my sensors start at a number much lower than my actual meter-confirmed BG. While it is easy to turn off Control IQ on my Tandem pump until the sensor is reliable, the stress of repeating false 55-Low alarms on both my phone and pump is sometimes unbearable. I want to STFU those alarms! Not forever. Just for a couple of hours until the sensor stabilizes. Here is a reminder photo from that August blogpost.

When I am losing the battle with Dexcom false low alarms, I can turn off my phone for a while or overnight if I am not expecting important phone calls. But the pump is different. I can’t turn it off or bury it in my sock drawer because I need insulin delivery. I can’t pause or completely silence the sensor on the pump without stopping the sensor session. I am stuck.

It recently dawned on me that there is a way to silence the 55-Low alarm on my pump until the sensor is stable and reading accurately. I recently purchased a small Faraday bag which magically prevents Bluetooth and other electronic signals from communicating with whatever device I put in the bag. The Faraday pouch allows me to keep my pump running without turning off the active sensor session. But it stops the transmitter from sending false low numbers to the pump and prevents the incessant low-55 alarms. (FYI you must turn off the Out-of-Range alarm for the period that the pump is in the Faraday bag or you’ll get that alarm. Options/My CGM/CGM Alerts/Out of Range.) If I am concerned that I might have a real low, I use my meter. For something short like a funeral, a real low is an unlikely occurrence as long as my BG starts at a good number. For a sensor startup, I’ll probably use my meter several times whether or not my pump is in a Faraday bag.

If you don’t know about Faraday bags, you can do an internet search and learn about how they work. People use this technology to protect key fobs, credit cards, phones, and other electronic devices from remote hacking. Scientists have lots of exotic uses for Faraday cages that block all electromagnetic interference. Me, I just want it to temporarily isolate my pump from inaccurate sensor readings. 

If you’re someone who doesn’t struggle with Dexcom inaccurate numbers and isn’t bothered by alarms, a Faraday pouch is probably not for you. But if you are like me and sometimes just want to be protected from alarms that are inaccurate and/or intrusive, you might want to give a Faraday bag a try. There are lots of choices online and I purchased this one for about $20 through Amazon. I wasn’t convinced that the Extra-Small size would work (although I think it would), so I bought Small. It is big enough for my phone and definitely roomy for the pump.

When you remove your pump from the Faraday bag, initially it will show the Out of Range symbol. It takes 5 minutes or less for the pump to reconnect to the Dexcom transmitter. 

Some people will appreciate the ideas in this blogpost. Others, especially parents of young children and people not diagnosed in the dark ages, will be askance at the idea of blocking Dexcom signals.

But me, sometimes I need my diabetes tech to leave me alone. I am not a total rebel and mostly I do a good job of managing my blood sugar and staying safe. But sometimes I am just an imperfect human trying to deal with imperfect D-tech and I need a way to protect my mental health. The Faraday bag is a new tool in my arsenal. 

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Note: The Faraday bag is not a solution for the siren of Tandem occlusion alarms. Fortunately with my recent pumps, I am rarely getting those alarms anymore. But I have memories of shrieking (false) alarms in yoga class and at the movies. So far none at a wedding or funeral….

Book Review: Still The World’s Worst Diabetes Mom

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I am a senior on Medicare and in a few weeks will have lived with Type 1 Diabetes for 46 years.

Stacey Simms is the mother of a son Bennie who has had Type 1 diabetes since the age of 23 months and is now a senior in high school. 

Stacey writes about parenting a child with diabetes and I write about living with diabetes. She is active on Facebook. I am active on Facebook. She is nice and supportive of other people affected by diabetes. I try to be nice and supportive of others. She is a podcaster and has written her second book. I…um…well…haven’t written any books although I was once a guest on the long-ago #DSMA podcast with Cherise, Scott, and George….

I was given the opportunity to read and review Stacey’s second book, Still The World’s Worst Diabetes Mom. In general I turn down most opportunities of free stuff because although I usually write favorable reviews, I rarely (or never) continue to use the reviewed product. It seems a bit fraudulent to advertise things to my readers that I don’t use. But books are different. It is a rare book about diabetes that I don’t learn from or at least get inspiration from. Plus I want to support the authors of  the Diabetes Online Community (DOC).

I purchased Stacey’s first book published in 2019, The World’s Worst Diabetes Mom. I enjoyed it and found her openness about mistakes refreshing and amusing. Most of her story wasn’t my story. I was diagnosed with Type 1 as a young adult and never lived as a child with diabetes, much less a toddler with diabetes. I never had a parent caring for my diabetes. Every day I give thanks that I am not the parent of a child or grandchild with diabetes. There was no Internet or social media for my first 20 years living with diabetes. I had no pressure to be perfect and I didn’t share my journey with anyone. I made lots of mistakes and still make lots of mistakes. For some reason, I find Stacey’s mistakes funnier than mine.

Stacey lives in the online diabetes parenting world where there are illusions of perfection and pressures to live up to that standard. Years ago someone on Facebook accused her of being an awful parent and things got a bit ugly. Rather than continuing the argument, Stacey embraced the criticism and came to terms with being the world’s worst diabetes mom.

Stacey is not a negligent or uninvolved parent. In fact she is the opposite. But she has firmly established her diabetes and parenting philosophy as “not perfect, but safe and happy.” This mantra has matured from her first book to her second as her son has grown up and she has grown as a diabetes parent. The second book chronicles a lot of her son’s journey from Mom and Dad being in charge to him being the pilot of his D-world. More of the D-mistakes and D-victories in this second book belong to Bennie and fewer to his parents. In my opinion that is exactly what a D-parent should hope for their child. But for sure it is not easy for a parent to step back and let the child manage the disease. Especially a disease where mistakes are par for the course and there are 42 factors that affect blood sugar results. 

My favorite part of Still The World’s Worst Diabetes Mom are the pages with words of wisdom that precede every chapter. The chapter titles in the book are standard topics for books about Type 1 diabetes. Things like School Days, Choosing an Insulin Pump, The Numbers Game, etc. But the introductory sentences are heartfelt and it is those blurbs that link Stacey’s journey as a parent to mine as a person with diabetes. 

 For example, although Chapter 5 is titled “Reframe Your Diabetes Parent Brain,” the introductory words shown below are incredibly relevant to my senior life with diabetes.

I simultaneously struggle with and accept my inability to be perfect with diabetes and have frequently wondered “How Good” do I have to be. I suppose this dilemma is even harder for parents who of course want the best for their child. What parent doesn’t want their child to have a perfect life with perfect blood glucose numbers! It is not my job to give parents advice except to remind them that with today’s insulin and technology, their child’s worst days are usually better than the best days of we seniors 40, 50, and 60+ years ago. And lots of us are doing fine. Their child can probably do well and be healthy even if things aren’t perfect. But complications do happen and unfortunately parents don’t have a Magic 8 Ball to predict the future. I applaud Stacey’s “not perfect, but safe and happy” philosophy. But that doesn’t mean I live in that spot on the diabetes perfection continuum. My endocrinologist says that I am doing great and my numbers are in range. But I find it too easy to remember the failures and not the safe and happy.

In summary, most of us in the diabetes community will read and enjoy Stacey’s book and come away being kinder to ourselves and to each other. For sure a sense of humor helps keep diabetes in perspective. Until then I recommend that you keep up the good fight for yourself and your children. Aim high but remember that “not perfect, but safe and happy” is a good place to be.

Still The World’s Worst Diabetes Mom will be available at Amazon and other book outlets on November 1. if you’d like to preorder the book, go to the Diabetes Connections Book Store. Use the promo code “spooky” for $3 off in October. 

Remnants of the Pandemic

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The title of this blogpost might indicate that I think Covid has gone away and is no longer a risk.

I don’t.

But I am fully vaccinated with two boosters and will have a third booster this week. I have chosen to believe that vaccinations will protect me from severe illness. Amazingly neither my husband nor I have contracted Covid in the last 2-1/2 years although we have had numerous close and not-so-close exposures. We don’t feel virtuous; just lucky. Some of our friends have had the virus and fortunately none with serious illness. My children and their families have taken Covid seriously with masks and vaccines. Even still, three of the four parents have had the virus in the last 6 months as have six of the seven grandchildren.

My daughter-in-law from the East Coast contracted Covid while staying at our house in August for a family wedding. My son (her husband) and the three children returned home on schedule so as not to get Covid one-by-one at my house and spend the rest of the summer with us. My poor DIL posted on Facebook that she had long dreamed of a solo getaway from the family. She just didn’t expect it to be in her in-law’s basement….

My current Covid behavior could be classified as inconsistently cautious. I wear a mask to Costco. I go to senior fitness classes at the YMCA unmasked. If the grocery store is crowded, I wear a mask. If it’s not, I don’t. I wore a mask on the crowded bus to the Minnesota State Fair but didn’t on the uncrowded bus on the way home. I wear a mask on airplanes. I don’t wear one for outdoor activities. I have never once had anyone criticize me for masking although I rarely see others masked. I’m not sure if I am wasting my time by wearing a mask sporadically or if I am putting myself at risk by not wearing one all of the time. 

Like everyone else, I just don’t know.

I am aware of how much the last two and a half years of pandemic life have changed me. Some of the changes are positive. Some of the changes are probably negative or at best iffy. Some changes are nothing more than doing things differently. For sure “Covid Caution” has given me a great excuse to avoid things I don’t want to do. 

Here are some good things.

I started Duolingo Spanish in 2020 and am now at Day 752 of daily Spanish lessons. I have learned a lot but am miles away from being a fluent Spanish speaker. I am currently on Unit 50 with Unit 211 as the end goal. I can read many things in Spanish and understand random words from Spanish speakers. I occasionally stumble through a sentence or two with my grandchildren’s nanny from South America. 

On an early walk during the pandemic I saw a pileated woodpecker and was inspired to learn more about birds. I am pretty good at common birds but not so good at LBB’s. (Little Brown Birds.) I enjoy the Merlin Bird ID App which gives size, color, and habitat clues to identification and identifies birds with recordings of their calls. 

Although I have always been a reader, I have definitely read more since the beginning of the pandemic. I am not reading important literature or much nonfiction. My reading can mostly be categorized as “high quality trash.” Interestingly I watch much less TV. 

I have let my hair grow out and proudly wear a ponytail. Much less work than shorter hair, especially hair that curls in weird places and frizzes in humidity.

Diabetes-wise my biggest bonanza from the pandemic has been Medicare coverage for telehealth visits. Hopefully this change will be permanent. I spend 5+ months in Arizona and telehealth allows me to easily satisfy Medicare’s requirement for endocrinology visits every 90 days. Other than that I don’t think my diabetes has changed much. 

Here are some iffy things.

I have gained weight. Some of this weight gain started before the pandemic with my slowing senior metabolism. My endo is thrilled and reminds me that frailty is a huge risk as I age and a little ”pudge” can be helpful if I get sick. I had a bone density scan in May and my scores improved significantly. More weight: stronger bones. I am okay with some of the weight gain but hate that a lot of my clothes are too tight. Plus I don’t like what I see in my bathroom mirror. (Maybe I never did.)

I have always been aware of personal space and am increasingly uncomfortable with people getting too close. When my local YMCA resumed in-person fitness classes after a year of the pandemic, the workout rooms had big colorful dots on the floor to show proper spacing. Unfortunately they removed the dots last fall. Now when I am at yoga and someone lays their mat too close to me, I want to yell “Go back to your dot!” But there are no dots….

As a senior with multiple autoimmune conditions, I think that Covid Caution continues to be a good way for me to live. But I know that I use it as a copout. I didn’t want to go to a large indoor wedding reception this summer because I wouldn’t know anyone. I just said “Covid Caution” and was excused without hurt feelings. I don’t love traveling a lot and am a happy homebody. Covid caution and I can stay home or at least avoid trips outside the continental USA. I am not a party person and probably use Covid too often as an excuse to avoid large groups. At the same time I am aware that as I age, it is not good to be socially isolated. 

So where am I?

I don’t lose sleep over Covid. In early 2020 I was concerned that if I got the virus my overactive immune system might drive me into a cytokine storm. I live now trusting that my up-to-date vaccinations will prevent that. I have been lucky to have not lost close relatives or friends to Covid and don’t have traumatic memories from the last couple of years. I realize that not everyone is so fortunate,

Looking forward, as a senior I think that the biggest risk to my longevity is a fall. I dutifully hold onto stair railings and pay attention to my environment. I go to senior fitness classes where balance exercises are emphasized. A broken hip with a resulting surgery, hospitalization, and forced inactivity seems a bigger risk to me than Covid. My internist would say that as a person with longterm diabetes, heart disease is my biggest risk.

I don’t know my future and at some point it is just pick your poison. (Actually it probably won’t be my choice….) Until then I will do my best to stay active–both physically and mentally. I will work to avoid total social isolation but mostly with outside activities and gatherings. I will hope that vaccinations continue to help most of us avoid hospitalization and death from Covid. I will listen to experts and adjust my behavior accordingly.

For the time being I will continue to hope that what I am doing is good enough.

Diabetes Mental Health: Every Ten Days

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Every ten days my diabetes mental health is in jeopardy.

If you use insulin and diabetes tech, you probably know what happens every ten days.

Yep. I have to start a new Dexcom sensor.

The vast majority of my sensors have a horrible Day 1. 

I have used CGMs for 14 years. Dexcom is aware that body chemistry affects sensor starts and that some of us struggle with Day 1. Unfortunately they don’t have a solution and have not promised improvement with G7. That being said, once I get to 18-24 hours of a sensor, my results are excellent and 95% of my sensors work well through Day 10. 

Starting with Medtronic in 2008 and continuing through Dexcom 7+, G4, G5, and G6, I have a history of bad sensor starts. I’ve used arms, legs, lower abdomen, upper belly, and upper chest. I have started sensors on time. I have pre-inserted sensors for 4, 6, 12, and 24 hours. Every time I think that I have found a solution (something like make sure my BG is above 130), that solution fails with the next sensor. I am constantly frustrated with the ubiquitous Facebook advice to hydrate more. How much water can someone drink?!?

A large number of my sensors start with LOW even when my blood glucose is above 100.

 Or maybe I am lucky and get a number. I take a BG test with my meter. 94

Of maybe the sensor starts at a number reasonably close to my meter and then quickly decides to nosedive.

I get sirens from my phone and my pump that I am low. But I am not.

Once in a while, a sensor magically starts at a good number and stays there. I don’t know why.

Then I get to the d*mned-if-I-do and d*mned-if-I-don’t issue of calibration. Many people on Facebook consider calibration to be a sin but both Tandem and Dexcom have advised me that it is okay to calibrate. The people who insist on no calibration are probably not sitting with a sensor in the 40’s that has constant Low-55 alarms from their phone and pump. If my sensor read 110 and my meter said 130, I would be okay letting that ride. But that is not my experience. I use several “rules” when I calibrate to prevent getting pushed into an endless calibration loop. I never calibrate more than 40 points at a time. I wait 15 minutes between calibrations. I try not to calibrate more than 50% of the difference between the sensor and the meter.

Sometimes a calibration or two fixes everything. Other times the sensor over-reacts to the calibration(s) and gets jumpy in a higher range or heads back down to the previous low. Sometimes the next day the sensor reads higher than the meter. But if that happens, it usually only takes one calibration to put the sensor back on track. Starting on Day 2 I am confident with almost all of my sensors and rarely use my meter through Day 10.

So why is this a mental health challenge. I understand what is happening and one would think I could just chill as I move through Day 1 of a sensor. 

Number 1:  I can turn off my phone for several hours to stop the 55-Low alarms. But I can’t turn off my pump and therefore can’t eliminate those alarms. Plus I want/need my phone for other activities. 

Number 2:  I can turn off Control IQ on my pump and manually handle my blood sugar. But when the sensor returns to a sensible number, I get suckered into turning back on Control IQ. I am stupidly optimistic about my diabetes tech and always expect it to work correctly. 

Number 3: I don’t know how to fix the problem. I probably spend too much time on social media where people who have no problems blame people like me for our problems. Just because you haven’t used a meter in 4 years doesn’t mean that my Dexcom is reliable on Day 1. Calibrate or don’t calibrate? How to calibrate? Presoak my sensors or not? If so, how long? There is only so much water I can drink, so quit telling me to hydrate. 

Where to from here?

At this stage I am committed to staying with Dexcom so I need to work this out. I don’t think Abbott’s Libre would be as accurate for me as Dexcom and doesn’t integrate with my pump. Senseonics’ Eversense would solve my Day 1 problems because the sensor is inserted surgically (Argh!) and lasts for 6 months. No warming up every 10 days. But Eversense doesn’t integrate with my pump and I’m not keen to face surgical implantation and extraction. After my disastrous experience with Medtronic’s Sofsensors (okay 14 years ago!), I won’t return to Medtronic without the ability to try out their current sensors and I am not enamored of their automated insulin system.

So I need to either figure out a plan to improve my Day 1 results with Dexcom or get better at coping with the Day 1 dysfunction.

My current plan is to dutifully put my sensor expiration date on my calendar and pre-insert my sensors 12-15 hours ahead of time. Interestingly my experience has been if I pre-insert 24 hours ahead, the sensor reads high on startup. And maybe that would be better than low and more easily calibrated? So I assume somewhere between no pre-insertion and 24 hours is the “magic brewing time.”

I’ll continue to start new sensors mid-morning to minimize false low alarms overnight. Frankly I don’t really have a plan to deal with the alarms from start-up LOWs and numbers in the 40’s. Maybe eat some uncovered snacks and let my BG levels rise higher than my normal targets. Something about that seems wrong….

Some of what I am dealing with is alarm fatigue, If I could turn off 55-Low alarms for a few hours on Day 1 of sensors, I could more easily deal with the inaccurate Dexcom numbers. Unfortunately the future control of unwanted alarms by the patient seems bleak. The latest Dexcom update on the Apple platform requires the acceptance of Critical Alerts and those alerts glaringly interrupt other functions on the phone for seemingly non-critical notifications. My understanding is that the release of Dexcom G7 has been delayed due to the FDA’s concern about patient notifications. Unfortunately IMO that probably means more mandatory alarms and less patient control.

I think lack of control is the biggest stressor on my diabetes mental health.

But enough ranting for now. 

And please don’t tell me to drink more water.

Medicare, Dexcom, and Test Strips 2022

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It was a wonderful day when Dexcom G6 was approved without the requirement for daily calibrations. One less chore in my diabetes life and fewer alarms interrupting my day. But unfortunately for many of us seniors, the labeling of Dexcom as therapeutic and non-adjunctive** has made it more difficult to receive Medicare-reimbursed test strips or at least the test strips of our choice. 

** Per CMS Policy Article A52464:  “A therapeutic or non-adjunctive CGM can be used to make treatment decisions without the need for a stand-alone BGM to confirm testing results.”

Like everything with Medicare, people are having totally different experiences with the test strip problem. Some seniors on Advantage Plans are able to get test strips in addition to CGM with no problem. A few people on Facebook claim to get coverage for 3 strips a day (the Medicare allowance for insulin users) from their pharmacy because the doctor wrote the prescription saying that the strips were for calibrating their Dexcom. Others have had no success getting pharmacy coverage for strips regardless of what the prescription specifies. I have read many times our Medicare CGM suppliers are required to provide a meter and I recently got a meter and strips from Solara. But it was not the meter and strips of my choice.

I started this blogpost ten days ago writing that I could find no CMS document outlining the exact guidelines for test strip coverage. All of my info was from word-of-mouth on diabetes social media. Then a few days ago a Facebook friend posted a link to Glucose Monitor – Policy Article A52464C as updated on 4/7/22. Finally for better or worse a clear delineation of the policy.

Some of the History

When Dexcom began providing Dexcom G5 to Medicare recipients in 2017, we were shipped a blood glucose meter and test strips packaged with our monthly sensor allowance. What was amazing was that Dexcom picked a high quality meter system (Contour Next by Bayer) for Medicare recipients rather than the cheapest kid on the block. At that point Contour Next was rated as the most accurate meter by the Diabetes Technological Society (DTS).

Meanwhile some pharmacies quit providing test strips to seniors on CGM due to Medicare denying payment because we were getting test strips from Dexcom. Fast forward to Dexcom G6 when Dexcom quit being a Medicare distributor and moved us to Walgreens and online DME suppliers. All of a sudden many of us were no longer getting test strips. It wasn’t a big deal to me because I had lots of extra strips that I used well past their expiration dates. Only now have I run out of those strips and need to investigate my alternatives.

The Present–My Interpretation

Despite the different experiences of Medicare recipients in getting test strip coverage along with CGM coverage, Glucose Monitor – Policy Article A52464C clearly outlines the policy. (Please note that Advantage Plans are Medicare benefits administered by private companies and can have different rules than Medicare. Similarly people with TRICARE and retiree plans can have different benefits. I am writing about Basic Medicare with or without a Supplement Plan.)

As stated above, Dexcom is labeled as a therapeutic and non-adjunctive CGM. The test strip policy is: 

“For non-adjunctive CGMs, the supply allowance (K0553) also includes a home BGM and related supplies (test strips, lancets, lancing device, calibration solution, and batteries), if necessary. Supplies or accessories billed separately will be denied as unbundling.”

So yes, you can get test strips under Medicare as part of your CGM supplies. The crucial part of this policy is the mention of supplies billed separately being denied because of being “unbundled.”

Bundled versus unbundled. Bundled is when my CGM DME supplier provides me with a meter and strips as part of my Dexcom sensor order. Those test strips are covered by Medicare. Unbundled is when I try to get test strips from my pharmacy. Those test strips will be denied. Unfortunately to carry this further, bundled is when my CGM supplier sends me a cheap meter of its choice. Unbundled and denied by Medicare are strips for my highly rated Contour Next meter. 

I do not have the knowledge to address the policy for Medtronic CGM users. Those sensors are considered adjunctive and it looks to me that meters and strips are not part of their bundle. So I wonder if Medtronic users can still get test strips at the pharmacy??? “For adjunctive CGMs, the supply allowance (A4238) encompasses all items necessary for the use of the device and includes but is not limited to, CGM sensors and transmitters. Separate billing of CGM sensors and transmitters will be denied as unbundling.” I also do not have experience with Libre and Eversense systems.

My Choices and My Experience

I don’t use a lot of test strips compared to pre-CGM days. Most of my testing is on Day 1 of new sensors when I consistently have erratic results and lots of false lows. I would estimate that I use 7-10 strips per sensor and I’ll call that 25 strips per month.

One choice is to keep using Contour Next and pay out of pocket. That is not as horrible as it sounds because Walmart and Amazon sell Contour Next strips labeled Over-The-Counter for $26.58 for 70 strips ($0.38/strip). Walmart also sells an online bundle of 200 strips for $54.99 ($0.27/strip). If I use 25 strips/month and thus about 300/year, I can get by on $81-$114 annually. I can afford that but not all people can.

A second choice is to use the Omnis Health Embrace meter and strips provided by Solara, my DME supplier. The upside: this choice has no out-of-pocket cost. The downside: did I mention that it is a Talking Meter? Fortunately I have good eyesight and don’t need a talking meter. But if I turn off the talking which is quite obnoxious, I get loud beeps that are equally obnoxious. Two other negatives are that the meter must be turned on and off and the strips are difficult to insert. Plus this meter did not pass DTS’s benchmark tests.

A third choice is to buy a cheap ReliOn meter system from Walmart. In the original DTS study, there was a Walmart meter that was rated highly and passed the benchmark tests. Walmart ReliOn Confirm Micro. When I go to the Walmart website, I can find the ReliOn Confirm Micro BG test strips but I cannot find the meter. So it is obviously not in production. About two months ago I purchased a ReliOn Premier Compact meter that included 50 Premier test strips for $19.88. My first two concurrent tests were 100 and 130. For me the most important accuracy test for a BG meter is repeatability. Those two tests were too far apart for me to have confidence in the meter and strips. It is now my fountain pop tester.

A fourth choice is that I bought a CVS Advantage meter and strips that were highly rated in the DTS study. So far the results have seemed reasonable and the OOP costs for strips are less than for Contour Next. But not a lot less. 

I could go forever trying other meters and strips and I am not sure that there would be a definitive or right answer.

Interestingly yesterday morning, I did a bunch of BG tests, each with a new fingerpick of blood. The noisy Embrace meter tested 102-102 on tests two minutes apart. Repeatability: Surprisingly great. Then I used the CVS meter and got 107-118. Not exactly the same but meanwhile my Dexcom went 109-116. And then the Contour Next was 80-82. Repeatability great, but the numbers were totally out of the ballpark from the other meters and my sensor.

Today I did similar tests. Embrace meter 114-115. CVS 114-112. Contour Next 106-105. Dexcom sensor 134.

So what does this mean and what should I do?

I have no idea.

All I know is that according to a common saying:  “A man with a watch knows what time it is. A man with two watches is never sure.”

Along that line:  A woman with one meter knows her blood glucose. A woman with a CGM and three meters doesn’t have a clue.

*******

TBD what I decide to do about test strips. I have a few months worth of Contour Next and CVS strips. I will continue to use the ReliOn strips for testing Diet Coke. But I am flummoxed that the Contour Next readings were significantly lower on the first tests than my Dexcom and the other meters and moderately lower on the second tests. And the free Embrace meter is being surprisingly consistent. 

Yes, I’m Still Here

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In recent years blogging has become passé in the Diabetes Online Community (DOC) and replaced by Facebook, Twitter, Instagram, and other platforms. I still miss the informative and heartfelt posts of my peers and would love to see a resurgence in real writing about life with diabetes. There is no doubt that over the past couple of years I have joined the decline. My most recent post was published 10 months ago! In general I feel as though over the last nine years I have said it all and no doubt I am now mired in laziness.

(There are a still a few active diabetes blogs in my Feedly Reader such as The Savvy Diabetic, Diabetes Stories, Diabetogenic, Embrace, and Scott’s Web Log. But there used to be well over a hundred.)

I am not 100% ready to abandon Test, Guess, and Go. Amazingly I still have readers and Google links my posts to searches for things like Tandem occlusion alarms. I periodically get emails from people wondering if I am okay since I haven’t written in so long. Once in a while I have diabetes friends on Facebook or in real life who tell me how much they miss my writing. I still pay over $100 a year to WordPress for a premium blog and the url. If I knew how to back up my content on a free blog and just pay for the url, I might do that. But it is easier to just pay the money and stay with the status quo.

There are things about my blog that should probably be updated. The name of the blog mostly refers to testing blood with a meter. Test, Guess, and Go. Test it with a meter, guess what the heck is happening, and then go on with life. The evolution of CGM technology from a cra*pshoot number to a mostly trustworthy technology has changed the landscape of my diabetes. I get numbers every 5 minutes and graphs with trends. Alarms vibrate or scream if I am going too low or too high. A Tandem pump adjusts my insulin in response to these numbers. I suppose that I could change the blog name while keeping the same url but then I would have to redo the header and graphics. I could change the WordPress theme but I am terrified that everything would go up in a puff of smoke and disappear. Remember I am 70 years old. Although I am somewhat tech savvy, I remember the early days of PCs when it was easier to get a new computer than figure out how to fix a problem.

If I really wanted to move my blog into the future, I would need to update the information provided in many posts. Quite a few links I previously shared are no longer active. Some of the information is outdated. For example I started my yearlong Countdown to Medicare series before CGMs were reimbursed by Medicare. In a nod to my present life, I did update my thumbnail photo to show my pandemic ponytail.

One thing that I would like to figure out is how to make my older posts more accessible. If someone wants to read my early posts (and some of them are really good IMO!), you have to click on a month and year. No way to start at the first post and read uninterrupted to the present. But will I do that? Probably not. 

I don’t know how much I will keep writing in the future. But I still have strong opinions on things diabetes. I wake up most days trying to do better and rarely get into too much of a funk about my d-life. My doctor thinks I am doing great and I work at accepting what I hope is “good enough.” I truly am in awe of how difficult Type 1 diabetes is to manage and how well most of us do. I feel a strong connection to my fellow seniors with diabetes and hope that I have words of wisdom for younger people affected by diabetes.

I am still here today. I have started working on another post to publish soon. After that I don’t know. Thanks for reading!  

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For those who read my blog from 2013-2015, I want to share the sad news that Sue from Pennsylvania passed away unexpectedly this spring after a fall. Sue wrote passionately about her crusade to get Medicare CGM coverage for her husband and I strongly believe that her emotional writings are one reason that seniors now have access to CGM technology. Thank you, Sue. You truly made a difference and I was privileged to know you. 

About Sue from Pennsylvania

Writings by Sue from Pennsylvania

When a Medicare Supplier Makes a Mistake

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There is a nursery rhyme about going to St. Ives in which there are seven wives, seven sacks, seven cats, etc.

As I was going to St. Ives,

I met a man with seven wives

Each wife had seven sacks

Each sack had seven cats

Each cat had seven kits:

Kits, cats, sacks, and wives

How many were there going to St. Ives?

On Saturday I received a 90-day supply of Dexcom sensors from my Medicare supplier. My order should have been 1 box containing 3 boxes of Dexcom sensors with each Dexcom box containing 3 sensors. 9 sensors. Imagine my surprise when there were 3 boxes on my front porch. Each with 3 boxes of Dexcom sensors. And each box containing 3 sensors. So 27 sensors instead of the 9 sensors required for 90 days.

I called my supplier this morning and had several levels of customer service reps telling me that I should have received 3 boxes of sensors. No one seemed to understand what I was saying. I knew that I could have kept these sensors and no one would have been the wiser. But I am an honest person and even with hoarding, I don’t need 27 sensors! I would have happily shared the extra sensors with D-friends, but it would have been Medicare fraud.

Talking to my supplier I tried to reword the issue by distinguishing brown shipping cartons from boxes of sensors. The first agent still didn’t have a clue. But I finally convinced the next agent that I needed to return some of these sensors. No, I didn’t need 1 shipping label. I needed 2 return labels. That will require another level of customer service. But didn’t I need to keep 3 boxes of sensors for the next 3 months? Yes, I do. But I don’t need the extra 18 sensors contained in the other 2 cartons.

if I am lucky, tomorrow I will receive by email two return shipping labels.

As I received a shipment on my front porch,

There were three cartons

Each carton contained three Dexcom boxes

Each box contained three G6 sensors

Cartons, boxes, sensors:

How many sensors do I need?

I think that the answer is 9.

1 brown carton containing 3 Dexcom boxes of 3 sensors….

And yes, this is a #1stWorldProblem blogpost.

Control IQ: Like Gerald I Have Tried!

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I probably write about Control IQ more often than I should. Some people with Tandem pumps love it and others hate it. I never love it but I often appreciate the benefits of a computer algorithm helping me out with my diabetes. Unfortunately I sometimes think that Control IQ  sabotages my D-efforts more than it helps me. In general I am frustrated with the Tandem algorithm because I want different ranges and averages than the software targets. Instead of making my diabetes easier, Control IQ often just gives me another indecipherable variable in figuring out the beast that is my diabetes.

After many marathon negotiations with the Control IQ gods, I have reached a compromise where I turn Control IQ off during the day and rely on it overnight. Fortunately Tandem makes it easy to turn Control IQ on and off. The only glitch is that if you use Sleep Mode, you have to turn it back on when you resume Control IQ. Sleep will not restart automatically even if you have a schedule. 

I use Control IQ during the night because it is extremely effective in preventing lows. I am willing to be responsible for monitoring lows in the daytime but have accepted that somewhat higher numbers during the night keep me safer although I chafe at some of those numbers. Remember that my endo says I am old enough that I don’t need to worry about complications 20 years from now….

I have used Control IQ for over a year and a half. I have accepted an average BG between 112 and 120. What I can’t deal with is Control IQ suspending my insulin when my BG is flatlined at 100. I am amazed watching my BG tracings throughout the day without Control IQ. I can flatline for hours at a time with minor up-and-down waves. But add Control IQ to the mix and I have insulin suspensions as my BG drops below 110. The pump screams that I will drop below 70 but without Control IQ it usually stabilizes in the 80’s or 90’s. Then future highs from those suspensions are another unknown as I navigate my next meal or my next couple hours of D-existence. Ups and downs and more ups and downs. 

Many Control IQ gurus would claim that I just have bad pump settings.

Maybe. Probably. But maybe not.

I have tried. I have tried and tried. And tried….to get agile and effective settings that worked yesterday, will work today, and will be great tomorrow. I have not succeeded. 

I have fiddled with my settings more times than I can count. I always come back to the idea that my diabetes philosophy is just at odds with an algorithm that is good at improving the numbers of the “average” population of people with Type 1 but not able to keep up with all of the variables of my diabetes. As a senior my skin and tissue are not as durable as they were in my younger days. Although I change my infusion sets every two days, I can still have a big difference in day-to-day absorption of insulin. I dutifully take the daily aspirin mandated by my internist and sometimes get bruising and bleeding that interfere with insulin. I am better at changing my pump cartridges more often than I used to but still have discernible (but not predictable) differences in insulin action from Day 1 to 4. Heaven only knows how to quantify the variance in what I eat and drink from day to day and how my body reacts.

This stuff is complicated.

I am lucky to have 7 (!) grandchildren and some of my favorite books are the Elephant and Piggie books by Mo Willems. Gerald’s frustration (“Elephants Cannot Dance!“) at not being able to dance is a good reflection of my journey with Control IQ. He is an elephant and elephants just cannot dance. I have type 1 diabetes and I just cannot be as perfect as I would like with Control IQ. 

Although Gerald thinks that he has failed when it comes to dancing, the squirrels and Piggie end up begging him to teach them “The Elephant.” Maybe my journey doesn’t have a bad ending as Gerald ends his dancing book exclaiming “Keep trying! You are getting it!”

Some days I am grumpy about my diabetes software and hardware. But I really have no choice except to….

Keep trying!

And that is what I do.

And This is Why We Struggle

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I recently filled out a long diabetes survey where I had to rank the potential benefits of a hybrid artificial pancreas system. One of the choices was a good night’s sleep. I think I rated that as Benefit #2 and I can’t remember what was #1. Probably accuracy of the CGM sensor.

Last night I had proof that a good night’s sleep is hugely important to me and proof that it is occasionally an elusive unicorn.

From the CGM history on my Tandem pump.

7/30/21     12:45am     Out of Range Alert

7/30/21     1:20am       Out of Range Alert

7/30/21     1:20am       Fixed Low Alert

7/30/21     1:20am       Fixed Low Alert

7/30/21     1:45am       Fixed Low Alert

7/30/21     3:40am      Fixed Low Alert

7/30/21     4:35am     Fixed Low Alert

7/30/21     4:40am     Fixed Low Alert

7/30/21      4:45am     Fixed Low Alert

I am not sure how many of those vibrating alerts I slept through and for sure the Out of Range alarms were the result of me sleeping on top of my pump. But I was woken up 7-8 times during the night. My husband probably 3-4 times. At some point I turned off my phone to stop the “Nerd Alert” 55-low alarms.

Last evening we flew from Baltimore, MD to Minneapolis. Several hours waiting at the airport followed by an unpleasant boarding experience and an uncomfortably hot flight. But as always with flying, if you have an equal number of take-offs and landings, it is a good day. But it was still a cr*ppy flying experience with Delta which is normally good for us.

In general Control IQ protects me from most lows and it is rare that I have an overnight like last night. I had several carb-loaded snacks on the plane (there was nothing else to eat) but all of those boluses should have disappeared several hours before I went to bed. At 7:30pm mid-flight I took my 5u nightly Lantus bolus with an insulin pen. (I use the untethered regimen with Control IQ to give my body some insulin that the Tandem pump can’t suspend. It works well. Usually….)  I remember in previous years reading articles indicating that insulin pumps might not deliver insulin correctly while taking off and landing on airplanes. Air pressure issues. Does that affect insulin pens? And my bolus was mid-flight, but probably at 35,000 feet. I have never worried or taken precautions about my pump. Should I have not trusted my pen-bolus?

Our flight landed at 8:30pm and we were home within 30 minutes. A little TV and straight to bed. Here is a photo of my 12-hour pump screen from 10:00pm last night until 10:00am today. The red areas show where my insulin was suspended. As you can see, there were several hours overnight where I was in the 50’s despite hours of getting very little insulin from the pump and eating at least 4 glucose tabs. I actually tested with my meter once to confirm that the CGM was correct and it was. I never soared high after all of these suspensions and that is unusual. So the Lantus must have been super-charged. I don’t think that any of the early-evening Novolog pump boluses could have still been active. I am never someone  who thinks that my body occasionally produces insulin. It doesn’t. So something was definitely awry last night.

The two hours from 8:00am to 10:00am reflect a typical breakfast bolus for 20 carbs (oatmeal, almond milk, and chia seeds) followed by a 3-mile walk. That insulin suspension is expected and common. It is the previous 10 hours that is crazy.

I had a bad night’s sleep and awoke today tired and achy. But when I got up, I was mostly fine and I had a good day with no fatigue. But gosh darn-it! It is horrible to be awakened over and over again by my diabetes devices. Or is it my diabetes devices communicating the craziness of my diabetes? Either way, I hope that future generations of D-tech, improved artificial pancreas algorithms, and faster insulin products can eliminate nights like last night.

I am thinking that I should move “a good night’s sleep” to the #1 position in my diabetes surveys.