Monthly Archives: October 2017

Whole30 or Almost?

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I am a firm believer that food choices make a huge difference in making diabetes easier to manage. I personally cannot eat lots of carb-yummy foods along with bucketfuls of insulin and expect anything other than roller coaster blood sugars. I am not good at moderation and usually do better with none rather than one. I can’t stop at a single potato chip or one chocolate chip cookie. In general I eat a diet that would be categorized as moderately-low carb. I do okay most of the time and then drift into patterns where I’m eating foods that trash my blood sugars. Most of my over-snacking with big boluses is in the evenings and I end up with lows at bedtime followed by 2:00AM spikes. Multiple Dexcom alarms destroy my sleep and blood sugars rebel well into the next day. Before- and after-dinner glasses of wine magnify the blood sugar swings and sabotage any semblance of willpower.

Occasionally I need a total reset to break the pattern. For the most part I don’t do diets with names and I have never followed the South Beach Diet or gone Paleo, Keto, Bernstein or Mediterranean. Last spring I decided to investigate the Whole30. The only reason I knew about the plan was that Kelley of Below Seven had blogged about her successful Whole30 experience in February and March of 2017.

The Whole30 describes itself as “a short-term nutrition reset, designed to help you put an end to unhealthy cravings and habits, restore a healthy metabolism, heal your digestive tract, and balance your immune system.” I bought the book in May and dove in headfirst. In general I hate to cook but tried a bunch of the recipes in the book. My husband was patient with the whole experience and we quickly agreed that we mostly like meat, fish, vegetables, and fruit with few spices or add-ons. The Whole30 is a do-or-die plan where sugar, grains, dairy, and all sorts of food are forbidden. Interestingly potatoes are allowed and after rarely eating them for several years, they were a treat. I was quickly amazed at how much fruit I could eat with minimal blood sugar disruption. Absolutely forbidden were diet soda and alcohol. I technically flunked the plan on Day 10 when I put lemon pepper on my chicken without knowing that it contained sugar. Unwilling to go back to Day 1 as the plan requires, I continued towards Day 30 as an imposter with lemon pepper on my conscience.

All of a sudden on Day 25 I didn’t care anymore. My first sin was Diet Coke and a wonderful carbonation buzz. The second was a glass of red wine. Surprisingly the food restrictions of the plan didn’t bother me much. I had few sugar cravings and my most-missed foods were string cheese and peanuts. I felt little guilt about quitting so close to the finish line because I lacked the conviction that Day 30 was going to change my life.

Fast forward to October. After a mostly-okay summer, I was again mired in bad habits. Too much diet soda, too much alcohol, too many snacks. I hit bottom two weeks ago when my husband was out of town and I determined that three old-fashioned donuts (two chocolate-covered and one sour cream) would be an acceptable dinner. You can imagine how well that carbohydrate binge went. Despite massive doses of insulin, my blood sugar soared and crashed all night long.

I started the Whole30 again the next morning. The first day was rough as my blood sugars relived the last 24 hours. Since then it has been smooth sailing. The food part of this diet continues to be easy for me since I really like vegetables, fruit, nuts, meat, and eggs and it is not intended to be a forever-diet. I have made my two favorite recipes from the Whole30

Spinach Frittata Whole30

cookbook—Spinach Frittata and Classic Chili—more than once along with basic dinners of meat, vegetables, and potatoes. Mixed nuts and honeycrisp apples have worked great for snacks and bananas, grapes, and juice have combatted the occasional lows. I am not missing Diet Coke which is kind of a miracle.

Am I cheating? Yes, but within the ground rules that I established at the beginning of the diet. I use glucose tabs for lows when away from home and obviously they are a big no-no. But they are convenient and “medicinal.” I am also allowing things like lemon pepper and soy sauce which are forbidden. Other than that, I am toeing the line.

Will I make it 30 days? Probably not and that is not my immediate goal. I have an endocrinologist appointment tomorrow and that was my original target end date. Unfortunately the donut bender will show up as Day 1 of my 14-day CGM tracings. Other than that, my BG numbers have been good. If I don’t indulge in a post-endo Diet Coke reward, I might keep going for another week or two. Maybe all the way to Day 30….

Is there anything magical about the Whole30? Probably not. It is one of many diets with a rigid no-cheat framework that can help people break bad habits in the short run while providing motivation for the future. It is probably an oversell that it claims to change your life in 30 days. At the same time both of my “almost Whole30” experiences have been successful in steering me back to healthy eating and better diabetes numbers.

If you have interest in trying the Whole30 plan, you can explore the website and probably learn everything you need to know. I bought the book at Amazon and haven’t regretted having it for reference and recipes. You should read Kelley’s series of blogposts at Below Seven because she details what she cooked, how she felt, and how it affected her diabetes. And unlike me she made it 30 days without breaking the rules!

A final question which I don’t address today is: If following a plan like the Whole30 makes diabetes easier and allows me to almost flatline my blood sugars, why don’t I eat like this most of the time? Good question.

Tandem t:slim X2:  Experiments with Clips and Cases

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In early August I wrote a review of the newly-released Tandem t:case. My views of the case were mostly favorable but I wrote one sentence that was more significant than I knew at the time: “IMO the clip is slightly too short when wearing the pump vertically and is not as tight on my waistband as I would like.”

A month after the Dexcom G5 software update for my X2 pump, I revisited the case issue and wrote: “Wearing the pump on my waistband has brought back the problem that the clip on the new case is neither tight enough nor long enough to keep the pump secure in the vertical position. Over two days it fell off 5 or 6 times.” I followed that statement with one case hack that failed and one clip option that was successful. I promised to experiment more and share the results in a later post. So here we go.

Three Successful Hacks

Success #1:  Knowing that Velcro is my hack solution, I applied a square of Velcro (hook side) to the back of my pink t:case. In one week of use, the pump did not fall off once. There was a little tugging and scratching of the Velcro as I slid it onto my pants, but it was a solid and reliable solution. The pump mostly stayed vertical but was easy to rotate when I wanted to see the pump screen.

Success #2:  I considered that the scratchiness of the Velcro might cause damage to the front of my pants. (Actually I don’t care because I always have a shirt or sweater covering my waist, but you might.) So my next experiment was to attach Velcro to the inside curve of the clip which would only come in contact with the inside of my slacks. This amazingly worked great and once again the pump did not fall off during the weeklong experiment.

Success #3:  In my September post I mentioned that I was using the Nite Ize Hip Clip attached directly to my pump. I removed the clip in order to do the case experiments described in this post. (To remove the clip, I carefully used an X-Acto knife to cut through the adhesive and peeled off as much of the tape as possible. Then I used a tiny bit of adhesive remover to get the last bit.)

After all of my experiments, I decided that the t:case added unnecessary weight to my pump and I went back to the hip clip applied directly to the pump. As before I had a small piece of Velcro (hook side) on the inside of the clip. Although the pump has never fallen off with this solution, it did spin more than I liked. So I added another piece of Velcro—the loop side this time. Just so you know, the Velcro FAQ calls this side “the softer mate.” Almost pornographic, isn’t it?  This provides enough friction (Stop the pornography!!!) to stop most of the tilting but is still easy to turn when I want to look at the screen.

BTW if you decide to apply a clip to your pump, be careful not to cover the vent holes. To give credit where due, I learned about the Nite Ize Hip Clip several years ago from Kerri at Six Until Me and Sarah at Sugabetic.

The Failures

Failure #1:  In my September post, I indicated that I had tried attaching a piece of Velcro to the curved tip of the clip. The Velcro solved the pump-falling-off problem but unfortunately made it difficult to slide the pump onto my waistband. Ultimately I broke the case by trying to open the clip wide enough to pull onto my pants. A definite user error and because I was given this case for free, I did not try to get a warranty replacement.

Failure #2:  To repair the broken case, my next hack was to attach a Nite Ize Clip directly to the case. It was a previously-used clip and I purchased 3M Scotch Outdoor Mounting tape to attach it to the case. I used a piece of Velcro on the interior of the clip as described above in Success #3. The 3M tape is guaranteed to hold 15 pounds and the clip stayed attached to the case with no problems. The issue was that like the Tandem clip, this clip was not tight enough to keep the pump on my waistband. The Velcro pad was not successful in dealing with the combined weight of the pump and case.

Summary:

I am currently using a Nite Ize clip applied directly to my pump. Two pieces of Velcro keep it secure on my waistband. Before the Dexcom G5 integration, I was content with the pump in my pocket and I used a case which seemingly prevented false occlusion alarms. Now I am wearing the pump on my waistband most of the time because of the convenience of seeing my Dexcom G5 info when I bolus. I have not had any occlusion alarms and I will keep my fingers crossed that they don’t reappear.

If I had to pick my favorite pump clip ever, I would pick the Animas clip which attached directly to the pump and was super tight. Tandem pumps are designed differently and the Animas clip layout wouldn’t work. At the same time I would argue that Tandem could have designed a clip that would keep a t:cased pump secure on users’ waistbands. But they didn’t. So know that Velcro is your friend and don’t be afraid to experiment. If you find a great solution, please share.

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Please note that I have not damaged my pump, clips, or cases (except the one I broke!) with these hacks. I suspect that you won’t have damage either, but I can’t guarantee it. So hack at your own risk.

Talking Types with Lloyd Mann

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I first met Lloyd Mann four or five years ago at a Saturday diabetes meet-up at a local Panera Bread. He was sitting at the end of the table with a big smile, an iPad, and a copy of his book about diabetes. He was discussing the possibility of being tested for MODY because of insulin signaling problems. A resident of South Dakota at that point, Lloyd was in Minnesota visiting family and had previously hooked up with this group through online friend Scott Johnson.

Fast forward a couple of years and Lloyd now lives in the town next to me. We have begun to supplement the every-couple-of-months group meetings with one-on-one lunches at the Panera Bread near his home. Yes, our relationship is built on Lloyd’s love of tomato soup and “Scott Johnson-esque” grilled cheese sandwiches along with endless cups of Diet Pepsi (definitely not Scott-inspired but Panera doesn’t carry Diet Coke).

Lloyd and I are close in age. In diabetes we are simultaneously far apart and eerily close. Lloyd has Type 2 diabetes and I have Type 1 diabetes. In most ways we are stereotypical depictions of our diabetes types. I was diagnosed with diabetes as a young adult in the mid-1970’s. I was hospitalized in an unquenchable-thirst skeletal state with high blood sugars and large ketones and have never had a day since then without injected insulin. Lloyd was diagnosed with Type 2 diabetes in 1994, took pills for many years, and then started insulin 11 years later. Lloyd’s insulin resistance is off the charts and on a daily basis he uses over 10 times as much insulin as I do. His story personifies the fact that Type 2 diabetes is a progressive disease.

So here you have two Medicare people with diabetes. Lloyd uses a Medtronic 723 pump and changes his 300-unit reservoir every day. When his warranty expires in January, he plans to move to a Tandem t:slim X2 pump and continue to change his cartridge every day. He likes the t:slim platform because unlike his Medtronic pump, it allows him to program a bolus larger than 25 units. I use a Tandem t:slim X2 pump. I change my cartridge once a week and rarely bolus more than 2 units at a time. Because Medicare CGM coverage does not exclude people with Type 2, Lloyd is in the process of obtaining a Dexcom G5 CGM. I use a Dexcom G5 CGM. Currently neither of us is using sensors provided by Medicare and we both wear an Apple Watch and carry iPhones. Lloyd and I are technology twins.

Lloyd and I are students of diabetes. Yeah, we are “Know-It-Alls.” You may like us. You may find us annoying. But we don’t care. We know our stuff and we want to learn more.

I recently asked Lloyd if I could interview him and we met at Panera two weeks ago. I did not record our talk so Lloyd’s answers are in my words with scattered quotations. I also throw in an occasional comment.

Lloyd, I know that your diagnosis story is in your book but please give me a short timeline. I was diagnosed with thyroid disease in 1980. Fourteen years later at age 44 I was diagnosed with Type 2 diabetes. What was your reaction was to the diagnosis?  I just thought “Oh no, one more pill to take!” Do you have a family history of Type 2 diabetes?  Both of my sisters have Type 2 but neither of my parents did.

How long have you had diabetes?  23 years.

How long have you been on insulin?  12 years since 2005.

How long have you been on a pump?  Since 2005. Less than one year after starting insulin, I convinced my doctor to order me a pump. I had used Lantus followed by a mixed insulin and wasn’t having good results. I did my homework and presented my doctor with a list detailing why the Deltec Cozmo was the best fit for me. Rather than specify Type 1 or Type 2 in the letter of medical necessity, he just put “Insulin Dependent” and I was immediately approved for pump therapy.

You indicated that you will be purchasing a new insulin pump in January. What features are important to you as you make that decision?  I need a pump with multiple basal rates. I currently use 8 different rates and my highest hourly rate at 3:00AM is 5 times as high as my lowest rate. Because of high insulin requirements, I require a 300-unit or larger reservoir and the option of taking boluses bigger than 25 units. I also need to be able to set an insulin sensitivity factor of less than 1 unit per 10 points. (As someone with Type 1 who is very sensitive to insulin, I want to put multiple exclamation marks after each of those numbers!)

I am planning to order a Tandem t:slim X2 to replace my current Medtronic pump. Although the  t:flex has a larger reservoir, I prefer the upgrade features, Bluetooth, and CGM capabilities of the X2. I am used to changing my reservoir every day and will continue with that practice. I expect that my total daily dose of insulin will go down using the X2.

Tell me about your decision to order a Dexcom G5 CGM. How do you think it will help you? I plan to use the G5 to help reset basal rates. Although I use more insulin now, the basal patterns are the same as I figured out using the Abbott Navigator over 6 years ago. I rarely get lows (insert another exclamation mark here!) but need a CGM for highs. I have always been forgetful and that is increasing with age. My  insulin mistakes are almost all related to forgetting to bolus and the CGM will alarm when I forget and my BG soars. I’ve been working with Dexcom since earlier in the summer and I am “waiting as fast as I can” for the arrival of my G5.

So Lloyd, what do you think of the Medicare ban on smartphone use with our G5’s?  “You can’t print that.”

What year was your book published and why did you write it?  Successful Diabetes Management was published in 2011 and I wrote it because I was doing well managing my diabetes and wanted to help others. I chose the cover from Amazon’s stock photos and the image spoke to me as “Follow the Path” to good diabetes management.

I had also been one of the many people at Diabetes Daily who knew Richard Vaughn and goaded him to write his book published in 2010–Beating the Odds, 64 Years of Diabetes Health. After Richard’s book was published, he contacted me and said “Your turn, Lloyd”.

Lloyd continues his mission to help others with Type 2 diabetes and his Diabetes Daily forum sticky note titled Type 2 in a Nutshell has over 16,000 views. He was previously a moderator at Diabetes Daily.

As we consider Type 1 and Type 2, Lloyd, how do you think our diabetes lives are similar?  Our daily tasks are the same. We count carbs, we bolus, we deal with highs and lows, we test BG, we change pump sites. And most importantly, we live with fear of complications.

How are our diabetes lives different?  My lows are not nearly as debilitating as yours and my risk of DKA is about 1/20th of yours. I think that people with T1 can eat a bigger variety of foods than a T2 aiming for tight control because they process food more normally and insulin works better. (Like many people with Type 2, Lloyd’s weight issues are intensified by high insulin use.)

What is the hardest part of diabetes for you?  “It’s forever” and “knowing what to do and doing it are two different things.”

What are your thoughts on Type 1 versus Type 2 diabetes?  I think that the naming of Type 1 and Type 2 leaves a lot to be desired. Type 1 and Type 2 are based on how you got to where you are but they don’t always address where you are. Type 2’s need to restrict carbs more than Type 1’s and we also have a problem with our livers. Metformin addresses that and I am still taking it after 23 years of diabetes. I think that my diabetes is more predictable than yours.

As this stage of your diabetes career, do you identify more with people with Type 1 or those with Type 2?  My day-to-day life is like a Type 1. My medical team thinks that I have completely quit producing insulin and that is unusual for Type 2. I have more in common with T1’s than with T2’s on pills.

Conclusion:  I asked Lloyd if he had any questions for me and he wanted my opinions on hiking and exercising. We talked about lows and he indicated that he used to get lows on older Type 2 medications and when he used to walk a lot. But he has rarely gotten lows since moving to insulin 12 years ago. Sometimes I think that my Type 1 diabetes is most defined by 40 years of lows: while driving, while taking care of my children, while mowing the lawn, while wandering lost at the mall, while peering up at concerned policemen and paramedics. Even with improved CGM technology which now mostly protects me from severe lows, my treatment decisions are always influenced by the possibility of lows and I might argue that’s the biggest difference between Lloyd and me.

Do lows make me have the “bad” kind of diabetes compared to him? No, because lows mean that my insulin is working. I can’t imagine the frustration that Lloyd must feel when oral medications in addition to hundreds of units of insulin daily are required to tame his blood sugar. Metabolic syndrome and insulin resistance are powerful opponents and I kind of wonder if my life is easier.

When I look at the differences between the types of diabetes, I mostly end up in the “I don’t know” and “I don’t care” camp. I don’t want to fight about labels, blame, stigma, cost, and who’s got it worse. I just want and need the appropriate care for my diabetes and I think that Lloyd would say the same thing. Diagnose me correctly and treat me correctly. That’s not asking too much.

In summary, I would say that the most fitting end to this blogpost is that no matter how you look at it, Lloyd Mann and I are just friends who both happen to have diabetes. Types don’t matter.