From Findlay, Ohio, USA:
My five-year-old son, diagnosed on 12/12/09, is on a nighttime basal dose of Levemir and has a daily bolus of Humalog after breakfast, lunch and dinner. He sometimes has snacks between meals, sometimes carbohydrates and protein, sometimes just carbohydrates and sometimes just protein. How important is it to maintain a log book of his meals/snacks to establish any patterns?
Since my work requires me to travel, my wife is primarily providing the care and recording any data. She is refusing to record the carbohydrate intake for the meals as she claims she is bolusing him accordingly so there is no need to record these carbohydrates. The carbohydrates for snacks are not recorded. Thus, when I look at the log book and see just blood glucose reading and insulin doses, it is hard to see a pattern, as my son seems to have wild swings, as much as 200 mg/dl [11.1 mmol/L] every day. The endocrinologist seems to agree with her, that he does not need this carbohydrate data.
I understand that the blood glucose level is not merely a function of the carbohydrates and insulin dose, but can also be affected by other factors (i.e., blood pressure, pulse, stress, exercise, etc.), but these are the two main factors in our control, and it would seem in our best interest, especially now in the winter months, before it gets warmer he becomes super active running around, that we look for and establish patterns now to have better control and understanding, so that when his blood sugar readings seem to be out of line, we can then look to these other factors such as stress, exercise, etc.
I have even suggested, and it has caused many arguments, that we should document certain foods (keep a food log), where bolusing does not seem to have the intended effect. For example, oatmeal or oatmeal cookies seem to make him go high even if properly compensated with insulin.
Also, by not noting in the log book the carbohydrates he has eaten for a snack then I am not sure, if I take him somewhere, if he has had a snack or not, unless I have spoken to my wife, so this sometimes can lead to communication issues.
Sometimes you round up the number of carbohydrates to that next level as the doses are (one-half unit per 15 grams of carbohydrates). Perhaps there are times you would want to round down the number of carbohydrates depending on is pre-meal blood sugar level (i.e., if he ate 22 grams and was at 249 mg/dl [13.8 mmol/L] pre-meal, would you round up the 22 grams to 30 or round down to 15 grams?). In my opinion, as he would be near the 250 mg/dl [13.9 mmol/L] blood sugar threshold level for an extra dose, I would probably round up the carbohydrates to 30 grams and dose accordingly, but I believe it would be good to be logging this data.
Please advise on the importance of logging carbohydrates to determine patterns.
Your approach and thoughtful questions are excellent. My experience has been that a parent (usually a father) who has this approach and similar questions commonly has been an engineer. (Are you?)
If my answer is incomplete, please feel comfortable in writing back.
I will say that for many patients, I do tend to pass over the log entries for carbohydrate intake, for those families who are good diary keepers. I do look at glucose values and I do look at insulin doses, with emphasis on the former; after all, glucose is the target, albeit a moving one.
With your child's insulin regimen, you are following a basal-bolus dosing schedule. The nighttime Levemir (detemir) provides the basal insulin while the rapid-acting Humalog (lispro) functions as the bolus (or mealtime) insulin. Typically, the bolus is calculated with an insulin-to-carbohydrate ratio. An example that you gave would be one-half unit for every 15 grams of carbohydrate consumed at the meal. The purpose of this program is to try to better mimic the natural physiology of insulin secretion by the normal NON-DIABETIC human pancreas. But such a supplemental insulin plan is NOT a normal pancreas (nor is insulin pumping for that matter, another method of providing basal-bolus insulin). As you have recognized, it is not always easy to "guestimate" carbohydrate intake or give fractions of insulin units (without a pump). Furthermore, such plans often tend to "ignore" the caloric intake of protein when it comes to bolusing insulin. Then again, there are the effects of exercise, activity, stress, concurrent illness, etc. on metabolic utilization of glucose. (I'm not sure that I agree with your statement regarding the effects of blood pressure and pulse, per se.)
In order to help correct for unanticipated higher glucoses, most basal-bolus plans also provide a "correction formula." You somewhat allude to this, when you say that a value of "250 mg/dl" [13.9 mmol/L] is the "threshold" value for giving an extra dose. A common approach to giving a "correction" includes knowing your child's "target glucose" and also knowing your child's "sensitivity factor." The sensitivity factor is most easily thought of as the degree of blood glucose lowering that is commonly achieved when the patient receives one unit of quick-acting insulin. As your child is newly diagnosed and young, I would presume that he is very sensitive to insulin and would anticipate that a unit might drop his glucose by, perhaps 75 mg/dl [4.2 mmol/L] or more. Also, in my patients, even some of the younger ones, I commonly target a glucose of about 120 mg/dl [6.7 mmol/L] (to maybe 150 mg/dl [8.3 mmol/L]). So, a way to calculate your child's "correction formula" is to compute the following mathematically: (Current glucose reading minus the target glucose) divided by the sensitivity factor. If your child's glucose were 246 mg/dl [13.7 mmol/L], then the numbers I might plug in would be: (246 minus 120) divided by 75. The resulting value of "1.7" units would be the amount I would give IN ADDITION to the bolus based on carbohydrate intake. Of course, insulin pens and special syringes cannot dose "1.7" units. So, typically I would round up to 2. But, if I knew that an activity were pending a little after the meal where the child were to be more active than usual, I might round down to 1.5. If I knew that there was going to be LOTS of exercise (say a soccer game and the child is a little banshee) then I MIGHT ignore the bolus (but probably not); in such a case, a little trial-and-error with some glucose monitoring during the activity adds to your database to look for patterns. A correction such as I used in the example above can also be given BETWEEN meals (typically two or more hours after the meal) in order to correct for higher glucoses. This stresses, especially in recently diagnosed patients such as your son, the need to check glucose readings two hours after a meal (some clinicians prefer one hour).
Another important consideration with basal-bolus insulin plans (compared to older plans using different intermediate-acting insulins) is that between meal snacking is NOT always REQUIRED. After all, do non-diabetics ALWAYS eat between meal snacks? But the flexibility of basal-bolusing allows snacking, if a snack is desired. And many five-year-olds (and other children and teens) do like "after school" snacks. Your child may have a mid-morning snack at preschool and kindergarten. If YOU as a non-diabetic ate a snack, your normal pancreas would make the correct amount of insulin accordingly. So, many clinicians will advise that a bolus of insulin be given to the diabetic child for snacks as well as meals. (I am distinguishing here between a between-meal snack and the treatment of hypoglycemia; I also tend to not dose for a bedtime snack, if I can avoid it.) As your son is so new into his diagnosis, his own "diabetes honeymoon" may preclude need for snack bolusing right now.
I would talk to your pediatric endocrinology team about snack bolusing, clarifying corrections (if you haven't already), two-hour after meal glucose checks, and even consider that the Levemir be given twice daily, depending upon the patterns that you see.
Now, back to logging in the diary. Again, for many clinicians, this information is not as pertinent to them, as long as the insulin-to-carbohydrate and correction boluses are correct (and noted) but I think they are a TERRIFIC teaching tool for patients and parents so that indeed they can learn to see patterns. The 15 grams of carbohydrates in a glass of juice will probably not have the exact immediate impact that 15 grams of carbohydrates in half a baloney and cheese sandwich will have. So, certainly at this time, I agree with you.
Having said that, your wife sounds as if she is the primary caregiver at home ("Dr. Mom") and she has to find a workable method for her to incorporate all this new (and overwhelming) information and procedures into her and the boy's lives. If she finds that logging the carbohydrates is too much, then that may be fine. A compromise certainly will be to log this information when new foods are introduced ("pizza from Domino's" versus "frozen pizza at home" versus various brands of frozen pizza; different degrees of sweetener in different tomato sauces, differences in crust thickness, for examples). Many families find pasta dishes even more vexing to calculate. Trial and error and logging really can help, even if it means a little more paperwork. Even a check mark by a snack in the logbook will let you know that a snack was given! But, your child need not be passive in all this; indeed, he should be actively involved in aspects of his diabetes care, as "age-appropriateness" allows. He can learn to recognize "good foods" from "not as good foods" and he can recall his snacks for you and he can choose where insulin injections can be given and which spot is the place for the current glucose check, etc.
Finally, I know that having a child with diabetes is stressful, given all the new information and techniques and worries that you have. You have already indicated that you and your wife are arguing about matters and have miscommunicated. PLEASE see the forest from the trees: the goal is to raise a healthy, active, bright, wonderful child who "happens" to have diabetes; you should not think that you are raising a "diabetic child." Diabetes can and does drastically change your lives and that of your son. Don't multiply the stresses. It may be wise NOW for you and your spouse to seek out the guidance of a professional to help you cope. Too often I have seen mothers resent fathers because the mom is indeed Dr. Mom, and often the "bad guy" because she is nagging about glucose control, giving insulin (needles!), checking glucoses (more needles!), and limiting food choices, etc. while dad often gets to be "Good Cop" - coming home from work and getting to play with the child (wrestling around, playing hoops, etc.) as the exercise is good for the child with diabetes. I've seen dads resent moms because of real and perceived lapses of togetherness and intimacy while fretting over the child while out to a show, for example. A professional (perhaps the diabetes specialist or their social worker or psychologist, marriage counselor, or even a trusted clergy person) can help guide you trough troubled waters. If your marriage were rocky before, the stress of the new responsibilities at home might prove to be too much. Be proactive now please.
Original posting 30 Jan 2010
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Last Updated: Tuesday April 06, 2010 15:10:20
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