Walking the tightrope: what to eat, what not to eat, and insulin – by Helen German
Then there’s the carbs. I manage my diabetes by carb counting and working out my insulin on a certain ratio for each meal. Before I was pregnant, all my ratios were 1:1 – so one unit of insulin for every carbohydrate portion (which is 10g of carb). This stayed roughly the same for the first trimester and then around week 16 my blood sugars started to creep up out of the target range. I am now on different ratios for breakfast, lunch and dinner and my background insulin has gone from 16 units per day to 22 units. Having to increase the insulin amounts is quite normal during pregnancy, especially during the second trimester. As baby begins to grow and there’s another influx of hormones, your body becomes insulin resistant.
In the early stage of pregnancy I found my increase in appetite and cravings hard to manage, especially when I was craving big bowls of noodles, or bags of cheese and onion crisps, or Cadbury Double Decker bars! Not ideal when I’m diabetic and carb counting. I tried to balance it out by having only two carb meals a day, I would sometimes have just scrambled egg or an omelette for breakfast (no carb), maybe a big soup for lunch (still low carb) and then a bigger carb portion for dinner. Throughout the day I’d snack on digestive biscuits, celery, cucumber, carrot sticks, fruit, the occasional yogurt or just a glass of milk.
At 22 weeks it’s harder to manage carb counting now as my insulin dosages are much larger due to the change in ratios. Dinner for example is 1.7:1 so I have to split my insulin across two doses; on the pump there are different options for delivering insulin which I can choose according to what I’m eating. And this is what I’m struggling with at the moment. There is a set maximum bolus amount I can do in one dose, and before pregnancy this was 6 units. I’m still working with this limit but nearly every meal bolus I do is above 6 units. How do I deliver a bolus for 11, 12, even 15 units of insulin at a time? If I split the dose across a 15 minute window, how does that then impact my post-meal blood sugar test? For those who are diabetic reading this, you will understand the complexity of counting carbs, calculating ratios, and the mind-field that is the Glycaemic Index. For those perhaps not diabetic, let me explain.
Carbohydrates are divided into an index with three main categories: low, medium and high. How a carb is indexed depends on how slowly or quickly it is digested and absorbed by the body. For example, wholegrain carbs and foods high in fibre (fruit, vegetables, etc) are low GI and are slowly digested over a few hours. This slow absorption means it raises blood sugars over a prolonged period of time. Carbs that are classed as high GI, such as breakfast cereals or white bread for example, increase blood sugars very quickly for a shorter length of time. The carb’s GI is also affected by other factors such as fat content. If it’s high in fat then this will slow down the rate of absorption. Plus fat may result in a resistance to the insulin too. For example, whenever I eat pizza, I have to give 50% of my insulin 10 minutes before I eat, then the other 50% I set the pump to deliver over the next 45 minutes to an hour. This is called a multi-wave bolus. With pizza, if I do all my insulin at once, I tend to hypo after the meal and then my blood sugar rises for the rest of the night. This is because the fat content in a pizza slows down its digestion, meaning I still need to have insulin three to four hours after eating. The multi-wave option allows this to happen meaning I can manage my blood sugars better.
The GI is also influenced by the actual meal size – a larger carbohydrate meal will take longer to digest than a smaller portion. And the way the carb is cooked can affect how slow or quickly the body processes it. Oh, plus different GI groups added together will change its category, so a low GI served with a high GI equals a medium GI…But most importantly, there’s the huge influencing factor of a small thing called ‘individuality’. Every ‘body’ is different and will react differently to the same foods. Luckily, for a non-diabetic, the pancreas manages all of this very well; adjusting insulin dosages according to the information it receives back from the body. Unluckily for us diabetics, we have this job to do.
The only way I managed this when I was first diagnosed was to keep a food diary. We are usually creatures of habit and will tend to eat similar meals over a two week or even four week period. Think about your regular food shop for example, rarely will there perhaps be a planned meal that you have never eaten before. Initially I wrote my meals and blood sugars down in a page-to-a-day diary. I kept this up for a few months while I learned how my body reacted to certain meals and identified a pattern. This got me through my first three years until I eventually got a place on a carb counting course and my diabetic life changed, for the better.
So, bearing in mind diabetics who carb count base their insulin dosages on all this information, not forgetting pre-meal blood sugar readings, time of day, and any planned or unplanned exercise… then that little word ‘control’ is a huge ask. Throw in pregnancy too with cravings and a bigger appetite… well you get the idea! This is the tightrope we walk along every day. One miscalculation of carbs or one missed blood glucose test can upset our balance…
How do I manage it now? Especially with my insulin needs changing every couple of days? Well, it’s a case of writing everything down. The diabetes and midwife team have given me log sheets to complete for the next nine months. I have to write down my blood sugars before each meal (breakfast, lunch and dinner) and one hour after each meal, plus before bed and during the night. If I’m testing my basal (background rate) insulin during the night then this is another three tests – 1am, 3am and 5am. (I’m telling myself this is perfect practice for night feeds once our baby arrives!) The log sheet also includes insulin for each meal plus any given correction dosages. The joy of being on the pump is that all this insulin information is downloadable so I don’t bother writing all this down.
There’s a lot of numbers, and a lot of factors that then influence those numbers. So I keep a diary to make additional notes, plus post-it notes which are life-saving! To help me see the wood from the trees, I do colour-code my log sheets – yellow are hypos or below target; greens are within target; and pinks are hyper or above target. I also download the data from my pump and print out glucose averages for each log sheet (each one lasts 6-weeks), including insulin trends and pie charts. I keep all this in a folder I especially made which is separate to my maternity book issued by the hospital.
I know from experience that when my blood sugars aren’t written down or I don’t keep an eye on my diabetes that it can very quickly become unmanageable. And usually what I thought was the problem – say my breakfast ratio – isn’t a problem at all, it’s the hypos I have the night before.
Then there are days like today. I’ve done two nights of testing my basal rate. I’m tired and the post-breakfast high blood sugar has agitated me. The pump says I still have insulin on board so I don’t correct. Another hour later, I’m still in double figures. But I still have insulin working, so I don’t correct. (I’m trying to avoid hypos, remember?)
Another hour later, my blood sugar is the same. I’ve had enough. I override the pump and deliver a correction bolus. I test negative for ketones. But I’m tired and fed up and down. I try not to cry but I do; I try to stay calm but I don’t. An hour and a half later, I hypo. And there’s that tightrope again. But don’t look down they say, keep looking up and forward they say…