Hate Math? Tips for Managing Diabetes With Fewer Numbers
Editor’s Note: This content was originally published at OnTrack Diabetes, acquired by EndocrineWeb, and is republished with permission.
Carbohydrate grams. Insulin ratios. Basal rates. Correction factors. Meal boluses. There’s a lot more to diabetes than taking your insulin and eating a healthy diet. I’ve lived with diabetes since 1999 and I can tell you that injections are not actually the hardest part of living with type 1 diabetes. (After a few weeks, the needles are no big deal!) If you ask me, the hardest part is the juggling act of insulin, food and activity and that—unfortunately for people like me who have never been good at math—is a numbers game.
But if math has never come easily to you, does that mean that you’ll never be able to achieve healthy blood sugar levels? Not at all! Fortunately, there are many ways to daily life with diabetes—and one of them actually involves very little math at all!
Why Diabetes Math is So Complicated—and Stressful!
Carbs. Protein. Fat. Exercise. Stress. Growth hormones. Menstrual cycles. Growth spurts. Everyday colds and fevers. Weight-loss. Weight-gain. Even a small cup of black coffee can raise your blood sugar (although not for everyone!) even though it contains zero carbohydrates.
Sometimes counting the exact grams of carbohydrate and calculating your dose based on the insulin-to-carbohydrate ratio your doctor prescribed at your last appointment will work beautifully to keep your blood sugar in your goal range after you eat.
But there are meals like pizza or Chinese food or lasagna or cake with buttercream frosting, where the exact number of carbs is nearly useless because the intense quantity of fat combined with all those carbs has such a severe impact on how quickly (or slowly, as the case may be) that meal is digested, that you need gargantuan amounts of insulin spread over the course of hours to keep your blood sugar in-range. Or even just close to your hopeful range.
When it comes to preparing your blood sugar for exercise by adding carbs or by reducing insulin, the type of exercise you’re doing (anaerobic vs. aerobic), how long you’re doing it for, and even what time of day you’re doing it can all affect the equation.
So much about diabetes is complicated and involves numbers that it can make a math hater like me really frustrated.
Doing Less Math is Possible
Experts say developing your own approach to making sense of how you dose your insulin for different meals is the secret to success. In other words, know your diabetes and how food and exercise impact it.
“This is very specific to each person. Helping to develop charts based on insulin-to-carbohydrate ratios can give people a sense of relief [for those who are newly diagnosed] as it makes more things like a sliding scale,” explains Nicole M. Bereolos, PhD, MPH, CDE, clinical psychologist and certified diabetes educator. Dr. Bereolos has also been living with type 1 diabetes (T1D) since 1992.
The “sliding scale” is an old-fashioned and outdated approach to carb-counting used back before insulin pumps and basal insulins were invented.
Early in your diagnosis, carb-counting and the sliding scale can be very helpful as you learn more about the impact of different foods on your blood sugar. But many people find it’s limited with more complicated meals.
The sliding-scale method groups carbohydrate quantities into 15 grams. Every 15 grams is considered “1 carb.” When put on NPH insulin, which is rarely used today because it peaks significantly every few hours, a patient would be required to eat “3 carbs” or “5 carbs” based on their dose and calorie needs. Essentially, you had to feed your insulin.
Thankfully, today, newer insulin and newer technology allows you to choose what and when you’d like to eat, and dose your insulin appropriately. But again, determining how much insulin to dose is a very personal process.
A few other tips to get you started:
- Show your work to help you see the connection: “Writing it all out, like showing your work for a math problem, can help those who are visual learners,” says Dr. Bereolos. But you can also skip the ongoing math entirely, by making cheat-sheets or taking pictures.
- Let your cell phone camera be a visual aid: If you eat the same lunch every day, take a picture of that meal on your phone and write (with the “edit” option of the photo) the carbohydrate quantity along with the insulin dose you would take assuming your blood sugar is in-range at the time you’re eating. This allows you to simply open up the “Meals” photo album on your phone and quickly remember how much insulin you need.
- Unfortunately, it isn’t always that simple because if your pre-lunch blood sugar, for example, is higher than ideal that day, you’d likely want to add a correction factor dose, too. Again, more math. But once an accurate correction factor is determined, the math can be simple. If 1 unit drops your blood sugar by 30 points, and your pre-lunch blood sugar is 200 mg/dL, you would likely add at least 2 or 3 units of insulin to your insulin dose for lunch. (30 x 3 = 90 mg/dL. 200 mg/dL – 90 = 110 mg/dL.)
- Photos can help make dining out easier: If you have a favorite restaurant, taking a picture of the meal and making a note of how much insulin you took for that meal is an easy way to handle dining out. Of course, you’ll also want to make a note several hours after that meal to determine if your estimated insulin dose did, in fact, keep your blood sugar in your goal range.
- Make a quick reference chart for foods you eat frequently: Especially in the early months of diabetes management, having a long sheet of paper stuck to the fridge with simple notes like, “apple = 2 units” and “1 cup spaghetti = 4 units” based on your original math. Developing a solid understanding of how much insulin you need for your consistent meal choices will help you make better estimates for the meals that don’t come with an easy to calculate carb-count.
- Understand the impact of low-carb eating: For those committed to low-carb diets, carb-counting becomes a very different beast because instead, you’ll find you need to bolus more for protein. The body needs insulin, even on a low-carb diet, but it simply needs less. When you swap your potato for cauliflower, you suddenly find yourself needing to cover the chicken on your plate with insulin because your body is going to make some glucose from some of that protein. This again, comes down to a great deal of self-study.
The No-Math Approach
“I don’t pay any attention to the math of diabetes,” explains diabetes dad, Scott Benner of the Juicebox podcast. Benner’s daughter, Arden, was diagnosed with T1D when she was 2 years old. Today, she is a bright and healthy 15-year-old with an A1C below 6.0 and very few low blood sugars—something most children and teens would have great difficulty achieving on their own. (Arden now uses a closed-loop insulin pump which assists in maintaining tighter blood sugar management.)
“I stopped thinking about the numbers and became bold with insulin,” says Benner, who knows most parents likely lean on giving less insulin, not more, to avoid the risk of low blood sugars.
Some might consider the Benner family’s approach unusual but it clearly works for this father/daughter type 1 management team. They don’t do a single math calculation. Instead, develop your own “feeling” for how much insulin you need based on data from a continuous glucose monitor (CGM) or frequent blood sugar results with your glucometer.
Benner and his daughter work as a team, texting each other throughout the day to determine how much insulin she needs, based entirely on the data from her CGM and educated guesses for the food she’s about to consume.
“I find the idea of diabetes math to be a cumbersome and antiquated concept that tries and fails to put an insane disease into a pretty box,” explains Benner, who is a full-time stay-at-home dad. He and his wife decided early on that it would be best if one parent was dedicated to Arden’s day-to-day diabetes management to prevent having “too many cooks in the kitchen,” so to speak.
Getting Over the Fear of Insulin
At the beginning of Arden’s diagnosis, the Benners used traditional diabetes math but eventually came to the realization that it created too much anxiety.
“There was a time that I tried the math and the math made me nuts. Arden’s A1Cs were high, her variability was all over the place, and she felt terrible,” says Benner. “Today, Arden’s A1C has been between 5.6 and 6.2 for over four years. How did I do it? I stopped thinking about the numbers. I lost my fear and became bold with insulin. That’s it.”
Benner is referring to the common fear that both parents of children with T1D and adults with diabetes have about taking too much insulin. Being afraid of low blood sugars leads, quite obviously, to allowing your blood sugars to run higher.
While that fear may be quite valid for many—like someone who no longer feels the symptoms of low blood sugar or someone who has experienced a seizure from hypoglycemia and struggles with anxiety as a result—even a slight increase in basal insulin can bring blood sugars down without regular hypoglycemia.
“You need to create a tug-o-war that neither side wins. That is only possible through understanding insulin and how it works in your body.”
Benner’s personal philosophy in a nutshell:
- Do the work to better understand how insulin works in your body simply by observing and learning.
- Stop being afraid and hedging your bets; stop airing on the side of caution when you’ve already seen that that doesn’t work.
- Then be bold. Pre-bolus your insulin (i.e.: take your insulin about 10 minutes before eating a basic meal).
- Adjust your basal rates if they aren’t working.
- Carefully attack consistently high blood sugars with insulin adjustments.
- Do not over-treat low blood sugars.
- “Oh, and you must redefine what low means. Stop treating 120 mg/dL as a low blood sugar. While you’re having your child eat carbs to treat a blood sugar of 120 mg/dL, I’m giving Arden more basal insulin to get her blood sugar lower.”
When Too Much Data Makes You Crazy
Benner’s approach to managing his daughter’s insulin is not unlike the intensity required to maintain healthy blood sugars during pregnancy for a woman with T1D. It’s a constant reflection of the blood sugar data you have access to via glucometer and CGM. A huge part of success in pregnancy comes down to a willingness to make small adjustments in your own insulin doses rather than waiting for your next doctor’s appointment and allowing your doctor to make a quick guess after a 15-minute discussion.
“If your blood sugar is high you’ve mistimed your insulin, miscalculated your insulin or a combination of the two. Use more,” says Benner firmly. “If your blood sugar is low you’ve mistimed your insulin, miscalculated your insulin or a combination of the two. Use less.”
For some, this degree of micromanagement simply isn’t possible—both parents might be working full-time, or you are the adult with T1D and one can only sustain that degree of micromanagement for so long.
As Arden grows up and leaves home for college and her evolving adult-life, Benner will inevitably have to step back and let her develop her own approach that will likely be partly what her father has taught her and partly what she needs to do in order to find a micromanagement intensity she can sustain on her own.
Regardless, Benner’s point is simple: create your own understanding of your own diabetes. While he isn’t counting carbs, per say, he is doing a great deal of observing and studying. He’s identifying patterns and taking action, rather than throwing his hands into the air and saying, “High blood sugars are just part of life with diabetes for a kid.”
If an A1C of 5.8 is too intense for you or your child, that doesn’t mean some of Benner’s philosophy can be applied while aiming for an A1C of 6.5 or 7.0 percent. The general goal is the same: improving blood sugars for long-term health.
My Personal Approach
As someone who barely passed any of my math classes as a kid, I laugh at my surprising ability to handle “diabetes math” successfully today, but what I’m doing on a daily basis isn’t really math. It started out with math, in order to learn the basics of insulin vs. food vs. exercise, but similar to Benner’s approach for his daughter, most of my insulin doses come down to an educated guess for that meal.
That “sense” comes from many years of observing and learning. I don’t just take my insulin and hope for the best. I take my insulin and observe what happens. If I’m high or low after that meal or that workout, I know I need to adjust my approach slightly next time. It started from math but it evolved into real life, where carb-counts simply don’t always add-up.
Steak and broccoli may not contain more than 10 grams of carbs, but I know from experience that I need at least 2 units of insulin for that meal.
Sharing a rack of ribs with my fella is a very low-carb meal, but I know from experience that the vast quantity of fat and protein means I’ll need at least 3 to 4 units of insulin—and usually after the meal is finished because of how much more slowly protein and fat digest compared to carbohydrates.
At this point in my life, the extreme micromanagement I’ve applied during pregnancy isn’t practical because I am a full-time mother to two small children, hanging out with a blood sugar at 70 mg/dL only feels safe if I’m in a fasting mode, and thus have no fast-acting insulin on board that would lead to a low blood sugar.
When I’m eating very low-carb (fewer than 50 grams per day), it’s easy to manage blood sugars around 70 to 100 mg/dL without fear of hypoglycemia because every insulin dose is so small.
When I’m eating more carbs, I simply have to make a lot more careful estimates and check my blood sugar more frequently to catch the highs and gradually learn how much insulin I need for those meals.
It’s math, in a way, but I’m not adding things up with a calculator because I’ve lived with T1D for 20 years, and I know that high-fat/high-sugar cookies and cupcakes affect my blood sugar far more than their carb-count implies they will.
When Too Much Technology Is a Bad Thing
In addition to Benner’s advice on not being afraid of the average low blood sugar, especially in your child, Dr. Bereolos strongly believes it’s crucial that children and adults learn what hypoglycemia feels like.
“There are some kids who do not know what a high or low feels like, and I believe that, in itself, can be dangerous. Taking a break from technology—insulin pumps and CGMs—can be incredibly helpful,” she explains.
“I ended up going into diabetic ketoacidosis (DKA) on a plane from Tokyo to Washington, DC because of pump malfunctions. But I was able to stay calm because I knew what was happening. I had no syringe on me, unfortunately.”
If your life with diabetes management revolves around all the technology thinking for you (and you don’t even remember how to count carbs or how to determine your own insulin dose), it may be time for a brief pump vacation.
This also brings up the ever common issue of assuming that the information programmed into your insulin pump is accurate. Insulin needs change throughout life, even as children. Growing up means increasing hormones, getting taller, increasing muscle mass and more activity.
Even adults will see their background insulin dose change over time. If your blood sugars aren’t what you’d like them to be, it’s time to take a closer look at the settings in your insulin pump or your prescribed doses for daily injections and make adjustments—whether you receive help from your diabetes health care team or not.
If you don’t own a copy of Gary Scheiner’s Think Like a Pancreas, get it now. It’s an essential diabetes management tool for teaching you how to assess the accuracy of your own insulin doses.
Parting Wisdom: Find the Approach That Works for You
There will be times in life where intense diabetes management simply doesn’t fit, because of major life events like a divorce or a death. Or when you just gave birth to your first child and have a whole new creature demanding constant micromanagement. Or when your teenager heads off to college and everything about life (including what they’re eating) suddenly changes overnight.
Sometimes diabetes has to take a backseat, which can mean blood sugars go up a bit in order to cope with life—and that’s okay. But if you’re focused on improving blood sugar levels and how you manage your “diabetes math” on a daily basis, it’s essential to create your own style.
“It takes a lot of practice,” emphasizes Dr. Bereolos. “And a standard education with your CDE (now called CDCES – Certified Diabetes Care and Education Specialist), which is usually one hour, won’t cut it. It’s like any new skill: practice makes you better.”