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At a recent annual physical, I was discouraged to see that despite a healthy diet and more frequent trips to the gym, I was gaining weight (the unwanted, non-muscular kind). “How could this be?” I asked my doctor.

Dr:   [glancing at medical record] Let’s see… oh, you’re turning 40 next week.
          Happy Birthday! And welcome to your 40-year-old metabolism.
Me:  For real? Doesn’t reaching my target A1c count for anything metabolically?
Dr:   Nope.
Me:  Here’s the thing: I don’t want to gain weight.
Dr:   Great! Do you count calories?
Me:  (Pause) No. I don’t count calories.
Dr:   Have you ever counted calories?”
MeNo. I count carbohydrates.

(She’s my endocrinologist. She knows I count carbohydrates. And fiber. She knows I consider exercise. And stress. And how much sleep I got last night. And what time of the day it is. And what day of the month it is. Every. Single. Time. I. Eat. Calories? Hell, no!)

DrOkay, so from now on you’ll count carbohydrates and calories.
(I’m sorry, did you not hear everything I just thought?)
Dr:  You get 1,500 calories per day. 50% carbs / 30% protein / 20% fat. Got it?

(Damn you, slowing metabolism, how dare you take more fun out of eating?
But… I don’t want to gain a pound a year either.)

Me:  Okay. I’ll do it. I’ll get an app.

That night I downloaded LIVESTRONG’s Calorie Tracker app and played with it for way longer than I should have. It's pretty cool. It incorporates a large database with nutrition info for most of the foods I eat. There’s a place to track exercise. At a glance I can see progress toward my daily calorie threshold. I like this app! It’s going to help me reach my goals. It’s even going to remind me to drink water. Awesome.

         

The following week, my schedule was dreamily predictable. I exercised, ate, worked, and slept at consistent times. I had complete control over the carbohydrates in my meals. There are were no unexpected twists, no curve balls. It was the perfect week to be a carb-and-calorie-counting diabetic.

But, really, who has weeks like that? Life is full of schedule-wreckers. Within three weeks I had fallen off the calorie-tracking wagon. And yet, I like Calorie Tracker and continue to reference it for counting carbs (and the odd calorie).

But as far as a strategy to prevent weight gain, it’s more time in the gym for me.
And maybe I'll consider drinking my coffee black.

Three mornings a week, I head to the gym, dial down my insulin, insert ear buds and spend 45 minutes ellipticizing. There's a lot of motivation: I want my clothes to fit, I'll enjoy the post-exercise calm, I want to model healthy habits for my daughters, etc. But really gets me out the door is knowing that I'll be able to dial back my insulin by about 15% for several hours following the workout.

This morning I broke from routine and attended a WillPower & Grace® class taught by my friend Jen. The class was part of the One Billion Rising movement, which is itself pretty fantastic.

I was apprehensive about trying to keep pace with the über-fit regular attendees. But the class was terrific. I worked hard, broke a sweat and stretched long-forgotten muscles.

And! Just before the class started, I saw a woman I recognized. Where did I know her from? Work? The neighborhood? Then I noticed her wrapping the plastic tubing around her insulin pump. And I remembered meeting her last summer at our kids' swim lessons.

We chatted briefly this morning after class, exchanged contact info and just appreciated the ease of connecting with someone who "gets it" without explanation.

I’ve been on a salad kick lately. This one is my favorite right now:

Twice-a-day-Salad

It's so good that sometimes I eat it twice a day.

A rough recipe follows, but the ingredients are easily varied according to what you happen to have on hand. The key lies in combining greens, crunchy vegetables and color, and adding the essential ingredient: tinned jalapeño-tuna packed in olive oil. Conveniently, the oil doubles as the salad’s dressing.

Recipe for Twice-a-day Salad

Some greens, such as:
Spinach, chopped
Romaine lettuce, chopped
Kale, rib removed, shredded (thin strips are essential)

Some crunchables, such as:
Red cabbage, shredded
Red onion, sliced thin
Snap peas, chopped
Red peppers, chopped

Some color, such as:
Baby yellow tomatoes, halved
Baby cherry tomatoes, halved

Tuna packed in oil with jalapeños
(there are various brands – this one is readily available where I live)

The flavors, textures and appearance of the salad are all great, and it's very low carbohydrate count means that I don't have to dose for it.

Kindly take note: if canned tuna is on someone’s list of foods it’s not OK to eat right now, I would prefer not to know it until my enthusiasm for this salad has waned.

I love my endocrinologist. She’s research-minded, supportive, sees the big picture. In eight years she has adeptly co-managed my endocrine system through a pump transition, two pregnancies and steroid treatment for a ruptured disc.

Which is why I was hugely disappointed to find among the usual bills and assorted holiday cards the following letter from her office:

Endo Letter

<Exhale>

I wish briefly for a Netflix-style doctor selection tool where I can filter for all the characteristics I'd appreciate in a new endo – respectful, empathetic, personable, sincere, irreverent, research-minded, knowledgeable about MODY…

And then I tap my local advisors – the people with diabetes, the physicians, the fantastic moms. I get several solid referrals and make an appointment for April with someone new: Dr. G. And if she’s not super awesome, I’ll move to the next on the list. Because I really want a good fit with this doctor.

I change my pump's infusion set every 2-3 days. Today happens to be a site-change day. I considered documenting the process for you, but a quick search on YouTube yielded plenty of good examples of people changing their sites so I just picked one I liked to share with you.

Do you know the website Foodily?

You can use it to compare the nutritional content of different versions of a recipe. It's especially helpful if you cook for people with dietary (or gustatory!) constraints. Here's how it works:

Say you want to make tomato soup for a dinner party. And you want it to be low-fat and low carb. And one of the guests is allergic to dairy. You just input "tomato soup" and check the appropriate filters. In seconds, Moodily serves up a bunch of recipes that meet your criteria. The recipes are displayed in a side-by-side format (often with images), so it's ridiculously easy to compare ingredients and nutritional data, and determine which recipe is right for you.

One downside for me is how the nutritional content is calculated. It's calculated per recipe rather than per serving. That makes the site less helpful for calculating insulin dosages. (You can read here why Foodily doesn't generate per-serving data.) Even despite that shortcoming, I like the site a lot.

Thanks to Foodily, I'll be making this tomato soup tomorrow night.

Estimating portions is more fun with attractive cheat sheets, no?

estimating-portions-infographic

I talked with my friend Katie yesterday. Her six-year old daughter was diagnosed last year with T1 diabetes. Among other things, we talked about insulin pumps and she asked how I like mine. I love my insulin pump (it's a Medtronic MiniMed Revel Pump). But I didn’t always wear one, and in talking with Katie I remembered that it took me a while to warm up to the idea. I had to overcome some worries which felt big at the time.

These were my fears:

Pump Fear #1: Malfunctions
What if the software malfunctions and delivers too much insulin?
I looked into it and learned that multiple safety checks are built into pumps to prevent such malfunctions.

Pump Fear #2: Becoming a Cyborg
I'm not a big on accessorizing. Could I really have a battery-operated, external, plastic pancreas connected to my body 24/7?
I felt self-conscious for about a week. Now the pump is part of me.

Pump Fear #3: Having Cyborg Sex
This one I addressed with my (super awesome) endocrinologist:

So… even if I temporarily disconnect the pump, the plastic port remains attached to my body?
Yes.
All the time?
Yes.
When I swim?
Yes.
When I bathe?
Yes.
So. Um... the plastic port, it's still affixed to my side or thigh during sex?
Yes.
Ok, then.

Turns out it's no big deal. I’m aware that the port is there but it doesn’t bother me (or my husband for that matter). Total non-issue.

Pump Fear #4: Nighttime Low
What if I go too low during the night when I’m asleep and I never wake up?
OK, so this one's still a worry. But wearing a pump hasn't made it worse.

I have a bit of a thing for Greek and Roman myths.

As a kid, I loved learning about the gods and goddesses and their varied gifts and shortcomings. In college I traveled around Italy, revisiting the myth in paintings, frescoes and statues. As a parent, I encourage my girls to explore these heroic tales over the ones that are thrust upon them. (Seriously, can any Disney princess hold a candle to, say, Athena, Goddess of wisdom, battle, and craft, who sprang from Zeus's head ready for battle?)

But the tale of Icarus and Daedalus (read a summary of it here) remains a favorite.

***

Sad though the ending is, I have always been fond of this myth. I admire the father’s courage and ingenuity. I like that Dad and son hatch a plan, build wings, learn to fly, and set off on an adventure. And, even though it didn't work out for them, I've always imagined that it could have. The story celebrates human potential. People are smart. We have the ideas, knowledge, and courage to do amazing things. At the same time, it's about moderation  overriding temptation and following good advice.

So, that's the diabetes metaphor I’ve had in my head since adolescence. The reminder to remain optimistic and to steer clear of the highs and lows.

When people first learn that I have diabetes, right away they always ask if it's type 1 or type 2. Well, neither. The question underscores the lack of awareness outside the diabetes community of the other varieties - like LADA and MODY diabetes. Because I get asked this question at least once or twice a month, it may be valuable to post a primer on the different varieties of diabetes.

Type 1 Diabetes: An autoimmune condition that damages/destroys the pancreas's insulin-producing cells (called beta cells). People with type 1 diabetes produce little or no insulin, so their bodies can't process glucose for energy. This causes blood sugar to rise. People with type 1 must take insulin to control their blood sugar (hence the nickname "insulin-dependent diabetes.")

Type 2 Diabetes: A condition in which a person either produces insufficient insulin or they are unable to utilize it properly. As a result, glucose in the blood can't enter the body's cells for use as energy, causing blood sugar to rise.

Of note: two mothers of type 1 children recently petitioned the ADA to rename types 1 and 2 to better reflect some of the differences.

Gestational Diabetes: A condition in which pregnant women who have not previously been diagnosed with diabetes present with high blood sugar levels during pregnancy, usually during the third trimester.

Latent Autoimmune Diabetes in Adults (LADA): LADA, sometimes referred to as "Type 1.5" shares characteristics with types 1 and 2. As with type 1 diabetes, LADA involves the destruction of the insulin-producing beta cells by the body’s own immune system. Unlike with type 1, there is a relatively slow progression of beta cell destruction so the need for insulin is not immediate. (For more info about LADA, see this post at the Joslin Diabetes Center.)

MODY - (Maturity Onset Diabetes of the Young): MODY is a monogenic form of diabetes that usually first occurs during adolescence or early adulthood. However, MODY sometimes remains undiagnosed until later in life. A number of different gene mutations have been shown to cause MODY, all of which limit the ability of the pancreas to produce insulin. (Definition from the National Institute of Diabetes and Digestive and Kidney Diseases.)

My version of diabetes is MODY. Since it's monogenic - meaning that a mutation in just one gene causes the disease - MODY clusters in families, occurring throughout multiple, successive generations. The affected gene is dominant, so a person who inherits just one copy of the mutant gene (i.e., from one parent) is likely to be affected. Because I carry a MODY gene, each of my two daughters has a 50% chance of inheriting it. (Yeah, bummer.)

Many people with MODY show no signs or symptoms, thus MODY often goes undiagnosed or is misdiagnosed as type 2. As with all other forms of diabetes, untreated MODY leads to the elevated blood glucose levels which, over time, damage body tissues, nerves and blood vessels. Therefore, the treatment goal for MODY is to minimize complications by keeping glucose levels within a specified range. To date, 12 distinct MODY subtypes have been identified, each with its own characteristics and implications for treatment. The University of Chicago’s Kovler Diabetes Center, a good resource on monogenic diabetes, estimates that 1-5% of Americans with diabetes have MODY.

Which type of diabetes are you dealing with? What should people know about it?

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