Thursday, November 5, 2009

Blood Sugar Management As A System

Professor Landel, my favorite professor at Darden has often talked to me about blood sugar management as a system or a process. Professor Landel teaches operations consulting and systems design classes at Darden and has had performed some pretty influential consulting work throughout his career. Like me he tends to think in terms of inputs and outputs, lever points and strategic design. Also, like me Professor Landel has often been frustrated by the infinite variables that affect blood sugar management as he has many times asked his wife to design a system for her insulin controls (she is also a type 1). This often results in Mrs. Landel telling Professor Landel to stop thinking like a business professor!

My conversations with Bob and my most recent A1c has gotten me thinking about the precision and accuracy of our blood sugar management. Disappointingly my last A1c was 6.7; while the ADA would consider that in the healthy range, that number is a bit too high for me. I had some issues with blood sugars around lunchtime over the summer and a few very high days were mixed into that. So there are certainly some explanations for why my blood sugar moving average has crept up, it provides little solace.

What I’ve started to consider is whether basal and bolus rates need to be actively managed on a daily basis, or if there are periods of stability. Putting my systems thinking cap on I realize that historical actions influence future blood sugars. Nutritionally, the level of fat, fiber, protein and glycemic index of the carbohydrates in the food we eat and amount of alcohol we drink can alter the rate of conversion for food to glucose. Our level of exercise will alter a body’s insulin sensitivity as will hydration rates and metabolic functions. Those are the variables we can record, but then there are environmental variables which we have almost no control over. Environmental variables include quality and duration of sleep, outside temperature and humidity, level of stress for a given day and just about anything else under the sun. So when we combine things that affect metabolic rate with environmental factors is it possible to really predict blood sugar levels or are we stuck in an ebb and flow of recalculation?

Then I started thinking about bolus ratios, and how they change throughout the day. Why is it that my bolus in the morning is 1 unit of insulin for 14 grams of carbohydrates, at lunch it is 1 unit of insulin for 12 grams of carbohydrates and at dinner 1 unit for 17 grams of carbohydrates. Additionally, these ratios have all been calculated more by feel and experience than anything else. I really feel that to calculate these ratios properly I need to eat the same exact food at each meal with the same exact metabolic influences for a week to calculate the ratios properly – that’s a huge pain the a** but one that might be worth it for tighter blood sugar control.

So if I view blood sugar control as a system, to better calibrate my insulin intake I need to control the variables I can control so that my insulin rates are as right as possible ceteris paribus. Since life isn’t lived inside a vacuum it makes blood sugar management much more artistry than science. The question then becomes how do you use insulin to become more like Picasso than a 3 toed sloth on crack with a paint brush?

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