Getting the munchies

When I'm at work, I tend to get the munchies. I don't know why the urge to snack comes over me more often at work than it does at home, but when I'm at work I really, really want to snack the day away.

Unfortunately, my snacking choices tend to be really high-calorie, high-carbohydrate foods such as muffins, chocolate bars or potato chips. None of those is a very good choice when I'm spending my day sitting in front of a computer, moving only to go the washroom or to grab a cup of coffee from the kitchen.

Last weekend when I was shopping I decided to look for better snack options. I found some mini rice cakes that came in flavours like chocolate, caramel, cinnamon and peanut butter. The cakes are packed into little pouches, and each pouch has about 15 grams of carbohydrate. "Oh, those look good," I thought, "and they're not super-high in carbohydrates."

So what happened? I bought a box, I took the box to work with me, and I ended up downing three pouches of rice cakes in about ten minutes, requiring an insulin bolus. It's one thing to eat a snack that has 15 grams of carbs; it's another to eat a snack that has 45 grams of carbs.

I'm not exactly a low-carber, but I try to be sensible about what I eat. And eating three bags of rice cakes is probably not terribly sensible of me.

The problem of cheating

A couple of days after Halloween I saw a post on a diabetes forum that asked: "Did you cheat this weekend?" "Cheating" in that context referred to eating Halloween candy.

I objected to the wording, and it was revised to "Did you give in to temptation?" A better choice of words, perhaps, but it got me thinking about the concept of "cheating."

I've often heard both diabetic and non-diabetic people refer to "cheating on my diet." This means eating something that is apparently forbidden; you can't have food that you might actually LIKE to eat. That would be cheating. You're supposed to give up sweets. No chocolate. No candy. No ice cream. No cake, cookies or pie. No juice or regular (non-diet) pop. Some people give up bread, pasta and potatoes.

Now, I'm not going to deny that all of those foods are pretty darn high in carbohydrates and/or sugar or that they can be pretty tough on diabetes control.

My problem is in making any food seem "forbidden" so that if you eat it, you are "cheating." Cheating makes you feel guilty. Cheating is a bad thing. It's something you do in secret. You don't talk about it.

Other people make you feel bad about it, too. My ex-girlfriend used to go online and post to various discussion forums about how I was a bad diabetic because I dared to eat an ice cream cone. Other people point and laugh at the person who orders a burger and fries and a Diet Coke "as if the Diet Coke is going to cancel out all the calories in the burger and fries" without knowing that maybe the person who ordered that food is not counting calories, but carbohydrates.

I don't think there is anything wrong with eating that Halloween-size chocolate bar, or having a piece of cake at your friend's birthday party, or a piece of pumpkin pie at Thanksgiving dinner, or an ice cream cone on a hot day, as long as you know how to calculate enough insulin or exercise to cover for it. I remember one summer afternoon when I had an ice cream cone at the recently opened Ben & Jerry's stand at the mall; I fully intended to give myself some insulin to cover for it, but I was waiting for the effects of the fat in the ice cream to wear off first, because the fat delays the carbohydrates making your blood sugar rise. Well, I did so much walking that afternoon that my blood sugar never did rise, so I didn't need to take that extra insulin after all.

Calling something "cheating" gives it a stigma. It makes us ashamed of eating that chocolate, pie, ice cream, whatever. It makes us hide what we're doing instead of asking for help: how do I calculate the carbs in this piece of birthday cake? How long after eating this ice cream should I take this insulin bolus? I think maybe I'm eating too much pie, cake, ice cream, chocolate -- what should I do?

As I've said before in this blog, I don't advocate eating piles of cake, cookies, candy, chocolate, etc. I believe in moderation. What I don't believe in is self-denial. Denial and deprivation can lead to binging. I found this blog that talks about the "deprivation binge." Quote: "when certain foods are restricted because they are ‘bad’ or ‘forbidden’, tension builds up and a breaking point is eventually reached with a binge."

I think that is one of the biggest reasons to get rid of that "cheating" stigma. Binge eating is bad for everyone, but it can be especially bad for a person who has diabetes.

Trick-or-Treat with diabetes

Today is Halloween, and many little ghosts and goblins will be out collecting treats from their neighbours. Most of those treats will be candy. Sure, some people give out toothbrushes or raisins or apples, but the vast majority of little Junior's haul will be full of sugar.

What does that mean if Junior has diabetes?

These days most diabetics and parents of diabetics know about carb-counting and carbohydrate-to-insulin ratios. They can calculate how much candy is "safe" to eat and how much insulin to take to compensate for it. This was not the case when I was a young diabetic. Remember, this was the 1970s.

When I was a kid, sugar and candy were big no-nos for diabetics. Diabetic-friendly candy was not nearly as popular as it is today, and even if it had been, none of the people whose houses I went to would have known about my diabetes. We were still on what was called the "food exchange" system (where a slice of bread equalled "one bread exchange") and candy and chocolate didn't fit into that system.

However, I still dressed up in costume, and I still went Trick-or-Treating. I collected my fair share of candy. But I couldn't eat it. My mother would go through my goodie bag and take out the raisins and apples that I could eat, but the rest was stored away in a cupboard.

I did have an older brother and sister. And while I was young enough to go Trick-or-Treating, they -- older than I by seven years and five years -- were not, once I hit about eight years old. This did not, of course, stop them wanting candy.

My parents and I hit on an idea. It was still my candy, even if I couldn't eat it. So I sold it. My brother and sister would give me a quarter for each fun-size chocolate bar or other goodie they wanted, and I used the money to buy myself some sugar-free candy, or even a non-food treat such as a comic book.

Not only did this solve the problem of how to accomodate my diabetes, but it probably also made my dentist happy!

Canadian health care, part 2

In yesterday's post I said I was going to write about what the Canadian -- or, more specifically, British Columbian -- health care system was like for me as a diabetic person, but it turned out more to be a factual account of how the system works rather than a personal account. So today I'm going to write a more personal account.

When I'm sick, I go to the doctor. I don't have to ask my HMO if my particular doctor is "approved" by them. I don't have to ask if a particular doctor accepts the kind of insurance I have, because everyone in the province has the same insurance. I either call up my doctor's office and ask to make an appointment, or I go to the nearest walk-in clinic. I tend to use walk-in clinics a lot, actually, because I hate making telephone calls. Regardless, I go to the doctor when I'm sick. I don't sit around worrying about whether I can afford to go to the doctor; I just go. I don't have to pay anything. There is no deductible. There is no co-pay. No bill will show up in the mail.

Three times a year, I go to see my endocrinologist. I get a referral from my GP to go see my endocrinologist; specialists appointments are by referral. You can't just walk in to see a specialist. Specialists don't get paid if there is no referral. But I don't have to pay anything, not even for a specialist. I don't have to ask anyone's approval; I don't have to submit any kind of request to an insurance provider asking if they will "approve" my seeing this doctor. And no, the government doesn't "decide for me" if I can go see the endocrinologist.

My endocrinologist wants particular tests run. They include a hemoglobin A1C and a urinalysis. About a week before my appointment with the endocrinologist, I go to the lab, I give them my medical card, and they run the tests. My endocrinologist will have sent them a request for the tests. Again, I don't pay anything. I don't have to search to find out whether the lab closest to where I live accepts my particular brand of insurance, because as I said, everyone has the same insurance.

It's kind of like everyone in the province has the same HMO, except that for us, the HMO is the government. That's why it's called a "single payer" health system; everyone's health costs are paid for by the same provider, but for us, that provider is the government rather than a private medical insurance company.

Say I was in an accident, or my diabetes care got screwed up somehow and I ended up in DKA (diabetic ketoacidosis), and I had to go to the hospital. No one is going to make me fill out a whole bunch of forms if it's an emergency. No one is going to ask me how I'll be paying for my care. Eventually someone might ask for my MSP (medical services plan) card so that the hospital can bill the government for my care, but that won't be the priority.

Last year I went off disability benefits while I was going to school, and because I'd had a large windfall of money from an income tax refund, I lost my "medical only" income assistance (see yesterday's blog entry for an explanation of medical-only income assistance) and had to pay my own medical premiums. This wasn't a hardship, because I did have enough money. I was just unused to having to pay premiums, having been on either disability benefits or "medical only" assistance for the last ten years. I hadn't had to pay premiums in those ten years. So I forgot about it for awhile, and then I got a letter in the mail reminding me that I hadn't yet paid my premiums.

I had an endocrinologist appointment coming up, and I knew that my payment wouldn't be processed in time for that appointment, so I phoned up the medical services plan call centre and asked if I would still be able to go to that appointment and whether I'd have to pay for the lab tests I'd just had. "Oh, no, that's not a problem," I was assured. "Even if you don't pay your premiums, you still get health care. It's a necessity! We're not going to make you go without."

The Canadian health care system

There's been a lot of talk about the U.S. possibly implementing a "Canadian-style" health care system, and also a lot of misinformation about what a "Canadian-style" health care system actually is. So I thought I'd write a little about what it's like for me, as a Canadian with diabetes (as well as a few other chronic health conditions), under this system.

First of all, to be perfectly accurate, there is no "Canadian health care system." There are multiple systems -- one for each province and territory. I live in British Columbia, so I can really only talk about what the system is like here, though there are more similarities than there are differences between the different provincial system.

British Columbia is one of only a few provinces that charge health care premiums. These premiums are based on your yearly income. People with an income of less than $20,000 pay no premiums. The maximum premium, for people with an income of $28,000 a year or more, is $54 a month. Between those two amounts are various income levels with various levels of subsidy.

These premiums cover almost everything: doctor visits, hospitalization, lab tests, X-rays, etc. They do not cover prescription drugs. They do not cover psychotherapy. People with the highest premiums, the ones with an income over $28,000, do not get certain services covered, including physiotherapy, chiropractors or massage therapy. People who have lower premiums have these services covered, but do have to pay small "user fee" of about $10 to $15 per visit. People with higher incomes usually have these services paid for by their employers through various benefits packages.

Many of my American friends are surprised to find out that Canadian employers offer medical benefits, since the government does cover most of our health services. Benefits packages usually cover things that the government doesn't cover, like the aforementioned physio, chiropractors, and massage therapy, and prescription drugs. Some cover psychotherapy or offer "employee assistance" packages. Some pay the medical premiums for their employees.

For those who do not have employers who pay for their prescription drugs, we have what is called Pharmacare. Pharmacare is another sliding-scale plan that is based on a person's income. People whose income is less than $15,000 pay no deductible, but must pay 30 percent of their drug costs until they reach a maximum of 2 percent of their annual income spent on prescription drug costs. People whose net income is between $15,000 and $20,000 pay a deductible equivalent to 2 percent of their annual income, and then the government pays 70 percent of drug costs, until the person has spent 3 percent of their annual income on prescription drugs, at which time the government pays 100 percent of the drug costs. And people whose annual income is over $30,000 pay a deductible equivalent to 3 percent of their income, and then the second deductible is equivalent to 4 percent of annual income.

People who are on welfare or disability benefits have all their prescription drug costs covered by the government, and they don't have to pay medical premiums.

Because I am currently on disability, all of my diabetes supplies (and my other prescriptions) are covered by the government. If I go back to work, they will still be covered by the government under a program called "medical-only income assistance." This is a program that pays the costs of medication for people who have left disability assistance to go to work, but who would have trouble paying for their prescription drug costs if those costs were no longer covered by the government. The government sees this as a way to encourage people with disabilities to go to work and get off disability assistance.

What do I think of the British Columbia health care system? (As I said, there is no universal "Canadian" system.) I think it's not perfect, but I prefer it to the lack of a system in the United States. It has its flaws, certainly; the government has a tendency, in my opinion, to see health care as nothing but a big expense, and they tend to stigmatize certain diseases -- especially diabetes -- as being a "drain" on the health care system.

But I know too many Americans who have no health insurance. I know too many who are terrified of losing their jobs because if they do, they lose their health insurance. I have met people who say things like, "I think I'm having a miscarriage, but I can't go to the hospital because I have no money," or "I have diabetes, and I can't afford to pay for my insulin/syringes/test strips/etc."

There must be a better way.

Diabetes and hot weather

While it's not technically summer yet, my city has been experiencing some record-high temperatures over the last few days, and these temperatures are expected to last till the end of the week. When hot weather comes, there are some precautions I have to take when dealing with my diabetes.

One concern is dehydration. Dehydration is a concern for everyone, of course, but people who have diabetes have to be even more concerned. High blood sugar can cause dehydration, and some diabetes complications, such as certain forms of neuropathy, can impair the body's ability to sense dehydration symptoms. So I have to make sure I drink plenty of fluids on hot days.

I've discovered that the symptoms of low blood sugar seem to be pretty similar to the symptoms of heat exhaustion -- sleepiness, lightheadedness, confusion, etc. This causes me to check my blood sugar a lot more often when the weather is hot. Unfortunately, this means I use a lot more test strips than usual! Unfortunately, heat exhaustion is harder to treat than low blood sugar is. I'd rather have low blood sugar.

Heat also seems to lower blood sugar fairly quickly. I've noticed that I have to lower my insulin dosage on days when the temperature is abnormally high. There have been hot days when it seems like no matter what I eat, my blood sugar refuses to go above 4 mmol/l. While it's kind of nice to be able to eat anything I want, it's rather frustrating to have to be constantly treating myself for low blood sugar. I'm also sure it's not good for my weight to spend the day eating anything I want.

Then again, on hot days my appetite is diminished, so then I don't want to eat a lot. This means lowering my insulin dosage even more! Unless, of course, I decide to get a double-chocolate-chip frappucino from Starbucks. It's a lovely, chocolatey, cool drink, and Starbucks has lovely air conditioning, but it's going to wreak havoc on my blood sugar if I'm not careful and don't bolus appropriately for it.

And I'm probably not going to feel like exercising off the carbohydrates in that frappucino if the weather is hot. Exercise plus hot weather can equal dehydration and heat exhaustion, which brings us back to where I started this post.

So I will enjoy this hot weather while it lasts, but I'll also have to keep an eye on my diabetes while I do so.

Feline diabetes

A few days ago, my cat Poupée was diagnosed with feline diabetes. To me, this was a relief. Her symptoms could have been caused by kidney failure, and I'd already lost a cat to kidney failure two years ago. Having another cat with kidney failure would be devastating.

She had the usual signs: drinking a lot (three bowls of water a day), peeing a lot, being sleepy all the time. So the vet told me to start giving her injections of Lantus. I was surprised, but relieved, that I didn't have to give her a particular cat-specific type of insulin. I don't have a job right now, and the government program that pays for part of the cost of my prescription drugs wouldn't pay for medication for a cat.

I can give Poupée my own Lantus. I can even use my own insulin pen. I'm actually much more comfortable with pens these days than I am with syringes. I tried using a syringe on Poupée, and she squirmed away from me. So the next day I used my pen, and she seemed to be more comfortable with that. So as long as she's taking an even number of units of Lantus, I can use my pen. (The pen only goes in increments of two.)

Diabetic kitties should have their blood sugar tested, but so far I have failed at this. You're supposed to use your lancing device (the one you would use to poke your fingers as a human diabetic) to poke the kitty's ear. Well, I've tried, and Poupée has been amazingly tolerant of my efforts to get blood from her ear, but so far I haven't succeeded. I'd really like to know what her blood sugar is like and how her insulin is affecting her. At least she's not drinking nearly as much water as she was before she went on insulin.

Poupée also has to go on a low-carb diet, which means all the cats in my household have to go on a low-carb diet. She's eating Purina diet cat food. The vet calls it the "catkins" diet.

I think for many people it's a big deal when their cat is diagnosed with diabetes. Maybe because I've had diabetes for almost my entire life, it's not such a big deal for me. Granted, it cost me a lot of money to get her diagnosis in the first place, but at least I can share my own diabetes supplies with Poupée so they won't cost me any extra. Sure, I would prefer it if my kitty didn't have diabetes, just like I'd prefer not to have diabetes myself. But at least it can be treated, for both of us.