Sushi Boat
T1Ds can eat the same thing as non-T1Ds, it just sometimes takes a little more planning. Many times it takes a lot more planning. Sure there are some things we don't eat, but that's mostly a choice that has nothing to do with the fact the kids have diabetes. And there are things we've opted to cut out of our diets because the hassle and unhealthiness of it just isn't worth it, like breakfast cereal and quick Chinese food; the kids never liked it enough to make it something we would find a way to work through. But there are some foods that are particularly difficult to dose for but are too enjoyable to pass up. Enter: the sushi meal.
Last week Walker turned 8 and the celebrating continued on through the weekend. Saturday evening we went out for sushi, one of Marshall's and the kids' favorite food. Non-T1Ds probably don't know this but sushi is a carbohydrate mine field. And when you eat as much sushi as they do, it's downright ridiculous. We rarely plan ahead when it comes to going out for sushi, it really depends on how the day has gone with their blood sugars and where they're at right before we eat. If we were to go into the meal with elevated BGs it would be next to impossible to avoid the rollercoaster throughout the night, so we really have to be flexible when we eat out.
What makes sushi such a pain for people with Type 1? Lots of things. Mostly, it's the short-grained white rice. White rice has a very high glycemic index, which means the carbohydrate of the food hits the blood stream much faster and spikes blood sugars quickly. We typically choose foods with a lower GI rating; this works better with the way the insulin reacts with the food, as well as the fact that it's simply a healthier way to eat. Quick changes in blood sugars aren't good for anyone and especially diabetics who rely on fast-acting insulin that peaks at 1.5 hours after dosing and continues to work another hour or so after that. Not only does white rice have a GI rating above 70, white rice also takes a longer time for the body to digest so it's like a double-whammy. Sometimes the carb hits quick, spiking the number, but usually it is slow to digest, so it ends up causing a BG crash early on with a crazy spike 4-6 hours later. And, sushi isn't made up of just rice. Depending on their choices, whether they opt to eat maki, nigiri, or sashimi, the carb count varies wildly. There's always the fun add ins like avocado, tempura, cream cheese, pickled ginger, etc. A single piece of sushi can vary from zero carbs to 10g. That means a single roll, consisting of 8 pieces, could be upwards of 80g of carbohydrate. And Ollie eats much more than that!
4 pieces of Philadelphia roll = 20g of carb
The other tricky thing about sushi is the high amount of protein and fats. Protein and fats can lower the glycemic load of an otherwise high GI food. As good as this sounds it makes dosing insulin quite frustrating, especially for something like sushi which has such a high hit of carbs. Thankfully all three of my T1Ds are on insulin pumps, and the insulin pump is able to extend the dosing of insulin. This is called a "square wave bolus". Most doses of insulin are given all at one time, as if it were a shot being delivered. But with a "square wave bolus" we are able to dose small amounts of insulin over a longer period of time, like 2 or 3 hours. We often utilize this when the meals are high carb with high fat.
So what does this mean? Well, each person has a different need for insulin. It depends on their weight, their age (hormone levels), how long they've had diabetes, their individual sensitivity to the insulin hormone, yada yada yada ad infinitum. Walker, for example, needs 1 unit of insulin for every 8 grams of carbohydrate in the morning; in the evening she needs 1 unit for every 15 grams of carb. Ollie, on the other hand, is at a 1:12 ratio for breakfast, and a 1:15 ratio at dinner time. So, continuing with the example, if Ollie were to "only" eat 2 entire sushi rolls equaling 160g for dinner, he would need a little over 10.5u of insulin to cover his meal. (You really DO need to learn algebra when you're a kid, it really WILL come in useful!). Ten units is A LOT of insulin to dose for our 10yr old boy! Our typical dinner carb load is 15-30 grams. If 10 units of insulin was introduced into Ollie's 90 pound body it would surely send him into a hypoglycemic fit, especially since the sushi will sit undigested in his stomach for many hours. If, however, we're able to dose this insulin bit by bit over a greater amount of time, the medicine will have the opportunity to interact more naturally with the glucose as it slowly gets dumped into the bloodstream.
How do you know how long to extend the dosing? How do you know how quickly the food will get digested and the carb will get converted into glucose? How do you know how the body, whether it's Walker, Ollie, or Marshall, will actually digest this food? We don't. It's a guessing game. Every. Damn. Time. Sometimes we miss the boat (yes, we miss the sushi boat), and sometimes we nail it. And those days we nail the insulin dosing for meals like sushi, pizza, or burrito bowls we feel like rock stars. Because it's really hard to get it right.
When we got to the restaurant and everyone decided what they wanted to eat, we started dosing the insulin. Ollie estimated he would eat 105g, and we set the square wave to dose over 2.5 hours. Walker is less of a sushi fiend, and guessed she would eat 60g, which we set to dose all at once (she ate less rice, and had more sashimi). Marshall's pump works differently than the kids', his pump is a closed loop and it works in concert with his CGM. One of the drawbacks to this is he cannot do square wave boluses when it's in auto-mode, and to get around that he had to stagger his boluses every 20 minutes to mimic an extended boluses. (I will go into more detail of his pump in a later post.) Twenty minutes later the food arrived and everyone started eating, and Marshall and I held our breath.
And Saturday night we nailed it! Not just for one of them, but for all three of them! We went into the meal with all three blood sugars in range, we had a few appetizers and soups, we leisurely ate sushi for 30-45 mins, and blood sugars stayed pretty steady all night long with very little intervention. We should have played our lottery numbers that night, because clearly our luck was running hot. Aikmans - 1. Sushi boat - 0.
