The rule of small numbers

When M was diagnosed, her teacher gave her a very useful gift.

It is a book entitled Dr. Bernestein's Diabetes Solution, which was written by a doctor who is, himself, a diabetic. In the book are many interesting anecdotal stories regarding growing up as a diabetic over the years. Some of the stories involve boiling syringes, using daily urine tests, and general health inconveniences. The man became a doctor in order to learn more about managing diabetes well, and having the authority to teach people to manage their diabetes well. He claims that he has patients whose myopathy, retinopathy, etc, have actually REVERSED after learning to manage their diabetes using his methods.

One item that he brought up in his book is the "rule of small numbers". I am not sure if Dr. Bernstein is the first to call it such, but it seems to make sense, and it taught me a lot.

First of all, did you know that the FDA labels need to meet a certain accuracy level? I am sure you assumed that was the case. I know I did. What I didn't know, is that nutrition labels are permitted to be off by up to 20% and still meet FDA standards.

I really don't have that big a problem with this: food is a messy business. However, for people who rely on accurate nutritional information, labels can be disappointingly inaccurate.

Diabetics who are dependent on insulin use what they call a "carb ratio" to calculate how many units of insulin to give themselves when they eat. M's current carb ratio is 7. That means that for every 7 carbs M eats, she must give herself a unit of insulin. If M gives herself a unit of insulin without eating, it generally brings her bg down about 20 points (mg/dl).

The good doctor, therefore, recommends that diabetics stick to low carb food for accuracy purposes. Since the margin of error in food is 20%, a food whose label claims that it has 10 carbs in it may actually have somewhere between 8 to 12 carbs. The amount of insulin that covers 8 to 12 carbs does not vary that much; in M's case, it's about a half unit of insulin. If she gives herself 20% too much, her bg will be about 5 mg/dl less than the ideal. If doesn't give herself enough, her bg will be about 5 mg/dl higher than ideal. 5 mg/dl off is no big deal at all.

However, if a food claims to have 60 carbs in it, then the actual number of carbs in the food can range from 48 to 72 carbs, which can make a big difference in the amount of insulin you give yourself to cover it. Let's see: If she gives herself 20% too much insulin, her bg will be 40 mg/dl lower than ideal, which brings her into dangerous territory. If she gives herself 20% less than she needs her bg will be 40 mg/dl higher than ideal.

M's target bg - the one we shoot for every day- is 120.

In reality, we are very happy if it's between 85-145. Because she is a teen, and because some foods don't have labels, or portions are over estimated, underestimated, and because of other factors like exercise or lack thereof, most days it goes over 200 at least once. Nearly every day it drops below 70 at one point.

We notice that when M eats steak and salad, and minimizes bread, her bgs are much better under control. During the holidays, when the house is full of carb-loaded sugar-filled nutritionless crap, her bgs need to be monitored much more closely.

While many low-carb foods are delicious, sometimes a kid just wants a bagel, which we then pay for in extra test-strip usage and monitoring, or, alternately, higher bgs.

The argument in the DOC has been that, while "the rule of small numbers" seems to make logical sense, it doesn't always work.

I think it is true, but brittle diabetics and diabetics with other factors such as unrelated illness, medications, etc. might not be able to rely even on something as seemingly straightforward as the rule.

Currently, we use the rule as a guideline in determining a balance in food. For example, M is smart enough to realize that eating a large Blizzard from Dairy Queen  (at a labeled 160-190 carbs, depending on flavor) or a slice of cake is not only not worth it to her, but it can also be dangerous. But she knows that if she wants a big slice of Italian bread, she best eat it with a steak and salad so that her total meal is less than 70 carbs.

Verdict: I like the rule of small numbers, but while M is off at school, with high carb quick lunches and hot lunches, sticking to the rule can be a challenge. Let's hope she makes good food choices when she is out of sight.

Here's a small number. I'm pretty sure I can cover for that.