In my mind the 50% basal/bolus is a starting place when you are dealing with someone who is completely out of whack, or you have no idea how much you will need and it is a swag starting place.
But the only way that works in someone who has been optimized, is controlling what they eat. I mean if my son ate 80-100 carbs at every meal, then he would either need to crank up his bolus or would be completely out of balance according to this “rule”. Since he eats about 100 carbs a day on average, his basal is 55% of his insulin needs.
Having someone try to apply that without understanding if they are in control or not, would be scary.
Right, that is exactly my point. It is a general guideline, a starting point. Useful for someone who is just starting out. But trying to make a well-controlled and experienced diabetic fit into that percentage is not helpful.
That is one of those things that distinguishes a good endo from a bad - when they understand the difference between general guidelines and unique situations for each individual.
I agree. But I guess I also think we can overemphasize the significance of being an individual in this disease, to the detriment of common sense.
I feel like people are very fond of saying “your diabetes may vary” – and it certainly may vary and does vary. But I think that we overestimate just how much it varies from person to person – and that even that variation can be quantified in some way. For instance, if 99% of people who have an A1C below 7.0 have a basal/bolus split that ranges between 30 and 70, then if you fall into the 1% who does not have such a split, there should at least be some explanation for why that difference in settings makes more sense for you. Are you in honeymoon? Do you eat very low carb? Are you taking a ton of corrections all day long and essentially sugar surfing, so that your basal rate is essentially a wash?
In which case, I think it’s definitely reasonable for an Endo to see something like 15% basal and 85% bolus and think “hmm, something is up with this.” If the person truly is well-controlled, then the Endo should eventually stop harping on getting the numbers to fit a cookbook prescription, for sure.
But because there are so many parameters, it’s also possible that the same person could be well-controlled (or even better controlled) with more canonical settings. Basically, what I’ve learned from Looping is that a wide range of parameters can produce the same outcomes… so it’s possible sometimes that both the Endo is right and the patient is right, so to speak. But in the end, maybe getting the endo parameters to work could require a lot of experimentation and frustration.
Anyways, I’m not saying that Endos can’t be terrible. But I just think we as a community, having experienced the day-to-day variability, are living a woeld of seeming randomness and patterns on a certain scale, but that doesn’t mean there aren’t intelligible patterns that endos may be more privy to which are very visible and clear on a larger scale. And we shouldn’t discount that information.
The variability is not unintelligible randomness unless you don’t put in the effort to figure out the cause of the variability. Sure, many times it can help to have an endo who will work it out with you as a partner, but all too often our endos don’t work that way.
I am almost out of endo options here in San Antonio because my endo, who treated me like an intelligent partner in my therapy, recently passed away.
I’ve been through four endos in the past five years, but I won’t stay with any doctor who will not take into account that I have been managing my disease successfully for twice as long as he’s been a doctor.
I’m just about ready to start looking in Austin. But that’s a whole day off from work, whereas I usually only have to miss a couple of hours for an endo appointment.
What can I tell you, I’m a workaholic. And I’m also not sure if I’ll have any better luck in Austin. I’m really fairly difficult to get along with.
Exactly. The basal is whatever the CGM says it should be during fasting for a give time of day. The bolus is whatever the CGM says it should be when eating a given number of carbs at a given time of day after already having the basal properly determined and set.
Do I care what the daily percentage of basal/bolus is? Not even a little… Am I even going to have a conversation about what percent it is when I consider the concept stupid? No. Just enough to end the appt with that particular NP and get out the door.
That being said, I love our actual Endo (Doc) and the “other” NP and our previous (long time) NP. The vast majority of our providers are awesome. Which gives me even less of a reason to put up with nonsense.
I do think that percentage can be useful for an individual to analyze their own changes, perhaps during different seasons or changes in activity level, or when they are dieting. It can be an interesting thing to look at and analyze. But it’s not something I strive to hit.
As you’ve mentioned the whole concept is being taken from intended context. The 50/50 split is the baseline for new diabetics on insulin therapy completely lacking any information or observations about what their actual needs are. They assume a dose of basal based on weight, and assume a similar amount of bolus split between meals… this is a reasonable place to start assuming zero known information or experience… once the actual dosage needs are observed and recognized it is meaningless… somehow that gets lost in translation sometimes
I’m curious what fraction of people who have wildly divergent ratios from this general rule still maintain very good control. i suspect that if your ratio is, say, 90% bolus and 10% basal and you’re not in honeymoon, that you’re unlikely to be well-controlled, for instance. But I don’t have hard numbers on that. But I’m sure there are some studies out there showing the range and standard deviation on both basal/bolus split in the population, and how that tracks with A1C.
Day to day the basal/bolus split is useless. But I actually find it useful for the 3-month average.
If we’re dealing with a lot of lows and I have a lot of basal relative to bolus over several months, that is a sign I need to back off the basal. If I am doing a lot more boluses than basal and I’m looking at spikier, more roller-coastery graphs and a lot of corrections post-meal, that’s a sign that maybe I need to increase basal. Not a hard rule but it really does help to think in these rules of thumb for us-- especially because we’re using a program that institutes hundreds of basal changes a day and is constantly microbolusing our son, so looking at specific times of day or specific meals is a lot more complicated.
I know this is a thread about bad endos, but I’ll digress and discuss bad doctors, and a rather comical experience:
When my children were very young, their pediatrician was great. Each visit, I would bring my index card of questions and she would patiently address my concerns and answer the questions over my daughter’s screams. She was terrific! My daughter did have a strange rash that the pediatrician thought may be best examined by a pediatric dermatologist. I went prepared with questions. The doctor was not as patient, prescribed the medication which my daughter applied. Then my daughter had some other reaction (I can’t quite recall the specifics, it was about 25+ years ago). So I phoned the dermatologist and asked if the dosage were too high, after having read the package insert. To this, he wrote me a letter, something to the effect that he was upset that I would question him. I probably ought to have kept the letter just for a laugh. At the next pediatric appointment, I mentioned to our wonderful pediatrician my experience with the pediatric dermatologist. To which she replied, that he has the personality of a cardboard, but he is competent. A few years later, my daughter had another skin situation that required a visit to the same dermatologist. He was much better this time addressing my concerns and questions. So maybe they get better with time like a bottle of wine.
Doctors definitely have different phases in their career, and there are certainly different types of doctors. I will provide my observations from working with a good number of great cardiologists over 12 years. (these were only the good guys, don’t get me started on the bad guys).
I used to work extensively with a number of cardiologists, and their patterns were eerily similar. They get out of training in their late 20’s/early 30’s and are excited about everything they have to learn, by their mid-30’s they are hitting their stride, in that they have attended a fair number of conferences, digested all of the research available and can keep up with new research without too much effort, they have seen a good number of problems and have developed approaches to deal with these.
Around their late 30’s/early 40’s things get a little dicey. There really isn’t much new to learn in their field area, the patient problems that used to confuse, are now routine, being a type A hard charger and not having much left to learn is a hard pill to swallow (metaphorically), they have developed approaches that work with those hard cases, and new problems that they haven’t seen are hard to find. This is the make or break phase, either they come to terms with things, or quit medicine, or they develop hobbies that are difficult to master.
Those that are still around in their 50’s are usually really good doctors, they have a lot of knowledge and personal experience dealing with the easy and complex in their practice. They will have deviated enough from standards to know when they are willing to explore this with their patients, and they are still energetic about their practice.
60’s is when they usually have to start to give up doing the procedural work, and consider only working in the office. Sometimes this happens a little earlier if they have back issues wearing lead and things like that.
In my mind the best time to see a doc for a procedure is in their 40’s and 50’s.
The best time to see a doc with a complicated and unusual problem is in their 50’s-60’s. Great mix of book and practical knowledge.
So I conclude doctors aged somewhere around 50’s, or are in that stage of their lives where they have a lot of knowledge and personal experience dealing with the easy and complex in their practice…and are still energetic about their practice are good prospects for us to consider as our healthcare providers.
This stage in live of sufficient knowledge/skills and still energetic varies from individual to individual. Some people reach it earlier, and others later in life. But it’s also a generally good observation in other professional areas too. Many engineers hit their stride around late 40’s early 50’s and become very productive and inventive with patents and innovations.
This is such a terrific community - I feel at home and “safe” bringing up controversial topics because we all respect each other and no one will be banned for voicing their opinions.
