At 10:30 BG was 223. I took 1 unit for correction and didn’t check until just now. I took 2 more units and will have to stay up. I’m using the 8mm pen needles. This post is the continuation of the pasta, cannoli cheesecake and more cheesecake post.
I enjoyed the cannoli, cheesecake and the pasta tremendously,…but I panicked at the low reading and probably ate too much ‘correction cheesecake’. . And now I am dealing with the aftermath of BG too high.
We won’t tell anyone and we certainly won’t judge. I hope the food tasted good. Now you have one experiment down, adjust and get it closer on the next test.
The first tentative conclusion is that maybe 1 hour is too long a pre-bolus for the cannoli. Maybe start with the pasta bolus, and 20 minutes or a half hour before the cannoli, bolus for that. The late rise could have been from too small a bolus to cover the cheesecake. Thinking about the correction of 1u at 223, how long after the last bolus was this? Was the meal bolus pretty much all used up by this time? Is 1u your usual correction to drop from 223 to 100? And at 223 you may have had additional insulin resistance. These are things I’d think about if I were in a similar situation.
So your BG got down to 47 and went up into the 200s without your knowing it. Nobody likes when that happens, but no harm came of it because you were running an experiment and so you checked your BG and intervened. To reduce the chance of large BG excursions I only know of two nice options, one is to check more when running an experiment, and the other is to have a CGM check for you. There’s another option that I consider more of a last resort but others would say it’s reasonable, which is to reduce the total carb intake so insulin doses are smaller so errors in dosing are smaller. I have only gone a little ways down that path because I’m getting what I consider to be a quite good A1C and time in range by watching and correcting pretty frequently.
During this experiment your BG excursions could have been smaller if you had tested sooner, and you did a good job of following it from 47 to 70 to 92 to 115. It turns out you needed another test before 10:30. How could we anticipate that? Well, what time did you eat the cheesecake? So how long was it actively digesting? That’s the kind of reasoning I’d use to plan when to take the next test.
I think one underlying reason for the excursion high is that you corrected with food, and it was an uncalibrated correction to boot (which you correctly identified in your post). I would always correct a low in the 40s or 50s with glucose, both because it rescues me from the low sooner, and because it’s all used up relatively soon. In the 40s I’d take enough glucose that I’d expect to get to 120. But if I were in the 60s, then I’d probably think about eating something tasty, but with a known carb content that would send me to a good BG, and I’d combine it with a bolus if it was more carb than I needed just to get to a good BG. And in a case where I rescued myself with glucose but then saw the BG starting to fall again, I’d consider eating something tasty too.
The fact that I couldn’t reliably know when I was getting out of range is what motivated me to get the CGM. As far as the lack of awareness at 48 but awareness at 70, there are many plausible explanations. One is that you drifted down to 48 slow enough that it didn’t provoke a reaction. Another possibility is that your body knew you were low but it also knew that you ate a lot, so it it waited awhile before panicking. Or perhaps you were paying closer attention at 70 after recovering from the 40s.
Lilian, it is really exciting to see you do all these experiments! You are truly going for UNLIMITED!
Some feedback from our experience, which always needs to be taken with a grain of salt, since we are all different:
First, the really good is that you did NOT peak after eating the first part of the meal, when you had peaked the last time! That is a nice victory!
your procedure was quite complex. You ate many different things, had several injections, and used different pre-bolus times. It is quite difficult to figure out what worked and what did not.
as a consequence from previous point, I would suggest going for simpler tests to start with. Maybe try pre-bolusing then eating one hard thing, then seeing what the result in time is
variable pre-bolus: For us, we have a “standard” pre-bolus that we have arrived to after a bunch of testing. It is 45mn (for us). We modify it according to the circumstances, but, really, most of the time we use the regular pre-bolus. So I suggest that you figure out what the right pre-bolus duration is for you in general first. It will simplify a lot of things. Like bkh, I would be nervous about a 1 hour prebolus (but, of course, you did eat something before the 1 hour wait time).
of course, if you are low when you pre-bolus, it is another matter: you clearly need to treat first.
Finally, in terms of changing location after 5 units: for us, FYI, this limit is 8. If we inject more than 8 units, we do it in more than one location. But we still use 4mm needles in general (we use 8 or 12 for IM), so, with your 8mm needles (right?) I would feel pretty comfortable with larger boluses than 8. But that is us, of course.
I understand that the above is a bit sloppy because the pre bolus times are not consistent; the foods are varied…etc. Variety of food is my preference. For far too long, I avoided variety of carbs. I was partly experimenting with what-can-i-get-away-with. I guess probably one dessert is ok.
This raises a question:
Do you eat your fruits with a meal or separately? I recall a nutritionist telling me to try to eat a fruit with protein to slow down the fruit spike. It was 5 pm today, and I was famished. Pre Bolused for 20 minutes and ate half of a banana with a few walnuts (I was much too hungry!!)
My first comment is that you can get away with just about anything, so long as you test often enough to shape the outcome by correcting as needed to steer your BG in a good direction.
Second, I’d like to contrast the old fossil technique I was first taught with what we’re doing now. When I started, it was straightforward: count the carbs, take the corresponding amount of insulin, and evaluate what happened 2 hours later. If it was a good number I passed, if it was a bad number I failed, and count carbs more carefully next time. If I fail twice, just don’t eat that food anymore. Sheesh. Now I weigh and calculate carbs when convenient, and otherwise I just guess. It doesn’t matter, because either way I’ll watch what happens and adjust as needed. If I got the insulin dose way wrong I’ll have more corrections to do and I may wander up into the 200s or fall down to the 60s, but that’s no big deal because I can bring it back into range pretty quickly, especially with the lows. That said, I have made some adjustments to make things easier. For instance, in the old days I would sometimes have 4 slices of pizza. Now I usually have two, and occasionally 3, because it means less effort correcting afterwards.
Or 2, or 3, accepting that to do so may mean more effort to steer the BG later.
Which ever I feel like at the time. It is true that eating a spiky food together with a slower food will moderate the spike, but so will a prebolus or an overbolus, with corrections as needed. For me, it works out ok in any case. Now if I had a rule where I must never have a BG over 170 or something, then I’d have to accept more drastic restrictions on my eating. But I don’t mind sometimes going to the 200s provided I generally can get it right back down into range. Which I can do, using IM and rage boluses as needed.
I’ve tried the IM, 8 mm pen needles, in my deltoid and my calf.
I’ve used 1 unit, 0.5 unit , 1.5 , 2 units- so far, I have not noticed the increase in speed of the effectiveness of insulin. It may be because during these correction scenarios, I have been insulin resistant, and maybe the quantities of insulin have been insufficient, therefore, I wasn’t able to see the effectiveness of the “faster insulin”.
If that happened in my case, I’d try a modestly larger injection next time, and keep increasing bit by bit until there’s a good response. When I resort to an IM injection for myself, typically I’m well into the 200s, still rising at a pretty good rate, and I take anywhere from 6u to 10u — for me 6u would usually drop my BG by 150 mg/dL, but in these circumstances it often won’t. Have you run the test to see how many mg/dL you would drop from 1u of insulin? I’m not asking about your usual dose, but for the actual experiment when you are at a steady BG with no food or exercise or stress or anything, and you see what 1/2 unit IM actually does to your BG.
Some people like to add exercise on top of a big correction to improve insulin sensitivity — I don’t do that, but maybe I should.
We often add a significant temp basal, typically for 1.5 hour. We find that, for us, it very significantly improve insulin sensitivity (way beyond the quantity of additional insulin). But that would not help Lilian who is on MDI right now.
I disagree with your statement. @Kaelan published a thread a couple of years ago that was showing the difference, in BG Graphs, between temp basal and same quantity bolus: huge difference. As I wrote earlier:
What’s the difference between a pump increased temporary basal and an extended bolus then… assuming that they’re delivering the same amount of insulin over the same timeframe?
In my opinion there is no difference at all in what it actually does. An extended bolus with no initial quantity is exactly the same as a temp basal. It is just semantics.
But they are both very different from a regular one-time bolus injection, in our experience with my son. I am not assuming this is true for everyone. But I do know that it is true for some other kids like my son: I have discussed this at length for some other parents of T1Ds in how we deal with night peaks: it appears to be, in combination with mid size boluses, a good working strategy for night-time peaks for teens of both genders, and safer than going with much higher boluses.
My local patisserie is closed temporarily because of COVID. I won’t be able to experiment with cannoli. Instead, I must sacrifice myself experimenting with rainbow cookies. Sigh… The sacrifices that I have to make in the name of diabetes.LOL.
My most recent experiment:
Zero IOB
ate two hardboiled eggs, walnuts, espresso, and two rainbow cookies, bolused 4 units (3.5 units is my best guess bolus for two ). because I did not pre bolus. I know, I know.
2 hour BG =137. For me this is not bad.
Bolusing is a skill and it looks like you really are getting the hang of it. Based on what you are doing and how you are thinking about it, I expect you’ll get this kind of good result more and more often.
Thank you @bkh for the encouraging words. And I want to thank everyone for putting up with my, at times, incoherent posts. Please forgive me if the topics have been covered elsewhere. I don’t think I ever learned to bolus well for “real foods”. For too long, I ate reduced carb and the BG’s were good. I realized that I was missing out on too much enjoyable foods I haven’t been able to repeatedly not-waste-a-good-low by chowing down a few donuts. I have corrected in the past using Dex tabs or smarties.
On a slightly different topic - how important is it to stay hydrated as a 1. diabetic
and
2. if using the Dexcom?
Please, you don’t need to thank us, that is why we exist!!
It is important to stay hydrated if you use Dexcom. Additionally so if you are very skinny. I don’t think diabetic’s have any special corner on it being good for them to stay hydrated.
Hydration is important for our health because we are more prone to kidney problems, and because it flushes out ketones that we make sometimes. The combination of dehydration and ketones in a sick-day scenario is reason to go to the emergency room for IV fluids, because high ketones plus dehydration can cause acute kidney failure.
Good hydration does help with CGM accuracy, according to some of the posts I’ve read here. I think that in my case the difference in hydration between morning and evening accounts for about a 10mg/dL change in the CGM readings, but I’d guess this experience varies a lot for different folks.
I suspect that hydration and dexcom may have been an issue for me. I stayed hydrated, I went to the bathroom often. And still, when I used the Dexcom, I experienced the ???, the drifting, the no data, from compression The transmitter was always nearby. Sensors were not falling off.
. And now I am dealing with the aftermath of BG too high.
). because I did not pre bolus. I know, I know.