…and i haven’t changed anything!
20u of Tresiba
3-5u per meal of Novorapid, and plenty of correcting (clearly i overrcorrect, but i can’t see how not to, otherwise i languish at 20)
I gave up carb counting 10yrs ago as found it never worked, and just went by feel.
I averaged around 6.5mmol/u per day and A1c at 6-6.5ish.
Now i’m up to daily average of 8.
I run a lot, and am very lean, so i need a lot of calories…so i’m high fat and relatively high carb, too. yet my body seems not to deal with fat well (my stools float, suggesting all my fat goes straight through me) and the carb just makes my BG go wild.
i have no idea what to do.
just here for thoughts/ideas…there’s no panacea.
…and i haven’t changed anything!
It helps to know IOB; bolusing with a high IOB (corresponding to the rapidly descending BG) will often cause problems. The xDrip+ predictions can help if you are doing MDI but if you are using a pump it should report IOB and correct for it on a bolus. I’m guessing you are using MDI and that makes things much more difficult because we have to do our own insulin models. This is why there is this thing about “stacking”, which you are doing because some of your boluses are close (30 minutes to 2 hours). Pumps do handle this, sort-of, with the IOB calculation.
You could install one of the loop programs like AndroidAPS and use it in “open loop” mode where it makes suggestions about what to do; this works with both MDI and with a pump.
My bolus estimates are pretty much by feel too; if it’s a big meal I do 4IU, if it’s a moderate one 2IU but lower I don’t do anything and rely on corrections. For a while now I’ve been using a hybrid closed loop which automatically handles the corrections and I’m trying to do full closed loop (no carb boluses at all). That was working sort-of ok; a range of 4-11 maybe 95% of the time and peaks limited to about 3-14. I swapped from that to doing one bolus a day with my main meal (the only one that goes over 10g). Peaks have been manageable despite the fact that I wasn’t using the algorithm that I though I was (AndroidAPS problem…)
I agree with @jbowler that a pump and a DIY Loop app would help get better control. One has more control over insulin dosage for running when using a pump. You can actually reduce or stop basal in preparation for a run which should reduce hypos. This was one of the reasons I switched from MDI to OmniPod pump, and eventually, 4+ years ago to DIY Loop.
It looks like your last dosage was around 10:30 pm then about hours later your BG climbed straight up then straight down a few hours later. The delayed up and down could be the result of high fat. I know when I eat high fat, say nuts, at night as a snack, I will often have a similar reaction, but not as pronounced as what you are seeing, presumably because Loop autocorrects while I sleep.
Im not sure about the other two spikes that you see. They appear to occur around post meal times. Do you pre bolus? I usually need to pre bolus at least some insulin if not for the full estimated carbs. I also just estimate my carbs, and then monitor my BGs to see if corrections are needed, and they usually are needed.
How long have you been on 20 units of Tresiba? It might be that your basal needs have increased.
You can try slowly increasing your Tresiba to see if that makes a difference.
Why does fat content do that?
I believe it is due to fat slowing down the metabolism. If one has not taken insulin to compensate for the fat, then there will be a rise in BGs. At least for me, I’ve noticed high fat food such as nuts, effecting my BGs 5+ hours after they were consumed, in the middle of the night. Here is an example from last night after having 2 fist fulls of nuts, and the resulting BG rise overnight… To me, it is similar to the OP’s graph of his overnight spike. Had I not had the nuts, I would not have had the steady BG rise to 140mg/DL.
I agree with Eric try increasing by 1 or max 2 units see how that goes for a week. Slow and easy is best. You may need to adjust your bolus carb: unit ratio. These things work together.
This is just me, we can all vary with what works. And remembering that our systems can decide to change at any time. Gee, things can change weekly sometimes.
I find it’s a lot easier to stop going high than to try to correct it after the fact. But maybe some of your meal bolus a little earlier before you eat. My standard meal was 50% 30 minutes before and the rest when I ate, that way I could second dose more to what I actually ate. And timing can be key to stopping high rises. Right now I am mostly doing 65% 30 minutes earlier as I am still dealing with being a little resistant from a steroid shot over a month ago. I’m going to have to adjust some back again as I’m starting to go a little low before I end up eating now. But some it might work to do 25% 15 minutes earlier. And once I notice I am going above an 7.8 (140) I commonly get on my exercise bike to stall the rise until my insulin can kick in. That works really well, it’s like nitro to my insulin. But a high carb normal fat meal is a different prebolus than one that has higher fat. A higher fat meal and I can just take all my insulin when I eat. And we all can vary so you have to find what works for you.
But the other thing is if you changed what you are eating. I can tell the difference from a high fat meal for 24 hours after I eat it. Fat delays the absorption of carbs, fat also makes you more insulin resistant. I also have to add extra units for protein if I eat a high protein and a low carb meal. Try fasting for a day and see how much better insulin works, or try high carbs with very low fat for a day and you can usually tell the difference for 24 hours.
Thos orthopedist will insist that a steroid injection in a joint capsule will not affect blood glucose levels. Yeah, right.
Curious to know if your stool is also light or even yellow in color in addition to the floating. I wondering because this could be a sign of poor bile flow. Bile production is a necessary component of toxin drainage. If it’s inadequate, you might be looking at an overburdened liver which could be a contributing factor for the instability you’re seeing?
Thank you, that’s very interesting- yes, i do observe that, and have for years. I think malabsorption of fat via insufficient bile is a likely situation, particularly as i have recently lost appetite, sometimes feel nausea, and sometimes have itchy skin, which appear to be other symptoms. What causes this poor bile flow, and how can it be remedied? And through what process does it result in BG volatility?
To be honest, I’m not sure what pathway leads to inadequate production. I imagine it’s a signaling issue. But, I will report back with that information, plus a suggestion for restoring function. My daughter is experiencing the same thing currently, minus the instability and I have this exact question in for a Q&A call with my quantum biology instructor this coming Tuesday. I know that she typically recommends bitters to stimulate bile production, but I don’t know which ones or in what dosage. My thought is that if one is experiencing a heavy toxin burden because that drainage pathway is not open, you’d see an increase in inflammatory markers, mitochondria dysfunction and overactive histamine response.
Thank you for coming back. I of course agree…but when i’m up at 20 (360), and seemingly not coming down, despite having 2/3 units of IOB, i’m not sure what else i should do, other than just hang around at 20?(!) i feel i have to get it down, and there’s not much else i can do, when just waiting it out seems to be an awful alternative.
correct. having the Libre sensor in my arm is already about as much irritation i can bear in the shower/putting on/taking off tshirts/banging my arm on doorjams etc., so the idea of pump (among other things) i find quite repelling.
Despite nearly 20yrs of being T1DM, i have never understood what a loop (or closed loop) program/system is, nor had it explained to me or suggested to me by any of my healthcare providers. In a nutshell, what is it, and how powerful is it?
Glad to hear that’s working for you. Generally my peaks have been manageable on my own MDI ‘system’, but recently (the last 10days or so) instead of jumping to 10/12 post-eating, i’m jumping up to 18/20 (or even higher) after every meal and into the every night, which is clearly totally unmanageable. high fat/low carb or low fat/high carb - seems to make no difference.
i’m just baffled and increasingly frustrated as i haven’t changed anything…!
See my readings from last night. I was woken up four times, and each time i tried to inject less than i normally would (for such an incredibly high reading), to avoid stacking and crashing. but as a result, i just ended up being super-high the whole night, and kept getting woken up… so that’s no good either.
Thank you @Trying, you are always extremely helpful - we haven’t spoken for a couple of years now (not sure you remember me? we were trying to get Libre2 to work with xDrip+, and frustrating ourselves, although i recall you being one of the most helpful people i had ever spoken to…!)
A pump is just antithetical to me. I honestly don’t know how you do it, the Libre patch is more than enough things attached to me, although perhaps that is partly my (minor) autism. i have no real understanding of what loops are and how they can help me on MDIs, but i should look into this…
Correct. Some years ago, i switched to a higher fat/lower carb diet, in an attempt to assuage such BG excursions, but ultimately nothing changed, i suspect due to fat blocking the insulin receptors and hence driving insulin resistance. but if i have a high carb/low fat diet (which i find far less palatable), i shoot up for sure… so i feel while i can’t win, i might as well go for the more appetizing/wholesome diet.
Currently, i’m going high every night, and i’m having to bolus 2-4u on going to sleep, hours after eating anything, which feels pretty reckless to me… but yet i’m still going high.
i tried upping my basal from 18 to 20u, perhaps that needs to go higher still.
but my current pattern, which repeats most days currently is:-
go to sleep at an ok level
get waken approaching 12-15 - bolus c. 2u
get waken again approaching 20 - bolus c. 2u
get through to morning but then hypo at 6am, often down as low as 2.0
fix my hypo, where my sugars seem to take a very long time to enter my blood…i end up overcorrecting, and then i shoot back up to 15-20.
and then i’m battling a yoyo all day until bedtime.
i’ve just no idea how to break this! i know others have said that your former BG levels have nothing to do with your current levels, but i just can’t believe that. my BG behaviour gets caught in a loop… if i’ve messed up and go high, the probability of it happening again within 12-24hrs is 5x the probability of it happening otherwise, and same with hypos. a rollercoaster seems to predict a further rollercoster, whereas a period of calm tends to predict further calm… until i make a mistake.
others have (quite robustly) argued this is utter nonsense, but it is categorically what i observe…which is a little dangerous as it makes me ‘personify’ my BG levels, and hence get angry and personal with them, cursing loudly whenever my xDrip alarm beeps. i find i need a way to dehumanize it, but i’ve become so frustrated over what i would currently categorize almost zero control, i find it extremely difficult not to get personally very frustrated and angry with it…!
Thanks for coming back, @Eric.
A couple of weeks, i was formerly on 18u.
The problem with upping it is i tend to go low on waking…but only after bolusing throughout the night to correct for these outrageous highs i’m suffering from.
I guess i should try a basal test but i find fasting the whole day so difficult, especially when working in a high pressure job and trying to do 30-60 mins of physical exercise each day.
You think yoyoing is generally suggestive of having a basal dosage too low?
It’s difficult to know which is the bigger evil for a T1 diabetic… too much fat or too much carb. Fat is where all the flavour is (i tried switching my full fat yoghurt for 0% Skyr last week, and found it almost inedible).
After a recent monitoring exercsise, i found my percentage of calories from macronutrients to be: 47% fat, 37% from carb and 16% from protein.
i’m slim and don’t want to get any slimmer, despite doing quite a bit of running, so tend to find fat a useful contributor of daily calories… now whether i can actually absorb/metabolize that fat is another matter!
Basically these are insulin pumps combined with CGM sensors that have some degree of automated insulin delivery in response to CGM data. The term closed loop is often used as a synonym for artificial pancreas, but what constitutes an artificial pancreas is debatable of course. Hybrid closed loop indicates less automation and thus require the user to do more work, whereas closed loop systems work mostly autonomously and often allow very little user input.
I agree strongly with this.
For some reason, i find this very difficult. I tried it last night, when going out for dinner… i bolussed 4u (was c. 10 at the time, and envisaged a carby dinner) 30mins before expected eating, only to arrive at the pub and be told they’d run out of food…after much faffing around, we sat down late and before my dinner arrived, i’d crashed to 2.5.
I am of the opinion that pre-bolussing is generally very risky. Even at cooking/eating at home… you just don’t know what’s going to happen and even if 99 times out of 100, you get to eat when planned, 1 time out of 100, you’re going to have a mighty big hypo. why would you want that?
i guess you’ll argue without pre-bollusing, you go high 100% of the time… so which do you rather? seems the occasional hypo, but still, something doesn’t sit too well with me conceptually.
i like the idea of this (and agree physical exercise is quicker acting than rapid insulin!), but not sure how this (or anything like it) is possible when working in an office, or just generally trying to lead anything approaching a normal life.
Interesting. Chimes with @Trying’s comments that high fat will result in much later spikes. i tend to find i go high immediately, whatever i eat… and then (at least at the moment in my current, unmanagable regime), i go higher hours later, too. It’s as if i have two post-prandial spikes, one immediatlely and one 3-5hrs later.
The first part sounds great, the second part sounds awful.
Is fat good or bad for a diabetic? i’m hearing it’s dreadful, but surely it’s better than carbs?
If i switched my 47%/16%/37% (fat/prot/carb) diet to be higher carbs, i’m convinced i’d be having even bigger spikes. but perhaps i’m wrong and should try it. it feels reckless.
Thanks very much for this @Eaden.
I have procured some Ox bile tablets and having been using them for 4-5d, seem to be absorbing fat a little better. But no change in my BG management, i’m still pretty much out of control currently, hitting 20 frequently (which i never used to).
The idea is this. You have a CGM, a suitable insulin pump, and a computer program. The program listens to the CGM numbers as they come in, and if it sees the BG rising it tells the pump to give a little bit more insulin, and if it sees the BG falling it tells the pump to give less, or even stop giving insulin entirely for a while. The diy LOOP program runs on an iPhone. The t:slim loop program runs on the t:slim pump. The Omnipod 5 program runs on the Omnipod 5 pump.
When the system is properly adjusted (i.e., it knows the right basal and insulin to carb ratio and insulin sensitivity for treating lows) it tends to greatly reduce the amount of manual work we have to do to keep a good BG. Especially overnight it can give pretty close to a flat BG line at a good level. The program is looking every 5 minutes and adjusting insulin as needed. So far they don’t seem to be able to completely replace our work, but they do seem to take away some of the drudgery.
I agree with you on this. If my BG is too high and I don’t have confidence that it is heading back down, I’ll take more insulin, every 20 or 30 minutes, until I get a response. I’m prepared with a good supply of glucose tablets at hand, and I expect that I will have to watch the CGM and take some glucose later to catch the falling BG before going low.
If your BG is too high you need more insulin. If I were having your experience, I would change my insulin to carb ratio to give a bit more meal bolus insulin. I’d watch for a couple days, and adjust again, bit by bit, until it was enough.
You describe the pattern of going high overnight, waking repeatedly to take insulin corrections, and then waking up low. That’s what got me to start pumping after 8 years of MDI. It turned out that my body needed around 1u per hour overnight, but only around 0.15u per hour in the morning. There’s no practical way to get that with something like Lantus or Tresiba, but the pump can easily handle it.
Are you using pure glucose with water? That’s usually pretty fast, like a response starts within 15 minutes, and a good response is well underway within a half hour. More complex foods are much slower for me.