I have heard the argument that you should only have one single 24 hour basal rate on your pump. People like Stephen Ponder, the sugar surfing author, have said that. Sorry Stephen, won’t even waste time with that idea.
I also hear comments from people saying their endo has told them they have too many basal rates on their pump. That they only need a few rates for 24 hours.
Okay sure, maybe too many rates makes it harder to track down things, or identify things or make the correct adjustments.
However I wanted to give a quick rational for why I have 8-12 rates on my pump depending on the circumstances.
I need more insulin around 4am. Nothing from Ponder will change that fact.
But why do I have several different rates leading up to 4am? Do I actually have different basal requirements at 2am compared to 12am? Probably not.
So why do this?
Quite simply, if I waited until 4am to bump up my rates, it would be too late! Basal rates are such a small amount to counter a rise in BG. So the ramp-up that begins at 2am for something I don’t really need until 4am is a preemptive measure.
The alternatives would be to jack it way up at 4am, which would probably still be too late. Or just have a spike at 4am.
I agree as well. However, recently, when I wanted to work on a second Profile for Control IQ, I brought all but my nighttime basals, which were right on, to the same level, then adjusted as per need for daytime rates. Made things simpler. I ended up again with about 12 different ones for the 24 hours.
I see nothing wrong with having multiple steps rather than a single abrupt large change. That said, I tend to use one intermediate step rather than the two you show, just for diagnostic simplicity: with fewer steps that last longer before the next change, I can more easily see in the CGM graph whether any particular step needs adjusting in height or in start time. I do agree that it is important to start a basal change a good amount of time before it is needed, like 1.5 or 2 hours before.
Liam’s basal rates are a result of careful observation and identification of patterns during specific times. No human body is the same so to believe a cookie cutter approach will accommodate everyone, i believe, is foolish. We have about 10 rates at present and as i continue tweaking over time these grow or shrink based off of my observations.
Hi @Eric, I agree with you and I also have a few different basal rates especially over night. I will say for me, during the day and until bedtime my basil rate doesn’t really change. In my mind there are way too many variables from day to day activities for me to try to nail down a specific basil rate for the various things going on in my life. Some days maybe my basil is a little to low(sitting on my ass, stress, what I ate at lunch, etc…) and some days too high(yard work, a lot of errands, what I didn’t eat at lunch). I just adjust as needed( some carbs, a small correction bolus, etc.) For me just having a set basil during the day, just makes the math easier. If I had 5 different basils during the day going on, I think I would struggle. I have heard people say, for me, they have a crazy number of basil rates. I think I would struggle with that. I like a baseline basil and just adjust as needed(during the day).
I think if basal needs change throughout the day/night then absolutely, use multiple basals. For me, I have just one basal which largely works for me. And if it looks like I’m going awry, I take corrections (or Loop does), but that only works while awake! And yes, exercise is totally different, I definitely adjust the basal for exercise, usually to zero for a period of time.
With you all the way. I must have a good endo, she also is all in on multiple basal rates. In fact when I started on pumping she looked at my CGM data and came up with multiple daily basal adjustments.Right now I use 6 rates, varying from a low of 0.6/hr to a high of 0.95/hr.
If I am noticing that something is off and I need to adjust my basal rates I am more inclined to use a temp basal than to tweak my preset basal program. When I find myself using temp basals several times daily it’s time to dive into the numbers and adjust the preset daily basal routine.
To be honest, I don’t think Ponder’s ideas are that crazy. We shouldn’t dismiss them out of hand. By his own admission, the idea of reducing basal rates would have challenged him a few years ago too.
To be fair, he doesn’t say everyone should have only one basal rate, he says you might not truly need more than one or two. (Personally, I usually have about 5 or 6).
Ponder: I prefer to ask the pumper the following question: if your BG trendline maintains stability in the absence of any known influences which would deviate it significantly up or down (30 mg/dL or ~ 2 mmol/L) then I feel your basal settings (however many you use), probably work for you. But I’m not just talking about every now and then, I mean consistently keep you steady.
Let’s face it, we here on FUD are a rare species in an endo’s office. Generally we know what we’re doing and our level of control is pretty exceptional. Most patients endos and CDEs see have much worse control than we do, despite their myriad of basal rates and their steadfast belief their body really needs all those basal rates.
In Ponder’s own words: It’s not uncommon that I encounter pump using PWD’s and CWD’s wearing insulin pumps with up to a dozen basal rates, sometimes more. At the same time, I note their overall control may still be struggling (based on high A1C results).
Ponder furthermore asserts that many of them have fallen into some kind of cognitive trap and I think that’s right (even we might not be immune to it). I suspect they don’t know what they’re doing. Too many people don’t realize that basal rates are just a bunch of mini-boluses with varying sizes and frequencies. Neither do they realize that insulin plasma concentration and activity don’t instantly follow the basal rate. Tweaking one basal rate has consequences for the next few hours. If people are not aware of that, things can easily spin out of control. So people keep adding and tweaking basal rates and it ruins their basal rates down the line. They adjust those rates, it ruins the next few… and repeat. I can see how this might go wrong with many patients. They end up constructing overly complicated and perpetually collapsing systems of basal rates while erroneously thinking that’s what their body needs, but their perception is wrong.
Endos should be skeptical when patients come in with a large number of basal rates and mediocre control. They should try to remove all the redundancy from the system and find the minimal number of basal rates required to achieve good control. When e.g. a patient comes in with 24 alternating basal rates of 1 U/hr and 3 U/hr, an endo should point out that one average basal rate would probably accomplish more or less the same thing. He should challenge the patient’s firm belief to the contrary.
Now please don’t take this as some kind of attack on or criticism of anyone’s diabetes management in particular. I don’t know what methods you use. I can’t judge how well they work for you. They may be unconventional. They may achieve better results than me. Good luck to everyone.
I think this is the . If you have a lot of basal rates and you still have BG control issues then i agree with Ponder.
I have, in the past, completely wiped everything when this happened because i i had to many variables and figuring out the problem would be next to impossible. So i go slowly and begin fresh with minimal basal rates, I:Cs etc.
If the control isn’t there with many basal rates then i agree you have to many rates and probably too many of three other settings as well.
My thoughts are that multiple and elaborate basal rates are beneficial to a tiny fraction of patients but that a large majority of patients believe that benefit applies to them… I believe they’ll to a large extent disregard evidence to that effect because there is a very powerful human psyche element that the more control you have the more effective your efforts will be, but In my personal experience this hasn’t proven true, and in my opinion the objective analysis of evidence doesn’t really bear it out either in most cases on this subject
And I think we should watch out for the tendency to “permanently” adjust a basal rate when a temp basal adjustment would have been more prudent. Example, I was working on a house renovation and going low every afternoon, so I lowered my basal for after lunch and all was good. Until my afternoon routine changed to less strenuous and suddenly I was high every afternoon. A temp basal every afternoon I worked would have been better (for me) than a global change…to avoid having to change my basal program back to where I started when my afternoon routine changed.
Why not jack it up at 2 a.m. (or whatever your lead time needs to be)? What’s your rationale for the gradual ramp-up, rather than just one step up? Or is it such a big jump that it risks driving you low before your natural rise?
It is akin to a pre-bolus for a meal. If I waited, I would need a much higher amount later.
Yes, I could probably do it with a single huge rate later. But ramping it up sooner covers a little wider time-gap too. Like if the rise is a little later or earlier, depending on when I go to bed and things like that.
I don’t know how my body knows it is 4am. I assume it has to to with how long I’ve been asleep, or sleep patterns or something like that.
Our bodies do not have the luxury of “instant insulin” like the non-D’s. But we have a clearer understanding of BG patterns. We study that and know how it works. So us D’s can take our slow insulin and be more proactive or preemptive with our “pancreas’s”.
Another note - I do this because I have a fairly consistent pattern. Since it always happens fairly close to the 4am time (3:30am, 4am, 4:30am, etc), I can be proactive with it. If it was random, I certainly could not do it like that.
I also have many different basal settings on my pump and I find that the most of them are for my overnight, and that during the day I stay relatively flat. After many years of studying patterns, I have found settings that work rather well for me, despite having to tweak them from time to time. I also love the ability to use TBs. They are very helpful for all sorts of reasons: exercise, sick days, stress days, bad nights sleep…
currently, I have 10 different setting on my pump. They range from a surprisingly wide setting: .40 U/H to .95 U/H My greatest need for insulin is at midnight, while just 2 hours later, I barely need any insulin. Then, at around 8am I need a large amount again. Yet, throughout the day, I need only one setting of .525 U/H and then after 7pm I need .6 U/H. Go figure.
But when I began on a pump, I only had 2 settings. of course this was due to my idiot endo who did not educate me on anything like A1cs, or target ranges, etc. My A1cs were over 10% during this period with him. Once I changed endos and learned about my pump and all I could do with it, my life changed as much as my basal did Now my latest A1c is 5% and I have, as previously stated, 10 basal settings on my pump. D life is MUCH more manageable. AND HEALTHY!!!
I usually have about 8 different rates and 6 of those are between 12 midnight and 12 noon.
I have the lowest need for the first 4 hours of sleep, then I have DP, then I am “normal” then I have 2 fotf increases and then back to “normal”. And this can change.
My pump is for my purposes, not an endo’s. But keeping the different ones allows me to not wake up at 200 or to climb to 150 in the morning when I haven’t even eaten. (I also have 4 different basal programs I keep in my pump).
@Eric, I am currently using 8 basal rates. I am in the 70-170 range 90% of the time. If I used a 70-150 range, I would not be so successful. Maybe I should crack down and work hard to have 90% in the 70-150 range, like several friends on Facebook do. But I am satisfied with my current numbers. With no serious complications after 75 years of T1D, I don’t feel I need to make any changes in my diabetes management.
I have messaged Stephen Ponder many times on Facebook. He is a pediatric endocrinologist, and he has many followers who follow his routine as described in his book “Sugar Surfing”. I have not bought is book. I don’t think I need it. My routine ain’t broke, so I don’t need to fix it. lol