Poor BG Management, Running, Switch to Higher Carb Diet

Type 1 & LADA
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I wanted to write a post specifically about my boyfriend EH’s present state as a LADA T1D. Sadly, EH’s current diabetes management is not going well. He’s spiking to 200++ daily, and then crashing after exercise or misgauged boluses. He feels like crap often. He’s not sleeping well, because of bad BG management. So, it’s not working. And the worst of it is, he’s trying to eat right, inject right, and is willing to try new things in his treatment.

Currently, he’s on MDI of Humalog and Toujeo. On @Eric’s suggestion, and our endo nurse who’s also T1, he’s split the Toujeo into two doses, morning and night. He’s using a Dexcom G4 Platinum and we just got Share working.

His current IC ratio is 1:12 and 1u Humalog takes care of about 50 points of correction. He thinks these numbers might be a little off. Last couple A1C’s were around 7 or just below.

He likes to run, but was the type of guy who wouldn’t run for a week or two, and then could go out and do 10 or 12 miles. Which was kinda murder on his BG stats. It’s been revealed to us recently that running every day would be a better bet, so he’s committed to doing this instead (the guy is a champion - fitting in a 6-8 mile run everyday takes some committment).

Historically, we’ve been quite low carb, starting back in January 2012 on the paleo diet, drifting away from that somewhat and now on a paleo-ish diet, we do dairy and corn, very infrequently he does gluten. Total carbs somewhere between 30g and 100g on a day where we cook at home, a little higher if we eat out. High carbs used to equal a BG disaster - big spike, chasing that high all day or night, so we avoided them.

Once we started to better understand the carb requirements for running/exercise, we realized we needed to make some major dietary changes. So, in the last week, we’ve substantially upped the carbohydrates that he’s eaten, and added a serious post-run recovery drink plan. We are shooting for the goals outlined in this post (50% of calculated required carbs w/in 45 minutes of run, bolus for carbs and running, and more carbs for dinner and breakfast):

While this carb increase has made EH feel better during the runs as far as muscle strength and running ability, he’s having a really hard time staying steady during and after the run. So, his muscles appreciate our work, but his diabetes doesn’t.

His observations about exercise and blood sugar: “I feel like I start my exercise around at a BG of 170 or 200 and then within the first hour I consume 60g of carbohydrates and find myself at 100 BG or lower.” The minute he stops running, his BG beings to spike. He does the bolus for the carbs and the run immediately after stopping running, drinks the chocolate milk, and then he crashes or spikes. I want to say it’s unpredictable, but I recognize it is predictable, and I just can’t figure it out.

The Dexcom Share app won’t let me look back further than 24 hours (which I didn’t realize until I sat down to write this) and we haven’t figured out how to get the data off the Dexcom onto a Mac yet. So, I’m missing a critical piece, and I now know I need to figure that part out. And while xDrip seems cool, we have a G4 currently. I’ve been keeping track in a Notes file on my phone, but it’s been suboptimal.

I’ve been helping EH carb count and record a huge pile of data from the last week, but I haven’t been able to make sense of it. Also, it’s put a strain on our relationship (which is fine, we will hold up, but we are both tired of cooking at home and carb counting and eating cold dinners due to my inability to figure out the carbs before I plate the food, and waking up to the call of the CGM, and having to correct all the time).

And, since someone might ask, yes, we change things. All the time. EH travels for work about 60% of the time, so we eat out a ton, we have erratic schedules, he drinks alcohol, and our meals happen at strange times and are often unpredictable.

Yes, I understand, I should tote around 12 PBJ sandos, and a case of OJ, and he can just. eat. that. But he won’t. He lives to eat and drink and run, so we’ve got to sort this out so he can get back to that. :slight_smile:

It is sad to see someone so formerly vital be taken down by the depressing aspects of this disease. I need to help him get back to the unlimited part and not feel like crap all the time! For the record, he was running really high and feeling crummy for two weeks prior to our run-everyday-carbo-load-and-carb-count experiment. So, it’s not the change to the exercise+more carbs that’s the major problem. I think generally, his BG management is out of whack and has been for quite some time.

So, I guess I am asking for some help figuring this out. I’ve read the Daisymae’s Swimming BG Thread, and I’ve read all of the Sports Wiki, and found all invaluable. Honestly learned more here than ten years worth of different endos and books that were too dense for post-work reading.

I believe we are going to get the OmniPod and give that a whirl - next endo appointment is September 11.

If you managed to hang in and read this whole thing, thanks! Being concise isn’t a strong point. And I still feel like I haven’t even asked a question, exactly!

Ah, the question has come to me:

I understand how to calculate amount of carbs required for recovery from exercise. The question is how to bolus for those carbs and also how to maintain steady BG before, during, and after the run? And how do you deal with days you don’t run?

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@TravelingOn, once you figure that piece out, the Clarity app will make a world of difference to you. We use a G5 with an iPhone for a receiver, so we automatically upload our data to the Dexcom servers, which is really convenient.

As a engineer, I tend to decompose problems as much as I can :slight_smile: Is EH able to run clean and in control when he is NOT running? I am asking because sports introduce very significant complexity into the daily balance. For us, puberty hormone peaks and sports are the two hardest things to deal with.

If he is NOT in control without sports, would it possibly make sense for EH to try and balance his day without sports for a couple of weeks, then add sports to the mix?

I know you just added regular sports back into the daily routine, so this may not be what you want to do. For us:

  1. we check our basal balance every few days simply by looking at the later part of the night after a day with a very early dinner. That deals with the basal requirements.

  2. we adjust IC for each meal separately (for us, big difference btw breakfast and everthing else, small diff btw lunch and dinner).

  3. For us, CF is the hardest and the most variable. As a note, EH’s CF appears to me to be very low for someone past honeymoon – I would expect more like 1:20-1:30, although this could well be due to high amount of running.

  4. After all the rest is in balance, we work on the sports sessions. They can cause poor nights with us (lows until 1 or 2 am).

That works for us, but, of course, many have different methods.

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Maybe it would be helpful to do something similar to @daisymae for EH – i.e. do some systematic data recording and tracking experimentally? Perhaps someone who is an expert like @Eric or @Michel or now @daisymae can chime in after each experiment so you can converge on better results over time.

From your description it sounds like his underlying basal and bolus rates may need to be adjusted before you can glean strong suggestions for exercise. EH’s erratic schedule means his basal and bolus needs could vary also, so it will possibly take a longer time to see the pattern, because it will be obscured by more noise.

One thing that might help is to commit to just making 3 days of something he really likes but is repeatable and commit to eating that for just one meal of the day (I’d start with breakfast), then doing some data analysis. BTW, it doesn’t have to be 3-4 days back-to-back, you can alternate days off and on or figure out which days he’ll be waking up at home, for instance. Figure out the carb-count and nutritional information one day in the week (like Sunday) and then just use the same information all week. After that, you can try eating almost the same thing, but maybe with a different carb count or fat content, and then figure out if you have a different pattern later. I agree that eating the same thing all the time is super boring and unsustainable with erratic schedules, so don’t try to make each day identical – just have enough repeatability in the week, and days “on” and “off” the data collection, so you feel like it’s manageable and not too intrusive. This process could take about a month if you’re stepping through it systematically, so it’s helpful to pace yourself and recognize it will take at least that long to converge on a pattern potentially. (@Daisymae’s swimming thread I believe spans 2 or 4 months of data.)

For instance, for us, we would start with breakfast and our control meal is: English muffin with avocado at breakfast. If he has a post-meal rise 2 -3 hours out for several days, we know it’s a trend. Then if I switch it up and give him an English muffin without avocado (same carb count, less fat) or an English muffin with a smear of honey (higher carb count but maybe same amount of calories as English muffin +avocado), I can see if there is still a rise 2-3 hours out, if he goes higher post-meal, or goes low on the tail end. Based on this information I can glean whether the issue is my carbF or the basal, or a late fat spike that will just need another mini-bolus. But if you walk through this, you can see that means basically 12 or 15 meals of the same thing, which translates to about 3 or 4 weeks to nail down a pattern.

Also another recommendation for Dexcom Clarity. It took us about 20 minutes to set up and it provides almost all the information you’d need. I’m a numbers person and am happy to take a look at whatever data you do have if you post it. I think looking aat the numbers will really help with suggestions.

Another option if you’re using finger sticks is mySugr. They have a cheapo version and a paid version. Pretty easy to use.

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While I agree his CF numbers seem a bit low for a Type 1, many people with LADA have a slower progression with their disease, so he might still have some of his own insulin working.

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A pump can be a wonderful addition to the equation, but please plan for 2-3 weeks to get it dialed in. Once dialed in, they are really nice, but the process isn’t what I would call easy. Unless of course, you have been on a pump before, then you won’t have that learning curve.

On the basal front, what happens when EH skips a meal, or delays a meal by 2 hours? That will tell you a lot about his basal needs in that part of the day?

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It’s possible that his numbers are off, I have no idea. But a 50 point correction is not that crazy for an adult. That’s close to my ballpark for a normal correction (not when I am in a hurry and I add more than I actually need to speed it up :slight_smile: ) It just kind of depends on so many things.

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Wouldn’t that mean his carbF is too strong then? Our son’s IC is 1:17 at breakfast, and about 1:24 the rest of the day. At diagnosis he was on a 1:30 carb ratio. Maybe I’m getting the numbers flipped somehow.

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I think they were talking about correction instead of IC.

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we were talking about correction factor, and that ladies and gentlemen is why we either need to use our abbreviations consistently, or write them out, since CarbF and Correction Factor (CF) are really close. Lesson learned.

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Go to Dexcom clarity site. Click on the Dexcom CLARITY for Home Users, and sign in using your Dexcom username/password. That should take you to your Clarity page, with 3-step instructions on how to upload data using your Dexcom G4 receiver and Mac. Once you have Dexcom CLARITY Uploader on your Mac, then all you need to do is plug in the G4 receiver to a USB port on your Mac. The Uploader will then upload the data to the Clarity server, and you will be able to see all past data in various reports.

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But you are nowhere near the normal:-) I think much of what your insulin response is driven by the very high amount of exercise you do.

My son’s CF is also much lower (? Bigger ratio, I am like @TiaG, I am never sure to call them larger or smaller) when he exercises a lot. And there is also what @Chris said.

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I haven’t heard CarbF much. Is that particular to looping or one particular pump?

Some of the pumps use different jargon, so it’s difficult for us to all be on the same page with terminology. Like DM was talking about square bolus, which is “extended” on other pumps.

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Not directly related to your post, but if a low-carb diet was working well for BG control, it is possible to do exercise (or even be an athlete) while following a low-carb diet. I have no experience with this book, but it might be a starting point if you ever do want to combine low-carb and serious exercise.

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@TravelingOn - I switched to Omnipod earlier this year after about 29 years of MDI. The option has been working well for me.

My big push towards a pump was to be able to reduce the basal for exercise and to get the basal rate dialed in for a normal day, which makes setting IC ratios and correction factors much easier. Basal first then other stuff is my mantra. With MDI, either my basal rate was too high or too low. I could never get it just right for the whole day.

As a background - I had most recently been doing Humalog / Levemir MDI. I then went briefly to Humalog on a Pump and now I am using Fiasp in a Pump. (Fiasp is a little bit faster than Novolog).

I am really happy with the Omnipod (although I do have my list of frustrations) because I can now dial back the basal rate before major exercise to stop myself having to continually shove huge amounts carbs in my mouth.

For unplanned exercise (which for me is most exercise), I used to think that I should’t use temp basals, but now have changed my mind. I now take the approach “better late than never”. I will cut back the basal as soon as I know I am going out and just eat carbs to cover the first little bit of exercise.

Here is an example from last night of where adjustable basal helps. I went out for an unplanned run with my kids last night before bed. I was woken around 2am with a CGM alarm and looked back at the trend and saw I was trending down which means to me too much basal. I ate some carbs and set a -20% temp for the rest of my sleep and ended up with a flat line.

image

I am still working on it, but have been comfortable just tweaking basal rates to dial in the line to where I want it. I use certain %‘s for certain scenarios’.

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First of all, wow! And thanks to each of you for your thoughtful replies which are full of good suggestions. I will try to reply here, because that seems to make the forum robot happy.

Dexcom stuff:
@Michel and especially @dm61 thanks so much for the step by step walkthrough of the Dexcom Clarity. We’ve figured out how to download the app, and when EH is home, I will be checking out how that worked. I wanted to make a note of one of the reasons we were so confused about the Dexcom data download for Windows vs. Mac issue - might help someone else. If you’re looking at the linked site on an iPhone, the ONLY file download option is an .exe/Windows file. It doesn’t appear to HAVE a version for the Mac/.dmg file. Turns out, from a computer, there is an option. We tend to do a lot of reading from our phones, and I swear I Googled the heck out of this, and didn’t manage to figure it out until today thanks to you two.

Yes, once we get this data it will be immensely helpful and I will post images. We are working on that now. Not successfully, will call Dexcom this week.

Low Carb/Lifestyle/Exercise
@Michel on the subject of I:C, I agree it could be off. However, one factor is the low carb diet. Once we’ve been eating low carbs the amount of required insulin goes down due to the lack of carbs. I wonder if this could be affecting the I:C ratio overall?

On control outside of exercise, nope. At this point I think we are just having a problem with control all over the map. Mostly because of our experimental running+higher carbs experiment as of the last week. I believe, in reading all of your replies, we are ready to limit variables (diet changes and exercise), and attempt to gather the data about the things mentioned here in a more systematic manner. Hopefully this will lead to improvements in control. Then, we could add running regularly back into the equation. (EH is so happy when he’s running!)

So, I’m hearing that pausing on the exercise might be wise. @Eric, we are still totally interested in your trainer, but were holding off until we’d gotten a better handle on the situation (which, in writing this, might have been a silly decision).

@Jen I’ve tossed that book into the shopping cart, and will give it a read. I’m open to whatever diet options are best for EH. Or at least understanding the options. The lower carb diet seemed to help when we started it years ago, less carbs, less bolus, less correction. Now, I am not so sure. And we were screwing it up way before FUD came into our lives, as far as marathon/half distances and glycogen goes (poor man fell down in the last mile of his first, albeit insanely difficult off trail, marathon. He made it, but it was hard-fought).

@TiaG Excellent suggestion on the rate adjustment before exercise. Will do this. And committing to making the same thing with the tweaks makes a lot of sense (it is not a lifetime of scrambled eggs and green beans, but I’d better come up with something we can live with - toast would make this easier for sure). Thank you so much for being a numbers person. The long, detailed posts are very helpful, and including the examples helps me visualize what we should be doing.

Pump
@Aaron I’m thrilled to hear your OmniPod has been a good switch! Thanks for the data, and nice work on the flatline! I think the pump makes a bit of sense because of the ability to switch off the basal (basically, I know there are nuances from what I’ve read in other threads). And until the OmniPod came out, the tubes were a deal breaker for Eric. I will look forward to referring back to this post when we get the pump hooked up.

And, yes, @Chris, I figured there’d be a warm-up period to figuring the pump out. And on that note, I think @TiaG’s comments on underlying basal and bolus rates needing adjustment, and @Michel’s thoughts in the same directions are so wise. Maybe cutting out the exercise while we get the hang of the pump basal and bolus settings AND ensuring that the Insulin:Carbs and Correction Factor numbers are correct. I don’t want to tempt fate and say it couldn’t be worse than it is right now, but…it’s not going well.

Basal
On the above note, in reply to @Chris I think that delaying a meal or skipping a meal happens daily in our house and doesn’t seem to carry a change in BG with it - we will look more closely in the coming days. The basal dosage is off, and until we correct that, everything will be more out of whack. (Presently on 14u a day split of Toujeo, when running we think it might be much, much less needed).

We are rather irregular eaters (man, this stuff is painful to admit, it’s like failing at adulthood :wink: ). Lately he’s been waking up around 180, because he’s gone low overnight and over corrected (I know the answer! PM basal amount is too much!) We are struggling to figure out how to adjust the AM basal too. The running really changes the numbers, hence the thought that the pump and it’s temporary basal settings might help. Anyhow, wake up around 7:45am, a bolus upon getting up to crush down the dawn effect (he will drift up about 60 he thinks upon waking, and he’s correcting for the 180), caffeinated tea with half and half by 10am. Work for a while. “Breakfast” around 11, 12 or 1pm depending on the work - there doesn’t seem to be a meal missing issue with BG. (Low carbs mean we are not famished nearly as early as on higher carb diet.) Dinner later, 7, 8, 9pm generally. Spike after if we guessed wrong. With running, tend to crash in the evening post run, and with running crashing overnight.

So, that wasn’t exactly about basal, but I think it would be true to say that it’s quite erratic presently. EH notes that he’s not slept through the night without either needing insulin or carbs in the last week or two. So we will work on the basal numbers and get back to you.

Gathering data on…
I think some things have become clear to me by reading your replies and writing my own. A few things we will be working on in coming weeks:

  1. Dexcom Clarity setup, and stats to share
  2. Insulin to Carb ratio via control meals
  3. Correction Factor
  4. Improved basal amounts and results
  5. The OmniPod deployment

Phew. I feel like I ran a marathon. You smart cookies, you. Everyone here needs a blue ribbon. Thanks for your help now, and in advance. Stay tuned for more data to follow!

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You’ve got a lot of factors to consider there, and great advice!

I just thought I’d throw out that I also enjoy running, and it took a lot of testing to figure out how much to eat and when. I can usually avoid exercise lows but is not uncommon to have post-exercise highs. Overall it helps keep my BG down the rest of the day and less insulin needed.

It all got a lot easier for me when I switched to a pump. Now I can reduce my basal before running and depending on how long often I’ll just disconnect and I don’t need to eat so much while running to avoid lows. The basal from the pump also did a better job of keeping my BG smooth compared to when I was on Lantus. If you’re dealing with dawn phenomenon you could program an increased basal for that.

Did you already commit to an Omnipod? I know most podders really love it. I had my heart set on one, but when I demo’d it the bulk kind of turned me off. I’m on a minimed now and the tubing does not bother me nearly as much as I thought it might and the infusion site is basically flat so I can sit or sleep on it without getting annoyed. I use a flipbelt when running and there is no bouncing or anything.

The new t:slim x2 also has dexcom 5 integration which might be attractive for dexcom folks, one less device to carry around :slight_smile:

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Not to mention that it will be upgradeable to the insulin suspend feature when they get that through the FDA.

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