question

[henry2002]

I have really low basal rates and my diabetes educator said they were too low (40%basal 60%bolus) and she wanted me to increase my basals and reduce my boluses so I made the changes to my pump and the results were my blood sugar was high (11-13) 2 hours after meals and it was too low (2.3-3) before the next meal. This was not pleasant and no matter what I seemed to do these results persisted so I changed back to my old basal and bolus settings and my blood sugars are much better controlled with only occassional lows and highs. My basals are around 40% and boluses 60% as before but do fluctuate slightly from day to day depending on what I eat. If I plan exercise I reduce my bolus with my meal and exercise shortly after that meal because if I do a temp basal it will further reduce the percentage of basal which I'm sure my DE will not like. Does anyone have any suggestions for me, do you think my basals are too low? These settings seem to be working so I'm thinking if it works, keep it. I am slim and fairly active. How does this affect things, anyone know? Suggestions, comments appreciated.

[Mindstorm]

What works for you and keeps your sugars best in line is the way to go.

Your diabetes educator made a bad call based on prejudgments and expectations about what's "right" for a diabetic to have as far as daily insulin intake goes.

I have low basals (lower than yours, percentage-wise) because I eat a decent number of carbohydrates each day because otherwise I feel like I'm starving to death (having a high metabolism is kinda awesome but can also kinda suck). I keep knocking out good A1C results so they don't give me a hard time about it, and that's more or less how your diabetes educator needs to handle your case.

Also, I'm slim and used to be fairly active (sort of on a hiatus from "doing things" right now, lol) and as a carryover from that I have low basal rates and respond well to insulin (i.e. low resistance). If you're slim and active you're doing what doctors want you to do to keep your health in line and to keep your diabetes complications low or nonexistent. As a result of being slim and active you respond well to insulin and can afford low basal rates!

As for how to "break the news" to your educator, simply inform them that their settings did not work and left you high after meals and low before meals, whereas your previous settings worked well and there was nothing wrong with them. My diabetes educators have pulled this on me once or twice as far as misinterpreting my blood sugar numbers (easy to do when your schedule sucks and your testing isn't perfectly consistent) and telling me to change some settings around. After some ridiculous highs and lows I change them back and everybody's happy. :)

[shiftzor]

Ah seems to me like your Diabetic Educator has been reading that book again :D. If only it was that simple however if you wish to persuade her otherwise you could basal test. I would definitely recommend basal testing as it proves that the basals you have set work. Basal testing involving fasting and avoiding anything that could affect your blood sugar level such as sport for an 8 hour period testing every hour to two hours depending on how comfortable you are with your basals. Splitting the day up into chunks such as morning to lunchtime, lunchtime to afternoon and afternoon to just before bed. Watching for trends and adjusting, then retesting ensure that your basal rates are perfect.

The books do suggest that a 50:50 split works best however I believe it really depends on how accurate your carb counting is and how active you are. If you are really activity you may need large quantities of carbs to maintain weight and to help your body recover which could mean your bolus doses where much higher than basals. This week it's been my birthday I have been doing 65% Bolus and 34% Basal, I know that I haven't basal tested enough but my BG is slowly getting more stable as long as I keep tweaking. My point is do what works for you as its your body and you spend the most time with it.

[jenb]

I'm the opposite. I use 60% basal and 40% bolus since I eat about 1100 calories and under 60 grams of carb a day. You need to do what's right for your lifestyle. If the 50/50 basal/bolus "rule" doesn't work, don't do it. You're the captain of your ship!

Jen

[xMenace]

Smack your DE in the shins with a hockey stick, and take that ****ing book away from her!

Basals cover basals. Totally disregard food. Your basal needs are pretty much static: they don't easily change. Aging, weight changes, and maybe diet changes might affect them. Activity level and seasonal changes are more likely to. In my personal experience. I've been taking 24u a day for the last 14 years. I've tested them extensively too. That's as little as 25% TDD on previous diets and is 44% of my TDD with my current diet.

Basal test: http://www.diabetesforums.com/forum/pumping-insulin/28110-how-do-basal-testing.html#post330495 This is the only way to determine your real needs. Basically you skip a meal and test. Your basal insulin should keep you flat.

[DeusXM]

If it ain't broke, don't fix it.

Generally there's an idea that it's supposed to be about 50/50 but it totally depends on so many factors it's ridiculous to try and apply a rule to everyone.

Basically you skip a meal and test. Your basal insulin should keep you flat.

Does this really work? I've found that in my experience, fasting seriously distorts my BG readings and causes my liver to dump spectacularly.

[Subby]

Does this really work? I've found that in my experience, fasting seriously distorts my BG readings and causes my liver to dump spectacularly.

I find that basal testing helps a great deal for modifying basal settings on the pump. Unfortunately my basal requirements do shift around a bit (similar overall amounts, variations on a theme on hourly trends) and basal testing is the way to go. For example, my basal needs "crash" to 1/2 in the afternoon, and it can shift a few hours this way or that over the weeks, or the peaks and troughs can change.

You need to first clear 4 hours to start getting useful data, but after that the amount of time you fast is entirely up to you. I usually just go for another 4 hours myself. There's no rush, you can take your time.

I don't find, and I find it highly doubtful, the human body can't generally go for 6 or 8 hours without needing food or causing huge liver dumps. Yes, it can happen at some times and one would need to be cognizant of trends - something that basal testing is designed to provide constant feedback for. "Fasting" is rather a strong word to use for the process of short term basal testing.

[foxl]

Smack your DE in the shins with a hockey stick, and take that ****ing book away from her!


I am reading one of those ****ing books written for clinicians right now, and as someone working in a medical library, I heartily concur. The quality of information provided to medical professionals absolutely sucks. I have gone from being resentful of my missed diagnosis, to feeling sorry for even the Endo who presumed me to be straight Type 2 ... :banghead:

But, what else can a fresh outta school professional with minimal experience DO, but rely on the literature? Disgusting. Too bad there are no malpractice suits against authors ... ?

[henry2002]

Thanks everyone for your replies. I have done basal testing and have had to make a few changes as a result--to decrease basals not increase them. I plan on doing more testing again this week to confirm my current settings and I'll be taking my test results with me the next time I see my DE. My basals may need some minor tweaking but nothing major, I know I'm close to where I should be. I've also been monitoring how exercise affects me so I can change my I:C ratios before long periods of activity such biking or skiing. I'm quite sensitive to insulin,1 u lowers my bld sugar 6.5 mmol, so to me it makes sense that my basals are low. I'm going to stick to my guns and do what works for me. See my endo next week and I think he'll agree with me, he takes the approach "if ain't broke don't fix it"
Once again many thanks to all of you.
Henry

[KCP]

Stick to your guns!

I am reminded of something one endo said to me once: I dont care what your numbers are. If you are giving 10 units and it works then do it. If you are giving 2 units and works, then do it. Just stick to whatever works.

This was when i was scared to use too much basal and was having highs.. He wanted me to up my use..

[Gordonm]

I'm just the oppisite also. 60% basal and 40% bolus on most days. I do eat around 180Gs of carbs but this works. My endo always tells me I should be closer to 50/50 but he has given up on enforcing it due to my good numbers. I tell him this works for me and I'm keeping it this way.

I love these dieticians and such that tell you what you should be. Do they live with you 24/7. They have no idea what you and your body are doing. Do what works and keep at it.

[Ray4Rick]

Can someone explain to me what 60% basal and 40% bolus means? I've never heard those terms (basal & bolus).

thanks

[Mindstorm]

Basically, these are terms we use primarily when referring to pumping insulin. When I was on MDI I didn't hear these terms, but I got a crash course in them once I got my Cozmo 5 years back.

Your basal insulin is your steady supply of insulin that's necessary for you to survive. Anywhere from 0.4-3 U/hr may be typical for most diabetics, and insulin pumps will take your hourly rate and inject a bit of insulin every few/several minutes so you have a steady supply of insulin to reduce peaks in your blood sugar. If you're on MDI, this is your levemir, your NPH, etc your slow-acting insulin.

Your bolus insulin is what you'd consider your insulin for your food or to correct a high blood sugar. It's basically a rapid injection of insulin (usually injected in a minute or less by an insulin pump) used to cover carbohydrates consumed during a meal or to correct a high blood sugar based on a known/assumed correction ratio (i.e. you inject 1 unit for every 30 mg/dl that your blood sugar is above the target level). If you're on MDI this is probably your fast acting insulin that you inject with your slow acting insulin (or independently) around meal time.

The percentage in front of the basal/bolus amount (i.e. 40% basal & 60% bolus) is just how much of your total insulin injected goes towards either basal rates or bolus injections. The ratio can indicate how many carbs a person eats in their diet and how responsive they are to insulin, among other things. The 50/50 rule is just a lousy rule of thumb that gives you an extremely rough target of how to set your basal insulin rates and how to set your insulin:carb (I:C) ratio and correction ratio (i.e. 1 unit for "X" mg/dl) for bolus insulin.

[zoelula]

Many of us on MDI are on basal/bolus regimens as well as it is considered the standard of care for insulin usage. Some people may start with just one but not the other, but then progress to both. The idea is to mimic what the pancreas of a person without diabetes does normally: a slow steady stream of background insulin all the time (basal) and then spurts to manage the carbs from meals (bolus).

[Ray4Rick]

Thank you Mindstorm for the explanation. I guess I will be learning these terms fairly quickly because I have just ordered my 1st pump. I should get it next week.