High BG on Pump

[bigpurpleduck]

I've now been on an insulin pump for 3 months. To begin with I noticed an improvement, but now am struggling to retain control.

My HbA1C was 8.3% on injections (I have an appointment next week to see if there's been any improvement on the pump). Every time I ate, no matter how much insulin I injected, my blood glucose shot up to 20mmol or more, and then returned to earth with a bump, often causing severe hypos.

Initially, the pump seemed to stop this. However, I am now experiencing a similar reaction, although not quite as extreme. Most of the time, I eat and bolus and my BG is 13/14mmol 2 hours later, then 2 hours after that returns to 7 or 8.

2 hours after every evening meal, my BG has shot to 19, and correcting has only brought me back down to 11/12.

Any advice? Has anyone else had difficulty gaining tight control on the pump? Spoke to my nurse yesterday and was left with the feeling that it's just me!

[dbaratta]

2 hours after every evening meal, my BG has shot to 19, and correcting has only brought me back down to 11/12.

Any advice? Has anyone else had difficulty gaining tight control on the pump? Spoke to my nurse yesterday and was left with the feeling that it's just me![/QUOTE]

UGH,,,,I was just going to ask how people liked the pump, I am thinking of getting one and not sure what to expect. Your experience doesn't sound too good.....but I highly doubt that you are the only one. My doc told me I was the only one he ever heard of a BG raising after exercise. :eek:

[fgummett]

I'd suggest you first need to look to basal testing.

You might also read up on Dr Bernstein's Law of Small Numbers.

[jer.lawrence]

What are your meals like? Or is that completely irrelevant and you just shoot up no matter what you eat?

[SueM]

I've now been on an insulin pump for 3 months. To begin with I noticed an improvement, but now am struggling to retain control.

My HbA1C was 8.3% on injections (I have an appointment next week to see if there's been any improvement on the pump). Every time I ate, no matter how much insulin I injected, my blood glucose shot up to 20mmol or more, and then returned to earth with a bump, often causing severe hypos.

Initially, the pump seemed to stop this. However, I am now experiencing a similar reaction, although not quite as extreme. Most of the time, I eat and bolus and my BG is 13/14mmol 2 hours later, then 2 hours after that returns to 7 or 8.

2 hours after every evening meal, my BG has shot to 19, and correcting has only brought me back down to 11/12.

Any advice? Has anyone else had difficulty gaining tight control on the pump? Spoke to my nurse yesterday and was left with the feeling that it's just me!

Have you got the book pumping insulin by John Walsh? If not get it from amazon. It's the pumpers bible.
Have you done any basal testing? If not you need to do so.
If your basal is wrong everything else is wrong.
Reading your post everything screams basal is wrong.
What pump have you got? If it's the veo is it working correctly as there seems to be a major problem with them. So much so they are being replaced.

Also what food are you eating? The type of foods you eat will have an impact on your numbers too. Do you use the different type of boluses?
Basicaly though the pump is only as good as the user. If you have no understanding of it or it's workings you are on a hiding to nothing.
Another thought if none of the above apply is have you tried a different insulin?
Oh and your pump nurse sounds as good as useless. Ask her what she is paid for :mad:

[Subby]

Yes, I had that problem. With shots and the pump. Spiking like that suggests a problem with the speed at which insulin takes action.

My answer, though trial and error, was to square bolus everything. It seems my body resists a certain amount of insulin delivered "instantaneously". That meant holdups 40 min - couple of hours, during which obviously the food could spike me at will. For my body, if I keep the instant part under 2 units, and square the rest over half an hour, my boluses work as they should: predictable action within 30 min.

The ideas of prebolusing and carefully removing carbs that excessively spike you, may be invaluable.

The fact you are returning to 7 - 8, suggests you're not getting enough insulin anyway. Either basal or bolus (what did you start with before the meal?) You want to be aiming lower. I know it sounds low if you've been used to higher, but explore the notion that lower numbers can actually lead to better control (to a degree: one can go overboard). Yes, your health professionals may resist this. I leave it to you to decide if you want to move the goalposts or not.

Basal testing is very recommended and may well be impacting on your boluses. Pumping Insulin by John Walsh highly recommended from me, too, you couldn't make a wiser investment than buying, reading and using that book.

[Russell A.]

I would try a couple of things:
1.) Pre-meal bolusing, trying taking your bolus about 15 minutes before you eat.
2.) Try Increasing your overall bolus by around 25%, take 50% upfront than the other 50% over the next 1/2 hour.

Basal testing seems critical with your issue as well.

Your carb ratio may be off as well.

Russell

[xMenace]

I would try a couple of things:
1.) Pre-meal bolusing, trying taking your bolus about 15 minutes before you eat.
2.) Try Increasing your overall bolus by around 25%, take 50% upfront than the other 50% over the next 1/2 hour.

Basal testing seems critical with your issue as well.

Your carb ratio may be off as well.

Russell

Agree.

I also suspect dietary changes and weight management may be in order too. What's your daily carb load?

http://www.diabetesforums.com/forum/pumping-insulin/28110-how-do-basal-testing.html#post330495

[JJM335]

Ditto on the suggestions about basal testing. If I don't have enough basal before I eat, I will have a huge spike.

Alternatively, when do you give your bolus? If you are spiking to 13/14 then returning to normal, you might try giving your bolus 20 mins before you eat. If you are pumping Novorapid, that can take a bit of time before the levels peak, and the carbs can get into your circulation before the insulin.

Joel

Off topic, but where in Scotland are you? You may find the following organization of interest:

Welcome to the Insulin Pump Awareness Group (http://www.ipagscotland.co.uk/)

[lark 27]

I think several key thoughts have been shared so I won't reiterate. I do have one question. Can you think of any reason why the numbers were better for a while but are now back to where they were at pre-pump? I don't want to jump to any ill-founded conclusions since I don't know much about you, but for me personally when I first went on a pump I experienced something that was a bit like when I moved to a new apartment in college. I was pretty much a slob in college so my dorm room and then my apartments would become a mess. Then the next year would come and I'd move in and have goals of being neat and tidy and that would last for a few weeks and then I'd be right back where I had been the year before. In other words I had goals that impacted my behavior for a short term, but the goals never really led to habits. Similar thing happened to me on the pump. When I first became bionic I improved my diabetic related actions, (diet, exercise, carb-counting). Then I started to fade a bit, but now feel pretty entrenched with improved HABITS that are natural and sustainable. Of course good habits are hard to make and easy to break, but i'm trying to keep them.

Good luck,

[Russell A.]

Lark:

You bring up a good point. My thought is: has he relaxed his eating habits/ portions b/c of the pump? Causing higher BG all around.

Russell

[Subby]

Kind of similar to that, is keeping up the act of checking in on settings (for those it may shift around a bit, week to week or month to month). I do seem to have better consistency these days (thanks met) but often, I would be struggling with control for a time, maybe a week or two, and in fact getting fuzzy and disorganised and hazy because my BG was slipping a lot. Where the actual problem was, I wasn't checking or updating my settings enough: not realising that at 8pm, I would be getting lows, or at 4am, I would always be high, or that I was always high after breakfast... not so much getting sloppy with my actions, but not reacting... one of the things I see as vital to using the pump or any insulin therapy, if as I said, things can change on you...

[bigpurpleduck]

Loads of useful comments guys! Thanks loads.

In answer to some of the questions (I'm sure I will forget some of them, sorry!):

My average carb intake is 250g a day (I think this is okay?).

I'm a very healthy weight for my height: 5'6" and 8 stone 8 pounds.

Exercise could be better. I practice yoga two or three times a week and take short walks, but don't do anything that really gets my heart and lungs going.

When I first started using the pump I was off college for the summer and doing very little. I have since returned to college, and am thinking my increased BG may be because of increased stress levels. I have a lot going on at the moment!

I have fasted at mealtimes and found my basals are not too far out, but after talking to my nurse have decided to put them up anyway.

I have a VEO. Should I be concerned?

An average daily food diary for me:
- Weetabix, banana, milk & orange juice
- Toast, apple
- Pasta or baked potatoes
- For snacks, grapes, cereal bars, crisps

Haven't experimented with square wave or dual wave yet, was trying to get my BG to a semi-normal level before doing so. Would this help a lot?

I think the point about my understanding of pump therapy may be a good one. I live in the UK so get free NHS care, which I sometimes feel is inadequate (although I'm grateful for it, as I couldn't afford anything else!). I know very little about pumping other than basals are background, and bolus is for food. Think I will order the book which has been suggested a couple of times.

Thanks again. Any more suggestions would be much appreciated!

[bigpurpleduck]

2 hours after every evening meal, my BG has shot to 19, and correcting has only brought me back down to 11/12.

Any advice? Has anyone else had difficulty gaining tight control on the pump? Spoke to my nurse yesterday and was left with the feeling that it's just me!

UGH,,,,I was just going to ask how people liked the pump, I am thinking of getting one and not sure what to expect. Your experience doesn't sound too good.....but I highly doubt that you are the only one. My doc told me I was the only one he ever heard of a BG raising after exercise. :eek:

I didn't mean to put anyone off! I still feel the pump is much better than injections. It's easier to identify patterns, allow for exercise and different types of foods, and allows you to correct without an extra shot. There are loads of advantages to it, the main one for me being I don't have to constantly eat and drink fruit juice to keep BG up. It definitely gives me much more freedom. I think in my case my BG is very sensitive to stress and hormone levels. I would recommend it, but do talk to others and consult your healthcare team. Changing to a pump is a big deal, and can be difficult aswell as rewarding.

[Russell A.]

BPD:

You are going sky high between Breakfast and lunch, correct? I eat a similar breakfast and until recently had the same problem. You are taking in a fair bit of sugar in your milk, juice and cereal. It may infact overload your system.

I have done the (slightly) increased by 25% bolus, take 50% upfront and the rest over the next 1/2 hour. Seems to improve my mid morning numbers.

I am working on pre-bolusing and seeing if my peak/spike is lower. I sometimes get up to 200 but drop back below 100 by lunch time.

I would give the 50% upfront bolus a try for a couple of days and see if it works. I read the suggestion on DF and know several folks who use it with most meal boluses.

Good luck.

Russell

[GeishaGirl]

Yes, I had that problem. With shots and the pump. Spiking like that suggests a problem with the speed at which insulin takes action.

My answer, though trial and error, was to square bolus everything. It seems my body resists a certain amount of insulin delivered "instantaneously". That meant holdups 40 min - couple of hours, during which obviously the food could spike me at will. For my body, if I keep the instant part under 2 units, and square the rest over half an hour, my boluses work as they should: predictable action within 30 min.



Funny, that's exactly what I have to do, too. Anything over 5u seems to get "lost" in my body and either doesn't work for a long time, or never works at all. I have to square or dual bolus everything over 5u, even corrections.

I wonder if it has something to do with the insulin resistance? I know you're on Met like I am.

[SueM]

Loads of useful comments guys! Thanks loads.

In answer to some of the questions (I'm sure I will forget some of them, sorry!):

My average carb intake is 250g a day (I think this is okay?).

I'm a very healthy weight for my height: 5'6" and 8 stone 8 pounds.

Exercise could be better. I practice yoga two or three times a week and take short walks, but don't do anything that really gets my heart and lungs going.

When I first started using the pump I was off college for the summer and doing very little. I have since returned to college, and am thinking my increased BG may be because of increased stress levels. I have a lot going on at the moment!

I have fasted at mealtimes and found my basals are not too far out, but after talking to my nurse have decided to put them up anyway.

I have a VEO. Should I be concerned?

An average daily food diary for me:
- Weetabix, banana, milk & orange juice
- Toast, apple
- Pasta or baked potatoes
- For snacks, grapes, cereal bars, crisps

Haven't experimented with square wave or dual wave yet, was trying to get my BG to a semi-normal level before doing so. Would this help a lot?

I think the point about my understanding of pump therapy may be a good one. I live in the UK so get free NHS care, which I sometimes feel is inadequate (although I'm grateful for it, as I couldn't afford anything else!). I know very little about pumping other than basals are background, and bolus is for food. Think I will order the book which has been suggested a couple of times.

Thanks again. Any more suggestions would be much appreciated!

Hiya,
In all honesty, most of your problems are due to the type of carbs you are eating. Plus the basal I would suspect.
A non diabetic would have problems with that lot :eek:
As you are not that active how come so many carbs anyway?

Breakfast.......... try a bowl of bran flakes instead of all the other stuff. Or porridge with some flaked almonds on it. Banana's will put you sky high for ages and juice is really just for treating a hypo.
Instead of baked potatoe try new potatoes instead. baked spuds are a complete sod to get right.
Pasta........ it's very rare anyone can eat that without using a split bolus.
Crisps again I think you will find will shove your blood sugars right the way up and keep them there. Grapes are very high sugar too. Cereal bars! Don't touch with a barge pole.
Why are you snacking anyway? With a pump you should not need to snack at all.
Have you looked at the Glycemix index and Glycemic load of foods?
These will give you a good idea of how to manage the carbs you eat.
Collins little gem books have carb counting and GL and GI in their titles. Well worth investing in them.
I hope you are sorted soon.
Best wishes
Sue

[JJM335]

Hi Sue:

I suspect that it depends on your outlook vis-a-vis carbs. For a dedicated low-carb Bernstein acolyte, 250g per day would be a horror show. OTOH if you believe that D's and non-D's should ideally eat a similar nutritional balance(still regarded as best practice by the majority of dieticians at least), you should be aiming at 60% of calories from carbs. Therefore, 250 g per day would point to a total daily intake of 1667 Calories. That's hardly overeating.

Your point about the type of carbs is fair, but again, the effect of any particular food varies so much from person to person (which is why pumping involves such a long learning curve). Personally, I never use a split bolus for pasta (it's one of the few foods that keeps in synch with my bolus) and the GI of grapes is in the low 40's. Not much more than an apple, and with a carb factor of 0.17, hardly a big GL if you don't eat too many (or eat them after pasta).

Joel

[Subby]

Funny, that's exactly what I have to do, too. Anything over 5u seems to get "lost" in my body and either doesn't work for a long time, or never works at all. I have to square or dual bolus everything over 5u, even corrections.

I wonder if it has something to do with the insulin resistance? I know you're on Met like I am.

This is a bit OT sorry OP. But is interesting.

The best reason I can think of, considering I have not had an endo take this seriously so not had medical feedback - is that at some point, the presence of a certain amount of insulin causes a response, an allergy or perhaps inflammation at the site of insertion. This "traps" the insulin until the reaction subsides, in me, I think it's 30 min to 2 hours if it's set off big time.

That's all supposition. Seeing that metformin has not reduced my dosage much as all, and seeing that I'm not greatly overweight and my insulin use was still high when I was a stick a few years ago, I am actually thinking that I might have high antibodies that neutralises a lot of the insulin I inject. (Result being it seems a lot like "insulin resistance", but is a bit different - rather than having trouble utilising insulin, insulin is watered down in potency on entering the body). I would not at all be surprised if my problem with instant doses, and my high insulin use and potential antibody reaction causing it, are very much linked.

Again, all theoretical. I hope to get a test for insulin antibodies in the future. Will be interesting to see.

[SueM]

Hi Sue:

I suspect that it depends on your outlook vis-a-vis carbs. For a dedicated low-carb Bernstein acolyte, 250g per day would be a horror show. OTOH if you believe that D's and non-D's should ideally eat a similar nutritional balance(still regarded as best practice by the majority of dieticians at least), you should be aiming at 60% of calories from carbs. Therefore, 250 g per day would point to a total daily intake of 1667 Calories. That's hardly overeating.

Your point about the type of carbs is fair, but again, the effect of any particular food varies so much from person to person (which is why pumping involves such a long learning curve). Personally, I never use a split bolus for pasta (it's one of the few foods that keeps in synch with my bolus) and the GI of grapes is in the low 40's. Not much more than an apple, and with a carb factor of 0.17, hardly a big GL if you don't eat too many (or eat them after pasta).

Joel

Hi Joel, don't me wrong I love my carbs :D
Spuds and pasta are many peoples down fall hence I suggested a dif type of spud. OP obviously does have a major problem with them her blood sugars prove this.
She is eating grapes as a snack again very many people find they spike dreadfully, that why I suggested she had a good look at what she was eating and the amount.
I work on a farm and there is no way I could consume that amount of carbs or type unless I had a tanker full of insulin and a hypo kit for the rebound.
So this is just my take on things OP has to take in what she has been told by everyone and decide what she is going to do.
With an A1c in the 8's things are obviously not right so she has to sit down and have a good think of how she is going to sort it.
IN the UK if you don't make progress with a pump it is taken away. It's a pity she has not been shown how to use her pump properly. Hopefully pumping insulin will help her no end as will reading this forum.
Sue

[bigpurpleduck]

Am a little confused about my diet?

I have quite a big appetite, particularly when I'm stressed and my BG is high (as is the case at the moment).

I make a conscious effort to eat well and limit my calorie intake.

I eat bananas, grapes, apples & drink orange juice to get my 5-a-day. Am concerned I would be unable to get my 5 without doing this.

Also, when I started on the pump, I was told it meant I could eat all foods, no matter what their carb content, so long as I bolused. Was this wrong?

[Subby]

Yes, I think it was wrong to have it stated that way at you... the pump allows more flexibility of delivery that's for sure, it might deal better with different foods and carbs, have different tricks... but it does not get around the inherent slowness of exogenous insulin. Thsi means that for a lot of people, fast carbs are going to outrun the action of the insulin, every time. (Others might get really fast insulin reaction time that can deal with a lot of those carbs. Lucky them.) But it is simply nothing like the insulin reaction a non-diabetic has, and won't be, until we use very different insulin delivery systems (not through the fat).

I think it is much more sensible and useful to say: you might still need to modify your diet. 5 serves is all very well but there are many types of carbs and foods out there. Start by eliminating the foods that obviously cause you problems, and if you want to keep eating a large amount of carbs go for carbs that don't spike you as much. You need to do the leg work your self, everybody is different. You can start, by cutting out some degree of refined foods, pastas, juices, and the like. The GI index is a list of foods that have been tested on non diabetics and ranked according to how much it spikes. It is nothing like foolproof but may give ideas of better choices to try, and obvious foods to avoid. It is here for example you can find that potato has a very high GI rating, and sweet potato (yam) may well be a better choice, if you feel the need for a "starchy" vegetable. Likewise it suggests Basmati rice over the likes of Jasmine, as significantly less spiking. I find that myself, and though I tend to avoid the likes of rice and pasta full stop these days most days, it's good to know the better options. You might find better fruit options, all the ones you mention are common offenders for spiking. I would highly recommend stop OJ full stop, if you need vit C take a supplement. In fact, I use OJ as a hypo fix, it is so fast to act!

You can find GI information in books and on the net. Again, it's just to be treated as a potential guide, you may be completely different to the "norm" of the people they tested the foods on.

In the end, your tester is the ultimate authority. I suggest once you have your doses in the ballpark, if you eat something and you spike, take note. If you spike twice, just don't eat it.

[JJM335]

With an A1c in the 8's things are obviously not right so she has to sit down and have a good think of how she is going to sort it.
IN the UK if you don't make progress with a pump it is taken away. It's a pity she has not been shown how to use her pump properly. Hopefully pumping insulin will help her no end as will reading this forum.
Sue

Sue:

Good points. I am a bit surprised at how poorly the OP appears to have been advised. Scotland has a very low proportion of pumpers compared to the rest of the UK, and in the West of Scotland numbers are particularly low, but in my experience, the training at least is extremely thorough.

How many people actually have pumps taken away? I am well aware that this is a threat that can be routinely used on new pumpers, but how often does it actually happen?

Joel

[bigpurpleduck]

Thanks guys.

Definitely need to look at GI! I feel another book purchase coming on.

[Subby]

OK, but don't treat it like a bible, it's just one potential avenue of finding candidates for eating/ removing. In fact some have said they find the ratings just don't correlate with their body at all. Don't forget you can get on with removing the worst carbs, today! Good luck.

[Gary_W]

I think a lot of healthcare professionals tell us T1 folks that we can eat what we like as long as we bolus for it.

I would put the caveat that eating too much of certain carbs in one go can be a bit of a killer... The problem is that, once your BG goes into double figures, you are likely to become insulin resistant and it's a swine to get it down again.

Possible answers are less of particular foods, pre-bolusing, or the super bolus. I find that the super bolus will allow me to eat toasted white bread with jam for breakfast and have a BG between 6 and 8 at the two hour point followed by a gentle descent into a 5 ish for lunchtime. I am (apparantly) speaking at one of our future pump meetings locally to tell the clinicians how it's done, but I just use John Walsh's idea so they could find out from the web anyway...

250g of carbs is do-able for me, though I tend to be closer to 200 these days and a higher fat content. Bananas kill me if I'm not careful. OJ is hypo treatment :) I cope perfectly with pasta, even a decent sized bowlful. Baked spuds are evil (they absorb at the speed of light for some odd reason) but I cope just fine with all other styles of potatoes. It's just a case of experimenting and finding which bits you can get away with and which bits need a bit more TLC.

Gary

[mortis505]

Just my 0.02 cents here. more carbs = higher BG. Higher BG = increased insulin resistance.

You have been given some great advice. Best thing to remember is YMMV = Your Mileage May Vary.

We can all tell you what works for us, but ultimately, its up to you to find what works best for you.

I would however look into reducing portions sizes a bit and see if this helps. Then you can decide on what foods to eliminate.