[Jonathan_R]

I started a thread earlier this week about my blood sugars. Some advise was given, to mich I have applied that advise.

The good news: Sinse applying the advise of eating lower carbs, that has helped with my morning sugars. I have also split up the lantus a 2/3rd to 1/3rd ratio. So 30 units in the morning, and 15 units at night.

The problem: My standard deviation is still large. About all its done is shift closer to 0. I'm starting to have more hypos. The hypos could be cause my bolus ratio is off.

For breakfast I have 1 serving of cereal, which works out to about 25 carbs. I round that to 30. I also have a 2 egg omlet.

For lunch, I have 1 sandwich (double fiber whole wheat bread) of peanut butter and jelly. That's about 32 carbs. I round that down to 30.

My bolus for the morning is for every 10 I'm over, I take 1 unit. So if I'm 230, I subtract 230 from 105, which gives 125. 125 divided by 10 is 12.5, so I round up to 13. for the food, it's every 15 carbs I take 1 unit. So because I consume 30 carbs, I take 2 for a combined, a total of 15 units.

The rest of the day my bolus is every 15 I'm over, I take 1 unit. For every 15 carbs I eat, I take 1 unit.

I seem to have the most trouble after lunch. I am consistently crashing, having hypos after lunch. This would seem to indicate I am getting the peak of the lantus at around lunch time. I probably need yet another bolus ratio. Maybe 1:18 or something.

Anyway, I have included a link to my updated, published log. Complete with graph and corresponding to the correct measurements.

diabetes log

[Tribbles]

I think your ratio is wrong and I'm not sure your carb counts are right either. Do you look up the count and weigh the food? My breakfast cereal is typically around 45g including milk and sugar which is why I am wondering.

Are you accounting for residual insulin? You have some shots less than four hours apart so some of the previous bolus will still be in your system.

You want to check your basal rate as well as I think that is low.

Bottom line I would see your diabetes team.

[Jonathan_R]

Not only do I look at the nutrition information, I also look up the glycemic index and glycemic load. I also do weigh, or measure the portions.

I don't do shots more frequently than 4 hours. I was advised not to. That it was called stacking.

When I was seeing my endo, dietician, and nurse, my figures were worse.

Golden Puffs, is 24g of total carbs per 3/4 cup. As to the milk, that is 12g of carbs per 1 cup of milk. Obviously, I have considerably less than 1 cup. So my calculations are spot on.

As to seeing my diabetes team, I am in the process of changing primary care doctors, due to the last incident they pulled on me. I need a referal to an endo, which that comes from the primary. So that will have to wait.

Golden Puffs® Nutritional Facts

Nutrition Facts and Analysis for Milk, reduced fat, fluid, 2% milkfat, with added nonfat milk solids and vitamin A

[Subby]

Originally Posted by Jonathan_R

I don't do shots more frequently than 4 hours. I was advised not to. That it was called stacking.

Yes and no. If you shoot a correction, without taking into consideration previous boluses, that is stacking. If you eat in 4 hours, you need to bolus for it, and that is not stacking.

It can get more complicated than that but the upshot is: you eat food, you need correct bolus in your system, no matter when.

When I was seeing my endo, dietician, and nurse, my figures were worse.

I know that feeling. If you can't get basic help, change medical team. In the meantime have you ordered the book "Using Insulin" by John Walsh? If your medical team is not usefully educated about this stuff, you need to become more educated and knowledgeable yourself. That book is easy to read and will step you through adjusting your insulin doses to work better.

Golden Puffs, is 24g of total carbs per 3/4 cup. As to the milk, that is 12g of carbs per 1 cup of milk. Obviously, I have considerably less than 1 cup. So my calculations are spot on.

That's as may be, but the persistent question is "is your I:C ratio correct?" (and you ISF and your basal, these three things are the main points of tweaking). If you see a trend such as going low at some stage after a meal, the answer is your I:C is too agressive, it doesn't reflect on anything else. I said it you before, I can say it again: you may need to adjust your I:C ratio. In the aim of lowering dose, than means going from 1:15, to 1:16, or 1:17, for example, and seeing if that reduces the lows.

As for post meal spikes, I've also suggested your insulin (no matter how much you take) may not keep up with fast carbs, highish GI or GL food, or anything you find spikes you too quickly. That may indeed still be an issue. You can't just take high GI and GL into account as far as shooting more insulin. There may be a range of these foods that simply have to be avoided. That's the limitation of not having "normal" insulin response in your body.

[Jonathan_R]

Subby, thank you.

I knew I could count on you. Yes, you did say in previous posts that my I:C needs tweaking. I did that for breakfast and just about nailed it.

It seems I need about three different boluses, at the moment.

Today I split my lantus from a straight 40 something units to 2/3rds in the morning and 1/3rd in the evening. I am still working on raising my basal 1 unit every 2 days.

I have also started to lower my carb intake, although not so agressivly yet.

I have also started doing different boluses as someone suggested in another thread. Currently I have 2 boluses. My morning bolus (for every 10 I am over I take 1 unit, every 15 carbs I consume I take 1 unit), and the rest of the day bolus (every 15 over take 1 unit, and every 15 carbs I consume take 1 unit).

The more agressive bolus is the morning dose, and for now is working fine. It's the lunch time bolus that is giving me hassle. 4 hours after I take my lantus, (I take my lantus when I eat breakfast), I have lunch. So I take lantus at about 8 am, then eat lunch at noon, and do my bolus for lunch.

Am I making sense?

[matingara]

these are very interesting numbers. to my way of thinking you eat way too many carbs. but that is your choice.

i am not an expert, but it seems to me your blood sugar is on a huge roller-coaster.

i get freaked out if my blood glucose is over 180 mg/dl. this only happens very rarely - once every two weeks or so.

i don't worry about lows until my bgl drops below 45 mg/dl or so.

but, we are all different.



-- Joel.

[Jonathan_R]

I wont disagree that I might be eating to many carbs, but to change to many things...I'd never know what is really happening. So I'm working on the med side right now.

Yes, my blood sugar is on a roller coaster. This is what I'm trying to fix. So far, no one has ever been able to. Not my primary care doctor, not my endo. Flat out, no one.

I don't get freaked out by large numbers. I can deal with those. I can always take insulin. With low numbers, those bother me. I am already prone to seizures, throw some low numbers in and you exaserbate it. Wanna give glucose to one who is seizing? I do understand the complications that can, and will develop as a result of high numbers, but the low numbers can certainly kill me.

Indeed we are different. I wish I could be more like what you have. The tolerance of the lows. Blood sugar under control. That would be great. That is my goal. I just wonder if I'll ever reach it.

[matingara]

hi!

yeah - i tried to take that all into account when i read what you wrote. i do not understand seizures etc - so it is not my place to advise you on that - but i do understand why you would be wary of the lows.

however, with a really low carb diet you will need less insulin. small inputs=small numbers et al.

you seem to be a bit of a scientist - so i don't need to explain that any further. but that could be the next parameter that you vary in your testing!



-- Joel.

[Jonathan_R]

Indeed, and it shall.

Right now I'm trying to read up on neuroendocronology. There is a lot I'm trying to make sense of.

I guess you could say I'm a scientist, although this is a bit out of my area of expertise. I'm more familiar with Physics, Quntum Physics, Particle Physics, and the like. Get me down to the particles and I can make sense of it. It's at molecules and so on that it becomes complex to me. You might think Particle Physics is complex, but really it's not. It's when you start combining other particles, and atoms to make a molecule and combining molecules, that's when it gets complicated cause then you need to take into account the relation, and the role of each particle to really understand the molecule.

My degree is in Electronics/Computer Engineering. I can remember when I was attending school, I'd ask questions. The professors would routinely tell me I should be in Physics. I had one of my former doctors offer to sponsor me for med school. I turned it down, explaining that I was terrible in Biology. Funny how that goes. Now I'm being forced to learn quite a lot about Biology and Micro-Biology.

[Lizzie G]

Originally Posted by Jonathan_R

Subby, thank you.

I knew I could count on you. Yes, you did say in previous posts that my I:C needs tweaking. I did that for breakfast and just about nailed it.

It seems I need about three different boluses, at the moment.

Today I split my lantus from a straight 40 something units to 2/3rds in the morning and 1/3rd in the evening. I am still working on raising my basal 1 unit every 2 days.

I have also started to lower my carb intake, although not so agressivly yet.

I have also started doing different boluses as someone suggested in another thread. Currently I have 2 boluses. My morning bolus (for every 10 I am over I take 1 unit, every 15 carbs I consume I take 1 unit), and the rest of the day bolus (every 15 over take 1 unit, and every 15 carbs I consume take 1 unit).

The more agressive bolus is the morning dose, and for now is working fine. It's the lunch time bolus that is giving me hassle. 4 hours after I take my lantus, (I take my lantus when I eat breakfast), I have lunch. So I take lantus at about 8 am, then eat lunch at noon, and do my bolus for lunch.

Am I making sense?

Hi Jonathan!

Sounds like you are having a lot of fun....stick with it and you will get there.

With a 24 hour (however you split it) insulin like lantus it makes it tough to determine the culprit when things go wrong and to an extent you end up compensating by adjusting your bolus upward or downward at certain times of day.

This aside, even on the pump, my carb ratios are different first thing in the morning to lunchtime/afternoon (I notice you change your correction factors which helps but the actual carb ratios need work sometimes too); for example until about 10 or 11am i bolus 1u for every 10g of carb, then lunchtime/afternoon that is about 1 to 15g, then later in the day/evening maybe around 1 to 12g (unless I have been exercising). As well as this my basal is a lot lower in the afternoon. These days Im pretty good at sensing what to take when depending on all the factors that impact on this rather complex equation!

Whilst you are on lantus it is fairly difficult to control the fact that you need different basals at different times of day, so knowing that you are going low in the afternoons, maybe you should try adjusting your carb ratio at lunchtime to compensate.

When I was on lantus I found that if I took a level that was adequate to cover me overnight I would always be hungry and have hypos during the day, so I reduced my lantus, then bolused agressively in the evening, and woke myself around 5am to take some extra novorapid to cover the insulin resistant dawn hours. this little routine, which sounds annoying, worked really well for me. not everybody's ideal but i much preferred it to the constant hunger of having too much circulating insulin in the afternoons and worry of hypos driving home from work!

Liz x

[Lizzie G]

Originally Posted by Jonathan_R

Indeed, and it shall.

Right now I'm trying to read up on neuroendocronology. There is a lot I'm trying to make sense of.

I guess you could say I'm a scientist, although this is a bit out of my area of expertise. I'm more familiar with Physics, Quntum Physics, Particle Physics, and the like. Get me down to the particles and I can make sense of it. It's at molecules and so on that it becomes complex to me. You might think Particle Physics is complex, but really it's not. It's when you start combining other particles, and atoms to make a molecule and combining molecules, that's when it gets complicated cause then you need to take into account the relation, and the role of each particle to really understand the molecule.

My degree is in Electronics/Computer Engineering. I can remember when I was attending school, I'd ask questions. The professors would routinely tell me I should be in Physics. I had one of my former doctors offer to sponsor me for med school. I turned it down, explaining that I was terrible in Biology. Funny how that goes. Now I'm being forced to learn quite a lot about Biology and Micro-Biology.

I hear you! my degree is in chemistry. organic chemistry is one of the most painful and challenging things i have ever done, you are away from the logical mathematics of particle mechanics and into the realms of multiple factors affecting a macromolecule, polymer, whatever....a bit like diabetes you can change one really small factor and the rules go out the window!

[Jonathan_R]

Yes, working with lantus is annoying, to say the very least. When they had me on Metformin along with it, that was disastrous.

How can I do different basals at different times with lantus?

I don't mind coming up with different bolus ratios, even if it's for every dose I do. I just want this under control.

It also annoys me that I am the one doing the work and not my doctors.

I often take prednisone for my degenerative disk disease and carpal tunnel. I used to take morphine, vicodin and flexeril for my degenerative disk disease. You can imagine the fun that played with my blood sugars.

[Lizzie G]

Originally Posted by Jonathan_R

Yes, working with lantus is annoying, to say the very least. When they had me on Metformin along with it, that was disastrous.

How can I do different basals at different times with lantus?

I don't mind coming up with different bolus ratios, even if it's for every dose I do. I just want this under control.

It also annoys me that I am the one doing the work and not my doctors.

I often take prednisone for my degenerative disk disease and carpal tunnel. I used to take morphine, vicodin and flexeril for my degenerative disk disease. You can imagine the fun that played with my blood sugars.

ouch it sounds like you have quite the array of painful conditions. i feel 'lucky' to have only the diabetes!

you cant really do much about lantus itself as its profile is flat, but tweaking the boluses can go a long way to helping.

where are you based? in the uk doctors tell you the basics then if you want to have decent control you pretty much work it out yourself. i know in the beginning that seems wrong but over time you will realise that is is far better than you are in the driving seat from the word go, as things change so much and for so many different reasons that you need to be able to work out quickly what you need to do; it would be crippling if you needed medical advice all the time.

why did they put you on metformin by the way? that seems odd.

[Tribbles]

Originally Posted by Jonathan_R

I don't do shots more frequently than 4 hours. I was advised not to. That it was called stacking.

...

Golden Puffs, is 24g of total carbs per 3/4 cup. As to the milk, that is 12g of carbs per 1 cup of milk. Obviously, I have considerably less than 1 cup. So my calculations are spot on.

I was going by your spreadsheet. There are definitely times when you are taking shots less than 4 hours apart hence my comment. As Subby said you can take shots closer provided you allow for the insulin already in your system.

Likewise for cereals you have 60g in your spreadsheet but ir sounds like you are only eating 30g (I have 1/2 cup of milk with my cereals). I'm not sure how you arrive at 60g unless there is something you are not noting in the food section.

I agree with Subby about Using Insulin - definitely get that book.

[Subby]

There is one thing that tends to strike me here Jonathan, as something that might be contributing to instability.

First, let me say I agree with reducing carbs if needs be to find some more predictable and reasonable results. The actual amount you go can be up to you. Some go "extreme" and have maybe 40g of carbs. I find I can get pretty good results in a number of ways, with what around 100 - 120g daily at the moment. I find it easier to dose for and get good results with, than eating higher carbs or anything near the mainstream recommendation for my body (about 300g I think?)

Just as important is picking the right carbs, I avoid foods that spike (may well be high GI, high GL, but the tester is the ultimate authority) I concentrate on good natural foods.

Now, lets talk about something completely different. Your basal situation. I wanted to bring up what some people like me find.

If you take insulins like Lantus or Levemir and think about how they work, what is occuring is that they are "metering out" insulin at a steady rate over the time of action (usually 20 - 24 hours). So, you can translate that into a relatively steady stream of x units per hour, for example.

This, in a perfect world (well, in a perfect world we wouldn't have D... but I digress) will match your body's internal releases and usage of glucagon, or - sugar. This process is occuring all the time, it's the basic body fuel being released by the liver (and other sources), both as a kind of maintenance feed and in response to further stimulus such as waking up, stress, activity.

The majority of the population appears to have a relatively flat basal needs from hour to hour. So a person might only have the need for let's say, 1 unit an hour all day. So a dose of 24 units of Lantus might do quite nicely. And blood sugar is kept relatively steady (and a kind of table upon whith food and boluses work on top of).

For these people, providing basal converage is pretty much a case of finding a good Lantus dose and sticking to it.

BUT. There are some lucky people who seem to work differently. They have a real graduation of "basal" needs through the day, as a mysterious part of their 24 hour biological body clock. So they might need 1 unit per hour for 8 hours of the day. But then they only need .5 units per hour for another 8 hours, so the Lantus dose is far too much for that time period. And they might need 2.5 units per hour for another 8 hours of the day, and the Lantus dose is woefully inadequate for that time period.

I'm one of those people, and was very unstable on MDI largely for that reason. I was kind of aware of it, but it's easy to see trends around food and boluses (and especially LARGE amounts of food and bolus) and get stuck on thinking they are the cause of the trouble. Think of it this way, the lake has already got ripples and waves on it, but if you keep throwing stones and boulders in creating waves, as far as you know it's your actions that cause the entire problem, and in your imagination if you did stop throwing rocks it would become still. But without doing it, you really don't know.

So that leads on to what I suggest you might do to work out if, for you, your basal situation is stable or not. Basal testing. I don't know if it's mentioned in Using Insulin, I have the companion book Pumping Insulin. In that book basal testing is described thoroughly. It's seen as a "pump" tool, but there is no reason you can't use some version of it to at least gain insight into whether you have problems with your basal coverage, even before you pile food and boluses on top.

Because there is something else I wanted to mention too. Like the lake with waves crashing and rebounding, once a certain amount of instability occurs things get very confusing and chaotic. There may be no real pattern to be seen because you might be in a state of "general flux" from such issues as basal problems. So what I am saying is it's worth using the tools to look into this, even if you feel intuitively that the problems lie elsewhere.

Anyway, basal testing is just short term fasting (like, 8 hours at a time, or skipping a meal) and regular tests through that period to observe what BGs your basal insulin is generating. The idea is to do it in segments (at your leisure) over the whole 24 hours. There are rules and regulations to make sure the waves are not going to interfere: you can see a good list of those rules here. Basal Testing Rules There is a good link to basal testing for injections here, well worth a read. Basal Testing for MDI - Diabetes Daily

I realise that is a lot to take in, but have a read and let it sit with you. It's not a hard thing to do, just takes some patience really. It would be undertaken in your case to see if there are definite stability problems you might be able to improve, either by changing dose or dose time, or other things like strategically eating snacks.

The answer for me to fix my basal instability, was to go on a pump, which allows you to program that units per hour (or, 30 minutes). I dread the idea of trying to deal with rigid long acting again if I have to. Not only do I get inevitable periods of horrible highs or crashing lows even with the "best fit" injection, I find basal problems can significantly affect how well a bolus works.

But I do seem to be the exception, not the rule. Maybe you have some simple basal problems you can really improve with your long acting regimen, if you basal test and adjust accordingly.