Argh. I need help, advice, etc. … maybe just a place to vent. Despite my decent A1c levels, my BGs over the past few years have seemed all over the place. I was looking at the basal rates on my pump today and thinking, “Where do these numbers come from? Is there any logic here?” Answer: not much.
Any medical or paramedical support I’ve sought recently has, reasonably, pointed me in the direction of basal rate testing as a starting place. And I’ve tried. But how to make sense of any of that data when (and here’s the big source of my frustration) my unpredictable monthly hormone shifts mean that any given basal pattern will be pretty much useless a few days later and not at all reliable one month after that? Exercise adds in a whole other set of complications.
I’ve read Walsh’s Pumping Insulin, Colberg’s Diabetic Athlete’s Handbook, Bernstein’s Diabetes Solution, and I’ve got Scheiner’s Think Like a Pancreas on order. I’ve done camps and seminars and phone consultations. I’m hooked up to my CGM pretty much all the time. But I’m feeling like diabetes is controlling me, rather than vice versa.
Any suggestions or ideas for dealing with roller-coaster basal needs would be much appreciated! Thanks!
I’ve been experiencing the same thing. EXACTLY the same thing. I don’t have a pump, though, so unlike you I haven’t been varying my basal rates - I use Lantus twice a day in equal injections which provides a very constant basal delivery. But I know my basal rate is varying from one day to the next from the record keeping I’ve been doing (I’m now testing 12-15 times a day - something I’ve never done before). I just haven’t been able to figure out how to predict what my basal needs will be on any given day so it is easier for me (pumpless) to vary the boluses I take with meals. As part of that I’m measuring (and recording in a spreadsheet) my observed carb/insulin ratio. And my carb/insulin ratio varies dramatically from one day to the next. So the variations in my carb/insulin ratio reflect differences in my insulin sensitivity - just as you are seeing differences in your insulin sensitivity while trying to adjust your basal rates.
I have three months of detailed observations so far and am still trying to fine tune what I’m seeing. But I have seen dramatic changes in my insulin sensitivity caused by two things.
The first is high BG excursions. Are you going high - like into the mid-200’s and above? And is it happening at night when its more likely to last for at least a couple hours? I found that after two or three nights of high BG’s - high enough to spill ketones in my urine - that my insulin sensitivity crashes and I need up to ten times as much insulin to handle the exact same meal as before (no kidding - really ten times as much - so the same meal that requires 5 units of insulin one day can require 50 units the next). And of course when this occurs unexpectedly you start by under bolusing - increasing the chances of getting another high BG excusion that day and night. Also it takes up to two days of constantly good BG for this effect to wear off and for my insulin sensitivity to return to where it was before. And (surprising to me) this effect is seen even if I am exercising during this period of insulin insensitivity.
But although the BG excursions have the largest effect, once they have worn off I have found that the other thing that has a big effect on my insulin sensitivity is exercise. And not just exercise, but rowing (and I see by your picture that you row too!) Yes rowing - I got T1 as a senior in high school and started rowing crew as a freshman in college and continued to row - and as you know if you rowed in college - when you go out for crew you are rowing year round - every day of the year. Rowing was the best thing for me - it got me in incredible shape and I continued to exercise - running, playing squash, jumping rope, and using and eventually buying myself a Concept2 erg.
My rowing these days is limited to the Concept2, and I’ve found that if I row 5K in under 20 minutes that I can get a great workout in minimal time - it’s easy to find 20 minutes right? That burns calories at a rate of 1000 calories an hour. And I’m still testing the exact impact of this rowing - for example although my usual habit is to row three times a week, I rowed my 5K for five days in a row Monday through Friday this week so I could measure the effect of doing this on my sensitivity. But it is abundantly clear that the day after my 5K rows that I am much more insulin sensitive - like by a factor of about two.
I don’t know - maybe everyone is affected by different things and these only apply to me. But I was struck by the lack of concrete information on the extent of these effects in the books I have. And I have all the books you have including Scheiner’s (in my case I have the Bernstein book on order). In fact the only book I have that really talks about the high BG excursion effect I noted above is a book I highly recommend that you don’t have: “Type 1 Diabetes” by Ragnar Hanas. As far as increased sensitivity due to exercise, you should check out pages 33 and 34 “How exercise affects insulin action” in the Colberg book.
Good luck and stay in touch - I’m curious what you’re doing for rowing workouts?
Thanks for all those details, Jag … although our specifics might be different, it helps psychologically to know I’m not alone in this business of shifting insulin sensitivity. Thanks, also, for the additional reading recommendations. I’ll check out the Hanas book.
And nice to know another rower in D-land! I’m currently in a casually competitive recreational league. We practice year-round, 1-3 times a week, depending on the season, in Vancouver’s Coal Harbour. I’m usually in a mixed quad, but I also row singles, doubles, and the occasional 8+. Those 2-hour sessions on the water, combined with biking to and from, almost always cut my insulin needs (though not quite as predictably as I’d like). I run and do gym workouts as well, but they’re a distant 2nd and 3rd behind rower’s high!
Thanks again, and happy erging!
Just to be clear, I wasn’t talking about the lows you get immediately after or during 2 hours on the water - I’m talking about the increased insulin sensitivity you have for 24 to 48 hours afterwards (which can lead to lows if you don’t adjust your insulin to accomodate).
Maybe it would help if you could make your workouts more predictable so the calories and burn rates are more similar. A lot of the athletes profiled in Colberg’s book have pretty predictable workout schedules, which are undoubtedly easier to manage. I know that’s easier said than done - I have “fond” memories of dragging ourselves out of boats to be followed by ten mile runs one day, stadium step circuits the next, weight circuits on another - crew coaches always seem to have another novel form of torture ready. But if you are able to shape your own workout, maybe you can manage to make it more equal and predictable from one day to the next. If you can do that, then you should be better able to predict how it will affect you.
Yeah, I’m on MDI but I’ve logged and logged and logged and logged without having much luck finding a consistent pattern. I thought that my main problem was an inconsistent workout schedule so I made a concerted effort to keep the same schedule for two straight months. The only thing that changed was my overall insulin requirements but the underlying roller coaster pattern didn’t go away. I just deal with it now. There will be days when I’m running consistently low and need to eat a bit more. Then there will be days where I run consistently higher and will have to up my premeal Novolog a bit. There are occasions where I trend for a few days and have to change my Lantus dose by a couple of units but it will always change again. There doesn’t seem to be any rhyme or reason to the shifts.
I’m just gonna blame it on sun spots and space aliens.
Thanks, FHS! Sun spots and space aliens work for me. 
Seriously, though, I’m finding it very interesting to read about men dealing with changing/unpredictable basal rates. I’d long been thinking (mistakenly, it appears) that it was mainly a women’s hormonal phenomenon, and that guys tended to truck along more or less consistently with one or two basal doses, which they’d tweak for different exercise levels. I stand corrected! I’m also thinking, more and more, that the “just deal with it” attitude (as opposed to trying to find some magical way of making the issue disappear) is best — psychologically anyway.
Without having experienced life as a T1 woman, I’m just gonna go out on a limb and say that my roller coaster is probably trivial compared to yours. =)
The changes I have to make are no more than a unit or two either way, 10 units of Lantus versus 12 units for example or a premeal Novolog dose of 5 units instead of 7. Still, those dose changes make enough of a noticeable difference that I have to pay attention to the need to make them.
My A1c has been steady for months but I do notice that my BG standard deviation changes dramatically. Last week, overall, my SD was less than 30 for a mean of 103. I had a prelunch SD of 18 for a mean of 87. 3 weeks ago, I couldn’t keep my prelunch SD below 30 but the mean was practically the same at 89. It’s crazy how my different pre, post, and nightime means and SDs can change from week to week while my overall numbers stay rock solid over a period of 90 days.
So, as a guy, I don’t think my changes are dramatic, but when it’s just me trying to keep track of myself, I do notice that I’m not just set and forget.
I have an idea. I think that some people have a very nervous adrenal gland. It will secrete hormones to trigger the liver to release glucose. These little amounts of glucose are responsible for the reduction in sensitivity for insulin. The solution could be to reduce the reaction of the liver. This can be achieved by taking metformin in addition to your insulin. I recommend to talk to your medical team about this approach.
So metformin works by “suppression of hepatic glucose production”; i.e. it supresses your liver’s production of glucose. Without a lot research it looks like a good drug for T2’s. But I would not want to take it as a T1: it is the liver’s production of glucose that has undoubtedly saved me from low BG’s that would have gone even lower (think overnight insulin reactions). This is how glucagon and other stress hormones work - tell your liver to dump insulin. I’ve had more than a few memorable seizures (uncontrollable full-body shaking) but I’ve have never had a BG go below this to the point that I was unable to eat sugar to recover - and I certainly hope to avoid that.
In addition I am a firm believer in KISS (keep it simple stupid). The fewer drugs I take the better - at the moment the only I take is insulin and I’m happy with that (the one exception I can think of is that I would be happy to include c-peptide with the insulin if there is found to be an advantage - after all if my Beta cells were working correctly they would be naturally producing c-peptide along with the insulin).
When you were doing the same exercise for a couple months, were you exercising every day? Did you ever have periods of a few days where you weren’t exercising - if so was there a change in insulin sensitivity then? And how many calories were you burning, and at what rate?
Same basic routine, 30 minutes on the treadmill, burning somewhere around 300 calories, 5 days a week, with some type of weightlifting 3 to 5 days a week. I took two days of rest a week, but never two days in a row. I was on vacation at the time so I was able to spend a lot more time in the gym. It’s the same basic routine I continue today except that I might miss more days or work out less due to work or other activities.
I don’t think my insulin sensitivity changed all that much during the two months. I work out pretty consistently for the most part. If I take more than a few days off, which I have in the past, I do notice that my overall sensitivity and basal rate does adjust.
Hi, Holger ~ Interesting hypothesis! I think the concerns that Jag raises, above, would make me hesitant to try metformin. I am, however, interested in the ways estrogen and progesterone affect my liver and insulin sensitivity etc.
Hey, I just noticed you and I were first diagnosed within a month of each other. Going on year D23 for us, if I’m not mistaken. =)
Heather, not necessarily any hints here, however I can commiserate .
I enjoyed dragon boating , participated in several festivals , including in Vancouver . I never mastered my insulin dose …Alcan Festival numbers far too high to even think of exercising and here in my community low enough , that my fellow paddler, seated behind me noticed , that I had a LO . I gave up after 4 years , that’s how I dealt with it …my reasons were not monthly hormonal shifts, I think …I was in my sixties .
I can locate , I think, Canadian Chris Jarvis, Olympic rower , marathoner , cyclist, insulin pumper , GCMS wearer 's e-mail address , if you like to chat with him as well about the exercise end of your concerns .He used to have a blog on Medtronic’s website, however I tried that today and was unsuccessful in connecting .I’ll keep tuning into this discussion .
Chris is right with his concerns but still:
-we have T1 diabetics in this community with insulin and metformin treatment. It is rare but not bizarre.
-it is my personal belief that the counter regulation for lows will get lost for T1 diabetics anyway. But let us assume that there is some sort of benefitial reaction: metformin does not suppress but will regulate the reaction of the liver down. So I think it can be dosed in a way that the reaction pattern of the liver is still preserved. It is quite possible that there is treshold for the metformin dosage that will also normalize the liver reaction (if you are one of those nervous types).
-I am convinced about the KISS approach too. But I am also convinced that the cause of a problem should be addressed not the symptom. If the quality of glucose control is heavily influences by the liver reaction it should be considered to moderate that first. If your medical team is open about this idea it would be a chance to find out more about your physical reactions. Metformin can be stopped from one day to the other. Combined with a high test frequency and a CGMS and a quiet weekend it should be possible to find out if metformin will have any benefits in your situation. You can expect that your sensitivity for insulin will increase so there is a risk of lows. But in exchange you will get more reliability and you can adjust your basal and bolus dosage to match the new sensitivity to normalize the risk. Just feed for thought as always.
I’ll sent you a pm with the e-mail address I have on file .
I’m not familiar with using metformin so maybe input from people who do use it would help.
But, I think that if you add exercise into the equation, especially something as demanding as rowing, you might be asking for more problems than solutions by suppressing gluconeogenesis from the liver. Sure, random breakdown of glycogen from the liver when you don’t need it can be problematic, but not having glycogen stores from the liver available when you do need them during exercise would be the suck, especially if you are not sure what the underlying causes of the rollar coaster BGs really are.
Again, being unfamiliar with the effect of metformin, does it suppress breakdown of glycogen from muscles as well as the liver?
Yes … without knowing the underlying causes of the swings (I suspect there’s more than one), I’m hesitant to medicate … and definitely don’t want to be without glycogen when I need it!
Still, it’s an interesting possible solution, Holger … thanks for the additional details. I’m seeing my endo this week and will ask him what he thinks.
Another idea: how long do you use your pump? Is it possible that you are experiencing absorbtion problems with the pump site (scar tissue and other skin changes)? Best way to find out is a pump vacation for some days or weeks (back to two shots of Levemir and Apidra/NovoRapid/Humalog).