Better control, but is this ok to do?

Type 1 and LADA
1

i am about two and a half years in with t1, almost 40 years old (omg, really?!?) and had quite a long honeymoon but thats all finished now. i started out on like 2 units of lantus, low carbed and exercised loads, secretly convinced that i could exercise things away. i knew and know that i really cant but some days i still cannot face that this will be with me the rest of my life.

i had been struggling with control for a couple of months due to various things, but the big one was new work environment where snacking between classes seems to be a competitive sport. i teach and during breaks people are gulping down whatever. baaaad for a diabetic. i joined in, with bad results at first and things just got worse.

i kind of got into a funk and had some quite crap numbers, wasnt counting carbs, only correcting and not bolusing before because of exercise right after to cycle to work and not realizing i was going to eat so many carbs (deep down i think i did, at least after the first 475 times...) the fact that 1 unit of novorapid lowers me about 100 points without moving at all makes me very resistant to fast acting insulin use. that stuff is ferocious!

over the easter break i have been re-reading using insulin, have been skulking around on tuD and keeping AMAZING logs of everything, eating between 50 and 60 carbs a day. i feel good and very accomplished, have energy.

i know the honeymoon is over because since the end of march i have increased my basal doses by a third. i was taking 10 units of levemir (3 in AM, 7 in PM) and now taking 15, in a more even split of 7/8. the first couple of days i had to bolus 1 unit for the 25 carbs or so in dinner but after that, no bolus. NONE, JUST EXERCISE, hour long walks witht the dog, astanga yoga, kettle bell workouts. so im rereading this using insulin book about tdd and basal and bolus splits and yadda yadda yadda but my way of doing things is so different from the 45-65% basal and all this. i am having great fasting numbers, like in the 80s and 90s and even my wake up numbers are there. im going to the endo in a couple of weeks and will ask her about it of course, but does anyone else handle their insulin needs in this way? could a t1 possibly only live on bolus if they exercise after meals?

i am also terrified of getting fat from so much insulin. i know its not a lot for t2s but its killing me every time i dial up 7 or units and stick it in my belly i think, omg fat fat fat.

2

50-60g carbs a day pfft to that. On a very active day I've had over 1100g on very little insulin but I was also burning over 7k calories in that (point of interest on that day only had 3u of basal, and had my bolus for the time at between 20-30% normal to attempt keep my levels as up as possible). But on a similar note I normally just run along happily on about 120-150g a day if I'm stuck at work. But that is the balance, it's what you are going to burn off on your activity you are doing. It's basically working out (from past experience usually or those Garmin cal meters are handy also) what you are burning, and providing the fuel necessary to do that before moving onto working out how much or little insulin you will need to metabolise that fuel.

Someone in the low carb brigade who sits in an office all day than it's fine as they aren't burning anything and don't need the fuel, thus if they do have a load of carbs and a lot of insulin to balance it than they get the omg fat fat fat. But if you burning it off, than eat like a horse and don't worry about it.

The other thing I would suggest, if you can wrangle one anyone is getting a pump. At least than it's easier to not have to have 1 unit of things, that 0.1 on a pump could give you the little you need for adjustment much more finely. Also makes snacking easier by just being a button press :)

3

That's exactly what you have to do. I think that the best way to stay on top of your weight, or at least what's worked for me, is to have tight control of my BG. If I nudge my ratios and rates too high, I can see 1) more hypos and 2) weight gain, from chasing the hypos and cut it off quickly when it starts. Last year had several disasters for me (leg hematoma during race, surgical removal of cyst...) that took me out of exercising for like 7 weeks, the longest I'd been without since 2007. It perhaps didn't help that I got into therapy chips but, by the time I got running, I was back up to 199 lbs or so, not where I wanted to be so I freaked out, made some adjustments and hooked up with some weight loss/ workout people through Facebook and have been pretty successful at that, while BG is still very good most of the time.

I think you could live on bolus but would see more fluctuation in your numbers (which I have read doesn't matter but when my SD was say 40 or 50, it was much more crazy than when it's around 17-22 where it has been for the last several years for me...). It may be too that you are overshooting a bit with the basal so that, combined with the bicycle riding, is helping you eat without bolusing but maybe a different timing pattern, multiple smaller shots (1 each? I used to do things with the meniscus on the shots, having it lower or higher depending on the situation that was going on...) or something like that. With small doses, a pump would likely allow you much finer control as well as helping with the record keeping aspect of things. I recall you're in Spain and they aren't available but perhaps given the situation, there's some type of exceptionalism that could provide one or something? Do they give them to expectant mothers? I don't want to say "get pregnant" but perhaps that sort of angle might help.

4

yeah, im going to beg my endo for a pump again when i see her in a couple of weeks.

my real question though, is, can people live on just the basal and exercise? is this a sustainable way to do this insulin thing? and while using insulin and think like a pancreas are informative, my way of doing things is not addressed, is there any info about doing things VERY high basal and very little bolus?

5

In my view there are a couple of good reasons to consider a pump. One is a wicked case of Darn Phenomenon. A pump can really help since you can fine tune your basal profile. Another is when you have real problems dosing insulin precisely for food and highs. You seem to have this issue. But don't think a pump will let you go and eat 1000 g of carbs a day and it won't fix your snacking issues. But if you are 150 mg/dl three hours after a meal then you can actually correct. And finally if a pump lets you take of your day in the face of a busy stressful life, it can make a difference.

6

hahaha! i should run out and get pregnant, see if they give me one. half unit pens are due to come out in the next couple of months so i guess i can try to use those if they say no to the pump.

there is not much fluctuation if i count carbs and am careful and make sure i get enough exercise. my lowest in the five days since im logging EVERYTHING was 85 and my highest today was 186, which i didnt like. besides that one the highest has been 179 and lots of post prandials in the 150s, which is ok. i live on lots of salad, which is fine, as there are so many things you can throw into one, it can be different every day.

the omg, im gonna be fat is just the result of the constant attention and vigilance to what im eating. the more i pay attention, the more obsessed i get about it, the less i want to eat, it drives me crazy!

7

no, brian, i dont want to eat lots of carbs! i have better control when i eat less carbs. i feel like i am doing this insulin thing more like a type 2, controlling everything with just the basal. or, like a person on those old insulins, on two shots a day!

8

It might relax some of that feeling of obsession and worry if you tried a combined basal/bolus regimen. It seems to me (and I could be totally off base) that the need to constantly be vigilant to food intake and exercise is creating a cycle and making you crazy. I know whereof I speak because I had 13 years recovery from an eating disorder when I got diagnosed and having to monitor everything made me pretty shaky again. But I finally realized if I eat relatively low carb and kept the fat lowish as well (which I know is counter to what most people believe), I would keep my insulin at a reasonable level and my weight stable.And I am 65 years old and gain weight very easily! A pump would certainly help because you could fine-tune both basal and bolus doses but you can do it on MDI as well. And I cringe at the thought of someone getting pregnant to get a pump. Yikes!!

Bottom line: Using basal to cover meals just isn't practical or effective. Don't be scared of bolus insulin. If you eat lowish carb your doses will be small.

Oh, and 7 units basal is a low dose even for a type 1.

9

But back then we were told exactly what to eat and when also...the old two shot a day routine was "fun" for the flexibility it gave you of being none whatsoever hehe. Corrective injections, nope none of that back then. You go low, you eat. You go high you tweak the next injection along. Ahh the good ol' days. I can still remember having my primary school teacher carry me back a couple of miles to school when were all out on a walk (no BG meters back then before you ask, testing consisted of peeing on strip and guessing the colour change):P

10

Zoe, the constant vigilance really IS driving me nuts, i am surprised that not everyone with diabetes does not have an eating disorder. when i am counting carbs and doing everything right, i get all obsessive and then i dont want to eat because i want to avoid highs but also because it gives me this ridiculous feeling of being virtuous almost, i cant explain it. its like the control of everything makes you kind of euphoric, i want to stay without eating, as its like i have even more control by NOT eating.

im gonna positively BEG for a pump when i see this lady. like i said, half units would help a lot, as one unit lowers me about 100 points, sometimes more. im on 15 units of basal, 7 in the AM and 8 at night. i think thats normal for my weight, at least, as thats what they started me on when i was diagnosed...

thanks for the obsession response, i really needed it!

11

I think if you include people with some "eating disordered behaviors" (short of an actual diagnosis), many many do, especially women. And "control" is the name of that game!

Oh, I thought you meant 7 units total. 15 units basal is a pretty normal basal dose for a type 1; it doesn't really go by weight as much as by insulin sensitivity. And some of that is probably meeting your bolus needs, so it would be lower if you did both.

12

Another thing that I'd suggest is to get into other activities. From all your posts, you sound really active and that's the best freaking medicine. "I'm playing golf and I have band practice and I'm going for a bike ride tomorrow...oh, and I have diabetes" has always helped me minimize it. Maybe it's an unhealthy form of denial but I beat the crap out of diabetes every day. So I can do other stuff that's more fun, including sitting on my butt reading a book!!

13

The answer is whatever works for you. My honeymoon period was 3 years after my misdiagnosis of T2, and honestly I was having diabetes symptoms for 5+ years before that, so true honeymoon period was probably a decade with late onset T1 for me, It was a slow depletion of insulin production. Also, with LADA I think going low carb and exercise is a good way to keep your body's insulin production going longer. Anyway, IMHO the percentages are bull crap with high exercise, low carb dieting, and/or a late onset T1 slow honeymoon.

Figure out your basal and then figure out your bolus, and don't worry about what the percentages are. Understand the advantages of a pump and if you have problems that those advantages will help, then give it a try. I love having a Dexcom though. Even if I only used it once ever few weeks, it is a very useful tool.

IMHO insulin doesn't necessarily make one fat. You get fat if you are taking too much insulin and then eating carbs to counter a lot of lows, or you get fat from eating too many (especially carbs) calories. A low carb diet with lots of salads and fresh greens plus exercise is generally going to keep the carbs down. If I don't eat simple carbs, I can eat almost as much food as I want. So don't worry about taking the insulin you need. Worry about your food intake.

14

I'm a later in life T1/LADA. Dx'd at 60. Control for me came with education, lots of testing and willingness to micromanage my basal/bolus regime. Using Insulin and Think Like A Pancreas were my two reference manuals. Now that I'm pumping, it Pumping Insulin. The true lightbulb went off when I got a dexcom G4, and I'm very glad I got the CGM before the pump.

The info I got on what my meals did, what activity/inactivity did to my numbers, and how time of day changed my sensitivity to insulin was huge. I still have a low TDD (less than 10U total) at this point, just 2 years in, but that may eventually change. The more normal I can keep my numbers safely, hopefully the longer my honeymoon will continue.

I don't worry about the 50/50 basal to bolus thing. I am on my feet all day at work so have a very low basal rate for the daytime, have a higher requirement in the evening when I veg a bit and then get a 4 AM darn phenomenon. With my pump I can adjust each time segment and minimize my insulin requirements. My bolus I:C ratios vary depending on time of day as well, so I can get best fit to my sensitivity at the moment. I'm currently about 40% basal, 60% bolus and that will vary depending on the meals I eat and when I eat them.

I will say that for me the microdelivey system the tslim pump uses has made a big difference in my insulin requirements. The general rule of thumb for a pump start is to reduce your MDI basal by 25-30% as you work out your pump doses. For me it was a 50% decrease with a slant set, only 30% with a straight set.

Activity/exercise can be usefully in stopping a meal time spike but I'm finding that it works best if you are out of shape. For me, as I get in better condition it has less and less effect on my post meal numbers, but does drive my basal down. What has helped my with my weight management has been portion control, not necessarily carb control. I find total calories are just as important for me as total carbs.

15

I don't have my reference books (I lent them to a friend who's son was just diagnosed with T1), but I'm pretty sure the average T1 TDD insulin requirement is about 2 units per kg body weight. So 15 units TDD would be the expected dosage for a T1 weighing only 30kg or 66lbs. So I think it is fair to say that pancreaswanted is still producing a fair amount of her own insulin. More fun yet to come...

16

I was commenting on 15 units as a basal dose, Jag. My experience is that insulin dosage has to do more with, as you say, endogenous insulin production as well as insulin sensitivity.

17

I also can't get a pump approved because of my "good control" (A1C at 6%) but I do have a half unit pen and I think it's a really important piece in my diabetes management. I think it's made for kids - bright green frog cartoon on the box!

My TDD varies quite a bit (7 - 13.5) depending on how many carbs and how much exercise. I'm pretty active and often have days like you describe above - just basal (7 units lantus, split dose) and exercise. I eat between 15 - 100 g carbs per day and my ratio is 1u:15g carb.

I'm also a late-in-life diagnosis (age 28), 2.5 years ago.

Good luck connecting with a half unit pen :)

18

Her setup was that she takes only basal, so only 15 units per day and no bolus insulin. Thus she is taking a TDD of 15. There is certainly a range and no one should expect an average to hit their numbers spot-on, but I'm certain the 2 units per kg body weight is for T1 not overweight (i.e. nomal insulin sensitivity). This was in the Walsh and Hanas books if you have them to check.

19

Ok, my math can't be this bad: If someone weighed only 30 kg and the "prescribed daily dose" were 2 units per kg, wouldn't their TDD be 60 units, not 15??

I just checked Walsh, he has a table on page 109 of Using Insulin. He lists a starting dose of 16-22 for 55 kg (120 pounds) and 19-26 for 64 kg (140 pounds).

I wasn’t debating that Walsh lists this formula, only that, in my own experience the various formulas in Walsh are less useful than trial and error as there are more variables than weight, and insulin sensitivity and endogenous production are more significant (though harder to quantify).

20

Yes, of course, you're right. It's 1 unit per 2kg, not 2 units per kg. (The numbers I gave for OP were correct, however - she would be 66 lbs). That's why I always like to refer back to my books. I've only been without them for a week and am going through withdrawal. I don't want to ask for them to be returned, though, since I know how hard it must be for the dad I lent them to.