Exercising & Type 1

Type 1 and LADA
1

Hey gang -

If you read my last discussion post, I am attempting to "understand" my body and make my diabetes management a reality.

My 2AM sugar was 76. I felt really terrible. I ate a small snack and dosed for it. I woke up at 9AM and had a sugar of 198. Ate a small breakfast, dosed accordingly. Went for a short run (1.5 miles). Checked sugar at 11:30 and my sugar was 262.

I've always been an avid runner. Is this something that I should consider changing?

MH

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2

You probably feel pretty terrible at 76 because you're so used to running high. The first thing you need to do is SLOWLY bring down your highs. This will make a moderate low of 76 less debilitating. When I've previously let my care slip, the HARDEST part I had was how horrible I would feel at, say, 130. When you bring your BG down suddenly after running high for a long period of time, a 130 can feel like a horrible low!

Are you using a pump or MDI? If you're using MDI, it sounds like your basal insulin might need to be increased or you could benefit from splitting the doses.

Keep in mind that for T1s, not all exercise is created equal. For me, a short, fast run will cause my BG to go up, not down. Conversely, a long, slow run by myself will cause me to go down. Yet another twist, an adreneline-packed road race (regardless of distance) will make me soar into the upper 200s.

Bottom line: You have to experiment and find what works for you. Annoying, I know, but I like to think of it as a game sometimes, a challenge if you will.

Regarding the 9AM 198 - did you dose for the whole snack, or just a portion? When I'm low at night, I generally try to just eat something really small, just enough to bring my BG back up to a safe range without dosing. But I use a pump, so my basal rates are automatically programmed to increase a bit in the early AM.

That all said, I am far from perfect....especially considering I just checked my BG and it was 260. ARGH.

3

My goal right now is a BGL of 120. This is what I am striving for. I did dose for the whole carb ratio with the snack...

I am currently dosing like this:

Lantus: 45 units at 10PM.

Novolog:

My correction is 15 for my goal... (Ex: 320 BG - 120 Goal = 200/15 = Dosage.
and I am on a 10 carb to 1 unit of insulin.

4

Lots of things going on here. First thing that jumps out at me is whether your insulin to carb ratio is correct. What did you eat for your small snack at 2 a.m.? How many carbs? 9 am sugar of 198 could have been as a result of an under bolus and/or dawn phenomenon. Again, for the small breakfast - how many carbs did you count? What was your bolus?

Now on to the running portion of it. Busted is absolutely correct in that running impacts everyone differently. For me, anytime I run my BS drops dramatically. Figuring out how to tweak my basal rates (on pump) and my BS to make sure I don't go low on a run has been a challenge, but well worth it.

Don't give up. It's trial and error. You will get there.

5

My experience suggests:

a) skeletal muscle cells all have glucose pre-stored so depending how long one exercises, the temporary muscle glucose storage sites provide the energy. The Blood stream glucose does not get pulled down till more room in muiscle stores that then accelerates the glucose transfer. Available insulin affects this but latest data out there suggests that if muscles really need more glucose they will tunnel it into the muscle cells from blood stream - insulin be damed.

b) if you have cgms, are you carefully watching sequence of events?
how soon before exercise did you consume food. If you exercise too soon - under 30 minutes - one will cause stomach to rush stomach contents into intestine causing a glucose jump.

c) you may have something else here namely:
- initial exercise causes drop in glucose in blood till sub - 70.
- depending upon total nature of your T1 and insulin available, one will get a liver dump when BG is sub 70 and liver pushing up blood glucose back above 100 and higher depending upon insulin present and how liver deals with signalling. SOme times under low insulin levels, liver prone to dump whole/most of liver store on a dump.

From data provided - not clear what issue is here and why.

6

I am a runner too, I had a difficult time dealing with my basal insulin, ( lantus for you Ultralente for me back then.

The trouble is that when we run our insulin resistance is reduced and our need for insulin is reduced as well.

I am on a pump so I can reduce my basal insulin to only 30% of what I normally need.
and continue that for 2 hours after.

It is much more difficult to manage lantus this way because you can't reduce it for exercise,

The best way to do it is to bring some carb gel with you and learn how much you need to stay in the normal range. Maybe half a packet per 2 miles or so,

On days that you run you can reduce your lantus a bit too.

You look young and thin, I'm guessing your carb to insulin ratio is too low.

You can easily test it, Start in the morning with a stable sugar, say 100.

Consume fast carb of say 30 carbs, Juice or something sweet works best.

Then wait 30 min and see the result. You will be able to see how 30 g of carb will raise your sugar, Then you will be better able to correct it ahead of time,

Then take the appropriate amount of insulin, for you it would be 3 units for 30 carbs which sounds like a lot to me. After about an hour more you sugar should be where you started if the carb ratio is correct. If you end up low, then you should change to maybe 12 to 1 or 15 to 1.

You need to start out stable and use a fast acting sugar, If you eat a meal the sugars will late longer to metabolize.

I have calculated my ratio to be 16carbs to 1 unit, On days that I run( about 7 miles) I change my ratio to 20 carbs to 1 unit.

When I was taking my injections I split my dose, I took half in the morning and half at night, It gave me better flexibility,

It will take a while to find your exact ratios.

It is also likely that you are going low at night and your liver dumps sugar to compensate and you end up high. It would appear you did not bolus enough, but it is just as likely to be you bolused too much.

If you could get a CGM you could see it more clearly. Either that or test more often,

7

I have had many similar experiences while taking Lantus. Fewer, but still too many since I have been pumping.

In my experience, Lantus isn't really a 24hr insulin, or a flat basal. 3 endos have told me that some or most of their patients take it twice a day. I was getting low after taking it in the morning, then high at night. My A1c improved after I broke it up.

I find my BS crashes immediately after exercise, then again, 24-48 hours later, it suddenly drops about 200-300 points. I feel that it is very hard to tack any sort of true, stable "fasting" BS. It swings up and down very easily and violently.

I have been t1 for 25 years. Mostly poorly controlled, for various reasons. I believe that I have avoided serious complications so far, because I've always kept in shape and exercised regularly. This is based on my anecdotal, rather than any scientific evidence that I know of.

Right now, I am trying to restrict my carb intake and take less insulin. Currently I am 185 lbs and using a little under 20u basal / day. Trying to follow some of Dr. Bernstein's advice. I assume you're eating a lot of carbs and taking pretty big shots. I'm thinking that with less insulin in my system, exercise will not Drop my BS so dramatically and unpredictably. I hope it works.

8

I agree w/ the other suggestions, as if I ate at 2:30 and bolused and woke up high, I'd assume the carb/ insulin ratio was off and turn it up a notch and try again, although I generally don't test in the middle of the night because well, I'm lazy.

Another question would be "what is a small [snack/breakfast]"? You mention "dosed accordingly" but, if the post eating BG was 262, it may have been more like .5-.85 accordingly, depending on the particulars?

I'm still a pretty avid runner. Today, my BG was running up in the AM so I ran and then came home and ate and it worked out ok. I'd keep working at the BG numbers. One thing that I picked up online is that sometimes it can work more effectively to focus on one number at a time, like "after lunch" and keep investigating the ratios until it comes out where you want it. Then do 10 celebration pushups and move on to dinner. Breakfast is particularly annoying and probably the most work. Or basal insulin, that can also be a project that can, if not correct or at least in the ballpark, throw off the rest of your numbers?

9

Why in heavens name were you up at 2am in the morning? If your goal was to raise your blood sugar from that 76 reading than covering the snack you ate (injecting insulin) was probably a mistake. If you overdid the snack (the whole bag of pretzels versus only 5 of them) then coverage was probably a good idea. So the answer is relative to why you covered...

The readings of a single day are difficult/impossible to pin down EASILY. That is why 3 days are the usual recommendation of how much data to collect before we make the big decisions/changes.

Your "spike" could easily be a byproduct of your run, and represent an adrenaline dump caused by the intensity of that specific run.

The 262 could be a bounce caused by a low you detected the remains of at 2am. If you had checked at 115am instead maybe you were far, far lower... by 2am, your body was triggering your liver and adrenaline system to save your butt, rescue you?

The 262 could be misjudging what was in breakfast or the time frame that breakfast got broken down into your blood sugar. More fat, more protein something that's usually quick fast spike of BG takes a while longer to be broken down because the protein/fat alters the process, extends it.

The 262 could perhaps be the result of low you never picked up and the 262 is a bounce and is only surfacing on your radar and you by luck just happened to catch it this time.

Myself, I would literally not worry in the least about any of those readings initially. Collect data for 2, 3 days and then crunch them, pin them down.

When are you taking your lantus, your long acting? For most there is a gap in the 24 hour coverage that is promised. Depending on when you shot the lantus, maybe the 262 was when the lantus was off line and the gap began.

Too many what if's for just one days numbers...

Jeff

10

I am not sure about the order of your goals here. Yes, exercise is important and it will help you to improve your glucose control. This will work by increasing your muscle mass and your basic metabolic rate. The muscles can act like a buffer for glucose and the higher rate will make your more sensitive to insulin. The problem is that excercise adds another variable to your life. Right now you are about to understand how your body reacts and I really think you should focus on that.

The most imporant goal is to find the correct dosage and application pattern for your basal insulin. Your needs of basal insulin must be covered for all 24 hours of the day. This means that you should be able to just inject the basal insulin and have 1 day without eating and your blood glucose should be stable the whole time. Of course you do not have to fast for 24 hours. The basal rate test can be done on two days. On the first day you do not eat for 12 hours and on the next day you do not eat on the second half of the hours. The outcome of this experiment will tell you about the quality of your basal coverage. Likely you will find that Lantus does not cover all 24 hours for you. This will show with a rising glucose level just before the next injection of Lantus. If your basal coverage needs an improvment you have these options: a) two shots of Lantus every 12 hours. You distribute your current dosage on these two shots. b) you switch to Levemir and inject two shots every 12 hours. I would recommend option b) but please consult your medical team with your findings about your basal coverage first.

The second goal is to find the correct I:C ratio for every hour of the day. These ratios are also depending on the active basal insulin in your body. Thus you need to find the correct basal dosage first. You start with the meal times and the ratios between these times can be found by interpolation. For the I:C you will eat defined amounts of carbs like 10g (the same food, the exact same amount). Then you try to find the right I:C to cover the carbs in this meal. If you manage to reach your target glucose after 3 to 4 hours you have found a good ratio (fine tuning will optimize them later). If you experience a spike within this time that is too high (higher than 160) you should address that too. The solution is a waiting time between injecting and eating (like 10 minutes, not more for the first experiments).

After these goals are met you can intensify your excercise. At least it would help to focus.

11

I really like Holger's suggestion. Maybe it is just time to get back to basics. And starting with a basal test to get your basal levels straight makes a lot of sense. If you don't have the books "Using Insulin" by Walsh and "Think Like a Pancreas" by Scheiner on your bookshelf, get them and read them. Read them again if you already have them. Your I:C and correction factor will be different once you normalize your blood sugars.

signed ... the entity formerly known as bsc

12

LOL @ Tim.

I think I put UI and TLAP in the other thread but I agree with Tim(s) that those are great tools and I found them both awesome when I transitioned from winging it to (sort of..) winning it?

Another thing to consider if you find the prospect of adjusting things from 'woah' numbers to something closer to your goal all, or 80% or even 50% of the time is that insulin is strong stuff and even small adjustments can turn 'woah' into 'w00t' in no time, if you are organized and sort of methodical?

13

Honestly, I had a really hard time exercising when using basal insulin. I could do it, but it just required so much effort and planning. Pumping has made running infinitely easier. Have you considered a pump? The ability to adjust basal rates immediately before (or during) exercise is so helpful for me.

14

Holger -

Thank you so much for your advice. Thanks to everyone here. Today seems to be a much better day. I am ranging between 74 and 149.

I'd like to try this 12 Hour Basal Fast. I do have a question... I'd like to do it on Saturday and Sunday...

So if I took my Lantus at 10PM on Friday night.. I shouldn't eat anything until 10AM Saturday Morning.

When I take my Latus Saturday night at 10PM I can eat until 10AM on Sunday and then eat again at 10PM Sunday night?

15

Wow!! Congratulations!! That range is as good as one can expect as a T1 (IMO). Don't forget that all of us T1s, even if we're doing everything possible to "control" our diabetes, have days when we're off. I had one such day yesterday. Despite my best efforts to carb count, diabetes was just NOT playing fairly. Keep in mind that even if you do everything right, you're going to have days when all those other factors (hormones, weather, stress, etc) muck up your control.

Have you considered an insulin pump? Is that an option for you? In terms of exercise, they really are great tools.

16

@Matthew: roughly it is like you describe it. I would just like to add that it is recommendable to have no insulin on board when you start the fastening period. So your last bolus injection on Friday should happen before 7PM. The last injection on Sunday should be before 7AM. Well, maybe 8AM - it is Sunday ;-)

You should stop the experiment if you need a correction. At the beginning a correction might be acceptable but not in between. Your goal is to find out if your basal needs are covered. With additional corrections this will invalidate the experiment.

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Fasting that long, will glycogen interfere with the experiment?

18

Come on - just 12 hours.

It is not likely that the release of glycogen will interfere with the experiment. Even small amounts of basal insulin will block the liver from releasing more glycogen than the usual amount by the minute. Thus this helpful reaction is broken in insulin dependend diabetics. If there is a gap in basal coverage the basic rate of the liver will cause a nice high. I do not think that the liver will release more when the glucose is already on the rise. The hormonally induced dawn phenomen (DP) from 5 to 8AM might be tricky. In the DP the liver will mobilize more glycogen to prepare us for the day (we had no breakfast for millions of years). The extend of the DP is very individual and the experiment will show it.

19

Actually, I was thinking that the liver will release more glycogen, once it senses that the stomach is empty. The insulin will block this as well?

20

RE: sams comment about glycogen,
Glycogen is dropped when your sugars go low,it has nothing to do with being hungry or your empty stomach. The presence of insulin blocks its too, so the basal insulin should prevent it.

Of course if you go low during your experiment you should eat something and try another day. But that would show you that your basal insulin is too high, at least for that timeframe.

When i was diagnosed, I had to sit in the hospital for 2 days while we worked out my basal needs. I know they dont keep you in the hospital for that now, but I know many will hang out at the doctors office for a day while it is figured and tweeked.
Did you ever do anything like this? It's fine to do it on your own, but a doctor or a RNP or even a diabetic educator could help make the process easier and more precise.