I have been struggling in the last six months with over-treating lows. Are there any tricks or tips some of you guys have had success with?
My basic problem: My CGM will ring and tell me that I’m approaching a low. I realize that I still have a little insulin on board and that starts the 1st moment of panic. I’ll pop a glucose tab and wait a little bit and if my blood glucose gets anywhere under 70mg/dl my body starts the 2nd panic.
In the past six months it’s been pretty consistent that every single hypoglycemic incident I face is followed by a high.
One of my major roadblocks, I believe, is that I don’t know exactly how many glucose tabs to eat for a specific low. How do you figure that out without “experimenting” while low? I know that my insulin/carb ratio is about 1:10.
Aside from figuring out how many glucose tabs to eat, I also need to figure out a way to STOP eating after I eat the proper amount. What do you guys do?
I’ll eat more tabs (like two) if I’m under 50 mg/dl and verified by a finger-stick. I don’t follow the 15:15 rule. For me that’s over-treating. I’ll chase with a glass of water if under 50. Don’t use the CGM number for additional low-BG treatment decisions. I’ve made this mistake more than I care to admit. It’s led me to eating more glucose in response to a CGM time-lagged low number when a fingerstick would reveal a nicely responding uptrend. Always base low-BG treatment decisions on fingerstick numbers and wash your hands after handling glucose tabs and before testing.
If I feel like I’ve over-treated, I immediately add insulin to counteract the expected high.
If I’m at say 60 and my CGM approach line is shallow, I will only take one glucose tab and wait. If I’m at 60 and the approach line is steep with some IOB, then I’ll start with two tabs.
Are you confident in your duration of insulin action setting on your pump? A valid IOB number is helpful when deciding how to treat lows. If your DIA number is too short, it will undermine the validity of the IOB.
first thing i do is correct the lows. then i would think that if you are consistently having lows, you might want to change your basal rate, reducing it to protect you from having the lows in the first place. are you on the pump? or do you do MDI ? the pump makes all of this much easier.
as i am not a doctor, i would recommend that you talk w/ your endo and carefully map out a new plan of action. lows can be very dangerous.
I have a fair amount of hypo-unawareness. The good part of that is that I no longer have the desperate and terrifying feelings of lows. Gone are the nights of eating multiple bowls of Frosted Flakes at the kitchen table at 3:00am freezing cold in a soaking wet nightgown. Gone are the cups of juice followed by an entire box of Wheat Thins.
I think that I often under treat hypos. Technically 1 glucose tab should raise my BG 20 points, but that ignores the insulin that is driving my BG lower. I think that if I just ate 2 or 3 of them at the beginning, I would have fewer moderate lows that just won’t go away or turn into severe lows.
Although I use glucose tabs a lot and rarely drink juice, I find that juice in one of those 15 carb boxes works the fastest for me. (We don’t have sugared soda in the house, so don’t know if a real Coke or Sprite in the proper amounts would work as well.) IMO the faster you can get rid of the hypo feeling, the less apt you are to binge.
Now that I don’t have hypo binges, I still struggle with “regular binges” where one bite of a cookie, ice cream, etc. cause me to overeat. I need to confess here, Mike, that yesterday I had two chocolate-covered donuts and had to blame them on that darn Mike Lawson who talked about them on Facebook this week. They were really good though…
Back to your question, I don’t have much good advice. It has gotten easier for me as I’ve gotten older but that might just be hypo unawareness. It is a natural response to a low to want to eat everything in sight. What’s not natural is being able to just eat 3-4 glucose tabs as “medicine.”
I’m the last person to ask how to avoid overtreating lows. My wife chastises me for doing that as some lows tell my brain to eat a bunch of carby things, far beyond what I really need, but at the time it just doesn’t seem that way. Moderate lows I usually can more appropriately treat w/o going too high. Notice I wrote,“usually”.
In order to know how much a single gram of carbs will raise your blood sugar you need to known your ISF. Since your ICR is 10, let’s just say your ISF is 50. This means that a single gram of carbs will raise your blood sugar by 5 mg/dl. Bernstein recommends that a gram of carbs raises the blood sugar of a T1 from 5-10 mg/dl. But I think it is good to personalize this as saying that the ISF/ICR tells you how much a gram of carbs raises your blood sugar. This also means that in my example the 15:15 rule of taking 15g of carbs will raise your blood sugar by 45 mg/dl. As long as you don’t have insulin on board or are exhibiting double down arrows this should leave you pretty much good to go. But it is also important as Terry notes to understand the delays that occur in absorption and measurements. CGM measurements are delayed by perhaps 15 minutes as they measure interstitial fluid. So never use your CGM as a measure of whether your hypo treatment worked, always use your meter. And also understand that even if you use glucose tabs only a portion of the glucose will have taken effect after 15 minutes. If you are in a “safe zone” after 15 minutes (i.e. above 70 minutes) you might not want to treat further unless you believe you have marked insulin on board.
ps. As others have said, if you are experiencing lows after meals on a consistent basis it may mean that your duration of action is set too low.
One of the hardest aspects of the whole disease right there. Partly because most of the time you’re job is to resist the carbs, especially really sweet stuff, so when it suddenly flips from “I can’t” to “I gotta!” there’s the whole problem even non-D’s have of making yourself stop with this other emotional stimulus added on, not to mention there’s a significant lag between eating something sweet and shutting off that horrible “EAT NOW OR DIE!!!” thing that’s going off throughout your entire system. My own problem with it is colored by the far-too-long time I spent on R/NPH, which in ways too numerous to go into amplified this problem.
One thing that works for me: I actually hate the taste of those damn tabs, so the temptation to eat more than minimally necessary is, well, minimal. Also I’ve gotten better at just bearing down and waiting out the craving beast after I’ve taken whatever I think is necessary for the correction. Figuring that out is pretty individual too–I don’t know if there’s a single ratio number that always works no matter how severe the low is, plus having IOB is going to complicate that as well, and it’s not like my math abilities are at their best when that alarm system is firing all through my body. So I try to just treat minimally and give it some time. As long as you’ve done that you’re not likely to actually pass out or lose the ability to treat further if you need to. I have noticed that as soon as the plunge bottoms out and starts back up that feeling fades back considerably and is easier to ignore, even if my actual number is still down in the red. Which direction it’s moving seems to make a huge difference, at least to me.
Well, how severe do you mean? It is the nature of the beast to oscillate; we’re just trying to damp those down to stay within a certain range. I almost always find some degree of bump after this sort of correction, and CGM makes me much more aware of it so the temptation to whack it with a correction bolus is there, but you can really get on the roller coaster that way. Unless you’re soaring up into the 200s–in which case, yeah, you probably overdid it–it may just settle back from what your basal is doing.
Echoing some of what has been said . . . I basically do it by the numbers. One gram of CHO will raise me about 5 pts. (That’s based on empirical testing.) So I will eat enough tabs (sometimes need to break one in half) to take me into or just slightly above my target zone. Then I’ll monitor closely for the next half hour or so and if the response is sluggish, I assume the insulin is still working and eat another tab. Eventually I reach a point of stable equilibrium and can go about my business.
As for the temptation to overeat . . . yeah, that’s the toughest thing. If I’m low, I usually don’t want to be physically active anyway, so I generally plant myself in front of this computer and keep busy meanwhile. This has the effect of (a) distracting me, and (b) accomplishing some work. Of course, like everything else with this insane disease, it doesn’t work every time. But usually.
Have you considered raising the level at which you get the “approaching low” warning? Perhaps if you were given the warning sooner you might be better able to treat it “in moderation”?
Yep. To get an estimate (aka guess) on how much carb you need to raise your BG from the current low, your Insulin Sensitivity Factor (ISF) seems like the most reasonable starting point.
To estimate how much carb is required to balance any remaining “insulin on board”, you would turn to your Insulin to Carb Ratio (ICR).
Update:
In hindsight, I didn’t think enough before I posted. Brian is right that … at least going by the algebra … your ISF/ICR should give you a better guess on how much a gram of carb will raise your BG. In symbols the units are something like: ISF / ICR is (BG reduction/change per 1 U insulin) / (grams of carb per 1 U insulin) so ISF / ICR is (BG change) / (gram of carb)
Of course, the best way to see how much your BG is raised by a given amount of carb is to actually try it and see what happens. But the ISF/ICR value at least gives you a guess about what you might expect to happen, no?
Do you use a pump? If so, which make/model? I’m wondering how much help the numbers calculated by a pump’s “Bolus Wizard” might be of use to you in this situation.
In my case with my Medtronic pump I will plug in the BG value and a tentative amount of carbs like 10, 15 or 20 and then look at the confirmation screen which lists the “Active Insulin” and the suggested “Correction Factor” to guesstimate how I will respond.
Warning: Because of the wacky way pump’s can calculate the resulting “correction bolus” I pretty much always override what the pump suggests in the context of a low. Generally, I give myself less … typically a lot less such as 0.0 U … than what the wizard suggests because, heck, I’m already hypo or soon will be.
The main reason I use the bolus wizard is to get an idea about how much a certain amount of carbs will raise my BG as well as how much potential IOB there might be. The pump and I seldom agree on how to combine those values.
@mrmikelawson, as always when conducting science experiments on our own bodies, the first step is eliminating as many variables as possible.
For me, that means treating only with glucose tablets. Next, I frequently use my smartphone to give me a 15 minute alarm … “OK Google, please give me an alarm in 15 minutes.” Next, a bit of distraction helps … visit a website; watch a short video/YouTube/Vimeo; write some of the crazy, low-induced thoughts down (they can stimulate some good creativity later), etc, but don’t eat anything!
Yes, it takes some practice and yes, I am human, so I have my own weaknesses when it comes to treating lows, but this method works well for me. I typically find @ 60-69, I can treat with 3 tablets (12 grams). @ 50-59 I will use 4, sometimes 5 closer to 50.
BTW, my favorite non-glucose treatment is neither fast nor appropriate. I try to reserve it to a repeated low that I may get post exercise. 3 Chips Ahoy cookies and a glass of milk with 34 grams of CHO!
Unfotunately, I don’t think it’s as clear cut as you stated. none of this is linear. I too over-treat my lows, especially if I know I have just bolused and am already dropping (too much basal - too much prior activity). I see my CGM going low and I just start treating. When I start to feel the low I get really nervous. If you’re basal - bolus is off, you can’t count on anything scientific like this to figure out how much a gram of carb will or will not raise you. I use jelly beans if I’m just kind of low, glucose tabs and eat some protein if I’m low and have bolus on board and/or exercising. I never get the ‘starving’ feeling others talk about. I tend to feel nauseous when I’m low; I get a terrible headache, very bad - spotty vision and basically feel rather ill.
That’s good advice, too, Yoga…to try and do something to distract when going low. It’s a challenge to just sit there and wait, wait, pray, that your blood sugars are going to come up and you won’t just crash. This disease takes courage, IMO.
What I do when I’m dropping: immediately turn off my basal insulin for 15-20 minutes or longer and then treat according to my symptoms- if my finger stick and symptoms are ok I can always turn it back on right away or sooner.
If it’s a fast dropping low I treat with a larger amount and nearly always with liquid sugar as well as gtabs. Then when I’m out of the woods I turn basal back on and increase and or correct for whatever I ate or if I over-treated as needed. If I think I’m going to spike from over-treating(I think that term is somewhat misleading because some fast dropping lows need to have a lot of sugar thrown at them to stop them). I will also do some light activity or sometimes go for a walk.
For overeating when I feel very hungry I usually eat something fatty like nuts/chocolate/cheese and some veggies which will also help slow any spike for me.
If they’re always happening at meals I would investigate your dosing and what is going on with your digestive tract. If you are constipated/gastroparesis etc. you may need to bolus 20-30 minutes after you start eating and add more insulin in later. That is something I have been slacking off on lately and I’m going to start doing it again when it seems to be needed. btw- this doesn’t always work for me, cause my bg is just plain crazy a lot of the time, but it helps avert some disasters I’m sure.
I am somewhat an exception to the rule as I don’t use glucose tabs to treat lows. I use, fruit, juice, or bar sweetened with brown rice syrup or coconut sugar.
How I prevent over-treating is to eat 5 grams of carb worth…and wait. That’s the tricky part. I wait 10 minutes and, if necessary, repeat.
If I notice that the lows follow a pattern–time of day, relationship to exercise, etc–I adjust insulin.
i’m going to start doing this; eating first, maybe half, bolus, then finish meal. especially my lunch meal, that’s the time I’m having my worst lows. it just becomes a cycle, low, correct, too high, correct, try to eat…ugh!
Sounds like a good method to try. You might have too much basal on board; coupled with your bolus insulin leaves you with the classic mis-match between insulin in the bloodstream and the glucose it’s supposed to cover.
If you have a particular meal that causes you problem you might want to look at why you are having lows. If you are going low before two hours after your meal that might suggest that you are more insulin sensitive at that time of the day and that perhaps increasing your ICR might help. If you go low than go high then changing the timing and duration of your bolus might help (note that this type of issue appear to be overtreatment). If you are going low three or more hours after your meal that might suggest an issue with duration of action.
Correcting lows is complicated and there’s really no clinical formula. You can test your correction foods when your in range and have no IOB, you need to pick several diffrent options (like OJ , Dex4). If you still have IOB when you correct then you will also need to add the number of carbs needed to cover your IOB.
The time of day can impact what I eat, If I’m low at bead time I may also eat some cheese or peanut butter to stretch my BG rise out.
I’m very sensitive to Dextrose, 4 grams (1 Dex4) will raise my BG about 20 mg/dL in 2 hrs if I do not have extra IOB…If I have made a dosing mistake it’s just more compacted…YMMV
When I am low, one of the effects is lower willpower. If I start eating, I’m going to overdo it; this despite everything tasting terrible So I don’t treat a low with food; I treat it with glucose tabs. I do sometimes over correct with the glucose tabs, but not nearly as often (or as high) as when I eat.
My wife chastises me for doing that as some lows tell my brain to eat a bunch of carby things, far beyond what I really need, but at the time it just doesn’t seem that way. Moderate lows I usually can more appropriately treat w/o going too high. Notice I wrote,“usually”. 
So I don’t treat a low with food; I treat it with glucose tabs. I do sometimes over correct with the glucose tabs, but not nearly as often (or as high) as when I eat.