Highs and Lows

I have at least one high (over 190) and one low each day (60 ish). I am starting to think that is not normal as I feel others have much better control than I do. My last A1C was 6.6, but I am not thrilled about that either.

So am I in the norm for my treatment of Type1 using a pump and bolusing for meals with varying outcomes?

I just want to fit in. :wink: and I am curious about other Type 1 diabetics.

With a pump you should be able to achieve more stability than that. But your basal rates need to be right. Are you satisfied that your basal rate is correct throughout the course of the day? You can test it by skipping a meal and monitoring your blood glucose for a few hours. The other way to reduce variability is to reduce carb consumption, together with the corresponding boluses. It reduces the post-prandial spiking, as well as the depth of blood sugar valleys.

I’m not convinced that a pump will necessarily be the answer to all your issues – most of the clinical research has proven that the biggest benefits of pumping are realized in people who have poor control to start with (A1c’s of 9 or more), their need for basal insulin varies significantly throughout the day, or they need dosage precision greater than 1/2 unit (they’re very insulin-sensitive). However, for smoothing out the peaks and valleys, you might consider adding Symlin to your treatment plan – once you get over the nausea, many people have found it works wonders as far as smoothing things out.

Also, you should know that JDRF-funded studies find that even intensively managed people – doing 9 fingerstick tests daily – spend less than 30% of the day in a target glucose range (70-180mg/dL). Similarly, the NIH-funded DirecNet found that children with an average A1c of 6.8% – which is still decent – still spend nearly 9 hours per day above 180mg/dL. The key is that glycemic variability is significantly higher in type 1 than it is in type 2.

Dr. Zach Bloomgarden, a New York City endocrinologist with a huge clinical practice (over 1,000 patients) and is noted for his many articles on diabetes (nearly 250), and has also written over 150 columns, “Perspectives on the News” for Diabetes Care since 1994 described it this way:

“Type 1 diabetes is a hugely different burden from type 2 diabetes, and the easiest way to quantitatively understand that is to have a thousand patients or so with diabetes that you treat for years and download their meters day after day after day – when you do that, you’ll find that the standard deviation of the blood sugars in a person with type 2 diabetes is 10 mg/dl or 20 or at most 30 or so. The standard deviation of the blood sugar of someone with type 1 diabetes is at least 50 or 60 and often 90 to 100. So that translates into just huge, huge variability in blood sugars.”

The simple fact is that variability is more the rule than the exception with type 1, so don’t feel like your alone on this, or that its somehow not normal. Chances are, someone claiming not to show that much variation is probably not being honest. Carb reduction will reduce the variability somewhat, but the question is whether you really want to live with that kind of dietary limitation?


I think I must save your response some where, it made me feel so good, thank you. I will print and hang. :slight_smile:

I know low carbing is key (even though I soared on a salad the other day) and I am pretty sure my basals are good even though lately things have been changing for me big time, perhaps age, or insulin resistance, or, yada, yada, yada.

Thanks again

I beg to differ. Blood glucose variability is largely avoidable, especially if you are using a pump. The main reason why T1 diabetics using a pump are able to achieve much better blood glucose stability is that basal rates can be customised. As a T1 using MDI, my HBA1c is normally 6.0%-6.5%. So my control is acceptable. But it includes a huge amount of variability. This is because my basal rate requirement varies between .25 and .9 units an hour. I discovered this when I trialled a pump. There is no way that this variable requirement can be catered for using Lantus, without there being inadequate/excessive levels of action at different times of the day. The result is that blood glucose is either going up or down - lots of variability. When I got the right basal rates dialled into the pump, the stability in my blood glucose was uncanny. I would wake with my blood glucose at a similar level to what it was when I went to bed. And it moved in a very narrow range during the course of the day.

Unfortunately I could not keep the pump for financial reasons and I am back on MDI, using a Lantus/Actrapid basal insulin coktail that approximates my requirements. IMO, there can be no doubt that a pump is by far the best insulin delivery mechanism, and that it affords very stable control when it is used properly. Having said all that, reasonable stability is also possible with MDI but more reliance on low-carb eating is required.

Don’t fret–i have found that this site has many people that focus more on the victories than the defeats. I used to be just like you, and many weeks i still am—only my high was closer to 240— The CGM helped me tremendously…but it took a good 6 months to get there…of course i still hit 200 or more on occasion-never less than one time per week… and i go low at least 3-4 times per week—usually my own fault…

CGM has taught me that i have to bolus 30 minutes b4 i eat…if i do, i wont go over 170—if i dont i will easily hit 240— i often bolus, get distracted and dont eat…then go low. Also i have become fond of the combo bolus/square wave/dual wave—that seems to help a ton. I read today that for high fat meals, you should bolus then increase your basal by 60% for 8 hours after you finish eating—i may try that instead of the combo bolus and see how it works

Like most diabetics, and everyone out there, it is practically impossible to be right on all the time, or be on any resemblance of a ‘schedule’. I have read on many blogs, that what hurts you the most is hitting 180+ and staying there for hours on end…8+ hours straight…that is where the real damage starts to set in. I am almost sure Jenny wrote a post about that…but it was a long time ago… Jenny seems to know her stuff…so that made me feel alot better.

I am on the pump and have 8 different basals, I just feel that after 41 years, it becomes harder instead of easier. I totally agree that a pump is the best form of insulin delivery, but I can do the same thing every day and have different outcomes after I eat. With the sensor I have been doing a bit better, but it still cannot fix a high if you are heading that way it only tells you that you are going there and you can bolus to correct a bit sooner. I geuss I want perfection, and that will never happen with diabetes.

I do that for pizza, bolus for all the carbs upfront and then double my basal for 3-4 hours.

I agree that it seems to get harder over time. I have been at it for 30 years now, the first 20 of which I easily achieved good control. I ate what everybody else was eating and my HBA1c was consistently good. It has become a lot more difficult during the last 10 years, and there comes a time when you have to start doing things differently. For me, eating low-carb made the difference I needed. People using pumps often eat liberal amounts of carbohydrate and rely on extended bolusing, temp basal rates, super boluses etc. to manage the glucose challenge. I couldn’t get these features to work for me. But I achieved stunning control when I cut the carbs out.

I know you are right Mark as when i stick to 30-40 carbs per meal, things work fairly well, but for some reason I am having a lot of issues lately even with that. Thanks for all your replies and help.

That’s why I noted that the biggest benefits of pumping are realized in people whose need for basal insulin varies significantly throughout the day, as well as those who start with poor control, or those who are extremely sensitive to insulin and need dosage precision of less than 1/2 unit. But like anything with managing diabetes, there is no rule which applies to everyone and the same applies to pumping insulin being a great benefit to everyone, or improving control. I wore a pump for 5 years and found it did nothing for me in terms of improving control; when I returned to MDI, my A1c did not change. But in my case, my basal rates are extremely low and change very little over 24 hours except for overnight. In my case, Lantus is the worst possible replacement, but NPH works like a charm – for as long as its still available. Not everyone needs 24 hour basal coverage, but the drug industry hasn’t acknowledged that fact yet.

Karen, I keep very thorough logs that include what I ate and how it affected me. The next time I eat that same food I look back at my log an see whether I need more or less insulin than I did previously. This, in addition to what the others have said, has given me very good control with my pump. I stay in the 70-130 range about 90% of the time and my highest and lowest numbers have been 154 and 59 over the past 4 weeks. My latest A1c was 5.7. I had a bad start with pumping and it has taken more than 6 months to get to this stage . Good luck to you!


Funny you should mention logging, something I don’t do. At the Diabetic Expo last weekend I picked up a free one to stick in my purse and I am starting to log today. I also got the free download tool for my pump from Minimed last week, but that does not show what you ate just the carbs you entered and that to me does not always matter, I need to log the actual meal. I have to quit being a lazy diabetic.

Thanks for the reply.