Hourly bolus rates

Type 1 and LADA
1

Hey guys, im new to this forum, need some input… my daughter has been a diabetic , type 1 since age 7.she is now age 18…
her basal rates have had to be increased almost every year… she is now at 2. 0 to 2.5 basal hourly… if we cut back like her doctor wants to 1.0 hourly, her sugars go out the roof and they are unstable…

she had a bad A1C lst week at doctors visit, 8.5… but this is her first year in collage and working fulltime also and not eating as healthy…
the doctor really came down hard on her, which I disagree with… so much stress and still in teenage years with growth hormones, I feel if we cut back she will be spending all her time taking corrective doses…
the doctor told us average for basal is 0.9 to 1.0 an hour which I just do not know if I believe…
I am a MT in a hospital LAB and my experience is with age under 20, stress and not been able to eat as healthy is causing the increase in A1c…
And Im not sure I can believe those very low basal rates…
any thougthts??

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Hard to know exactly why the Dr is recommending this. Basal isn’t determined by some abstract “average”–average for what? Everyone’s metabolism and insulin requirements are different, so that part of it doesn’t make sense to me. I know there is a general rule about not “relying too heavily on basal,” and that with a “normal” diet (i.e., one that includes significant carbs) basal is expected to be 50% of your TDD. That’s an issue for those of us who stick to low-carb diets. I’ve had my own conflicts with endos about that over the years. But it doesn’t sound like she’s eating LC/HF. Did the doctor give you a reason for keeping it so low? Too many hypos maybe? Though again, with an 8.5 A1C that doesn’t seem like a real concern.

I don’t like to tell anyone they should ignore what their endo–I assume that this is her specialist?–is saying but in the end it’s up to us who have to live with this condition 24/7/365 to get these adjustments right. Doing that well requires a partnership between patient and specialist, but this sounds like the communication is all one-way.

ETA: It’s clear you meant to say hourly basal in the title. Everyone makes that mistake once in a while. :slight_smile:

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I don’t have an answer for you but I sincerely believe that the body needs what the body needs. A fingerstick will likely reveal whether insulin, both basal and bolus, are sufficient. If your blood sugar is consistently too high, you need more insulin.

If your daughter has gained weight since starting insulin 11 years ago, this may be a part of this problem. If she is 20 pounds or more over-weight she may have become resistant to her insulin. While this is not the defining characteristic of T1D, it can happen. Luckily, insulin sensitivity can be restored.

I’ve lived with an 8.5% A1c and I did not feel well. Cognitive work like academic endeavors is more difficult with high blood sugar.

The best thing would be for your daughter to educate herself about how she needs to take care of her body with respect to blood glucose. Learning what’s required could enable her to make her own decisions about how to treat her diabetes day to day. Diabetes, as you well know, is a 24/7 affair and even the most dedicated doctor in the world cannot be at your beck and call that often. So she realistically needs to step up her game and be her own agent.

Diabetes demands many decisions every day. If you decide not to pay attention, then that’s a decision. And that choice has a high risk of proceeding down a slippery slope with a string of secondary complication diagnoses. It is the secondary complications that are the real threat of diabetes, any type.

If she’s interested in gaining the skills needed to run her own show, I recommend Scheiner’s Think Like a Pancreas and Ponder’s Sugar Surfing. An even better book for her current state of mind might be Eichten’s The Book of Better, Life with Diabetes Can’t Be Perfect, Make it Better.

Finally, if your daughter has gained an extra 20 pounds or so and would like to improve how she feels, I recommend adopting a low carb, high fat diet. It’s a way of eating where you eat until you’re satisfied, there are no calorie limts, just carb limits. Many of us here use this way of eating to good effect. Good luck. I hope your daughter is open to changing her path. As humans we much prefer the devil we know to the devil we don’t. We don’t like to change, especially changing our eating habits.

Please report back if you need any further info or help.

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I agree, she is the one living with it and I think every diabetic should not be “pooled” together each person has a different system and nothing fits into one model…

She has had only 1 low this year and 1 low last year… she is not eating as good this year due to 1st year in college and now working full time…so, that is something that she can work on…

But, I just have never seen where the average rate is that low… and do not know what he is getting his numbers from, it has always been a sore spot with doctor…
but , when he turns those basals down so low, her sugar levels are out the roof and that is eating a good balance, with one cheat meal…

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Ok, that’s kind of disturbing. Is this a specialist or just your regular GP? This increasingly sounds like something a non-specialist might have hit on as a guideline, or a pediatric T1 thing that has outlived its applicability to your 18 year-old, or some combination of the two.

I’d like to see @rgcainmd or someone with more experience in pediatric T1 treatment weigh in because to me, a T1 for 33 years and a pump user for 3 years it doesn’t make any sense. An average has to be an average OF something. So… “average” for someone of her age, weight, activity level I guess? Even so I don’t get it. Other things being equal, if your A1C is too high you’re not getting enough insulin to cover your carbs, basal and otherwise. Assuming the doctor agrees that >8 is not acceptable for a near-adult (that’s not a rhetorical question), then what IS he or she recommending to get it down into an acceptable range? A different insulin-carb ratio setting? Bigger boluses? If you take less insulin, it’s going to get worse not better–that’s as basic as it gets.

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He is specialist Ped. Endo.,
and this is a sore subject between me and him…
And I agree A1C needs to be in 7 range, but I do not think changing basal is the miracle cure, getting a better eating schedule now that she is in college and taking time to eat right, should be top on the list…
I am thinking about going to our GPA, I do know I had to request a wanting a MIcro Albumin and vit D check…
I read that vit D has a tendency to become low with diabetics, and for that matter general public too.
she is low on D , but everything else LAB wise looks really good, her thyroid panel, Chol, Trig, etc… all are very good

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A1c should actually be < or = to 6.9.

To the best of my knowledge, there is no “tendency” for Vitamin D to “become low with diabetics”.

This however can be true, depending (in addition to other variables) on one’s geographic location and the amount of sunshine to which one is exposed.

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I think a good place for your daughter to start is with basal testing. Without a reasonably accurate basal rate, all other variables (I:C ratio, ISF) are going to be off. While I think adopting a more LCHF approach to food is great, it won’t matter if your daughter is eating a “healthy” or “unhealthy” diet as far as her A1c is concerned if she is not utilizing reasonably accurate I:C ratios and Correction Factors (which again depend on having a reasonably accurate basal rate).

Does you daughter utilize an insulin pump? If not, what insulins is she taking?

What is her ISF (a.k.a. ICF)? Her I:C ratios? Her basal rate(s)? What is her average TDD?

Does she use a CGM?

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Forgot to say WELCOME TO TuD, litaker66! :confetti_ball:

That should have been my first comment… :wink:

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Ack–mine too. Welcome @litaker66!

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Do you know where this “average basal” her endo is talking about comes from? I assume there’s some reasonable medical explanation but as it stands it doesn’t make sense to me.

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Did you mean for this question to be directed to litaker66?

(I constantly find myself making this same error… :unamused:)

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No–I thought you, as someone conversant with the pedo endocrinology world, might know why her endo is trying to fit her basal profile to some “average” rather than to what her actual test results are indicating, which is what she seems to be saying. Maybe I’m just misinterpreting the word as she’s using it, but I don’t think of basal adjustments in terms of some kind of “average” you’re trying to hit; you’re setting different rates that track with your metabolism through the diurnal cycle and keep your fasting BG at a normal level–“average” doesn’t enter into it. Seems crazy to me, but that makes me wonder if I’m missing something that might sound more familiar to someone in the pedo T1 world, like maybe there’s some general guideline…? Clearly I’m groping to make sense of it.

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I have nothing to add except I think you have already gotten good advice here. I don’t know why she would be told to set her basal to the average. Everybody has different basals, that’s why there is an average. And welcome to the group.

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I’m thinking what you’re thinking, DrBB. I’ve never thought of the amount of basal insulin a person uses in terms of an “average” or “target range”.

The only thing I can think of is that the OP’s daughter’s basal rate is on the high side, so perhaps her endo looked at her graphs (if she uses a pump or CGM) and felt like she was using a high basal rate to compensate for a too-low I:C or ISF. This is about the only sense I can make of it…

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That certainly sounds right, particularly the last part of it. But the more I look at this the more it seems like what the Dr may be concerned about is not so much the daily basal average per se, but the ratio of basal to bolus insulin as a signal of where that < 8 A1C is coming from. If your daughter is eating a standard teenage diet and not avoiding carbs, then the bolus-to-insulin ratio should be about 50/50. But bolusing accurately is the really hard pain-in-the-a** part of all this, and I think especially for a teen the temptation to just crank up the basal and rely on that to keep things more or less in control is pretty strong. If that’s really where the problem lies the Dr is basically right that you don’t want to “fix” it by just dialing up the basal rates even more. It should be dealt with by (as you say) getting better management of her diet, but also knuckling down and getting more disciplined about mealtime boluses for what she is eating. Does any of that fit?

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Hi there.

I don’t think I’ve ever heard anyone state something about an average basal rate. I’ve heard people suggest there should be a relatively even split between bolus and basal rates - not necessarily 50/50, but not 10/90 either. Caleb’s endo did a calculation of his body weight to his basal insulin and came up with something that validated his basal dosing. I don’t remember the calculation. But a blanket average? Within the context provided, this is making me scratch my head.

@Terry4 recommended Gary Scheiner as a resource, and I strongly second that suggestion. His book is fantastic - it’s very relatable, understandable and provides specific suggestions that are very useful. I attended a session of Gary’s at Friends for Life several years ago and took copious notes which included his suggested calculations for anything and everything related to dosing - or it seemed like it had that great of a depth at the time. There’s a power point presentation of his out there somewhere which goes over these calculations.

A friend of mine uses his services quarterly to review her daughter’s dosing and swears by it. She pays out of pocket and feels it’s worth every penny. I think your daughter could be a very good candidate for this kind of consultation. They do them in person and also via Skype. I have not used them myself, but have considered it. It’s something that might be worth considering. It’s not something you have to do regularly, so even if it’s a one time deal to get their input, which I find to be exponentially more credible than her endo based upon what you’ve stated here, it might be a great starting point for her.

Integrated Diabetes Services

I have no affiliation with them whatsoever. Gary has done live interviews here which are probably archived - @MarieB - is that something accessible?

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yes, there’s a lot of them Here
unfortunately the subject matter discussed isn’t so evident from the titles & description of the individual video. Like, “this is the one where he shows the new CGM”

but they were some of our best attended interviews and he is focused on type1.

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So sorry to say there is no correct basal rate for a person of a certain age. I wish, it would make the whole basal testing so easy. Just put in your age and get a number. And while there are formula’s used to help give someone a starting point, nothing with diabetes is pure science. So many variables.
I will tell you when I went away to college, my insulin needs went through the roof. It was back in the old day with just 2 injections a day but between the stress and the food and the drinking ( yes Mom I did drink! But back than the drinking age was 18 where I went to school). And while now, if I took that much insulin, I would be low all the time.
I think this is time for your daughter to have a talk with her doctor about what her goals are and how they can work together to make it happen. If she is comfortable with her numbers where they are at right now, he needs to help her maintain. If she wants better, he needs to help her get there. They really need to be having these talks about her diabetes and what she is willing to do right now. Reality is, it’s her diabetes and as hard as it is for a parent to let go, she needs to start advocating for herself.
I really didn’t start getting on board with intensive insulin program until I was around 19 or 20. And I did come around. Doing great, wonderful family, no complications and control right where I want it. Not where everyone else thinks it should be but where I’m comfortable.
So if 2.0 per hour works for her, great! Go with it. My thinking if it works don’t rock the boat. I really think you are all doing a great job with a horribly complicated disease. It will come in line. Hang in and would love to hear how her talk with her doctor goes.

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Yep, that is what works for her 2.0…
With college and working fulltime, her stress levels are high…
In not real happy with her doc. Thanks for the input