# How low is OK to go?

## I am with you 100%!

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Cleo - Standard deviation is just a way to characterize whether a set of data points, like CGM glucose data, is tightly packed close to the average or more widely dispersed. A tightly packed set of data points equates to a low standard deviation whereas a more dispersed set of data points will yield a higher SD.

I found this animation that visualizes it well.

I never took a college class in statistics and learned this concept solely from watching my CGM reports.

Is a DBE a diabetes educator?

Terry

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80 is not low. It’s a normal fasting glucose for any non-diabetic. Diabetics may need to worry about 80 only because it can be easy, depending on how much insulin vs. carbs are presently in your system and how physically active you’re being, to drop lower into an actually hypo range. My suggestion would be to observe your body, make your best guess as to the amount of insulin you have in your system vs. carbs and what you think you’re glucose is going to do in the near future based on that, and then correct accordingly. Be as conservative as you think is safe - for example, know about how much 1g of fast-acting carb will raise your blood sugar (if it’s stable), and eat an amount based on that and where you think your glucose is likely heading. Do you just need to stop any physical activity for 15-30 mins. and not eat anything? Or did you majorly screw up your bolus and need to eat one units’ worth of insulin in carbs? Or is is just going to go a bit lower, and you only need 2-4g? (I don’t use glucose tabs - Dot candies are my go-to - they’re 3g each. Fruity Lifesavers and Gin Gins are 4g. etc. If I need ~8g, I eat 1 tblsp jam or 1/2 tblsp honey/syrup.)

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Terry,

Thank you for the explanation. I get it. And yes DBE is a diabetes educator. Although now that I’m thinking about it a little longer, I think they are actually CDE, certified diabetes educator, yes?

That’s the title that sticks with me. But the organization that created that title decided that it needed to be changed. Now the official title is Certified Diabetes Care and Education Specialist or CDCES. Doesn’t exactly trip off the tongue, does it?

I think this is a branding failure. Lucky for us, they are much better at their job than they are at choosing their title!

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@Terry4 “slowly dropping into a hypo, I often find that I feel more alert and cognitively able”

I love that feeling! I don’t get it any where near every time I hypo but when I do it’s thrilling to feel so on fire. Always a pity it ends in a hypo

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This is one of those questions that there is no correct answer. Each person is going to have a different number, which will change over time. What your current treatment plan is, what your home life is like, new medications, new medical issue to deal with, how tight is the management plan? So this answer is different and varies. My goal now is different than it was 30 years ago.
And now with a CGM and a pump that turns off the insulin if I am heading down, these lows are not such a big deal. There are some that I do nothing for me just watch. Sometimes it takes an hour but it is great to not have to do anything but watch.
I also agree that treat and wait is the best thing and the hardest thing, especially when you just want to sit in front of the refrigerator and eat everything.
For me, it is glucose tablets. My favorite is currently out of production so I now use Smarties(the mega sized ones from Amazon), each has 3 grams of carbs, so one is sometimes all I need.
I will say to try and keep the variable down, I have my alarms set at 80 and 165 to keep things in a tighter line. But that range has been a work in progress and is always changing. This works well for me right now. But as with all things diabetes, what works well today might not next week.
Good luck with setting your goals with your medical team. And remember you know your diabetes better than anyone else. Even in a medical situation, you can push. I had to do that once in an ER situation and overnight observation where they wanted to remove pump. I put my foot down, demanded to speak with the ends on call or I would leave. And guess what, there was a CDE down to talk to me with papers in hand that I had to fill out. I said no problem as long as I get to keep all my equipment on! Being a hard nose works as long as you can prove you know what you are talking about.

Me too

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“It is what it is.” As you can see by the replies, everybody’s different. Your diabetic life is yours alone, and the sooner you learn yours, YOU can control it instead of it controlling you. I can only say what I’ve learned in 54 years, since age 11. No complications except hypo unawareness and a touch of gastroparesis. Unknown (prob bad, lol) control until 1986 with glucometers and MDI, insulin pump since 2004. My Dexcom is set to 100 and 180. Once I hit 100, I go down maybe 10 points every 10 minutes. Lately my lows have been “bulletproof” and I’m at 7 tabs or 7 gummy Lifesavers. When I’m out of Dexcom sensors (too often! Why won’t insurance believe they sweat off?!), I have to be constantly vigilant of scattered thinking and talking, and I do arithmetic in my head, lol; that’s around 60. I get low a few times a day, and high also; I don’t like that but “it is what it is.” Still, I’m constantly adjusting. Type I is a life of herding cats! I like to keep my A1C at 7 to 7.5, and my endos agree. I truly believe low is worse than high; it’s an immediate emergency and can kill brain cells.

Because Dexcom guarantees them to last 10 days, no matter the reason, so long as your sensor and transmitter are not in use past their expiration date. If the adhesive fails before then, you call into Dexcom for a free replacement, not your insurance or DME supplier.

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Actually you don’t even have to call. Dexcom has a form you can fill out on their website. You might want to take a look at it before you need to use it so you can what info they ask for. If you problem is sensors falling off, they’ll likely also send you a pack of overpatch adhesives in addition to replacing your sensor.

https://dexcom.custhelp.com/app/webform

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May have been stated already, but I recently learned from my Endo to take 15g very fast carb (I mix OJ with a teaspoon sugar), then WAIT 15 minutes. If still very low, repeat the cycle.
In practice, I find that if I’m urgently low (mid-60s down) I’m unable to control how much carbs I take in. But I’m having fewer and fewer urgent lows. They happen when I’m burning up energy working in the yard or hiking and forgetting to check my readings.

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Yes same issue with type 2. If I get busy I can drop from 180 to below 80 in a short amount of time. I use 80 as a low and 70 as a urgent low.
I use a four oz bottle of Granberry juice. Usually recovers with in 15-20 minutes.
Not all cranberry juice is the same, I use one that is lower in Potassium and Sodium.
These are factors that in my case are critical on my Kidneys.

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I’m having a challenging time bolusing for fruit (blueberries!), caffeine, work stress and changes to my routine.

I over corrected last night and was up u til 3am trying to “fix” my “correction”.

I think part of my learning journey (still under a year with a LADA diagnosis) is to give myself permission to not be “perfect” every time. I’m averaging at a 6.1 and under the 1/3 ratio. It’s much better than what the doctors expected.

I learn so much from others’ experiences (who knew I could shoot up insulin through clothes?!?).

The not panicking and avoiding swings is my next goal.

You are doing well Mika. I am 62 yrs in and I still have problems from time to time. I ate a celebratory dinner with my family the other night, and I gave too much insulin. I was awake on and off correcting lows until about 3:00 am. I didn’t want to overcorrect and wake up high. You are not alone. It is all part of the life of someone with diabetes.

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Perfection not needed; does, however, require a healthy good enough.

You’re curious, you’re learning, you got this!

Hi Mika,
I am NOT type-1, but HNF1-alpha (monogenic). As such I have only a 60% deficiency of insulin secretion/expression/function which is rock-solid stable. If one images the endocrine pancreas / islets of a diabetic of the HNF type one “sees” tiny beta cells – completely normal in distribution and number but abnormally small in size, due to underexpression of insulin because of the HNF (homeobox gene) mutations.
That said, I can tell you how a nondiabetic and/or I would/will respond to so-called iatrogenic hypoglycemia. That is, to a sort of miscalculation and too much administered subcutaneous insulin. Maybe simply by delaying ingestion of the meal for which I bolus.
My BG will go down to 55mg/dL or 60mg/dL. If I skip my usual one meal per day I will arrive at the same BG within 20 or 24 hours of my last meal.
I will feel absolutely no sensation, in brain or anywhere. None. I can only determine that I am at 55mg/dL, or even lower under some conditions, by using a BG meter.
This will not be the case for an insulin-dependent diabetic, and I will assume that this is what you are. The alpha cells become latent and sloppy – relatively unresponsive, but not completely unresponsive. But enough so that the insulin-dependent diabetic may, under conditions of iatrogenic hypoglycemia, pass out. If bad enough, worse yet. Used to happen regularly 50 years ago and more. Not much today, with the advent of better equipment. Nevertheless, the endocrinology and biology remain the same, now as then.
Hospitals want, and may INSIST upon, hyperglycemia at all times. 100 mg/dL or even 120 mg/dL. 80 mg/dL (roughly) is normal for the fully fed state. 55mg/dL to 60mg/dL is normal for the fully fasted state. I cannot drop below this, except under exceptional circumstances such as a long run of 12 to 16 miles, which I do regularly, depleting body glycogen including that in liver. And if I am in the fasted state due to prolonged fasting (e.g. one week) I can do this even more readily. I can go down to 30mg/dL. I feel a short-lived sensation at this level, but only for ten or fifteen minutes after finishing my run, and usually before getting back home in the car. I might stop at a grocery store in between, for example. Anyway, a bit of nausea is the most prevalent signal of very high ketones and low blood pH. Absolutely no mental deficit or sign of this at all, ever. Certainly no adrenal response, but this is usual for the insulin-dependent diabetic who does not produce significant endogenous insulin in islets. This is because I ALWAYS compensate with primary response (glucagon) to raise hepatic production of ketones virtually instantaneously. Whereas the mature T1D will NOT. Nor will an advanced T2D also producing little to no endogenous insulin.
The insulin-depedendent diabetic can, and often will, feel the jitters (from brain signaling to adrenal glands, and consequent “secondary” hormonal response of epinephrine (aka adrenaline) to raise BG hepatically) even at or a bit above normal fed-state BG, if BG suddenly drops (due to subcutaneous insulin administration) quickly and by a lot. Certainly this can, and generally will, happen while still no lower than normal fasted-state levels in the 50s. Depends upon the normal glycemia and diet, etc. of the individual. There is no CORRECT answer for all T1Ds.
So you should be very careful about hypoglycemia I think. I can make an occasional mistake and not even know about it. Big difference.
That said, the closer you can bring your hormonal response to that of a nondiabetic (and I am not much different with regard to iatrogenic hypoglycemia than would be a nondiabetic on a strictly animal-sourced food diet) the better I should think. Diet matters, big-time. Insulin therapy and BG management will be easier with lower-carb diet. But uniquely for those who produce insignificant endogenous insulin, carb’s can be predictably “covered” by bolus insulin. They cannot be in a diabetic such as myself who is not insulin-dependent, in the sense of being susceptible to ketoacidosis without exogenous insulin supplied daily. Because of prandial positive hormonal feedback in response to portal glucose. I have written about this elsewhere on the forum, many times.
I hope the guidance above can provide some insight, and might be helpful.
Once again, not being a T1D myself, and hence with no direct personal experience, if you can get to a condition, by diet primarily, for which a level of 70mg/dL produces no sensation or awareness on your part while in the fully-fed state, this might be a reasonable goal. Or this might already be true for you. Dr. Bernstein, himself a T1D diagnosed at age 12, certainly has been in this condition for many, many decades. Whether he can iatrogenically go down to 60mg/dL without awareness, as I can and do, I do not know. Possibly he himself does not either – he does not allow this to happen in general, but has mentioned that he occasionally skips meals due to being busy and has implied that he drops to the full fasted state sometimes. But he advises his patients, including the non-insulin-dependent ones, not to do so and certainly not iatrogenically. Iatrogenic transition would be rapid while that from fasting would be much slower and gradual. So very different for an insulin-dependent diabetic, with the former being more dangerous and unpleasant at least while the latter should be not dangerous nor unpleasant at all.
I come at these questions from the point of view of the endocrinology and the biology including the genetics. It is destabilization of the genome in the alpha cells, due to long-term loss of intraislet insulin signaling, that is the cause of the degradation of alpha-cell function which normally is responsive, second to second, in guaranteeing fuel supply to the brain without a hitch.
So that above is what I can say/write from the biological point of view. Fortunately I am not an MD and so cannot have my career ended by a single lawsuit. At least, I think not.