Increase time in range? (22-year type 1, manual injections)

Type 1 and LADA
1

Do have any strategies that have worked for pushing up the time spent in range? Recently started adding a large source of protein at meal time and that has allowed me to lay off the carbs a bit (thanks, Dave, and everybody else). I think that has pushed the post-meal spikes down. But, I'm still only managing to reach about 30% time in range. I think that's really on the low end of what everybody else is able to achieve. I'd like to reach 50% time in range. I think my basal/bolus are adjusted as well as I can get them. There's so much variability in the data, now, that I'm really having trouble collecting meaningful data for my Doc. I would like to, for once, walk into my next appointment and show her that I had improved something. I have a hole bunch of really crappy data, so it shouldn't be that difficult to do.

I'm really experiencing difficulty on the tail end of Humalog boluses, especially when there's added Humalog correction. One problem with the data is that I am essentially increasing morning basal via correction doses and that blocks out a four to eight hour window where I can't even test meal bolus. Why in gods name does it take the correction 4-8 hrs to disappear, but it only takes meal Humalog 2-4 hours? That just doesn't make any sense to me and I hate it. Does it help to eat 15 grams of carbs and does for 45 grams?

I might not be timing morning correction very well - sometimes I give one giant 12u bolus, mid-morning, and sometimes I break it up into two 6u boluses and deliver as needed at varying times. Both strategies have varying results. Lately, I have seen days where I required no insulin increase in the morning. Anyway, assuming that the amount of morning insulin required, varies between 0 and 12 units, that seems like lot of difference. I don't know how I would program a pump to do that. I think that I would deliver a healthy temp basal, say, a unit per hour for four hours, and I would assume it is active in my system from the moment of delivery, until four hours after the final temp basal dose is delivered. Wash, rinse, repeat.

Any ideas/experiences/suggestions would be greatly appreciated. The data seems to improve when I eliminate meals, but its still not very good.

I've been reading the artificial pancreas algorithm papers online and I am simultaneously very optimistic and very pessimistic. Mostly, just frustrated. Excited for the more rapid acting insulin that Dave or David mentioned to me. If I happen to grow any, maybe I'll experiment with your inter-muscular injections.

Here's a picture of a puppy to reward you for having the tenacity to read this. Diabetes makes me so sick of hearing my own thoughts. Thanks for any of yours that you have.

2

So there's no pattern to whether you need zero or twelve units of correction in the mornings? This is all about sleuthing patterns, while holding as many things constant as possible, though it doesn't sound like you need me to tell you that.

Humalog will have a certain duration in your body, perhaps varying a little at different times of day and as a result of differing activity levels. But the notion that it acts differently depending on whether it's taken with food or as a correction makes no sense--the Humalog doesn't "know" which category it falls into.

It sounds to me like you're riding the rollercoaster. And getting off the rollercoaster will probably require drastic carb reduction to stabilize BGs, and then gradually reintroducing carbs while staying as stable as possible. The fact that you've introduced more protein is great, but I think given how wildly variable your BGs are, more drastic action is warranted.

My two cents anyway. I can only imagine how frustrating it must be to have things seem so unpredictable, my sympathies.

3

I had this issue for a bit when I first got my pump since I was still in the process of figuring out my basal rates. Now I spend just north of 75% time in range. The only "out of range" times being postprandial spikes that are usually not too severe.
Having a CGM helps immensely in dosing decisions as well since you have a more reliable guide along the way.
Seeing as you are MDI like I was, the only advice I can give for now is to alter your food consumption and test a LOT. (Like 8-10x daily)
Niccolo was on point though, you really need to try and identify the pattern here.
Perhaps ask your Endo if they can give you a loaner CGM for a week while you try to sort things out?

Also, protein is great, but remember also that it comes on much later than a carb would so while it may not require as much insulin, the rise will still occur, just later than planned. Something to think about.
4

@niccolo, hmmm...my Doc says the Humalog knows. I still don't understand it, but I definitely think I can see it in the data. There's a much 'longer tail' on the correction bolus. Pumpers might ignore the tail because correction doses are so much smaller, it might not really be noticeable. IDK. You've got a pump?

5

First I have to say, that puppy kinda freaks me out.

It must be frustrating as heck to have these variations. How often are you testing? I'd hope 7-10 per day to try gather enough meaningful data for you and your doc to analyze. It's very important that you test at similar times each day, eg 15mins before a meal/snack etc.
Exercise is a key part of my maintaining BG balance and reducing insulin resistence(basically keeping my Total Daily Dose, TDD,low). Even the smallest amount can make a difference depending on how fit you are.

6

Thanks, Mario.

7

Thanks, man. If you think THIS is variable, just wait until I add exercise into the equation. LOL. Testing obsessively because my Doc wont look at sensor data points that aren't supported by a manual BG. Hoping to get this goofy data stabilized a bit so that I can resume my exercise routine. Its a bit dangerous, as the data currently stands.

8

I know one days worth of data is kinda useless, pulled out of context, from the rest of the week, but it does give you an idea of the paradigm that I'm working from. Sometimes it sounds different that your guys's. Way different. But, I know there are a lot of variables that make everybody so different.

9

Think it could be your insulin supply? Mine was freezing off and on for a couple months without my knowledge, all the while I was getting erratic BG patterns. Once I tried a vile fresh from the pharmacy, things stabilized dramatically.

10

That morning spike looks brutal. Once it's corrected it seems like you respond to the type of carbs you are eating similar to me.(candy canes and Doritos will do that to any of us! Doritos are made by the devil, but damn they taste good!)
It's likely from this limited data that this about your basal insulin, not your fast acting.

11

A combined meal+correction bolus will probably be bigger than a meal bolus only and this will make it take longer to finish working.

12

This is brutal.

You woke up in the 200s, is that typical? Can you tweak basal rates to get that closer to 100?

You corrected with 4 units and barely budged and then rose by noon, without eating anything? It's almost like you have a broken glucose "thermostat" set in the 200s and your body autocorrects to those levels, as seen in MODY2 (glucokinase mutation).

You corrected with another 8 units and that seemed to help. Then you ate something (for the first time that day?), while still experiencing dropping BGs, injected a bunch of bolus insulin, and set yourself up for a low.

You corrected the low with candy canes (fast acting sugar, good) and Doritos (slower-acting carbs, plus fat that slows carb absorption, not good for a correction). You overcorrected and went high again.

You took a small correction of only 2 units, and it seemed to be working, then you ate "French toast stix" and "chedder bites" (are those less carby than they sound?), injected a big bolus, and dropped a lot.

Then the cheese sandwich, a little more bolus, and a low-200s high that for you, is maybe manageable, and things settle into some good low-100s numbers. It looks like you probably woke up the following morning at a good number.

You're riding a crazy rollercoaster and your inputs are often worsening the oscillations rather than damping them. You really need to get your numbers in front of a coach like Gary Scheiner, who can help you learn to manage all this better. Getting a grip on this will almost certainly require significant diet, and perhaps other lifestyle, modifications.

Also, instead of correction doses or to complement smaller ones, consider vigorous walking. It is an incredibly potent blood sugar lowerer, with far less risk of a hypo.

13

@niccolo, Good eyes - The AM 200 was human error. Its the only high AM reading in weeks. Overnights are flat line. I blame a bagel, and myself, from the night before. I should have dosed an extra 2u, from experience, but my BG was low and I dosed straight off the 30g listed in the nutritional label, which never works for bagels. It was a stable 200 all night.

The morning number trend high - hence the 0 - 12 u morning correction to rectify. I'm calling that Dawn Phenomenon. Its been highly predictable for the past 3 months, in that, it always happens. The magnitude of the rate of increase differs. Today, I got flat line data without correction, which is a new trend that's been popping up sporatically - 3 days out of the last 12. I didn't eat anything until 2pm, so I can pretty well identify that there's something new and odd going on with that. Makes me nervous because I've so consistently required 12u between 7am and 2pm for three months. 0-12u variation in insulin requirements makes me nervous. Lot of room for human error there.

You guys just turned me on to having to worry about fat, protein, etc. This data is a month old, now. Nutritional choices are rightly condemed that day.

This is pretty stable data, for me. I think the data that come outta me is just chaotic. You all seem to have more stable data. Makes me mad! But, it makes me believe that better data IS possible.

I can keep it below about 250 in the AM, but because that pattern is over a sustained 7 hour period, so, I tend to get dehydrated. Dehydration + Exercise will tend to push me WAY high. But I haven't tried this, so it might very well work. IDK. This winter I've been skiing in the afternoon/eave once BG is stabilized and I'm re-hydrated. Doesn't hurt to try skiing BEFORE I'm dehydrated, right after I wake up in the AM. Its a good idea, it might work. As cross country skiers go - I'm real fat and slow, so I think it can be safely considered 'vigorous walking'.

I really appreciate you looking the data over. Here's a puppy for your trouble.

14

I can't say, for certain, about the insulin supply. I did notice that some mushrooms froze in the fridge last week and I turned the temp down. I had a different refrigerator preceding this 3 month block of unstable data. The previous fridge was small, new, and by in large reliable. I don't know about this one. I'm due for a new insulin RX. I'll get a one-month supply. The jury should come back with a verdict on that, this week. You deserve some kinda prize if that's it. Good thinking. I have been using the same 'batch' of insulin for 3 months because I picked up a 3 month supply last go around. I'm down to the last remaining pen.

15

That new puppy freaks me out even more.

16

I know, stay strong Kevin. I'm gonna really have to come up with something good to reward you if its been my damn fridge all along.

17

Are you saying bigger bolus acts sooner and lasts longer? I've never looked at that.

18

You got me thinking, Kevin. I don't think its my insulin, I think this is just me, but about the insulin - I tend to think the stuff freezes, or not. Its either functioning, or not, but maybe that over-simplified. It might freeze 'a little bit' and function 'somewhat' less effectively? I wish there was someway to test its efficacy outright, but I don't think there is. :(

I got the most flat line data ever, yesterday (no change in insulin). Makes no sense whatsoever.

19

WTF???? After 3 months of battling this morning DP trend in hand to hand combat, I think it just resolved itself. This is the fourth day of no DP in the last 3 months (2 consecutive days)
. So strange and aggravating!

20

Don't look a gift horse(or puppy) in the mouth! BTW, I've found if you study your BG's every day it can cause brain damage.
Have you thought of trying out Diasend for uploading your CGM/meter data? Excel spreadsheets are well and good, but why reinvent the wheel when Diasend is free.