So, I'm wondering if I could get some advice here, please? I keep having these really bad lows, happened again today. My last bolus was at 7AM this morning, was very active through the afternoon, cleaning, shopping, etc...(but no HEAVY workout) at 1pm I'm down to 43. I keep going low at around bedtime too with no active bolus on board but more from activity. I'm already down to 7 units TOTAL of levemir. If these lows are from increased activity, does this mean I need to lower my basal rate more? If I do and am not as active, won't I be high? Thanks!

I would say that if you are active and you are going low with no IOB then you probably do need to lower your basal rate. And yes, you'd need to put it back up if you subsequently become less active.

When I was on Lantus I split my dosage into two, one every 12 hours. Do you shoot Levemir once or twice a day?

twice, karen. 4u am 3u pm. now I think i maybe need 3u am but if i'm not active that won't be enough but i'm low towards bed, too...so maybe 4u levemir is too much for am dose. i can't keep up with this nonsense..ugh! that was another bad low, shaking so badly.

Hi Sarah -

If you're going low with no insulin on board the only thing you can do is lower your basal. Do you take a little snack (one glucose tab, a couple squares of chocolate, a couple ounces of milk) when you hit the 60s? While it is no fun to eat to insulin, it is better than spending quality time in the 40s.

A pump might enable you to better fine tune your basal and would certainly allow you to turn it up or down during a day that seems off.


thanks, maurie...yeah, i usually treat at 70's but my CGM didn't catch it nor did I. This is just becoming so challenging. I just ate nearly 40 grams of carbs and bolused hardly anything and my blood sugars are dropping. I must be taking too much basal and now I'll have to redo I:CR too. ugh!

My suggestion, Sarah is that you not redo I:C too right now. You have tended previously to react to "problem numbers" by making too many changes at once and then you roller coaster and get frustrated. Just make the small change in your basal and then sit with it for a couple days. And I agree with Marie about the pump. You have described several situations where a pump would be useful. It takes patience too to adjust pump settings. Hang in there.

well, I'm eating, just ate more jelly beans and I'm 72, what the heck. If one adjusts their basal my endo told me they have to usually adjust their I:CR too. But yes, I'll drop my basal to 3u am & 3u pm. I'm getting very nervous about this again..ugh!

In addition to lowering basal and possibly mealtime insulin( I agree not all at once) I would also consider having a snack before you know you are going to be very active, maybe that will help too. I usually eat some protein like nuts when I take my larger basal dose at 7 pm, depending on my bg level. I have also found that eating larger portions of protein and no yogurt the past few nights I'm generally more stable for the past week, not totally, but better enough to consider eliminating it completely.

No, that is not the case. I adjust my basals regularly and have made exactly two small I:C adjustments in the entire last year .

But what's important is that you make one adjustment at a time. and then sit with it a couple days. If you make more than one adjustment you risk going too far in the the opposite direction and you have no way to know which change worked.

The prevailing wisdom (John Walsh and many experienced Type 1's) is that you need to get your basal right first and when that is right then you see if the I:C needs changing.

I have had Type 1 for 38 years and over the last ten years have been gradually reducing basal rates. I exercise on a regular basis (mostly long walks and weights at the gym) and have my basals set to accommodate my regular schedule. Although I get a lot of mild lows, I get almost no severe lows. A lot of that is because my Dexcom alerts me when I’m at 70 and I treat that so I don’t go down to the 30-50’s very often. My basal is currently at about 9 units total per day and that is way lower than it used to be. Back in the NPH days I think my basal totaled about 30 units a day. I find that when I don’t exercise, I need to use temporary increased basal rates. That’s the advantage of a pump to make those changes. The advantage of low basal rates is that I don’t get catastrophic lows. This disadvantage is that I have no cushion for meal boluses and if I miscalculate carbs, I can go high pretty quickly. I do my best to eat low carb, but when I do eat carbs, I spike quickly.

yes, very true Laddie. It's the delicate weave - interplay between our basal and bolus. If one takes more basal they lower their bolus and or vice versa. I believe any of us can eat carbs, probably anything we want, if we get that interplay down. Clearly, it looks like I'm taking too much basal now and for lunch this afternoon, bolusing only 1 unit while eating almost 45 grams of carbs (which is what I typically eat in an entire day), including 6 jelly beans, didn't even move my blood sugars up at all. I'm going to lower my basal again. IDK, so frustrating.

I think you're still missing some important points several people have made. Your statement that "If one takes more basal they lower their bolus and or vice versa." is incorrect. If you are going low because your basal is too high, bolus amounts have nothing to do with it. Please re-read the excellent advice others have given you. You really should wait awhile (at least two days) before making additional changes, i.e. do not lower your basal yet again shortly after you already lowered it. If you make more than one change at a time or make multiple changes one at a time over a relatively brief period of time, you will end up rollercoastering and defeating the purpose of adjusting dosing in the first place. Maximizing control takes a maximum amount of patience!

Never experiencing lows is not a reasonable goal. If you have an exercise schedule that differs greatly from day to day, using a pump is necessary unless you want to ward off lows by eating more carbs before exercising. If you are not pumping, changing your once or even twice daily basal dosages frequently is not advised and will not be effective.

my point is, if one is constantly adjusting their basal on MDI, which I agree, one shouldn't be doing, accept of course, I'm going low all the time without bolus on board...so clearly i NEED to adjust it, then either one's basal is too much or too little, so of course this effects how their bolus insulin works. if one isn't taking enough basal, their bolus won't be right either, if they're taking too much their bolus will be off too. just walking and cleaning the house isn't exactly an exercise schedule and shouldn't be dropping me to 40's. Thus, if one basal tests, i.e., fasting with no bolus on board, it's supposed to keep us steady, i.e., we're not supposed to have to eat to feed the insulin. basal is the foundation. if it is not correct, ones ISF and I:CR will be off, too. I'm fully aware of not making too many changes at once. but clearly if I'm dropping this low and taking too much basal, dang straight i'm going to have to eat more when I bolus, too, they go hand in hand. We start with getting basal set first, I agree. It's the same concept, I suppose, if one has DP and wakes up high or really high in the AM or upon rising, they'll need a huge bolus typically too. If one gets on a pump and/or gets their DP under control, they'll probably also need to adjust their bolus as they wouldn't need to take so much because they're not waking to such high numbers in the AM. They work together. If one's off the other is off, too.

Basal and bolus are two entirely different animals. Your basal being adjusted absolutely will not affect your IC ratio or any ther variable to do with bolus. You are over complicating this. If walking and cleaning the house with no bolus is driving you low, then yes as you say it means your basal needs to be adjusted— however making that adjustment will have no impact whatsoever on your bolus needs— so FIRST get the basal dialed in and THEN tinker with the bolus only if needed. It is not a delicate weave, or an “interplay” between the two, it is one thing, and then another thing. Make it easy on yourself.

Being insulin dependent has some unpleasant and unforeseen consequences. One major difference to being healthy is that autonomous regulations of the blood glucose will not work anymore. Obviously this is true for lowering the blood glucose with insulin. In addition the counter regulation of releasing glucose to increase the blood glucose is also affected. With time we will loose this capability completely.

By the books you should not feed your lows. This means your basal rate should keep you steady. However this is only true for normal circumstances - meaning normal activity levels. Many of our activities are spontanous in their nature. With MDI you can not lower your rate because you do not know ahead of time what will happen when (with the exception of holidays or planned sport).

It is often argued that pumps offer more flexibility here. You dial down your basal and then you can start your activity. The truth is more that you will have to plan ahead for at least one hour. You dial down now and in one hour you can start your activity - theoretically. If you happen to become insulin deficit in between this might invite your liver to release huge amounts of glucose (insulin inhibits / moderates the output of glucose by the liver). It can be very delicate to balance these two extremes.

The point is that increased activity does consume more glucose (glucose is our fuel). Normally your body would reduce its output of insulin AND your liver would release more glucose especially for the muscles to keep your glucose steady. The missing glucose is the real problem here. Beginning with a specific level of activity you can not moderate with basal alone. You will have to feed your depleting glucose deposits. This is not feeding the basal but compensating a failed regulatory mechanism. This is why all approaches to the artificial pancreas will include pumps for glucagon too.

My solution is to always keep the same basal rate on MDI. With increased activity I do what the natural counter reaction would do in the first place: I refuel the depleting glucose. One or two glasses of juice are good for 30 minutes of high activity. Most insulin dependent diabetics doing very challenging sports will do exactly that. With time you will learn what your body needs to prevent the lows. Of course this will not increase your weight. Your body will consume the glucose right away.

you're missing my point! if one is taking too much basal, they'll be low, low all the time with a constant over basal dose. thus, i was low today from basal - activity, I did a 1:45 for my meal for lunch (usually do 1:13) and still had to eat more, thus it clearly effected my bolus too. I also know if I don't take enough basal, have DP or rise high in the morning, I need a ton more bolus. the fasting blood sugar certainly effects what we need to bolus, too. Also, if we're high from DP or not enough basal, we'll need a lot more bolus to correct down, too. of course there's an interplay between the two. that's why one needs to figure out their basal - fasting dose before one can accurately determine ISF and I:CR.

Cleaning the house is physically challenging! The same is true for driving a car at high speeds, buying some groceries, doing the garden, shopping in the city or having sex. All of these are challenges that will cause our metabolism to burn more glucose. All of these deviations from normal will need our attention - or better external glucose. The more we are used to these activities the less glucose is needed as a general rule.

I am very serious about this. The normal blood glucose is around 100 mg/dl. Low blood glucose levels start with 70 mg/dl. We just have 30 mg/dl to get there. These 30 mg/dl are burned quickly since we have no counter regulation to protect us.

yeah, i like to keep my fasting around 90's. today with no heavy running around I was already at 72 6+ hours after my last bolus and again for lunch had to eat a ton more and bolus less. I have to wait and see what these lower basal doses will do. i'm clearly taking too much. I've lost a bit more weight (certainly not trying at all) which effects everything too. If I'm having to eat glucose, jelly beans all day long, something isn't right???

Sarah, something else to consider is the duration of action you're using for short-acting may be too short, so you think you have no IOB when perhaps you still do.

Just another parameter that may be contributing to this. If so, fiddling with basal, I:C, etc. won't actually solve the problem -- you can tweak those things to get it to all seem to work right with an incorrect action period for certain scenarios, but then get outside that scenario (like some elevated activity), and it all goes screwy again -- and the things you changed weren't the right things to change.