New guy needs help

He is having trouble finding a Doc that will teach him how to make basal and bolus adjustments. He has some concerns related to gasteoparesis. He’s doing a lot of work collecting data, so I’m hoping you guys will take a look at the data and throw some perspective at it.


Another alternative is to contact

Gary Schniener, author of Think Like A Pancreas runs this service, offering online appts and guidance/coaching.

Several members here have mentioned use of their services. Think Like a Pancreas book is also a great resource.

4 Likes

Excellent suggestion. You got any intuition about his dosing, @MM1? Or, is that farther than you wanna go?

Before I started my pump 3.5 years ago, I had to start completely fresh with basal, I:C, and correction factor, because I was moving on from a “just wing it” R/NPH regiment. I used the MySugr app and religiously logged every insulin dose, every BG, and everything I ate for a month. It was able to reliably tell me what my factors were.

I wouldn’t want to use it long term, because it did require an excess of information to meet the daily goal, but it was VERY useful for me in the short term. Plus, I’m a giant kid at heart, so feeding my little sugar monster was a great motivator.

Since he’s already logging the data, might be a good fit.

3 Likes

Because of this…

He has some concerns related to gasteoparesis.

I think my experience/advice wouldn’t apply.
With gasteoparesis, it varies by person, and more unpredictable when fats, proteins are higher percent of total food intake.

However, this may be helpful, portions of article copied below.

The three phases are as follows:

  • First phase: You’re limited mostly to broth or bullion soups, as well as blended vegetable juice.
  • Second phase: You may work up to soups that contain crackers and noodles, as well as cheese and peanut butter.
  • Third phase: You’re allowed to have most soft, easy-to-chew starches as well as softer protein sources such as poultry and fish.

During all phases of this recovery diet, you need to avoid red meat and high-fiber vegetables because they take longer to digest.
When you have gastroparesis, the amount of fats and fiber that you eat can greatly affect how intense your symptoms are.

1 Like

I help my brother & he has Type 1. his GI told him to take a ginger supplement 4 times a day. She said prescription drugs don’t help with it & they have a lot of side effects. Ginger has done wonders for him. I told her, “I have tried to get him to take a ginger supplement for a year & he wouldn’t do it. But because a doctor told him to do it, he tried it.” She said, “My children will only do what their doctor tells them to do & I’m a doctor.”

2 Likes

I can’t speak to the gasteoparesis part, but from the table, this isn’t wildly out of whack. I’d say, bump the bolus a bit and calibrate the sensor. Good luck to him!

Look how much correction insulin he’s taking? You think he should bump up the bolus or the basal? He’s got 3 units of correction running all day long. I kinda wanna get rid of those yellow (correction) boxes by bumping up the basal. Maybe, bump up the basal by a unit per day and decrease each correction dose by a unit. ???

He’s doing a good job of managing it, but I feel like if he wasn’t taking correction all day long, then it would go outta control high.

I also have no input about the gasteo, which worries me.

One thing that’s problematic with the spread sheet is it shows the bolus insulin being simultaneous with the carb intake. You’re always going to get big post-prandial spikes if you actually do it that way. I can’t tell if he’s prebolusing or not, but if not he should be.

1 Like

Basically it mean inconsistent digestion and food moving out of stomach, intestines, where glucose is absorbed. Can vary by person. With cgms, if it were me, I would eat small meals, watch cgm for rise/fall, and eat/dose based on trends. Many small meals may be easier to manage bg, limiting fats, proteins.

Based on article, thats what I would do. I was tested years ago for gastro, but test came back negative. I reduced fats, limited protein, and things did get better. But I did research it a bit at that time.

2 Likes

Is it a known fact that he has gastro, if he does pre-bolusing does not seem to be the answer because stomach emptying is delayed. He is sometimes seeing a rise soon after a meal, I don’t know much about gastro but this is not what I would expect.

Would it be best to start with basal testing. Once he has confidence in his basal rates he can work on carb ratios.

1 Like

I’d suggest fine tuning basal and then work on bolus timing and I:C ratio one meal at a time. Eat an identical breakfast every day and fiddle with the bolus until breakfast is handled. Then stick with that morning routine and take on lunch, etc. Hopefully that will help figure out how to deal with the delayed digestion.

3 Likes

I met him, Gary Schniener. He is very nice and humble. Where is the guy located? Maybe we can post some suggestions for docs. He can also see a Nurse practitioner as well. If he is in PA you may try Intergrated Diabetes Services in Bala Cynwood just outside of Phila or Penn Endocrinology ( Dr,Shutta) or Nurse Practioner M.Devitt. Both are very knowledgeable.

Good book that was invaluable to me when first diagnosed and no access to an endo: Using Insulin by Walsh, Roberts, Varma and Bailey. It gives clear instructions for figuring basal dose and helped me to dial in my I:C ratio and correction factor. I would avoid the fast carbs like polenta and wheat. Also, can’t help with the gastroparesis but fewer carbs at a time is better unless doing that high carb/ low fat thing.

@Rleb

Thanks for the perspective, you guys. He’ll pop up in the next few days, I bet. He’s putting forth a lot of effort to collect data, so I just wanted to make sure people saw it and had an opportunity to offer input. Some of us have been talking to him here.

You all are the best!

Hey guys Thank you all so much especially @mohe0001. Im going Crazy trying to clock everything. I assumed Gastroparesis because early in the Covid pandemic When I started trying to eat very healthy and low carb I noticed low blood sugars after I ate and would rise much later. I never have analyzed my sugars in 20 years until now. I have been freaking out and endo is not much help. Was against me going to GI doc but when anyway and he ordered Gastric emptying test and it came back delayed. 100% at 1 hour Normal is less than 90%, 64% at 2 hours, Normal is less than 60%. 31% at 3 hours normal is less than 30%. 23% at 4 hours normal is less than 10%. The Gi doc called said its delayed and brushed me off said get a upper gi scope and colonoscopy. no explanation or any suggestions just said eat small meals and talk to endo. The endo said that’s not realistic lol. plus idk how you eat small meals and not stack all day. either way I became so scared to eat because I don’t know what’s going to happen. when I eat carbs. so I tried soft foods and low carbs for a little but didn’t know where to start. and was still getting crazy results. I know this is not suggested but I just started eating low carb and even tho its read meat and the only low carb meal plan I could find. somewhere to start many as time goes on I can switch out for a better digestible diet. This is second the second day of it and I’m doing better food still is kinda dumbing a little randomly and there are a few low events that I didn’t completely elaborate on yet this is kinda raw data not gone back and combed over and did have the second meter to check times of some lows. week_of_8_9_20.xlsx (19.7 KB)
I am in pa and live right out side of philly I will check this site out. I do have an appointment at Penn With a new endo on Thursday. she is new to penn but apparently not new to the field.

2 Likes

I am going to read more of what everyone has posted tomorrow, I’m super tired. Thank you all so much for posting and commenting. I have been really going thought this for sometime and its driving me crazy.

Also I am brand new to the pump about 25. days I started messing with the dual bolus and square wave from reading about it and have heard some people do it with normal digestion for protein. I figured at this point I don’t have much to lose.

@Rleb:

While I have no experience with gastroparesis or delayed digestion, I do find the extended bolus (to use Tandem’s term) to be VERY useful in a variety of situations.

Since I don’t know that the other pumps handle it in the same way, let me describe precisely how Tandem does it:

If I think I want X units, then I can specify what percentage I want now (from 0 to 100 percent) and the duration over which the remainder is given. That gives you a lot of “knobs” to turn.

For example, if I eat a piece of toast with peanut butter on it, I might specify 50% now and the remaining 50% drlivered over 2 hours … that both helps me to not run low in the first 30 minutes or so, but adds insulin gradually over time as the fat or the protein in the peanut butter kicks in. So, instead of giving myself a bolus of 5 U, I would end up with an initial bolus of 2.5 U with the remaining 2.5 U slowly delivered over the next 2 hours.

Let me give you another example of where the flexibility of an extended bolus REALLY pays off:

My dog and I frequently walk for 3 hours a day (2-3 walks, not one long one). In the summer, our first walk is immediately after breakfast before it gets too hot and our last one is just after dinner as it is cooling down.

If I give myself a “normal” bolus I can almost guarantee that I will run low within 45 minutes of starting our walk … and at that point I’ve got a lot of IOB to contend with. So, I will often give myself only 33% initially and the remaining 67% over the next two hours. In other words, instead of a 5 U bolus, this would result in an initial bolus of only 1.67 U followed by the remaining 3.3 U delivered more slowly over the next two hours.

Suppose I have guessed badly and I still run low? Well, for starters I have less IOB to contend with AND I can stop the extended portion of the bolus. It is really nice to still be able to cancel the undelivered portion of an extended bolus … particularly when I am running low!

Suppose I guessed wrong and part way into my walk, my numbers are running high? No problem! I can cancel the extended portion and replace it with either a simple bolus or a second, more aggressive, extended bolus.

Whatever I see happening with sugar levels, I can respond to. Plus I can avoid running low with large IOB!

While walking my dog has nothing to do with delayed digestion, I hope that this example helps you see what a powerful tool the extended bolus is when you are having a hard time getting insulin at the proper timing and dose to match changing glucose levels.

Good luck,

John

2 Likes

Until you find a Doctor this website walks you through it. https://dtc.ucsf.edu/types-of-diabetes/type1/treatment-of-type-1-diabetes/medications-and-therapies/type-1-insulin-therapy/calculating-insulin-dose/
Also I have Gasteoparesis as well and there is a newer med out (FDA approved about 6 months or so) called Motegrity if you have not heard of it yet. Because of the Gasteoparesis my systems tends to work really slow so I do not take my meal dose until I see my BS going up. If I am having a full on Gasteoparesis episode I have hard time keeping my BS up it starts dropping fast.
Data wise look for trends rather than focusing on each day individually. Also and I think this is covered on the website but your body may react differently to insulin through the day. I need more in the morning and less as the day goes on. Remember you can calculate everything perfectly and your BS can still be too high or low. As frustrating as it seems it is not an exact science.
When you find a Endocrinologist expect a wait for an appointment. I had to wait 6 weeks and that was bumped because I ended up @ the ER. Where I live there is only one in a 45 mile radius.

1 Like