thanks. i think i am almost there with the testing. went to bed last night at around 100 and had a flat line throughout the night. woke up this morning at 122, pre-bolused for breakfast and am about to cook myself up a yummy breakfast. i think i have this down. but time will tell.
i took your advice from yesterday. instead of waiting 10 minutes for my pre-bolus before breakfast, i watched my cgm and waited for it to come down slightly. this took 15 minutes. then i ate. no spiking, and after 2 1/2 hours, i am back to my waking BG. i just hope that i hold out at this level since there is still IOB. (which is not even 1 unit)
for lunch and for dinner, i usually wait the full 10 minutes, but i will do the same as breakfast later when those meals come up.
thank you!!!
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John,
okay, so i did my over-night and morning and lunch basal tests twice for each already. the consecutive days, each basal rate was perfect. steady, no ups or downs, or highs or lows. but then this morning after breakfast (5 hours post) my BGs started to climb very high and rather quickly. from 120 to 202 with an arrow trending up on an angle. i decided to try and curtail this by going backwards 2 hours before the climb and increase my basal rate from.350 to .375 . i donât know if i am doing the right thing, but it is such an incredible discrepancy from the past days that it makes no sense to me. i have been doing the same activity level, the same amount of stress (relatively none) and the exact same meals at the exact same time (every day, for each meal) .
do you have any suggestions? i am completely baffled by this. and i need help.
thanks, daisy mae
and BTW, i did change my pump/infusion set today.
daisy
Diabetes is not a static puzzle. I think basal rates, insulin to carb ratios, and insulin sensitivity factors all provide a great foundation to get you into the âright neighborhood BG-wise.â Then you need to deal with the âwild cardsâ that diabetes deals. Ponder calls this âsurfingâ and I think his analysis provides the missing dynamic piece to the formerly static pieces of the diabetes puzzle.
Contrary to the rest of life, âdoing the same thing and expecting different resultsâ is not the definition of insanity for people with diabetes. Thereâs a curious fourth dimension to our reality.
I like to use Afrezza, IM injections, carb nudges, and well-timed walks to respond to the unexpected.
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did you factor in fluctuating monthly hormones?
thanks for the thought; i am post menopausal. no more hormonal swings, thank god.
Hi, reading thru your post and all the replies, I wonder about you doing the basal testing after a no/low carb, high protein meal - for me these meals affect my BGs for many more hours afterwards than a medium carb, low protein, low fat meal as more of the protein gets converted to carb several hours after eating. Also depends on the size of meal though. I use an extended bolus of 4 hours for low carb, high protein meals ( I do a normal bolus for the small amount of carb and then an extension over 4 hours for the protein effect), and wouldnât eat one before doing basal testing as my BG would still be rising 6-8 hoursâ later due to protein metabolism. So Iâd need to wait much longer for the insulin bolus and post-prandial BG rise to be âout of my systemâ. This is usual metabolism for low carb/high protein meals.
I hope this makes sense!
Would bet the rise several hours post a low carb high protein and high fat meal is not the basal rate but rather the delayed conversion of the protein in the meal to sugar. Many who eat that way need to do an extended bolus with a small portion up front to cover the carb portion and a delayed does to cover the protein.
Take a look at the TAG ers United group. They may not be super active but will have lots of good info.
TAG = total available glucose
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overnight fasting isnât the difficult part, as you must know. there is no bolus or food on board. breakfast fasting is the same. but if i do chose to eat breakfast on a lunch âfastingâ day, i eat only eggs for breakfast and a cup of tea. this seems to work well for me. also, for lunch, i am having tuna salad and a cup of tea, and my typical dinner meal is chicken with spinach or some other low-carb/no carb veggie. but i am not trying to find my carb ratio. i am fasting to discover my basal rates. so i fast for 5 hours after my last meal, and then fast through the meal i am skipping for another 6 hours, as per Walshâs basal fasting plan.
i donât know if iâve misunderstood you or not. could you please elaborate?
Maybe i am just lazy, but this system seems way too mathematical and complicated for me. i am a very careful eater. very low carbs, high, but not fatty proteins (chicken, turkey, tuna, other fish)
my biggest splurge is peanut butter as a snack between meals and half and half in my teaâŚ
not certain if this classifies for your TAG diet and bolusing system???
Tagging is not as complicated as it may seem at first. And depending your preference/pump used can be covers by a extended bolus/square wave and then a temp basal increase to cover the longer tail of protein digestion.
Will be trial and error at first but if you have familiar meals that you tend to repeat can be worked out.
But understanding the it may take a few hours for the protein to convert when few carbs on board makes understanding why the delayed slow creep up happens. And allow a you to address it with a temp basal or a small bolus later.
For me I do find that a temp basal increase seems more effective then second or extended bolus.
You would need to see what works for you and also how your pump works with extended/split/square wave bolus. Different pumps deliver differently.
i am a huge fan of the temp bolus. but i do have one question about it: when i start up the temp bolus, does the increased amount of insulin hit me right away, or does it take the typical 2 hours before it âhitsâ my system? aways wondered about that. but i always use the temp bolus when i am totally stressed out or ill (flu or otherwise).
i understand a little better what you are saying about the digestion of proteins and fats taking longer than straight carbs, but i donât know if i have mentioned this before here (i know i have on another post) : i need to take insulin for everything, including proteins, even cheese. as well, i am not able to take a straight a regular bolus for simple carbs like and english muffin or even oatmeal. i MUST use the dual bolus feature on my pump (Medtronic Paradigm). why, i have no idea; it just is what it is. and trying to eat something like pizza is a complete and utter nightmare. of all my pumping years (14+) i have still not figured out the ârightâ formula for my favorite neighborhood pizza jointâŚ
also, i am pretty OCD and regimented about my eating. most would consider it boring as all hell. but, i am content, as i am a total control freak; i eat the same meals every day at exactly the same time w/ very very few variables. the two restaurants i go to, i order the same meal every time. i know exactly how many carbs to bolus for and i know how long it will take from when i place my order (which the waiters all know by now) and when the food will arrive at my table.
my current A1c is 6.4 but i feel i could do better. i am very hard on myself and have such little patience after all my years w/ D (30ish). (been pumping for 14+)
and, i am always willing to learn and not shy about asking for help. thanks. look forward to hearing back from you.
I use a tslim, so NOT quite sure how your MM does things. For me a temp basal can be set as a percentage of the current basal amount up to 250% of original rate. And I can run it from as little as 15 minutes up to a full 72 hours.
Tslim delivers basal every 5 minutes, so the basal increase is in repeated small amounts over the duration of the temp basal.
Tslim letâs me do a bolus, or and extended bolus, as well as temp basal changes. And once the initial up front portion of an extended bolus is delivers and the remaining extended is being delivered over time, I can still come back and add an additional bolus is I eat more or decide I counted carbs wrong.
So I can do a layered delivery that can be staged for the meals I eat if needed.
I find for me that using a temp basal will help break a stubborn high or trend up much more reliable then a correction bolus where an additional amount of insulin is needed. Donât know why bet it just seems that small constant trickle absorbs better for me and is active more quickly. I tend to get better response and fewer crashes. And a temp basal can be stoped whereas a delivered bolus canât.
Have you found Stoben Ponder and Sugar Surfing. He is a T1 pediatric endo who uses and teaches a dynamic treatment system. Donât know if you CGM but it makes a big difference in my level if control. Might be worth a read.
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I use a Minimed pump that has dual bolus. It delivers insulin in two waves: some immediately, like a regular bolus, and the rest over a period of time, like an elevated basal. I tell it what percent to deliver immediately, and how long the second wave lasts.
@Daisy_Mae I applaud you for trying to fine tune your pump use. Reading your posts has really driven home to me just how unique and individual we all are. When I read that it takes 2 hours for an increase (temp bolus; probably intended temp basal) for insulin to have an effect on your BG, that sounds about right. ish. The dawn phenomenon and I are old friends, and to fend it off, I have my night time basal rate move from .600 U/hr to .825 U/hr at 4.30 and that keeps my BG relatively flat at 6.30 when I wake up. An increase in basal rate is tiny, so the results of that increase will be tiny, too. If you look at my example, it can be thought of as 2 boluses. One delivered at 4.30, and one at 5.30. Each bolus is for .225 units. How much would .225 units move your blood sugar? Not a lot, right? Now spread it out over an hour, and you can begin to see how the effects are spread out, and more subtle than a regular bolus would be. This is one reason I personally donât use a temporary increase in basal all that often. If my BG is up now, I want to bring it down now, so I bolus. If I expect my BG will be going up I tend to bolus 20-30 minutes ahead of that so the insulin kicks in just as the increase does. @2hobbit1 makes a great point that I could stop a temp basal but I canât undo a bolus.
I too bolus for everything. Because I eat low carb all the time, I tend to bolus just as I start to eat, and I find that my digestion of protein and fat is slow enough that the insulin starts working just about the same time the digestion starts lifting the BG. I tried oatmeal once, maybe 8 years ago, and was utterly unable to figure out how to bolus for that. For sure, I need to bolus a half hour before starting to eat it because oatmeal starts lifting my BG fast, say 10 minutes? I find it interesting that you use the dual bolus for carbs. I need a dual wave when I have a mix of carbs + protein, like a hamburger with cooked cauliflower. The first wave handles the cauliflower (which I digest quickly) and the extended bolus handles the protein (which I digest slowly).
Pizza is right out for me. Itâs too complex for a simple pump program to deal with. The best I could ever do was to manually bolus at 4 intervals: one for the crust, one for the sauce, one for the cheese, and one for the meat. One of these days Iâm going to actually take a pizza apart and eat each piece separately and find the digestion curve of each part. Which I think will get me closer to understanding how the components react in me.
Sorry for the digression. Basal testing is an easy concept: remove all BG inputs except basal insulin and watch what happens. Executing that strategy is easy too: donât eat, donât bolus, donât exercise, donât be sick :-/ People who write books (like Walsh) have to have some guideline for knowing when a person has no insulin or food left, and typically thatâs 5 hours. So thereâs a rule about testing 5 hours after eating. But weâre all different, and the 5 hour rule isnât an inflexible law, itâs an example of how one person reacts. You and I are different, so 5 hours may not be long enough; maybe itâs 8 hours for me if I ate a hamburger (no bread), and an antipasto salad with pepperoni and olive oil. If I started watching my BG at 5 hours, Iâll see it rise between hours 5 and 8 as my digestion boosts my BG but my lunch time insulin has been used up. It wonât go up a lot, but it will go up. Now for the question: is my basal wrong, is my bolus wrong, is my lunch wrong, or are all 3 involved? Canât tell, and thatâs why Iâm not going to adjust my basal based on that.
Like @acidrock23 the most important basal test is my morning wake up number. Why? Well, for me, Iâm asleep, and canât manually adjust for my BG readings. During the day, I measure so often that correcting is pretty easy, so if my daytime basal is off by 20 points, meh. But that 100 point spike at night? No, no, no, I want that to go away, so that wee hour basal rate is the one I keep an eye on the most.
So, donât think of Walsh as rules, rules, rules. Think of him as one set of example numbers, to see how he came to his conclusion about setting a basal rate for that example. Dr Ponderâs book was very interesting to me. The biggest idea I took away from it was that I shouldnât be locked in to a rigid set of rules; that my burger (no bread) today may not - will not - affect me the same as it did yesterday. And thatâs OK, because by keeping an eye on things, I can tweak and push and pull my BG to the place I want it to go. Mostly, and thatâs OK too, because there are really no rigid rules when it comes to a dynamic system like the human body, but understanding a few guidelines helps a lot.
âbuck
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Thatâs exactly my point @2hobbit1 but youâve explained it much more simply and clearly!
I think for most of us when eating a low carb, high protein meal before doing a fasting basal test, weâd need to wait longer than the 5 hours after our meal (which Walsh suggests) due to the delayed protein effect still causing BGs to rise.
[I donât want to complicate matters (!) but as itâs all fast acting insulin in the end it doesnât matter whether the delayed bit is delivered as an extended bolus or - as I do - a raised basal for the same no. of hours to give the same total insulin.]
Hi @Daisy_Mae, Iâm not talking about carb ratios at all. Iâm talking about how long you should wait after a meal before starting your basal testing, based on food being totally digested (so BGs no longer rising) by then, and previous bolus already fully absorbed. Walsh gives 5 hours but this is not based on eating low carb/high protein meal like you have. With your meals, itâs very likely your BGs are still being affected 5+ hoursâ later due to delayed protein conversion to carb, so itâs not truly a fasting test.
Sorry - I know what I mean but I have rather complicated ways of explaining things!! (I studied Maths at UniversityâŚ)
Here is a official MiniMed work sheet for Basal testing.
Wrk sheet MM.pdf (121.7 KB)
Ingrid-
i am following your protocol, and am thoroughly frustrated. for one entire week of testing, my basals came down to a nice consistent range. i thought i had solved my basal problems. my BGs were all in target range. Phew. now i could eat my regular meals. but, i continued waking up during the night b/c i saw that my early morning BGs were on the high side. since then, my BGs have (during a fasting basal testing) started going high again. so, as per Walsh, i aborted the test (over-night) and adjusted my basals by .25 ( the lowest my pump will allow). last night, at 6:15 i woke up and tested; my BG was 234. from nowhere. i had been fasting since lunch the previous day when all i had eaten for lunch was eggs. ( i wasnât feeling too well yesterday.) this seemed to be happening all night long, which i saw by looking at my cgm. straight across the board, an entire night of high BGs. obviously, i have to re-do the test tonight. i will have a low carb/low fat meal for an early dinner (maybe 5-ish pm). i have gotten so frustrated. i canât seem to get a full day in a decent range. i have been losing weight (99 lbs) and my husband is very concerned, as i cannot afford to lose any more. how the heck do people do this? i feel like a complete failure/loser and that i will never get this right. i am beside myself. how the hell do Ds accomplish this w/out starving to death? when is good enough good enough?
please help.
Buck,
thank you for your very explicit reply . my question is this: if i go above my high BG range, do i bolus to correct and abort the test? or do i ride the wave through the morning and correct then if needed to? i have been trying to take notes during the night wee hours to do finger-sticks to see my actual BGs. if i donât correct during the night, can i use that info to make an adjustment for the next night, and then see how that next night goes?
i look forward to your reply. i had to abort the test last night, b/c i was steady, but slightly over 200 throughout the night. this morning i will eat my regular breakfast, lunch and dinner, and give myself plenty of time (early dinner) to have absolutely no IOB before i do the over-night testing. if i find the same results as last night, do i then correct and move forward and do a repeat of the previous nightâs fasting and look at the results? i am so utterly confused and frustrated, and my weight is dropping way too low. my husband thinks i am nuts. and i am waiting for my endo and my cde to call me back. (itâs 11:am in NYC right now.)
please get back to me.
thanks, daisy mae