Spiralling into Hypo-Fear – please help!

1

I am a relatively recently diagnosed LADA, so far I have some of my own production left so on a LC diet I require only small doses of Bolus insulin. Lately my overall BG have significantly changed so I am now about to start a small dose of Basal (Lantus) as well.
Until recently I have been doing ok. I measure my levels very regularly and it has been quite "easy" to achieve good control.
Now I m slowly getting an idea on how much harder it will become in the future. And I am getting more and more scared.
I have mentioned this before, but want to write about it again specifically since it is a major concern: Because I am a photographer I have very unpredictable days as far as activity goes – some days I am highly active, others I am in front of my computer all day. I can try to level out activity to a certain extend ( exercise) but certainly not so much that every day will be similar.
This is where my hypo-fear comes in. Without basal, I could stay in top of this, because I knew when the exogenous insulin was out of my system. When I have basal on board, I ll have to watch lows all the time. Pretty hard when in the middle of a shoot..People have said basal is easier to control because of its slow effect, but with my huge difference in activity I think it might still be a problem..
Yesterday (not on basal yet) I had a very active day, and while taking the train from one city to another, I had a scary low. I had bolused for a meal a couple of hours before (my usual ratio) but the walking /running around must have burned off a lot of sugar and while waiting for a connecting train I started feeling funny, measured and was 57. I panicked, although it had been only 3 units and I injected 2.5 h earlier, but still, I was insecure so (over)treated immediately. Came out 160 an hour later. I dont know why, but it has really shaken me up. Would I even had to worry? Maybe nothing much would have even happened with those numbers and units, even if I hadnt treated?

And what can I do to avoid lows when I m on basal? Will I have to change my basal rates EVERY day according to my activity level (hard to predict!) the following day?
I ve read such scary things about hypos killing people while sleeping (how common is this???), about passing out and so forth.I can already see myself setting hourly alarms to check BG at night. I have a history of panic-attacks so thats probably why I am having such a hard time.
I am already noticing my daily routines changing because of this fear of lows. I think twice before going out dancing with friends, or going for a swim. I REALLY dont want this to control my life and I want to lose some of the fear before it affects my life to the point where I cant live it properly anymore.
Any help and reassurance ("you will not die in your sleep because you were active the day before" kind of thing) are very very welcome. Thank you all.
Jule

2

Julez, in some regard I may not be much help. I have had lows at night and was totally unaware until I came too on the floor of my apartment with bed sheets and blankets every where. I am a type 2 however and really don’t know how a LADA would react.

If you are that concerned why not look into getting a continuous monitor. You can set alarms on these things and it is designed to wake you up.

I would not adjust my bolus unless it is to split the dose morning and evening. There are many on Tu that do that and I’m sure that someone can give you more advice in that area than I can. I take my bolus in the morning and have found if I’m going to go low it is usually about an hour after diner. But every diabetic is different.

I wish I could calm your fears more. I am married and when I first started insulin I maintained my control so tight (A1c of like 4.9) that i was going through glucagon shots by the gross.

Oh…there is an idea…ask your doctor for a script for glucagon emergency kits and carry one with you at all times.

I teach for a living and my schedule flutuates some. I tend to try and control higher on days that I teach as a just in case measure.

Last item…test…test…test…test. You will get a better idea of how you are responding. If you don’t keep a log then start. You can pick up trends easier when you can look at all the numbers.

Hope I have helped.

3


This chart, from "Think Like a Pancreas" has suggested adjustments to basal *or* bolus insulins when you are being active. You correlate the intensity of the activity with the duration and make the adjustment, say 67% for an hour of moderate activity. Maybe being active would be moderate or low but you might want to cut the dose more if your job can be an all day sort of activity. I think the point of the chart is for exercise but I think it's pretty adaptable to other purposes. I haven't tried it with injected basal shots but, if your activities are all day type of excursions, I would think that it would work fairly well and better with practice...

The problem with this is that if you are shooting the basal (I vaguely recall people, maybe Holger, mentioning that it's more challenging to get pumps in Germany, but I don't know for sure about that...) and cut the bolus and the day slows down, you get a ride instead of taking the train or whatever, you would sort of have to pound some activity in to keep your bg flat with a reduced basal rate. If you "miss" and end up running high but are still being active, you can consider cutting a correction bolus by the same factor.

I had a 4 day trip to Disneyworld w/ my daughter and her dance team recently that involved *a lot* of marching around and would just shut down the basal to a trickle when I'd run low. If it started to run up, I'd turn the basal back to normal or even up a bit to give it a "boost". This may be easier with a pump but could probably work with shots too, if you're engaged with the process and test a lot. The CGM line on my page is from the Chicago Marathon last year and you can see how my BG kind of ran up on me and I was hitting it with boluses and basal adjustments (the black boxes @ the bottom of the graph...) while I was running for 4 1/2 hours.

4

A fear of lows is natural and even a healthy response. If we don't have a healthy fear of lows we can expose ourselves to real risks. That being said, we can't let fear overwhelm our reason and draw us into making bad judgements. It is a little like driving. I don't know about you, but learning to drive involved dealing with some serious fear of a tragic accident. When I taught my daughter to drive, that fear was nearly so overwhelming that she refused to learn to drive. What teenager refuses to drive?

What helped her was continued exposure to exactly the thing that scared her. And that can help you. Looking back, you realize that the 57 mg/dl was not a harsh low and you likely were stable and not dropping fast, so you could have take a more careful measured action. And all of us who use insulin have some fear of a dangerous low overnight. But the prudent action is to go to bed with little insulin on board and perhaps wake at night to test. And over time, as you face the situations that cause you fear, you will feel better able to deal with them and it won't be so overwhelming.

So let me suggest an exercise. Hear me out. You say you have some lows between meals, particularly when you are active. Next time you have a mild hypo (say 60-70 mg/dl) I want you to wait 5 minutes before treating. As long as it is several hours since your last meal and you didn't run a marathon your blood sugar is just drifting down you won't pass out. During those 5 minutes you will feel anxiety and fear, but you are going to be ok. Do this a few times and you will start to feel comfortable and more confident. It is just like driving a car, when you repeatedly demonstrate to yourself that you can handle things and the risks are controllable you won't feel as much fear.

5

If you are on a low dose of basal, you'll probably need less bolus. In theory, the basal should keep you stable throughout the day. It's the bolus you'll be adjusting every day, not the basal. So your biggest adjustments will be in determining your activity level vs food, taking them both into account. When I know I'm going to be very busy or exercising, I'll take less bolus for the meal beforehand. Or will sometimes take a hint more with the knowledge I'll be fully sedentary over the next few hours.

You shouldn't stop doing the things you enjoy, but it is worth being careful. Always keep your meter and fast-acting glucose of some sort with you. The important part is being able to treat yourself as needed. Going dancing with friends? Either have a few carbs beforehand to help you get though the activity, or test a couple times and stay safe. Diabetes is a tweak-as-you-need-to disease. Adjust as you continue living your life. You'll figure it out.

6

Anyone can have a "change a flat tire" kind of day....you will be OK...;-)

Remember your life will be a balancing act between activity and your BG goals. When I was younger my BG was not as tight as it is now I managed to run two company's at the same time, raise two children, please my wife, and travel for work and play. Stop worrying about dieing in your sleep....life is short and anything can happen to you, try not to wast your life sweating the small stuff...just be responsible,achieve your goals and smile.

My BG will not rule my life, and it's not going to be part of my legacy.....I'm not defined by my A1c....

7

Hi Julez, first off I think you are doing a great job for being newly diagnosed...you're working hard to learn and you're testing frequently and both will serve you well. I was diagnosed Type 1 at the age of 27 and that was almost 26 years ago. You will be fine!

I agree with the others that having a little fear of insulin is healthy. The way I deal with the fear is to be prepared. I always make sure I have fast acting glucose on me, in my pocket - sweetarts, glucose tabs, glucose gel - something you can get to fast. If you're in a set location, grab a coke to have handy "just in case". I keep several small bottles of coke and gatorade on my shelf in my office at work "just in case".

Also, look into the tools of the trade that are available to help you - pump and continuous glucose monitor (cgm)- they will calm some of your fears.

I stayed on injections for 25 years but recently went to a pump because I needed to be able to vary my basal rates significantly. Having a pump makes dealing with unpredictable days a whole lot easier because you can reduce your basal or increase it temporarily depending on your activity. As someone else mentioned, if I'm doing something for work that I cannot interrupt, I may choose to run a tad higher during that activity so I don't worry as much.

A cgm will give you peace of mind when you're working and also at night. You can set alarms for peace of mind. You can also see downward trends that will allow you to make small corrections before you become low or scary low.

It will be ok. You can do this. :)

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Great post as always BSc!

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I rarely adjust the basal to my activity. I prefer to eat something instead. On a busy day you could eat an apple or banana (or one or two haribos). To start an intense activity right away will need something faster like orange juice (or perhaps glucose tabs). If you fear that you might go low at night due to your activity level for the day then chocolate is an option (not the diet stuff). Lows at night are often caused by the muscles refueling at night. The more you are used to activity the later in the night this will happen. Thus the slowly absorbed chocolate is a great fit for that. If you are absorbed in your activity you might forget to eat. This is something to keep in mind. I had many lows in my life due to nasty insulins like NPH. I really doubt you will experience more. Just be prepared and learn how your body reacts to activity.

10

Julez, You will NOT die in your sleep because you were active the day before. Changes in your routine may be necessary, but they should not be changes that prevent you from doing things you enjoy — more like, changes that support your ability to manage your blood sugar during the activities you've planned for yourself. It's like, you don't stop dancing and swimming because of D, but you DO start bringing fiber bars with you to the pool/club to make sure you don't have a low. And over time, you'll get to know how your body responds to activity, insulin, weather changes, and so forth, and be able to know when to just stick some glucose tabs in a purse, or when a backpack full of candy and juice is in order.

If you're anything like me, the biggest factor in your fear is that it's something you don't feel like you can control, and to some extent you can't, but there are certainly things you can do to have MORE control. Such as, read up on how insulin works in the body and learn how to make adjustments (Think Like a Pancreas is a good resource), and also, learn how different categories of foods are absorbed in the gut and get to know which foods/nutrients tend to "hang around" longer. Carbs by themselves tend to zip in and out, but if they're paired with protein, fiber, or fat, they last longer. Plenty of people make a habit of having a small snack with carbs and protein/fat/fiber just before bed for this reason. Think peanut butter and celery, or cheese & crackers. In the case of my young son, I have had the same fear of overnight lows that you have (pretty common thing for parents of diabetic children). We have discovered, though, that 6 ounces of full-fat chocolate milk will get his blood sugars up when he's trending low and keep them there for hours upon hours. The reason for this is that the protein & fat content slows the absorption of the sugars (both the added sugars and the natural milk sugars) AND the fat itself breaks down very slowly to add a bit more glucose into the blood. So if he's low low low all day, I generally give him chocolate milk in the evening, and bolus him for it in the knowledge that the carbohydrates in the milk may bring his BG up short term, but even with insulin aboard to address the carbs, the fats and proteins will keep his BG in range.

Knowledge is power!

11

HI Julez,

Take a deep breath. You aren't going to die in your sleep becuase of a low. My days are similar to yours. Sometimes i'm at a desk sometimes i'm on my feet, and somedays, I have no idea which one it'll be.Here are a few suggestions:

-Have a snack with you that you know will work to raise your Blood sugar quickly. For small and quick things, I use Wurther Butterscotch candy. I know exxactly how much it'll raise my sugars and it's pretty consistent. Try to find a quick and handy snack like that for yourself. The smaller and easier to pop in your mouth and forget, the better.

-I also usually have a slower acting snack that I know will take longer to raise my BS but will be more even out and not a quick spike like the Wurther's candy. I use Nature Valley Protein Chewy Bars (Peanut, Almond and Dark Chocolate). with 14g carbs, I know this won't spike me, but gradually raise my BS so when I know that I'm going low, and think a spike willbe too much, and when I know I'll have a few minutes to sit and eat it, I'll have the bar instead.

-A few folks above suggested getting a CGM. I can't recommend that enough. I got on one recently, and to be honest, I don't know why this isn't standard issue for anyone diagnosed diabetic. Particularly type 1 or 1.5. It opens your eyes and helps you prevent highs and lows rather than wait for them too happen. After getting my Dexcom (the one I use) i felt like having it was akin to walking a cave with a flashlight and headlamp whereas the before having it experience now felt like i was trying to use a cell phone screen to get through the cave. I could now see where my BS was going rather than waiting for it to happen. I tested and test BS often, but still, I felt having the CGm was a huge improvement and help in getting me data that I could use to take better care.

- I recently began using an insulin pump. I have to say that it has improved my care greatly. i could fine tune, like i never could on dadily injections. I was doing 10-15 injections to stay on top of things, but still, it has been much easier with the pump. one of the reasons is that on my pump (Animas Ping) you can set a several different basals basoed on hours ( I use 5 different basals for different times of the day). Also, You can increase or lower your basal by percentage for even more tweaking on the fly. You can do this based on half hour increments. So you can say drop your basal by 10% for half hour or four hours or go up 20% for 3 1/2 hours if you need to.

It sounds like this kind of thing would be very helpful to you as your day seems a bit different on daily basis as mine is. Feel free to send me questions if you like. I know what you are going through. I think many, if not all of us on here, have the same fear. Take a deep breath. Relax. Everyday is a learning process with diabetes. No two days are different and sometimes things just go crazy for no apparent reason. it's important to take it a day at a time, and sometimes a moment at a time, not burn yourself out with stress. Somedays, you'll do your best and it'll work out great, your numbers will be awesome. Other days, you'll do the exact same as before and it'll seem your numbers are terrible. Don't burn yourself out. Just take it as it comes and do your best. That's all that any of us can do. And also, know you aren't alone, though it sure feels like it sometimes. So go dance, hang out and live and enjoy. Just have the stuff you need with you in case you go high or low. Be prepared for the possible diabetes situations and you'll be fine. :) Anxiety comes with wanting to be in control all the time. Sometimes, that's not possible. You just need to know that you can always bring it back in control, but sometimes, it'll get out of control on its own. it just is what it is. you deserve a happy and healthy life, you just need a few more tools than most people cause your pancrease, like mine has, decided to go haywire on it's own. No matter, you can still have a great time without it. You just have to do the work it would've done for you m, mannually. :) Smile! Your job and friends sound like a blast.

Oh, one more thing, telling folks about what a low may cause for you and how to help you out of it, is important in case you ever do go so low that you can't help yourself. I read a book called Not Dead Yet (Phil Southerland), that recommends telling 7 of your closest family,friends and/or colleagues, folks you feel comfortable with and close enough to, let them know that you have diabetes and that if you ever went extremely high, or extremely low, this is what they should do. If you carry a glucogon pen, tell them how to use it. if you or they aren't comfortable with that, then instruct them to call 911 immediately for you. whatever you are comfortable with, but tell them what may happen if you go low and what to do about it. As it seems your fear is of having this happen to you when no one is around (during the night) maybe you want to tell your closest relative or best friend to check on you daily, or until you feel more comfortable in handling things, with a simple text or call in the morning and what steps to follow if you don't respond or can't. Anyway, Didn't mean to go on forever, but I hope this gives you some food for thought. Again, let me know if you'd like to talk about it more. By the way, I've set these up myself for the same reasons you are asking. :)
Best,

jeff