Struggling with moderate activity while still "carrying" some Bolus....Any tips?

Hey all,

I have been having issues with a fast-dropping BS when being active around 1-2 hrs after eating, and unfortunately it seems to be getting more severe.

Usually I have my ratios worked out pretty well, I measure post-prandially around 1.5 hrs after food, and most often than not I am landing comfortably at around 125-145 mg/dl, which is cool.
Mind you, this is within my typical workday routine, where I am usually not overly physically active while still having bolus on board. (I do adjust my life to that and whenever I can, avoid situations where I have to move around lots with IOB.
But I have just come from a holiday in Belgium, so I would inject for food and than soon would start moving around again, exploring the city by foot or walking on the beach.
I did factor in my activity and reduced my Bolus by one unit or two, ending up injecting an average of 2-4 units for lunch or breakfast.
I would measure around 1.5 hrs after that, just before going out, and was naturally higher than usual (around 145-170). As soon as I started walking, only 15mins in or so, I would feel sort of funny (but not clearly having low symptoms unfortunately – at what number do you guys start feeling those btw??), I measured, and was often down by like 70/80 points, so around 60-80mg/dl.

Knowing that my Apidra still has another hour or so to go, I would eat 1 or 2 glucose tabs, keep walking, measure again, would still be lowish, had to eat glucose again...SO ANNOYING!!

I just really would like to know what the solution is in a situation like this. Had I reduced the bolus even further, I would have been much higher than I like to see at the 1.5 hour mark, but probably still fall to low as soon as I started walking around. And I m not marathon running here, I am STROLLING, SIGHTSEEING.
Should I allow myself to be higher, would that make more sense, and in fact not do much harm since I know I would shortly be walking it off? Do you guys do that? Or just accept the lows and treat them as they come?

The other problem is, I am very scared and very inexperienced regarding lows. My DX was only 2 yrs ago and the lowest I have ever seen on my metre was a 53. And I didnt feel that coming really either. I dont sweat or shake or feel weak when I am say 68. Is that normal? I know what hypoglycemic feels like before my D days because I had an issue with it when I was a teenager, and my insulin-lows now dont feel anything like that. So Maybe I am hypo-unaware, but is that even possible without having had many lows at all so far?

I know this is a whole lotta questions at once, sorry! I guess my main concern is, how do I deal with moderate activity and bolus, and why do I drop soooo quicky, and am I endangering myself with the method I ve been using?
It is also just annoying to feel tense whenever I m on holiday and just bolused. Not really enjoyable, cant concentrate on sights if I am BS checking every 10 mins.
Any advice welcome, thank you guys.

Ps: Bruges is worth a visit if in Europe, as far as I can tell at least ;)

hi julez,
i have a similar problem with needing to bolus and then doing some physical activity. i take my dog out for walks/runs after brekkie and if i bolus 1 unit for my 25 or so carbs, i am low in 15 minutes, like you. and if im walking, im strolling-doesnt matter tho, just go low. so i try to just have a scrambled egg-no carbs, and a coffee-milk carbs. i get back and im in the 120-140 range. if im lower ill have a bit of fruit/yogurt/square of dark chocolate when i get back.

the same in the afternoon. right after lunch i cycle 30 intense minutes to work.
most of the time i try NOT to bolus and eat just the right amount of carbs to get me to work and be at about 140 after the cycle-about 15.
this method works most of the time, though sometimes i end up lower or higher than id like. it might not work for you if youre eating carbier/less fatty meals. i think we were diagnosed almost at the same time and i dont know if the honeymoon is still going on that i can do this or if its the benefit of lower carbing.
here in spain, i use novorapid pens and because of the low doses i take, i asked my gp for a pen with half units. they are not available at all here, but may be available where you live. do you think half unit measurements might make things easier? im going to the big deal hospital endo in a weeks time and im going to ask them to show me how to use syringes so i can try to do half units because of it. its either half units, very low carb meals or bolus 1 stupid unit and sit still for four hours.

regarding the lows, sometimes i feel them at 70, other times, especially when doing any kind of fun physical activity, i dont notice till im in the 50s or 60s. if im just sitting around i tend to notice them earlier, or that im dropping.

sorry i cant be more help, maybe you could get a cgm to give you piece of mind re the lows? i wish i could but all the money for health care in this country goes into some fatcats pockets-haha.

are you prebolusing before your meals, that can help with the 1 hour spike. Also, are you sure your basal is correct and you're not taking too much. I understand Apidra works very quickly, maybe try another fast acting that doesn't kick in so quickly? I too can drop quickly and a lot with just walking or doing any activity. I have a CGM, can you get one of those? With a CGM I can see when I start to drop and stop it before it gets too low, hopefully. The 1/2 unit suggestion was good. I use .5 unit doses (w/.5 marker syringes and draw up from pens or vial), with both basal and bolus, corrections too.

Hi Julez,

I had a similar problem when I was visiting Rome a couple of years ago. I was blousing on the conservative side and still picking myself off the floor (not literally) with numbers in the 50s after walking. In general, I try not to do any sustained exercise or long walks before 3 hours after eating. If that's not possible, I'll either skip the meal or have a nearly zero carb meal (a salad with tuna for example) and not dose. The worst that usually happens in that case is that I eventually have to correct a 120-140.

My endo had interesting advice when I brought up this issue at my last appointment. He recommended that I simply aim higher for the week or two that I'm away. Over the course of a lifetime, running 40 points higher for a couple weeks isn't going to do much harm and it will provide a much better cushion when sightseeing.

Maurie

Sight-seeing activity is more physical work than we think. Walking, going up and down stairs, and carrying a day-pack, all for extended periods. We can get so engrossed in the sights, we lose track of all the physical work our body is doing!

I've used a combination of tactics to defeat low BGs during the active insulin time. To start off, I try to eat a breakfast with relatively few carbs, like eggs with breakfast meat and maybe some tomatoes. Fewer carbs means less insulin and smaller insulin to carb mismatches. I've also lowered my basal rate on my pump by 20% starting one hour before I get active. I know you use MDI, so I'm wondering if you've tried backing off on the long acting insulin. Perhaps if you take 10 units of long acting, reduce that to 8.

If you don't want to back off on the insulin, then you could consume some extra carbs, like a snack bar, and don't cover it with insulin. I would eat the extra snack about 1/2 hour before you start sight-seeing.

You just need to work this out for your own needs. As time goes by you will develop your own strategies to make this work for you. You've only been at this game for a few years. More experience will definitely hone your skills! More experience leads to more confidence and the ability to relax and just roll with the punches. You will get there.

The biggest thing, I think is that we all tend to under-rate simple activities like sight-seeing. When I do house-work for more than 15 minutes, I need to either eat a small snack or reduce my insulin, either basal, bolus, or both.

Exercise, even just strolling as a tourist, is the sort of thing that has always been my biggest challenge with D. I tend to err on the conservative side, as Maurie suggests. I either lower my meal bolus or omit it, if going after a meal, or I lower my basal by 70% starting an hour before. I am a "blood sugar burner" so it's what I need to do, and you may be a BSB as well. I also carry sports gel with me, such as Gu or the Clif product. Those are really handy and easy.

I'm sorry you're having this problem Jules. I think what I would do is bolus even less and let myself spike and then just let the exercise take care of it. I really, really can't stand lows anymore and after fast dropping lows which don't respond to sugar I am being very careful now to avoid all lows as much as possible. I'm also insulin/exercise sensitive and sometimes I drop with little or no activity too. I can never tell when it will happen. You could also try snacking on things while you walk too? Not just waiting for the hypo. Try to prepare for it ahead of time if you can. I have been to Bruges a long time ago- it was beautiful...Good luck!

I think you are doing exactly the right thing reducing you bolus for activity. But you may be having these after meal lows not because of your bolus, but because you still have some remaining insulin production. If you go high as you say, that may trigger some insulin production and result in reactive hypoglycemia. I always have to watch out for that after meals if I undertake exercise.

If you know you're going to be active, cut your bolus some. There's a great chart in "Think Like a Pancreas", that proposes %age cuts for duration and intensity of activity, like if you plan 1 hour of moderate activity, you cut the bolus to 66% of what you'd ordinarily take. I know it's out there online somewhere but I haven't found it since like 2009 or so but I took a pic:


I find too that I prefer to eat some extra carbs to eating "emergency" sugar, if I can at all help it. Something like a glass of skim/ fat-free milk has quick-acting carbs but protein too and doesn't really get in the way of working out too much. Or adding a piece of toast to my breakfast. It doesn't have to be a ton extra, just a boost...

Just wondering what your diet is like, eg are you eating enough slow acting carbs combined with protein & "good" fat at every meal? This seems to work for our family. With your dietitian's guidance, maybe for days that you are going to be walking around, keep total carbs the same, but consider emphasizing "slower" carbs more heavily and adding a small amount of extra healthy fat in order to avoid being too high and then dropping too low once you start moving around? Generally speaking, a low-fat meal will raise the blood glucose level quickly (usually within an hour), & a high-fat meal may take two to four hours to produce a blood sugar peak. This "delay" could cover you for periods of moderate activity perhaps? Our family has noticed that blood glucose level rise overnight after a restaurant meal, or even after having a high fat snack during the day (like apple pie) . The culprit is most likely the fat content of these types of meals and snacks, not the carbohydrates.

I have observed the same thing ALWAYS happens to me. I just roll with it and turn my insulin down to adjust.

Even though I exercise faithfully three times a week while doing my office job, when I travel to a foreign country (for either work or pleasure), I find I am WAY more active just because there is so much to see and do. I don't go to the gym while traveling, but I walk all over, never take a taxi, and see as much as I can. It's like my metabolism goes into overdrive. I deal with this by expecting it, and then turning my insulin down in response. For example prior to a recent trip I was taking 38 units of Levemir basal per day; but when I spent three weeks in Japan for work I found I only needed 26 units of Levemir per day, and still had a significantly lower average BG than normal (while eating a higher proportion of carb in my meals - white rice and or noodles at every meal). My bolus insulin I/C ratio and TDD went down by a similar amount.

From there I spent two weeks in Italy on vacation, and my insulin needs went up a bit (30 units of Levemir per day), as did the proportion of fat/protein in my meals (Tuscan meats and cheeses), but it was still less than it was before I left, or after I returned.

It took me a long time to understand this, and yes it does require you to test your BG more while traveling to keep on top of it. Which sucks, but isn't so bad as long as you know to expect it and be prepared to adjust for it. I also carry a big bag of raisins and whatever I find for local fruits in my pack while I'm out and about (in addition to the emergency glucose I always carry) so I'm prepared.