TAGging for MDI help?

Treatment
1

I've been reading the discussions here, fascinated and deeply intrigued.

I'm not on a pump. I've only recently begun to use insulin, and only use Humalog before meals. My endo thinks that I don't need a basal insulin yet. My problem is that my BG spikes about 2-3 hours PP and often stays up there for quite awhile. My endo thinks that if these spikes can be managed, my fasting levels will come down, too.

I'm still working out what my I:C ratio should be at different times of the day and I have questions about measuring my I:BG and C:BG ratios, too. The endo sees me as a "self-starter," which is pretty accurate, but figuring out these ratios isn't easy for me. I understand the theory, I think, but I don't get consistent readings yet. I'm hoping that, once the holidays are over, it will be easier for me to have a few days of mostly fasting and testing without upsetting anyone because I'm not eating.

I eat a very low carb diet, with rarely more than 20 grams carbohydrate per day. I imagine that some of the spikes I experience are actually the delayed conversion of protein from breakfast showing up in the afternoon. I eat almost no carbs at all in the morning.

I'm considering asking for a prescription for Regular insulin to use along with Humalog in the hope that R's delay will help with the spikes. Maybe only R would be needed when I eat, say, bacon and eggs, for which there's almost no carb? When I have meat and veggies, then use the H before the meal and the R when I start to eat, calculating H for the carbs and R for the protein and fat?

2

Hi there...

From what I see based on your A1C level of 8.8 and your post meal highs, it sounds to me like you would sure benefit from some basal insulin. Low carb diets are mandatory for good control and low A1C's. If you can, try and get your A1C safely down to below 6. I know that sounds impossible, but, you can do it. You know your 8.8 A1C means your average plasma blood sugar is 206 (eAG scale). That is too high. Nice to see you got it down from 13 or 14.

I don't think I would mess with Regular anymore if you do go on a basal dose. The duration tail is too long and it takes way too long to bring your BS down compared to Humalog. So, why take it? To get your BS down post meal, try taking your bolus 30 mins before you eat (only if your BS is above 100+) and you know that you will in fact be eating soon (not like in a restaurant when you have no idea when you will get your food). That's my 3 cents for you! :) Ken

3

Thanks for your response Ken. I'm trying really hard to get my A1c down below 6 and I'm pretty sure I'll be able to do it. I know that my fasting BG was 6.4 when I had a blood test about three weeks ago, and my average BG readings are about 6.6-6.7. I think I'm doing pretty well, for the most part.

My endo thinks that if I can lower my BG overall, my basal rate will also drop. It may be that, for awhile, at least, I won't need any insulin if the BG comes down enough and stays there, so I'm very focused on low-carbing. Fortunately, I don't find the diet difficult to manage or adhere to.

The thing is, I do eat a fair amount of meat, eggs and cheese. I understand that about 50-58% of protein eventually breaks down into glucose; I'm wondering if that's what elevates my BG about 3 hours PP and keeps it high-ish up to 5-6 hours PP. (By elevated, I mean up to about 7.8 and high-ish can be 6.5 or 7.) By the time my BG rises, I'm long past Humalog's peak. I can bring my BG down by taking another couple of units of H 2-3 hours after a meal. I'm wondering whether it would be better to use R at mealtime, instead, because it takes longer to work and has a slower arc overall.

I'm also wondering whether, if I eat only protein--such as having bacon and eggs for breakfast--and my BG is at 5.5 or less, I shouldn't take any H at all until my BG rises 2-3 hours later.

4

I think you are on the right track in considering delaying the BOLUS (shot) of Humalog, but don't wait until your BG rises. Instead, I would first try giving the bolus 1 to 1.5 hours PP. Test @ 3 - 3.5 hours PP and again @ 5 - 6 hours PP. If your BG is still high, you should think about taking a second bolus @ 3.5 - 4 hours PP. If your BG dips @ the first PP test and then raises at the second, you might consider splitting the bolus 60/40.

IOW, work backwards from the peak and duration periods for Humalog to determine when to bolus.

5

Agree with Mike. Remember that the -log insulins take some time to kick in, you'll have to work out how much time that is for you, and how much time after eating the protein/fat kick in. I have no doubt it's the protein/fat that's raising you later. 58% for protein/10% for fat is a starting point, but it won't take long for you to figure out what your percentages are.

Low carb is absolutely the way to go for me. I'm usually ~30 a day. You have a good understanding of how things work, which is a huge plus. Why avoid bolus insulin if it will make life easier? I highly recommend Think Like a Pancreas and Using Insulin (both available in paperback). They'll answer your questions and more and give you more tools for working out ratios etc. and tweaking.

6

Thanks for the good advice, Mike and jrtpup. I've tried to work with it today and I think I've had some good success. When I got up, my BG was 4.8--very good for me! I had bacon and eggs for breakfast. An hour and a half later, my BG was 6.1. I decided to wait half an hour and see whether it went up anymore or was on its way back down. It went up to 6.2. I took 3 units of Humalog. An hour later--which was three hours pp--BG was 5.3. I was happy with that. But two hours later--five hours pp--it had risen to 6.4 even though I hadn't eaten anything since breakfast. I re-calculated the bolus and took 3 more units of H. An hour later, BG was 4.8, which was fine with me. But after another hour, it was 4.2, and I was about to go out. I didn't want to go low, so I ate 3 g of Smarties which I was sure would bring me back up 1.5 or 2 mmol/L. It was going to be difficult to monitor for another hour, though. Even so, an hour later, my BG was back at 5.8.

I'm going to try the same thing again tomorrow, with the same breakfast, but test and correct, if needed, at 1 or 1.5 hr pp and if I need to correct again later, use less H for the second bolus than I did today. I think I need to tweak my calculations some more: it seems I'm more sensitive to insulin than I thought. I'm feeling a lot more confident about getting this figured out, thanks to all your help!

I have a copy of Think Like a Pancreas on order. With any luck, it should be delivered tomorrow or Thursday.

7

Well done! You're well on the way. The book will help a lot ;)

8

Another day, another chance to learn how to deal with protein. When I woke up, my BG was 5.2--not bad! By the time I was ready for breakfast less than an hour later, it was 6.6. Before I had insulin, I would have skipped breakfast altogether and waited until I was lower than 6.2 to avoid a high spike, but I decided not to do that today. I went through with my plan to eat and test again after an hour, correcting then if I needed to. I'm still not sure how much Dawn Phenomenon I have or how it works for me. There's still not a lot of predictability in my early morning numbers.

One hour pp, my BG was 7.1. I took 3 units of Humalog. An hour later, BG=6.2. But an hour after that, 3 hrs. pp, it had risen to 6.6, not a huge increase, but an upward trend I didn't want to accept. I took two more units of H. One hour later, I was 6.00, and the next hour, 5.9.

I'm happy with these numbers. They're all within range and I think that using an I:C ratio of 1:10 and calculating my insulin sensitivity at 1:50, along with 58% for protein and 10% for fat seems about right, too. It's good to have an idea of where to start with those numbers since my endo had suggested trying my I:C anywhere from 1:5 to 1:10. I'm all for less insulin for more value!

9

Interesting that you rose after getting up without eating. The same happens to me. I don't really have DP- I stay flat all night - but as soon as I get up, boom. Happens if I nap too. If I'm between 70-90 when I wake up I take 1/2 unit, over 90 1 unit. That doesn't stop the rise but does level me out sooner. Totally unscientific, and not endorsed by my CDE, but works for me.

10

That's interesting! I sometimes have something to eat right away--like a piece of cheese or a slice of cold meat. Before I started taking insulin, that usually made it possible for me to be able to eat breakfast when it was ready. Otherwise, I'd go too high and would have to wait another hour, sometimes two, before I could eat without going much higher.

My Humalog is in a pen and the pen only dispenses full units. I think I should get some needles so that I can do half doses, too. It would make giving the bolus more accurate since my calculations often result in partial units. I'm a bit wary of rounding too much because I'm trying to work out my ratios. Maybe using both the pen and a needle would help.

11

I can't do this. I can't figure anything out and I realize that any success I seem to have is just a coincidence, not real at all.

I eat so very little, but everything makes my BG go up. I can't calculate with any accuracy how much insulin will lower the BG and so my calculations about how much insulin I need to cover whatever I eat are also off.

I have been focused on Think Like a Pancreas, but I don't seem to fit any pattern very well. What is my Insulin Sensitivity Factor? I have no idea. I've only been taking an average of 10 units of Humalog a day, not that it actually works in any predictable way. That would mean that my ISF is 8.3-10 (150-180), but that's impossible. One unit does absolutely nothing at all most of the time. Four hours after taking it, my BG is likely to have risen 1.5 mmol/L or more without eating anything at all.

Delaying insulin and dividing the dosage, as I did last week, only worked those days and I don't really understand what was happening then. The first dosage obviously wasn't enough. The second overlaps and brings the BG down, but how do I know if it will bring it down enough? It might. I might not. What it does do is prolong the time before I can have another meal, since the second dose won't be out of my system for four or five hours. That's not a problem in itself, but if I want to have a meal with someone else, it means I can't eat at all before that meal or the schedule will probably be off.

My I:C ratio? Who knows? The endo said to start out with 1:10. I rarely eat 10 g of carb at a meal. If I'm only eating 4 g of carb, the carbohydrate ends up being distorted by the amount of protein I eat, so I'm covering for a higher effective amount. At least, ideally. But if my BG needs to be corrected, too.... it doesn't make sense. I'm really only playing with numbers for the I:C. The tables in Think Like a Pancreas are all for someone who takes a lot more insulin than I do and who sometimes eats as much carbohydrate at one meal as I eat in five or six days. And he's not calculating anything for protein.

I haven't even tried to figure out what to do about "exercise." For the last while, I haven't been getting any exercise to speak of because it raises my BG too much. I thought that insulin would help bring it down, but there's no guarantee it will do anything. Right now, the insulin makes it all seem even more unstable. It's hard to understand what Think Like a Pancreas says about exercise, anyway. Gary Scheiner is as terrified of ketones as he is of high levels of dietary fat. I eat a lot of fat. I am always in ketosis. If I ate as many carbs as he suggests, or ate three times the amount of carbohydrate I would eat in a single day just to take my dog for a walk, I'd be the size of a barn before Easter!

Meanwhile, my family is becoming increasingly difficult because I don't eat for most of the day and they think I'm testing my BG too much.

It looks like I need to forget about using insulin to get my BG down where it should be. It may not work consistently, or maybe I'm just too stupid to understand the patterns and what to do with them. Maybe, if I'm super careful and eat as little carb as possible, I can just drive the BG down that way. If it stays within a reasonable range for a few weeks, perhaps I could use insulin and I have no option but to eat more than a very few carbs. Some PWD never can really eat carbohydrate, right? It's part of being diabetic for them? Maybe I'm one of those.

12

Anne, breathe ;) You sound like I did when I first used insulin. You CAN do this. A suggestion - don't try to TAG every meal, it makes things much more complicated. Scheiner is a guide, not a bible - we ARE all different, and I find that I don't fit 'typical' patterns either. It's a matter of trial and error, and takes time and loads of experimenting.

You're doing a lot of new things now, and it really can be overwhelming. Maybe start by eating the same thing, same amount, approximately same time, for breakfast every day and focusing on that. Keep tweaking until you get it - and you will! I also eat LC (~30 a day, except for very occasional splurges), and a lot of fat. My TDD is usually in the low 30s.

Remember also that your I:C ratio will probably be different at different times of day. Mine is almost double in the middle of the day what it is morning and evening.

You CAN do this. Keep posting please!

13

Thanks, jrtpup. Protein is a problem. A big one. Fixing the result of having eaten--there's no reliable way to do it. And I'm supposed to be working, which makes testing my BG all the time a problem, too.

Food is the enemy, so I'm going to avoid eating for the next few days and see what happens. I'll just have dinner with my son--meat and a salad, maybe 5-6 carbs. Maybe my BG will level itself this way. If it's too high before dinner, I'll try some insulin and see if it helps. I know that one unit is a waste of time because it changes nothing, but taking four or five units isn't a reliable method either. Grrr..... But at least I won't have to wade through the maze more than once a day!

14

Ann,



I switched to the pump about 2 years ago, but before that I used a combination of regular and novolog to cover my protein/fat and carbs respectively. This is a technique I read about from dr, richard Bernstein (the diabetes solution book). Basically, I shot up novolog to cover my carbs and then regular for protein using the TAG principle that about 58 percent of protein and up to 10 percent of fat will ultimately metabolize to glucose. It worked very well for many years for me and helped me get to a 5.0 a1c on MDI. Best of luck. (I was using lantus for basal).

15

My thought exactly! Can’t believe I am reading this :slight_smile:

16

How are you doing now? Did you figure it out?