Taking lows more seriously

Type 1 and LADA
1

I had my day yesterday well planned: lunch with a friend at 1, then do some errands, than teach my class at 3:30. But when I walked down my snowy hill to my car and turned the key nothing happened. So I had to have it towed to the repair shop, call my friend, cancel my class. While I waited for the tow truck I ate lunch and when I tested before leaving it was high so I treated and went on my way. It was a battery and fixed fairly quickly. I did my errands and then went home.

I felt fine when I got home, just a bit tired so I made a cappuccino and drank it as I caught up with e-mail then watched the news. I decided to test and get dinner going and when I tested I was 32! Didn't see that coming at all, but as soon as I saw it I felt it! I had a hard time with writing in my log and was confused because the BG and the carbs for dinner were close in number. I checked my pump to see how much the bolus would be and remembered to write it down. Normally if I'm in the 50s or 60s and it's mealtime I just eat and then test afterwards and bolus as soon as I'm up in range again. If I'm lower I correct...usually...but I don't like to. I know this is irrational and attribute it to my eating disordered thinking (yes, despite 19 years of recovery!). But somehow I "conveniently" forgot it though I knew I was disoriented and felt I was forgetting something. I then got confused over whether to rewarm my meal in the microwave or oven, got distracted because I usually watch tv while I eat and I hadn't looked at the listings. Doing these things sequentially was really stressful and realized I needed to eat NOW. I ate without much enjoyment. I moved to the couch forgetting to re-test and continued watching a boring movie I'd started at 7PM.

The next thing I knew I woke up and it was 9:50. I felt crappy, a bit nauseated and ended up watching Project Runway for a few minutes (not a show I'd ever watch intentionally) before I could motivate to get up. I don't fall asleep watching tv very often, certainly not for 2 hours! So who knows if I was asleep or unconscious.

All this to say I listen with compassion when people talk about falling into patterns of not caring for their D, but feel comfortable that I don't feel that urge. But I have a pretty cavalier attitude towards lows considering I am 65 and live alone. Part of it is the ED but it seems a bit more than that. They don't normally sneak up on me like that but I've been having some dropping of my insulin needs that has made me have more lows lately and I should be more cautious accordingly. (I did lower my ISF this morning). Lows can be dangerous and they certainly aren't good for us and I need to treat them with more respect. I should have followed up on my treatment of the previous high and I certainly should never let a 32 "ride" counting on the food to pick it up rather than taking glucose tabs and rechecking after.

I'm basically writing this commitment for myself, but perhaps someone else will relate.

2

I am so sorry for that scare, Zoe. That is kind of where I am and why I went to DO IT. I can't feel lows at all and I have been known to function fairly well as low as 32, once it was an 11. Paramedics did not believe me...until they did the finger stick. AND I have my husband to worry about--he is the one who has to save me most of the time. At 62 (almost) I found a need to relax some.

I am currently trying to find a comfortable place between what I was told to do at DO IT (130-180 and no correcting between meals or under 200) and what has worked well for me for a long time (A1C of 5.1.) It is hard to change my need for diligence---it has become a part of who I am.

Please be safe.

3

Thanks for your reply, Spock. It does sound like we have some similar issues at this time. Sometimes I feel lows coming and function well, occasionally they hit me hard like this.

Good for you for being willing to take a new approach and find a compromise that you can live with and that will reduce your stress and risk. It's all about checks and balances, isn't it? Especially as you get older. This morning I went to my front door and a mother and baby deer were standing right outside looking at my cat looking at them. The pine trees in the woods are covered with snow and I plan to decorate a small one I can see through my triangle. On the other hand I'm parked at the bottom of my hill and have to haul up groceries and I was very nervous driving down the main curvy hill the other day with snow on the road. Should I move to town? Checks and balances.

4

For those of us who live alone, thinking about the dangers of going low can be unsettling. Our most prized asset, our rational brain, is impaired when we go too low. If we let ourselves entertain too many "what if" scenarios, then we risk losing confidence.

If I understand your post correctly, you did the finger-stick 32 and instead of treating the low immediately, you dutifully went about trying to go through your dinner prep routine. That routine, of course, was much more difficult to do when your brain doesn't have enough glucose. I know what that's about. It's as if at some level you know that things are haywire and you hope that through sheer force of willpower by staying with the routine habit that things will then be OK.

I'm a firm believer that I can continue to learn as I get older and that every situation can instruct me to perform better next time. Sometimes it takes many iterations of a situation before I draw the right conclusion and act on it. That's life. We're not perfect. The key, I think, is not giving up and continually try to improve.

You're right that your inattention to the earlier insulin correction was the root of your problem. Something that I've thought about but never done, is to set an alarm for two hours once I take a correction. That way I'll be prompted to do BG check or at least be reminded of the insulin acting.

Once you're at a number like 32, you hope that your training just shouts, "Treat, now!" I think rehearsals improve performance. Perhaps going through the motions of seeing a low number and deliberately grabbing a Dex4 or a juice would be a beneficial exercise. Like strength training is built on repeated muscle flexing, maybe doing this mental drill for a few minutes every day for a few weeks would strengthen that brain function and move it to a more reflexive level of the brain. Just a thought.

One thing I notice is that whenever I have an extreme high or low, I tend to experience a "BG re-trace" of that event 24 hours later. I call it a BG echo.

Bottom line, though, you survived! Most importantly, you live to fight another day.

5

Thanks, Terry for your very insightful response. You are correct that I am fully aware that I'm functioning way below capacity yet I think I can will power my way through. What I get from that phrasing is the recognition that the other piece of the puzzle as to why I'd be reluctant to treat lows is ego. Isn't "I can handle it" largely considered a male failing not a female one? (Kidding). Thinking, "I'm good, I can beat the clock and avoid having to take glucose tablets". When you're at 32 the clock has wound down and the buzzer gone off...duh. I rationalized internally that it wasn't even technically cooking that was required, it was just re-warming, but as we all know even those simple steps can get difficult to complete when our brain is deprived of glucose! Then I even have my little busy perfectionist in the mix: Who the heck cares if phyllo dough crisps better in the oven than the microwave? Geesh!

You are spot on as well about moving the decision, "treat now" to a more reflexive level of the brain, which is part of my reason for this post as well. The kind of person I am is once I make a commitment it's carved in stone, nearly automatic. It's all that waffling and wiggling I do before the commitment that's troubling!

6

It is "because" I live alone that I treat quickly. No one to pick me up if I fall out or pass out. In earlier years I could function normally with a 20 (have had many observers witness this) but I do not want to chance it now. And I am sure that I could no longer function well at 20.
I keep a 4 pack of grape juice bottles (the 8 oz? ones) and keep one in fridge. I like grape juice very much but never drink it just as a juice. But a couple ounces of it when I am low gives me the temporary bump up I need until I eat or drink something more substantial. And I will grab it when needed because I do like it. And no, I never am tempted to drink it when I am not 60 or below. I have to do it before my brain gets fuzzy. Others have their own preferences but this one is mine.

Re your move issue. I live outside of town and think I should move also. On the other hand I have one set of neighbors that will help me if I ask. At my age and with my non-outgoing nature I don't know if I could make new neighbor friends or even get good neighbors if I move. So, it is a conundrum. You have a special issue with your driveway, though I am on gravel but have a flat driveway and garage.

7

The "I can handle it" overconfidence trait does, I think, occur more in men than women. I guess we think we can handle more than we're able and in the back of our minds we think trying and failing is better than counting yourself out from the start.

Your strong character trait of staying the course once committed combined with your sugar low brain prevented you from seeing the obvious solution to treat now. Hypoglycemia, especially below 40, has a strange hold on the brain.

Some decisions are best served with waffling and wiggling; whether to treat a hypo now or later is not one of them!

8

I must say--the idea of living alone with diabetes is scary. I travel alone a lot, but my husband always knows where I am and I check in with him every morning.

You are amazing.

9

Zoe, I'm so sorry to hear about your bad experience. Lows do sneak up on one, I can be high normal & then 1/2 hour later be in the 30s!

If I am low before a meal, I eat a suitable amount of fast acting glucose to bring me up to normal. Finish getting dinner, I usually test as I'm getting things ready not just before I eat. If I was in the 30s or low 40s I'll test again, if not I add the glucose carbs to my meal carbs & plug that into the pump EZCarb calculator & enter the low BG (or the ping picks it up automatically) if I got the correction glucose correct the pump will suggest a normal meal bolus or a bit lower. If I'm confused I know I need 3 Dex4 tablets, I usually manage by myself even in in the 30s, occasionally my husband does need to supervise.

I think you should definitely correct for the low with fast acting carbs & not count on your meal to bring you up, those are probably slower acting carbs.

I think I am too cavalier about lows but I am trying hard to keep my readings higher.

10

Why thank you, Spock! At this point I'm so used to living alone that it usually doesn't bother me, except for the rare time I don't feel safe.

Sounds like we share some similar issues about living situation, Nell. I think my neighbor below would help me, but I don't know them well enough to be comfortable asking. It is a very small town though. I don't know how far out of town you live but I'm only 7 minutes and it is nothing unless the weather is bad or my car doesn't work. So if I need help I do have friends in the town I could call.

Terry, for me, I think the problem is that I had not fully made the commitment to treat below a certain number, so let myself slide into "I'll just go ahead and eat". So I'm making it: "Under 50 I will treat with glucose tablets right away even if it's mealtime."

I know that in general we are split with some people treating under 70 and some under 60, but what about if it's mealtime. Do people treat or just go ahead and eat your meal (or break it down by numbers as I'm doing now).?

11

Thanks, Annabella for your sound recommendations. I think you are right about treating with fast acting carbs when I am that low. For me, though, I don't plug in my bg to the Ping because I've found my experience is that I still need my full carb bolus. I also don't add in the treatment carbs, so maybe the end result is similar.

The end result of my experience last night, btw was when I "woke up" (three hours after dinner) I tested at 66 so I never bothered bolusing for my food. When I was ready for bed I tested at 72 which I consider marginal for sleep so I took one glucose tablet. I woke up this morning at 199. Such fun!

12

Hi Zoe. I don't live alone, but still we're each alone in our own skin. If I go low just before a meal, I go ahead and treat with glucose tabs, because the tabs are immediate and the carbs in the meal are probably not going to hit for 20 min. or so. I decided on that strategy after the time I waited for the meal to treat the low, sat down and began eating, and woke up in the living room with my husband trying to treat me with something to bring me around. Well, I'm sure you've got a strategy by now.

13

Thanks, Kristi. I'm probably the only person on TuD, Kristi, who has zero desire for a CGM!Which is probably a good thing as I just started Medicare and they won't cover one!

Thanks, Trudy; I think you are right! This is why I posted this topic, to tell me what I should already have gotten through my thick skull!

14

Preventing the counter-regulatory system from kicking in influences my low-BG treatment strategy. I don't want adrenaline, other hormones, and my liver to turn a simple low BG situation into an extended trip on the gluco-coaster. As to the actual number that triggers my low BG defense, it all depends on the trend, the IOB, and timing of my meal.

If my BG is 70, cruising sideways in a slow downward trend, with little to no IOB, then I will not defend that number like I would with several insulin units on board and a more significant downward trend. It's situations like these that argue for a liberal allowance for test strips.

If I sit down to eat, have already taken my meal insulin, and my BG is trending down, I'll eat at least one glucose-tab, maybe two. I may also eat the carb portion of my meal first.

I, too, see glucose tabs as a defeat of sorts. They're just chalky empty calories. But I liken it to, in military terms, as a strategic retreat.

15

When you say "I did lower my ISF" do you mean you turned the number down? I think that's a backwards numbers as if your number goes down, the insulin goes up?

I sort of like "Project Runway" though. There is some hilarious stuff on there...

I'm glad you recovered ok too, jeez, here I am being all "oh, how can we fix this..." d'oh...

Also, what I usually do if I'm cooking and hypo (ok, not all that uncommon of an occurrence...), is treat it "normally" and then bolus for where the "fix" should put my BG. I also sort of keep different levels of carbiness beers around and have a carbier one in that situation too.

16

Thanks, AR. It's always hard to express that lowered and raised stuff! I mean I lowered the amount of insulin by raising the number (from 30 to 35).

17

I appreciate the info, Terry, but as a non-CGM-er I'm starting to understand how MDI-ers say they feel when we talk in basal rates, etc! "cruising sideways in a slow downward trend" makes me picture when I lived in Pacifica and used to watch the hang gliders coming low over the ocean and waving.

For me, the only time I treat a 70 is if it's bedtime, otherwise I just keep an eye on it. Can you translate that "sitting down to eat" sentence into numbers rather than "trends". (I can see how one might start to think more in trends so it's ok if not).

Yeah, chalky empty calories. I don't mind the taste as many do because I think of it as "medicine" (since I haven't eaten "sugar" in 19 years). But I do mind them more in close proximity to real food!

18

Oh man, I so hate to say this here, but...

Treating at 50 is kind of dangerous. I set my low CGM to alert below 60 (my CGM alerts disrupt sleep and I worry about them affecting my husband's health,) am totally insensitive to lows, and have paid for those lows, even the 60s. Once I am alerted at 60, I am often not "there" and the choices (like wanting to sleep over personal safety) get in the way of my better judgment. Please remember that lows affect not only your "right now" stuff, like balance, judgment thought processes in general, but have really long term affects on the brain in areas such as memory. After 50 years, I can attest that my memory is not what it would be without D.

I SO LOVE Project Runway. My favorite was the dress made of veggies. There have been several, but this one is a vegetarian winner....THE DRESS MADE OF VEGGIES

19

Sorry for the CGMese. I find it a potent technology that fundamentally changed my ability to make timely and smaller interventions. I know its not your cup of tea and I wonder how I would finger-stick if I were limited to that. To catch trends you need at least a pair of readings about 15 minutes apart. I'm not sure how often my guesses as to when to test would be correct.

I think it's a false economy denying CGMs to Medicare recipients. One avoided coronary artery bypass graft pays for lots of CGMs. They're stepping over dollars to pick up dimes. I'm hoping the policy changes by the time I get there.

When I wrote about sitting down to eat, what I had in mind was a BG in the 60s and trending down. The trend is the key, when considered with IOB and meal timing. I start to pay much closer attention when my BG is below 70 but don't always act until lower.

I treated three lows today but the lowest my BG got was 60. Most of the low time was in the upper 60s.

20

I'm confused about the context of your statement about "treating at 50", Spock. I stated that I consider low "under 60" like many people do while others consider it "under 70". What I meant referring to 50 was that at mealtime I would treat with glucose tablets under 50 but higher than that I would go ahead and eat without bolusing. My experience is that over 60 if I took glucose tablets and ate without bolusing that is pretty much a setup to go high. I don't have any disorientation around 60. Yep, we're all different.

Terry, I do and I don't agree with you about Medicare covering CGMs and I'll probably get people annoyed at me for saying this. Thinking about it from the point of view that they are very helpful for many people and I am the exception in not wanting one. But I think about other cultures and how very privileged we are in comparison and the expectations we have including things we "cannot live without". Medicare is designed to be a bare necessity medical support system. We are an elite on here with our pumps, CGMs and 5 A1C's. We don't need pumps or CGM's to live like we need insulin to live. Many of us had good control on MDI but chose pumps and/or CGM's either to have better control or just for a better quality of life. I guess I just wouldn't expect a national subsidy to pay for that. Test strips? Now that is entirely another story! Just out of curiosity: For the people living in countries with social medicine (all free provided to everyone). Do your systems cover pumps and CGM's?