# of times need to treat highs/lows

Curious as to others’ experience w/ these…

How often on average would you say you have to eat extra carbs you weren’t planning on eating in order to prevent or correct a low? How many of these carbs on average?

How often on average would you say you have to inject insulin you hadn’t anticipated needing to inject in order to prevent or correct a high? How much such insulin on average?

Hi Becky @BKN480 I like the way you asked these questions, and I believe that all reading will agree that the questions may help us “rethink” our decisions. I know that over the many decades that I’ve lived by insulin, my treatment methods have changed significantly.

First, correcting a “high” with additional insulin. Most often when I go high enough to need [or even consider] an extra insulin dose it is because I had undercounted carbs at a recent meal. Often times, especially when eating out] it is because I was uncertain of my carb guestimate and deliberately took a lower meal bolus than actually needed. The amount of insulin I take will depend on the graph [for me CGM] showing the rate of rise 90 minutes after eating and my new estimate of the meal carbs. my manual corrections are skipped when the CIQ has already delivered a correction, and usually done in “small” 0.25 increments.

For my “low” treatments, I have dropped the 1940s - 1960s 15/15/15/ rule which was used ages before quick blood sugar testing - back when a blood sugar test even when in hospital took two days, to doing corrections as small as 3 or 4 grams of carb. Even when exercising, such as extended walks or bike-riding, my food is measured at 8 grams of carb, unless the drop rate is rapid - “two down arrows” on CGM indicating 3+ mg/dl/min rate. I will skip treating even these lows if the numeric reading is high enough.

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Thanks for the info, I really appreciate it. I’ve wondered if I am on the “sensitive” end of insulin sensitivity, b/c so often I correct, depending on my numbers and when I last took insulin, even just using say half a unit for a 180, and then I go low or trend low later. So it’s good to know that even just a quarter unit correction is all others need as well (depending).

How frequently are you finding yourself having to buffer w/ carbs - even just 3-4 grams?

I’ve been trying for almost two years now since diagnosis to limit highs as much as possible without going low or trending low, including finally coming to the much stronger desire to avoid lows than highs, and I still have to keep buffering against lows so much, like 3-5 times per week. And the unpredictability is frustrating, even though I’m putting in so much effort to account for everything and learn lessons. I’m just wondering if it’s just normal for T1D’s to frequently buffer against lows, especially when correcting for and trying to prevent highs.

Anyway thanks again!

“A little high is better than an ambulance or hearse ride.”

I treat most lows pre-preemptively by predicting them and seeing them coming. I get less than one per month that I didn’t see coming, but still soon enough to self-treat. That’s with MDI and old- fashioned synthetic human insulin . I actually did worse using the latest analog insulins.

If you are experiencing lows often enough to be concerned about them, then you are taking too much insulin and/or taking it at the wrong times. With Humalog you can get fast acting good or bad results. You are also likely to be over-treating your lows.

There’s no excuse for overtreating lows using the generic 15/15 rule for 150 lb male strangers. Your carb to BG correction factor is the same as your insulin to BG correction factor. It just has the opposite effect.

To use insulin safely, you need to have accurate information. You must know your insulin to carb ratio(s) and your correction factor You must be conscious of what you eat, do a reasonably good job of counting carbs, and if you are uncertain about an unusual food, meter and intentionally under-bolus before, meter an hour to two after, and correct. Being high for an hour is safer than being low.

If you do these things you will reduce your lows. Preventing then os harder than it sounds in the books because humans are not machines. The need for insulin is not just dependent on food. Activity, and amount and quality of sleep changes the need. Varying hormones change it more. If you have a low one day the chance of your having one the next day are higher because you will deplete the stress response hormones that produce the warning symptoms. (Prolonged stress has the same effect; people without diabetes under extreme stress make mistakes more frequently because they experience the same symptoms (irritability, slower reactions, decreased awareness, fuzzy thinking, etc.)

Children, young adults and all women all have responses to insulin that can vary considerably form day to day due to growth and other hormones.

A person with “brittle” diabetes actually suffers from a lack of the right information about their body at the right time. Combine this with with a variable schedule, variable diet, variable sleep and variable activity and it’s nearly impossible to control your blood sugar unless you are a walking computer like Mr Spock or Sherlock Holmes.

If you are brittle, you ought to be seeing a professional and wearing a CGM
Keeping accurate* food, activity, and sleep logs for at least a month to get in tune with your body’s needs. Most people, not just women, have a monthly cycle. If you can identify yours and see the pattern of your uncontrollable changes, you can combine that with your controllable behavior to get a better grip on your lows.

*Accurate food logs have grams of carbohydrates based on weighing portions on a scale. The larger fast food chain restaurants should be able to give you a nutrition guide that lists carbs for their menu items. (imo, None of them have menus suitable for chronic eating, just emergencies and travel.)

byw, Frequent lows can have the side effect of persistent weight gains.

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Hi @BKN480 I am fairly aggressive with insulin and so my lows are almost always caused by a tiny bit too much unplanned activity while I have insulin on board. So I will estimate that I’m treating, on average, about 20 grams of extra carbs about 4 out of 7 days. 80 grams a week.

Since I have a pump I can add fractions of units and I can “treat” a 125mg/dl on my CGM or finger stick. I like to see my blood sugar between 70 and 100, I’d say I add about an average of 1-2 units a day (let’s say 10 units a week). These are generalizations. I occasionally forget to take insulin with lunch and I’m not “counting” those. Once in a while I eat something sweet at a restaurant and it can be “interesting” and I’m not counting that either.

Can I ask what your concern is?

Cheers :shamrock:

Do you know what someone’s glucose readings are like if they have brittle? I’ve only been able to find, “wildly varying numbers,” but without examples/explanation, who knows what that means?

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Thanks for the info, that sounds similar to my experience. I just hate going low, I hate preventing lows, I hate feeling my blood sugar drop. I also want to avoid highs as much as possible. But even though I have highs several times a week (over 180 or 200), or end up high 5 hours after a meal (say anything over 120), I still can’t avoid low or trending low either. It’s like I’d have to average a 180 blood sugar to totally not worry about going low. So I’m just wondering if everyday having to treat/correct for a low and/or high, or a trend in either direction, is normal. On the one hand I read about how this seems normal, and then I hear about how people are staying under 160 or something and somehow not needing to buffer against lows. And that they just “correct” highs w/ their correction factor, which if I did, without taking into account insulin on board, or activity, or carbs outrunning insulin momentarily, I’d end up low all the time. So yeah, I have my carb ratio, varying based on foods, I have my correction factor, I keep track of everything, but it’s so hard to prevent highs/lows and I’m often having to treat them after they happen.

Just the other day I had a lunch meal, ended up five hours later at 130, the next day I had the exact same thing, took just 0.3 units more to account for not ending up at 130, and I end up having to eat 7 carbs b/c the insulin that day was obviously way too much. Doing things prophylactically has just been really hard, I usually end up having to deal with a low trend or a high, pretty much everyday (maybe 1 out of 12 days things work out ok). It’s really tiring. But maybe I still have unrealistic expectations in terms of how this disease can be managed, even with keeping track of everything and trying hard to learn lessons. So I’m just trying to get a feel of where I stand, relative to what is normal.

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:grinning: yes this sounds very familiar! It’s the nature of using insulin I suppose. Insulin is slow and carbs are fast, I sometimes force a high down and then treat with carbs. Hang in there @BKN480

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Becky @BKN480 I can give you first hand experience of “brittle”; I was clinically diagnosed brittle while living in-house at Joslin Clinic for a week during the development of the glycosylated hemoglobin test [now called HbA1c]. My blood was drawn from artery every day and from my earlobe for lab rest every couple of hours, my foods were measured, and exercise logged and monitored - I was ambulatory, out-and-about, living a "regular normal life. On one particular day, my 11:30 AM BS Lab [from ear] tested at 368 mg/dl, no insulin injected and I ate a full dinner of 65 carbs. Following a two mile walk my BS lab-test [finger-stick stuff didn’t yet exist] read “less than 40”. I sat on the edge of my bed for a half hour listening to the world’s best diabetologists discussing me - the answer, “you are brittle” and will need to be aware and already ready. Yes, I was aware and drinking a carton of oj while my blood was being drawn.

I suggest that you might want to check your actual ISF - insulin sensitivity factor - several times at different times of day. Rather than go with the standard 1 unit to 50 mg/dl, I have set in my pump for calculations ISF of 80, 90, and 100. During the last 15 years I have become increasingly sensitive to insulin.

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Thanks for the info. That sounds like a roller coaster from hell, for sure. I guess what you’re saying is, brittle means wild fluctuations, including downard, even with absence of insulin. I wonder what causes that? Maybe a particular form of diabetes in which the person does have some islet cells that randomly decide to kick in and go gungo-ho sometimes…

I do have a correction factor of 80, which is only good if I have no short acting insulin on board. If I do have i.o.b., I do at least 100, more depending. I’ve found that I can be 150 five hours after eating lunch, and think, “ok, before dinner, I definitely need to take maybe 0.5 units,” and I do, and then I drop, or I drop soon after dinner (so I know it was probably the lunch correction, not dinner insulin). I’ve found in other words that for me, fitting the pattern of, “peak at +2 hrs. after eating, then go back down to fasting levels 3-4 hours later” is a joke, and caused me many more hypos in the past, which I’m trying to get better at. Anyway thanks again!

What you wrote in your second paragraph, Becky @BKN480 , hits the nail directly on the head. What works for you outweighs what may appear to work for someone else or what is written in the doctor’s textbook. Yes, my words here are what I learned many years ago, and were echoed this week at the big diabetes expert meeting in Spain when one of the diabetes experts said about diabetes management “… there is not a one-size fits all approach”.

“Brittle” not only encompasses unexplained drops in body glucose levels, but also sudden rise. About people with long-term autoimmune diabetes continue to produce some insulin, you are correct; a “honeymoon” that lasts 70+ years. Yeah! If you attended the TypeOneNation Virtual Summit, you may have heard some very interesting information presented by Dr. George King, director of the Joslin Medalist study. (The Medalist Group isn’t just to have a heavy piece of medal hung about one’s neck, but rather an opportunity for people who lived with diabetes for 50+ years to present themselves for extensive medical research and analysis.) One of the surprising findings was that many people who have lived with diabetes for 50, 60, 70 years produce some insulin. Lab tests spaced over a five-year period appear to confirm that I do not produce insulin.

By observation, I’ve found that some of the Lispro / Humalog insulin formulation I infuse appears to stay well beyond the “four hours” and beyond the 5-hour factor in my estimated-dose calculator. You may want to keep an eye on this and remember to deduct IOB from future bolus dosing.

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Even wearing a CGM, like I do, does not help for many. As my endo says, that is the life of a diabetic. No day is perfect and what works for a high or low correction may not work the next day. Even carb ratios differ from day to day. The proof is, and I know you all have had this happen to you, my glucose can be the exact same on 2 days in a row for a meal. Eat something that is X carbs and use Y units of insulin on 2 consecutive days. One day you are right on target, the next you are at 250. Diabetes’ only certainty is you are not bored. Plenty of what I like to call “opportunities.”

That gets straight to the heart of what I was wondering, thank you! That is exactly my experience despite putting in so much effort since diagnosis (July 2020) to figure out “what to do” - exactly what amount of insulin to give, given the particular carbs I’m eating, considering other relevant factors as needed. I’ve tried to do this so I can just give insulin w/out ever having to think about it or worry about glucose numbers, I thought this was a reasonable expectation, but that just has not happened. I’ve learned a lot, gotten better, my efforts have been worth something, but it still requires daily vigilance, effort, and unpredictability, even in the exact same scenarios, as you mention. And sometimes there are outliers in the variability that are so crazy I can’t even comprehend them, which really offends my rational capacities. I’m glad at least to know that this really is normal and that I’m not just uniquely terrible at giving insulin or have some weird physiology, and hopefully I can continue to also get better at calibrating my expectations going forward… thanks again for your input!

The “magic” of the human body. I had no clue that your mental state affected glucose as much as it does. I had a 6 hr drive as a passenger with someone that really prefer not to be around. They were picking me up early in the morning. I woke up and was at 88. Drank nothing, ate nothing. We drove 2 hours and stopped for breakfast. Checked glucose again, no CGM at this time, and I was a 320. The correction and insulin for the meal fixed everything so it was not a bad infusion set. It was purely the negative mental experience.

Yeah the mental and hormonal aspects, and whatever else can cause fluctuations, are evidently all major factors. It’s complex - I guess another way to look at it is, it’s amazing we can do as well as we can, given all this!

I don’t correct for highs very often. Maybe once every 2 weeks. If it’s not super high like in the mid 200s I’ll just wait til the next meal and fix it up then.

I do correct lows frequently however. Probably 5-7 times a week. Usually with my Freesytle I can catch it ahead of time and either ea something to correct or eat something so it won’t go low.

As far as the variability goes, I came up with the slogan years ago, “just when I think I have things figured out, it goes haywire.”

Just roll with it and don’t beat your self up or expect it to be any different I say.

You are so correct Larry @808IUFan , a negative mental experience, just like stress and unusual joy and excitement can affect our glucose level, causing spikes. Much like the increase we get from the steroid dump the body gives to wake us up.
A thought came to me when reading your post; have you recently validated the basal rates you have programmed in your pump? Periodically, I validate my morning basal rates by not eating after 10 PM and not eat [or take insulin] again until 1PM the following day. I would use a BG meter every few hours, now CGM, to see how I’m staying, and expect my BGL to be right on target. It sometimes took a couple of tries to get the basal right.

Oh yeah it was just for a few hours. The next day was fine. It was all “mental stress.”