Question for old timers

Hi All,

I have a couple questions for those of you who have been dealing with Type 1 for a long time. 1. What should my morning BS be on a regular basis? My doctor recently lowered my basal dose (Tresiba) to 3 units, and I am consistently waking up with BS of 115-130. I am guessing that now and then that is not a big deal, but long term? Also, because of this, my BS two to three hours after breakfast is often up in the 160s. Again, short term, no big deal, but what about long term?

A related question - i know that most people find their carb to insulin ratio is different in the morning, but my doctor was very surprised that mine was so different, and said it is not typical. During most of the day 15 carbs per unit of insulin works for me, but in the morning, it is more like 3-4 carbs per unit. Is that unusual in your opinion?

Thanks!
Jess

Hi @Jsich I like my blood sugar between 70 and 100 mg/dl. I thinks it is safe to say I don’t always get what I like. When my blood sugar is above hypo and below 140 I think “good enough” and if it’s below 200 I think “meh” and correct when I eat my breakfast. Above 200 I may ask myself what happened and if it is not apparent I may suspect a bad pump site. Type 1, for me, means I may have vastly different blood sugars from hour to hour.

How strange is a doctor calling a ratio that works for you atypical. The right carb ratio is the one that works and if it was 1 unit per 1 gram carb, and it works, it’s not atypical. Now that being said, a good basal rate or long acting shot will heavily influence your carb ratio. And the opposite is true. If you aren’t getting enough basal then you’ll have to make up for it with a meal shot. The way you tell if it’s basal is to skip breakfast and see if your blood sugar rises. It may be very difficult to adjust if you are injecting long acting insulin, it is much easier to adjust basal rate in a pump.

Hope this is helpful :shamrock:

1 Like

The way I was taught:

80-120 is the goal. On the lower side in the morning. But not much lower than 80.

160-180 is perfectly normal after a meal. It’ll go down. Taking the bolus 15-20 minutes before you eat can help flatten that curve a bit. But it’s okay. Really.

It’s better to be high than low. A low blood sugar is an imminent threat. It can cause brain damage, just like low oxygenation. If it gets too low, you can pass out or slip into a coma. A high blood sugar, on the other hand, does cumulative long-term damage. You don’t want to be too high if you can avoid it, but what matters is your overall average. That’s why we check A1C, which gives a look at your average BG over several months.

High sugar levels leave excess sugar clogging up your capillaries and joints and so on. But as your BG value goes down, that excess sugar can come loose and the damage can be mitigated or even undone (depending on location, severity, etc.).

I’ve been diabetic for over 30 years, and my control has generally been good but not great. A1C in the low 7s for most of it. And I’m fine. No complications yet. No retinopathy. No joint or circulatory issues. It’s okay.

Do the best you can. But don’t hyperfocus on it. Don’t stress over it. See what gets you better control and work with that, but don’t beat yourself up for being on the high side now and again. Don’t live your entire life in a state of anxiety because your BG values are slightly off now and again. Don’t limit yourself and keep yourself from enjoying things over it. Be vigilant. Be thoughtful. Plan ahead when you can. But give yourself some slack. Diabetes is a long game. Make a sustainable life. Make rules that are strict enough to keep your A1C in a range you and your doctor are happy with, but not so strict that you feel restrained, like it’s controlling and defining your life. Make sense?

As for carb ratio, like Joe says, it’s highly individual. 15 grams to a unit worked for my grandfather. I’ve developed more insulin resistance, and so my pump is set to 5 grams per unit. And, yes, it’s normal for your needs to vary over the course of the day. Your metabolism changes when you’re asleep, when you’re waking up, when you’re exercising, when you’re stressed, etc. I’ve got some other chronic health issues that make it difficult for me to get around. It takes an hour after I wake up before I attempt to sit up. Just the act of waking up, even lying still, tends to raise my BG by 20-30 points over that hour. So, yeah. If you need more insulin with breakfast, take more insulin with breakfast. And then keep an eye on your BGs to make sure you’re not going low before lunch. And adjust if you’re expecting to be more or less active that morning. See what works, and do that. Bodies are really complicated. Get to know yours. You’ll get the hang of it with experience.

1 Like

Thanks Joe and Paul, for your responses. I am not on a pump, and I haven’t tried skipping breakfast, but I think I might increase my basal back to 4 units, and then just make sure I am dosing correctly later in the day (meaning, maybe shift my ratio at times to more carbs per unit). The difference between morning and the rest of the day is HUGE. My biggest problem has been going low, often due to exercise. It is so tricky to figure out what I need for exercise, and it changes all the time! But I am guessing you both know that! My A1C has been 5, which sounds good, but perhaps not enough data because it doesn’t reveal all my lows. Anyway, I will keep at it, trying different things. I really appreciate the feedback, and if you think of anything else to add, please do so!

PS - I think I started out on the wrong foot with when I was diagnosed by reading Dr. Bernstein’s book, and another one, both of which push the idea of staying on the low (quite low) side, and the dangers of anything even remotely high. But regularly falling to 40 (which is what was, and sometimes is, happening) cannot be good…

Thank you for your words of encouragement. I’m a recent T1 diagnosis and I have found it so frustrating at times and anxiety provoking when BG numbers are all over the place. I appreciate your advice of getting to know what works best for each one of us, I’m beginning to trust that and not just rely on my endo’s opinions.

Good luck, Jess. It’s trial and error, but you can make educated guesses, see what works, and get the hang of it as you go. There’s a learning curve, so the first year or two is the hardest, but you’ll get there.

If you’re only going high in the morning, are you sure adjusting basal is the right approach? Maybe bolus a bit more? That will cover you for the morning and then wear off in the afternoon. Basal will stick with you all day.

Worth examining what you’re having for breakfast, too. For decades, I had a glass of milk with breakfast. My pre-breakfast BG values were good. My lunch BG values were good. Everything seemed fine. And then I got a CGM and I noticed that for a couple of hours between breakfast and lunch, my BGs were significantly higher than expected. I realized that it was probably the sugar in the milk. I switched to drinking tea or diet soda (I cannot stand drinking plain water) and took a little less of a bolus, and my BGs improved significantly.

The problem with carb counting vs. the exchange system I started with is that carb counting just lumps all the carbs together as if they’re all the same. But they aren’t. Simple sugars (glucose, sucrose, lactose, fructose, etc. - things like candy, milk, juice, regular soda, and so on) digest much differently than complex carbs like bread or pasta. Complex carbs break down into simple sugars as they digest, but it’s a gradual process. Simple sugars will make your BG spike (which is good if you’re running low) and then they’ll fade away (especially as the insulin kicks in). Complex carbs will raise your BGs much more gradually, and they’ll stay in your system much longer.

Holy heck. No. Not good. If you’re low enough to feel symptoms, you’re damaging and perhaps even killing brain cells. That’s what the symptoms mean. I start feeling it around 70-80. I try not to let myself drop below 60. I’ve been down to the 20s, which is on the threshold where you’re in danger of dropping into a coma, but only a couple of times in my life. You do not want to be messing around with the 40s.

Most CGMs and pumps have preset alerts or guidelines at about 70-180. That’s what they’re calling “in range.” You don’t want to drop below that, and you want to try to avoid going above that. That’s a good place to start. 70-80 in the morning, when you haven’t had anything to eat in 10-12 hours, that’s fine. 160-180 an hour or two after you’ve had a big meal, that’s normal. 200-250 for a while, that’s not great, but it’s not going to kill you. You can get it back under control, and if you’re doing better than that in the normal course of things, you’re fine. But if you drop low, you’re doing immediate damage and running the risk of passing out (at which point you’re helpless to do anything to bring it back up). 400-500 can put you in the hospital, but so can 20-40. Aim for 100-120. A little lower before meals, a little higher after. And better to be a little high than a little low.

Glad I could help. It is important to learn your own body and know what works for you. You’ll get there. But your endo has valuable knowledge and experience, and has likely worked with hundreds of diabetics for years. There are times when they’ll be wrong because you’ve got some weird quirk. But there are times when you’ll be wrong or not even know to consider something. It’s important to trust both yourself and your doctor. If you can’t do that, find a new doctor.

Robert Osthues T1D66+ yrs so far. I would give a limb to have your wake up values, in my estimation that is superb. My retina specialist and my endo say to aim for 150 waking up, I try!

Thanks for your response, Robert! It made me chuckle and also reminds me to put things in perspective. I have a tendency to want my number to be in too tight a range, which, or course, is not only very challenging, but often impossible. The stress that causes is likely more damaging that being slightly high upon waking (or any time of day).

I re-read a section of “Think Like a Pancreas” (If any of you are looking for help, this book has been sooooo helpful for me since I was diagnosed). It suggested checking basal rate by taking your BS before bed, then once in the middle of the night (to make sure you are not going “high” then next morning as a reaction to an overnight low), and then in the morning. If there is a 30 point difference, you need to look at the basal. I know others (Joe, maybe) have suggested skipping a meal to check basal, but this is actually easier for me. And of course, since I started the post, things have shifted, as they always seem to do with time, I am still waking up higher than I’d like, but less so, and my numbers to not seem to be rising or falling over 30 points at night.

Jess

Jess @Jsich , what I suspect is that your doctor may be following the current/latest protocol in teaching, that is to “avoid over basalization” which appears to be prevalent in emergency medical cases, and the suggestion that “older” PwD need not be as concerned with long-term complications as much as with unexpected hypoglycemia. As far as my settings [I use an infusion pump] for basal insulin and bolus insulin go, I’d rather be a little higher which can be corrected by taking a correction bolus than running the risk of running too low and incurring an insulin reaction. In my older age, I’ve become less strict with myself tet, still maintain Time-in-Range over 90% of the time based on CGM data.

I’m in my 80s and have lived with TypeOne for 65 years. My meal-time target, all meals, is 110 mg/dl currently dictated by the Control IQ algorithm. In themselves, your readings look good to me and in my non-professional opinion should not cause concern. Consider a few guide facts:
A laboratory HbA1c of 6.0% indicates a 24 hour per day average BGL of 120 mg/dl over the previous 90 days, ADA recommendations for Pwd is A1c of less than 7.0%;
Acceptable range for BGL is 70 - 180 mg/dl and “diabetes experts” push for patients to fit in that range at least 70% of the time to be rated at “fairly good diabetes management”;

As for varying Insulin: Carbohydrate ratios, most T1D have ratios that provide more insulin in the morning than what is needed later in the day. I regularly use 4 different ratios throughout the day ranging from 8 to 20 carbs per unit and my ratios may differ differently based on planned or experienced activity levels.

Thanks for this, Dennis. It is heartening (and somewhat amazing) to me that you are in your 80s and have had Type 1 for so long!!! I’ve got almost four years in and am still learning a lot. I know part (maybe most) of the reason my doc wanted to lower my basal was due to lows during exercise. I am finding it super hard to manage, since the low from exercise can occur during, after, or even WAY after exercise. I have listened to a lot of podcasts and read quite a bit, but so far have not been able to master the exercise thing. “The Athlete’s Guid to Diabetes” arrived in the mail today, so I will start on that soon. Plus, I may go with some 1:1 training as Dorie suggested (I think it was Dorie) if and when i decide to do another marathon. As usual, for me, I am most helped by hearing other people’s stories and realizing that IT’S OK if I run high at times, if I “screw up” and run low, and that this is REALLY HARD stuff! Thanks again for your input, it is always welcome!

Jess