Struggling with daily control - any feedback/help appreciated please

[asa35]

Hi, I've been T1 for 20+ years, and looking back, my control has never been too good - always struggled to get Hba1c below about 8.4%.
Since Christmas, I've been moved from Levemir to Tresiba; my short acting is Novo Rapid. I've also recently started using the Freestyle Libre reader/scanner - expense aside, this has given me a lot of invaluable information I wasn't aware of. In particular, how much and how quickly I spike after a meal, what happens in between meals and also through the night. This showed I could hypo and rebound in the night without knowing! It has helped me understand a lot more.
I'm now on a mission to get better control (but sometimes feel I'm obsessed, getting stressed, which I know doesn't help); my problem is though, I'm struggling to get reasonable control, no matter what I do or eat. I seem to 'peek and trough' constantly throughout the day, but run a lot higher than I should (certainly not often enough in a 4-9 range). After a meal, I spike usually to high teens (occasionally 20's), then gradually come down a few hours later before next meal. I'm finding it difficult to get my ratios correct, because no two days are ever the same. Working with my DSN, we think we have the Tresiba correct, but not Novo Rapid. I've been asked to consider an Insulin pump, and said I will go to a consultation. Can anybody possibly help me with any thoughts what may help me please?

 

[Lynz84]

Hey there. Good for you wanting to help yourself. Sometimes thats half the battle. Could i ask what your diet is like??

 

[cz_dave]

You could try low-carbing. That would decrease your bolus insulin needs and increase predictability.

 

[azure]

Hi @asa35

My suggestion is to try bolusing a little more in advance of your meals. That can make a big difference to controlling any spike.

To get ratios right, then you could try eating exactly the same each day for the meal you're trying to sort - eg lunch - until your blood sugar after is in range.

If your sure your basal is right, then sort the meals one by one. Getting the right basal is a good start

 

[noblehead]

Working with my DSN, we think we have the Tresiba correct, but not Novo Rapid. I've been asked to consider an Insulin pump, and said I will go to a consultation. Can anybody possibly help me with any thoughts what may help me please?

You need to be sure you have the basal dose right, when you get it right you can then look at I:C ratio's and bolus timings, have a look at the following which explains how to do a basal test in different time frames:

http://www.salforddiabetescare.co.uk/index2.php?nav_id=1007

With regards to a pump, I would certainly take up the offer if your consultant gives you the go ahead, the beauty of a pump is you can have multiple basal rates and can increase/decrease it in times of illness & exercise which can give you much more even bg control, plus the bolus options on a pump allow you to better match your insulin to the food you eat and comes in handy when you eat difficult meals like those that are high in fat.

In the mean-time do have a look at your bolus timings to reduce the postprandial spikes, on average I bolus 20 mins before eating to keep spikes to a minimum, the only time I don't bolus too far ahead is for meals that have a high-fat content. Sorry for providing another link but the following is a great read and discusses bolus timings:

http://www.diabetesselfmanagement.c...blood-glucose-management/strike-the-spike-ii/

 

[asa35]

Thank you Lynz84. On a normal working week, I would have a bowl of cereal for breakfast (porridge, weetabix, fruit & fibre, mini weetabix), usually about 3-4 CP (ratio 1.5:1): lunch is consistent of a sandwich, approx 3-4 pieces of fruit and a biscuit ( usually around 9-10 CP, ratio 0.8:1), evening meal varies of a rice dish with meat, or noodles and meat & a yoghurt for afters - CP approx 8-10 with ratio 1:1. I am active at evenings, either walking the dog, or taking my lad to football training/ games.

 

[asa35]

Thanks cz_dave. I have considered lowering my carb intake, and particularly at lunchtime, I think I eat too much fruit in one go which is too much natural sugar. I may look at my overall carb intake and discuss this with my dietician.

 

[azure]

Could you give us an idea of your blood sugars on a typical day like that @asa35 ?

There's nothing wrong with fruit, but I wonder whether a reduction in the amount of fruit you have for lunch would help.

 

[asa35]

Hi azure. Good point, I may need to get my insulin working before the food kicks in. I'll try doing this, maybe 10 mins before eating possibly? Thanks for that.

 

[asa35]

azure, this is a typical weeks readings for me

 

[asa35]

This is what my graph shows me from the week (using the freestyle Libre)

 

[asa35]

noblehead, very interesting, many thanks for these links. I'm going to have a proper read over these this weekend.

 

[azure]

Hi azure. Good point, I may need to get my insulin working before the food kicks in. I'll try doing this, maybe 10 mins before eating possibly? Thanks for that.

Yes, move it gradually and see how you go. Many people find 15-20 mins in advance works, but it depends on the person. When I was on Humalog, I had to bolus for my breakfast at least 30 mins in advance.

 

[azure]

I'd also add that I usually delay my food if my BS is too high. I correct and wait till it's come down because I find eating when I'm high and controlling my BS is a real battle. I know that's not always pratical, but I find it works best for me, particularly in the mornings when I'm fighting DP anyway. If I couldn't delay my food till my BS was in range, I'd delay as long as I could after my correction and bolus to give the insulin a chance to get working on the blood sugar.

I see you wake high quite a lot. If that's DP, a pump would help enormously

 

[asa35]

Good information azure, thank you. Anythings worth looking at I feel. Feel I'm going round in circles most of the time!

 

[Daibell]

Hi. Your meals are quite high in carbs. Can you replace breakfast cereals with eggs and bacon? What do the evening 'afters' consist of and so on. Also is the sugar 'no added sugar' type and not the low-fat super-high sugar that is mostly on display. Fruit is good but as you say sometimes it's too much at one time. Also is it non-tropical?

 

[asa35]

Hi Daibell, thanks for posting. On a working week, this type of cereal wouldn't realistically be an option, so will either try a piece of fruit of have a slower GI cereal, like porridge. Evening 'afters' (usually pre bed if going low), could be 1 or 2 plain digestives or piece of toast. Regarding the sugars, when we check labels, we look mainly at the Carb content, and also the "with sugar" amount; I notice the low fat foods generally have a high concentration of sugar in them. I do try and look for the "no added sugar" label where possible. My fruit really does vary: apples, oranges, kiwi, grapes, plums, nectarines, fresh pineapple, and bananas. I'll try and work them to be equal to 1 CP, unless it's the banana which may be 2, which I then build into my ratios.

 

[buckley8219]

Hi,

Bolus 15-30 mins before a meal that will help with the spikes.

I treat fruit as a desert, it's full of sugar and my blood sugar responds accordingly.

A piece of white bread will raise my blood sugar quicker than a mars bar. Same for grapes, pineapple, banana and kiwi.

Understand fruits are seen as healthy, but swapping fruit for leafy greens and veg would help here.

I gave up on cereal, toasts, biscuits etc as I had to load up on insulin and had increased lows, following a diet like this made my diabetes much less predictable.

I'd think about reducing carb intake, and eat more leans meats, fish, greens, salad, veg.

Perhaps keep a food diary for a month, experimenting with foods and carbs, trying to keep carbs 20-30g a meal and see how your bloods respond. It's no great surprise that you're experiencing high blood sugars if your staples are cereals, bread and fruit.

I can eat these things, but have to use twice as much insulin daily and my weight starts to go up and my insulin sensitivity suffers.

Carb to insulin ratio, carb portions etc are all well and good, but they are not an exact science and your metabolism can and will respond differently on a daily basis to the same inputs. This again led me to simplify my diet

It's also probably worth fasting for a day and seeing how good your basal is with the freestyle libre.

 

[nmr1991]

Ive recently changed insulin types, heres a picture of my glucose chart to give you an idea of how bad it looks lol i've given it a 4 week interval as it is on a trial basis, even though I got more of the insulin as I use a pen a week.

 

[asa35]

Thank you @buckley8219. Some good points which I will take and use. What would you take for breakfast then?