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Confusion over type 1 goals

Discussion in 'Ask A Question' started by EBartlett, Jul 8, 2019.

  1. EBartlett

    EBartlett · Member

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    Hi, I recently had a diabetic clinic session with my usual nurse. I recently switched from novorapid to apidra to try and get a faster working insulin. In the middle of the conversation I mentioned my goal was to try and smooth out the peaks around meal times wherever possible. She told me it was impossible and that peaks were fine. (From these threads and Dexcom forums I thought the less fluctuations the better). The nurse proceeded to tell me that peaks of anything even 18+ were fine. Is she right or am I right in my pursuit of more stable levels ??
     
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  2. Diakat

    Diakat Type 1 · Moderator
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    I’d be saying that you are right.
     
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  3. Knikki

    Knikki Type 1 · Well-Known Member

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    I'm not medically trained just a long time T1 so my info maybe tosh.

    A peak of 18+ is fine????????? :confused: Error no sorry not in my books.

    Yes you can get peaks after eating which is why many inject before eating, timing is variable depending on what insulin your using, to limit the peaks or spikes as you will sometimes see.

    But your right to try and level things out, trying to correct a spike of 18+ can be difficult, much better not to hit it in the first place.

    Take care :)
     
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  4. helensaramay

    helensaramay Type 1 · Expert

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    I believe the answer is "no one knows".
    Affordable CGMs that spot the post prandial peaks are new so it has not been possible to do long term research into the affects of those spikes.

    Personally, I find spikes higher than 10 will affect my short term well being (I am lethargic and get out of breath) so I try to avoid them with insulin timing and a bit of diet choice (but I am nowhere close to low carbing).
    I have taken 10 to be my target high from looking at Libre graphs from someone without diabetes. Sure, it was only one person but it seemed to be a good example from what I could tell. He spiked to 9 so I thought I would round up and give myself a little leeway.

    I am surprised a dedicated diabetes professional would consider a BG as high as 18 to be acceptable.

    One note of caution - I assume you are taking your peak readings from your Dexcom. My experience and others I have read suggest readings taken from interstitial fluids are less accurate outside the range of about 4 to 9. Unfortunately, they seem to be unpredictable in their inaccuracy (they may be higher or lower). But 18 is only going to be a very rough estimate of your highs.
     
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  5. Marie 2

    Marie 2 LADA · Well-Known Member

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    Oh gosh, an 18 would upset me! I'm unhappy if I go over 9! I prebolus. But are you new to insulin? Because they start you out with pretty easy guidelines at the beginning until you start to get the hang of it. Nobody wants you to have hypos!
     
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  6. EBartlett

    EBartlett · Member

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    Thank you for all your comments guys,

    No I am not new to insulin (diagnosed over 10 years ago). I aim to stay between 5-12 as I’m relatively new to my Dexcom G6 and being able to see my levels at all times. I will keep in mind the point about the accuracy of the Dexcom.
     
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  7. Marie 2

    Marie 2 LADA · Well-Known Member

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    The easiest way to smooth out peaks is to prebolus some of your dose, that way the insulin is working when you are digesting your food, more along the lines of what a "normal" persons insulin would do.

    I love my Dexcom G6. I calibrate mine to be the most accurate at the 5.2 to 7 range, because too low, I have to eat something and too high I have to take insulin to bring it down. I want the accuracy at the range I'm in the most as I rely on that range to give just small adjustments or no adjustments at all most of the day. I have a pump so it is easier to give small adjustments.
     
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  8. h884

    h884 Type 1 · Well-Known Member

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    Hi there

    I have also been given same advice from my Diabetes Team and like others who have responded I am concerned about this advice.

    My team also advised me not to bolus until food was on table. At my last review the doctor I saw gave me "a lecture" about why I should bolus early. I have tried taking my bolus early (20 to 30 mins pre meal ) but for me it has had little impact on post meal spikes
     
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  9. EBartlett

    EBartlett · Member

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    I have been told the same thing, I’ve been told bolusing 10 mins before food is more than enough. I’ve tested bolusing 10,20,30 minutes before food and it’s had little affect on peaks. The only thing I’ve found help is to restrict carbs to max 40g per meal (enough carb so I have enough insulin in my system but not low carb to cause issues)

    I worry about people that don’t use other sources of info like this forum, I used to take my DSN’s word as 100% correct.
     
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  10. Mel dCP

    Mel dCP Type 1 · Well-Known Member

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    Personally, I’d be pretty horrified if someone told me it was ok to run at 18+. That’s triple a normal BG level!
     
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  11. Circuspony

    Circuspony Type 1 · Well-Known Member

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    I can peak that high if I have something high in sugar - even with a pre bolus.

    I'm surprised the nurse was ok with it though. When I hit 19 in my glucose tolerance test in the hospital they got very jittery and tested for ketones. Obviously no insulin on board then, but no one was sitting there saying it was fine!
     
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  12. kitedoc

    kitedoc Type 1 · Well-Known Member

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    Hi @EBartlett,
    From my reading and not as medical advice or opinion:
    A study which might give you some semblance of an answer is looking Diabetes Control and Complications Trial of 1986 to 1993 of TIDs and ongoing study of the trial as the EDIC study, which has recently released its 30 year findings.

    My take on the DCCT, and a personal one, is that the more intensive the bsl control in the first 6 1/2 years and possibly longer on onsulin, the less diabetic eye, kidney and nerve complications occuured compared to a comparison group with less well controlled diabetes, called the conventional group.

    The EDIC study is showing that even if bsl control slacked off in the intensive bsl control group, the complication rates still diverged, And heart and blood vessel problems are ore frequent in the conventiional group.

    Problems:
    1)the measures of the degree of bsl control were the HBAIC readings. While that might sound dandy, it is known that good range HBAICs can hide fluctuations in bsls that might be deleterious.
    2) some say that what you do with BSL after the first 6 1/2 years no longer matters. A convenient interpretation if the fact that complications were still worse in the conventional group compared to those in the intensive group who slackened off.
    Maybe your nurse has picked up this interpretation.

    There is however, also the rather inescapable fact that non-diabetics' bsls tend to remain within a range variously set at about 3.6 to say, 6 mmol/l fasting and below say, 7 mmol/l , 2 hours after food ( i have simplified it a bit) or another assertion/ statment * is at an average bsl of 4.6 mmol/l and range 3.8 to 6.4 mmol/l, do not get the microvascular complications ( eye, kidney, nerve) or the same frequency of macrovascular complications ( e.g heart disease, stroke etc) as Type 1 Diabetics do.
    The logic of trying to maintain bsls as close to these ideals seems self evident. * Dr Bernsteapin's Diabetes Solution.
    That ideal at its best thus might translate to HBAICs of something like 4.8 % ( 29 mmol/mol with bsl variation of say 0.6 to 1.8 mmol/l.
    What might stop health professions or TIDs and others on insulin from aiming for and achieving these results?

    If you live in USA, the American Diabetes Association sets guidelines for TIDs for 2018 of HBAIC of less than 7% ( 53 mmol/mol, and a fasting range of bsl of 4.4 to 7.2 mmol/l and a 2 hour after foid kevel less than 10 mmol/l.
    Why such a difference from some of the non-diabetic ranges quotes above?

    The mysteries of the ADA are perhaps no stranger than any group in power. The anecdotal word is that as a doctor you might get sued if you advise lower bsls than the ADAguidelines and the patient suffers bad effects from a hypo. And the other side of that is, cynically, how likely is it that thecappearance of diabetes complications can be proven to be due to nedical negligence years later. ( anecdote per Dr Bernstein, Dr Bernstein's Diabetes University video series)
    And without necessarily knowing the possible underlying rationale for the ADA figures other nation's doctors may follow the ADA guidelines.

    For patients a target of less than 7% ( 53 mmol/l) is easier to reach than lower and if their insulin regime makes them prone to hypos if they get lower then that makes their immediate life easier. It is abit like assuming that 51 % as an exam result is good enough!

    And with this greater degree of so called freedom than achieving better results , diet and food choices become easier.
    The future with possible eye, nerve and kidnsy problems is unknowable.

    And you may have experienced how antsy health professionals may become if your HBAIC, gets to 6 % ( 42 mmol/mol), because they are concerned and have assumed that to achieve that level you will invariably be suffering from hypos, and possibly severe ones ( i assume that most doctors and nurses are concerned for patient's welfare rather than their own welfare)!

    I do not have the studies to hand but if you look through parts of the forum called True Grit Type One, you will see a study where even at levels of HBAIC of about 6 % ( 42 mmol/mol) progression of disbetic eye complications occurred.
    The possible bsl fluctuations that would still allow this type of HBAIC result seem just a mighty tad less than highs of 18 mmol/l!!

    I hope the above answers your question and gives you some 'food' for thought.
    BestvWishes:):):)
     
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  13. Daibell

    Daibell LADA · Master

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    Hi. The nurse is simply wrong. The goal is to smooth BS levels as far as you reasonably can. Peaks into the teens are best avoided.
     
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  14. h884

    h884 Type 1 · Well-Known Member

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    I am in agreement with all the above comments. The rationale given to me for the spike being ok was that my levels were back within range by the next meal time
     
  15. Mel dCP

    Mel dCP Type 1 · Well-Known Member

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    I think the new CGM tech has really opened our eyes as to what’s really going on in there. My rationale now I have CGM, is that if a non-diabetic’s sugars don’t do it, I don’t want mine to either.
     
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  16. h884

    h884 Type 1 · Well-Known Member

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    I completely agree. Not having much luck in achieving it though
     
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  17. Japes

    Japes LADA · Well-Known Member

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    That was the rationale I was given. I don't agree with it.

    I certainly hit a 19 2 hours after a higher than usual for me, previously untested, carby lunch and was back well within my range by the time I was ready to eat my evening meal. I enjoyed my lunch, but not the feeling of yuckiness and brain fog until it was down again.
     
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  18. therower

    therower Type 1 · Well-Known Member

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    @EBartlett . I personally use a Dexcom. Allowing BS to go as high as the high teens is totally avoidable and unnecessary.
    My ranges are set at low 4 and high 9. I have no problem with a spike up to 11 or 12 providing it’s a short term spike.
    Having my meter set at 9 allows me to act with a correction dose if necessary.
    The only time I would accept a high spike is if I knew it was coming because of my inability to turndown something really delicious ( and sweet ):):)
     
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