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Insulin troubleshooting: Need suggestions pls

Bluemarine Josephine

Bluemarine Josephine

Well-Known Member
Messages
259
Location
Northampton
Type of diabetes
Type 1
Treatment type
Insulin
Hello everyone!
I hope that you enjoyed the most wonderful festive season!

Here is something which is puzzling me and I need your suggestions.
3 different cases. I do not calculate protein and vegetables as carbs. Activity levels were similar during these 3 days.

Case 1:
Pre-lunch reading is : 11.8
1.5:1 ratio for 30 grams of carbs, rounded to 5 units. The carbs come from 312 grs orange + 1 digestive biscuit.
15:00 level: 7.7
16:00 level: 10.2
17:00 level: 11
18:00 level: 11.4

Case 2:
Pre-lunch reading is: 9.5. The carbs come from 89 grams banana + 1 digestive biscuit.
1.5:1 ratio for 30 grams of carbs, 4.5 units overall:
15:00 level: 12.5
16:00 level: 9.9
17:00 level: 7.5
18:00 level: 6.3

Case 3:
Pre-lunch reading is: 7.5. The carbs come from 136 grams pear+ 2 very thin slices of rye bread.
30 grams carbs but 1:1 ratio, overall 3 units:
15:00: 6.6
16:00: 8.2
17:00: 9.4
18:00: 11.9


I need your help because I am trying to “read” the inconsistency of this pattern.
Clearly, 1:1 ratio isn’t enough however, the 1.5:1 ratio creates a drop around 15:00-16:00 before blood sugar starts picking up again on its own whereas, there is also case 2 when 1.5:1 worked as a 1:1 + 1.5 correction.

Is this a case of mild gastroparesis (where stomach emptying happens inconsistently)? However, I only see it during lunchtime…
My meals are usually small however, in comparison, lunch is the biggest portion of the day, would this make a difference?

Otherwise, is this 15:00 dip (and the later blood sugar rise) something normal? Could it be from activity during the morning, from example?

Do you also experience similar patterns and if you do how do you handle that blood sugar dip around 15:00? I am worried that if I start with a pre-lunch number of around 5-6 mmols (which is my target) then the 15:00 hrs dip of blood sugar will need to be treated and that might lead to even higher readings later on when blood sugar picks up on its own again…(that is assuming it will.)

May I have your suggestions please (other than that a pump would solve the problem please as, for the time being I cannot have a pump and I need to tackle the problem until I get one.)

Thank you
Josephine.
 
i think you might be writing your ratios in a slightly different way? Or else Christmas has addled my brain! : D

So excuse me if I'm writing this back to front to you. You can try various ratios and just do the maths eg if someone found 1 unit to 10g carbs meant their blood sugar was slightly high, there's no reason why they couldn't try 1 unit to 9g of carb. Sometimes people think you have to jump to specific ratios, but there's no reason you can't do 'odd' ratios.

Would that help at all, do you think?

I noticed you have a few highs before lunch. Could this be due to your basal?
 
tim2000s said:
@Bluemarinejosephine What time was lunch insulin in all three cases?
Click to expand...

Hello Tim! You are spot on, aren't you...

Case 1: Insulin was injected at 13:00 right before meal.
Case 2: 13:00 hrs : 9.5
Carbs first, then main meal (tyna+ steak).13:15 Insulin was injected after overall meal at blood sugar level of 10.6.
Case 3: 13:00 carbs first, then main meal.
Insulin was injected right after meal at 13:20. I dont have the 13:20 reading though.
 
Last edited by a moderator:
azure said:
i think you might be writing your ratios in a slightly different way? Or else Christmas has addled my brain! : D

So excuse me if I'm writing this back to front to you. You can try various ratios and just do the maths eg if someone found 1 unit to 10g carbs meant their blood sugar was slightly high, there's no reason why they couldn't try 1 unit to 9g of carb. Sometimes people think you have to jump to specific ratios, but there's no reason you can't do 'odd' ratios.

Would that help at all, do you think?

I noticed you have a few highs before lunch. Could this be due to your basal?
Click to expand...

Hello Azure and thank you for your reply.
I deliberately keep my pre-lunch blood sugar level high because I dont know how to handle my post-lunch blood sugar dip at 15:00 and then my post-lunch blood sugar rise in-between 16:00-18:00.
The problem is not the ratio, neither the basal. (I think).
My problem is:
1. The inconsistent pattern
2. the blood sugar dip at 15:00.
This is what I am trying to fix in order to feel more confident to bring my sugar levels within target.
 
Bluemarine Josephine said:
Hello Tim! You are spot on, aren't you...

Case 1: Insulin was injected at 13:00 right before meal.
Case 2: 13:00hrs carbs were eaten first.
13:15 Insulin was injected right after carbs at blood sugar level of 10.6.
Then I had the rest of the main meal (tuna steak+ veg)
Case 3: 13:00 carbs first, then main meal.
Insulin was injected right after meal at 13:20. I dont have the 13:20 reading though.
Click to expand...
What else had you eaten with the meal? It's not just the carbs. Fats and protein can and do affect absorption rates and timing of glucose appearance in bloods.
 
tim2000s said:
What else had you eaten with the meal? It's not just the carbs. Fats and protein can and do affect absorption rates and timing of glucose appearance in bloods.
Click to expand...

Case1: Salmon, mayonnaise, cucumber/lettuce/tomato salad. 312 grs orange+ 1 digestive biscuit. Fish didnt exceed 130 grs.
Case 2: Tuna fillet, green salad, 1 tsp homemade slaw, 89 grs banana + 1 digestive biscuit. Tuna didnt exceed around 160 grs
Case 3: Salmon, mayonnaise, cucumber/lettuce/tomato salad, 136 grs pear+ 2 slices rye bread + butter (9.7 carbs each slice). Salmon didnt exceed 140 grs.
 
Ok, thanks for clarifying :)

I think a certain level of inconsistency is unavoidable as our bodies aren't machines and can be affected by a number of factors. But, of course, we'd all like to minimise those as much as humanly possible.

I've not used MDI for a number of years (I'm on a pump) but when I did I sometimes had to smooth out my blood sugars, either with a tiny snack eg if I dropped to 4.0 mid morning, I'd have a small amount of carbs then and that would mean my sugar stayed stable and I'd get, say, a 5.5 before lunch. Other times, I'd have to do small correction doses, but that was my least favourite option as I prefer to keep my sugars tight. That is, for me personally, I'd rather have had to have half a biscuit to raise a slightly low blood sugar, than reduce my bolus and then be too high after a meal.

Another thought - and this is just me throwing things out there to consider - are you confident that your correction ratio is correct?
 
I agree with Tim. Its protein/fat you ate with these little carbs (thats why going high few hours later). I would suggest taking a unit or so at 3pm. You can clearly see that mayonnaise slowed down absorption of protein
 
azure said:
Ok, thanks for clarifying :)

I think a certain level of inconsistency is unavoidable as our bodies aren't machines and can be affected by a number of factors. But, of course, we'd all like to minimise those as much as humanly possible.

I've not used MDI for a number of years (I'm on a pump) but when I did I sometimes had to smooth out my blood sugars, either with a tiny snack eg if I dropped to 4.0 mid morning, I'd have a small amount of carbs then and that would mean my sugar stayed stable and I'd get, say, a 5.5 before lunch. Other times, I'd have to do small correction doses, but that was my least favourite option as I prefer to keep my sugars tight. That is, for me personally, I'd rather have had to have half a biscuit to raise a slightly low blood sugar, then reduce my bolus and then be too high after a meal.

Another thought - and this is just me throwing things out there to consider - are you confident that your correction ratio is correct?
Click to expand...

Here is my concern.
If I treat, at 15:00 hrs, say with a biscuit of 10 grs carbs, the rise that this will cause, will be added to the rise that I see after 16:00 and until 18:00 and I fear that my blood sugar will rise even higher (because of the additional treat at 15:00.) If my blood sugar was dipping, say to a 7, then to a 5, then to a 4 and so on, I would not feel reluctant to treat for the drop. The problem is that, in most cases, my blood sugar dips by 2-4 mmols and then rises again on its own after about an hour.

I am, likewise, reluctant to correct at 16:00 which is the time that my blood sugar is rising, while I still have some 2 more hours of Novorapid on board (which was injected at 13:00).
 
ewelina said:
I agree with Tim. Its protein/fat you ate with these little carbs (thats why going high few hours later). I would suggest taking a unit or so at 3pm. You can clearly see that mayonnaise slowed down absorption of protein
Click to expand...

Can such a small amount of protein create this rise?
There was protein in case 2 but didnt have the same effect.

As for the mayonnaise, I think you are right. Looking at the low carb content on the label I considered it safe. I would have never thought that it could mess the absorption so much...
 
Bluemarine Josephine said:
Here is my concern.
If I treat, at 15:00 hrs, say with a biscuit of 10 grs carbs, the rise that this will cause, will be added to the rise that I see after 16:00 and until 18:00 and I fear that my blood sugar will rise even higher (because of the additional treat at 15:00.) If my blood sugar was dipping, say to a 7, then to a 5, then to a 4 and so on, I would not feel reluctant to treat for the drop. The problem is that, in most cases, my bllod sugar dips by 2-4 mmols and then rises again on its own after about an hour.

I am, likewise, reluctant to correct at 16:00 which is the time that my blood sugar is rising, while I still have some 2 more hours of Novorapid on board (which was injected at 13:00).
Click to expand...

I get your concern. It's stressful dealing with inconsistent sugars as you can't relax and are anticipating the next drop or rise, so even if things look good, you're waiting for them to go pear-shaped.

I would only treat a drop to a borderline blood sugar eg 4.5 approx depending on circumstances. I don't see drops like that in the figures you've listed. If I had a 12 before lunch, corrected and bolused, I'd be happy with something like a 5 something, 6 or 7 mid afternoon, so I wouldn't treat that.

When trying to improve my sugars, I tend to start at the beginning of the day because I've found that if things start rubbishy and high, then I'm forever chasing my tail. Are you saying you choose your breakfast bolus in order to be high before lunch because of your concerns about the mid afternoon drop? Or does your blood sugar naturally tend towards high then and you just choose to leave it that way because of the drop?
 
Bluemarine Josephine said:
Can such a small amount of protein create this rise?
There was protein in case 2 but didnt have the same effect.

As for the mayonnaise, I think you are right. Looking at the low carb content on the label I considered it safe. I would have never thought that it could mess the absorption so much...
Click to expand...
Because In case 2 you didn't have mayonnaise it shoot you straight away. Protein eaten without much fat affects me nearly the same as carbs.
 
azure said:
I get your concern. It's stressful dealing with inconsistent sugars as you can't relax and are anticipating the next drop or rise, so even if things look good, you're waiting for them to go pear-shaped.

I would only treat a drop to a borderline blood sugar eg 4.5 approx depending on circumstances. I don't see drops like that in the figures you've listed. If I had a 12 before lunch, corrected and bolused, I'd be happy with something like a 5, 6 or 7 mid afternoon, so I wouldn't treat that.

When trying to improve my sugars, I tend to start at the beginning of the day because I've found that if things start rubbishy and high, then I'm forever chasing my tail. Are you saying you choose your breakfast bolus in order to be high before lunch because of your concerns about the mid afternoon drop? Or does your blood sugar naturally tend towards high then and you just choose to leave it that way because of the drop?
Click to expand...

I am deliberately bolusing for breakfast in such a way so as that my blood sugar will not be lower that 9 mmols at pre-lunch.
The reason is that, when for lunch, I inject my correct ratio:carbs by 15:00 I see a dip in my blood sugar which is followed by an unexplained rise at 16:00 and this unexplained rise continues until 18:00 hrs.

If, at lunch, I inject my correct ratio:carbs, by 15:00 I have a dip of upto 4 mmols.
For example: on a 1.5:1 ratio.
Pre-lunch reading is : 11.8
15:00 level: 7.7
18:00 level: 11.4
So, 1.5:1 works nicely.
How do I avoid the 7.7?
 
JPTS said:
Hi Bluemarine Josephine. Your post could have been written exactly for me. For a long time now I have experienced the exact same issues you describe and for a long time it has been a cause of real frustration.
This issue is still a problem for me and at present am just having to live with the uncertainty with frequent testing. For a long time I had no knowledge that fat and proteins could have such an impact on readings, so Tim is spot on when he says the inclusion of these with a meal will effect after meal levels.
As this has been a huge problem for me for so long I will follow this post with great interest. Thanks for raising this issue.
Click to expand...

Thank you JPTS. I am happy that you find this thread interesting.
I will test Tim's and Ewelina's suggestion for lunch today.
I will have just a usual small amount of protein + veg and I will add nothing more than 30 grams of carbs coming from 1 banana of 128 grams weight. There is 0 fat in the banana. Veg also have little fat if any and I will deliberately skip any other fat (butter, olive oil, condiments)...
I will use my correct ratio and I will post my findings for you.
Hopefully, this will be the solution to our problem.
 
Got it :)

Have you done a basal test, and does that same mid afternoon dip then rise happen even without the bolus insulin?

Have you tried, for example, splitting your lunch bolus? (I appreciate that that might not be easy or even possible if you're not on a pump)

It must be frustrating for you. I sympathise. I found keeping in range hard on MDI sometimes. It was like trying to do some intricate task with boxing gloves on.
 
Bluemarine Josephine said:
I am deliberately bolusing for breakfast in such a way so as that my blood sugar will not be lower that 9 mmols at pre-lunch.
The reason is that, when for lunch, I inject my correct ratio:carbs by 15:00 I see a dip in my blood sugar which is followed by an unexplained rise at 16:00 and this unexplained rise continues until 18:00 hrs.

If, at lunch, I inject my correct ratio:carbs, by 15:00 I have a dip of upto 4 mmols.
For example: on a 1.5:1 ratio.
Pre-lunch reading is : 11.8
15:00 level: 7.7
18:00 level: 11.4
So, 1.5:1 works nicely.
How do I avoid the 7.7?
Click to expand...
When you start bolusing for protein you will need to lower your ratio for carbs. If you take smaller doses for carbs you wont see that massive drop.
If you think your basal is right, give it a go. No need yo run high for whole morning which is harmful.
start gently and dont inject massive doses for protein and start with good pre lunch reading
 
azure said:
Got it :)

Have you done a basal test, and does that same mid afternoon dip then rise happen even without the bolus insulin?

Have you tried, for example, splitting your lunch bolus? (I appreciate that that might not be easy or even possible if you're not on a pump)

It must be frustrating for you. I sympathise. I found keeping in range hard on MDI sometimes. It was like trying to do some intricate task with boxing gloves on.
Click to expand...

Thank you so much for the delicate way that you handle my case, I really appreciate you kind words.

I have not done a basal test however, my ratios work nicely for breakfast and for dinner. It is only the lunchtime hours that I have this peculiar situation. If my basal was incorrect then, I suspect that the ratios would not work in none of the 3 meals.(breakfast/lunch or dinner). However, my 1:1 for breakfast and 1:1 for dinner work pretty nicely. This, suggest to me that it might not be a basal problem...

I am leaning towards Tim's and Ewelina's suggetion because lunch is the most "complicated" meal for me in the sense that it is the only meal of the day which contains many different types of foods. For example, breakfast is pretty straightforward, fruit and greek yogurt or a glass of semi-skimmed milk. Dinner is same.

As lunch is the only meal which contains all different types of foods, protein+fat+carbs... I suspect there is something in the combination and the interaction of food that is causing the trouble...
 
Okay, I was going through my readings and I just noticed something funny...
Whenever, for breakfast and dinner, there is no protein presence (just fruits or bread and a little butter) my ratios work even better... Even my usual 1:1 gives me a nice correction of around 1-2 mmols...

I am confused while, at the same time, pleased that this may bring a solution to correct diabetes handling...
 
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