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T2, insulin resistant and not sure where to go

Annb

Expert
Messages
9,197
Location
Western Isles, Scotland
Type of diabetes
Type 2
Treatment type
Insulin
I am a 75 year old woman, T2 and insulin resistant. It seems possible that I started all this with gestational diabetes but since my younger son was born in 1969, it's not going to be possible to prove that. Whatever - it's been pretty long standing and well established in my body.

I have tried low carbing to both reduce BG levels and to lose weight. However, this has not worked. Certainly eating carbs does put my BG up to ridiculous levels, but cutting out all possible carbs doesn't bring levels down to the recommended range. I try not to have more than one or two meals a day. And I'm semi permanently hungry!

I have just been provided with a Libre 2 and am trying to get used to it. It seems to be indicating that with a change of timing of injecting my basal dose (Lantus Solostar) it seems to be helping a bit during the morning (as long as I stay off the carbs) but then on some days my BG drops down to the lower 4s in the afternoon - other days it doesn't. So far, it seems quite unstable. I also take a bolus dose of Humalog before any meals during the day. Both kinds of doses are higher than I would like and my diabetes nurse says she thinks however much I take, it's not going to make any difference, so don't bother increasing the dose any more.

Other health issues mean that I have to take a cocktail of pills and that I don't sleep any more than 3 hours a night and then am drowsy during the day whenever I sit down, which I have to do fairly often. Then I might drop off and sleep for an hour.

I wonder if this pattern seems familiar to anyone else and if there are any suggestions on how to deal with it or where to go from here.
 
Apart from the occasional drop to the high 4's (which isn't a bad thing), what kind of numbers do you see over the day? Going up and down over the day is quite normal, it depends on how high you go and how wild your swings are.
Would it be possible to post a picture/screenshot of the graph on your Libre to give us an idea on what is happening?
Annb said:
Both kinds of doses are higher than I would like and my diabetes nurse says she thinks however much I take, it's not going to make any difference, so don't bother increasing the dose any more.
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You have already found out changing things with your dose DOES make a difference! Both with the changed timing of your Lantus and with your recent experiments with having a small 'pre-breakfast' bite to take some insulin with to counter going high before breakfast.
 
@Annb

I don’t use insulin so am not best placed to offer any advice, but to assist those who might be able to help, I wondered whether you could clarify how the bolus doses you mention are calculated? From what you say it sounds like you might be using the same dose regardless of what you eat? Is that right, or have I assumed wrongly?

It’s surely a tricky business getting does right and I know you’ve had conflicting information from different healthcare professionals.

Do you happen to have screenshots of your Libre graphs? They might help people to make suggestions too.
 


Hi.. insulin resistance can be difficult... im going to post from a personal experience from a family member... i don't know to what extent it may help..

1, Low carb to some time(many weeks) to reduce both BG and weight.. the weight took longer due to suffering from stenosis of the spine.. mild exercise where possible helped as it forces the body to burn energy from the food eaten, and after a while to start eating some of the body fat..

2, Humalog/Novorapid, timing is to some point important about 10 minutes prior to food, they used to take with food.. libre will help you see when is right.

3, injection site... some parts of the body absorb insulin differently... they always injected in the belly, and had to take in the region io 200u a day.. they changed injection site to the thigh and found the insulin to be much more effective, to the point that they are now on about 40u a day. so maybe you could try different sites short term.. thigh, buttocks, back of arm in the fatty bit

4, constant hunger is quite common early on.. as your BG levels start to lower the body goes sort of panic mode as it is used to higher BG levels and expects them to be maintained.. your body should adjust to that feeling but again its not 'instant'

5, for many people basal insulin does not last 24 hours, libre will help you see if you are getting a rise after 16/18 hours a time change or split dose can help give better coverage

in this persons case they had been taking in the region of 180u a day and increasing for some years.. and they are now maintaining sensible BG levels most of the time.. and their health care team never said much other than take more insulin

its good you have the libre, as if you are coning to try different injection sites, you'll need to monitor your levels to make sure there no sudden drops!

good luck and hope you find a solution

as i say, this is from personal experience .. im in no way qualified to tell you what to do...
 
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Thanks for all the responses.

Bulkbiker Any idea what your daily intake actually is?
I can't say that I always stick to the low carb level I had set for myself (in the absence of support from medics) but for months now that has been below 20 g. On the odd occasion it has been up to around the 70-100 g mark. But those were very odd occasions. Just recently my GP changed her mind about the whole issue of carbs and told me to get rid of all carbs, except those in non starchy vegetables and, of course, to avoid all fruit. Not sure what the diabetic clinic will have to say about that, but I shan't get an appointment there for some months now, so that is a bit irrelevant.

Antje what kind of numbers do you see over the day?
Recently it has been between 4.3 and 18.4. The higher numbers are usually later in the day, although a couple of days ago, the level started to drop during the afternoon and evening (so the Libre sounded alarms about 4 times in the evening). Then again, yesterday I was struggling to keep it down and when it went up to 16.6, I took a "correction" dose and it came down to the 6s and 7s for the rest of the evening.

Would it be possible to post a picture/screenshot of the graph on your Libre to give us an idea on what is happening?
Sorry, I don't know, yet, how to do that.

Goonergal wondered whether you could clarify how the bolus doses you mention are calculated
The bolus dose has been gradually increasing over the months, just by trial and error, I suppose. The diabetes nurse advised me some weeks ago to start on Humalog at 40 (just changed from Humilin S), in case it was too much at my normal level of 54. It wasn't and I have edged it up over the weeks to 54 at each meal (low carb, of course). Now the nurse says, leave it at that and don't put it up any further. I suppose it is regardless of what I eat, but I usually eat about the same kind of food and amount, anyway.

Searley for many people basal insulin does not last 24 hours, libre will help you see if you are getting a rise after 16/18 hours a time change or split dose can help give better coverage
Looking at the results I am getting, I wondered if it would be a good idea to split the basal dose.

injection site... some parts of the body absorb insulin differently... they always injected in the belly, and had to take in the region io 200u a day
I usually inject into my stomach. I know I should rotate the sites but my legs and arms are so painful anyway that I have given up and just move around the available space on my abdomen (which is getting bigger all the time, so a fair amount of space there). So between basal and bolus doses I am usually taking 164, or, if I have breakfast 218. But I usually don't have breakfast until the afternoon and so only 2 meals in a day.

Actually, today my BG has been much more stable - from 9.6 at 3 am through 7s and 8s and then 5.8 by 3 pm and then 6.6 at 7.45 pm. Now that is a good day. Mostly just veg today (2 meals) with a piece of salmon this evening. The veg were not low carb - peas, beans onions and a potato. It's fine, but it just adds to the puzzle.
 
Annb said:
Then again, yesterday I was struggling to keep it down and when it went up to 16.6, I took a "correction" dose and it came down to the 6s and 7s for the rest of the evening.
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I think it looks like you're well on your way on figuring out what works for you!
 
Annb said:
I took a "correction" dose and it came down to the 6s and 7s for the rest of the evening.
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Getting the hang of correction doses could be useful to you. As a moderately insulin resistant T1 I stop my weight from rising by eating moderately low carb, and my insulin resistance definitely varies by time of day. So my lantus basal insulin can need a top up at various times of day, because it doesn't carry me through. Ideally, you'd learn from experience how much you need to take to bring your blood sugar down by 1 unit and then you'd be able to calculate correction doses when your blood sugar goes too high. But you have to be careful because short acting insulin can act for 4 or 5 hours, so if you've still got some in your system adding a correction dose can bring you down too low. Having a libre should help a lot with this.

As regards your other medications, some drugs are renowned for increasing blood sugars (eg steroids) and if you're on them you'll probably just have to accept that they make you need more insulin.

Keeping a good record of your food intake along with your doses and blood sugar levels may help to see a pattern, the libre is invaluable here.

Normally, as an insulin dependent T1, you are told to get your basal dose right first, and then mess around with the bolus. When are you taking your lantus? (Some people take it in the morning, others at night, some split the dose and take it twice daily so as to avoid any issues of it running out - it doesn't last 24 hours for everyone.) In an ideal world, you'd have your morning reading (before the dawn phenomena kicks in) roughly the same as your bedtime one.

Good luck. Don't give up. It sounds like your levels are improving.
 
Annb said:
Goonergal wondered whether you could clarify how the bolus doses you mention are calculated
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My understanding is that you work with your health care practitioner to figure out how to adjust the dose based on the carb content of each meal. However, I have zero experience of this! In your shoes I’d be paying more attention to @Antje77 @EllieM and @searley than to me!
 

It's a pattern that I recognise! I'm T2, insulin resistant, and have struggled to get my sugars stable. Firstly, carry on using the correction dosing like you are already doing. Sometimes the only way to get levels down is to correct the highs, and then once you are in a routine of keeping it more level, then think about what tweaks that you can make.
If your levels are starting off lower in the day, to my untrained eye, that's better news. You aren't fighting so much against the glucose that your own liver is making, and it may just be a case of tweaking the diet until you find something that worse. One thing that affects me, but doesn't affect everyone the same, is protein. I still find that higher quantities of protein will spike me, so I have to be really careful about how much I'm eating. So play around with adding a bit more fat, and a bit less protein, and see what happens.
 
Annb said:
Just recently my GP changed her mind about the whole issue of carbs and told me to get rid of all carbs, except those in non starchy vegetables and, of course, to avoid all fruit.
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Thats's not bad advice.. for once I'd suggest following it closely (I usually advise against following GP's advice but yours seems to know their onions) and keep a food diary for a week or so weighing everything so you can get a real handle on exactly how many carbs you are consuming. That way you'll know for sure. If you have irregular carb excursions it can take you out of ketosis for a longer period than you think especially if you end up being "carb sensitive".
 
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Still experimenting with the insulin.

This morning (3.45 am) BG was 9.4. Not sure if this can be considered a fasting BG since it is halfway through the night. Having taken painkillers, I went back to bed and woke at 9 am. By that time BG was 12.3. Took 30 u Humalog and about 9.45, 66 u Lantus. 7.3 at 10.35. So that's a good start.

However - then I got it wrong. Bacon and eggs for breakfast after 54 u of Humalog. That is what I would normally take before a non carb meal. But it was too much because BG started to fall and I struggled to keep it above 4 (symptoms of hypo, but not quite down to hypo level). Had a boiled sweet, but it still dropped to 3.9 by 12.35 and I was feeling awful - not the usual hypo feeling but still pretty bad. Had an avocado chopped with some crumbled potato crisps. Not spectacularly tasty but it did bring BG up towards 5.

So, I guess less Humalog is called for and that might get that part of the day under control. Finally began to feel better around 3 pm.

I haven't noticed any spikes with protein, although I have, in the past, with vegetables - usually the greens but I think I really have to keep eating greens, if only for the sake of minerals. However, as well as causing spikes, they also upset my stomach, so I do have to be a bit light on those.

I did look up some information on correction doses, against the advice of my diabetic nurse, but, I guess I'm just thick and couldn't work it out, so I'm just taking an arbitrary figure and will work from that.

I am still thinking about dividing my basal dose and having some in the morning and some in the early evening. That will probably take some playing around with as well. Still, one tweak at a time to see the effect without muddying the water. But I am hoping now that I can get somewhere with this.
 
Annb said:
I did look up some information on correction doses, against the advice of my diabetic nurse, but, I guess I'm just thick and couldn't work it out, so I'm just taking an arbitrary figure and will work from that.
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Normal starting figure is 1 unit to drop 3mmol.. obvious if insulin resistant you may need more.. but this is a good starting point

the trouble with arbitrary figures is that you don't really learn from them.. they work or they don't.. but if you have a starting point and try it for a week or so, if its not having enough effect you slightly increase so say 1u for 2.5mmol this way you will eventually learn how many units to take for the sort of drop you want... more hassle to start with.. but easier in the long run.. you'll just see you want a drop go 10mmol and immediately know how many units to take..

the nurses will always so don't correct without food.. which is why first its good to work on correct bolus dose, so that you know what you are doing correction wise.. no correction without food is something not every takes notice of.. i assume they think there is more hypo risk

again in an ideal world you'd be doing this with your care team.... but if they are leaving you to learn it alone please just make sure you test you bg at frequent intervals to reduce hypo risk
 
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Annb said:
Had an avocado chopped with some crumbled potato crisps. Not spectacularly tasty but it did bring BG up towards 5.
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Looks like you took the perfect amount of carbs to nudge it up a bit without spiking high!
Annb said:
Still, one tweak at a time to see the effect without muddying the water. But I am hoping now that I can get somewhere with this.
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Very happy to see you are starting to find some patterns and reacting to them. Take your time, getting it right won't happen in a day, and even when you have it mostly right there will always be days where nothing diabetes seems to make sense.
searley said:
Normal starting figure is 1 unit to drop 3mmol.. obvious if insulin resistant you may need more.. but this is a good starting point
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I think this is a starting point for T1's with no or very little insulin resistance, for who 1 unit is, say, 5% of their daily dose, or for people who are so new to insulin they don't have any information on the amount of insulin they need yet. If you take 50 units for a low carb meal, 1 unit won't make much of a difference.
 
Half of my thyroid had to be cut away 3 years ago - nothing wrong with it, just a tumour on my parathyroid. Unfortunately, my parathyroid was growing into my thyroid - so it had to go. But I am on Levothyroxine as a result and the levels appear to be OK. Poor sleep, apart from now being a habit, is caused by arthritic pain plus having to get up for the toilet a couple of times each night.

I have a GP appointment today to find out about more growths on my face and body (my brother also develops these - we call them our gerbils, since they are not moles; sometimes they have to be cut out, but usually not) but I have mentioned the lack of proper sleep and tiredness in the past, as well as other issues and none have ever been satisfactorily dealt with. Sometimes wonder if it's worth the bother. My elder son, Neil, will have to drive me in - I'm beginning to think my vision is less than it could be. It is actually better than average, but something is happening to the facility to refocus on anything that is moving in relation to me. Not good. Anyway, I don't comfortably sit behind the steering wheel these days - getting fatter and fatter by the day, it seems.

Yesterday I took 30 u of Humalog as a correction dose. It worked and today I have reduced it to 25 u to see if that is enough.
 
Annb said:
Yesterday I took 30 u of Humalog as a correction dose. It worked and today I have reduced it to 25 u to see if that is enough.
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Today I reduced that early dose to 25 u. It was fine but while in town, on my way home from the GP, BG dropped to 3.8. Just as well I had a tin of travel sweets in the car - been there so long they had gone all gooey! One stopped the drop anyway. But it was still 3.8 when I got home so I had a mint humbug out of the jar that stays in the larder for emergency use. That brought BG up to 5.3. That'll do me. So tomorrow will drop that early dose down to 20 u and see how we get on.

I also reduced the pre-meal dose of Humalog before breakfast - bacon and eggs, as yesterday. Instead of 54 u, I took 50 u. Don't know if this will continue to work, but so far, so good.
 
I am at 20 u for that first dose now - it seems to work but I still have to work on the bolus dose - BG is beginning to go pretty low and sometimes close to hypo level. That's all to the good. I've been around 5.0 all day (more or less) with one drop to 3.8. Currently I am at 6.4. This is all Libre figures - but it is only about 0.8 below the Aviva meter.

I really am beginning to hope that this regime is going to work! Thanks all for your good advice.
 
Annb said:
I really am beginning to hope that this regime is going to work! Thanks all for your good advice.
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So happy to hear this!
Now don't get disheartened when there are days when nothing seems to go right or follow logic, it's part of the game.

But I think you took the most important hurdle: believing and experiencing that what you do does make a difference
Well done for not giving up, despite less than helpful HCP's and all the other issues you are juggling at the same time as your diabetes!
 
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