Honeymoon is clearly ending ... and BG control is still great. Reflecting on it & giving some advice.

Honeymoon is clearly ending … and BG control is still great. Reflecting on it & giving some advice.

WARNING: Very lengthy posting.

It has been just a little over a yr since my prognosis, and the honeymoon part is clearly virtually over. Basal wants elevated considerably, and at the moment are at non-honeymooning ranges. Morning BG rise is kind of pronounced – I want 2-2.5 models of Humalog each morning to compensate. Some veggies like purple peppers noticeably deliver my BG up.

And my final HbA1c was … 5.1%. Time in vary 98%, vary is 70-150 mg/dL.

I had comparable figures throughout my honeymoon (extra hypos although, which may sadly be extra frequent throughout that part). I used to be repeatedly informed that I'd by no means obtain them once more post-honeymoon, that I must be completely satisfied if I ever obtain something under 8%, and that dropping limbs and eyesight are inevitable. Properly, I’m completely satisfied to show these individuals incorrect.

However: It requires significantly extra work now. That’s simple. It doesn’t eat my total life, however there may be much less wiggle room for errors.

My foremost level of this publish is twofold. First, it serves as encouragement for at the moment honeymooning T1s who bought informed comparable crap like I used to be. Publish-honeymoon doesn’t imply BG hell. And second, I wanna give some recommendation for BG management primarily based on how I do it. Maybe it helps you guys. (I write this on this sub as a result of although that is largely for T1s, some T2s who’re insulin dependent may profit, and different bits could also be attention-grabbing for T2s total.)

IMPORTANT: Please notice that many bits of recommendation I give right here require a CGM. That is significantly true of dosage and correction recommendation. I strongly suggest to NOT do these steps if you happen to solely have fingersticks.

So, right here it goes:

  1. If you’re on insulin, get a CGM/FGM. T1s ought to do every part they will to get a CGM. For T1D remedy, it’s a HUGE sport changer. The distinction is evening and day. BG ranges fluctuate all through the day, generally closely. Fingersticks alone are nowhere close to sufficient to even remotely seize the dynamics of your BG. So, once more, if you’re a T1, get a CGM ASAP, make it your #1 precedence. For those who can't get one, you possibly can attempt to get a FreeStyle Libre. That one is definitely an FGM, not a CGM, as a result of you’ll want to manually provoke the scan. However, you should buy a third occasion transmitter to show it right into a DIY CGM. I strongly suggest that you simply do this in case you have a Libre. The Libre can be helpful for T2s, particularly if they’re on insulin, however even for individuals who aren't, as a result of they will find out how their BG behaves after a meal and work to cut back the peaks for instance. (Extra on peaks under.)

  2. After getting a CGM, I like to recommend studying the e book Sugar Browsing by Stephen Ponder to take advantage of out of it. It promotes a way more "dynamic" type of diabetes administration, which isn’t doable with fingersticks alone, and might enormously enhance your BG ranges. You positively additionally must learn Assume Like A Pancreas from Gary Scheiner. Sugar Browsing is usually attention-grabbing for T1s and closely insulin dependent T2s, whereas Assume Like A Pancreas is attention-grabbing for all.

  3. Find out about diabetes. A lot. Don't simply blindly comply with your endo's advices. Attempt to perceive why they provide the recommendation. Perceive the fundamentals in regards to the liver's position in BG administration, what insulin does (it’s not merely about decreasing BG), why you want basal, what glucagon/cortisol/adrenaline do to your BG, what the daybreak phenomenon is, and so forth. Many of those matters are coated by the books I discussed earlier. Additionally, ask plenty of questions primarily based on what you've learn. That's a method how I discovered. Once more, all the time attempt to really perceive what you learn and listen to, don't simply copy-paste it in your thoughts.

  4. Right here I wrote a abstract in regards to the connection between excessive BGs, HbA1c, why the physique will get broken, and why occasional excessive BGs will not be an issue.

  5. Get your basal charge proper. That is completely important on your BG administration. Your basal is the inspiration for every part. If it’s not rock strong, every part else shall be manner off. The books I discussed have some suggestion for testing your basal necessities. I like to recommend doing basal charge exams possibly as soon as each few weeks. I do them by merely skipping one (!) meal (normally breakfast or dinner, since skipping lunch tends to be tougher in my case). Do not quick a complete day. First, it’s not really easy to tug off, and second, it could provoke the manufacturing of ketone our bodies in case your present basal is inadequate. The ketone leveles are nowhere close to DKA grade, however they will throw off your basal charge exams.

  6. As soon as your basal is strong, work in your components – the I:C ratio (what number of carbs are coated by 1 unit of insulin) and the ISF (insulin sensitivity issue). Once more, the books have nice recommendation for that. In the course of the honeymoon part, one I:C ratio and one ISF for all the day are normally sufficient. However later, you'll must have one pair for the morning hours, one pair for the center of the day, one pair for the night hours not less than, as a result of the insulin sensitivity varies throughout the day. Be ready for these components to alter over time. Throughout honeymoon, they will change quickly. However even later, they normally don’t remain fastened. I hardly ever do full issue exams anymore, and as an alternative appropriate them primarily based on the BG ranges after the meal and the mealtime insulin are each performed. If for instance my BG earlier than consuming is 90 mg/dL, I ate 40g of carbs, took Four models, and 5 hours later, my BG is at 130 mg/dL, then I didn’t take sufficient insulin. Assuming that my ISF at the moment is 30 mg/dL/unit, I calculate how a lot insulin was lacking: (130-90) / ISF = (130-90) / 30 = 40/30 ~ 1.33 models. If I observe comparable outcomes over the subsequent few days (as a result of it’d simply have been a fluke), then my I:C issue is seemingly off. I appropriate it by calculating that for these 40g carbs, I clearly wanted greater than Four models. I add to those Four models the quantity of lacking models (1.33) I calculated earlier. So, now I do know that for 40g of carbs, I want 5.33 models, not 4. 40g / 5.33 ~7.5. So, my up to date I:C ratio is now 7.5g carbs per 1 unit.

  7. Don’t be afraid of correcting already at one thing like 120 mg/dL. However, if you’re new, think about this one thing to be tried later, when you’re extra assured and skilled. However with the utilization of a CGM, it actually is doable to maintain such a good management with out going insane. Once more, Sugar Browsing strategies like microcarbin and microbolusing assist right here. And don’t try this with out realizing your components effectively. They’re "simply" beginning factors in fact, however the extra correct they’re, the smaller the potential errors are.

  8. To proceed from #7, in case you have a CGM, discovered the best way to use it effectively, and have a strong basal and correct components, do NOT hearken to those that say {that a} HbA1c under 6% will not be doable with out tons of hypos in case you have T1D. That is solely true if you happen to solely have fingersticks obtainable, or if the necessities I simply listed will not be fulfilled, or in case you have some further therapies comorbidities that make a secure BG tough or outright inconceivable to realize (like Addison's Illness or PCOS, which mess along with your hormone ranges, which in flip stir chaos in your BG, or the notorious prednisone, which is feared by many diabetics for good cause). sadly, many docs didn't get the memo, and nonetheless think about a diabetic with a 8% HbA1c "well-controlled". That is the yr 2019, not 1979, we are able to do higher than that. A lot a lot better.

  9. If you’re a T1D with no vital insulin resistance, I like to recommend getting a half-unit pen. For instance, half a unit drops my BG at midday by about 20-30 mg/dL, and covers about 5g of carbs. That's not nothing.

  10. Eat a lot of veggies, a lot of salad. Be ready for veggie induced BG will increase although. For instance, purple peppers have a noticeable quantity of carbs in them, as do carrots. It is extremely tough to estimate the carbs in a combined salad although (until maybe you make it your self), so I eyeball it and normally cowl it with 0.5 – 1 models that I add to the general meal bolus.

  11. Carb discount is mostly a good suggestion (particularly reducing down on carbs from unhealthy stuff like soda or sweets). Going very low carb might make sense in your case, however I don’t assume it’s the holy grail like others appear to assume it’s. Particularly, some individuals have gallbladder issues for instance, and thus can not eat massive quantities of fats. Or, they may have kidney points, so they can not eat massive quantities of protein. These individuals should eat a excessive carb meal to cowl their caloric wants. I personally am working towards a "secure carb" strategy: More often than not, I eat carbs I do know and might dose for very effectively. A couple of instances I bask in carbs that may spike my BG significantly, or carbs that I simply don't know the best way to bolus for but. That manner, I’m not restricted by the precise carb quantity, and nonetheless retain good management.

  12. HbA1c is of questionable use for T1s. That's as a result of the BG, on common, can range much more in T1s than in T2s. As well as, many individuals endure from iron deficiency, which may falsify the HbA1c. If you’re a T1, and have a CGM, then time-in-range and glycemic variability are usually extra helpful. My endo thinks that HbA1c will stop to play a major position in T1D remedy within the subsequent few years.

  13. Pre-bolus all the time until you know {that a} meal doesn’t require it or until you might have gastroparesis. The insulin you inject wants to succeed in the insulin delicate tissues (liver, muscle tissues, fats depots). For that, it has to journey by way of the subcutaneous fats over the capillaries and your cardiovascular system to those locations, which takes time. Pre-bolusing could make a enormous distinction. With out it, my BG simply spiked to >180 mg/dL post-meal. With it, it now hardly ever spikes over 130 mg/dL. Large Pharma likes to promote us the lie that the speedy appearing insulins are so quick they don't require a pre-bolus. Don't imagine that. My pre-bolus interval is 10-15 minutes. I simply begin consuming the salad and protein throughout that point, and after 10-15 minutes, begin consuming the carbs.

  14. Additionally don’t imagine that speedy appearing insulin solely acts for 1-Three hours. It’s extra like 5-6 hours. Right here is one paper about this. Or right here in regards to the Humalog pharmacodynamics on web page 6. Fiasp additionally lasts for five hours (it’s merely a tweaked Novolog in any case), it simply begins sooner and requires a smaller pre-bolus. If it appears that evidently your speedy appearing insulin lasts lower than 5 hours, then it’s possible you’ll be inadvertedly compensating for lacking basal (see #5 above).

  15. Inadequate basal insulin can drag down insulin sensitivity. I’m not certain why, however it includes the elevated quantity of fatty acids in your blood that come up because of the relative lack of basal. You’ll have to dial up your basal (a bit above your wants) for some time to flush these fatty acids out, after which can slowly dial it down a bit once more.

  16. Alcohol messes along with your BG, massive time. I wrote a bit about it right here.

  17. Most low BGs could be corrected by ingesting just a few grams of carbs. The "rule of 15" is usually overkill. This assumes that you realize your components effectively although. Because of your CGM, you possibly can see if the low BG is falling slowly or quickly. If my BG falls slowly, I calculate the quantity of carbs I must deliver it again to 90-100 mg/dL, and eat that quantity. For instance, 5g of carbs deliver my BG up by ~30-40 mg/dL. If the BG is dropping like a rock nevertheless I eat not less than 15g of pure glucose, since that is an emergency state of affairs. With these guidelines, I’ve prevented tons of rollercoasters.

  18. Final however not least: Progress within the diabetes subject is fast, and it’s accelerating. Consequently, many hospitals, endos, and particularly PCPs will not be updated. Right here is one instance. Too many nonetheless stick with woefully out of date pointers and coverings. Hospitals might wish to take away your CGMs, insulin pens, pumps and so forth. Don’t allow them to, ever. Threaten with authorized motion if crucial. (No, I’m not a Bernstein fan, however this letter of his is superb.) In case your endo insists on you having not less than a 6% HbA1c and even greater regardless that you might have a CGM and infrequently have low BG, go to a unique endo (until there are good causes just like the comorbidities I discussed in #Eight above). And don’t ever let a PCP deal with your diabetes until stated PCP can be an endo. PCPs hardly ever know something past the fundamentals. T1s particularly should guarantee that the endo really treats them as T1s and never the way in which they'd deal with a T2. T1D and T2D are very completely different illnesses.

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