Overnight Basal Rate Testing

I'm ignoring that outlier (281 mg/dl) - see how it doesn't fit?

Numbers and Lines

I had a hunch that I could use some fine-tuning.  But overnight fasting basal rate testing sucks, so I kept putting it off.  My doc finally convinced me to bite the bullet, and I’m actually very glad I did.

The idea behind basal rate testing is to eliminate as many variables as possible, so that any changes you see in your blood sugar are most likely from your basal rate.

Wait – am I getting ahead of things here?  Do you guys know what “basal” is?

You need insulin all the time.  I mean ALL the time.  Even when you’re not eating, you need a bit of insulin in you.  In a person without diabetes, the pancreas has a way of knowing exactly how much is needed for each minute of the day.  In my case, I need to figure out how much my pump should deliver on an hourly basis.  That hourly insulin is called my “basal” insulin.

In theory, if your basal insulin is set right, you should be able to fast indefinitely and your blood sugar should stay relatively stable (without extra influences like exercise or illness).

In order to test your basal rate, the idea, again, is to eliminate as many variables as possible.  The typical variables include food and bolus insulin (boluses are what you take for highs or when you eat).  There are a million other variables involved, but we’re only worried about the ones we can influence.  Get rid of as many of them as possible, and any changes you see in blood sugar are most likely from that basal insulin.

I woke during the night to test every two hours.  There’s nothing nice about doing that.  And every single time my phone alarm buzzed me, my wife popped upright and asked “what was that?!”  Poor thing is so accustomed to listening to any sort of pump or CGM alert coming from my side of the bed…

So we both had a less-than-great night of sleep, and I felt bad about how it disturbed her.  I thought about the torture that is overnight basal rate testing and how it affected more than just me.  It’s not fair that it should mess up her sleep too.

But look what I found!  Nearly 100 point rise between midnight and 8:00 AM!  I had a hunch, but holy smokes!  To be fair, this was only ONE night of information, and there were a couple things that might have skewed the results.  The only real way to know if it’s a fluke, or reliable data would be to do another overnight test.  Which I will, soon…  but not too soon.

I will probably make some adjustments based on this information, even though it may not be exact (what in diabetes is ever exact?), then recover a while before repeating the test.

Basal rate testing is a pain, but once you get your basal rates really dialed in, rumor has it that things with blood sugar management get a lot better.

Wise words from my friend Dan (who impressively maintains a 5.x A1C by the way…):

If you can own the night, you can also own a majority of the day AND the weekend! Keep at it! It sucks, but it will help!

A “Wake Up” Bolus?

Is there something more than Dawn Phenomenon?

The dawn phenomenon is typically described as the body releasing a handful of hormones overnight that cause some insulin resistance.  You see this as higher blood sugars in the morning, even though you went to bed with a great blood sugar.

I do experience the dawn phenomenon, and have been able to adjust my pump to deliver a bit more basal, or background, insulin during the early morning hours.

wakeupBut I’ve also got something else going on.  When I get up for the day, no matter what time it is, my blood sugar goes up.  If I wake up at 4:00 AM, it goes up.  If I wake up at noon, it goes up.  If I wake up anywhere in-between there, it goes up.  I’ve come to think that my body just hates waking up and squirts out some extra dawn phenomenon hormones to get me moving.

This is not something I can program my pump around because I wake up at different times almost every day (the “joys” of being self (partially) employed?).

Once last week I woke up with a low blood sugar.  I didn’t treat it because I knew that just waking up would make it rise.  I went from a 71 mg/dl on waking to a 92 mg/dl less than an hour later.  It didn’t stop there though.  It was on a fast road to hyperglycemia if I didn’t do something.

I’ve not gone as far as to track and measure the rise, which would be the smart thing to do.  But I have made a habit of taking a couple units of insulin when I get up, trying to keep my blood sugar level.  Sometimes it works, sometimes I’ve given too much, sometimes too little (a popular problem when living with diabetes!).

This wake up rise complicates a handful of things for me though.  My insulin needs are different for both meal and correction doses in the morning, and it really exaggerates the troubles I have with my infusion site changes in the morning.

One thing I learned in writing this, is that breakfast is critical.  According to this article from Theresa Garnero at dLife.com, eating breakfast signals the bodies counter-regulatory hormones to turn off.  Since I think those are the hormones messing with me, turning them off would be good.  I know that I am often guilty of skipping breakfast, so this is one thing for me to work on.

I would love to know, does this happen to anyone else?

Do you bolus for protein?

I have heard from two different groups of people on this one.  One group that does not bolus for protein at all, and another who boluses for a portion of their protein.

Somewhere in the big “diabetes info” vault of my brain, I think I can recall something about 60% of the protein you eat gets metabolized into carbs over an extended period.  Does that sound familiar to anyone?

When you eat a meal with a lot of protein, do you find your blood sugars go up much later?  I do.  I think that I need to experiment with bolusing for a portion of the protein, and running that bolus over an extended time.

So, now the meal math gets even more complex (because more complication in my life is exactly what I need, right?).  So we’ve got X% of the protein grams, bolused for over X amount of time, then 100% of the carb grams (minus fiber, if that’s your thing too), plus or minus some insulin based on your current blood sugar.

Is it worth it?

What do you do?

Pumping Symlin (part 4)

Q & A time!

Q) A question about your Symlin pump–do you use some basal Symlin as well as boluses at meals, or is that pump’s basal rate set to zero?

A) On my Symlin pump I run a tiny basal rate of 0.10u/hour.  This was based on advice from Gary Schiener (who pumps Symlin too).   Apparently Symlin is a little more prone to blockages or occlusions because it sticks to the infusion set material more than insulin does.  Running a small basal rate keeps the fluid moving enough to help minimize that.  I’ve not had a blockage/occlusion alert yet.

Q) Scott, am I reading correctly that pumping Symlin means one constant rate of 0.1u with no boluses for meals?

A) Before my meals I take a bolus of Symlin, above and beyond the basal (which is such a small rate that it really doesn’t do anything other than help prevent blockages/occlusions).  I take 10 units, which is the equivalent of the 60mcg dose on the pens, and try to get that Symlin bolus in 15-20 minutes before eating.  I also start an extended bolus of insulin through my insulin pump for the carbs in the meal when I actually start eating.  Again, mimicking what has worked for Gary, I run an extended (or square
wave) bolus for 90 minutes.  This seems to work pretty well, but (like everything else with diabetes) there is room for improvement.  There are also different situations where I need to time the bolus differently, and I’ll either stretch it out more or wait a while to start it.

Q) This is fascinating. Do you run out of sets? How do you deal with insurance?
A) I talked about this a little in the last Pumping Symlin post (part 3).

Q) Can you fill us in on the 2nd pump thing? Which model? Where do you put the 2 infusion sites?
A) I rotate both my insulin site and Symlin site (usually) at the same time.  I try to stick to a 3 day schedule, but may stretch it to  4 days to conserve supplies.  This is a hard balance because I don’t want to fight scar tissue in the future (from wearing each set too long).  I put the Symlin infusion sets in the same types of places that I put my insulin infusion sets.  A few configurations I’ve used so far is the insulin set on my upper rear end and the Symlin set on the love handle/side/lower back area.  Or maybe the insulin set on one side of my belly button and the Symlin set on the opposite side.  It really can go wherever you can put an insulin infusion set.  Today?  I’ve got my Symlin set in my lower back and my insulin set in my arm.

Q) Have you lost any weight as of yet?

A) I think about 4 pounds.  My weight fluctuates a lot, especially when I play basketball.  The first day of the week that I play basketball I usually lose a little over 5 pounds of water weight.  I play an additional 2-3 times more through the rest of the week, and struggle to drink enough to stay hydrated.  So, if I weigh myself on Monday (before any basketball) I might be 5-10 pounds heavier than if I weigh myself on Friday (after a week of heavy exercise and sweating).  I have not gotten into a routine where I weigh myself at a consistent time under consistent conditions, so it is hard for me to tell.  Does that make sense?  With that being said, I am trending down, so it is heading in the right direction.  Because I’m trending down I am not overly focused on the numbers.  I’m just going to keep doing what I’m doing and let it rock for a while.

Q) Do you think the pump will live much longer?  How old is it?
A) That is a very good question.  The answer is: I don’t know.  I think the pump will keep on ticking, but as we all know, stuff happens.  The pump is a little over four years old.  My two other old pumps still work (one is over 10 years old!), but I don’t have a steady line on supplies for them.   I guess I’ll cross that bridge when I get to it.

What other questions do you have?  Did I answer everything so far?  Let me know in the comments, and if there are enough I’ll throw up another post (otherwise I’ll answer them in the comments).