Checking In for Reassurance

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From time to time we need the help of others to make sense of our life with diabetes. Below, then, is part of an exchange I had with an endocrinologist. It concerns insulin pump use, and some of the terminology may be unfamiliar to those of you nonpumpers. For that, I apologize. Oh, and realize that the doctor’s portion of this e-mail should not in any way be used by you, dear readers, as advice for your condition. This is about me, and I’m simply sharing some of the correspondence. Also know that I’ve edited the text and worked through the order of the exchange so that it’s better suited for a blog entry. Do you care about that? I don’t think so. I hope not. Enjoy the enhanced version!

Dear Doctor,
I’m going to ramble here for a bit, because the past three weeks or so have seen my blood glucose jump pretty high pretty often, and I’m only wondering if you feel what I’m doing is sufficient (note that I haven’t gone hypoglycemic during this time, nor do I want to). Also, I guess some of what I’m asking about in my questions to you is part of the crap of the disease, too. Am I right? Can you corroborate this? I mean, I guess I have to suck it up and acknowledge that sometimes poop happens with diabetes, and there’s not one thing I can do to pinpoint it, nor immediately fix it? Yes?

Dear Eric,
Yup. You’re right. The delivery of insulin through a pump and the treatment options for people with diabetes, while better than it has ever been, is still a crude approximation of the real thing. Therefore, high blood glucose readings from time to time are expected.

So, Doctor,
As I told you at my September check-up, I’ve been exercising a lot more. My basal moved down to about 14.5 units a day, and I’ve left my meal bolus ratios in the 1 unit for every nine to ten grams of carbohydrates. Meals, routines, etc., all remained pretty steady — for a couple of months. Then, in the last few weeks, a juicebox or yogurt and low-fat granola breakfast, or even my standard meals that I know how to account for — and often even the littlest thing — when treated with insulin as I always have, will send my glucose way up there. I’m talking around 250 mg/dl. A couple times around 300 mg/dl.

Well, Eric,
This could be a couple of things. First, reducing your basal too much — and moving from around 20 units of insulin a day down to about 14.5 units is a significant drop — may mean you no longer have enough of a “floor” (i.e., basal or background insulin), so your blood glucose levels may shoot up after a meal. Also, how’s your weight been? Weight gain may also increase insulin demand.

To see how well balanced your basal-to-bolus ratio is, go into your pump and find the basal as the percentage of the TDD (total daily dose). It’s probably under the utilities or history menu. Ideally, it should be around 50% (yours was 42% the last time we spoke).

I do have to tell you, Doc,
My weight’s remained steady. If anything, I’ve lost a few pounds — or at least replaced some unhealthy weight with muscle weight! I’ve checked all the typical things, too: I changed my infusion site, checked carbs in foods extra closely, changed out insulin to a new vial in case for some reason the insulin I was using wasn’t fully effective. All that good stuff. It didn’t fix the problem.

I should also tell you that when I give myself a correction bolus, that does bring the blood glucose back down (and only once did I go slightly low because I overcorrected, but I was paying careful attention to my readings). I find, too, that if I don’t eat, that my basal rate seems to be keeping everything pretty steady in the 120 to 150 range. So maybe this does have something to do with a “floor.”

I wouldn’t suspect that I’m developing insulin resistance, because the basal and correction ratios are fine. But could it be? Do you ever see this kind of occurrence with bolus ratios? Maybe the dump of that large quantity into my system overloads me and I don’t handle all of it like I used to?

Let me leave you with this, then, Eric,
The bottom line is: Overall you’re doing wonderfully with your self-management. No, I don’t think it’s insulin resistance. The variations you’re seeing with your blood glucose probably aren’t having much of an effect. If you have concerns beyond these, you can record your carb intakes and ratios of boluses and basals over the next few weeks and I can examine them and provide more detailed feedback. Otherwise, let me know if you have any other questions. Have happy holidays and I’ll see you in the new year.

Thanks, Doc,
Happy holidays to you, too. And don’t worry, I’m doing fine. I’m not bummed about this, and I’m not worried about any potential increase, slight though it may/could be, on my A1C. This is all part of the whole dang disease, I know, and I’m OK with it.

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