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  • Insulin resistance curve through the day, any ideas?

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    Old 02-13-2008, 04:14 AM   #1
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    Insulin resistance curve through the day, any ideas?

    Just thought I'd ask about anyone with insulin resistances like mine. I am trying to see if there is something more I can do. I have an appointment with the only decent endo I know but that is a month away.

    Going on a pump has been a huge learning curve. Through using the programmable basal rate I have finally discovered the cause for constant blood sugar instability for me for years. It has tended to be blamed on diet, bad dosing, stress, etc etc you name it. But using the basal rate adjustment and experimenting I've discovered I have a great big insulin resistance curve through the day, independent of virtually all other factors.

    I don't know if this will make sense to non pumpers, but the best way to explain is show the best basal profile I've come up with:

    12 - 5am 1.60 u/hour
    5 - 8am 1.80 u/hour
    8 - 10am 1.95 u/hour
    10 - 2.30pm 2.25 u/hour
    2:30 - 5pm 1.45 u/hour
    10 - 12am 1.70 u/hour

    So broadly speaking I get an upwards curve increasing through midday then it suddenly drops right back at about 4pm, then high again in evening, a little lower for sleep.

    This basal curve is the first thing that has given me mostly consistent blood sugars through the day. Life used to be a nightmare of trying to control things through the day.

    If I don't "catch" my raising levels with this basal increase through 10am - 1pm, blood sugars in the 16 mml/l 288 mg/dl just tend to "happen" for no reason. It usually takes hours for insulin to effectively bring me down once I hit those heights.

    It is not linked to my food, I experimented with excluding food to get this rate right. Previously my spikes were often blamed on food. With this basal rate I get a much more predictable response from boluses.

    I am relatively fit and active through each day. I have chronic fatigue which I would say is now in a "mild" stage - if I over-do things I pay for a few days, but I am basically functioning ok and can exercise in moderation. I am just slightly overweight, being "in weight" does not affect my resistances. I have always needed a lot of insulin, twice the usual amount going by the total insulin formula.

    I have heard of dawn syndrome and I wonder if this is like a long, drawn out version of it. If any of this suggest something to people, I would love some more ideas as to what might be causing this and what I might do about addressing the cause. Thanks.

     
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    Old 02-13-2008, 04:31 AM   #2
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    Re: Insulin resistance curve through the day, any ideas?

    Everybody is different. That is why a pump is so fantastic. I'm quite different from you. I only have 3 basals. One is a bit higher between midnight and 6 am, then from 6 am to 2 pm I have a low basal, and then one in between from 2 pm to midnight again.

    Just think, you are your own little science project to see exactly what is going on. Enjoy your pump and keep up the good work.

    Cora
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    Old 02-13-2008, 03:02 PM   #3
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    Re: Insulin resistance curve through the day, any ideas?

    Subbster,
    Cora said it...CONGRATULATIONS! You are beginning to learn the amazing benefits of having a pump.

    I have three basal rates, too... 0.7 from 9:30 AM to 10:30 PM, .95 from 10:30 PM to 3:00 AM, and then 1.1 from 3:00 AM to 9:30 AM to counteract dawn phenom.

    Have you worked with the dual wave feature yet for meals?

    Ruth

     
    Old 02-14-2008, 01:37 PM   #4
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    Re: Insulin resistance curve through the day, any ideas?

    Thanks for the replies. It is good to see what some other people have found with basal rates. I'd love to hear more. Nope, I havn't learnt the dual/square wave bolus feature yet, thanks that reminds me to go back to the educator for that. Pizza is one example of food I have blown out on every time, so looking forward to see if those features help there.

    I know that all basal requirements will be different, but both yours seem examples of more typical ones I've heard of, with more minor adjustment through the day. My daily range between 1.45 and 2.25 units/hour was too much for my doctor to take on board as acceptable, she thought the variance was quite unusual. I had to break from her advice to discover these correct values. So I guess my area of interest is, is she just conservative (but, she does do a lot of pump set ups, at the same time - you think she's see all sorts of scenarios) or am I really quite out of the ordinary and if so, why?

    Of course I'm happy the pump helps so much more with it, regardless. But keen to discover more about my body if it can help address the root of the problem. For example, if my insulin resistance is really quite significant, perhaps I could go on type 2 meds as well? This kind of question goes through my mind. Especially those days I have where things change again and my basal rates are completely innefective. This seems to happen at least once a fortnight.

     
    Old 02-14-2008, 02:14 PM   #5
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    Re: Insulin resistance curve through the day, any ideas?

    There is no "normal" value for pump settings. Each person is different and the range is extraordinary. I recently changed and I only have 2 basal rates. From midnight to 6 am I take 0.75 u/hr and the rest of the day it's 0.65 u/hr. I take one unit of insulin for 20g of carb, and my insulin sensitivity factor is 1 unit lowers me 4 mmol (72 mg for folks in the US).

    Don't try to shoot for any specific amount. You need to take what works for you. I know some folks on other boards that take anywhere from 2 - 4 units per hour as a basal and others that take at most 0.5 units per hour.

    As an aside, I wouldn't worry about T2 meds for the moment. Get the pump stuff sorted out. It sounds like you have the right plan - keep testing and figure out for yourself. I haven't spoken to a pump trainer in years because I know more about what is going on with me than anyone else.

    Cora
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    Old 02-14-2008, 02:21 PM   #6
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    Re: Insulin resistance curve through the day, any ideas?

    Quote:
    Originally Posted by subbster View Post
    .... 12 - 5am 1.60 u/hour
    5 - 8am 1.80 u/hour
    8 - 10am 1.95 u/hour
    10 - 2.30pm 2.25 u/hour
    2:30 - 5pm 1.45 u/hour
    10 - 12am 1.70 u/hour

    So broadly speaking I get an upwards curve increasing through midday then it suddenly drops right back at about 4pm, then high again in evening, a little lower for sleep. ... I have heard of dawn syndrome and I wonder if this is like a long, drawn out version of it. If any of this suggest something to people, I would love some more ideas as to what might be causing this and what I might do about addressing the cause. Thanks.
    It is not unusual for there to be a lot of variation in basal requirements. When I was trialling a pump, my basal rate varied between .25 and .95 units an hour. The only unusual thing about this profile is that the peak insulin requirement is in the middle of the day. For most people, the peak basal insulin requirement is from 3am-8am. The release of hormones during the night increases insulin resistance, which is why it is caused the Dawn Phenomenon.

    I don't know why your basal rate should be so high from from 10:00am - 2:30pm, but it wouldn't be the Dawn Phenomenon. The DP shuts down when you get out of bed. How have you worked out this profile? Distinguishing between the effects of basal and bolus insulin can be difficult. And the only way to accurately establish the basal rate is to skip meals.

    On the insulin resistance issue, there are a number of problems with insulin sensitizing drugs. Long term use can cause other health issues, and the effects can be inconsistent. I found this with metformin - it reduced my blood glucose levels, but it made estimating the right bolus amounts more difficult. I have found the old-fashioned approach works best. Exercise and losing weight improve insulin sensitivity a lot. Cardio exercise has a temporary effect, but reducing fat and increasing lean muscle mass provides permanent benefits.
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    Last edited by Mark1e; 02-14-2008 at 02:33 PM.

     
    Old 02-14-2008, 04:47 PM   #7
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    Re: Insulin resistance curve through the day, any ideas?

    Thanks for your coments.

    Yes, distinguishing this basal rate was only possible by experiments of repeated skipping meals and many many tests. Also a period of very small carbs meals to minimise the bolus effects. I discovered that I can eat very few carbs and have virtually no bolus for break and lunch and have a very normal and active day, yet my blood sugar can rise from 6 mml/l to 18 mml/l by 3pm. And if a large corrective bolus is taken after about 12pm and if I've gone above about 12 mml/l, it will often have little effect until about 5-6pm, at which time is will "hit" in a crashing low. Yep it is a mystery. I lead a relatively normal daily life.

    Unfortunately I have little fat to trim, however I will look into the lean muscle option for sure.

     
    Old 02-14-2008, 06:56 PM   #8
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    Re: Insulin resistance curve through the day, any ideas?

    Subbster,
    Were you diagnosed as a T1 or T2? Just curious.

    As for pizza...I think the dual wave was invented for just for pizza!!! Pizza is a very high carb, very high fat food, even if it's just plain cheese pizza. If you add meats onto it, it's even higher in fat. I don't have pizza with meats on it, and I dual wave my bolus over 4 1/2 hours, half up front and half over the 4 1/2 hours. I've pretty much been able to stay under 150 even after three slices of pizza! If you had meats on it, I'd stretch the dual-wave part out at least another hour. And some people give less up front, more over the wave, or vice-versa. You do have to experiment with it a bit to figure out what works right for your body. Also, it's hard to estimate the exact number of carbs in each slice. If you eat the same pizza each time, you'll eventually figure it out. Of course, this could take months, unless you're eating pizza a LOT! I generally don't eat it more than once every 3-4 months. I eat Chinese food more frequently, and find I have to dual-wave it, too, over about 2 to 2 1/2 hours, depending on what I'm eating.

    And what Cora said was spot-on...you have to do what works for YOU, and that may not necessarily be what your doctor thinks is right. They go more by averages, and you are obviously not average. My doctor is pretty good about "guessing" what I need, but I don't even ask him any more. I recently developed dawn phenom big time...I didn't call him, I just tested, figured it out, increased my 3-8 AM basals until my morning numbers got back into the range I wanted them to be, and then just told him at my next visit. He usually asks me anyway..."any change in basals? Insulin/carb ratio? Correction?" He know what most good endos know...and that is, that the patient knows more about his/her own body than anyone else!

    Ruth

     
    Old 02-15-2008, 03:04 AM   #9
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    Re: Insulin resistance curve through the day, any ideas?

    Hmm the dual wave for pizza sounds good, thanks for sharing your strategy. I'll get onto those dual waves soon. I've been type 1 for 16 years now, since I was 15. I only got onto a pump 2 months ago, it should have been earlier. Apart from Australian insurance and medical world in general being slower on the uptake of such things than the US/UK, my endo basically repeatedly lied to me about it not being of benefit and not suitable. Needless to say when I got the proper picture of the pump's maturity and usefulness by chance from a third party, my endo was flicked and I'm with a great doctor now who is up to date and, as you say, responsive to me efforts and knowledge about my diabetes.

    However while transitioning to the pump I've been handed over to this other "pump specialist" who was the one not prepared to endorse proper experimentation. And spent far too many words ignoring my observations and towing the "average" line which got me nowhere. Ah well, as you say it's up to ones self anyway.

    But, I still would like answers about my out-of-ordinary insulin resistance and whether they may be other conditions underlying it that can be tackled. Yes, I take the point all diabetics have different basal rates. But usually things seem to follow SOME common form, eg the dawn phenomena, being overweight, etc. Perhaps there is no explanation for my variation, true. I am certainly happy to "live" with my IR, if nothing can be done. But that shouldn't stop me exploring the issue. I certainly know that each and every type 1 I have met has found bg control many times easier than I do. And that, I can promise you is not due to lack of action or effort!

    I also wonder if there are further tests I can take to discover the reasons or further clues for my IR? The doctors have simply never been prepared to discuss IR in further detail (that is until the pump, then low and behold! they acknowledge it exists and can be properly considered) so some basic education of how IR works at a metabolic level would be appreciated!

    Thanks again for your posts.

    Last edited by subbster; 02-15-2008 at 03:06 AM.

     
    Old 02-15-2008, 12:17 PM   #10
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    Re: Insulin resistance curve through the day, any ideas?

    Quote:
    Originally Posted by subbster View Post
    .... I still would like answers about my out-of-ordinary insulin resistance and whether they may be other conditions underlying it that can be tackled. ....
    While an understanding of what affects basal insulin requirements would be interesting, this needs to be seen in context. The basal insulin reguirement, as expressed in hourly basal rates required to keep blood glucose stable, is not simply a reflection of insulin resistance. The system is a lot more complex than that. Insulin requirements are the end-result of numerous interdependent processes and systems. Insulin resistance is just one of them.

    The counter-regulatory system, which regulates blood glucose levels, is complex. The main hormones involved are insulin, glucagon and amylin. Stress hormones, cortisol and adrenalin are also involved in that they affect glucagon levels. Sex hormones, testosterone and estrogen, also have a role in the transport of glucose. And then there are numerous other phisiological processes, like metabolic rate and exercise.

    The net effect of all this is your basal insulin requirement. Trying to balance all this out with injection/infusion of insulin is a bit like trying to fine tune a racing car when your only tool is a torque wrench. Having said that, the pump is the best delivery mechanism available. You are doing the right thing - experimenting to find out what works best for you. There are lots of variables involved, and the best you can do is focus on repeating patterns.
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    Old 02-15-2008, 09:50 PM   #11
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    Re: Insulin resistance curve through the day, any ideas?

    Thanks for your knowledge and perspective. As well as work on my basal requirements which is "the daily grind" for me anyway, I believe it is in my best interest to research into other factors that affect my dodgy insulin resistance. Expand my paltry mechanics toolbox, if you will. Of course I'm aware of diet, exercise and stress on a day to day level, I've tried to control type 1 for 16 years. But further info on the physiology of blood sugars is where I am looking. I've noticed a tendency in doctors and other people to say "oh, type 1, manage your blood sugars and that's good enough/all you can hope for". I beg to differ in this opinion. Apart from no islets of Langerhans it's another body which can have all sorts of ailments and other insulin resistance factors as well. Thus this thread in the first place.

    Thanks for the info on cortisol and adrenalin. Anyone have clues as to tests to determine if these are unduly affecting insulin absorption? I guess this is getting into "normal people's hypoglycemia syndrome" territory here. I will research into what is done in that case. Any further ideas really appreciated.

     
    Old 02-16-2008, 07:45 AM   #12
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    Re: Insulin resistance curve through the day, any ideas?

    Mark,
    Just wanted to tell you that I love your posts...I learn something new from nearly every one of them!

    Ruth

     
    Old 02-16-2008, 09:33 AM   #13
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    Re: Insulin resistance curve through the day, any ideas?

    Quote:
    Originally Posted by SamQKitty View Post
    Mark,
    Just wanted to tell you that I love your posts...I learn something new from nearly every one of them!

    Ruth
    Ditto.

    Cora
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