An older newbie

[RichardM75]

Hi, I’m Richard
I’m an active 75 year old (or was until last year) and have been Type 2 for about 15 years, well under control on Metformin and Sitagliptin, diet and exercise.
Then last year I had several emergency admissions to hospital with infections, giving me Rigors (fever) attacks. After 3 ERCP procedures clearing out my dilated and blocked bile duct and fitting stents, they also discovered that my Pancreas had stopped producing either Insulin or digestive enzymes. After the first ERCP I also got Pancreatitis, which I wouldn’t wish on anyone.
I am now awaiting removal of my gallbladder.

I have been rediagnosed as Type 3c because of the pancreatitis and started on insulin injections, which I clearly haven’t refined yet. I’m on 12 units of slow release Abasaglar daily and 4 units of Novarapid before each meal.
I feel I need to play about with these because I shoot up to high teens blood glucose after what is not a heavy breakfast (cereal, a banana and pomegranate juice to swallow my many pills) and the readings gradually come down over the day to 9 or 10. Other meals are not so problematic.
I’m happy-ish with readings towards the end of the day, but they’re still too high.
I earned my corn as a self employed Statistician, specialising in Statistical Process Control within manufacturing industry, so am really happy with studying graphs and looking for special cause variation. What is happening in mid morning is “special cause variation”
I’d love to hear from others who have been in a similar position, and what they did to get back to constant readings of 5 to 7, which I had for well over 10 years.

Just to add some trivia, I am still a Man Utd supporter, my local team, despite current travails, but remember the good times. I also support Wigan Warriors and am looking forward to Super League starting again this week.

Richard

 

[Leadinglights]

I know little about the effect of insulins you are taking but you say not a heavy breakfast but it is all carbs so it maybe that your dose of breakfast insulin is not sufficient to cope with such a heavy carb meal. Cereal, banana and juice are all high carb.
Many people who are 3c also take Creon.
There are quite a few 3c folk on here so hopefully they will offer some words of wisdom.
Welcome to the forum. It is annoying that something that you have managed well suddenly gets turned on it's head.

 

[RichardM75]

Thanks,
Yes, I take Creon. I also read that Pomegranate Juice was much better than, say, orange juice. I guess I need to change my breakfast or increase the Novarapid, or a mix.

 

[ianf0ster]

There does appear to be some possible evidence that pomegranate juice is better than most juices. On a scale of terrible to not too bad it's not too bad - it has a GI of 53.
Juice is always worse than whole fruit. Berries , kiwi fruit and rhubarb are good forms of fruit, low carb and low GI.

 

[nonethewiser]

Hi Richard, also Creon user here as was diagnosed with EPI 4 years ago, started on low dose then increased it only to reduce it again, take 4 for lighter meals 5 for normal meals, if meal is heavy on protein & fat then more is required. Also take calcium tab 2x daily with vit k2 mk7.

Last 40 years of type 1 just had traditional porridge for breakfast with plain yogurt, no fruit juice or toast just mug of tea, find oats keep bg in single figures & fuels me to lunch, take insulin 15 mins before eating to get head start on digestion.

 

[RichardM75]

Thanks, but I have loathed and detested porridge since I can remember.
But this is all useful information.

 

[ianf0ster]

Porridge isn't a healthy breakfast for most Type 2 diabetics, because oats are grains they spike Blood Glucose in most of us.
Greek yogurt with berries and/or seeds and/or nuts is quite popular and better tan porridge for those who don't like/can't eat eggs for breakfast - boiled, poached, scrambled or mushroom/ham omelette but no toast/bread!

 

[trophywench]

I'm with you on the porridge! tastes disgusting to me - and FWIW I feel exactly to same about peanuts in their natural state. Roasted and salted, well they're OK occasionally in very small quantities but they can still keep em as far as I'm concerned. Proper nuts, however they're served are 100% FINE ....

Doesn't matter at all what category of diabetes we happen to have - for that, the only foodstuff we cannot easily cope with any more, is carbohydrate, whatever form it happens to arrive in to consume.

Because our bodies need insulin in order to allow glucose into the cells and function, unless we get the right amount of insulin constantly, we can't properly adjust the extra insulin we need for the food we eat. Your body did not enter the swimming pool at the shallow end - it's been chucked straight into the deep end - which is very deep indeed cos it has an Olympic height high diving board. In 'normal' Type 1 diabetes the pancreas might continue to produce erratic spurts of insulin for an unspecified length of time, hence that's one of the reasons they are conservative on starting doses - the other is because it can cause more problems to reduce BG that's been too high for too long, suddenly.

As long as you don't fall into that latter category I would highly recommend you to embark on 'basal testing' to see exactly how and when that 12u of Abasaglar is affecting your body and see where it's lacking/too much and then taking steps to adjust the dose - either in amount or the timing thereof to try and get it as 'just right' as you can. Once you do that, then you can get your insulin to carb and correction rates nailed down for the Novorapid. Until you do the former, you can't rely on the latter cos you can't tell if some of the Novo is propping up the Abas sometimes, or vice versa.

Here's how to test https://www.mysugr.com/en/blog/basal-rate-testing/

 

[RichardM75]

Thanks Jenny,
The basal rate tesing sounds interesting. I’ve just had a quick look. I know from my statistical involvement with many different process the value of data collecting and analysis and making small changes to measure the effect and that’s what I meant by playing around with the input variables as well as the measuring variables. In hospital the nurses were regularly measuring my BS as was I with my sensor. The difference was fairly constant at about 10%. Theirs was always lower than mine, so I need to be aware of this. A measure from my sensor of 10, really means a value of 9.
I will pursue this and in fact today, on advice from a friend who has been type 1 for 40 years, I’m switching from a morning injection of slow release to evening. I didn’t see the point of a slow release and a Novarapid together in the morning - how do you know which one is doing what.
I still need to amend my diet, I think.
Richard

 

[nonethewiser]

Thanks, but I have loathed and detested porridge since I can remember.
But this is all useful information.

Suppose it's like marmite.

Word of advice, maybe just ignore suggestions above to have low or no carb breakfast as there's real risk of you going hypo taking 4u of novorapid, if in doubt speak with specialist nurse dr or whoever' looks after your diabetes.

 

[everydayupsanddowns]

I will pursue this and in fact today, on advice from a friend who has been type 1 for 40 years, I’m switching from a morning injection of slow release to evening. I didn’t see the point of a slow release and a Novarapid together in the morning - how do you know which one is doing what.

I think this is why @trophywench recommended basal testing to you. Absalgar is a glargine insulin, and I wonder if (like the Lantus I used to take) it might have a mini peak of action at around 5 hours? Interestingly after decades of taking Lantus at night, and having had quite a few overnight hypos on occasions, I found my best fit with glargine was to take it at breakfast time. So that the mini peak I experienced happened during the day, rather than at 3am amd coinciding with a natural dip in hormones and naturally lower BG.

The two insulins you are taking are performing different functions. The Absalgar is covering stored glucose naturally trickled out by the liver 24 hours a day in the background. While the NovoRapid, which only lasts 5ish hours is meant to cover the rise you get from carbohydrate in meals, and then disappear.

If your basal dose is too low, then some of your meal doses will be needed to ‘prop it up’ to prevent glucose levels rising. Conversely, if your basal dose is too high, your BG levels will always be on a downward trajectory rather than level, and your meal doses (and corrections) may appear to be acting too strongly.

Getting your basal dose as spot-on as you can get it will help your other doses work properly. 🙂

And eventually your meal doses need to be adjusted to ‘match’ the amount of carbohydrate in each of your meals. So if you are keeping to fixed doses for now and your levels after breakfast are too high, then you might want to incrementally reduce the total carbohydrate content of breakfast (smaller portion of cereal, or ditch the banana, smaller glass of juice or alternative).

Breakfast can be especially tricky, because some people get a pronounced ‘liver dump’ around dawn, or after getting out of bed (sometimes called dawn phenomenon or foot on the floor).

Your stats and analytical background and pattern-spotting will stand you in good stead in the weeks and months ahead!

 

[RichardM75]

I think this is why @trophywench recommended basal testing to you. Absalgar is a glargine insulin, and I wonder if (like the Lantus I used to take) it might have a mini peak of action at around 5 hours? Interestingly after decades of taking Lantus at night, and having had quite a few overnight hypos on occasions, I found my best fit with glargine was to take it at breakfast time. So that the mini peak I experienced happened during the day, rather than at 3am amd coinciding with a natural dip in hormones and naturally lower BG.

The two insulins you are taking are performing different functions. The Absalgar is covering stored glucose naturally trickled out by the liver 24 hours a day in the background. While the NovoRapid, which only lasts 5ish hours is meant to cover the rise you get from carbohydrate in meals, and then disappear.

If your basal dose is too low, then some of your meal doses will be needed to ‘prop it up’ to prevent glucose levels rising. Conversely, if your basal dose is too high, your BG levels will always be on a downward trajectory rather than level, and your meal doses (and corrections) may appear to be acting too strongly.

Getting your basal dose as spot-on as you can get it will help your other doses work properly. 🙂

And eventually your meal doses need to be adjusted to ‘match’ the amount of carbohydrate in each of your meals. So if you are keeping to fixed doses for now and your levels after breakfast are too high, then you might want to incrementally reduce the total carbohydrate content of breakfast (smaller portion of cereal, or ditch the banana, smaller glass of juice or alternative).

Breakfast can be especially tricky, because some people get a pronounced ‘liver dump’ around dawn, or after getting out of bed (sometimes called dawn phenomenon or foot on the floor).

Your stats and analytical background and pattern-spotting will stand you in good stead in the weeks and months ahead!

Thanks
I was below 10 all day yesterday having taken a lower amount of cereal (Sultana Bran) and added a bit of sugar free Granola, but keeping the banana. I was advised some time ago by my GP to have a banana a day, as there is history of Colon Cancer in the family and a banana (presumably the potassium) would help.
Re breakfast, I’m only changing one variable at a time, so I know which is causing the jump.
10 is, I know, still too high but I’ll work that through.
I’m still to get to Basal Rate testing, but one thing at a time and I want to understand the process better.
Richard

 

[Leadinglights]

Thanks
I was below 10 all day yesterday having taken a lower amount of cereal (Sultana Bran) and added a bit of sugar free Granola, but keeping the banana. I was advised some time ago by my GP to have a banana a day, as there is history of Colon Cancer in the family and a banana (presumably the potassium) would help.
Re breakfast, I’m only changing one variable at a time, so I know which is causing the jump.
10 is, I know, still too high but I’ll work that through.
I’m still to get to Basal Rate testing, but one thing at a time and I want to understand the process better.
Richard

That is still sounding like quite a high carb breakfast, are you actually weighing your portions of the various cereals and the banana so you can get a comparison of the difference in carbs, even low sugar granola has quite a lot of carbs. Eye balling can be deceptive in actually how much you are having.

 

[everydayupsanddowns]

That is still sounding like quite a high carb breakfast, are you actually weighing your portions of the various cereals and the banana so you can get a comparison of the difference in carbs, even low sugar granola has quite a lot of carbs. Eye balling can be deceptive in actually how much you are having.

Richard will have more liberty with breakfast carbohydrates because of the rapid acting insulin he can use, so cereal and fruit should still be doable with a little experimentation on dose and timing - though some people on insulin find cereals trickier and ‘spikier’ than others 🙂

 

[Leadinglights]

Richard will have more liberty with breakfast carbohydrates because of the rapid acting insulin he can use, so cereal and fruit should still be doable with a little experimentation on dose and timing - though some people on insulin find cereals trickier and ‘spikier’ than others 🙂

It just sounded as if he had substituted something high carb for something potentially equally high carb and I was just suggesting he made a good record of what he was having.

 

[trophywench]

Type 1 frequently does not manifest with the 'metabolic syndrome' effects which are just as frequently common in Type 2.

When they do Richard's 'armful of blood' tests one of the many things they check under the 'U&E' heading, is serum potassium so as long as that's still in normal range and other things are too - he'll most likely be fine. As long as his body and (exogenous) insulin can cope with the carbs of course! Sultana Bran is a bugger - even if you pick all the sultanas out of your serving before you eat it - cos they are high carb anyway for starters and also constantly transfer their sugar to the bran flakes in the packet with them, every time the packet is moved.

 

[RichardM75]

So I went from cereal etc for breakfast to sugar free yoghurt and berries this morning and my bs has been haywire all day. The change in breakfast made little difference to the morning jump. Otherwise my intake was much as usual. It’s just after 7pm and I’m now just about getting back to where I’ve been over the previous couple of weeks.
I’m beginning to think an obsession with numbers is leading me down a false track, instead of listening to my body. Thing is, I’ve felt fine throughout all this messing about.
Richard

 

[Pumper_Sue]

Thanks,
Yes, I take Creon. I also read that Pomegranate Juice was much better than, say, orange juice. I guess I need to change my breakfast or increase the Novarapid, or a mix.

Hello Richard, nice to meet you and welcome to the forum.
Cereal, banana and juice in one hit is one heck of a lot of carbs so suspect your insulin just isn't enough to cover it.
I'm sure you can work out carbs and insulin ratios, so count the amount of carbs in your breakfast and work out starting with 1 unit for every 10 gms of carbs eaten. Use those figures as a starting point and change the ratio as needed. Obviously making sure you have plenty of JB's handy in case you go low whilst sorting things out.

PS doing a basal test would be more than beneficial as once that's sorted carb ratios will follow very quickly.

 

[Proud to be erratic]

Thanks Jenny,
The basal rate tesing sounds interesting. I’ve just had a quick look. I know from my statistical involvement with many different process the value of data collecting and analysis and making small changes to measure the effect and that’s what I meant by playing around with the input variables as well as the measuring variables. In hospital the nurses were regularly measuring my BS as was I with my sensor. The difference was fairly constant at about 10%. Theirs was always lower than mine, so I need to be aware of this. A measure from my sensor of 10, really means a value of 9.
I will pursue this and in fact today, on advice from a friend who has been type 1 for 40 years, I’m switching from a morning injection of slow release to evening. I didn’t see the point of a slow release and a Novarapid together in the morning - how do you know which one is doing what.
I still need to amend my diet, I think.
Richard

Hi Richard, welcome to this forum.

I suspect you will know a lot more about this than I did 2 yrs ago, or still do. 15ish years of well managed T2 along with your keenness to grapple with your new status statistically will be a great help to you.

I wholeheartedly agree with the others who've talked about basal rate testing first. Until you have confidence in that, everything else can be misled by incorrect basal dosing.

You mention needing to adjust for your sensor being 1 point higher than actual. This will only apply for that sensor over its 14 day duration and might not be consistent over those 14 days. Almost like a clock pendulum, I find my sensors alternate between being high, then low and the differential can be as much as 2.5 points each way, allowing for being in a steady state and neither rising or falling. My last sensor started well high and after 8 days was well low, before I had to discard it and fit a new sensor; Abbott are replacing it - but that doesn't change the series of false readings and distorted reports on LibreLink. Have you spent time understanding the limitations of Libre 2 sensors? In case you haven't there is a lot on this site, just search (top right) for Libre 2. Libre 2 is great for trend spotting, but not so great for accuracy, particularly at low and high range.

I'm not clear if you are accurately carb counting or more loosely estimating. From my own experience (and everything I've read and heard from medical specialists) it is fairly inevitable that your diabetes will be erratic, with rapid rises and equally rapid lows. With little or no pancreatic functions you have to be sure that carbs, even when rigorously counted, are all being fully digested and absorbed into your blood stream. I suffered malabsorption for c.21 months, which took a lot of gastroenterologist and dietician time to resolve. Slightly irritatingly, as successive tests didn't reveal a problem I had to be pleasantly noisy and persistent in getting "heard" and getting further investigation and treatment.

Presumably your pancreatitis doesn't allow production of any of the 4 important pancreatic hormones for metabolism. With no glucagon being produced, then instructions to your liver to release glucose into your blood stream will come from elsewhere in your body; but in a much more unpredictable way. Your growth hormone will be small (insignificant) and infrequent; that leaves adrenaline - which is released as a consequence of events (but not necessarily metabolism) - plus cortisol and epinephrine. The effects of these latter two hormones don't seem to be well documented for our age group, but they, like adrenaline, can be erratic and not particularly related to metabolism - just daily living, which your basal insulin is intended to manage. Another probable missing pancreatic hormone is amylin, which helps balance the activities of glucagon and insulin. So now you have to do that "balancing". Since you can only subdue surplus insulin by taking on board more glucose (whereas a fully functioning pancreas does this very quickly and automatically) BG management now depends on how good your "balancing" actions are. The reality is that even taking the highest glycaemic carbs, such as glucose tablets or jelly babies, the outcome takes a little time and certainly isn't instant. But high GI carbs dissipate quickly and need to be followed up with other carbs. All of this takes time to learn and master, I think.

But there are so many other variables in this. Glycaemic Index and Glycaemic load are much more of an art rather than a science. Stress is a known factor affecting BG, but not quantifiable - just trial and error response, after the event; stress comes from worries, emotions and medical issues. You almost certainly have those in abundance.

I'm fortunate enough to have an android phone and thus been able to install the Diabox app, which provides me with Continuous Glucose Monitoring (CGM) rather than the Flash monitoring that comes from scanning Libre 2. It is free and uses the signals generated by Libre 2 to provide me with continuous readings using Diabox's own algorithm. After 12 months just finger pricking I found Libre 2 a big improvement in helping me manage my BG. But the real game changer for me has been having CGM. Now I can monitor my behaviour minute by minute (if needed, but usually auto updating every 5 mins). I can start a meal, see how the carb intake is affecting my BG and adjust whether I eat the low GI food on my plate or the high GI food, according to how my BG is responding. It is a time consuming process, but effective when I do it rigorously. Now I very rarely go hypo; I have lots of false low glucose events from Libre 2 reading inaccurately. But from Diabox alarms I can usually intercept a prospective low before it becomes a hypo and use a mixture of medium or high GI carbs to slow down a falling BG and quietly turn it into a rising trend.

What Libre 2 and Diabox do not do is explain why my BG changes so quickly or so apparently erratically. That feels like a complete mystery more often than not and understanding "why" is a different challenge!

I hope some of this adds to your "food for thought". Are you aware of the recent study "42 Factors that Affect Blood Glucose"? If not just Google that title.

Good luck.

 

[RichardM75]

Thanks for all your advice.
I’ve got all my readings down below 10 without making too many changes and without taking too much (what’s too much ?) insulin. Mind you I haven’t had any chocolate for weeks, but I am having a not so wee dram or a glass of Italian red every now and then.
I’m not at the smug stage yet, because I know I need to get down to a regular 5 - 8.