Change in Carb/Insulin Ratios, but basal remains the same

I am 22 years old and was diagnosed with type 1 diabetes about 8 months ago.  Things have been going relatively well so far, my insulin needs have been pretty straight forward and I started on the minimed pump about 4 months ago.  Recently, just these past few days, i have been having high blood sugars throughout the day despite waking up with normal blood sugars and maintaining normal levels throughout the night.  I've been gradually decreasing my carb/insulin ratio and am now taking twice as much insulin as i normally would to cover my carbs.  I recently met with my endo to discuss this, but he didn't have an explanation for me.  Has anyone ever experienced this or could give me an explanation for this?  It would make more sense to me if my basal rate needed adjustments too, but it doesn't so I am lost.  I've also noticed that my insulin sensitivity has changed in correcting high blood sugars.  I need more insulin than before.

[JDRF-Team-wak]

I am not a physician, but mom of type 1 diabetic on a minimed pump.
What you are describing sounds like it could be caused by several things:
One thing could be is the end of the honeymoon period.  When most people are newly diagnosed their pancreas still is producing some insulin, this can happen on and off for anywhere from a few days to a couple of years. When this happens the bodies need for insulin changes. With our daughter this happens anytime  she finished a growth spurt her numbers go out of wacky and we windup  adjusting her ratios and basal, we usually wait till we have 3-4 consistent days before we make a change, as stress, ill ness, types of carbohydrates and food can causes the weird numbers.

Another thing that it could be is if you are getting ill, your numbers can rise when your body is not well. This ca is o to menstrual cycle, stress. We have found that if our daughter is in the sun (even slight sunburn) and heat to much her numbers rise.

As for your endo not having an explaiation, i might suggest getting a second opinion.

[snowbunnyy]

Thanks for the info, I have considered that maybe my "honeymoon phase" was ending or perhaps I was ill, but wouldn't that mean that I'd also need to increase my basal rate?  I'm only taking .2 un insulin an hour, but my insulin to carb ratio is 1:5, which just doesn't seem right to me.  (It was 1:10 before).  I wish i could get a second opinion, but I dont know who else to go to if my endo doesn't have an explanation.  I've been reading about hypothyroidism online and I may have a few of the classic symptoms.  Does slowing down your metabolism increase or decrease insulin needs or does it affect it at all?

[Markie]

Another effect of of the onset of T1 diabetes is deterioration of the counter-regulatory system. One result of this is that your liver continues to release glucose into your bloodstream, even after you have eaten. The result is that you require more insulin per gram of carbs. So, while your basal insuli requirement may remain unchanged, you need to bolus more before meals.

Dealing with this effect has been an ongoing struggle for me. My insulin:carb ratio is 1:3 in the morning. I am not insulin resistant (total daily dose 36 units). So I am looking forward to trying Symlin (the amylin analogue) when it becomes available here.

Cheers,

Mark

[snowbunnyy]

Hello Mark,
I hope that is the case with me and not thyroid issues.  I wonder why my endo did not mention this to me at my apt with him.  Was your insulin/carb ratio always so low?  What is it like for the rest of the day?  I'm concerned because I've been told that insulin intake is correlated with weight gain and now that I'm taking twice as much insulin, weight gain seems inevitable.

[snowbunnyy]

Hi LRS,
Yes I am female and my insulin needs have been pretty straight forward so far as I haven't needed to make any changes due to my menstrual cycle and have been able to maintain stable blood sugars with a single basal rate.  I periodically do 3 am checks on my basal and they are just about always normal as are my morning blood sugars (doesn't seem like I have much of a dawn effect).  I've never really had a reason to question my insulin dosages until now.  I am using Novolog with my pump, which I've been told is supposed to work for about 4 hours, although it doesn't seem to have much of an effect on my blood sugars after 3 hours.  Which pump are you on?  I usually rotate my injection sites every 4 days, sometimes more if I am lazy or forget to, but haven't had any problems in that area.  Do you know anything about thyroid disease?  I've read that hypothyroidism is more common in diabetic females, but I can't find any info on what effect it would have on your blood sugars.  All I can gather is that it slows down your metabolism and causes irregular menstrual cycles(i started mine 2-2.5 weeks early this month).  My endo suspected a thryoid problem when i told him about my early period, but didn't sound too concerned after checking my heart rate and did not have much to say about my recent unexplainable blood sugars so im hoping this isn't the case, but then again I never would have thought I'd be diabetic.

[JDRF-Team-LRS]

Hi Snowbunny,
I'm also a pumper -- about 9 years of experience and many more than that as a DMer.

If you're female, you might also be experiencing the normal fluctuations due to hormonal cycles.  For many women, our need for insulin increases during the PMS days (could be 3 days, could be 7) and then also drops during MS days.

I used to need about 20% more insulin during PMS and now I notice that some months I need 40% more.  (I'm very close to menopause now, so my hormones may be as volatile as in adolescence).  I mostly make the adjustment on the basal, however.

Other pumping possibliities come to mind.  Are you rotating your sites well and changing the tubing & sets regularly?  These things would likely affect basal as well, but with all that additional bolusing, you are actually creating greater "tails," too, which may be providing additional basal.  Which insulin do you use in your pump?  The very fast insulins have a duration of about 5 hours in most folks.  Not all pumps allow you to program them for that reality however (it's a known issue that's getting attention).  Cozmo pump does allow that duration to be programmed and others will likely follow suit in their upgrades.

Thyroid also comes to mind ...  Do you have a pump trainer?  Is your basal .2 per hour ALL DAY LONG?  It's unusual that the rate is unchanged during the 24 hour day.  Most folks have a cycles within the day and often need more in the early morning (dawn effect) and other times of the day.

Hope that some of this is helpful.  You've asked good questions & perhaps other pumpers'll chime in.

[JDRF-Team-wak]

snowbunny- go to another endo,if your insurance company or your regular physicanshould be able  to help you locate another endocronologist.  THe endo should be checking yout thyroid on a regular basis at least 2 times a year.

as for our basal rate- do you have the same rate all day? yo might need to adjust the rate at differenttimes of the day. My daughter has 6 different rates from .30 -.65 depending on the  time of day.   some teenagers and women i know hwave seprate reates for certain times of the month and weekends.

Our daughter also has several carb ratios depending on the time of day. These are things that a good endo canhelp you with this. there is a book that came with your pump that tells you haw to check your rates and your ratios.  we found it very helpful.

[JDRF - Team- SS]

Hello snowbunnyy,

I am a mother of a 10 yr old son who is a diabetic.  He was diagnosed at age 3.

He started on the pump a little over 10 months ago and we love it!

I second the comment that was made about finding a new endocrinologist.  Your endo should be there to help with changes or at least have a pump specialist to refer you to.  You should have the freedom to make adjustments on your own, however, your doc or pump specialist should be there for you when you need him/her.

I was told that the way to know if you should change the insulin to carb ratio would be to do a 2 hour reminder after each meal - do this for 3 days or so without eating any snacks in bewteeen on those days (unless low, of course).  At the 2 hour mark after eating a meal, you need to see how much higher your BG goes.  It is expected to be higher than your pre-meal reading, but if it is too much of a jump, then you would change the insulin to carb ratio.

A way to test your basal which I can honestly say we have not done for our son would be to wake up and test your BG and erite it down, do not eat breakfast and then when it would be time for lunch test to see the difference in BG readings and if the reading is 30-40 points higher or lower your basal is good.  Now keep in mind that this is just what I have been told.

I have done all of the changes to the pump settings, including target, sensitivity, basal (we have several throughout the day) and insulin to carb ratios on my own, but I do not have a problem requesting help or advice from my son's endo.

My son's A1C went from 7.9 to 7.0 and we were very pleased!!!

Get that second opinion or find out if yor endo has a pump specialist or trainer you can see.

Take care!!

[galzee]

Hi Snowbunnyy!  I'm the mom of a 17 year old who was diagnosed at the age of 21 months and who's had a pump for almost three years now.  Just one quick thing I wanted to mention to you regarding how often you're changing your site.  My daughter was trained to change every three days and even then, sometimes by the third day, she has unexplained high's.  Just a thought & an easy fix if this is what's causing your elevated bg's.  Good luck to you!

[JDRF Team SGG]

I am a long-time type 1 female. The two things that immediately come to mind are both issues that have been already touched on here. 1) If your honeymoon phase is ending, then I could see a scenario that did not involve your basal rate -- if your pancreas was already damaged enough that it was ONLY spurting out some insulin when stimulated by eating carbs, then only your insulin/carb rate would be affected by the end of the honeymoon phase. Makes sense if this is where you were in the destruction of the insulin-producing cells. 2) Hormones can make a huge difference in glucose levels for several days at the end of your cycle as hormones that also act as insulin-blockers increase in your body. When they dissipate a few days later, your glucose levels may drop tremendously, so do keep close watch in case this is what is happening to you. Even if it was not happening before, your body may be healthier now that you are on insulin, and your cycle may be becoming more regular.

Either of those two things could cause changes, although I would suspect that hormones would affect your basal rate as well as your insulin/carb ratio. I vote for the end of the honeymoon phase being the culprit. Yet one other possibility is allergies... some people find that when exposed to things that they are allergic to, their glucose levels rise dramatically, and if the allergies are due to pollens, this problem goes away when they stay inside. This could affect daytime glucose levels and not night levels if you are outside breathing pollens during the day. This is only an issue for allergic folks, though.