My first suggestion would be to adjust his basal rate down some. I've found that when I'm in a heavier training cycle my basal will decrease between 10% and 20% of what my less heavy cycles are. For example, I take Lantus injections and over the winter when I'm training lightly I take 25 units. Now, I'm down to 22 units, and will probably end up around 20 units in another month or so. It doesn't seem to be an instantaneous adjustment for me (as in: oh hey, now I'm training 12 hrs/week as opposed to 5, I'll take 20% off my basal). It seems to be more of a stepwise gradual thing. So, if he started swimming 4x/week a few months ago, I wouldn't be surprised if you're seeing the effects on glucose right now.

If I don't adjust my basal, I tend to run into situations similar to your son's where I'll have a very difficult time keeping my levels from going hypo.

That being said. Sometimes it just doesn't make sense. There are frustrating times where you just throw your hands up in the air, check every 30-45 minutes for a few hours, and watch for things to stabilize. But, a number of times that I've felt frustrated (meaning my glucose readings weren't responding to bolus injections the way I was expecting them to), adjusting my basal has really helped me out.

There are quite a few diabetics on here, you could read through this thread to see what a lot of other people do, and I'm sure others will chime in here also (http://forum.slowtwitch.com/..._reply;so=ASC;mh=25;)

Feel free to PM me if you have any other questions.

Sounds to me like his basil is off. For larger training loads for me >15hrs a week I need to reduce my basil significantly and my insulin sensitivity increases, 10-15hrs a week I dose 1 unit per 16 grams of carbs, as I go over 15hrs I will dose 1 unit per 20 grams and after several weeks of >15hrs I will go as low as 1 unit per 30 grams. My basil rate will be reduced as much as 50% at different times.

Be patient it takes time to figure this out. You are doing the right thing by testing a lot and not over correcting. Im not a doctor but I have been living with Type 1 for 30 years. Talk to your endo about his basil and activity! Good luck and feel free to PM me if you want to know more specifics about how I go about this!

We've been messing around with his basal rate but have run into somewhat conflicting positions, which may not be conflicting at all just misinterpreted and we are going the wrong way.

About 4-5 months ago he started to get a really strong Dawn phenomenon rise. He would go to bed at 100-150 even be fine at a night check @10-11pm but would then end up being 250-400 in the AM. The doc said we should increase his basal which we did. However at the same time he started going low during the day and more easily with exercise.

I'm wondering if we are going the wrong way with the basil, up rather then down, and that the dawn effect is partially due to him going low in the early hours of the morning.

Thankfully he's really good at recognizing his lows. Can't imagine those poor parents who have kids that don't feel it.

~Matt

I think you are both confirming what I've been suspecting and we will call the doc and see what he says.

This week with the added activity, running for several hours a day combined with the swimming, appears to have exposed what we may have been running into for the last couple months. He was low again at school this AM and I underdosed his humalog for breakfast.

Be patient it takes time to figure this out.

He was diagnosed ~2.5 years ago and I'm not sure we have figured much of anything out :-) I have a close friend that is a diabetic and he has promised to come over to help us keep our sanity once the kid starts to go thru puberty. He said he was completely unpredictable for a few years.

~Matt

Quote:

About 4-5 months ago he started to get a really strong Dawn phenomenon rise. He would go to bed at 100-150 even be fine at a night check @10-11pm but would then end up being 250-400 in the AM. The doc said we should increase his basal which we did. However at the same time he started going low during the day and more easily with exercise.

I wouldn't be surprised at all if you had figured it out with a higher basal 4-5 months ago, and now you need to adjust down. Especially since it sounds like activity has changed.

I personally haven't ever experienced dawn phenom. My body seems to demand a pretty constant dose of basal insulin over a 24-hr period. If he was diagnosed ~2.5 years ago. I'm assuming he's on a pump? If so, I believe it's possible to have your basal rate change throughout the day. You might want to look into that. I personally haven't tried the pump yet because I've had great success with injections and I'm living by the motto of "if it ain't broke don't fix it". If I start to have trouble, I'll probably switch over to the pump (which my wife wants me to do 3 years ago).

If he was diagnosed ~2.5 years ago. I'm assuming he's on a pump?

No pump, injections. He's had very good A1C's so the doc doesn't want to mess with "What's working", similar to you. I'm also not sure how well he would deal with something being attached to him all the time. We did a continuous glucose monitor for a while and he did not like it at all.

I'm hoping that with in a couple years they will have an "All in one" unit that has a CGM/Pump and wireless data transfer. Seems they are close but not there yet. Will help with us being able to sleep knowing that if he goes low while sleeping and alarm will go off :-)

~Matt

As some have mentioned, you should look into both the insulin pump and a continuous glucose monitoring system. If he tries an insulin pump, I strongly recommend the Animas pump as it is waterproof and therefore he can wear it while he is swimming. I combine the Animas pump with Dexcom's G4 CGM and it is really nice.

The pump lets you set different basal rates by the quarter hour, so if he is consistently high in the morning, you just change your basal rate starting at 4:00 AM or whatever and you don't have to worry about it impacting his middle of the day readings. The CGM is a tool that I couldn't imagine a new diabetic (especially a child) living without. Why test every couple of hours when your numbers can change drastically in that time? It is nice to see a graph of what is happening and even though it is a little behind the actual numbers, you can take more insulin or decrease your basal rate before you get to a very high or low reading.

There is some downside but, in my opinion, the pros are far greater than the cons.

We did try the CGM and and for the reasons you suggested. Whether because of the unit itself or some other reason we had a lot of problems with it. It dropped readings pretty regularly and three out of the four nights we had it all night long, which was the data we were really looking for. They also had it covered over with a significant amount of tape and that drove the kid nuts. I think he reacted to the adhesive or something.

I really like the idea of the CGM and pump for the reasons you state. I'm concerned about him getting it caught on things, smashed, crunched and generally destroyed as young boys tend to do.

~Matt

Quote:

We did try the CGM and and for the reasons you suggested. Whether because of the unit itself or some other reason we had a lot of problems with it. It dropped readings pretty regularly and three out of the four nights we had it all night long, which was the data we were really looking for. They also had it covered over with a significant amount of tape and that drove the kid nuts. I think he reacted to the adhesive or something.

I really like the idea of the CGM and pump for the reasons you state. I'm concerned about him getting it caught on things, smashed, crunched and generally destroyed as young boys tend to do.

~Matt

I hear you, but I really haven't had many problems. I have had my pump replaced several times after bike crashes and other accidents. Animas has a 5 year warranty and I had a new pump in a couple of days. The CGM is a different story. While I haven't destroyed one yet, I did have one stolen and it is expensive to replace on your own. The good news is that insurance covers a new one every year.

As for getting it caught, it has happened a few times but maybe 3 times in 10 years? Not that I am a kid anymore but I wouldn't consider that a big negative.

You could discuss with your endocrinologist. They can usually get you a trial for either the pump or the CGM. The new Dexcom G4 has a much bigger range. I have been in the basement and my CGM has been upstairs and it was still receiving a signal. The one that I had before would never have done that. The CGM is also not waterproof but rumor has it that they are coming up with a case that would be. That would be really nice.

Both Animas and Dexcom really work with your insurance company to make sure you get everything covered that you are entitled to. Reaching out to them might be a good idea as well.

Best of luck and feel free to email me directly at rsfrech @ yahoo.com if you have any specific questions or just want more information.

This is just my opinion and I dont want to get slammed for it but here it goes. I switched to a pump (Animas) three years ago, and had the same concern as you "how well he would deal with something being attached to him all the time" I had a huge fear of having something attached all the time and figured I would get used to it in no time. Its been three years and I hate hate hate having this thing attached all the time. I have a lot more flexibility but my A1C is about the same 5.5ish as when I was on injections. I was 4 when I was diagnosed and I think if I had the pump as a child it would have been a constant reminder of the fact I had diabetes. Its a tough choice and you should obviously consider it but I had the same concerns as you and I have yet to fully accept the pump...

I was 4 when I was diagnosed and I think if I had the pump as a child it would have been a constant reminder of the fact I had diabetes.

I have a friend that was diagnosed young and is a bit older then me. Had done injections his whole life and tried a pump for a while a couple years ago and stopped largely for the same reasons you listed. I'm sure it'sa very personal thing and he's getting to that age where he wants to make those decisions. He's nine now, does his own shots, tests and is getting pretty decent at figuring out corrections, how many units etc. We have the discussion probably every time he has his doctors appointments and he's just not sure he wants to do it.

It would certainly make some things much easier for us as parents and clearly there are a whole lot of benefits, but there are also negatives as well as you point out.

~Matt

I was diagnosed at 12. I had a pump from 13-26. I'm 27 now. The pump isn't always the "answer" that everyone likes to give it. I've found Levemir to be a GREAT long acting insulin. That being said, if the pump works for you (or your child) then do that, if injections work, then do that. I hear a lot of people say things like "wow you're not a pump". A pump isn't a pancreas. The pump is only as good as the tube. Find what works for you (or your child in this case).

I will say the CGM from Dexcom is amazing. I don't wear it all the time but since starting to use a reliable CGM (the Medtronic one is terrible, Dexcom is wonderful), I've had better control simply by understanding how blood sugars react.

Insulin is like a gas gauge, you can use it that way. If sedentary you're using say 40 units then you should be hitting 40 units during intense workout times as well. The difference is during intense workout time the basal rate goes down but fast acting goes up. If you're not hitting the daily average usage then glycogen isn't full, just like a gas gauge.

Happy to speak with you further if you'd like, pop me a direct message. Whatever happens don't let any doctors tell you your son can't do anything. He can do anything.

I am a T1D newbie 8/14/13 dx(age 38) but I have been into endurance stuff for 15 years

There are so many stinking variables that can mess up my bg. Like another poster said, sometimes you just throw your hands up in the air.

I am a VERY routine person. I eat the same stuff nearly EVERY day for breakfast/snack/lunch and I believe that helps me big time! Through in some variables like eating out for lunch, a stressful day at work or something making me nervous and it can totally wrench my bg.

Different carbs affect my bg different ways. I can eat complex carb all day long really without much effect on bg but through in some simple sugar and I will go high(for me). We are all different but I really think "routine" a key.

---

"Keep those feet moving!" Me

Hey Matt,

Both of those things are true, and there are a couple of other factors at play. Glucose uptake without insulin (or with minimal insulin) does take place during exercise and for a short period afterwards (considerably less than a couple of years for me).

I have found that cumulative effects of exercise, especially when I increase the amount of daily exercise I am doing over a short period of time, do tend to drop my Blood Glucose lower and make me more sensitive to the insulin I take.

Also at play, at least in the overnight situation you talked about, is the body's natural rhythm. Your body naturally secretes a stress hormone, cortisol, at varying levels throughout the day. Your cortisol levels peak in the early morning, and are lowest around bedtime. Cortisol is a hormone that modulates many processes in your body, including how sensitive your body is to insulin.The more cortisol in your body, the higher your BG will go if you don't take additional insulin. This is part of the reason that many T1D people have a slightly high reading in the morning, even though their I have found that most of my overnight lows happen when I go to bed early and slightly low. If I go to bed at ~80 g/dL and had an early or low carb dinner, I can cuarantee that I'm going to need to get up in the middle of the night at 55, sweating and shaking. On the other hand, if I go to bed at 130 g/dL, and I had a late dinner, I'm guaranteed to wake up somewhere in the neighborhood of 180-200.

One other thing to consider is the rate of digestion and nutrient absorbtion. If the carbs he is eating are complex carbs, they're going to take longer to digest and absorb than simple sugars would. I have gone to bed a several occasions after large meals where my BG was spot on, only to wake up extremely high. A lot of this has to do with the delay between eating and the glucose actually entering the blood. Carbs aren't absorbed through the stomach, so if I'm testing with food still in my belly, my BG will look fine. Foods that are high in fiber are going to take even longer to absorb, because the fiber can't be broken down and interferes with absorption of digestible carbs (this is why they recommend high fiber diets for diabetics).

One other thing to consider- insulin response can be very individual. I take apidra, which is supposed to have an onset of 5 minutes, and a peak action of 30-60 minutes. I have noticed that for me, the maximum effect of the apidra is closer to 80-90 minutes. I don't know why exactly, but my body takes a little longer to use it then most for some reason. Your son may be different in that respect too, so keep a log and track these patterns. I found it very useful.

I hope that helps a little. Obviously everyone is going to be a little different. I think one of wvrunner hit it on the head- routine is key. If you give your body the same input every day, it is going to give you a similar, predictable response. There are a lot of factors that affect this (increased stress, illness and injury, even how many hours of daylight you have!), but a good routine makes a huge difference.

So true! I've tried every fast acting insulin; humalog, apidra & novolog. Apidra maybe worked slightly faster but not the peak the company claims. Now I'm back to Humalog (insurance stuff).

Quote:

Insulin is like a gas gauge, you can use it that way. If sedentary you're using say 40 units then you should be hitting 40 units during intense workout times as well. The difference is during intense workout time the basal rate goes down but fast acting goes up. If you're not hitting the daily average usage then glycogen isn't full, just like a gas gauge.

I'd just caution that this is very individual-specific. I've never had to dose my insulin in response to excercise like this. When my training volume increases, my basal rate does, indeed, go down. But my fast acting does not go up. My fast acting insulin/carb ratio will go down slightly. The only reason my fast acting would go up is because my carb intake has increased slightly.

The biggest thing I've learned from reading posts of other diabetics on the forum is that no two people seem to take the exact same insulin regimen during training. There seem to be a few "camps" people end up in (your camp, my camp, the "I have to bolus in T1 during a tri" camp, etc.) but the only similarities are in the generalities. This is probably the most frustrating thing, is that you have to figure out what works for yourself.

 


What RFXCrunner said along with your son's body trying replenish glycogen stores after workouts are going to be difficult to anticipate. I've been type 1 for 4 years now. Just check the numbers as often as you can and keep doing what you doing by keeping a good history of things. You'll figure it out, I don't believe blood sugars are ever random. It's always due to my current activity level and type/amount of carb I eat. I guess sometimes it's higher then normal when I'm sick.

Another point, I don't use a pump or continuous glucose monitor and my A1C has been 5.3 for at least one year and half.

---

Running is a gift.

Yes, carb intake should increase during intense workout to recovery properly unless one is going for a deficit.

Both of those things are true, and there are a couple of other factors at play. Glucose uptake without insulin (or with minimal insulin) does take place during exercise and for a short period afterwards (considerably less than a couple of years for me).

What is everyones experience with insulin right before a workout? We always check right before he does swim and if he is really high, typically 300+ we give insulin. This has only happened 2-3 times and in every case he seems to be "Hyper" sensitive to the insulin sometimes dropping him low during or right after the workout.

Again, simply guessing as I go, but I'm thinking that the correction should be 50% of what a normal correction would be if he was not going into the pool as well as any insulin given for food etc he has before he works out.

One other thing to consider is the rate of digestion and nutrient absorbtion.

This is actually something we noticed very early on. For this reason we have basically moved away from highly processed foods as many of these carbs tend to spike him quickly and out pace the effect of insulin causing a high followed by a drop. We've actually been timing the insulin intake according to our guesstimated glycemic index and load of the food.High index he will take the insulin and we will eat 20-30 minutes later. Low index or "Blocking foods" high fiber high fat we will actually eat and take the insulin 30-60 minutes later. We actually learned this with pizza. He get's a spike 2-3 hours after eating pizza so giving the insulin before he eats misses the food spike almost entirely. His doctor actually recommended we do two shots for those meals...but that's rough for him. After all, as you all know, he stabbing himself multiple times a day already and sometimes he simply has had his fill.

Thanks all for the great info.

~Matt

Quote:

Both of those things are true, and there are a couple of other factors at play. Glucose uptake without insulin (or with minimal insulin) does take place during exercise and for a short period afterwards (considerably less than a couple of years for me).

What is everyones experience with insulin right before a workout? We always check right before he does swim and if he is really high, typically 300+ we give insulin. This has only happened 2-3 times and in every case he seems to be "Hyper" sensitive to the insulin sometimes dropping him low during or right after the workout.

Again, simply guessing as I go, but I'm thinking that the correction should be 50% of what a normal correction would be if he was not going into the pool as well as any insulin given for food etc he has before he works out.

One other thing to consider is the rate of digestion and nutrient absorbtion.

This is actually something we noticed very early on. For this reason we have basically moved away from highly processed foods as many of these carbs tend to spike him quickly and out pace the effect of insulin causing a high followed by a drop. We've actually been timing the insulin intake according to our guesstimated glycemic index and load of the food.High index he will take the insulin and we will eat 20-30 minutes later. Low index or "Blocking foods" high fiber high fat we will actually eat and take the insulin 30-60 minutes later. We actually learned this with pizza. He get's a spike 2-3 hours after eating pizza so giving the insulin before he eats misses the food spike almost entirely. His doctor actually recommended we do two shots for those meals...but that's rough for him. After all, as you all know, he stabbing himself multiple times a day already and sometimes he simply has had his fill.

Thanks all for the great info.

~Matt

These are really good questions, that I've had some decent experience (and Dr. Recommendation for) on both.

First, regarding insulin sensitivity when bolusing right before a workout, YES it increases. When I swim in the mornings, I normally will eat a Clif bar on the way to the pool. I'll take 3 units of insulin for ~45 grams of carbs. Normally, for me, this would be at least 4 units. But, when I'm swimming, it's 3 and it will handle the food, plus lower my blood sugar by 20-40 mg/dL from where it was before my my injection/food/swim. Another important thing to consider that I didn't know about until recently is WHERE you do your pre-workout injections. My doctor told me to be very mindful of that. Even though we're not injecting into the muscle (but into the fat below the skin), if we inject in a location that has a muscle group that will be heavily used during a workout, it will increase insulin uptake due to the increased bloodflow to that muscle. So, for me, I'm always injecting in my stomach before a workout. Definitely avoid the triceps (I used to do triceps as a kid, but haven't now for years) and probably also the legs as they get some good use during swimming. Cycling/running/anything else that is land based should definitely avoid the legs.

Second, you'll definitely see different foods affecting BS differently. Pizza is notoriously a weird one because it has a good mix of simple and complex carbs as well as fats. So, a lot of people will actually see a double spike like you're describing. I've personally never witnessed anything significant from it where I've had to take a second injection from the 2-3 hour spike, but I know it's common. One idea is to suggest he eat a small snack at 2-3 hours out that requires a shot. That way, he feels like he's getting something (more food) out of the shot, instead of just having to poke himself again.

Kudos for you to learning all about this stuff for your son, awesome stuff... For training, if my blood sugar is high I will rarely correct unless I'm hitting those higher numbers of 10mmols or more and even then it's one unit. So your correct definatly err on the cautious side... Racing is very different though, I'm finding bolusing has to be a bit more aggressive.