Hello All...

I'm relatively new to TuDiabetes, which is to say that I've only recently begun to interact with it although I've had a profile for quite a while... I also apologize in advance for what will undoubtedly be a long-winded question!

I need the community's help sorting something out...or to tell me that it's just "normal". Background: diagnosed late-onset T1 ~ 2 Yrs ago...sequence of A1cs went 11.3 at diagnosis, 6.9, 6.7, 6.9, 6.5, 6.2 and Monday's most recent TBD... I strongly prefer injections and plan to stay that way until I cannot maintain a sub 6.5 A1c, and have recently started pursuit of the CGMS. I appreciate all of the enthusiasm those of you with pumps have for the device, but it's not for me yet.

I've been active most of my life (notable and mostly unavoidable exception of graduate school) and it took me about 9 months/1 year to get over my horror over exercise and insulin after diagnosis, although I got religion on carbs in about 2 days. I have a 14 month old son, my wife and I both work, and we do everything we can to exercise 4-5 X/week, which means we trade off mornings at the gym etc...

Breakfast is a complete enigma. I rotate between a couple of things (one Van's whole grain waffle - 12g carb with fat free cottage cheese and a protein shake with water - 2 carbs in the protein mix...eggs/egg whites/EggBeaters depending on my mood and one serving of McCann's steel cut oatmeal with LOTS of cinnamon (in cast what they say is true) with a handful of blueberries...or if I'm running late, I'll go with one of the egg/turkey sausage/cheese whole grain sandwiches from the store). None the less, most all of these meals have about 25 net carbs "all in". I simply cannot get the exercise/insulin/breakfast routine down.

Here's what happens: I wake up anywhere between 110 - 140...I go to gym...I work out (mainly resistance training in the mornings) for about 30 - 45 minutes and almost always end up ~160-175. Okay, I get it...either dawn phenomenon is still going and/or weight lifting causes adrenaline causes increase BG, etc... I get home, take my 22 units of Levemir and anywhere from 3 - 6 units of Novolog...2-3 correction + meal amt...(~1:10, sometimes I get aggressive and go 1:7). I try to account for lower circulation in the morning, an empty stomach and some morning resistance with timing etc, but sometimes nothing works and I'm just curious if there is any wisdom for me on the subject or if that's just the tuition of the disease.

Occassionally, 5 units won't move me even before I eat anything - like today. Took 5 units and waited about 45 minutes...nothing. I want to see a change in direction before I put any of that carb in my stomach and it just didn't happen, so I did what I usually do for a REALLY quick correct which is two units in the bicep...and again...nothing. So now I have 22 Levemir about to kick in slowly and 7 units of fast-acting floating around somewhere and am not budging off of 175 and too nervous to eat anthing because I've trained my body to abhor anything north of 190 and it hurts like hell...(I realize I will receive no sympathy from those of you with much higher spikes).

I'm just waiting for a massive crash, but it hasn't happened. (It's been 3 hours since the begging of today's saga) I'm certain it's not the insulin because it is basically brand new, was working last night, and was in the refrigerator all night. Lastly, I've had occassions where a 3 unit correction bolus sent me from 170 to 50 in an hour an a half without ANY physical activity so I'm reticent to take more...I'll just burn up some test strips and move on...

If you're reading this far, you have my gratitude. If you have any thoughts/suggestions, I am all ears and would greatly appreciate it. Heck, any suggestions on low carb breakfasts that DON'T involve eggs or egg derivatives would be huge. I used to love the suckers but cannot stand them now.

Many many thanks,


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Thanks Xanthasun,

I've tried what I think is every derivative of no bolus, small bolus, small bolus with small snack, and small bolus with larger snack with regard to exercise... Nothing seems to be predictable, although a few days ago I got bold and took 3 units 15 minutes before the gym...came home around 120 and no problems afterward with breakfast. I am just uncomfortable doing that and then "letting go" to work out. I should probably chill out about it all... I think you're on to something about the morning issue though. One time I went to the gym on a Sat afternoon with my wife ~150...didn't work out much harder than I usually do (probably less actually) and was a little dizzy for the last half. Tested in the car at a wonderful 95...held around there rest of the day. I have drops like that which don't affect me at all, so was surprised...probably just fatigue...CGMS should help.

How do you like the CGMS versus not having one? Has it been as informative and confidence-inspiring as you hoped? (That's what I'm counting on anyway)
I would also like the CMG but when I went to a conference on Patient Choice for diabetes patients there was a discussion on it and they said that the CMG actually uses other bodily fluids, namely sweat, to measure glucose levels and that they are not accurate because it is not blood! Jury is out on that one.
CGMS has been a great experience for me and in particular in regards to exercise because it shows where I am trending. That is going on a run at 89 and steady is different than 89 and dropping (where with the latter I would probably eat). It's also been really helpful because I have next to no awareness of being low so while it's not always 100%. In general it's been close enough to what I test (+-5 points beside the first day or so) that I don't worry about unexpected lows and also lets me better see what effects that different food and exercise has. In short, highly recommended.
Thanks! Just about exactly what I'm hoping to get out of it...
You sound like me! I do not exercise the same as you. I cannot. Physical problems. I just inject, know that I am going to go up, but also know that I am going to go down, so try not to worry about it.

If I am ill, namely a chest infection or something similar, am under stress for some reason (and I have been under terrible stress recently!) it will be higher too. I have to test every hour or so - if I remember - but I know that it will eventually go down.

As for the breakfast, you could try burritos, wraps, etc with bacon (well done and dried on kitchen paper). You do need some carbohydrate. However, like you, I am bored of breakfast!

I sometimes have porridge oats - but rather than fruit or jam, I prefer something savoury so will put in some chilli sauce or similar.
Have you tried giving your Levemir dose before your workout? If you try it, certainly check your blood sugar DURING the workout in the beginning to watch for lows. This may ensure that you have enough insulin in your system during the workout to prevent these spikes, but you need to be sure that it will not cause lows.

If you are waking up between 110-140, then I guess that you do not need more basal insulin at night. We all have different basal needs depending on the time on day. On the pump, I know that I need a lot less basal at night, but then I need a lot more from 7-10am. What might be happening is that your exercise time is combined with your time of higher insulin resistance and the evening Levemir dose is not cutting it.

Exercising with insufficient insulin can be highly dangerous and lead to ketones quickly. You may be still producing a very small amount of insulin, which could prevent ketones, but you want to avoid those spikes during exercise not just because of the blood sugars, but also because in the future the spikes could become much worse if your body's insulin production decreases.

After my honeymoon was over, I once went from 100 to over 400 with almost no carbs during a 5k run simply because of having insufficient insulin in my system.

I can completely understand your desire to stay on injections. The pump is a wonderful tool, but if you are doing OK on MDI now, then good! One thing to consider for the future though is that the pump can allow you to adjust basal during exercise. It takes some trial and error, but I figured out a way to do 1 hour of intense rollerblading while keeping my blood sugar between 100 and 140 and almost never needing to consume extra carbs. Spontaneous exercise is not possible (I needed to turn my basal down at least 30 minutes before exercise began), but if you roughly know your exercise schedule, then the pump can be a great help in keeping stable numbers during exercise!
Thanks Kristin,

I've tried varying things including a small bolus before working out (this works but makes me nervous and is a big distraction from actually exercising)... I don't do anything relatively intense for more than 30 minutes at a time and agree that I am probably getting a little honeymoon help...

Appreciate the feedback. Have a nice day.
re the AM spikes, it might be that the 160-175 afer lfiting in the AM could be combined w/ DP and that the "point" you measure may be on a line that isn't done going up? Have you tried testing in like 10 or 15 minute intervals? It will burn some test strips but it might give you a more accurate picture of what's going on?
Yessir... I am pretty sure I am one of the most flagrant over-users of test strips ever... If I don't believe a number it's not uncommon for me to go ahead and test 2-3 more times on different fingers, new lancet, etc... I try all the "mapping" experiments...

It holds pretty steady under 180, although there was one time when I registered a 180 followed very shortly by some kind of nauseating 270! Big bolus in the bicep and I was back at 100 in about an hour and a half... I think the CGMS is going to solve a lot of things for me.

Thanks and have a great day.
What about eating and bolusing before you workout? This way your body gets carbs and the liver does not have to inject additional glucose into the bloodstream (the liver has no idea you have no insulin production). In addition you will have insulin on board. Combined with physical activity this should help to reduce the spike.

I really question your Levemir routine. Basal is your background insulin. It has nothing to do with your eating pattern. It should keep you at normal levels if you are not eating anything. The only valid adjustments of basal insulins are: illness (increase of basal) and high physical activity (decrease of basal to prevent lows).
I've tried that. Last time I took that route I spiked to well over 250...as I mentioned above...I ate a Balance Bar, bolused for it and a v small correction, worked out for 45min and bang! I never went low either... Bad JuJu. This morning I went with a 2 unit bolus before working out...125 before and 125 after...10 almonds before to try and shut off the dawn effect...45 min after got back, took my Levemir and 5 minutes later, right back at 160. 2 units in bicep, 5 in abdomen, and high protein breakfast and I was back to 110 heading toward a nice comfortable 85...

What do you find objectionable about my Levemir routine? It works doesn't it? I'm generally between 80 - 120 when not eating (other than the occasional waking up ~135ish....) I know what "basal" insulin means and what it should do...

Not all physical activity causes lows. Depending on the intensity and type, there is an adrenal response that causes BG to go higher. I also appreciate what you're suggesting re: "the only valid adjustments of insulins are:" BUT...I still have smallish, but wholly unpredictable levels of c-peptide and insulin production so frankly, I can't agree with you in my particular case. Once that c-peptide goes to zero and I have full confidence that my pancreas isn't going to "help out" at an inopportune time, I'll get more religion about consistent and reliable basal rates. I can always correct.

Good luck to you and I appreciate the commentary.

Like you I think that what works is right. I just wanted to point out that sometimes we develop some strange strategies. These can make it hard for ourselves and our medical team to understand all the factors involved in our glucose management. Of course I understand your reasoning about the irrational behaviour your are sometimes confronted with as someone with LADA. It makes it difficult to identify the cause of fluctuations. I just mentioned the basal because sometimes a small gap in basal coverage can cause irrational numbers around the injection time of the next shot: an hour difference in injection times (9 instead of 8 hours), one unit more or less, unprimed pens (big problem of the NovoPen 4) etc.

Just out of curiosity: do you think that your liver is always dumping additional glucose for physical activity? Or is it the combination of dawn and physical activity that is the challenge here? What happens if you exercise after dinner?




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