Hello,
My daughter has had T1 for a year now. She has been on an insulin pump and CGM for 6 months. Just recently, she has started having low events and then, it rises to mid 300s. It takes it about 3 hours to come back down. Yesterday and today, her trend looks like mountains and valleys. At her last endo visit, they lowered her active insulin time to 2.75 hours and decreased her sensitivity factor from 1u for every 50 over 150 to 1u for every 40 over 150. This was because she was having the same issue (highs after lows) but, at that time, she was only going as high as 250s. I’m at a loss. She levels out in the early morning hours and almost flatlines at 110s to 130s. I’ve tried adjusting carb ratios according to her trends, but it doesn’t seem to help. I’m wondering if I need to put her sensitivity factor and active insulin time back to how it was.
Hi @Bekah. I have two thoughts about what may be going on:
- What you treat with affects the numbers “after recovery”: juices/sodas will raise them faster than solid foods; but while the speed is great they don’t have “staying power” which may cause a drop later. And despite the relative speed of those beverages the lows never seem to come up as fast as we would like - so it’s tempting to keep eating until you start to feel a response, also leads to a high. Some people find that milk has a gentler effect when bringing the numbers up (I rarely drink it so can’t say myself). If you use juices it’s good to have a snack such as peanut butter- or cheese crackers to prevent a drop later. Your doctor or nutritionist can give you some snack ideas and recommend how much to drink.
My second thought is that she’s in the honeymoon stage, where her body still produces some of its own insulin. You can’t predict for it (in which case you would know to cut back on insulin from her pump) so you have to keep an eye on her numbers and respond accordingly. If you do a search on the forum you’ll find it mentioned and may get an idea of how long it lasts.
@wadawabbit Thank you for the input. She doesn’t typically overtreat a low, but I guess it is possible sometimes. And, she does treat with a fast-acting carb and follows with a protein when back in range.
It is possible that she is still in a bit of a honeymoon phase. She is also going through puberty. So, I’m sure the hormonal swings are in part to blame.
I guess I’m just at a loss of how to keep her from getting those lows and highs. Didnt know if someone might have input on her pump settings. The adjustment in carbs ratios don’t seem to be working. We go back and forth…so, I’m wondering if her active insulin time and sensitivity factor are to blame.
Thanks again so much for your thoughts!
Puberty and hormones can be tricky to say the least. If you’re not already doing so I suggest documenting the times of the lows, details and times of meals and snacks, period dates, exercise,etc. She may be getting more basal insulin than she needs at certain times of day, and it’s not unusual to have different settings for that and carb ratio. A log can help your doctor figure out if that’s the case. I have 4 different timed settings myself (what can I say - the pancreas wants what the pancreas wants…), and those might change from time to time (arrgh!).
@wadawabbit I didn’t even think about maybe needing different basal rates at different times of day. I’m not sure if that matters with Auto-mode on her pump though. I’ll have to look into that further.
Thank you for the suggestion to keep a log for snacks, meals, periods, etc. We don’t currently do that, but have recently discussed it. It would sure be beneficial to see which foods and how periods affect her. She hasn’t quite started her cycle. So, hard to tell when those hormonal swings are coming beforehand. 
There are a number of smartphone apps you could try - MySugr and SugarMate are popular and I believe free, but there are many others out there and it’s really a matter of personal preference. I came up in the days where we used pencil and paper, and lots of people prefer that. My handwriting is so bad I really need something electronic!
@Bekah Hello Rebekah, and Welcome to the JDRF TypeOneNation Forum!
I don’t know your daughter nor have I observed how her glucose levels react to insulin, so I can only make a few observations and offer thoughts for you [and her medical team] to consider. First, her continuous monitor is the most valuable and useful tool for managing diabetes, use it fully along with notes you keep to help make adjustments. Tidepool, a JDRF sponsored group, has what I think is an excellent tool to see the interaction of insulin and food while watching fluctuation of her glucose level.
A pump is only as good as the information YOU program into it and your thought process. In my opinion, two of her pump settings you mention, if you base her meal-bolus and correction bolus on the ESTIMATED provided by the pump built-in calculator, are major contributors to her “mountains & valleys”. FIRST: the figures you provide for ISF [Insulin Sensitivity Factor] do not decrease sensitivity but rather increase sensitivity - thus providing more correction bolus. SECOND: Unless your daughter is extremely unusual, 2.75 hour insulin duration may also contribute to the pump-calculator recommending too much insulin because it ignores possibility for her to have active insulin in her system [UOB]. Over the past 65 years I’ve used many types of insulin, including the Ultra-Rapid, and none of those insulin formulations have finished their work in me in less than 4 hours. My observations are based on the work I did in the 1970s developing the formula for introduction of MDI and is the basis of the software in infusion pumps. A good way to observe how these factors [ISF, IOB, and Insulin Duration] interact in calculating an insulin dose is to use the basic formula either on paper or in your head; doing that calculation is a contributor to improved math skills among kids with T1D.
Pump Basics: The first phase for setting up a pump Profile / Pattern is to work on basal delivery and validate the rates by extended fasting. Then move to the Insulin:carb Ratios [ICR]; the insulin delivered should be sufficient to bring her BGL within 3 to 4 hours to the point it was before eating.
The safest and easiest way to find her ISF is to wait until she is holding level at about 150 mg/dl and when she has not recently eaten [taken insulin] and not engaged in heavy activity. Give 1 unit of insulin and then record BGL at one hour, 90 minutes, two hours, etc. Observe the amount of change for at least 4 hours and you can get a good idea of sensitivity and duration. Keep in mind, that ISF, as with Basal and ICR will differ throughout the day.
None of this is easy, but over time will become almost second nature. And please, try not to make your daughter feel overwhelmed - do things bit-by-bit so she can “be a girl”, grow and enjoy life. Diabetes will not prevent her from doing, being active and living a long and full life.
I hope my writing didn’t sound too negative - please feel free to ask questions and seek clarification.
@Dennis Thank you so much. This is very helpful. Your recommendations on finding ICR and ISF are explained very well. And, it doesn’t sound negative at all. I appreciate the reminder to try not to make her feel overwhelmed. We do have a great relationship and I try not to overwhelm her. But, even with my best efforts, she becomes overwhelmed anyway. Not just from diabetes, but several things (homework, choir, growing up, etc). She has always tended to worry about things most kids don’t. I try to remind her to enjoy her childhood while she can. And, right now, I do a lot of her diabetes management myself. She knows how to do most, but when she doesn’t want to count carbs or do a fingerstick, I do it. 
I have not heard of Tidepool. I guess I can just Google it. I would like to check it out.
Thanks again!
@Bekah , try tidepool.org. Use this in addition to the site provided by pump and CGM. Tidepool updates from all pumps and all CGM, plus many meters. I find the “dayly” page Mos helpful, using the arrow to move from daY to day.
Occasional day off from Intensive management won’t hurt your daughter too much as long as she is aware when dropping low and will eat something, and if she is staying too high you know how to correct safely