COVID-19 & Diabetes: A Great Time to Evaluate Your Diabetes Regimen at Home!

Video Transcription:

Steve:

Hello Nation! I’m here with my good friend and colleague, Jeremy Pettus. And today we’re going to talk about how you evaluate your diabetes regimen. And it’s a great time to do it when we’re all quarantined. These are important evaluations that we should do every 3-4 months, actually, not just when you’re stuck at home for two months. First we’re going to talk about type 1 diabetes, then we’re going to talk about type 2 diabetes.

Jeremy:

We get a lot of questions about this. People are at home, they’re eating differently, they’re exercising differently, their blood sugars are probably all over the place. It’s a great time to check in and fine tune your diabetes. So for people with type 1, we’re going to start with your basal dose. And that can be the amount of basal insulin you take from an injection or it can be through your pump, but starting there is a really good way to figure out where the ground floor is. Once you get that figured out it doesn’t change too much, and then you can move on to carb ratios, sensitivity factors – things like that. So what is the point of a basal rate or a basal does? It’s to keep your blood sugar flat. So if you go to bed at 150, you should wake up around 150 or so, give or take 30 points. It’s hard to do much better than that.

Steve:

What if you go to bed at 250 mg/dL and you wake up at 250. Do you need a higher basal rate for that?

Jeremy:

That’s a great trick question, Steve. The answer is no! If you’re going to bed at 250 and you’re waking up at 250, your blood sugar is flat! Your basal is doing its job. It’s just that you’re going to bed high, so you need to take more mealtime insulin so instead of going to bed at 250, you’re going to bed at 150, and then your basal just kind of keeps you there. So how do you tell patients to test their basal rate overnight to figure out if they need more or less?

Steve:

This is really important to do. You try to have an early dinner, say around 6 o’clock. You make sure your post-meal blood sugar is under good control and that your blood sugars are steady.  If you’re on a continuous glucose monitor, you’ve got that trend arrow that tells you you’re steady. If you don’t have a continuous glucose monitor, then you need to prick your finger a little bit more during these tests, but the information  you’re going to get is very valuable. So then you don’t eat anything all night long. When you wake up in the morning, check your blood sugar. Sometimes we try to tell people to sleep in or not eat for a while so they can really test to see if that basal rate or basal does is keeping them flat.

Jeremy:

Do this multiple times and see if there’s a pattern. If you notice that you consistently are going to bed at 150 and you’re waking up at 250, that means you’re not getting enough basal insulin. If you check in with your provider you can increase your injection by 1 unit and then try the test again, or you can increase your basal rate by .05 or .1 and keep doing that until you get to a place where you feel pretty confident that if you go to bed with a flat number you’re going to wake up with a good number. There are all kinds of variables in diabetes, so you don’t want to pick a night for this test when you’re already going high or low, or you exercised late or you stayed up late. Pick a typical night when you’re cruising and your blood sugar is  flat.

Steve:

There’s never a better time to do it than now, when you’re sitting at home. You can really focus in on your own regimen. Jeremy let’s talk about the insulin sensitivity factor, otherwise known as the correction factor.

Jeremy:

First of all, what is it? It’s a ratio of how much 1 unit of insulin will drop your blood sugar. So a typical type 1 number might be 50 points, or a correction factor of 50. So if you take 1 unit of insulin it will drop your blood sugar by 50 points. And you can test it just like testing basal rates. You pick a time when your blood sugar is high – let’s say it’s 200 – and you take a unit of insulin. Then you just wait and watch, at least a few hours, to see how far your blood sugars come down, and that gives you an idea of what your correction factor is. And you can do this multiple times to give you an idea.

Steve:

I was just going to emphasize again that you have to make sure you’re in a steady state, that your blood sugars are flat, you’re not going to be eating or exercising for several hours before and after. And that’s the best way to test it. That information is so valuable because we use it all the time to correct our blood sugars when they’re high. Okay, next – the famous insulin to carbohydrate ratio.

Jeremy:

Carb ratio is basically how many grams of carbohydrate 1 unit of insulin will cover. So if the carb ratio is 10, that means 1 unit of insulin will cover 10 grams of carbohydrate. A good way of testing this is getting a packaged meal that has the number of carbs exactly written on it.  So if it’s 40 grams of carbs, you use your carb ratio to bolus for that meal. If you’re 1:10, that would be 4 units of insulin for those 40 grams of carbs. Take the insulin 20 min or so before you eat, and then you want to look at what your blood sugar does 2 hours after you eat. The best thing you can do is keep that 2 hour blood sugar about 50 points or so higher from where you started. Meaning, if you started at 100, and you go up to 150, that’s good! Everybody is going to have some rise in your blood sugars. You can’t just keep your blood sugars completely flat all the time. That’s really really hard. But if you notice that you start a meal around 100 and you bolus for those amount of carbs, and you’re going to 280 all  the time, you might want to make your carb ratio more aggressive.

Steve:

I just want to emphasize that there is a lot of variability, so you should do this test more than once. The timing of when you take the your insulin is key. If you take your insulin at the time of meal, you’re going to bounce up a lot higher than if you took it 20 minutes before. So it’s a really good exercise to not only look at the timing of the insulin, but also how to control your blood sugar depending on how many carbs you’re eating. Just think about it – how many carbs is kind of a crapshoot, and the timing of the insulin is variable. You’ve gotta have that insulin to carb ratio correct, otherwise it’s not really going to be that helpful.

Jeremy:

And even time of day is a factor.  I know you love your Egg McEdelmans in the morning, so if you eat your McEdelman in the morning versus having it at night, you probably need way more insulin for that same exact meal in the morning when you’re more insulin resistant. So it’s another thing that you can play with. Your carb ratio might be different depending on the time of  day.

Steve:

Yes, it can get pretty sophisticated. Okay, let’s talk about type 2s. For many of you type 2s on multiple daily injections or a pump, a lot of  those rules apply to you.  Many of you type 2s are using a CGM – either the Dexcom or the Libre – and that’s awesome, but it’s probably not that many of you. So you’ve got to get out the glucose meter and get off the cobwebs, get out those expired strips (they’re still good) and prick your finger a lot more for these tests. But it will pay off. So basically there are two areas to check. One is how you do overnight. We call this paired testing. Test Friday night and Saturday morning and then Monday night and Tuesday morning. Those deltas are really important. As Jeremy said earlier, the numbers should be pretty close. Even if you go to bed high and you wake up at the same “highness”, that’s important information that you have to work on, to go to bed at a better blood sugar. The only other area that you really have any control over is looking at your pre and post meal blood sugars. As Jeremy says, you cannot adjust the dose of  your oral pills, you can’t adjust a dose of your injectable GLP-1s like Trulicity, Bydureon, Ozempic (I love those commercials) or Rybelsus. You cannot adjust those, and you should not adjust those, but you want to tell your caregiver what’s happening overnight and how high you’re rising after meals.

Jeremy:

The one thing you can adjust in your diabetes life though, is your lifestyle. That’s always something we shouldn’t forget about that people can address. Especially now that you have a little bit more time to focus on your health. So what you’re doing with your diet, how many calories you are eating, are you trying to go more low carb, are you trying intermittent fasting…some kind of mindful plan for your diet is important. As well as exercise. It’s much easier right now to be a couch potato. So you have to make yourself get up and move everyday. We always recommend at least 30 minutes a day, 5 days a week. It doesn’t mean you have to put on spandex and go to some kind of fancy gym, just walk around the block. Do something. Move your body, it really makes a difference in your blood sugar control.

Steve:

Alright Nation, remember to check out the TCOYD website – we have different Facebook groups you can join and if you go to the living library or resources there’s a blog there with lots of great educational articles. Feel free to ask Jeremy and myself any questions. So with that, we say be healthy, and have fun evaluating your diabetes regimen. If it’s no good, fire your doctor! No I’m kidding….so long Nation!