September always feels like a time of transition, whether we’re headed back to school, back to the office after summer vacation, or just feeling the inevitable shift of summer to fall.
Whether you’re moving into a new routine or this time of year is just giving you some motivation to ‘get back on track’, our diabetes educators would like to provide you with some tools to help you re-evaluate your diabetes management.
We’d like to introduce you to some tools to help you evaluate whether your current insulin regimen is working well for you or if a bit of tweaking would help improve your management (and quality of life!).
Multiple Daily Injections (Pens)
If you use multiple daily injections (pens), you can test out your long-acting insulin dose by looking at how steady your blood sugar remains overnight when you’re not eating. Try doing a blood sugar test before bed (at least 3-4 hours after your last meal or snack), around 3am and again in the morning, or looking at your CGM tracing from bedtime until before breakfast. If your blood sugar tends to stay within about 1.7mmol/L of where it started before bed, you long-acting insulin dose is probably pretty spot on. If your blood sugar rises more than that amount overnight, consider adjusting your dose by 10% every couple of days until it stays fairly steady and your fasting blood sugar is <7mmol/L (or the level at which your endocrinologist suggests). If your blood sugar tends to drop overnight or your wake up low, you may need to decrease your dose by 10%.
If you use an insulin pump, you can test out how your basal rates work at different times of day. This one is tough – it requires fasting for an 8 hour-period a few different times in order to evaluate what happens with your blood sugars when you’re not eating. Does your basal rate keep you steady? Have a look at the basal rate testing worksheet to guide you through the process. Start the basal test at last 4 hours after you’ve last eaten and continue for another 4 hours, testing or monitoring your blood sugar every 2 hours. If your blood sugar rises during the basal rate test, you probably need to increase the basal rate at that time of day. If your blood sugar goes low (<4mmol/), treat as usual and take it as a sign you might need to decrease your basal rate for that time of day. Remember, when adjusting basal rates, you want to make the adjustment about 2 hours prior to when you want that change to be reflected. For example, if you blood sugar starts to drop around 10am, you would want to lower your 8am basal rate. Increasing or lowering by about 10% at a time will ensure you’re not making too much of an adjustment at once.
Carb Ratio Testing
Carb ratio testing is a good first step to take if you find yourself struggling with highs and lows around meals. It will help you determine whether you’re actually taking the right amount of insulin for the food you’re eating. You might also consider the accuracy of your carb counting and the timing of your dose (try to dose 10 minutes before with Humalog, NovoRapid or Apidra, and 0-2 minutes before with Fiasp if possible). A carb ratio test is best done at a time that your blood sugar is in range before the meal. Choose a meal that you know the exact amount of carbs (no guessing!) like a frozen dinner. Check out our Carb Ratio Testing Worksheet to help you work through the process! If your blood sugar drops within 4 hours of the meal, your carb ratio might be too strong. To weaken our carb ratio, we actually want to increase the number (ie. from 10 to 11 – that will suggest less insulin). If your blood sugar goes above 10mmol/L 2 hours after or is not back down into normal range 4 hours after, your carb ratio might be too weak. To strengthen your carb ratio, decrease the number (ie from 10 to 9 – that will suggest more insulin).
Correction Factor Testing
Your correction factor or insulin sensitivity factor (ISF) tells you how many points (or mmol/L) 1 unit of insulin will lower your blood sugar by. For example, if your ISF is 3, we are assuming that 1 unit of insulin will lower your blood sugar by 3 points. Test your ISF when you are correcting for a high, but not eating at the same time. If you are finding your blood sugar tends to drop too much (goes low within 4 hours) after correcting, you may need to weaken your ISF. Similar to carb ratios, to weaken our ISF we want to increase the number (ie. from 3 to 3.3). If you find your blood sugar doesn’t come back into range within about 4 hours of correcting, you may need to strengthen your correction factor. To strengthen your correction factor, decrease the number (ie from 3 to 2.7 – that will suggest more insulin). Check out our ISF Testing Worksheet to test out your correction factor!
Putting It All Together
It can be overwhelming to think about doing all of this testing and evaluating at once. Our advice? Take it in very small simple steps. Think about what you might be struggling most with and start there. Decide what is manageable for you at this time and spread it out over a number of days or weeks. Hitting refresh and establishing a new baseline can be extremely beneficial. It will allow you to see what things look like on a ‘usual’ day and from there you can start to look at how things like exercise, insulin timing, stress and other factors affect your blood sugar.
Remember – small, simple steps. If you’re feeling ready to evaluate things and make some changes, reach out to your diabetes educators. We’ll lend a second set of eyes and can review how to make incremental changes to basals, carb ratios and correction factors. If you don’t have a regular diabetes educator, reach out to firstname.lastname@example.org to get connected to one of us!
If you’re not yet using a carb ratio or correction factor and you’re interested in getting started or getting a refresher on carb counting, carb ratios, and corrections, check out our Carb Counting and Advanced Skills workshops here.
We hope this helps you re-establish your diabetes management routine as you transition into fall!