Hypos

How I Manage My Blood Sugar During Exercise

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I’ve learned a fair bit about physical activity, and how to manage my diabetes around it in the past year. I guess having my job and my income depend on it, is a big motivation.

I am physically active at work every day, which means that I am more sensitive to insulin and more prone to going low through the day. Combine this with trying to offset dawn phenomenon when I wake up each morning, and you’re left with one very tricky equation.

One positive of combining work and exercise, is that every day is Groundhog Day. There is no shortage of opportunities to experiment. And when something does go wrong, I get to repeat it the following day in almost identical conditions. Not to mention that I don’t need to feel guilty about telling my doctor that I don’t go to the gym!

The negative is that at times, diabetes has felt very gruelling to manage while I am at work. The motivation to basal test, or to conduct experiments, isn’t always there. There have been days where I’ve literally been juggling highs and lows with insulin and food, respectively. There have been weeks where I felt like I haven’t gotten anywhere, and it’s often hard to pick myself back up and carry on.

Your diabetes, and the kind of physical activity that you undertake, will likely be different to mine. However, here are a few of the strategies that have worked for me while I have been physically active in recent months.

I would class my level of activity as mild – being on my feet, lots of walking around, some climbing up and down ladders and lifting. There are some days where it is more intense than usual – particularly if we are busy. But I find that most days, my level of activity is identical.

I find that for this mild level of physical activity, I need 30% less basal insulin compared to when I am vegging out at home. The 30% reduction in basal insulin needs a lead time of around half an hour before I start work. Most would suggest an hour’s lead time, however I don’t feel that my level of activity is at full speed until half an hour into my work day. I.e. I’m spending too much time chatting to people in the morning!

Mealtime boluses are still a work in progress. I’m currently sitting on 1 unit for every 8 grams of carbohydrate. At breakfast, my full insulin dose does its job, as I’m not on my feet for another hour and there’s probably some dawn phenomenon in play. I’ve tried reducing my insulin dose for meals during my work day with mixed results. At morning coffee time, I’m dosing insulin or snacking while I’m on my feet. Whereas at lunch time, I’m dosing insulin at the start of my break and not going back out to work for another hour. I’m working with a 30% bolus reduction with morning tea, and 15% with lunch.

I’m probably about two thirds of the way there. My overnight, and morning BGLs are looking fantastic. I just need to focus on getting some more green numbers into the afternoons, so that I’m not going home and snacking or eating dinner on higher numbers. It’s been an ongoing issue.

Work has been a gruelling journey, but I have finally began seeing results in recent months. Putting the hard work into fine tuning my basal rates and mealtime boluses has been invaluable towards a productive day, free from the stress of highs and lows.

I’m not so terrified of going to work without wearing a Libre sensor anymore, and I can comfortably go for two or three hours without needing to check my blood sugar. When I uploaded my meter data to Diasend on the weekend, I realised that I had only had three lows in the last fortnight. Freaking awesome. I finally feel a level of confidence in what I’m doing. 

Another piece of advice that I never gave myself: give yourself a break. When I was on injections I would often come home with exhausting lows, crash on the couch and eat my way out of it with junk food. I failed. Constantly. The task of fine tuning insulin felt overwhelming, and the motivation was never there. After my pump start, I was under the illusion that I’d have everything down pat in a number of weeks. In hindsight that was such an unrealistic goal. Give yourself some room to breathe. Maybe basal test every second day. Or have a few days off from your experiments if they’re feeling overwhelming. Set small goals.

As with any element of managing diabetes, it takes a lot of time and patience. You won’t necessarily get it right the first time. Or even the tenth. Goal posts are always moving, because diabetes is always changing. You’re always learning, and putting two and two together.

But with time, you pick up these valuable little skills that will make fine tuning your next diabetes scenario a little easier.

Multiple Daily Injections, a Second Time Round

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I definitely felt hesitant about going back to Multiple Daily Injections when I was contemplating a pump break.

I didn’t really have too many fond memories of managing diabetes prior to insulin pumping. Lantus was very uneven and inconsistent the last time I used it. I felt I could never get the dose quite right. I remember lots of carb guesstimates, and the wildly fluctuating levels that followed.

But at the same time I knew that I was armed with a lot more knowledge, and motivation compared to when I last did injections. I was actually curious as to whether I could apply these newfound skills into Multiple Daily Injections a second time round.

I gave 9 units of Lantus at around 9pm on the first night of my pump break, which was the sum of the 24 hour basal profile on my pump. I was pretty pleased to see that it did keep me fairly stable when I woke up the next morning.


I was definitely contemplating splitting my Lantus dose, but I wasn’t sure how best to go about it. The general consensus in forums seemed to be that Lantus lasted around 18 hours at best. After running high during the first two afternoons, I decided to experiment with a smaller second dose at 1pm to cover the final third of my day. 3 units seemed to be enough to cover, without sending me low overnight.

After months of diligent carb counting, I knew I definitely wouldn’t be able to survive without a bolus calculator. Although there were plenty of flashy diabetes apps to choose from in the App Store, many of them lacked a bolus calculator. I eventually found RapidCalc for $12.99. Although it didn’t have the flashiest interface, it fitted my needs nicely. I was able to set up my insulin to carb ratios, correction factors, insulin usage profile, and reminders for my Lantus doses.


This break definitely reinforced that to me that you tend to use less insulin on the pump. On the pump, I was using a carb ratio of 1:10g and a correction factor of 1:2.6mmol. On injections, I needed a ratio of 1:6g and a correction factor of 1:1.6mmol. Being off by even half a unit of insulin had a big impact on my blood sugar levels after meals.

What I loved most about injections was the simplicity of it all. There was instant relief from the lows, and far less thinking about where my blood sugar was heading. Small activities around the house had minimal effect on my blood sugar levels. I witnessed steady trend arrows on my Libre during afternoon walks, rather than downward ones. Using Lantus for my basal, rather than rapid acting insulin on the pump, made a BIG difference here. The only time I had to think about lows was when I had mealtime insulin on board.

Gotta say, it was also just awesome to sprawl out on the couch or in bed and not feel that chunk there in my pocket. And I loved having a little less weight in my pockets every time I left the house.

Overall, my blood sugar levels were just as good on injections as they were when I was pumping.

But shots were definitely a LOT of work. Although I carried my pen around with me in my pocket everywhere, I don’t shoot up in front of others. So I really had to make a point of finding a quiet corner to do so when I wanted to eat or correct a high blood sugar level. Speaking of, morning blood sugars were a LOT harder to manage. I didnt have the flexibility of increasing my basal insulin to cover the morning rise after I woke up. I often found myself giving at least 3 corrections after breakfast to bring me back into range. If I had stuck with injections for longer, I would definitely basal test with a few extra units of rapid acting insulin to cover the morning rise.

My pump break definitely reminded of something that Ginger at Diabetes Daily wrote recently. She says that neither pens or pumps were perfect, and that we were choosing between the flaws that bothered us the least. I couldn’t agree more.

For me personally, an insulin pump is a LOT more work than injections. Keeping on top of site changes, dying batteries and insulin cartridges, and having to be on my game in setting basal rates around my activity. It’s more careful thinking about what you’re doing. Not to mention the extra chunk in my pockets pulling my shorts down!

But a pump also offers me more convenience when I’m on the go, more precision in my basal rates and greater flexibility with insulin dosing to cover different kinds of meals.

For the time being, those benefits outweigh the flaws when managing my diabetes.

The First Hypo of 2017

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I went seven days into the new year without a hypo. And then this happened…

My blood sugar level was 8.8 an hour after dinner on Saturday night. I let things be and went about brushing my teeth, clearing the debris of diabetes waste on my desk, and putting away the clothes and shoes I had worn earlier in the day.

When I checked my blood sugar an hour later, my meter came back 19.8. What? I couldn’t believe I had risen so quickly in such a short space of time. I probably should have tested again, just to be certain.

I entered the reading of 19.8 into my insulin pump so that it could suggest a correction dose for me. I reactively overrode my pump’s suggestion, giving the whole correction dose and ignoring insulin I had on board.

When it was time for bed, I suspected as much. Sure enough, my meter came back with a 2.9. I reached for my insulin pump, which told me I had 3 units of insulin on board to eat my way out of.

I shoved four Chocolate Cream biscuits into my mouth, struggling to recall how many I had eaten by the time I got to (what I think was) number 4. Side note: Christmas biscuit tins are proving to be awesome hypo supplies. Unless they’re tins of shortbread. Shortbread is simply too good to waste on hypos…


I shuffled into the kitchen to weigh one of the biscuits, just to be sure that the serving size was right and I had eaten enough carbs.

As I lay down on my bed, and placed the back of my head on the pillow, the hypo really hit me. The sweat, the shakiness, the feelings of exhaustion, the paralysis. I didn’t want to do anything else other than lie there, willing my eyes not to shut.

Those hypo feelings weren’t subsiding, but almost half an hour had passed and I knew it was time to check my blood sugars again.

My meter came back at 1.8.

I frantically shoved another 2 biscuits in my mouth. My hypo brain decided that those Chocolate Cream biscuits needed to washed down with a glass of Cadbury drinking chocolate. I shuffled my way into the kitchen, driven only by the cravings of chocolate milk. Stirring the powder and the milk together in my glass was absolutely painful. Making sure I scraped every visible bit of powder stuck to the bottom of my glass in my stirring action, and waiting for it to come to that perfectly blended consistency before I could skull it down.

Satisfied, I shuffled back to my bed, once again waiting. The next check came back at 3.6, followed by a 4.7 minutes later. I knew I had overtreated. Not wanting a repeat of the night’s events, I set consecutive alarms for the next three hours until I had brought my levels back into range.

Post Pizza Lows

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I had Pizza for dinner on Sunday night. Coincidentally, it was a meal identical to the one I’d eaten for dinner the Sunday prior.

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Pizza is one of those foods that I could simply eat and eat and eat, and easily lose count of how many slices I’ve had. I’ve been playing around with extended boluses on my pump a lot lately. Although I was extremely tempted to eat more, I behaved and stuck with two slices to keep my experiment on par with the pizza I ate the weekend prior.

Last Sunday, I had estimated 30g of carbs per slice, and gave a 30/70 split bolus extended over 4 hours. I went low on the tail end of the bolus, which carried through into the night and left me hypo again after midnight.

This week, I went for 25g of carbs per slice, and gave a 40/60 split over 3 hours. Levels were smooth sailing through the first two hours of the bolus. By the time I entered my third hour, insulin for 40 of the 50g of carbs had been delivered. Levels were still steady, and I had an inkling that I needed to cancel the remainder of that bolus.

Intuition proved right, and I was bordering on hypo territory within an hour of cancelling the bolus. By some strange miracle I managed not to over treat my hypo, and ended up at a perfect 5.9 mmol by bedtime.

By 1.37am, I found myself slightly hypo at 3.8. Being uber cautious not to over treat once again, I ate 5 skittles. When I woke up at 5.45am, my blood sugar was 3.4. I honestly don’t know what I felt more guilty for – running low for more than four hours or for sleeping over it.

You know how some people with diabetes say that certain foods just aren’t worth the effort? I’m starting to think that Pizza might be mine.

When I want to eat a donut, I can simply back up the math with a pre-bolus and avoid the skyrocketing levels.

But with Pizza, the effort is full on.

The low defies logic. I’m struggling to understand how I could end up so low. I find it impossible to believe a slice of pizza had fewer than 20g of carbs in it. I’m doubtful I need to spread out my extended bolus for longer than 4 hours. No matter how many different variations of extended boluses that I try, I always seem to end up low on the tail end.

Then there’s the night spent warding off lows. It’s been a while since I’ve had a night like that one. Sure, I still wake myself through the night to check my blood sugar levels. Some nights small correction doses are needed. But I normally go back to sleep and wake up in range by morning without even remembering anything. Nights where I wake up sweaty and shaking are a rarity these days. Yet an extended insulin bolus that runs much closer to my bedtime than normal, was enough to bring me back to the days of Lantus lows.

I never thought I’d say it, but maybe the day has come that Pizza is not so bolus-worthy anymore.

Dawn Phenomenon, Breakfast, Physical Activity and Diabetes

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A couple of months ago, I wrote about the relentless hypos I was having at work. There have been days where my blood sugars have been bouncing up and down like a yoyo. The smallest insulin correction would be enough to send me plummeting within half an hour. My Libre would then show me rebounding after a hypo (and I now know that the Libre tends to pronounce movements in my BGLs). I would have the urge to correct it again, only to end up low once again. This seemingly vicious cycle made it impossible to obtain a steady line while I was at work and left me feeling exhausted at the end of the day.

The one thing I genuinely do miss about injections is that insulin sensitivity during physical activity was hardly an issue. I don’t remember having to pay half as much attention to my diabetes at work while I was on injections. I’ve felt very conscious of the number of times I’ve had to tend to diabetes in a day. Unlike a Lantus injection, my pump delivers basal insulin in tiny amounts throughout the day as I’m working. In addition to physical activity, dawn phenomenon and breakfast boluses are also thrown into my morning diabetes equation.

After a lot of trial, error, and notes in my diary, I finally feel as though I’ve got my mornings down pat in recent weeks.

The obvious one has been making sure that my basal rate is right. I cannot stress how difficult morning blood sugar levels are to manage if I do not wake up in range. No amount of correction seems to be able to fix them, and I end up really grumpy at 8am as I see my levels soaring after breakfast.

A couple of weeks ago, I noticed that my levels were climbing at around 3am each morning, warranting a change in overnight basal rates. Until that was fixed, I wasn’t able to properly focus on the mornings. Another thing I’ve learned is that my waking basal rate (when my liver begins dumping extra glucose) needs to run for at least a full hour before I wake up. Even a gap of 15 minutes is enough to screw up my morning basal test. Going on intuition seems to have done the trick in fine tuning the remainder of my morning basal rates.


Breakfast really has been a case of trial and error. I’ve learned that I do not need to subtract any carbohydrates from my breakfast insulin dose. Subtracting 5g from my breakfast dose is the difference between a post prandial result of 9mmol or a post prandial result of 15mmol. My pump will also add a correction dose to my breakfast bolus if my blood sugar level is over 7mmol. 


I’ve learned that I need to ignore it unless my blood sugar level is above 8mmol, and that I need to subtract insulin accordingly if my blood sugar is lower than 6mmol.

Morning coffee at work normally happens anywhere between 8.30 and 9am. My medium cappuccino with no sugar probably has around 15g of carbs, 10g of which I do not need to bolus for. It’s been so hard to wrap my head around these tiny insulin doses, but they are indeed enough! Pre bolusing is also not necessary, as I slowly sip my hot coffee when it first arrives.

Morning tea comes anywhere between 10 and 11am, and is usually a banana which is weighed before I leave home. Again, bolusing for 10g less carbs seems to do the trick, as do the rules for correcting.

Not foregoing what I love in the mornings has been really important to me. It would have been easy to simply forego breakfast or the morning coffee, but I know that would have made me unhappy (and hungry!). I work diabetes around my life and my activity, and not the other way around.

It’s been a lot of hard work, but I do genuinely feel that I have my mornings down pat. Instead of going up and down multiple times in a day, it might happen 2 or 3 times in a week. Levels are also looking great, thanks to continued pre bolusing and my moderate carb approach. I plan on taking a break from my Libre after today, and I’m quite confident that I will be able to manage just fine on finger sticks for a while.

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