November 4, 2007

Debugging Unexpected Blood Sugar Highs

Every time I get things working, as far as balancing food and insulin, something changes and I get knocked back to square one. And, surprise, surprise, it has happened again.

Out of the blue, last week, I started seeing highs after meals using doses of insulin that up until then had matched specific food inputs perfectly. Over the week they've gotten worse until yesterday I spent most of the day well over 150 mg/dl and partly over 200, though I used more insulin yesterday than I've ever before used in one day.

I checked the Usual Suspects that I always consider when my blood sugar goes blooey on insulin, which I'll list here:

1. Meter problem: I tested highs on two different meters with strips from two batches and they matched within 4 mg/dl. No meter problem. (Of course, I washed my hands after seeing the first high, to make sure I didn't have sugary fingers.)

2. Insulin problem: Because I use very small doses of insulin, one vial or pen can last me a very long time. But over the past two years I've learned that any vial of insulin that gets used 3 times a day can deteriorate after six weeks, even if I've only used 100 units out of the 300 in the bottle. Sometimes I can see tiny crystals in the previously clear insulin. Sometimes I can't see anything, but replacing the vial or pen solves the problem of mysterious highs.

I replaced both my R and my Novolog pen with new ones. The problem did not go away.

3. Getting Sick? Sometimes we see rises in blood sugar days before we get sick.

I did end up developing a nasty viral outbreak in my mouth this past week, which is something I get from time to time. But I'm not sure that would be enough to cause the dramatic deterioration I'm seeing. I've had it before without seeing highs. And the outbreak is clearing up while the blood sugars are getting worse.

4. Carb Creep/Wrong Carb Insulin Ratio: Is that 30 grams of carbs really 60? Sometimes we get sloppy with our carb counting.

I thought that might be the problem, but yesterday I weighed portions and had a very good idea of what I was eating and saw crazy high numbers. More importantly, the timing of the highs was really strange--with the highest reading almost 3 hours after eating and injecting Novolog. When I did a Novolog correction at 3 hours, I ended up with a wicked low an hour later. This is NOT the usual pattern I see at all, but it does require further investigation.

5. A Change in Meds or Supplements: Any medication or supplement we take, whether for diabetes or not, can impact on our blood sugar.

In this case there were two obvious suspects. The high blood sugars started before I stopped taking Metformin again, and ideally I should have NOT stopped taking metformin when I developed highs, because my blood sugar will go up a bit without metformin, though not a lot. But I had no choice, as the Metformin was giving me continual burning stomach pain and I was also feeling very exhausted after taking it, which is something that had gone away when I stopped taking it before. So I decided that I had to stop taking it, because it was clearly not helping me out anymore.

But that said, I had stopped taking Metformin for several months only a few months ago without seeing dramatic highs. Usually I see a rise of about 10 mg/dl in fasting blood sugar and maybe of 20 mg/dl after eating when I am not taking Metformin. In the past, to correct for this I had only had to add another unit or so to my dose at meals, and 1.5 unit of NPH at night to knock down the fasting blood sugar. This was nothing like the 50-70 mg/dl rise I have been seeing this past week.

A I blogged earlier, I have also recently started taking 1000 IU of Vitamin E, which initially was causing lows which stopped after a week or so. Then after reading up about Vitamin E I added 2 Calcium/Magnesium supplement pills to my daily regimen, since it turns out that without available Cal/Mag Vitamin D may store metals in your bones. Hmmmmm. Needs further investigation!

6. Too Much Insulin Causing IR? It's one of the ironies of insulin use that if you use too much insulin the body may get into a counter-regulatory mode where surges fight and flight hormones push blood sugar up out of the low range and the body becomes more insulin resistant out of self-protection. I have always had a huge problem with unwanted counter-regulation in the past, which is characteristic of MODY-2, the kind of genetic diabetes I'm currently being tested for.

So this idea isn't so far fetched. When I figured out the right dose of Lantus to use to avoid hypos last year, I saw very high post-prandial numbers--and that was why I stopped the Lantus. I have been using increasing doses of NPH for the past month to try to get my always high fasting bg down and had added a unit or two every morning, too. Requires investigation.

7. Deteriorating Beta Cells: While this is not a likely explanation, we can't rule out that something may have caused my beta cells to shut down or otherwise misbehave. I don't think this is likely, because the last time I stopped using insulin (with a very low carb diet) my post-prandial control was a lot better than it had been 2 years ago when I started insulin, suggesting that beta cell rest had given me more function in my beta cells, not less.

Into Debugging Mode!

Since I come from a computer engineering background, I'm familiar with the techniques used to debug problems that develop in large, complex, poorly documented systems. So now it's time to sort out what might be causing these highs.

Key to doing this is the basic debugging concept: When there are multiple possible causes for a poorly understood problem, go back to something that works (if possible) and then change one thing at a time and see if you can reproduce the problem. Start with the most likely and work back to the least likely.

So here's what I'm gong to do:

1. Cut out everything that looks like it might be causing the problem: the Vitamin E/Cal/Mag supplementation, carbs, and NPH. I can do this because I am fortunate to still have some natural insulin production left. A Type 1 could not cut out a basal insulin, because cutting out the basal could make them very, very sick.

2. Cut carbs way, way down and stick to foods where I'm certain about the carb count. My most recent stint of low carbing wasn't that long ago. I was able to stay between 95-120 most of the time if I kept my carbs under 12 grams per meal and 6 at breakfast, a la Bernstein diabetes diet. I have some other problems that this diet makes worse, but for now I'm going to eat that way to get to an acceptable baseline. It mostly eliminates the problems caused by mismatching insulin to meals.

3. Add back one suspicious element at a time to see if I can determine what is causing the problem. Here's my thinking:

a. Add nighttime NPH. I started using NPH at night when I was off Metformin before because without Metformin my fasting blood sugar is always around 100 or more. It did not seem to cause a rise in my day time blood sugars. Because my fasting bg on a Bernstein diet will quickly go up to 110-120 mg/dl I want to address the high fasting value first before doing anything else.

If after doing this I don't see daytime highs:

b. Raise the number of carbs I eat in each meal gradually using my old reliable R insulin and my usual Non-Met carb/insulin ratio (1:10-1:12). Use measured portions of foods I'm familiar with. This should quickly tell me if using the wrong carb/insulin ratio was the problem.

If this solves the problem of daytime highs:

c. Add back the Vitamin D and Calcium/Magnesium.

If this doesn't cause daytime highs:

d. Add back the morning NPH dose.

Obviously, if one of these elements DOES cause the daytime highs, I'll have to stop using it.

I should wait a couple days before introducing each element.

Obviously, this is all a pain in the neck, but when I'm done, I should have a better idea of what is going on. I hope! If the problem was that I'm really about to come down with a cold, I might add everything back in and not reproduce the problem, but that works too.

Any other debugging suggestions from you folks who live with this crap day in and day out?


nonegiven said...

You said the vitamin d made you less resistant? Maybe that effect is only temporary.

Lili said...

How about hormones?

Jenny said...


I'm at the age where the only hormones I have come from pills. My hormone regimen hasn't changed in the past couple months so I don't think that could cause a sudden change.

If I were under 55 hormones would be a major factor.

Jenny said...


I had the same thought about the Vitamin D effect being temporary.

It's possible that it is temporary or that it somehow causes a counterregulatory upsurge. But there were just TOO many variables here so it's fruitless to speculate.

That's one of the huge mistakes medical researchers always make. They study one factor without controlling for a ton of other stuff. So they say, "Meat causes cancer" based on questionaires about how much meat people eat but forget that they are eating potatoes and rolls with the meat, hence it is possible that the carbs cause the cancer, not the meat.

Bad Decision Maker said...

hey Jenny,
It's nice the way you've laid out the list of possible problems/solutions. Sometimes when things aren't going well I get frustrated/burned out/overwhelmed and it's hard to figure out what to do next.

There is one glaring thing missing from that list to me: insulin absorption. This is a bigger deal and more problematic from insulin pump sites, but can definitely be an issue with shots as well. I am having major problems with this right now, and your high 3 hours after eating & injecting and then low after that is suspicious to me for delayed or erratic absorption.

I assume you would've mentioned if you switched injections sites (eg arm to leg), but that's one thing to look at. Different tissues will have different absorption and you may need different doses. It obviously depends on your individual body, but I've heard stomach (including side love handle) sites are the best - quickest absorbing and least variable sites. Arm sites are next best, and then legs/hip/butt. I personally find my arms and stomach to be similar but have TERRIBLE absorption from butt or leg sites or shots.

Another thing is scar tissue. Insulin causes tissue changes where you inject it. Maybe you have built up scar tissue in your usual injection sites and need to give them a break for a while while you try a different site. Usually you can feel with your fingertips that the tissue feels different - possibly harder (this hasn't been the case with me though - my tissue is acting like scar tissue but doesn't feel like it to the touch).

Hope you get it figured out soon.

Jenny said...

Bad Decision Maker,

That is a very good point! I am aware of the difference in injection sites. I had to stop using the tummy because I was getting huge, hideous bruises there. I have been using the upper leg for the past couple months but changing the site each time. I use only 2-3 units at a time and so far no lumps or other signs of problems. My understanding is that scarring is more of a problem for people who have been injecting for many, many years.

But I'm really glad you mentioned this as an issue as it can be a big one!

Jen said...

Hi Janet,
I used to be on your contractor's discussion group in 1999 & 2000.
We meet again.

I'm wondering if weather change could be at the cause of higher bg readings. Here in FL, we had temps in the 90's. Now they are in the 60's. I suspect you've had some temperature changes in MA also. Or perhaps you've had more stress than usual; stress can cause BG to go up.

Paul said...

Something rang a bell for me - the viral outbreak in your mouth. My own experience is that I went from good health to a health crash starting in 2003 (including development of prediabetes even though I have always been low end of healthy BMI). It has been a rocky road since then and I have come to depend on my own health investigations, and recently started to wonder about systemic bacterial infection (two pointers - I had a big dose of intravenous antibiotics in the six months prior to my decline, and I have developed gum disease on top of other stuff in the interim).

There are no certainties of course but sometimes small insights can lead to beneficial changes. If you did decide to focus more on oral health and need some tips, there's a book by Senzon on natural methods for oral hygiene, Panasonic have a $35 oral irrigator on Amazon to soup up cleaning, it's good to chew on licorice root, eucalyptus leaves, sage, and finally try swishing with tinctures of goldenseal or calendula. I also chew on raw garlic now!

p.s. I was very interested to see your Good Germs Bad Germs book review - just received my copy.

Jenny said...


Those were the days!

Your point about weather is a good one. Bernstein does say that cooler weather can raise insulin needs.


There's very good evidence that bacterial infections in the gums can raise blood sugar a lot.

This is a viral thing I've had periodically since the early 1970s when I lived in a communal situation sharing tableware. I've shown it to dentists and they have all pretty much said it is a viral thing and there isn't anything you can do about it. Once you get it, the virus lives inside the body and emerges from time to time.

But since I have had it for years, I know it doesn't raise my blood sugars.


On day 2 of very low carb eating (20 grams max) my blood sugar is staying between 100-110 mg/dl which is about what I'd expect based on previous stints of low carbing. It's about 10 mg/dl higher than it would be with Metformin.

So I don't think infection is at work here, because the baseline looks pretty good.

My diabetes is characterized by near-normal fasting bgs and very little post-prandial secretion. So I'm going to give it one more day at the very low carb level. Then tomorrow I'm going to carefully test my insulin/carb ratio using the R insulin that is most predictable for me and see if it has changed.

Jen said...

The date of your post about unexpected BG highs was on November 4. Hurricane Noel caused power outages in MA on Saturday & Sunday (Nov 3 & 4). I believe you live in Springfield - about 123 miles away from Plymouth (as the crow flies would be shorter).

Here in FL, we had 4 hurricanes in 2004. I noticed changes - even before the hurricane was close like humidty increase so our air conditioner at the time could not keep up with the humidty. Hurricane system is fairly large and effects on the weather cover a large area.

So if your BG went up around Nov 3-4 (or as the hurricane approached Cape Cod / South Shore MA), I suspect hurricane Noel had something to do with it.


Jenny said...


Actually we completely missed the weather pattern the hurricane brought. All it did was destroy the undefeated season of my poor old UMASS football team that had the misfortune to be playing at the University of RI right in the teeth of the storm.

I'm almost an hour north of Springfield, very close to Vermont. We have mountains separating us from the coast.

I don't know whether that kind of weather would affect blood sugar. I was at my due date with my second child when we had the biggest hurricane to hit the Northeast (Gloria in 1985). We lost a bunch of roofs in our neighborhood and were without power for a week, but I did not go into labor, but just drifted into a very deep sleep and woke up after the hurricane had passed. Scared my poor husband, though, since he was wide awake!

Paul said...

You know a lot more about it than I do, that's for sure. But if gum infection is bad for blood sugar, then doesn't that mean any bacterial infection is bad e.g. blocked sinuses. And I read that gum disease (hence bacterial exposure) is associated with heart disease, dementia, and depression as well as poor blood sugar control. I wonder if there's a common mechanism. I may just not have been reading the right things but I feel I hardly saw any mention of the tie-in between bacteria and blood sugar, feels like it should be higher profile,

Anonymous said...

I am having my second episode of high readings and am using 5mg of glipizide x2/day. The last time this happened, I took my generic pills to the pharmacy and the pharmacist threw them out and opened a fresh bottle and gave them to me. Immediate good results. Now it is happening again and the pharmacist insists it is not his tablets. Any ideas? Will check with another pharmacy to see if I can get a different generic brand. Or am I doing something wrong?