Using insulin is an art, not a science. Whether it's finding the right time to inject or finding the right dose to take, our Ask D'Mine host Wil Dubois, veteran type 1, diabetes author and community educator, explores just how individualized the options can get...

{Need help navigating life with diabetes? Email us at AskDMine@diabetesmine.com}

 

Amber from Oregon, type 1, writes: I've had type 1 diabetes for almost two years and recently started a new job. Once the training period is over my shift will be 8:45 pm-7:15 am four days a week.  I've worked nights before, but that was before diabetes. My question is: how will this affect my diabetes, and what can I do to keep my blood sugar under control? I plan on checking my blood sugar frequently to see if I need to adjust my insulin doses (I use Lantus and Novolog). Is there anything else I should do? Any tips would be much appreciated.  Thanks!

Wil@Ask D'Mine answers: I don't envy your new working hours. Uck. But how living like a vampire will affect your diabetes depends in large part on how well your therapy matches your diabetes in the first place. In theory, if your Lantus dose is right, you could be shipwrecked on a deserted island and have perfect blood sugar control until you starved to death talking to a volleyball. The job of basal is to keep your blood sugar in good range while sleeping, and between meals when awake. It shouldn't really matter when you sleep and when you eat. Theoretically.

But unfortunately, diabetes theory almost always breaks down in the face of the real world. So you're smart to plan extra testing while you adjust to your new nocturnal life.

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I think the biggest factor that will impact your blood sugar is what hours you will keep the three days per week you're not working. Are you planning to live your whole life at night? Or are you going to try and have "normal" hours on your days off? Shifting back and forth will be wicked for your body, and thus for your blood sugar control, but your options may be limited depending on the working hours of the other humans you share your life with.

FYI to readers: I touched base with Amber, and right now she shoots her Lantus at bedtime, which for her has previously been 10 p.m. That's about an hour and a quarter after she'll get to work on her new schedule. She could still take her Lantus at work, but it's a hassle and not really necessary. As Lantus is essentially a time-release insulin, with a good 24-hour duration of action in most folks. It really doesn't matter much when you take it. Morning, noon, or night. But you really need to take it at pretty much the same time every day or you risk Gaps and Stacks.

Gaps happen when a basal shot is late to the party. The previous shot can run out of steam before the next one arrives at the station, causing high blood sugar. (OK, OK, I'll quit mixing metaphors while changing hats on my horse in the middle of the stream).

Stacks happen when a basal shot is taken while the previous shot is still on the job, causing low blood sugar.

Amber: as your schedule is changing and likely to be erratic, you need to pick a time of day when you can take your shot everyday: workday or restday. Once you pick your time, I'd suggest you set a cell phone alarm to remind you daily for a while until you get into the new habit. I'm told it takes 30 days to make or break a habit.

The only other thing worth mentioning is that insulin to carb ratios tend to be different for most type 1s at different times of the day. Whether those patterns are pegged to the rising and setting of the sun and moon, or to the tides of the hormones inside your own body from waking and sleeping patterns is anyone's guess. For some people, their IC ratio goes up as their Lantus wears off. So I suspect you might get some unexpected results at first. Let trial and error be your guide on this one. Play close attention to your postprandial numbers while you discover the effects of your nocturnal Novolog on your moonlight banquets.

Note: Beth also shares her brand-spanking-new medic alert tattoo with us, telling D'Mine: "I chose my left wrist because I am left-handed and that is where I usually wore my bracelet when I remembered it."

 

Beth from Indiana, type 1, writes: I am severely insulin resistant and my doctor has tried everything under the sun with not a lot of success. I am on a diet and I exercise regularly. I only weigh 103 pounds and wear a size 1. For being almost 5 foot 6, I cannot afford to lose any more weight. I take 20 units of Lantus two times a day and I am on a pump with Humalog, but still I am almost always in the 200s. My last A1C was a little high at a 9 but for me that is pretty good. I have always been at or around a 12 since I was diagnosed at age seventeen. I am now almost 29. I just really want to know what else I could do to get my blood sugar lower. I work full time and have 3 children that keep me on the go at all times and I just want to get healthy so I can be here for them for a very long time. Thanks for your advice in advance.

Note: Beth also shares her brand-spanking-new medic alert tattoo with us, telling D'Mine "I chose my left wrist because I am left-handed and that is where I usually wore my bracelet when I remembered it."

Wil@Ask D'Mine answers: Yes, readers. You read that right. Beth uses both an insulin pump and takes basal shots; I wrote her back to make sure! That's a slightly wild approach, but it can work. She also shared with me her almost type-2 like insulin to carb ratios, which are pretty amazing given she's literally one hundred pounds soaking wet. But that's what makes diabetes so interesting, we're all different and the condition is full of surprises.

Insulin resistance is usually tied to weight gain. The more you weigh, the higher your insulin resistance. Bigger people tend to need more insulin and smaller people tend to use less insulin, and Beth is living proof of the need to use words like "usually" frequently in the world of medicine. Your mileage may vary, and Beth, your mileage really, really, really varies!

I don't know what is causing your insulin resistance, but it sure as hell isn't your weight. Given how thin and light you are, even if it were healthy for you to lose more weight (it isn't), I don't think it would help. Your BMI is only 16.6, making you seriously underweight as it is. Why is a tiny little thing like you so resistant to insulin? Beats the crap out of me. It might be that you have a predominance of small particle LDL cholesterol to match your small waistline; that's been linked to insulin resistance. The small particle LDL that is, not the small waistline. But I don't think the cause matters, it's just an underlying fact. I think we should focus on treatment.

So Beth is practically drinking insulin and it really isn't having much luck keeping her sugar down.

Here's the deal: unlike almost any other medications in the world, there's no maximum dose of insulin. It isn't possible to overdose solely based on the number of units taken. You take what you need to take to get the job done. Naturally, if you take more than you need to get the job done, you'll suffer a low blood sugar.

Forty units of Lantus may sound like a lot for a hundred pounds of girl, but clearly, it isn't getting the job done if you're always in the 200s. My prescription (reminder: I'm not actually allowed to write prescriptions, I'm being metaphorical again) is more insulin. Why not 60 units? Or 80 units? Or 100 units?

The sky's the limit when it comes to insulin. Until you reach 250 units. Then we break out the secret weapon: U-500. No, it's not an undersea German secret weapon. I'm talking about U-500 insulin. Now, if you look at a bottle of insulin you're using, you'll notice that somewhere on it will be a cryptic legend: U-100.

That's the strength. It tells you how many active units of insulin there is in a milliliter (mL) of diluent fluid. Your garden-variety vial of insulin is 10 mL. 10x100=1,000. That's why a vial has a thousand units in it. But who says insulin has to be mixed at a strength of 100 units per mL? Actually, prior to the early 1970s in the States, we had U-20, U-40, and U-80 insulins. It was a whole wolf pack of insulin. Which of course, lead to all kinds of dosing errors when people got the wrong syringes or wrong insulin at the drug store. That's why we only have U-100 now. Well, except we don't. We also have U-500, which most PWDs have never heard of.

U-500 is super-sized insulin, kept on the market for the unusually insulin resistant. It's five times more concentrated than U-100. If you needed, say, 400 units of U-100 (and some people do), you'd only need 80 units of U-500. This keeps the volume down, which is important, as there's only so much insulin your tissues can absorb in one shot. Literally.

Your pump is not designed for U-500 but anyone who can divide by five can figure out how to reprogram a pump to deliver U-500.

Excuse me while I evade the FDA hit team.

Now, I'm not really sure you really need U-500, but it's something you could talk to your doc about. Or maybe it's time to see a specialist. One thing's for sure: you do need more insulin. Whether from pump or from shot. Whether from U-100 or new U-500. Anyone who's using insulin and is still having high blood sugar isn't using enough. It's as simple as that.

Oh, and as an afterthought, I should also mention that any time insulin doesn't seem to be working the way one would expect, it's always possible you aren't injecting it "right." You should review your injection technique with your doc. Also make sure that you haven't gotten into the habit of injecting into a favorite place—that can lead to scar tissue, and scar tissue doesn't absorb insulin very well at all, causing it to perform poorly..

Oh, and Beth... Can I introduce you to all those people who believe that taking insulin makes you fat?

This is not a medical advice column. We are PWDs freely and openly sharing the wisdom of our collected experiences — our been-there-done-that knowledge from the trenches. But we are not MDs, RNs, NPs, PAs, CDEs, or partridges in pear trees. Bottom line: we are only a small part of your total prescription. You still need the professional advice, treatment, and care of a licensed medical professional.

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This content is created for Diabetes Mine, a consumer health blog focused on the diabetes community. The content is not medically reviewed and doesn't adhere to Healthline's editorial guidelines. For more information about Healthline's partnership with Diabetes Mine, please click here.