Wil Dubois

Happy Saturday, and welcome back to our weekly advice column, Ask D’Mine, hosted by veteran type 1 expert and diabetes author Wil Dubois.

This week, Wil takes on a longtimer's question about the mysteries of high blood sugars -- why they happen and why they are sometimes so darn difficult to bring down.

Got your attention? Read on…

{Have your own questions? Email us at AskDMine@diabetesmine.com}

 

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Rick, type 1 from Indiana, writes: I am a 59-year-old male who’s had diabetes for 42 years. My A1C is hanging in the upper 5’s these days, but I have had long periods of much greater A1C’s. For the last 15-20 years, however, I have been well-controlled, never exceeding an A1C of 7 and sometimes (last five years) I have been in the 5’s consistently. In the last year, I have noticed that I am chasing the occasional higher blood sugar with more Humalog than usual. Of course, if I cover correctly it seems to take even less Humalog than when trying to bring it down later. So what gives? Why do I have to use more Humalog to bring a lingering high blood sugar down than is required if I catch it earlier? By the way, why do I get high anyway? I mean, yeah, that kind of high? The kind of high no one wants, and we do not even try for. 

PS: I love high humor, do you know any good high jokes?

Wil@Ask D’Mine answers: So a priest, a rabbi, and a diabetic go into a bar in the Alps…

Actually, sorry, Rick, no. I don’t think I have any good high blood sugar jokes. But your blood sugar control is no laughing matter. It’s awesome. You should be proud!

So you’ve really got three questions woven in here: Why do highs happen despite excellent diabetes control skills and tools? Why do corrections take more insulin to fix than the amount of insulin that could have prevented them? And why would blood sugar issues all of a sudden become more common after being sort of a non-issue for years?

I think we have time to cover all of those this morning.

High blood sugar readingYou are 100% correct that for many of us, it takes more insulin to fix a problem than to prevent it. There are several reasons why—but they are connected—and it comes down to location, location, location.

The location of the sugar, and the location of the insulin.

The insulin we T1s use doesn’t enter the blood stream directly like it does in sugar-normals. Instead, we inject it into fat and it eventually works its way into the blood stream.

Slowly. 

Meanwhile, let’s consider the sugar’s location. If you have a high reading on your meter or your CGM, your blood stream is coursing with sugar, while if you are eating, the digestion is just starting, and the sugar is still partly locked up in the food and just beginning to enter the blood stream. The timing just works better with meals. The insulin, getting on the job slowly a little at a time during the digestive process, matches better with the slow infusion of sugar, and it only takes a modest amount of insulin to properly process the glucose into the cells, keeping it out of the blood stream.

On the other hand, if your blood is flooded with sugar, a little bit of insulin, coming on the job slowly, is going to make slow progress—if any at all. Plus, there’s really more sugar. Or at least more sugar all at once, so cleaning up a big pool of sugar takes a serious insulin mop.

Think of it this way: Let’s say the priest, the rabbi, and the diabetic have joined the Forest Service as wild land fire fighters high in the Rockies. If they want to do a controlled burn, it doesn’t take that much water to keep the fire small and where it belongs. But if a strong wind comes along, scatters the embers and lights up the whole frickin' forest, well, they’re going to need a lot more water, right?

High blood sugars are forest fires.

And just like the locations of sugar and insulin play a role in the different volumes of insulin needed for meals and corrections, there is a connection between your other two questions as well. And it’s complacency.

Especially with vets of the Diabetes Wars like you, over time, many people’s management skills begin to, shall we say, slip? Let’s see -- 42 years of diabetes is 15,330 days. Assuming three meals a day, that’s 45,990 meals you’ve taken insulin for, give or take a few. Given your stellar control, you clearly know what you are doing. But also given that recently it’s becoming challenging, I suspect you might have gone onto autopilot, winging many of your meals rather than properly calculating them.

I think the new onset issues covering meals may suggest a creeping new onset sloppiness in your diabetes control skill set.

The cure is to return to your roots. Get on your smart phone and look up those carb counts. Break out the pencil and paper and start crunching those numbers again.

The vast majority of meals gone awry can be traced to the same cause. I often hear people bemoan that the “perfect bolus” didn’t work. Really? How many carbs? How did you count them? Did you weigh the food? Did you do the math in your head or on a calculator?

Complacency. Ninety percent of the time. Complacency.

Then, of course, sometimes the truly perfect bolus still goes awry. Why? Simple: There isn’t a super computer on the planet sophisticated enough to calculate the "perfect bolus." There are just too many variables. Really, what we are doing here is trying to build a space station using stone tools and bearskins.

We often think of a meal bolus as simply matching a carb count to an insulin-to-carb ratio, but there’s more to a functioning bolus than that, never minding the fact that’s it’s impossible to actually get a truly accurate carb count of anything. Each and every “identical” plate of food in history varied from its clones, depending on its exact blend of ingredients, and even how and where each were harvested and cooked. Even plates that come from boxes and cans are still members of the Wild Kingdom, and therefore wildly different from each other.

But assuming for a moment that the magic carb-counting wand is finally perfected, our troubles aren’t over yet. Where you inject on your body affects insulin uptake speed. As does the temperature of your skin. Your body’s hormones can speed or slow insulin onset, while that tricky liver is sometimes adding sugar to the mix and sometimes isn’t. Your metabolic rate varies from day to day. Caffeine levels, alcohol levels, and anything recreational that makes you high can all interact with the dance between sugar and insulin. 

And that’s just the tip of the iceberg.

Different insulins have slightly different action curves, and do we really know that it’s the same stuff from bottle to bottle and pen to pen? And even if it is “perfect” leaving the factory, how did it travel to you? How does it travel in you? How old is it? How long does it take you to use an open vial?

The bottom line here? It’s by no means hopeless. We get it right and overcome these overwhelming odds frequently. But other times, it goes hopelessly awry—from one of these hidden variables, or a pack of them working in concert against us. A mystery blood sugar spike isn’t like the Bermuda Triangle—it has a real cause. It’s just that the cause may be so subtle and twisted that we can’t fathom it, much less have predicted it in advance.

Well, that really killed the mood, didn’t it? I better lighten things up.

So a priest, a rabbi, and a diabetic walk into an insulin factory…

 

Disclaimer: 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.

Disclaimer: Content created by the Diabetes Mine team. For more details click here.

Disclaimer

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.