If you’ve had T1D for a while, I’m sure you’ve noticed that good blood glucose control can be quite periodic in nature. At least that’s how it is for me. A good day with a nice time in range (TIR) is likely to be followed by another (at least semi-decent) day. Sadly, this is especially true for the opposite as well. If my BG spirals out of control, it might take several days or even weeks to get everything back under control again. If this is the situation you’re finding yourself in right now and you just don’t know where to start, then you’ve come to the right place. This post will tell you just that, and more.

It almost goes without saying, but I’ll do it anyway: it’s impossible to generalize exactly how everyone should treat their diabetes. This is by no means an exhaustive guide. It has also been written from a CGM + insulin pump perspective, so that may affect it’s overall usefulness to you as well. Nonetheless, my hope is that I can still give you some good tips here and there that may help you get back in control again.

With that out of the way, let’s start by going through some of the basics.

The periodicity of diabetes treatment

Let’s face it. There are simply too many factors that can affect your BG at any given moment. Carb intake, fluctuations in insulin sensitivity, exercise, stress, active insulin, accuracy of carb counting… The list goes on, and it’s important to realize that for most, if not all people, solving a problem with this many parameters is bound to be complex and hard. Now, what does this have to do with the periodicity of good and bad BG control? Well, if you get just one of these “inputs” wrong, it will affect your BG in a negative way. The detective work of trying to find out what has gone wrong begins. And having a soaring BG that just wont come down or that keeps bouncing back and forth between extremely low and extremely high is quite an undesirable state, so we often become impatient and try to tweak everything at once, unknowingly obscuring the original source of the issue. As a result, the downwards spiraling trend of poor BG control continues and eventually it becomes hard to figure out how the hell to get back on track again. The same goes for good changes and upwards spiraling trends of good BG control. Once you hit a sweet spot with one of the many parameters you can tweak (finding the correct basal dose, ISF factor etc.,), it slowly becomes easier to identify and tweak any remaining parameters that might be off. The changes start snowballing and eventually you’ll get a few days of more or less perfect BG control. That is, of course, until something changes again. But that’s the periodicity of diabetes!

Get in the right mindset

If you wish to get back to a state where you are in control of your diabetes instead vice versa, you must first get in the right mindset:

• Don’t panic. You have a serious, complex illness that takes a lot of work and time to figure out. It’s going to be with you for a looong time, so the sooner you start viewing mistakes as opportunities to improve rather than something bad to blame yourself for, the better. It’s ok for your BG to be crap for a while. It wont matter even the slightest in the long run as long as you eventually get out of it and regain control.
• Be patient. It takes effort and time to solve complex problems and your T1D treatment is no different.
• Be methodic. Just as in research, you have to be highly disciplined and methodical in your work or else you might miss all those little details that matter the most for the outcome. Adjust one thing at a time, make a note of what happens and repeat until you get everything right.

Fix your nighttime BG first

Once you have the right mindset it’s time to simplify the problem at hand by eliminating as many variables as possible. For most of us, there is one big chunk of time during any given that that typically has fewer factors affecting the diabetes overall: night time. It’s a long stretch of perhaps 6-9 hours where your carb intake is, if not completely eliminated, at least a lot smaller than the rest of the day. As a conseequence, the need for boluses should be smaller. Physical activity is also generally low at this time. In fact, the only thing you should have to think about during nighttime is your basal rate (or your long acting insulin dose if on a pen treatment) and this is exactly why fixing your sleep is the very first, logical step to fixing all of your current BG control issues.

Actually, there are more reasons why fixing the nighttime BG first makes sense as well. The payback is rather large, for example. If you get it right, you will sleep better, wake up more well rested and get to start your day with an already good BG, ultimately having one less problem to think about straight away. But it doesn’t stop there! Perhaps the single greatest benefit of fixing your night time BG is the amount of time you’ll get in range once you succeed. If you sleep the generally recommended 8 hours a day, that’s one third of your day with your BG in range already before having woken up.

So, you’ve zeroed in on your nighttime BG. What now? Assuming you have a CGM, review your nighttime BG curve every day. Enjoy your breakfast or a cup of coffee while you analyze what happened during the night and try to figure out how your basal rate program can be adjusted. If your BG is getting too low around 2 AM every night, perhaps add a section to your basal program that starts an hour or so before this with a decreased basal rate. If your BG goes through the roof in the early morning, increase the basal rate a little prior to that. You get the point. Simple, incremental adjustments. Then watch and see what happens the next night and keep going until you get a perfect night. Oh, and forget about those late night snacks (unless you really need them to avoid a hypo). Don’t eat close to bed time, or you’re just begging for trouble. Finally, consider how your nighttime BG is affected by what you did during the day. If you are doing more heavy exercise some days for example, then you might need a separate basal program for thay. The same goes for weekends, which typically require different overall insulin rates than weekdays.

What about the rest of the day?

When you’ve gotten your nighttime BG in control, fixing the remainder of the day will come more easily. You could try eating the exact same breakfast for a few days to figure out the perfect insulin sensitivity for breakfast time. Same goes for lunch and dinner, although I find it way too boring to eat the same thing every day. For those meals, I instead try to recalibrate and fine tune my carb counting by weighing the food before every meal to calculate the exact carbs. If I get a bad BG two or three hours later, I know I’ll have to adjust my insulin sensitivity so that the bolus calculator can get a better chance at doing it’s job well. As for the basal rate during daytime, it’s slightly more complex to figure out compared to that of the nighttime. But the same principles apply here as well. Be methodic, look at the BG in between meals, try to spot any trends and adjust your basal rates accordingly.

As you fix your BG bit by bit throughout the day, the improvements will eventually start snowballing and before you know it you’ll have the TIR you know you deserve.