The #3Rs technique – what T1Ds do when Reviewing and Reacting #DOC #gbdoc

The #3Rs technique – what T1Ds do when Reviewing and Reacting #DOC #gbdoc
The #3Rs technique – what T1Ds do when Reviewing and Reacting #DOC #gbdoc

Following a very positive response to the 3Rs technique for diabetes management, the questions that have been raised to me a couple of times “What am I looking out for?” and “How do I react?”.

My initial reaction to these was to suggest that they are something that one might expect a person to have a chat with someone in the Diabetes professional care world about, but then the first half of that post is about taking responsibility for managing diabetes yourself, and learning about how to manage it, so this post attempts to highlight some common patterns (Review) that can be observed in the data, and some of the things that people do to manage them (React).

I want to make it very clear that you should proceed carefully if you are not confident in making changes yourself, and you should obviously seek healthcare advice if you are unsure. Many of the common problems that people see can be resolved relatively easily, and as a result will allow you to sort yourself out more quickly. Hopefully this will give more confidence in what you are trying to achieve. I’ve tried to pull together a few of the more common ones into this post, and if you have any concerns, I’d still recommend talking to your Diabetes care team.


In the review process, what are common patterns that are often seen by people? Here are a few that we’ve seen regularly observed on the forum:
  1. Blood glucose level spikes after eating
  2. Hypos shortly after eating
  3. Hypos 3-5 hours after eating
  4. High blood glucose levels after exercise
  5. Low blood glucose levels after exercise
  6. High blood glucose levels 6-10 hours after eating when a basal test has confirmed that there are no issues with basal
  7. Constant rollercoaster blood glucose levels
  8. High blood glucose levels early in the morning
  9. Unexpected hypos within 4 hours of taking long acting insulin (often nocturnal)
This isn’t an exhaustive list, but it starts to describe some of the patterns that you might be starting to see in the review phase of the 3Rs process. There are various techniques available to try and manage some of these things, but they all require care and need some monitoring.


You’ve seen some patterns starting to appear. What are the strategies for dealing with these? Can it be done without reaching out to your HCP, at home, with you in control of your diabetes? The answer to the first question is in the list below. The answer to the second question is yes, if you are confident enough about it, but as always, if you have any concerns, speak to a Diabetic Specialist. 
So let’s look at the list of patterns, and see what people usually do in response.
1 & 2: High or low blood glucose levels shortly after eating
This is usually caused by one of two things. Either incorrect Insulin to Carb ratios or incorrect timing of insulin dosing, however this can also be a symptom of not having correct basal insulin levels.
  • Insulin timing – if you go low shortly after eating, then you may be dosing too early; if you go high, you may be dosing too late. What is “too early” and “too late”? Short acting insulins generally take 20-45 mins to work, but this can vary on a person by person basis, and the effect can vary based on the food you eat alongside the insulin. For example, a high fat and protein meal alongside the carbs will generally delay the time it takes for the carbs to have an effect, so some people may need to dose ten minutes before to just before eating.  Something with a lot of carbs and not a lot of fat or protein can have a much faster impact, and some of us therefore need to dose considerably earlier than the meal. This all requires observation and is a micro-pattern within the 3Rs model. 
  • Incorrect Insulin to Carb ratio – if this isn’t quite right, some find that they aren’t taking enough or are taking too much insulin. The easiest way to deal with this is to go away and review the BDEC On-Line system. It walks through from the basics of working out ratios to more advanced topics, such as how to adjust insulin or carbs for exercise.
  • An error in Carb counting. You may have miscalculated the carbs in your meal and ended up with too much or too little insulin to cover them. This is usually not a pattern, and more usually a one off. 
3: Hypos 3-5 hours after eating
This is usually caused by an insulin to carb ratio that is a little too high but it can also be caused by an incorrect basal level. To confirm which it is, generally people need to recalculate the Insulin to Carb ratio, as outlined above. If this is proving problematic, it’s worth checking out how to do a basal test. The link uses US units, but divide by 18 to get UK units. 
As the link says, once basal problems are identified, the way to progress is very slowly. Make adjustments of no more than 10% of total basal dose at a time and give them a couple of days to bed in, allowing observation and careful management. This is where the 3Rs pattern once again comes into play at the micro level. Unfortunately it takes patience. 
4 & 5: High or low blood glucose levels after exercise
Exercise can both raise and lower blood glucose levels dependent on a number of factors. Aerobic exercise of various types generally lowers blood glucose levels and some recommendations for dealing with it can be seen in the table below (taken from BDEC):
In a presentation from the Diabetes Professional Care 2015 conference, the following slide was also shown in a talk about exercise, which discusses something similar:
The principle for Aerobic exercise is less insulin and potentially more carbohydrate. 
Anaerobic exercise is slightly different, due to the way it requires the use of glycogen in the muscles. As a result, a prolonged period of Anaerobic exercise can result in Hyperglycaemia! In fact the tests done in various pieces of research suggest that if you undertake weight training composed of three sets, you’ll see a liver dump resulting in an increased glucose level followed by the muscles sucking the glucose back and the levels dropping again. If it’s fewer sets, the glucose level often stays higher. 
Again, the advice here is to record regularly to see how your body reacts. If high post anaerobic exercise, keep an eye on it. It may be necessary to do some post exercise insulin, but once again, small doses and test regularly to get to the right levels. 
6: High blood glucose levels 6-10 hours after eating when a basal test has confirmed that there are no issues with basal

This one is a frustrating one and is nearly always associated with the type of food eaten. This demonstrates why keeping a record of food eaten is really important. What types of food are we talking about? Generally foods with a high fat content and plenty of carbs. Immediate culprits that spring to mind are Pizza, Fish and Chips and Saucy Curry with Rice and Naan. Typically the carb counts on these foods are relatively high, but they also contain a lot of fat, and this causes two things. The first is often a decrease in insulin sensitivity and the second is a delayed action of the carbs entering the bloodstream. 
How is it  dealt with it? Firstly by learning about what actually happens in your case. For many of us, the initial absorption is followed by six to eight hours of increasing blood glucose levels. Dealing with it can be difficult, and if using MDI, you are limited to being able to inject additional doses at regular intervals post eating, to try and keep the levels down. This was up to four additional doses for me. 
On a pump, I’ve found that an initial standard bolus followed by an extended bolus seems to sort this out, with the extended bolus lasting up to six hours and having the same insulin units as the original bolus. But that’s me. To understand what happens with you, you have to go back and test while you adjust your dosing. We call it “Your diabetes science experiment” for a very good reason!
7: Constant rollercoaster glucose levels
If you are up and down all the time, it usually points to all ratios and doses not being quite right. In this scenario, it’s a case of going back and reviewing what’s going on, whether your dosage is correct, and starting from scratch. Really, this is about ensuring that your basal is correct and working from there. For most people, if it isn’t, keeping everything aligned, steady and under control is extremely difficult.
As I’ve mentioned before, firstly, the basal level needs to be correct, and to sort this out, use the basal test, then adjust insulin levels is small steps, patiently.
Once this is done, then review the short acting dosage, with the help of BDEC.
If none of these work, then start to consider changing what you eat. It may be that you’d be better of reducing the amounts of carbohydrate in your diet, and reducing the amount of insulin you need (as long as you are carb counting). As always, recording and reviewing to make sure it’s working the way you’d hoped.  
Finally, this may also be caused by absorption issues with the basal insulin that you use. If this is the case, you can try using different injection sites that perhaps haven’t been used before and consider site rotation. If this isn’t possible, you should get in touch with an HCP and look at whether a change in basal insulin is beneficial and whether you have hyperlipoatrophy . 
8: High blood glucose levels early in the morning
This is another of those patterns that can have multiple causes, and therefore different approaches may resolve it. The most common issue is likely to be Dawn Phenomenon, where the body’s hormonal system prepares you for the start of day. What you’ll typically see is an increase in glucose levels starting from as early as 3am and continuing throughout the morning. Some people get this worse than others, and it is estimated that up to 55% of all T1Ds suffer from it. 
There are limited options for dealing with DP when using MDI. Essentially, the only way to handle it is to give a correction dose of bolus insulin on waking. Correction doses are also discussed and calculated in BDEC.  If using a pump, the basal rate can be set to manage the timing of the rise, but this is done by recording and reviewing to see when this all occurs.
Other causes of high levels in the morning can include: 
  1. When on MDI can be basal insulin running out. This may be an issue if basal is Levemir or Lantus and is taken on getting up. Unfortunately, this looks a lot like Dawn Phenomenon, and often the two can be interlinked.
  2. The Somogyi effect, which is where an overnight hypoglycaemic event occurs and the body’s natural mechanisms release glucose to push the blood glucose level back up, resulting in hyperglycaemia on waking. 
  3. High carb, high fat meals eaten late in the evening, resulting in an increase in glucose levels as described under point six.
For items one and two on this list, the options are limited, require basal testing overnight to identify, and have similar options as those described in the next section.
9: Unexpected hypos within 4 hours of taking long acting insulin (often nocturnal)
This pattern may be as a result of poor absorption or incorrect dosage levels when trying to achieve a 24 basal insulin. The best way to identify it is back to the basal testing, as previously detailed. 
Having undertaken a basal test, and identified whether it is Somogyi, whether the basal dose is too high in a single dose, or whether there is dawn phenomenon, there are a couple of strategies.
If struggling with overnight hypos, then really the only answer that people have come up with is to reduce the amount of basal insulin taken, and this is done in a careful, step by step fashion. The issue with reducing basal is that it can result in later exhaustion of the basal and unexpected highs 18-24 hours later, which are often handled by extra bolus insulin. Alternatively, the timing of night time insulin can be adjusted and moved to the morning, so that observations can be made as to what happens during the day. Most people’s hormonal cycle has a greater requirement for basal insulin during the day making a hypo less likely. 
The alternative that many of us have done is to split our basal insulin into two doses. When I first did this, I split it 50:50 and through careful monitoring, adjusted the doses. Due to some issues with unexpected hypos, I eventually went to see my HCP to change insulin from Lantus to Levemir, and finally, went on to a pump.  

As mentioned at the start of this post, this is not an exhaustive list of all the patterns that are seen, but they are many of the common ones. It goes without saying that if you are not comfortable with testing and using the 3Rs to monitor yourself, then before making any of these changes, speak to a diabetic healthcare professional. Insulin is a dangerous substance, and playing with it is not recommended. 
Making carefully observed, small changes is the safest way to proceed in dealing with any of the patterns noted.

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