You only need a few days of living with type 1 diabetes under your belt to realize just how powerful insulin is. It has the power to both keep you alive for another day and threaten your life on a daily basis. Somewhere in the middle is the perfect dose your body needs in response to over three dozen variables that can impact blood sugar levels and insulin needs.
Getting the right “background” or “basal” insulin dose is a critical part of staying in your personal goal range. Without accurate basal rates in your pump, or an accurate injection dose of basal insulin, the rest of your day can feel like a frustrating and confusing mess.
Just 1 or 2 units more than you need is an emergency.
On the other hand, not having enough insulin in your bloodstream on a daily basis can leave you feeling like you’re failing at the biggest (and constant) test of your life.
Here, we’ll take a look at some very common yet subtle factors that can require some finetuning in your basal/background insulin doses!
When constant lows mean you actually need more background insulin, not less.
It’s very easy to conclude that constant lows and frequent rides on the “blood sugar roller coaster” actually mean you need less insulin, but I’m going to suggest the exact opposite is often the case.
When you’re not getting enough background/basal insulin, the foundation of your “house” is off-kilter, and you’re probably trying to fix it by taking constant correction doses after eating to get back into your goal range. This is about as helpful as throwing a couple bricks under one corner of your house’s off-kilter foundation.
Let’s imagine you’re taking 3 units of insulin via correction doses every day, spread throughout the day. It’s not the same as 3 more units in your basal rate or your long-acting insulin dose because those doses are delivered in a smaller drip, drip, drip over the course of several hours.
When you start stacking constant correction doses on top of mealtime doses, you run the risk of low blood sugars. Then, of course, if you’re overtreating those low blood sugars, you bounce up into the 200 mg/dL range again. Then you try to correct the high, and the rollercoaster ride continues.
Tip: Talk to your doctor about increasing your background/basal dose by 1 to 2 units, seeing how things go for a few days, and making another small increase if needed. For basal rates, this can be done by making a small increase in all basal rates that add up to a total of 1 or 2 units, or it can be focused on a large chunk of the day.
When your baseline stress level has gone up a few notches…even if it’s due to temporary circumstances.
Allow me to get a little in an effort to demonstrate just how much a little background stress can affect your basal/background insulin needs despite your bodyweight or eating habits.
In early 2019, I weighed about 120 pounds and was taking 10 to 11 units of long-acting insulin once a day.
By May of 2019, I had begun the process of divorcing my husband and finding somewhere temporary to live while we figured out how to separate our lives, sell our home, and acquire more permanent housing while also juggling the needs and care of our two young children.
By August of 2019, I still weighed 120 pounds but my background insulin dose had gradually increased from 10 units a day to 15 units a day in order to stay in my goal blood sugar range. Clearly, I was stressed.
(Note: increasing my background insulin did not cause me to gain weight! Instead, it merely helped me maintain blood sugar levels in my goal range.)
I was driving between 3 different towns, waking up at the crack of dawn in my “temporary housing” that didn’t have room for children, driving to our family home to get them ready for preschool, then getting myself to work, yada yada yada…while also juggling being the “realtor” selling our home without an agent, and working things out with my then-husband.
The stress wasn’t something you might’ve seen on my face. I was certainly having a lot of fun with friends and my kids despite the chaos. But my default stress level — which means my cortisol and adrenaline levels — was much, much higher than usual.
Compare 15 units at 120 pounds to today, two years later, where I weigh more at 125 pounds but my background insulin dose is only 9 units.
Why? My stress level is much, much, much lower.
Tip: If you just experienced a significant shift in your day-to-day stress level — because of a change in your home, your work, the loss of a loved one, dealing with a new medical condition, Thanksgiving with your in-laws, yada, yada, yada, etc. — talk to your healthcare team about increasing your background/basal insulin doses by 1 or 2 units. See how things go for a few days before making another small increase.
When you’ve gained weight…even just 4 of 5 pounds.
It’s extremely normal to see your weight fluctuate throughout the day or the week by a few pounds due to water retention, menstrual cycles, etc., but when that fluctuation turns into 4 legit pounds of body fat you’re now carrying around, it means one clear thing: increased insulin resistance.
And increased insulin resistance means: you’ll probably need a bit more insulin in order to stay in your goal blood sugar range.
Personally, I weigh myself no more than once a week, and I can usually tell if I’m up a few pounds based on how comfortably my favorite pants fit.
Allow me to share another personal example: In October of 2020, my 5 year old had major surgery on her bladder and her kidneys. The surgery was significantly more intense than the surgeons anticipated, and her post-op recovery went from expecting 1 week of couch-rest to nearly 5 weeks before she was stable enough to return to school. Dr. Ginger was on-hand most days while also trying to juggle work and another kiddo.
At the very same time, there was an attempted murder at the condo I own and rent out. (I’m not even kidding! Holy moly!) The stress and demands on my schedule during this time meant my entire food and exercise routine was thrown out the window.
I gained 4 or 5 pounds during the two months amidst this chaos, but it snuck up on me because of those little fluctuations on the scale that I was used to being temporary. Suddenly I realized, my baseline body weight was no longer 125 pounds but now 129.5 pounds.
You wouldn’t have noticed it much by looking at me, but those 4.5 pounds had a big impact on my background insulin needs. I raised my background dose from 9 to 12 units until I was able to shake-off those extra 4.5 pounds by returning to my usual routine.
Tip: If you’re noticing that your pants are fitting a bit more tightly, take a look at how your blood sugars have been lately, too. If you’re hovering above your goal range between meals and overnight, chances are you and your doctor may need to make a few basal rate tweaks of at least 1 or 2 units. See how those changes work for a few days before making another small increase.
When your food and activity habits change…even if you’re still very active every day!
The nutrition part of this is pretty obvious, especially during the holidays when you’re eating heavier foods and more indulgent treats in November and December.
Boosting your background insulin dose can make a big difference on your body’s ability to handle the extra carbs and dietary fat of those meals — even though you’re technically taking insulin via a bolus for your meals, too! Your basal insulin does help your body manage the food you’re eating! It’s all connected!
But the activity level thing can be a little sneakier.
Daily exercise? I get plenty, no matter the season or the amount of snow outside, but even just small changes in activity levels can have an impact on your background insulin needs.
Another personal example for you: As long as the temperature is above 10 degrees (I live in Vermont), I take my dog on 2-mile ways twice a day. In the winter, I also run or walk another 3 miles on my treadmill along with a mini strength-training routine most days.
One would think that’s plenty of exercise and my body shouldn’t need more insulin in the winter with that much activity, right?
Wrong.
It’s important to contrast your winter activity level with your activity level during the warmer months! The rest of the year, I am jumping-rope instead of walking/running on the treadmill, and jumping rope is definitely more of a full-body workout than jogging. In free-time with kids, I take them to empty parking lots where we can scooter and ride our bikes. Plus swimming with kiddos in the pool, and usually going on a third evening walk several nights a week with my boyfriend and pup. That’s a big change from my winter routine.
Tip: When winter hits, keep a close eye on your blood sugars and your frustration level with frequent highs after meals. Chances are, you’ll need a boost of 1 or 2 units in your background insulin doses, increasing again after a few days as needed. The same goes for those holiday months when everybody’s cooking extra yummy things and there’s a constant assortment of cookies around! Your background insulin does help with your body’s ability to manage the food you’re eating!
Is it time for basal insulin testing? Or just bump your dose?
Basal insulin testing is essential, but it’s also pretty tedious. If you’re not willing to do basal insulin testing too frequently, sometimes a little tweaking of 1 or 2 units is an easier approach with quicker results. However, if your blood sugars are truly all over the place or you’ve just started a new insulin regimen (like switching from Lantus to Tresiba, or from injections to a pump), working with your healthcare team on basal insulin testing is the wisest plan of attack here!
Either way, the biggest takeaway is that a tiny adjustment in your background insulin doses can make it so much easier to stay in your goal blood sugar range for most of the day! The tiny adjustment of just 1 or 2 units has a big impact! If you’ve been frustrated with highs, roller coasters, and an inability to get your A1c down a notch, it’s likely time to do some fine-tuning with the help of your healthcare team!
LEARN MORE: Exercise with Type 1 Diabetes
