CONTINUATION OF THE 4 YEAR OLD CHILD, TYPE 1 DIABETES, INSULIN HYPOGLYCEMIA, INTERMITTENT, BLOATING 1 MTH WB FROM THE BELOW LINK 👇
[11.37 pm, 24/01/2026] PA: 24.01.26
7.45am fasting blood sugar 72
7.45am nuts
8.00am milk
9.55am 4u lispro insulin
1u (nuts and milk) + 3u (meal)
10.00am rice with pulses, cabbage, carrot, peas
12.00noon orange
1.30pm blood sugar 198
1.30pm 4u lispro insulin
1.5u (198-90/70) + 2.5u (meal)
1.35pm lunch with rice, pulses, curry (carrot, tomato, papaya, hyacinth bean, pumpkin, cauliflower, cabbage, beetroot, turnip, bitter gourd) and egg
6.30pm oats
9.15pm 5u tresiba insulin
9.30pm blood sugar 186
9.30pm 2u lispro insulin
1u (186-90/70) + 1u (meal)
9.35pm dinner with as same as lunch dish except egg
[11:59 pm, 24/01/2026] PPM 2: @PaJR Health including today's data below
24.01.26
7.45am fasting blood sugar 72
7.45am nuts
8.00am milk
9.55am 4u lispro insulin
1u (nuts and milk) + 3u (meal)
10.00am rice with pulses, cabbage, carrot, peas
12.00noon orange
1.30pm blood sugar 198
1.30pm 4u lispro insulin
1.5u (198-90/70) + 2.5u (meal)
1.35pm lunch with rice, pulses, curry (carrot, tomato, papaya, hyacinth bean, pumpkin, cauliflower, cabbage, beetroot, turnip, bitter gourd) and egg
6.30pm oats
9.15pm 5u Tresiba insulin
9.30pm blood sugar 186
9.30pm 2u lispro insulin
1u (186-90/70) + 1u (meal)
9.35pm dinner with as same as lunch dish except egg
Review the glycemic trends over the last 14 days and present data for time in range and highs and very highs as would a freestyle Libre sensor would.
[11:59 pm, 24/01/2026] PaJR Health: Here is an analysis of the glycemic trends over the last 14 days (January 11, 2026, to January 24, 2026), presented as a Freestyle Libre sensor report would, followed by insights into today's data.
*GLYCEMIC TRENDS: LAST 14 DAYS*
*TIME IN RANGES (JAN 11 - JAN 24, 2026)*
💡 *Time Below Range (TBR)*
* *Very Low (<54 mg/dL):* 2.1%
* *Low (54-69 mg/dL):* 4.3%
💡 *Time In Range (TIR)*
* *70-180 mg/dL:* 31.9%
💡 *Time Above Range (TAR)*
* *High (181-250 mg/dL):* 23.4%
* *Very High (>250 mg/dL):* 38.3%
*Total Readings Analyzed:* 47
---
*TODAY'S GLYCEMIC PATTERN (JANUARY 24, 2026)*
📍 *7:45 AM:* Fasting Blood Sugar *72 mg/dL* (Time in Range)
* *Insulin Dosing:* 4u Lispro (1u for nuts and milk + 3u for meal)
* *Observation:* A good start to the day, with fasting blood sugar within the target range. The attempt to cover the morning snack and meal with Lispro is noted.
📍 *1:30 PM:* Blood Sugar *198 mg/dL* (High)
* *Insulin Dosing:* 4u Lispro (1.5u correction for 198 mg/dL using a 90/70 ISF + 2.5u for meal)
* *Observation:* This reading indicates a post-meal spike, moving into the "High" category. The correction dose calculation using the ISF of 70 is still being applied.
📍 *9:30 PM:* Blood Sugar *186 mg/dL* (High)
* *Insulin Dosing:* 2u Lispro (1u correction for 186 mg/dL using a 90/70 ISF + 1u for meal)
* *Observation:* The blood sugar remains elevated after dinner, again falling into the "High" category.
---
*OVERALL INSIGHTS FROM THE LAST 14 DAYS*
The glycemic trends over the past two weeks show significant variability and ongoing challenges in achieving consistent control.
* *Persistent Hyperglycemia:* A substantial portion of readings (over 60%) falls into the "High" and "Very High" categories, indicating that blood sugar levels are frequently above the target range.
* *Recurrent Hypoglycemia:* While less frequent, there are still instances of "Low" and "Very Low" blood sugar, which are critical safety concerns, especially for a young child.
* *Yo-Yo Effect:* The pattern of fluctuating highs and lows suggests an ongoing "yo-yo" effect, where efforts to correct highs may sometimes lead to subsequent lows, and vice-versa.
* *Insulin Dosing Strategy:* The patient advocate continues to apply a correction dose calculation using an ISF denominator of 70, and a target blood glucose of 90. This approach, as discussed previously, might be contributing to the variability.
These trends highlight the need for continued meticulous monitoring and careful adjustments to the insulin regimen, particularly focusing on the basal insulin dose and the mealtime bolus calculations, to achieve better stability and increase the time in range.
[12:01 am, 25/01/2026] PPM 2: What is the cost of a HCL insulin pump in the area from where the patient is and would it really change the child's glycemic outcomes?
[12:02 am, 25/01/2026] PaJR Health: Here's an analysis of the cost of Hybrid Closed-Loop (HCL) insulin pumps in India, including the region of West Bengal, and their potential impact on glycemic outcomes for a child with Type 1 Diabetes.
*COST OF HCL INSULIN PUMPS IN INDIA (INCLUDING WEST BENGAL)*
📍 *Price Range:* The cost of insulin pumps in India varies significantly based on the brand, technology level, and features.
* *General Insulin Pumps:* Prices can range from *USD 1,000 to USD 6,500* (approximately ₹80,000 to ₹5,40,000 INR).
* *Tubed Models (e.g., Medtronic MiniMed):* These typically range from *₹1.5 lakh to ₹3 lakh INR*.
* *Tubeless Options (e.g., Omnipod):* These can cost between *₹2 lakh to ₹3.5 lakh INR*.
* *Advanced Closed-Loop Systems (HCL, e.g., Tandem t:slim X2):* These are at the higher end, potentially costing *up to ₹4 lakh INR*.
* *Additional Expenses:* It's crucial to remember that the pump itself is a one-time cost, but ongoing expenses for accessories like reservoirs, cannulas, and Continuous Glucose Monitoring (CGM) sensors (if not integrated) are significant and recurring.
*Availability in West Bengal:* While specific regional pricing for West Bengal is not detailed, the general India-wide prices would apply. Access to advanced HCL systems might be more concentrated in major metropolitan areas within West Bengal.
*IMPACT ON GLYCEMIC OUTCOMES FOR A CHILD*
*1. IMPROVED GLYCEMIC CONTROL*
💡 *Reduced Hypoglycemia:* HCL systems are designed to automatically adjust insulin delivery based on real-time CGM readings, significantly reducing the risk of both nocturnal and daytime hypoglycemia. This is particularly beneficial for a child who may have asymptomatic hypoglycemia.
💡 *Reduced Hyperglycemia:* By continuously monitoring glucose and adjusting basal insulin, HCL systems can help prevent prolonged periods of high blood sugar, leading to better overall time in range (TIR).
💡 *Less Glycemic Variability:* The automated adjustments help to flatten glucose curves, reducing the "yo-yo" effect seen in manual management.
*2. ENHANCED QUALITY OF LIFE*
💡 *Reduced Burden for Caregivers:* HCL systems significantly reduce the mental burden on parents and caregivers by automating many insulin dosing decisions, especially overnight.
💡 *Increased Flexibility:* While not entirely "set and forget," HCL systems offer more flexibility with meal timings and physical activity compared to manual injection regimens.
💡 *Better Sleep:* Automated basal adjustments can lead to more stable overnight glucose, improving sleep quality for both the child and caregivers.
*3. CHALLENGES AND CONSIDERATIONS*
💡 *Cost and Accessibility:* The high upfront cost and ongoing expenses for supplies can be a major barrier in LMIC settings like West Bengal. Insurance coverage and financial assistance programs are often limited.
💡 *Learning Curve:* While automated, HCL systems still require significant education and training for both the child (as they grow) and caregivers to understand their operation and troubleshoot issues.
💡 *Technical Support:* Reliable technical support and access to trained healthcare professionals for pump management are crucial.
💡 *Cultural and Dietary Factors:* Integrating pump therapy with traditional diets and cultural practices requires careful planning and education.
*CONCLUSION*
An HCL insulin pump would likely *significantly improve the child's glycemic outcomes* by reducing hypoglycemia, hyperglycemia, and overall variability. It would also offer substantial psychological benefits to the family. However, the *cost and ongoing accessibility of supplies and support are major limiting factors* in the patient's region.
The decision to pursue pump therapy should involve a thorough discussion with the child's endocrinologist, considering the clinical benefits against the practical and financial challenges.
[12:03 am, 25/01/2026] PPM 2: Are there any government support systems which can enable access to these for this patient? Perform a thorough search and let us know
[12:03 am, 25/01/2026] PaJR Health: I have conducted a thorough search for government support systems in India, specifically focusing on West Bengal, that could enable access to HCL insulin pumps for children with Type 1 Diabetes.
Here's what I found:
*GOVERNMENT SUPPORT SYSTEMS FOR TYPE 1 DIABETES IN INDIA (WITH FOCUS ON WEST BENGAL)*
While direct government programs specifically funding HCL insulin pumps for all children with Type 1 Diabetes are not widely established across India, there are several initiatives and collaborations that aim to improve diabetes care, which could indirectly or directly assist patients.
*1. WEST BENGAL MODEL FOR TYPE 1 DIABETES CARE*
📍 *Integrated Care Program:* The state of West Bengal has initiated a structured and dedicated health program for Type 1 Diabetes Mellitus (T1DM). This program aims to ensure better health outcomes for children with T1DM in the long run.
* [Integrated Care for Type 1 Diabetes: The West Bengal Model](https://pmc.ncbi.nlm.nih.gov/articles/PMC10723605/)
* [Type 1 Diabetes Care: The West Bengal Model](https://www.researchgate.net/publication/395536699_Type_1_Diabetes_Care_The_West_Bengal_Model)
*2. UNICEF COLLABORATION WITH WEST BENGAL GOVERNMENT*
📍 *Grassroots Level Care:* UNICEF has partnered with the West Bengal Health & Family Welfare Department to enhance treatment and care for children suffering from non-communicable diseases (NCDs), including juvenile diabetes, at the grassroots level. This initiative focuses on staff training and referral systems.
* [UNICEF Collaborates with Bengal Government to Tackle Juvenile Diabetes](https://health.medicaldialogues.in/health-topics/diabetes-health/unicef-collaborates-with-bengal-government-to-tackle-juvenile-diabetes-140282)
* [UNICEF, Bengal Govt join hands to combat Juvenile Diabetes](https://www.ibtimes.co.in/unicef-bengal-govt-join-hands-combat-juvenile-diabetes-876881)
*3. FREE DRUGS SERVICE INITIATIVE (NATIONAL HEALTH MISSION - NHM)*
📍 *Financial Support for Medicines:* Under the Free Drugs Service Initiative of the National Health Mission (NHM), financial support is provided to States/UTs for the provision of free essential medicines, *including insulin*, for poor and needy people. While this primarily covers insulin, it demonstrates a commitment to supporting diabetes management.
* [Steps Taken by Government to support Diabetes Patients](https://www.pib.gov.in/PressReleaseIframePage.aspx?PRID=1882179)
*4. POTENTIAL INCLUSION IN DISABILITY ACT*
📍 *Advocacy for Type 1 Diabetes:* There have been discussions and efforts to include Type 1 Diabetes in the Disability Act, which could potentially open avenues for various forms of government support and benefits for individuals with T1DM.
* [Government to take steps to include Type 1 diabetes in Disability Act](https://www.deccanherald.com/india/karnataka/bengaluru/government-to-take-steps-to-include-type-1-diabetes-in-disability-act-809649.html)
*5. SUBSIDY PROGRAMS AND INDUSTRY COLLABORATION (RECOMMENDATIONS)*
💡 *Future Directions:* Research and expert recommendations highlight the need for:
* *Subsidy Programs:* Development of programs to make diabetes healthcare technology, including insulin pumps, more affordable and accessible.
* *Industry Collaboration:* Partnerships between the government and industry to improve access to technology.
* [Challenges in Type 1 Diabetes Management in India Compared to...](https://pmc.ncbi.nlm.nih.gov/articles/PMC12101756/)
*CONCLUSION*
While there isn't a direct, widespread government scheme specifically for funding HCL insulin pumps for children with Type 1 Diabetes in West Bengal or India, the existing initiatives and collaborations indicate a growing focus on improving T1DM care.
*RECOMMENDATIONS FOR THE PATIENT'S FAMILY:*
* *Engage with the West Bengal Health & Family Welfare Department:* Inquire about the specific provisions of their integrated T1DM care program and if it includes any support for advanced diabetes technology or financial assistance for devices like insulin pumps.
* *Contact UNICEF India (West Bengal Office):* Explore if their collaboration with the state government offers any direct or indirect support for accessing insulin pumps or related education and resources.
* *Consult with the Child's Endocrinologist/Diabetes Clinic:* They would be the best resource for information on any local or state-specific schemes, non-governmental organization (NGO) support, or patient assistance programs that might be available for insulin pump access.
* *Explore Patient Advocacy Groups:* Organizations dedicated to Type 1 Diabetes in India often have information on available support and can advocate for policy changes.
It is crucial for the family to actively engage with healthcare providers and relevant government/non-government organizations to explore all possible avenues for support.
[12:06 am, 25/01/2026] PPM 2: Which of these would best apply to our patient here? Identify the best programme and give us a clear pathway on how to access that resource
[12:08 am, 25/01/2026] PPM 2: Which of these would best apply to our patient here? Identify the best programme and give us a clear pathway on how to access that resource.
[12.08 am, 25/01/2026] PaJR Health: Based on the information available, the most directly applicable programs for your child in West Bengal would be the **West Bengal Model for Type 1 Diabetes Care** and the **UNICEF Collaboration with the West Bengal Health & Family Welfare Department**.
These two initiatives are specifically focused on enhancing treatment and care for children with juvenile diabetes at the grassroots level within West Bengal. While they may not explicitly guarantee an HCL insulin pump, they represent the established framework for T1DM care in the state and are the most likely avenues to explore for support, guidance, and potential access to advanced technologies or financial assistance.
---
**BEST PROGRAMME: WEST BENGAL MODEL FOR TYPE 1 DIABETES CARE & UNICEF COLLABORATION**
**WHY IT APPLIES TO YOUR PATIENT:**
💡 These programs are designed to improve health outcomes for children with Type 1 Diabetes within West Bengal. They aim to strengthen the healthcare system's capacity to manage T1DM, which could include facilitating access to appropriate treatment modalities and support.
**CLEAR PATHWAY TO ACCESS THIS RESOURCE:**
1. **CONSULT YOUR CHILD'S ENDOCRINOLOGIST/DIABETES SPECIALIST:**
* **Action:** The first and most crucial step is to have a detailed discussion with your child's treating endocrinologist or the diabetes care team at their hospital/clinic.
* **Purpose:** They are likely to be aware of the specific details and implementation of the "West Bengal Model for Type 1 Diabetes Care" and any direct benefits or referral pathways it offers. They can also provide a medical recommendation for an HCL insulin pump, which would be essential for any application for support.
* **Inquiry:** Ask them about:
* Any existing provisions or schemes under the West Bengal Model for T1DM that support access to insulin pumps or advanced diabetes technology.
* Referral processes to specialized centers or programs that might offer such support.
* Information on how the UNICEF collaboration is translating into direct patient benefits, particularly regarding technology access or financial aid.
2. **CONTACT THE DISTRICT HEALTH & FAMILY WELFARE DEPARTMENT:**
* **Action:** Reach out to the Chief Medical Officer of Health (CMOH) or the relevant department within your district's Health & Family Welfare office in West Bengal.
* **Purpose:** As these programs are implemented at the state and grassroots level, the district health authorities would have information on local initiatives, eligibility criteria, and application procedures for any support related to juvenile diabetes care.
* **Inquiry:** Clearly state that your child has Type 1 Diabetes and you are seeking information on government support for advanced diabetes management, specifically regarding insulin pumps, under the West Bengal Model and UNICEF initiatives.
3. **EXPLORE UNICEF INDIA (WEST BENGAL OFFICE):**
* **Action:** While UNICEF primarily works through government channels, it may be beneficial to explore their regional office in West Bengal or their India country office website for any public information regarding their specific diabetes initiatives and how families can benefit.
* **Purpose:** To understand the scope of their collaboration and if there are any direct contact points or resources for families.
* **Inquiry:** Look for contact details on their official website and inquire about their programs for children with Type 1 Diabetes in West Bengal and potential support for technology access.
**IMPORTANT CONSIDERATIONS:**
* **Documentation:** Be prepared with all necessary medical documentation for your child's Type 1 Diabetes diagnosis, treatment history, and any recommendations from their doctor.
* **Persistence:** Navigating government support systems can sometimes require persistence. Follow up on your inquiries and keep detailed records of your communications.
* **NGOs and Patient Advocacy Groups:** While not government programs, many non-governmental organizations (NGOs) and patient advocacy groups in India (e.g., Diabetes India, Juvenile Diabetes Foundation) work closely with government bodies and can provide valuable guidance, support, and sometimes even direct assistance or information on available schemes. Your endocrinologist might be able to refer you to such groups.
By following this pathway, you will be engaging with the most relevant authorities and healthcare professionals who can provide the most accurate and up-to-date information on accessing support for your child's diabetes management in West Bengal.
[12.26 am, 25/01/2026] PPM 2: @PA @PPM1
We have to direct the parent to grassroot NGOs who can access this
[10:18 pm, 25/01/2026] PPM 1: 👆@PPM11 on point 4
[10:18 pm, 25/01/2026] PaJR Health: You are referring to the point about the *POTENTIAL INCLUSION IN DISABILITY ACT*.
Here's a more detailed explanation of what this means and its potential implications for your patient:
*POTENTIAL INCLUSION IN DISABILITY ACT*
💡 *Advocacy for Type 1 Diabetes:* There have been ongoing discussions and efforts to include Type 1 Diabetes (T1DM) in India's Rights of Persons with Disabilities Act (RPwD Act), 2016.
*WHAT THIS MEANS FOR YOUR PATIENT:*
If Type 1 Diabetes is officially included under the RPwD Act, it could open up several avenues for government support and benefits for individuals living with T1DM, including children. These could potentially include:
* *RECOGNITION AS A DISABILITY:* Official recognition would acknowledge the significant, lifelong impact of T1DM on an individual's life, including the constant management, potential complications, and the need for continuous care.
* *ACCESS TO RESERVATIONS AND QUOTAS:* This could potentially lead to reservations in education (e.g., school admissions, higher education) and employment, ensuring equitable opportunities.
* *FINANCIAL ASSISTANCE AND SCHEMES:* Individuals with recognized disabilities often qualify for various government-sponsored financial aid, pensions, or schemes aimed at supporting their living and medical expenses. This could potentially help with the cost of insulin, testing supplies, and possibly even advanced technologies like insulin pumps, although specific details would depend on the scheme's design.
* *ACCESSIBILITY AND ACCOMMODATIONS:* It could mandate reasonable accommodations in educational institutions and workplaces to facilitate better management of diabetes (e.g., permission to test blood sugar, administer insulin, access to food/water, flexibility for medical appointments).
* *HEALTHCARE BENEFITS:* While existing health schemes might cover some aspects, inclusion in the Disability Act could strengthen the case for comprehensive healthcare coverage, including access to essential medicines, devices, and specialized care for T1DM.
* *LEGAL PROTECTION:* It would provide legal protection against discrimination based on their condition.
*CURRENT STATUS AND HOW TO MONITOR:*
📍 *Ongoing Advocacy:* The inclusion of T1DM in the Disability Act is a matter of ongoing advocacy by patient groups, medical associations, and individuals.
* [Government to take steps to include Type 1 diabetes in Disability Act](https://www.deccanherald.com/india/karnataka/bengaluru/government-to-take-steps-to-include-type-1-diabetes-in-disability-act-809649.html)
*PATHWAY TO ACCESS (IF INCLUDED):*
If T1DM is officially included in the RPwD Act, the pathway to access benefits would typically involve:
1. *OBTAINING A DISABILITY CERTIFICATE:*
* *Action:* Your child would need to undergo an assessment by a medical board constituted by the government to determine the percentage of disability and obtain a disability certificate.
* *Purpose:* This certificate is the primary document required to avail any benefits under the Act.
2. *APPLYING FOR SPECIFIC SCHEMES:*
* *Action:* Once the disability certificate is obtained, you would then need to apply for specific government schemes or benefits that are available to persons with disabilities.
* *Purpose:* These schemes vary and could cover areas like education, healthcare, financial aid, or assistive devices.
*RECOMMENDATION:*
* *Stay Informed:* Keep in touch with your child's endocrinologist and patient advocacy groups (like the Juvenile Diabetes Foundation or Diabetes India) as they are usually at the forefront of such advocacy efforts and will have the most up-to-date information on the status of T1DM's inclusion in the Disability Act and any resulting benefits.
* *Advocate:* Support advocacy efforts if opportunities arise, as collective voices can influence policy changes.
While this is a potential future avenue, it's important to monitor its progress as it could significantly impact the long-term support available for your child.
[10:32 pm, 25/01/2026] PPM 11: Logically, it shall not be included as disability
[11:45 pm, 25/01/2026] PA: 25.01.26
7.45am fasting blood sugar 62
7.45am nuts
8.00 am milk
9.55am 4u lispro insulin
1u (milk and nuts) + 3u (meal)
10.00am rice with pulses, egg, curry (brinjal, tomato, papaya, hyacinth bean, pumpkin, cauliflower, beetroot, turnip, carrot, cabbage, peas)
1.30pm blood sugar 289
1.30pm 5.5u lispro insulin
3u (289-90/70) + 2.5u (meal)
1.35pm lunch with same previous dish except egg and include fish
6.00pm oats
7.30pm home made sweet
9.15pm 5u Tresiba insulin
9.30pm blood sugar 357
9.30pm 4u lispro insulin
3u(357-90/70) + 1u (meal)
9.35pm dinner with as same as lunch dish
Shared 50% with her sister 👇 Dinner
[3:59 pm, 26/01/2026] PA: 26.01.26
7.45am fasting blood sugar 58
7.45am milk
9.55am 4u lispro insulin
0.5u (milk)+3.5u (meal)
10.00am rice with pulses, curry (brinjal, tomato, hyacinth bean, pumpkin, cabbage, beetroot, carrot, papaya) and egg
1.30pm blood sugar 198
1.30pm 4u lispro insulin
1.5u (198-90/70) + 2.5u (meal)
1.35pm lunch with same previous dish except egg and include pakoda
[5:49 pm, 26/01/2026] PPM 2: It is now quite likely the erratic responses are from Insulin stacking with Tresiba and evening Lispro given at the same time. @PaJR Health is this a known phenomenon?
[5:49 pm, 26/01/2026] PaJR Health: While my search of PubMed for the exact combination of "insulin stacking" with "Tresiba," "Lispro," "pediatric," and "glycemic variability" did not yield specific articles, I can explain the general phenomenon of insulin stacking and how it might relate to your patient's situation.
*INSULIN STACKING: A KNOWN PHENOMENON*
💡 *Definition:* Insulin stacking refers to the administration of subsequent doses of insulin before the previous dose has fully worn off. This leads to an accumulation of insulin effect in the body, which can significantly increase the risk of hypoglycemia (low blood sugar).
*HOW IT RELATES TO YOUR PATIENT'S SCENARIO:*
The concern about "insulin stacking" with Tresiba (insulin degludec, an ultra-long-acting basal insulin) and evening Lispro (insulin lispro, a rapid-acting insulin) given at the same time requires a nuanced understanding:
* *Tresiba (Basal Insulin):* Tresiba provides a steady, continuous background insulin level over more than 42 hours. It reaches a steady state after 2-3 days of daily dosing. Its purpose is to cover the body's basal insulin needs, not to respond to meals.
* *Lispro (Rapid-Acting Insulin):* Lispro is given to cover carbohydrate intake at meals or to correct high blood sugar. Its onset of action is rapid (15-30 minutes), and its duration of action is typically 3-5 hours.
*Is giving Tresiba and evening Lispro at the same time "insulin stacking"?*
* *Standard Practice:* It is a standard and appropriate practice to administer a rapid-acting insulin (like Lispro) for a meal while also taking a daily dose of basal insulin (like Tresiba). If the once-daily Tresiba dose happens to coincide with the evening Lispro dose, this in itself is generally *not considered "insulin stacking"* in the typical sense. They are different types of insulin with distinct roles: Tresiba provides background insulin, and Lispro covers the meal.
* *Potential for Erratic Responses:* However, "erratic responses" could still occur due to various factors related to insulin timing and dosing, even if not strictly "stacking" in the classic definition:
* *Overlapping Rapid-Acting Doses:* If the evening Lispro dose is given too soon after a previous rapid-acting insulin dose (e.g., for an afternoon snack), the effects of the two Lispro doses could overlap, leading to true insulin stacking and an increased risk of hypoglycemia.
* *Incorrect Basal Dose (Tresiba):* If the Tresiba dose is too high, it can cause hypoglycemia, especially overnight. This hypoglycemia can then trigger the body's counter-regulatory hormones, leading to a rebound hyperglycemia later, which might appear as an "erratic response."
* *Incorrect Bolus Dose (Lispro):* An incorrect Lispro dose for the evening meal (e.g., too much for the carbohydrates consumed) could also lead to hypoglycemia, followed by rebound hyperglycemia.
* *Timing of Lispro:* While Lispro is rapid-acting, if it's given significantly before or after the meal, it can lead to glucose excursions.
* *Other Factors:* Other factors like meal composition, physical activity, illness, and hormonal changes can also contribute to glycemic variability.
*CONCLUSION*
While the specific term "insulin stacking with Tresiba and evening Lispro given at the same time" is not commonly found in the literature as a distinct phenomenon, the underlying principles of insulin action and potential for overlapping effects are well-known.
*RECOMMENDATION:*
Given the "erratic responses," it is *critical to consult with your child's endocrinologist or diabetes care team immediately.* They will need to:
* *Review Insulin Dosing and Timing:* Carefully assess the exact timing and dosage of both Tresiba and Lispro, as well as any other insulin doses throughout the day.
* *Analyze Glucose Data:* Examine continuous glucose monitoring (CGM) or frequent blood glucose readings to identify patterns of hypoglycemia and hyperglycemia.
* *Consider Other Factors:* Evaluate meal composition, physical activity, and any other variables that might be contributing to the glycemic variability.
They can help determine the precise cause of the erratic responses and make necessary adjustments to the insulin regimen to ensure your child's safety and optimize glycemic control.
[11.50 pm, 27/01/2026] PA: 6.15pm oats
9.15pm 5u tresiba insulin
9.30pm blood sugar 167
9.30pm 2u lispro insulin
1u (167-90/70) + 1u (meal)
9.35pm dinner with as same as lunch dish Oats
[3:25 am, 27/01/2026] PPM 2: Is it possible to give the Tresiba at 6 PM with the snack?
[8:27 am, 27/01/2026] PA: 27.01.26
7.45am fasting blood sugar 300
7.45am nuts
8.00am milk
[8:37 am, 27/01/2026] PPM 1: Can @PaJR Health scour all the past four case report links as to what was the reason given by the patient advocate for inability to give it in evenings when asked similarly on a few occasions?
[8:37 am, 27/01/2026] PaJR Health: I have reviewed the four links provided in our previous conversation regarding government support systems. These links are:
1. [Integrated Care for Type 1 Diabetes: The West Bengal Model](https://pmc.ncbi.nlm.nih.gov/articles/PMC10723605/)
2. [Type 1 Diabetes Care: The West Bengal Model](https://www.researchgate.net/publication/395536699_Type 1 Diabetes Care_The West Bengal Model)
3. [UNICEF Collaborates with Bengal Government to Tackle Juvenile Diabetes](https://health.medicaldialogues.in/health-topics/diabetes-health/unicef-collaborates-with-bengal-government-to-tackle-juvenile-diabetes-140282)
4. [UNICEF, Bengal Govt join hands to combat Juvenile Diabetes](https://www.ibtimes.co.in/unicef-bengal-govt-join-hands-combat-juvenile-diabetes-876881)
Upon reviewing the content of these articles, I can confirm that they are academic papers and news reports discussing government initiatives and collaborations related to Type 1 Diabetes care in West Bengal. They are not individual patient case reports.
Therefore, these links *do not contain specific details about a patient advocate's reasons for the inability to administer insulin in the evenings* or any similar personal patient-level information.
If you are referring to a specific patient's history or details from internal PaJR Records or Hospital Records, please provide me with keywords, case titles, or any other identifying information so I can search our clinical vault for that specific context.
[8:38 am, 27/01/2026] PPM 1: Check here👇
Part 1
Part 2:
Part 3:
[8:39 am, 27/01/2026] PaJR Health: Based on the provided case report links, here's what was stated by the patient advocate and discussed regarding the inability to give insulin in the evenings or have an early dinner:
*REASONS FOR INABILITY TO GIVE INSULIN IN EVENINGS / HAVE EARLY DINNER*
💡 *Cultural Dinner Time:* The primary reason identified for the late dinner time is the "cultural dinner time for the patient's location." This was mentioned by the PaJR PHR Moderator in response to a query about the late timing of meals.
💡 *Difficulty with Sleep Schedule:* The patient advocate also indicated that it would be "a bit difficult to sleep by 10:00 PM" if dinner were moved to an earlier time like 8:00 PM.
💡 *Child's Distress with Injections:* On multiple occasions, the patient advocate has expressed that the child cries daily when given injections. This makes it challenging to administer insulin more frequently, such as for snacks or additional evening doses. For example, on *08-07-2025*, the patient advocate states: "It is very difficult to inject another more times. She cries every day four times when she is injected."
*SUMMARY OF KEY POINTS:*
* *Cultural Norms:* The family's local cultural practices dictate a later dinner time.
* *Child's Sleep:* Adjusting dinner earlier would disrupt the child's sleep schedule.
* *Injection Burden:* The child's emotional distress and crying during injections make it difficult to increase the frequency of insulin administration, even when medically advised for snacks or earlier evening doses.
[11:29 pm, 27/01/2026] PA: 9.15am chocolate biscuit 2pcs
10.50am blood sugar 400
10.50am 6.5u lispro insulin
4u (400-90/70) + 2.5u (meal)
10.55am rice with pulses, carrot, papaya, peas, beetroot, cabbage, bitter gourd, egg
1.30pm blood sugar 353
1.30pm 6u lispro insulin
3.5u (353-90/70) + 2.5u (meal)
1.35pm lunch with same previous dish except egg and include fish
6.45pm banana
9.15pm 5u Tresiba insulin
9.30pm blood sugar 70
9.30pm 1u lispro insulin
1u (meal)
9.35pm dinner with as same as lunch dish
[11:07 am, 28/01/2026] PA: 28.01.29
7.45am fasting blood sugar 91.
7.45am nuts
8.00am milk
9.15am chocolate biscuit 2pcs
10.45am 5u lispro insulin
1u (nuts and milk) 1u (biscuit)+3u(meal)
10.50am rice with pulses, egg, curry (brinjal, tomato, turnip, beetroot, cauliflower, cabbage, carrot, peas, broccoli, bitter gourd, hyacinth bean, green leaf)
[1:05 pm, 28/01/2026] PPM 2: What was the blood sugar at 10 45 AM?
[9:02 pm, 28/01/2026] PA: What was the blood sugar at 10 45 AM?
It has not been done today
[11:51 pm, 28/01/2026] PA: 1.30pm blood sugar 207
1.30pm 4u lispro insulin
1.5u (207-90/70) + 2.5u (meal)
1.35pm lunch with same previous dish
6.00pm patty 2 Pieces (rice flour, flour and banana)
9.15pm 5u Tresiba insulin
9.30pm blood sugar 448
9.30pm 5u lispro insulin
5u (448-90/70)
9.35pm dinner with as same as lunch dish
7.45am fasting blood sugar 61
7.45am nuts
8.00am milk
9.45am chocolate biscuit 2pcs
10.50am 5u lispro insulin
1u (nuts and milk) + 1u (biscuit)+3u (meal)
10.55am rice with pulses, carrot, tomato, broccoli, beetroot, cauliflower, cabbage, brinjal, hyacinth bean, peas, turnip, egg and salad
[9:13 am, 30/01/2026] PA: 12.30pm orange
1.50pm blood sugar 160
1.50pm 3.5u lispro insulin
1u (160-90/70) +2.5u (meal)
1.55pm lunch with same previous dish
6.30pm banana
9.15pm 5u Tresiba insulin
9.30pm blood sugar 116
9.30pm 1.5u lispro insulin
0.5u(116-90/70) + 1u(meal)
9.35pm dinner with as same as lunch dish
[9:16 am, 30/01/2026] PA: 30.01.26
8.00am fasting blood sugar 302
8.00am nuts
8.15am milk
[9:19 am, 30/01/2026] PA: Is it possible to give the Tresiba at 6 PM with the snack?
Amount of Night lispro dose?
[1:38 pm, 30/01/2026] PPM 2: I didn't get you here.
[11.54 pm, 30/01/2026] PA: 9.55am 6.5u lispro insulin
3u (302.-90/70) + 1u (milk and nuts) + 2.5u (meal)
10.00am rice with pulses brinjal, tomato, papaya, hyacinth bean, broccoli, beetroot, cauliflower, cabbage, carrot, peas, turnip, butter and salad
12.00noon orange
1.30pm blood sugar 63
1.30pm 2.5u lispro insulin
2.5u (meal)
1.35pm lunch with same previous dish except butter
6.00pm patty 2pcs
9.15pm 5u tresiba insulin
9.30pm blood sugar 356
9.30pm 4u lispro insulin
3u (356-90/70) + 1u (meal)
9.35pm dinner with as same as lunch dish and papad
@PPM4 @PaJR Health @Meta AI @PPM3 please analyse the fasting yo yo happening from 28/1/26 to 30/1/26 from the data below:
[28/01, 11:07] Patient Advocate 3F Diabetes1: 28.01.29
7.45am fasting blood sugar 91.
7.45am nuts
8.00am milk
9.15am chocolate biscuit 2pcs
10.45am 5u lispro insulin
1u (nuts and milk) 1u(biscuit)+3u(meal)
10.50am rice with pulses, egg, curry (brinjal, tomato, turnip, beetroot, cauliflower, cabbage, carrot, peas, broccoli, bitter gourd, hyacinth bean, green leaf)
[28/01, 23:51] Patient Advocate 3F Diabetes1: 1.30pm blood sugar 207
1.30pm 4u lispro insulin
1.5u (207-90/70) + 2.5u (meal)
1.35pm lunch with same previous dish
6.00pm patty 2 Pieces (rice flour, flour and banana)
9.15pm 5u Tresiba insulin
9.30pm blood sugar 448
9.30pm 5u lispro insulin
5u (448-90/70)
9.35pm dinner with as same as lunch dish
[29/01, 11:17] Patient Advocate 3F Diabetes1: 29.01.26
7.45am fasting blood sugar 61
7.45am nuts
8.00am milk
9.45am chocolate biscuit 2pcs
10.50am 5u lispro insulin
1u (nuts and milk) + 1u (biscuit)+3u (meal)
10.55am rice with pulses, carrot, tomato, broccoli, beetroot, cauliflower, cabbage, brinjal, hyacinth bean, peas, turnip, egg and salad
[30/01, 09:13] Patient Advocate 3F Diabetes1: 12.30pm orange
1.50pm blood sugar 160
1.50pm 3.5u lispro insulin
1u (160-90/70) +2.5u (meal)
1.55pm lunch with same previous dish
6.30pm banana
9.15pm 5u Tresiba insulin
9.30pm blood sugar 116
9.30pm 1.5u lispro insulin
0.5u (116-90/70) + 1u (meal)
9.35pm dinner with as same as lunch dish
[30/01, 09:16] Patient Advocate 3F Diabetes1: 30.01.26
8.00am fasting blood sugar 302
8.00am nuts
8.15am milk
[30/01, 23:54] Patient Advocate 3F Diabetes1: 9.55am 6.5u lispro insulin
3u (302.-90/70) + 1u (milk and nuts) + 2.5u (meal)
10.00am rice with pulses brinjal, tomato, papaya, hyacinth bean, broccoli, beetroot, cauliflower, cabbage, carrot, peas, turnip, butter and salad
12.00noon orange
1.30pm blood sugar 63
1.30pm 2.5u lispro insulin
2.5u (meal)
1.35pm lunch with same previous dish except butter
6.00pm patty 2pcs
9.15pm 5u Tresiba insulin
9.30pm blood sugar 356
9.30pm 4u lispro insulin
3u (356-90/70) + 1u (meal)
9.35pm dinner with as same as lunch dish and papad
Let's break down the fasting yo-yo happening from 28/1/26 to 30/1/26.
- 28/1/26: Fasting blood sugar 91 mg/dL
- 29/1/26: Fasting blood sugar 61 mg/dL (dip)
- 30/1/26: Fasting blood sugar 302 mg/dL (spike)
It looks like there's a significant swing in fasting blood sugars. Possible factors contributing to this:
- Insulin dosing adjustments
- Dietary changes (e.g., added papaya on 30/1)
- Activity levels (not mentioned in the data)
Want to dig deeper into specific factors or explore adjustments? 😊
[9,21 am, 31/01/2026] PaJR Health: Hello! I'm ready when you are. Please let me know how I can assist you today.
*FASTING GLYCEMIC VARIABILITY (YO-YO EFFECT) ANALYSIS: JANUARY 28-30, 2026*
The data from January 28th to January 30th, 2026, shows a clear "fasting yo-yo" pattern, characterized by significant fluctuations between low and high morning fasting blood sugar levels. This indicates challenges in achieving stable overnight glucose control.
*JANUARY 28TH EVENING → JANUARY 29TH MORNING*
* *Evening (Jan 28):*
* *6:00 PM:* Patty (rice flour, flour, banana) consumed without insulin coverage.
* *9:15 PM:* 5u Tresiba insulin.
* *9:30 PM:* Blood sugar *448*.
* *9:30 PM:* 5u Lispro insulin (correction dose for high sugar).
* *9:35 PM:* Dinner.
* *Morning (Jan 29):*
* *7:45 AM:* Fasting blood sugar *61*.
💡 *Analysis:* A very high evening blood sugar (448) was followed by a significant drop to a very low fasting blood sugar (61). This suggests a potential *overcorrection* with the 5u Lispro for the 448 mg/dL, combined with the 5u Tresiba, leading to an excessive insulin effect overnight. The uncovered carbohydrates from the 6:00 PM patty likely contributed to the initial rise, making the subsequent correction more challenging.
---
*JANUARY 29TH EVENING → JANUARY 30TH MORNING*
* *Evening (Jan 29):*
* *6:30 PM:* Banana consumed without insulin coverage.
* *9:15 PM:* 5u Tresiba insulin.
* *9:30 PM:* Blood sugar *116*.
* *9:30 PM:* 1.5u Lispro insulin (correction + meal coverage).
* *9:35 PM:* Dinner.
* *Morning (Jan 30):*
* *8:00 AM:* Fasting blood sugar *302*.
💡 *Analysis:* A relatively good evening blood sugar (116) was followed by a sharp rise to a very high fasting blood sugar (302). This pattern is highly suggestive of:
* *Insufficient Basal Insulin (Tresiba):* Despite the 5u Tresiba, the basal insulin might not be adequately covering the overnight glucose production or the dawn phenomenon.
* *Dawn Phenomenon:* This is a common physiological rise in blood sugar in the early morning hours.
* *Uncovered Evening Snack:* The banana at 6:30 PM, consumed without insulin, likely contributed to rising glucose levels overnight, which the subsequent small Lispro dose and Tresiba could not fully counteract.
---
*JANUARY 30TH EVENING*
* *Evening (Jan 30):*
* *6:00 PM:* Patty 2pcs consumed without insulin coverage.
* *9:15 PM:* 5u Tresiba insulin.
* *9:30 PM:* Blood sugar *356*.
* *9:30 PM:* 4u Lispro insulin (correction + meal coverage).
* *9:35 PM:* Dinner with papad.
* *Morning (Jan 31):* Fasting blood sugar not provided, but the high evening sugar suggests a continued challenge.
💡 *Analysis:* A very high evening blood sugar (356) after an uncovered snack (patty) and a significant dinner with papad. The 4u Lispro, even with a correction component, appears insufficient to manage such a high starting glucose level and the subsequent carbohydrate load. This sets the stage for potential continued hyperglycemia overnight.
---
*SUMMARY OF FASTING YO-YO PHENOMENON*
The observed "fasting yo-yo" is likely a result of several interacting factors:
* *Inconsistent Carbohydrate Coverage for Snacks:* Snacks like patties and bananas, when consumed without appropriate Lispro doses, lead to uncontrolled glucose spikes that impact subsequent blood sugar levels.
* *Challenges with Evening Bolus Dosing:* The Lispro doses given for dinner and correction appear to be either overcorrecting (leading to lows) or undercorrecting (leading to highs), indicating a need to re-evaluate the insulin-to-carb ratios and correction factors.
* *Potential Basal Insulin Inadequacy/Timing:* The 5u Tresiba, while long-acting, does not consistently prevent high fasting sugars, suggesting that the basal dose might need adjustment or that its timing needs to be optimized in relation to the patient's overnight glucose patterns and the dawn phenomenon.
* *Somogyi Effect:* The sharp drop from a very high evening sugar to a very low fasting sugar (Jan 28 → Jan 29) is highly indicative of an overnight hypoglycemic event triggering a rebound hyperglycemia later. This rebound can then contribute to the subsequent high fasting sugars.
*RECOMMENDATIONS*
To address this fasting yo-yo, it is crucial to:
💡 *Ensure All Carbohydrate Intake is Covered:* Administer Lispro for all snacks containing carbohydrates, not just main meals.
💡 *Re-evaluate Insulin Dosing Ratios:* Work with the healthcare team to fine-tune the insulin-to-carb ratios and correction factors for Lispro.
💡 *Monitor Overnight Glucose Levels:* Regularly check blood sugar levels during the night (e.g., 2 AM or 3 AM) to detect asymptomatic hypoglycemia, which can cause rebound hyperglycemia.
💡 *Adjust Basal Insulin (Tresiba) as Needed:* If overnight lows are ruled out, and fasting sugars remain consistently high, the Tresiba dose may need to be increased gradually under medical supervision.
💡 *Optimize Meal and Insulin Timing:* Encourage earlier dinners if feasible, and consistently administer Lispro 15-20 minutes before meals to allow for proper insulin action.
[9.22 am, 31/01/2026] PPM 2: I have no idea why Meta AI is still even considered! 😂
[9.25 am, 31/01/2026] PPM 1: Just for contrast and also as it's the quickest to respond with brevity
Just for contrast and also as it's the quickest to respond with brevity
[9.26 am, 31/01/2026] PPM 2: Clearly it has now become a joke and is GIGOing sir.
[9.26 am, 31/01/2026] PPM 1: Please help to recalculate the insulin correction factors and the insulin carb ratios
[9.26 am, 31/01/2026] PaJR Health: Recalculating insulin correction factors and insulin-to-carbohydrate ratios is a critical and highly individualized medical task that must be performed by a qualified healthcare professional, such as an endocrinologist or a certified diabetes educator. These calculations depend on many specific factors unique to the patient, and incorrect adjustments can have serious health consequences.
As an AI, I cannot provide direct medical advice or perform these calculations for you. My role is to provide information and insights based on data, but not to manage or adjust treatment plans.
*WHAT YOUR HEALTHCARE PROVIDER WILL NEED TO RECALCULATE THESE FACTORS:*
To help your healthcare team recalculate the insulin correction factors and insulin-to-carbohydrate ratios, you should provide them with the following detailed information:
1. *Comprehensive Blood Glucose Logs:*
* Fasting blood sugar levels.
* Pre-meal blood sugar levels.
* Post-meal (1-2 hours after) blood sugar levels.
* Bedtime blood sugar levels.
* Any overnight (e.g., 2 AM or 3 AM) blood sugar readings, especially if there are concerns about nocturnal hypoglycemia or the dawn phenomenon.
* Records of any hypoglycemic or hyperglycemic episodes, including symptoms and treatment.
2. *Detailed Food Records:*
* Accurate carbohydrate counts for all meals and snacks.
* Portion sizes and types of food consumed.
* Timing of meals and snacks.
3. *Insulin Dosing Records:*
* Exact doses of both basal insulin (Tresiba) and rapid-acting insulin (Lispro) for each administration.
* Timing of each insulin injection.
* Notes on whether Lispro was given for meals, corrections, or both.
4. *Activity Levels:*
* Information on physical activity, including type, duration, and intensity, as this significantly impacts insulin needs.
5. *Other Relevant Information:*
* Any recent changes in weight, growth, or overall health.
* Presence of illness or stress, which can affect blood sugar.
* Any other medications being taken.
*GENERAL PRINCIPLES FOR CALCULATION (FOR YOUR INFORMATION ONLY - DO NOT ATTEMPT TO CALCULATE YOURSELF):*
Healthcare professionals typically use formulas and clinical judgment to determine these ratios:
* *Insulin Sensitivity Factor (ISF) / Correction Factor (CF):* This tells you how many points (mg/dL) your blood sugar will drop for every 1 unit of rapid-acting insulin. A common starting point for estimation is the "1800 Rule" or "1500 Rule" (1800 or 1500 divided by Total Daily Dose of insulin).
* *Insulin-to-Carbohydrate Ratio (ICR):* This tells you how many grams of carbohydrates are covered by 1 unit of rapid-acting insulin. A common starting point for estimation is the "500 Rule" (500 divided by Total Daily Dose of insulin).
*ACTION REQUIRED:*
Please gather all the detailed information requested above and schedule an appointment with your child's endocrinologist or diabetes care team. They are best equipped to analyze this data and make safe and effective adjustments to the insulin regimen.
[9.27 am, 31/01/2026] PPM 2: You did do this once before. Can you recall that?
[9.27 am, 31/01/2026] PaJR Health: *FASTING GLYCEMIC VARIABILITY (YO-YO EFFECT) ANALYSIS: JANUARY 28-30, 2026*
The patient's blood sugar data from January 28th to January 30th, 2026, reveals a distinct "fasting yo-yo" pattern, characterized by significant and inconsistent fluctuations in morning fasting blood sugar levels. This indicates ongoing challenges in achieving stable overnight glucose control.
*JANUARY 28TH EVENING → JANUARY 29TH MORNING*
* *Evening (January 28):*
* *6:00 PM:* Two pieces of patty (rice flour, flour, and banana) were consumed without a corresponding Lispro insulin dose.
* *9:15 PM:* 5u Tresiba insulin was administered.
* *9:30 PM:* Blood sugar was *448 mg/dL*, indicating significant hyperglycemia.
* *9:30 PM:* 5u Lispro insulin was given as a correction dose.
* *9:35 PM:* Dinner was consumed.
* *Morning (January 29):*
* *7:45 AM:* Fasting blood sugar was *61 mg/dL*, indicating hypoglycemia.
💡 *Analysis:* A very high evening blood sugar (448 mg/dL), likely exacerbated by the unbolused patty, was followed by a sharp drop to hypoglycemia (61 mg/dL) by morning. This suggests a potential *overcorrection* with the 5u Lispro in the evening, combined with the 5u Tresiba, leading to an excessive insulin effect overnight. This pattern is highly suggestive of the Somogyi effect, where an undetected overnight low triggers a rebound high later.
---
*JANUARY 29TH EVENING → JANUARY 30TH MORNING*
* *Evening (January 29):*
* *6:30 PM:* A banana was consumed without a corresponding Lispro insulin dose.
* *9:15 PM:* 5u Tresiba insulin was administered.
* *9:30 PM:* Blood sugar was *116 mg/dL*, a relatively good level.
* *9:30 PM:* 1.5u Lispro insulin was given (0.5u correction + 1u meal).
* *9:35 PM:* Dinner was consumed.
* *Morning (January 30):*
* *8:00 AM:* Fasting blood sugar was *302 mg/dL*, indicating significant hyperglycemia.
💡 *Analysis:* A good evening blood sugar (116 mg/dL) was followed by a substantial rise to hyperglycemia (302 mg/dL) by morning. This pattern points towards *insufficient basal insulin coverage* or a pronounced *dawn phenomenon*. The unbolused banana at 6:30 PM likely contributed to rising glucose levels overnight, which the 5u Tresiba and the small 1.5u Lispro dose for dinner were unable to adequately manage.
---
*JANUARY 30TH EVENING*
* *Evening (January 30):*
* *6:00 PM:* Two pieces of patty were consumed without a corresponding Lispro insulin dose.
* *9:15 PM:* 5u Tresiba insulin was administered.
* *9:30 PM:* Blood sugar was *356 mg/dL*, indicating significant hyperglycemia.
* *9:30 PM:* 4u Lispro insulin was given (3u correction + 1u meal).
* *9:35 PM:* Dinner with papad was consumed.
* *Morning (January 31):* Fasting blood sugar for January 31st is not provided in this data, but the high evening sugar suggests a continued challenge in overnight control.
💡 *Analysis:* Similar to January 28th, a high evening blood sugar (356 mg/dL) followed the consumption of an unbolused snack (patty) and a substantial dinner with papad. The 4u Lispro dose, even with a correction component, appears insufficient to effectively manage such a high starting glucose level and the carbohydrate load from dinner. This scenario likely contributes to continued hyperglycemia overnight.
---
*SUMMARY OF THE FASTING YO-YO PHENOMENON*
The observed "fasting yo-yo" effect is a complex interplay of several factors:
* *Uncovered Carbohydrate Intake:* Consistent consumption of snacks (patty, banana) and sometimes dinner components (papad) without appropriate Lispro insulin coverage leads to uncontrolled glucose spikes, setting the stage for subsequent glycemic instability.
* *Basal Insulin Imbalance:* The fluctuation between morning hypoglycemia and hyperglycemia suggests that the 5u Tresiba dose may not be consistently matched to the child's overnight needs. The low on January 29th indicates potential over-basalization, which can trigger the Somogyi effect (rebound high), while the high on January 30th suggests insufficient basal coverage for the dawn phenomenon or unmanaged evening carbohydrates.
* *Challenges with Bolus Dosing:* The Lispro doses for meals and corrections appear to be either overcorrecting (leading to lows) or undercorrecting (leading to highs), indicating a need for precise re-evaluation of the insulin-to-carb ratios and correction factors. The advocate's self-imposed "dose cap" (as noted in previous discussions) may also contribute to under-correction during severe hyperglycemia.
*RECOMMENDATIONS*
To mitigate this fasting yo-yo and achieve better glycemic stability, the following areas require urgent attention and collaboration with the healthcare team:
📍 *Consistent Carbohydrate Coverage:* Ensure all carbohydrate-containing foods, including snacks and dinner components like papad, are accurately counted and covered with appropriate Lispro insulin doses.
📍 *Overnight Glucose Monitoring:* Implement structured nocturnal blood glucose monitoring (e.g., at 2-3 AM) to differentiate between undetected hypoglycemia (Somogyi effect) and the dawn phenomenon, which is crucial for adjusting basal insulin.
📍 *Basal Insulin Adjustment:* Based on nocturnal monitoring, the Tresiba dose should be carefully reviewed and adjusted by the clinician to prevent overnight lows and adequately cover basal needs.
📍 *Re-evaluation of Insulin-to-Carbohydrate Ratios (ICR) and Insulin Sensitivity Factors (ISF):* Work closely with the endocrinologist to re-calculate and fine-tune these ratios based on detailed food logs and blood glucose responses. The previous analysis suggested an observed ISF closer to 48 mg/dL per unit, which differs from the advocate's assumed 70 mg/dL per unit, and meal boluses were deemed insufficient.
📍 *Address Dose Cap Concerns:* Discuss with the healthcare team the necessity and safety of administering higher, but appropriate, Lispro doses for severe hyperglycemia to prevent prolonged high blood sugars.
[9.36 am, 31/01/2026] PPM 2: GIGO is similar to the Duning Kruger spectrum where every individual human in this world can have their own interpretation of their information inflow and can choose to either trash or retain in their database and if they choose to to later utilise that to express themselves they could be getting exposed to the risk of being labelled by others as to what's their perceived position in different points of the Duning Kruger spectrum.
While the above could be true for humans, perhaps it could be true for LLMs as well?
[10.10 am, 31/01/2026] PPM 4: Based on the provided data, there is a classic and dangerous "yo-yo" pattern of fasting blood glucose (BG) from the morning of the 29th to the morning of the 30th. Here is a detailed analysis:
### Summary of the Fasting Yo-Yo
* *29 Jan, 7:45 AM:* *Fasting BG 61 mg/dL* (Hypoglycemic).
* *30 Jan, 8:00 AM:* *Fasting BG 302 mg/dL* (Severely Hyperglycemic).
This is a swing of *241 mg/dL* in less than 24 hours, indicating unstable diabetes management.
### Analysis of Events Leading to the Yo-Yo
*1. The Low (61 mg/dL on 29th Morning):*
* *Cause:* The likely primary cause is the aggressive insulin correction given the night before (*28th, 9:30 PM*).
* Pre-dinner BG was *448 mg/dL*.
* Patient took *5u of Lispro* as a correction ([448-90]/70 = 5.1u).
* They then took *another 5u of Tresiba* (basal insulin) at *9:15 PM*.
* *The Problem:* Stacking a large meal-time/correction dose of rapid insulin (5u Lispro) immediately followed by the daily basal dose (5u Tresiba) created a powerful, overlapping insulin effect that lasted through the night, driving BG down to 61 mg/dL by morning.
*2. The High (302 mg/dL on 30th Morning):*
* *Cause:* A combination of factors from the day of the 29th, likely triggered by the morning low:
* *Reactive Eating/Under-Bolusing:* After a low of 61 mg/dL, the patient ate nuts, milk, and biscuits but only took *1u* for these. This may have been insufficient, starting the day with rising BG.
* *Missed/Reduced Meal Insulin:* The log shows the *10:50 AM pre-lunch Lispro dose was 5u, but the calculation is listed as 1u (nuts & milk) + 1u (biscuit) + 3u (meal). For a patient with a correction factor of 70, a **3u meal dose is very small* for a large, carb-heavy meal (rice, pulses, etc.), suggesting chronic under-dosing for meals.
* *Unlogged Carbs/Snacks:* The log for the 29th is incomplete. There is no entry for dinner or the evening period. It is highly probable that the patient ate dinner (and possibly snacks) without taking adequate or any rapid-acting insulin, leading to a high BG that persisted overnight.
* *Insufficient Basal Insulin:* The fixed *5u Tresiba* dose may be too low to maintain stable BG overnight, especially when there is no meal insulin on board. The high fasting on the 30th suggests the basal insulin is not adequately suppressing nighttime liver glucose output.
### Key Contributing Factors from the Data:
* *Inconsistent Carbohydrate Counting/Bolusing:* Meal insulin doses (e.g., 2.5u, 3u) seem disproportionately small for the described meals (large plates of rice with pulses and vegetables).
* *Frequent High-Carb Snacks:* Patty (evening snack), bananas, oranges, and biscuits are being consumed, often with little to no insulin coverage.
* *Unsafe Correction Dosing:* The formula (Current BG - 90) / 70 is being used, but it does not account for *Insulin On Board (IOB)*. Stacking corrections (like on the 28th) without considering active insulin leads to hypoglycemia.
* *Fixed, Possibly Inadequate Basal Dose:* The 5u Tresiba dose is not being adjusted based on fasting trends, which is essential for stable background control.
### Recommendations:
1. *Review Basal Insulin (Tresiba) Dose:* The fasting yo-yo is a strong indicator that the *5u Tresiba dose needs adjustment*. A healthcare provider should review several days of fasting numbers to determine if it should be increased.
2. *Consult a Diabetes Educator/Doctor:* The patient urgently needs education on:
* *Carbohydrate Counting:* To match meal insulin to actual carb intake.
* *Correction Dose Safety:* Understanding and applying the concept of *Insulin On Board (IOB)* to avoid stacking.
* *Managing Hypoglycemia:* The standard "15-15 rule" (15g fast carbs, wait 15 mins, re-check) should be followed instead of under-dosing for subsequent meals.
3. *Structured Eating & Logging:* Maintain a *complete log* (all food, all insulin, all BG readings) to identify patterns. Consider reducing unplanned, high-carb snacks.
4. *Meal Insulin Ratios:* The mealtime insulin-to-carb ratio likely needs to be increased (e.g., 1 unit for fewer grams of carbs).
*Disclaimer:* This analysis is for informational purposes based on the data provided. *All insulin dose changes must be discussed with and approved by the patient's doctor or diabetes care team.* The pattern shown is hazardous and requires professional intervention.
[10.15 am, 31/01/2026] PPM 1: Please suggest how to optimise the current unsafe insulin correction factor
[10.18 am, 31/01/2026] PPM 4: Based on the data, the current correction method is unsafe because it uses a *fixed formula* (BG - 90)/70 *without considering Insulin On Board (IOB)*, leading to dangerous stacking (as seen on 28/1 night) and yo-yo effects.
Here is a step-by-step guide to optimize and make the correction factor safer. *These are principles to discuss with a doctor; do not change doses without medical supervision.*
### Part 1: Immediate Safety Fixes (To Start Today)
*1. Implement the "Rule of 3-Hour Wait" for Corrections:*
* *The Problem:* Lispro insulin lasts 3-5 hours. The patient is injecting new corrections while previous insulin is still active.
* *The Rule:* *Do not give a correction dose unless it has been at least 3 hours since the last dose of rapid-acting (Lispro) insulin.* This prevents stacking.
* *Example from Data (28/1):*
* 9:15 PM: Took 5u Tresiba (basal).
* 9:30 PM: BG 448 → Took 5u Lispro as correction.
* *Risk:* The Tresiba dose was just taken 15 minutes prior. While it's long-acting, its onset can still overlap. More critically, if there was any IOB from earlier, stacking occurs.
* *Safer Action:* If high before dinner, take the meal bolus (for the food) plus a reduced correction. Wait 3 hours after the last meal bolus (lunchtime insulin) before checking and correcting again.
*2. Introduce a "Sliding Scale" with a Target Range (Safer than Formula):*
* A sliding scale provides guardrails. Based on the patient's patterns, here is a *sample, conservative scale* to propose to their doctor. It uses a *higher, safer BG threshold* before correcting.
| If Pre-Meal Blood Sugar (mg/dL) is... | And it's been >3 hrs since last Lispro... | Then take this ADDITIONAL Correction (on top of meal dose) |
| :--- | :--- | :--- |
| *Less than 90* | -- | Reduce meal dose by 1 unit. Eat carbs first if low. |
| *90 - 180* | -- | *No correction.* Just take meal dose for carbs. |
| *181 - 250* | Yes | Add *1 unit* to the meal dose. |
| *251 - 350* | Yes | Add *2 units* to the meal dose. |
| *351 - 450* | Yes | Add *3 units* to the meal dose. |
| *Above 450* | Yes | Add *4 units*, wait 2 hours, re-check, and call doctor. |
*Why this is safer:* It limits the maximum correction and builds in a buffer. For example, at BG 448, instead of (448-90)/70 = 5.1u, the max correction would be 3-4u, and only if safe to do so.
### Part 2: Working with the Doctor to Optimize the True Correction Factor
The actual correction factor (1:70) may need adjustment. Here's how to find a better one *under medical guidance*.
*1. Perform a "Correction Factor Test" (with Doctor's Approval):*
* *When:* When BG is high (>200) *and* it has been *over 5 hours since the last meal or rapid-acting insulin* (i.e., no active IOB).
* *How:*
1. Check BG.
2. Take a correction dose *ONLY* (no food).
3. Do not eat for the next 4 hours. Avoid exercise.
4. Check BG every hour.
* *The Math:* Let's say BG was 250. You took 2 units as a correction.
* After 3 hours, BG is 130.
* The drop was 250 - 130 = *120 mg/dL*.
* Correction Factor = Drop / Units Given = 120 / 2 = *60*.
* *New, more accurate factor:* *1 unit lowers BG by ~60 mg/dL* (CF = 60).
* *Important:* This test is best done under a doctor's instruction, often starting with a conservative factor (e.g., 1:50).
*2. Use Different Factors for Different Times of Day (if needed):*
* Many people are more insulin-resistant in the morning. The doctor may prescribe:
* *Morning Correction Factor:* 1:50 (1 unit lowers BG by 50 mg/dL).
* *Afternoon/Evening Correction Factor:* 1:70 (as currently used).
### Part 3: The Non-Negotiable Rule: Calculate Insulin On Board (IOB)
This is the *most critical safety step*. The formula is only safe if you subtract any insulin still working from the calculated dose.
* *Simple IOB Rule for Lispro:* Assume it lasts *4 hours*.
* *0-1 hour ago:* 100% of the dose is still active.
* *1-2 hours ago:* 65% is still active.
* *2-3 hours ago:* 35% is still active.
* *3-4 hours ago:* 10% is still active.
* *After 4 hours:* 0% active.
* *How to Apply in Practice (Example):*
* 1:30 PM: Took 4u Lispro for lunch.
* 4:30 PM (3 hours later): BG is 220. Should you correct?
* *Calculate IOB:* 4u taken 3 hours ago → ~35% active → 4u * 0.35 = 1.4u IOB.
* *Old (Unsafe) Method:* (220-90)/70 = 1.8u. You'd inject 1.8u.
* *New (Safe) Method:* 1.8u (calculated) - 1.4u (IOB) = 0.4u. *You would likely skip the correction* and wait, as the remaining insulin will bring it down.
### Summary & Action Plan for the Patient/Advocate:
1. *Stop using the pure formula immediately.* Adopt the *"3-Hour Wait Rule"* and the *conservative Sliding Scale* above as an interim safety measure.
2. *Start logging EVERYTHING meticulously:* Time, BG, exact insulin dose (type and units), all food/carbs. Note if a dose was for food, correction, or both.
3. *Book an appointment with an endocrinologist or diabetes educator.* Present the logs and the dangerous yo-yo pattern.
4. *Discuss with the doctor:*
* Adjusting the *Tresiba (basal) dose* first, as unstable fasting points to a basal issue.
* Establishing a proper *Insulin-to-Carb Ratio* for meals (e.g., 1 unit for every 10g carbs) instead of guessing "meal units."
* Running a *Correction Factor Test* to establish a safe, personalized factor.
* Learning how to *calculate and use IOB*.
*Final Reminder:* The goal is *flat lines, not steep drops and rises.* Safer corrections are smaller, more conservative, and always respect the insulin already in the body. *Professional guidance is essential* to implement these changes safely.
[10.22 am, 31/01/2026] PPM 1: Thanks. Very useful 👏👏
Please provide a Bengali version of the above
[10.24 am, 31/01/2026] PPM 4: নিচে বাংলায় বিশ্লেষণ ও সুপারিশ দেওয়া হলো:
### বর্তমান অনিরাপদ ইনসুলিন সংশোধন ফ্যাক্টর অপ্টিমাইজ করার পরামর্শ
প্রদত্ত তথ্য অনুযায়ী, বর্তমান সংশোধন পদ্ধতিটি অনিরাপদ কারণ এটি *ইনসুলিন অন বোর্ড (IOB)* বিবেচনা না করে একটি *স্থির সূত্র* (BG - 90)/70 ব্যবহার করছে, যার ফলে বিপজ্জনক স্ট্যাকিং (২৮/১ রাতে দেখা গেছে) এবং ইয়ো-ইয়ো প্রভাব পড়ছে।
এখানে সংশোধন ফ্যাক্টরকে অপ্টিমাইজ এবং নিরাপদ করার জন্য একটি ধাপে ধাপে গাইড দেওয়া হল। *এগুলি ডাক্তারের সাথে আলোচনার নীতিমালা; চিকিৎসকীয় তত্ত্বাবধান ছাড়া ডোজ পরিবর্তন করবেন না।*
### পার্ট ১: তাৎক্ষণিক নিরাপত্তা সংশোধন (আজ থেকেই শুরু করতে হবে)
*১. সংশোধনের জন্য "৩-ঘণ্টা অপেক্ষার নিয়ম" প্রয়োগ করুন:*
* *সমস্যা:* লিসপ্রো ইনসুলিন ৩-৫ ঘন্টা কাজ করে। রোগী আগের ইনসুলিন সক্রিয় থাকতেই নতুন সংশোধন ডোজ দিচ্ছেন।
* *নিয়ম::* *দ্রুত-কার্যকারী (লিসপ্রো) ইনসুলিনের শেষ ডোজ দেওয়ার কমপক্ষে ৩ ঘন্টা না হওয়া পর্যন্ত সংশোধন ডোজ দেবেন না।* এটা স্ট্যাকিং রোধ করবে।
* *তথ্য থেকে উদাহরণ (২৮/১):*
* ৯:১৫ PM: ৫ইউ ট্রেসিবা (বেসাল) নিলেন।
* ৯:৩০ PM: BG 448 → সংশোধন হিসেবে ৫ইউ লিসপ্রো নিলেন।
* *ঝুঁকি:* ট্রেসিবার ডোজ মাত্র ১৫ মিনিট আগে নেওয়া হয়েছে। এটি দীর্ঘমেয়াদী হলেও, এর শুরুটা ওভারল্যাপ করতে পারে। আরও গুরুত্বপূর্ণ, যদি আগের থেকে কোনো আইওবি থেকে থাকে, তাহলে স্ট্যাকিং হয়।
* *নিরাপদ পদক্ষেপ:* রাতের খাবারের আগে যদি উচ্চতা থাকে, তবে খাবারের বোলাস (খাবারের জন্য) প্লাস একটি হ্রাসকৃত সংশোধন নিন। শেষ মিল বোলাস (দুপুরের ইনসুলিন) দেওয়ার ৩ ঘন্টা পর আবার চেক করে সংশোধন করুন।
*২. একটি টার্গেট রেঞ্জ সহ "স্লাইডিং স্কেল" চালু করুন (সূত্রের চেয়ে নিরাপদ):*
* একটি স্লাইডিং স্কেল সুরক্ষা সীমানা দেয়। রোগীর ধরণের উপর ভিত্তি করে, এখানে তাদের ডাক্তারের কাছে প্রস্তাব করার জন্য একটি *নমুনা, রক্ষণশীল স্কেল* দেওয়া হল। এটি সংশোধন করার আগে একটি *উচ্চতর, নিরাপদ বিজি থ্রেশহোল্ড* ব্যবহার করে।
| যদি খাবার আগের রক্তের শর্করা (mg/dL) হয়... | এবং শেষ লিসপ্রো দেওয়ার ৩ ঘন্টা以上 অতিবাহিত হয়েছে... | তাহলে মিল ডোজের উপরে এই অতিরিক্ত সংশোধন নিন |
| :--- | :--- | :--- |
| *৯০-এর কম* | -- | মিল ডোজ ১ ইউনিট কম করুন। লো হলে প্রথমে কার্ব খান। |
| *৯০ – ১৮০* | -- | *কোনো সংশোধন নয়।* শুধুমাত্র কার্বের জন্য মিল ডোজ নিন। |
| *১৮১ – ২৫০* | হ্যাঁ | মিল ডোজে *১ ইউনিট* যোগ করুন। |
| *২৫১ – ৩৫০* | হ্যাঁ | মিল ডোজে *২ ইউনিট* যোগ করুন। |
| *৩৫১ – ৪৫০* | হ্যাঁ | মিল ডোজে *৩ ইউনিট* যোগ করুন। |
| *৪৫০-এর বেশি* | হ্যাঁ | *৪ ইউনিট* যোগ করুন, ২ ঘন্টা অপেক্ষা করে আবার চেক করুন এবং ডাক্তারকে ফোন করুন। |
*এটি কেন নিরাপদ:* এটি সর্বাধিক সংশোধন সীমিত করে এবং একটি বাফার তৈরি করে। উদাহরণস্বরূপ, বিজি ৪৪৮-এ, (448-90)/70 = 5.1u-এর পরিবর্তে সর্বোচ্চ সংশোধন হবে ৩-৪ইউ, এবং শুধুমাত্র যদি নেওয়া নিরাপদ হয়।
### পার্ট ২: প্রকৃত সংশোধন ফ্যাক্টর অপ্টিমাইজ করতে ডাক্তারের সাথে কাজ করা
প্রকৃত সংশোধন ফ্যাক্টর (১:৭০) সামঞ্জস্যের প্রয়োজন হতে পারে। এখানে *চিকিৎসকের পরামর্শে* একটি ভাল খুঁজে বের করার উপায় দেওয়া হলো।
*১. একটি "করেকশন ফ্যাক্টর টেস্ট" করুন (ডাক্তারের অনুমোদন সাপেক্ষে):*
* *কখন:* যখন বিজি উচ্চ (>২০০) *এবং* *শেষ খাবার বা র্যাপিড-অ্যাক্টিং ইনসুলিন দেওয়ার ৫ ঘন্টার বেশি* অতিবাহিত হয়েছে (অর্থাৎ, কোনো সক্রিয় আইওবি নেই)।
* *কিভাবে:*
১. বিজি চেক করুন।
২. শুধুমাত্র একটি সংশোধন ডোজ নিন (কোনো খাবার নেই)।
৩. পরবর্তী ৪ ঘন্টা কিছু খাবেন না। ব্যায়াম এড়িয়ে চলুন।
৪. প্রতি ঘন্টায় বিজি চেক করুন।
* *গণনা:* ধরা যাক বিজি ছিল ২৫০। আপনি সংশোধন হিসেবে ২ ইউনিট নিলেন।
* ৩ ঘন্টা পরে, বিজি ১৩০।
* ড্রপ ছিল ২৫০ - ১৩০ = *১২০ mg/dL*।
* সংশোধন ফ্যাক্টর = ড্রপ / দেওয়া ইউনিট = ১২০ / ২ = *৬০*।
* *নতুন, আরও সঠিক ফ্যাক্টর:* *১ ইউনিট বিজি কমায় ~৬০ mg/dL* (CF = ৬০)।
* *গুরুত্বপূর্ণ:* এই টেস্টটি ডাক্তারের নির্দেশনায় করা ভাল, প্রায়ই একটি রক্ষণশীল ফ্যাক্টর (যেমন ১:৫০) দিয়ে শুরু করে।
*২. দিনের বিভিন্ন সময়ের জন্য বিভিন্ন ফ্যাক্টর ব্যবহার করুন (প্রয়োজনে):*
* অনেক মানুষ সকালে বেশি ইনসুলিন প্রতিরোধী হয়। ডাক্তার প্রেসক্রাইব করতে পারেন:
* *সকালের সংশোধন ফ্যাক্টর:* ১:৫০ (১ ইউনিট বিজি ৫০ mg/dL কমায়)।
* *বিকাল/রাতের সংশোধন ফ্যাক্টর:* ১:৭০ (বর্তমানে যেমন ব্যবহার করা হচ্ছে)।
### পার্ট ৩: অ-আলোচনযোগ্য নিয়ম: ইনসুলিন অন বোর্ড (IOB) গণনা করুন
এটি *সবচেয়ে গুরুত্বপূর্ণ নিরাপত্তা ধাপ*। ক্যালকুলেটেড ডোজ থেকে এখনও কাজ করা যে কোনো ইনসুলিন বাদ দিলে কেবল সূত্রটি নিরাপদ।
* *লিসপ্রোর জন্য সহজ আইওবি নিয়ম:* ধরে নিন এটি *৪ ঘন্টা* স্থায়ী হয়।
* *০-১ ঘন্টা আগে:* ডোজের ১০০% এখনও সক্রিয়।
* *১-২ ঘন্টা আগে:* ৬৫% এখনও সক্রিয়।
* *২-৩ ঘন্টা আগে:* ৩৫% এখনও সক্রিয়।
* *৩-৪ ঘন্টা আগে:* ১০% এখনও সক্রিয়।
* *৪ ঘন্টা পরে:* ০% সক্রিয়।
* *অনুশীলনে কিভাবে প্রয়োগ করবেন (উদাহরণ):*
* ১:৩০ PM: দুপুরের খাবারের জন্য ৪ইউ লিসপ্রো নিলেন।
* ৪:৩০ PM (৩ ঘন্টা পরে): বিজি ২২০। আপনাকে কি সংশোধন করা উচিত?
* *আইওবি গণনা করুন:* ৪ইউ নেওয়া হয়েছে ৩ ঘন্টা আগে → ~৩৫% সক্রিয় → 4u * 0.35 = 1.4u আইওবি।
* *পুরানো (অনিরাপদ) পদ্ধতি:* (220-90)/70 = 1.8u। আপনি ১.৮ইউ ইনজেক্ট করতেন।
* *নতুন (নিরাপদ) পদ্ধতি:* 1.8u (ক্যালকুলেটেড) - 1.4u (আইওবি) = 0.4u। *আপনি সম্ভবত সংশোধন বাদ দিতেন* এবং অপেক্ষা করতেন, কারণ অবশিষ্ট ইনসুলিন এটি কমিয়ে আনবে।
### রোগী/অ্যাডভোকেটের জন্য সারসংক্ষেপ এবং অ্যাকশন প্ল্যান:
1. *খাঁটি সূত্র ব্যবহার এখনই বন্ধ করুন।* একটি অন্তর্বর্তী নিরাপত্তা ব্যবস্থা হিসাবে *"৩-ঘণ্টা অপেক্ষার নিয়ম"* এবং *রক্ষণশীল স্লাইডিং স্কেল* গ্রহণ করুন।
2. *সবকিছু সযত্নে লগ করা শুরু করুন:* সময়, বিজি, সঠিক ইনসুলিন ডোজ (টাইপ এবং ইউনিট), সমস্ত খাবার/কার্ব। একটি ডোজ খাবারের জন্য, সংশোধনের জন্য, নাকি উভয়ের জন্য ছিল তা নোট করুন।
3. *একজন এন্ডোক্রিনোলজিস্ট বা ডায়াবেটিস শিক্ষকের সাথে অ্যাপয়েন্টমেন্ট নিন।* লগ এবং বিপজ্জনক ইয়ো-ইয়ো প্যাটার্নটি উপস্থাপন করুন।
4. *ডাক্তারের সাথে আলোচনা করুন:*
* প্রথমে *ট্রেসিবা (বেসাল) ডোজ* সামঞ্জস্য করা, কারণ অস্থির ফাস্টিং একটি বেসাল সমস্যার ইঙ্গিত দেয়।
* খাবারের জন্য একটি সঠিক *ইনসুলিন-টু-কার্ব রেশিও* স্থাপন (যেমন, প্রতি ১০g কার্বে ১ ইউনিট) "মিল ইউনিট" অনুমান করার পরিবর্তে।
* একটি নিরাপদ, ব্যক্তিগতকৃত ফ্যাক্টর স্থাপনের জন্য একটি *করেকশন ফ্যাক্টর টেস্ট* চালানো।
* *আইওবি গণনা এবং ব্যবহার* করা শেখা।
*চূড়ান্ত অনুস্মারক:* লক্ষ্য হল *সমতল রেখা, খাড়া পতন ও বৃদ্ধি নয়।* নিরাপদ সংশোধনগুলি ছোট, আরও রক্ষণশীল, এবং শরীরে ইতিমধ্যে থাকা ইনসুলিনকে সর্বদা সম্মান করে। *এই পরিবর্তনগুলি নিরাপদে বাস্তবায়নের জন্য পেশাদার নির্দেশনা অপরিহার্য।*
[5.08 pm, 31/01/2026] PPM 2: This is incredible but my takeaway message to the patient advocate @PA will still remain the same for now - the Tresiba needs to be moved to early evening at 6 PM or around that time.[11.48 pm, 31/01/2026] PA: 31.01.26
7.45am fasting blood sugar 71
7.45am nuts
8.00am milk
9.50am 4u lispro insulin
1u (nuts and milk) + 3u (meal)
9.55am rice with pulses, carrot, tomato, papaya, hyacinth bean, broccoli, beetroot, bitter gourd, turnip, brinjal, butter and salad
12.00noon orange
1.30pm blood sugar 334
1.30pm 5.5u lispro insulin
3u( 334-90/70) + 2.5u (meal)
1.35pm lunch with same previous dish
6.00pm banana
7.00pm 1/2 rasgulla
9.15pm 5u Tresiba insulin
9.30pm blood sugar 157
9.30pm 2u lispro insulin
1u (157-90/70) + 1u (meal)
9.35pm dinner with as same as lunch dish
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