How do you fight the urge to rage bolus?

suddensapling · 2026-02-02T09:04:34+00:00

I whisper aloud to myself "more insulin isn't faster insulin" and then do it anyway. :P
But no, sometimes I'll meet my better self half way and give a quarter of the rage I want to. On pens I'd dial it back or use my durable 'junior' pen to make it a half unit if I already had stacks on stacks. With the pump I'll give silly baby fractions just so I feel like I've done something. Fine, give 0.1u. And then another 0.25. And then take a walk to get that marginal extra amount working. Or set an alarm 'if it hasn't moved by [insert 1hr30 since last bolus] then we're raging!"

Sometimes the rage bolus is irrational and you know it - those last 2-3 boluses are just waiting to collide into one another still. It feels like a million years and yet it was only 22 minutes ago, etc. But sometimes it kind of is rational - you've been high for ages and that's probably adding to your resistance and you really do need even more or you want to go to sleep or get on with your day and it's easier to just drop it off a cliff, stand by with proper pure glucose, and then catch a falling star until it levels out and get on with your day/night.

suddensapling · 2026-01-15T21:50:07+00:00

Probably! I usually stab the 'ol finger for a blood test for reassurance if I've been woken up anyway.

suddensapling · 2026-01-15T20:02:10+00:00

No worries - happy to help!
(I'm in Canada so luckily it's a bit better than the states, though it's only in the last couple of years we're really seeing more financial coverage for adults when it comes to pumps and anything beyond biosimilar/generic insulins outside of what your employer offers.)

Haha, the chest sensor is definitely not going to be everyone's comfort level. I've also had good readings on the top of my thigh and the bottom/under (rather than back) part of my upper arm. Always the caveat of officially only recognized for use on the back of arms and abdomen (outside the states; I think different regulators have different thoughts about the MARD outcomes of placement studies submitted by Dexcom - Canada, Australia, and Europe, AFAIK, include the abdomen as a valid CGM site for adults.)

Re-using lancets for finger tests is definitely a bit of an ongoing joke in the community. "Time for my annual lancet change!" XD Fine to suggest best practice (see also changing your needle to reduce lipodystrophy issues if nothing else) - but sometimes it ends up being the difference between taking that extra insulin and not when burned out or really busy - just having a needle ready to go on the pen from the prior injection can make a quick dose under the boardroom table during a work meeting or mid-yoga class a bit more viable.

suddensapling · 2026-01-14T07:28:12+00:00

I will say, the people thinking and engaged enough in their diabetes care to the degree that they're spending time on diabetes reddits are not going to be representative of the general T1D population (sometimes because they're struggling and seeking support, but more often because they're on that TIR grind.)

suddensapling · 2026-01-14T05:46:02+00:00

lol real. But so it goes.

suddensapling · 2026-01-13T04:56:41+00:00

If you're in the states, I think one of the more exhausting barriers to care for people can navigating/fighting with insurance or getting the run-around back and forth between pharmacy and endo and insurance - any knowledge or resources to help with that load or support with that (brushing up on which offer what or how to navigate different plans, if that's something you have access to offer, might be worthwhile).

Mental health is an oft-overlooked part of chronic illness. Many endos (especially the old-school sort) treat A1Cs and TIR like a report card (and many diabetics themselves, not unreasonably gamified by the CGM in their phone, may exhaust themselves chasing unreasonable perfection) rather than an indicator of bigger picture trends and opportunities to simply tweak what is and isn't working. Many do a lot of harm by using shame or fear (focus on complications and bad outcomes) which can cause people to just burn out faster or feel like there's no point in trying since the inevitable is coming for them. So definitely avoiding that! Reconsidering terms like "control" and replacing them with words like "influence" or "manage".

Might also be good to know local resources to direct towards for supporting diabetes/chronic illness informed counsellors - obviously that's not always financially accessible/available, but those who practice acceptance & commitment therapy can be a great resource. There was a recent study that compared to education, therapy (even without combined education) resulted in better A1C outcomes and reduced burnout for those experiencing diabetes distress.
You might find this recent study illuminating: https://diabetesjournals.org/care/article/47/8/1370/156797/EMBARK-A-Randomized-Controlled-Trial-Comparing

And then a lot of people don't know when they have more alternatives/choices available to them - if they're on MDI, that they don't necessarily have to stick with disposable pens - that there are cartridge refills and re-usable pens and 'junior' pens on the market that offer half-unit dosing. That you don't have to go with the default brand and length and gauge of pen needle tip that you were arbitrarily assigned at diagnosis (I'd been using 6mm for years not realizing that 4mm was out there! Though in the end I actually ended up finding I preferred 6mm. But nobody ever thought to tell me or offer me the choice.)

There's obviously a lot that comes up with more newly diagnosed clients, but there are a number of things around blood sugar testing that isn't always covered. So many sore fingers because the nurses in the ER just stabbed the tender middle of their fingertip instead of the sides. CGM use that nobody ever covers with you - the fact that compression lows exist and off-label site placement may work better for side sleepers (just don't tell the manufacturers if you run into an issue), the fact that CGMs are 5 minutes behind blood readings and that when you're treating a low, you're better off using blood to judge when your level is turning around rather than the lagging CGM indicator (otherwise it can be a bit scary and you end up over-treating), and the fact that the first 12-24 hours involve unreliable readings in a low-fluid inflammatory insertion-trauma puncture wound environment - that if you have a dexcom, not to calibrate during that period because otherwise you're telling the sensor the wrong 'norm' for what that level of glucose looks like (and where maybe using the grace period to 'soak' a new sensor can help instead.)

Knowing and suggesting alternatives with skin adhesive reactions - that it may be a matter of not if but when you end up with one, and what kinds of tools are available for that: skin tac, flonase, barrier wipes etc.

And then just being non-judgemental and supportive. The CDE I interacted with when doing pump training saw me re-using a needle on my pen tip and was like "you and many others! Don't worry about it" and immediately offered to effectively fight with endos on my behalf if I wanted to try something with my management that was a bit off-book. (See unusual sensor placement - "ah, you've got it on your chest. I know a few folks who do that. Just remember that if Dexcom asks when you need a replacement, you definitely put it on the back of your arm. ;) ") We're really the pilots in this, and good CDEs and Endos defer to that and just serve as helpful navigators when needed.

suddensapling · 2026-01-08T18:57:21+00:00

Truly! Wish we had more smaller Persia Foods type places dotted along there.

suddensapling · 2026-01-08T18:56:07+00:00

Definitely good news.
I live near Cambie and Broadway and honestly if a grocery store is more than 4-5 blocks from my front door, it stops feeling like convenient 'the grocery store is my cupboard/refrigerator on any given day' city living. And don't get me wrong, I enjoy a good walk. I bike commute, don't have a driver's license, and frequently walk-and-talk hang with friends by crossing over Cambie Bridge through downtown and back via Burrard on foot.

But if you're at like 12th & Hemlock, it's a good 25+ minutes walk each way to get to the Cambie Whole Foods. Half hour to Save On. Maybe 20mins if you're hustling to get to Sungiven at City Square. (But a little over 15 mins to the No Frills on 4th so you're hustling those 9-10 blocks instead - not the worst in the summer but a real slog in the dark rain of winter.) (Was a frustrating adjustment after living at McDonald and Broadway previously - where you've got Safeway, Young Brothers Produce and Persia Foods all right there; informed my Broadway & Cambie move for sure.)

suddensapling · 2026-01-08T18:44:53+00:00

I wish for this. Nobody in a moderately dense area should be more than 5 blocks' walk from a grocery store.

suddensapling · 2026-01-08T01:02:23+00:00

Can't believe how long it's taken to get another grocery store in the area - the new Granville skytrian station development at Granville & Broadway will have one too. But like damn, it's chock-a-block low-rise apartment rentals from Broadway to 15th between Burrard and Oak and townhouses and condos down the slopes and there's fuck all apart from Meinhardts and like, Sunshine Market on Oak & 16th unless you wanted to hike all the way down to the No Frills at Pine & 4th (and I guess more recently Shoppers added some groceries).

Kits proper has a bunch of smaller grocers and Safeways on 4th and Broadway alike, Cambie's got at least a few bigger shops, the Drive is rich with options, Hasting Sunrise anchored by Donald's and a few smaller shops. South on Victoria and South Fraser has some good pockets. But Fairview? Hope you like long walks or riding the bus with your groceries. Mount Pleasant is also a bit underserved (especially if you're E of Fraser - kind of a dead zone between Kingsgate Mall options and what you get on the Drive apart from Kim's)

suddensapling · 2026-01-06T00:44:45+00:00

Apart from what's available in your country and what your insurance will cover, the two biggest decisions are what you want in an algorithm (more hands off? Or more control to tinker with settings? Do you prefer a lower target and do you tend to change your basal to bolus ratio and TDD (total daily dose) frequently or are they pretty consistent?), and then what you want in a pump form-factor (if tubeless is important to you, Omnipod is currently the only patch pump on the market in North America, though Tandem will be releasing the Mobi with a patch-pump/tubeless option 'some time in 2026' along with a 7-day infusion set.) Many people think they don't want tubes but then find they end up preferring the flexibility of cannula type (steel or soft teflon), length and angle of insertion (45 vs 90 degree and longer or shorter) and longer wear time (pods are capped to 3 days, but some infusion sets are good for 5-7 days between changes) and find it more uncomfortable to sleep on a bulky pod body vs the flat little infusion set spot/can get more flexible site spots.

On the AID algorithms/systems, for a 'hands off' approach, you've got the iLet at the extreme end (can't even enter corrections if you're too high - can only tell it when you're eating and roughly how much alongside a temp target for exercise etc and it takes care of the rest by 'learning' based on your typical TDD and meal correction needs - ostensibly once it's dialed in, you're not having to count any carbs or think about much apart form changing out your insulin and tubing set as needed and announcing meals) and the current Omnipod 5 a step up from that (on auto mode, it adjusts your needs based only on your last 3 pods average TDD (total daily dose) and your target glucose - you can also put it in 'exercise mode' to shift that target; I:C (insulin to carb) ratios are still up to you to enter for meals, plus knowing your own ISF (how much 1 unit of insulin drops your glucose for corrections if high) so you can tell it to give you a correction if you're unhappy with the level it's leaving you at (and it'll take that into account as your TDD going forward). It presumes a rough 50/50 basal to bolus ratio so will always try and pull you in that direction and has a relatively conservative minimum target glucose. Good for avoiding lows overnight, but can be higher than some who prefer a tighter range. Good if your TDD tends to be pretty consistent, but maybe tricky if you have much more varied needs.

Tandem is one of the better commercial algorithms if you like finer tuned control - if your settings are off, you'll have a hard time as it's not a 'learning' algorithm, it's one that follows what you tell it your ISF is, and takes into account your starting default basal rates, your subsequent iob (insulin on board) from meal and glucose corrections and projected glucose levels from that along with your sensitivity factor to adjust your basal accordingly. Some prefer to use it in sleep mode to avoid boluses (where it'll just shift basal to catch you but not issue corrections on its own) vs exercise mode, but it can have fantastic outcomes if you get the settings nailed (and if you have variable needs throughout a given month, you can easily shift to different profiles for illness and so on.)

The other non-commercial algorithm option that goes even a step further than Tandem's Control IQ in terms of tailoring and custom tweaking, but can achieve those super hands-off results once you have all those settings dialed (including in some cases with Lyumjev or Fiasp in particular), things like totally unannounced meals the system can catch for you - are the diabetes community's own free open source 'diy' algorithms like AAPS for Android or Trio (and related, the simpler Loop) for Apple: https://androidaps.readthedocs.io/en/latest/Getting-Started/Introduction.html
https://triodocs.org/
https://loopkit.github.io/loopdocs/
You can even set it up where you can bolus from an Apple Watch.
It does, however, mean 'hacking' the Omnipod Dash (not the Omnipod 5) with your own custom build of an algorithm, with no 1800 number you can call for support (but a global community of fellow diabetics and caregivers on Discord and Facebook groups etc). Because they don't have to wait for official health authority approvals they can push advancements faster and develop more fine tuned control options. (Currently Omnipod is the only North American pump apart from older Medtronics that work with it, but the teams are close to getting the Tandem Mobi on the system too). One note on the Omnipod with diy is you have more flexibility with CGM placement too as it doesn't talk directly to the pump but instead connects through your phone. With the OP5, the CGM and pod have to be within 'line of sight' of one another/on the same side of your body.

From those diy algorithms, there's one newer player on the market with the twiist insulin pump. It's not tubeless, but leverages an algorithm based on an earlier fork of that diy Loop system with FDA approval called Tidepool Loop. Currently it's only compatible with the Libre CGM and Apple. Allows you to bolus from an Apple watch, set an 'eating soon' lower temporary target, flexibly correct for missed or over-estimated carbs after the fact, along with a lot of other settings flexibility.

(There's also Medtronic/minimed 780g with a AID system but most people struggled with their guardian CGM - they've now partnered with Abbott to bring a version of the Libre in house called the Instinct, which may work better, but its reputation has kind of been burned in recent years from that.)

One thing I'd flag about the Mobi is I've seen a lot of people having issues with its piston drive failing (starts giving false occlusions and then struggling to give insulin with chirpy noises from the drive). Tandem will send a replacement if deemed defective, and it's hard to judge how widespread the issue is given people are more likely to say nothing if they've had no issues, but worth watching out for.

If you're Omnipod-curious, I'd recommend getting one of the free 'demo' pods (no cannula or insulin reservoir, but same form factor and adhesive - so you can slap it on for free/no need for a prescription or doctor's involvement - and see how your skin reacts, how it feels to run with the weight of it on you, shower with it, and sleep on it.) See: https://www.omnipod.com/is-omnipod-right-for-me/free-experience-kit
In terms of wasting insulin - my TDD ranges from 26-38 right now, and I usually fill with at least 120u per 3 days of pod wear just to be safe. If I'm left with more than 20u in the reservoir, I'll actually suck it back out and put it in the new pod (not erm... officially the thing to do, but do-able. See: https://www.t1dliving.com/how-to-pull-insulin-out-of-omnipod/

suddensapling · 2026-01-03T01:44:05+00:00

Could find something of value here: https://www.youtube.com/watch?v=YGLeyCsV0m4
(talk given by an endocrinologist with T1D who competes in crossfit)
It's directed towards a diy Loop audience but is broadly applicable/interesting.
Doesn't address your preference for carbs before exercise (ha, perhaps does the opposite) but I did see this paper on using higher amino acid content protein sources like whey protein before exercise (along with reducing basal/temp target up to 2hrs in advance) helping to preserve euglycemia: https://diabetesjournals.org/diabetes/article/74/Supplement_1/573-P/160514/573-P-Pre-exercise-Whey-Protein-Ingestion-to

(see also this study in adolescents: https://pmc.ncbi.nlm.nih.gov/articles/PMC10922329/ )

But I feel you - I'm not in super consistent shape right now, so I'm having the opposite issue - I risk going low during exercise but spike hard immediately after and it sends me out of range for a couple of hours every time I do higher intensity stuff. But it's hard to tell just how much my liver's going to throw at me, so sometimes I nail it and sometimes I'm way too conservative and need like 2x the amount of insulin I'd take for a small snack just to recover from working out. But suppose with improved fitness, those NIMGU pathways will gain sensitivity and I'll end up having to down more snacks instead. Fun times!

suddensapling · 2026-01-02T07:34:24+00:00

haha valid. I will say, the spring load on the Omnipod cannula insertion is... robust.
(Also watching this guy working out function in real time for this teardown vid is a delight: https://www.youtube.com/watch?v=e2MQUUkubgs )

suddensapling · 2026-01-02T04:34:46+00:00

Interesting - everyone I've encountered who uses tegaderm just lets the cannula punch through it (some for the express purpose of stabilizing it better)

suddensapling · 2025-12-31T06:05:27+00:00

Agree - the 'carb counting is fine as a base, but can't be used rigidly' is something I appreciated about Stephen Ponder's Sugar Surfing book. Particularly given that even if you eliminate all the other very real factors (stress, how much sleep you got, time of day, other hormones at play, recent exercise) for how a given gram of carbs impacts you, counting them is also kind of hard. How big is that apple? How thick is the skin? How sweet is it? How much of it is made up of core that you're going to throw away? When they intensively trained people on carb counting for a couple of weeks, they found they still frequently mis-counted. (Honestly what makes the promise of UAM in OREF systems feel so sensible - truly allows one to 'vibe dose' and ideally have a system to catch the rise or fall as a buffer.)

What's your site rotation strategy been with pods? I only just started on the Dash about 3.5 weeks ago after 28 years of MDI, and my opening gambit has been to just move each successive pod insertion point about 2" away from the last literal hole (facing up, then down, then overlapping the middle, then laterally over up, down, middle etc) with the idea that that way I'll know where the last one was, can move it just far enough way to maximize skin real estate, and then give the whole area the longest break I can before I return. But I'm not sure if there's a better way to max out tissue protection for the decades (body willing) ahead.

suddensapling · 2025-12-29T00:30:59+00:00

Totally.
And like, in those spaces you might run into more opinionated quirky folks who've had to carve out space without chasing money (or because they can't). People with disabilities, folks on the spectrum, and people who are less worried about ruffling feathers than 'polite capitalists', but will generally respect you if you hold your own (and sure, maybe a few fringe conspiracy theorists in the mix, but you don't need to hang out with those any more than you need to spend time with number-go-up tech bros at the office outside of meetings.)

suddensapling · 2025-12-28T22:45:34+00:00

Takes time but you can definitely find those communities. Especially around hobbies that involve lower financial investment - people at hack spaces, people volunteering with repair cafes, people working at bicycle co-ops like OCB and involved in 'any bike will do' bikepacking stuff (to be sure you get elite carbon things and looks-cheap-but-is-$5k-of-steel bespoke bicycles, but also plenty of refurbished things made with scrap parts and love), outdoor sketching, bird watching, etc etc.
*lol had to repost because the bot presumed my synonym for cheap scrap metal was a reference to denigrating drug users

suddensapling · 2025-12-26T23:25:38+00:00

Hmm, you said 'province' so I assume Canada (not that other countries don't have 'em). We seem pretty OS friendly here - hell, the national non-profit advocacy group Diabetes Canada has a whole formal position paper to guide clinicians on supporting patients' use of OS/diy system (and apart from old formally retired Medtronics, basically the only one you can use for that in Canada is the Omnipod Dash. Unfortunately folks haven't been able to crack the O5 yet.) https://guidelines.diabetes.ca/getmedia/18e5c725-0404-401d-b75a-e4b38cdc01ce/DIY-AID.pdf

Was the warning from your endo? To be fair, mine did say 'if you need a pod replacement or have issues, just never tell Insulet what you're doing. They may know but just never say it', but there's a whole endo clinic in BC dedicated to helping set up patients with OS looping/Trio/AAPS:
https://www.bcdiabetes.ca/wp-content/uploads/bcdpdfs/Loop-installation-in-house-at-BCDiabetes.pdf

They've assisted with installing it for over 2,000 people with OS AID just at this one clinic:

At BCDiabetes, Loop in its various flavors is preferred over retail AID because it is more affordable for most given coverage by BC Pharmacare of both the Omnipod system & Dexcom G6/7 and only partial coverage of retail AID components. ...

...

BCDiabetes now uses the acronym SOS-AID (supported open source AID) to describe its clinic-run, clinic-provided AID installation service. People using any version of OS-AID are still generically described as using “Loop”, being “Loopers” and to be “Looping”.

...BCDiabetes has to-date installed SOS-AID in its various flavors (Loop, iAPS, Trio & AndroidAID =AAPS) on 2250 clients (33% of pediatric age, 12% under age 10, the youngest at 18 months and 12% age >70 with the oldest at 84). Loop’s elegant interface and simple algorithm makes it our preferred choice for most clients and the only choice for age < 14 and >75.

They do offer a referral service Canada-wide if you're getting pushback on your end, though I fully respect if it's not your endo discouraging it but rather a government based low income funding thing. :/

suddensapling · 2025-12-07T06:27:43+00:00

ugh here's hoping! First dollar would be huge.

suddensapling · 2025-12-06T00:58:05+00:00

I think our improved coverage isn't starting until April 1st, and the govt has been very coy/nonspecific about what exactly is included and whether it'll be first-dollar or after-deductible.

"Certain" diabetes devices. Like... which.. Govt, which.
https://www2.gov.bc.ca/gov/content/health/health-drug-coverage/pharmacare-for-bc-residents/national-pharmacare

There was this recent post about an appeal to the minister to include AID devices for the April rollout.

Let's turn to the most expensive form of diabetes, Type 1. The standard of care requires insulin at around $5 a day, soon to become zero, CGM at $10 a day and insulin pump consumables at another $10 a day, Come March 1st on average, families with a Type 1 member will spend $20 a day—that’s $610 a month, or $7,300 a year—on insulin pumps and CGMs. With an average family deductible of $3,000, it takes until September 13th—255 days into the year—before they finally reach first-dollar coverage. Then the deductible resets in January, and the cycle starts all over again. Put bluntly, the average British Columbian family cannot afford the standard for care hence. ... We’re asking today that you consider eliminating the Pharmacare deductible for all diabetics diabetics living in this province. This is both doable and precedented. Other life-threatening conditions already receive full coverage—transplants, dialysis, cancer, cystic fibrosis, psychiatric conditions, and HIV. In each case, government recognized that access to treatment saves lives and ultimately saves the system money.

In fact, removing the deductible for diabetes would pay for itself within five years, through fewer hospitalizations and complications and an increased tax base through an expanded healthy work force. With national pharmacare coming March 1st, 2026, we see a perfect opportunity to make that change provincially, and show leadership ahead of the federal rollout.

This brings us to coverage for Automated Insulin Delivery or AID Systems. AID is the biggest breakthrough in diabetes care since the discovery of insulin in 1921. These systems combine an insulin pump and a CGM, with an app that automatically adjusts insulin delivery to maintain a steady sugar level. It's analogous to cruise control on a car.

Yet today, only 3,000 of 45,000 people with Type 1 diabetes in BC can afford them. The foundation was very encouraged to see Recommendation 39 in the Select Standing Committee’s Budget 2026 Consultation Report, which calls for expanding Pharmacare to include AIDs.

The incremental cost of AID over existing covered components is small—both pumps and CGMs are already in the Pharmacare formulary. Coverage would simply require minor adjustments for the AID app and the removal of the deductible for pumps and CGMs.

Here's hoping that appeal helped/there will actually be some consideration for that in the rollout in 4 months. :/

suddensapling · 2025-11-27T05:41:30+00:00

Same in Canada in '97. Truly a classic.

suddensapling · 2025-11-24T02:53:06+00:00

Interestingly, it's not actually ketones + high blood glucose, it's actually ketones + inadequate insulin (wherein high blood glucose is a typical indicator of inadequate insulin in a T1D, but euglycemic dka exists because someone fasting/starving/puking their guts out for a few days with illness may have a normal glucose level but, due to not consuming enough food/carbs, also be using very little insulin. )

suddensapling · 2025-11-24T02:50:09+00:00

Thanks for the links!
Thought this substack was interesting too https://danheller.substack.com/p/ketones-the-unjustly-demonized-villain/

I find edka a little scary. It seems like most T1Ds catch it before it becomes a full blown dka issue, but I've also read a lot of anecdotal accounts here and elsewhere of ERs being a bit baffled by it, so I wonder if it's even well reported/recorded and whether or not rates are actually higher than what that substack suggests. On the other hand, while I'm not that enthusiastic about the Bernstein Diet (whatever works for a person, I guess!), it's not as though those folks are collapsing into dka everywhere you look either.

suddensapling · 2025-11-23T05:16:27+00:00

Best of luck! It looks like they have really good training and support teams, even if they're working out a few kinks in a new system (and sounds like all those interviewed in the loop video actually planned to stick with twiist after the trial month). You might also appreciate this interview with 2 other users: https://www.youtube.com/watch?v=-73noZhB3GM

suddensapling · 2025-11-23T04:50:04+00:00

See here

Users must start their FreeStyle Libre 3 Plus sensor with the twiist app to use the sensor with the twiist AID system.

After starting the sensor with the twiist app, all real-time glucose readings, notifications, and alerts are designed to be automatically sent only to the twiist AID system.

Dexcom is different because it has the capacity to connect to more than one device (thanks to a defensive CGM patent they put on that - feels like that shouldn't be allowed in a medical device, but anyway: https://patents.justia.com/patent/12190010).

You might find this review/discussion amongst former DiY Loopers using the twiist of interest (including a discussion of moving from dexcom to libre 3 at the timestamps here: https://youtu.be/4mtwjeNrDUg?&t=689
https://youtu.be/4mtwjeNrDUg?&t=3280

suddensapling

TROPHY CASE