Linking xDrip+ to Amazon Alexa

I managed to link my Dexcom to Amazon Alexa today via xDrip+ so I thought I would step through how it works so others can do the same. As usual, a summary is at the end in the tl;dr section.

Why Would You Do This?

I can think of a few reasons why you might want to set this up:

  • Anyone in my home can now ask Alexa what my blood glucose level (BGL) is, regardless of where I am.
  • If I have a Spot or Dot by my bed I can ask Alexa my BGL without having to move anything more than my mouth
  • If looking at screens is problematic, this provides an alternative way to know your levels

My Setup

As if often the case with diabetic hacks, there are a few links in the chain. Let us go through the applications and devices.

  • The Dexcom G5 (although any CGM/Flash Monitor will work which is compatible with xDrip+). The Dexcom G5 has a Bluetooth connection to my Android phone running:
  • xDrip+: An Android app which displays the Dexcom results and uploads them to the:
  • Dexcom Share Server: An online repository of your BGLs. This is accessed by:
  • SugarMate: An online report generation app, similar to Tidepool.org which has a Skill in:
  • Amazon Alexa: Invoke the SugarMate app and you have your BGL and when it was last checked

Dexcom G5

Not much to do here. Attach it to your arm.

My slightly hacked Dexcom G5

xDrip+

Install the app, go to the Settings and connect your Dexcom.

You will know if it is working because you will get a pretty graph of results when they come in.

Dexcom Share Server

To get the data from xDrip+ to the Dexcom Share Server we first need an account on the Dexcom site.

Once we have this we go to the xDrip+ Cloud Upload Settings, choose Dexcom Share Server Upload and give it the Dexcom account details.

As I am in Australia I am not using the US servers. If you are in the USA, your setting may be different. Also, as I am not using a Dexcom Receiver, I left the 10 Character Serial Number blank.

Amazon Alexa

I will work backwards from here (it just makes life a little easier). Firstly, enable the SugarMate skill through the Alexa app on your phone. This will give you the option of signing up for SugarMate and it will also give you an email address to add as a follower.

Once signed up and linked to Dexcom, go back to xDrip+ and add the email address as a Follower (the other name fields do not matter so make them something friendly for you).

That is it. With all that in place you can simply say “Alexa, ask Sugarmate for my latest reading” and it will tell you your reading and when it was last checked.

Using Routines

I was hoping I could use a Routine to modify the invocation command to something more ‘middle of the night’ friendly such as “Alexa, what is my BGL?” but at this stage it is not possible to invoke a Skill from a Routine.

tl;dr

Using xDrip+ with your preferred CGM/Flash Monitor, uploading to the Dexcon Share Servers, linking it to SugarMate and enabling the SugarMate Alexa skill, anyone in your household can ask Alexa what your blood glucose is.

This is useful in the middle of the night or if a loved one is at home and concerned. It is also useful if sight impairment is an issue.

Unfortunately I have found no way to simply the invocation phrase “Alexa, ask Sugarmate for my latest reading” but if I do I will add it to the article.

What Do Those Blood Tests Mean?

Diabetics get a lot of blood tests done and sometimes we should ask for others. Here they are broken down so you know what you are getting done and what you should ask for.

Summary at the end for those who find the article tl;dr.

‘Sugariness’ And Insulin Measures

HbA1c

Practically every diabetic knows their HbA1c (Hemoglobin A1c). This is a measure of the number of hemoglobin proteins in the blood with glucose attached. This gives an indication of how sugary a person’s blood has been for the last three months.

Why three months? Hemoglobin is part of your blood’s red blood cells. In a healthy human, red blood cells survive for around three months in the blood before dying.

This has a few implications. Firstly, if you have a disease which affects the life of your red blood cells, such as anemia, this will throw off your HbA1c measure, shortening the time over which the HbA1c is a representative average. Also, the measure is not a linear average; the result is biased to the more recent ‘sugariness’ because not every red blood cell lives for exactly three months. Not all of those ‘born’ three months ago will be around but most of the one born a month ago will.

It should be noted that there is around a 10% relative error in this test so if you have, say, an HbA1c of 7% and it moves on your next test by less than 0.7%, this could be nothing more than measurement error.

Finally, while a lot of emphasis is put on the HbA1c, it is only a number to indicate your average blood glucose level (BGL); it says nothing of the fluctuations. Some doctors will get nervous at lower HbA1c results because they have no visibility of the fluctuations. If you have excellent blood glucose control do not be afraid of lower HbA1c results.

C-Peptide

When beta cells produce insulin they actually produce a thing called proinsulin which is two halves of the insulin molecule and a ‘connecting peptide’ (c-peptide) which joins them. Through the magic of biology this eventually transforms into insulin and a residual c-peptide molecule.

By measuring the amount of c-peptide in the blood we can get an indication of how much insulin the pancreas is producing (injected insulin is not in the form of proinsulin so there is no c-peptide residue).

A typical Type 2 will have a high c-peptide reading because their pancreas is trying to overcome their insulin resistance. A typical Type 1 will have a low c-peptide because the immune system has destroyed their beta cells and with it the ability to produce proinsulin. I say typical because for a LADA like me with insulin resistance, my c-peptide is normal/high even though I am Type 1.

Fasting Insulin

This measures the level of insulin in the blood for a fasting individual. Unlike c-peptide this cannot distinguish between insulin made by the body and injected insulin.

Fasting Glucose

The blood sugar level when fasting. For an individual producing enough insulin to keep their liver in check, this should be normal.

HOMA-IR/HOMA-β

The ‘Homeostatic Model Assessment of Insulin Resistance’ (HOMA-IR) and the ‘Homeostasis Model Assessment of β-Cell Function’ (HOMA-β) are mathematical formulae using the blood’s (fasting) insulin and glucose levels to give an indication of the individual’s insulin resistance and beta cell function.

In other words, for someone not using insulin, their fasting insulin and glucose results can be used to determine how much insulin resistance they have and how much beta cell function they still have.

Vitamin D

Linked to insulin sensitivity, this may be useful to see if you are low (many of us office workers are).

Vitamin B12/Active B12

If you are taking Metformin/Diabex/Glucophage (different names for the same thing), you should check your B12 levels as Metformin can affect the body’s ability of absorb vitamin B12 from food. The difference between ‘B12’ and ‘Active B12’ is that, while different forms of B12 are circulating in the blood only the ‘active’ form can be used by cells in the body.

Autoantibodies Against Islet Cells (ICA), GAD, IA2, ZnT8, and Insulin

This is the definitive test for determining if someone is a Type 1 diabetic as it proves the immune system is attacking the body’s insulin production machinery.

If this test is positive, you are Type 1, by definition. However, there are people with all the hallmarks of Type 1 diabetes who do not get a positive result on autoantibody tests. Possible reasons for this include:

  • The person has had Type 1 diabetes for so long that there are no longer any beta cells left to provoke an immune response
  • Their Type 1 diabetes is caused by an as yet unknown autoantibody

Whether these ‘idiopathic’ Type 1s should be classified as Type 1, given the lack of autoimmunity evidence, is a matter of debate but, from a treatment perspective, it makes sense to align them to ‘classic’ Type 1s.

Body Mass Index and Waist Measurement

While not blood tests, the Body Mass Index (BMI) and a person’s waist measurement give a general indication of obesity. Obesity is linked to insulin resistance so, in an ideal world, diabetics of any Type would stay within a healthy weight range.

Oral Glucose Tolerance Test (OGTT)

Although I never had one of these myself (presenting with mild DKA at diagnosis was enough to establish I had diabetes), it is something often used to determine if a person has diabetes.

The test is relatively simple: the patient, who has fasted, is given a fixed measure of glucose syrup and blood is taken at the one, two, and maybe the three hour mark to measure the patient’s glucose response. If the patient cannot bring the blood glucose levels down fast enough and they go too high, the patient is diabetic.

Heart and Kidney Disease

Diabetics, due to damage from high BGLs, are prone to kidney disease and have a higher rate of heart disease, compared to the general population

Blood Pressure

Not a blood test, but the test the doctor does with the arm band and an air pump. A high blood pressure can be a risk factor for kidney and heart disease.

Albumin/Creatinine Ratio

This is a urine test and, for healthy functioning kidneys, there should be little to no albumin in the urine. It is measured as a ratio because creatinine is generated at a reasonably constant rate in the body so, if creatinine fluctuates in urine, this is likely due to relative levels of hydration in the body. So, by measuring the ratio, we get a stable indicator of albumin in the urine, independent of hydration levels.

Cholesterol (LDL/HDL/Triglycerides)

The prevailing thinking in conventional medicine is that the different types of cholesterol play a role in a person’s risk of heart disease. A metastudy (review/compilation of multiple actual studies) in 2016 found the evidence for this was not strong. I am not going to settle this debate in this blog article so discuss this with your health care team and do your own research if it is important to you.

For myself, I eat a lowish carbohydrate diet which means I have moved to eating more proteins and fats. My thinking is that, even if there is an increased risk of long term heart disease, this is outweighed by my short term desire to preserve my beta cells and remain insulin free for as long as I can, while keeping my BGLs in a healthy range.

Assuming cholesterol measures are relevant to a person’s heart health, here are the measures on interest:

  • Total cholesterol: ideally low
  • LDL: ideally low
  • HDL: ideally high
  • Triglycerides: ideally low
  • Cholesterol/HDL ratio: ideally low i.e. you want relatively low cholesterol or high HDL with the absolute amount being less important (useful for diets higher in fat)
  • LDL/HDL ratio: ideally low based on the above and again, talks at relative levels, rather than absolute levels

Sodium

High levels of sodium can indicate kidney dysfunction.

Bicarbonate

This is a measure of how acidic your blood is (low levels suggest more acidic blood). Again, this can be an indicator of kidney health but, be warned, if you are engaging in a low carbohydrate diet and producing ketones, these are acidic and may throw off the test. I have seen this in my test results on occasion.

The idea that one blood test can be the result of one of many causes speaks to the need to get multiple tests done to confirm something like kidney disease. While my blood may sometimes be slightly acidic, my albumin/creatinine ratio is always within range, confirming it is my keto-like diet that is the cause and not organ damage.

Urea

Like the bicarbonate test, urea can be indicative of a number of things. Most importantly it can indicate kidney damage or heart failure. Urea in the blood is a result of protein breakdown so, again, if you are engaging in a low carbohydrate diet and eating more protein, a higher urea level may be the cause. It is no coincidence that on those blood tests where my bicarbonate was low, my urea was also high and was indicative of nothing more than me being a little more keto than usual.

Liver Disease

The other organ that gets a battering from diabetes is the liver. We have a raft of tests available to us to ensure our liver is doing its job and keeping us healthy.

Gamma Glutamyltransferase (GGT)/ Lactate Dehydrogenase (LD, LDH)/ Aspartate Aminotransferase (AST)/ Alanine Transaminase (ALT)

These are enzymes found in the liver and usually only in small amounts in the blood. An elevated level of them in the blood can indicate kidney damage. It can also indicate a bumpy ride on a motorcycle leading up to the test so always regard blood test results with caution until confirmation tests have been conducted.

Total Protein

This is related to the Albumin/Creatinine test as Albumin is a protein. Abnormal total protein levels in the blood can indicate kidney damage but can also indicate liver disease. A high protein diet has no effect on protein in the blood.

Globulin

Total Protein = Albumin + Globulin so, again this is a protein test where abnormal results can indicate kidney or liver disease, among other things.

Alpha-Fetoprotein

Another protein test which can test for severe liver disorders in non-pregnant people.

Infection Markers

White Cell Count/ Lymphocytes/ Eosinophils/ Monocytes

Lymphocytes, Eosinophils, and Monocytes are all types of white blood cells. All of these can be tested to get an idea of infections, allergies, and other disorders which may be affecting the body.

While I occasionally have elevated levels of these, it generally settles down by the time of my next quarterly/biannual blood test. If it did not, it could be indicative of an undiagnosed prevailing condition e.g. cancer or infection and would warrant further investigation.

tl;dr

Here is the list of common blood (and other) tests done for diabetics and their meaning.

  • ‘Sugariness’ and Insulin Measures
    • HbA1c: An average of your last three months of blood sugars
    • C-Peptide: A measure of how much insulin your body is still producing
    • Fasting Insulin: How much insulin is in your blood to keep your liver in check
    • Fasting Glucose: How sugary you are without food
    • HOMA-IR/HOMA-β: Mathematical formulae using the fasting insulin and glucose used to determine insulin resistance levels and beta cell function
    • Vitamin D: Low levels can contribute to insulin resistance
    • Vitamin B12/Active B12: B12 absorption can be hindered by diabetic medications such as metformin
    • Autoantibodies Against Islet Cells (ICA), GAD, IA2, ZnT8, and Insulin: Tests whether diabetes is caused by an autoimmune response and is therefore Type 1 diabetes
    • Body Mass Index and Waist Measurement: Body measurement tests to give an indication of obesity and potential insulin resistance
    • Oral Glucose Tolerance Test (OGTT): A test involving the drinking of glucose syrup to assess whether a person is a diabetic
  • Heart and Kidney Disease
    • Blood Pressure: The test with the armband and pump. This can indicate an increased risk of heart and kidney disease
    • Albumin/Creatinine Ratio: A urine test for kidney health
    • Cholesterol (LDL/HDL/Triglycerides): Measures of fatty acids and fatty acid transporters in the blood. Abnormal levels are traditionally considered a risk factor for heart disease
    • Sodium: High levels can indicate kidney disease
    • Bicarbonate: Low levels can indicate kidney disease but can also result from a ketogenic diet
    • Urea: Used as an indicator for heart or kidney disease but can also be indicative of a high protein diet
  • Liver Disease
    • Gamma Glutamyltransferase (GGT)/ Lactate Dehydrogenase (LD, LDH)/ Aspartate Aminotransferase (AST)/ Alanine Transaminase (ALT): Liver enzymes not usually found in the blood which can indicate liver damage
    • Total Protein: Abnormal levels can indicate liver or kidney damage. Not affected by dietary protein intake
    • Globulin: Abnormal levels can indicate liver or kidney disease
    • Alpha-Fetoprotein: Can indicate severe liver damage/disease
  • Infection Markers
    • White Cell Count/ Lymphocytes/ Eosinophils/ Monocytes: White cell tests which can indicate infection, allergy or disease.

You Are A Newly Diagnosed Type 1! What Next?

Welcome to the club no one wants to join. If you are reading this it is likely you, or someone close to you, has just been diagnosed as having Type 1 diabetes. This is the guide I would have loved when I first got diagnosed. Do not have the time to read? Go to tl;dr.

Everything Is Going To Be OK

First of all, while it may feel overwhelming, everything is going to be fine. There are Type 1 diabetics in most walks of life from elite athletes to pilots. Around 1% of people in the UK, USA, and Australia (1 in 100) have Type 1 diabetes. That is one in three or four school classrooms. Type 1 diabetes affects both genders roughly equally, people of all ages, and people from all walks of life. You are not alone.

You may not know someone with Type 1 but they are out there and dealing with it every day. For me, it was 11 months from diagnosis before I met another Type 1 diabetic in the flesh. There were plenty of resources along the way to help me though.

Quick Reads

Two excellent online documents my endocrinologist pointed me to was the Australia JDRF’s Adult Guide, and the Australian Type 1 diabetes Starter Kit. These sites also have guides for parents, and guides for family and friends.

In the USA there is the US JDRF, and in Canada there is Diabetes Canada. If you live somewhere else Google: ‘diabetes “type 1” <your country>’ for local resources.

Longer Reads

There are some really great resources for Type 1s in book form, written by Type 1 diabetics. Some of the ones I rate or which other Type 1s I know have rated are:

  • Dr Bernstein’s Diabetes Solution: Even if you do not subscribe to Dr Bernstein’s very strict low carbohydrate diet, the book is full of information about diabetes and tips for managing it.
  • Think Like a Pancreas: Great advice on how to manage diabetes with insulin as well as covering the essentials of what diabetes is.
  • Bright Spots and Landmines: This is a more general guide for Type 1s and Type 2s. I have not read it, I hear good things.
  • Sugar Surfing: While books such as Dr Bernstein focus on the more traditional basal + mealtime bolus insulin regimen, Sugar Surfing incorporates the use of a continuous glucose monitor (CGM) to do regular micro-adjustments of insulin. The people I know who do multiple daily injections (MDI), all rate this book strongly as a guide for keeping blood sugars within range

Online Communities

By far it was the online communities that helped me the most in the first 11 months. Practically every form of social media has some kind of diabetes group in it. While I do not ask a lot of questions on social media, it is great to listen to the questions and answers of others. Ones which I found (and continue to find) useful are:

  • Facebook: So many diabetes communities here; some friendlier than others. Embrace the ones which work for you
  • Twitter: Around the world are Twitter chats for diabetics. Basically, each week, diabetics gather to converse on a topic of the week. The format is a series of questions, thrown out to the group and people answer with the relevant hashtag. Ones I have participated in are:
    • #OzDOC: The Australian Diabetic Online Community, this group is, sadly, all but wound up.
    • #ADEAChat: A gathering of the Australian Diabetes Educators Association but diabetics are also welcome. The weekly chat is at 7:30pm AEST on Tuesdays
    • #DSMA: The US-based Diabetes Social Media Advocacy meet at 9:00pm EST on Wednesdays
    • #GBDOC: The UK-based chat which runs weekly at 9:00pm UTC on Wednesdays
  • Reddit: A relatively new medium for me, Reddit has two Type 1 channels and the karma system ensures people are, mostly, on their best behavior.
  • YouTube: Arguably the best diabetes resource on YouTube is Dr Bernstein’s YouTube channel. If his book is too expensive or you want to try before you buy, watch his hundred or so free videos.

A Good Health Care Team

At diagnosis it surprised me to learn it would take a team to help me manage diabetes but it is absolutely true. The best advice I can give is do not accept anyone into your health care team you are not comfortable with. You are paying good money for their expertise and service but this does not give them the right to make you feel bad about yourself. Diabetes is stressful enough without a health care professional exacerbating the problem. Get a good health care team and it will make managing diabetes so much easier. People you have on the team might include:

  • An Endocrinologist (endo) for specific disease-related advice
  • A Diabetes Educator to give you more practical day-to-day advice for managing the disease
  • A General Practitioner (GP) for general medical advice (and generally cheaper than the endo)
  • A Podiatrist for regular feet checks (diabetes-related damage often reveals itself in the feet)
  • An Optometrist/Ophthalmologist for regular eye checks (diabetes-related eye damage can often be prevented through an eye check and early intervention)
  • A Nutritionist to assist, if required, with food and nutritional advice. Try to make it one who specializes in Type 1 diabetics otherwise you will likely be told advice which may be useful for muggles (non-diabetic folk) but of limited value to someone who cannot process carbohydrates well.
  • An Audiologist for regular hearing exams (or benchmark yourself with an online test list like this one and get the specialists involved when there is a measurable change)
  • A Dentist for regular teeth checks (a diabetic’s sugary nature makes their teeth more susceptible to problems).
  • A Cardiologist for regular heart health checks (diabetics have a higher risk of heart problems than muggles)
  • An Exercise Physiologist if you are looking to get into shape to help manage the disease

Get Educated

With the internet you have the ability to go into as much detail as you like on any topic you desire. You are the best advocate for your health and well-being so be the strongest advocate you can be.

Topics worth researching include:

  • Food and nutrition. Understanding which foods have low carbohydrate levels, which foods are low GI (glycemic index), and how you can ‘hack’ the GI of foods can be very beneficial in managing blood glucose levels
  • What those blood tests actually mean (and do not be afraid to suggest additional tests if you think they will help inform your management. In my experience endos and doctors are happy to add other measures to their list of blood tests if you ask)
  • What do your medications do and how to avoid the side effects e.g. taking Metformin in the middle of my meal helps me to avoid embarrassing side effects
  • How does diabetes work. Understanding how Type 1 works means you can effectively assess the relevancy of information you come across. It might be information useful exclusively for Type 2s or it could be complete nonsense. With a good knowledge of Type 1, you will be able to discern the difference.
  • What is the latest medical research? An excellent source of information is NCBI which contains a vast repository of the latest medical research. I try to review this at least once a month for new findings to help inform my management. For example it was through NCBI that I found the growing evidence that DPP-4 inhibitors help preserve beta cell function in newly diagnosed Type 1s. With this evidence I then convinced my endo to prescribe me saxagliptin to help extend my honeymoon

Another way to get educated is through courses set up by diabetes groups in your local area. Often these are free and provide a great foundation for the newly diagnosed. Your endo or Diabetes Educator should be able to point you in the right direction.

If you are venturing onto the internet for information, you will need to be discerning about the quality of the sites you visit. As mentioned, NCBI is an excellent source of information but there are plenty of junk sites out there promoting their own snake oil products and feeding fearful diabetics a lot of nonsense.

Similarly, do not take medical advice from strangers online, me included. Some self-important bloggers and Facebook pundits take it upon themselves to insist, for example, that every newly diagnosed Type 1 should go onto insulin as soon as they are diagnosed. While this may be true for many Type 1 diabetics, it is far from a blanket rule (I am a prime example of this as I am still in insulin-free honeymoon as I write this, two and a half years after diagnosis, with well-managed blood glucose levels). If someone online is telling you to start or stop a medication, especially one as serious as insulin, walk away. This is a decision for you and your health team with careful consideration of your specific symptoms and medical history.

Get To Know Your Blood Better

What I mean by this is start keeping track of your blood glucose levels. I initially started with a glucometer (the machine with the strips). Using an app like MySugr I was able to record my blood glucose readings before, during, and after meals, and understand which foods were ‘friendlier’ than others. This allowed me to make smarter food choices and bring my HbA1c under control. These days I use a CGM which provides a wealth of information about the things that affect my sugariness.

tl;dr

While Type 1 diabetes may seem daunting and overwhelming when first diagnosed, it is manageable and the proof are the millions of Type 1 diabetics out in the wild doing it every day.

By educating yourself with quality information and getting involved with online and offline diabetes groups, you can get through this and thrive as a Type 1.

Online Resouces

PDFs and Pages:

Online communities:

  • Facebook groups
  • Twitter chats:
    • #ADEAChat: 7:30pm AEST on Tuesdays
    • #DSMA: 9:00pm EST on Wednesdays
    • #GBDOC: 9:00pm UTC on Wednesdays
  • Reddit Type 1 channels
  • Dr Bernstein’s YouTube channel

Medical Research:

Offline Resources

Books written by Type 1 diabetics:

A good health care team:

  • An Endocrinologist (endo)
  • A Diabetes Educator
  • A General Practitioner (GP)
  • A Podiatrist
  • An Optometrist/Ophthalmologist
  • A Nutritionist
  • An Audiologist (or an online test list like this one until there is a measurable change)
  • A Dentist
  • A Cardiologist
  • An Exercise Physiologist

Online courses run by local diabetes organisations.

A glucometer and an app like MySugr, or a CGM to help you understand how your body reacts to different foods.

What Does Insulin Do? Basal Vs Bolus

It surprises me how often questions come up online about what insulin does and the purposes of basal and bolus insulin. As usual, there is a tl;dr at the end, although this blog article is relatively short.

The Two Roles Of Insulin

The most well known role of insulin is its role in taking glucose from the blood and moving it into the cells of the body. In fact there are parts of the body which do not require insulin to access blood glucose, such as the brain (the thing that uses most of the fuel and is too important to go without it), and the liver (the thing that makes the fuel when fasting). For most of the rest of the body though, to use glucose as a fuel, requires insulin.

The second and less well know role of insulin is in helping regulate the liver. In “What Is Ketosis And Diabetic Ketoacidosis?” I talked about this in detail. In short, when there is less insulin in the blood, the liver becomes more active at producing fuels for the body and when there is more insulin the liver is substantially less active at doing it.

So What Does This Have To Do With Basal and Bolus Insulin?

For those that do multiple daily injections (MDI), the two roles of insulin are reflected in the two types of insulin used i.e. rapid- and long-acting insulins.

The role of a long-acting insulin is to mimic the slow and continual release of insulin from the pancreas to offset the slow and continual release of glucose from the liver, keeping the liver in check and blood sugars stable.

The rapid-acting insulin is designed to mimic the release of insulin by the pancreas to offset spikes in glucose from things like exercise, and carbohydrate intake.

In the case of a pump, the basal rate and bolusing reflect the same thing.

Consequences for Insulin Use

The big takeaway from all this is, if you are not doing things which cause glucose spikes, your blood sugars should be flat and in range. If, when you fast, your blood sugars and trending up or down, your long-acting insulin/basal rate needs adjusting.

Get your basal right and it will be a lot easier to manage your blood sugars.

tl;dr

Insulin serves two purposes in the body: moving glucose from the blood into cells and to assist in the regulation of the liver’s fuel production. Rapid- and long-acting insulins tries to reflect these two roles. A consequence of this dual-role is, at least in theory, if a person is not eating or undergoing anything else to spike their glucose levels, their glucose levels should be flat and controlled exclusively by their basal insulin. If glucose levels are not flat the person’s basal insulin routine/rate needs adjusting.