He ate 45 carbs (banana, milk, eggs, and sausage), which is what I consider on the low end of carbs because he usually eats around 60 for lunch and it varies at dinner.
I gave him insulin at 8:30, and he didn’t eat until 8:50.
His target BG during the day is 120, his starting BG was 125, it spiked at 232, was 172 at the 3 hour mark, and finally 115 at 5 hours.
I don’t just want the spike to be lower, I want his sugar to be at his target BG at 3 hours instead of 5, and I don’t want any activity after that third hour.
This was an unusual morning because we are on Christmas break right now and I delayed lunch to see what happened with his sugar. He normally would have received his insulin at school at 11:50, and then not started eating until 12:00. So his sugar would have went up again starting at like 160 because it was in the middle of a bolus.
I have also tried to talk to his school nurses about timing his bolus to what his sugar is. They have a handful of nurses that drive around to all the schools in our district, so they can only be out at a set time everyday. I just now have got them to understand that he can’t have his insulin until after he starts eating if his BG was 80, because it is still going down from breakfast.
I don’t usually try to lower fat during the day, he ends up eating moderate amounts. I do try to limit fat at dinner though, because I don’t want to deal with elevated overnight numbers while sleeping.
I just finished reading Pumping Insulin because everyone always references that book on this forum. It is a great source of information that I wish our endo office had told us about years ago when we first got on the pump. I just recently learned about basal testing, can you believe that? No one ever told us what it was, and we have always tested insulin dosages the way we did with shots.
I’m looking at the Clarity report that shows your son’s post-breakfast blood sugar excursion with a 20 minute pre-bolus. I agree with Dave that you may benefit from experimenting with longer pre-bolus times. The CGM will show a definite downward deflection showing you an optimal time to eat. Stephen Ponder, T1D and author of Sugar Surfing calls this “waiting for the bend.”
Looking at just this one chart, I think your son would benefit a lot from an optimal pre-bolus time. When it works, it flattens out the post-meal rise a lot. Pre-bolusing is an under appreciated and under-used blood sugar control technique. I pre-bolus about 60 minutes in the morning and 30 minutes at dinner. Your son’s ideal pre-bolus time may vary by time of day and also from day to day. If you have time to do this on an off day from school and work, I’m sure it would give you better results.
I agree with Brian about a reduction of carbs and increasing fat will help you control post-meal rises. Even cutting the banana in half and drinking six ounces of milk instead of twelve would help with the breakfast you served. Adding another egg and/or another sausage could easily make up the calories. Further experimenting will help identify what will work – until you need the next adjustment. It doesn’t end.
I have been using humalog for over 20 years. What your asking is certainly possible. I do similar with a lot of success. I often do what some deem a super bolus where I will take my bolus and basal insulin up front as a quick bolus for high carby meals that tend to not stay with me very long; think desert items. Then I will either run a reduced basal or I may set a 0 basal for x amount of time as a temp basal. I do this to control the tail out effects of the humalog. But I will caution that suspending the pump for too long can have a sky rocketing effect if you go much beyond an hour. To get the proper effect you will really need to understand your sons metabolism. You also need to always account for the variability of this disease. You can start at the same number and have different results, doing exact measures of food and insulin. Just make sure you have plenty of fast acting carbs around should your son drop unexpectedly.
You certainly have a lot of background and experience, so much of what I have to say may be a repeat of what you already know or do. But I just want to mention few thoughts. Just disregard stuff you already know. You are probably already a master at so much of this!
I agree strongly on the idea of pre-bolus. But I want to add, that you can be even more aggressive when you are at home, are around him, or when you have food easily available. And be more careful when he is at school, or aren’t near your own fridge. Ideally, his BG will be on its way down and just getting close to low when he gets his first bite. That timing varies for everyone, but that’s something you should experiment with, and can even use extended bolusing to make it just right. He can have a meal with normal carbs and not spike, but it just takes practice.
Along the same lines, when you bolus, you can be more aggressive with the amounts when you are at home, because you can easily correct that low if you catch it in time. And a little higher bolus, when used with a supplemental snack a little after the meal, will also help reduce the spike later after the meal.
Taking care of a low BG at home doesn’t have to be a disaster. It can just be an opportunity for him to have a small treat, or something he enjoys. It doesn’t always have to be 5 ounces of orange juice given like it is medicine! It can be something pleasant, which will bring his BG up just the same. Lows can be dealt with quicker than highs. That’s the way I do it, just my preference. But it can be viewed as an opportunity for something tasty, which makes it not seem so bad.
If he isn’t already, involve him in the process. I took over it pretty early, and when I left home it wasn’t so hard, because I was ready. I think that is a very important thing to do for him.
Sorry, I am going on a bit. I am passionate about wanting to help the young ones have the best.
I think what you are referencing when you say I want him to eat lower amounts of fat is from a previous post I made about him wanting to eat high fat foods all the time, and that was raising his sugar up for hours.
I should have been clearer in my previous post, but the problem we were having is that he wants to eat foods all the time that were high in fat and carbs, like pizza and cheeseburgers and fries. Not so much high fat and low carb. I am not 100% comfortable with bolusing for those types of food yet, and especially at dinner time. I end up staying up half the night to correct, so I am trying to avoid them for awhile until I can fix some other issues.
I am very interested in the advanced pumping technique you are describing. Very interesting. On a separate but related tangent, my 13 year old committed to a two week trial period where we limited him to 30-35 carbs per meal. At the end of the two week “test” my son asked us to keep 90+percent of his meals around the 30 carbs mark, since his blood sugar was so much easier to control and he felt better not swinging high to low as often. Worth a thought if your son is bothered by the swings.
It seems like that’s the most common Afrezza experience but for me I’d like a 2 unit cartridge. I have to be well above 200 before I can correct with a 4 unit cartridge or watch my CGM and have Skittles at the ready. The Humalog tail (I was on MDI) was the reason I switched to Afrezza.
Thanks for your’s and everyone’s advice! I am trying to work some kinks out in his rates right now, and my next phase in this operation will be to try longer prebolus times! I will post my results as soon as I can to let you guys know how it worked out.
I homeschooled him until the 3rd grade because we didn’t trust the school system where we lived to take care of him properly. We got on a pump and a CGM, moved to a smaller town, and things have been pretty good. The school nurses and teachers are wonderful, and we even text each other throughout the day if something comes up.
His attendance clerk at school has even texted me before because they were having extra physical activity outside of a normal day, and she wanted to know if he needed a snack. I was like, Holy Crap they get it!
Anyway, my point is that even though I have been able to relax about the school issue, his A1C’s have progressively gotten worse since starting school because I am not dosing as aggressively as I was when he was at home with me. I am not even doing it on purpose, it just sort of happens. I guess I have become a little obsessed recently about perfecting the art of the bolus, so I can get his A1C back down and not subconsciously keep his sugar on the higher end just because he’s not around.
I think the swings bother me more than him lol. We eat 3 meals a day, averaging about 55-60 carbs a meal. He likes a glass of milk at every meal, and the carb ends up being about 40g. I guess we could somehow add in a 4th meal and distribute the carbs better, so that each meal is around 40g.
It is not available for kids per the FDA right now, although your endo could potentially prescribe it anyway outside of guidelines. The concern has to do with risks inherent to inhaled products and lung cancer.
I am also looking at it - it would be so much simpler for our kids. No lows to worry about once you have waited about an hour or so I think,
Yeah, the 30 carbs works really well, but we wouldn’t have done it if he didn’t physically feel better. He feels the big swings and hates them, so he was motivated to adopt. It also didn’t hurt that he loves meat and cheese above all else. We work in 1/2 a fruit four or five times a week with breakfast. On a side note, I don’t think we would have done the 30 carb test if we were only going up as high as your son’s example above. With 60 carbs my son’s BG normally goes up 200 or more points, which leads to a large drop later. I would love to find out what works for you, since I think we could use it when we eat out.
I think you want to lower his meal boluses just a little bit. I know that a lot of folks here really are super-sensitive to the size of their after-meal spikes, and I don’t want to be completely insensitive to those concerns either, but letting the concerns for the after-meal spike set the bolus dose is a mistake if it results in hypos at other times of day.
I myself have had spells where I have bad hypos right after meals due to the timing of Humalog too. These can be EXTREMELY disconcerting. I’m all for tight bg control but having repeated after-meal hypos requiring correction, every day or every meal, is just wrong long-term. Occasional after-meal hypos is not so bad, but every day or every meal is a sign that basal has to be lowered.
I think there is some value in finding meals that work well with the insulin curve. Adding proteins to the meal (or replacing some of the carbs with proteins) to slow down carb absorption can result in happiness…
I guess it’s just a difference in how they digest carbs because I don’t really do anything special to get the 100-150 rise with 60 carbs at lunch and dinner. He use to have huge spikes with that many carbs but that was when he was a toddler.
We do have huge spikes in the 300’s if we eat out and he eats closer to 80 carbs. We would probably have beautiful post meal numbers if he ate only 40 carbs at meals.
However, breakfast time is a different story. I do a slight super bolus in the morning to keep the post meal spike down, because his BG wants to soar at that time no matter what he eats. For example, his basals are .50 from 6:00 am until 9:00 and .35 after. I set them an hour in advance, with a slight increase of .55 between 7:00 and 8:00 because his sugar rises for about an hour when he wakes up at 8:00. These rates keep his sugar at a steady rate when fasting. His IC ratio is 1 unit per 15 carbs. His sugar will go up to 300 with very little carbs, but be in target 4 hours later.
So what I do is decrease his basal rate to .35 all morning, but use 1 unit for 14 carbs. This keeps the spike closer to 100-150, and his sugar doesn’t go low afterwards.
It is ideas like this that make me angry that we who are doing well and quite well with existing insulins aren’t allowed to participate in the even-faster insulin clinical trials. I would think that people who are achieving their A1C and overall bg range goals (to a large extent) would be a good measure of the efficacy of newer insulins. I am not about to sacrifice my control in order to achieve nan A1C of8+ nor experience major swings just to see if the investigated faster insulin is indeed better.
According to Dr.Bernestein it is not an option. And as a diabetic, i say high carbs vs high boluses is never that easy, specially humalog. I’ve tried 58 minutes not even 20 but failed. Other times 7 units only in 11 days made me hospitalized 2 times, both times were only 7 u100 humalog units
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