Crash Course

It was easy before and now I have to get this happening fast and accurately.

Blood sugar is way harder to manage now that I’m pregnant. Just 6 weeks actually.

So I’ve been generally testing at 2 hours and adjusting if I was high (ie. miscalculated carbs). Calculating carbs isn’t so easy as a lot of the foods here don’t have carb counts on them.

Just this week I decided to test at 1 hour (after eating a meal with carbs).

Breakfast yesterday took 3 units of humalog and got 150 at 1 hour (took 3 extra units of insulin and was down to 97 after 1 hour later), and 70 before lunch.

Lunch today took 3 units of humalog and got 180 @ 1 hour. Quite surprised. Anyway, took 3 extra units of insulin and 1 1/2 hours later was 119 (probably should have taken 4 units).

Anyway, how to avoid going so high at 1 hour, other than not eating carbs. Should I be taking the humalog earlier? How long before eating?

I’m guestimating about 20 g of carbs per unit of insulin. And also 1 unit to drop 20 points.

Target bs is < 120 at all times (range 60 - 120).

I had a difficult time using Humalog were the efficacy of the Humalog caused me to have high post prandials. It wasn’t until I switched to Novolog that my post prandials were under control.

I use Humalog. It peaks at 0.5-1.5 hours, but that doesn’t mean that it will necessarily bring your blood sugar down to goal at 1 hr, that is the time when it has a peak in action. The action of insulin is cumulative and you should not adjust your bolus dosage to keep your 1 hour number under goal, you adjust the dose to make sure you return to a normal fasting 3-4 hours after your meal (altho I am well back there at 2 hrs).

To address a sharp peak at 1 hr (when you are fine at 2-4 hrs) you need to adjust the profile of when the humalog takes action typically by move the injection time forward or backward (although you can also do some other things). Humalog claims to have an onset of 15 minutes, but you may find you react slightly differently. I typically inject 15 minutes before I eat, 30 minutes before if I am slightly high preprandial, and right when I heat if I am a bit low. All this to adjust the profile of action.

And finally, you are using an insulin to carb ratio of 20 which suggests high insulin sensitivity, but then you are using an insulin sensitivity factor of 20 which is somewhat insulin resistant. Part of your observation of highs at 1hr may be bolusing too little and then having to correct. You should probably work with your doctor to do more testing to determine a more accurate insulin to carb ratio.

Your goal is to bolus for meals with an accurate enough dose that you only have to correct as an exception. Regular corrections are a signal that you need to make some adjustments.

Couple things, Sally: You don’t mention how many carbs you actually eat, so that certainly makes a difference, obviously as low as you can tolerate will control your numbers better. Also yes, I found it absolutely necessary to take my insulin 20 minutes before eating, and I take Apidra which is the fastest of the three. You also might consider if your I:C ratios are right. I see you only have one ratio for all day (and a fairly generous one). Many of us find our I:C ratios vary by time a day, for example mine are now 1:12, 1:14 and 1:30. If you are having consistent highs one hour after eating you might try altering your I:C ratios (and perhaps pregnancy necessitates more insulin? That is definitely one subject I know nothing about!).

You say many foods you have there don’t have carb counts. If the carb counts for your meals are consistently off that will really affect your control. I don’t know if they are ingredients unique to the Phillipines, or if you can break the dish down to its ingredients and then look it up on something like Cooking at home also gives you more control over what is in the food. It’s funny, when I lived in Guatemala, I would say I only rarely ate Guatemalan food because I mostly ate at home and was able to get ingredients I’m used to there. Except black beans, which I still eat here.

Finally, I don’t know if this is at all an option for you but I am now using Symlin and it allows me to take almost half the insulin I took before and get much more stable results.

Oh, and do you have Using Insulin by John Walsh, it’s a great book on all things insulin and covers some of the things both bsc and I have mentioned. I wonder if there is a specific book on diabetes and pregnancy? I’m sure the people in your pregnancy group would know if there were - you would think there should be!

Hi Sally, I am currently at 17 weeks so I understand quite well what you are going through.

Here are my tips and thoughts.

There are two main ways I avoid going high at 1 hour. The first is not eating more than 10g of carb in one sitting. 10g of carb raises my BG about 55 mg/dl and my fasting blood sugars are normally pretty good. So keeping to 10g greatly reduces spikes.

Obviously it is kinda hard to only ever eat 10g of carb in one sitting. So if i am eating more than that, I bolus early and I bolus extra. I found that if I bolused the correct amount of insulin for the carbs (if it was more than 10 of carb), my 1 hour PP would be too high, 2 hour PP would be under 140, and 3 hour PP back to truly normal. So the only way I can hit the 1 hour target is to bolus a bit extra. That means 1 hour PP will be under 120, and then you have to be ready to correct the guaranteed hypo on the way at 2 hours, and possibly a little extra at 3 hours as well.

At first I was a little worried about this but my diabetes team said not to worry about the excess insulin and that it’s more important to hit the 1 hour target. Fortunately for me, I use the 2 hour hypo as a chance to eat fruit which I would otherwise need to bolus for. The key is to test vigilantly so you catch the hypo before it occurs. After lots of testing I knew that if I was 4.0 1 hour PP, then I have to start on the fruit, otherwise a really nasty hypo will be coming along soon. I’m now comfy with the trajectory - you’ll have to find out what sort of trajectory works for you.

I would strongly suggest against guesstimating your insulin:carb ratio. In pregnancy, the extra precision is necessary! Having said that though, things are very fluid in pregnancy and your insulin requirements could change a lot and everyone’s experience is different. Some people find they are more insulin sensitive, others find they are more insulin resistant. Don’t get scared if things literally change overnight, just adapt.

As you’ve noticed, it’s not only the number of carbs you eat but also the amount of fat & protein that effects when the spike occurs. Also, some carbs hit faster than others depending on fiber content. Timing is just as important as doses.

It’s a whole new game with pregnancy–congrats on your baby! Best way to get ratios fine-tuned is to try to be consistent with carbs & protein. Makes it less of a moving target.

Approximating carbs isn’t helping. Need to be as precise as you can. Even foods with nutritional labels aren’t necessarily accurate. Don’t know if you can get this shipped, but EatSmart is a wonderful, easy to use scale that calculates carbs, protein, fat, sodium, etc. for both raw & cooked food.

I am currently 5 months pregnant and I wait a minimum of 30 minutes before eating after taking my Humalog (unless I am under 90 and if I am under 75 I usually eat right away). In the morning I wait one hour after my Humalog shot to eat my breakfast which after telling my endo this I thought he was going to fall off of his chair as his jaw dropped to the floor but this is how I prevent huge spikes after eating. I have never ever had a low doing this and according to my meter and CGM my humalog does not even kick in until after the one hour mark. Of course I may just react strangely to “fast acting” insulin but this is my experience, and waiting before eating makes a HUGE difference in my post prandial blood sugar. Also, after eating and testing at 1-2 hours if I am high instead of taking a correction bolus I just exercise for 15 minutes and it works faster than correcting my bg, my bg usually comes down immediately. I try to exercise a minimum of 15 minutes after every meal and it also makes a huuuuge difference in the post prandial as well as keeping you fit and preventing too much weight gain during pregnancy.

I have had huge success with increasing my basal to control my ever increasing blood sugars during pregnancy. I have not had to adjust my mealtime insulin to carb ratios at all. Whenever my blood sugars start to creep up which is every few days, I add an additional unit of basal (levemir). I also split my Levemir dose taking it two times a day instead of one and it has made all the difference in the world!

I too am continuing my low carb lifestyle while pregnant which angers my doctor but I refuse to eat more carbs and have less control over my blood glucose. I was eating 30 carbs per day before pregnancy and am currently 5 months pregnant and eat 40-45 carbs per day.

It is sad & also frustrating. Protein, good fats & vegetables are needed, not a ton of starch. Our ancestors didn’t eat high carb meals. Excellent point that it’s not carbs that cross the placenta.

Injecting IM hurts like mad! I did this by accident & it dropped BG like a stone. I wouldn’t recommend a rapid drop like that, unless you use a very small dose. It hit me hard in about 10 minutes or less. I sure wouldn’t use insulin IV. I had IV insulin with DKA, but of course it was a slow drip with fluids.

Congrats Super Sally!!!

Don’t forget that i:c (insulin to carb ratioo) is different with each meal. Insulin affects most people more at night than in the morning. I’ve never been pregnant, but I have read that the bolus amount changes depending on your trimester, so you may need to keep adjusting your basal as well as the bolus.

Most OBGYN’s are familiar with helping people with insulin doses during pregnancy. THey are typically familiar with type 2’s, but your OBGYN might be a good resource.