My son’s honeymoon appears to be over or at least petering out, so we need to make some adjustments to his routine. He’s going way too high sometimes between meals (200-250) but then coming back to normal (90-100) before his next meal. So, I’m thinking this is a timing issue and not an I:C ratio issue. Am I thinking about this the right way?
He was advised at the beginning to bolus after eating, but I know adults are advised to bolus before. I think it’s time he starts bolusing ahead of time on most occassions. Is it okay for him to bolus for what he plans to eat or his first serving of a food before, then “top off” if he goes back for seconds or has dessert or does that mess up the timing too much?
Man, just when we think we’re getting the hang of all this, something changes! Sad to see the honeymoon go.
I agree that bolusing before is the way to go. If I’m at 100, I wll try to wait 15-20 minutes after I bolus and that seems to get the best results. Our situation currently doesn’t always allow that to work, as I am 1) the chef 2) work out before dinner a lot and 3) try to time things so dinner is ready when MrsAcidRock gets home, since her commute sucks a lot more than mine.
I think the main reason for bolusing after eating is smaller kids, who parents may not be sure will eat everything on their plate. Unless it is chicken fingers?
I always bolus before I eat; also, I tend to eat high fat/high protein meals, so I make good use out of my square-wave and dual-wave bolus features. Have you tried those?
Yes, you can “top off” if you go back and eat more. They generally recommend post-meal bolusing for kids because kids are more picky and unpredictable when it comes to eating. However, there are times when I’m just not sure how much I will eat and on those occassions, I will manually split up my bolus just to be safe.
Do you bolus 15-20 minutes before like AcidRock or immediately before you eat? I think we can make the switch to bolusing immediately before without too much difficulty, but 15-20 minutes before is more difficult - earlier wake up times, stopping to test in the middle of chemistry class before lunch to test and dose, and stopping homework (or me remembering to give him a 15 minute heads up that dinner is almost ready in that hectic after school/dinner prep hour).
At my son’s age, I don’t have to worry about the picky eater thing, but variations in appetite are an issue. He also knows that if we’ve dosed for something, he has to eat those carbs one way or another, like it or not, so he wants to be pretry sure he’s still hungry before taking more insulin.
My son’s Ping has a combo bolus feature and we have been experimenting with that for high fat meals. We don’t eat particularly high fat most days, but for pizza and Mexican food out, it works well. We’re still trying to find that sweet spot but we’re narrowing it down. I’d like to be a bit more scientific about our approach, but I’m trying to strike a balance between getting data and bugging the kid so much that our entire relationship centers around me telling him to poke his finger. Lately, he’s been a little more resentful about the whole diabetes thing, so I’m trying to back off and make sure diabetes doesn’t take over our relationship.
If he’s in chemistry class, he’s probably quite a bit sharper about the scientific method than I am and probably capable of running his own show? I was dx’ed @ 16, or maybe it was 15, I’m still fuzzy on that, and don’t recall too much in the way of precise conversations with well, anyone ever, until I started hanging out online?
I would stress too that 15-20 minutes @ 100 is a goal but I probably only do it occasionally, since I’m always running around getting stuff done and then dinner’s done and I’m like “oh yeah bolus…” right before I start shoveling, so I compromise and eat the meat first? I could see the school thing would be sort of tough. In the district where my daughter (12) grew up, they were “no talking, eat, eat, no talking” during lunch so they kids didn’t have the luxury of time. I think they are a bit more laid back in the district we moved to but I dunno what strategies the kids would use.
Yes, bolusing 15-20 minutes before eating is ideal. If you bolus after eating you are bound to go high. The only time I bolus immediately before eating is if I’m on the low side. I understand it can be difficult with a busy schedule, but it’s something you can adjust to. If you want you can try bolusing right before eating and see how that works for the highs, but the best is to adjust the schedule. The insulin doesn’t start to work for at least 15-20 minutes so if you wait, the food will “win” everytime.
I think when you start insulin, bolusing after you eat is a “safe” way to manage things. But it does not match your glucose profile very well and others have clearly suggested that the best results come from bolusing before meals. And while your son now has a pump and he has much greater control over the timing of his insulin he may not always have control over when he eats. If your son is at a normal blood sugar and boluses 15 minutes before his meal, he needs assurance that he will get his food in a timely manner. Sometimes for a kid, life is full of surprises. As Zoe suggests, a reasonable mix might be to simply bolus right before the first bite and see how that goes. For some people that are particularly sensitive to insulin, that actually works out well because food also can take 15 minutes or more before it actually starts to impact blood sugar after eating.
I would not go from bolusing after meals to 15-20 minutes before for a child. I only bolus 15-20 minutes before eating if I’m around 140 before the meal. if I’m around 100, I bolus right before I eat and if I pre-bolus I’m likely to go low. Everyone is different and this is a situation to make adjustments conversatively.
With my son’s honeymoon, we got away with being lax on the timing without it having any significant impact on his numbers. We almost never saw a number above 140-150 until the past several weeks. I agree with going the conservative route as he’s pretty sensitive to insulin. He’s generally 85-100 before a meal, so he’s not going into the meal high and there’s not much margin for error should the insulin hit before the food.
I think I’ll get him to work on bolusing upon sitting down to eat, then, If that doesn’t resolve the issue, we can work on backing it up a bit, at least for the meals he eats at home.
This disease is just one big experiment, isn’t it?!
We all have different target numbers. Many of us use under 140 as a two hour pp target. Studies show that complications begin to develop with significant time spent over 140. Others use tighter control and try and stay under 120. The reason for the two hour testing time is because that is when most of us “spike” - have our highest blood sugar after eating. Some people do spike sooner, say at 1 1/2 or 1 3/4 hours and if that is a person’s consistent spike time I think that’s when they should test rather than an arbitrary 2 hour point.
Morning is when most of us are more insulin sensitive. I seem to remember you use the same I:C ratio all day, Lynne? You might try using a different ratio or eating less carbs for breakfast. My ratios for the three meals, for example are 1:7, 1:8 and 1:20. My usual weekday breakfast is 20 carbs. I also find that if I am high before a meal I’ll inevitably go even higher after even if it is the same amount of carbs I usually eat. I always add a correction if I’m high before the meal, or if I can I just correct and wait to eat. I also always correct if I’m high on rising or after a meal to prevent a cycle of just going higher all day.
I don’t know whether guidelines are different for adults vs. kids (mine is 13), but our endo/CDE only ask my son to test before meals, before bed & before exercise. They aren’t opposed to him testing at other times, but those are the times my son must test. I don’t make him test at the 1 or 2 hour mark routinely, but he ends up testing during those times frequently because of sports practices. It’s because of him testing before sports that I noticed the spikes.
The guidelines we were given is that ideally, if we timed it all right and the stars aligned, his bg would never go over 180 and 140 or less at the 2 hour mark would be great. Before meals, they want him at 80-120. He’s usually within that range before meals which is why I think his ratios are okay and that it’s a timing thing. When his insulin needs started increasing around the beginning of August, we did have to make adjustments to his basal rate and his I:C ratio. The biggest thing our CDE has emphasized from the beginning is that under most circumstances, only change one thing at a time so you can evaluate the cause of whatever result you get.
I agree with Lynn. I find the test two hours after my meals is one of the most useful ones for me, because it tells me if the food I ate in the amount I ate it works for me - especially early on this is really useful information to accumulate. It also tells me if I need to correct. If you are high after a meal (which is when most of us tend to experience our highs) and don’t correct you’ll just be playing catch up all day (and spending way too much time high!). And, as Lynne says, I:C ratios do change, and I understand they change even more frequently for children and adolescents as their bodies are changing. I look at a page (about 4 week’s worth) of numbers and if I see highs or lows frequently after a meal I know that I:C ratio might need tweaking. Being in range before the meal doesn’t give you any information about how well your I:C ratios work, because by that time you have come back down from any spikes from the previous meal. What before meal numbers (and fasting and bedtime numbers) tell you is how well your basal rates are set
Finally, I know this is harder when you’re responsible for another person,Austinmom, but I think in time you will find you do more what you have discovered works for you and for your son rather than exactly what the endo suggests, as you are the ones living with this condition 24/7.
I’m atypical - breakfast is my “easiest” meal - but I want to describe my pattern to give you a broader sense of you might do to keep flatter blood sugars. I eat (in the same order every day) a plain eggbeaters omlet, 2 pieces of sprouted wheat toast with 62 grams of peanut butter, 8 oz of low fat milk and an apple. That’s around 69 grams of net carbs. I dose for about 59 grams of carbs before I eat and then test and bolus for another 14 grams at the two hour mark. I will correct anything over 95 at 2 hours for this meal. All the fat and protein hit late and I will often run up to 130 two or three hours later before lunch.
I assume that my basal is set a touch low and my insulin to carb ratio is a bit high so that my meal time bolus keeps me very tight for the first couple of hours. if I hit 140 two hours post, I know something is up. On the other hand, I don’t think you’ll find many people here saying that 130-140 is acceptable four hours out. . But given my patterns I don’t worry about them. Insulin management is an art and menu creation including the timing of various foods within a meal is an important part of it.
Good luck in getting breakfast worked out. 272 couldn’t have been any fun.
Yeah and I have found out that doesn’t work out as well when other people are involved. I asked my friend whose house I went to last Thanksgiving for an “ETA” for dinner and she gave me a time but then everything ended up taking longer. I also did that in a restaurant where I’d gone with my family. They all ordered pizza and I ordered pasta as a marginally better food for me (I didn’t pick the restaurant!). The waiter was very helpful about giving me an ETA of 20 minutes as I’d asked but then there was a problem with the pizza oven and everyone’s pizza was delayed by 45 minutes. My nephew’s wife who is an RN kept urging me to eat bread, but I didn’t want to add bread to the pasta high! I think she was worried about having to take care of me when I went hypo. I was fine, and the delay probably made it so my blood sugar was in target range despite the pasta. (Which was delicious!)
Zoe, please help me understand your comment regarding fasting and basal rates. I’m not considering his pre-lunch test or his pre-dinner test a fasting test because it has been a matter of 4-5 hours since he last ate (maybe less if he snacked). His pre-breakfast test, when he hasn’t eaten in 8-10 hours, I would consider fasting.
How does being in range before a meal give you no information? If your basal was perfect and you didn’t bolus properly, wouldn’t you be high (or low) at your next meal?
I hope that doesn’t sound argumentative - I don’t mean it to be, but I just want to understand. Your comments made me wonder if I am all screwed up with my thinking about the whole basal/bolus thing. I kind of thought I was getting this, but maybe not as much as I think.
We are trying to figure out what works best for my son with a little help from the CDE/endo team and a little help from those of you on this site who are the experts in dealing with this day by day. And, yes, managing this for another person, particularly one who is at an age to be fairly independent and feequently out of my sight and out of my control is hard. I would give everything I have to take this disease from him and take it upon myself.
I agree, Lynne. No,Austinmom, I don’t consider pre-meal tests “fasting” and I’m not saying that before meal tests “give you no information.” What I’m saying is that pre-meal numbers (as well as fasting and bedtime numbers) give you information about how well basals are working. And two hour “post prandial” tests are needed to show how well bolus covers carbs (how accurate I:C ratios are).
If your basal was perfect and you didn’t bolus properly you would see a spike (if you did too little insulin) or a low (if you did too much) two hours after a meal. But you might or might not be out of range at your next meal. This is because carbs cause a spike in blood sugar (that insulin is supposed to even out) at around the two hour mark. Then the blood sugar could drop back down into normal range before the next meal. (or not!) So let’s say you’re 90 at 1PM before lunch and don’t take enough insulin for the carbs you eat. You could spike to 180 two hours after you eat at 3PM and remain there let’s say to 5PM. By the time you are ready for dinner at 6 you might have come down to 120. So if you didn’t test at 3PM you wouldn’t know you were too high for two hours.
No, you don’t sound argumentative, just like you are trying to understand! This stuff is complicated! But the bottom line is you need to test at different times and after awhile when you look at your records you will see information that will help you tweak both basal and bolus.
Acidrock once commented that when you try something new and it doesn’t work out as well as you hoped, you were experimenting not making a mistake. I try to take that to heart.
