Thank you for all these suggestions, it's very helpful. My reluctance about bolusing before a meal is what if you end up not eating as much as you thought, but you've already given insulin? Do you think that if I started out doing half before and half after that it would still help to stabilize my bg? I agree that it's probably necessary to bolus before and I'm going to try to start doing that, but I'm slightly worried about giving more insulin than I end up needing
This is significant information.... the larger the delay between the food and the insulin, the bigger the spike will be as the glucose from the food is uncovered by the insulin longer. Try bolusing when you start or a little before instead of at the end and you will see a difference.
You could, for example, take 2/3 of your expected dose 15 mins before and 1/3 delivered over a two hour period. If you ate less, you could cancel the extended bolus.
I generally don't find that to be a problem. It just isn't that exact a science. If I would normally go up 30 points if I ate everything and I leave some, so I might only go up 10 points. I just haven't found it to make that much of a difference. I'm also pretty good at knowing how much I want to eat.
I was wondering if the bolusing after eating might be an "artifact" from when reberman was younger? I know parents sometimes do that to avoid kids not eating as much as the parents guessed they would and perhaps a habit like that would linger on if things were working ok? I think that most of the adults I've encountered seem to pre-bolus to give the insulin a head start. If post-meal bolusing were a plan, it might offer a great opportunity to try something new and get a significant improvement fairly quickly, at the cost of breaking a habit. Which, of course, can be very challenging.
I find that post meal blood sugar spikes are unavoidable...but I will correct a high BG as soon as detected and if I can predict a high BG I will correct it before it happens.
I think I'm going to try the 2/3 before and 1/3 after and see how it goes and then eventually try to give it all before. That way I can ease into the transition knowing that if I don't eat what I thought I would, I'd still be okay. Thank you everyone for the advice and suggestions
The beta cells will inject the pro-insulin directly into the portal vein. In comparison the absorbtion in the top layers of the skin is very slow. To inject before the meal - perhaps with some additional time on top - makes sure that the insulin has been absorbed partially when the glucose from the digestion hits the blood stream. With the older insulins like Acctrapid I had to wait 15 minutes or longer depending on the BG. For that I had a wrist clock with countdown timer. Coming from these times it was a great relief to switch to NovoLog and to just inject before the meal. If my dosage is greater than my appetite which happens rarely I will make sure to get all the carbs necessary - by drinking juice instead etc.
Are you going to bolus twice or do a dual wave with 2/3 of the insulin up front and 1/3 over the next hour? If split you insulin that way you'll have an easier time fine tuning.
Maurie
The biggest problem I have with taking two separate mealtime doses is remembering to take the second dose. This is especially a problem for me when I’m eating with other people. That’s one of the reasons that I like the dual wave or combination bolus.
Excellent question and answers, I struggle as well.
very very good list of suggestions! once again, I m amazed by the helpfulness of everybody!
So I just had this same discussion with my physician as it seems regardless of what I eat, I spike to these levels too after a meal.
1. I asked her what I should spike to as a diabetic after a meal - she said 180.
2. I am on humulin and really all insulins even humalog has a delay before it kicks in. In my case with the humulin, its usually 60-90 min, so I see this spike on my CGM.
3. Obviously, simple vs. complex carbs effects this, but I see the spike a lot no matter what as well.
I am fine except for those spikes....GAHHHHH!
Your doctor is giving you the ADA line: 180 is not fine! Studies have shown that damage can accumulate with sustained highs over 140, so that is a more reasonable pp goal. Having said that, spikes cannot always be avoided, and the key, as John says, is to correct promptly. However, if you are seeing a pattern of pp highs, than you are not using enough insulin and need to tweak your I:C ratios.
I've had this conversation over and over again with my Endo and CDE's, actually, there is no significant 'proof' BG's over 140 cause damage, it truly is the overall A1C's and blood sugars. There are many on here and in the 'general' type 1 community who, as children, had significant high blood sugars, they didn't have pumps, CGMS, used 1 shot per day, etc...and have no damage at all many people have fastins at 150. Some who have good BG's have complications. It's the overall numbers that count. We, as T1's, have no brakes and no accelerators when it comes to blood sugars....so we do the best we can and the best we can do is to keep blood sugars as close to normal as possible, of course.
Deannan, i think the best way to attack ppl spikes is to prebolus. I too have a CGM and can see when blood sugars start to rise and when the food actually starts to hit. I wait up to 30 minutes sometimes, if on MDI's, after bolus to eat, if not low. That's what I do and it seems to help. But, i hear ya...i see, sometimes, those spikes and arrows going up on my Dex and I'm like...stop, stop, stop. For me, I like tight control and do correct anything over 130's usually and try 'not to spike' but sometimes it happens, we're all just our own science projects, ya know.
I did not say there was proof that BG's over 140 causes damage, Sarah. I said that studies show that sustained time spent over that number increases the likelihood of that occurring. Someone else can quote the well known studies to that effect. Personally it makes me quite angry when doctors tell their patients that 180 is a reasonable pp goal, quoting the ADA party line and dissuading their patients from attempting the tighter control that will best serve them. Again, note I said "attempting". There are people on here who successfully keep their pp's under 120 much of the time; for some of us that is not possible on a regular basis. But why not set goals based on known information? And yes, I agree, it is the overall numbers that count.
I think being high for a short period of time is not horrible, but not desirable long term. I mean my A1C is good, I’d like to ideally weasel out the lows and highs and 220 after meals or higher than 180 is not where we want to be, but I kickbox and go from 95 to 65 in an hour too. Sustained highs as many have said are an issue.
Sarah -
There was no proof that there was any relationship between sustained high blood sugars and an increased risk of complications until the DCCT. That didn't mean that high blood sugars weren't a problem before then.
I'm not sure how researchers could even test the hypothesis that frequent spikes above 140 (or 180 or 200) lead to increased risk of complications. To do a large scale study would require large numbers of people uploading CGM data for an extended period of time.
We're not only our own science projects but our own crap shoots.
Maurie
Well, actually there was a lot of evidence that uncontrolled diabetes led to complications. Elliott Joslin believed this. In fact, the ADA was created to combat the influence of Joslin and has traditionally advocated an approach; live your life, eat what you want and treat the consequences. That is the real issue. I don't trust the ADA. I don't worry about short spikes above 140 mg/dl, but I work hard to make sure I don't spend much time above that level.
There have been studies showing increased risks with greater glucose variability. In fact, there is a test Glycomark, which tests for spikes. But the real issue is that so many people don't even reach our fairly liberal targets of HbA1c 7% that then asking for better control on top of that is not even perceived as achievable.
Thanks for the link to the Glycomark test, I had no idea it existed.
My comment was directed at the idea that the absence of proof - a series of experimental results that convinces the medical community at large - does not mean that the hypothesis is untrue. Joslin had a theory based on evidence and those who were lucky enough to be treated by his followers had a better chance than those who followed the ADA path. But Joslin (like Bernstein) didn't have proof.