So we called the Endo because I’ve been concerned that it seems that after every meal he many times spikes above 250. The feedback I’ve ascertained here in TuD indicates that 250 isn’t good AT ANY TIME…BUT…that’s not what the Endo just told us. He told us there isn’t any Insulin that works as fast as food works and that spikes after meals are typical and are going to happen, especially for someone his age. What they’re most concerned with is that his BG goes back down to normal ranges before his next meal.
I’m worrying about highs and our Endo is telling us not too…who’s right???
I know it’s a fact that toddlers spike a lot more and have much higher (and lower) ranges, but I just want to be sure and get this communities (especially those with Toddlers around our sons age of 2 who have experienced what we are experiencing), what, if anything we may be doing wrong (if anything).
According to the Endo, the spikes are what they are and we have to deal with them…that’s kind of how it came off to me.
Well, we aren’t “within” the recommended range if we’re > 250 (which we are a lot). The recommended puts it < 250…so that’s the goal for us then. We aren’t TOO FAR off from the recommended though. When we go above 250, it’s not 270 or so at highest.
Not quite. The book says BELOW 250, which isn’t quite what he’s experiencing.
The problem of matching the speed of insulin to the speed of digestion is a tricky one for an entire host of reasons. Here are just some of the variables:
Different insulins work at different speeds
The same insulin can work at different speeds in different individuals
Timing matters enormously; if the insulin isn’t administered early enough, you will always be playing catch-up
Different foods digest at different speeds (carbs fast, protein slow), so matching the speed of the insulin to the type of food can become an issue too
Amplifying the third point a bit, prebolusing allows the insulin to begin working as the glucose hits the blood stream. That’s a key element in keeping the line as flat as humanly possible.
To lend some perspective, it takes time to dial this stuff in, particularly with a child whose metabolism is constantly changing. Keep learning and plugging away. You’ll get there. “Diabetes is a marathon, not a sprint.”
Reading Think Like a Pancreas and Sugar Surfing and trying some of the methods in there (particularly pre-bolusing) is what I’d suggest.
Also, many of us find that there are some foods we just can’t eat. For me, it’s cereal. I can pre-bolus by an hour in the morning and still spike to 300 after eating cereal. At other times of the day the spike is less, but still huge considering I’m pre-bolusing and measuring carbohydrates correctly. So I just avoid cereal as much as possible.
Anyone can take the amount of insulin that their I:C ratio calls for, but that is just a starting point. Quoting myself from another post:
How much insulin and when are not dictated by one factor, it’s a multiple of factors.
What is my BG now?
Have I been physically active? (Am I about to crash?)
Do I plan on being physically active? (Should I lower my dose because my activity level will be high?)
Will the meal I’m about to eat have a lot of fat in it (which will delay the action of the insulin–sometimes for hours)?
Have I been experiencing long periods of serial hypoglycemia? (Do I need to sit down, treat and WAIT to get up to a higher level?)
Have I been experiencing long periods of hyperglycemia?
Have I been sick or am I becoming sick (I may need a lot more insulin)?
These are questions I’m always asking myself.
It’s only in the last four or five months that I started waiting to eat–depending on my BG level. Well, I almost always wait.
How long I wait is completely different each time. It’s based on my experience AND the answers to the other questions above PLUS where is my BG headed?
180-↑ Treat high and wait for some sign of ↓ on my CGM.
150-180 Usually 15 minutes
130-150 Usually 10 minutes
110-130 Usually 5 minutes
85-110 Usually right awayish–unless I’m in the 80s and ↓ or ↓↓. Then I treat the low and wait for → or ↑ on my CGM.
So, I adjust a minute here or there. It helps immensely to keep my spikes from getting too large. That’s what I do, but everyone has to figure out their levels
But pre-bolusing with a toddler can be very dangerous because you’re never guaranteed little ones will eat as much as you think they might.
@ClaudandDaye, it sounds like you’re doing a great job and the spikes now are just part of your learning curve. Eventually I’m sure you’ll see them less often or at least not as high.
One strategy I’ve used for this, when I’m not sure what I’ll be eating, is to bolus 1/2 ahead of time, and then the other 1/2 immediately after finishing. It doesn’t avoid spikes completely, but is usually better than doing the entire bolus after eating, and isn’t any riskier than doing the entire bolus immediately prior to eating.
But I’m not a toddler with diabetes, and when I was a kid bolusing for meals wasn’t yet a thing, so I’d proceed with caution in trying any of these strategies.
With MDI right now .5 is the lowest we can go. That’s a huge dose for a 2 year old that doesn’t eat. Things will hopefully get easier with the pump as we can dose at much smaller rates.
Yes, I think the pump would definitely make things easier. You can also dilute insulin. Might be something to ask a CDE or endocrinologist about if the pump is a ways off.
Yes, I’ve been investigating this and we’ve discussed it with our Endo. If we weren’t so close to getting our pump it would definitely be something we would do. Our pump is in process now so we should have it within a couple weeks! Can’t wait!!
If you read the text surrounding these recommended values you will see that there is a great deal of variation in recommended targets. The ADA is the “loosest” and is the source of the below 180 mg/dl 1-2 hours after eating in adults and for the most part the other targets in that table are probably from that same source (Gary doesn’t say). But if you read earlier you will see that the other main sources of advice from European Diabetes Policy Group recommends keeping the peak below 165 mg/dl and the AACE and IDF say keep the peak below 140 mg/dl (again all in adults). These other guidelines are more stringent and I actually believe will lead to measurably better outcomes.
That being said controlling mealtime spikes is a balancing act, between hitting your blood sugar target and avoiding hypos. Starting out it is prudent to work towards getting the mealtime dose “amount” right so that 1-2 hours after your meal you hit target. Once you can reliably do that, you should then move to trying to worry about peaks. Peaks often can only be properly controlled through careful timing of the dose (when you inject and whether you shorten or extend the bolus). Just take things one step at a time, revel in achieving control of the recommended 250 mg/dl at 1-2 hours and then consider whether you want to step up your game.
What’s I’ve garnered so far from Think Like a Pancreas is that 6 to 7% A1C is the goal…less is OK, but more isn’t. Above 7% is where liver, kidney, brain, etc., etc., damage is done…so shooting for that target is our goal. That means trying to eventually shoot for an average of 154 or less mg/dl.
. . . and as Brian says, once you reach the point where you pretty much are hitting your targets and have developed confidence, you can start dialing it down for greater precision. Baby steps first. You’ll get there.
