Preventing a Low

Our daughter has T1D but because she has a disability, I make all the decisions about her diabetes management.
I’ve been wondering something…. If you’ve pre-bolussed for a meal, have begun to eat but then your BG begins to drop (again—while you’re eating), how low do you allow yourself to go before becoming concerned? In other words, do you add a few glucose tabs to your menu just in case? Or do you assume that your BG will level off and climb because you’ve been consuming food?

Like everything else in diabetes, it depends. If you pre-bolus and your BG drops while you are eating, that means you pre-bolused too much, too early unless you did that intentionally. Ideally, we pre-bolus to stay mostly flatline during our meals. On the other hand, it is important to know how fast you will drop if you pre-bolus earlier or a larger dose. That is sometimes done when BG is higher than you want it before a meal.

Pre-bolus really needs to be fine-tuned using a cgm as the amount of time to pre-bolus as well as the pre-bolus dose depends on how fast the BG reacts for given foods. Typically pre-bolus is about 15 minutes before the meal, but for some people they pre-bolus even 1/2 hour or more in advance and some don’t start to eat until they see their BG to start dropping.

This is a DIY trial and error process and each of us is different so testing with a CGM or multiple finger sticks and recording results are the only way to achieve the results you desire.

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If I’m eating at the time, I wouldn’t bother trying to correct it, unless you are eating low carb,then I would add something like bread to boost you

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Depends on what my meal is. I typically start with lower carb salad items while I wait for insulin to kick in. But if trending low, would eat the higher carb foods first, or drink non-diet liquid.
If have cgm trend, the trend will also help to know how quickly and what to treat with.

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I find having a low during a meal super unpleasant.
I would recommend a small glass of sugary soda or juice, if she likes those, in that situation over glucose tabs (just for taste, no medical reason.)
As others have said, it really depends on a lot, but it can make sense to pause the meal for 5 or 10
minutes to let the sugary liquid or glucose tabs start correcting the low rather than just continuing on with the meal since whatever fat or fiber there is in the meal could slow down overall digestion.
Plus, you can’t really enjoy a meal if you’re in the midst of reacting to a low.

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Oh, and in terms of how low specifically, I don’t like to be under 70 so I would take action if it looked like I was going to be under 70 in the next ten or fifteen minutes, Otherwise, I’d figure the meal I was in the process of eating would bring my BG up without any extra help (depending on the carb content of the meal of course and the size of the meal bolus)

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I avoid taking sweet things to correct lows. Since I’ve been on cgm, I don’t panic unless I’m symptomatic. But I’m ok in the 60s.
My pump will cut me off of insulin before it gets too low and usually levels me out before it gets that low.
I’ll eat something if it’s feeling low, but I stopped using glucose tablets and I don’t even keep soda at home.

Those put me on a rollercoaster thats hard to get off.

It really only happens when I make a serious bolus miscalculation. Then a banana or apple is plenty.

I used to eat the entire contents of my fridge before I learned a lesson or two.
Cgm has really helped me prevent serious lows

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Different people might go low for different reasons.
I really like to be active!
Exercise always presents me with challenges. I will often need up to 100 g of fast acting carbs in order to complete, for example, a 20 k mountain bike ride or cross country ski.
This, despite lowering my basal ahead of time, taking a lower bolus for any meal within an hour or two prior to exercise, and switching the Tandem Activity to “Exercise”.
Often an hour after I finish my ride or whatever, I’m trending higher.
Super frustrating!

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It’s so helpful to hear everyone’s feedback! Since our daughter’s diabetes is pretty challenging because she’s so insulin sensitive, I so appreciate the input of people who live with T1D themselves.

You left out the pantry. :sweat_smile:

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One other consideration is how does your daughter react to a low? If she gets really freaked out from the symptoms then you might want to be more aggressive in giving her some extra carbs. If she doesn’t seem to mind the feeling of a mild low, then you can take more time seeing how things are working out. Are you using a pump? Control-IQ? Injections?

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Our daughter has a Dexcom G6 and the Tandem X2 T slim pump with Control IQ, both of which are an enormous help.
She doesn’t freak out when she starts going low but she does ask for extra food.
I’ve been experimenting with shortening the pre-bolus time—we’d been waiting 10 to 15 minutes pre-meal—
to only 5 minutes and so far that’s helped.

I feel like every pre-bolus is a game of Russian roulette. I’m a homesteader and just about everything eaten is made from scratch without the benefit of nutrition labels, so I can’t really count carbs or check fat/protein content to see how quickly the meal will absorb. Every bolus and it’s timing is a guesstimate. Something we call SWAG (smart wild “butt” guess).

I feel like I’m always watching the CGM after a bolus to see how low it’s going to go. I’m perfectly fine with sixties, but start to worry if it dips below that. I find the series of sirens that go off on the phone and pump at ≤55 upsetting and try to avoid it at all costs, even if I do still feel fine. So if I hit 59, I’ll stop eating and start drinking a sugary beverage instead. Tang drink mix is my go-to just because it’s shelf stable and convenient. I prefer liquid carbs for hypos because they seem to absorb fastest.

You didn’t mention how your child takes insulin. Pumping has an advantage here with the ability to customize the rate of delivery. It doesn’t have to be all in at once, like with MDI. I don’t always remember to do it, but one of the things I’ve found that really helps is using the extended bolus feature on my pump, even for meals that generally don’t need it. For instance, if I’m serving rice with dinner, which I know is going to hit me fast and hard… The normal instinct is to take the full bolus up front early, so the insulin is working when the carbs absorb. But what I actually try to do is deliver half of my bolus immediately and extend the rest to be delivered incrementally over the next 20-30 minutes (depending on how close I think we are to dinner). It buys mean little extra time if I mis-time the cooking, or am not able to eat everything I planned.

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Most of the time, I don’t pre-bolus at all. Everyone is different – you’ll know when you hit the sweet spot.

~WRD0000.jpg

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Everyone eats differently as well. Pre-bolus timing for the same individual will vary considerably on a day eating a high protein vs a high fat meal.

I accept that different people get different result, but there are differences that can’t be controlled, and those that can. I reluctantly accept what I can’t change.

But I’m an engineer. Other people’s generalizations about variables aren’t useful in any way when I have a problem regarding my health and safety.

I don’t blame peope, on a forum who are trying to be helpful, for not having enough data to make a useful response when the person asking for advice doesn’t or can’t provide that data. But each of us needs guidelines or rules that work good enough most of the time.

Here’s my experience that may help the OP find theirs.

I’ve had T1D for +40 years, but I’m new to pumping. I know how to deal with high and low BG quickly and effectively, so I didn’t worry as much about my short term variations as much a someone new to T1D - until I started using a CGM.

It took me was while to realize emotionally that the numerical precision of CGMs is an unhelpful distraction because their accuracy is frankly poor, they don’t tell me what my BG is, and they make guesses at the future using insufficient data.

Those guesses are only useful to Control-IQ for control when BG is within target range, and not within an hour of a bolus ending, or when BG is changing at a fast rate (more than 2mg/dL/minute )

Lacking specific “rules” from any diabetes educator or authiority to follow on how to apply my T:slim/G6 to my actual meals, I’ve been paying very close attention to what’s been happening to me, trying to find patterns and turn them into personal guidelines.

What I’ve seen:
My BG drops after bolus before it rises for every meal that isn’t pure simple carbs. That initially worried me.

When it was projected to go below 80 within 30 minutes, 15 minutes after bolusing, is when I got very concerned. I believed that it meant I bolused too early or my BG was too low before I bolused.

I’d never worried about this when using MDI but now I had a DIGITAL READOUT every 5 minutes!! It’s TECHNOLOGY!! Could I have been having assumptomatic premeal hypoglycemic episodes without suspecting it? Was my life now in danger because I was using a pump instead of syringes?

I didn’t think so, but I like doing experiments and measuring things. The work helps me feel like I have more understanding and control (even when I don’t). I was already doing some tests so I added one more. to see exactly what was happaienig with meal boluses.

So I I calibrated the CGM to match my BGM when I was steady for an hour between 120 and 150mg/adL. I adjusted my pre-meal BGs using a BGM and glucose tabs an hour before many dinners to get my BG to 110mg/dL +/- 10. And I disabled my pump’s IQ software.

My “base” pre-eating bolus time is 15 minutes. I timed the minutes to my first mouthful of brown rice followed by water. I ate my meal in strict rotation of carns, vegetables and protein in a consistent amount of time. I tested with a BGM at predicted low times, when the CGM showed a peak staring to flatten, and after I ate at 30 minute intervals until I was within 60 mg/DL of the premeal CGM value. I logged the CGM readings along with the BGM values.

I proved to myself what most experienced pump users probably know by education and instinct.

  1. No two days had exactly the same BGM results. My relative preprandial BG dips and the postprandial highs varied by 10% for the same exact dinners. My 3 hour relative post-prandial values varied by <10%, the 6 hour by ~ 10 mg/dL.

  2. Each infusion site change produced a slighly different response, but the same 6 hour postprandial result, +/- 10 mg/dL.

  3. The CGM curves weren’t just time delayed, they were also distorted. Sharp peaks never reached peak BGM values. Sharp dips never matched BGM values.
    The 30 minutes low predictions before meals weren’t overly pessimistic, they never happened except when I delayed a meal by miore than 30 minyres.

  4. When my bolus was at - 15 minutes, I got a dip to below 80 (CGM) and a projected below 58 low within 30 minutes. The CGM never showed me going below 70.

  5. When my bolus was at -25 minutes (10 “too early”), within 20 minutes my CGM dropped to under 80, estimated a below 58 within 30 minutes. It bottomed at 70.

  6. When my bolus was within a minute of my first bite - I still got a dip in the CGM value, but I went higher, faster, above 180 and needed a small correction later.

  7. As long as I knew wahat I was eating, measured it and matched my bolus, I didn’t feel any different. I didn’t have any symptoms of hypo- or hyerglycemia,

  8. When I turned the IQ software back on, my results within 1 hour after bolusing and eating didn’t change; my meal peaks happen too soon, Basal IQ did nothing useful for meals. Control IQ helps between meals, at night and before a bolus to get my BG closer to target.
    .
    So my advice to avoid hypoglycemia before meals when using a t:slim and G6 is simple.
    Do what you would to establish good control if you didn’t have a pump.

You can not rely on a Tandem pump and Dexcom sensor to do what you couldn’t if you had the time and energy. The pump is not smart. It folows directions that work pretty good most of the time -if it has all the information it needs.

I’d be willing to bet that it doesn’t have that all information. It has the bare minimum to warn you when it decides things are getting out of control , which it will do often. The more accurate information you give it as the child grows and changes physically, the better the job the pump can do for you, but it is an assistant., It will never replace an educated human manager who is able to intervene and takae iover control when needed.

  1. Use a BGM to get the child’s BG between 120 and 150 before every meal.

Why? ( 180-70/2= 125) Thats the middle of the control range for Control-IQ. When trying to avoid lows that’s the sweet spot to start training a new assistant .

  1. Standardize the child’s meals to a predetermined amount of complex and simple carbs at every meal, with measured amounts of fiber, protein, fat and vitamins each day for proper nutrition of a child their age and weight. Use a scale to weigh carbs.

There wil be very vew foods than can’t be worked into such a plan, duirng a week, only the amounts of carbs, especially simple carbs, will need to be carefully controlled - not forbidden.

  1. The pump now has accurate weight and estimated average total daily insulin dose from your doctor. You need to determine the child’s average basal profile over a 24 hour day, correction factors for typical meal periods, and insulin to carb ratio.

A person of average education who ca read can determine this numbers by following dirctions in the book “Think Like a Pancreas”, by Gary Scheiner. Is not hard. All you need is the willingness, the equipment you have. ap$10 digital food scale, a calculator, and a bound paper notebook to keep your records. Don’t use a computer. I’m in IT and wouldn’t. Paper record don’t need to be recharged, can’t be easily lost.

4 As you learn the numbers,add them to the pump by copying the original profile and modifying the copy. Let your doctor know what you have found out and ask for advice, before activating the copy. The copies will let you switch back if you see worse results. Over time you will grow miore confident about your competence to mae refinements, less dependient on the doctior to watch you.

I’m on my 6th profile version and still learning. You may take 6 weeks or 6 months to get to where I am. What’s important is getting there. ones tep at a time.

  1. Keep asking questions.

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Our daughter is almost 37. She has an intellectual disability (not unlike someone with Downs Syndrome) so although she is able to talk and tell me if she’s “still hungry” while going low. Fortunately she can also articulate when she’s feeling shaky from a low. The Dexcom has helped prevent the shakiness most of the time.
That said, I agree that the G6 isn’t terribly accurate especially during the first 2 days. We too do quite a few finger sticks during that time.
Your input is super helpful. Thank you!

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Our idea of accuracy is skewed. Remember the test strips are also not very accurate.

We somehow decided that test strips are the holy grail and that the dexcom need to be the same, but we are calibrating an inaccurate device with another inaccurate device.

That’s why I almost never do finger stick testing anymore, unless my dex is questionable near the end of the run.

Lucky for me my hypo awareness came back after I tightened my glucose numbers and I am pretty much aware when I go low, if my dex doesn’t concur, I will know it.

I find my dexcom pretty much imperative in keeping me in range. I have no faith or need them to be exact.

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I agree. I definitely have a skewed perspective when it comes to our daughter’s BGs. In my stronger moments, I can be rational and tell myself that it’s “just a number” and the readings aren’t necessarily exact but rather a “ballpark” number.
In my weaker moments, watching her BGs skyrocket or showing double arrows down have me almost in a panic until they settle down. In some ways, I miss the days when I didn’t know her numbers all day long.
‘Trying so hard to not let my wish to keep her in range drive me crazy.

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