You Too Can Bolus for Chinese Take Out

A successful insulin bolus is all about the balance between amount and timing.

Arden recently had Chinese takeout that consisted of sesame chicken, white rice and edamame. 

Take a look at her 24 hour Dexcom graph and see if you can guess what time Arden ate the Chinese food. The yellow block represents a restart of her Dexcom CGM.

Now lets talk about the insulin that we used for the meal. Try not to look at the next graph yet...

History tells me that Arden will need between 9 and 10 units of insulin for this food. I don't know how much she'll eat and I don't know how many carbs the food contains. Honestly, I don't care about the carb count for two reasons. 1. I know historically how much insulin this food requires, the trick is to time it correctly. 2. Even if I use the correct amount of insulin the bolus won't work if it's mis-timed.

Example of Correct Amount of Insulin not leading to desired result

Bolusing the entire amount too soon will cause a crash while eating because the carbs will get overpowered by the insulin. Correcting this low will lead to a crazy high later (unless you add insulin, which you'll likely be afraid to do because of the initial low. However, that would likely be the correct thing to do). Outcome: UNDESIRED

Bolusing the entire amount too late will cause a spike that won't come down because the carbs will overpower the insulin, rocketing the BG. This result now voids the "correct" amount of insulin. Yes you used the correct amount of insulin for the food initially but the unintended spike has not been compensated for by insulin. Mis-timing the insulin created another insulin requirement. This spike will last forever without more insulin. Outcome: UNDESIRED

Take away: The insulin, even in the correct proportion, will inevitably not be successful if it is mis-timed. 

What does timing mean in simple terms?

The fight between carbs and insulin needs to be balanced. Imagine a tug of war. If one side pulls first, the flag in the middle of the rope becomes uncentered. Now the side that pulled first has a huge advantage that the other side probably can't overcome. When we bolus we want the insulin and the carbs to pull at the same time so that the flag stays right in the middle. 

The first step to a balanced pre bolus is understanding the insulin. Man-made insulin does not work immediately and you need to figure out how long it takes to work for you. It may be five, ten, fifteen or more minutes, figure it out. None of this will work without pre bolusing. Trust that. 

Once you know how long it takes for your insulin to begin to reduce your BG, consider the food. Something sugary will hit your BG quicker while a heavier less volatile carb like bread may take longer to start pulling up your BG but then last much longer in your system. Each food type will need different timing considerations and hence a different pre bolus. 

None of this needs to be perfect because you can always readdress as you go (made easier with the Dexcom CGM and an insulin pump but not undoable with injections).

Understand the roll of basal insulin. Pumpers have a basal rate set that is trying to hold a steady BG during the day. When carbs are added and your insulin needs increase, you aren't just stuck with one weapon (bolus) you can also blanket the carb richer hours with more basal insulin. (Extra basal also does wonders bringing down a spike or stubborn high BG). So don't just use a targeted strike (bolus), carpet bomb too with an increased basal rate. Decreased basal rates are also effective in handling stubborn lows without carbs. 

Okay lets take a breath because none of this is nearly as complicated as it seems. Lets go over some basic tenets and then look at the Chinese food graph.

• You have to pre-bolus to create a balanced fight between carbs and insulin.

• Temporary basal rate increases and decreases are a vital tool.

• If your BG is too high. You didn't use enough insulin, you mis-timed it or a combination of both.

• If your BG is too low. You used too much insulin, you mis-timed it or a combination of both.

• When your BG gets high do not spend time trying to figure out why, just get it down. Figure it out later.

• When something goes wrong, its not a mistake to beat yourself up over. It is actionable data, a learning experience that will help you make a better decision next time.

• CGM users: Stop the arrow without causing another one. Bump and nudge the graph line. Small adjustments will keep you off the diabetes rollercoaster.

• It is far easier to stop a low or falling BG then it is to effect a high and stubborn BG.

• Often you get what you expect so expect BGs in the 70 - 110 range and make them your goal. CGM users: Set thresholds that allow you to react before it is too late.

• Be bold with insulin.

It's time to look at the graph from the Chinese food. Do you remember when you thought Arden ate? Did you guess around 3 pm? Actually, the spike at 3 pm was one tiny snack with a mis-timed pre-bolus. The take-out was at 7 pm. Check it out.

View fullsize

Simply put. I cranked up Arden's basal about 20 minutes before the food arrived and bolused 3.00. Thats 4.00 units in, 6.00 more needed. The next 1.50 went in when the food began to create space between pre-bolus. I need to stretch the insulin impact because there are two different carbs at work in this example. The sugar on the chicken is going to act fast so the pre-bolus and temp basal needed a head start. The next issue is the white rice which brings a heavy impact that is also long-lasting so we need force and staying power. I held the balance of the insulin until the rice started to make its impact around 7:40 pm. I should have bolused the remaining 3.80 all at once but I played it a bit safe because I knew that we were about to lose the Dexcom data for two hours. Had I sent the entire 3.80 at 7:40 the BG wouldn't have made it to 140. Thats it. We tested half way through the Dexcom restart to be safe and to make sure that Arden didn't need more insulin. 

You may be inclined to say that this is too much effort but I contend that the few moments that it took to make these adjustments is a far better world to live in then spending the next five hours bolusing a high number that just won't move. It will take you a few tries to make sense of everything but one day you'll have it and all of this will feel easy. Arden eats what she wants and her A1c has been between 5.6 and 6.2 for four years. Be bold with insulin!

You many also like:
Blog post: Anatomy of a High Carb Breakfast
Podcast: Bold With Insulin

If you want to continue to find out more about how we manage type 1 diabetes please check out my podcast. The Juicebox Podcast is free and available on all podcast apps and online. Subscribe and start listening today!

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I am not a doctor and this is not advice. Disclaimer is here.

A REPURPOSED DIABETES WORD

Arden got a new puppy in mid-December and that was a huge deal around our house because I had been steadfastly saying no to more pets for years. 

Then one day I softened on the topic but not because I was worn down by constant badgering - though there was constant badgering. I softened because of something Arden said to me during one of her impassioned, "I need a puppy" pleas. I could see in her eyes that she was making more than just an emotional decision when she asked for a pet, something in her had matured. 

it was time for me to say yes and so I relented and the puppy search began, in earnest.

After an exhaustive research process Arden settled on a French Bulldog/Boston Terrier mix that some affectionately refer to as a Faux Frenchie. We found a lovely woman who breeds the mix and awaited his arrival.

After we chose the puppy every waking moment in our home was spent in deep contemplation of a proper name. Arden looked in baby name books and online, we mused around the dinner table, and once seriously considered naming him after a boy that Cole plays baseball with – because of the way that the boy's mother says his name. So much fun to imitate!

I pressed hard for a few days to name the puppy Heisenberg. Though Arden has no knowledge of 'Breaking Bad', I liked the name a lot and tried to explain that if she named him Heisenberg we could also call him Mr. White, The One Who Knocks, The Danger or Walter - she didn't much care for my argument but did actually consider my request for a hot second.

 

One afternoon Arden walked into the house after school and calmly told me that she had chosen a name for her puppy, she was going to call him Basal. 

At first I didn't like the idea because we already hear, say and think diabetes related words so much. One of the things I look most forward to if a cure is ever found, is not saying 'diabetes' ever again. I must say, think, write or speak that damn word hundreds of times a day. But Arden loved the name and so I smiled and said, "GREAT name, we'll call him Basal!".

It's only maybe six weeks since Arden choose the name and I am so happy that she did. Repurposing that word and applying it to something so innocent and adorable has reprogramed my brain. No longer do I clench my teeth at the thought of a high BG that needs more background insulin or contemplate with worry if shutting Arden's basal delivery off for an hour will stop a low blood sugar.

Now Basal means this...

Basal - Almost 5 months old

The lesson in all of this is simple in my eyes, we CAN teach ourselves not to react to how type 1 diabetes tries to make us feel. 

Following in the spirit of Arden's puppy name choice and what it taught me, I've named my new podcast after another word that I just hate saying in the hopes of repurposing that word as well.

I hope that you can check out and subscribe to The Juicebox Podcast, my new type 1 diabetes parenting show. It is live on iTunes, Stitcher and Soundcloud, please subscribe at www.JuiceboxPodcast.com and give it a try.

I'm off to prep for my first interview for the podcast, you are going to love the guest - Adam Lasher from American Idol!

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Basal Adjustments

I was asked on FaceBook to explain how I made the adjustment to Arden's overnight basal rates that resulted in the graph above. I'm sorry that it took me so long to write about my (less than technical) process. Here's how I did it...

Somewhere around the second week of overnight lows it became obvious to me that I was dealing with a trend and not an anomaly. Something had changed about her physiology and I was going to have to adjust - basal adjust.

I'm not going to lie, I didn't do any basal testing. I have the procedure around here somewhere, the page or so of directions from Arden's endo that explains how to do basal testing - but I tried a more, let's say, personal approach. Luckily CGM technology lends a distinct advantage and unless we are averting a low, Arden doesn't eat at this time of night so trend graphs are a perfect way to understand where we have too much basal insulin.

I broke out the stupid PC laptop that we had to buy, because the damn device manufacturers refuse to port their software over to OS X (Apple), then I downloaded Arden's DexCom data. It only took a moment to see what time of night that her blood glucose was drifting lower.

Arden's overnight basal rate was .30 per hour, all I did was dial it back to .20 starting one hour prior to when her BG was beginning to fall, not terribly scientific I know. The possibility that this adjustment would be too little or too much wasn't a huge concern, because let's face it, I'm awake anyway.

As you can see in the image above, the slow drift that was beginning around 4 am leveled off nicely. The picture you see here shows that there was room for a little more basal insulin. I waited two more nights to verify that this graph was accurate and then I moved the basal to .25 an hour. That adjustment caused a slight dip and so the next night I staggered the hourly rates .20, .25, .20, things have been golden since.

The reasons that I like handling basal adjustments myself are simple. Waiting until Arden's next endo appointment to discuss this doesn't feel like an option - too long. Continuing to live with lows would have not only taken the rest of the precious little energy that I have left, but also it would leave Arden in danger - not doing that. People living with diabetes will always need to make adjustments like this. Their bodies, like everyone else's, are constantly going through ebbs and flows. My pancreas doesn't secrete the exact same amount of insulin every hour and it makes sense that Arden's pump shouldn't either. Arden's body has needs, ever changing needs - I have to keep up with them.

We all have to be comfortable making decisions like this autonomously at some point. As parents we don't always have the time to call for an army of help and our children's bodies shouldn't have to wait days or weeks for balanced control. Don't get me wrong, I wouldn't make a grand change to Arden's care without our doctor and I don't chase every night that doesn't go perfectly, but basal adjustments when they obviously are needed... We can do that!

If you are going to make basal adjustments please don't forget to write down your old numbers in case you have to switch back. Actually, if you don't already have that information recorded somewhere, take a moment to do that. Write down basal rates, IC ratios, alarm thresholds and all of the other personally inputted data that your pump and glucose monitors retain, just to be safe.

Later this week I'll be talking about Pre-Bolusing, Arden's latest A1c and more... stop back, like Arden's Day on FaceBook or follow the RSS feed to stay in the loop.

Good luck getting those basal rates where they need to be and then enjoy the huge difference in your BGs!

Basal the spike away

Standard Disclaimer: I'm not a doctor, please read the disclaimer at the bottom of the page. Always speak to your doctor, especially before trying something that came to me while I was in the shower. 

Stubborn Highs: Arden's blood glucose can rise and at times be resistant to returning to 'normal'. Happens to all of us. I bolus and wait but nothing, so I bolus again and sometimes again. It's around the second bolus when I begin to wonder, "is the site bad", "maybe the pump has been on too long", "did I grossly miscalculate carbs", a person can go batty trying to decide what has happened. It's likely that before you (or I) can ever come to a conclusion, the BG in question will return to 'normal' or head in the complete opposite direction. Either way, the whole unsightly mess is forgotten becasue you're busy chasing the next problem which leaves you no closer to understanding why this happened or figuring out how to avoid it next time.

Sound familiar? 

This type of BG struggle isn't just associated with stubborn highs: Breakfast or meal time spikes can also lead to an urge to bang your head on a nearby firm surface. Over the last few months I've been experimenting with an idea that came to me in the shower one day and I'm seeing a lot of positive results. I'm going to do my best to explain without being boring or confusing... Please note that what follows will only work for pumpers because it involves manipulating basal rates... sorry MDI and pen users!

Using increased temp basal rates in place of a portion of your bolus

Arden is a really good eater, that is that she eats healthy foods most of the time and in acceptable portions. If the kid has one 'vice' it's that she likes a bowl of Fruit Loops in the morning - just one cup. The BG devastation that this handful of cereal visits unto Arden was, in the past,  terrible. Her BG would rocket to 400 or more after a bowel of the colorful rings. The Loops would seem to laugh in the face of a pre bolus and administering more insulin before the meal or an extra bolus after could not penetrate their sugarific force field. Once I even thought that I saw Toucan Sam give me the finger as I put the cereal box back in the pantry.

I hate this song and dance. I hate that Arden can't have a flippin' bowl of cereal once and a while and I double hate the feeling that I live with when she eats cereal and her BG goes crazy. Foods like this don't just send her BG too high, they ruin most of the rest of her day. I'm full aware that cereal isn't a good choice for my diabetic daughter but I'm not writing about that today. Today I am talking about how, with the help of an insulin pump, we can all fight meal time spikes associated with not so great food choices and manipulate stubborn high blood glucose values more easily and smoothly.

My formula

Things you need to know to follow along: 

• Arden's basal rate is .30 in the morning and much of the day.
• For a serving of Fruit Loops she requires 2 units of insulin.
• Giving say 2.5 units for the cereal does not change the trajectory of her BG.
• If I go higher (say 3 units) the spike is not effected enough, topping out at 350 and Arden's BG will plummet between the three and four hour mark.

Time to visit me in the shower where I am apparently about 20 IQ points smarter then I am anywhere else. (I've heard that the hot water on the back of your neck may be the reason why).

I was in the shower one day pondering life and Arden's breakfast BG spikes when I first began putting the pieces together. Overnight Arden's basal rate is .20, if she's high I have to put her basal back to .30 for a bolus to have the desired effect... I wondered what would happen "if I increased the basal beyond .30", could I bring a high BG down in a safer way, steadier perhaps (because she's sleeping) then if I just bolused? I tested my idea at the next opportunity and not only did a significant temp basal bring down the high overnight BG but it did it with less insulin then a bolus would have required and the drop was smoother, it's 'landing' less erratic. My inner mad scientist was intrigued and I had just unknowingly found a big piece to the puzzle that is stopping mealtime spikes.

Proof of concept: Arden sits down and begins eating on a school day at 8:20 am. Today at 7:45 am her bg was 140, I bolused for the first 15 carbs of her upcoming breakfast, which was 1 unit or half of what a serving of Fruit Loops requires. This is a pre-pre bolus, I find that after a long night of no boluses and a decreased basal rate it can take a little longer for insulin to begin working (maybe this is part of the morning insulin resistance many experience?). At 8:10 am I bolused again this time for the remaining 15 carbs but I reduced the 1 unit of insulin by .30 (the equivalent of an hour of Arden's basal rate). Last, I increased her basal by 95% for one hour. (OmniPod won't do 100%), giving the last .30 of the 2 units via an increased basal rate. The temp basal in conjunction with a significant pre bolus seems to be the key to eliminating a BG spike. Pre bolusing alone won't effect a severe spike enough because you can't perfectly sync the insulin peak with the food spike so the BG rises quickly, drops suddenly and often bounces back up. However, when you add a pre bolus to a significant temp basal, the basal acts as a constant drag on the spike and the two together win out.

Breakdown

15 carbs or 1 unit, 40 minutes before breakfast - 7:45am

I can prebolus that far off in this situation without an issue because her basal was .20 all night and she's resistant in the AM, so the insulin is a bit slower to respond first thing in the morning. Plus, with Apidra, Arden rarely experiences significant BG falls so prebolusing this far out feels safe. Additionally, I have 70 points in her BG to play with and the cereal will be releasing sugar into her blood far before she gets too low... (having a DexCom CGM doesn't hurt either).

Another 15 carbs 15 minutes before the meal (withholding the equivalent of an hour's worth of basal)- 8:10

This insulin won't begin working until after Arden begins to eat, so I'm not worried about stacking. Two boluses also mean two insulin peaks while the Fruit Loops are trying to spike her BG. 

Double the basal rate for an hour to complete second 15 carb bolus.

This .30 will work better then if it was given as part of the bolus, why? I don't know, I told you, I'm not a doctor... it just does - Maybe I know this because hot water in the shower makes me smarter. btw, more then an hour of the temp basal is too much and results in a fall in the 3-4 hour range. Doubling for an hour is perfect.

Result: At 9:30 am Arden's nurse called... Arden was 240 by her CGM. The CGM indicated 2 arrows up (which was why she was with the nurse) but the double arrows only lasted for about 4 minutes. So my little science experiment took a double arrow up event that in the past would have sky-rocketed to 400 (or more) and held it to a 4 minute double arrow that never went above 250!

Arden's BG (by the CGM) at 11 am (pre recess) was 145 diagonal down, she drank 2 ounces of juice (7 carbs) and went outside to play. When she returned her BG at 11:30 am (post recess, pre lunch) was 129 by a finger stick, 140 and steady via the CGM. 

I choose and extended bolus for lunch because she was having a bagel. 60% of the 2.20 units at 11:30 am the balance over an hour (to combat the slow breakdown of the bagel). Her BG was 145 three hours later before snack time.

Summation

It goes without saying that what works for Arden won't work for everyone but after months of using this method I am 100% comfortable telling you that what I wrote here is well worth speaking to your endo about. The concept of using a temp basal to complete a bolus holds many possibilities beyond what I wrote about here today. Slow to break down foods and high carb meals for example are also good places to try this method. I'm using a temp basal as part of Arden's bolus on almost a daily basis. It is also invaluable in bringing down stubborn high BGs and getting a BG lower during sleep, avoiding the fear of a sudden drop and without going too low.

I wish you all good health, luck and steady BGs. I'll do my best to answer any question if you have them.