Looking for some input

General
1

Just trying to figure it all out still. Was wondering how you all correct and bolus.

Say you test and eat a meal and you were really accurate about the carbs and did a bolus or shot.  Then you tested in an hour or two because you feel high or just want to see where you are at. Then say your test was 275. How do you handle that .

I guess part of my question is how long does the fast acting insulin stay in the body countering the carbs and when do you when the next test is an accurate read. I have heard some say that you should wait 4 hours after you eat because if you were accurate on the carb count the end of that 4 hours is where your numbe should be.

Now if you test and your at 275 and you correct - say 3 units and the other insulin is still working in the body an hour or two later than your giving more than you need and if you do nothing and it rises then you should have done something.

What is happening now is that I am testing my son 10-12 times a day. What is hard is that I will test and he could be at 306 and test a minute later because he should not be that high and get a result of 246.

Two different reading within a minute.

Would love some input

2

Hey Keith -

On the differing blood test results, does your son use rubbing alcohol before doing the finger stick?  Blood mixed with the alcohol can adversely affect results.  That has happened to me before, many times.  Just need to let it dry all the way before you poke.  If this isn't the case, you need to use control solution to check the accuracy of the meter.  That big of a discrepancy doesn't seem right.

The rest of it:  is he eating high-carb meals?  Those will spike the blood sugar a little more, no matter what.  Is he taking insulin 10 -15 minutes prior to when he starts eating, or right when he starts eating?  This was my problem.  I wasn't letting the insulin have time to work first.

To my knowledge, Humalog is on board for about 3 1/2 hours, and peaks 1 - 2 hours after you've taken it.

Most Endos will tell you to test 2 hours after your meal - you should be back to normal (or close).

Good luck!

 

3

In terms of differing readings that are almost back-to-back, blood glucometers have a target range for the result they give.  I think the legal guidelines are being plus or minus 15% of laboratory test results.  This means that 2 tests within a single minute can give very different results and still be considered accurate, even though in reality your blood glucose level may not have changed at all.

4

hello Kieth,

I don't want to sound negative, but there is no "really accurate" way to determine carbs in a meal, or how fast calculated carbs will absorb into your body, or how long analog insulin will take to start to work, or how long (total) analog insulin will work in your body.

so then sugar control becomes an art, with a science minor.

regarding your question - I know my sensitivity (how many mg/dl a unit of insulin will drop my blood sugar)  I know, on the average how many mg/dl a gram of carbs will raise my blood sugar,  and I know my carb ratio (how many units of insulin pre grams of carbs).  I also grossly estimate that analog insulin stays active for 3 hours in my body.  THESE ARE ALL ESTIMATES>  but you can test yourself and find your  "kinda" average numbers, which btw, for me, are 32, 5, and 9

If I was going to eat a 40 gram carb meal and I am 160 at the start of the meal, and I have no active insulin (I have not had an injection for 3 hours).  then I would shoot 4.4 units for the carbs and an additional 1.9 units to drop my 160 to 100 for a total shot of 6.3 units and then I eat.

If I were to test at 1/2 hour, I might see a blood sugar of 300, but I would have an active insulin of almost all of the original 6.3 units, which if the planets are all perfectly aligned, would be a blood sugar of 100 at the end of 3 hours.  Shooting a correction at 1 hour is risky because it can CAUSE a very low blood sugar a few hours from now.

I find the following things very helpful - knowing my active insulin (my pump keeps track) and knowing a few things about myself which is: if I am very sedentary and if I eat potato or rice or chinese buffet food, my sugar will be astronomical at 1 hour postprandial.  If I am going to eat these things while sitting on my ass - I compensate by taking my insulin 20 minutes before I actually eat.

your overall best bet is to read "Using Insulin" by  John Walsh and Ruth Roberts, and "Think like a Pancreas" by Gary Scheiner and Barry Goldstein

good luck

 

5

Hi Keith,

After an hour blood sugar is going to be its highest and then it starts to come down. If you are using humalog or novolog it usually leaves the body at 3- 4 hours. When testing your hands should be cleaned with soap and water that will give you the best results.

I don't really have an answer as to why there was a 60 point difference. Sometimes it happens. Highs happen! That is the nature of the beast we call diabetes.

Why did you test again after 1 minute anyway? did you not trust the result? What your son ate can also factor in as well. If you are trying to see how the food affects your son test at 1 hour then 2 hours and the last at 4 hours. Then you will know how fast your humalog or novo is working but I would only do that if you were testing to see certain foods. Like pizza, chinese food and other higher fatty foods. But that is just me.

We all tend to become obsessed with checking. Have you thought about the CGM? That may help you guys out. It shows trends ...

Well I am not sure if I am helping much, maybe I did haha

6

Just need to let it dry all the way before you poke. If this isn't the case, you need to use control solution to check the accuracy of the meter.


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7

[quote user="cogaivotchong"]

Just need to let it dry all the way before you poke. If this isn't the case, you need to use control solution to check the accuracy of the meter.

[/quote]

Hmm, this advice sounds oddly familiar.

8

As for me, I test before I eat and that's it pretty much.  If I'm going to drive or exersize or think I might be high or low I will test.  I have tested 2 1/2 hours after a meal and been 275 and not corrected and then when the next meal came around I was 120.  If I had "corrected" I would have gotten low and probably eaten too much and been high again. 

I'm not advising this for anyone, only what seems to work for me.  I know many on here do the test 2 hours after eating/correction thing and it works for them.

There are no absolutes on this unfortunately.  Doctors and educators make it sound like if you eat X carbs and take X insulin your BS will always be 120.  Just doesn't always work that way.

9

Keith to be honest, I am not the best counter in the world. In most scenario's I can more or less guess my bolus needed. I will mentally figure out the sugar first. so in your scenario of BS of 275, I will first figure out how to bring that down I know my sensitivity is 1 unit brings me down by about 30. So I will think about 5 units puts me in my target range. Than in thinking about the food I am eating I usually go with about another 4 - 5 units based solely on if I am eating many carbs. Like if I am eating salad and a piece of bread, I will go with 3 units or so. However, since I use my CGM to watch things if I start to spike hi I will catch it and adjust quickly if needed. However, things do not always go smoothly even with my best try. Pizza, fries, chips, basically anything potato based can throw me off, but I am getting better at that. Just need to keep tweaking things.

10

Bolusing is tricky!  I feel like I do half based off of the science part and half is off how I feel.  I did notice a bigger ability judge the accuracy of my bolusing after I got a CGM.  It must be tricky to do it for someone else (I really appreciate my parents being so involved when I was a kid now more than ever!), and a CGM may take some of the guesswork out of the equation.  If this is not an option, you may want to test every hour after eating once or twice, just to see what is happening. 

It may be that the food absorption and the insulin absorption is just not lining up quite right, but is still working, so in effect you could be getting a food spike then an insulin spike after- always bringing the BS down, but makes you feel kind of crappy during it.  I was able to see that pattern with the CGM, and consequently switched insulins, and then the time I bolused from before a meal to after (only if I was low or good before the meal, otherwise if high, I do it before the meal so the insulin hits before the food) and was mostly finding that my post meal spikes were decreasing.  It is different for every one, so the best advice I have is to test often to figure out some of these mysterys if possible.

11

So with the blood sugar issues and the meters, I have had the same issues with multiple finger sticks on one meter, then on another, and comparing to my CGM.  If the legal limit of accuracy is 15%- the higher the blood sugar the higher the variance.  So a 300 could potentially have a 15% (45pt) difference.  I vaguely remember seeing an article about tightening up the variablity of meter readings.  Anyone else read this?

12

my endo has advised me to test no less than 4times a day but no more than about 6times a day unless i'm low/high, sick or exercising, when i was getting used to the pump it was around 6times a day min, but I rarely went over 8-10 unless i was having a REALLY bad daymost of the days sucked..but not that much haha). 10-12 is a little much for everyday unless you're testing due to exercise or think you're low/high (or sick) like DDRumminMan said. overtesting can lead to over-correcting is what i've been told.

i've also been advised to not correct until 2hours after my meal, and don't test until at least 2hours after(when i do). i only correct at that point if my bg is over 10, more often i give it til it's above 12 though.

13

Hi Ginny

Thanks for the input. I am coming to that point where my son has to know his body but I can still help. I talked to my son's endo about the CGM because my wife and I both thought it was a great thing. He said he had a number of teens my son's age try it and it did not work for them because its hard enough for 13-16 year olds to maintain their pumps and adding another device (especially one as large as the Dexcom) wasn't something they would and I so see that same thing happening with my son.  However, when Animas updates the Ping to include the CGM I will certainly upgrade for that feature. Having both units combined is what I am looking for. In the meantime I have finally gotten to a point (its been just about a year since diagnosis) and 8 weeks on the pump -) to really start learning what foods set him off.

Today I am trying Pizza. I will let him eat what he would normally eat in the way of Pizza and bolus for it. Then check on the hour for 4 hours to see how his numbers move. Will also try the combo bolus feature soon on a food like pizza and see if that is any different in regard to the results.

 

14

Hi Kieth,

As said above, meters are not going to be the same with a back to back test. I will do a double test if I fell the results are very far off from what I feel they should be.

As for the Pizza, that is an entirely different beast. It is full of fat, and fat can slow the digestion/absorption of the pizza. My CDE had me try a number of different things to properly bolus for my high fat foods, and after a bunch of trial and error discovered that I needed to split the bolus up (of course, we're talking an entire pizza here, not just a slice). So I would take an injectino of half of the insulin needed at the time that I ate, and half about an hour later. Now that I'm on the pump, I use a Dual Wave Bolus, with a 70/30 % split, given over 2 hrs.

Of course diabetes is different for everyone, I just hope this example helped a little. Good Luck!!

15
  1. First things first - carbs are (like someone said earlier) 80% science and 20% art. For example, I have been told by my nurse and nutritionist that if you have high fiber food ( > 3g per serving) that you should subtract those grams from total carbohydrates. My favorite bread, 100% whole wheat, has 22 g of total carbohydrates but 3g of fiber. So I dose for 19g of fiber. Some higher fiber foods (greater than 5 or 6g) will also slow digestion ("gastric emptying") which means it may be best to break up your insulin dose into two parts given over a period of time. (My pump does it automatically via dual or square wave bolus, you may have to do it via two shots.)
  2. According to the pharmaceutical information given with my Humalog, and with any insulin information, fast-acting insulin stays active in the body for 3 hours, begins reaching the bloodstream within about 15 minutes, and peaks in concentration in the bloodstream at approximately 1-1.5 hours after injection. This may differ if you use Novolog etc. Check with your health care professional or pharmacist if you're unsure.
  3. I get a good, accurate reading of how I've done as a whole ~ 3 hours post prandial. If I've had something deep fried or rich, I may see a new peak or rise in BG at 4-5 hours post prandial. My dad sees it with a good t-bone steak, I know at 5+ hours.
  4. If you correct at 2 hours, using your example, by giving 3 units for a BG of 275, then you won't know until 3 hours after that correction injection. However, going back to your question regarding how the two doses work together - the insulin response curves are also included in the packaging when you buy insulin. Its a bell curve. The bulk of the insulin is delivered in about the middle third of the three hours, or at 1-2 hours. I usually drop about 30-50 mg/L of BG after 2 hours is over..... you should test your son at 2 and 3 hours with the same food and time of day a few times and average the results... then you can see how much he loses during that time to correct accordingly.
  5. Finally - on to your question regarding how checking one minute to the next can give two very different results. Like all scientific instruments (and that's really what a glucometer is!) - glucometers each have a standard deviation (SD) and a margin of error ("drift" "MOE" "plus/minus" "+/-") that together can cause a radically different result each time. My meter (Lifescan OneTouch UltraLink) lists a margin of error of up to approximately 20%. So that means you could test back to back and if your "actual" BG was 150... you could get 180 one time and down to 90. (Most common is +/- 10-15%). It can also differ from finger to finger and arm to hand. That's why testing so often is a great idea.... but realize it isn't an exact science.

I should add that my father, who has been a Type 1 for 36 years, before the modern glucometer, has had no ill affects from not guessing exact or using a glucometer that had 20% drift. This is where the art comes in....

I hope this helps.

/ Michelle

16

Since I've been dealing with T1 for over eight years, I've got a pretty good idea about where my blood sugar is headed a couple of hours after a meal. If I check after a meal that I counted pretty accurately, and I am 275, then I am almost positive that if I don't do something, then I'll continue to rise. If I were to try to do a correction this soon after a bolus, my pump would probably lower that correction to account for the insulin on board. I usually do the full correction, though, because if I don't, then I'll still be high in a few hours. 

It's all a matter of getting to know your body (or your son's, in this case). Some people are very sensitive to insulin, and doing a full correction two hours after a meal would make them go low. 

17

Hi Keith,

My son is also T1 and we go thru the same things you are.  We've been at it since July with Blake, so here's what I see in his trends so far.  Blake is 2.  

1.  Testing an hour or two after a meal and seeing a spike:  This happens to Blake as well.  I write every single thing down on a tracking sheet that happens throughout the day to see what is affecting him and how things affect him.  Different foods act differently in eat person.  For example, strawberries will spike his sugar but then come back down within 30 minutes.  Crackers will spike his sugar and keep it elevated for an hour and a half or more.  

****Track his foods and levels of activity.  I write down what he did (did he sit and watch tv all day or did he run 15 miles? Those will be factors

2.  What do you do about a high after a meal?  Nothing, except make sure he's hydrated.  You can't correct for sugars <3 hours if using Novolog/Hum. anyway.  Just be patient and see what's happening b/w meals and boluses.

3.  How long does insulin stay in the body?  Open your box of insulin and read how it acts.  The paperwork that came with your insulin (find it on line too) will give you a graph that shows how it works in the body.  We use Novolog, so I know that around 2.5 hours after I give the bolus, it's working its hardest.  That's when I'm most concerned with checking sugars and giving a carb snack.  Blake's target is 150, so if it's higher than 150, I wait for about 30 minutes then check again.  

****You're dealing with a child, who may or may not communicate with you properly, so if you are concerned about the sugars, check them!  "Check, don't guess".  Don't worry about what other people are doing.  You know your kid better than your Endo.  

4.  Your 275 question about doing something or doing nothing:  You shouldn't correct for BS >3 hours b/c your Novolog/Hum won't be working it's hardest until 2.5 hours.  What you CAN do is track what's going on and how foods affect him.  

****Some things to think about that increase BS:  illness (ear infections, URIs, etc), stress, anxiety (meltdowns), different types of foods (milk, juice, grapes, any food in the high glycemic index) will raise sugars to undesirable levels.  I still give them b/c I'm not going to neglect nutrition in terms of fruits or fiber foods for a fear of having high sugars.

5.  Readings with a minute:  Yep, that's actually what's going on in his body.  Children, especially those who are younger than puberty, are going to be fluxtuating dramatically.  From what I've researched, there is no clear link for children younger than puberty to have long term complications related to continuous highs.  However, we should try to reign it in.  The reason is that in their time before puberty their going to grow about 5 new pancreases and kidneys b/c they're growing.  

Keith, all you can do is do your best.  As long as he's eating nutritious meals, low saturated fat and exercising, it's going to be ok.  There was a time when I freaked out for a few days.  All you can do is do your best.  It's going to be ok!  I promise.  People who take care of themselves live to their 90's with diabetes and your son won't be any different if you're trying to figure his body out and work on the best ways to reign the sugars in.  

Hope this helps.

Ryan

~Blake's mom

18

Hi Keith -

For the most part - everyone has hit it on the head. Mastery of carb counting takes practice. To blunt the post-prandial spikes, giving insulin with a lag time is the most beneficial. When the rapid-acting analogues were releases, they were touted as being so fast-acting that one could even bolus or inject after a meal for good effect. This is true if compared with Regular insulin but not at all physiologic.

Along with insulin, beta cells secrete a 2nd hormone called amylin. This acts to stop the other part of the pancreas (alpha cells) from releasing glucagon. It also regulates the rate that food leaves the stomach and goes to the intestines. Glucagon goes to the liver to make it spit out more sugar. With type 1 diabetes, as our beta cells are obliterated, we not only lose the insulin but we lose the amylin as well. What does this mean? Without amylin, those of us with type 1 diabetes typically have a more rapid rate of absorption of glucose AND our liver paradoxically kicks out MORE sugar when we eat (its the opposite for those without diabetes). This causes the "biphasic" glucose response.

So, when your son eats, the food goes into his system more quickly, his liver kicks out more sugar, and he's relying on the insulin to blunt these effects. Insulin counters the effect of glucagon and cares for the glucose from the meal. However, contrary to the original claims, it takes much longer for the rapid acting analogues to take effect. In fact, after 1 hour, only 10% of the humalog has taken effect. And half of the insulin is active 2 1/2 hours after injection. The amount of time for all of the insulin to be metabolized varies  but the 3-4 hour rule is not entirely accurate. I think 4 hours is a good estimate for "insulin on board" because most of the insulin has had a chance to take effect.

A couple of suggestions:

- ask your son's doctor to devise a lag-time scale based on pre-meal blood sugar. For example, if he is 120 mg/dl before eating, he can wait 15 minutes. if he's 50 before eating, he can eat immediately and bolus post-prandial. If he's 300 .. .he'll have to wait longer.

- Practice carb counting. Buy 5 or 10 Calorie King booklets and have them handy for whenever he eats. He should give a bolus based on the amount of carbs he things he'll eat. If he eats more - then he can always add more insulin at that time.

- Combo boluses are great for Pizza. They aren't so great for most other things. Again, only 10% of the insulin has actually taken effect after 1 hour. The post-prandial high blood sugars are likely there because the timing of insulin is mismatched to the glucose and only part of it has even started working.

I hope this helps. Of course, you should consult your son's physician before making any changes to his regimen.

Hope that helps!