Pre-Bolus

Original art by Mike Lawson - Check out Mike's YouTube page by clicking on the image

This story begins in 2006 just moments after I asked Arden's nurse practitioner if she was "nuts".

NP: <blank stare>

Me: <incredulous gaze>

Only moments before our staring contest began Arden's NP became the first person to suggest that I give Arden her mealtime insulin before she started to eat. I can't be sure if she referred to the practice as pre-bolusing, probably not as we were MDI, but she definitely wanted me to inject before Arden ate.

"Are you nuts?"

I responded emphatically that I could never give Arden insulin before she ate. Arden was two years old and there was no way to be certain of how much food that she would finish. The NP repeated her very reasonable request but I could not wrap my head around this new idea. Pre-Bolusing, bah, Arden would be safer if I left her alone at the mall with money pinned to her shirt.

I was 100% correct on that day. There was absolutely no way to be sure of Arden's appetite. However the inability to guess how much she would eat wasn't the only reason I didn't want to inject before meals. Arden weighed maybe nineteen pounds at the time and Novolog had a way of peaking intensely in her body. She had already experienced a seizure from an insulin miscalculation that I made. That mistakes lesson was still very fresh in my mind and with that bad memory still looming over me, I just couldn't bring myself to administer insulin that wasn't already covered by food or a high BG.

Of course everything that the NP said made total sense. I wanted to give Arden's insulin a head start, I dreamt of a moment when her food would begin to expel it's carbohydrates just as the insulin was pulling her BG lower. I could picture that perfect image in my mind, a tug-of-war with food on one side and insulin on the other. Both combatants pulling furiously without once moving the rope that is Arden's blood glucose value - the dream of a steady mealtime BG. I wanted very much for that to be our reality and so I promised myself that I would make the adjustment when the time was right.

Fear and poor timing stopped me from taking the NP's advice all those years ago. Eventually the day came when I found my footing with the idea and gave up on being scared... that's the day Arden's A1c began to decrease.

We haven't looked back.

The beginning of our trip down the road to pre-bolus freedom was littered with pot holes. The first bump took some time to traverse, we first had to wait until Arden was old enough to give thoughtful consideration to her hunger. After that hurdle was cleared we took the first step, bolusing ten minutes before a meal. Those next ten minutes were the most tense of my day, I would test and worry so much after the bolus that I barely had time to finish cooking. Initial results were less than stunning so I moved the pre-bolus to fifteen minutes before a meal. The extra five minutes increased the impact of the insulin and lessened Arden's post meal spikes, but I still wasn't seeing a huge return on our efforts. I wanted to take the process to another level but I couldn't, in good conscience, give Arden insulin farther from the beginning of her meal. If only I could see the insulin work, I needed a crystal ball...

... or a DexCom CGM

Arden's CGM turned pre-bolusing into the most valuable weapon in our arsenal. It's one thing to have a good idea of how long it takes insulin to begin working in the body. But when you are able to not only witness the movement of the BG, but also the speed with which your glucose level is rising or falling... it's the difference between rumor and fact... between guessing and knowing with reasonable certainty. The day that my eyes were opened to the benefits of wearing a CGM, that was the day that everything changed.

Arden was 149 before dinner last week. I bolused for the elevated BG and pre-bolused for 50 carbs, it was a significant amount of insulin for her. Before DexCom I would have panicked and served the food in less then ten minutes. Now I take my time finishing dinner while Arden and Cole do their homework and leisurely prepare their plates as I wait for the CGM to tell me when to serve.

I put dinner on the table when the arrow on Arden's DexCom G4 turned south, waiting until her BG was below 110. The amount of time between Arden's bolus and her BG decline can vary most days depending on a number of factors. Glucose monitoring grants the flexibility to wait, providing a level playing field for the insulin and those scrappy carbs to wage their battle on.

At least now it's a fair fight.

Don't forget what the bottom of the site says... Always consult your doctor before making changes to your health care. I am not a doctor.

More about the art: The art work displayed at the top of this post is an original piece from Mr. Mike Lawson. Mike is a tireless advocate for people with diabetes, a friend and extremely talented artist. You can find him working at TUdiabetes, on Twitter and through his fantastic YouTube channel.

Insulin to Carb Ratio

It doesn't matter if you infuse insulin with a pump or inject, you probably know how many units of insulin covers one carb. We use multiple Insulin to Carb Ratios (IC Ratio), in the morning Arden's IC is 1 to 16. One unit of insulin, for every sixteen carbs consumed. Her lunch, dinner and evening ratios are all slightly different. 

Two weeks ago Arden began experiencing unusual BG spikes after lunch, I'm happy that this happened, not because I want to see her BG high but because the anomaly caused me to draw a mental line between these new lunch spikes and a similar spike that I see too frequently after dinner. Post dinner spikes have been an ongoing issue for us this year. I was certain that they were happening due to bad carb counting but this new situation jarred something loose in my head and allowed me to see the problem from a different perspective.

I had become lulled into a false sense of calm by consistently good BGs from other times of day. Those triumphs clouded my ability to see simple issues that caused BG spikes, spikes that shouldn't have been difficult to diagnose. I made a mistake, focusing too much on the food in the equation and ignoring the insulin.

Diabetes: "Knock, Knock..."

Me: ("I'm just going to ignore that and see if he leaves")

I wonder now if I didn't subconsciously just need a break, maybe I didn't have enough energy to tackle another diabetes riddle. Whatever the reason, I figured it all out the other day... the answer ended up being so simple that I'm now annoying myself by retelling the story. 

Arden's insulin to carb ratios needed to be changed, one quick adjustment is all it took. I'm still fine tuning the dinner number and the breakfast ratio needs a little help from a temp basal but her BGs haven't been going above about 160 (CGM) after lunch or dinner since I made the adjustments. Everything has been so quiet around here for the last few days. No crazy highs, no panic inducing lows... it's almost too quiet, but I'll happily take that calm for as long as it lasts.

I'll be writing more this week about other simple adjustments that make a huge difference. Don't be afraid to make small changes, you can always put them back if they don't do what you expected. Please remember to record the old numbers before you make any changes in your pump.

Don't forget what the bottom of the site says... Always consult your doctor before making changes to your health care. I am not a doctor.

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!

Why does basketball make Arden's BG rise?

Arden brings the ball down the court, passes and looks for a rebound.

Last week during Arden's quarterly Endo appointment I brought up an issue that I had identified but couldn't figure out. I explained to our nurse practitioner that when Arden exercises her BG falls. Riding a bike, running around, recess at school, really all of the her physical activities decrease her BG... except sports.

I, of course, am aware that activity can cause a decline in BG but our issue didn't seem to be following that "rule". It took me a while to be able to see past the expectation that physical exertion would decrease Arden's blood glucose level. Inexplicably, I was having trouble with her BGs actually going up during basketball games and practices this winter. When I finally thought back, I realized that I saw similar BG trends last summer during softball.

Our NP asked about Arden's level of competitiveness, as she spoke I began to understand what she was getting at...

Arden is a very competitive little girl, when it counts. That is to say that if she goes out back with her brother to shoot baskets her BG falls from the activity as you may expect but when she is in a game, when there is a score being kept and winners and losers are recorded - Arden's BGs go up.

I explained to our NP that Arden entered her last basketball game with a BG of 125 and that by the end of the game, just one hour later with no food or carbs in her system, her BG was 220 and climbing. I was bolusing during the game, which was nerve wracking when you consider that the expectation is that there will be a fall from the activity.

The NP described to me that this is a phenomenon that they generally see with boys, then she turned to Arden and said, "so, you like to win huh?". Apparently it's common for very competitive people to access their flight or flight response (also known as 'the stress response') during a sporting competition. Their desire to win is so strong that they feel the game on a different level. Adrenaline is released and their body prepare to battle as if they are fighting for their lives.

Next week when we arrived at the gym. I am going bolus as if Arden was about to consume a 15 carb juice box (the ones we use for low BGs). I'm confident that the insulin begins to act it will find a rising BG to tussle with, if I'm wrong... we'll just drink the juice. I'll report back and let you know what happens... Never a dull moment with type I diabetes.

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.