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.

Anatomy of a High Carb Breakfast

A step-by-step guide to how I managed a massive breakfast...

This image is here to help you to visualize what I am describing. Clicking on it will open a new page so you can refer back and forth.

Arden had a couple of friends sleep over last weekend and before they went to bed the girls asked if they could have french toast in the morning - I said, "sure!"

The meal consisted of:

• French toast with home made bread, eggs, milk & a sprinkle of powdered sugar
• Sliced Bananas
• Green Grapes
• Chocolate Milk
• No Carb Syrup
• Bacon

Let's start at the beginning...

Arden's BG was steady at 75-80 from midnight until three in the morning when I decided to do a thirty minute temp basal off (probably should have tried 50% decrease). I was woken at six in the morning when her Dexcom alarmed as it reached the high threshold of 160 (since changed to 130). I waited fifteen minutes before acting because I noticed that the line was beginning to trend down. Decided to do nothing (probably should have bolused). A little after seven I decided that this BG wasn't going to move (morning BGs are stubborn for Arden) on it's own and I began to try and nudge it down. I only used tiny boluses because I was trying to get her BG down, while also letting her sleep; all with an eye on being prepared to eat a high carb meal soon.

Ask yourself - Do I find morning BGs difficult to effect? Meaning, do they take more insulin and time then normal, to get moving?

Over the next hour and a half I used three small boluses (refer to image) to get Arden's BG moving, without it moving so fast that I may have to wake her prematurely. Her BG leveled off around 120 for a while. It began to drift down again as the girls appeared in the kitchen. It was time to get a portion of her pre-bolus going, but not too much. She was still dropping albeit slowly and I wasn't totally sure how long it would take for the meal to be completed. But French toast without a pre-bolus would not go well, so I started small (1 unit) with something that I could effect with the fresh fruit - if needed.

Food and Carb Counting - So I've got three girls to feed, a plate with a randomly sliced banana and a bowl of grapes as back-up (in case my pre-bolus gets wonky). Time to get cooking! I never specifically counted any of the carbs Arden would soon eat. I was sure that she would have some of the banana, probably a few grapes, lots of french toast - maybe with some powdered sugar. She was definitely going to drink the milk because we don't so chocolate milk very often, so that was looking like a treat. I made all of my insulin decisions based on my historical knowledge of how much Arden eats on average and what that amount generally requires in insulin. I was counting on her Dexcom CGM to tell me the rest of what I would need to know.

My definition of a successful Pre-Bolus - If Arden's BG is between 75 - 100 and falling when food consumption begins, I'm a happy pre-boluser. The girls threw a monkey wrench into my plans by asking for the fruit plate before I was planning to put it out - no matter, now I could bolus the balance of my intended initial insulin. I say initial because this meal was going to be a free-for-all and undoubtably require more insulin as it went on. The fruit and milk went on the table and I bolused again soon after, this time 4 units - again that amount was based on nothing but my feeling for what the meal, as it appeared so far, would require.
 

Feeding frenzy: Soon after the french toast hit Arden's fork her BG leveled off around 100, I knew then that an increased temp basal was in order. Why, you wonder? Five units is a good amount of insulin for Arden and the fact that it wasn't causing a fall in BG at this juncture indicated to me that the food was now pulling in the other direction and would soon overtake the bolus. I mean this is a lot of carbs. A combination of a heavy dose of simple sugars and more complex carbs. 

So I increased the temp basal, 95% for one hour. Not long after that Arden asked for seconds of french toast (it is good!), I bolused for what I believed the seconds would require, 2 units. That bolus brought the total to 7 units of bolus insulin and an .60 of additional basal. I was happy with where we were and ready to see what would happen next. Oh wait... the girls want one more banana sliced up. Would Arden take two slices of it? Would she have four? I couldn't be sure but as I was deciding, I saw her put a fork full of powdered sugar on her french toast and so a bolused 1 more unit.... based on nothing but my gut feeling. Arden's BG began to drift up past 120 about an hour after I set the first increased temp basal so I extended it for another thirty minutes.

The girls finished eating and went back upstairs to do what ever little girls do during a sleepover. Three hours after the meal began... Arden's BG was 97 mg/dl by finger stick.

I wish that I could tell you that I was a great carb counter or that we have a perfect insulin to carb ratio figured out. I could lie and tell you that we do a lot of basal testing, but that's not true (I've actually never done that once). It certainly wasn't a low carb approach that got us to 97 three hours after this breakfast.

So I'm assuming that you want to know how I did this?

• Pre-Bolus
• Proper Insulin use; timing and amounts
• I trusted myself and what I've learned from past experiences
• I relied on the Dexcom G5 to tell me where I went wrong
• I bumped and nudge BGs instead of over-reacting and climbing on the diabetes roller coaster
• I was bold with insulin!!!
• I made my decisions based on the singular idea that I would rather (because it is far easier) stop a falling BG with a juice box, then spend five hours fighting with a high BG

I want you to remember a few things. First, this isn't medical advice, second the amounts of insulin and it's timing is different for everyone so you can't copy what I did and think it work. Third, I didn't do anything special, I don't have some super diabetes secret that you don't have. Anyone can do this. I mean it. It takes a little bit of practice and some trial and error - of course, the Dexcom sure does make the entire process simpler. But I promise that you can do this too and just imagine how easy regular meals and snacks will be if you can do this with a high carb, sugar infested meal like the one I described here. Right?!

Last bit. You may be inclined to think that what I described was a lot of work or that it was insanely time consuming... it was not. It just seems like it when it's written out and explained in detail. This blog post is representative of a few minutes of my focus during this morning. Trust me, it's far simpler than it seems and incredibly less stressful than watching, chasing and feeling the guilt that a high BG could bring after food. 

You can do this too, I know that you can! Believing that is most of the battle!

If you are interested in following these thoughts further, I recommend listening to my podcast to hear these themes spoken about in real-life situations with people just like you. Best, Scott

You many also like:
Blog post: You Too Can Bolus for Chinese Take Out

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Giveaway: Sugar Surfing

'Sugar Surfing: How to Manage Type 1 Diabetes in a Modern World'

Giveaway!

Stephen Ponder, MD, FAAP, CDE is my guest on episode 45 of the Juicebox Podcast and he's giving away his book in celebration. Shipping physical books out of the US is expensive so in an effort to include everyone, Stephen is breaking up the giveaway by where you live.

The Sugar Surfing giveaway includes one paperback, (U.S. Residents only) and one eBook, (Non-U.S. Residents only). There are plenty of ways to enter and but be sure to chose the correct entry box below and good luck! 

After you enter you can listen to Stephen talk with me about his type 1 diabetes management ideas that you'll find in his book, your days with T1 will definitely be better if you do. I couldn't believe that our methods were so similar.

a Rafflecopter giveaway

a Rafflecopter giveaway

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Carb Wars: Going to the Movies with Type 1 Diabetes

Star Wars: The Force Awakens is breaking records at the box office in it's opening weekend. The film made 57 million dollars on Thursday and another 100 million on Friday and those numbers tell me that many of you will be in a theater something soon. 

Trying to bolus for food that is carb heavy, nutrition light...

So there I was this morning sitting in a theater waiting for Star Wars to begin (it was amazing by the way) when I began to think about all of you and I decided to compile carb counts for popular movie theaters and include them in this post. That however turned out to be more difficult than I originally envisioned.

Of the big five theater chains, the two largest, Regal and AMC don't not provide nutritional information for their concession stands. Cineplex has a fact sheet online that I'd call "better than nothing", Carmike has a simple webpage that lists the values of their popcorn and Cinemark includes a partial list on their website. The thing is... there is no consistency between the theater companies and no good way to estimate based on the limited information that is available.

Blog post interruptus... 

I wanted to provide at least a guideline to follow but from what I am seeing the variables between theater chains, package sizes, how full some theaters fill their bags and some significantly incomplete data; we're going to have to roll over guidelines and talk about strategy.

You're going to have to make some educated guesses. We could theorize that one nacho is between 2 and 2.5 carbs. I'd guess a pretzel bite to be about 4 carbs but that popcorn is just too wonky. How do you measure it? How many carbs, how much will they eat... ug. So here's what I'm going to do when we head back to the theater tomorrow afternoon so the family can see Star Wars, yea I went by myself today... what of it?

Arden has a Dexcom CGM so I'll be leaning on it heavily. I'll pre-bolus at least 15 minutes prior for food and try to time her food consumption with a diagonal down CGM arrow. From there I'll decide between either an increase temp basal or over estimating the carbs to combat effects of the crappy movie theater food. One way or the other I'd prefer to need to give a fast acting carb (Juicebox) for a low than watch Arden suffer with a high BG through the entire movie and beyond. When I estimate (guess) her carbs I won't only be taking my carb count into account, I'll also keep in mind the average amount of carbs Arden usually consumes at a sitting. For example if the food is 90 carbs but Arden usually doesn't eat more than 70 in a sitting; I'd probably pre-bolus for the conservative 70, set an increased basal (that I could always cancel if I need to) and watch the CGM for signs that it worked or didn't -- and then react appropriately. 

May the force be with you...

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Check out the Juicebox Podcast!

Having a Happy Thanksgiving with Insulin

What do you think about when I say the words mashed potatoes, stuffing or pumpkin pie?

Most people hear those words and think "mmmmmm, it must be Thanksgiving" but some of us immediately begin to wonder how many carbohydrates are in stuffing. Many of the people who live with or care for someone who lives with diabetes, begin to panic. Instead of family and football they begin to think about Thanksgiving as a day that is trying to defeat them, they immediately feel stress and either decide to, sort of just give up and "do their best" or search for the measuring cups focused on getting the carb counts of every tasty Thanksgiving treat exactly right. In my opinion; there is a better response.

When I'm giving my daughter Arden insulin at a meal I focus on two things - How insulin works in her body and about how many carbs are in the food she is eating. In an effort to keep this, if you'll pardon the pun, digestible... I'm going to break this post into individual thoughts on subjects.

Questions I ask myself before I begin...

Is it more important to know A. exactly how many carbs are in a scoop of potatoes or B. how long it takes for insulin to begin to effect the blood sugar and how long it lasts in the body? - Answer is B

Will the day include a lot of grazing, am I planning for set meal times or is it both?

Do I have a reasonable understanding of the amount of carbs in the foods that will be consumed?

Am I afraid of insulin? - Be honest with yourself

My Goals...

My blood glucose goals for Arden are simple, yours should be too...

I am trying to maintain the steadiest blood sugars as I possible can. I want to avoid spikes and significant lows.

I consider a BG over 150 (after food) a high blood sugar.

I do not want Arden's BG to fall below 75 but steady at that number is a huge win, especially today.

For CGM users: I don't want to see arrows pointing straight up or straight down. If I do, I've mistimed insulin, miscalculated carbs or (for pump users) would have benefited from extending my bolus. When we were non CGM users: If Arden's BG is above 150-160 forty-five minutes after your mealtime bolus, you probably didn't use enough insulin. More insulin, more testing.

I want to create a stress free, carefree and happy day without frying my brain.

Insulin...

I have two steadfast rules about managing my daughter's type 1 diabetes. Read them, memorize them, live by them. 

1. It is far easier to stop a low or falling blood glucose then it is to return a high blood sugar to a safe range. In my experience most low or falling BGs can be stopped and steadied in a short amount of time, maybe 15 minutes. A high BG can take 3 to 5 hours to return to a safe place. I'll say it again. It is easier to stop a fall or a low then it is to effect a high. This thought guides everything I do with insulin.

2. If Arden's BG is high any time after a meal (140-150), I did not use enough insulin at the correct time. Two VERY important considerations in this sentence, they are AMOUNT of insulin and the TIMING of the bolus relating to when food consumption begins.

Before we move on I want to say this, these are my rules but you know as well as I do that diabetes will, on some random day, act in no way like you expect. That is a fact of living with manmade insulin. I refuse however to allow the fear of that random day to make me except high BGs on all of the other days. I would rather battle a low a few times a month then live with a daily average BG that is any higher than it needs to be. Bold with insulin!

Lets talk about giving insulin for a meal...

There are generally one of three situations I experience before a meal. 1. A higher BG then I want, 2. A lower BG then I want, 3. A BG in our comfort range. All of these may be steady, rising or falling. 

Let’s have some examples:

Step one for each possible situation is to pre-plan. Don’t start thinking about insulin at 4:55 if dinner is at 5, if that’s what you are doing... I’m willing to bet you see a lot of high BGs after food.

If our dinner is at 5 pm, I want to find out what Arden's BG is at 4 pm. 

If Arden’s BG is 160 at 4 pm I would bolus for the 160 with the goal in mind of getting it as close to 90 as I could by 4:45 pm because (in this example) at 4:45 pm, I am bolusing for dinner. Here’s me counting carbs. Scoop of potatoes… eh 30. turkey 0, gravy, let’s call that 7, probably have two dinner rolls… I’ll call that 30, corn lets say 10, green veggies nothing. Okay that’s about 80, how much insulin is 80 carbs? Last thing I do is ask myself if the amount of insulin that 80 carbs indicates sounds like enough or too much? “Sounds like” means based on my past experiences with similar meals. If it doesn’t, I adjust it manually. One way or the other I’m hoping to have a 90 BG 15 minutes before the meal begins and I am bolusing with the thought that the mealtime insulin (In Arden) won’t begin to work for at least 15 minutes. The goal is for her BG to be 80ish when two things happen. 1. Her mealtime insulin begins to work and 2. The carbs from the food begin to have an effect on her BG. I want these things to happen at the same time when her BG is around 80. Then I watch the struggle between insulin and carbs play out on her Dexcom CGM. Most times this results in no spike and a steady BG for the next two hours. Adjustments (In Arden) may be needed around the two hour mark. More insulin, some carbs… one never quite knows.

A steady and in range BG gets the same pre bolus. Again, I want the struggle between the carbs and insulin (insulin pulling the BG down, carbs pulling it up) to happen as close to the 70-80 range as possible.

If Arden’s BG is low or falling an hour before dinner I only want to bump it ever so slightly. I don’t want it rising or high at 4:45. On the lower side is a great way to approach a meal - But you still have to pre bolus. I can’t say to myself, “her BG is 80 at 4:45 pm so I can’t pre bolus”. I have to trust the process, I have to trust that new insulin won’t cause a low for at least the amount of time that I believe it takes for the pre bolus insulin to begin working. 

In the end, I can count the amount of times on one hand that a meal has gone well without a significant and well timed pre bolus. Only you know how long it takes for insulin to begin working in you or your child, so adjust accordingly with great deference to how long it takes the food to begin to effect the BG. 

Remember, it is easier to effect a low than it is to correct a high....

I know there is a ton of other variables that I haven’t discussed. What if my child is too young to properly assume how much they will eat… in that situation I'd pre bolus half and then get the rest of the insulin in as soon as I could confirm that the food will be eaten. Easier with a pump sure, but even when you are injecting... it’s either two shots at dinner or one shot at dinner and another an hour later while you are battling a 300 BG. Which sounds better to you?

Arden has a CGM which makes all of this so much easier. I can see when she’s falling 5 minutes before we eat and hand her a roll. I can see the speed and direction that her BG is moving. No doubt what I am talking about is easier with a CGM but it is not impossible without one. Pre bolus (or inject), test 45 minutes later, test again 2 hours later. Stay on top of the BG.

Don’t fall prey to the drama! Don't ell yourself that, “I did what the endo told me” or “I counted the carbs, what else can I do”. That's all bull%$#&. You can do plenty with a positive attitude and a calm reaction to the things that don’t go as planned. Keep it easy in your mind; BG too high, need more insulin. Too low, need more carbs.

Is it a grazing day? Try using a temp basal rate. Perhaps an increase of (maybe) 30% to start, then adjust as needed. Don’t be afraid to let it run all day and don’t forget that the effects of a new basal rate may not be visible on a BG for 30 minutes to an hour. Also, when you stop a temp basal, it will take that much time to return to a level that you are accustom to.

I won’t let a BG that has gotten crazy high ruin Arden’s day... I crush it with insulin. Then test often or watch my CGM closely - sometimes both. If it falls too far or too fast, I catch the fall with a fast acting liquid carb. I give myself enough time to treat the fall without having to over treat - stay off the rollercoaster! Sometimes the hardest thing to do is to just wait and retest, I know, but that is how you will avoid chasing highs and lows all day. At some point you have to say to yourself, "we need to find a plateau and start over".

Last things and this is important. Lots of insulin is going to be used today. Watch your overnight BGs closely. Look for lows, unexpected falls and even high BGs from those carbs that just won’t digest and be gone. No telling which reality you’ll experience over night. Best to be on the look out. Give yourself a chance to battle on a level playing field, don't begin Thanksgiving with a pump site that is failing or on it's way out. Get your tech going and stable before the stuffing hits the table.

Wishing your family a very Happy Thanksgiving… don’t forget my disclaimer nothing you read here today is to be taken as advice, medical or otherwise. I’m just telling the story of how I manage my daughter’s BGs. Okay, thats enough diabetes talk for me today, I have to got make the stuffing!

Go kick some carbs right in their ass! You can do it...

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