Delaying between bolus and food

[Subby]

Does anyone use this technique with the pump?

I used to have to delay up to 2 hours with actrapid shots. Not just to "come down" but also to attempt to stop a hike as the carbs hit my blood. (could be low GI, too)

My team has told me that delaying isn't used with the pump. Yet I have scenarios where I wonder if delaying wouldn't be effective to avoid spikes.

Example just now.

Had a good steady blood sugar the last 5 hours. Testing hourly, as I do sometimes. (between 6 and 7.2, going down if anything) No reason for it to co-incidentally hike now.

Carefully weighed a bowel of low GI muesli. Bolused correctly. Ate it.

at 30 minutes: 11 mml/l
at 1 hour: 10 mml/l

I can provide further tests but my point is, the spike may be:
#1 incorrect carb ratio
#2 good old variable IR I get (yep I got it bad)
#3 that the insulin just didn't get in quick enough

#4 would be incorrect basal influencing things, yes I am struggling with my complex basal but it is ballpark and this was a particular time of stability.

Should I be considering #3 as a factor, and delay accordingly? My health team thinks not. I decided not to fight them at the time on that. But I find it hard to see why not.

*I use mml/l, if anyone wants me to convert particular numbers please ask. After all it's in my interest to encourage your understanding :)

[Jan B]

Subby,

First, yes . . . I wait after bolusing if I'm higher than 110. I'm having a hard time taking advice from my health care people right now!

What is your bg 2 hours after eating? Even a non-diabetic will have higher bgs 1/2 hour and an hour after eating. For us, the two-hour mark is more important. If your 2-hour post prandial is still high, in my understanding, it could be your carb ratio, or even basal if you tend to go high in the mornings and your basal isn't also going up (that's my problem).

If my bg is higher than 125, for instance, I'll wait about 15 minutes after bolusing to eat. If it's higher, I'll wait a little longer.

Right now, I'm trying to follow the advice of my pump trainer, and it's driving me nuts!! I know my basal is not high enough after waking, but she told me to NOT correct any time except at meals, unless it was up to 250. She's trying to pin down what/when my basals should change. Thank God, I only have to do this one more day. I'm feeling very rebellious -- right now I'm at 175 and getting very antsy. I'd been running 80-100 and feeling great. I don't feel well now at all! But, a couple weeks ago, I wasn't noticing lows until at 60 or lower . . . sometimes even 45 before realizing I was low, even in the daytime.

[Subby]

Hi Jan. Yes, I tested at two hours, I was just too impatient to wait to post it!

so:
before: 6
30 min: 11
1 hour: 10
2 hour: 9

So it seemed to start being affective and held with a gentle curve down - but slipped up too high first. To me it seems like it may have been the right dose - but delivered too late.

By slipped too high I mean a 5 mml/l (90 mg/dl) jump. I want to aim for a reasonable 2 or 3 mml/l post prandial jump instead to keep things under control. I get major physical and mental effects once I get past 10 mm/l (180). Once I get to 13 or 14 mml/l it's all over for hours. I get increasing insulin resistance from that point on. And my day is stuffed.

My carb ratio is tricky to change, because it is already 6. With such low numbers a whole number change (which my pump does) is very substantial compared to those with more typical higher ratios. I've tried going down to 5 but hypos do start occuring generally.

It's also important to note that at some times I get very little spike even after a high carb meal. Sadly my basal, and my whacko insulin resistance curve through the day, are still not as accounted for as I would like, to see if these are affecting things. I am about to embark on basal refinement too via some of the forms I found here. They seem much more promising than the half baked guessing my doctors did. (I ended up just going my own way with experimenting with skipped meals etc, but it will be good to try some of those protocols).

I hear you about impatience and uncertainty. Can't comment on your educator's approach! Keep thinking about it though. Good luck with it.

[RLK]

Does anyone use this technique with the pump?

I used to have to delay up to 2 hours with actrapid shots. Not just to "come down" but also to attempt to stop a hike as the carbs hit my blood. (could be low GI, too)

My team has told me that delaying isn't used with the pump. Yet I have scenarios where I wonder if delaying wouldn't be effective to avoid spikes.


All the time! Even the fast-acting insulins (Novorapid/Novolog, for example) can take anywhere from 15 minutes or more to begin working, and even longer to hit their peak action. In my experience, Novolog takes a good 30 minutes to begin affecting my BG and really works its hardest between 1 and 2 hours for me. So I will routinely "pre-bolus" by 15-30 minutes, especially for sugary, high GI foods. Same deal with corrections before meals- "double team" that high BG with the correction bolus and the meal bolus, and then delay eating until the BG has dropped some.

There's a lot of pumpers on DF who are using this technique- I learned about it here first!- so I wouldn't believe your healthcare team in this particular instance. If it works for you, and you know how your body reacts to this technique, go for it!

[xMenace]

I listen to my team, but I make my own decisions.

Eggsellent article: Insulin pump - Wikipedia, the free encyclopedia (http://en.wikipedia.org/wiki/Insulin_pump#Bolus_Timing)

Spuer bolus: http://www.diabetesforums.com/forum/pumping-insulin/25508-super-bolus.html

I try to always bolus early. I can't get my am pp's down without it. It's the most effective treatment IMO. Other things that help are higher GI, lower carb quantities, and super bolusing.

[Alice]

The advice you were given is typical of "trainers" and "educators" who have never taken insulin or managed numbers...high or low. Do what works for you.

More than anything, I split my bolus for meals...usually anything more than 60 carbs and slow acting carbs.

[Subby]

Thanks for the replies. Yes I will indeed start to experiment with this, who knows why my educator was so insistent about not doing this but it managed to blind-side me (hmm, I suppose I get psychologically attracted to occasional bits of certainty to help simplify matters, amongst the confusion and variables. Ha!).

The superbolus looks promising too, thanks for pointing that out.

Would you believe I meant "Novorapid shots" rather than "Actrapid shots" when I mentioned previously delaying my injection shots? I used Actrapid for about 10 years, but switched to Novorapid 6 years ago! Every now and then I slip back to saying Actrapid, I think I have a whole section of my brain devoted to the word.

[Alice]

One caution (ask me how I know!) is forgetting to eat...within a reasonable amount of time. Sometimes I will lose track of time to only go low very soon after my "delay"...

I think most doctors/educators want to make sure you have food in your system when taking a bolus. They know that sooner or later, the insulin will lower your numbers.

I find we get impatient for the drop in our quest for "perfect numbers"...you don't have to be so perfect that you are bottoming out needlessly. That stuff will bring you down whether you eat now or later.

[Subby]

Yes I'm sure you are right about all three issues. In my current case though, I am looking not for perfect numbers, just trying to work towards a body and mind that doesn't get battered by blood sugar spikes multiple times daily. For small things like being well enough to keep working for a living and perhaps just feel healthy enough to enjoy life a little now and then :)

Incidentally the pump has already provided much improvement in the couple months I've been on it. The difference in evenness of blood sugars was immediately HUGE from day 1. I don't know about my A1c yet (about time to do my first post pump A1c actually), in some ways at this stage I dont care. For after 16 years of managing extremely brittle diabetes that knocked me around from hour to hour to have a little predictability is just like relaxing in sunshine at the moment.

But still there is some way to go. :)

[Subby]

I wish my pump had just a plain old easy to use alarm system, for many things and here is yet another example, rack up a 20 min alarm to remind to eat after a delayed bolus!

You can set alarms with it by burrowing through menus, but it could hardly be called user friendly or convenient at all.

I also wish it has BOB displayed on the main screen or the status screen. Always dialing up a false bolus to get to see what insulin I have on board.

Ah well.

[xMenace]

I wish my pump had just a plain old easy to use alarm system, for many things and here is yet another example, rack up a 20 min alarm to remind to eat after a delayed bolus!

You can set alarms with it by burrowing through menus, but it could hardly be called user friendly or convenient at all.

I also wish it has BOB displayed on the main screen or the status screen. Always dialing up a false bolus to get to see what insulin I have on board.

Ah well.

I oftern use my stove alarm because it's simple and loud or my cell phone alarm away from the house or if wifey's using it..

[xMenace]

I don't know if it was mentioned, but I will often pre-bolus a partial amount if I am in doubt. The amount would be proportional to my confidence in my expected carbs.

[RLK]

I wish my pump had just a plain old easy to use alarm system, for many things and here is yet another example, rack up a 20 min alarm to remind to eat after a delayed bolus!

You can set alarms with it by burrowing through menus, but it could hardly be called user friendly or convenient at all.



Funny you mention this....I had this exact same discussion with my Medtronic sales rep a few months ago. She seemed to think that no one would use it, and shot my idea down cold....if only she knew the truth.

You're right- the alarms are handy, but difficult to get to. I want a timer that's at one of the top-level screens.

[Subby]

Easy to access Alarms (and just as if not more importantly in this case - countdown alarms, or timers, the simple egg timer affect) go hand in hand with improved pumping in my humble view. At the moment my phone can act as a timer, but it would be significant to simplify things and remove extraneous dependencies. Don't have a gadget to do alarms well. Don't want a watch because I find them very annoying and uncomfortable.

The alarms are for me virtually unusable. For a start you can't have a once occurance which would be most of my alarms. Instead they are on until you burrow through and paistakingly turn them off or turn the feature off. It's especially great if you alarm for a night test one night, then keep getting woken for days later becuase you forget to turn them off or are too tired to cope with the menus at that time. Ugh!

As something you live with so intimitely, these little useful details really would be boons, and I think time management is central to pumping (it's not feature creep). This kind if thing will probably become more important as pumps become more accessible and changeable. Therefore I imagine they will have to compete in usability and feature stakes more, and lets hope they will increasingly listen to usability ideas more receptively than you found with that rep!

Ooo.. waffly post :)

[Cyborg]

Unless I'm near hypo or taking Symlin, I almost always pre-bolus. Does wonders on those post meal bg spikes. Just make sure you know exactly what you are going to eat and that you don't wait too long...

[pegasus]

This is one I'll have to wrestle with too; I used to do it a lot when still using Novolog (was *so* glad when BD came out w/half-unit syringes!). As inconvenient as it is, I'm grateful to have any kind of alarm this close. I've wanted to have one for a long time to test at 2 hours, because my work involves a lot of reading and I get totally absorbed. So this has been great--but I can see how having it more available would be handy.

The feature I'd like to see is a history of temp basals. I like the feature, and I suspect that if I find myself using it too often, that there's something wrong w/my preset basal, but I have to make certain I record it, because it disappears once the time's up. And with everything else to record ...

[Subby]

Yes, temp basal history, FANTASTIC idea. Are you listening, pump reps?

I really like the alarms you set at the end of the bolus process. They work great for post meal tests etc. But it's other times not at the end of a bolus when you think "ok, I want to set a timer alarm for 30 minutes to remind me of... dose/food/whatever...." and you have no remotely easy way to do that. listening, pump reps? :)

(Actually, I wonder if the temp basal comes up in the software records... will have to check)

[pegasus]

Let me know if it does. I don't use software (I'm assuming you mean the computer-recorded datat that's sent by USB?) yet; still working on the basics ~)

Thanks!

[Xonelith]

I don't post here often (mebbe 2 years?), but I'm curious, what pump are you using and what insulin? I have never pre-bolus'd. In fact, all of my bolus's are at least a 15min extended.

Cozmo pump with Novorapid insulin.

[Subby]

Hi Xonelith,

I am using a paradigm 722 with Novorapid. With the Quicksets I probably needed to pre-bolus between 40 to 90 minutes. Now I have moved to silhouettes I am getting much better results with 20 - 40 minute before meal, depending on where my sugars are at the start of course.

Not sure I can see the pump being a factor - I have always been sluggish to respond to insulin, Actrapid, Novorapid, injection or pump. The pump is faster but by no means negates the need for me to pre-bolus, contrary to my educator's claims.

[MarieD]

I have a particular problem spiking two hours after my lunch going up from a good 4/5mml reading to between 13-16mml at two hours after. The by evening meal time I'm back down at 4/5mml or hypo.
I've tried having my bolus up to 30mins pre-lunch but this does not have any effect on my 2 hour after meal reading. I've also tried increasing my carb ratio but this has no effect either, only hypos late afternoon.
Other meal times everything is fine. My nurse says that she has not met this before and asked me as to what I suggest to try now...
So from tomorrow I'm going to decrease my carb ratio and put up my basal for a couple of hours pre-lunchtime and see what happens. Maybe this would be something you could try too?

[w5wjp]

Hi Jan. Yes, I tested at two hours, I was just too impatient to wait to post it!

so:
before: 6
30 min: 11
1 hour: 10
2 hour: 9


That curve looks reasonably normal. Even non-D's will show a spike 1/2 to 1 hour after eating.