[fenagle]

I am stuck and need your help!!!! My doc is only so so about giving me guidance.

My post meal BGs almost always run high. Before I eat I may be at 108, I then bolus for the carbs I am going to eat. 2 hours later I may be at 180-200. 2 hours later I may be at 100 or definitely back within my target range.

It really doesn't matter what I eat. It still goes up a bunch. I do notice that if I eat pasta or any meal with high carbs it seems worse.

I have only done over night basal testing and only increase 9 mg/dl.

Any thoughts or input of any kind will be greatly appreciated.

Thanks

[Subby]

Pre bolusing may well be your answer. I am suprised your doctor didn't suggest it, it's a very common concept.

Basically, take your bolus and then wait a certain amount of time before eating. This has the effect of giving your insulin a headstart on the carbs. If your insulin is closer to it's peak when the carbs hit your system, the spike should be relatively minimised.

Pretty simple huh? My control would have been through the roof after meals for 15 years without this simple tactic. You may need to experiment with the lead in time - usually it's a set few minutes you can count on, for example 5 minutes or 20 minutes. Half an hour is probably at the outside for common usage, but I have had times when prebolusing up to 80 mins has been useful for my situation.

Of course, be careful not to take a shot and then forget to eat. Use an alarm of sime kind if you are forgetful. Also I recommend taking lots of tests, half hourly or even 15 minutes apart, while sorting out what kind of pause you should be using. Bear in mind too that your dosage may just need reducing if you better match the profile of the carbs and don't go so high. At the moment its possible you use slightly too much to compensate for that spike.

[fenagle]

Thanks Subby, I have tried that but not as a suggestion from my doc. It was from someone on another forum.

I have only tried that for breakfast. I always have cereal, Cheerios, for breakfast. I eat at 5:30 AM and have tried bolusing as early as 5:00. This did not seem to work. For a while I even changed to 3 eggs, nothing else. I would spike but not quite as high but 1-2 hours later I am back in the normal range.

This happens less with lunch than it does with breakfast and supper. I am wondering if I need to change my I:C ratio for those two meals. I am just afraid of lows.

Again, thanks for the thought.

[fgummett]

First job is to get the basal rate(s) working for you - there are threads here on basal testing.

Next suggestion is to reduce your use of carbohydrates (pasta and cheerios for example) - higher fat and protein meals will lead to fewer peaks and troughs in your BG levels... less need for bolus with likely changes to your basal; but overall more stable and manageable BGs

[Subby]

Originally Posted by fenagle

Thanks Subby, I have tried that but not as a suggestion from my doc. It was from someone on another forum.

I have only tried that for breakfast. I always have cereal, Cheerios, for breakfast. I eat at 5:30 AM and have tried bolusing as early as 5:00. This did not seem to work. For a while I even changed to 3 eggs, nothing else. I would spike but not quite as high but 1-2 hours later I am back in the normal range.

Lets stick with the prebolusing for a moment then move on. I often find it useful to go to extremes to illustrate the potential of something. So the two logical extremes of prebolusing are:

1. No prebolusing. Maximum spike from carbs. Result>High
2. Huge prebolusing (lets say no meal for 4 hours). Maximum effectiveness of insulin possible>Result>Low ASAP

The question is, what time period is it between 1 and 2 where you get a match in carb and insulin profile. You've already answered, not at 30 minutes. But can you see that logic dictates that if you try longer periods you have to at some stage be going low from the insulin action. The ideal prebolus is obviously some point before this. Whether the actual period required is practical or not is another (important) question.

I just wanted to put that in because whether prebolusing is the be all and end all for your issue or not, some prebolusing is likely to be helpful no matter what else you use to minimise the issue, considering that insulin action delay appears to be a big factor, and prebolusing will always give the insulin a head start .

I always have cereal, Cheerios, for breakfast.

Hate to say it, but I and many diabetics simply have "problem" foods. Cheerios may be one of yours. I'd suggest you try something different, preferably less processed (wholegrain, low GI, just try some options). Lower carb is worth experimenting with. To say again, there is absolutely no guarantee that you will be able to find a suitable resolution with Cheerios in the picture.

Now lets talk a bit about what might be happening. You could be getting insulin resistance in the early morning. I know I do. This means that insulin takes longer to work and may be less effective. When it comes to food/boluses the best way to deal with this is to try and not demand too much of the system. (And again prebolusing may help). Which again suggests a lower carb option as Frank mentions. Smaller amounts (insulin, food) = smaller problems. As you found out with the eggs.

But the first thing really: highly recommended you do basal testing through the morning to find out if there are background issues going on, especially ones that might be correlating with your mealtime (and confusing the picture).

This happens less with lunch than it does with breakfast and supper. I am wondering if I need to change my I:C ratio for those two meals. I am just afraid of lows.

Hmm... well I won't beat a dead horse. Prebolusing could be the perfect tool to reduce the spike without lows, especially for these less resistant times but if you feel you've exhausted the idea from trying it in the morning - I'll just shrug my shoulders.

Also remember that for the vast majority of diabetics some upward movement after meals is to be completely expected. A very very rough guide is that 30 - 40 mg/dl might be expected. But hopefully not more than 50 mg/dl.

This is because we just can't expect things to match up perfectly, and that this rise reflects the dynamics going on but should not cause problems.

Again, thanks for the thought.

Don't mention it.

[fgummett]

As Subby mentioned: it is not at all surprising to need different basal rates and different Insulin:Carb ratios through the day... for example, I use twice as much basal insulin around the waking hours as I do for the rest of the day.

[JJM335]

Frank:

+ 1 to Subby's suggestion of pre-bolusing.

Also, which insulin are you using in your pump? I also have problems with post-meal spikes and I found that switching from Novorapid (Novolog in the US) to Apidra made a big difference. Many people seem to find that Apidra cuts in significantly faster than Novorapid and also has a shorter duration of action. This means that you get more insulin action in the first couple of hours, and none after 4 h (perfect for dealing with Cheerios).

You might want to discuss a trial of Apidra with your Doctor. It certainly cannot do any harm to give it a try.

Joel