Thursday, April 25, 2013

Tidbits and Tricks

Today's Prompt: Learning. Share something you learned from another Health Activist (that everyone should know!).

First of all, I am not a licensed medical professional. I'm not trained to give advice on anyone's diabetes but my own.

That being said, I want to share a revelation that I picked up online that changed the course of my diabetes. It changed my blood sugar spikes. It lowered my A1c. I credit this piece of advice more than any other in getting my body ready for pregnancy. It changed everything.

It matters when you take your insulin.

Online we call it pre-bolusing.

The last few years, continuous monitoring has taught medical professionals a lot about how insulin works in the body. When the newest fast-acting analogs came to market, we were told we could take them right on top of meals. When my doctor started me on Apidra just after it was approved by FDA, we thought it would help me because I usually bolused after meals and this insulin would supposedly accommodate that habit.

Fast-forward to the days of continuous monitoring.

We now know that the "fast" insulins are not as fast as we thought. When taken on top of (or worse, after, meals), Humalog/Novolog/Apidra miss the post-prandial (post-meal) spike entirely. They should be taken earlier. I won't give advice on how early, as I think it can vary from person to person, but I know how many minutes before the first bite of food works for me at most meals.

The pushback I get from most people when I suggest pre-bolusing involves one of the next two arguments: 1) But what if I go low before the meal? and 2) But who knows how much little Timmy will eat? It's easier to bolus afterward.

I'll address each of these valid concerns.

What if I go low before the meal? Again, insulin is not as fast as we thought. But if that's your concern, you have to consider where your pre-meal number is, whether it's dropping or not, and what you're eating. If my pre-meal number is 70, I might not take my insulin that early. If I'm at a restaurant and don't know when my food will arrive at the table, I might not take it that early. If I'm headed out to go pick up some food at the drive-thru and come home with it, I might not want to take the insulin early and then run into a road hazard that's beyond my control.

But when I'm in decent control of the situation - like I'm the one prepping the meal or opening the lunch pail - and my number is above a threshold that might make me nervous, I go ahead and take it early. By the time the insulin starts to work, the food I'm eating will peak, too.

And here was the mind-blowing part for me. Your highest BG at any point in the day is that post-prandial spike about an hour after the meal. If you've controlled that, you will see that A1c drop dramatically.

Now to the second point. You may not know how much of their meal a child will finish. My thoughts on this are that (a) even a little insulin on board ahead of time is preferable to all of it afterward. A child on a pump can have a small bolus - maybe just the correction, maybe just for what you know/assume they'll eat - and the rest after. And (b) that's how we used to do it, so maybe I'm biased.

When I was a kid on R insulin, I was supposed to take it 30 minutes before my meal. (Now they know that R should have been given 45-60 minutes ahead of time.) I remember every day of fifth grade, I had music class before lunch. My music teacher was very accommodating and, at a specified time, I was allowed to slip into her instrument closet and check my number and take my insulin. I was allowed to carry my syringes and lancets on me back then - no one complained. I carried it all in a little purse. No school nurse ever stood over me, but our school nurse was practically useless - she was good at passing out band-aids and that was about it.

Like I said, it was a different time. And I was an older child.

We had to know how much we were going to eat. We had to plan ahead. But we knew we had to take insulin beforehand.

I think the habit of taking insulin afterward has become the norm for three reasons. First, it's convenient. Second, it feels safer - especially for parents of CWD or for PWD who live alone. Third, we aren't told to do otherwise.

But if you're frustrated by your (or your kid's) A1c, consider asking your endo if there's any credibility to this claim. I asked my team and they were absolutely on board, so we went with it.

But I didn't learn it from my team. I learned it from health activists online. I learned it from Kristin and KellyR and countless others who now swear by it across the internet.

We share what works out here.

Like Code 18. Freestyle meters that still require codes and the older coding strips (Omnipod, Flash, Freedom, etc) instruct you to use Code 16 on the meters. Those of us out here in the wild have been concerned that Code 16 runs significantly lower than our lab results. Some parents I know are using Code 17. What do I use? Code 18. I heard about it from SarahK and Stacey. Code 18.

When I check it against the One Touch Verio IQ - which I've been using with great success and which tested within 10% of my plasma value, I'm tremendously satisfied with how the readings compare. So I've jumped in with this code and am not looking back.
But if I were to ask my team about it? Or the folks who make the device? The answer would be that I shouldn't be playing around with the company's recommendations.

Then again, they also tell us not to restart our CGM sensors. =P


  1. The lessons we learn from other PWD is invaluable! Licensing is necessary but that doesn't mean that's the only people who can teach you something about your D. Great post

  2. Us? Restart our CGM sensors!? *Gasp!* Nooooooo. LMBO! ;-) Code 18 FTW!

  3. Ahhh, I know I should be pre-bolusing, but it scares the crap out of me! I get such horrible anxiety that I will go low within SECONDS of bolusing that I chicken out. I know it's completely ridiculous (that's why it's called anxiety). It's a huge goal for me because I want to start trying to get pregnant next year and I have a long way to go (A1c wise). Thanks for the tips.

  4. i'm trying to understand this "code" thing. So if the code on the strips is 25, you don't put 25 in the meter and instead put 18?

    1. Landi, Freestyle developed non-coded strips called Freestyle Lite a few years back. Since the Cozmo, Omnipod, and Navigator weren't approved by FDA to use the new "non-coding" strips, Freestyle produces their new strip in the old packaging (a yellow box rather than the blue Lite box) as a coded strip with Code 16. Some of us believe it reads way too low and fiddled with the codes until we found one that read closer to other meters or our lab values - in my case, both.

    2. So are you using Freestyle Lite or the old Freestyle strips? I am using the old (original) Freestyle strips that I think come with a code.

  5. Another great post, Melissa! I'm working on pre-bolusing more often and agree that it seems to make a LOT of difference.

  6. Oh, how I wish I had a certain body part that isn't even available in my gender to pre-bolus. Now that delayed gastric emptying has reared its ugly little head again, my bolusing at all is all sorts of crazy town. (50g carb meal? When did you think it might hit your system? 1 hour? 3 hours? 6 hours? Place your bets now.) Hoping that it quiets back down soon, because I'm totally going to try it.

  7. A hearty HEAR HEAR to this post!!! For years, I bolused after meals. And then, because bolusing all at once often hurt or burned, I would combo bolus anything more than 4-5 units over the course of half an hour. So...the insulin wasn't getting into my system until at least an hour AFTER eating instead of 20 minutes before! Why don't more health professionals talk about this? I'm sure I had ghastly spikes because of that!