Conflict of Interest?
I am often frustrated by the absorption times of the insulins we use these days.
Don't get me wrong! They are much faster than what we had back when Regular was the best tool for the job.
Back then we were told to take our insulin something like 30 - 40 minutes before we started eating. Talk about impossible!! I don't know about you - but I simply could not follow that rule, and accepted settling for just getting it into my system as soon as possible.
Now that I'm using Humalog, the "lead time" is much, much easier to follow. But it's still something like 10 - 15 minutes right?
There are many times that I dish up a meal, carefully counting all of the carbohydrates, and punching the information into my pump and allowing it to calculate my insulin delivery down to 0.01 units accuracy.
I'll do my best to get the bolus in my system and working ahead of my meal - but I'm still not very good at it. When I start splitting things up (bolus, wait, eat), I'm just begging to screw something up (getting sidetracked after taking my insulin or something like that).
Once I start delivering my insulin, I have a five minute window for which I can stop the delivery (assuming I am using a standard bolus, rather than an extended or combination).
But what do you do when you have reached the point of being content with what you have eaten, and you still have a bunch of food on your plate?
What do you do when you've bolused for 65g carbs, but have only eaten 25 or 30?
You have kind of put yourself in a shitty spot - but you were only trying to do what you've been told you are supposed to do!
There are a few approaches you can take to this scenario, but none of them are really ideal.
1. You can bolus for your food as you eat it, or shortly after eating it. The problem with this approach is the timing of the absorption. The carbs you are eating will spike your BG faster than the insulin you are taking can counter that spike.
2. You can stuff your content stomach to the point of being uncomfortably full, because you bolused for more carbs than it took to satisfy you. This just plain sucks. Having to eat when you don't want to is just crappy.
3. Work to balance meals to satisfy you, but with a much lower total number of carbs. Hmmm. Now this one has a lot of potential - but I'm not there yet. The idea behind this is that designing a meal to satisfy you with fewer carbs, your potential risk is not very great. It's much easier to cover 20g of carb bolus than it is to cover 40g or 60g of carb bolus. Even if you don't want to, you can pretty easily find something you can get down that has 20g of carbs.
The point I'm after here, is that to stop eating when you are no longer hungry, and to pre-bolus in time for the insulin absorption and digestion curve to match up, is a conflict of interest.
I don't much like conflicts of interest. They make life a little too confusing and complicated. I'm a simple guy - I don't do confusing and complicated well.
I manage to pull it off somehow, most of the time, but that doesn't mean I like it, and that doesn't mean I do it well. There's a lot of room for improvement with this one for me.
Don't get me wrong! They are much faster than what we had back when Regular was the best tool for the job.
Back then we were told to take our insulin something like 30 - 40 minutes before we started eating. Talk about impossible!! I don't know about you - but I simply could not follow that rule, and accepted settling for just getting it into my system as soon as possible.
Now that I'm using Humalog, the "lead time" is much, much easier to follow. But it's still something like 10 - 15 minutes right?
There are many times that I dish up a meal, carefully counting all of the carbohydrates, and punching the information into my pump and allowing it to calculate my insulin delivery down to 0.01 units accuracy.
I'll do my best to get the bolus in my system and working ahead of my meal - but I'm still not very good at it. When I start splitting things up (bolus, wait, eat), I'm just begging to screw something up (getting sidetracked after taking my insulin or something like that).
Once I start delivering my insulin, I have a five minute window for which I can stop the delivery (assuming I am using a standard bolus, rather than an extended or combination).
But what do you do when you have reached the point of being content with what you have eaten, and you still have a bunch of food on your plate?
What do you do when you've bolused for 65g carbs, but have only eaten 25 or 30?
You have kind of put yourself in a shitty spot - but you were only trying to do what you've been told you are supposed to do!
There are a few approaches you can take to this scenario, but none of them are really ideal.
1. You can bolus for your food as you eat it, or shortly after eating it. The problem with this approach is the timing of the absorption. The carbs you are eating will spike your BG faster than the insulin you are taking can counter that spike.
2. You can stuff your content stomach to the point of being uncomfortably full, because you bolused for more carbs than it took to satisfy you. This just plain sucks. Having to eat when you don't want to is just crappy.
3. Work to balance meals to satisfy you, but with a much lower total number of carbs. Hmmm. Now this one has a lot of potential - but I'm not there yet. The idea behind this is that designing a meal to satisfy you with fewer carbs, your potential risk is not very great. It's much easier to cover 20g of carb bolus than it is to cover 40g or 60g of carb bolus. Even if you don't want to, you can pretty easily find something you can get down that has 20g of carbs.
The point I'm after here, is that to stop eating when you are no longer hungry, and to pre-bolus in time for the insulin absorption and digestion curve to match up, is a conflict of interest.
I don't much like conflicts of interest. They make life a little too confusing and complicated. I'm a simple guy - I don't do confusing and complicated well.
I manage to pull it off somehow, most of the time, but that doesn't mean I like it, and that doesn't mean I do it well. There's a lot of room for improvement with this one for me.
posted by Scott K. Johnson | 8:32 AM
9 Comments:
Scott,
In this situation, symlin would help GREATLY! I take my symlin about 10-15 minutes before I eat, eat what I can, and then depending on which meal Im eating I take my insulin based on what Ive already eaten. I NEVER take my insulin before I eat because that would result, invariably, in a low. Symlin slows down the absorption of your food quite a bit, you don’t want the insulin to be ahead of the food! Ive actually stopped taking symlin for meals other than breakfast and lunch. I seem to have much slower food digestion in the evenings, even without the symlin, and with much of my food finalizing digestion at my bedtime (I go to bed around nine pm, I know, Im so boring!), I end up with weird highs which it is hard to determine if they are highs from my night time snack or from my dinner finally finishing digestion. I HATE not knowing what my sugars are doing right before I sleep so I decided no more symlin at night. And I can eat all my high carb stuff during the day if I’m so inclined to do so and avoid the spikes because of the symlin and resultant SUPER slow food absorption. Even without the symlin I have to do my boluses at night on a 1 hour square. That is much easier than a 2.5 hour square, though.
I have an incredibly fast response to Humalog (and I did to Regular also) so I actually have to take my dose 20-30 minutes after I begin eating. And within that timeframe I usually have a reasonable idea of where my "satisfied" level will be. I guess I'm really lucky in that respect.
I agree with Sarah that digestion and absorption rates vary within the times of day and one's individual biorhythms.
Scott, you are just putting out so many useful questions and getting back so many helpful responses.
hmm, How would bolusing for half your meal pre-eating and the rest after you've decided you're full work? I haven't messed around with checking blood sugars near or close to eating, so I don't know if that would help the spike or not be enough. Just a thought.
Hmm...I know what you mean. I can't tell you for how many meals I bolused at the end, letting myself go a little high until it kicked in.
Since you pump, you could try a combo/square bolus with half upfront and then just cancel the back half at some point it if you decided not to eat it all...or maybe try using a temp basal rate of 0 for a long enough period to make up the difference.
I have tried Symlin as well. In theory, you take Symlin after the meal and everything is hunkydory. It works for some people, but not me.
When I have a meal, I give myself 2 units about 10 minutes before the meal, and correct up to what I actually ate right after the meal. It works pretty well, and 2 units for me is 20g of carb, so I am always confident that I can at least drink that much extra juice if I don't eat the carbs.
The wait time is a problem, though. And i think that the next generation of pumps should definitely come with an "Undo" button. ;)
Interesting food for thought scott.. (pun intended ) I often at 2 or 3 carbs for cream in my coffee but never thought of the caffine part .. I am gonna look into this more
I've also got a quick response to Novolog(take it 20-30 minutes post meal).Symlin worked great for me(when I tried it), but my insurance company has stopped covering it.
It might be worth it to try..for me, it didn't matter what I ate, post meals were absolutely amazing on that stuff.
Hi Scott,
Thanks for all your comments and I especially agree with the last one about how everyone responds differently. We can be complicated and diabetes is definitely complicated. Good thing there are people like you who are a real inspiration, especially for those of us new to the game. The wealth of knowledge and experience emanates from your blog.
Your fellow carb junkie,
Kathy
Scott,
I have a love/hate relationship with my carbs; I'm not willing/ready to cut them way down aka Dr. Bernstein.
I think I can live with ingesting less carbs, and it seems that I have better luck myself with about 50 grams at one sitting, but I often like to do more than that, so I do the delayed bolus things about 15 mins. prior to eating. You're right, sometimes I get it OK, sometimes I don't. I'm hoping to use CGMS to more closely guage my insulin response: when is the peak, really?
This is very hard work, I've only been D1 since 1999, don't know how you guys have done it all of these years. I appreciate what my father/sister have had to go through.
-Gary
'When do I get my D vacation?'
http://www.mydiabetescgms.blogspot.com/
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