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Arc of Bolus Action?

Discussion in 'Parents of Children with Type 1' started by bamaboyd82, Apr 14, 2015.

  1. bamaboyd82

    bamaboyd82 Approved members

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    I have questions about how the 2-3 hours following a meal and bolus "ought" to look on Dexcom. If my son is in range at mealtime, we generally prebolus by only about 5 minutes, sometimes just as we are serving his meal. It used to be that we would see the food hit on the Dexcom, with a big spike, followed by a decline that (ideally) ended somewhere near his target number (140). Now, we very often see a small bump in the numbers after eating, followed by a slow drop to the bottom of his range, where he hovers around 80-90 for 30 minutes or so, before beginning a slow rise. Sometimes, the rise stops around his target number, but other times, it blows right past it.

    What causes this? Are we off on basal, off on I:C ratios, dealing with different foods, different sensitivities? I've been thinking that we're making better choices as far as GI load goes, so maybe that could explain it, but the same thing happened with cereal today.

    Or, is this how it's supposed to look? I definitely prefer it to the big spikes and rapid drops, but we find that we are dropping him off at school at the very bottom of his range lots of mornings, just because of the timing of breakfast and the start of school, and the nurses (understandably) get nervous and are likely to treat.

    Is it possible he would do better without a prebolus? Is there a magic time in there where we could keep him even steadier?

    Would love to hear any thoughts!
     
  2. Lakeman

    Lakeman Approved members

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    The big spike following a meal happens when the food hits the bloodstream faster than the insulin brings it down. You are right to prefer the flatter graph. You are also right to think that the GI of the foods eaten and pre-bolusing can effect this. Being at the lower end of his range is a wonderful thing as long as someone is watching for lows and carbs are eaten before activities.
     
  3. bamaboyd82

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    Thank you! Yes, at home, we are totally comfortable letting him hang out in the 80s, but at school, he usually ends up getting a treatment in that scenario, which defeats the good of it.

    I guess my next question is why does he go to the bottom of his range and THEN rise? Is that to be expected? We just had never seen that pattern until recently.
     
  4. sszyszkiewicz

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    it depends on the meal and the child.

    A high carb meal generally will spike quickly. A high fat meal with carbs will dip and then maybe spike...sometimes hours later. Its all about timing and how fast you CWD digests the food and what metabolic pathway his body takes as it processes the food. That is when it gets converted to blood sugar.

    so for example
    Oatmeal at breakfast and not much else: spike unless you prebolus very early
    pizza: you will likely see a drop and then a rise later, sometimes much later as the fat first slows the digestion of the carbs and then makes your CWD more insulin resistant hours later

    With the dex you will start noticing general patterns with your son. They are his patterns. In some ways I have given up looking for spcific things and have simply come down to if out of range 3 hours later (high) I correct.

    This all assumes your basals are ok. if you are correcting all the time then likely the basals need adjusting.
     
  5. emm142

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    If he's dropping before going up, that means the insulin is hitting a bit before the food. On days where you don't want this to happen, like when he's at school, you could either do the bolus a little later (5 mins may well be enough) or do a dual wave bolus (I think this might be called a combo bolus on the Ping?) and set a large percentage of the bolus to deliver immediately and a small percentage of the bolus to deliver slower e.g. over the next 30 minutes. That way you might be able to see a flatter line, rather than a dip followed by a peak.

    I find things just change sometimes, with digestion and insulin action. There was a period of maybe a year or two where I had to give dual/square boluses for all food, otherwise the insulin would hit before the food. But now I need to prebolus to avoid a massive spike. I think there are too many variables at play for me to get a straight answer on all the seemingly random changes... it's everything from the weather to my stress levels on any given day (and everything else inbetween!!!).
     
  6. bamaboyd82

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    Thank you, sszyszkiewicz and Emma. It seems like prebolusing is always touted as being very important to avoid spikes, so it's interesting to know that perhaps in some people, digestion makes it not so important, or even not desirable in certain instances. He only just recently started going low after high fat foods (pizza, cake, and cupcakes being the foods he's done it with so far) before having the delayed fat spike, so maybe that's an indication that other foods may be being digested more slowly too.

    He often complains of stomach pain (even when in range), which in combination with seemingly delayed digestion, has had me concerned about celiac, but he tested negative again at his most recent appointment.

    Emma, you're right that there are just too many variables to be able to get a completely clear picture, but I think I'll try bolusing just after he begins eating and see if that fixes the issue. Glad to be aware of your experience.
     
  7. KHS22

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    Sounds like maybe his I:C ratio is too high (bringing him too low after a meal) but maybe his basal is too low - given that he rises once bolus is wearing off…
     
  8. bamaboyd82

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    I've wondered that too. We did some basal testing a few weeks ago, though, and his basal settings at the time crashed him in the absence of food, so we lowered them. Of course, everything changes so quickly, that this week could be a totally different situation!

     

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