Diabetes BAMF… Or Not

Until a man is twenty-five, he still thinks, every so often, that under the right circumstances he could be the baddest motherfucker in the world. If I moved to a martial-arts monastery in China and studied real hard for ten years. If my family was wiped out by Colombian drug dealers and I swore myself to revenge. If I got a fatal disease, had one year to live, and devoted it to wiping out street crime. If I just dropped out and devoted my life to being bad. — Neal Stephenson, Snow Crash

It’s tempting to think that I could become a badass diabetes mofo. (I would say “ninja,” but that title is already taken.) If I could go back into the hospital as an inpatient, start over again, and get the right basal rates while in the hospital. If I had the world’s most dedicated support team. If I had a CGM and all the time in the world to learn from its chirping and charting. If I spent five years and read every journal article and textbook about diabetes self-management.

But I can’t just put my life on hold, drop out, and hope that I could be the baddest PWD around. None of us with diabetes can really expect that. There’s just too much life to be lived to give it all over to avenging the wrongs our pancreases visited upon us. However, I can get better results than I have now, even if I can’t be the zen/kung fu master who parries away every blow from the Big Bad.

I certainly can’t do it all by myself — although I am stubborn enough to feel that with the skills and knowledge I already have I should be able to do a lot. The last week hasn’t been anywhere near perfect, but the little bit of info from the CGM trial has been good and helped me make some much needed changes. I’ve banished the NPH demon and started to get more confidence with larger bolus amounts. Now I feel like I have learned enough to ask dumb questions (i.e., questions I don’t know the answers to). Because it’s diabetes, when I get these questions answered, I’ll have a new set of questions to ask; but that’s progress, and I can live with it.

Here are my questions. If you have any pointers, tips, generalizable experience, or just plain-old speculation or advice, I would be happy to read it.

  1. How do you know when active insulin (a.k.a., “bolus on board” or “insulin on board”) matters for preventing lows or highs? If I ate three hours ago and have five units of active insulin, will my BG likely go up, go down, or stay the same?
  2. When should I add an extra bolus for protein or fat?
  3. What is the correct way to do a combination/dual-wave bolus? I’ve mostly been winging it, but I don’t know if it actually does any good.
  4. When should I bolus for meals? I’m way past bolusing afterward, but should it be right when I eat? (That seems unlikely.) 5 minutes before? 15? 30? Does “it depend” on the meal?

Any other sage advice for becoming a BAMF would be greatly appreciated and accepted with the greatest of humility and with full knowledge that my diabetes may behave differently than yours. And I promise to share more of what I learn along the way.

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2 Responses to Diabetes BAMF… Or Not

  1. Kim says:

    I lay no claim to being a BAMF at this, but I’m happy to share what (usually) works for me. YMMV, I don’t have medical training, yada yada you get it.

    1. That’s a great question. If your basal insulin is doing what it “should”, your number should be unchanged at the 3-hour mark after eating. That’s providing you didn’t eat a high-fat meal, or up your activity level in that amount of time, or other such things.

    2. When there is a lot of either one? I don’t know a hard and fast rule for this number-wise, but I know that generally if my meal wasn’t prepared at home, I need an extended bolus.

    3. According to the last CDE I talked to, the “normal” way is 50/50 over 2 – 3 hours. This doesn’t work for me.

    I tend to need more up front – 75 to 85 percent – and then I also up my basal rate to +60 or 70% for at least 4 hours. It’s not a pretty system, but it mostly works for me. There have been some situations, like when I have wine with a high-fat pasta meal, that a square bolus works beautifully (meaning, 0% up front, 100% spread out over 3 or so hours). I’ve become pretty solid at SWAGing my way through combo bolusing.

    4. Again… it depends. As a general rule, I bolus 15 minutes before. If I’m running on the low side, it might only be 5 minutes before. If I’m running high, I’ll take the correction and food boluses all at once, 20 – 30 minutes before I start eating. What kind of fast-acting are you using again? I use Humalog, and I was always told that it doesn’t start working until the 10-minute mark.

    I hope you get some more feedback that helps!

  2. Jeff Mather says:

    Kim: Thanks so much for the feedback. This information is very helpful. (Very helpful, even knowing that it won’t translate completely from you to me. That should go without saying, but it is worth saying.)

    Your first answer has confirmed something I already thought. If my BG is significantly higher a few hours after eating, it’s okay to give a correction — even though Mr. Pump Wizard says there’s enough active insulin to cover the correction. And I’ve been a lot more consistent with giving a bolus 10-15 minutes before eating, which really seems to make a difference, too.

    Don’t sell yourself short. You’re pretty badass.

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