The Miracle of Timing

Egg_timer A wonder has occurred.  One of my own making, I might add.  Wasn’t it me who said the ‘T’ in RUT was for Troubleshoot?  Well, I’m proud to say this time I’ve had miraculous results.

The new strategy I’m testing is injecting at least 20 minutes (to half an hour) before eating, and for about 10 days now, things have been GOOD.  It’s absolutely Earth-shaking to see my post-prandial BG levels drop from 240+ to 140 and under. 

Now before you mumble, Duh Amy, everyone knows timing matters, consider: I used to be so insulin sensitive that ONE UNIT at breakfast sometimes knocked me below 60.  An extra half-unit could also make or break my afternoon.  And I used to get shaky within 10 minutes of a bolus injection, no matter how small. But those days are over!  Goodbye, honeymoon. Hello, pre-meal timing hassles.

What the DexCom continuous monitor helped me gauge, btw, was the insulin’s current “speed of onset and duration of action” in my body — vital information to which I was heretofore most certainly not tuned in.  Score points for (even the early) CGMS systems on that one.

What surprised me most was learning that so-called “fast-acting insulins” are in reality not so fast.  Of course, the renowned Dr. Richard Bernstein has been touting this fact for years: “If you’re a Type I diabetic, fast-acting (regular) insulin can be injected 30–40 minutes prior to a meal tailored to your diet plan to cover the ensuing preventable rise in blood sugar.”  OK, got that now.  And it works like a charm — this week, anyway. 

The only thing I don’t get is what went on before the “fast-acting” analogs came on the scene.  I always heard about those poor patients who used to need to inject a half-hour before mealtimes.  How inconvenient!  What if the food was delayed?!  But if today’s “quick stuff” takes that long to kick in, how long did it take back then?  And when will we get a truly fast-acting version that will mimic the Phase I insulin response of a healthy body? 

Hmmph… for right now, we’ve got to appreciate Small Miracles where we can get ‘em, I suppose.   

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12 Responses

  1. Laura
    Laura November 29, 2006 at 6:56 am | | Reply

    I need to start doing this myself. I usually shoot, depending on my reading, after my meal. Sometimes I don’t even check my sugar and just eat my meal, check after, and then do my shot. Bad habit. But it keeps my after meal readings too high. Thanks to your blog today, I have set my goal to begin doing my humalog shots at least 15 minutes before my meals to keep my readings from spiking so much. THANKS AMY!

  2. Kevin
    Kevin November 29, 2006 at 8:26 am | | Reply

    I’ve worked on this myself, though with mixed results. There have been times where I haven’t seen any change in my blood sugars for more than an hour after a bolus.

    It’s really *not* fun waiting around and testing every 15min before you can eat lunch.

    But I agree, it’s pretty crucial to smacking those post-prandials down.

    And, I’m not sure, but the insulin Dr. Bernstein seems to be refering to is Regular insulin rather than Novolog or Humalog. The literature says the former takes 30-40 minutes to start working and the latter take 10-20 minutes (I think).

    But then again, like I said, I’ve seen lags much longer than that on my own human-guinea pig experiments.

  3. Anne
    Anne November 29, 2006 at 9:43 am | | Reply

    The old “Regular” insulin did take a long time to start acting, and a very long time to stop acting. It was annoying. I think analog insulins have been one of the most important break-throughs since I was diagnosed, at least. I remember after using it for the first time and thinking, “Wow this actually works!” In combination with pump therapy, it has been a revolutionary improvement, I think!

    I’ve also been working on my insulin timing, and have found some improvements. It’s been complicated trying to throw Symlin in the mix, as well. I don’t know what the activity profile is for Symlin.

  4. Molly
    Molly November 29, 2006 at 9:47 am | | Reply

    I have also been working on giving bolus insulin before I eat.
    Honestly, I know that it helps with post meal blood sugars. Realistically, I often forget. I start eating and then realize that I didn’t bolus. It’s on the list of things that I am working on…:)

  5. Brian S
    Brian S November 29, 2006 at 12:31 pm | | Reply

    Amy:
    I noticed you mentioned Dr. Bernstein in this post. Dr. B has been my endo for the past year, and he is truly remarkable. Regarding “what happened before fast acting insulin”, the same timing adjustments are true.

    In fact, Dr. B almost always recommends that his patients use Humalog only for correcting highs or to offset the dawn phenomenon, but prefers Regular for meal boluses. He adjusts the timing to each person, which can go both ways. For example, he may have patients with gastro paresis inject after beginning a meal because of the delay in stomach emptying. He will also vary the timing based upon the timing of each meal, because the intra-day variation can be great.

    Good luck with your fine tuning.

  6. Steve
    Steve November 29, 2006 at 5:31 pm | | Reply

    I’ve only been doing this for a couple of days, so I can’t say if it works for a Type I diabetic, but Apple Cider Vinger is supposed to lower post prandial glucose by about 25%. This was supposed to be an “old wives tale” treatment, but it seems to work in lab tests. I’ve heard it temporarily increases sensitivity to insulin and also slows the digestion of carbs.

    It only cost a couple of bucks at the store, so I though I’d give it a shot for a little while. My Dexcom CGMS hasn’ t been working well lately, but I just got a new batch of sensors today, so I’ll see if this indeed lowers the after- meal spike. I just bought whatever brand of organic, unfiltered apple cider vinegar they had at the store. I’ve heard the Heinz stuff is just regular vinegar with apple cider added to it, so I didn’t get that brand.

    I add a tablespoon to a glass of water and drink it a few minutes before a meal. Honestly, I’d drink horse piss if I thought it would moderate my diabetes. :-)

    Steve

  7. Michael Park
    Michael Park November 29, 2006 at 9:06 pm | | Reply

    I remember regular insulin and trying to time it with meals. Once in particular our family went out for dinner and I took my dinner dose with (seemingly) enough time before the food, but after 30 minutes passed and no sign of food and then we were told our order wasn’t put in…. A certain stressed mother of mine had some unpleasant words for the waitress….
    Comment – Analog insulin = Wonderful for those of us multiple daily injectors, BUT it was damn scary when humalog stopped working for me (doses were doubled and still not effective enough). I’ve had no problems with Novorapid, but I fear the day when I start showing signs of insulin-resistance there…
    Question- the dawn phenomena – can someone explain/give me helpful link which will explain why my Lantus still works for the remaining 12 hours after it has been eaten up by the liver in the early morning?

  8. JasonJayhawk
    JasonJayhawk November 30, 2006 at 9:17 pm | | Reply

    This message is for Steve (if he gets it) regarding his use of Apple Cider vinegar. Anything with an acidic pH will cause the same effect. You might find fresh squeezed lemon in water to do the same thing. This is because the acidity slows down the stomach emptying. This is also called the “Chinese buffet syndrome”; many buffets will augment their water with lemon so that you feel full faster. The resulting fullness is due to delayed stomach emptying, resulting in a delayed or slower peak which can be met with fast-acting insulin.

    I think lemon is more flavorful than vinegar, but to each his or her own. :-)

  9. Steve
    Steve December 1, 2006 at 12:25 am | | Reply

    Jason, thanks for the tip about lemon juice. I actually don’t mind the Apple Cider Vinegar, so I think I’ll just stick with that for a while. I decided to try this after seeing the following study: http://care.diabetesjournals.org/cgi/content/full/27/1/281 It is also discussed here: http://www.thehealthierlife.co.uk/article/3239/diabetes-type-2.html I know the studies are for Type 2 diabetics, but I don’t see why it wouldn’t help Type 1′s as well.

    I’m mainly interested in improving my morning/after breakfast glusose readings. Unfortunately, I couldn’t watch the results on my Dexcom this morning because I was resetting a sensor. However, my post meal check on my One Touch meter said 150, which is very good for me after breakfast.

    Steve

  10. Michelle
    Michelle December 4, 2006 at 3:40 pm | | Reply

    I notice that with my 6 year old his best 2 hour post prandial numbers come at lunch time – and why is that? Because he walks to the nurses office at school, gets his insulin, walks to the cafeteria, picks up his milk, sits down and eats. About 10 minutes in all. But he’s ALWAYS spot on 2 hours later, so I know this works. My only trouble is what you do about pre dosing foods like pasta. I can’t really weigh it until it cooks unless I give him a set amount each meal. And if I can’t weigh it and calculate the carbs then I can’t pre-dose. It’s often pretty hard to do. I wonder how you all handle doing it?

  11. kelly
    kelly December 8, 2006 at 10:08 am | | Reply

    Excellent blog – I know there are so many things we are supposed to do that are easy to forget! I’ve also started injecting about 20 minutes before my meals, and it makes a huge difference. I did do it in a restaurant the other day and didn’t get food for an hour, so it does take being careful (I would’ve been very low but we got some OJ!) … as to when a real fast-acting insulin (or, VRAI – very rapid acting insulin!) might come out, one is being tested right now in phase 3 trials. It’s called viaJect, and some people who read DiabetesMine are probably in the trial — I decided not to be, because you couldn’t be a pumper, and if you were randomized to the non-treatment group, you had to go back to REgular insulin – but, everyone in the trial will ultimately be able to try Viaject. I look forward to watching and see how it does… I could definitely use something faster.

  12. shesgg
    shesgg December 2, 2007 at 12:41 pm | | Reply

    I know some of this is about a year old but I was on Dr. Bernstein’s conference call the other night and he suggested starting with a half unit of fast acting Lantus before bed and if you continue to read higher into the morning hours, take another half when you wake up.

    There are studies now suggesting that you are never more than 120 at anytime to avoid losing beta cells and other complications such as neuropathy.

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