So I gather some parents have kids who don’t spike after they eat (at least not above 250) and I’m wondering how the heck that’s possible? Every single meal (well, 8 out of 10) he eats, he goes up over 250…sometimes around 300. He goes back down within 3 hours and that’s been our main concern thus far is just ensuring that his postprandial comes back down to within +/- 30 points from his pre-meal BG…and when he doesn’t we adjust I:C accordingly. I’m just wondering how we can avoid the big spikes (the roller-coasters)…does it boil down to really food choice?
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No - food choice is not a requirement or a problem, except in the morning for us.
What we do, which works 80% of the time or more:
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we do a very good job at calculating carbs. We use apps for that, and weigh everything
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we prebolus early (typically 40 mins or more): we have studied how early it needs to be
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we don’t start eating until his BG has turned the corner (going down sharply) and is in range if he was high
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we stage the meal (see my other post about that) over a period of time. Particularly desert and milk end up almost always waiting for a while: he eats them to the meter. This way, we never spike high.
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we eat dinner early so that we don’t have to make corrections too late at night after the meal
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In the morning, my son is insulin-resistant. So we spent several months coming up with a menu that he LOVES but that is very low carb. This is the only thing where we really control food choice.
As a note, as we all know, nothing ever stays the same with diabetes. We find, for instance, that, while our typical pre-bolus duration is fairly good and reasonably stable month to month, it changes with time (in Nov it was 30 minutes for instance), and, occasionally, it does not apply. For instance, last night at dinner, he did not turn the corner for 90 minutes. But we ride with the flow, and eat to the meter as much as possible.
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I know its tricky but really there are only a couple fundamental variables in managing mealtime blood sugars… namely the timing and amount of the insulin and the amount and glycemic load of the food consumed…
And from those few variables have evolved every discussion of and struggle with blood sugar control ever had… seems like it should be simple enough… but anyone whose ever juggled it can attest to the contrary
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I do think food choice plays a role. You can still eat whatever you want, but the type of carbs determines how fast they come in.
Ideally, the insulin curve will match the rate the food is metabolized. But when a food is metabolized faster - example, a cookie versus mashed potatoes - you can see a spike.
The spike will depend on the timing of the insulin dose, the amount of carbs, the types of carbs, the current BG, the direction the BG is moving, how quickly the BG is moving up or down, and the current insulin sensitivity. A lot of those things are not factors that are used by bolus calculators!
If you are worried about dosing too soon or too much, simply having a stronger basal for an hour or two leading up to the meal can help alleviate some of the spike. If the BG is trending down, you should see less of a spike. But you only want to do this when you are in total control of the timing of the meal, i.e. when at home not at a restaurant!
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This was my theory in my previous Basal program that I had created (I had a bunch of different basal profiles based on the time of the day, whether it was before meal, etc.,) And I had gotten under 7% AIC…then the Endo requested I scrap my program. But I had this accounted for meals in my basal program regimen that I had built. I’m thinking of starting that back up. The problem with it was that I was hearing “That’s not what Basal is for (meal BG control)”…but, to me, it makes perfect sense. If you increase Basal 1 hour before meal time, it can prevent such large spikes because more insulin is being injected to accompany the bolus.
Your son’s age is the biggest factor. If he’s anything like mine–he can be quite unpredictable in deciding to eat. We have been experimenting with an extended prebolus lately. Basically we give an extended bolus about an hr before eating. Then we give the main bolus as needed. We deduct from the initial extended bolus with the idea that if we over bolused, we can catch it easier–as it will fall slower.
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This strategy lets you know/cancel IOB and acts like a meal basal.
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We do this at a restaurant all the time 
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we figure out whether the order will take longer to arrive than the prebolus (very important, can be known 90% of the time or more)
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we prebolus an approximate amount (including dessert), less rather than more so that all corrections are additive
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we order, and discuss timing/ order with the waiter/waitress. We also discuss dessert (if any) and timing of dessert at this time with waiter/waitress.
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we adjust bolus to what actually ordered if need be
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we have the meal. We make sure we have some bread around if necessary while we wait, but it is hardly ever necessary. If any eaten, must inject addl bolus.
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Typically, dessert comes right in time for staging by the meter, or within a few minutes. We often try to have the waiter ready to bring it to us when we ask (even better), making sure it is all lined up to go, with only a couple of minutes of last prep left. If need be, we wait a few minutes with dessert on the table – very rarely necessary.
it really works! Although we have had a few hiccups and funny stories…
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Sure, that can be done at a restaurant too. I’ve had to order a coke at dinner because the dinner was late. I am just suggesting for caution that you have to be more careful whenever somebody else is in charge of the meal timing!
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So true!
When we have a concern, particularly for elaborate meals, we tell the staff that we have a diabetic, and ask if it is possible to have reliable timing. If not, we make do,
I always remind them about 10 minutes before time if they told me they can make a certain timeframe.
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In theory yes, basal is not for meals. But…any insulin you put in the body is treated like…insulin. The body does not care if you call it basal or bolus!
To satisfy your Endo, call it a pre-meal bolus. A pre-emptive bolus. Bolus Part 1.
It serves the same purpose as giving a bolus 30 minutes before the meal, but you are doing it 1 or 2 hours before, and at a slower rate. It is actually a safer way to do it.
Lemme meet your Endo. I can straighten him out. 
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You are not allowed to take a baseball bat with you.
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That was my guiding principle also.
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+:100:
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One other comment. So many of those recommendations are built for the masses.
People make mistakes - forget the meal, skip the meal, are late with the meal. In those circumstances, a higher basal program would cause a problem!
So Endo’s will make recommendations for everyone that apply to the worst case - forgetful, negligent, non-diligent, or careless patients.
Find an Endo that makes a distinction between careful and pro-active parents like you, and others. In the long run, that will be a much better fit for you.
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People here are pointing out something useful, which is that you can use basal programs to cover for a lot of the eating spike. But for us, keeping track of and debugging a bunch of basal programs (like 7 or 10) was really tricky. If he has lows at a weird time of day, I just couldn’t figure out if it was from a too aggressive meal bolus or from a 2-hour-long basal spike I had programmed to cover a meal bolus 3 hours earlier. And having a preprogrammed higher basal that required constant snacking was frustrating because our son is too little to diligently eat to his meter. Plus we don’t want to teach him to eat based on his BG. Then too, I found I was never changing the basal program because I found it really frustrating to click through all the different menus in the 10 minutes when the pump is off my son’s body. We now have 3 time periods: night (0.1 units/hr) morning (0.3 units/hr) and afternoon+evening (0.2 units/hr). Evening growth hormones ideally (when I don’t fall asleep) are dealt with by a bolus as soon as he is actually sleeping; otherwise he would crash low if he took too long to fall asleep. I’m not sure it does quite as good a job at controlling spikes but it’s a lot easier for me to troubleshoot and it’s more handsoff – meaning I don’t have to constantly be alert to possibly lows.
If I were you i’d just put on an extended bolus or a temp basal before an anticipated meal. It has the same effect but it’s not as “baked in” and if you forget it’s fine. Because we use openAPS, for us it’s easier to just give 0.2 or 0.3 units an hour before the meal (temp basals would be automatically canceled by the program and extended boluses mean the program won’t run until it finishes). Our son doesn’t spike to 300 with breakfast hardly ever and he typically hits about 160 to 180 before plateauing. For some meals I can get him completely flat for 2 hours after he eats, with a little 30-point rise late in the game. However, we still have times when he spikes high! Last night he hit 315 around 11pm, several hours after some chocolate mouse cake and chicken strips for dinner. He handled the mealtime spike fine, but big meals like that always hit him 30 minutes after he conks out and I too fell asleep and didn’t remember to give him his little sleep bolus.
For us the bigger problem is if he eats a ton of food, we usually do a good job of controlling the initial spike but he may have a later spike at night 4, 5 or even 8 hours later. It’s really hard to anticipate those especially at night.
Food choice may play a role but if your basal rate is sufficient it shouldn’t be huge. Our son can eat pancakes in a restaurant, cake, popsicles, white rice, pasta, pizza and all the usual unhealthy nonsense. The only thing we haven’t been able to crack is boxed cereal. (which I hate and think is pointless anyways, but I guess is a normal thing for kids to eat?)
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We are not pump users (yet). But I did note that Steve Ponder, who wrote Sugar Surfing, recommends a single basal for pumps.
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See what I said, 2 posts above 
Same thing applies to books written for the masses.
EDIT:
Just to clarify this. With the OmniPod, you can do it as a temp basal, or an extended bolus ahead of the meal. But it is basically the same thing as you do with your boy when you give a bolus 40 minutes before a meal.
It accomplishes the same thing. Whether you call it basal or bolus does not matter, except maybe to keep it straight and keep track of it.
It goes back to what I said earlier - insulin does not care what you call it, once you inject it, it acts the same.
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Agree 100% on this - a temp basal would be better than baking it into the basal program because you don’t have to always worry about eating at the same time.
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Would the temp basal just be active leading up to the meal, or would we have it active throughout the meal? Also, with regards to the extended bolus, if we start it an hour before the meal, how long would such an extended bolus need to be ran for? Also, if using an extended bolus, how much would be a good amount to give? I know that this may change based on what kind of spikes we’re seeing, but traditionally, we never have a meal that doesn’t cross over 250 and most times, it crosses above 300. Here are some examples. The spikes you see in the below graphs are mostly from meals, but a couple are from juice corrections.
