The Art of the Pre-Bolus.
“So it’s a Wednesday night … what’s the chance we might not be seated right away?”
“Are you talking to me?” Chris asked, pulling the car into a parking spot near the entrance of the restaurant.
“Yeah. Sort of. I’m trying to decide if I should bolus now, because I’m 200 and I don’t want to be high all night. Or eat ice for dinner,” I responded.
The science of a pre-bolus makes sense to me. Take your insulin before you eat so that it’s active in your system when the food hits. Or, in smarty-pants terms: “A bolus of rapid-acting insulin 20 min prior to a meal results in significantly better postprandial glucose control than when the meal insulin bolus is given just prior to the meal or 20 min after meal initiation,” states the conclusion of this study from 2010 examining the influence of timing pre-meal boluses on post-prandial blood sugars.
I put this theory into practical application during the second and third trimesters of my pregnancy, when insulin resistance was constantly on the climb, as were my actual insulin needs (thank you, hard-working placenta). Around the 22 week mark, I needed to pre-bolus approximately 25 minutes before a meal. Around the 30 week mark, I was upping that time frame to 45 minutes prior to eating. And now, without a baby on board, I still try to bolus at least 20 minutes before I eat.
Making the decision to pre-bolus is a precarious one, because the success of that decision rests in the quiet of variables. (What, too esoteric? I wrote that sentence from a cloud.) Pre-bolusing only works when nothing else gets in the way of eating.
Yesterday morning, I woke up to a shiny 218 mg/dL on my glucose meter, so I wanted to make sure I pre-bolused for breakfast, since morning highs tend to stick with me well into the early afternoon. (Little jerkfaces.) I took my correction bolus and my meal bolus in combination with one another for my meal (eggs, avocado, and a slice of toast do not judge me for eating toast), and set about playing with Birdzone until it was time for breakfast. Only the best laid plans of this PWD were derailed by a phone call, a frantic search for Carrots (Birdy’s stuffed rabbit, who happened to be in the dryer, a la Knuffle Bunny), and falling down the email vortex for a spell. End result? I skipped the toast and ended up chugging some juice with my breakfast.
Before dinner out at a restaurant, I decided not to pre-bolus in the car, assuming it would be some time before we were seated. But (of course), we were seated and eating within 20 minutes of arriving. Even though my blood sugar was in range when I sat down, I had a post-meal spike that looked like a rocket ship taking off.
Timing is only part of the art of the pre-bolus. For people dealing with gastroparesis, trying to predict the absorption of insulin and food is tricky. For kids with diabetes, the art is more Pollock-y, because who knows what a kid will eat/won’t eat/might lick and then hide in a plant? The blood sugar number you’re starting from makes a difference (or at least for me), too. I’ve found that if I’m high, I need to wait until I see a downward slope on my Dexcom graph before I can start eating; otherwise, I start high and end up higher. And the time of day matters for me, too. A breakfast pre-bolus definitely needs more time to kick in than a dinner one.
Pre-bolusing, for all of its variables, is one of the most useful things I’ve done to help lower my A1C. Keeping my post-prandials lower helps my overall control, and every time I see my endo, she nods in agreement when I mention pre-bolusing. (She also warns me about lows every time, because she’s a doctor and also extremely smart and always has cool sneakers on /digression)
Do you pre-bolus?