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Basal Bolus Regime

stoney

Well-Known Member
Messages
321
Location
South Wales
Type of diabetes
Parent
Treatment type
Pump
My 13 year old son has been very well controlled since being diagnosed when he was 3 years old but since hitting puberty his HbA1c was 8 on his last visit. We have been toying with the idea of going on the Basal Bolus Regime. I have had very good support from the Diabetic Nurse as well as the Dietitian but I am wondering if any other teenager is on the MDI regime and if so what sort of carbs are recommended for each meal as on looking through various websites there is very conflicting advice and mainly I think suggestions are for adults wishing to lose weight.

Can anyone advise me as my son seems to be keen to go forward, but I am very nervous.
 
There are lots of kids on basal/bolus injections.
What is he using now?
You can get very good control on MDI but accurate carb counting is essential. It doesn't really matter about the amount of carbs as long as you have a balanced diet, you take enough insulin to cover the carbs that you eat.
Another option is a pump but some people have to wait a long time to get one.
My daughter who is 8 was on MDI untill recently and now we are using a pump and find it to have many advantages.
Hope this helps.

Harry
 
Thanks for that Harry. My Son is on Humalog mix 25 at the moment, and will be going on Novorapid and Lantus which we hope to start next weekend. We also have to take into consideration that he is also a coeliac and on a gluten free diet. He is also a keen footballer and likes his football every weekend. The other thing that worries me is during sickness and exercise. I also wonder if we cannot get to grips with this can he go back on 2 injections a day.

Yvonne
 
Hello Yvonne,
I think you'll be pleasantly surprised at how much better MDI is over a twice daily mixed insulin. I have experience of both and, as Harry says, as long as he accurately works out carbs. to match insulin,your son will have much more flexibility with his eating.I too was nervous of making the change but I wouldn't go back to a twice-daily mixed insulin now.
I'm sure your son will not regret the change. It takes time to get used to having to work out carbs. to insulin matches but I promise, it DOES get easier over time.
All the best,
Chocoholic.
 
My doctor refused to let me even try twice daily insulin, he said it was so inflexible and gave much poorer control, so I assume basal-bolus is quite a lot better!
 
stoney said:
Thanks for that Harry. My Son is on Humalog mix 25 at the moment, and will be going on Novorapid and Lantus which we hope to start next weekend. We also have to take into consideration that he is also a coeliac and on a gluten free diet. He is also a keen footballer and likes his football every weekend. The other thing that worries me is during sickness and exercise. I also wonder if we cannot get to grips with this can he go back on 2 injections a day.

Yvonne

Hello stoney

Although basal/bolus regime offers a bit more in the way of carbohydrate flexibility, that's not everything. Basal/bolus is well known for non compliance issues amongst young people and also because it means doing an injection at lunchtime together with also doing more in the way of bg testing, many kids don't like it and some find that their friends turn against them.

If your son is still keen to use the regime then he should be aware that he will need to test bg levels at least 5 or 6 times a day and that for decent control he should also learn how to figure out an insulin to carb ratio that he can use throughout the day. It will only be by logging down the amount of carb that he eats at each meal and snack against the insulin he injects, that he will be able to adjust the bolus insulin up or down so that his bg levels start to balance out. If you feel he will be all ok with this and won't mind, then of course he should try it. He may need to do 5 injections per day in the end as many people find that just injecting the basal Lantus once a day causes unstable control with hypos a plenty.

If he doesn't like bolus/basal, then he should be able to go back to Humalog Mix 25 and can ask his doctor to also let him have an Apidra insulin pen, then if he decides to eat more carb than he should for a meal, he always give himself 1 or 2 units of Apidra (bolus insulin) and that will act as a 'booster' to the already injected Humalog Mix. I did fairly well using this approach and in many ways wish I still was. I'm glad that I've now got an insulin pump now though.

Good luck. Do have a long good think about it all.
 
Thank you all for your replies. I have been all weekend, weighing and working out different foods, meal menus etc in readiness for next weekend, hoping this would help us get started. What came to mind as well was, what if his bg is high before his meal, how would you calculate the insulin then. I think when he is at home he could probably inject after his meal, but when he is in school, he would need to inject then have his planned lunch box already calculated for him. What would be the guidelines then.

Also is there a strict rule for how many carbs should be eaten at each meal. My son is not a big lad but being only 13 would like to be able to eat a bit more and actually put on a bit of weight.

I will be seeing his diabetes nurse this week, but would like to know what other people are going through.

Help.
 
There isn't a strict rule for how many carbs to eat at each meal. The whole point of a basal bolus regime is to give you some flexibility so that you can increase the amount of insulin taken at each meal (the bolus dose) in line with the carb content of each meal. This is so that you can begin to attempt how it is for non diabetics ie a non diabetic will secrete the exact amount of insulin the need naturally, to combat the carbs at each meal, more for a bigger carb meal and less for a smaller carb meal.
A good book which explains this is 'think like a pancreas'. Forgotten the author but you should be able to find it on amazon if you are interested
 
Your son can eat however many carbs he feels he needs and calculate the bolus to cover the amount of carbs being eaten, there is no strict guideline that he must keep to. For my daughter I pack her a lunch for school and write on a sticky note inside her lunchbox how many carbs the lunch contains or how many units of insulin she needs to take to cover the contents of the lunch. The basal bolus regime gives you flexibility in that the lunch doesn't need to be a similar amount of carbs each day so if on a Friday for example he wants a treat which means more carb content then he simply needs to inject more insulin to cover the carbs on that day. Maybe he finds PE days he's hungrier then those days you can give him a bigger lunch. If his reading is a little too high before lunch then he can add more insulin into the total amount needed to be injected to bring that reading down a bit. With a little testing you can work out how many mmol 1 unit of insulin will reduce his blood sugars by. Once you have that established then it's quite easy to work out how much extra insulin is needed to bring his reading back to your target level. We found the basal bolus was much more flexible than the twice daily injections, I think you will find the same.
 
My Goodness Me you all sound sooo in control of the situation, I hope myself and my son cope with the change. Went to get his script for the insulin today. Seeing his school nurse and diabetic nurse on Wednesday and here we go on the weekend.

SophiaW you said that if he is too high before lunch he can calculate the amount accordingly, which we will be able to work out in time. What if he is too low before lunch what happens then. Also when your daughter is at home, does she inject before meals or after?

As far as exercise is concerned my son has games last lesson on a Tuesday, he also has football training in the evening, and on Wednesday he has PE second lesson and again football training in the evening, then he has a football match on Saturday mornings. I would appreciate any suggestions as to what we would do on those occasions.

Thanks Everyone
 
My daughter now uses a pump but up until the beginning of Jan this year she was on the basal/bolus injections. She injected before meals unless we were unsure how much she was going to eat, for example trying a new meal that she might not like. Once we knew how much she was going to eat then we'd inject as soon after that as possible. Sometimes it meant injecting twice, for example out at a restaurant we'd inject for the main meal as we were unsure if she'd have dessert or what she'd be having for dessert. If she had dessert after the meal then she'd take another injection to cover the dessert.

It might seem a lot to take in now because it's going to be a new regime for you but you'll soon get into the swing of things and feel more organised about it.

I found with lunches that she liked a similar thing each day in her packed lunch so sometimes the amount of insulin being injected each lunchtime was pretty much the same. But we had the flexibility of being able to inject more or less if we needed to on those days that she wanted something extra in her lunchbox.

If she was low before lunch then we'd treat it as a hypo (glucose sweet) and then proceed onto lunch as normal with the same injection as she would have had with lunch even if she wasn't hypo. The glucose remedies the hypo so lunch follows as usual after that. If you find your son is going hypo frequently at the same time of day then either his basal or bolus ratio needs to be checked as it may not be right.

It took a little time with testing and experimenting but we also soon learnt how much her blood glucose would drop with different types of sport and different times of day and how long since the last injection. We found if she did sport within 2 hours of a bolus injection then her readings would drop more quickly than if the sport with 3 or longer hours after the bolus injection. In the beginning it's kind of trial and error but if you keep a log of injection times, sport type and BG readings you'll soon get a feel for things. It does make life easier if the sport is routinely at the same time of day each week. Our consultant did say that for sport rather than eating before the event we could reduce the insulin taken at the previous meal time, but we never did that because we found Jess wanted a snack before sport anyway (usually after school) so the snack worked well for us. Just to be clear, the biscuit was eaten without any injection done to cover the carbs, the exercise would burn off the carbs from the biscuit. If she wanted a snack after school and wasn't doing exercise then she'd have an injection to cover the snack.

Everyone is different but with my daughter we found a plain digestive biscuit before sport was sufficient to get her through without any hypos. She did half hour swimming lesson and 45 mins tennis lesson (not at the same time, two different days of the week). It all depends on the type of sport and the duration too so you may find some sports need more carbs on board than others.

For school make sure your son has access to a carb snack for sports. We found general PE didn't cause too much problem but they did cross country for a while at school last year and that really dropped her readings so she needed to snack on a biscuit before they started the session. It's a good idea to test BG before exercise and if it's an active session or a long session to test during the exercise too.

The book I'd recommend is "Type 1 Diabetes in Children, Adolescents and Young Adults: How to Become an Expert on Your Own Diabetes", it's around £20 at Amazon but well worthwhile. It's the book that really helped me a lot when we switched from the two injections a day to basal bolus. I know the consultants are there to help but the information you can learn in a book is so much more than what they can try and tell you in a 10 minute appointment once every few months.

Sorry for the long essay, it looks like a got a bit carried away! :)
 
Thank you SophiaW Need to digest all that and thank you very much for taking the time to answer my questions. Going to order book from Amazon now.

Will be back sometime next week to let you all know how we are getting on.

Onwards and Upwards

Thanks
 
An absolute must for everyone using basal/bolus is an insulin pen that will deliver in half unit measures. This enables a bit of fine tuning when using insulin to carb ratios and also using guesswork as well. Novo do a Junior pen but Aventis do nothing. Aventis cartridges will fit in a Lilly Humapen Luxura HD pen so all is not lost.

Another is to get hold of a blood glucose monitoring diary that includes columns or rows for entering carbohydrate eaten, bolus, correction bolus, basal. If everyone using the regime had a diary like this, then everyone would get the hang of adding up carb. It's really really bad that the bg meter companies are not giving out diaries to cater for the bolus/basal regime and complaints should be made. Accu chek will send out a pump bg monitoring diary if it is asked for. As long as you have one of their meters, I'm sure they will not mind :)

Good luck.
 
iHs said:
It's really really bad that the bg meter companies are not giving out diaries to cater for the bolus/basal regime and complaints should be made.

Good advice iHs and agree on the half unit pens. I normally pick up the diaries in my diabetes clinic at my local hospital, these are obviously given to them by the drugs representatives free of charge but have yet to see one in my gp practise.

Nigel
 
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