T-Slim X2: What do you do for meals with multiple courses?

[RobertJ]

I have just had my work Christmas lunch and I really tried to get things right. I did not succeed. Now I'm on a reading of 14.0 mmol/l, and I've been out of range for an hour and a half. I assume I'll be high for at least three hours now.

This was a standard Christmas dinner: turkey, one pig in blanket, stuffing, roast potatoes, swede, carrots, Brussels sprouts and gravy. For dessert I had a dark chocolate cake with cherries.

My strategy was to dose for the main meal fifteen minutes in advance (which ended up being twenty because of how long it took to queue up), and then dose for dessert while I was still eating the main course.

Previously, I've tried giving one big dose for two courses and splitting it, but I'm not sure that works.

I am just so sick of the way large meals always end up like this. The pump is supposed to prevent nasty spikes but I've had some awful experiences recently. It seems like once it starts rising fast, it's a guarantee I'll reach at least 14.0mmol/L and be high for at least three hours. It should be possible on such an advanced system to have large, high-carb meals and only experience a brief, moderate spike.

 

[searley]

Times like this will always be difficult

Personally when eating out I will go course by course as it arrives that way it’s easier to judge how many carbs you thing will be on the plate as you never know the plate size until it arrives

And if I’m still high a couple of hours after eating I would give a correction


Because you are dosing a little later than you should you will get highs but to be honest the odd high reading isn’t really going to do any harm

 

[Africanaussie]

It’s tough to balance dosing for meals like this, especially with the timing and how unpredictable things can be. Maybe next time, you could try splitting your dessert dose into two part of it with the main meal and part right before you eat the dessert? Some people find that helps slow the spike.

 

[Chas C]

You didn't mention what your BG was before your meal, if it was on the high side then unfortunately you need to accept it will take some time and go higher. I always bolus 20 mins ish before I eat then take roughly 30% with rest over say and hour but the % and time varies depending upon pre-food BG (if BG was high I sometimes go to 50%) and food type. Then add a single extra dose for pudding or any additional food or drink I'd not allowed for. If its a long meal over few hours then I have added another bolus spread over time after first one has finished. I now avoid flour based foods or potatoes so it make it a little easier.

 

[RobertJ]

@Chas C, it was 5.4mmol/L so I was starting on a good level. I try very hard to ensure I do not start a meal above 7.0mmol/L.

So it sounds like you do in fact use one dose for a meal with multiple courses, albeit with splitting. In recent experiences with large meals, what sort of levels do you peak at before it comes back down? This is the big issue for me. I want to know if I can actually have large meals without reaching 14 or 15mmol/L and being high for three hours.

 

[Juicyj]

Try not to feel defeated - there are times where despite the strategy and tech we cannot achieve the desired result - slow stomach emptying on a full load is quite often the case with these events.

Personally if I can do some exercise after a big meal - dancing/walk, can often get me back in range quicker, but just try to write off these event's and enjoy the moment if you can.

 

[RobertJ]

Thanks, @Juicyj. I find it hard to enjoy any meal if it causes so many problems afterwards. It just ruins any positive memories of it. For example, on Tuesday I had a burger with chips and one pint of ale in a pub and went to 13.8mmol/L (starting at about 6.0mmol/L) and was high for over three hours. This was despite going for a twenty-minute walk after the meal.

I've had some wonderful periods with the closed-loop system (in the first two weeks of August I had several days of 90-100% in range) but now I almost forget I'm on it. It feels like I've slid back into my days of manually controlling the pump.

I'm considering simply avoiding large meals after how bad things have been in the last few weeks.

 

[Hopeful34]

Is there any possibility you're under estimating the carbs in the meal? Do you come back to where you started from after the lunchtime insulin has stopped working (without either the pump or yourself giving extra insulin)?

 

[Juicyj]

Other question is what fast acting are you using ?

I am using Ljumjev now so get the insulin hit straight away, it tends to help the arrow from hitting mid teens, however it can be stubborn with high BG levels too if I do go high.

 

[Chas C]

@Chas C, it was 5.4mmol/L so I was starting on a good level. I try very hard to ensure I do not start a meal above 7.0mmol/L.

So it sounds like you do in fact use one dose for a meal with multiple courses, albeit with splitting. In recent experiences with large meals, what sort of levels do you peak at before it comes back down? This is the big issue for me. I want to know if I can actually have large meals without reaching 14 or 15mmol/L and being high for three hours.

Hi Robert - I rarely go over 11 post meal, mostly between 8 and 10.

 

[Chas C]

Is there any possibility you're under estimating the carbs in the meal? Do you come back to where you started from after the lunchtime insulin has stopped working (without either the pump or yourself giving extra insulin)?

This is a very good point, as I've got older my insulin to carb ratio has changed a lot - I'm not on double the insulin from what I was as a teenager.

 

[RobertJ]

Hi Robert - I rarely go over 11 post meal, mostly between 8 and 10.

I've been through phases of that on the closed-loop system, but now I'm hitting 14 or 15mmol/L several days a week.

 

[RobertJ]

Is there any possibility you're under estimating the carbs in the meal? Do you come back to where you started from after the lunchtime insulin has stopped working (without either the pump or yourself giving extra insulin)?

I think there is a possibility I'm underestimating things, yes. Maybe I need go back to basics and have the same meal several times to see if my ratios are correct. I find the basal rate something hard to work out on the closed-loop system. The pump is increasing and decreasing my basal so much throughout the day: how do I know the base number is right?

 

[fozzie84]

I don't know the exact setup of the tslim, but on my pump (insight, diy loop) I would start by fasting on an open loop to check my basal rates, once you know if that's ok, then eat a known meal on an open loop to check if your ratios are right. Completely understand your frustration with eating out, but it could be your ratios are out and easier to fix, especially if it's happening other times through the week.

Sometimes I also "superbolus" when eating out and can't dose ahead as easily, but it's always a bit hit and miss! In case you're not familiar with the term, you add your next 2 hours basal rates to your food dose and have a temporary basal of 0% for two hours, it can smooth the spike.

 

[Hopeful34]

I think there is a possibility I'm underestimating things, yes. Maybe I need go back to basics and have the same meal several times to see if my ratios are correct. I find the basal rate something hard to work out on the closed-loop system. The pump is increasing and decreasing my basal so much throughout the day: how do I know the base number is right?

To work out your basal rate, you have to turn off control IQ, and fast for periods of time. Split the day into 3 and test each period of time on different days. The easiest one to do first is overnight - make sure your last bolus/meal is 4 hours previously and there wasn't a lot of fat in the food. Make sure you're in target range before you start.

If you start to hypo, stop the test and eat carbs. Similarly if you go too high, stop the test and give insulin.

 

[Chas C]

If I'm having trouble after doing all the above I go back to basics with the Correction Factor and Insulin to Carb Ratio, using the 100 rule for Correction Factor and 500 rule for the Insulin to Carb ratio. Just in case over time (years) I've tweeked these to much but then find I can't get it working correctly. You can find these with a google search.

Correction Factor – 100 Rule
Divide 100 by your total daily insulin dose (basal and bolus) to provide you with your correction dose.

Insulin to Carbohydrate Ratio – 500 Rule
Divide 500 by your total daily insulin dose (basal and bolus) to provide you with your ratio dose

 

[RobertJ]

If I'm having trouble after doing all the above I go back to basics with the Correction Factor and Insulin to Carb Ratio, using the 100 rule for Correction Factor and 500 rule for the Insulin to Carb ratio. Just in case over time (years) I've tweeked these to much but then find I can't get it working correctly. You can find these with a google search.

Correction Factor – 100 Rule
Divide 100 by your total daily insulin dose (basal and bolus) to provide you with your correction dose.

Insulin to Carbohydrate Ratio – 500 Rule
Divide 500 by your total daily insulin dose (basal and bolus) to provide you with your ratio dose

Thanks, I did the correction factor one mine was 2.4. On my pump settings it was 2.6 so I've changed it.

On the second calculation, I ended up with 12.2. What do I do with this number?

 

[Hopeful34]

Correction factor and insulin to carb ratio can be different at different times of the day, so really need testing at different times of the day, and your pump settings adjusted accordingly.

 

[Smetana]

I have just had my work Christmas lunch and I really tried to get things right. I did not succeed. Now I'm on a reading of 14.0 mmol/l, and I've been out of range for an hour and a half. I assume I'll be high for at least three hours now.

This was a standard Christmas dinner: turkey, one pig in blanket, stuffing, roast potatoes, swede, carrots, Brussels sprouts and gravy. For dessert I had a dark chocolate cake with cherries.

My strategy was to dose for the main meal fifteen minutes in advance (which ended up being twenty because of how long it took to queue up), and then dose for dessert while I was still eating the main course.

Previously, I've tried giving one big dose for two courses and splitting it, but I'm not sure that works.

I am just so sick of the way large meals always end up like this. The pump is supposed to prevent nasty spikes but I've had some awful experiences recently. It seems like once it starts rising fast, it's a guarantee I'll reach at least 14.0mmol/L and be high for at least three hours. It should be possible on such an advanced system to have large, high-carb meals and only experience a brief, moderate spike.

I think that sort of reading after a Christmas meal isn’t bad at all. It may be worth splitting your insulin by course. Or taking it after the starter. Too much panicking over the odd high reading.

 

[Chas C]

On the second calculation, I ended up with 12.2. What do I do with this number?

So this means 1 unit of insulin for every 12.2 grams of carbs.