It is said that breakfast is the most important meal of the day. One of diabetes’ little jokes seems to be making the most important meal of the day the most challenging for many of those living with diabetes, Caleb being one of them.
I think back to the short time that Caleb was on injection therapy and I would drop him off at preschool in the morning and check his blood sugar and see mid 200s about two hours after breakfast only for him to be below 100 at lunchtime after also eating a mid-morning snack. During my daily calls with his doctor the response I remember and remember strongly disliking was, “well that’s diabetes”.
It became my mission to tackle breakfast. For years now, I have been applying my own technique to this time of day and it’s evolved to something that I think I can somewhat confidently say we may possibly have some sort of handle on. At least until tomorrow when it all goes kablooey because I was silly enough to think such a thought and bold enough to write it down and share it.
Nevertheless, I will proceed.
I am a fan of the super bolus and its theory. Big fan. For a long time now, in some way, shape or form, I have been frontloading Caleb’s insulin at breakfast time to get it working in advance to avoid a peak after eating while also shutting it off on the backend to avoid a crash.
It started with his basal. This was way before we started using DexCom and I was able to see between the dots. My goal was simply to get him in range 2 hours after he ate. Caleb, and all my kids, woke up early and predictably in the morning (they still do). Scheduling breakfast was not only easy, it was pretty much forced upon me. So I would schedule his basal to be a little higher than his actual basal need about an hour before he woke up. I would bolus upon eating and not too long after that my phone would alarm with the melodious tones of Caleb’s voice saying, “zero basal please, zero basal please” and I would shut down his basal for two hours.
I’m imagining some of you thinking me crazy at this point. I’m sure it sounds a little nuts. It really wasn’t. It was just routine and the routine worked.
The outcome: Caleb would be in range at the 2 hour postprandial mark and the tail of insulin from the disproportionately large bolus that he needed to cover carbs at breakfast would take the place of the basal insulin mid morning. Because I turned off the basal delivery, Caleb’s bg stayed in range – no dangerous drop from the large breakfast bolus tail of insulin.
There has been evolution of this over time. Most recently, I have something much closer, although not exact, to a true super bolus. It’s the same theory – move the insulin up to avoid the early peak and the later low. Move it – don’t add it.
These days, the kids are a little older and not as demanding about eating as soon as they wake up so I don’t schedule the basal like I used to. Typically everyone wakes and begins their “getting reading” routine. Shortly thereafter Caleb is bolused for the expected carbs he will eat, but I add a little more and then reduce his basal a little too. About fifteen minutes later we eat.
The picture of the DexCom receiver depicts one such day. He woke up at 82, had a little peak from breakfast and ended at 106. (The gaps in the line are because I was holding the receiver at church and Caleb is in choir and at times separated from me.)
Though not always this pretty, more times than not it is, or at least close.
Until tomorrow of course….
This is Caleb... 
Handling morning BGs is really hard at times. I do the very same thing with the Superbolus in the morning. It helps a lot because it seems like the body response to everything is slowed down in the morning, so insulin works slower, then the insulin resistance due to cortisol peak etc. No matter how many carbs I eat for breakfast, the peak is still there, but with an increased bolus it’s usually managable…
Or, on some mornings when I have time, I bolus for breakfast with a needle and then exercise, which increases the absorption of insulin…
ps: I like the snowflakes on your blog 🙂
I have been trying to figure out the elusive super bolus for some time now. I keep reading about it but it just never “stuck” in my head… until now. I think I sort of understand it thanks to your post!! I can’t thank you enough.
I envy the R&D you go through for Caleb.
I’m not sure I’ve ever heard of the super bolus before. I may have to investigate this!
Helpful post! We’re still on MDI. Nonetheless, you have given me food for thought.
The snowflakes are fun! Living in AZ, they’re the most snow I’ll see all winter! 🙂
I’ve been doing something very similar. I can’t do a true Superbolus yet because Ainsley’s basal needs are still low enough that the addition is not enough to handle the breakfast spike. So I crank up basal before breakfast, bolus aggressively, and then shut off basal for a couple of hours following breakfast. It’s helped a lot but it still needs more work. Thanks for the post!
Yep that’s essentially what we did too when his basal needs were lower. I like the way you think Alicia! 🙂
I too, relied on a technique of sorts when the boys were a bit younger. That after breakfast spike was the bane of my existance! BUT, for the life of me, I have blocked out said technique. I’m sure it was similar to the Super Bolus as well. I had no idea that later in life I would have the opportunity to help others. I wish I kept better records!
Hey…it is freakin’ snowing on TIC! At first I thought I had “floaters”…it creeped me out a bit. LOL.
Thanks to your older post on the Super Bolus I now have it in my arsenal as well in dealing with breakfast. I cannot use it all the time…depending on what is going on with Joe, but I do use it on and off and refer people to your post.
Thanks Lorraine for sharing this awesome information…although, I have to say I have rarely seen Joe not spike to at least 300 after breakfast. Makes me feel like a LOSER!
Interesting stuff… Since we’re on MDI, I can’t use it right now… but I will file it away for later use. Thanks for posting it!
I have NO idea what a ‘super bolus’ is, but when we get the pump I am going to make a cape (for me, of course) so I am ready! 😉
That really is impressive. I never thought about doing it that way… but I don’t have a CGM so I can naively believe we don’t have those crazy morning spikes. 🙂 Some day I’m going to have to try this though. Right now, with 4 kids under 5, we’re flying by the seat of our pants, so every day is different. But someday, maybe. I’m going to have to tuck this bit of info away for later use. Thanks!
Love this post! I’ve heard a bit about the superbolus, but haven’t really investigated. We’re just starting on the pump next week…so I will eventually tackle this.
Now that I think about it……isn’t Caleb on Omnipod? That’s the pump we chose. One week from today! Wow!
He is indeed Tracy – more than three and a half years. Good luck! I’ll be keeping a close eye to hear how it goes!
The last line in this post sums it up for us… Some days Adele would really need this, others not.
She has a higher basal 1 to 1.5 hrs before she wakes to give her an insulin “head start”. Up to 2 days ago that seemed to be enough to avoid the post-b’fast spike, but as of yesterday it doesn’t seem to be working anymore.
Do you find that the insulin debt caused by the no basal period preceding the morning snack tends to cause a spike after snack? I guess you could super bolus again, but that could very well cause a similar pattern for the rest of the day?
No sir, not at all. No spike. Caleb typically goes into lunch at a great number. I have seen that issue with a superbolus for a correction, but that usually relates to there being an insulin delivery issue which is what caused the need for the correction in the first place. But never for breakfast *knock wood*. 🙂
Genius Lorraine! We don’t have breakfast issues around here, but we do sometimes have dinner time ones which sets up a high for bedtime. I am going to try this, after the holidays, cause if I do one more thing right now it will make my head burst when it comes to diabetes!!! Thank you for the great advice!
Awesome, thanks for sharing! I am SO looking forward to getting my son on a CGM and pump as soon as possible! Your post is so encouraging and informative!
okay, this is just wonderful to read! we still have issues with breakfast making C go sky high! and i remember the “early” years…no matter how much we bumped up her bolus for breakfast, she would test super high mid-morning…only to drop and bottom out by lunch…It was such a battle. super bolus could have rescued us! now, it seems better, but still an issue with problem foods. thanks Lo!
I talked to my Endo about extended boluses for breakfast and she said it would “probably” not work. We see a big spike 2 hours after breakfast too but by lunch his numbers were often in range. For this reason she said it is “good enough” since lunch numbers were good. My concern is obviously the spike and the fact that it is EVERY single day that this would occur it is affecting his A1C. I may revisit this at my Advanced Pumping class at the end of the month. Thanks for the post….and all your other posts and videos and…..XOXO