Basal/Bolus Ratio

My 12-year old daughter is on the Medtronic pump.  We always pay careful attention to the basal/bolus ratio and try to keep it around 50% - 50%.  We also pay careful attention to how certain foods affect her BG levels, and usually pre-bolus up to 30 minutes or more depending upon the type of food (pasta is the opposite and requires extended bolus for six hours).  Just wondering how many pump users spend as much time analyzing these factors and what your results have been.  P.S. - her last A1C was 6.5%.

Hi Michael,

It took 24 years of diabetes before I heard this 50/50 guideline!  No doctor had ever told me about this, prior to the new endocrinologist I saw a couple of weeks back.  I wonder if this is a fairly recent suggestion.

Everyone's body needs something a bit different.  I tend to take about 30% basal and 70% bolus, but that's me.  I take a lot of insulin, relatively speaking, in general.  I also have increased insulin resistance now, compared to when I was younger.  It just seems to happen that way - and of course weight gain doesn't help either (and that's another factor for me).

I have also found that bolusing prior to eating - 15 minutes for me, usually - is immensely helpful.  If I bolus much before that with an in-target BG reading, I will end up going low before my food has a chance to start working.  Again, that's just me.

I don't really analyze that kind of stuff too much.  I do what works for me, and try not to worry if it's "normal" or "average".  Who wants to be normal or average, anyway?  :)

Hmmm, I didn't realize it but I am right around the 50/50 range.  No doctor I have ever had has said anything about it.  I just noticed on this new online equipment that Medtronics gave me that, yes I do average around 50 percent bolus and 50 percent basal.  It varies a bit but for me as a general rule I am right there.

My 8 year old daughter is at about 40% basal and 60% bolus.  I, too, spend a ton of time analyzing her numbers in order to gain insight on how to better control her diabetes.  Her last A1C was 7.3, not as good as I had hoped for.  Her endo is very pleased with her A1C.  I'm just a bit of a perfectionist when it comes to this stuff because I'm a pediatric nurse.  My daughter has been having lows in the 40's lately and she doesn't feel them at all.  The endo is putting her on a continuous glucose monitor as soon as the paperwork clears our insurance.  I am thrilled to have yet another means of tracking her blood sugar and seeing what effects certain foods, exercise, illness, etc have on her.  However, our diabetes educator cautioned me that all this extra data might just drive me nuts.  She warned me of becoming "burned out" from all the analyzing and I know she is right.  I will have to walk a fine line between gathering helpful data and obsessing over perfect numbers.  Obviously you are doing a great job with your daughter if she has an A1c of 6.5. All any of us parents can do is try our best and not loose sight of the fact that our kids are kids first and diabetics somewhere else further down the list.

This deserves repeating: "Our kids are kids first and diabetics somewhere else further down the list." -BlessedMom. Thank you for saying that! As a 34 year old woman who has had Type 1 since she was 10, I can look back and now fully appreciate how hard it must have been for my parents to not overwhelm me with managing diabetes and to let me be a kid first. They spent time analyzing and discussing and investigating and analyzing again, but what I remember from my childhood is that they let me feel independent and strong as I learned how to manage the disease. I have grown into an adult who loves to crunch numbers and see where I can fine tune to better control my blood sugars and I thank my parents for setting a healthy example. An A1C of 6.5 is wonderful; congratulations!

I'm 72 Type 1 "A" since I was 15, been very brittle, and a Pumper for * years.  Since the late 1970s I have done "intensive" treament and over the last dozen years maintained HbA1c between 5.9 and 6.1 with bolus/basil ratio of about 30/70.  A month ago my Endro insisted that I change [reverse] my ratio and aim for 60% basil and 40% bolus - saying this would avoid "insulin stacking".

I should also say that I lead an active lifestyle; peddle my mountain bike about 50 miles a week, visit a gym on non-bike days and walk a "few" miles all days.  I also eat a moderate carb diet averaging about 230 - 240 carbs per day.  Carbs include about 40 ounces of sugar-type gatorade on biking days.

Since following the new orders of the Endro [I'm now at about a 50 / 50 ratio], I'm unable to do any real exercise because of fear of my blood sugar level dropping - the maximum exercise I have been able to do is a 2 mile walk and a 10 mile bike ride after I set my pump to 50% 60 minutes before beginning my exercise.

Does anyone have suggestions?  I'm thinking that the Endrochronologist may have overlooked something [activity] when recomending this revision.

Go back to what works for you Dennis!  

Recommendations like the 50/50 rule are just a starting place based on statistical data.  You are a person, not a statistic.  And you are a person who knows your diabetes and has managed it for decades.  

I take doctors' recommendations with a grain of salt and only use them if they work for me.  Frankly, if you had an A1c below 6.1 with your level of exercise with few lows, your doctor was kind of a dope to think he/she could do better.  

Thanks Jenna.  Yes, I will take the doctor's suggestions with a grain of salt and currently I'm stopping the transition at 52/48 rather than the 60/40 he wants.  I do understand a need to eliminate "insulin stacking" and I'm consciously refraining from any correction bolus and starting next week I will attempt long-term fasting in attempt to validate basal settings - wish me luck on that.

You're smart to fast to test your basals.  I've had the best luck fasting for a day to test them, but even if you pick just an 8-hour chunk of time you can verify your basal for that part of day, then go on to the next 8-hour time block.  

I'm sure you're already doing this, but I really rely on the pump's bous wizard to prevent insulin stacking.  The catch is the settings for insulin sensitivity and insulin duration time have to be accurate for it to dose right.  

Interestingly enough, my endo (he is a t1D and wears a pump) says to limit the number of basal settings in a 24 hr period.  The fewer the better because it makes it more simple to figure out other changes that need to be made and the less complicated the treatment for pumpers and t1d(s), the better control we have.  Go figure!  :)

Thanks Marci, I think I tend to agree with your endo and you.  I'm now in the process of doing fasting tests [such as from after eating dinner until the following noon-time] to validate my basal settings; I've had to stop the testing by 2 AM every time.  Soon I'll be back to where I was before I accepted my endo's advise.  I had originally set my basal rates so that I could go an entire day without needing a correcting bolus or 'emergency' snack as long as I didn't engage in any exercise other than very moderate and as long as I didn't eat.  Best thing I liked about that is that I was comfortable.

I actually have a different philosophy on what a good number of different basal settings is. We have about 10 for my 10 year-old son, and I am convinced that this helps us control his diabetes more effectively. There are two reasons for this:

1. If we change a basal it only effects a couple of hours, making it easier to make changes without large consequences. For him we find that even a change of .025 (the smallest his medronic pump supports) can have a substantial impact on his blood sugar, so limiting the amount of time that each basal covers also limits the impact that a change in the basal has.

2. His basals vary by about a factor of 2 over the course of the day. He actually has no dawn effect (yet) and his overnight basals are less than half what the are during the day. His basals vary a bit during the day, and (as I think is common) go down in the early afternoon. It seems unlikely to me that the drop in his basals is a one minute to the next thing. Having multiple basals lets us taper between one setting and another over the course of a couple of hours.

anyway, I know this is not the common wisdom among endos and DNEs, but I think it works well. I hope it helps.


Bruce - My son was diagnosed at a year and will turn 13 next month. He's always been very sensitive to insulin. We too have many basals set for all the reasons you listed above. For a long time we would get a random nurse that would want me to take it back down to three basals and EVERY time he would be low ALL the time. I finally came across a nurse practitioner that worked with me daily for several weeks to document what was happening. She ended up putting a big note in his file to not reduce the number of basals. I'm fortunate that our endo very much subscribes to the philosophy that no two people with diabetes are the same and each body needs something different.

Bruce and Angie - Yes, every person with T-1 diabetes should or must be treated as an individual and NOT as some "text book" case; I'm now in my 4th consecutive day of 18 hour overnight fasts proving my basal settings.  I was diagnosed in 1957 and have been pumping since 2005 and have had about 9 basal rates over the course of the day that proved effective in maintaining my HBA1c generally between 5.9 and 6.2 for the last dozen years.  I just wish that my control had been good as a teen - keep up the good work!!!  You probably know what is best for your sons' good health - they are real people living with diabetes, they are not "diabetics".

My endo - NOT  a diabetic - has me on 3 basal rates.  I told him he is goofy, but he did not understand that dealing with diabetes is a job - full time +++