More tips for timing insulin

A few posts ago I extracted some very valuable information from an article CDE and dietitian, Hope Warshaw wrote titled, “Rapid-Acting Insulin, Timing It Just Right” and I’d like to share a little more of her knowledge.

 Fine-tuning the timing of your premeal boluses or injections is important, but no more so than knowing how to count the carbohydrates in a meal or snack. If you don’t know how to count carbohydrates or to match your insulin dose to the amount of carbohydrate you plan to eat, speak to your health-care provider. Many people find themselves in a reactive mode when it comes to dosing insulin, taking it in response to high blood glucose rather than using enough of it before a meal to cover the rise of blood glucose in the hours after a meal or snack. Experts agree that it’s much harder to bring high blood glucose back down than to control blood glucose levels with sufficient insulin in the first place.

Glycemic Index: The glycemic index of foods as well as the fiber and fat content dramatically affect how quickly or slowly blood glucose level rises. (The glycemic index ranks foods based on how quickly they raise a person’s blood glucose.) One tip since most people’s blood sugar rises most quickly in the morning is to eat low glycemic foods at breakfast like yogurt or a bowl of oatmeal with a piece of fruit rather than foods with a higher glycemic index such as some cold cereals, pancakes, or muffins.

In general, foods and combinations of foods that have a low glycemic index and high fiber content will raise blood glucose more slowly. Conversely, foods with a high fat content tend to cause a delayed rise in blood glucose. The extent to which the glycemic index or fat content of a meal speeds or slows the rise in blood glucose following a meal varies from person to person. 

Meticulously timing your rapid-acting insulin dose and carefully calculating your dose according to the carbohydrate you will eat is usually best for blood glucose control, but it may not always be possible. There are times when you know exactly when and how much you will eat and times when you don’t. The following  tips may help you adjust for the realities of daily life:

High blood glucose before a meal. If your blood glucose is high before a meal, use how much your blood glucose level falls in response to one unit of insulin to calculate a dose of rapid-acting insulin to cover the high, then wait until that insulin begins to lower your blood glucose before you eat. 

Claudia Shwide-Slavin, a dietitian and certified diabetes educator in private practice in New York City, advises the following: “If your blood glucose level is between 140 mg/dl and 180 mg/dl, take the rapid-acting insulin and wait half an hour before eating. If it’s between 180 mg/dl and 200 mg/dl, wait 45 minutes. If it’s higher than 200 mg/dl, wait at least an hour.”  If a person is hungry or must eat at a specific time, Shwide-Slavin recommends limiting the amount of carbohydrate at the meal by eating mainly protein and nonstarchy vegetables.

Low blood glucose before a meal. If your blood glucose is low before a meal (below about 80 mg/dl), “Wait to take your insulin,” says Shwide-Slavin. “Let the food have 15 minutes to raise your blood glucose before taking your insulin.”

So, a few few more helpful hints to put your management “in the zone.” 



Secrets to a longer, healthier life

Intrigued already aren’t you? This is just one of the 15 self-assessment quizzes and tools for better managing your health and diabetes on the MayoClinic’s web site. The Secrets quiz asks just 10 questions and while I can tell you the answer doesn’t involve an anti-aging pill, it does involve some basic lifestyle changes– but the quiz will help you personalize what those changes are for you.

I’ve often used the MayoClinic web site as a valued resource for information but wasn’t aware what a plethora of diabetes tools and information it offers. It was actually meeting Julie in Queenstown, New Zealand, while on my recent travels, that I learned more about the MayoClinic’s dedicated diabetes work. Julie, who has type 2 diabetes, participates monthly in a research focus group with the clinic so that they get a fuller perspective on patient issues. 

While diabetes blogs and social networks are mushrooming like a fungus, it never hurts to go back to basics and review treatments, management strategies, coping, and ask questions of specialists from a well-trusted resource such as this.

Learning more about timing insulin

I know a lot about diabetes and working with my insulin. But recently a friend sent me an article, “Rapid-Acting Insulin, Timing It Just Right”, written by well-noted certified diabetes educator and registered dietician, Hope Warshaw. It helped confirm some of what I know and helped clarify some of what I didn’t know about timing insulin with your meals. Here are some of the article’s highlights.

Warshaw points out that even when you think you’re doing everything right with your diabetes care regimen, your blood glucose levels can seem hard to control. One potential source of difficulty is how you time your injections of rapid-acting insulin with respect to meals.

Most diabetes experts recommend taking meal-time insulins (Humalog, Novolog and Apidra) within 15 minutes of starting a meal. This advice is based on the belief that rapid-acting insulin is absorbed quickly and begins lowering blood glucose quickly. However, this may not be true for everyone. 

Howard Wolpert, M.D., editor of the book Smart Pumping and Senior Physician and Director of the Insulin Pump Program at Joslin Diabetes Center, cautions against blind-faith acceptance of insulin action curves or standard advice about when insulin works, noting that insulin can show “a lot of variability…between individuals and even within the same person from day to day.” The time ranges given for an insulin to reach its peak action are averages, so they may not fit everyone or every situation. You may find through blood glucose monitoring and experience that rapid-acting insulin typically reaches peak effectiveness within 45–90 minutes or possibly sooner or later. In general, people with normal stomach emptying can expect some glucose from the carbohydrate they’ve eaten to start raising their blood glucose level within minutes of starting to eat. Blood glucose level tends to peak about one to two hours after the start of a meal and gradually drops over the next three hours.

If rapid-acting insulin always started working almost immediately and peaked one to two hours later, injecting it anytime within 15 minutes of starting to eat would work well. But newer observations suggest that rapid-acting insulin doesn’t get absorbed and start working that quickly in all people. John Walsh, P.A., C.D.E., coauthor of the book Using Insulin, for example, believes the maximum blood-glucose-lowering effect of rapid-acting insulin may occur much closer to two hours after an injection rather than 45–90 minutes. If this is the case, the optimal time to take rapid-acting insulin is 10 to 15 minutes before eating rather than with the first bite or 15 minutes after starting a meal. Walsh’s belief is based on research suggesting that insulin may be measurable in the bloodstream before it begins actively lowering blood glucose.


Some other factors that may cause insulin action to differ from the action curve given in product literature or to vary from person to person include thickness of the subcutaneous fatty layer at an injection site, temperature, blood flow, exercise, and dose size. (The choice of injection site—abdomen, thigh, arm, buttock—does not seem to affect the absorption rate of rapid-acting insulin as it does for slower-acting insulins.) Injecting into areas that have more subcutaneous fat tends to slow insulin absorption. Widened blood vessels (caused by higher temperatures or exercise) allow insulin to be absorbed more quickly; constricted blood vessels (caused by colder temperatures or smoking) can cause slower absorption. Large doses of insulin may also be absorbed somewhat more slowly than smaller doses.

Thank you Ms. Warshaw. Since this is a lengthy article there’ll be more from Hope’s article over the next few posts.

From sun to snow and back to diabetes doings

Some would say “All good things must end” as my tropical travels are over; I left San Francisco’s sunlight and temperate 74 degrees to arrive home to New York City’s snow and freezing temperatures. But I am also of a mind that other good things will continue to happen this year. In fact, I have just been invited to speak at this year’s American Association of Diabetes Educator’s Conference in Atlanta August 5-8 — I will keep you posted. And, in a month or so there’ll be a Spanish version of The ABCs Of Loving Yourself With Diabetes available and I’ll be creating a self-management coaching book based on The ABCs for patients and educators.

Meanwhile, fellow blogger Amy Tenderich of DiabetesMine has passed along a notice and request for you to positively impact the future of diabetes care. I pass it along to you here. 

From Amy Tenderich on behalf of the Diabetes Community: “There are a lot of things going on at the troubled Food and Drug Administration (FDA) right now that could have a profound impact on the future of diabetes care, but most of us patients never hear about them… Most importantly, the FDA has created excessive regulatory hurdles that threaten to slam the door on progress in treating diabetes.  

  • Even Rebecca Killion, the FDA Patient Representative who sat in on the infamous Avandia andPfizer Exubera hearings, is speaking out against the commission’s latest moves. Please see this post for her public comments. 
We’re imploring the new FDA leadership to recognize the urgent need for more safe and effective treatment options for diabetes and to reduce barriers to innovation. Please see the online petition and letter at  We ask you to help speak out and get our voices as patients heard! This grassroots initiative is shooting for 20,000 signatures by mid-February.


Back, back, back in the USA

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It’s a slow re-entry here in San Francisco from Tokyo before heading home to New York. I would have liked to add a post while in Tokyo, but I was just too busy. Having lived in Tokyo for six years, from 1986-1992 and worked for Dentsu at the time, then the world’s largest advertising agency by billings, I was just having too good a time visiting friends and soaking up every lovely and kooky thing about Japan. 

Part of that soak included an overnight stay at an onsen (hot springs) in the countryside in a traditional Japanese inn with hot, relaxing baths both inside and under the stars. The kooky part included warm-seat high-tech-toilets in every major department store and restaurant with so many buttons for cleaning and air drying one’s self that I feared pressing any one of them– and often had to search voraciously just for the flush button.

Suffice to say my answer to Asia in general is: “Drink wine,” it will help lower your blood sugar after all the noodles and rice have raised it. And, as therapists advise, use your numbers as information, not an excuse to beat yourself up. My blood sugars throughout this trip have been far less “in the zone” than usual because my eating has veered from my routine low-carb diet and my exercise has been erratic. I tried for the most part to accept that and to see anew how different foods affect my blood sugar. Luckily, most of the time, I was successful in this attempt.

I did learn while in Japan that the rising epidemic of diabetes has not left them untouched, and why should it when McDonalds and Kentucky Fried Chicken are now staples. Also, one doesn’t speak of diabetes very openly. There are no TV commercials selling meters and strips and if you’re standing in the bookstore in the toonyobyo (diabetes) section you keep your voice down, because to have diabetes is seen as very unfortunate. The Japanese will admit to having “metabolic syndrome” much more easily than diabetes, for that is only a syndrome, while diabetes is an illness. And with many things Japanese, presentation is very important.

Yet, you can see my friends didn’t mind that I have diabetes, and in fact they used it as a great learning opportunity. They got to see up close what it really means to have and live with diabetes and how to take care of it. The constant shots and blood sugar testing were eye-opening, and of course gained much sympathy. And, my friends also went out of their way to provide the unofficial Japan launch of my book, The ABCs Of Loving Yourself With Diabetesat a Chinese restaurant. To my great surprise the book is posted on Amazon in Japan, as well as the U.S., as is also my new book arriving in book stores in July: The 50 Diabetes Myths That Can Ruin Your Life: And the 50 Diabetes Truths That Can Save It. 

In all, it’s been quite a ride. Home Saturday to nurse my coming depression ;(

A hospital where patient experience is paramount

Need a snack? Fruit-only


The Botanical Garden


Me and the CEO, Mr. Liak


Kind reminders to be healthy


 Can you imagine a hospital where floors are carpeted so you feel calm, soothed and protected? Where doors open silently so as not to jar your jangled nerves? Where vending machines are only filled with fresh fruit and the healthier the meal in the cafeteria the less it costs? How about elevator doors covered in exotic floral motifs and a Diabetes Center where you never wait more than ten minutes to be seen?

I could never have imagined these things but instead I saw them with my own eyes here in Singapore at the Alexandra Hospital. The hospital sits amid a lush and beautiful botanical garden that volunteer employees care for and each floor of the hospital has a view of greenery. In this tropical paradise even medicinal herbs are flowering in the gardens.

This hospital is the vision and result of its CEO, Mr. Liak, and his passionate staff. It is their mission to create a place of healing where people are helped to make healthy choices, even if it’s just taking the stairs instead of the elevator.  No wonder stairways are easily accessible throughout the hospital, not hidden behind impenetrable or locked doors, and they are marked by big wooden red hearts that say, “Please give your heart a lift, use the stairs.”

I had the pleasure to meet Mr. Liak and discuss the state of healthcare in Singapore and the U.S. and the work I am doing bringing a more positive attitude to managing diabetes. Mr. Liak spent three hours with me and my husband, who has worked with him in the past, generously sharing what some would call a contrarian view: give diabetes patients a year of treatment and education and if they improve and own their management, encourage them to be peer-mentors wherein they can give back, help other patients and help the hospital provide its services to more patients. If they don’t take responsibility for their care after a year, patients are free to seek help elsewhere and leave space for new patients at Alexandra Hospital.

To say the least it makes one think. In the U.S. the health care system does not particularly motivate patients to become self-reliant and responsible for their care, and we know this is paramount managing diabetes. In fact, I have heard upon occasion a critical tone from my own endocrinologist’s office when I come in for a yearly visit rather than every three months. But why do I need to come four times a year? I am a well-educated patient managing my diabetes daily and getting the necessary tests as appropriate. I can easily discuss my test results with my doctor over the phone and make any necessary adjustments. I am doing what medical professionals say they want patients to be capable of doing, managing my own diabetes!

After chatting about societal influences on health care and patient behavior, I gave Mr. Liak five copies of my book, The ABCs Of Loving Yourself With Diabetes. His face lit up, he loved it. He said this is what we need, a more cheerful and optimistic attitude about managing diabetes. And with that he toured my husband and I through the hospital halls including what resembled a “war room” filled with storyboards, flow charts and feedback circles reflecting plans for the new, expanded hospital they are building. At every touch-point in the new hospital the patient will be accommodated, from a simple registration process to remote controls where patients can control the light and air temperature of their room. Where room furniture is being built with drawers and countertops that allow patients to put more than one thing in and on them. And who is in the hospital bed photo testing all the equipment? None other than Mr. Liak himself.

Our tour stopped at the Diabetes Centre where I was introduced to the staff and two copies of my book were handed to the Diabetes Centre Director and diabetes nurse. Talk began of translating my book into the Malaysian language, Malay. Thank goodness my head had not grown so large that I could not still get it through the door to the cafeteria where our tour ended. And over a bowl of vegetables and tofu Mr. Liak told me it was a dream of his to employ someone such as myself to consult with his professional staff and help inspire and encourage other patients. Can you imagine? In Singapore, you don’t have to, it’s on the drawing boards.

Leaving Alexandra Hospital I thought if I ever need to be in the hospital maybe I would consider, if time permitted, hopping a flight to Singapore. Meanwhile, I’m happy to do what I can to help the staff and patients here. And now that I’ve finished this post, do what most people who are not in the hospital do in Singapore, shop. 

Slices of diabetes-life in 4 short stories

Through my friend who lives here in Sydney I had two contacts to make while here. One was with the General Manager (GM) of Diabetes Australia, no slouch there, although he was working in his wife’s candle shop when we met and absent shoes. Well, we are in Sydney mate. Diabetes Australia is the equivalent of the American Diabetes Association. Turns out after a nice chat he suggested I send him my new book when published this July, The 50 Diabetes Myths That Can Ruin Your Life: And the 50 Diabetes Truths That Can Save It, and he’ll get it to his media person to possibly distribute in Oz (that’s  Aussie-speak for Australia.)

The other meeting was with two mums of children with type 1. One is the mother of a five year old boy who had to be yanked out of public school because the principal didn’t want to deal with his diabetes and supply a nurse. Now the family are paying private school fees and she told me the law is very grey here as to what services a child is entitled to in regards to a school nurse. Actually the GM of Diabetes Australia said he’d be happy to advocate for her as last year Diabetes Australia took a case to court and won getting a type 1 ambulance driver’s job back. 

The other woman I met is the mother of an eight year old girl diagnosed almost a year ago. Since, she has become very involved in JDRF (Juvenile Diabetes Research Foundation) here and inspired many others. It is interesting to sit a world away and share the same stories and feelings. And I knew beside sharing my knowledge and experience that just having these two women see someone who’s in as good shape as I am after living with type 1 37 years that they would gain something invaluable. The eight year old’s mum sent me this response after our breakfast by the beach:

Hi Riva, 
It was lovely to meet you and I take loads of comfort in meeting folk like you who play to win with diabetes. Sometimes I may sound too blasé about diabetes; it is a tough 24/7 disease but I refuse to let it take me and Emily (her daughter) down so I hang on to every positive role model that I can and I know that one day she too will be sitting with someone else over breakfast and be sharing her positive story on diabetes; so a huge thank you. 

Later that day I also met Emily’s dad who is an accountant by trade and has been working nose-to-the-grindstone on an algorithm whereby people who use a pump can better optimize how much to dose and how often to test their blood sugar. My husband came to this meeting as well and being a “systems” guy shared that when dealing with diabetes there are many complex systems to take into account in addition to meds, like food, exercise, stress and emotional resilience. 

Emily’s dad nodded his head, and perhaps gripped his graphs and charts a little tighter. I suspected that they were what was helping him feel he can have perfect control over something he can’t, diabetes, and feel he can protect his child. 

One day I’m pretty sure Emily will be the one to let her dad know that life is O.K and that she is O.K. even living with diabetes, and maybe even recognize that in some way she is “all the more” for what she goes through managing this disease.