My current Medtronic pump and previous Medtronic pumps (that I can remember) have all had a nice feature called the “Bolus Wizard”. The bolus wizard was made to help take the mathematics out of diabetes, or at least ease the pressure of needing a math degree to stay healthy. Based on your blood sugar, your carb count, your insulin to carb ratio (I:C ratio) and your correction factor, it will figure out how much insulin you need for a meal or for a blood sugar correction. I rely on it so much now that I’m not sure I could even tell you my I:C ratio (I now have 4 different I:C ratios so that complicates things further).
This feature is so nice but before I got pregnant, it was a feature that I used about 25% of the time and mainly just for a correction. I got my first insulin pump back in 1997. I can’t recall when Medtronic added the bolus wizard feature but I know in my 20’s (I got pregnant right after I turned 30) I never used it. I’ve gone back and looked at notes from my endocrinologist visits and every appointment for the past ten years was a note that I need to use my bolus wizard more. My old endocrinologist in Northern Virginia would get mad at me every visit because I wouldn’t use my bolus wizard. Luckily, I only saw her once a year because she would look at my Medtronic reports and see that I wasn’t using my bolus wizard so she would yell at me and tell me she can’t help me to make corrections to my I:C ratios or basal rates because she couldn’t make any sense of my numbers since I didn’t use the bolus wizard. The other three visits per year (since I would go quarterly) were spent with the nurse practitioner at the endocrinologist’s office and she would actually look at my data and ask me questions to help analyze what was going on (but that’s a whole other story).
So, why would I not use the bolus wizard and subject myself to lectures every time? Because I didn’t trust the bolus wizard. Before getting pregnant (or trying to conceive) I can’t recall if I ever did any basal testing. I definitely didn’t carb count. I would pig out on chips and randomly put in 3 units of insulin to cover the over-indulgement. I didn’t trust my bolus wizard because I didn’t have good basal rates or even good I:C ratios, so when I would use my bolus wizard it would usually result in a low. I spent my 20’s just winging it when it came to my diabetes care.
I still remember when I graduated college I saw a great nutritionist (Hope Warshaw, who is actually AADE’s 2015 President) and she took one look at my basal to bolus ratio, which was around 90/10 and realized I needed a change. I’m not sure why my college endocrinologist didn’t realize that but it made me realize the poor care I got while in college. I made some changes during that visit, but unfortunately, my insurance only covered one visit to see Hope. Since I had just graduated college, I wasn’t in the place to afford going to see her more on my own so I wasn’t able to get my rates perfected. At the time I graduated college, I hardly ever put insulin in to cover carbs. I would eat just so I wouldn’t go low because my basal rates were so high. Thanks to the visit to Hope, things started to improve.
My visit with the nutritionist got me going in the right direction with getting my diabetes in control and after seeing her, I started to see the endocrinologist in the area that I saw for the remainder of my time in the area until I moved to Richmond two years ago. Because that endocrinologist would look at my reports and tell me she couldn’t make any sense of them because I wasn’t using my bolus wizard, I never got to improve my care. Like I said the nurse practitioner worked with me so I was improving my care but it was a slow process.
Because I never had good rates, I never trusted my bolus wizard. But if I’m being honest, I never carb counted either. I would go out to lunch with coworkers or out to dinner or happy hour with friends and I would just wing it all. I never measured anything. I knew which foods had more carbs than others so if I was going to eat a 75 carb bagel from Panera, I would place it in the higher carb category and maybe bolus 3 units, versus a lower carb food where I would bolus 1 unit. It made no sense but somehow I got by. I still remember going to McDonald’s and getting an 8 piece chicken nugget and large french fry and bolusing about 2-3 units. The meal has around 80+ carbs in it so now I would need like 8 units to cover it! I can’t believe I would eat that and hardly bolus anything. My A1Cs throughout my 20’s were in the 8’s and started to get in the 7’s as I approached 30.
Since I never really carb counted, I’ve spent the last two years “learning” how many carbs are in certain foods. For the most part, I eat the same thing so I have mastered carb counting. Problems arise when I go out to eat and going out to eat always seems to be a problem for me. I ALWAYS under count french fries. I usually under count how many carbs are in bread. The other night I went out and thought I did a good job carb counting for onion rings and hush puppies but I think hush puppies had a lot more carbs than I realized and I was fighting a high all night.
Given my history with carb counting and my bolus wizard/insulin pump settings, what has changed recently to where I now trust my bolus wizard? Well several things have changed. The first was the introduction to my continuous glucose monitor (CGM). My CGM made me aware of how bad my blood sugars were. Having to set a high alert on my pump was sort of the pushing factor. I think joining the Diabetes Online Community had a lot of help with that too because I had my high setting initially at 240mg/dl and I slowly learned through blogs and tweets that 240 probably wasn’t the best (not that I didn’t already know that but I was sort of in denial). I saw people who had high alerts under 200 and thought “wow, they are amazing”, not realizing that I could get there myself. The third factor was deciding I wanted to try and conceive. I couldn’t continue on going to bed at 200 to avoid lows overnight if I wanted to get my A1C below seven to try to conceive.
Because of these three factors, I decided to be proactive. When I moved to Richmond it took me a LONG time to find a good endocrinologist, but I didn’t let that deter me from getting my blood sugars in control. I started basal testing and got my basal rates in good shape. This was the first step towards trusting my bolus wizard. If my basal rates were good then I knew when I used my bolus wizard the results were a direct consequence of my I:C ratio being off. If I was high after using the bolus wizard, then maybe my I:C ratio needed changing. However, I think the main factor that has contributed to my 100% use of the bolus wizard was working with my current CDE. Every week we review my blood sugars and make changes to my I:C ratio and basal rates. While reviewing every week is pretty aggressive, I think once I’m not pregnant, it will be a lot easier to get these rates good and only need to review them every few months or so.
I guess my takeaway from this post is that endocrinologist shouldn’t discount their patients as not caring or not trying. If they aren’t doing something like not using their bolus wizard, there could be a good reason. For me, I didn’t trust my bolus wizard and while I tried to convey that to my endocrinologist, she didn’t listen to me. She thought since I wasn’t using it, how would I know I couldn’t trust it. However, I did try to use it and often went low (something I feared until getting pregnant). So it was just easier for me to “wing it” then risk going low. Since I found a team of doctors (my current CDE and endo) that actually take time to analyze my reports with me and make changes, I’m using my bolus wizard 100% and my diabetes care has improved a TON (last A1C was 5.5!).