My seven year old son, who has type 1, is having lows one hour after dinner and sometimes after lunch. He is on NovoLog and Lantus. We adjust in small portions, i.e., one-half glucose or two carbohydrates at a time but he still ends up high at the end of five hours. This confirms that our carbohydrate count is correct, but the insulin is not digested at the same time as the foods. We know NovoLog peaks at between one and two hours, but when is food actually digested into the bloodstream? We get the impression that, for example, brown rice can take up to four hours and, if he eats a high percentage of carbohydrates of rice, he will have a low. We’ve tried giving the NovoLog after dinner, but with similar consequences. Do you have any ideas? Is this common? Today, it happened with white pasta.

Congratulations! You have recognized that “not all carbohydrates are created equal.” Not only do some more starchy foods have a different “glycemic index,” but other foods taken at the same time may alter the digestion. For example, quite commonly, fatty foods slow digestion.

You wrote that the “insulin is not digested at the same time.” I don’t know what that means, since insulin is not taken by mouth and is not digested at all. But, if you mean that the insulin is not metabolized best to match with what he eats, then that is true — especially relative to meals.

Diabetes management by shots or even insulin pumps is not at all perfect. We estimate the best we can constantly to balance meals, activities, and insulins. An insulin pump, while more cumbersome, can attempt to fine-tune things even more for you.

I would first talk with your local Diabetes Team about adjusting your “insulin-to-carbohydrate” ratio. You did not indicate what it was but if, for example, you dose 1 unit of NovoLog for each 10 grams of carbs that he consumes and then the glucose bottoms out an hour later, perhaps he might only need 1 unit for every 15 grams of carbohydrates. Talk to your team, especially the dietician, about high and low-glycemic index foods. You must also allow some recognition of his activity relative to meals, etc.

DS