Does anyone bolus for protein and fat a little later than the bolus for carbs? I have been bolusing for protein and fat right after the carbs in a separate bolus, but am beginning to think that I should do the second one about 30 minutes later. That seems to be more like a real pancreas action. What do you think? I have read Pumping Insulin, Sugar Surfing, Dr B. and Think Like a Pancreas. I just wanted some input from some other experts…you.
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I do think that the protein/fat bolus, if taken as an extended pump bolus over time, can deliver good results even if delayed by 30 minutes. I’ve used it that way when I’ve forgotten to deliver it right away as I usually do.
Remember that it’ll take endogenous insulin about 20-30 minutes to begin action. I say, do the experiment and find out what’s true for you! I’m curious as to others experience, too.
Thanks, Terry. You helped me before learning to do the extended bolus. I have been using it every meal since and have had better results than when I didn’t count protein and fat. I always prebolus by 20 minutes unless circumstances prevent it. I appreciate your input. I consider you one of the experts here.
I bolus for carbs before my meal and for those proteins that raise my BG, notably red meats and pork in my case, I bolus after I finish my meal using a slower absorption injection site. This has eliminated delayed post-meal highs I used to get when eating those proteins. I tried bolusing for both before my meals but it caused me lows followed by highs! Luckily, I don’t eat those types of proteins very often.
I bolus for protein counting half the grams of protein as carbs. I also “modify” my bolus based on protein or fat. If I have a high fat or high protein meal I will often delay or split my bolus to account for longer digestion times.
If I’m going to eat a meal dominated by protein, I use Regular insulin since its slower action matches up better with the slower digestion of protein. If the meal is high in carbs, I use a faster acting insulin that peaks sooner. It all depends.
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how do you calculate how much to bolus for protein and fat? I’m trying to do basal testing with my 2-year-old son, who is too young to fast, so i’ve been giving him one zero carb meal a day and then seeing how his basal dose is affecting things. But he seems to be having a very slow, steady, pronounced rise after these meals and so I’m not sure how to disentangle the meal from the basal requirements.
Bernstein discusses the rate at which protein is converted to carbohydrate in chapter 9. I use the ratios he describes and for me, at least, they seem pretty accurate.
Fat is another matter; I’ve never been able to determine a practical guideline because what it’s eaten in combination with seems to make a really huge difference . The only allowance I make for fat is when a meal is high in fat, e.g., ice cream (which I seldom eat but which makes the point well). In that case I will bolus for slightly less than the actual carb count because I know the fat will slow down absorption significantly.
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That is very interesting. I will have to try this. I have never used ‘regular insulin’! What is its name and how long does it hang around in your blood?
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Regular insulin is the nearest thing there was to “fast” before the true fast acting analog insulins were invented. It is sold under several brand names; Lilly’s is called Humulin R. Novo Nordisk makes a version too, and Walmart sells one also (I don’t know who makes it for them). It has been around long enough that it’s now off patent and—at least where I live—can be purchased without a prescription. In fact, it’s the first insulin I used, before I had any prescriptions. 
The advantage for me, as mentioned above, is that it ISN’T as fast acting as the newer analogs. Its onset is slower (40 minutes for me as compared with 15 for Apidra), and it has a longer “tail”, i.e., it has a lesser peak and stays in the system longer. That’s why I use it for high-protein meals.
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@David_dns - how’d you get your doctor to prescribe multiple insulins for mealtime, and did your insurance company give you any hassle?
This was like I was thinking. Thanks for responding.
I also count half the protein and ten percent of the fat. I consider what I eat when I am deciding on how long to extend it. I have felt that the insulin was on its way out by the time the protein gets digested, hence the discussion. Thank you for replying.
I have regular insulin in my stash if the world gets in crisis mode. I asked the endo about the IC ratio and she said I may need a little more than apidra. Do you find that to be the case? I always appreciate your input. I think you and I were both 57 when diagnosed if I remember correctly.
The short, snappy answer is that I have a good doctor. The truth is actually that, but it’s not an accident. The last time I was faced with needing to change doctors, I went to the trouble of sitting down and interviewing prospective ones. When I found one who actually said (in these words), “I don’t know everything” and who I could see would treat me like a teammate instead of a wayward, insubordinate employee, I became his patient. (He doesn’t know this yet, but I am going to forbid him to retire.)
What that means is that we collaborate. When he thinks I should do something, he explains the reasons why and we work through to a consensus. When I want to do something (like, hypothetically, use three different insulins 
) the same process takes place. In this case, we discussed the specific purpose of each one, and he understood. Nor does it hurt that he can see the good numbers that result.
As far as insurance goes, I have had one problem but that’s not it. As of January 1, my drug plan dropped one of my insulins from its formulary, so I have to pay retail for it until I can choose a new drug plan in the Fall. Grrrrrrr. That’s another rant for another time.
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I have the good doctor. I meant, more, how did you explain what you wanted and how you planned to use it.
I’ve pondered, as of late, if a slower-acting insulin might be better for high-fat meals. Or I could just keep splitting my bolus I suppose. It works, but then I have to set a timer, take two shots.
I don’t eat out enough at high-fat/-high-carb places like Mexican but maybe once a week, and pizza twice a month. I might be able to get her to just give me a couple of Humalog pen samples. That’d last me a couple of months if I only used that once in awhile.
Very straightforwardly. The basal is for . . . well, basal. The Regular, with its slower action, is for protein-dominated meals. The fast acting is for carb-dominated meals or rapid corrections. QED.
I have only found a few types of foods where I need to use the dual wave. One of them is pizza, I do 75% up front and delay the other 25% over 3 hours. Sometimes a really creamy or gravy-laden dish I will do the same thing but only an hour. Everything else, I have better luck just giving it all up front and just checking myself about 90 min. later and correcting if necessary, but that’s not very often.
My reply applies to pump users mainly. For high-protein, high-fat meals, I’ve had the best results with extended boluses (or, equivalently, high temp basals) activated well before the meal, about an hour or so ahead. I keep such high temps for about 3-4 hours at the level of about 4-5 times my normal basal rate. Once I know what the meal is, I standard bolus for the carbs only. Given that high-temp is already working, pre-bolusing is not very critical, as long as the meal does contain significant amount of fat. Finally, I use CGM to shorten or extend the high temp as needed. In my experience, there are a number of advantages to this tactic:
- some up-front insulin signals the liver to absorb incoming glucose (similar to phase 1 insulin response in sugar-normal people)
- the extended insulin wave seems to well match the relatively slow protein-to-glucose conversion
- knowledge of protein or fat content does not seem to be very critical - I do not need to know up front what I am going to eat as long as I know there is going to be “plenty” of protein+fat.
- timing is not very critical; high temp an hour before the meal seems to work fine, but I’ve had reasonably good results with anything between 0.5 and 1.5 hours.
- the pre-temp is safer than classical pre-bolusing. If the meal plans change, I know I can just abort the high temp and correct if needed with relatively small amounts of fast carbs.
I’ve been doing this in many situations that are considered “difficult,” including social events, restaurants, etc. To illustrate, here is an example.
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Wow - I did not know that endogenous insulin takes 20-30 minutes to begin action. 
That’s slow.