Help Wanted: Bolus tips and tricks

Hi everyone,
I am looking for your fantastic advice for some trouble I’ve been having with moderate carb + higher fat meals. My CDE’s standard answer for a meal like this is to do a 50/50 combo bolus over 2 hours. Been there, done that. I’ve tried a 40/60 split, a 35/65 split, a 60/40 split, whatever, and tried it over 3-4 hours instead of 2. And I don’t feel like I can get anywhere. Occasionally, I’ll run a temp basal for 2-4 hours after eating and that will sometimes help, but I usually can’t avoid a spike no matter what.
The usual scenario is this: I will run relatively flat for the first two hours, then will slowly rise, and sometimes rise very quickly (per my cgm) after that. Then the highs cling like an anxiety-ridden toddler to its mother. For hours and hours. I have recently done repeated basal testing, so it’s not that. I suppose my I:C ratios could be off a bit, but when I eat a meal without a lot of added fat, I don’t seem to have the problem.

For example: A couple of weeks ago, I had a ham and cheese sandwich for dinner. A 28 g carb roll, 2 thin slices of deli ham, and 2 thin slices of deli cheese. I went to bed at 155 with a correction on board, and must have slept through my cgm alarms, because I zipped right back up after that and was in the 200s all night. I think I took 5 corrections overnight and still wasn’t coming down. This will happen anytime I have anything with a moderate/high amount of fat.

At this point I am desperate. My CDE’s answer was that “there must have been another variable, you wouldn’t have remained high all night from a sandwich”. Except that it happens all the time. I already have several food allergies, so most of the go-tos for low carb are out for me, and for other reasons I’m not ready to share, I can’t low carb right now. Even a spoonful of peanut butter will send me up and I’ll be stuck there for hours.

Any thoughts or helpful hints or examples of what you do would be so appreciated. I know we are all different and respond in different ways, but I am truly desperate for help with this! Thanks!

Hi Shelby - It appears that you need more insulin in the period 2-5 hours after eating. I think you’re on the right track with trying a temp basal. If you write down what you eat, the up-front carb bolus, the temporary basal increase and % amount, and the resulting blood glucose numbers, then you could draw some cause and effect conclusions.

I wouldn’t be afraid to ramp up to even +200% temp bolus if you trial some lower percentage amounts leading up to that. It would probably be safer to experiment with earlier meals in the day so that it wouldn’t compromise your sleep safety.

You could experiment with the timing of the temp bolus with respect to meal time, but I would try setting it at meal time first, so that it would start to be felt two hours after the meal.

Once you find a temp basal that works, then you can convert that to a fixed insulin amount that you can deliver as an extended bolus.

I never liked the combo bolus based on percentage splits. It just seems too complicated when trying to analyze what happened after the fact.

I know what you mean about bringing a stubborn high down. I find it takes less insulin to keep it from rising than it does to bring it back down.

Good luck! Don’t give up. Experiment and write stuff down. It’s easier to analyze and make valid conclusions that way.

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I agree with @Terry4 that a 200% basal can be a good way to catch those. I’d think that the protein component might factor in a bit but it doesn’t sound like > 10G of protein so not likely > maybe 5G of carbs worth of protein from a couple oz of ham and cheese. Not really what I would consider a big pile of fat either, compared to say pizza or a bacon cheeseburger! One possible culprit might be the roll itself. 28G sounds like a pretty precise figure however I’ve used my scale to check pieces of bread and found they can be +/- > 5G of weight, for pieces from the same loaf. I haven’t checked rolls recently however it might be interesting to weigh the rest of the bag (if they came in a bag?) and see how they stack up? Another 5G of carbs might contribute to some adjustment there.

I usually only use combo boluses for bigger, fattier meals like pasta, pizza or the bacon cheeseburger. I usually add about 5G of carbs to my guess for sandwiches to cover the protein, fat, whatever’s in the mustard, spinach (I started using spinach instead of lettuce a while ago, as it’s better for you and yummy!), etc. If it’s a bigger hunk of stuff, I use 10G figuring a moderately sized burger is about 20G of protein or 10G converted. If it’s a big meal and I want to use a combo, I put about 75% up front and the rest over 3-3/12 hours depending on what I’m up to. Sometimes, I don’t want to manage IOB that long but it seems to work reasonably well.

I’d do the bolus ahead of time. Most rolls seem to jack up my BG pretty quickly. One trick I use is to set my kitchen timer for like 15 minutes. We have one really handy on our stove so I just set it and wait for the beep!

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I empathize with shelby 76 and echo much of what she said and often face similar challenges, also unexplained. Last night for dinner I bolused one unit of insulin to cover 15 g carbs for dinner that consisted of pan sauteed chicken thighs, green beans, endive, avocado, 1/2 cup raspberries, less than 1/2 cup soy milk and Haagen Daz Vanilla ice cream - measured to 6 g carbs on a scale. Two hours after the meal, BG was 104. That’s pretty good. Then the Dexcom showed that there was a slow rise to 128 3 hours after the meal. I was watching a scary movie, Insidious. Does that have something to do with the rise? Was the fat from the ice cream that caused the rise? The ice cream was 6 g of carbs which isn’t a lot of ice cream. Any help would be greatly appreciated! Thanks.

When you add in the protein, is it only for combo boluses or any bolus? I am experimenting with this and have had mixed results.

If you only went up to 128, I wouldn’t worry :-). Your blood sugar was essentially normal at 2 hours and you never even hit 140. I suggest correcting with a whiff of insulin at 4 hours and declare victory.


The rule of thumb I’d seen, probably here or maybe even the ADA forums when I used to hang out there is 53% of protein converts and 9% of fat, which I am totally comfortable approximating to 50% and 10%. So if a 1/4 lb burger is c. 20G of protein, it would have a carb equivalent of 10G that I have been comfortable adding in for a while now. The combo depends on how I want the insulin to hit. Ideally, I’ll do some combo with a big hunk of protein and, with say an 18G of carb bun, a 20G of protein burger and, oh what the hell, 13G of carb worth of potato chips, it would come to about 31G of straight carbs but maybe toss in another 10 for the burger, do 75% up front (pretty much the 31…) and the spread the rest out for 2-4 hours, depending on how things are going. And if say this is lunch, and I was gonna run after work, I’d skip the extending as that would leave more IOB than I’d want on board.

Thanks still_young_at_heart. n
Stayed below 140, didn’t whiff or snort any inhalable insulin (that Afreeza actually sounded fast acting from having read the other posts. It’d be nice if it were less expensive, more available and measurable).

acidrock23, I feel like an idiot because I do not count protein or fat in my carb counting! When I count my carbs, I don’t count green vegetables (for ex :broccoli), meat/fish/any animal; nor do I count fat (cheese, oils, avocado). Am I showing my lack of experience? darn…carb counting is difficult! How much of a mistake would I be making in a meal if I ignored chicken thighs, avocado, haricot verts? (I count tomatoes, red peppers)

Don’t ever feel like an idiot @lh378! One interesting concept discussed by Dr. Stephen Ponder in “Sugar Surfing” is that counting carbs is, to some degree, a “false idol” in which we shouldn’t drive ourselves crazy about. I just use a “boost” in counts when there’s other food groups involved. Another thing to consider is that if you generally eat items in those groups, you will perceive the impact on your carb: insulin ratio and, at least the way I do things, artificially “cook” your ratio to anticipate and “cover” the carb counting error through a different sort of math, if that makes sense. I just add 5-10G of carbs to cover miscellaneous and, if it seems like there’s more, a salad or whatever, toss in some more. It doesn’t have to be a huge amount but I find that fine tuning and contemplating what I’m eating can help and this seemingly flaky approach seems to work for me. But it might not work for someone who is interested in being super precise.

But being super precise can lead to errors too. I’ve gone so far as to weigh different pieces of bread from the same loaf (rated at 15-30G of carbs/ 35-40G slice…) and have seen quite a bit of variance.

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I wonder what sort of roll it was.

I find that with sourdough bread products found in a lot of deli type sandwiches, pizza, paninis, pretzels, etc, that I have to double the listed carbs and frequently those “extra” carbs don’t kick in for some 2-5 hours after eating. Add to that the need to increase your correction factor when your BG rises above 200, and there’s a recipe for a long night of high BG.

I therefore try to avoid sourdough, but that doesn’t always compute to life in the real world. Another tactic is to eat those items earlier in the day, so I am awake while trying to combat the belated high BGs. I also, use a variety of temporary basal rates or extended bolusing to work against the highs. I frequently don’t start them for 3 hours AFTER eating. Doing a combo bolus will frequently cause me to run low 2 hours after eating.

I looked up “Pretzel Roll” once and discovered they can be rated at like 60-70G of carbs! I will admit to having eaten them, but it may have only been once, probably because of my memory of the huge mess to be cleaned up on the back end.

I read somewhere that sourdough is supposed to “slow” absorption but
I find if I eat some and don’t count in at least 10 more carbs and/or get some exercise right away, I will spike. So, sourdough has to be just an occasional treat for me.

Oh yeah, and that’s even waiting 30 minutes after bolusing!

Thanks @Terry4. I did forget to mention that I do try and pre-bolus for everything and that obviously makes a big difference. What I am terrible at doing, and need to be much better at, is writing things down. I just hate it and find it so tedious. And it seems that I never get the same result twice anyway! As a point of clarification for both you and @acidrock23, how do you view the % of a temp basal? When you say 200%, do you mean the basal rate doubled, or 200% of the basal rate, thus quadrupling it? So the basal rate itself is the first 100%. I guess I have always looked at the basal rate as ground zero, so anything above that starts at 1% and so on. Does that make sense? I think you are saying to double the basal rate with a 200% temp, correct?
I guess the other thing that frustrates me is that I never know when a meal is going to hit me like this. This one in particular didn’t seem like it would give me such trouble. I do like the idea of converting the temp basal to an extended bolus. Almost like a superbolus but over time rather than upfront. Thanks for your thoughts!

Thanks @acidrock23. I have not been very good about bolusing for protein…something I have picked up on this forum but was never taught (like most D-strategies, I’m afraid). I got the carb count for the roll off of myfitnesspal. It was a roll from the bakery at the grocery store, so who knows how accurate the number was? And it was white, so I should know better, but sometimes it just happens!
It’s interesting that you mentioned Sugar Surfing. I had just downloaded it and started reading through it a few days ago. I’m not sure how comfortable I am with his ‘intuitive’ approach to management, as I’m definitely someone whose brain works better with precision, but that comes from growing up doing exchanges, I’m sure, as well as my personality. Some of those habits are hard to break, especially when you’re told you don’t have to do exchanges anymore, but you can eat whatever you want, as long as you bolus for it.
I have been trying to add in those little bits of extra bolusing for things like salads and veggies, rather than leave them out or try to count them precisely, and I can see where that’s made a difference. I do also pre-bolus as often as I can, which I forgot to mention in my OP. Thanks again for your input…very helpful!

I’ve never heard of having to increase your correction factor when you’re over 200. Tell me more! And it was a white roll…sometimes I just hate having to make a different food for myself than I’m making for the rest of the family, and this was one of those nights that I succumbed and paid for it later. :disappointed:

I find that for BG readings over about 250, that my correction factor goes to 1:50 for 1:60. That’s my practical way of handling it, the reality is there must be some continuum as my BG creeps up, say 1:55 @ 180.

“Exchanges”–dear god! There’s a blast from the unpleasant past. I never could get the hang of that whole business. Though I did at least manage to get the idea back in my R/NPH days that you had to account for fats and proteins–it wasn’t all about just carbs. The training for MDI and pumping is so focused on carb-counting that they really neglect this side of the equation I think.

On my Animas Ping pump, +100% temp basal doubles the basal rate. A +200% basal is 4x the usual basal rate. In essence, my suggestion was to trial an extended bolus as a temp basal rate increase.

I’ve enjoyed good results from using an immediate bolus as well as an extended bolus for each meal. For dinner tonight I delivered 1.3 units immediately to cover carbs and then took 3.7 units over three hours for the protein and fat.

I don’t suggest to log everything beyond solving this problem. I find I can untangle BG problems more quickly if I document what I’m doing. I could never put up with the tedium of documenting all the time. Yikes! :grinning:


Have you experimented with adding insulin to account for fat and protein?

There was a thread on another diabetes forum that I frequent that discussed using a fat-protein-unit (FPU) exchange method as a way to counteract delayed BG spikes (or for me, spiking immediately and staying high for four hours) because of the meal containing larger amounts of fat and protein. With the FPU method, every 100kcals that are from fat and protein is equal to 10g of carbs, or one FPU unit (I look at it as approximately a 1:1g fat to carb conversion and a 2.5:1g protein to carb conversion). The bolus is a dual-wave with the initial bolus covering the calculated net carbohydrates and the wave bolus covering the fat and protein part of the dosage (the duration of the wave depends on how many FPUs are present).

I’ve been experimenting with accounting for fat and protein for the past few days (for some meals, I add a half hour pre-bolus), and I noticed that it’s been helping a ton with some problem foods and breakfast. Some foods would normally spike me into the 200s very quickly and keep me there for hours (curse you, Chick fil a cool wrap and side salad), but doing the FPU method with a pre-bolus caused me to experience no spike at all with the meal.

That’s interesting…I don’t ever remember being taught to account for protein/fat back when I started on R/NPH. The only thing I remember being told was to have protein with my bedtime snack to keep that nasty middle-of-the-night NPH low from creeping up on me. Which sometimes worked, and sometimes didn’t. Of course, I was an older teenager at diagnosis, and probably didn’t get much info beyond the basics and my parents didn’t do much management on my behalf, so who knows what made it into my hormone-addled brain back then? :wink: