How would you handle this combo bolus situation?

Lets pretend we all have the same requirements, ICR’s etc…

The meal is a double double burger and fries from In -N-Out. Your I:C is 1/10 and your pre-meal BG is 135. The Burger has 39 carbs in it, and the fries have 54.
Burger has 37 grams of protein, 41 grams of fat. Fries have 7 grams of protein and 18 grams of fat.

Using the info above, How would you calculate your percentages? 70-30 over three hours? Bolus for all the carbs up front and square the protein?

I realize we all have different requirements, and this is only for discussion sake.

Your I:C ratio suggests a need for 9.3 units. You do not mention wht your BG goal is (mine is 100) so for me I would need to dose for the 35 points og BG above my goal. You also do not mention what your correction factor is. Mine is 1:18 - therefore for me a 135 BG befor ethe meal would require 2 units insulin. Grand total wold be 11.3 units.

Combo bous I use is to cover the 2 units for correction immediately plus 20-25% of the meal bolus immediately. Therefore I would do about 4.5 units immediately and the remainder over 1 hour.

The 1 hour works very well for me for most meals - even those like you suggest. Pasta and pizza I do maybe 3 hours. Everyone is different and you would have to test trial different lengths to see what works for you.

I would suggest skipping the burger and fries and order a nice salad!

70/40 over 3 hours.

I may even do 75/35 because my target is lower than your pre-meal. Also are you pumping Humalog / Novolog or Apidra?

If so, then I would tweak the numbers even more.

That is a TOUGH meal. For me, the super-fast carbs of the fries and bun, plus the extremely high protein & fat of the burger = doomed to be up all night testing and correcting. But it’s IN-N-OUT, so it’s definitely worth trying to find a way. It’s the only “fast food” I would even consider. Yummmmmm…

Despite the fat & protein issues, I would probably still need to bolus for the entire meal’s carbs up front. 100%. Those fries hit me hard and FAST. I know that would be the case for a single burger in this scenario. The double-double might change that though since there’s a lot more fat. Ok, so I would likely either bolus for the carbs 100% up front, or do a slight combo, maybe around 70/30 for an hour. I usually give my Humalog 25-ish minutes before eating and I would definitely still do that here, especially since 135 is over my target bg for pre-meal and would have a correction bolus involved as well.

After dealing with the carbs (either up front or combo’d an hour), I would then have to think about a second bolus for the protein. The double burger would definitely spike my bg way down the road. For me it’s usually in the 4-6 hour range. This is where it gets tricky. I would probably take the protein (37g in this case) and treat about 60-70% of that as if it were carbs. So I’d bolus for 20-25g of carbs and spread it over 4 hours or so.

It’s a tough one!

What, no chocolate shake?!!!

Seriously, take your best guess and refine your combo method every time you eat that meal. And don’t do what I’ve done which is forget to write down my latest best guess!

My cell phone is maxed out with notes on how to bolus for different meals, so I printed out a full list and put it in my glove compartment.

Wow, Don, my cell phone is the same way! I have all these little notes about how I bolused for an out-of-the-ordinary meal, what my BGs were like afterward, and what I think I should do differently if I have that meal again.

Writing it down is key!

Seeing as I use MDI and have no pumping experience whatsoever, I would probably take 10u (don’t forget that ketchup has a few carbs in it too) after I eat. It will cover the late spike a little better than if I took it before and there are some days when I can’t finish a meal like that, and I would rather not be trying to scrounge up 15 carbs on a full stomach.

Just realized this was in the pumping forum… oops. Well, thats what I would do anyway


Ok, this meal was my meal yesterday. I ask though, because there are a few threads (great threads) about square waving, and combo bolusing, but I see very few actual numbers. Even the info I get from the diabetes teachers has no hard data. I us=understand that each of us is different, but I want to see your data. I want to compare and contrast and maybe come up with a rational solution that might work better for me. Thanks for sharing, btw.

So, I tested before I had this meal, and I was 139 or so. I did what I normaly would have done, 10 or so units, 70/30 over one hour. The following four hours I hung out at about 215, with the spike going up to 260. I think I should have drawn out the 30% more than 1 hour. My workbooks say meals with this much fat should be extended 3-4 hours. I’ll try this next time. Its just really frustrating giving correction boluses, only to see no change.

Hi Chris,
Most of my combo boluses are trial and error, but here is an idea of what is working for me. Generally I only bolus for carbs (not using TAg yet!)

Regular meals/healthy-like chicken, veggies, and rice–I take the full bolus for the carbs before eating.
Pizza-I take the bolus at 60/40 over 1.5 hours
Pasta-takes forever for me! So I take 30/70 over 3 to 3.5 hours.
Burgers and fries-50/50 over 2 hours

Good luck figuring out your ratios!

12u, 50/50 over 3 hours I think would work… the fat delays the absorbtion of the carbs, but the protein will also kick in later.

That’s what I’d do, anyways :slight_smile:

And no judgements here… I actually do eat like this sometimes.

Nadine - this is the 3rd time today I’ve come across this TAg word. I’m going to have to do some research.

Chris - that is one HUGE meal. I couldn’t even contemplate eating it. My meals tend to be in the 30 g carb range, and only once in a blue moon have I gone up to 60 g (I just about flipped out at the amount of insulin I took). I overestimated - and ended in the dog house later. I generally would do a combo bolus, but as others have said, it’s hit and miss. Depends on the position of the moon / stars … :wink:

i love:

  1. pint(s) of Guinness
  2. hot wings(to go with the pints)
  3. steak and garlic mashed potatoes

being a new to the pump i have tried to combo bolus with limited success. although, yesterday at my daughters birthday party we had pizza and cake and beer for the grow ups. my bg only went up to 10 mmol (i have metric blood) average but spiked to 16 in the morning. its definitely like throwing darts blind folded to me. hopefully in time i’ll get the hang of it.

so to answer your question…I have no idea…sorry…but love the topic

Metric blood… Love it!

Me too; hello there fellow Canadian!

well, I did the exact meal today, (was at Fishermans Wharf, shoot me, please!). My weekends are much harder on my sugars than during the week. I finally got my BG down to 146 pre double double and half an order of fries. I did 6 units (1/10) 50/50 over 2.5 hours and my BG is 119 right now. I have about 1.2 units on board as of now, so I might go a bit low, but we will see.