MDI strategies for dealing with tricky meals (rice, pasta, cheesecake..etc)

Hi All,

I am on MDI and am looking for guidance dealing with tricky meals. I define tricky meals as those that cause my BG to rise after 2, 3 possibly 4 hours. In my case, I noticed that if the meal contains rice, pasta, some types of bread, cheesecake, even if the BG is <140 at 2 hours, BG at 3 or 4 hours are >140. (Many PWD have chosen to avoid all grains and stay with LCHF. I would like to know if anyone has successfully managed grains, fats and BG FYI - I do not eat cheesecake all the time,LOL; only once every few weeks.)

I’ve read elsewhere that pumpers would use extended bolus. How do we mimic if we use MDI? do I inject small quantities of insulin once an hour for 2 to 3 hours?

When I was on MDI, I used to give ~70% of my insulin just prior to eating and ~30% at two hours. Seems to work just as well as an extended bolus on my pump does.

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I’ve always been on MDI, never a pump. My strategy for difficult meals is pretty much what you described: repeated incremental doses of insulin.The amounts depend on the specific meal and timing, of course, but that basic technique is what works for me.

I have a healthy respect for insulin so I wish to not over inject insulin.

@Jen. Do you separate the injection times by 2 hours with more insulin at the beginning of the meal? I’ve experimented thus far with just a little more insulin in my second injection (2.5 units for the first injection, 3 units for the second injection; the time separation between the two injections is about 1 hour - BG was 144 at 2.5 hour after the second injection.) My BG management is not the greatest. I have yet to reach the elusive target of 100. I would really like to have a bedtime BG of 100. Presently, the best that I’ve done is about 125 after a 0.5 unit correction from 140’s.

Yes, I took the amount of insulin that I needed to cover the food and gave about 2/3 up front and 1/3 after about an hour and a half to two hours. I should note that my BG control has never been extremely tight and I’ve always had daily highs and lows. On MDI, the lowest A1c I ever achieved was about 7.3% or so. On a pump and especially with a CGM it’s been lower, but I’ve never in 25 years had an A1c in the 5% range. So I may not be the best example if you are looking for ultra-tight control, but I found the strategy I used helped (though I had no CGM at the time, being ten years since I’ve used MDI, so it’s very likely that I was breaking >140 mg/dl and didn’t know it, since I find it difficult to stay <140 mg/dl after eating any carbohydrates even with a pump and CGM!).

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@David_dns - how many times is the “repeated”? Anecdotes will help me put things into perspective. Thanks!

I do follow a relatively LCHF diet, but I am also MDI and do occasionally ahve some rice and higher carbohydrate foods.

Like the others have suggested, the only way I can keep my BGL in a range I am happy with is multiple injections with meals. I tend to give all my insulin for my carbohydrates with my meal, and then two hours after that I give a lesser amount, which is usually about half of what I gave for my carbohydrates, to cover the rise I get in the 3-4 hour post-meal period.

As far as I can gather, this 3-4 hour rise seems to largely be related to Protein.

Like everything, it depends on specific circumstances. From lots of practice, I have gotten reasonably good at estimating. Meals that are mostly protein are fairly easy. I use R for those meals because it has a slower response curve, which lines up better with the slow digestion of protein. In a case where I can’t estimate very well, e.g., dining out, I will usually check at 2 or 3 hours to see whether a rise is occurring. If not, then I go away happy. If so, I take a dose of fast acting insulin based on my best estimate of how much more there is to digest. Again, experience is the best (really the only) teacher.

For a high-carb meal, I will bolus with fast acting based on my best estimate of the amount of carb, then test hourly and take additional small dose(s) iif the spike isn’t coming down fast enough to suit me.

I see - a lot of testing. Got it. Thanks.

so @David_dns, next time you go to that fabulous breakfast spot and have the full-on meal with the creme brulee French toast and/or other tantalizing sounding platters, I’d love to know your bgs and boluses.

I’ll try to remember. That place is a VERY occasional treat. Once a year (maybe twice in a good year).

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I do MDIs and have found that if I give half my bolus about 30-40 minutes before the meal and the other half as I start to eat I do reasonably well. With Thai or Vietnamese food, I may still need a correction since it is hard to estimate carbs in sauces. Also, I strictly limit the amount of rice (1/4-1/3 cup) that I eat with stirfry or curry.

I try to limit the rice to 1/3 cup too. It’s very little rice. ( I realize that many on LCHF have succeeded in maintaining A1C’s in the 5’s or 6 range. Also LCHF would mean no grains. I like the combination of rice with my protein meats…etc) I am wondering if anyone has been successful in having rice (1/2 cup to 1 cup) and maintaining reasonable BG.

With Afrezza, I expect that eating more rice or pasta would not be a problem (but I only have 4-unit cartridges right now and am saving them for corrections). On MDIs, I’d need additional insulin or some moderate exercise to cover those extra carbs. I must admit that eating a limited amount of carbs (tho’ not low carb) I am able to keep my weight stable.

If you don’t want to go LCHF, with more work you may get better levels than you have now. You may need to multi-bolus to cover a 6 hr period. Ideally you can get a CGM for a couple of months, I don’t know if your endo could access a loan/hire of the hardware and you buy the sensors.
some I’ve read use a rapid and/or a regular to get the desired action curve.

what hasn’t been mentioned yet is that a high fat meal, may also delay the carb digestion. pizza/pasta/indian would be an example of high carb, normal protein, high fat, yet slow digestion

This may also help with understanding what is happening and I would also google TAG ‘total available glucose’
https://healthonline.washington.edu/document/health_online/pdf/CarbCountingClassALL3_05.pdf

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Thank you very much.

If I eat a “balanced meal” of some rice and beans, green leafy veg and protein cooked in olive oil, would my BG rise be delayed by the protein and fats, and will the BG rise occur 3+ hours after I begin to eat? If that were the case, why would I pre bolus? According to the chart, if I consumed only fruit juice, I can expect a rapid rise in BG that can be addressed by Novolog (5 min to 3 hours). That works well with the action profile of Novolog. If I had a little from each of the Carb, Protein, Fat group - it could be 3-6 hours. That would not work well with a single shot of Novolog. Wow…such challenges!?

When I eat lean meat, such as a flank steak, with some carb and some veg, there is not much of an effect. But if I eat a similar portion of NY strip or ribeye, oops! gonna need to divide the dose and/or correct. Of course, it’s worth it now and then, IMO. :smile_cat:

just remember to ask your endo, this is the internet and I’m T2, this is just stuff to think about, till your health care team ticks it. (this is where it falls apart)

your finger tip is about a 5-15 minute delay to your arterial blood and similar for a CGM.

but generally, you wouldn’t give more that 50% of the bolus as prebolus for HC/HF and the other 50% is one or two shots, say at 1 and 2 hr or the whole 50% at 90 minute or so.
it’s suck and see what works,

without a CGM, buy cheap strips and meter (walmart etc) and test a lot when you test a meal, to get a good idea of the curve.

I think fast acting novolog works best for for high carb low fat…regular works best for low carb high fat profile
there isn’t one for high carb high fat, so it’s suck and see with multi bolus, till you get what works the best for you,
a lot of people just give up and don’t eat high carb/high fat. or have it very occasionally and accept the hickup and correct.

I never thought about my meals as -

high carb/ high fat
or
high carb /low fat

How do I determine if the meal will be “slow” digesting?

A typical dinner for me may be 1/3 cup to 1/2 cup of brown rice and 1 piece of chicken (about the size of a flat hand) some leafy green vegetable like kale, perhaps 1/2 of an avocado. Would this be considered a high carb, high fat, high protein meal?

Is a fettucine alfredo dish with chicken, a high carb, high fat, high protein meal? (I don’t eat it. I ask out of curiosity)

depends, chicken with or without fat and skin,… ‘perhaps 1/2 avocado’ adds fats
1/2 cup of cooked rice is about 20g carb, kale is 5g a cup. butter on the kale?
put it into a food counter like myfitnesspal, fatsecrets etc. it varies with what it is and how much.
with high fat, It should be ok

pizza is hchf and slow
toast, juice or cereal and low fat milk, is hclf and fast.

if your weight and A1c is good, do what you are doing, if not, read this to see if it makes sense