Sorrry, no pump. But I do know of several low carb people that use R a pump and love it. Some people also use a pump but bolus with a pen or syringe.
I’m curious. When your were experiencing these keto flu symptoms, did you supplement with sodium or drink any bone broth?
I eat low-carb (< 30 net grams/day) and use Apidra in a pump and have found that using the pump extended bolus, I could successfully dose for the protein content of my meals. I count 50% of protein grams as a “carb equivalent” and then deliver an extended bolus that doesn’t exceed 1.2 units per hour for the total time it takes to metabolize the protein. (While this is suited to my metabolism, I’ve read about others here who use this technique successfully.) These extended boluses last anywhere from 2-5 hours. I found this technique highly repeatable. I could give an example if you’re interested.
I used R in my pump for nine years (1987-1996) but my insulin dosing skill set was not as well-informed back then. I think using the faster insulins and then exploiting the extended bolus feature of the pump is a great way to address both the need to respond to the fast acting carb content of the meal as well as the slower acting protein and fat components. If I went back to MDI, I would likely use R to target protein and fat content in my meals. I might also use NPH in certain situations.
I would love to have an example. I have tried the extended bolus option. It seems to work at first but when it is over in 3-4 hours my blood sugar will rise. I can get a rise as much as 6-7 hours later, with even blood sugars until then.
Let’s say you intend to eat a six ounce ground beef hamburger patty. According to Calorie King, that serving contains 45.9 grams of protein. I count 50% of the protein grams as a “carb equivalent.” That means 45.9 x 50% = 22.95; I would round this to 23 for calculation simplicity.
If your insulin to carb ratio is 1:8, then I would divide the 23 gram protein carb equivalent by 8. 23/8 = 2.875, round to 2.9. I use a 1.2 units per hour limit to determine the duration of the extended bolus. (Your extended bolus hourly limit may be different, but this is a reasonable place to start.)
Now, you want to extend delivery of 2.9 units of insulin with a 1.2 unit/hour limit. I calculate 2.9/1.2 = 2.4 hours. I round up the 2.4 hours to the nearest one-half hour or 2.5 hours. I do this since the pumps I’ve used only increment extended boluses in 30-minute increments.
On my MiniMed 722 insulin pump, the sequence would proceed as follows: Bolus > Manual Bolus > Square Wave Bolus > Set Square Wave Bolus (input 2.9) > Square Wave Duration (input 2:30) > Act.
Unfortunately, different brand pumps use different terminology to describe the exact same things. Medtronic uses the term square wave while Animas called it an extended bolus. I suspect Tandem and Insulet have their own terms for this same function. Are the pump companies just trying to confuse us??!
I don’t recommend using the “dual wave” or “combo bolus” technique. That would combine both the up-front carb bolus with the extended bolus. You can do it this way but you’re often required to split the insulin dose in a percentage fashion between the carb bolus and the extended one to cover protein. I think it needlessly muddies the understanding of what you’re doing. Best to do the up front carb bolus separately and then follow it with the extended bolus.
In summary, if eating 46 grams of protein in a six-ounce hamburger patty, I would deliver an extended (square wave) bolus of 2.9 units over 2.5 hours. My explanation might look too complicated to you, but once you’ve done a few, it will appear simpler.
I’ve found extended boluses to be much less risky than the immediate carb boluses. You can always kill the extended early if you find that your BG is moving too low during that 2.5 hour time. The success of this technique is, however, dependent on a well-calibrated basal insulin profile and reasonably accurate insulin to carb ratio.
I think this is could be due to under-dosing your basal rate or under-dosing the protein extended portion of your meal dose. Did you count 50% of your protein grams as a “carb-equivalent”?
Yes, I would say so in general, as I stick to a breakfast of either flax meal and chia seeds, bacon & eggs, black pudding, oily fish or a homemade fresh fruit smoothie, and at weekends I indulge in 3 slices of Hovis lower carb bread toasted with butter & marmalade (with just 6 units of fast acting insulin when I have the toast).
Lunch times include such things as a lower carb sandwhich, beans or mushy peas on lower carb toast, tinned peppered Mackerel or other tinned fish with or without lower carb bread, cheese and pickle.
At evening meals I have exchanged all potatoes, rice and pasta for cauliflower or broccoli rice which I have with every meal adding different herbs and spices or selective sauces to my own taste. I do indulge in icecream with a thin slice of Madeira or a Solero lolly depending on my blood readings. Occassionally I will indulge in thick chips but not very often and always when my bloods are in the lower range.
@Amie - Here’s an example from 18 hrs ago (dinner last night).
Full Disclosure: I’m on a low carb (< 10 grams / day) keto diet, and prior to eating at 5:00PM I’d been fasting 72 hrs (no glycogen in my system).
Prior to eating at 5:00PM, I pre-bolused 2.0 Units Humalog at 4:30 PM (with extended bolus window of additional 90 minutes for 0.5 of the 2.0 Units).
Between 5-5:30 I ate 5 thin strips Canadian bacon (high fat), 2 fried eggs (fried in coconut oil + bacon fat), approx 70 grams of cheddar cheese, and 3 thin slices of lean ham
Total Carbs eaten: 4 grams; Total Fat eaten: 66 grams; Total Protein eaten: 55 grams (Total Calories: 704)
At 5:55PM, I bolused additional 1.75U (with .50U on 90 minute extended bolus). My BS at that point was 4.1mmol/L (74mg/dl)
8:20PM, I bolused 0.85U; BS was 4.4 and rising (79mg/dl)
Between 9:30-10PM, bolused additional 1.25U (no extended window) wth BS rising to a peak of 6.2 (112mg/dl) at 10:05 PM.
That was a total of 5.85 Units Humalog over 5.5hrs for 55 grams Protein and 66 grams of fat. I’m not insulin resistant; I’m on a pump & Dexcom G5.
I ate slightly fewer grams of protein than fat, but at this protein / fat ratio, my Insulin / Protein (Fat) ratio is 1.0 unit Humalog per 10 grams of protein / fat. This is 33% higher than what my insulin / carb ratio is, which was 1 unit / 15 grams carbs. Everyone is different, but this seem to work for my metabolism.
Jim in Calgary
Thanks for the detail. I see that you continue to chase your blood sugar for many hours after this high protein meal. I guess thats just the drill? with carbs , I take insulin according to ratio and stay pretty much in range as long as the carbs are moderate, below20 gms per meal but when there is a lot of protein and almost no carbs I am chasing the blood sugar for a long time. I can go to bed with a perfect BS and wake in the middle of the night over 200. Just don’t know how long to extend that bolus for.
thanks for your example. The mathematical calc is helpful. I have just guesstimated
in the past. Being more precise may be helpful.
Aime - I often awaken in middle of night with higher BS after bolusing for as long as 5 - 6 hrs for protein + fat . Normally this happens when I exceed my body’s limit for daily protein, and whatever the excess was is then converted to glucose via gluconeogenesis. It can also mean more glycogen being stored in liver which makes the next day interesting too
I follow a strict plant based diet with complex carbs. A1c 5.9
Agree, however in my and many other cases, low carb may mean reduced kcal and wt loss. For me being trim already, I need the kcal to sustain wt due to high metabolism and exercise. Modify carb diet may be more the road to travel?
I’m low carb compared to the diet they started me on way back when. Down to approximately 100g per day instead of 200.