Questions about prebolusing for protein/fat and the combo deal

Type 1 and LADA
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I am hoping someone with more experience can guide me. I have just finished Dr. B’s book and have tried lowering my carb count per peal some…baby steps, you know. I have seen how the protein does kick in, but not sure how to count it. I have tried taking 1/2 by tagging and many times I find myself headed south for a low. ( I fingerstick alot as I experiment. A CGM isn’t for me with the plastic cannula) I have tried bolusing at the front end for carbs and then figuring out the percentage for the protein to hit later. But for how many hours. The # recommended by Medtronics doesn’t seem to work. This is:
50/50 over 30 min. for normal meal
30/70 to 50/50 over 2-4 hours for high fat foods
30/70 over 30 min to 1 hr. for higher fiber foods
75/25 over 30 min for all meals that include correction for high BG

The second part starts clicking right after the first wave. I have a 530 MM pump. I also prebolus 20 min. for lunch and dinner and around 25 or more for breakfast. This seems to work well for me. I have been checking the bend in the BG.

For instance last night we went out to dinner. Prebolused around 20 minutes. Salad, steamed broccoli, and grilled chicken. The grilled chicken they said was 8 ounces so going by Dr. B’s figures of 1 ounce = 6 g. protein I figured there was 48 g of protein which I included 1/2 of =24. I set it for 1 hr. 30 minutes for second wave. I checked with figure sticks every hour. My bg kept inching by the 70 mark for which I conservatively took 1 glucose, suspended pump. Added some lunchmeat which usually stabilizes me. The second time I figured out how many carbs to eat to offset the IOB. (1 to 16 ) Decent bg and after 4 plus hours after dinner and a couple of hours after last snack, I figured I was good. .4 left on board. I got up a couple of hours later only to find a 210 on my meter. What do you think happened or what am I doing wrong? Advice needed from you experts. By the way, if you have read any of my earlier posts, you might remember that I ate vegan. Well that is a thing of the past. My bg was a constant roller coaster and protein is great.
Thank you for your help. I am sorry I am such a word windbag.

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My initial take on your protein dosing for the chicken is that you didn’t extend your protein bolus nearly long enough. Your 4 hour + BG of 210 confirms that.

I don’t think of my extended bolus as the second part of a combo as in MedT’s 50/50, 30/70, or 75/25 percentage split of a single bolus dose. For me, that combination makes it harder to draw helpful conclusions when post meal BGs get off track.

Here’s how I would have dosed for that meal. (I’ve written about this here a few times recently; I’m sorry if I’m repeating something your’ve already considered!) I would do the normal carb estimation and divide that by the insulin:carb to come up with an immediate bolus delivered separately. Then I’d consider the 48 grams of protein. Like you, I’d count 50% of the protein grams as a carb equivalent carbs, 48 x 50% = 24 grams. Next I’d take that 24 grams and divide it by the insulin:carb number. Let’s use 1:6 for the sake of round numbers. So, 24/6 = 4 units of insulin. I would deliver that 4 units at an hourly rate that does not exceed 1.2 units per hour. 4/1.2 = 3.33 hours. I round up to 3.5 hours and deliver the 4 units over 3.5 hours or at an hourly rate of 1.14 units per hour.

This system works well for me and I’ve had pretty good feedback from others that tried it. Perhaps it could be a starting point for your personal experiment. When trying something new, it’s good to pay attention, do the needed fingersticks, and keep your safety glucose close at hand. Write down your results and design your next experiment informed by that result. Lather, rinse, repeat.

I also count 10% of the fat grams in my meal and add that to 50% of the protein grams. I find that this extended bolusing is a safe and mild way to bolus insulin because it plays out more slowly than an all-at-once carb bolus.

Play with the prebolus times as well. I’ve discovered, by watching my CGM trace, that my ideal pre-bouls time in the morning is usually about 45-60 minutes and in the evening 15-30 minutes. It does vary, however, and using a CGM is a big help to me. You can do strategic fingerstick to help you learn about the best pre-bolus time for you. Good pre-bolusing makes all the difference to me. It often means staying under my upper limit of 140 mg/dl post-meal instead of going up to 180, with the same meal and insulin dose.

Good luck. You are on the right track. You just need to find what your body needs. I’m sure you’re aware, however, that the time of day and many other factors can degrade this system, like any other system. Insulin dosing is as much art as science. Roll with the punches, adjust, make your best guess, pay attention and repeat.

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Everything I’ve recommended above assumes that your current basal insulin regimen keeps your blood glucose relatively flat (within a 30 mg/dl range) absent eating and any unusual exercise or activity. A solid basal rate is the foundation to build good meal-time insulin dosing.

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Thank you, Terry! I appreciate the time you have taken to answer this. Would you immediately do the normal bolus and then do ANOTHER bolus at a later time? You said “separately” and wondered how to do that. How much time would you wait between the boluses and would you just plug in the food and not the bg? Is there a reason for no more than 1.2 units an hour? Do you always divide by 1.2? Wow, that’s a lot of questions. Sorry. Thank you for your patience and info. I feel pretty good about the basal as that is something already tweaked. Also, when I have questioned it recently, adding amount of bolus versus amount of basal, it is always a bolus problem. Again, my thanks. I write down everything as I’m kinda compulsive that way. In my delusional state, it makes me think I have control over D. Ha Ha

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You’re welcome, yeagen. I deliver my carb bolus first, then immediately start my protein/fat, extended bolus. You could reverse these two without any ill effect. My use of “separately” was an attempt to distinguish between what I do and a “combo” bolus which consolidates, and I think, confuses the situation. The carb bolus and the protein/fat bolus are two separate, stand-alone events. I do one right after the other.

The 1.2 number was something I picked up in the Flatline and TAG groups here on TuD. I don’t know who first wrote about that, but I tried it and it worked well. I’ve mentioned it in a Bernstein FaceBook group and at least one other member tried it successfully. Your personal and careful experiment will be the best measure if it will work for you! Yes, I always divide by 1.2 so that I can calculate the time needed to deliver the extended bolus such that I do not exceed 1.2 units per hour. I suspect this rule is not exact and going over some will probably not change things much. I haven’t done the experiment to substantially raise or lower that rate.

I like writing things down when I do a trial. Otherwise, I confuse myself! I think it’s a good habit; others may not like the burden. Writing helps clarify my thinking.

Yeah, “control over D” is a rather elastic concept for me. Today I have it, tomorrow I may not. I think of diabetes as a formidable foe; it makes me give it its due respect. When I have the upper hand, I feel like doing the happy dance. Good luck with your extended bolus testing!

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I would do a separate bolus correction for a high BG. I know the pumps allow you to consolidate a correction into a meal bolus but I don’t like to combine these things. I will generally delay a meal if my BG is above 140. That’s just me.

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Thank you so much, Terry. You have been a HUGE help and I appreciate it.

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Terry, tried this at breakfast and lunch…success!!! Thank you so much.

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Great! I hope it continues to work for you.

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Do you notice a difference between animal protein and plant protein? After adding the protein divided by 2 and 1/10 of fat, you said you divided it be 1.2 to see how long to extend it. Right? What about if you don’t even get a whole unit to space out? Do you just extend for 30 minutes or maybe an hour? I am sorry to keep on and on, but I have had some successes which is a plus, but here I sit recovering from a 54 and am wondering if the meatloaf I so carefully counted is going to hit. I am going to swing the other direction as I always cover a low with glucose and then depending on the IOB, add some protein and fat like in cheese and peanut butter. Thank you for all your help. I also suspect that the low could come from the newly opened vial I started today when I changed my set. That seems to happen quite frequent as I am very insulin sensitive in the afternoon and evening.

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Sorry you’re having a low! I deliver the protein/fat bolus at a maximum rate of 1.2 units/hour. So if my calculation comes up to say 3.7 hours for the extended bolus, I’ll just round up to 4 hours, or the next 30 minute increment. If you start to see a pattern of lows, say 3-5 hours after eating then you could extend this bolus for longer. You might find that 1.0 units/hour to be better for you.

If you went low soon after eating then you might want to consider the insulin to carb ratio for your carb dose.

The system I use, like any insulin dosing system, is subject many variables. Food and insulin absorption can vary from meal to meal and time of day. That’s why I like to monitor my BGs with fingersticks and a CGM so closely. This is a dynamic game we play and we need to adjust when things change.

I hope you recovered OK and are back on track!

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Thank you, Terry. I probably average about 14 fingersticks a day and when I am not sure about something, more than that. I can’t wear a CGM because of the plastic cannula. I have one sitting in a box. I switched to the Sure-T because of the no deliveries of the plastic cannulas. So much for all that…Do you notice a difference in the different kinds of protein? You are right about alot of different factors. I only hope I can get better at this. I know everyone is different and maybe for me there is a difference in the kinds of proteins. I know that overall I am doing better accounting for the protein and fat. Thank you again.

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No, I don’t. If you think your body treats meat protein different from dairy protein, you could experiment around that.

Not sure I understand this. The Dexcom CGM doesn’t have a plastic cannula (tube) left under the skin. There is some plastic on the skin side for the transmitter to lock into. But, as I understand it, when the introducer needle is withdrawn, it only leaves a very small diameter wire (size of an eyelash) in place. Are you talking about the Dex or the Medtronic CGM?

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I have the enlites by MM.

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OMG. this all sounds like chemistry to me. do you do this w/ a square bolus over a period of about 3.5 hours? or do you keep looking at your watch and re-bolus 1.2 units every hour for 3.5 hours? this is very curious to me as i have had little success w/ eating red meat, such as steak or juicy hamburgers, which i know contain a lot of fat. i go low and then i re-bound high and then higher during the night. basically, i have given up on eating certain foods such as the 2 already mentioned, pizza, grilled cheese sandwiches, and basically any fat-oriented type of food. i do understand how the fat content slows down the metabolism and therefor the absorption of the foods. i jet can’t seem to get the “chemistry” right.

very frustrating for me. UGH :frowning:

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It’s not that complicated. My meal-time insulin is split into two separate boluses. One is an immediate bolus for carbs. The second is a bolus delivered over time. My pump calls this bolus over time an “extended bolus.” I think Medtronic pumps call this bolus over time a “square wave bolus.”

Here’s a graphic representation of my typical breakfast meal bolus:

I don’t put these two boluses together as a “combo bolus” (Animas term) or a “dual-wave bolus” (Medtronic term). Instead I deliver them as separate transactions but one right after the other. Combining these two boluses only makes my dosing more math-complicated. I try to keep it simple, although you may disagree!

The “1.2 units per hour speed limit” is something that was arrived at through personal experimentation by others and confirmed as dependable for me. For example, if you decided that you need to take 2.4 units as an extended (square-wave) bolus then you might deliver it over two hours at a rate of 1.2 units per hour. (1.2 x 2 = 2.4 total units).

This system has worked very well for me and has proven reliable for the last three years. I use it every day. This morning I took 4.5 units at 9:50 a.m. to cover my carbs and 2.0 units over two hours to cover the protein and fat. I used my personal breakfast pre-bolus time (yours will vary) of 60 minutes. The post meal CGM trace shows a successful insulin and meal dosing and timing match.

red line = 65 mg/dl, yellow line = 140 mg/dl

As you can see, I added a 30 minute walk to blunt the post meal rise at about 130 mg/dl.

Now I know that diabetes control is more complicated for some due to their personal circumstances. I am grateful that these methods work for me and I suspect that they could work for many others.

Good luck with your efforts.

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thank you for your very understandable and uncomplicated explanation of your method. next time i am going to eat the protein/fat laden meal, i will most deffinately put this at play.

one of the problems i encounter with insulin and BGs is that i take anti-psychotic medication for schizophrenia. it makes BG control a bit more challenging. ( i must say that as of this past tuesday, my A1c was a sweet 6.4%) but, i work my butt off to keep things in check. as probably everyone on this forum already knows (probably by heart) I LOVE pizza, yet i haven’t figured out a system for blousing for it. i try every combo possible that i can think of that will keep me somewhat w/in a decent range. i go low, i spike high, i spike higher, etc. so, that being said, the next time the urge hits me, i am trying out your method.

i do have one more question: how do you know how long to do the extended (“square”) bolus for? what would be the diff btw eating a lg. juicy burger w/ a bun and ketchup v. two slices of thin crust pizza with only a moderate amount of cheese on it, or, for example, a grilled cheese sandwich? what i mean is, at what rate do you gage how long the food will take to digest?

any suggestions are greatly appreciated !!!

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is there a book that has info on how long diff foods take to digest, for example hamburgers versus cheeses, both of which are mixed w/ carbs like buns and bread? like, if i want to have a really juicy fatty hamburger with ketchups and a large bun, how many hours would i set my square wave bolus for? Etc, etc…

did you already answer this and i misunderstood? sorry if i am so slow at figuring this all out.
i don’t mean to be a pest.

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OK. The length of time is determined by the total amount of 50% of the protein grams + 10% of the fat grams divided by 1.2. I know, there are a few moving pieces here, so let me use an example.

A few nights ago I ate a 6.2 ounce boneless pork chop accompanied by 10 ounces of onions sauteed in butter along with a half cup of apple sauce.

The carbs totaled 38 grams so I just divided 38 by my 1:7 insulin to carb ratio to calculate the immediate bolus.

38/7 = 5.4 units of insulin as a carb bolus.

Then I added 50% of 46 protein grams to 10% of the 30 fat grams.

(50% x 46) + (10% x 30) =
23 + 3 = 26 “equivalent carb grams”

Then divide the equivalent carb grams by your insulin to carb ratio. Mine is 1:7 and will use for this example.

26/7 = 3.7 units of insulin total for the protein and fat extended bolus.

How do you deliver these 3.7 units? For me (your insulin speed limit may be different!), I limit the delivery to a maximum of 1.2 units per hour. Here’s the calculation:

3.7/1.2 = 3.08 hours. You could round this down to 3 hours or up to 3.5 hours. To be conservative, round it up.

So, the extended bolus, for me, would be 3.7 units over 3.5 hours.

Remember, this example uses my insulin to carb ratio.* You’d have to plug in your insulin to carb ratio to customize a starting point to experiment for you.

Please - this is basic arithmetic but with some complication. You should understand well how all these parts relate before you try to use it for yourself. It should make sense to you and not look like so much chemistry!

I’d be happy to answer more questions to clarify if you’re interested.

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