# Super Bolus

I have finished reading Lorraine’s post about Super Bolus and was wondering if anyone thought about adding this into TAG? I find this an intriguing topic. The math might start driving me a little crazy though. And I took Calculus in high school! Does any have any thoughts about this?

Very, very interesting, Jim. Frankly, the math doesn’t seem any harder than TAG, and I got used to that very quickly (and I DID NOT take Calculus - or any other math class if I could avoid it

As I am a low carber, I typically do not wind up with spikes - however, for the times I mess up or eat something out that obviously has ingredients I’m unaware of, this would be a great “fixer-upper.”

So - if I understand it - this would be used when you’re high but want to eat. Let me make sure my feeble brain gets this. You would:

1. Calculate the correction for your current BG
2. Add to that the amount of the bolus for the food you’re about to eat (for a TAGger, that would include proteins & fats)
3. Add to that what your basal rate would be over the time period you would normally use for an extended bolus (depending on the food)
4. Turn your basal off for that same period of time.
5. Give the total of 1, 2, & 3 as a bolus.
6. Make sure your basal is back on after the period of time is over.

Do I have that right? Sounds like a great addition to the “tool box.”

I also agree with Don in that original post when he talks about it being time that pump manufacturers update their bolus options “to allow multiple, simultaneous extended boluses, ability to deliver variable amounts over different time segments, and ability to save meal presets that deliver combo/extended.”

Cheri

Yeah, I didn’t even focus on using it to eat foods I normally don’t eat…because…well, I don’t eat them! But I could definitely see using it as I described above.

I’m with you, Danny - the “law of small numbers” keeps me in smooooooth sailing territory and as a result, reduces stress.

Cheri

Hi Jim,

The concept of a Superbolus on top of TAG is a great concept., especially for foods that cause the typical diabetic to spike, such as white rice.

I experimented with the SuperBolus a few years ago. It does work, My only problem is that current pumps are not set up to properly account for the Superbolus in the pump math. By moving the basal quantity into the bolus, that quantity of basal insulin will now be incorrectly included in IOB. Think about it for a second. Basal insulin is never included in IOB and just because you pre-load the basal does not mean it should be included in IOB.

A fellow pumper came up with a work around. Inject the basal insulin using the prime cannula function on your pump to avoid it from being included in IOB. You may have to prime several times to get the total quantity.

Oh yes, that’s a good point. This is why having a super bolus option within the pump functionality would make using it not only simpler but safer.

When using the OmniPod, if I bolus without using a BG and just input a dose, that amount is not included in IOB. OmniPod has a different way of calculating IOB than other pumps though (it does not include any IOB for meal bolus’ either). It sounds like the prime option is a good work around, but a little awkward.

Cheri,

The extended portion of the bolus is an interesting point. In Caleb’s case, I don’t think I would include that in the initial bolus because I use an extended bolus only for specific long lasting foods like pizza, Chinese, ice cream, etc. I would still want that insulin to be delivered later when the food releases in his system and raises his BG. If I included that amount in the super bolus, I would expect Caleb’s blood sugar to drop too low initially, followed by persistent highs later.

I did a super bolus once when we were about to sit down with friends for pizza, Caleb had an elevated BG and I didn’t want him to have to wait to eat alone later. I included the correction, normal meal bolus and 2 hours of basal in his initial bolus (turning off the basal for two hours of course) and delivered the extended portion I normally do over the 8 hour period we use for pizza. In this example, keeping the timing of the extended portion the same as usual worked for us.

Other uses of extended bolus’ may make including it in the super bolus appropriate though.

Did you find that donut Danny?

Sounds like you don’t even need it Danny, which is fabulous.

Hi Lorraine

Interesting - I use an extended bolus (combo) each and every time because I calculate fat & protein, not just carb (which should work well for things like pizza, by the way). So I’m thinking it would still work in this case because I can regulate (to a degree) how much is released now and how much later. However - it much scarier to “try things” when we’re talking about a child - by the way, he is gorgeous and I really like your blog.

But we should ask Ricardo - he understands all that stuff. As far as IOB - my Ping calculates it but I am free to ignore it…I can override, which I like.

Cheri

I see - you are always using the extended bolus feature, so it’s a little bit different scenario. I’m going to one day take that leap to incorporate that into Caleb’s regimen - I have to get through that Dual Wave bolus discussion because I know it’s chockful of good info. Right now, what we do is working, but I have this extended bolus concept in my toolbox expecting that as he grows and the volume of what he eats increases, it will come in quite handy to match everything up. I find that when he has bigger meals, they take longer to get through his system, but maybe it’s not the size of the meal at all and it’s just increased fat content. Lots of analysis in my future.

I think my pizza example is an extreme one. Caleb needs to cover 100% of his carbs upfront and then almost that amount again in the extended bolus.

Oh and thanks so much re: Caleb and his blog.

Hi Lorraine,

As you probably already realize, superbolusing and TAG are different.

With superbolusing, the objective is to get the insulin on board as quickly as possible, by adding future basal quantities into your bolus. The purpose is to prevent spiking due to high glycemic foods.

TAG is a variation of that. Instead of shifting basal quantities into the bolus, with TAG you add additional quantities of insulin onto the bolus, based on the fats and proteins in the meal. Whereas the goal of superbolusing is to get the insulin on board all on the front end, for TAG you want to regulate the release of the additional insulin using the extended bolus.

I am a believer in trying things to improve my diabetic control, but I am an even bigger believer in, “if it ain’t broke, don’t fix it”. In addition, it sounds like Caleb may be going through his growth spurts and has many growth hormones in his system, which will only serve to complicate things. It sounds like you are doing a great job. I would keep doing what you are doing and wait until after the growth spurts to experiment with TAG.

Yes sir, I understand. They are two completely different scenarios. And I agree with the “ain’t broke” theory which is why I’m keeping the TAG/extended bolus concept in my toolbox for now.

I’m glad you provided this explanation. I think it’s important for anyone stumbling across this discussion to understand the distinction in order to determine for themselves whether or not adding the extended portion to the super bolus makes sense. Not having personal experience with TAG I cannot provide the appropriate perspective on it. I can only say the way that I currently use extended bolus’, I believe it would cause a problem.

Thanks Everyone for the input, and a big thank you to Lorraine! I think she helped clarify a couple of things I started here. I used her SuperBolus example because this is the first I heard about this and I she gives a nice example. She also pointed me to more information.

I have only recently being using a CGMS. Started back earlier this month and I am still trying to figure out what certain foods do to me. I normally only use a straight bolus for just my carbs. I seem to eat more carbs than anything else.

I was thinking that there will be occasions where I will still use only my regular bolus, others for the SuperBolus (which I forgot last night with pizza), and then TAG (Out to dinner tonight with wife, chicken and beer), but than I was wondering if there might be occasions to combine the SuperBolus with TAG, say when I start out high and want to bring my bg down quick, but need to cover protein, such as the chicken I plan on having tonight. (Yes I’m hungry right now.

Its just nice to know that we have tools in the box to help so many different situations. I still need to print out some of those cards to help me figure out the TAG boluses.

I tried a Superbolus this morning with a cream of wheat breakfast. this is a hard meal for me to bolus for cause of the carbs. I calculated the bolus for the cereal, added 2 hours of basal and bolused that amount. I set my pump on temp basal at -90% for 2 hours. I went a little higher than i wanted, but didn’t spike like i used to with that same meal and then crash because of the need to do a correction bolus later. Is this the TAG concept?

I might say no. This sounds like it would have been better with just TAG. The other people here might be better able to explain it. I wish the Calorie King would also show protein. Cream of Wheat apx 21 carbs.

I think you are correct, David, that the super bolus was a good approach to deal with the spike, just as John Walsh suggests.

What I understand about the TAG concept, and I hope the experts will correct/validate, is that it is appropriate to add carbs for both fat and protein of what is eaten. I think traditionally we are taught to ignore these items when adding up carbs. I don’t know how much fat and protein is in cream of wheat, but if it is more than a little, adding those carbs to the initial bolus may have been to trick to avoid the “little higher than I wanted” BG. That combined with the super bolus might be the answer to dealing with cream of wheat for you.

Hi Lorraine

It’s not really adding “carbs” per se, but I guess you could look at it that way - I look at it as “adding all my grams” - actual # for carbs, 40% of protein grams, and 10% of fat grams. This compensates for the reality that a percentage of proteins and fats are indeed converted to glucose. So, once I have the total grams, I divide by my I:C factor for that time of day, and determine what percentage I want now (usually, just the amount needed to cover the actual carbs) and then extend the remainder over 1.5 to 3.0 hours, depending on the meal. The longest times used for high fat meals, middle for high protein meals, and so on. And this means, by the way, that I use an extended (or combo) bolus for each and every meal.

The GREAT thing is - unless I screw up - I no longer get unexplained spikes when I’m sure I’ve covered the carbs. TAG has been a wonderful discovery for me. It has given me the consistency I had been searching for.

Yes, of course - my mistake entirely. I am thinking in terms of carbs bc that’s how I input the insulin dose into the pump, but by definition it we are talking about Total Available Glucose, which is carbs plus a portion of of protein, plus a portion of fat, just as you state. I’ve completely muddled things with my way of viewing it. Thanks for setting it all straight!

Hi Dave and Jim,

I checked CalorieKing.com and it gives the following for 200 grams of cooked, Regular Cream of Wheat,

• Carbs - 22 grams
• Protein - 3 grams
• Fat - .4 grams
• Fiber - 1 gram

Based on the above and assuming your TAG percentages are 40 - 60% for protein and 10% for fat, TAG would not have added significantly to your bolus.

Cream of Wheat is primarily carbs with very little fat or fiber to slow the metabolism of the carbs. Wikipedia describes it as “ground wheat”. The finer the grind, the faster the product cooks, but also the faster the carbs are metabolized and the faster your BG will rise.

Hopefully, you are not using the instant variety, which I think has the finest grind. The regular variety takes longer to cook but may be slower to impact your BG. Carb particle size impacts carb metabolism. This is a reason Glucose tablets are made in a chalk consistency. Ground Cream of Wheat of the instant variety is closest to chalk.

Boiling Cream of Wheat with milk instead of water, will also increase its glycemic index. The sweetener of choice will also impact the glycemic index. So if you boil with milk, add sugar or maple syrup and use the instant variety, you will have a super high glycemic food which will be very difficult to bolus for.

IMHO, the best strategy for bolusing for Cream of Wheat would be to bolus before you eat to give the insulin a head start. Better yet, choose a whole grain cereal, as opposed to the processed Cream of Wheat.