Zero carb meals

Do you need to bolus for pure fat/protein meals?

Twice I’ve had eggs and sausage in the morning and gone from 6-7 to 13.

Yet, when I fast or sleep through breakfast I’m fine. Same with once when I corrected a 9 and had eggs and sausage with no bolus, and was 5 afterward.

Hi Jen and Happy New Year.

I generally don't bolus for protein or fat and assume this is only necessary for very low carb diets. (but others seem to do so and my belief is that it simply works itself out in your I:C). However, one of my breakfasts is an omelet which is really minimal carbs, maybe 3 or 4 for vegies. Whenever I ate this with no bolus I went high, so I now bolus for 6 carbs when I eat this, which I assume is analogous to the experiences of those who regularly have this low level of carbs.

Everyone is different. I eat very low carb so I have to account for protein. I've also found that my body can have a blood sugar rise simply because I eat. Bernstein calls this the chinese restaurant effect. Those of us who are insulin challenged can have messed up signaling, when we eat anticipatory signals are sent from our digestive system to tell the pancreas to produce insulin and glucagon. The glucagon buffers the insulin action, but when we fail to release insulin the glucagon can trigger an inappropriate insulin dump from our lives. Having some insulin on board can suppress this. So that is my rule #2, you can't win.

I bolus for protein, especially in the morning. Like Zoe, eggs for breakfast cause me to rise. It's hard to tell if it's from the protein/fat or those lovely morning hormonal bursts. Either way, my 10g carb bolus keeps me stable.

I do bolus for sausage and eggs at breakfast. Using Calorie King, I find that 2 large eggs and three small breakfast pork sausages have 3.8 grams of carbs. This is few carbs but my insulin to carb ratio is 1:4 in the morning. So I do give 0.9 units of immediate insulin to cover the carbs.

I then use an extended bolus of 3.9 units over 3.5 hours for the protein and fat. I calculate 50% of the protein grams and 10% of the fat grams as "carb equivalent grams"

That gives me a total of 4.8 units of insulin for this meal, not an insignificant amount. This meal is great for consistent well-controlled post-meal BGs for me.

I'm not sure what happened with your correction insulin covering both your high BG and the meal. At least it had a good result!

The balance between carbs and protein in the meal is the prime determinant of whether you need to bolus for the protein and if so, how much.

Normally the carbs you eat are used for energy and the protein is used for tissue building. However, when a meal contains few or no carbs, then the body "steals" part of the protein and converts it to carbohydrate.

The biochemical process by which this is done is relatively slow and inefficient, so a BG rise caused by protein is slower and longer acting than the quick spike you get from eating carbs. I tend to eat low carb/high protein meals, so I need to allow for the protein in my bolus calculations. It's also the reason I use Regular insulin much of the time; its slower, more gradual response curve matches up to the digestion of protein much better, compared to the fast analogs. At least it works that way for me.

There are some approximate guidelines for determining how much insulin you need for protein (when that applies). Both Bernstein and Scheiner discuss it in their books. But as with everything concerning diabetes, you need to determine emprically the ratios that apply to you personally, and as always, the only way to do that is to keep records and test, test, test.

David - It's interesting to me that you use Regular insulin to cover protein metabolism. I've often thought that if I went back to MDI that I would use rapid acting analogs, Regular, and a long-acting insulin like Levemir. I would even experiment with NPH again, an old nemesis.

How do you keep track of your insulin dosing? I fear I'd have a hell of a time remembering whether I took my injection or not. The pump memory is a terrific asset for me.

This is the sort of thing I’m hoping a CGM will help me figure out. For me the rises weren’t slow, though - both were two hours or less after eating. While yesterday’s jigh lingered all morning, today’s came down within an hour and a half of correcting (slightly worried I might end up low). I’ll have to experiment with a small bolus next time.

Your explanation makes a lot of sense, including why a correction bolus would prevent a spike.

I thought it was only for low carb diets, too. It definitely seems to be pretty common. I’ll experiment with doing a small bolus nect time and see if it helps.

I’m not sure what happened with the correction bolus, either. Maybe something like what Brian said (insulin on board preventing the liver from releasing glucose). The weird part, too, is that the spike was prolonged testerday, but this morning I came down from 13.1 to 6.1 within two hours of correcting. Next time I’ll try a small bolus when eating this for breakfast and see what happens. Also looking forward to my Dexcom trial which will hopefully start early next week (I have the sensor, just waiting to hear back from the rep about the loaner transmitter and receiver) - maybe it will help provide some insight to what my blood sugar is doing.

Taking things in sequence . . .

The combination you describe (fast acting, Regular, and basal) is precisely what I use. For me it works well.

And for the other question . . . I keep a written log. A touch of OCD comes in really handy for a PWD. LOL

Hi Jen,

I have to bolus more for the fat/protein for very low carb meals such as eggs, cheese & green veggies. I tried calculating at first how much to add according to formulas in books but it was way too much and made me go hypo. Now I add 1 unit or so depending on the meal and the size, I usually have an idea of what I need for those meals from experience but it doesn't always work. I can eat some walnuts with no bolus one day and be fine and spike from 70 range to 150 another day. My experience has been that most of the time eating anything usually causes bg rise of some sort.

My pump trainer said the fat delays the carb release for a long time but I'm wondering for how long, I guess it depends on your digestion rate too which can vary from day to day.

I don't usually have a pure/fat or protein meal- when I have I do bolus something for it. For nuts & cheese as a snack which have some carbs, they can also spike me especially in the am. But it also may have to do with basal on mdi, dp etc. I'm not sure yet. Sometimes eating drops my bg due to dp. If a regular bolus doesn't work maybe an extended bolus will help? She said that would probably help.

Nope, not just low carb.

Excess protein will be converted to glucose by the liver, whether you're in a ketotic metabolism or not. It has to go somewhere :-)

Fat is mostly just used to make hormones, connective tissue and cell membranes, among other structural components, and stored in adipose tissue. The latter is stimulated by insulin -- i.e. cranked up -- so quite a bit more will be stored when there is plenty of carbs in a meal along with the fat.

TAGgers account for all three every time they eat, no matter what the mix. That's what I'm doing these days -- bolus carb weight 100%, 1/2 protein weight as carb equivalent, and 10% of fat weight as carb equivalent.

I always pre-bolus the carb insulin, wait 20-40 minutes, then start a 4 hour square-wave bolus with the protein and fat insulin when I start eating.

Works really well, and gives me the chance to cut the protein/fat insulin short if my BG's fine and heading south. Bolusing the entire ball of wax in a single impulse doesn't give you this flexibility.

Of course, this is only possible with a pump. Can be done without a CGM, but it's a lot more work.