Okay! So one of the most frustrating parts with diabetes is the random spikes from fats and proteins. I’m noticing spikes from it like 4-5 hours after eating it. I’ve tried everything from split boluses to taking a small walk in between boluses (careful not to over do it so I don’t go low) but no matter what I do I can’t seem to nail it down and have a higher spike after my meal bolus runs out. I’ve read other posts and online posts about upping your temp basal on your pump a certain percentage, but most of the time when I have these meals, it’s dinner and I’m scared to go to bed if my pump is +20-30% even. Just curious if anyone has tried this, how long they do it for and what percentages you’ve had success at. I also really hate night time highs and will be that person that wakes up every 2-3 hours to see if I need to take a correction so that I can ideally wake up in range. Any suggestions are much appreciated!
I once read (famous last words) that meal size should decrease during the course of the day, so dinner should be smaller and lighter than we’re used to. You might want to check it out for yourself or discuss with your nutritionist but I mention it to suggest you try having those foods for lunch rather than dinner. If you increase your basal at lunch you’ll be awake if the increase turns out to be too much (you might be nearing dinner time too). You would still need to experiment with how to set your temp rate or extended bolus but you’d be awake and alert to what’s going on so you could correct.
Does your pump have Control IQ/closed loop with a CGM? Even without a loop you could set your CGM to alert you when you are approaching your designated high number so you don’t have to wake up so frequently.
Totally agree with all those points! Typically my dinner is fairly light and my lunch is typically my heaviest meal of the day. The only thing that’s hard is when you have dinner with people. For example, last night I went out with my sister, ordered a turkey burger(ate without the bun and only ate the avacado, burger, tomato, and wrapped it in the lettuce it came with) and sweet potato fries. I counted out the fries, did my best to guesstimate carbs (this could be more of the issue from yesterday as it’s never the same as it is making them at home). Perfect blood sugars until my iob for dinner ran off then I started to slowly but surely climb. Took a bolus went for a 10 minute walk, and ended up being 85 when I woke up. I do have my high threshold on dex set at 200. I only wake up so frequently because sometimes I need multiple boluses to get my sugars down after protein and fat.
Be careful if you’re taking multiple boluses - aka stacking insulin. It’s tempting, especially if the numbers keep going up. My doctor told me not to take any additional for a certain number of hours unless I realized I had under-counted my carbs. Sure enough, once the time had passed I started coming down but I didn’t go low the way I had when I kept adding on.
If you haven’t done so, check with your doctor on additional doses and how long to wait.
Hi Taylor @Tee25 , what you describe and your attempts at finding a solution sound very familiar - what I and many, many others experience. Now you have a pretty good idea what doesn’t work for you - at least until the next day, the next week, or the next year; what I’m saying, possibly sometime in the future the solutions that didn’t work today MAY work for you in the future. Yes, CHANGE is the one constant with diabetes management. My solution, is “try” to remain calm and know that stuff isn’t always your fault.
You are very correct with your thought to avoid entering a temp basal of plus 20 - 30% before bedtime - dangerous. As a general rule, NEVER use increased basal rates to compensate for inadequate Food-Bolus estimates - this is referred to as “overbasalization”, one of the major causes for hypoglycemic hospitalizations (*).
The method I’m using now to help manage " delayed protein, fat highs" is to count ALL carbs on my plate and bolus this full amount of insulin at meal-time - this especially when I visit the steakhouse and eat a large “prime cut” slab of meat. Later, I observe what my body glucose levels are doing [a CGM is great for this], and if I observe a delayed glucose rize or, if my reading has been staying level at 140 mg/dl or higher even four hours after the meal, I will take a carefully calculated correction bolus before bed.
() The 2021 Physicians Guide for treatment and management of autoimmune diabetes [Chapter 9, if U remember correctly] discuses overbasalization in an attempt to encouraging physicians to monitor patients and discuss proper management of diabetes by properly counting carbs AND taking sufficient food-bolus and correction-bolus.*
@wadawabbit thanks for the follow up! I don’t stack insulin boluses but did years ago. Found out the hard way that it can lead to some bad lows. I always wait 3 hours now although it feels like a lifetime when you’re high.
@Dennis thanks so much for sharing that info. I’ve definitely done conservative temp basals of 10-15% when I have miscalculated before but definitely won’t be moving forward. That’s actually kind of scary to know (but also good to know) Curious on your comment about the steakhouse- so you take 100% of your normal dose at time of meal consumption? Or you still split, watch your cgm and then decide 3-4 hours later if you need more?
Thank you for the article! I’ll take a close look later. Much appreciated.
This is super interesting! I’m going to have to dive into this further for sure!
Taylor @Tee25 , the most simple answer to the question you asked me, is both YES and NO; most often my “additional bolus” for the protein is in a separate infusion a few hours after eating. Also, with my steak I would most probably have a large baked potato counting 45 grams of carb, and I’d slather on plenty of sour-cream which is fat so the meal would require an Extended Bolus.
The key word I used when describing the steak was “Choice-cut”; to be labeled “choice”, a considerable amount of marbling is required - this means the meat could have lots of fat content which only becomes identifiable by watching BG after the meal is finished; hence my reason for the late bolus. The 30% in the link posted by @987jaj may be conservative based on my experience.
I skimmed that study — thank you for posting, @987jaj! — and they were testing high protein with some carbs and NO fat (some kind of protein shake). I’m guessing that explains the 30% additional, versus your experience of needing more than that, Dennis. They weren’t testing for fat, too.
It’s great info, though, for those of us still figuring out how to best manage those extended-release boluses. We haven’t gotten those nailed down yet. They’re tricky!
My first pumps were from Minimed and I recall they had a square wave bolus - which I believe is known in Tandem as an extended bolus; as well as a dual wave, which let you start off with a normal bolus, and deliver the rest over time. Attached is some info I found online from one of the older models - it says the dual is meant to help with high fat/high carb meals. Our forum friends using Minimed can let us know if those features are still in use with the newer pumps, and if you find them helpful.
Thank you, Dorie, and thank you, Minimed! We still need to do the trial-and-error part of figuring out how much to give up front and how much to deliver over time, but that’s a really nice explanation of the features!
If you have diabetes - or a child who does - I think you can add to your resume:
proven dedication to ongoing learning
… to name just a few
Seriously! I’d have to agree.
Okay thank you! That’s super helpful. I’ll have to continue playing around with mine but did one today and landed at 110 so happy I found something that at least worked for today!
@wadawabbit is correct. Not only Tandem, Animas called it an extended bolus. Here is some information I found out beating the bushes.
DEFINITION: (from Tandem doc site) The Extended Bolus feature allows you to deliver part of the bolus now and part of the bolus slowly over a period of up to 8 hours (up to 2 hours if Control-IQ technology is turned on). This can be helpful for high-fat meals such as pizza or if you have gastroparesis (delayed stomach emptying).
DISCUSSION: Proteins and fats delay gastric (stomach) emptying into the small intestine. The small intestine is where most carbohydrates are absorbed into the blood stream with ‘heavy’ meals (Heavy meals here are high in fat, protein, or both, like pizza or lasagna).
The extended bolus helps by dividing the insulin given by the pump into a pattern most closely aligning with the individuals digestive pattern. Some individuals empty their stomachs faster than others while consuming the same meal. Because of these individual differences, experimentation or clinical evaluation must be used to determine the percentage for:
[a] pre-meal bolus and its lead time
[b] deliver now portion of the bolus
[c] deliver later portion of the bolus
[d] expected bolus when the up to 2 hour extended bolus has completed.
If I have repeated experiences going high at a certain time after eating a certain type of food, my lesson is always: use more insulin, at the appropriate time. If it were me, I’d be saying, “yes, I most definitely do need a split bolus, probably a tri-split, with the third dose given 2.5 hours after I start eating, and I need extra insulin for that last dose than my carb ratio tells me.” If I’m consistenly 180 (for example), I know I probably missed by about 1.5 units, perhaps less perhaps more, but that’d be my starting point. High blood sugar either means not enough insulin, bad timing, or both. You tried the split bolus and that didn’t correct by itself, so I’d try giving more insulin based on how high you’re going and how much a given amount of insulin lowers your blood sugar, as well as continuing to split your bolus (again, you may need a significant amount, like 2-3 units, for example, for the third part of your split fairly late (~2.5 hours) after you start eating).
@987jaj , @BKN480 , @wadawabbit , @srozelle , @987jaj , what I’m waiting for is release of the new pump algorithm under development at the University of Virginia. As you know, the BOQ and the CIQ algorithms were developed by this team, and this new venture appears to make a giant step forward addressing the two major limitations I identified in CIQ.
To date, I’m aware of only one trial - a very small sample size [18 PDW], in a controlled environment, with both dual and parallel testing. Very favorable results. The algorithm is designed for use with Tandem t-Slim x2 with Dexcom G6 and Taylor, would certainly work well to satisfy your “High BS” caused by protein & fat.
Proteins will impact sugars several hours later as you describe as they are first broken down in the liver then as they are further digested, the sugar will spike. I’d figure out “the protein carbs” you’re eating. For instance if I eat 14oz of salmon, I’ll take 1-2 units of fiasp once my sugar starts to slowly rise but it crescendos much later that night and I’ll require 2 more units. Nutritionally the way calories & carbs are measured can’t calculate this aspect. I had a long conversation with my Endo about this and he agreed this is the situation. Best bet, figure out the carb ratio. Based on Oz of the different meat. Seems to correlate with calories. For instance salmon takes less insulin (for me) & is around 58 calories/oz where ground wagyu takes more insulin and is around 83 calories/oz. hope that helps. If I can be of any assistance - reach out. Been working with this aspect for years and it took many docs who basically had no clue.