Split bolus timings

[gillrogers]

Me again . So is there any guidance or tip on split bolus timings for high fat and protein meals. So im using a calculation of my carbs plus 20% , taking 75% at my usual bolus time and the balance an hour later. Sometimes i find i dont need all of the balance but othertimes my bgs arnt showing any sign of rising an hour later so im wary at this point of when to give the balance so it doesnt conflict with my next meal. Are there any tips on this?

 

[helli]

The tips I would give are

1. You only need to consider bolusing for protein if you have zero or very low carbs.
2. The right split and timing will depend on what you eat (how much fat - fat mostly slows down the digestion) and you (we are all different). The only recommendation is trial and learning
3. Don't make it too complicated. If it cannot become habit, diabetes control will take over your life. The recommendation is 70% in target range (between 4 and 10) with less than 5% too low. If you are close to this, any increased Time in Range will have very little benefit in terms of diabetes management but may have negative impact on the rest of your life.

 

[gillrogers]

Ok ta, so that ties in with some yhings ive seen with me but do i still need to bolus for the protien?

 

[helli]

Ok ta, so that ties in with some yhings ive seen with me but do i still need to bolus for the protien?

Only if you eat no or very little (for me this is less than 5g) carbs.
The way I understand it is that our body will get glucose the easiest way. If it has carbs, it will use them. With no carbs, it will try other things like protein.

 

[gillrogers]

Sorry just re-read and realised i misread no 1 ‍♀️

 

[gillrogers]

What made me think that i do is that evennwith carbs my line stays relativly good for an hour or two then start slowily going up for the next hour or two when ive eaten foods with over 25g of protien

 

[helli]

It could be the protein - we are all different.
It could be the fat - fat slows down the carb digestion.
It could be that your basal dose is not correct - you mentioned previously that your BG rises throughout the day.

I would start with a basal test to make sure my basal keeps my levels stable.

 

[gillrogers]

It could be the protein - we are all different.
It could be the fat - fat slows down the carb digestion.
It could be that your basal dose is not correct - you mentioned previously that your BG rises throughout the day.

I would start with a basal test to make sure my basal keeps my levels stable.

I seem to be doing basal tests every week. I find that when its on the rise i dont come down lower than 10 for lunch and corrections are ignored. When my basal starts dropping i have troubke at lunch time as i seem to have this darn drop off where i can drop 1.5mmol over an hour and screws up my bolus timings sending me into a faster drop the minute my lyumjev hits. So i then start munching the glucose as my food digestion cant keep up with the two and cos im on mdi i cant turn anything off. Its happened yesterday and again today so i know i need to drop my basal again tomorrow. E ety darn meal time is a confusion for me. And it has taken over my life.

 

[helli]

@gillrogers I am confused when you talk about Lyumjev when doing a basal test.
The basal test is to work out whether your basal is correct in the absence of anything such as food or bolus insulin.
That is why we usually do a basal test for 8 hours at a time (and do it 3 times to cover a full 24 hours but over multiple days). It has given your body time to get through any bolus insulin on board.

 

[gillrogers]

@gillrogers I am confused when you talk about Lyumjev when doing a basal test.
The basal test is to work out whether your basal is correct in the absence of anything such as food or bolus insulin.
That is why we usually do a basal test for 8 hours at a time (and do it 3 times to cover a full 24 hours but over multiple days). It has given your body time to get through any bolus insulin

No im not talking of kyumjev when doing a basal test. Sorry thats how i wrote it. ‍♀️ Im saying how i know my basal has dropped without doing the basal test first. Then do the basal test the next day.

 

[gillrogers]

Thanks for your help @helli . Did usual bolus for my teeco free from burger, homemade airfrys and mixed veg. Didnt apply the split dose rule even though a comined count of 44 grams fat and protien and everything has worked.

 

[pawprint91]

What made me think that i do is that evennwith carbs my line stays relativly good for an hour or two then start slowily going up for the next hour or two when ive eaten foods with over 25g of protien

Hi gill, this happens to me too with higher protein meals! I don’t split bolus when this happens as would find I would just go higher or lower early on, I pre bolus for the carbs and then correct if I need to when the rise starts happening. I eat most meals quite far apart so this doesn’t impact me really, but understand why you’d need to be mindful if correcting close to another meal - in which case, could you include it as part of the pre bolus for that one? Not sure what the answer is re: closer together meals, but you are not alone in protein causing a delayed rise after eating.

 

[SimonP]

Out of interest what duration do you find the protein is absorbed over?

 

[rebrascora]

For me, Protein starts releasing about 2 hours after eating and will be a slow, steady release over 4-6 hours although I inject a correction at 2 hours and I might need another one in another hour. I don't calculate protein release, I just do a correction based off my Libre, so once I get to 8 (after the carbs have gone) and my levels are still drifting upwards, I will do a 1.5-2 unit correction and if an hour later, it is still drifting upwards or hasn't come down, I will jab another 1-2 units. This is me with my body/digestive system and Fiasp insulin which has a shorter action time than NR and is usually spent in 3 hours for me. I work on the basis that I can always have a JB or prune/dried apricot if I over egg the correction a bit and my levels are falling a bit quicker that I would like but that rarely happens, because the protein is still slowly releasing as the insulin is working. It is not uncommon that I will need 3 injections for a low carb high protein meal. A unit or 2 upfront to deal with the carbs, a couple of units a couple of hours later and maybe another one an hour after that. I am guided by my Libre for when and how much but I do my utmost to prevent levels going above 10 because once they do, it is much harder to bring them down.

I never worry about how long it is to my next meal because as long as you don't add a correction at that time, and just bolus for your carbs in the next meal, then there is no problem in my opinion.

Yes, this means that I am breaking the guidelines as regards not stacking corrections etc, but it works well, partly because I follow a low carb way of eating so BG levels are slower to rise and fall and the protein releases over a long period so the stacked corrections are needed to deal with it. I make a point of record every time I inject insulin on my Libre and how much, so that I can keep track of roughly how much active insulin is still in my system when I come to bolus for my next meal but it isn't calculated as such, I just think there must be say about half a unit left by now and then factor that in. It is very slap dash but it seems to work really well for me.

The key for me is keeping a close eye on my Libre. I average over 30 scans a day every day and I have done since I got Libre, so I have a very good idea of how my body responds in most situations.

I think the key for me was learning not to be afraid of my insulin and that came out of frustration on my second trial of Fiasp.... I think it kind of started as "rage bolusing" and then gradually settled into a more set routine when my levels went high and wouldn't come down and I learned that stacked corrections actually worked well for me, with Fiasp with my low carb way of eating. I used to feel guilty that I was breaking the rules, but now I am confident and would challenge anyone, including my consultant if he remarked negatively about it.

Diabetes is about finding what works for you as an individual, not blindly following guidelines that were set to keep the majority of people safe, who had no way of knowing what their BG levels were doing between finger pricks. Libre makes this style of management possible. I take responsibility for the decisions and actions I take to manage my diabetes and I assess the risk I am taking, and I learn how to mitigate it and have a back up plan for if I get it wrong and I keep a close eye on Libre once I inject corrections.

 

[pawprint91]

Out of interest what duration do you find the protein is absorbed over?

Sorry for my far less detailed reply than @rebrascora ’s, but I am very similar to her. I would say last the 2 hour mark I see levels start to rise after a high protein meal, and like her, I just correct when I need to, but 2/3 units would not be uncommon for me to need to deal with it. 🙂

 

[Inka]

@rebrascora If you’re regularly seeing protein rises, you could try a regular insulin. You’ll get a load of rubbish from most HCPs as soon as you ask for it, but the slower action more closely matches the protein rise.

Regular insulin can be animal or human. It served us well for many decades until the invention of the analogues, and it’s still useful today in situations like yours and others’, and simply because some people don’t get on with analogues or don’t wish to take them.

 

[everydayupsanddowns]

This was the old DSF ‘rule of thumb’ graph that @Pattidevans ,indly allowed us to share here when DSF closed.

https://forum.diabetes.org.uk/boards/threads/glucose-conversion-from-dsf.103031/

So you’d need quite a lot of protein to see a big impact I think (though as folks are saying, everyone is an individual, and your own observations trump ‘internet wisdom’).

My basic big meal strategy was and remains a split of somewhere between 60:40 and 75:25 (partly depending on the meal, partly on pre-meal BG) over 1.5 to 2hrs.

I seem to remember seeing a research paper years later that backed that up as a reasonable starting point.

I’m not on Lyumjev, but when I started on Fiasp (before the quick action stopped working) I was needing to use more splits and square waves for regular-sized meals to ease the insulin in over 30-45 minutes or so.

 

[everydayupsanddowns]

This may have been the study, but I can’t seem to find the full text

The dual-wave bolus feature in continuous subcutaneous insulin infusion pumps controls prolonged post-prandial hyperglycaemia better than standard bolus in Type 1 diabetes - PubMed

The dual-wave bolus delivers a combination of an immediate normal pre-meal insulin bolus (approximately 3 min) followed by an extended (or square-wave) bolus that is evenly delivered over several hr as programmed by the patient. The purpose of this study was to compare post-prandial glycaemic...

pubmed.ncbi.nlm.nih.gov

 

[rebrascora]

@rebrascora If you’re regularly seeing protein rises, you could try a regular insulin. You’ll get a load of rubbish from most HCPs as soon as you ask for it, but the slower action more closely matches the protein rise.

Regular insulin can be animal or human. It served us well for many decades until the invention of the analogues, and it’s still useful today in situations like yours and others’, and simply because some people don’t get on with analogues or don’t wish to take them.

Thanks for that Inka but I am not sure I would get on with it in other aspects of my diabetes management like prebolus time on a morning which is 45 mins even with Fiasp and a slow release breakfast of full fat yoghurt and berries. It was 75 mins with NR and by the sound of it "regular insulin" could take longer.
It took me months of hard work and frustration to get along with Fiasp and to find ways to make it work for me but I have now cracked it and 2 years down the line my current 90 day stats are 92% TIR and that is pretty consistent, so I am extremely reluctant to change anything and a few extra jabs are no big deal to me in the scheme of things. If I was still struggling to make Fiasp work I would have tried anything but there is no way I would rock the boat right now. I will keep it in mind though if things change..... as they often do with diabetes of course so always useful to have a back up plan to investigate.

 

[Inka]

I totally get that @rebrascora When you get things working, you definitely don’t want to risk too many changes! I’d be the same - and that’s a great TIR.

Just to be clear, I was suggesting the regular insulin in addition to Fiasp - ie a bit of Fiasp to cover the carbs, then regular to cover the protein rise in whatever proportions the meal demands. I’ve used regular insulin to cover meals with very low carbs, eg salmon and a salad, and it worked surprisingly well. I actually injected it after my meal and it kept my blood sugar level for hours. I only did it as a bit of an experiment, but I was impressed. I’ve also used regular to cover higher fat low carb treat items.

Just another tool that we can choose to use or not 🙂