Bolusing for fat, protein AND carbs in a meal

[RuthW]

I have had my pump for a year now and my control is much improved. I have worked through learning about basal rates, insulin to carb ratios, manipulating doses for exercise, changes in the weather, etc, etc, etc.

I am still having spikes late in the evening, though, and I realize that this is caused by the fact that I eat my main meal in the evening and my blood sugar rises about four hours after I have eaten. With my other meals, my blood sugar is back below 7.8 within an hour and remains steady around 5-ish till my next meal.

My main meal is likely to contain more fat and protein than breakfast and lunch. I am not low-carbing, and have no plans to start doing so.

My question here for pumpers is: how DO you count fat and protein?

I mean, after nearly 50 years I am accustomed to carb counting. How on earth do you "protein count"? And fat count? Where are you getting the info from? How accurate is it?

Secondly: what ratios do YOU use personally?

Or do you prefer a TBR? If so, how do you calculate it.

(I am aiming this question at pumpers and diabetics on insulin.

I am not interested in re-hashing the argument over low-carbing. There are tens of thousand of posts about that topic already. My questions is specifically about managing T1 diabetes with a pump, while eating a diet that includes carbs.)

 

[novorapidboi26]

Personally I don't count fat and protein, but I am not on a low carb diet, in fact the last few months my carb in take has been shocking....;(

my ratios vary between 8g:1u to 13g:1u, so nothing too complicated....

I don't know what you mean when you ask if we prefer TBR, prefer it to what......?

TBR for me is used for exercise, illness, to prevent lows and to get highs down quicker.....

some people find that protein and fat do have an effect and for them the dosing rules with vary I suppose with each individual......

these people may be able to provide a good starting point I suppose.......

the first thing I would do is establish whether or not you are seeing an effect from the fat/protein and is it significant enough to add in another dimension to your dose calculation...

 

[RuthW]

Yes, like you, at two meals, I don't count fat and protein, and have no problems or post-meal spikes. I guess it is because I don't eat as much at those two meals, and I am more physically active during the day.

However, it is at the evening meal that I am more likely to eat the "fancy stuff" that contains higher protein and fat proportions. I do know my spikes are coming from that. I have kept good records.

 

[ewelina]

I use a Polish method mentioned on the forum before. Every 100kcal from fat and protein is one PF portion. My ratio for this is 0.4 u. For example if I eat 40g of potatoes with some protein and fat worth 400kcal I would have 4carb portions and 4pf portions. My ratios in the evening for carb is 0.8u and for protein and fat 0.4 u so I would give 3.2u for carbs +1.6u for fat/protein. This 1.6 u need to go as a extended bouls but how long you need to test for yourself. With simple carbs I do like 30 mins but with low GI or low carb 2-4h depending on how much fat in a meal
With this method your carb ratios will be probably a bit lower to what you use now

 

[Kristin251]

I think there may be a dosing difference between carb burners and fat burners (ketones). I am low carb so I do have to dose for protein as it will raise me in the absence of carbs. As far as fat goes I can't dose for it but I eat it as the highest percent at every meal as it keeps me steady. Saturated fat raises me MUCH later than mono fats. Mono just slow things but saturated raise me for too long and I am out of insulin by the time it is digested. I will generally go low 1st with a high sat fat meal and then pop up and stay up. I inject insulin and don't pump but I do think a carb burner and a fat burner require somewhat different dosing practices. I do believe saturated fat can have the same effect on both though. Just something to watch for I guess.
It is also said that without adequate insulin gluconeogenesis will proceed rapidly from protein. That may or may not apply to carb burners.
I also find any more than 3 oz protein raises me. I eat guac and celery for BF so no P. Lunch is veg and 2 oz protein and dinner is veg and 3 oz P. All with additional fat but my P sources are more lower fat poultry or fish. Red meat can be a different story (sat fat). I have heard many that say P raises them if they eat more than 3 oz in meal. I also never eat protein closer than 3.5 hours apart. The lower P and spacing the meals 4 hours has helped me a lot

 

[tim2000s]

@RuthW have a look at this: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2901033/

It goes into some detail about the Warsaw School's method for dealing with Protein and Fat. Something I think is known as The Pankowska Method which @ewelina has talked about. It is widely used in Poland and Germany for pump users. There is a piece of software called Diabetics that can be run on a Windows PC that will do the calculation for you.

My own observations as regard to eating Protein and Fat are as follows:

I always bolus for protein as though it was 50% of the weight of carbs, so for a meal containing 25g carbs, 30g protein and 15g fat, I'd bolus for 25g Carbs and 50% of the ratio for protein, i.e. as though it was 15g carbs. Then an additional 10% of the weight of fat. Seems to work out alright. I've experimented with extended bolusing and multiwave on this, and keep coming back to the opinion that sugar surfing is actually just easier to manage, as digestion and absorption aren't constants, and vary depending on the make-up of the food I am eating.

For things like fish and chips and Pizza, I've found I need to take the a multiwave bolus that is split with a standard carb ratio for the standard bolus component for the carbs in the meal and then between 75% and 100% for the extended component over about 5 or 6 hours. For Pizza, that can be as long as 8 hours and with curry, I find I need to do a normal bolus for the carbs in the curry, then a TBR that starts about 3 hours after the curry has finished at about 150% for five to eight hours from then.

It seems to be very much driven by experimentation and observation.

 

[CarbsRok]

If I have a high fat meal (fish and chips) on a rare occasion I eat at 5.30 and a temp basal of +30% then goes on at 4AM for a couple of hours to make sure I don't start to climb. I also inject when I start the meal and not 30 mins before.

 

[ewelina]

Counting 50%protein and 10%fat, gives more or less the same amount of insulin for a meal that is not very high in fat, as Pankowska method. It is not that precise for higher in fat meals. Extending boluses can be a bit tricky though. I find that I don't need to extend them as much as Pankowska method recommends and now with libre I bolus the whole thing all together and monitor how it goes. If its not very fatty meal I don't go low. I suppose it acts like a super bolus

 

[RuthW]

I use a Polish method mentioned on the forum before. Every 100kcal from fat and protein is one PF portion. My ratio for this is 0.4 u. For example if I eat 40g of potatoes with some protein and fat worth 400kcal I would have 4carb portions and 4pf portions. My ratios in the evening for carb is 0.8u and for protein and fat 0.4 u so I would give 3.2u for carbs +1.6u for fat/protein. This 1.6 u need to go as a extended bouls but how long you need to test for yourself. With simple carbs I do like 30 mins but with low GI or low carb 2-4h depending on how much fat in a meal
With this method your carb ratios will be probably a bit lower to what you use now

I looked at that thread and the links before but I found the methodology of the calculations a bit mind-boggling, to be honest .

However, "Every 100kcal from fat and protein is one PF portion," makes it all sound a bit easier. That just means that after all these years, I will finally have to learn to calorie count. And there is loads of info out there about calorie counting (even for innumerates like me). So the next thing to work out is the timing of the extended bolus.

 

[Kristin251]

I pretty much eat the same macro at each meal at each time of day (B, L, D) and this way I found my bolus for each meal. I cannot eat P at BF without spiking hence the guacamole. For dinner I can eat more veggies and P than at L and bolus the same. I take 1 unit per meal but different meals act different at different times of day. So no P BF, 2 oz lunch and 3 dinner. Then the veggie portion gets larger at dinner. I found keeping P, carbs and fat basically the same consistently every day keeps me the most steady without highs and lows. So I pretty much know where I am going to go. So maybe if you try to eat basically the same macros at each meal daily you will find a bolus that is consistent. I find it easier than counting everything. Of course the type of carbs you eat (pasta, rice, donuts etc) may make a difference too. Of course I vary my P F and V but eat about the same ratios for each meal

Just a thought

 

[RuthW]

@RuthW have a look at this: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2901033/

It goes into some detail about the Warsaw School's method for dealing with Protein and Fat. Something I think is known as The Pankowska Method which @ewelina has talked about. It is widely used in Poland and Germany for pump users. There is a piece of software called Diabetics that can be run on a Windows PC that will do the calculation for you.

My own observations as regard to eating Protein and Fat are as follows:

I always bolus for protein as though it was 50% of the weight of carbs, so for a meal containing 25g carbs, 30g protein and 15g fat, I'd bolus for 25g Carbs and 50% of the ratio for protein, i.e. as though it was 15g carbs. Then an additional 10% of the weight of fat. Seems to work out alright. I've experimented with extended bolusing and multiwave on this, and keep coming back to the opinion that sugar surfing is actually just easier to manage, as digestion and absorption aren't constants, and vary depending on the make-up of the food I am eating.

For things like fish and chips and Pizza, I've found I need to take the a multiwave bolus that is split with a standard carb ratio for the standard bolus component for the carbs in the meal and then between 75% and 100% for the extended component over about 5 or 6 hours. For Pizza, that can be as long as 8 hours and with curry, I find I need to do a normal bolus for the carbs in the curry, then a TBR that starts about 3 hours after the curry has finished at about 150% for five to eight hours from then.

It seems to be very much driven by experimentation and observation.

Yes, I looked at those links before. I will try to download the software onto my aging Android phone, and try it out, but I am generally working with Apple products, so it has its limitations for me.

The sugar surfing "thing" is effectively what I am doing, but since I don't have CGM, I am playing "wait and see and sore fingers", to measure what direction my BS is traveling and how fast, then guessing what bolus to administer round 11pm to midnight. You know how nervous T1s can get about midnight boluses, I am sure! And it doesn't prevent a spike for that reason.

Your extended boluses, though, strike fear into my heart! I would have that much insulin floating around while I am asleep? And it is all a bit chancey?

I just will never eat pizza again!

Also, how exactly are you working out the protein and fat content of meals? To me it doesn't seem so measurable "by eye", especially when you are talking curries and Pizzas and eating out. Are you working on experience?

 

[RuthW]

If I have a high fat meal (fish and chips) on a rare occasion I eat at 5.30 and a temp basal of +30% then goes on at 4AM for a couple of hours to make sure I don't start to climb. I also inject when I start the meal and not 30 mins before.

Almost 12 hours later!! Wow!

 

[RuthW]

I pretty much eat the same macro at each meal at each time of day (B, L, D) and this way I found my bolus for each meal. I cannot eat P at BF without spiking hence the guacamole. For dinner I can eat more veggies and P than at L and bolus the same. I take 1 unit per meal but different meals act different at different times of day. So no P BF, 2 oz lunch and 3 dinner. Then the veggie portion gets larger at dinner. I found keeping P, carbs and fat basically the same consistently every day keeps me the most steady without highs and lows. So I pretty much know where I am going to go. So maybe if you try to eat basically the same macros at each meal daily you will find a bolus that is consistent. I find it easier than counting everything. Of course the type of carbs you eat (pasta, rice, donuts etc) may make a difference too. Of course I vary my P F and V but eat about the same ratios for each meal

Just a thought

To be honest, I would be concerned about eating so little protein. On the other hand, my strategy is largely the same as yours: keep it consistent.

But now I want to learn to deal with those days when I eat out, or eat a someone else's place, or fancy something different!

 

[RuthW]

Counting 50%protein and 10%fat, gives more or less the same amount of insulin for a meal that is not very high in fat, as Pankowska method. It is not that precise for higher in fat meals. Extending boluses can be a bit tricky though. I find that I don't need to extend them as much as Pankowska method recommends and now with libre I bolus the whole thing all together and monitor how it goes. If its not very fatty meal I don't go low. I suppose it acts like a super bolus

I'm going to have to pull my socks up and give it a go, I see.

Tbh, my most horrifying spikes are when I eat a big chunk of salmon. I guess it is the fat and protein combined.

But I can give up pizza, but I'll never give up salmon. So I must master this.

 

[noblehead]

Hi @RuthW, I use a dual-wave bolus which covers most high-fat meals that result in delayed spikes, but the I:C ratio does go out of the window with these sort of meals and generally I need a lot more insulin than I would if the meal contained moderate amounts of fat & protein.

I don't have a formula as such and just go from past experience of eating that meal and recording it in a diary when I get the dosing right, but much like CarbsRok, if the meal is particularly high in fat I'll also use a TBR as I do find I become more insulin resistant night as the night progresses, sorry can't be more precise but I don't really count fat & protein in meals and just go from past experience (as already said).

 

[tim2000s]

Also, how exactly are you working out the protein and fat content of meals? To me it doesn't seem so measurable "by eye", especially when you are talking curries and Pizzas and eating out. Are you working on experience?

Ordering from the likes of Dominoes, they have the content on line so you can make an estimated guess, but the majority of it has come from observation with the Libre and then trial and error.

 

[RuthW]

I'm going to start recording my evening meals in my bs records, I think. I will beat the spike back down that way, I hope.

 

[noblehead]

I'm going to start recording my evening meals in my bs records, I think. I will beat the spike back down that way, I hope.

I do find this is the best approach, we have to remember what works for one person may not work for another.

 

[RuthW]

Yes, but some handy guidelines and suggestions on this thread. Thanks, guys.

I can't get the Diabetics software, though. Web page not available. Maybe they're updating.

 

[Kristin251]

The big chunks of salmon would spike me for sure. Have you read The Rosedale Diet? He speaks od P turning to glucose and recommends no more than 3 oz per meal. I was eating much more and was always seeing high numbers. Then I tried his approach and they immediately dropped. New research (for what it is worth) is most adults only need 45-60 g protein a day divided into 3 meals. Lower my P as well as dividing it between meals made a huge difference.

It is VERY hard to eat out and get it right. You never know what is in the foods. I tend to just order salads and eyeball the protein. It is not fun eating out anymore and it is not fun trying to correct mistakes. It takes days to get back to normal.