How much protein is bolus calculable? (26.01.2016)

[Bluemarine Josephine]

Hello everyone,
I hope that you are very well today!

I am reading with interest that many of you consider protein and fat in your bolus, when these are in large quantities. I have, lately, started considering doing so myself (despite the DAFNE guidelines that I do not have to).

Please, be patient with me as I need to explain my following observation.
Example: Breakfast.
30 grams of carbs.
1:1 ratio.

For a breakfast made solely of carbs, where no protein or fat are added.
309 grams of orange : around 18 grams of sugar
1 very thin slice of rye bread: around 10 grams of carbs
Rounded up to 30 grams, bolusing 3 units of Novorapid.

On the basis of this example, the 1:1 ratio works like a dream. Sometimes, even better than a 1:1.

If on the same breakfast, I add just a little butter on my bread and 40 grams of cheddar cheese (in my mind, 40 grams of cheese is not a lot of protein but, I may very well be wrong) by lunchtime my blood glucose level shows me that the breakfast ratio changed to 1:1+1. In other words by lunchtime my blood sugar is higher that I would have expected. (not massively higher but, still, not accurately 1:1).

If in this breakfast I add 200 grams of 0% fat Fage Greek yogurt which accounts for 8 grams or carbs (instead of the rye bread) then my lunchtime blood sugar level would reveal that my breakfast ratio has actually changed to 1.5:1.

In fact, on days where I expect a busy morning ahead, I choose yogurt with breakfast, feeling persuaded that there is no way that my 1:1 ratio would work accurately.

However, in my mind, cheese or yogurt do not carry big amounts of protein…
I do understand that I am playing with small numbers. When I explained my observation to my dietician she replied ‘Josephine, I think you are reading too much into it. You won’t be at 5.0 by lunchtime but, you will be somewhere around 7.0-7.5, no big deal…”

When I asked other diabetics from the DAFNE course how they handle protein/fat they also seemed to perceive my observation as somewhat peculiar, as no one really bothers with the small numbers…

But, I am trying to understand the principle and the strategy behind food choices because, I feel, that I will understand my diabetes better in this way.

So, my question is, in order to consider bolusing for protein, how much protein do you consider sufficient/high enough?
Also, please let me have your comments, have you observed similar patterns with different food combinations (although the overall carbohydrate intake remains the same?)

Thank you in advance for your replies.
Diabetic hugs
Josephine.

 

[tim2000s]

@Bluemarine Josephine Cheese is ~33% Protein and Fage Greek Yoghurt is 10%.

You therefore get 20g of protein in 200g of yoghurt, plus the eight grams of Carbs.

Many of us account for 50% of the protein weight as carbs and bolus accordingly, which, in your Yoghurt example, would give you 18g to bolus for, which is much closer to your 1.5:1 ratio.

Personally, I operate with a breakdown of 100% of carb weight, 50% of Protein weight and 10% of Fat weight for bolus calculations. PredictBGL (a phone app) makes this very simple.

Likewise on your cheese, it contains ~13g of protein, which I equate to 6.5g of carbs, so you would see an increase. If you also take into account the increase of fat in this meal (from the cheese and butter), you will get a delay effect on the glucose raise, which will also affect your pre-lunch reading.

I typically always include any protein or fat in the meal. I've found this to work well, and we haven't even got on to the "polish method" yet!

 

[Bluemarine Josephine]

@Bluemarine Josephine Cheese is ~33% Protein and Fage Greek Yoghurt is 10%.

You therefore get 20g of protein in 200g of yoghurt, plus the eight grams of Carbs.

Many of us account for 50% of the protein weight as carbs and bolus accordingly, which, in your Yoghurt example, would give you 18g to bolus for, which is much closer to your 1.5:1 ratio.

Personally, I operate with a breakdown of 100% of carb weight, 50% of Protein weight and 10% of Fat weight for bolus calculations. PredictBGL (a phone app) makes this very simple.

Likewise on your cheese, it contains ~13g of protein, which I equate to 6.5g of carbs, so you would see an increase. If you also take into account the increase of fat in this meal (from the cheese and butter), you will get a delay effect on the glucose raise, which will also affect your pre-lunch reading.

I typically always include any protein or fat in the meal. I've found this to work well, and we haven't even got on to the "polish method" yet!

So, in order to achieve accuracy, the protein intake doesn't need to be a feast in order to make a difference... even a low carb yogurt or some cheese could change the equation... I find it fascinating!!
Thank you for your explanation.

 

[Griffter15]

This is interesting. I'm trying to get to grips with this myself at the moment.

My personal experience so far is that I only need to count protein if my carb intake in the meal is very low (under 20g) or the protein content very high (over 60g)

But I'm sure I'll discover more, especially when I get my libre.

 

[novorapidboi26]

I don't even consider it to be honest ............

when I do go for carb free meals with protein and fat in there, I don't see any significant increase in blood sugar so making an effort to complicate my calculations isn't worth it..........



It is interesting though......

 

[tim2000s]

I don't even consider it to be honest ............

when I do go for carb free meals with protein and fat in there, I don't see any significant increase in blood sugar so making an effort to complicate my calculations isn't worth it..........



It is interesting though......

Lucky you!

 

[novorapidboi26]

Lucky you!

Agreed....

 

[ewelina]

If you're on MDI, calculating 50% protein and 10% fat should work well

 

[smag3]

@Bluemarine Josephine Cheese is ~33% Protein and Fage Greek Yoghurt is 10%.

You therefore get 20g of protein in 200g of yoghurt, plus the eight grams of Carbs.

Many of us account for 50% of the protein weight as carbs and bolus accordingly, which, in your Yoghurt example, would give you 18g to bolus for, which is much closer to your 1.5:1 ratio.

Personally, I operate with a breakdown of 100% of carb weight, 50% of Protein weight and 10% of Fat weight for bolus calculations. PredictBGL (a phone app) makes this very simple.

Likewise on your cheese, it contains ~13g of protein, which I equate to 6.5g of carbs, so you would see an increase. If you also take into account the increase of fat in this meal (from the cheese and butter), you will get a delay effect on the glucose raise, which will also affect your pre-lunch reading.

I typically always include any protein or fat in the meal. I've found this to work well, and we haven't even got on to the "polish method" yet!

That is as clear an explanation as I have seen. Thanks so much.

 

[petepontiac]

Brilliant I am no longer confused: will lower my carbs and increase my protein now I know how to calculate my dosage. Was getting paranoid to say the least.

 

[petepontiac]

Hello everyone,
I hope that you are very well today!

I am reading with interest that many of you consider protein and fat in your bolus, when these are in large quantities. I have, lately, started considering doing so myself (despite the DAFNE guidelines that I do not have to).

Please, be patient with me as I need to explain my following observation.
Example: Breakfast.
30 grams of carbs.
1:1 ratio.

For a breakfast made solely of carbs, where no protein or fat are added.
309 grams of orange : around 18 grams of sugar
1 very thin slice of rye bread: around 10 grams of carbs
Rounded up to 30 grams, bolusing 3 units of Novorapid.

On the basis of this example, the 1:1 ratio works like a dream. Sometimes, even better than a 1:1.

If on the same breakfast, I add just a little butter on my bread and 40 grams of cheddar cheese (in my mind, 40 grams of cheese is not a lot of protein but, I may very well be wrong) by lunchtime my blood glucose level shows me that the breakfast ratio changed to 1:1+1. In other words by lunchtime my blood sugar is higher that I would have expected. (not massively higher but, still, not accurately 1:1).

If in this breakfast I add 200 grams of 0% fat Fage Greek yogurt which accounts for 8 grams or carbs (instead of the rye bread) then my lunchtime blood sugar level would reveal that my breakfast ratio has actually changed to 1.5:1.

In fact, on days where I expect a busy morning ahead, I choose yogurt with breakfast, feeling persuaded that there is no way that my 1:1 ratio would work accurately.

However, in my mind, cheese or yogurt do not carry big amounts of protein…
I do understand that I am playing with small numbers. When I explained my observation to my dietician she replied ‘Josephine, I think you are reading too much into it. You won’t be at 5.0 by lunchtime but, you will be somewhere around 7.0-7.5, no big deal…”

When I asked other diabetics from the DAFNE course how they handle protein/fat they also seemed to perceive my observation as somewhat peculiar, as no one really bothers with the small numbers…

But, I am trying to understand the principle and the strategy behind food choices because, I feel, that I will understand my diabetes better in this way.

So, my question is, in order to consider bolusing for protein, how much protein do you consider sufficient/high enough?
Also, please let me have your comments, have you observed similar patterns with different food combinations (although the overall carbohydrate intake remains the same?)

Thank you in advance for your replies.
Diabetic hugs
Josephine.

I am so glad you wrote this as I was having difficulties understanding the carb protein dosage regime. A big thank you.

 

[Bluemarine Josephine]

@Bluemarine Josephine Cheese is ~33% Protein and Fage Greek Yoghurt is 10%.

You therefore get 20g of protein in 200g of yoghurt, plus the eight grams of Carbs.

Many of us account for 50% of the protein weight as carbs and bolus accordingly, which, in your Yoghurt example, would give you 18g to bolus for, which is much closer to your 1.5:1 ratio.

Personally, I operate with a breakdown of 100% of carb weight, 50% of Protein weight and 10% of Fat weight for bolus calculations. PredictBGL (a phone app) makes this very simple.

Likewise on your cheese, it contains ~13g of protein, which I equate to 6.5g of carbs, so you would see an increase. If you also take into account the increase of fat in this meal (from the cheese and butter), you will get a delay effect on the glucose raise, which will also affect your pre-lunch reading.

I typically always include any protein or fat in the meal. I've found this to work well, and we haven't even got on to the "polish method" yet!

Thank you so much Tim, for taking the time to give me the breakdown, it makes so much sense to me now.
Especially knowing that protein is an element that I should consider regardless of the portion.

You see, in my mind, protein had an effect on blood sugar only in considerably big dosages (like a very big Christmas or Easter meal, for example). It had not occurred to me that small, daily protein intake from a yogurt or a glass of milk or 60 grams of cheese, combined with other carbohydrates (like fruit or bread) can make a difference.

Likewise, I calculate 100% carbohydrates.

I am not as adventurous to consider 50% of protein in order to bolus. I am thinking to start with a “safer” 25%, see how it goes and how insulin responds to this and take it from there.

I generally don’t touch fat, (it is a personal preference, I don’t like it) so, I wouldn’t go, at this stage, as far as bolusing for 1 tablespoon of virgin olive oil in salad or a thin spread of butter on toast…I might do it after I figure out bolusing for rpotein first... one step at a time...

Thank you for your recommendations and for your guidance as to how to handle it.
Regards
Josephine

 

[Bluemarine Josephine]

I am so glad you wrote this as I was having difficulties understanding the carb protein dosage regime. A big thank you.

Hello and thank you for your comment.
I feel as if I had an epiphany when reading this thread!

When I vaguely discussed my findings regarding protein during my DAFNE follow-up appointment, mildly suggesting that “maybe I should consider blousing even ½ a unit for protein?” I received from the Diabetes Nurse educator this look of disapproval and disbelief, as if I am completely stupid disregarding the DAFNE guidelines.

I do appreciate the DAFNE guidelines however, I cannot take seriously an educator or a nurse or a dietician (no matter how educated he/she is on diabetes) who has never injected even one insulin injection in their lives.

They have the manual, they have read it and know it very well but, they have never taken the car for a drive.

Regards
Josephine

 

[tim2000s]

Hello and thank you for your comment.
I feel as if I had an epiphany when reading this thread!

When I vaguely discussed my findings regarding protein during my DAFNE follow-up appointment, mildly suggesting that “maybe I should consider blousing even ½ a unit for protein?” I received from the Diabetes Nurse educator this look of disapproval and disbelief, as if I am completely stupid disregarding the DAFNE guidelines.

I do appreciate the DAFNE guidelines however, I cannot take seriously an educator or a nurse or a dietician (no matter how educated he/she is on diabetes) who has never injected even one insulin injection in their lives.

They have the manual, they have read it and know it very well but, they have never taken the car for a drive.

Regards
Josephine

For the first time, in his new book about pumping insulin and CGMs which is aimed at HCPs, Nick Oliver does discuss protein and fat in the same breath as "bolusing for carbohydrate". I think it may be the first bit of medical literature where this is observed and actually written down!

 

[Bluemarine Josephine]

For the first time, in his new book about pumping insulin and CGMs which is aimed at HCPs, Nick Oliver does discuss protein and fat in the same breath as "bolusing for carbohydrate". I think it may be the first bit of medical literature where this is observed and actually written down!

Tim, you are ever so right.
When I raised the issue at DAFNE, our nutritionist said that it is only recently that some nutritionists have started to consider suggesting bolusing for protein but, only in the cases of diabetic children and provided that the meat/fish (protein in general) exceeds the size of a deck of cards.

However, my meter shows me the exact opposite (hence, the point of my question and this thread) even for small protein amounts (like a glass of milk)

And, for the life of me, I cannot believe that I have been (officially) in a bolus/basal scheme for a bit over 2 months now and, still, I made this observation myself while, the educators who have been teaching DAFNE for 30 years (as they told us while introducing themselves during DAFNE) are, still, considering the possibility that maybe (just maybe) protein should be calculated for bolusing...

Haven't they heard this from any other diabetic during their 30 years of experience? Haven't they ever read a thread in diabetic forums? Aren't they listening to our findings during our consultation meetings?

It upsets me, it really does!!
They would have saved me so much time, energy, effort and worry...

 

[tim2000s]

Tim, you are ever so right.
When I raised the issue at DAFNE, our nutritionist said that it is only recently that some nutritionists have started to consider suggesting bolusing for protein but, only in the cases of diabetic children and provided that the meat/fish (protein in general) exceeds the size of a deck of cards.

However, my meter shows me the exact opposite (hence, the point of my question and this thread) even for small protein amounts (like a glass of milk)

And, for the life of me, I cannot believe that I have been (officially) in a bolus/basal scheme for a bit over 2 months now and, still, I made this observation myself while, the educators who have been teaching DAFNE for 30 years (as they told us while introducing themselves during DAFNE) are, still, considering the possibility that maybe (just maybe) protein should be calculated for bolusing...

Haven't they heard this from any other diabetic during their 30 years of experience? Haven't they ever read a thread in diabetic forums? Aren't they listening to our findings during our consultation meetings?

It upsets me, it really does!!
They would have saved me so much time, energy, effort and worry...

I spoke with one of the directors of the DAFNE curriculum at a JDRF meeting before Christmas. There were a number of us at the meeting who eat lower carb, and this topic came up. It seems that among dieticians there has been an ongoing discussion about including bolusing for protein and the effects of fat for some time. It was originally taken out of DAFNE as it was considered too complex for patients to deal with, but they have encountered significant support for making sure it goes in.

So while I can't say with any certainty where this is going, it is certainly on the radar and we will hopefully see it provided in structured education in the not too distant future.