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Official TAG link?

Discussion in 'Type 1 Diabetes' started by Spiker, Sep 16, 2014.

  1. Spiker

    Spiker Type 1 · Well-Known Member

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    Does anyone have a link to an official description of the Total Available Glucose dose calculation system? @jack412 posted this link from Joslin which is slightly critical of the original (1996) version of TAG, but says it has been 'recently updated'.

    http://blog.joslin.org/tag/total-available-glucose/

    As stated it there anyway (by a 'hostile source') TAG is just saying bolus 50% for protein and 10% for fat, in addition to 100% for carbs. I know from my own experience that is not going to work. Protein conversion to carbs is variable, not fixed, and varies based on multiple factors - how much protein you eat, (independently) how much carbohydrate you eat, structural protein needs, maybe more. Protein conversion is anything from 60% (ultra rare) to 0% (common) in practice. And it is at least debatable whether any *net* conversion of fat to glucose occurs at all. Yes there is a reaction in lipolysis that liberates a glucose molecule, but arguably that glucose molecule needs to be recycled back into the process to keep lipolysis running and is not available for use. (I may be wrong on that). And dietary fat has been shown to lower insulin sensitivity, increasing insulin requirements for other nutrients in a variable way.

    Not to mention the timing issues of protein and fat boluses.

    But does anyone have a link to a more modern 'enhanced' version of TAG?
     
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  2. LucySW

    LucySW Type 1 · Well-Known Member

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    Oh. Can you post some links on that?
     
  3. Spiker

    Spiker Type 1 · Well-Known Member

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    @noblehead, could you oblige please re +fat -insulin sensitivity? I think you were the source for that iirc?

    The Newcastle Diet studies mention it as part of the negative spiral for T2s.
     
  4. jack412

    jack412 Type 2 · Expert

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  5. phoenix

    phoenix Type 1 · Expert

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    Original TAG was in this book here http://www.amazon.com/T-G-Diabetic-...4583/ref=sr_1_1?ie=UTF8&qid=1327712993&sr=8-1
    (it's come down in price, I remember someone saying that they could only get one for 200$ but not all US dealers ship outside.
    I think you will find most recent experimentation here http://www.tudiabetes.org/group/tagers The group seems to have become inactive.

    I suspect the links that Nigel gave will be to Scheiner and Wolpert.
    http://www.mendosa.com/The-Fat-of-the-Matter-How-Dietary-Fat-Effects-Blood-Glucose.htm
    http://care.diabetesjournals.org/content/36/4/810.full
     
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  6. Spiker

    Spiker Type 1 · Well-Known Member

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    Thanks both!

    Hmm Scheiner (on Mendosa) doesn't quantify the small, slow fat-> carbs effect.

    The Wolpert paper from Diabetes Care is the business. @LucySW, this is the one.
     
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  7. Spiker

    Spiker Type 1 · Well-Known Member

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    Ha ha the Wolpert study is the famous "pizza test"!

    Criticised as being an extreme example of a HCHF meal. But still interesting.
     
  8. jack412

    jack412 Type 2 · Expert

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    what this guy seemed to do was to wack for the carb upfront and delay for the protein/fat
    http://www.insulinpumpforums.com//index.php?showtopic=4708
    "I use a bolus calculation technique that is usually referred to as TAG (Total Available Glucose). The premise behind TAG is that a portion of the protein and fat content of the meal will also contribute to carb loading above and beyond the actual carbs in the meal. Whereas 100% of the carbs are accounted for when calculating the bolus, only a percentage of the protein and fats are expected to be eventually converted to glucose. The carb bolus is delivered immediately and the protein and fat bolus is delivered using the square wave/ extended bolus.
    "I have found through trial and error that for my metabolism, approximately 40% of ingested protein and fats are eventually converted to carbs (my percentages have changed over time as I played with the technique). I total the grams of protein and fat and multiply by 40%. As an example, if the protein and fat total to 80 grams, I would multiply by .40 and come up with 32 grams. With an i:c ratio of 1:10, this 32 grams of protein and fat carb loading would need to be covered by 3.2 units of insulin, in addition to the carbs in the meal. Since proteins and fats are digested more slowly than carbs, the 3.2 units have to be delivered using a square wave/ extended bolus to
    prevent a person from dropping too low.
    "How do I time the square wave/ extended bolus? Again, through much trial and error I find that a delivery rate of approximately 1 - 1.2 units of insulin per hour delivery rate for the square wave/ extended bolus keeps me from dropping too low or spiking too high. So in this example, I would deliver the 3.2 units over a time span of 3 hours (3.2 units per hr/ 3 hrs = delivery rate of 1.06 units per hr, which is within the 1 - 1.2 target delivery rate. The 1 - 1.2 delivery rate is used assuming I was in BG target range to begin with. If my BG is above target, I would use a delivery rate higher than this range or transfer part of the protein/ fat bolus to the carb bolus for immediate delivery. If my BG is below range, I would use a delivery rate which is lower.
    "As you all have noticed, I also experience a much smaller spike after eating a meal when using this technique. Typically, I see my BG spike as little as 20 - 30 points after eating a pasta meal which will have over 100 grams of carbs. After such meals it is common to see 1 hr post prandials of 100 - 120 and 2 hr post prandials of less than 100. If I delivered the insulin correctly, I will be at or near target several hours after the meal, without ever going low.
    "TAG is NOT taught or recognized by most medical professionals I have talked with. My TAG percentages are essentially a personalized algorithm for my metabolism of a meal and should not be seen as percentages that anyone else can pick up and run with.
    "Why does the technique work? Better absorption may be one reason the technique works. My explanation however is that the square wave/ extended bolus on top of a carb bolus simulates secondary phase insulin release, which is how a non-diabetic pancreas would handle a meal. Having once tried Symlin, this technique works better to control my post-meal spikes. However, if you are not sensitive to protein/ fat carb loading, the technique may not work well for you. My understanding is that TAG will work best for someone whose second phase insulin release is less than satisfactory. Unfortunately, most of us are simply given a catch all diagnosis of "diabetes" without any further classification of inadequate first and/ or second phase insulin release."
    Many thanks, Ricardo & RIP.
     
  9. Spiker

    Spiker Type 1 · Well-Known Member

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    In other words "figure out what (fat and protein) ratios work for you". :-/

    Odd to apply the exact same ratio to fat and protein. Physiologically 40% -> carbs is way too high for fat. I bet this guy does not eat much fat.
     
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  10. noblehead

    noblehead Type 1 · Guru
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    It was the Mendosa site that I first read about it Spiker after searching for articles on the net to do with Gary Scheiner, after reading his book Think Like a Pancreas (although it may have been mentioned on the forum before then). Last year I read about it all over again on the ADA website and on Science Daily:

    http://www.sciencedaily.com/releases/2013/03/130327190328.htm

    But I do think the best approach for bolusing for meals is trial & error, this is especially so for those who reduce their carb intake and make up the difference with protein & fat, if you get good readings after a low-carb meal then it's best to record it all( food, portion sizes, insulin dose, pre & postprandial bg readings and any other factors such as stress & exercise) and try the same meal again, if it works out well for a second time then the likelihood is it will for a third and thereafter.

    I do think that as insulin dependant diabetics we do forget that there's so many factors involved in controlling our diabetes, some we are aware of and others not known to ourselves until it is brought to our attention, the following is an excellent overview of the things that can effect bg control and is worthy of a mention on the forum:

    http://diatribe.org/issues/68/adams-corner
     
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  11. LucySW

    LucySW Type 1 · Well-Known Member

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    Yes, thanks all three.

    Lucy
     
  12. LucySW

    LucySW Type 1 · Well-Known Member

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    From the Wolpert article:

    "Dietary fat and free fatty acids (FFAs) are known to impair insulin sensitivity and to enhance hepatic glucose production (3,4). Furthermore, pharmacologic interventions that lower FFA levels in nondiabetic and type 2 diabetic individuals lead to both improved insulin sensitivity and glucose tolerance (5,6). Studies in patients with type 1 and type 2 diabetes have shown that dietary fat delays gastric emptying, leading to a lag in glucose absorption (7,8). Although there has been considerable interest in the role of dietary fat and circulating FFAs in the pathogenesis of type 2 diabetes (9,10), relatively little attention has been given to the possible implications of FFA-induced insulin resistance for the treatment of type 1 diabetes. Review of continuous glucose monitoring and food log data from our adult patients with type 1 diabetes led to the observation that, contrary to the current treatment recommendations, higher-fat meals usually require more insulin coverage than lower-fat meals with similar carbohydrate content."

    Yikes !! FFA-induced insulin resistance? Delayed gastric emptying? Do we really WANT to eat a HF diet then? I am intimidated and confused .. Ow, ow, ow.

    Boo hoo.Do we have to worry about this, or is this just another fine wrinkle in advanced bolusing ?

    Lucy
     
  13. Spiker

    Spiker Type 1 · Well-Known Member

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    Well it was @noblehead who first alerted me to this and I think (unfortunately) it is relevant to anyone who is doing LCHF. There are definitely reports out there of insuiln resistance (and carb ratios) rising as low carbers add fat. Creating a "floor" of minimum insulin that you can't get below other than a low calorie diet. It's a drag but it seems to be a fact. My own experience weakly corroborates it.

    My gut feeling is that the time-delay and insulin-resistance effects of fat are much bigger than any possible direct conversion of fat to carbs.
     
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  14. jack412

    jack412 Type 2 · Expert

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    a bit more about TAG protein over 20g

    http://www.diabetesmine.com/2014/02/tweaking-my-basals-with-protein-tips.html

    Jenny http://integrateddiabetes.com/ explained the whole high-protein conundrum: I often eat meals with loads of the stuff and pat myself on the back for going as low-carb as possible. But then I still end up high. ***?
    Yes, I know we recently reported right here at the ‘Mine about how experts are saying PWDs definitely need to account for protein and fat content when dosing insulin. But heck, I’m old school (and lazy, like most humans), so I wasn’t doing that. It seemed awfully fussy, and not guaranteed to work.
    But Jenny explained that it really does make a difference if you eat a meal with a protein count above 20 grams: what you need to do is account for the amount of protein over 20g as if it were carbs. So for example, if you ate a meal containing 40 grams of carb + 25 grams protein, you would dose for 45 grams carb (the 40 plus the protein amount beyond 20). On top of that, you’re supposed to take the bolus at the end of the high-protein meal and extend the portion of the dose covering the protein (5g) for two hours.

    yet the link is actually saying 50% and 10% ...
    http://www.diabetesmine.com/2013/12/counting-those-carbs-may-not-be-best.html
    . Honestly, I was hugely relieved when I eventually went on an insulin pump and started using carb counting to achieve more flexibility in my diet. (I still do factor in non-carbs for setting extended boluses, as about 50% of protein grams and about 10% of fat grams turn into carbs over several hours.)
    Thankfully, no one seems to be suggesting going all restrictive again, and whatever new approach may replace carb counting is still being worked out. But it’s fascinating to see that this now-established method is being second-guessed.

    here is a guy using 2 different bolus insulin
    http://www.tudiabetes.org/forum/topics/tagging-for-mdi-help?groupUrl=tagers&groupId=583967:Group:1001547&id=583967:Topic:2506051&page=2#comments
    I shot up novolog to cover my carbs and then regular for protein using the TAG principle that about 58 percent of protein and up to 10 percent of fat will ultimately metabolize to glucose. It worked very well for many years for me and helped me get to a 5.0 a1c on MDI. Best of luck. (I was using lantus for basal).

    pizza
     
    #14 jack412, Sep 17, 2014 at 12:55 AM
    Last edited by a moderator: Sep 17, 2014
  15. noblehead

    noblehead Type 1 · Guru
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    I do also think it depend on the type of fat that is added to the diet (as Scheiner says in the Mendosa article). There's been two type 1 members who follow a LCHF diet and have found that reducing saturated fats has helped with their insulin resistance, one of which mentions so in the following:

    http://www.diabetes.co.uk/forum/threads/saturated-fats.48599/#p438010
     
  16. LucySW

    LucySW Type 1 · Well-Known Member

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    So do we LCHF, or do we LC and starve? Dairy fats are much easier than non-sats to get into an LCHF diet.

    This defeats me.
     
  17. noblehead

    noblehead Type 1 · Guru
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    I don't have the answers I'm afraid Lucy, there are members who say they low-carb and don't overdo it on the fats, perhaps these people are best placed to help you.
     
  18. Ian DP

    Ian DP LADA · Well-Known Member

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    An interesting thread....
    I have never detected any BG increase after I have a bulletproof coffee in the morning (20g butter 20g coconut oil).

    I do detect BG rise after a large protein meal.

    My observation indicates a zero increase for fat, and an increase in BG levels only after eating a large protein meal. Eg. 1/2 a chicken increases my BG levels (but even then only by around 1/2 a point), a single rasher of bacon not.

    I also find it depends on previous protein meals, if I have eaten a lot of protein in the previous 3 days, my BG levels will rise more on a large protein meal. If my protein consumption has been low over the previous 3 days I could have a large protein meal with little effect.

    LADA, no insulin or meds yet.
     
  19. Spiker

    Spiker Type 1 · Well-Known Member

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    Thanks @IanDP

    That fits with my experience too. No BG rise from fat.

    I'm not sure how the Wolpert pizza experiment differentiated
    a late rise caused by fat, from a late carb rise delayed by fat. Anyone?

    The protein effect you see makes sense because there is a fixed daily structural protein requirement. The structural part is not turned to carbs but once you have eaten the structural amount an increasing proportion of protein turns to carbs, maybe rising up toward the 59% theoretical limit.
     
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  20. phoenix

    phoenix Type 1 · Expert

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    Have a look at hyperlipid on what he calls physiological insulin resistance.
    http://high-fat-nutrition.blogspot.fr/2007/10/physiological-insulin-resistance.html
    One has to bear in mind that he is not diabetic and has insulin of his own.
    This is the first of several posts over the years on the subject,(you'll have to search for the rest though I think @Indy posted them all recently.)
    Too me it is important, I find that I can almost predict my HbA1c by my fasting levels, I wouldn't want them to rise from where they are.(indeed I don't like to see them at the level quoted at the start of the blog )
    As used to be said far more often than now, YMMV.
     
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