Experimenting with more aggressive bolusing

Type 1 & LADA
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I want to first thank everyone in this community for sharing their experiences and encouraging me to take a more aggressive approach to bolusing. I am still timid because I can’t seem to sense hypoglycemia accurately, I don’t use a CGM, don’t use a pump. Thank you all for your patience in putting up with a scaredy cat like me. I’ll explain in the example below:

Today, I lazed in bed until about past noon.

1 pm - BG 120 (previous reading from the night before was at midnight BG 100)
pre bolused 5 units (only 10 minutes…I know, I lack discipline) , ate chicken with some teriyaki sauce, rice
2 pm - bolused 4 units for a mini cannoli (I did not pre bolus - my rationale is that it contains sugar, fats, and it’s so complex, may be there will be an initial BG rise and there will be a delayed BG rise)
2:30 pm BG 202
3pm BG 214
I know…do I correct at these levels? I have 9 units running through my body, so I didn’t want to correct. I was also going out for a walk for about 2-3+ miles for more than an hour.
3:30 pm BG 103 - this is encouraging. Still walking.
4:15 pm BG 65. I felt NO SYMPTOMS. NOTHING. I felt fine. Still walking. On previous occasions, it seemed like the cannoli may kick in later, causing a delayed rise. Just to be on the safe side, I took 2 smarties, just in case.
5 pm BG 85 - At this point, I am famished, feeling like I want to wolf down 2-3 donuts, a little jittery; I can’t even think about cooking dinner…so hungry! So I settle for some delicious cheese and tomato: I ate quite a lot of mozzarella cheese with 4 slices of tomato, some walnuts. The ravenous feeling subsides. Begin to cook dinner. I often, not always, get this ravenous feeling between the hours of 4-6 pm.
5:30 pm BG 112 - feeling better at this point.
5:45 pm 2 units for dinner : chicken rice, stir fried red, yellow peppers
6:10 pm dinner: chicken, stir fried peppers: red, yellow
; rice
6:30 pm 4 units for cannoli

I would appreciate your thoughts and analysis about the spike into the 200’s and the subsequent drop to 65. In truth, the rise into the 200’s for approximately 1 hour doesn’t really bother me. If I were to remain elevated for 4-5 hours, habitually, I would be concerned about long term complications. It’s perplexing to me that at 65, I had no symptoms, and at 85 I was feeling awfully hungry.

Stay tuned for more adventures and misadventures with BG fluctuations from Lilian :slight_smile:

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(Do any of you recall the PSA from many years ago : It’s 10 pm, do you know where your children are?)

It’s 10 pm - do you know what your BG is?

So continuing from the thread my adventures and misadventures:

8:30 pm BG 168
10 pm BG 135.

I think that I will call it a night. I know…I can gather additional data points and take some additional fingersticks. I may, if I am up. At this point, the insulin is mostly gone. The possibilities are that parts of the cannoli may cause a delayed BG, or nothing and BG would slowly decrease. I would imagine that tomorrow morning’s fasting number may give me a clue.

At this point, one of my goals is just trying to determine how to bolus for a mini cannoli without resulting in 200’s for a sustained long period. I think today, I managed to eat 2 mini cannoli’s, one at lunch and one after dinner without staying up in the 200’s for too long.

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@lh378:

OK, my first feedback is on the 200 peak.

We always get a peak when we don’t prebolus, even for very complex meals.

We have measured that we need 45 minutes for a Novolog prebolus action, and 25 for a FIASP prebolus action. So, if we use Novolog, we would prebolus, probably by 35 minutes, to give 10 minutes lead time to carbs for a complex meal. If there was not much fat in the meal, we would wait until we “turn the corner”, i.e. when we see the insulin starting to act.

The timing, of course, will be different for you. For us, we aim for no peak at all, and that always requires prebolus (except for very light carb meals, below 10 carbs).

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I was wondering about that too. …although, there was the BG 65 at 4:15 pm. It’s about my trying to find a balance between minimizing the highs and the lows.

Dinner was less than 30 minutes pre bolus; I had a lot less rice than my customary quantity, therefore I took only 2 units. For something like cannoli, I am conflicted about the pre bolus because of all the fat and sugar. The 4 units is likely a slight over bolus, and there may be a low BG, like a dip. Then another part of the cannoli may kick in later.

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You are asking the right questions. Trial and error was the only sane way we arrived at our practices. Once dialed in you will be like a cyborg, but a human one without the sensor and pump.

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There are two things going on in your initial story. The first is bolusing for the mini cannoli, how much insulin and how much ahead of time to pre-bolus. You are going about your experiment in the right way, and can make small adjustments to what you tried to see what gives the best practical results. In general, when eating if I have an early excessive high followed by a later low, there was too much total insulin because I went low. But the excessive early high says the digestion of the food ran faster than the insulin action, so I needed to pre-bolus earlier to give the insulin a bigger head start so it could keep up. So for a too-high peak followed by a low, I’d try a smaller bolus given further ahead of the eating.

But there’s a second thing at work in your story. You exercised (by walking) while you still had the active bolus in your system. That’s actually a good thing, but it affects the insulin dose because exercise makes the body more sensitive to insulin. If you had bolused exactly as you described but sat on a couch instead of going for a walk, maybe your BG would have stayed high rather than dropping to 65. To learn how to adjust insulin dosing to handle exercise, it’s just more experiments to figure out how it works for your body. If you’re looking for inspiration, you could read daisymae’s swimming thread to see how she started with wild BG swings and fear, and experimented her way to a real mastery of dosing strategies that work for her body. Daisy Mae's swimming BG thread

The way to deal with being conflicted like this is to run the experiment. Of course this means you’ll have to eat mini cannoli’s again and again, but if you are willing to make that sacrifice it should be possible to figure out a strategy that works. Folks here will offer suggestions if you describe what you did and what happened. The nice thing about figuring out insulin dosing is that you have as many do-overs as you want. And you can say that you’re eating cannoli for science.

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This is exactly how I figured out my BareBuger/fries and guacamole and my pizza bolusing; I ate them over and over again until I got the results I was seeking. (the best flat line in-target range as possible.) Oh, how I suffered :rofl:

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In the name of science, I am willing to sacrifice and suffer :slight_smile:

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Let me make up an example:

I take 5 units insulin for food.
I matched the quantity of insulin to the food perfectly. However, I timed my insulin injection poorly; no pre bolus or insufficient pre bolus.
I believe that my BG numbers at 1.5, 2 hours may be high or low.

Would my 4, 5 hour BG numbers be decent? With enough time, the digestion is complete and the insulin is finished and ‘used up’. This assumes that the food is not too tricky.

I’m trying to think about

  1. Insulin quantity
  2. Insulin timing

If my 5 hour, post injection BG were consistently too high, I may have miscalculated insulin quantity.

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True, but I think there is another data point. If you timed the injection poorly, then went to 300, now the amount of insulin required to get you back to baseline would be different than if you had peaked at 150. So it not only matters how much insulin is required, but also how high you go to determine whether something was a successful test.

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If the quantity of insulin were ‘correct’ or close enough, but timed the injection poorly, would I shoot up that high, to 300? I don’t know. I thought, maybe 200’s??

I do understand that it may be more difficult to correct high BG, like 200’s, IIRC, because of insulin resistance when our BG is high.

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As a follow up:

If the food contains fast acting carbs, medium to high GI, and pre bolus is insufficient:
The BG will skyrocket, how soon?in 30 minutes to 1 hour? am I on the right track?
The insulin will peak between 1-2 hours after injection.
The insulin peak effectiveness is late compared to the carb peaking. Doesn’t the insulin do some work to knock down the BG? Am I underestimating the skyrocketing speed of BG caused by a meal/food? as fast as 10 minutes after first bite? A piece of fruit, I think can be fast, maybe 10 minutes? I hope these don’t sound like stupid questions.

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My son can mistime an injection and shoot to 300 no problem. Will you? Not sure only testing will tell. When we were doing the MDI thing, our goal was to try and have the insulin match his digestion as closely as we could. So we wanted the meal bolus and the food to peak at the same time. In practice this is really difficult, so we settled on giving extra insulin and monitoring for a few hours and having him eat out of the lows. That was the only way we were able to get consistently flat results. Now he was a teenager, so doing the same thing day after day wasn’t going to work. With practice I think you can develop a bolus strategy for each meal type that you eat. I was just trying to point out, as your bg goes higher your resistance changes and this makes the equation harder to quantify in real life. Lots of variables.

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That’s what I did!! I read all of @daisymae’s 1000+ posts! Many thanks to @daisymae and @Eric for these!

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Basically, yes. There are other possible explanations, like the basal is too low so you would have gone high anyway, or you have stress or a cold coming on or you’ve been unusually sedentary so you’re extra insulin resistant. But if I see that I’m usually tending to end up high after meals, I change my insulin:carb ratio a little tiny bit to increase my meal boluses. And I keep doing that little by little until I start to end up a little low after eating, and then I back off on the insulin:carb ratio a tiny bit so I’m good. But I also like Chris’s approach of having the meal boluses a little too strong to give a better chance of avoiding a high, knowing full well that it usually will cause a low if you’re not paying attention to the CGM. I would not recommend that without a CGM, and it is not a strategy for beginners or intermediates.

Finding the right insulin:carb ratio, or finding the right basal dose is kind of like tuning a guitar or steering a bicycle. On the bike you can’t hold the handlebars rigidly motionless, there’s a continuing need to make small adjustments. For me, I need to adjust the insulin:carb ratio and basal schedule on a seasonal basis. Some women need to make rather large adjustments on a monthly basis to match insulin sensitivity changes driven by the hormonal cycle.

Yes, you are on the right track. The speed and height depends. Let me try to distinguish the two cases.

When it turns out I underbolused, what I see is a steady rise in BG that just keeps going up and up. The speed depends both on how badly I missed, plus the speed of digestion of that particular meal. If I get into this situation it will probably turn into a stubborn high. To overcome this high I may eventually be forced to take a “rage bolus” — an absurdly large correction like 4 or 6 times the amount I “should have” needed, and even then the recovery may take a long long time (eventually followed by plummeting BG that I would solve with glucose.) What I actually do when I’ve gone to 300 is take an oversize correction, like 2 times the expected amount, via IM injection. My thighs have very little fat cover so I can go into the clearly visible muscle with a normal syringe. It works better with a longer needle, and it’s best to have a medical professional show where and how because you do not want to accidentally hit a nerve or inject into a vein. There is one other approach that a couple people use, and that’s an IV injection. It is fast and requires much less insulin, but there is a very real risk of a bad or a very bad outcome. I don’t do IV injections of insulin and I really don’t think anyone should, because there’s a safer alternative. My endo warned me about the comorbidities and I believe he is not a nervous nellie, he’s just experienced enough to know how things can go wrong. If you really need the speed, a safe alternative is to get a prescription for Afrezza — the inhaled insulin.

When it turns out the insulin dose was right but I needed more time before I started eating, I’m more likely to see the BG rise too high for too long, but then come back down part way. It gets stuck without coming all the way back down because the extra insulin resistance from going too high “uses up” some of the insulin, so there’s not enough total insulin in the meal bolus to bring it all the way down. I can deal with this next time with a mild overbolus, which will give me a “too high” spike, but the extra insulin from the overbolus will be big enough to bring me back down. Better would be to try to give the normal bolus but with a longer head start before eating: smaller peak.

So the TL:DR is if I see a steady BG rise that goes up and up I start to think maybe I underbolused, and if I see a BG rise that eventually turns and comes part way back down, I think maybe I’ll try a longer pre-bolus next time. The immediate solution in either case is more insulin.

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I think I understand about insulin resistance as we get too high. It happens when I have pizza - I thought maybe it was related to the fat and carbs in the pizza ( or some other really oily, greasy, Carby food).

Thank you!

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What’s TL:DR?

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TL;DR is internet for “too long; didn’t read.” It means “Summary:” while including an acknowledgement by the author that the author was perhaps too long-winded about it, thereby trying the patience of some fraction of the readership.

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I have found this to work incredibly well for all of my meals. in the morning, my first meal of the day, even if I am on the low side of my TR (69-70ish) I will pre-bolus 20 minutes before I put any food into my mouth. for regular meals I wait 15 minutes (of course for high fat, high protein, high carb meals I must wait longer). but I have found with a longer pre-bolus, I don’t rise much at all. I might go from 85 - 105, but no higher than that.

you guys taught me that neat trick. I use to pre-bolus only 10 minutes, but waiting just that extra 5 min really seems to have made all the difference in the world. amazing, huh?

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Today, I bolused 8 units (split 5, 3 at different injection sites - I recalled someone saying that one should not inject too much insulin at one site) for pasta and a mini cannoli. It was a 15 minute pre bolus for the pasta, and I ate the cannoli after 1 hour of insulin injection. I wanted to eat a slice of Italian cheesecake too. This is one hour after the initial 8 units of insulin.
I bolused 3.5 units and ate the small cheesecake immediately.
I realized that I forgot to check my BG!! .
I checked my BG (it’s 1 hour after the initial 8 units, and eating the cannoli and cheesecake.) The BG was 48, rechecked, yup, 47. I ate a little bit more cheesecake. There are approximately 11.5 units of insulin in me…more than what I’m used to. Checked in 15 minutes BG 70, checked in about 20 minutes 92.
At 1.5 hour after the 3.5 units, my BG= 115. I think even if I go high because of the correction cheesecake, I’m just going to call it a night.
What was odd was that at BG=48, I felt no symptoms, but at BG= 70, I felt hot.

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