Eric is why I’m referring to them all as “extended bolus”… So if I am wrong in that I’d like to pass blame.
The “extended boluses” I’m aware of are: “square wave” and “dual wave” boluses (per Medtronic), the super bolus (maybe?), and, for kicks, we’ll mix in just a good old temp basal… because I don’t know enough to know that that one is probably not really a good candidate…
Here’s the scenario: All resolve is gone (I’ll start with that because that’s how it starts for me), and now in front of me is some kind of pasta dish, but I’m also thinking about the cookies that I bought for someone else but conveniently forget to mention to that person their existence. Now it’s just me, the pasta, and the cookies… The pasta alone could be 50g of carbs. The cookies are harder to determine because I PLAN on only having a serving or two (say 38g), but the best laid plans… always turn into way more cookies than planned on. So I’m not sure, AND I’m not too keen on putting more than 90g of carbs in at once because it’s an awful lot of insulin on board.
So? Other than not actually eating a whole bunch of junk I don’t need and will regret in the morning, is there one way to handle this that’s better than the rest? One that will help me save face?
I would LIKE to try to understand the different effects the various forms of extended bolus would have on blood sugar in a situation like this. I currently, among other barbaric and imperfect practices, do a “big” bolus and sometimes set a temp basal at a 110-125% for an hour. I often add “micro boluses” as needed. There’s a lot of error in such a technique, and I’d like to move into the computer age along with the rest of you and try to let my pump do the work…
To me this is a press and pray situation where you bolus for more than 90 grams (probably more like 3 cookies’ worth), and plan on potentially eating more later…
Another option is to bolus up front for 90 grams and then set an extended bolus over four hours for, say another 50 to 60 rams worth of food (why 50 60? who knows, just seems like the amount that my son generally needs for fatty foods or slow-digesting food like pasta).
When our son has a huge carby meal, we find he can only process so much of it in the first hour or two. So let’s say he eats 30 grams of carbs, he can probably process that all in a few hours, so we’ll bolus for it all upfront. If he eats 50 however, we’ll bolus for the 30 grams and then wait 1 to 1.5 hours and bolus for the remaining 20. If it’s something like cookies, which also contain fat, it will need another follow-up bolus for an addition 25grams of carbs (I sort of assume for high-fat foods that it’s like half the grams of carbs but they hit like 3 hours later).
If Liam ate that meal, we would bolus 25% up front and the rest extended over 1 to 1.5 hours (with the Omnipod). When he ate would depend on his bgs at the time. We like to feed him when he’s between 80 and 120… if he’s not, we correct first and feed when he is in that range.
We would probably also turn on at least a 50% more temp basal per hour beginning an hour after he eats and running five or more hours.
Liam has eaten 100 carbs at one setting on a few occasions and came out ok because we trusted the science for what we know works for him.
Seeing a huge amount of insulin on our 4 year old is a scary feeling but knowing our math is correct, we trust science. (And keep corrections nearby if needed.)
Also, with the extended bolus, we “follow the sugars.”. So, if he begins rising very quickly only 30 minutes into the 1.5 unit extended bolus we frequently just take note of the insulin amount remaining, then suspend the current extended bolus, start up a new one and give 25 or 50% of whatever was remaining, up front, then extend the rest over 30 minutes to an hour. This slows down the huge rise that does begin happening sometimes.
So for example, if we extended 3.5 units over 1.5 hours after a heavy pasta dish but we saw him turn double arrows up and say 180, only 30 minutes into the extended bolus, we would:
take note of the remaining insulin that still has to be delivered… Let’s say 3 units are left now.
suspend the extended bolus.
start up a new extended bolus
set the total amount to 3 units
give 25 to 50% of that NOW, extend the remaining amount over 30 min to an hour.
This has helped us keep Liam from going sky high… Once he’s high he requires triple the normal insulin to get him back down, so we avoid it if at all possible.
If “pray” is interchangeable with “finger-cross”, then you’ve pegged my current strategy. It definitely sums up about how calculating I’ve been with those jumbo extended boluses thus far. But now I’ll go finish reading your response to see if you do more than button mash and cross fingers…
…I like the rest just as much. So you kind of go with it, bolusing and programming an extended bolus as you see fit, according to the total carbs. I THINK this is what I am doing, using my own needs and calculations, the majority of the time. I tend to think of it as “making stuff up”, which doesn’t feel so methodical, but I guess that IS the method. Or I’m just so far into my justification of things that I just made all your words fit into what I wanted to hear.
SERIOUSLY?? I’m a lightweight… and this might explain my problems. At least my diabetes ones. I’m terrified to do anything more than a 125%, and I only do that when things are COMPLETELY out of control. And not for more than 45 minutes… because that is already very risky. I often do 110%… and now I’m asking myself why.
I really, very much so, from the bottom of my heart, DO NOT ENJOY sugar crashes. Too much of what I do is done with that thinking, and it makes good control more difficult. So now I’ll picture you’re little soldier carrying around his 150% for 5 hours, and I’ll try jacking that percentage up a little. So as to avoid the shame of knowing what I know now.
I’m kidding… but I really will try to be a little more aggressive now that I know there are little people out there doing the same. [quote=“ClaudnDaye, post:3, topic:4124”]
So for example, if we extended 3.5 units over 1.5 hours after a heavy pasta dish but we saw him turn double arrows up and say 180, only 30 minutes into the extended bolus, we would:
take note of the remaining insulin that still has to be delivered… Let’s say 3 units are left now.
suspend the extended bolus.
start up a new extended bolus
set the total amount to 3 units
give 25 to 50% of that NOW, extend the remaining amount over 30 min to an hour.
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I really appreciate this. I also trust science, and I don’t have a science for these things. I try to use activity to get through periods where my blood sugar begins to climb, but that certainly gets tough later at night. Thank you for the example.
Keep in mind that when I say 50% more basal, I’m talking about this…
Let’s say he’s got a normal basal rate of .10 (he’s 4 remember) during the day.
If I add an additional 50% more basal, it means I increase his basal between those hours to .15.
I have to stipulate this because some people misunderstand what I mean when I say 50% more basal. But yes, we have “temp basal” profiles created where we give him 1.5 or double the basal during specific foods and that prevents the spike AND the crash for us.
I’ll take Lucky Charms for instance…most diabetics hate cereals in general, but we’ve found a combination that allows Liam to eat them. We DOUBLE the dose automatically…so he would normally get 20 grams for 2/3 cup of lucy charms, and we double that to 40 grams. Then we turn on a 50% basal for 3 hours and he goes up to 200 usually, then back down. When he’s on his way back down, we turn off the temp basal and correct if we have too, but it’s normally that much of a correction that’s needed.
For pastas and high starch foods, we don’t give more bolus up front naturally because he would drop low since they take so long to digest. Instead, we extend the bolus over 1 or 1.5 hours and IF we see him rising before the bolus is up, we have no qualms with suspending that extended bolus and giving MORE NOW (and even a little extra if we feel he needs it) and extending the rest. But the temp basal is set to 90% more for pasta, pizza, etc.,
But these “formulas” are always moving targets for us so we just keep testing and finding what works FOR THE MOMENT. Diabetes is ALWAYS a moving target so we want him to get in the habit of not fearing experimentation. There is no reason he can’t enjoy any food that a non-diabetic enjoys…he just has to do the due diligence to figure out what combination works for him. Once it’s dialed in (especially when he’s older and he’s not got the hormone issues any longer), he can enjoy his favorite X, Y, and Z foods for the rest of his life.
Also, one thing I’m learning is to correct EARLY…we get into trouble playing the “how low can we let him go before correcting” game and losing every time. As a result, if we know he’s got quite a bit more insulin on board than he should, we bolus him as soon as he comes under 100 (if double arrows down.) That’s just how we do it!
Because I’m not sure HOW someone could misunderstand what you mean when you say 50% more basal, I’d like to make sure I’m not that person. If I were to set a temp basal, I’d set it at 150%… right? Or if I’m adding it in for some reason, and I’m at 1 unit an hour, we’re talking 1.5 units…
Potato = Potato, except it would be really kind if the industry came up with a definition that they all had to follow, for ease of communication and so no one screws up when they switch pumps. It is not like insulin is a dangerous drug or anything…
I think it really is different with kiddos though. For instance, my son’s TDD may be 8 units and his basal rate is 0.2 during the day. But a greasy cheesy pizza at a ICR of 1:25 might take 1.5 units upfront and another 1.5 units over 4 hours… so if you were to express that as a temp basal, that would be .375 units EXTRA per hour that he’s receiving, which is roughly a temp basal of about 0.55 units per hour, which is basically a temp basal of 275%. If you were to program it as an extended bolus you might not recognize that’s essentially what you’re doing, but it is.
Because of the nature of high starch food digesting slowly, the back end of the digestive cycle is more important where insulin delivery is concerned. If you don’t have enough insulin in the body in hours 2 - 6 after eating high starch foods that will definitely (for Liam anyway) cause massive spikes.
At least for Liam, we hardly ever give any up front for pizza. If we were to give him a unit up from with pizza he would crash. Pizza just takes hours to process in him. The only time we would ever give a unit or more up front is if he’s also having fast carbs with his pizza. In that case, we bolus the fast carbs up front but all the pizza carbs are extended over 1 to 1.5 hours (with the willingness to suspend and redo if he does begin rising sharply shortly after the pizza because that does happen on occasion, also.)
Maybe I’m missing something here, but what is the difference between the pizza crust and these other fast carbs? If the protein and fat on the pizza slow down the absorption of the crust carbs, wouldn’t they also slow down the absorption in other fast carbs eaten with the pizza?
I’m not sure what conventional wisdom or science says but in Liam’s case, if he eats fast carbs with slow carbs and we don’t bolus for the fast carbs immediately, his bgs will go through the roof. So it appears the body has the ability to absorb and process each independently.
While I am sure there is an explanation that escapes me at the moment, I am just happy most of us have access to Dexcom and can figure out the dosing without understanding the physiology. That is quite the technical marvel.
If eaten at the same time, could it be that the body just “processes” the fast carbs before it begins processing the slow carbs and this could result in what we see? When we combine fast and slow carbs we always see a huge spike if we don’t bolus for the fast carbs up front, so there has to be a reason.
I’m not sure how the actual digestion process works but I’m thinking that IF he eats the “fast carb” foods first, before beginning to eat the slow carb foods, that perhaps the body somehow begins processes those first?
Would love to hear someone’s scientific explanation - if there is one.
where you bolus for more than 90 grams (probably more like 3 cookies’ worth), and plan on potentially eating more later…
