With the holiday season quickly approaching, the prospect of bolusing for all the delicious food can feel intimidating! Holidays and special events are challenging because you are likely eating differently from how you normally would on a typical day. That’s why we’ve compiled advice from past slipstream presentations about how to bolus for tricky meals.
Important disclaimer: Everyone’s body is different, so please speak to your health care team before making any changes to your insulin dosing!
Consider a carb counting refresher
As a pretty seasoned carb counter, I know I get a little annoyed when my diabetes team suggests I may not be as brushed up on nutrition facts as I think I am. But…it’s true. Over the years, some of my estimates have definitely turned into wild guesstimates. Making sure your carb counts are as accurate as they can realistically be might be a simple way to help make bolusing for a tricky holiday meal a bit easier.
Luckily, Alanna Chambers reminds us in her slipstream presentation that our carb counts don’t have to be accurate right down to the gram. People with diabetes can still achieve optimal post-meal control with some carb estimation error and counting in 10-15 g increments is a-okay if that’s the way you prefer to think about it.
For packaged foods, you can always check out the nutrition labels and measure out your serving. For other foods, there are quite a few apps that can help with carbohydrate estimations. There’s even one called Figwee that shows you what different quantities of foods look like on a plate if you prefer not to deal with actually measuring!
Glycemic Index and the Power of the Pre-Bolus
Unfortunately, not all carbohydrates are the same. Glycemic index indicates how quickly a food causes blood glucose levels to rise. High glycemic index foods such as sugar, white bread, potatoes, white rice, and cereal, cause a rapid spike in BG. Lower glycemic index foods like some fruits and vegetables and whole grains cause a more gradual increase in BG over time [1].
There’s a couple things you can do to help minimize a big BG spike after eating high glycemic index foods. Adding protein, fat, fiber, or even acidity to a meal can all slow the effect of the carbohydrates on blood sugar [2, 3]. Another powerful tool is bolusing earlier to give the insulin a chance to kick in (this is known as pre-bolusing).
While it can be really hard to remember to bolus 15-30 min. before eating, it could potentially be more feasible on a holiday when you are anticipating or preparing a special meal! Ultra rapid acting insulin, such as Fiasp, could also come in handy for getting a bolus to work as quickly as possible. Some people also find it helpful to eat proteins and vegetables first, before higher glycemic index foods [2].
Another option for high glycemic index foods is something called the super bolus [3]. This involves borrowing some basal insulin and using it upfront during the bolus. So essentially you would give a bit of extra insulin for a meal, and then cut back or suspend your basal rate temporarily afterwards.
Carbs, Fat, and Protein, Oh my!
Just in case all this wasn’t complicated enough already, the fat and protein content of a meal has a pretty significant effect on BG in addition to carbohydrates. High amounts of fat and protein both result in delayed and sustained hyperglycemia. This effect can last for quite a long time; many fat and protein-rich meals can elevate BG levels for 3-8 hours! [3].
There’s a lot of options for how to manage this phenomenon. For insulin pump users, you can try using an extended/combo/dual wave/square wave bolus to give some insulin upfront, and the rest over an extended period of time. How best to actually implement this depends on a lot of factors including what you are eating, how many carbs you are eating, what your activity levels are that day, if you are giving a correction bolus, etc [3]. One study showed that people need at least 60% of the meal’s insulin requirements upfront [3]. Studies have also shown that fat and protein can increase the total amount of insulin needed for a meal. However, be cautious delivering extra insulin, especially if you are being active or drinking alcohol! [3]. In one approach called the Warsaw School of Pump Therapy Method, Fat Protein Units (FPUs) are used to determine how much additional insulin might be needed and over what time period [2, 3]. An alternative pump-based strategy is to set an increased temporary basal after a high fat/high protein meal [3]. In general, it is important to be aware of how your pump works and how different boluses might affect it, especially if you are on a hybrid closed-loop system such as Tandem Control-IQ [3].
How to Calculate Extended Bolus with the Warsaw School of Pump Therapy Method
MDI users can consider decreasing the mealtime dose and giving additional doses of rapid acting insulin after a meal to mimic a combo bolus. Other types of insulin, such as short acting, can also be helpful for giving a slower, more sustained response [3].
Warsaw School of Pump Therapy Method. Fat Protein Unit (FPU) Calculation: Calories from Fat and Protein / 100 = Number of FPUs. OR Grams of Fat / 11 = Number of FPUs for Fat, Grams of Protein / 25 = Number of FPUs for Protein, and FPUs for Fat + FPUs for Protein = Total FPUs. Insulin Amount: Treat each FPU like an extra 5 – 10 g of carb. Insulin Duration: 1 FPU – 3 hours, 2 FPU – 4 hours, 3 FPU – 5 hours, 3+ FPU – 8 hours.
With all the factors that go into how our bodies respond to food, it’s no wonder post-meal BGs can feel unpredictable at times! Thankfully, there are many available strategies out there to help us bolus for tricky meals. If you want any further information, make sure to check out Type 1 Diabetes and Nutrition: Lessons Learned at Slipstream and Diabetes, Food & Nutrition – Virtual Slipstream Session Recordings.
References
[1] NHS Choices, NHS, “What is the Glycaemic Index?” www.nhs.uk/common-health-questions/food-and-diet/what-is-the-glycaemic-index-gi/.
[2] Anderson, Lorraine. “Type 1 Diabetes and Nutrition: Lessons Learned at Slipstream.” Connected in Motion, 3 Dec. 2018, www.connectedinmotion.ca/blog/lessons-learned-diabetes-and-nutrition/.
[3] Chambers, Alanna. “Diabetes, Food & Nutrition – Virtual Slipstream Session Recordings.” Connected in Motion, 16 June 2020, www.connectedinmotion.ca/blog/diabetes-food-nutrition-virtual-slipstream-2020/.
