Learning How to Bolus for Protein

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When we began managing our son’s diabetes with a low carbohydrate diet, the lines on his continuous glucose monitor changed from wavy and turbulent to beautifully even and flat. I bolused for his meals through his pump for the small amount of carbohydrate, and it was smooth sailing. However, after about two weeks of eating high-protein low-carbohydrate meals, we started to notice a slow rise in his blood sugar after meals. I would attempt to correct them with rapid acting insulin, but it seemed to do nothing to bring his number down. It would take 2 or 3 corrections and a few hours to get him back into normal range. This process was especially frustrating at night because most of the rise would begin after we were all asleep. I wouldn’t catch the rise soon enough and he’d peak overnight at close to 200 md/dL.

We went back to the drawing board, and re-read Dr. Bernstein’s Diabetes Solutionthe book that had originally inspired us to implement a low-carb diet. Dr. Bernstein explained, “Protein can cause a blood sugar rise, but this takes place much more slowly…” That was it: it was the protein that was causing these steady rises. The only trouble was that Dr. Bernstein’s dosing guidelines for protein required injections of Regular insulin; we were using a pump with rapid insulin. We were at a crossroads: should we switch our insulin management system completely, or tweak our pump and insulin usage to mimic Dr. Bernstein’s recommendations?

We decided to keep using the pump and try to figure it out. Why? Our son loved and still loves his pump. Even though he’s 5 we feel that giving him control over as much as we can will empower him to continue to manage this disease. Using a pump was his decision and we would work to uphold it. But we did feel pretty rebellious and isolated in our quest to treat protein rises this way. As far as we knew no one else did this.

We decided to use breakfast as our control meal since our son eats the same exact thing every morning. We figured this would give us consistency. Next, we needed to address the insulin difference; we had to make rapid insulin mimic Regular. Rapid insulin is just that: rapid. It starts to work faster, peaks sooner, and is more potent. We found that we had to use half as much rapid as regular due to its potency and then slow it down to match the slow protein rise. Slowing down a dose of insulin sounds impossible, and it would be, without the extended bolus or square wave bolus feature built into my son’s pump. This allowed us to automatically let that dose drip out over a specific period of time instead of giving it all at once. How long of a period of time would we need to extend the dose? That was the key question.

We had been watching and recording the protein rises that our son was experiencing so we used that information as our starting point. The rise would start about an hour after eating, so starting the extended bolus about 30 minutes after a meal would allow the insulin to start working and meet that protein rise as it started. Now, for how long to extend it? This took some trial and error to nail down, but in the end, an extended bolus over 1 hour seemed to work best. Once we had a dosing baseline we could take it and apply it to other meals through the day and see what happened. My son digested lunch and dinner more slowly than breakfast, so we found we should start the extended bolus 1 hour after meals and then let it extend over 2 hours to better match the slower breakdown of these meals.

It took us months to figure out how to mimic Regular insulin injections with a pump. In the end, we succeeded. Those flat beautiful CGM lines returned; the pump wonderfully matched the latent protein rises. He had normal blood sugars.

At our next appointment, our endocrinologist asked what we had been doing to keep such tight control. Feeling very proud of myself, I explained that learning how to dose for protein was a game changer for us. Our doctor said that most people never figure out that protein has a big effect on blood sugar. But I’m not that smart: I didn’t “figure it out,” I read it in a book written by an expert. I dwelled on this for a while after leaving the doctor’s office. It began to trouble me that our doctor had this information but had not shared it with us. We shouldn’t have to “figure out” critical information like this. We were taught carb counting at diagnosis, but why weren’t we taught how to bolus for protein?

Thankfully we had a resource in Dr. Bernstein that explained all these things in detail. His technique empowered us to achieve better blood glucose control and normal blood sugars for our son.

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Melanie Smith
Melanie Smith

Thank you for sharing this story.

Kate
Kate

Great read, thank you. We are mdi and moving to pump probably next year (son is 6) and are doing well but the protein rises are hard to manage by injection. (Especially in the night!) will bookmark this for when we’re pumping. Any low carb resources you could share? Thanks!

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