Bolus Breakdown: Waffle Edition

November 17, 2018Scott Benner

Insulin is about timing and amount…

Listeners of my podcast hear me say all of the time that type 1 diabetes is about understanding how insulin works in you. With that understanding you can make good decisions about the timing of your insulin and how much you use. You need the right amount of insulin… at the right time. The goal is to create a tug of war between the insulin and carbs/body functions that neither side can win. You want both sides to pull in their respective directions, get tired and stop at the same time. When you create that battle properly the blood glucose can end where it began, creating stability.

If that makes sense, check out this plate full of waffles and chicken and then read on.

The day we are discussing was a school day. Arden had an appointment at 10:45 am that I picked her up for at 10 am. She texted me around 9:30 to say that she was hungry so I made a warm bagel with butter and brought it to school.

Use the graph below to help you visualize and follow the events. The graph has a low threshold of 70 and a high of 130.

10 am - Bolused for bagel on the way to the car. There was no opportunity to prebolus because of the situation so instead we overbolused.

10:50 am - Overbolus overpowered the bagel. She needed the large upfront infusion to squash the spike. Because the timing of the insulin was off, a low was not unexpected. Drank a small juice box in exam room to rebalance carbs with insulin.

11:55 am - Small bolus to stop creeping rise from juice.

12:17 pm - Decided to get lunch but not sure where or what - doubled basal insulin for an hour. Did this in part for lunch and in part because I didn’t think the previous bolus was having the effect I hoped for.

12:37 pm - Arrived at restaurant, talk of waffles began. Small bolus in parking lot to get BG drifting down. Bump and nudge.

12:45 pm - Order placed. Handmade chips as an appetizer, Waffles and chicken for lunch. Bolus 9.15 units extend. 5.50 in now and the rest over an hour. — Funny aside: 9.15 may seem random and it is. That’s just the number that it landed on when I took my finger off of the button. I was shooting for 9ish.

1:15 pm - Chips are obliterated (so good) and waffles (with real syrup) arrive. Cancel extended bolus (I saw the Dexcom line on 3 hr view beginning to curl up), immediately bolused the 2 units from 12:51 pm extended bolus that had not yet delivered.

Now we eat, laugh and talk. The main topic… is the guy two tables over being too friendly with the woman he’s eating with? He had a wedding ring but she didn't. Anyway, he was trying too hard and her smile looked forced. I digress.

1:34 pm - Dexcom line again looks to me like it’s about to break up. I like to say that we stop the arrows with small amounts of insulin to stop large amounts from being needed later. I wasn’t sure about this bolus but I like to err on the side of bold so we threw in a little over a unit for good measure.

Result: Good fun, a crazy carby Friday lunch and BGs that sat around 100 all afternoon. The gentle rise you see around 4 pm has been happening for a few weeks, I don’t think it had anything to do with he lunch. We bolused and stopped it.

Synopsis: Trying to count carbs for this (honestly for most things) is a fools errand. I mean, where would you even begin? Here’s what I did. I trusted that what I knew was going to happen, was going to happen. Meaning: I assumed (based on history) that Arden would eat 2/3 of the waffles and maybe two chicken fingers with honey mustard. I knew the restaurant didn’t have low carb syrup. I knew that in the past this has taken around 14 units of insulin. I knew how long insulin takes to work in Ardens body. I knew that I needed to give that insulin a head start over the carbs. I wanted to create momentum for the insulin (think about the tug of war) that the carbs couldn’t overwhelm. Why? So that when all of those chips, syrup and waffle batter began to “pull”, the insulin had a chance to hold those carbs in place. Not wanting to get the insulin too far ahead of the carbs, we bolused in stages to keep the power of the insulin up without overdoing it. Why? Because you aren’t just balancing the insulin, you are also balancing the carbs - like adding ballast to either side of a scale to keep it from tipping too far in one directions.

TOO much work! That’s what youre thinking, right? “This is too much” or “ I can’t do this”…. you can and many, many people do. Arden’s A1c has been between 5.2 and 6.2 for five years. She has no food restrictions and is an active and healthy 14 year old. What you see here represents fleeting moments of thought. And while this isn’t easy to describe in writing (mainly because it feels laborious when spelled out) it is easy to talk about and that’s why I hope you try listening to the Juicebox Podcast. All of this can be second nature in less time than you think. One day you’ll look at a plate and think, “that’s 14 units”.

I haven’t counted a carb in many, many years and it is wonderful!

On the Juicebox Podcast I talk about everything you read here and so much more. The show is 100% free and available on every podcast app and at JuiceboxPodcast.com. You’ll hear conversations with people just like you, industry professionals, the latest tech news, and even some famous folks living with diabetes. If you’re most interested in insulin management a good place to start is with episodes #4 Texting Diabetes #11 Bold With insulin, #29 Fear of insulin, #37, Jenny Smith, #44 Diabetes Rollercoaster, #62 Unfounded Fear, #100 Revisiting Bold, #105 All About A1c, #121 Insulin, Insulin, Insulin and #193 Live from the JDRF SW Ohio. But if you just want to jump in, go for it!

If all of this is a little hard to believe, I understand. Actually, how could any of this make sense when all you’ve been told is to count carbs, inject, wait… BG got high? “That’s just diabetes”. All I can tell you is that my daughter has had type 1 for 12 years and with a few simple concepts that I’ve honed over those years we, with relative ease, keep her A1c where I described. Diabetes doesn’t have to be like those people told you. This can be diabetes. What do you have to lose?

If you’d like to use the same tools that Arden uses to obtain these results please consider using these links to learn more. Its easy to get started with the Dexcom CGM and the Omnipod tubeless insulin pump today. Dexcom and Omnipod are sponsors of the Juicebox Podcast. Thank you for your support!