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[IP] fat and insulin

<<<(I'm about 1:33 for ratio) that I'm okay, but if I try for something 
fatty, it always spikes later on. And I understand that, but how do I figure 
for that? For example: Went out to eat the other night. I had green beans, 
cole slaw, 6 oz sirloin (grilled) and a skewer of grilled shrimp. All very 
healthy. I'm on Novolog 70/30 and I bolus for snacks with plain. I take 6 
units of mix before dinner. Did my usual thing, took my 6 units. Two hours 
later, my sugars were beautiful, but before I went to bed it jumped to 158 
without anything b/w dinner and bedtime. So I know there's a later jump with 
fat (assuming they cook with more fat in restaurants), but how do I adjust 
for that in the beginning, or do I just do a corrective bolus later.>>>

Don't forget protein too!  What I've found is that something high fat will 
cause the carbs in the meal to be digested more slowly, but I don't 
neccessarily need more insulin (or at least not much more).  What the fat 
does is cause you to need your insulin delivered slowly over several hours 
to stay flat.  With protein, I find that I actually need much more insulin 
than the carbs alone would suggest, and I need to give some insulin 
delivered up front and more delivered slowly over the course of several 
hours (or sometimes as a second bolus altogether 2-3 hours later).  For the 
meal you described above, I would need about 1/3 of my insulin up front with 
dinner and the remaining 2/3 delivered as a square wave over 4-6 hours.

While you are still on 70/30, it will be very difficult to have much 
flexibility about how much insulin you can take and how you can deliver it 
since 70/30 is a very inflexible regimen.  It sounds like you are still 
making some insulin on your own so you can get by using 70/30 right now (if 
I ate the meal you described and gave only my normal dose of insulin, I 
would have spiked well into the 300s--I would have been thrilled with a BG 
of 158), but long term it might not be the best thing for control, and 
certainly not the best thing for flexibility.  If your doctor is resistant 
on the insulin pump front, you can try to get on a more flexible basal/bolus 
type regimen and do MDI (multiple daily injections).  This is usually one or 
two shots a day of Lantus as strictly your basal insulin, and Novolog when 
you eat or for high blood sugar corrections using a proper insulin to carb 
ratio and correction ratio.  This can be up to 6-8 shots a day for some 
people.  Others can get by with less than that if they have a more regular 
schedule.  Working with 70/30, however, you would probably need to give a 
correction bolus an hour or two later of just Novolog, if you want to treat 
yourself occaisionally.

There is some discussion about whether or not it is better to count only 
carbs and calculate boluses based on that (works fine for most meals since 
most meals are not super high in fat or protein and the fat and protein are 
"taken care of" in the ratio), or to count carbs, protein and fat and 
calculate boluses based on that.  Carb counting alone tends to fall apart 
when you eat out at restaurants or eat high fat/high protein foods (pizza, 
take out chinese, steak, etc.).  The second method is called TAG (total 
available glucose) and generally you count 1 for 1 grams of carbs, 1/2 g for 
1 g of protein, and 1/4 g for 1 g of fat (can vary from individual to 
individual).  Note--you do need a different ratio for your bolus if you do 
TAG versus just carbs, all of which are very individual.  For example, if 
you just count carbs your ratio might be 1:15, but if you count carbs, 
protein and fat, you might have a ratio closer to 1:20.  However, you 
probably will end up taking the same amount of insulin for most meals, but 
you'll only have say 30 g of carbs in the first case, but 40 g of carbs + 
1/2 protein + 1/4 fat in the second.

I hope this isn't too much information!

Sarah, dx'92, pumping'00
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