Super Bolus for Breakfast

pre and post breakfast superbolus

It is said that breakfast is the most important meal of the day. One of diabetes’ little jokes seems to be making the most important meal of the day the most challenging for many of those living with diabetes, Caleb being one of them.

I think back to the short time that Caleb was on injection therapy and I would drop him off at preschool in the morning and check his blood sugar and see mid 200s about two hours after breakfast only for him to be below 100 at lunchtime after also eating a mid-morning snack. During my daily calls with his doctor the response I remember and remember strongly disliking was, “well that’s diabetes”.

It became my mission to tackle breakfast.  For years now, I have been applying my own technique to this time of day and it’s evolved to something that I think I can somewhat confidently say we may possibly have some sort of handle on.  At least until tomorrow when it all goes kablooey because I was silly enough to think such a thought and bold enough to write it down and share it.

Nevertheless, I will proceed.

I am a fan of the super bolus and its theory. Big fan. For a long time now, in some way, shape or form, I have been frontloading Caleb’s insulin at breakfast time to get it working in advance to avoid a peak after eating while also shutting it off on the backend to avoid a crash.

It started with his basal.  This was way before we started using DexCom and I was able to see between the dots. My goal was simply to get him in range 2 hours after he ate. Caleb, and all my kids, woke up early and predictably in the morning (they still do).  Scheduling breakfast was not only easy, it was pretty much forced upon me.  So I would schedule his basal to be a little higher than his actual basal need about an hour before he woke up.  I would bolus upon eating and not too long after that my phone would alarm with the melodious tones of Caleb’s voice saying, “zero basal please, zero basal please” and I would shut down his basal for two hours.

I’m imagining some of you thinking me crazy at this point. I’m sure it sounds a little nuts. It really wasn’t.  It was just routine and the routine worked.

The outcome: Caleb would be in range at the 2 hour postprandial mark and the tail of insulin from the disproportionately large bolus that he needed to cover carbs at breakfast would take the place of the basal insulin mid morning.  Because I turned off the basal delivery, Caleb’s bg stayed in range – no dangerous drop from the large breakfast bolus tail of insulin.

There has been evolution of this over time. Most recently, I have something much closer, although not exact, to a true super bolus.  It’s the same theory – move the insulin up to avoid the early peak and the later low.  Move it – don’t add it.

These days, the kids are a little older and not as demanding about eating as soon as they wake up so I don’t schedule the basal like I used to. Typically everyone wakes and begins their “getting reading” routine.  Shortly thereafter Caleb is bolused for the expected carbs he will eat, but I add a little more and then reduce his basal a little too.  About fifteen minutes later we eat.

The picture of the DexCom receiver depicts one such day.  He woke up at 82, had a little peak from breakfast and ended at 106. (The gaps in the line are because I was holding the receiver at church and Caleb is in choir and at times separated from me.)

Though not always this pretty, more times than not it is, or at least close.

Until tomorrow of course….

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Super Bolus

Super Bolus by John Walsh
Super Bolus by John Walsh

First things first: this approach works for Caleb. It may or may not work for you. I am by no means suggesting that anyone should apply the following theories to their diabetes care. I am only explaining what I do for Caleb.

For weeks, Caleb’s most predictable BG of the day was pre-lunch. Without exception it had been in range. It was sensor change day and we were operating in the blind start-up period. No worries though because this time of day hadn’t posed an issue in quite a while.

It’s approaching lunch time so let’s do a finger stick. 289.

289?

Okay. Oh well. It happens. There was more fiber in his breakfast than usual and he was a little low at the postprandial check. Ah yes, hindsight is 20/20. Moving on.  Now back to this 298 and we are getting hungry for lunch.

Super bolus.

John Walsh explains it as follows: “A Super Bolus is created when some of the basal insulin delivery is stopped or partially reduced, and delivered instead as additional bolus insulin on top of a normal carb or correction bolus.”

The intent is to get glucose levels back in range quickly without inducing hypoglycemia. Here is how Caleb’s super bolus went that day:

Correction: 1.50 units, plus

Meal bolus for 50 carbs: 2.00 units, plus

Basal for the next two hours: 0.70 units, equals

Total units delivered: 4.20 units.

Lastly (this is critical) turn basal to “off” for two hours.

The change in the timing of the basal insulin makes all the difference.  Front-loading it and delivering it with the meal and correction bolus makes it act faster and all at once, thus bringing glucose levels back in range sooner.  If left as basal, the end result will be the same, but it will take more time and hyperglycemia will last longer.  The same amount of insulin is delivered when using a super bolus, it is only the timing that is different.

Back to life, start preparing lunch.

1/2 hour after superbolus: 169

Perfect. Coming down fast and lunch is ready, let’s eat. 50 carbs consumed.

1 hour after superbolus (1/2 hour after eating 50 carbs): 109

Excellent. The first time I tried this, I panicked a little at this point.  A 109 an hour after a bolus that large is cause for worry.  But his basal had been zero for an hour and he still has food in his system.  Plus his basal will be zero for another hour.

DexCom had been calibrated with that lovely 289, which we confirmed after washing hands with a 288. DexCom showed him cruising between 85 and 100 over the next hour.

2 hours after super bolus: 89.  Wonderful.

I know a bolus of that size is still hanging around in Caleb’s system beyond the 2 hour insulin duration that we use. However Caleb’s basal insulin has just now resumed.  He hasn’t received any basal or other delivery of insulin for the last two hours.  Any tail of insulin duration from that super bolus is required for his basal needs.

And it worked.  He continued to hover with a nice flat arrow through the afternoon until dinnertime when a finger stick confirmed a BG of 98.

I invite you to read more of what John Walsh has to say about using a super bolus. He suggests its use for high glycemic foods or large intakes of food in order to avoid blood glucose spikes. I haven’t tried in those situations yet, but I plan to. He also speaks of pumps giving us the option to deliver a super bolus automatically. The thought of it gives me chills.

In what ways have you used the super bolus?