By: Bill Burton
Editor’s note: Before changing your treatment plan, always advise your physician or health care practitioner.
I was diagnosed with type 1 diabetes in December 1980. My doctor told me to take a long-acting and regular insulin before meals. He recommended one dose of regular for breakfast, one for lunch and one for dinner.
A year or two after my diagnosis, I had a wonderful meal in a German restaurant with baked Alaska for dessert. After this meal, my blood sugar was quite high. When I asked my doctor whether I should take more insulin when eating more food than usual, he replied, “Eat less,” which I thought was an unrealistic response. It seemed more logical to me that if you eat more food, you should take more insulin.
Searching for a System
I started to analyze my records to see how certain doses of insulin (boluses) worked for certain meals. I wanted to know what worked and what did not. I developed my list of restaurants, meals and insulin dosages, based on the scientific method: theory, experiment, observation and analysis (see list on page 53).
Of course, I also use the carb-counting method. If we can find out how many carbs we are going to eat, and if we know how many grams of carbs each unit of insulin will balance, we can do the math and figure out a bolus. For most meals (and desserts and snacks), I don’t know the carb amount, so the scientific method works better.
Everyone who knows about diabetes suggests that people with diabetes keep records of insulin, food, exercise and other things. I’ve based my weekly chart (see page 54) on one developed by the Diabetes Control and Complications Trial (DCCT). I’ve been using the weekly chart since 1985.
Diabetes Control and Complications Trial (DCCT)
I worked with the DCCT clinic in New York from 1985 to 1988, when I moved to Los Angeles. From 1988 to the conclusion of the study in 1993, I worked with the clinic in San Diego. DCCT doctors and staff in both New York and San Diego knew about balancing food and insulin. Knowledgeable people went over my records frequently and helped me to take the right amount of insulin for what I was eating. My A1c levels improved as I learned to avoid highs and lows, although it was not uncommon for me to have at least one episode of hypoglycemia per day.
The DCCT staff was very concerned about low blood sugars. The emphasis was not on getting blood sugars down, but on getting BGs under control and avoiding lows as well as highs.
Because I had passed out from low blood sugar before starting the study, I was not considered a good candidate for a pump, and I wasn’t much interested in using the pump. I wish I had been. I started using the pump in 1995, and I love it.
The Bolus List-and How it Works
The bolus list is a vital part of the system: it is my food-exchange list for whole meals, not just for individual pieces of food. The list has information on restaurants, boluses and meals. With the help of the bolus list, I record meals, boluses and other information.
The system is simple. Before a meal, I decide what I am going to eat and estimate how much insulin will balance it. That’s the theory. Then I do the experiment: I bolus and eat. After eating, I test my blood sugar. I analyze the data-the bolus, meal and result-and modify the theory so next time I can take a dose that works better.
If I go into Sayaka, a Japanese restaurant where my wife and I like to eat about once a month or so, I order my usual: tofu steak and stir-fried udon (thick wheat noodles). I bolus 19 units of Humalog from my pump. I have plum wine ice cream for dessert. If I have the tofu steak with the nabeyaki udon (meat and noodles in broth), I do 15 units.
When I go to a new Japanese restaurant, I look at my list and order the meal that is most similar to Japanese meals I have eaten before. If the servings look larger, I bolus more. If the servings are smaller, I bolus less. I can also add or subtract desserts to keep in balance, and frequent checking is very helpful. I update the bolus list occasionally to add new meals and adjust boluses for other meals.
Recently, I had dinner at a restaurant that was new to me. I ordered pasta primavera, which I often do, and estimated, based on previous pasta primaveras, that 21.3 units would balance the carbs. Well, the meal seemed skimpy, so I ate three pieces of cheesecake for dessert instead of one. At 10:30 pm, I was 55. Some sugar brought my BG up to 166 at 18 minutes after midnight.
DCCT Experience and Bolus List Help Improve HbA1c
In my 20 years of living with diabetes, I have had no complications. I credit my good health to balancing the food I eat with the insulin I take. My HbA1c used to be in the 8s and 9s before I was in the DCCT and before I developed my bolus list. After being in the DCCT using my bolus list, my A1cs have been in the 6s and 7s.
My wife has been very supportive of my work to control my glucose levels, and I’ve been lucky to have good physicians. I work pretty hard to keep my sugars under control, and I test about five times per day. Still, sometimes my BG is 62 and I’m desperate for sugar. At other times, my BG is 462, leaving me wondering what I’ve done wrong (or whether my infusion site is blocked). On average, I get a low once a day and a high every other day.
A sampling of my lows and highs during a week:
Feb. 20, 2000: low of 50, high of 248
Feb. 21: low of 128, high of 191
Feb. 22: low of 58, high of 264
Feb. 23: low of 59, high of 302
Feb. 24: low of 55, high of 166
Feb, 25: low of 104, high of 251
Feb. 26: low of 55, high of 229
Color coding Highs and Lows
I use a Profile blood glucose monitoring meter which can plug into my doctor’s computer. I make copies of my BG records for the past four weeks and mark my lows in blue and highs in yellow so when we look at these color-coded record sheets we might see the patterns that emerge. For example, by looking at the records, we can see that I am often low before lunch, and so on. My doctor looks at this information and changes my medication accordingly. The information also helps me adjust my insulin from meal to meal, or on a daily basis.
I use Humalog in the pump.
Feb. 23, 2000: 59.6 units
Feb. 24: 72.9
Feb. 25: 44.1 (no real dinner-just ice cream)
Feb. 26: 69.1
Feb. 27: 49.3.
Feb. 28: 58.2 units.
Breakfast: When I am at home, my usual breakfast is one cup of Fiber One cereal, one cup of milk, and 3 prunes.
Lunch: Usually tofu with vegetable soup, a banana, an orange, and an apple.
Dinner: Kidney beans and green beans with tofu. I am now experimenting with different dinners.
Snacks: No regular snacks.
William Burton’s Personal Bolus List
I started to analyze my records to see how certain doses of insulin (boluses) worked for certain meals. I developed this list from my own experience and based it on theory experiment, observation and analysis. Your experience could be vastly different.
For me, 1 unit of insulin covers about 13 grams of carbohydrate. My temporary basal (TB) standard is 6 hours at about 2 units per hour (UPR).
Airplanes: Delta breakfast=16 units.
United snack=10.2 units.
Buffets: Salad, pasta, pie=27 units.
Korean BBQ, large servings with dessert=23.2 units + TB.
Sizzler=2 main dishes + 2 servings of dessert=25.5 TB, 2.4 UPH for 7 hours.
2 plates salad, pasta soup, 2 small desserts=30.2 + TB 3 UPH.
Continental breakfast: Typical 2 muffins and apple=13.
Oatmeal and prunes=20.
Vegetable omelet, etc.=25.
Chinese: Lo mein (stir-fried noodles) + vegetables=12.
2 Chinese dumplings, vegetable lo mein=24.
Veggie chow mein (stir-fried noodles)=12.9 + TB.
Stir-fried noodles and egg foo yung=15.
Typical chow mein + vegetables=20.
2 bowls chow mein=18. Eggrolls, chow mein with vegetables=17.
Coffee shops: Quesadilla, lasagna=20.5+TB 2.6 UPH.
Breakfast burrito, fried mozzarella cheese sticks=16 + TB.
Denny’s cheese sticks, vegetable omelet=22.6.
Continental: Vegetable frittata and vegetable soup=35.
Caesar’s salad, tiramisu with ice cream=13.
Ritz-Carlton=2 appetizers, 3 desserts=25 + TB 2.2 UPH.
Muffins, pasta, vegetables=23 + TB.
Salad, bread, eggrolls, pasta=25.
Delis: Seafood salad and spaghetti=16.
Sandwich and banana=5.
Desserts: Peach cobbler with ice cream=11.5.
Cookies (15 to 20) + 3 donuts=25 + TB 9 hrs, 3 to 4 UPH.
Hot fudge sundae, 1 scoop ice cream=15.
2 scoops of Hagen Daaz=7.
Fast foods: A &W=2 burritos, 1 bag on rings=10.7.
Burger and hot dog=18.
2 Burger King fish burgers=12.2.
KFC Burger with fries=13.4.
Taco Bell large burrito=6.
Greek: Bread, salad, dolmas, 1 spanakopita=21.
Grills: Garlic bread, salad bar, fries=25.
Quesadilla, pasta, bread stick=14 + TB.
Caesar’s salad, bread, pasta with vegetables=18.
Garden burger + fries=18.
Large Caesar’s salad, garden burger=16.
Health food: Quesadilla, enchiladas=14.
Hotels: Holiday Inn=lasagna and soup and salad=38.
3 bowls muesli with fruit=l7.6
Italian: Bread, Caesar’s salad, Eggplant parmigian with pasta=30 + TB.
Calzone = 7.4. Cob salad + fettucine=28. Caesar’s salad and ravioli= 15.
Salad, cheese and tomatoes, penne=22.3 + TB 6 hrs 2.5 UPH.
Breadsticks, manicotti=23 + TB.
Breadsticks, salad, artichoke hearts, cannelloni=18.5.
Bread, salad, pasta and vegetables, cake= 21.
Salad, appetizers, eggplant, pasta, 1/2 tiramisu=27.5+TB.
Spaghetti with salad= 7.
Salad, spaghetti, pizza=26 and TB 6 hrs 3 UPH.
Appetizers, salad, bread, pasta, desserts=29+TB.
2 slices Pizza Hut pizza=12.
Japanese: Assorted sushi, salmon and seafood tempura with plum ice cream=30 + TB 2.1 UPH.
Large serving of teppanyaki (stir-fried meat with vegetables)=35.
Tofu steak, stir-fried udon (wheat noodles) with plum wine ice cream=17.
Tofu, nabeyaki udon (wheat noodles and meat in broth)=15.
2 servings each of shabu-shabu and ice cream=25 + TB 6 hrs 1.5 UPH.
Sashimi, sushi, udon, etc. with ice cream=23.
Mexican: Cheese enchilada, rice, beans, muffins=15.
Quesadilla, 2 burritos=20+TB.
Combo, quesadilla, vegetable chile relleno burrito, fried ice cream=24.
Typical huevos ranchero =15.
Mideastern: Bread, dolmas, salad, falafel sandwich=21+TB 1.8 UPH.
Half extra large w cheese salad and cheese sticks=33, TB 6 hrs 2.8.
Private homes: Thanksgiving turkey, etc, with ice cream and pie=42.
Seafood, pasta, bread, salad, 2 desserts=32 + 7 hrs 2.2.
Salad, biscuits, rigatoni, vegetables, peppermint=22, TB 3 UPH 8 hrs.
Rolls, salad, seafood, pasta=30.6 + TB 7 hrs 1.9 UPH.
Appetizers, Caesar’s salad, seafood salad, pasta, chocolate Oreo cheesecake with ice cream=42.3 + 7 hrs 3.0 UPH.
Thai: Eggrolls + pad Thai (stir-fried rice noodles)=22; add rice=25.
Snacks: Big carrot=0.8. Bag of popcorn=3.5. 1 oz popcorn in popper=5.7.
Editor’s note: Mr. Burton’s list is only provided as a reference. His boluses are individual and are not suitable for others.