A (2:56)

Yeah.

B (2:56)

Clearly that's the reason that your blood sugar is really high and then stuck high for hours later with the other nutrients that we would have to consider.

A (3:03)

I mean, as I'm looking at this, let's go through it, right. Let's measure the meal. Look at the carbs, the fat.

B (3:08)

Yep.

A (3:08)

Glycemic index, et cetera. So not only does a slice of this have 36 grams of carbs, but it has 17 grams of fat. And you know, most people don't bolus for their fat.

B (3:20)

No.

A (3:21)

If you sit down, you're saying it would not be crazy for somebody's teenager to eat three slices of this.

B (3:28)

Absolutely not.

A (3:29)

Okay, so 30, 60, 90, 100, and. Geez, that's a lot. Right? Like, so we're looking at 30, 60, 90, 102. Like 100. Well, it's like. It's like 110, 115 carbs.

B (3:44)

Well, 90 plus another 30. 90 plus another what? 24 grams.

A (3:49)

Yeah.

B (3:50)

Right.

A (3:51)

And then 17. Three slices of pizza. Oh, my gosh. Jenny, we have to take a half a break for two seconds. I'm going to be back in 30 seconds. I'll explain why when I get back.

B (4:02)

Yay. Oh, there's your puppy. Oh, my gosh. He's so cute. Did he need to go potty?

A (4:11)

No, he. He doesn't like to be by himself for too long. Oh, just lay down, buddy. You can hang with me while I make the pocket. Friday.

B (4:18)

His name is Friday.

A (4:20)

His name is Friday? Yes.

B (4:21)

Oh, my. Is that because you got him on a Friday?

A (4:24)

No, no. It was an exhaustive search for a name. So Arden. Arden's. He is. He is very cute. Arden is recovering from a tonsillectomy. Yeah. And so she's loaded up on the perks right now and sleeping. So I thought I could get away with him being downstairs, but he just. He was downstairs. Like, maybe Rob can leave enough of it in while you were talking so that people could hear it. But he was just like, oh, no, no, come get me.

B (4:51)

Oh, I couldn't. I could not hear any of it.

A (4:54)

So. But yeah, I just didn't want him down there, like, freaking out the whole time. So anyway, 17 grams of fat. So 10, 20, 30, 44, 45, 40, 50. There's like over 50 grams of fat in there. Most of you don't bolus for your fat.

B (5:13)

And why. I think the reason to bring up there, it's even less visible than protein.

A (5:19)

Sure.

B (5:20)

Right. Fat is hidden in the foods that we eat. Unless we're physically adding it like sour cream on top of something, heavy cream in something, butter on top of something else. You know that that's fat. Right. Salad dressing, all that kind of stuff. But when it actually is already in the food, not only the crust with making probably has got oil in and then you've got the cheese and the pepperoni which have natural fats in them. It's not like there's been added to it, but it's hidden. You don't visibly see it, so you don't think, well this can't be that bad.

A (5:54)

Right? Right. And the breakdown of what's in this Pizza Hut pizza. I think of Pizza Hut as like fast food pizza. But in a lot of the country you don't have mom and pop hand tossed pizza places everywhere. Like you know where I live. You do. You're getting pre made doughs that are probably made off site or something. They have stuff in it called datum D A T E M enzymes and stabilizers to keep the dough uniform and extend shelf life and storage or transportation, you know, versus a homemade pizza that's probably just flour, water, yeast, salt, maybe some oil, maybe not even. Obviously there's ingredients differences, but the fat difference is insane. Like I make pizza here. I don't know that I even bolus it differently for Arden than any other food really. We just count the carbs and eat it and. But it's thinner crust. It doesn't have like an inch of cheese on it. You know, it doesn't have whatever datum is. And you know datum, that's a new one.

B (6:53)

I haven't heard of that one.

A (6:54)

We got to figure out what datum is. So how do we bolus for this? Right. Like I mean that the why we're.

B (7:00)

Here, really pizza is the age old reason that pumps even years ago first came out with the idea of an extended bolus.

A (7:11)

Right.

B (7:11)

It's in fact we call it the pizza bolus. Really Instead of even extended bolus, we just refer to it as a pizza bolus. But it encompasses all foods that could have similar nutrient content to pizza being pretty high in fat carbs, not low, but often high along with the high fat content where you're going to need if we build our meal bolus. Right. With the lovely acronym that you came up with. Meal bolt meal bowl by the way.

A (7:42)

Juiceboxpodcast.Com meal-bolt now if you want to learn more about it. Sorry, I have a website.

B (7:48)

Oh yay.

A (7:49)

You measure the Meal out the carbs, the fat. Now, glycemic impact. Right. There's an interesting one because I find there's a need to pre bolus for pizza, but not the entirety of the carbs. Because if you put too much up front, the digestion happens slowly. The insulin ends up crushing you long before you get the impact from the pizza. So.

B (8:07)

Correct.

A (8:08)

Talk about how to stretch it out.

B (8:10)

So in general, most pizza probably falls somewhere more moderate glycemic. It's not high glycemic, like sitting down to just white sticky rice or watermelon or anything like that. And the higher the fat and higher the protein content would lower the glycemic impact potentially even further. But somewhere around 55 to 60, 70, maybe at the most in terms of glycemic index, which means that that extended bolus ide is relevant. And you would usually use as a starting place a 50, 50. Right. And as you definitely said, we still need a pre bolus for it.

A (8:52)

Yeah. Something's gotta start happening.

B (8:54)

Correct. Especially again, another thing to evaluate is the next step. Evaluate. Right. What's happening on your cgm? What's the trend looking like? Are you sitting flat at 100, are you rising from 120? And you've been going up already? All those things to evalu might tell you a little bit more about the pre bolus time, but not necessarily what you need to do to cover the meal in the aftermath is still gonna be a starting place of like a 50, 50, 50% of the carbs upfront, 50% extended out. It could be a minimum of two hours. Maybe you have a child who really eats two pieces of pizza. Well, in this case, 17 grams per slice is 34 grams of fat that that child is eating. And along with maybe something else, maybe they had a salad that had salad dressing on top of it or whatever. Breadsticks that went along with the meal.

A (9:49)

French fries, stuff like that. Right.

B (9:51)

Yeah, the other stuff. So again, building that idea of extending your bolus could be a limit, a minimum of two hours, could be as long as four or five hours after the meal.

A (10:05)

Yeah. So to talk about it the way we'd probably talk about it more in like the Pro Tip series, the impact of your insulin needs to be lined up with where the carbs are are trying to make your blood sugar go up. So if you take a slice of pizza and start eating it's heavy dough, it doesn't get broken down right away. It's not a lot of simple sugar. It's gonna, you know, get Absorbed through your cheeks or, like, hit you real quickly. There's not a high glycemic index. You're not gonna, like, start flying up right away. If you go say to yourself, like, I'm gonna eat three slices of pizza. I'm gonna bolus for a, you know, 36 carbs three different times, right? Now, that insulin is going to crush you long before that pizza impacts your blood sugar. So. But you do have to get some in. I still want you to. What Jenny just said, like, it occurred to me, like, some of you are putting your kids in a car and driving to a pizza place. Sometimes just getting in a car makes people's blood sugar go up, right? They sit still, they start going up. Many of you might be ordering pizza for a party, and then maybe the kids have been outside running around like crazy, and then you bring them in and go, hey, here, pizza. Then your brain goes, oh, no. Pizza. A lot of carbs put in a big bolus, and they were falling already, and you didn't realize it. I mean, that stuff's all. You're gonna have to figure that out, like, from situation to situation, right? But stretching out that bolus with an extended bolus, or if you can't do an extended bolus, making, you know, your own, you know, boluses along, little boluses along the way to kind of put. Make sure that this insulin is in you and active while the carbs are kind of coming online, being digested and still hitting. The reason the fat's so important in all of this, the way I try to think of it is just that the fat kind of slows down digestion. It holds those carbs in your stomach longer, and it extends the impact time that the food's gonna have.

B (11:52)

It does. And the fat part of it, beyond extending the carb digestion, because digestion slows with all the fat, is really the resistance factor that larger amounts of fat at a time add in, like we've said before, fat sort of sits on your insulin and it makes it work less effectively. So building into this potential picture of this kind of a food is not only the extended bolus, which you may just end up with 50, 50, 50. Now, 50% over two, maybe three hours at the longest. But, you know, your hit point from fat comes in somewhere around two and a half to three hours. Well, in that, then you might bring in another piece, which could be use of a temp, basil or an override or something else to allow the system to give a little bit more where the fat is Actually hitting.

A (12:45)

Yeah. I mean, as an example, a lot of people are using aid systems now. Some of them are going to be more adept at this than others too. Right. Because you could set an extended bolus in tandem. Right. But you couldn't in Omnipod 5 and automated. So maybe if you're in automated in Omnipod 5 and you're having pizza and you're seeing this happen, maybe you want to go into manual for that. Yep. Keeping in mind that you put in initial settings in Omnipod 5 that now the algorithm has changed and your manual settings might not be anywhere near correct. So there's another layer to this too. You have to keep on top of your program settings so that if when you do switch back into manual, they're where they need to be correct. And then, yeah, just keep looking like, you know, an hour later, if you're having pizza at an hour later, you're 200 and it's going up. I mean, you need more insulin.

B (13:35)

Something was missed. And so next time it's a. And when I work with families, I say, well, it was an experiment. There's no beat yourself up about it. It was. This is what happened. You've got information. You can now tell little Johnny, gosh, we can have pizza again. Let's try it again. And this time we're going to put more in the picture or at a different time or whatever.

A (13:56)

And yeah. So when you tweak it for next time, just think of it as another pizza night. That's aw. Yes. But now keep in mind something simple here that I think gets past people. That was Pizza Hut. If you go look at Domino's, Domino's Pizza doesn't have that. As many carbs in a slice, actually lower by a fair amount.

B (14:15)

And so I'm curious if there's a difference in slice size, meaning the weight of each slice may be different enough.

A (14:23)

I mean, for my memory, Pizza Hut pizza is pretty heavy. Thicker. Right. And Domino's might be a little thinner, but still more like fast foodie pizza. Although I would. I'm gonna tell you that even a hand tossed, like a slice that I would make here at the house, I still think for Arden I'd go like 20, but I'm making like a Neapolitan pretty thin. Not a ton of cheese. Right. I'd go about 20 carbs for a slice for her.

B (14:47)

Yeah. And in general, that's a. That's pretty close to what I teach as just a. A guesstimate in terms of pizza. You know, a slice, the Size of adult woman's kind of. Or a smaller hand. Right. Tip of finger to wrist, covering the whole hand for thin crust is about 20 grams a slice. Sounds like what you're probably making at home. And then if you're looking at more of the typical pan style like a Pizza Hut or a Domino's or whatever, usually that's about 30, maybe 35 grams.

A (15:19)

Right.

B (15:20)

And then when you look at more Chicago style deep dish, I mean, you're looking at probably 50 to 60 grams per slice.

A (15:26)

Yeah. Some of those could be an inch or more thick. Right? Yeah. I think pizza is a great example of people are like, we need to know how to bolus for pizza. And I was like, you need to know which pizza you're eating before you even ask that question. And you need to understand fat and you need to understand extending boluses. And if you don't, it's just not as easy as like, throw in this number and go for it. Like, pizza is probably the culprit of more low blood sugars for people who don't know what they're doing than anything I've seen online. Right. Because they think big number, they get all that insulin and they finally have decided, like, I know I need this insulin. And then digestion doesn't work the way they're expecting and boom, now they're doing right. And you know, the other side of what happens, Jenny, is they, they'll pre bolus their pizza with all this insulin, get super low, drink a bunch of juice to fix it, and now they're shooting up from the juice, don't have any nerve to put in more insulin because that seems crazy. And then they eat the pizza on top of it and they're like, I was 500 all day from pizza.

B (16:25)

Yeah, absolutely.

A (16:26)

All right.

B (16:26)

Yeah.

A (16:27)

Good luck, everybody.

B (16:28)

Enjoy your pizza.

A (16:29)

Yeah, bye. In each episode of the Bolas 4 series, Jenny Smith and I are going to pick one food and talk through the bolusing for that food. We hope you find it valuable. Generally speaking, we're going to follow a bit of a formula. The Meal Bolt formula. M, E, A, L, B, O, L, T. You can learn more about it@juiceboxpodcast.com meal-bolt but here's what it is. Step one. M, measure the meal. E, evaluate yourself A, add the base units. L, layer A, correction B, build the bolus shape O, offset the timing L, look at the CGM&T tweak for next time. In a nutshell, we measure our meal. Total carbohydrates, protein, fat. Consider the glycemic index and the glycemic load. And then we evaluate yourself. What's your current blood sugar, how much insulin's on board, and what kind of activity are you going to be involved in or not involved in? Do you have any stress hormones, illness? What's going on with you? Then a we add the base units, your carbs divided by insulin to carb ratio. Just a simple bolus. L layer a correction, right? Do you have to add or subtract insulin based on your current blood sugar? Build the bolus shape. Are we going to give it all up front 100% for a fast digesting meal or is there going to be like a combo or a square wave bolus? Does it have to be extended? Offset the timing? This is about pre bolusing. Does it take a couple of minutes this meal or maybe 20 minutes? Are we going to have to again consider combo, square wave boluses and meals? Figure out the timing of that meal and then l look at the cgm. An hour later, was there a fast spike? Three hours later, was there a delayed rise? Five hours later, is there any lingering effect from fat and protein? Tweak, tweak for next time. T what did you eat? How much insulin and when? What did your blood sugar curve look like? What would you do next time? This is what we're going to talk about in every episode of Bolus 4. Measure the meal, evaluate yourself, add the base units, layer a correction, build the bolus shape, offset the timing, look at the cgm, tweak for next time. But it's not going to be that confusing and we're not going to ask you to remember all of that stuff. But that's the pathway that Jenny and I are going to use to speak about each bolus. Hey, thanks for listening all the way to the end. I really appreciate your loyalty and listenership. Thank you so much for listening. I'll be back very soon with another episode of the Juice Box Podcast. The episode you just heard was professionally edited by wrong way recording wrongwayrecording.com.