This section is for everyone.
If you are on a fixed dose insulin regime for any reason about the only thing you can manipulate to control blood sugar control is what you eat and the timing of your meals in relation to this.
These fixed insulin regimes are less common in the US but are very popular in the UK especially type 2s and also for type ones who are just starting on injections. Carb counting is not usually taught outwith special education courses such as DAFNE in the UK.
This educational course has given you lots of information that you can use to improve your diabetes control. If you have not yet got to grips with carb counting and the other advanced insulin techniques you may like to have some simple techniques that will improve your control meanwhile.
If you expect a meal to take longer to digest than is usual for sugars and starches eg it is high in protein, fat and low glycaemic carbohydrates (eg lasagne, pizza, lamb curry) you can:
- Bolus 15 - 30minutes after you start eating for rapid acting analogues.(RAAs)
- Split the bolus into two or three parts and give at 6-90 minute intervals. (RAAs)
- Take regular insulin with the meal instead of a RAA.
- Extend the bolus delivery time to over 2.5 hours if you are on a pump.
For people who are on or prefer to use a single injection of a RAAs:
- For foods that are high GI foods - bolus before eating. eg a jam sandwich.
- For moderate GI foods - bolus while eating. eg fish and chips.
- For low GI foods- bolus after eating.
Your pre-meal blood sugar will also affect the optimal time you give your food boluses:
BS above target range:
High GI 30 - 45 minutes before a meal.
Medium GI 15 - 30 minutes before the meal.
Low GI 0-5 mins before the meal.
BS in target range:
High GI 15-30 mins before the meal.
Medium GI 0-5 mins before the meal.
Low GI 10-15 mins after you start the meal.
BS below your target range:
High GI 0-5 mins before the meal.
Medium GI 10-15 mins after you start the meal.
Low GI 30-45 minutes after you start the meal.
If this sounds complicated, well it is! But you have diabetes as your constant companion for the rest of your life. You will be having at least 2 meals and more usually 3 to 4 every day. You have plenty of time to experiment to get the best results.
For people on or who prefer fixed basal/bolus regimesIf you are on a fixed basal/bolus regime much of what you have been learning about the versatility of different insulins will be irrelevant to you. You can only use the tools you have after all. One thing that is particularly relevant to you is the delaying or advancing injections in relation to breakfast and your evening meal.
If your pre-meal sugars are high you can give the insulin dose and then wait longer for your sugar to drop before eating. For instance on Mixtard you normally wait 30 minutes before a meal but you could extend this as far as an hour and a quarter depending on how high your sugars are. For novomix or humalog mix the usual instruction is to bolus just before eating. You could inject 14-40 minutes before depending on your level.
The opposite applies to low blood sugars. For mixtard users you would inject and eat right away or earlier than the usual 30 minutes. For novomix/humalog mix users the injection could be delayed part way into the meal or afterwards. There is no substitute for experimentation and learning from your efforts.
How do I change my insulin regime if I am an NHS patient?
Many US readers will be splitting their sides laughing at the very idea of these detailed schedules for fixed insulin users. Why not learn to carb count and use separate bolus/ basal regimes? Why indeed?
As a UK General Practitioner I realise how difficult it is for patients to change their diabetologist's mind about what insulin is considered right for them. I hope you will read about all the different food patterns and insulin regimes so you can consider if what you are doing now is what you really want to do. Are you getting the results you want? How much effort would you be willing to put in to experiment to get the best results for you?
Fixed basal / bolus regimes offer little cover for lunch time meals. To remedy this you can either eat a very low carb meal at lunch time or ask the diabetologist to give you some rapid acting analogue or regular insulin to inject to cover your lunch.
The diabetic staff may not want to have to train you in the use of a multiple daily injection regime. They may not want to teach you carb counting. A lot of this has nothing to do with their perception about how you will cope or whether they like you or not. It is to do with resource allocation in the NHS. NHS staff don't call it the National Sickness Service for nothing!
Please consider going through this entire programme thoroughly. Prove that you are better informed about what will work to improve your diabetes than they are.
If you get stuck your Member of Parliament or a letter of complaint to the Clinical Director of the Hospital may help.
And the Best of British Luck to you!
1. When a type one is eating in a restaurant it could be risky to to one of these...
a Inject your regular insulin right after ordering.
b Inject your rapid acting insulin right after ordering.
c Ask for vegetables instead of potatoes or rice with the main course.
d Tell the waiter you are diabetic and need food right away if you have been waiting for a time or feeling low.
2. For insulin dependent diabetics they should avoid large amounts of alcohol at one go because...
a It will make them fat.
b It causes acute peripheral neuropathy.
c They will lose their inhibitions and eat sugary food too.
d It can suppress gluconeogenesis and give severely low blood sugars.
1.B is unduly risky. Food tends to arrive 2-40 minutes after ordering and you may be putting yourself at risk of a hypo by injecting a rapid acting insulin too soon before the meal. The waiter is there to help you. Ask if you need done specially for you.
2. D is correct. Insulin users in particular should always be moderate about their drinking and eat slowly releasing carb or protein with drink to avoid delayed hypoglycaemia from alcohol. A and C apply to some extent too of course. Prolonged heavy drinking can cause peripheral neuropathy.
Acknowlegements to Gary Schiener.
Where to Next?
Please all continue onto the section How To: Help Diabetics Who Can't Afford Insulin section.
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