How To: Use Bolus Insulins Effectively

This section is for everyone. It is slightly more applicable towards type one diabetics but has information that will also help type twos.

Bolus insulins are given to cover your food and also to correct high blood sugars at meals and other times.

The total amount of carbohydrate and its rough glycaemic index, fat content, protein content, and  the presence or absence of delayed stomach emptying  all affect the speed and duration of blood sugar rises after meals.

If you are on the strict end of low carbing most of your meals will be meat/egg/fat/low starchy vegetable combinations which take longer to digest than if you were eating sugary or starchy foods such as breakfast cereal and milk. The techniques you use to cover different kinds of meals will therefore vary.  You are doing your best to match the insulin to the meal. The sorts of meals you will be choosing to eat will depend on your goals for your blood sugars and your health.

We will be discussing techniques to cover several types of meals.

Dr Bernstein’s strict low carb meals at 6-12g of low glycaemic carb, moderate protein and high fat.

This is the gold standard. It can give you truly normal blood sugars over the entire course of the meal when optimal insulin techniques are used. All diabetics need to seriously consider how far they could adapt themselves to this diet for the long term prevention and indeed reversal of complications.

Dr Jovanovich’s typical low carb meals at 13g- 30g of mixed glycaemic carb, moderate protein and high fat.

This is the typical diet that most low carbers and lower carbing diabetics use. All of the popular low carb diet books by eg Dr Atkins, Drs Eades, Barry Groves, Dr Agatson, Drs Allen and Lutz, and Dr Annika Dalquhist are in this meal range. It gives you more variety in fruit, vegetables and grains but probably not completely normal blood sugars. You may get some sugar spiking at meal times but are likely to have a normal blood sugar by the time the next meal comes with the appropriate insulin techniques.

If you are in transition from the high carb so called, “Healthy Eating Plan” this is where you want to be for some time. This gives you time to:

Adjust your insulin or oral medications downwards slowly and safely.

Helps reset your “Hypo clock” downwards.

Helps prevent a deterioration in  retinopathy from too rapid blood sugar improvements.

Gives your lenses in your eye time to adjust to lower sugar levels.

Gives you time to learn new low carb baking skills and improve on your range of meat, egg and vegetable dishes.

Gives your family time to adjust to a new eating routine.

Gives you time to organise your planning, shopping and meal preparation times.

Dr Morrison’s techniqes for dealing with  higher carb meals of 40-90g are a useful addition for times when you are having a planned indulgence or  when your  food choices are  extremely limited.

Eating meals with this carbohydrate content approaches what many consider to be “normal” eating. The problem is that if this is done too frequently it will certainly have an adverse effect on your diabetes. Blood sugars at meals will spike and for some time afterwards but you are likely to have normal blood sugars when the next meal comes.

Why do I have to change my eating and insulin routine?

If you have been doing what you have most likely been told at your diabetes clinic you will be here for a very good reason.  It isn’t working.

You are looking for solutions to your blood sugar problems:

Too high. Too low. Too wide blood sugar swings. No idea what number that meter will show next.

The techniques I will shortly be describing are often seen by newcomers as a bit of a drag. All those blood sugar tests! All those injections! All those donuts I’ve to bin!

What I would like to do here is explain what is wrong with the dietary advice given out in most diabetic clinics and why the simple insulin regimes they advise are not adequate.

The poor control you have been experiencing up till now is not because you haven’t listened, asked questions or done as you have been asked. It’s not worked because the advice you have been following has been wrong.

Here is what you are told to eat according to “Healthy Eating” guidelines.

Protein should be 15-20% of your total energy intake. Optimally 0.8g/kg body weight a day.  It is neither necessary or advisable to have more than 20% of your energy from protein. Cereal foods and pulses add considerably to the protein content of the diet.  Most adults eat at least 50% more protein than required.

What it should say is:  The minimum protein requirement for a healthy person is 1g/kg of their ideal body weight of protein a day.  You can find this amount by an easy calculation.

Take your ideal weight in kilograms and divide it by 6. This is the minimum amount of lean protein to eat in a day in ounces. Eg a 60kg woman would need at least 10 oz of lean protein a day.

If you are eating this and you are a healthy weight fine.

If you are eating more and are too heavy you may need to cut down.

If you have kidney problems keeping normal blood sugars are very important. You may need to reduce your protein intake a little but may need more if you are on dialysis. The help of a dietician with experience in this area is important if you have established severe kidney failure.

Cereals and pulses may have some protein in them but they are also high in carbohydrate.

Quick Quiz:
There is no quiz in this section.

Where to Next?
Please all continue our exploration of what passes for science in How To: Know the Truth About Fats section.

Reference Info:
The standard nutritional information “What they say ….” is based on the dietary guidelines in Dr L.Steven Levene’s “Management of Type 2 Diabetes in Primary Care: a practical guide.”

This book was published in 2003. I don’t think a second edition has been printed yet as I received it free of charge from Boehringer Ingelheim in 2006. General members of the public cannot buy this book.

In it’s present form this is just as well.

For General Practitioners who may be taking this course I can recommend the other chapters as sensible, well informed stuff.In particular the is not overburdened with information. It has just the right amount of information pitched at the right level of scientific detail and interesting and sometimes quite yuccky photos.

In the foreword Professor Alberti of the University of Newcastle, previously a President of the International Diabetes Federation, and Vice President of Diabetes UK has (sort of) stated:

( I took out some boring UK only details and changed lot of hard words like axiomatic, lacunae and educational armamentarium. Being working class I went to a state school in Scotland and I would have been duffed up if I had used this sort of language in public.)

“The prevalence of type two diabetes has reached pandemic proportions. Figures are set to rise by 50% in the next decade. In the UK there are 1.5 million diabetics and approximately another one million who have not been diagnosed.

The National Service Framework has identified the shortage of health professionals to deal with this pandemic. There are over 30,000 GPs compared to fewer than 600 specialists. Better, more convenient care can often be given when patients are in the familiar surroundings of their own general practice.

If GPs are to take an interest in managing diabetes they need knowledge, practice and continuing education. This is often not available. This book fills a large gap in the educational materials available.

It is a must for GPs who run diabetes services for their patients. I would go further and suggest that it should be read by practice nurses, community podiatrists and the rest of the team. With potentially two million plus people with diabetes in the UK alone to look after, we need all the help we can get!”

You certainly do!

Perhaps Steven would like to produce more accurate and helpful nutritional information in his next edition? Call me.

Perhaps Professor Alberti would like me to proof read his next foreword?