How To: Do the Atkins Diet

This section is for everyone. Even those of you who may have done the Atkins or lived with someone who has.

The easy way to do the Atkins diet is to buy one of Dr Robert Atkins books and do it.

The book I would particularly recommend is Atkins for Life the Next Level.

This is a simple introduction to low carbing and it covers all the basics you should know about.  The book discusses the research information, the relative importance of protein, fat and carbohydrate in the diet and gives you various meal plans and recipies that you can incorporate into various total daily carb plans.

What I like about it is its versatility between carb plans from 20-120g of carb a day.  Compared to the Zone diet it is more versatile about the amount of carb that may suit you and compared to the South Beach diet there is no unnecessary restriction on saturated fat.

When you do a traditional Atkins diet you start at 20g of carb a day and gradually increase your carbs as far as you can till your weight loss levels out.  For many people who are just plain fat and who are not on any medication that could affect their blood sugar this is usually fine.

For anyone who is on insulin or blood sugar lowering medication  such as sulphonureas which includes gliclazide or metaglinides this would not be such a good idea. In fact such a drastic reduction could be dangerous.

But the Atkins diet has in my opinion still a great deal to offer. For those people who have pre-existing heart disease or are otherwise at greater than average cardiac risk, or who are on medication or who perhaps are getting on a bit – over 45 – for instance why not do Atkins in REVERSE?

What I am proposing is to take things nice and slow.  If you have any glucose metabolism problem you are going to have to restrict your carb intake for the good of your long term health sooner or later. You have to face this sometime.

From my previous discussions about how to measure the carbohydrates you eat you can surely find some way that suits you to find out how much carb you are currently consuming.

Whatever this is you need to start here.

That’s right.

Start wherever you are and start to cut down.

Week on week. Day by day. Meal by meal. Carb by carb.

If you are over 120g a day that is okay. If you are already on say 90g a day that is okay too. Simply look at the weight loss and blood sugar goals you want to achieve for your future health and start right away.

Many people will get what they need at the higher ends of the Atkins range such as those following the Zone or perhaps Dr Lois Jovanovich’s guidelines at about 120g of carb a day.

Some will want to drop their carbs further such as those people who are following the Drs Eades Protein Power plan or the diet advocated by Dr Allen and Dr Lutz or Dr Jorgen Vestig-Nielsen or Barry Groves at around 70g a day.

Others will not get to what they want until they get to Dr Bernstein’s diet of between 30-42g of carb per day.

You decide.

What do you want to achieve?

What amount of carb restriction is likely to be necessary to acheive this?

How slowly must you go down for safety?

Whatever the answers are for you, I hope this internet course can help you get what you want with safety  and with the knowledge of companionship along the way.

Quick Quiz:
There is no Quiz in this section. All the questions in this section have been ones to ask of yourself.

Where to Next?
The last few sections may have been a lot tougher than you were expecting. Have you got an idea of the amount of food recording and sums that you are going to be doing from now on?

I think it’s time for a little change of scene.

It’s back to Home Economics 101 for your lessons on How To: Cook and Bake the Low Carb Way.

Even if you’ve never boiled an egg your life, the quality of food you will soon be able to serve to yourself your family and friends will greatly improve when you’ve taken the plunge.


How To: Look after yourself with Type 2 diabetes

This section is for all type twos and any type ones who think they are developing insulin resistance. This is often recognisable by an increasing waist line, blood pressure and need for high doses of insulin relative to your thinner years.

Slim type ones may proceed to the How To: “Eat to Meter” section.

When you eat carbohydrate it gets broken down by the digestive system and appears in the blood stream as glucose.  Insulin is immediately released by the pancreatic beta cells.  Insulin is the hormone that tells certain types of cell in the body to take up glucose in the bloodstream.  In this way the glucose level in the blood stays within a narrow range.

In insulin resistant states such as metabolic syndrome and type 2 diabetes the cell wall insulin receptors are less sensitive to insulin and in an effort to keep blood sugar levels normal the pancreas releases more insulin.

High insulin levels causes inflammation and stiffening of the lining of your blood vessels. This lining is called the endothelium. This stiffening causes high blood pressure.

The pancreatic cells can initially make plenty of extra insulin to compensate for the weakened effect of the insulin but eventually become exhausted and start to die off. This causes higher blood sugars.  Unfortunately blood sugars higher than 6.1 are toxic to beta cells and they start to die off with higher and higher blood sugars. The whole thing is a vicious circle.

Type two diabetes is often thought of as being less serious in some ways than type one diabetes. It is certainly true that a type two will not die as rapidly if they don’t get insulin as in type ones. On the long term however type two diabetes causes all the same complications as type one and can be just as fatal. Instead of it being obvious that something is drastically wrong with your health as in type one, those with type two can have it creep up on them over many years, slowly causing damage to the blood vessels, eyes, kidneys and nerves and not even know about it.

In type two diabetes there is initially more insulin produced to try to overcome the effect of insulin resistance. In early type two diabetes there can even be episodes of low blood sugars when the pancreas releases too much insulin at the wrong time. As time goes on the beta cells become exhausted and produce less and less insulin and  die off. In many people insulin injections are eventually needed to give anything like normal blood sugar control.

Type two diabetics store less immediately available insulin than normal people. In addition they also need to produce more than normal because their cells are less sensitive to insulin. As their ability to produce insulin on demand declines they get higher blood sugars after eating and this persists for much longer than in non diabetic people.

High blood sugars after eating can be minimised by eating fats, protein and carbohydrates that release sugar gradually so that their pancreatic insulin factory (phase two insulin response) can keep up. This effectively means eating non starchy vegetables as the main source of carbohydrates.

For type two diabetics who do not need insulin they may get better results from eating  4 or 5 small meals a day rather than sticking to three bigger meals a day.

Many people have inherited their tendency to insulin resistance.  If your parents or grandparents had heart disease, high blood pressure, fat round the middle, high cholesterol, high triglycerides, type two diabetes or swollen ankles you are more at risk.

The diabetes tendency becomes noticed at times such as pregnancy, ageing and if the person tends to eat a high sugar or starch diet.  Lack of exercise also affects how rapidly the tendency will appear.

Insulin primarily affects blood sugar but also affects blood pressure, cholesterol and triglycerides and the storage of fat. No medications can reduce excess insulin production: only a low carb diet. A low carb diet works by reducing the oversecretion of insulin and helps restore balance.

Beta blockers and diuretics which are often used to control blood pressure also increase insulin resistance and are best avoided in some people.

Although there are cut off points in blood sugar tests to say who is normal, who has metabolic syndrome and who has diabetes, the condition is really a continuum.  Someone who has metabolic syndrome can get retinopathy, kidney disease and cardiovascular disease just the same as a diabetic.

The worse your sugar control is the worse your cardiovascular and complication risk.  A popular test to do is the hbaic. This is the percentage of sugar attached to your red cells in the blood. Although a normal range of 4-6 is often given for instance it has been found that your risk goes up progressively from levels of just 4.6.  It therefore makes sense to have as good blood sugar control as you can, particularly if you have a moderate to long life expectancy.

Tests that you can have done to find out your risk or severity of metabolic syndrome and type two diabetes include measuring your waist/hip ratio, hbaic, glucose tolerance test, fasting lipids and blood pressure.

There is a progression in how type two diabetes is treated:

Low carbohydrate diet
Appropriate weight loss
Drugs that enhance insulin sensitivity or insulin action
Insulin injections with or without oral drugs.

People who have lived with high blood glucose levels for years can feel shakey or ill at normal blood sugar levels.  They also can have blurred vision. A gradual adjustment of the target blood range and progressive reduction in carbohydrates can help these symptoms settle down.

Quick Quiz:
1. One of these is true for type two diabetics…
a They get less serious complications than type ones.
b They can have slowly developing damage to tissues without realising it.
c They need the same level of daily monitoring as insulin using type ones.
d Those not on insulin get on best with three meals a day.

Have you got it?
1. B is correct. Unfortunately the myth that type twos get less serious complications than type ones persists. Diabetes is certainly not as dramatic in onset as in type ones. It’s insidious nature makes it harder to detect and so damage goes unchecked. It is the case that monitoring of blood sugars needs to be done a lot less often than in insulin dependants but dietary habits must be just as good. If reasonable amounts of a person’s own insulin are being made type two diabetics may have better sugar results with smaller and more frequent meals than the 3 or 4 a day advocated for type one diabetics.

Reference Info:
Most of the information in this section is from Dr. Bernstein’s Diabetes Solution: The Complete Guide to Achieving Normal Blood Sugars.
Where to Next?
You are now ready to proceed to the How To: “Eat to Meter” section.

How To: Know What Things Beyond Food Can Affect My Blood Sugar

This section is for everyone.

Often you may notice that the blood sugar in the morning is higher than when you went to bed at night even when you have not had any bedtime snack. This can be due to a variety of causes including gluconeogenesis, the dawn phenomenon and delayed stomach emptying which is also known as gastroparesis.  There are many other variables that affect blood sugar besides just the macro nutrients of the food you eat.


Gluconeogenesis (Latin for “The making of new sugar”) is the process where the liver converts protein to glucose. This goes on all the time to some extent but is suppressed in the presence of adequate amounts of insulin and drinking alcohol. In type one patients who are no longer able to make enough  of their own insulin this  process accelerates and is what causes their sugars to rise so high and for them to lose so much weight.

Dawn Phenomenon

The Dawn phenomenon is called this because the liver clears away insulin more efficiently first thing in the morning compared to other times of the day. At the same time growth hormones and sex hormones are manufactured during the night and these make cells less sensitive to the action of insulin which normally moves sugar from the blood into the cells. These two mechanisms result in higher blood sugars in the morning for most people after puberty gets underway. Various dietary and insulin techniques can be used to minimise the effects of this phenomenon. Another great read on this topic can be found here: The Dawn Phenomenon – Why Are Blood Sugars High in the Morning?

Delayed Stomach Emptying / Gastroparesis

Delayed Stomach Emptying is due to the effects of long term nerve damage on the way the stomach works. The rate of stomach emptying is reduced and the bottom end of the stomach called the pylorus can go into spasm. It can be difficult to know how your stomach will respond from one meal to the next.

For type two diabetics who are not on insulin or drugs which stimulate insulin secretion this may simply give you very unpleasant indigestion.

For insulin  users and those on drugs that stimulate insulin secretion, these are usually timed to act over the time the food of the meal is getting digested.  When food digestion  becomes imbalanced, blood sugars can be too low immediately after a meal only to go too high some hours later.

Special dietary measures are needed to overcome the effects of this condition and they are carefully explained in Dr Bernstein’s book  Diabetes Solution.

Like many complications of diabetes it tends to become apparent after 5-20 years of diabetes depending on the level of blood sugar control. Although the condition can certainly make diabetes control much more difficult it is possible to reverse delayed gastric emptying and some other complications by careful maintenance of normal blood sugars for several years.

Genetic Factors

Blood sugars can rise over the long term from effects you can’t control like inheritance.  Excess weight has both genetic and environmental components from the womb onwards.  Excess weight gain  raises your blood sugars because it makes you more insulin resistant.


Undiagnosed  and untreated infections particularly  gum and dental infections can raise your blood sugar.  Careful examination by a dentist is often needed. Treatment  can take months.

Acute Illnesses

Dehydration and acute infections such as gastroenteritis, viral infections, acute injuries, surgical operations  or stress can raise blood sugars.

An important consideration is that once the blood sugar is high you become more insulin resistant because of this and vicious circles of high blood sugars, not being able to control them and dehydration can occur.  This topic is further explored in the section on sick days in the Type One Section.

Chinese Restaurant Effect

The Chinese Restaurant effect named so by Dr Bernstein is the high blood sugars that rise disproportionately to the carb count of the meal due to the actual bulk of the meal.  Moderate distention of the stomach produces the stimulation of the hormone glucagon which acts in opposition to insulin. This makes the liver produce more sugar from protein. The main thing to remember is not to stuff yourself at meals.


Exercise affects blood sugars considerably.  Different sorts of exercise can raise or lower your blood sugar.  This also varies according to how much insulin you have working at the time. The factors are very complex and there will be more discussion and sources of information on this in the Type One Diabetes Section which follows soon.

Exercise can improve many aspects of your life. Even if you have never been to a gym in your life and like me ran away from the ball at  enforced school P.E. sessions there are so many activities you can enjoy.  You can be active indoors, outdoors, in teams, alone, with help from instructors or by self discovery.  Your mood, physique, strength, stamina and flexibility can all benefit in some way.

Insulin Effectiveness

Tainting a bottle of insulin or exposing it to extreme temperatures can both cause it to lose some of its effectiveness and hence will increase one’s blood sugar even though the same dosage is administered.


Quick Quiz:
1. The dawn phenomenon affects teenagers and…
a Makes their blood sugars particularly high when they wake up in the mornings.
b Makes them sleepy and unable to get up in the mornings.
c Makes their breakfast digest more slowly than usual.
d Makes their blood sugar high by releasing glucagon.

Have you got it?
1. A is correct. The DP as it is often referred to also affects many adults.

Reference Info:
This section is based on the work of Dr. Bernstein’s Diabetes Solution.

The Dawn Phenomenon – Why Are Blood Sugars High in the Morning?

Where to Next?
Please all proceed to the How To: Keep Healthy with Diabetes section?

How To: Deal with High Blood Sugars

This section is for everyone. As you will need your helpers to help you deal with aspects of seriously high blood sugars they need to read this section and do the quiz too.

An excellent training course  for dealing with high  and low blood sugars can be found online at the online pump school at the medtronic minimed site .   Even though you may not even intend to use an insulin pump the course goes through a realistic and methodical training that is just as relevant for injectors.  Your immediate family and important carers should do it too. After all, what happens when you are too ill to help yourself?   You may  need to have a  calculator handy. The blood sugar levels are given using the US system and if you are used to UK figures, as indeed also happens in Canada and Australia, you will need to divide the US figures by 18.

Vomiting, Dehydrating Illness and InfectionWhen do I ask for professional help?
When you get vomiting on more than one episode, nausea to the extent you cannot eat, fever of more than 24 hours duration, severe diarrhoea or any form of infection you need to contact the triage nurse, diabetes nurse or your doctor for advice.

With diabetes it is much safer and easier to prevent the potentially dehydrating illnesses from getting worse than it is to fix you if you are in a severe state. Please don’t put off that phone call.

How does diabetic ketoacidosis develop?
Any infection will raise your blood sugars. This in turn leads to increased urine output and higher blood sugars. The higher the blood sugar the more insulin resistant you become. Higher insulin levels will then be needed to get things under control.

If your peripheral circulation shuts down your cells will start to metabolise fat and make ketones. Ketones take water from the body on the way out of your kidneys and you will get more dehydrated.

High levels of ketones also make you vomit.

Symptoms of DKA are:

  • nausea and vomiting
  • rapid deep breathing
  • loss of appetite
  • abdominal pain
  • weakness
  • visual disturbances
  • sleepiness

It is a truly awful vicious circle. The thing to do is to prevent it happening in the first place.

What do I do if I am not getting better ?
If you become unwell at any time it is important to keep your fluid intake up, continue your usual medication or insulin, check your blood sugar levels more frequently than usual eg every 2.5 hours.

Check your urine for ketones if your blood sugar level is above 13 / 230.  In fact even if your sugars are normal and you feel queasy check for ketones. Remember that ketone testing stix are unreliable 6 months after the container is opened regardless of whether they appear to be in date.

Get prompt medical advice if your symptoms don’t settle or your blood sugars are too high.  Information you can give about your current blood sugar, the trend in blood sugars, ketones or not, your insulin doses and your correction doses and how well you are keeping down fluids and passing urine are necessary for the doctor or nurse to make an accurate assessment.

If you attend A and E bring your Emergency Cards especially if you do not speak the language they are likely to speak in the hospital fluently. Bring all your kit and a reliable bi or multi lingual helper.

Do not sit politely at the back of the waiting room if you are a vomiting insulin dependent diabetic. They must assess you RIGHT NOW.  They may have to drip you RIGHT NOW to SAVE YOUR LIFE.

If you are incapacitated or having surgery a friend, parent or sibling who knows how to manage your diabetes must be with you at all times to test and treat you as needed.

They may have to insist on saline drips until your blood sugars are in your normal range. Current hospital practice is to switch to dextrose ie sugar drips when you go below 10 / 180.

They may need to bring you in diet drinks or special food when you are in the recovery phase.

How to Manage Blood Sugars When I Actually Feel Okay?

Well, I hope you understand. I just had to get the blood and thunder stuff out of the way first.

If you think your blood sugars could be running high check your blood sugars. Tiredness is probably number one symptom of high blood sugars. If you are high you can do some things to bring it down.

15-30 minutes of gentle walking or other exercise can bring it down.

Drink plenty  of water if you are high.

If you are high three days in a row at the same time you need to consider an adjustment to your insulin dose.

Watch out for high blood sugars due to old or contaminated insulin. If in doubt throw it out!

Then watch for lower blood sugars when you start a fresh vial.

If you have been high due to an illness, stress or surgery and have gradually upped your insulin to deal with it be prepared for low blood sugars when you recover.

Girls and women often go high just before their period starts.

Remember your flu jag each autumn. It could spare a lot of grief.

High sugars and widely swinging blood sugars both cause complications that among other things age your blood vessels.  So does smoking. You don’t need smoking on top of all this diabetes stuff. Do you?

Correction boluses can be given for high blood sugars.

One rule of thumb is that one unit of a rapid acting analogue will deal with about 2.5 /  45 units of blood sugar. But this is an adult average and you are not average. You are you.

The more you weigh and the higher your total daily insulin dosage the less your blood sugar level will drop for a given measure of insulin. For many people a given unit of insulin will drop you much more if it is given at night compared with during the day.

Your correction dose will also depend on your individual insulin sensitivity for the time of day just the same as for your meals. You’ve worked this out for your meal coverage haven’t you?

Dr Gary Schiener has charts you can use to estimate your correction doses in his great little book “Think Like a Pancreas.” Again this is simply a guide. It is safest to start at correction doses a little lower than he recommends and take it from there. Guess and test. Again and again.

Hang on a minute.  I’ve not done yet. You cannot go off and correct high blood sugars with insulin willy- nilly. You also need to consider how much previously injected insulin is still active or you could drop too low.  Gary has charts for this too. Gary has loads of charts!

If you do go ahead with a correction bolus please check your bs after an hour to make sure it is on the way down and that you are not going too low.

Dr Bernstein thinks that the residual insulin on board calculations just makes the whole correction dose thing just too complicated.  I agree with him.

Dr Bernstein recommends that you only correct with insulin at your pre-meal and pre -bed times.  This is so that you can assume that no residual effect from the insulin other than your basal is present. This is not quite true of course. Remember the tail effects of regular and rapid acting insulins?

You also need to consider if your sugars are high due to a meal that took longer to digest than usual. Pizza for instance is notorious in this respect. It takes 8 hours to digest and a minimum of two spaced doses of regular insulin or three spaced injections of rapid acting analogue insulin to cover it completely. You need a five hour space between strict low carb meals before food will be having no effect on your blood sugars at the next meal.

I found it easier to give half a unit for a high blood sugar of a certain figure at a certain time of day and then see what results I got.  Progressively I was able to chart Steven’s exact correction doses for different blood sugar levels at different times of day. If half a unit didn’t take him to his target blood sugar level of 5.0 I simply gave more the next time.

I don’t do correction doses for high blood sugars at bedtime. I am too worried about possible night time hypoglycaemia. I simply put it down to experience, give Steven his night basal insulin, a big glass of water, say “Night Night”. Then I figure out how I could have done it better for the next time.

For any teenagers out there who are now desperate to get on with managing their own sugars some final words of wisdom from Spike and Bo.

“Let your parents take as much care of you as they want and help you out as long as they can. Someday you will be on your own and they won’t be there to remind you to take your kit and make you a healthy high protein breakfast.”

Quick Quiz:
1. Three of these tend to raise your blood sugars….
a Menstrual hormones.
b Hypoglycaemia rebounds.
c Weight gain.
d Alcohol.

2. If you have a blood sugar that is unexpectedly high you could have…
a An infection brewing somewhere.
b Been drinking too much diet coke.
c Given yourself too much insulin at the last injection.
d  Eaten too little carbohydrate with your last meal.

3. If you are insulin dependent and your blood sugar is 13/235 or over the next thing you should do is…
a Call your doctor.
b Check for ketones.
c Exercise vigorously to bring your sugars down.
d Have your usual amount of insulin and food.

4. You decide to give yourself a correction bolus to bring down a  high blood sugar. After giving the injection there is one of these things you really should NOT do….
a Check your blood sugar 30-60 minutes later.
b Drink a large glass of water.
c Go for a gentle walk.
d Go to sleep.

5. Before you give a correction bolus you need to consider three of these…
a Whether any previously injected insulin is active and for how long.
b Your insulin senstitivity for that time of day.
c  Recent previous exercise.
d Your current weight.

6. If you are insulin dependent and ill and vomit more than once you should do one of these things..
a Go to bed till you feel better.
b Check your blood sugar and call the doctor or nurse for advice.
c Have some lucozade to aid recovery.
d Stop taking food and fluids so as to give your stomach a rest.

7. You are vomiting repeatedly. Your sugars are high and you have ketones. What single course of action is best…
a Go to bed.
b Call NHS 24 from some advice from a nurse.
c Phone a friend.
d Go straight to A and E with your overnight bag and diabetes kit.

Have you got it?
1.       ABC do. Alcohol tends to give low blood sugars due to its effect on the liver of suppressing gluconeogenesis.  Menstrual hormones give a cyclical monthy pattern. Weight gain has a very gradual effect. Whether hypoglycaemia rebounds are due to overtreated lows or adrenaline and cortisol rushing in to save the day is a controversial phenomenon.  You may have to find out for yourself.

2.       A is correct. Dental and gum disease can be a hidden cause. Any flu like illness can play havoc with your blood sugars.

3.      B is correct. Remember that ketostix lose effect even while in date if the container has been opened more than six months before.  Exercising when you have ketones and are relatively insulin deficient can push you into very high blood sugars and ketoacidosis.

4.      D. You must NEVER give a correction bolus and go to sleep. You may overcorrect and have a severe hypo.  Rechecking  is mandatory and the water and walk may help.

5.      ABC are correct.

6.      B is correct. Although the other things listed are often done by non diabetics these activities no longer apply to you. Don’t do what your mum did with you were six. Do what you need to do NOW. And don’t delay making that call.

7.      D is best. You need a DRIP and you need it NOW. Phoning a friend is absolutely fine. They can help you get your kit, drive you to hospital, collect your kids from school and look after any pets.  No  going to bed while they make you a pot of chicken soup though!

Reference Info:


Dr Bernstein’s Diabetes Solution has a particularly important chapter on the subject of dealing with vomiting, dehydrating illness and blood sugars. If your carers read nothing else they must read this. Diabeticketoacidosis is a frightening run- away- train sort of illness. There is significant mortality rate even if DKA is treated in the best of hospitals.

Prevention is therefore paramount. Dr Bernstein’s recommendations may vary a bit from those of your diabetic clinic. In particular he emphasises aggressive and early management of any condition that has the potential to develop into DKA, hydration with a non sugar electolyte mixture which you can easily make to his instructions and close liaison with an experienced and  knowledgable health professional early in the symptomatic phase.

There is no point in reading all about it when you are throwing up rings around yourself. You must have the supplies he recommends and know what you are going to do AHEAD of events.

Having metoclopramide injection (UK) at home with the appropriate syringes and needles came in really handy when Steven was in this situation. You would benefit from having this drug or similar one in your emergency kit. It can be necessary after vomiting from glucagon administration as well as to terminate a vomiting attack from a viral infection or high sugars.  It is not to be used instead of medical advice but as well as. After you have vomited twice you must contact your doctor. If they think that an injection is required at this stage you can give it yourself or have the diabetic person do it. This can save valuable time on a house call or trip to the clinic or A and E department.

Where to Next?

How To: Match Insulin Reduction to Carb Reduction and Get The Best out of the Insulin Calculator

How To: Help Diabetics Who Can’t Afford Insulin

This section is for everyone.

From time to time I expect you feel pretty miserable about having diabetes. Especially about these interminable injections.

Diabetes for everyone is a life sentence. But for some poor people in developing countries parents cannot afford insulin for both a diabetic child and  food for the rest of the family. Hard choices have to be made.

Insulin for Life

The insulin for life organisation aims to help. They will ship your unwanted but in date insulin to those who would die without it.  They also help coordinate insulin supplies to disaster struck areas.

It is an Austrialian based organisation whose president is Ron Raab.  Ron has been a type one diabetic since he was 12 just like Dr Bernstein. He became one of Dr Bernstein’s patients and reversed many of his longstanding diabetes complications (read his success story here).

Insulin for Life is the website for the organisation that has affiliates in the US, Europe and the UK.

The Insulin Dependent Diabetes Trust

This is the UK organisation who will send your donated insulin to Insulin For Life.

Please send your no longer needed insulin – unused vials or cartridges and in date in a jiffy bag to:

Jenny Hirst
PO Box

The IDDT is a charity whose staff and membership is formed by diabetics and by those caring for diabetics. They aim to listen and support your needs.

They have an excellent website with articles of interest to insulin users about many different aspects of diabetes at:

Enquiries can be sent by e mail to:

The IDDT was formed from original members of Diabetes UK who were not being supported in their needs and preferences for animal insulins. Unlike Diabetes UK they receive no funding from pharmaceutical or food manufacturers.

Today is the 30th July 2007 and at the present time there is no pen form of regular insulin available in the UK apart form pork or beef soluble insulins. These are available for use in one unit increment  Owen Mumford Autopen Classic.
Thanks to the political lobbying that IDDT have continued for years the UK still manufactures animal insulins. These are obtained  and purified from pigs and cows that have been slaughtered for their meat.

A small variety of long acting, short acting and mixed duration animal insulins are available in pen cartridge formulations and  vials from Wockhardt Pharmaceuticals. These can be shipped overseas.

Prescriptions for the insulins and pens are available from your UK GP in the usual way. A GP however may want a diabetologist to approve.

If you are  keen on a pen form of regular insulin animal insulins are the only option currently available. The biggest drawback is that there is no half unit increment pens. Hypurin Pork Soluble insulin is what you need as it is a little quicker  acting than the Hypurin Beef Soluble insulin. You may remember that regular /actrapid/ soluble insulins are  a particularly good option for covering protein in meals.

Alternatively you can use Hypurin Pork Soluble or the GM Human Actrapid insulin  manufactured by Novonordisk in vial and syringe form. The advantage of the syringe is that you can still use half or quarter unit doses.

Quick Quiz:
1. Unopened and in date insulin vials and cartridges that you no longer need can be put to good use by two of these….a
a Pharmacies
b Diabetes UK, the ADA or your equivalent national diabetes organisation.
c Insulin for life.
d The Insulin Dependent Diabetes Trust.

Have you got it?
1. C and D are correct. IDDT in the UK will send it to Insulin for Life who will arrange for worldwide distribution.  Please send  insulin with at least 3 months to go to expiry.  You can read more about this organisation and how you can help on this site.

Where to Next?
Please now proceed to the How To: Deal with Low Blood Sugars section.

How To: Time Insulin Injections for Simple Insulin Regimes

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 regimes

If 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!

Quick Quiz:
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.

3. Type ones need to consider extra insulin when the protein portion to be eaten amounts to…
    a One pound of meat.
    b The size of a man’s palm.
    c The size of a woman’s palm.
    d The size of a boiled egg.
4. Three of these methods can effectively cover protein for insulin users…
     a  Using a single injection of rapid acting insulin such as novorapid/novolog orhumalog.
     b  Using  single injection of regular acting insulin such as actrapid.
     c  Using two insulin injection of rapid acting insulin separated by a length of time. (split bolus technique)
     d  Using an extended bolus of rapid acting insulin in a pump.
5. Ways of extending the length of time an insulin is active also helps to cover three of these foods such as…
     a Pizza
     b Lasagne
     c Mashed potatoes.
     d Chicken korma.
6.  You are using rapid acting insulin to cover your meals. Which three of these techniques could be appropriate around mealtimes…..
    a If your blood sugar was low you could take the appropriate amount of glucose and delay your meal till your blood sugar was back to normal….
    b If your bood sugar was low you could inject 15-30 mins after starting to eat.
    c If your blood sugar was on target you could inject 15-0 minutes before eating.
    d If your blood sugar was high you could inject 15-3 minutes before eating.
7.  You decide to have a  high carbohydrate dessert to celebrate your birthday.  What three measures could you take to minimise adverse effects on your blood sugars…..
    a Eat it early enough in the day when you can exercise vigorously after eating and have plenty of time to check your sugars and correct accordingly.
    b Add a little more insulin than the carb count and your insulin sensitivity would suggest to compensate for the relative insulin resistance caused by high blood sugars.
   c Add lots of unsweetened heavy /  double cream to the dessert to slow the blood sugar spike down.
   d Take the amount of insulin you think you will need but induce vomiting to prevent it digesting fully.
Have you got it?
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.

3. C is correct. This is around 3-4oz (apparently!) Other visual clues are the size of a deck of cards or a quarter pound burger.
4. BCD are correct. A single injection of rapid acting insulin will tend to spike too early and could give you a hypo soon after you start to eat.  It will have stopped working before the protein has been digested so will give you higher sugars a few hours after the meal.
5. ABD are correct. These have a high fat/protein content and digest fairly slowly. Mashed potatoes on the other hand are converted to sugar very quickly.
6. BCD are correct. With high blood sugars you do need to bring them down for optimal control before eating. Otherwise you would be starting off a meal with a degree of insulin resistance which then tends to require a disproportionately high amount of insulin to sort out after the meal is eaten compared to the levels needed to reduce a highish blood sugar before the meal is eaten. You don’t need to correct for low blood sugars with glucose though. Just eat earlier and  time your insulin a little later…
7.  ABC are correct.  High carb treats can be enjoyable. To eat them very sparingly will enhance the sense of specialnesss and need not damage your health.  The problem of course is if you can’t stop once you start or you eat them too frequently. Some people are best to avoid them completely.
Vomiting to control your blood sugars, your weight or anything else is a bad idea. It plays havoc with your teeth, blood sugars and metabolism.
Unfortunately diabetics have a higher rate of eating disorders such as bulimia and anorexia than the general population.  Sometimes the pressure to be thin can feel so great that insuln injections can be missed so that the calories are passed as sugar in the urine. Life threatening complications such as diabetic ketoacidosis can result. Rapid development of complications such as proliferative retinopathy can appear in a fraction of the time they would with just “average” control.
If you think you could be developing an eating disorder please seek help from your doctor or diabetic clinic. You need expert psychological help and they can get this for you.

Reference Info:
Acknowlegements to Gary Schiener.

Where to Next?
Please all continue onto the section  How To: Help Diabetics Who Can’t Afford Insulin section.

How To: Do Dr. Morrison’s Carb Weighting System

This section is for everyone who wants to “cheat” on their low carb diet and minimise the consequences.  If you can see yourself happily low carbing without the need to cover higher carb meals you may skip to the How To: Time Insulin Injections for Simple Insulin Regimes.

You need to wean yourself gradually off your high carb diet.

You need to be in a typical transition period at the very least.

You need to adopt the 7 unit per shot guidelines.  Every single shot.

Your need to find out which methods of carb counting work best for you and do them every meal.

You need to keep your basals, exercise, and fat and protein intake consistent over the testing period.

You need to be well and free of infection or undue stress so your meal profiles will be accurate.

You need to test at 3am on an experiment day to see you have not over done your insulin.


What you are going to do is find out at what level your insulin stops working in a linear way.

You will recognise this by high blood sugars before the next meal compared to when you eat low carb meals. I don’t know when this will kick in for you. For Steven it was good bs at 30g and higher bs at 40g for the same carb insulin ratio.

The best meal to test on is your lunch. Your dawn phenomenon is not active. Your dusk phenomenon is not active. Your carb sensitivity is usually at its best. You are awake and can deal with any adverse effects on your blood sugars by correction doses before your evening meal.

It is too risky to experiement on yourself at your evening meal. Throughout this experimentation process the only sugars that were consistently perfect for Steven were the before bed ones for this reason.

You need to add a smaller incremental dose of insulin to the one calculated for your carb sensitivity for that meal.

Test yourself on items that are easy to calculate eg breakfast cereals that are easily weighed and bread slices that are listed on the package. Packaged processed food with carb labels are helpful for these experiments.

Decide on how many units of insulin extra you will give per 10g over the baseline figure.

Make this a very low amount. If you can change to a half unit pen. The novonordisk demi pens and junior pens have this facility and humalog has just become available in half units too.  Of course this is not a problem with a syringe.  For a child you may wish to consider extra accuracy from diluted insulin.

We started on 0.5 units novorapid for each 10g extra increase in carb.

If your figures are showing that this is giving sugars higher than your next pre-meal target you can up the amount of additonal carb weighting insulin by a small amount.

If your figures are showing that the next pre-meal bs is too low then up the amount of carb stages eg in 5 or 10g increments till you figure out what works.

This carb weighting method is accurate for Steven up to 90g of carb per meal. After this our levels are inaccurate.  They are usually lower than expected on this exponential weighting but sometimes are higher.

You could find that you need to start carb weighting at levels of less than 40g.

You could find that you don’t need to start carb weighting till levels of 50g or higher.

You may find half unit increments  need to be used at additional carb levels of  5g, 10g or 15g or 20g levels.

You will need to determine when this system stops being accurate for you. This could be at levels considerably lower than 90g or could perhaps be higher.

Remember to only do the experiments when conditions are optimal for this.

You are well.
Your carb levels are accurate.
You are starting at normal bs.
It is lunch time.
No unusual exercise is involved.
You are not particularly stressed.
You have help to figure out what you are doing.

By a slow process of guess and test you can find out how to extend the carb in your meals and still get normal bs levels before the next meal.

I would again stress that low carbing is the safest option.

Once you know how to deal with higher carbs at lunch safely you can test this out at other meals.

Once you have learned this method use it wisely. It is for emergency situations and special indulgences. If you use it day in and day out you may indeed have normal bs levels before your meals and at bedtime, but you will be spiking a lot more than any non diabetic will.  It is not only high blood sugars but widely fluctuating blood sugars that are causes of complications.

Quick Quiz:
There is no quiz for this section.

Where to Next?
Please continue on to the How To: Time Insulin Injections for Simple Insulin Regimes section.

Reference Info:

NOTE: the calculator is no longer available, but the methodology below may be of interest for those interested in creating their own app or tool (e.g. spreadsheet).

The insulin calculator in the download section of this site is a great help AFTER you have done your personal experiments and calculations.

It is a simple programme with three background tables that can be adjusted by you if your insulin sensitivities change.

The first factor which you adjust for are your insulin sensitivity at breakfast, lunch, dinner and bedtime. This has been covered on a previous module on the course.

The second factor which you adjust for is the carb weighting factor. This module shows you how to do this.

The third factor which you adjust for is your correction bolus for certain high blood sugars. For simplicitity I recommend that this is only done before meals. The module on how to deal with high blood sugars further on in the course covers this aspect.

The insulin calculator is useless and even dangerous if you rely on it for your insulin doses without having done the necessary background study, experiments and personal calculations.

What it does do however is make it unnecessary to do the same calculations every time you are about to eat a meal. Once up and running you only need to change it if any of the three factors need adjusted. The one most frequently changed is the carb sensitivity factors which can vary according to monthly cycles in women and seasonally im most other type ones.

Steven has a portable version on a palm top and we are hoping to put a downloadable version on this site very soon.

How To: Cover a Strict Low Carb, Moderate Low Carb, and High Carb Diet with Insulin

This section is for everyone.


Dr  Richard Bernstein, Dr Annika Dalquhist’s, and  Dr Atkins diet have been described in previous sections. They can all take you to the strict low carbing end of things amounting to about 30-42g a day of carbohydrate.
I have chosen this level of carb for your meals to differentiate a strict low carb diet from a typical low carb diet. All of these diets in this strict  range  will give you the possibility of entirely normal blood sugars.

Dr Bernstein’s diet is more specific about what sorts of macronutrients you eat and in what amounts. For simplicity of eating and insulin regime combined with effectiveness it is my opinion that this is the “Gold Standard.”

If you are eating faster digesting carbs even within the  12g total carb limit you would need to experiment to see if a single insulin type covers your meals to entirely normal blood sugar standards or not.  The levels you may be aiming for have been described previously. If you get what you want this is perfect and if you don’t you may wish to try the specific insulin regime for the typical section which follows.

Dr Bernstein recommends using regular insulin to cover meals. These are of no more than 12g of non starchy vegetables three times a day with 6g allowed for breakfast because of the effect the dawn phenomenon has on insulin resistance at this time of day.

The regular insulin is best injected 45 minutes before eating. Because you are having such small amounts of carb and therefore insulin at each meal you don’t really need a separate insulin for the carb and protein. Just a little more regular  such as actrapid to cover your protein.  The usual formula for most people is 2 units regular insulin to cover 3oz lean protein or meat the size of a deck of cards.

The protein amount and consistency depends on your goals concerning weight gain or loss.  For people with delayed gastric emptying they may be on quite small portions of protein at their evening meal such as 2oz.  With guess and test you will quickly learn what works best for you.

Rapid acting insulin analogues are used for correction doses.


I have chosen Dr Jovanovich’s carbohydrate limits as the border between what could still be considered low carb and what is out with that range.  Dr Atkins and Drs Allen and Lutz diet’s have been described previously and fall in this range.  If you are  on another diet such as Protein Power, South Beach or Barry Groves “Eat fat and Stay Slim” diet you are in this range.

Once you get to higher carbohydrate levels of 13-30 g a meal of carb you increasingly need a bit more oomph with your insulin to deal with more rapidly rising  blood sugar levels.  At the same time protein continues to digest slowly so you need techniques to deal with that.

The most accurate technique that I know of was perfected by Dave (Iceman) from Alaska.  Sadly he died of cardiovascular complications of his longstanding diabetes. For all our benefits he passed his method throught the Bernie forum onto Adam (Adam DMer) who graciously passed it onto me. It is a beautifully simple technique that can also be used at lower and higher carb levels than I am describing in this section if desired.

Use rapid acting analogues to cover carb. This can be done according to your individual carb sensitivity for that time of day.

Use regular insulin to cover protein. This is to the tune of 2 units of regular insulin for each portion of lean protein which is a deck of card in size.

Both are optimally injected 15 minutes before eating.


The higher carb your meals the harder it is to get perfect  or even acceptable blood sugar control.  You can usually get an improvement from what you have been getting however,from the techniques I will be describing.

Although I much prefer to eat a typical low carb diet myself I was aware that my son Steven did miss the occasional treat. What was more important was that the meals provided at school emphasised high carb /low fat dishes in keeping with the ubiquitous “healthy eating” guidelines. The odd high sugar due to either of these reasons didn’t bother us at first because it was so infrequent.

For almost 18 months from diagnosis Steven did excellently on a typical low carb diet and twice daily mixtard combinations. Due to his lower carb diet and lengthy honeymoon his hbaic was 4.8.

Then his growth spurt and reduction in endogenous insulin became obvious. We continued mixtard but started on novorapid for lunch coverage in a half unit increment pen.

After 4 months on this we started an intensive insulin regime on levemir and novorapid.  By this time he was growing faster than our high fat/mod/protein/ low carb diet could sustain and his bmi was just under 16.  This is the bmi of eg Liz Hurley the actress who is indeed slim.

The dietician and diabetologist started threatening me. “Feed your kid a high carb/low fat diet and he will fatten up. Or else.” Presumably child protection procedures.

They did have a point.  Indeed I had never seen a skinny diabetic  on a high carb/ low fat diet.  It did seem to work like magic to fatten people up.

The problem was that Steven was just not hungry.  Effectively reducing hunger is  a major reason for the success of low carb diets in weight loss . But it is a disadvantage if you are hitting adolescent growth spurts.

I increased the carb in his diet knowing that he needed to have more carb for weight gain but also knowing that this would play havoc with his beautiful blood sugar pattern.

I decided to go for it and fatten him up like a goose destined for pate de fois gras. “Have what you like Steven. We have to learn how to control whatever effect it has on your bloods sugars. You could eat a bit more bread and potatoes than that couldn’t you? Please.”

I started this intensive fattening regime while on holiday abroad when we had almost unrestricted access to foods of all types and while I could monitor his sugars day and night.

To start with it seemed quite fun to Steven. “You mean I can eat a whopper with fries?”

“You certainly can. You must.”

Soon the wildly fluctuating blood sugars and blurred vision got us both down. “Please mum. Can’t I go back to low carbing? ”

“Please, Steven. Just keep going with this a bit longer. I am getting nearer and nearer to perfecting the carb weighting figures.”

We had a three month period of hellish sugars.  We did loads of blood sugar measurements including most nights between 2-4 am.  I could hardly sleep with anxiety.

This is what your average mother with an average kid with type one diabetes goes through all the time. It was bloody awful. I had no idea how bloody awful till I did it myself.

Fortunately I had some ideas about why Dr Bernstein strongly advised limiting carbs. The reason is to stop any spikes after meals that normal people don’t have.

And why does Dr Jovanovich limit a meal to 30g of carb? The reason I figured out is that linear doses of insulin based on reliable carb insulin sensitivities become increasingly unreliable above this level.

The more carb you eat the higher your blood sugar goes.

The higher your blood sugar goes the more insulin resistant you become.

The more insulin resistant you become the more insulin you need.

There is no longer a linear relationship between carb and insulin dosage after 30g.

There is an exponential curve.

Figuring out the sweep of that curve will vary from person to person.

To do this you MUST do extensive self experimentation.

Your carb counting skills must be well developed.

You must increase your carb counts above 30g in a progressive way.

You must keep meticulous records.

Give yourself a break every so often.  It is best only to do these experiments when you have help around and you are able to monitor day and night.

Unless you absolutely have to, you are much, much better off on a typical and preferably strict low carb regime. Low carbing is extremely efficient at curbing your appetite. This is a major benefit for most diabetics but I can see where it can be a problem for skinny toddlers and teenagers. If you need to resume a higher carb diet I hope our experiences and learning of techniques can help you through this process.

I know that for many diabetics the hectic blood sugar patterns that they simply accept as the package deal that comes with diabetes is actually due to the high carb diet.

I found the high carbing process extremely traumatic.  Steven was unhappy. I was unhappy. Yet, no matter how much fat I added to his diet I could not fatten him up. He is not as much as a carnivore as me and carb seemed the only answer. The high carb diet has worked and now Steven has a healthy bmi at 18. Teenagers have lower bmis than adults but your dietician won’t know this. They don’t know a lot about a lot of things you no doubt are finding out.

Quick Quiz:
There is no quiz for this section.

Reference Info:
Acknowledgements to Dr Bernstein, Dave (Iceman) and Adam (AdamDMer) from the Bernstein Forum and my son Steven.

Where to Next?
Please continue onto the How To: Do Dr. Morrison's Carb Weighting System section.

How To: Turn My Pen Into Pump

This section is for everyone.  If you are managing successfully on your pump you may skip this section and proceed to the How To: Cover a Strict Low Carb, Moderate Low Carb, and High Carb Diet with Insulin section.

Well, of course, you can’t really change your pen into a pump. But what you can do is look at why pumpers often get better meal coverage than the injectors.

Pumpers can do several things with their pumps to get better meal coverage.

They can pump in several units at once – an immediate bolus.
They can give the dose over a few hours – an extended bolus.
They can programme the pump to give two smaller boluses within a short time of each other – dual wave bolus.

Fortunately you can get the same results with your  pens and vials.

Pumpers are told that to avoid a lump of insulin under the skin they need to pump  5 units or less at an immediate bolus whether for correction doses or for covering meals.  They may go on to cover the meal with a dual wave or extended bolus if they need more insulin than this for that meal.

The absence of the lump of insulin under the skin makes its absorption much more predictable. Did you know that 70 units of insulin injected under the skin takes a week to fully absorb?

Dr Bernstein has found that 7 units injected at once is the  absolute highest amount of insulin per shot that will ensure accurate enough absorption of that insulin.  Otherwise the insulin you think is going to cover that meal won’t work as well as you expect and it is likely to release when you don’t really want it to.

Now the 7  units per shot tip is something that often fills newcomers with dread. They say things like, “You mean I’ll need four jags to cover one meal!  You have got to be kidding!”

Why is this? It’s not just because they can’t divide by 7. It’s not just because they object to the slightly increased time the injection procedure will take. It’s because up until now they have been having injections that are really quite unpleasant and often painful. They also worry about the lipoatrophy at their injection sites. Does this mean more of these?

The answer is no. Not only do the smaller amounts give you an insulin that “does what it says on the tin”.  They give you a lot less discomfort per shot and virtually no lipoatrophy at all.

You will have noticed  that I almost expect that you will be eating a high carb/low fat diet right now. Let’s face it, you are only doing what you have been told to do by your doctors and dieticians. As you get further into the low carb way of eating you will find that you need less and less insulin to cover your meals. And that means many fewer injections as time goes on.

When someone goes from a multiple daily injection regime to a pump they need to cut down on the total daily amount of insulin they go on with the pump.  This is usually a decrease of 20%.  This is because the slow leakage of insulin under the skin is more efficient at getting the insulin into the body. Its not just sitting in a big lump doing nothing any more.

The 7 unit per shot system is not quite as efficient as a pump but gets you results that can be pretty close. I therefore recommend that you also reduce your bolus amounts by 15% to start with.  You do this for your current basals as well as for your current meal boluses. This would not apply if you inject 7 units or less at that time normally of course.

Dual wave bolusing can be done by two or more injections to cover a meal of the more slowly digesting type such as meaty dishes, pizza,  and pasta with creamy sauces. You simply need to remember to give the second or third jag at the time you planned.

Fortunately there are different durations of insulins that can be used that can give you the same effect as an extended bolus.

Most  insulin users have been put on rapid acting analogues for meals.  Novorapid and Humalog. These peak at about 70 minutes and last about 3 and a half hours with a tail to about 5. What the usual blurb  says is that they cover “most meals” and so this is all you need.

Before analogues were invented however the older regular insulins were used to cover meals. These peak at about 2 and a half hours and last 5 hours with a tail to about 8 hours. What the usual blurb says is that these take longer to work and are less convenient than analogues to cover meals.

These characteristics are however just what you want to cover higher protein, higher fat, and more low glycaemic carbs. Its rather wonderful in fact.

When you give these regular insulins on their own to cover carb you need to remember two things. Firstly they do take longer to work so you need to inject them optimally 45 minutes before eating that carb.  30 minutes will do but is not optimal.  The second thing to remember is that these are less potent insulins and you need to give a third more of them than with analogues for the same amount of carb. Actrapid would cover 8g of carb compared to  one unit of humalog that would cover 12g.

When you use these insulins to cover protein and more slowly digesting meals the fact that they take longer to start working becomes an advantage and you can get on with injections optimally 15 minutes before a meal.  Just before you eat will often do.

Quick Quiz:
1.The same amount of insulin to cover the same high carb meal at the same time of day can have a varied effect on your blood sugars by:
a 5%
b 15%
c 30%
d 90%

2.Insulin effect predictability can be improved by one of these…
a Keeping injections to 7 units or less.
b Having regular snacks.
c Having a low fat/high carbohydrate diet.
d Taking plenty of aerobic exercise.

Have you got it?
1. C is correct. The Joslin Institute have put it as high as 30-50%.
2. A is correct. The other options are likely to make blood sugar control more difficult.

Reference Info:

Where to Next?
Please now continue to the How To: Cover a Strict Low Carb, Moderate Low Carb, and High Carb Diet with Insulin section.

How To: Know How Different Insulin Regimes Compare

This section is for everyone.

Basal insulin holds the blood sugar steady between meals and during sleep. A bolus is a dose of fast acting insulin given to cover meals or to reduce a high blood sugar.

Here are some popular ways of using these insulins.

Two mixed doses

Eg Novomix or Mixtard.  The basal and bolus insulin is premixed in a fixed combination so that only two injections are needed in a day.

A high level of consistency is needed for meals and snacks. What is eaten and when it is eaten can be manipulated to give good results. The difficulty is that there is very little flexibility and you can’t just miss meals or eat more than usual and get away with it.

If your blood sugars are running high with this regime the main technique to get back in track is to give the injection and wait till the blood sugar has dropped before eating. Lows can also occur and you need to develop snacking routines to even these out.

This regime is often used for people who need help with their injections or who want to avoid injections such as younger school children and in the elderly or visually impaired.

Where money is an issue mixtard is cheaper than then newer analogue insulins.

The best coverage with this insulin is at breakfast and the evening meal. The injections are usually given 15-45 minutes before these meals depending on the type of fast acting insulin used.  A lower carb meal can be eaten for lunch to help keep sugars normal. Alternatively a separate injection of regular or a rapid acting analogue can be given before lunch.

Morning mixed with evening split

Eg Mixtard am, Actrapid pm and Lente bedtime.

This regime covers the dawn phenomenon quite well because of the duration of the lente insulin. The mixed insulin in the morning means that injections during the school day can be avoided.

The minus points are a tendency for lows before lunch and high blood sugars after lunch.

This regime is not used frequently but it can suit some people very well. I know of a teenage girl who has a degree of intellectual impairment.  She has  a considerable dawn phenomenon.  She uses this regime to avoid having to give insulin injections while she is at school.

Multiple daily injections with long acting basal

Eg Humalog for meals and snacks with Lantus once or twice a day.

This regime gives much more flexibility for meals than mixed insulin regimes.

The disadvantages are the number of injections. There can be 4-10 a day.  Insulin pens are generally easier to carry but are more expensive than vials and syringes. The insuflon device can be useful for babies or toddlers on a MDI regime as the insulin is put in the same channel for a day or two so can be less uncomfortable.

This regime is the most popular for most older children and adults. In the USA all children are started on an intensive regime from diagnosis. In Europe there is more tendency to use a mixed regime at least to start with.

When it comes to advanced insulin techniques this is the method that I will mainly be discussing.

Insulin Pump Therapy

This is also known as a continuous subcutaneous insulin infusion system or CSII. It has been developed in the US and is much more popular there  than in the UK.

Plus points are that finer tuning with insulin is possible with this technique particularly due to the ability to alter basal rates.  Most people need to change the insertion device every 1-3 days.  Once this is done there are a greater variety of bolus patterns you can use without having to have another injection.  Many users love their pumps and greatly prefer it to the MDIs especially once over the first few months.

Disadvantages are that it is comparatively expensive. It costs about  £5000 for a pump for five years use with an additional £1000 a year for sterile consumable supplies. You still need to have pens or vials and syringes handy  in case of pump failure.  It is available in some UK centres but the cost is not borne by the NHS and must be paid for in person or from a charity.  A great deal of learning and monitoring is required to use this method successfully.

There are also problems that can occur on the short and long terms. Pump failure through the night can result in you going to bed with normal blood sugars and waking up in diabeticketoacidosis.  Long term scarring at the infusion sites and the occasional abcess can also be problems that result in users going back to MDIs.

Quick Quiz:
There is no quiz for this section.

Reference Info:
Acknowledgements to Dr Gary Scheiner’s Think Like a Pancreas.

Where to Next?
Please all continue to the How To: Calculate My Insulin Sensitivity section.