This section is for everyone.
The Joslin Diabetes Centre have a check list so you can see what sort of things you need to know to look after yourself with diabetes. This list covers type one and type two diabetes. For each heading I will list what we have already covered on this course and what we will be covering in more depth in the Type One Section *
There is a considerable overlap between both types of diabetes. To start with most people with insulin dependent diabetes diagnosed in childhood or young adulthood are not overweight or insulin resistant. As time goes on this may change so Type Ones would benefit from reading the earlier sections to see if any of it applies to them. The majority of the carb counting methods have also already been covered in the Metabolic and Type 2 section.
For type twos who start off on diet or oral medications they may find that after a while this is no longer sufficient to maintain normal blood sugars. You may benefit by reading on to find out how to deal with insulin now or in the future.
If you don’t feel really confident about any of the things I have listed please take advantage of some of the books and internet resources in the help sections. It is important that you know what to do ahead of any emergency developing so please contact your diabetes support team for further personal training.
Your own meal plan
know how carbs, proteins* and fats affect the body
special foods and occasions
how to fit in treats*
blood glucose goals
how to use the meter
interpreting blood glucose values and making decisions in diabetes treatment plan*
Action and side effects of medication*
timing and schedule*
insulin injection techniques*
storage, refrigeration and disposal of supplies*
what to do if you miss a dose*
What type, how long, how hard, how often and when.*
preventing high and low blood sugars*
Factors that cause high and low blood glucose*
how to treat*
when to call a healthcare provider*
how to prevent*
daily foot care*
emergency treatment for cuts, sores and abrasions.
how to do a proper foot exam*
When and how to check for ketones*
What ketones mean*
When to call a doctor*
A1C ( 2-4 times a year)*
cholesterol, ldl, hdl, triglycerides*
general health check eg thyroid, tests for coeliac disease and anything relevant to you*
Your own meal plan
The medication you are taking
Your glucose monitoring system
The treatment of high and low blood sugars
How to manage your sick days
Your risk factors for developing other health problems
Your foot care
1. A test type twos should have done every six months is…
a Liver function and creatine kinase.
c Fasting lipids.
d Sex hormone binding globulin.
Have you got it?
1. You must have your hbaic checked every 3-6 months. If statins are being taken, fasting blood lipids, liver and creatine kinase levels may be taken episodically.
Where to Next?
Please all proceed to the How To: Safely Dispose of Needles and Other Sharps section.
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.
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.
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?
Part of Dr.Katharine Morrison’s “How To” series as posted in this forum post (requires registration).
The best way to find out the best basal for you is usually to look at the 3am bs. Do this several times but don’t look at the averages, look at the lowest number you are getting. The aim is to give you normal night sugars but not hypoglycaemia.
If your lowest bs at 3am is 5.0 your basal is right for you.
If your lowest am bs is less than 5.0 you are having too much basal.
If your lowest 3am is less than 5.0 you are also having too much basal.
If your average am bs over at least 3 but preferably 10-14 is higher than 5.0 with good 3am bs you are having the dawn phenomenon. If you gave a higher basal to get this down you would be giving yourself a high risk of night time lows.
If your lowest 3am is higher than 5.0 you can try a slight increase in basal.
Make changes in insulin doseage in the smallest increments your pen allows. Vial and syringes do give more flexibility. Diluted insulin can also make incremental changes more precise and is particularly helpful for young children and babies who are on low amounts of insulin.
When you have made a change in basal insulin sit it out for about 3 days before you adjust again. This is the time it can take for this to stabilise.
This section is for everyone. For the purposes of this module I am going to assume that you are currently on a high carb/ low fat diet, that you are on a basal bolus regime with a long acting insulin and a rapid acting insulin analogue. This could be in vial and syringe or pen form.
The total time that you can expect to take from going from where you are to normal blood sugars is about 3 months if you follow this programme. This can be considerably shortened if you already have a high degree of background knowledge and do not encounter any particular problems with your carb reduction and insulin adjustments.
This step can be expected to take 4 weeks if you allow 30 – 60 minutes a day.
Before you are ready to reduce your carbohydrate and therefore insulin it is best to do the modules appropriate for you and have a buddy to help you. Help from your diabetes team is most helpful but they may not have the time to help you or may not be happy with carbohydrate reduction. If you haven’t already joined an internet support group this could be the time to do it.
You should already have:
Reviewed thoroughly the modules:
You now know a great deal about your diabetes: the sort of insulin regime you are on, basal insulins, meal insulins, correction doses, carb sensitivity at different times of the day, how much insulin you need for most commonly eaten meals, and how much carbohydrate you are consuming for meals and snacks and the effect that exercise has on your blood sugars. You also will have an idea of what you are aiming to eat in the future compared to what you are doing now.
You may need to obtain extra testing stix, glucograph sheets, regular insulin and syringes/needles or pens. If you are already using a pen a half unit one is best. You will need one for each type of insulin you are on. Unfortunately the Autopen Classic which is used with Hypurin Pork (regular) insulin only comes in one unit pens.
This step can be expected to take about a week. If you don’t have any hypos you won’t need to do this but you are likely to need to know about it once your insulin regime gets better control of your blood sugars.
Are you having regular hypos? If so what time of day or night?
You need to cut back gradually on your insulin that governs that time of day.
Night hypos – reduce basal.
Morning hypos – reduce breakfast insulin
Afternoon hypos – reduce lunch insulin
Evening hypos – reduce lunch insulin
In order to get the best match between insulin and food the insulin needs to be delivered in a predictable way. The key to this is the 7 units per shot rule.
Write down how much basal you take in 24 hours.
If you are only on one injection of basal a day you can improve 24 hour coverage by changing to an injection on rising and an injection before bed. The gap between the night insulin is best to be 9 hours or less but up to a 12 hour gap may be fine if you don’t have a pronounced dawn phenomenon. The aim is to stop over dosage of basal which at some points during the day may make you need to eat to stop from going low. We also need to keep the basal high enough at other times of the day so you are not overdoing meal insulin to cover gaps that can arise in the evening if you are only on a single night dose of eg Lantus or Detemir.
How much insulin will you need at each injection when you go to twice daily basal injections?
If this is over 7 units per shot you may need to reduce your basal slightly. You will be checking your 3 am blood sugar in this phase to check how accurate your basals are. If your basal insulin is currently over a 24 hour total of 14 units you need to reduce the total insulin injected by 15%.
Example: Mary is on Detemir 34 units once before bed.
This is going to need a reduction of 15% to start with. This leaves 29 units over 24 hours.
Divide this by two to find out the amount this will be when split into two injections:
14.5 units each.
The total number of injections to cover basal will therefore be expected to be 7u x 2 separate injections both night and morning. This does leave a deficit of 0.5 units but as this is quite a small amount it would be okay to see how this regime goes. If this regime is tried for three nights and the 2-4 am blood sugar is 4.4-5.6 this would be satisfactory. If the readings were higher the additional half units or progressively more insulin could slowly be added. It is best not to change basals more than every 3 days as it takes a while for insulin levels to balance out. If hypos occur through the night and you are certain it is not the effect of two much meal insulin beforehand you would need to reduce the amount of insulin given at your basal injections eg to 6 units x 2 morning and night and gradually adjust upwards for fine control.
Within one to two weeks I would expect your basals to be much more stable. You are now ready to proceed to sorting out your meal insulins.
The first step to sorting your meal insulins is to know what effect the insulin you gave yourself for the last meal actually had. You have little chance of getting this right till you stop snacking.
If you have a hypo and usually snack you need to change what you do when you have a hypo. The best thing is to have a small quantity of pure glucose in liquid or gel form and be careful not to overtreat. Over correction of hypos is hard to prevent if less than very rapidly acting carb is taken as it acts too slowly to get you feeling better fast enough.
If you have a hypo due to exercise and this is a regular thing the best way of dealing with it is to have the snack – which could in this instance be a food item – before or during the particular exercise. Getting this right can take some practice. This is fine for regular activities eg twice weekly supermarket shop, a weekly game of tennis. If the exercise is not a regular thing can you put it off till you have finished this run in phase? It will only take a few weeks.
Hunger and a need for snacks can also be due to basal insulin being too high. Is this well under control now?
You now have got the hang of the 7 shot rule, no snacking and have sorted out your basals and hypos.
Breakfast is usually eaten at home. It is beneficial to eat a high protein meal to reduce the tendency to snack from hunger late on. The lower amounts of carb usually eaten at this meal to help deal with the dawn phenomenon. For the purposes of all your meal experiments in this second month however we are going to aim for the following plan meanwhile.
Plan out the minimum amount of protein you need for the day. This is your ideal body weight in kilograms divided by six. Eat no less than one third of this in ounces of lean protein for breakfast. Do the same for lunch and dinner.
Lets assume you are a bit overweight but ideally are 60kg. You would be looking at 10oz of protein a day and would want to eat at least 4oz of protein at breakfast.
E.g. three egg omelette with some ham chopped into it.
It is amazing how filling this sort of breakfast is compared to a high carb one.
For carbohydrates you will already know the approximate carb count for what you eat.
Glass of milk 15g
2 slices of toast 40g
Breakfast cereal 40g
The total is 130g.
To start with reduce your carbohydrate by half of what you are on or to 30g whatever is the highest.
What of these foods could you do without?
Work it out.
Say you go for 65 g and go for the breakfast cereal, milk and a half slice of toast with butter instead of marmalade.
Give yourself the insulin you would normally give in proportion to the carb you intend to eat.
Eg If you normally give 13 units for the 130g breakfast give yourself 6.5 units for the 65 g breakfast.
If the insulin injection is more than 7 units then you need to split the insulin into more than one shot.
You may need to have obtained regular insulin in syringe and vial or pen form. In the UK pen regular insulin is only available in pork or beef versions from Wokhardt Pharmaceuticals. This is able to be imported to other countries however.
Use 2 units of regular insulin for each 3oz portion of lean protein you are eating. This is a starting dose to use till you start to profile your meals and fine tune them with different proportions of different insulins. Ideally inject this 15 minutes before eating. Alternatively you can use a small amount eg 1- 1.5 units of rapid acting insulin to cover protein but inject this 1.5 – 2 hours after eating.
The next step is to cut back your breakfast carbs to 30g or less. Again adjust your insulin accordingly. At this stage you are aiming to have your blood sugar before your next meal within your target range. It is unlikely that you won’t spike at one or two hours on this amount of carb without running low before your next meal. The goal however at this stage is simply to work your way down gradually and particularly to avoid hypos.
Follow the same steps for your breakfast.
Your insulin sensitivity is likely to be best at this time of day. You may well be able to cut insulin doses somewhat.
Follow the same steps as your previous meals. Your insulin sensitivity will be a bit lower than at lunch but usually not quite as high as at breakfast.
Follow the same steps as your previous meals. If you don’t usually have a bedtime snack you don’t need to have one just for the sake of it.
Your final level for this phase is a bedtime snack of 15g or less.
You should now be on three meals a day of 30g carb and an optional bedtime snack of 15g maximum of carb. You may also be having some extra carb to cover planned daily exercise. Your insulin doses should be much less than usual and your predictability should be much improved. You may have had hypos in this reduction phase and you should have been adjusting your insulin doses downwards to sort this out. The main blood sugars that are of most concern right now are the fasting, pre-meal and 3am blood sugars that you can expect to be around target by now.
How low in total carbs would you be happy to go for each meal?
Can you reduce higher glycaemic carbs that you may have been eating?
Can you substitute lower glycaemic options eg avocados at breakfast instead of bananas?
The optimal is 6g for breakfast and 12g of carb for each other meal. This is based on Dr Bernsteins work which aims to give no blood sugar spikes at all and highly consistent blood sugars 24 hours a day.
It is perfectly acceptable to have higher amounts than this. The important thing is that you reckon you can be consistent about what you are going to do.
You know how much protein is considered a minimum for you and you’ve been eating this for a few weeks. Is this completely satisfying for you?
If you are hungry before your next meal is due perhaps you could do with more? Some of us need a lot more!
Alternatively you may have delayed stomach emptying and need to reduce your dinner portion of protein?
You will now have good experience of varying your regular insulin to your protein at various times of day and you can adapt what you have found out to sorting out the right dose for the protein you prefer to consume.
The good news for variations in your fat intake is that you don’t need insulin to cover fat.
How is your weight doing?
Have you lost weight on this regime? Have you gained?
You need to adjust your fat intake to reflect the calorie balance you want to have. This is easier than previous adjustments. Eat enough fat to make your meals enjoyable as a reasonable minimum and up the fat as needed to keep your weight at a level that is ideal for you.
Now you are eating your ideal or near ideal diet regarding carb/ protein and fat proportions it is time to again fine tune your insulin.
For each actual meal that you are going to profile you need to:
Eat the same food in the same proportions each time at around the same temperature and the same time of day. Eat it at around the same speed.
Weigh or measure your portions. You may as well have the portion size you really want to eat.
You need to have a blood sugar in your target range, you need to avoid unusual exercise and you need to be well ie not coming down with a cold or have a gum infection for instance.
Take the insulin you think you should take at the time you should take it and then eat the meal when you plan to. Check the bs every half hour – one hour after finishing the meal until the next meal is due.
You can see several patterns.
No hypos till next meal. Well done. You have not overdone the insulin.
Hypo in the first two hours after eating. You need to reduce the rapid acting insulin for that meal.
Hypo in the 2.5- 5 hour mark after the meal. You need to reduced the regular acting insulin for that meal.
Spikes in the first 2 hours after the meal. You need to increase the time interval between giving the rapid acting insulin and eating OR you need to up the dose.
Spikes in the 2.5 – 5 hours after the meal. You need to increase the regular insulin for the protein or carbohydrate component of the meal.
Hypos in the early post meal period and spikes in the later post meal period may indicate that the meal is best covered by a higher proportion of regular insulin than rapid acting insulin. This is common for high fat meals as carbohydrate absorption is delayed. This phenomenon is called the “Pizza Effect”. It is discussed more in the insulin calculator section which follows.
Once you have hit the right dose for that meal put a note of it in your favourites list. You can add this to your insulin calculator should you choose to use this.
You are now almost at the end of the course. The next three sections are all about making life a bit easier for you.
What do you really miss, or know that you would like to eat sometimes?
Have a good look at the carb cooking and baking modules again. This is the time for you to experiment with something you haven’t tried so far. If you can find a good substitute and you won’t miss that item eg cauliflower mash instead of mashed potatoes or low carb muffins/ cheesecake you simply have to organise yourself to have a regular cooking/ baking day and prepare packed lunches for when you need them.
If there is an item that you think you must have eg pizza, a burger bun or so forth you need to review the carb weighting technique section again. To do your experiments on this it is best to do these at lunch time and when you have company to help if you over do the insulin and have a hypo.
There are two versions of the insulin calculator available. One is for downloading onto your pc and the other is a more sophisticated programme for a palm top which has the advantage of greater portability.
The insulin calculators have background tables that you programme yourself. What you are doing is putting in your particular information into several of these background tables. When you are using the calculator you will usually be putting in the carb values of the food you intend to eat, the particular meal involved and your current blood sugar. The machine calculates the amount of insulin you need to take. As there are differences between the calculators I will explain them separately. For using either of them is essential that you have done all your experiments to find out the correction factors, carb sensitivities and weightings that work for YOU. It also helps to understand more about the “Pizza Effect” so that you can adjust the proportion of rapid acting and regular insulin for the type of meal you are having.
The Pizza Effect is the pattern of blood sugars you get when you use the correct carb sensitivity for the total carb content of the food but don’t take into consideration the effects of delayed glucose absorption when high amounts of fat or protein are also in the meal. It isn’t just pizza that can do this !
If you use a single injection of rapid acting insulin to cover these types of meal you will end up with low blood sugars soon after eating the meal and a delayed rise in blood sugars after the meal. To counteract this you need to be prepared to allocate some of your total insulin dose to regular insulin taken at the same time as your pre-meal insulin or another separate injection of rapid acting insulin some time after eating the meal. A pragmatic way of doing this is to allocate 50% of the carb allowance to rapid acting insulin and 50% to regular insulin. You then can see what results you get and vary the doses for that meal in the future accordingly. Some meals eg toast and jam are likely to need all rapid insulin. Others eg thin crust pepperoni pizza or a meaty lasagne are likely to need all regular insulin. Mixed meals like fish and chips could well be a 50: 50 split between the types.
There are a few things to remember:
Say your carb content of the meal is 30g and you wish to give half of this to rapid insulin and half to regular insulin. Your sensitivity happens to be one unit of rapid for each 15g of carb. You would therefore need to give one unit of rapid acting insulin and 1.5 units of regular insulin.
This is the basic programme. The background tables are needed for your:
Insulin sensitivity for breakfast, lunch, dinner and bedtime snack.
Carb weighting values.
When you use the programme you will enter:
Current blood sugar.
Breakfast, lunch, dinner or bedtime snack.
Total carb count of the meal.
You will receive an insulin dose based on any correction dose needed, carb sensitivity you have registered for that particular meal and any additional carb needed for carb weighting factors. This will be the total rapid acting insulin dose equivalent.
You then need to:
Consider how much of the total dose may need to be split between rapid and regular insulin if this applies to the type of meal you are having.
Calculate the conversion factor ( 1.5 ) to change rapid to regular insulin.
Visually estimate your protein amount in the meal and add this to the amount of regular you are going to inject. The sum is approximately 2 units of regular for each 3oz size of lean protein. This is the size of a pack of cards.
You should then have the total amounts of rapid and regular insulin you are likely to need. You need to profile each meal. Are you happy with the results? Feel free to adjust your insulin for that meal. From time to time you may also need to adjust the background tables. Remember the maximum your are going to inject is 7 units per shot.
This programme has some extra features that are not available on the pc version.
The same background tables are filled in for correction doses, insulin sensitivities for different meals and carb weighting values.
When you use the programme you enter the same data regarding blood sugar, time of meal and total carb count of the meal.
These features are all exactly the same as the pc version.
The difference with this calculator is that additionally you have another programme in which you can:
Things to be aware of:
The palm version offers the advantage of portability, a favourites list and calculates the protein insulin for you. It is a bit more complex to use and programming the protein is not quite as straightforward as programming the carbs. It can be helpful to use to get specific meals sorted out. I would recommend that for most meals you start with a 50:50 rapid: regular split to avoid the worst of the “Pizza Effect” and adjust according to your results from there.
Neither insulin calculator is a necessary feature of good meal profiling and manual collection of information is just as good. What they do is make the sums that you would be doing as a matter of course for new meals easier. This particularly applies to larger meals and processed ready meals that contain nutritional information.
Where to Next:
We have now completed one of the toughest parts of this course. Well done. Congratulations to our helpers too.
To complete our journey I would like to read you a little story. There is no quiz in the next section.
Please all continue to the Endings and New Beginnings page.
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.
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.
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:
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: www.iddtinternational.org
Enquiries can be sent by e mail to: firstname.lastname@example.org
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.
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
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.
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:
For people who are on or prefer to use a single injection of a RAAs:
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.
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.
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!
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.
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.
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.
There is no quiz for this section.
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.
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.
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:
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.
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.
This section is for everyone.
Insulin sensitivity may not change much at all throughout the day in pre-pubertal children. After this most people find that they need more or less insulin at different times of the day.
To find out how much insulin you will need to take to cover carbohydrates taken at different meals you will need to find out your carb to insulin ratio.
An average insulin:carb ratio for type ones who are thin is one unit of novorapid or humalog for 12 g of carbohydrate. As regular insulin is a third less potent one unit of actrapid for instance covers 8g of carbohydrate.
If you eat the same amount of carbohydrate for breakfast, lunch, dinner and bedtime snack with the same dose of insulin you will find that sometimes it works better than at other times.
Most adolescents and adults need more insulin to cover the same amount of carb at breakfast than at lunch because the dawn phenomenon makes them more insulin resistant for a few hours, often up till 11am in the morning.
Most people have the best insulin sensitivity in the early afternoon eg 2-4pm.
Some people get a “dusk” phenomenon and become a bit more insulin resistant at dinner time.
My son Steven’s insulin to carb ratio is 9 at breakfast, 14 at lunch and 10 at dinner. Because I particularly want to avoid night time hypoglycaemia I give him only 2/3 of the amount of dinner insulin to cover a bedtime snack. The figures are therefore 9-14-10-14.
You have to guess and test to work your own figures out.
If you are writing down your blood sugar figures in a book or chart add and take the averages of your bs on pre-lunch, pre-dinner and pre-bed for at least 3 and preferably 10-14 days.
If you have averages that are above your personal target figure or 5.0 for those who are seeking optimal control you need to have more insulin to cover your breakfast, lunch and dinner respectively.
Accurate basal insulin levels and carb counting skills are essential to do this accurately. If your sugars are running particularly high for any reason eg you have a dental infection or the flu or your exercise pattern has changed over the test period your figures will not be correct for you.
1. Insulin sensitivity….
a Varies according to a person’s individual daily and monthly patterns.
b Worsens with the duration of type one diabetes.
c Is the same for a given amount of carbohydrate for any given person.
d Is irrelevant if a diabetic follows a low carb diet.
Have you got it?
1. A is correct. Once the honeymoon is over there is no particular reason for insulin sensitivity to decrease over time although weight gain and change in exercise and hormone patterns can affect insulin sensitivity in their own right.
Where to Next?
Please now continue to How To: Turn My Pen Into Pump section.