How To: Know How Proteins, Fats, and Carbs Affect My Blood Sugar

This section is for everyone.  The information is somewhat more applicable to type one diabetics but type twos need to know some of this as well.



You have read a lot about how carbohydrate affects your blood sugar but what is less known is the effect that protein has on your sugar levels.

About a third of the energy from protein is made into sugar. This process is slower than for carbohydrates and can take 2 or 3 hours or more. Delayed blood sugar rises are likely to happen if your meal has a significant amount of protein in it. By this I mean over 3- 4 oz of lean cooked meat, chicken, fish or 3 eggs.

A ready reckoner is to compare the size of the meat you intend to eat to a  pack of cards.  If you have steak the size of a woman’s hand or a deck of cards this is about 3 – 4 oz.  Chicken to the size of your palm plus the first finger joints or fish the size of a woman’s whole palm is about the same. When you have this amount you must give yourself extra insulin one way or another to cover it or you will go higher than you expect after the meal.

These are the average to small portion sizes such as you would be served in a hospital canteen. Restaurant servings can be a lot bigger. When looking at omlettes, quiches and scrambled egg you need to imagine how many eggs may be in there.  Three or more need extra insulin coverage. One egg is equivalent to about one ounce of protein. Big hamburgers eg quarter pounders are easier to recognise and also need extra insulin coverage.

Immediately delivered insulin which covers high and medium glycaemic carbohydrate dishes is no good for covering the much more slowly digested protein. The extended bolus and split bolus techniques familiar to pump users works well however. Using two or more rapid acting insulin boluses can work well and so can using meal insulins with longer action such as regular insulins.

In the UK actrapid is the regular insulin available.  It can be in pen form only from Wockhardt in the form of soluble pork or beef insulin. This is being exported now to several countries and can be used in the Owen Mumford Autopen Classic.  This pen comes in one unit or two unit increments. Genetically Modified Human Actrapid from Novonordisk is still available in vial and syringe form.  Sadly they discontinued their pen actrapid which could be delivered in half unit increments. Pens tend to be easier to carry and syringes can give more versatility over dosage.  It all comes down to personal preference.

These insulin delivery techniques and much more is discussed in Gary Scheiner’s excellent book, “Think Like a Pancreas”.  Gary was diagnosed as a type one diabetic at the age of 18. He became an exercise physiologist and diabetes educator and is particularly enthusiastic about pump therapy.  His book covers important details regarding insulin use that are not always covered in much depth in diabetic clinics. For anyone on insulin I recommend this book so you can get the best out of your current insulin regime and consider other helpful strategies to optimise control of your blood sugars. This book usually gives several different options regarding problem solving.  It goes into more depth about insulin than Dr Bernstein’s book regarding insulin use and takes a neutral stance on dietary aspects.

Meals that have a high glycaemic index or load will usually need a standard food bolus such as supplied by novorapid/novolog and humalog as the food is quickly converted into sugar in the blood stream.     Examples of these are bread, cereals, potatoes, parsnips, cooked carrots, rice, biscuits, cakes, tropical fruits and sweets.

Meals that have a very low glycaemic index / load may require a method to lengthen out the insulin delivery time just like meat.  Examples of these sorts of foods are pasta, especially with creamy or cheesey sauces like lasagne or spaghetti carbonara. Very high breakfast cereals eg all bran.  Curries made with lots of fat eg kormas. Battered fish and chips. Chocolate, most dairy food and nuts.

A major difficulty with the glycaemic index is that it gives artificial categories of supposed blood sugar rises for a given amounts of carbohydrate containing foods.  One problem is that these tests were done on healthy non diabetics who still have a phase one insulin response. Both type ones and type twos do not have this capacity to immediately release stored insulin. The rate of absorption is also dependent on the temperature of the food, bite size and what it is eaten with and in what order.

To really know what is going on in your body you need to do extensive testing to get the best results for each meal you eat.  This involves testing every 30 minutes or so for three or more hours after each meal  you eat.

You can only test a food accurately if your baseline blood sugar is normal. Even then insulin sensitivity can vary throughout the day. Typically you are quite insulin resistant at breakfast and are at your most insulin sensitive in the afternoon.

Although this sounds a terrible chore most people only eat about 20 different meals on a regular basis and some a lot less.  Please don’t ask me what to do if you are a type one restaurant critic!

To give smooth protein curves it is best to eat some of the protein and fat before you eat the carbohydrates.

If you are having a high glycaemic item leave it till the end of the meal if possible.  Can you add some fat to it?  This will reduce the rate of absorption. Eg fruit and cheese, potatoes with butter and cream, cake and cream.

Lots of fat in the diet improves the taste, fullness after meals, vitamin absorption and slows down carbohydrate induced sugar spikes.

Other Food Tips

If you are going to have a snack consider low glycaemic carbohydrates, protein and fat so you are fuller for longer and sugar spikes are minimised. Eg full fat yoghurt, crackers and peanut butter, toasted cheese with butter on thin sliced wholemeal bread.

In a restaurant you can take your regular insulin once the waiter has taken your order as long as there is bread on the table. You only eat this in an emergency however!

If you take rapid acting insulins take it with the starter if you have a normal blood sugar, your main meal if you are low and when the waiter takes your order if you are high.

Tell the waiter you are diabetic and need food right away if you have been waiting for a time or feel low.

It is best to let toddlers eat and then gave them rapid acting insulin to cover what they actually ate.


Quick Quiz:
1. Three of the following make food digest more slowly. Which one does not?
a A lot of sugar or starch in the meal.
b A lot of fat in the meal.
c A lot of protein in the meal.
d Delayed stomach emptying also called gastroparesis.

Have you got it?
1.A is correct. Protein and fat make meals digest more slowly. Sugar and starch are digested quickly. Gastroparesis is when stomach emptying is delayed or erratic due to nerve damage from chronically high blood sugars. Like foot neuropathy it can develop after around five years of having poorly controlled blood sugars.

Acknowledgements & Reference Info:

Where to Next?
Please continue to the How To: Know What Oral Medications I May Be Offered for Diabetes section.

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

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.

 

THE FIRST MONTH

STEP ONE: KNOW YOUR STUFF ABOUT DIABETES, INSULIN AND DIET

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:

  • Read and understood all the course modules that have been selected for insulin users.

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.

 

THE SECOND MONTH

WEEK ONE

STEP TWO: SORT OUT ANY HYPOS

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

 

STEP THREE: GET YOUR INSULIN ACTING PREDICTABLY

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.

BASAL

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.

STEP FOUR: STOP SNACKING

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.

 

WEEK TWO

STEP FIVE: SORT OUT YOUR BREAKFAST

REDUCE BREAKFAST CARB BY HALF

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.

Banana  30g

Glass of milk 15g

2 slices of toast 40g

Marmalade 5g

Breakfast cereal 40g

Coffee 0g

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.

STEP SIX: COVER BREAKFAST PROTEIN WITH REGULAR INSULIN

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.

STEP SEVEN: CUT BACK TO 30g of CARB FOR BREAKFAST

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.

WEEK THREE

STEP EIGHT:  SORT OUT YOUR LUNCH

 

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.

STEP NINE:  SORT OUT YOUR EVENING MEAL

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.

WEEK FOUR

STEP TEN: SORT OUT YOUR BEDTIME SNACK

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.

THE THIRD MONTH

WEEK ONE

STEP ELEVEN:  FINE CONTROL OF CARB INTAKE

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.

STEP TWELVE: FINE CONTROL OF PROTEIN INTAKE

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.

STEP THIRTEEN: FINE CONTROL OF FAT INTAKE

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.

WEEK TWO

STEP FOURTEEN:  PROFILING YOUR MEALS

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.

WEEK THREE

STEP FIFTEEN:  WHAT DO YOU REALLY MISS? CAN YOU SUBSTITUTE IT?

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.

STEP SIXTEEN:  WHAT DO YOU STILL REALLY MISS? CAN YOU CARB WEIGHT IT?

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.

WEEK FOUR

STEP SEVENTEEN: PROGRAMMING YOUR PORTABLE INSULIN CALCULATOR.

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:

  1. Rapid acting insulin has x 1.5 the potency of Regular insulin.

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.

  1. Correction doses are always rapid acting insulin.
  2. Protein cover is always regular acting insulin.
Personal Computer Insulin Calculator Version

This is the basic programme.  The background tables are needed for your:

Correction doses.

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.

Portable Palm Insulin Calculator Version

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:

  1. Add your estimate the amount of protein for your meals. The insulin needed to cover this is automatically added to the amount of regular insulin total.
  2. Decide how much of a percentage of the carb count should be allocated between rapid acting and regular insulin.
  3. Put your profiled meals on a favourites list. When you are going to eat any of these meals the calculator will adjust the doses according to the time of day you intend to eat it.

Things to be aware of:

  1. You do need to calculate any pre-meal correction doses separately when you use the protein calculator. A pop up box reminds you of this when this applies.
  2. When putting in the protein value from nutritional information on a meal packet you multiply the protein amount in grams for the portion you are eating by 4.6 and put this total in the protein box.
  3. When putting in the protein value from a visual estimate or measured amount of lean protein that does not have nutritional information you need to estimate the amount in ounces, multiply by 30 and put this total in the protein box.

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.

Reference Info:

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.

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.

Ready?

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.



HOW DO I COVER A STRICT LOW CARB REGIME WITH INSULIN?

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.

HOW DO I COVER A TYPICAL LOW CARB REGIME WITH INSULIN?

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.

HOW DO I COVER A HIGHER CARB REGIME WITH INSULIN?

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.