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
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.
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.
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.
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.
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.
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.
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
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.
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.
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.
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:
- 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.
- Correction doses are always rapid acting insulin.
- Protein cover is always regular acting insulin.
Personal Computer Insulin Calculator Version
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.
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:
- 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.
- Decide how much of a percentage of the carb count should be allocated between rapid acting and regular insulin.
- 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:
- 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.
- 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.
- 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.
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.