A Low-Bolus Strategy

So for the last couple months, I’ve been playing with the following strategy: I take a slightly higher basal dose than I need so that my fasting BG hovers around 85. I walk everywhere and stay active. I find that these 2 things give me the wiggle room to not bolus for about half my meals (ones that contain under 8g carb or so). I typically go anywhere between 100 and 130 after a meal w/no bolus and don’t think this is a problem. If the meal has significant amounts of carbs in it, or if I’m already towards the top of my range, I’ll take a bolus as appropriate. Is this crazy or do others do something similar to this?

Obviously the risk is hypos…I generally just treat them as I find them and always have an unbolused bedtime snack with fat, carbs, and protein.

I am trying the opposite cutting the basal to try and loose weight. Not sure what is best.

cool, glad to see i’m not alone. fwiw i don’t do this for every meal (and wouldn’t want to, ymmv) but i have lots of steak-and-salad type dinners and don’t really like the idea of adding carbs just so that i can take insulin…that seems to be putting the cart before the horse if you ask me.

I’ve been type 1 for 26 years. The low carb thing can actually keep your A1c in normal range. I try to do the following:

Stay below 5 carbs at breakfast.

(I used to eat 13 carbs-1/3 c rolled oats w/ cinnamon-4 breakfast 4 years & never went up more than 40 points)

Walk a half hour b4 lunch and I can eat 20 carbs without bolusing, so sometimes I eat 30 or 40.

Keep it between 10 and 15 carbs at dinner time.

That helps me keep my bg more normal. Remember, normal for a non diabetic should be 83. There is no reason we should have to give ourself complications worse by eating a bunch of carbs and jumping up after a meal. If you were a pregnant woman, the doc would want you to stay below 110 an hour and 2 hours after a meal because it is healthier for the baby. If it is good for a fetus, why isn’t it good for us? That is my question for the docs.

You might be testing positive for ketones because you are in ketosis, not ketoacidosis. They are completely different. Gluconeogenosis is what is is called. It happens when your carb intake drops below 50g carbs/day. I can’t really describe it well, but there are some discussions about low carb diets here on tu.

Also, when you take large amounts of insulin at once, I think it is like 7 units or something, it takes longer for it to start working and it takes longer to drop your bg. It also works less consistently when you inject a large amounts. One more reason not to eat too many carbs. Oh yeah, and insulin is a growth hormone which means the more we inject, the fatter we will get. = )

Ultravires, I hate to admit it, but there used to be days when I wanted a sweetened iced tea and took too much basal so I could slowly drink it all day long, or I might take too much basal and eat a piece of licorice every half hour or so. I kept my bg in normal range, and I don’t have a problem with it. I am low carbing it now, though, so I only have tea sweatened with stevia or something now, and no licorice. I feel better now.

Dr. Bernstein says that doses over 5 units (it’s either 5 or 7 units) don’t absorb as predictably as lower doses & suggests people taking in two separate injections. It isn’t that 7 u of Lantus is a large dose at all. I believe he was referring to rapid acting, not basal.

My doc has given up harping on low carb. At this point he knows I’m going to keep doing what works for me & I refuse to discuss it. If I change docs, I’m not going to mention it.

I’ve never checked for ketones, but assume eating 30-35 carbs daily I’m in mild ketosis frequently. I don’t feel anything being in ketosis.

I hear you, sister! Our bodies, yes.

Yep, I get weighed. When I get the tsk, tsk thing, I say I feel great, have no lack of energy (true). After DKA, I was frightfully thin & looked awful. Took a while to get weight back from that, but now my weight is fine with me. I’ve always been thin. My doc says eat pasta. I look at him like he’s crazy.

Ketones from high BG made me feel quite sick also. Interesting that this also effects you from low carb. Are you drinking enough water? The only time I felt yucky was when I was somewhat dehydrated.

In our Glucosurfer project we have integrated the concept of neutral carbs. This means if you are below your target value it can be calculated how many carbs are needed to reach this level. For this calculation we use the carbohydrate sensitivity that can be set for every hour of the day. Usually this sensitivity is set to 30 mg/dL - meaning 10g of carbs will bring you up 30 mg/dL. In carbs this means that 1g of carbs will bring you up 3 mg/dL.

With this value at hand the neutral cabs can be calculated. These neutral carbs are taken out of the equation for the bolus. So the bolus is only for those carbs beyond the neutral amount. This may be more refined than your approach but I think it has the same rationale behind it.

For someone recently diagnosed and in the honeymoon (possibly a long-lasting honeymoon) so they are making a lot of their own bolus insulin, this isn’t so bad. It’s sort of like how LADA or T2 folks in the past were put on Lente, or today on 70/30.

By no means are they “intensive” or “fine tuned” approaches in the modern sense but the point is, halfway decent control can be maintained this way as long as the body is still making a good chunk of its mealtime insulin. And they and their docs don’t have to worry about all the minutae of a true basal/bolus routine.

In my honeymoon phase I could not skip the bolus but the dosage was low. Much of the insulin needs have been covered by the basal. Would I have increased the basal to reduce the bolus even further? Maybe not. My doctors would have recommend to keep the current relation between bolus and basal for the TDD. Today I think to give the remaining Beta cells the burden to cover the spikes alone may be not advisable. The longer the Beta cells can be preserved the better.

I think you are neglecting a big factor in favor of basal-only regimes, their simplicity.

By no means are they “intensive therapy” in the same sense that’s been used ever since the DCCT. But for someone with a lot of remaining insulin production/self-regulation, it’s just so much simpler.

Now, once a LADA has lost enough insulin production that they are basically starving themselves to avoid going onto a bolus… that’s taking it too far. I honestly don’t have a good feel for where the OP is on this.

And as to “preserving the beta cells”, and having been through the honeymoon myself decades ago: my opinion is the quicker they’re killed off the easier it is. Just my two cents. This in-between regime where someone is dependent on the beta cells and trying to guess how much they’re gonna help, yeah sure I can see how newbies might be attracted by it, but it’s a temporary and fluctuating place and sometimes it just feels better to get away from those fluctuations and to be standing on solid ground of not depending on it. Again, my opinion :-).

I expect we all do some experimenting, in part because our needs keep changing, whether day by day or year by year. On MDI now: I find that my morning coffee/caffeine spikes my BG unless I take extra in my breakfast bolus. Also my small dose of Levemir in the morning leads to a late morning low. As a result of these two things, I eat an early lunch without a bolus. On MDI, the insulin tells me when I have to eat.

On the pump, I just have to deal with the morning coffee/caffeine, so there is less extra insulin (asking for food) and a smaller adjustment with lunch.

I started insulin in Dec and am on a NPH/R regime. At this time, I am following a strict low carb diet and only “need” to bolus for dinner. Generally, if my meal is under 15 g carbs, I have been well under 140 mg/dl at 2 hrs. If I bolus to more promptly bring my blood sugar to a more normal level, I have to struggle with lows before my next meal. So in the end, although I am using my basal to cover my meal it works out reasonably. I think a good measure of whether this works is whether at 3 hrs, your blood sugar is still elevated, having elevated blood sugars between meals is a recipe for weight gain. In my case, with NPH/R, I really have to consider much more the overlap where my R affects my basal rates between meals and the role that has NPH in covering my meals.

I’m not sure there’s a huge problem with basal in lieu of bolus but I’m not sure there’s a huge advantage either? I have a pump and don’t hesitate to bolus like .3U for 7G of carbs in some nuts if I want a snack.

While this can work, I think it requires a lot more routine than other schedules.

You should have scheduled snacks to avoid lows. If you have lows too frequently, it can become more difficult to feel them. There are also theories that lows can lead to highs hours later (called Somogyi effect). I’m not sure that I actually experience this (unless I overtreat a low), but it is something to watch for.

If you can avoid lows (instead of just catching them) while doing this approach, then I don’t see a problem, but lots of testing and snacking is required.

@Tim: If the remainig beta cells show irrational behaviour I can understand your wish for killing them off. But this disregulation with over- and underreaction in insulin production is very individual. I want to stress that the beta cells play an important role even in full grown T1 diabetics. The first results of the research of Joslin with diabetics having T1 for more than 50 years show that. There seems to be a strong correlation between the absence of complications and the number of remaining beta cells.

I’ve been wondering about this…thanks for posting!

I agree with this too, sort of the N strategy of timing snacks to match stray peaks floating around in you. I am totally habituated to snacking but have gone a very long way towards reducing the carbs/ snack very signficantly over what they used to be. Holy smokes…

Ok wait…

I take a slightly higher basal dose than I need so that my fasting BG hovers around 85.

Dont we all do this? I shoot for my basal to keep me around 80-90mg/dl. I suppose some folks try to sit around 90-100, but thats what were all shooting for here right?

I dont think its crazy the way youve implemented this, although with more carbs / irregular exercise in a control regiment, there could easily been a requirement to eat more carbs for hypos. I find with low carb eating the foods consumed (more fat / protein) take longer to be processed which makes for fewer ups and downs (meaning over 6 hours it may happen once as opposed to 3-4 times). With over basaling you are required to compensate for that basal in some method which is usually well timed carbs (or lack of regular exercise).

Im not on MDI, but even on a pump, I tend to think of basal / bolus as two completely different things. This (I guess) is the standard way of looking at it.

So that said, what changes are taking place? different eating? exercise? any health change at all? infection? etc. I dont personally notice a difference in my BGs with those type of things, but I know some do. When things change though, first thing I look for is the changing variable. be it my insulin, infusion set, time of eating, what i ate, etc. Even the slightest thing may change numbers or delay effects.

Also, when you have your low carb meals, are you checking the fat / protein in the meals as well? I have this Cobb salad, lettuce, bacon, chicken, avocado, blue cheese, a small amount of cilantro dressing, and low carb blue cheese dressing. Its about 14-16 catbs when all is said and done. My BGs are 80-90 for 3 hours post meal, then spike at 5pm (I eat lunch at 2pm). I figure more fat / protein takes much longer to break down. I still have to bolus for the carbs, 1/2 the protein, and now it seems the fat. Pretty strange meal, huh?

If you want to increase, start small and be prepared for lows. Better yet, check your bg often when you change the basal. My old endo would ask me to do the same thing for 3 days and record the results. Its a pretty good measure of whats going on and if something is basal or a bolus issue. Exercise, food, sleep, etc. all the same. Good luck and keep us posted.

I was less scared to bolus than basal because once you increase that basal and take that shot you have a risk of going low for 24 hours, once you take a bolus you only have to worry about going low for 4 hours.