A Low-Bolus Strategy

Back to the future - like the 1970’s? You are essentially describing the insulin regime those of us with T1 lived with back then. One shot a day of NPH, and then do the best you can to eat and exercise to follow the movement of your BG. I’m not sure why you would prefer this to taking an injection to cover your meals - the huge advantage of MDI when it gained popularity was to allow you to eat what you want and when you want it. Nothing wrong with eating to your basal if you want to do it, but what is the advantage?

Lynne, I think what you are going through is a fairly common version of what they call “bargaining”. There’s a process people go through when they accept a loss, it was originally described for someone who was dying (Elizabeth Kubler Ross, the Stages of Grief), but can be applied to any loss. The stages are Denial, Anger, Bargaining, Depression and Acceptance. You don’t necessarily go through them all in order and you can return to an earlier stage. The bargaining is like "well, I’ll take basal, but not bolus; or I’ll take two shots but not four, etc. When I first started on insulin I’d read somewhere about corrections, but hadn’t really understood it. So I informed my doctor I wanted to take my insulin “PRN”. Trust me, that idea came to a bad end! I can be very creative in my “bargaining”. But your wisdom is in saying “I know this isn’t going to last much longer”, but it’s ok to hang on for a bit.

Well, welcome to the party, sorry you had to come. Its my welcome to diabetes tag line.

So, you sound like your honeymooning and your pancreas is still making insulin. Thats one huge messy variable and Im sorry. So, heres the thing to reconcile and talk to your endo about. if you continue to hold back on your basal/bolus rates you are utilizing you pancreas’ insulin. but since your holding back (no bolus) your pancreas is doing its best to keep up and its not doing well. This is the standard MO and eventually your pancreas burns out and stops producing insulin all together. With the addition of a basal shot, you can prolong the pancreatic insulin production which is better than an synthetic insulin. It will mean that you have to bit the bullet and take more shots, but it will be better for you in the long run. Give it some thought and talk it over with your endo.

Essentially, your now allergic to carbs and insulin qualms the allergy. Its just like taking benadryl for alergies, except slightly (ok much) more severe. Its tough, no doubt about it, but you can handle this hurdle and it will become second nature after a while.

DKA happens when your way up there. I used to have BGs in the 3-400s with no DKA. Mind you I believe its relative to mean BGs. The trick is, those C-pep and other by products along with the insulin are what keeps you in good running order. Thats why I say try to keep it going as long as possible.

And of course! Being new to D is a whirlwind. Ive been at it 25 years and only got my house in order last year. So, your doing wonderfully!

It’s natural to be scared and the only thing that really helps that is time and routine and getting some sense of control over this whole thing. Like if I take x dose or x I:C ratio chances are it will keep me in range, and if I’m low I will test or recognize symptoms and treat it long before it becomes dangerous. Ditto with DKA (I can’t really talk never having experienced that particular horror), but if we test we know if we are in the danger zone and can get ourselves down. I know you like working things through with your endo, but you definitely want him to help you on corrections because that is your tool for highs like glucose tabs are your tool for lows. And if you are 140 before a meal then it’s a lot easier to just build a correction into your bolus then be scared to eat when you’re hungry!

But there is fear, and then there is FEAR and if your fear feels intense then working on it in therapy is absolutely the right thing to do. We all deal with this crap differently and some of what we have to deal with pushes buttons we didn’t even know were there! If I had been diagnosed at your age I don’t think I could have dealt with it with anything like the grace you are bringing to the table!

Ok! Lets take one day at a time. Even one meal. This is new and your going to get through it just fine. Look at the folks here, they all had simular experiences and have pushed on, so will you.

With readings like 130mg/dl, Id say the ketones are from the low amount of carbs, not DKA.

I went through major eye surgery a few years back and a good deal of fear and depression fallowed because I didnt know what was happening now what to do. In the end, I got through it and am better off now and in control. Youll get there too. Increasing your insulin is ok to do. Your numbers are in good shape and just getting tighter. Your not hitting 3-400s so your doing great. But, remember, day by day, meal by meal. You can do this and we’ll all help.

I agree w/ onesaint about one day at a time but I’m not sure I’d say that you actually want to take it one day at a time if you are making dosage adjustments? Whenever I change anything, it seems to take several days for it to “settle” (<----- totally made up, unscientific term…) and get to where the numbers are ‘accurate’ or stable, even if they are messed up? Over the last couple of months, I’ve gone from 6G/U to 8-9G/U while concurrently adjusting my basals down a bit too. I’ve been running a lot and was starting to run lower than I like to. And I don’t mind trimming my sails tightly but I’m also intrigued by losing a bit of weight.

The two goals should be stable basal, that doesn’t push you up and down. it’s supposed to keep you level. For years (21, 22 maybe?) I overshot basal AND bolus insulin and was really chasing a large dragon. With cheese and bacon.

Now, like 12-15G of carb meals or 7-10 G snacks will still spike me without bolusing. I think that it’s a mistake to cover meals, even low carb ones with basals because you are trying not to bolus. I think that if small carb meals are not enough to bolus for, you should bolus for the LCD # of carbs that your calculated rate will sustain accurately? If you can shoot 1/2 units or 1/3 units, that’ll work but if you can, I’d have more carbs? I think that if you are trying to ‘catch’ very low carb meals with basal peaks, you are going to be very challenged to guess when the basal is peaking, unless you have a CGM or test like 18x / day (been to both. CGM is easier…) and you will end up eating to your schedule. I think that in the long run, you can hit a smoother curve with basal/ bolus combo of some sort?

Well, for what it’s worth, I’m reading “Using Insulin” right now, and he suggests that your insulin ratio should be about 50% total daily insulin via basal and 50% total daily insulin via bolus.

So if you usually inject a total of 30 units per day, 15 would be Lantus (for example) and 15 would be your total Novolog (for example).

I haven’t gotten to the good part yet, so please don’t tell me who done it!

It is important that you remember that the “Using Insulin” guidelines are against the “recommended” diet of 45-65% of calories from carbs. If you follow a low carb diet, you will likely find that a much higher proportion of your ratio comes from basal. Right now, my ratio is 85/15. There are additional adjustments that need to be made to his calculation rules for low carb as well.

I am not taking 2 shots, I am only taking one shot at 9pm and some days before dinner my bg will rise a lil but I just take an extra unit with my dinner if it is over 140-150 no big deal (usually only have to do this about once a week). I have had no lows under the 60s and all of my lows have been after exercising. I am still on 2 units Levemir at night and a maximum of about 4 units of humalog a day, usually only 2-3. I eat 15 carbs for breakfas (which morning is one of my best times for bg and one of your worst so maybe you could eat somethin like this for lunch and then bolus with dinner?)- 2 ozs almonds, 1/2 cup unsweetened almondmilk,1/2 cup eggbeaters OR 4 egg whites with 2 tbsp salsa and 1 tbsp peanut butter with no bolus and about 2 hours later I do cardio for about 30 minutes and every other day weight lifting and after the exercise my bg is in normal range. For lunch I usually have just an ounce of cheddar cheese. Then at 5pm I eat dinner usually 20-30 carbs and take 2-3 units.
On weekends I eat much less breakfast and prepare a large lunch (or just split my lunch in half and box it up if we are eating out), split it in half and bolus 1-2 units for lunch then eat rest 5 hours later with 1-2 units.

I’m doing great! I’m even starting to go to pre-conception appts with ob and endo to try and conceive again after a few years of infertility and then diabetes diagnosis…I’m very worried about it but just trying to learn all that I can!

Come on Lynne you can do this! :slight_smile:

Maybe you should start just bolusing one time a day to start with like 1 unit:15 carbs and eat that same one meal a day with a bolus for a while and you may get more comfortable with bolusing and then increase it to more meals a day.

lol jag…this is EXACTLY what my endo told me and I got in “trouble” for not bolusing with more meals and eating more carbs so I will gain some weight. He said why would you do that?? Thats what people did before MDIs! EAT!!

Lynne-I think you are living my life! This is how I felt before they finally gave me insulin to help I was literally starving myself because my bg was high and now I FEEL more in control and better. Yes, I am still carb restricting and not taking bolus with every meal but I am just taking it slowly and eating the same # of carbs actually the SAME meal at the same times of days with the same # of units humalog. I was scared before I first did it but then after I did it and ate 20 carbs which I had not done in forever and I saw my 2 hour reading was normal I felt GREAT! I felt like I acheived something. My endo is still trying to force me to increase my carbs, insulin, and weight but I am doing it very slowly. I know once I get pregnant I will not have a choice because I will be forced to eat a certain amount of carbs so I do not have ketones so I am trying to add in 5 more carbs at a time per week. I am up to 40 carbs from 30 now.

I agree, bsc. It is the one flaw in John Walsh’s books. I haven’t read Think Like a Pancreas but I’m assuming it is similar? He actually does back off from that strict 50/50 by Pumping Insulin, giving alternative formulas and saying people can vary, but he still doesn’t account for low carb eaters.

Sounds good. Keep us posted on the results. =^)

how do you know you are getting ketones? are you testing for them and seeing the evidence that way? Or is this something your endo tells you that you must have, based on your endo’ theories about such things (in the absence of a test)? I always thought ketones came from high BG. My understanding too was the Bernstein type low carb diet is healthy for diabetics. Just trying to figure this out (with a newly diagnosed child).

Thank you Baby Tee, for explaining that, it is most helpful to me too.

NO ONE has to eat 30 gm carbs/meal. Read Bernstein. Get your CDE to read him. No, No, NO. You’re doing well. Let them rail, and you smile. Sit back and know you’re doing right. There are over 100 members in the Bernstein group, and I dare say none of them is eating 30 grams carb per meal.

I actually bought a copy and gave it to my endo. Then I showed her the Dexcom results from the control I have attained with Berstein’s method. Ill find out if she read it next appt.