Conventional food habits vs flexibility on basal-bolus insulin

I just visited a diabetologist (not my regular doctor who is in another city) today and my HbA1c stands at 8.3% (which though still far off the ideal < 7%) is a big improvement from my previous level of 9.7%. Probably I could have edged closer to 7% if not for my hospitalization (for diabetic ketoacidosis, which was till now undiagnosed because the doctor who treated me during hospitalization didn't suspect or treat it :(, but the diabetologist immediately made sense when he told about diabetic ketoacidosis).

He was so adamant about me getting to the 7% mark to avoid complications as I am just 23 years old as of now and have a long life ahead to live.

I currently use a flexible food routine with my NovoRapid-Levemir regimen. Whatever I eat, I count the carbs and then take the bolus. I adjust the basal if and whenever needed. By flexible, I don't take sweets, bulbous/root vegetables and other things that any diabetic shouldn't take. But I take other food items that are higher in carbs than the very safe, but I scale my insulin to that level.

But this doctor and dietician advocated a food regimen that involves spreading my eating over 6 times (which imho is a good idea) and restricted the eatable things to include only the fully safe foods in very restricted quantities. (In fact almost all the doctors in India including my regular doctor do the same). This is a new, difficult change for me to try and get used to. I can understand that this will surely help better control, but I fear that I am losing the flexibility that is possible with the basal-bolus regimen.

The doctors approach sounds very orthodox, conventional and inflexible. My heart wants me to make full use of the flexibility without compromising control. But I am scared about the control that I'd actually end up achieving.

What could be the best position to draw the line between the 2 extreme approaches?

I am always interested to hear about approaches to treating T1D in other countries. How often are you able to test each day? If you're able to test upwards of 6-8 times per day, I would think that you could achieve decent control while maintaining flexibility. I eat flexibly, but I use a pump and test upwards of 14 times/day. I avoid foods that I know cause me a lot of difficulty in controlling my BGs (pasta, rice, and bread products). If you can test frequently, you should be able to (more or less) successfully match your insulin to your carbs.

However, if you are unable to test that many times per day, sticking to a more regimented schedule and sticking to "safe" foods may be a better idea in the long-run. To be honest, this is the same approach I take (even with a pump and testing so many times per day) when I know my control is slipping and my A1C is creeping up.

I can test 6 times a day ideally to keep very good control, but considering the cost of the testing strips and the fact that there is no concept of medical insurance for diabetics in India, that would be quite a luxury and futile exercise. Since I am a vegetarian and the variety of dishes that I normally eat is very limited, once I have the carbs and the insulin effect on each of those dishes, occasional testing should do.

But I want to try that after I achieve the target control of 7% HbA1C. That is the first and foremost priority for a healthy living and I don't mind being a bit too restricted in terms of food and flexibility. This makes sense since my bad cholesterol is just above the threshold and that my doctor thinks I am a borderline case and has got me started on mild cholesterol tablets. But hearing from people from different countries would be great.

Also he has suggested switching to Lantus from Levemir to reduce the basal shots from 2 to 1. But I am not fully convinced.

Hi Guruprasad. A couple thoughts: I too am a vegetarian and it is definitely harder for us. It sounds like your doctor is recommending low carb which is kind of cool because few doctors do that, but they give you outdated suggestions to eat lots of carbs! The eating six times a day thing, however, is pretty outdated and based on the older insulins. If I ate six times a day I'd gain tons of weight, but you don't look like that is a problem for you, so whatever works!

For me, especially as a vegetarian (and one who loves to cook varied foods - at least for dinner). I compromise and eat what I call "low/moderate" carbs which for me is under 100 a day. I don't believe in the "eat whatever you want and bolus for it" theory, because it doesn't work (at least not for me), but I'm not willing to go truly low carb. There are many people who do it, most of them not vegetarians, but some who are, notably Gerri. So I would basically look into the various possibilities and find what works for you. You sound like you might end up compromising like me, with more flexibility than your doctor suggests, but less than you might eat now. (You don't say how many carbs you eat per day)

I do understand though the desire of both you and your doctor to get you down below 7%. I was diagnosed at 58 so I don't worry as much about developing complications over time as if I had been diagnosed at your age. Some other ways to get your numbers down unrelated to food: exercise of course, though that can be complicated. Some things that I do that got mine down is: test a lot I do understand the problem with affording strips though. I do have insurance but try and conserve for when I need them by tricks like eating breakfast soon enough after I get up that I just use my waking blood sugar. But testing with a purpose is a good way to go, like before meals to judge dose. But after meals is also important to correct highs. If I could say the single thing I do regularly that helps me it's correcting promptly so I don't stay high too long.

The switching from Lantus to Levemir to reduce shots from 2 to 1, doesn't make sense to me as Levemir is generally prescribed in two doses!

If there is any option at all, maybe down the road for you to get a pump, that would of course be a great way to improve control. In the U.S. at least some of the pump companies do have fee waivers for low income, but I don't know if that applies to people living in India. It's probably not an option for you, at least right now, but I just wanted to throw it out

And congratulations on getting your A1C down; that's a big drop!

I read this and your other post about morning lows and I think the best thing you can do for yourelf is learn more about using insulin to control your diabetes. Not sure if you can get a copy where you are, but if you can, I highly recommend "Think Like a Pancreas".

I'm sorry, but I don't agree with your doctor that you should be eating 6 times a day. You're taking quick-acting insulin, Novorapid, so this would require you to take 6 shots, plus the two you're taking of the Levemier. That's ridiculous!

I had good succes taking Levemier once at bedtime, having three balanced meals a day (and taking novorapid for them) then either having snacks with no carbs, or taking an extra dose of insulin if I was hungry and wanted a snack with a carb. My A1c was never over 6.5.

If you can, use this book to help you figure out the problems you're having. Once you understand how much you need to take and when, you will have the flexibility to eat when you want to.

I guess I'd need more information about what you've been eating, but I can completely relate to you not being excited about the rigid, six-meals, pre-set meal times, so many carbs at each meal routine. I find that many health professional want to put us into a rigid plan that is antithetical to normal human life.

What if I'm exhausted and want to sleep in for an extra hour? What if I go to an afternoon party and dinner is delayed by my hostess? What if there's a huge wreck on the freeway and I'm delayed an hour getting home. What if my elderly mother calls just when I was about to start dinner? What if I have a mild illness and I just don't feel like eating? What if it was raining hard in the morning so I postpone my Big Walk until the afternoon?

On the one hand, there are The Rules and on the other hand, Reality. I think the basal, bolus, correction regime is MUCH more reality-based than the old way of managing diabetes as it gives us the information and tools we need to cope with real-life variations in sleep, eating, exercise, etc.

If you're eating way too many carbs, you can cut back to a more moderate-to-low carb routine without giving up the flexibility you need to have a normal life. Plenty of people do this and get their HbA1C down in the 5's.

One final point about the Lantus/Levemir: Dr. Bernstein and a lot of other experts point out that neither Lantus nor Levemir have a precisely level, 24-hour profile, so with both medications it's better to take two shots, approximately 12 hours apart, in order to minimize the peaks and valleys.

Hi Zoe, thanks for sharing your insights. My doctor has recommended a 6-times eating schedule with the 3 main food times and the in-between times with very very low carb food. Don't know how practical and sensible it is to try following that.

Also he has asked me to switch to Lantus from Levemir to reduce one shot as I am taking two split shots of Levemir. Probably since this is a different doctor from the one I regularly go to, this could be due to the fact that the new doctor has been long prescribing Lantus to his patients.

I guess I eat somewhere between 200-300 carbs every day from a rough calculation.

Lots of great suggestions here. Perhaps you can manage the strict schedule temporarily while you get your A1C to where you want it, then re-introduce flexibility and other foods gradually, one thing at a time, with lots of testing to see what it does to your BG.

We are all different, so you'll have to do lots of experiments on yourself. Please keep us posted.

Congratulations on getting your A1C down!

One more question that keeps nagging me is that, whatever carbs we take, I match the bolus dose to that. This effectively means that my blood sugar level will be back to normal only after 4 hours (the acting period of my bolus). But my doctor vehemently asks to target normal blood glucose level 2 hours after food. Won't this put me in a risk of getting into frequent lows because there would still be 50% of unacted insulin. For example if I had taken 10 units of bolus, a scary 5 units will still be acting for the next couple of hours and will definitely lead to low sugar. But my doctor has suggested eating 6 times a day with a maximum gap of 2.5-3 hours between. So I guess the overlap will take care of the yet-to-act insulin, but I am kind of scared.

Thanks for your feedback Kelly. These are testing times for my health and am easily getting confused by what the doctor says and what I have learnt from experimenting and experience. I have read "Using Insulin" by Walsh and a lot of things mentioned there make a lot of sense. Against that backdrop, whatever my doctor has recommended seems too rigid and orthodox and totally wasting the flexibility that the basal bolus regime gives me.

I eat about 200-300 carbs every day. I was enjoying the flexibility of basal, bolus, correction regime. But this sounds like a life imprisonment. This kind of plan will make me feel that I am a diabetic every single second.

I have the exact same questions and concerns that you have raised in the second paragraph. Today I wanted to sleep for an extra hour or so, but my parents wanted me to wake up at 6 and have something as advocated by the dietician. :-( Can't talk sense to them as they don't have a very good idea about diabetes, insulins, basal-bolus-correction regime. For them it will always be a case of the doctor's word against mine and I stand no chance.

And I also have the confusion regarding bolus dosing. My bolus lasts for 4 hours, but doctors want the blood glucose level to be < 160 mg/dl after 2 hours. Doesn't it make sure I will get into a hypo very soon after that? I am scared to think of the scenarios where my bolus is as high as 10 units. There will still be 5 units of unacted insulin!

The concern about going hypo is one of the main reasons that Dr. Bernstein came up with the phrase, "the magic of small numbers".

If you eat some chicken, low-glycemic vegetables and oil/lemon/garlic dressing (i.e. a chicken salad) you only have to bolus for, say, 15 carbs.

If you eat some chicken, rice and a sweet sauce, you might have to bolus for 60 or more carbs.

The more carbs, the bigger the bolus and the bigger the bolus, the greater the odds that you'll go hypo.

If you aim to keep your carbs under 100 grams per day when you used to be over 300, then you'll be using 1/3 of your former injected insulin load and you'll be that much less likely to over-correct and go hypo later.

You don't have to go cold-turkey. Just learn the carb counts and replace high-carb things with lower carb things and watch your BG's and insulin requirements as you make small, steady changes. Green vegetables are your friends. ;0)


I'm not a vegetarian. I was for about 30 years, but didn't have good BG being a diabetic vegetarian. I tried. My hat's off to anyone who can. To get enough protein, I had to eat higher carb than I could comfortably control.

I understand your concern. The old regiment of eating constantly is a throwback to the days of older insulin. People had to eat on a very regular schedule & snack to avoid lows with unpredictable insulin. Unfortunately, the old guidelines exist despite the fact that they're outdated. Agree that this is very unflexible & limiting. There's no reason to eat six times a day. To get your numbers to <160 after meals (an excellent goal) is by timing bolus to hit the spike. Since you eat a lot of carbs & carbs digest quickly, you'd probably need to take an injection earlier than you're currently doing. The best way I've found to control BG is by restricting carbs significantly. Realize that's difficult being vegetarian. As Jean said, less carbs=less insulin=smaller mistakes that are easier to correct. Smaller doses also act more predictably because of absorption rates.

I am having trouble counting carbs in vegetarian Indian (particularly south Indian foods that I eat) foods that I eat. Learning by trial and error. Couldn't find a comprehensive food database that has the details for the food I eat. :(

I guess I should start using some measuring tool to measure the carbs. Even my carb measurement for cooked, boiled rice is some times not giving the right results. Time to dig deep into carb estimation and learn to calculate the carbs accurately.

Thanks for the motivating words. You exactly said what I am trying to achieve now. Achieve target A1c levels with extremely conservative food habits and then introduce flexibility once the target control can be achieved with regularity.

I love Indian food. I live in the DC-metro area and we have a large Indian population, and some really good Indian restaurants (mostly in the Maryland and northern Virginia suburbs). That said, I don't eat at these places too often because the food wreaks havoc on my BGs.

Apologies, Gerri; I knew that! And I respect your choice because when I realized I had to make changes in diet (when I started insulin) I told myself that if I needed to give up being a vegetarian for my health I would do so. If I didn't have good insurance and lots of free time to "obsess" about my diabetes (check, correct, cook - wow, three "c's") I wouldn't be able to stay a vegetarian and have good blood sugars.