Does Anyone Else Have A Pattern Like This?

I'm preparing to start on insulin and trying to establish some baselines for determining dosages, timing, etc. My doctor and I are looking at this very hard and the specifics are in my blog if you have a lot of time to kill :) but I have a particular question for this group.

My daily pattern using just metformin, low carb with tight portion control, and exercise is like this: good to excellent fasting numbers nearly every day, but then BG climbs steadily through the day until it's 150 or more by evening. I exercise in the evening and that brings it right down so it's good at bedtime and in the morning. But during the day, that steady unstoppable rise.

As I said, the blog goes into this in much greater detail, but what I'd like to ask here is, has anyone else here had a pattern similar to this? If you do, what insulin regime do you use to manage it?



Hi David, I did read your blog. I get the impression that your belief is that you do not need basal insulin but rather short acting bolus insulin such as Novalog to cover mealtime carbs. Your assumption may be correct but I want you consider that your first response insulin may be impaired because you pancreas is unable to build up insulin stores because it is constantly playing catch up. In this case basal insulin may be needed to help replenish those stores. First response insulin is for the most part insulin stored by the pancreas for quick release when carbs are ingested, if insulin production is to low to rebuild those reserves then first response is impaired. I believe first and second stage insulin response is covered in Bernstein's book and just such a scenario is mentioned. It seems to me that by the time your pancreas catches up it has nothing left to cover the sudden onslaught of mealtime carbs.

I love the fact that you are putting so much effort into analyzing this. I just want to give you another solution to ponder.

Gary S

Hi Gary,

Thanks for responding. Plenty of food for thought there. You sent me scurrying back to the book to find that scenario. Took me a while to track it down, but yes, you're right.

I still wonder, though. If the problem is simply that my crippled beta cells can't keep up with the demand and therefore can't build up a stockpile for the next event, then fasting all day should have replenished the supply, yes? Then dinner should have resulted in a better recovery than usual. Or, maybe not . . . maybe that is exactly what is occurring, but one day just isn't enough time for an adequate recovery. There is too much about this picture that still isn't clear.

There are a lot of ways to think about this, and you've definitely given me a new one.

Bernstein's entire approach is and always has been empirical. Ultimately, the only way to really know what effect a given regime will produce, is to try it and measure the results as precisely as possible. So I may have to just try one way or another, see what the result is, and then adjust as indicated.

Whew. Well, nobody ever promised this would be simple, did they? :) One thing I'm sure of -- whichever scheme I try first, the "Laws of Small Numbers" are a paramount principle. Make very small changes, measure the results, and proceed from there.

Thanks for your thoughtful comments. Keep 'em coming.


My guess is that either remedy will probably work. If your adding bolus insulin to cover the mealtime carbs that your pancreas is unable to handle I think that will work. Or you can add basal insulin and allow you pancreas to rest and prepare itself in advance.

Of course you could require both but I don't see that need in you case. Your numbers have crept up but they are not over the top at this time. I think it's great that you are taking measures now instead of waiting till it's (diabetes)a full blown monster that is even harder to tame.

Gary S

I think you're right about either remedy being effective. My current thinking is that boluses will be marginally less risky, especially for a beginner. Since morning numbers are already very good without insulin, basal could increase the chance of lows during the night. Only a possibility, but why go there when a feasible alternative exists?

P.S. And, of course, whichever path I end up following, I will need to check at fairly frequent intervals to make sure the pattern is holding and has not changed.

Basal versus bolus. I don't know which will be best for you. I do both and I find that basal insulin is easiest to deal with. Once you establish your basal rate it changes less often. Granted it must be revisited and adjusted periodically it does not change that often at least it doesn't for me. With bolus insulin every dose is an adjustment unless you eat the same thing day in/out. Bolus insulin requires that each injection be calculated accounting for several factors such as current BG levels and how many carbs you plan to eat. If calculated wrong the undesirable effects such as hypoglycemia become apparent much more quickly.

Whatever you and your doctor decide you are correct in that you must continue to track things on a frequent basis. Outside of frequent daily testing you must still track your trends so that you and your doctor can make good decisions. I don't see you having any trouble continuing to do so.

Gary S

Meeting with the Dr. tomorrow and we will go into this in depth. But here is my current thinking.

Basal at bedtime isn't the answer. Since my morning numbers typically are in the 80s, evening insulin would increase, by some unknown amount, the risk of an overnight low. So then I would have to eat a bedtime snack to counteract that, and now we're into Rube Goldberg territory -- complexity for complexity's sake, aka a solution in search of a problem. Seems to me this would also implicitly violate Dr. Bernstein's "Laws of Small Numbers."

So that leaves the possibility of basal in the morning. But since the long-acting insulins take several hours to reach operating strength, I would either have to wait 2 or 3 hours to eat breakfast -- which ain't gonna happen -- or else still be dealing with the same old spike, though (possibly) with a slightly shorter recovery time.

So I am inclined to begin with carefully calculated boluses, on the low side, monitor very closely, and see where that goes. As I say, we will discuss this in detail at tomorrow's appointment.

P.S. Also per Dr. B, for a T2 such as myself, I might not need to bolus for every meal. It could turn out that one or two a day would give the beta cells enough rest to handle the remainder themselves. No way to know other than to test.

Please keep us informed on what you and the Doc decide. I'm not trying to convince you what the best approach might be I just want you to consider more options. I'm anxious to hear what the Doc has to say.

Gary S

Most definitely. Will do.

Met with the Doc and showed him my charts and graphs. (In fact, I even printed out a copy of this thread and had him read through it.)

We're agreed on the initial strategy. First I need to eat a calibrated amount of carb after a fast and monitor closely to determine exactly how much my blood sugar rises per gram of carb. Then I need to do it again, this time with a bolus of 1/2 unit, and monitor to see how much, and how fast, it comes down.

That will give me the two yardsticks I need to begin calculating appropriate boluses for meals. I will begin with less than the calculated dose (probably half), and creep up slowly until the balance point is reached.

I will monitor it closely for the first little while, then continue checking it in detail occasionally -- every week or two, to make adjustments as needed.

Doc also agrees that I may not need to do this for every meal, or forever. Time will tell.

P.S. We are also agreed that I will probably be dealing with VERY small doses. I'm going to have the pharmacy dilute the insulin 2:1 to make it easier to control the amounts with precision.

So you showed him this thread. Did he think I was a total nut (Ha Ha)? I'm glad you have a path foward now. Please keep us informed on how it's working.

Gary S

No, he didn't think that at all. He was favorably impressed (and, I think, a bit surprised) by the thoughtfulness, support, and experience on display here. In fact he wanted more information about this site in order to direct some of his other patients to it.

I have a doc who is open minded and willing to work with me instead of trying to steer me in some rote, preconceived direction. I'm lucky, and don't think I don't know it.

David, I was going to post that I would not have the pharmacy dilute your insulin, and I doubt that they would even agree to do that. I see that you've already found that out.

It does poses a risk of contamination and infection, and it won't last as long, as the preservatives won't be effective.

The syringes with half unit markings should be sufficient, but there are also pens that do half unit doses. NovoLog can be used in these pens, as they are made by the same company.

I don't think you're going to need to worry about diluting the insulin anyway. If you start treating for your highest carb meal of the day, when your blood sugar is already at its peak, (which sounds like your supper meal), you could try .5 of a unit, (as long as your doctor approves it). Monitor it closely, and see how it goes. I would start with only one dose per day, because that may be all you need for now. I would not do more than one until you know how your body handles it.

Make sure you wait at least 4 days to see how it affects you. It can take that long for the true results to show. I would wait a week before making any increases, as you are eating such a low amount of carbs, and don't have a lot of room for error.

Take it slowly.

The other option would be to take a basal insulin in the morning, which would help keep your blood sugar lower during the day, without as big a risk of lows, as using the mealtime insulins. If the mealtime insulin doesn't work well because of the Dr Bernstien "diet", you could give that option a try later on.


Thanks for the thoughtful comments. Actually I would prefer to do my own diluting as opposed to trusting it to someone else -- I have more skin in the game, so to speak. But it turns out that I may not even be able to do that -- it's not clear that a diluent is even available for my insulin (Novolog), but in any case, no one within 50 or 60 miles of here will admit to being able to obtain it anyway.

My syringes are calibrated in half unit markings (I made sure of that) and yes, I can inject half a unit. I thought it would be helpful to be able to use larger quantities to get greater precision, which diluting would have facilitated. But it looks like that dog just won't hunt. So be it. It is what it is and I will manage the process accordingly.

Actually, dinner is not (strictly speaking) my highest carb meal of the day. I follow Bernstein's pattern of 6-12-12, so lunch and dinner are essentially the same. My reading is highest at the end of the day (but not on a day when I fast) so it seems clear that my phase 1/phase 2 response is present but just too weak to keep up; thus, I fall progressively further behind as the day goes on. I've done enough experimenting and charting to be pretty certain of that. So very small doses will probably give me just the tiny extra push I need.

And yes, I intend to take it very slowly. I am keenly aware that insulin is a two edged sword and razor sharp on both edges. I'm keeping plenty of test strips (and glucose) handy, and I'm a compulsive record keeper.

Yes, I see that your meals are pretty low carb, and that supper isn't really any higher than lunch. What I should have said is that supper is when you are at your highest reading of the day, so that is where I would start treatment. Since you are starting higher, you'll be less likely to run too low. Keep in mind that Novolog can keep working in your system for 4 to 6 hours. You'll want to test about every hour, right up to about 7 hours later. Keep some glucose tablets handy by your bed, with a glass of water, and your meter, so if you wake up sweaty or feeling funny, you can test, and treat any unexpected lows.

I find that the new basal insulins are less likely to cause lows, so if it was me, I would start on Lantus or Levemir, taken in the morning, rather than dealing with short acting insulins like Novolog. My experience has been that basal insulins are more predictable to start with. I began with NPH which is a mixed insulin, and I was experiencing lows every day, several times a day, and headaches all day long, but then I started treatment with extremely high blood sugar (DKA). I was bound to feel lousy, given the huge drop in blood sugar that I was experiencing over a short time. The nurse gave me unclear instructions and instead of increasing my dose every four days, I increased it daily. What should have taken 4 months, I achieved over the course of one month. I felt terrible the whole time, and my eyesight was affected. She should have written it down, then I might have caught the error.

When I switched to Lantus later, most of the lows stopped, (although not all of them - I take Novorapid for meals and it can make you go low if your calculations are just a bit off, or if your activity level is higher than anticipated, or if you are later for a meal than planned).

There are a lot of factors involved, and injecting insulin is a lot more complicated than people expect. Once its in your body, its going to do its job whether you need it or not. Unlike naturally produced insulin, there isn't a built in system to stop it.

With Lantus, the insulin doesn't have the same type of peaks, and isn't absorbed or used the same way as Novolog/Novorapid. Lantus and Levemir tend to be a lot safer to start with, which is why most doctors would probably put you on a basal insulin first. It also may be all you need at the beginning.

In any case, I hope you can get your dose safely figured out. Just go slowly, very very slowly. You might even want to consider increasing your carb intake for supper, for the first few nights, just to be on the safe side. You might have blood sugar that's too low before morning, since you are usually back down in the AM. anyway. Its something to consider.

My endo instructed me to have a snack before bed because I'm so prone to lows, even on Lantus. 15 to 20 complex carbs, with protien and/or fat. Hopefully you won't need to do this, but if you find yourself going too low, remember that you can always raise your carb intake to counter it, if needed. It will take time to find the balance, so be patient.

Yes, it occurred to me already that I may need to tweak my carb input in order to maintain a balance. I'm also going to start with doses that are deliberately too low. I'd rather undershoot in the beginning and inch my way up to the right level. BTW, your point about waiting four days to see the full effect of a change agrees with just about everything I have ever read.

I'm also doing some experiments -- did one today, in fact -- to determine as exactly as possible (it's never 100% precise, as we know) how much my BG rises in response to a known amount of carb. I will use that metric in figuring dosage. And, as mentioned, I'm going to err on the very conservative side and then adjust gradually as the results indicate.

I feel fortunate in having been able to do a lot of homework heading into this. I have (and am continuing to) read and study everything I can find that has a bearing on this, from books to blogs to discussions like the one we are having now. When I think of all the people who had to negotiate this minefield with insufficient or inadequate guidance (like your early experience), I count myself lucky.

I will keep the blog updated as I go along. It's an ongoing learning experience.

So I see from your blog post that 1/2 unit isn't enough, let us know how the 1 unit works out. I suggest that you stick with that dose for at least a couple of days, as its going to take time to see much effect. Just saying don't go too fast. :)