Dr Bernstein on Insulin Pump Therapy

Type 1 and LADA
23

you are right on with the ps Brian! "recycle" is the perfect word. Dr Bernstein is on the Advisory Board there at DiabetesHealth. The part where they say Each issue includes cutting-edge editorial coverage of new products, research, treatment options, and meaningful lifestyle issues is questionable in this case. I notice Dr Bernstein is interviewed a lot but don't see anything I'd call "new" from them.

I do wish Bernstein would interview folks who have been pumping for decades and can speak for their improved health as well as control of diabetes. There are many of us :)

24

Here's a perfect example of how much individual physiologies differ!

I have heard from others whose experience was the same as Christy's, or at least very close. My case, on the other hand, is the opposite. Low carbing has allowed me to get rid (and stay rid) of almost 35 lbs.

Same old, same old: Your Diabetes May Vary. We're each individuals. As everyone here seems to agree, you use what works for you.

25

Wow Belina, I hadn't heard that Dr. B had changed his meter recommendations. For some years, he has recommended the Roche Aviva Accu-chek, but recent strip changes led to real problems. He has been trying to work with Roche, but he may have gotten to the point where he changed his recommendation.

In the end, everyone is different. And even Dr. B notes that there are reasons that a pump can achieve better control, such as Gastroparesis or Darn Phenomenon. And all that really matters is what works. And on this, Dr. B has always been clear and in total agreement with us. "What works, works."

26

Indeed they do. That's why I use a cocktail of analog AND regular -- regular for the protein, analog for the carbs. Works great for ME, but as always . . . . YDMV.

27

I hadn't heard about the different meter recommendation, either. Good to know -- thanx!

And to echo Brian's last sentence, one of the things I like most about Dr. B is that his approach is always relentlessly empirical. Coming from an engineering background myself, that resonates very strongly. All the theory in the world is trumped by actual results, in my book.

At the end of the day I don't care where a particular bit of advice comes from; if it works, I'll use it. If it doesn't -- forget it. Even if it comes down from a Harvard mountaintop carved on stone tablets.

28

Thanks for update om meter recommendation, belina. When I called Dr Bernsteins office in September they told me that Aviva was the only one to be trusted, but I had to add 10% to the value (or was it subtract?) because of the new strips. When I asked about the Bayer Contour meter they told me it used to be a good one but after they started producing their strips in Thailand (donĀ“t remember this but it was somewhere in the far east) it was no longer reliable. So I called Bayer to confirm this and they said they still produced their strips in Europe (Germany if I recall right) and had never even heard about this "rumor" before. I guess I write this just to say itĀ“s sometimes more than one "truth" and that I have no clue to which one is the "right".

29

Dr. Bernstein aims for very tight blood sugar controls. He'd consider 5.9 AIC too high. I believe he aims for 4.7.

My wife also aims for 4.7. It's also our experience that we can not get very tight control with the pump (which is why she is currently going off the pump). At the very best, it hasn't offered much advantage over needles, in our case.

The largest meal bolus Nicole ever needed on the pump, eating a ketogenic diet, was 1.3 units of humalog. We are pretty convinced, between the tubing and the injection site, that the pump had a big problem giving small boluses. The technology seemed very precise, but where tech met flesh, there seemed to be a lot resistance. After 5-years of pumping, she had developed a lot of "scar tissue" and insulin resistance.

It may also partly depend on how people use their pumps. We always ignored some of the features on Nicole's pump. For example, you could input the carb count for a meal and it would calculate the insulin dose.

The obvious problem with this is that carbs are not the only factor in what causes a blood sugar rise after a meal. My wife can eat zero-carb kefir/yogurt (we ferment it for 36 hours so there is no sugar left) and her blood sugar will still rise 2 mmol/L within 1-hour.

The amount of fiber and protein in a meal has a significant effect on her blood sugar. The more her gut expands, the more glucagon her body releases into her bloodstream. The pump's software didn't account for these critical variables.

30

I also read the interview. I think some of the motivation comes from the fact that he wrote a book. The examples of pumpers that have high glucose levels is not an indication that the pump doesnā€™t work itā€™s an indication that the people with the pump are not managing their diabetes. The forums are overwhelming filled with success stories of the benefit of the insulin pump. After 30 years of MDI and a dozen BG levels in the 20ā€™s I moved to the pump and I am so much better off. I can manage my diabetes mores effectively.

31

Keep in mind, also, that Bernstein didn't say in the interview they were having out-of-control blood sugars. He just said he hasn't seen someone on the pump who has blood sugars like a non-diabetic.

32

I understand that you are a Bernstein follower and kudos for taking on the challenge of diabetes in such a considerate manner.

As others have mentioned here, however, the whole idea of what Bernstein thinks of as "Non-diabetic" blood sugar levels, itself, is controversial. The available data simply do not exist on a large enough sample of any population to support the finding that non-diabetic equates to A1cs in the mid to high 4 range.

Not that it isn't possible, or desirable to achieve this level of BG control, certainly Bernstein and a number of his patients do, but when it's difficult to find too many people outside of the Bernstein circle actually doing it (apparently none of them on a pump) then if stands to reason that you're not going to find a whole lot of non-Berstein pump users in the mid to high 4s.

33

In an interview with James Hirsch that is included in Cheating Destiny: Living with Diabetes, Richard Bernstein says that he has a medical condition not related to diabetes (that he doesn't specify) that causes him to have hypoglycemic episodes. So he isn't achieving "normal BGs" just by his stated techniques.

34

I definitely have better BG control on the insulin pump, but mine was more "smoothing out" than lowering my A1c. I started on the pump back in the dark ages, when the "long-acting" insulin was NPH (which I simply hated). NPH caused a lot of lows for me, and going on the pump reduced those lows. I would also say that an insulin pump is one of the significant advances that made my life with diabetes easier (fast acting insulin and the CGM are the other biggies). It's way easier to exercise/do athletic things--I just turn my pump way down in advance. A pump does take a decent amount of effort, especially at the beginning, but in my opinion the rewards are so worth the initial effort.

35

Yeah, I started on NPH as well. To be honest, when I moved on to Lantus it was marginally better at best. I still battled the wonky curve that used to make me to go to bed with elevated BG numbers just so I could get a good night's sleep without waking up in a hypoglycemic puddle of sweat sometime around the witching hour. I wish I had discovered a pump, any pump, a lot sooner.

My A1C isn't that much better, but it is a lot more consistent and has, at least, been under 6 for the last two years straight.

36

That is one of my fav things about pumping, too. I hated never knowing when my Lantus dose was going to inexplicably drop me.

37

Been on the pump for 1 1/2 yrs and absolutely love it. Only been T1D for 2 yrs now, so im lucky to have caught it early before any scar tissue buildup. however, after 1 1/2 yrs, i have absolutely no scar tissue and cant even tell on my skin that i wear a pump. I use the omnipod and that seems to be MUCH better than the minimed infusion sites i tried out in the beginning as far as canula size and comfort goes. And i know the pod was just coming out when bernstein's book came out, so maybe he didnt get a chance to review it.
Overall, bernsteins approach is a fool proof way of maintaining perfect blood sugar, but its definitely not the only way. I eat about 100g carbs/day from mostly veggies and nuts(i do the paleo/primal diet)and rarely does my bs go over 100(thanks mostly to the pump!). Absolutely unnecessary to limit(or starve) yourself as bernstein does, just have to know your body and how you respond to different foods

38

Thanks for sharing this, Shawn. IĀ“m going back to pumping in a couple of days, trying the short steel cannulas this time. Hope I get great results.

39

Shawn, you said: "Absolutely unnecessary to limit(or starve) yourself as bernstein does, just have to know your body and how you respond to different foods."

I think, in all fairness to Bernstein, such a statement may not be true for those who do not produce any of their own insulin. Since you are still in the first five years of diabetes (honeymoon period), you probably produce 20% or more of your insulin needs -- which offers the fine-tuning necessary to achieve normal blood sugars in combination with a carbohydrate diet. I've yet to see a type-1 diabetic, who does not produce any of their own insulin, achieve normal blood sugars on 100g carb/day diet.

My wife produces no insulin and the only way we've ever been successful at controlling her blood sugar (tightly controlled target blood sugar of 83 mg/dL) is by limiting her diet as Bernstein prescribes (essentially 5-10g of carb a day from veggies).

It's by no means a starvation diet. In fact she's gained 4 pounds of bone mass in the last three months (her osteoporosis has reversed itself).

It seems like a 100g/day of carb works great for you; but I thought I should point out the "honeymoon factor" for other readers who may not be producing any insulin.

Certainly, though, 100g/day is much easier to control than 300g/day. But, in Nicole's case, 5g a day still makes a 83 mg/dL blood sugar a moving target. For a type-1 diabetic, producing no insulin whatsoever, I've yet to see another option for blood sugar control outside of a ketogenic or gluconeogenic diet (that would offer a A1C under 5.0).

You also mentioned: "And i know the pod was just coming out when bernstein's book came out, so maybe he didnt get a chance to review it."

Actually, he does review it in the 2011 edition (page 332):

"The OmniPod uses both a slimmer needle (28 gauge) and short length of very fine tubing. The pain is virtually eliminated, and the long-term problems caused by a large foreign body (i.e., the tubing) under the skin are considerably reduced. The basal infusion rate, however, is still a bit to great (0.05 units per hour) for most people taking physiologic doses of basal insulin. This may be improved in the future."

All-in-all, it sounds like if you are going to use a pump, the OmniPod is the best candidate. Nicole used a Medtronic, and scar-tissue/insulin resistance was pretty obstructing after 5 years (well, maybe 3 years).

We are now switching her over to long-acting insulin (turned the pump off at 6am this morning) and we're very interested to see if her basal needs are maintained better with Levemir.

One big problem we were having with the pump was the warm weather. Two days of really hot weather seemed to ruin the Humalog in the pump. She had to put her basal rate from 0.25u/hour to 0.35/hour. But once she changed the site and put in a fresh Humalog, 0.35u/hour sent her blood sugar crashing.

Maybe one day they'll have a pump with a built in refrigeration unit.

40

not every type 1 has a honeymoon period (many are DKA) and certainly not five years worth of a honeymoon. many type 1's achieve good control with eating normal diets or a lower carb diet and certainly more then 100 carbs per day, they're posted on this site all the time. there is no substantial benefit in achieving 83 bg's vs. 100 or 120 bgs, they're all within normal levels and what a non-diabetic has even a nondiabetic has fluctuations in blood sugars. the basal rates you suggested .25 - .35 does not support any type of insulin resistance. humalog is known to be a bit heat sensitive and there are other insulins out there, novolog, apidra, to try.

We're all different in the way we manage our disease. I low carb..about 60 grams/day but I eat bread (low carb whole wheat organic), fruit, veggies, yogurt, a snack)...tons of foods out there to eat. IMO, the day I would ever attempt to only eat 5 grams of carbs a day or have to to try and maintain my blood sugars is the day I'd be looking at some serious insulin (incorrect basal/bolus) rates, doses.

41

Actually, one study I found tracked LADA patients and found that on average they went 6 years before requiring insulin. There is widespread acceptance in the medical community that tight blood sugar control can prolong the honeymoon in LADAs. The fact that nobody has done a study of 83 mg/dl vs. 120 mg/dl does not change this.

42

ask a "LADA" on here how long it took before on insulin and usually they'll start with at least basal or bolus to preserve any remaining beta cells. and why use the term LADA, which is a ridiculous new name in my opinion, what does it even mean...late onset, latent onset..why use that term, it's just type 1 diabetes. children who present without DKA, who have a honeymoon, maybe require a low amount of insulin initially, aren't called LADA, they're just diagnosed type 1, so again using this LADA term just confuses people..so why that term is used is beyond me. I've never known one type 1 diabetic (regardless if they had/have a honeymoon) who went 6 years without insulin. Guess one can find anything on the internet. 80 - 120 are all normal blood sugars. a non diabetic can go up to 180 1 hour after meals. why would they study a normal blood sugar range?