I need help, pls. Very lost with low carbs and MDI

Type 1 and LADA
1

Hi!
I hope someone can help me to figure it out. I am completely lost.

Some facts:
33 female. Dx November 2012.
I was sent home with following dosages: 12 NHP at night, 8 + 8 + 8 units of Novorapid. I needed to adjust those myself, because we don’t eat that amount of carbs at home and I got very low glucose values all the time.
I am breastfeeding my baby - that's why I've got NPH I guess. My fasting sugars are good within my target. Sometimes if I sleep longer than I should it could be around 6,7 (121).
I've adjusted my doses to: 4 NPH at 10:30 pm, 4 NPH +2 units or 4 units depending on carbs of Novorapid at breakfast (usually at 8:30), 2 lunch and 4 dinner of Novorapid.

I’ve split NPH myself because i got spikes during the day. Especially between lunch and dinner. One week it worked very good, together with cutting carbs but recently I had to increase carbs from 30 a day, because I’ve developed horrible rash the same i had prior to dx (described as ketosis rash). So 30 carbs are not good for me. So now it’s more like 50-60 a day.
So the problem is that injecting Novorapid at those dosage before dinner gets me nowhere - I get low 2 hours after the meal and then it spikes more like 4 hours after. I guess this is all the protein and fat.
I read both Bernstein and Scheiner and one seems not to eat all that amount of protein :-) and uses Regular and another’s calculations are based on much more carbs. If I eat less protein I am constantly hungry and increasing fat to 80% didn't help, I felt noxious, so I went back to "normal" amount.

My questions:
1) What should I do to address spikes 4 hours after food? I read TGA groups and they recommend splitting Novorapid into 2 dosages. One before dinner and one after. But how do I figure out how much? 2 and 2 units? Is Novorapid too fast for me?

2)How should I proceed in the evening?
I eat my dinner usually at 19:30. My basal injection is at 22:30. Last week I had good numbers before injecting basal, but this week when I added carbs back at 00:00 I am very high, like around 7 (126), than it goes down during the night.

3) what should I do if I get very hight at 3:am? Should it be corrected with Novorapid?
I am totally lost.

4) How do I calculate 1:C ratio if i need to consider fat and proteins? Is there any approaches that worked for you? 500 rule or weight rule doesn’t really work for me, I get very high numbers, like 1:22, and I don’t feel it is the case or at least I can not get it to verify because of protein and fat. How can I do that?
I know about 50% and 10% converting to glucose in 4 and 8 hours. But how do I do it in practice?

5) How do I calculate sensitivity factors? Based on average total I get 3,9 - 5,5 and it is not really a case.
I get it to 4,5 (81 mg/dl).
Does this need to be re-checked on an empty stomach?

I’ve had 6,6 (118) and after 15 min it went to 7,7 (138) I’ve panicked and took 2 units more, going down to 4,6 and eating. Now it's 6,1.

Please don’t send me to my diabetes team :) they were not much of a help
:( because I am honeymooning they said.And they are not much for lowcarbing. I got very bad response there.

Thanks!

2

Wow, all these questions. And these are good questions. But first things first.

You need to go look in the mirror and tell yourself "I'm doing great and I am going to be ok."

Your blood sugars actually seem really good to me. You aren't pregnant are you? Many of us would love to have the blood sugars you have quoted.

So please don't totally ignore your diabetes team, just don't get into an argument about your low carb diet. They can help you adjust your insulin if you let them help you. So I would recommend that you work slowly and deliberately to establish your basal levels and then after you feel good about them, work on your bolus.

Here are my answers to your questions.

1. blood sugar rise 4 hours after a meal are often because you basal is too low or your rapid insulin wore off before a mostly protein meal was digested.

2. I don't understand adding carbs at midnight? And a 126 mg/dl is not bad, especially if it goes down overnight.

3. If you go totally high at 3am (like 300 mg/dl), then you correct. But right now you are just starting, so wouldn't worry about correcting a 126 mg/dl, heck I probably wouldn't suggest correcting unless you are over 200 mg/dl. You need to be safe, don't take a bunch of insulin and then go to sleep. Worry about it in the morning.

4. For a low carb high protein meal I might inject after the meal, perhaps even a half hour after eating. But don't be sweating this stuff until you are confident you have your basal set properly.

5. You adjust your sensitivity factors over time to achieve your target goals, but you can't do that until you are confident your basal is set properly.

And don't forget what I told you. You are doing fine. You sounds like you are stressing yourself over this with unreasonably high expectations. I think you are doing great.

3

Can I ask the fundamental question of why you feel that you should be eating ultra low carb? Very few T1's in the real world eat the extremely low carb diet dictated by Bernstein. It is an extreme diet, and it is hard to follow eating real food.

If you like the restricted food choices that come from limiting your carb intake to 30 grams a day, or if you think there will be an advantage to of doing so, then that is fine. But it is NOT necessary to try to limit your carbs so dramatically. There are a lot of very vocal pro-low carbers here on Tu, but most of them are T2 and not T1. The T1s who follow this diet are in a distinct minority in the real world.

If you eat a more normal diet of 100g carb per day (or more), then the books "Pumping Insulin" and "Using Insulin" by Walsh are invaluable. I highly recommend buying one of them, since they spell out in detail how to adjust your insulin to match your daily needs. I imagine these books would also work if you choose to follow the Bernstein diet, though most of the ultra-low carbers use the Bernstein book "Diabetes Solution" instead.

I own all these books (plus others) so please follow up if you want some specific details.

4

Brian’s advice is excellent. With your diagnosis just a few months ago and breast feeding a baby, you have a lot to deal with. You’re asking all the right questions. Now you just need time to find some answers and experiment. The best thing you could do for yourself at this time is write everything down. There are so many variables to consider, it’s easy to get confused. You don’t have to log everything forever, just until you can settle into some kind of routine.



I think you are doing well. You are not in crisis. Pick up the suggested John Walsh books or Gary Scheiner’s Think Like a Pancreas. You will have to deal with this for a long time. Learn as much as you can, experiment with your insulin dosing (size and timing), and log everything so you can actually learn what your unique needs are.



Good luck and try to relax. You seem like an intelligent person that will figure this whole thing out!



BTW - I starting using a low carb diet, 50-70 grams/day, about a year ago. It’s one of the best things I’ve ever done for my T1 diabetes. While those of us that use low carb as a BG control technique are probably a minority, I suspect that we are not a small one!

5

Here is something that should be considered - when breastfeeding there is so much else going on, and you should not be limiting your diet - your goal should be nutrition as you are feeding another for g'ness sake!

For your ???'s, there are not ready answers...because you are honeymooning, breastfeeding, and making such drastic change/choice in your effort. There is no such thing as "normal" in this thing.

The one thing I worry is that you describe 126 and 138 as high and needing correction. I keep a tight watch and would not correct those numbers.

Please do the best you can as it is all you can do. The main thing is that you are in a world of metabolic shenanigans, and as others have already said you sound like you are stressing yourself over this with unreasonably high expectations.

I think also you are doing great. The book recommends are good ones. I am not a fan of the lchf wagon train and would like to suggest that your nutrition is more important during this time in your life. Wait until the honeymoon is over, and your kiddo is not dependent on you before you start making restrictions.

6

I second Brian's advice. You are doing fine. The advantage of eating LC is that in eliminates, or at least reduces a major variable. Honeymooning and Breastfeeding are variables that you cannot completely understand or account for.

Non-diabetics often go over 120 after meals. I wouldn't be too concerned.

I have had good results following Bernstein's diet recommendations. Previously, I had poor control, My BG was over 200 almost every day for decades. Yet never experienced major complications.

7

Thank you, Brian for your insights! No, I am not pregnant.

About 2. - I wrote very clumsy :)
What I meant is when this week I've added more carbs, I get PP BS within my range at the time of injecting basal, like 5,1 -5,7, but later on, without eating anything, it goes up and could be like 126 or a bit more around midnight.

I am trying to cool down, but it is so hard. I understand that I have a lifetime worrying, but it feels like if I get in control right now or at least close enough, it will save me tons of time later. Or I don't know... I guess I'm scared of all possible complications.
I'm trying to inject Novorapid aftereating today, I'll see how it goes.
I will talk to diabetes team about basals.
According to Scheiner the dosage is right if you go up with +- 1,3 mmil/liter difference, so far I have it like these. The problem always was the time between lunch and dinner, around 4 pm-5 pm. These got much better when I cut carbs and split the dose of NPH.

Even with taking a walk it goes up. I hope it will settle down soon. Thank you!

8

Hi!
Thank you for your question. Actually I was fed up with feeling "drunk" of the spikes. It felt like it was a roller coaster, which I couldn't control. I could get 7-8 PP and then crash. I was reading Bernstein and thought I could try. It did actually help. The whole week before I went to ketosis my sugars were very stable and I felt very clear in my head for the first time since November.
I will order Using insulin, I know it is highly recommended but reviews says that it is quiet old, e.g Levemir didn't come out yet back then (I am planning to switch after I'm done nursing)

9

Thank you! I am trying to calm down, It is very very hard, the part of me still grieving and having hard time accepting my DX. I know I shouldn't complain but right now there is not even time for me to sit down and read couple of pages and try to figure out how to proceed with a little baby and all that. I don't know sometimes I feel that it is good that everything happened "so late" in life, but sometimes I'm very angry at my pancreas :) It could at least wait a couple of years, until my baby a bit older :)and not to give in so easily to my stupid immune system :)

I'll pick up Walsh. I have Gary's book, thank you!

10

Thank you karen! It helps talk to you, guys. I feel like my family even though want to help me but they simply don't have time to go in such details I need them to. It's hard on all of us right now.

11

Thank you! When I read dr.B, I got hopeful. I will try to balance it without getting ketosis rashes. That was not a good experience at all.

12

Congratulations on the birth of your child and kudos to you for breastfeeding! I'd like to repeat that your blood glucose readings are good. The only time I panic about a blood glucose of 126 or 138 is be pre-exercise. I totally agree with Brian.

I also agree with Jag1 and Karen. Low carbohydrate diets never helped me to control my BG or overall health. I would guess that those who have had success in blood glucose control with low carbohydrate diets experienced that success because by reducing carbohydrates, one reduces the amount of measuring food that needs to take place in order to assess and calculate the insulin necessary. Measuring food has always been my biggest challenge and the best equipment available (as far as I am aware) has not yet addressed this adequately. Eliminating excess protein and fat, and investing more effort in measuring my food has helped me to control my blood glucose immensely.

I have not had the pleasure of reading Dr. Bernstein's book in particular. Does it address lactating women? I would be concerned about vitamin and mineral deficiencies that may be presented by eating so few carbohydrates.

How is the breastfeeding going?

13

Hi!
No

have not had the pleasure of reading Dr. Bernstein's book in particular. Does it address lactating women? I would be concerned about vitamin and mineral deficiencies that may be presented by eating so few carbohydrates.
How is the breastfeeding going?

I haven't read anything about lactating in his book. I was very nervous when I got DX, so I was asking different doctors at the hospital and read research papers about BF being safe to continue with it. I'm taking supplements as well as I'm eating a lot of veggies, but not those with starches. I do miss fruits, but I sometimes eat berries in small amounts, like blueberries and raspberries. I think it could be managed, I need only to figure out what amount of carbs is my my bare minimum in order not to develop rash. Thanx!
14

I don't know what's happening but I'm having no luck with splitting boluses. I can't get the timing right. HAd to increase basal, got rather high BG in the mornings. Like 113 average.

15

I have to tell you, I've followed Bernstein for years. I am a T2. I am really diligent about things and I test 6-8 times/day and take 5-6 injections/day. I would love to get a 113 mg/dl average in the morning. I think you need to think about your expectations and goals. Set reasonable expectations. You aren't going to make yourself non-diabetic and you won't completely eliminate the risks of complications. But you can manage diabetes very well and live a long healthy happy life. And it doesn't require making yourself all stressed out over not being able to achieve perfection and getting your blood sugar below 113 mg/dl.

16

You've gotten great advice here already but I just want to echo Brian about not being able to achieve perfection. You will learn to do the best that you can do every day and then you have to let go of the anxiety over not achieving perfect results.

You can do everything "right" and you still won't find perfection. It's not possible with diabetes. Sometimes there are variables that we have no control over and may not even be able to figure out... hormone fluctuations, viruses, the weather... these things will "mess up" your numbers at times. It happens and you can't always figure out why. You just have to react to changes as best you can and move forward.

I can really relate to how you are feeling because I was diagnosed at the age of 27, had only been married 3 years, worked full time and had an infant to care for. It's stressful because managing diabetes can feel like a full time job. But it will get easier and you'll find your routine that works for you. Just don't be too hard on yourself and take the time to enjoy your family. Those little ones grow up way too fast - mine is 25 now. Take care. :)

17

I feel like if I don't get in control of that thing right now everything will be much worse once I will stop honeymooning. I can't really explain this :-)
I read somewhere here that people after 15 years of type 1 have less TDD than me right now. I feel like I am burning out beta cells but doing something wrong right now and injecting more insulin than I should.
Crazy, I know...

18

Thanx! I'm not really trying to perfection. I am just scared I guess

19

Echoing the advice you have already received. Just strive for better not perfect. You sound like you are doing a great job coping not only with an infant but with D as well. And it does get easier.

20

I have had two low carb pregnancies and several years of low carb nursing and I don't believe for a second that carbs are necessary for making nutritious milk. Of course, I'm not a scientist and I haven't done any controlled studies, but when we're pregnant and/or nursing, I think our bodies make baby a priority. My kids have been very healthy and well nourished.

Someone above posted that most type I's don't eat low carb. I have no idea how many of us do, but I do know that trying to eat the standard american diet was like trying to force a square peg in a round hole for me. I absolutely could not have decent blood sugar control that way.

And I don't think Dr. B is so radical. I'm much more radical than that now. ;)