Insulin usage question

Hello, I'm an AF-AM woman, 51yrs old, weight #256 height 5'4"( i know I'm Severely overweight) diagnosed with T2 in 2005. I am very mildly T2, my morning fasting numbers range from 100-127. I can't tolerate Actos and Metformin or Glucophage at all. Severe gastric distress no matter how long I take it and I swell up like a balloon on Actos. So I asked my md to put me on insulin. But I didn't get much guidance other than Start on 5U Levemir at night and 2U Humalog after meals if your numbers go over 140. I tried that and got no real change in my numbers. I have gradually moved up to 11U Levemir in the morning and at night with no change of my morning numbers and I have taken 6U Humalog after eating and my numbers only go down by 20 points after eating. This seems like a lot of insulin for very little effect. I eat a very low carb diet, about 40g a day but I currently don't get much excercise. Does any one have any suggestions what may be going on? I don't have access to a CDE right now, the one my MD suggested won't see me if I don't eat 40g carb /meal and I gain weight at that level. I'm trying to go in the other direction. Also 40g / meal shoots me up to about 200mg/dl which is too high.
I am trying to figure out how much Humalog lowers my BS per unit. I can't seem to get a handle on this. How do you figure this out? And do I just keep upping the Levemir until I begin to see numbers in the morning under 100?
Thanks in advance.

My heart goes out to you. I think many of us feel like the health care system has let you down. Your doctor started you out on a very low dose of Levemir. I actually started at I think 10 units. Today, nearly three years after starting insulin I use 50 units a day of Levemir, split between two injections 20U in the morning and 30U at night. It is likely that you will have to further increase your Levemir until you see some effect. In the end, it is probably best if you become smart about insulin use and that will really help you on this journey. Two good books on this matter is "Think Like a Pancreas" by Scheiner and "Using Insulin" by Walsh. Most advise raising your basal (Levemir) 5-10% and then observing over several days whether you have the desired effect. Eventually, you will see lower blood sugars, but due to what I call Darn Phenomenon you may always suffer some morning highs which Levemir won't completely fix.

And as to the CDE, she is out of line. Even the current ADA guidelines suggest that low carb is an option. In my opinion, for people with T1, low carb is often the best diet option. I am a big fan of Dr. Bernstein who has recommended low carb diets for decades and I really value his book, "Diabetes Solution." If you really want insulin help from the CDE, then visit her, listen to her dietary advice and then do what you know is right. Before I was diagnosed, I used to place blind faith in doctors and other health professionals. But no more, I feel like I have to protect myself from harm at times and I will refuse to do things that I believe are just wrong.

I second everything Brian said. All of it.

Hi and welcome to TuD. You are right about the Levemir, just keep upping it until you see numbers under 100, but do it gradually giving each increase a couple days.

For the mealtime insulin you have been given terrible advice on the mealtime insulin. You don't take your mealtime insulin after but beforeeating. Some of us have found we need to take it anywhere from about 10 to 25 minutes ahead to let the insulin start working along with the food to keep our blood sugar from rising too much. Waiting until after and then only doing it if your numbers go above 140 is a recipe for disaster. The person who told you this is confusing mealtime (bolus) insulin with corrections which we do after meals if we are over 140.

Also a set dose of mealtime insulin is not an effective way to go unless you eat the same exact thing meal after meal and that sounds so You need to figure out your I:C, your insulin to carb ratio - how many carbs one unit of insulin can cover. And this ratio will be different for each meal. Mine, for example are 1:6, 1:10 and 1:16. Yours, as a Type 2 with insulin resistance will probably be closer to the first figure. To figure out your I:C, pick a place to start, say 1:10 and then test at the two your mark. If you are consistently high, lower it to 1:8 and see how that works.

I highly recommend the book Using Insulin by John Walsh; many of us have learned what to do from that book and from coming on here. Good for you to request insulin. Some experts are beginning to think Type 2's should be put on it much sooner. Good luck!

You've already received some great advice from Brian and Zoe. I can't believe that the CDE demanded her patients consume that level of carbohydrates! I admire your wisdom in seeing the folly of that stance.

You own your diabetes. No doctor or CDE shares how you feel when diabetes gets you down. I've lived with T1D for 30 years. It was only when I started to act on my own advice that I made some great gains on my metabolic health. No doctor ever advised me to eat low carb, one of my biggest breakthroughs.

The curiosity that brought you here will serve you well. Learn all you can, act on that knowledge, write your data down, and repeat. It's a powerful cycle. Good luck with figuring out your insulin dosing. You can do this!

Zoe makes some excellent points, particularly about taking insulin before eating. (This is called prebolusing.) The idea is to take the insulin enough in advance that it begins working just as your blood sugar begins to rise. Basically what you're trying to do is duplicate as closely as possible what a normal, healthy pancreas does.

The Walsh book is quite excellent as well.

One other note about I:C ratios: the ratios will vary according to the TYPE of insuilin. Different insulins have different strengths, something the manufacturers don't tell you (criminally irresponsible in my opinion). For example, 1 unit of regular insulin covers about 8 carbs for me. 1 unit of Novolog or Apidra covers about 12. So you need to work out the ratio(s) for the particular type of insulin you are using.

As an addition to the ratios, they usually also vary by the time of the day, you probably need another ratio for breakfast than for dinner and so on…
other than that, i have nothing to add, you are given excellent advice, good luck!

I don't think there's a CDE as Brian alludes to, it sounds like it's the *doctor* who's the 40G/ meal or else guy. If you don't want to eat 40G and he won't see you, I'd look into finding a new doctor. I fired a doc recently (I had seen labs online and knew A1C= 5.2, she came in and said "well, 6.2, that's not what it was but is still pretty good..." so I pointed out the discrepancy between the online numbers and she showed me they got the results on a tickertape thing that was marginally legible so...not double checking a marginally legible result of a test I would think an endo would consider pretty important= strike one and saying going up 20% is pretty good (I agree it's pretty good however going up 20% is not pretty good...) = two strikes and, well, we're not playing baseball so she was out.

The new doc seemed good at first but I am *highly* frustrated with the office taking 10 days (business days, of course, so like 2x weeks...). I don't deal with them that much but, when I do, I would appreciate things moving along more quickly.

It sounds like you are approaching things correctly slystr, looking at your empirical data and working to make changes. The other's suggestions are good but I'd add start shopping for a more useful doctor to the suggestions. You should be able to eat what you want and the doc should help you balance your BG on whatever you want to eat. Ok, maybe not eat *everything* you want as if you eat burritos and cheese fries all the time, it's probably not very good for you but your approach sounds very sensible.

Great advice from all the posters and great of you to seek out help, sylstr. Welcome to Tudiabetes. You are making great strides to get your diabetes under control. I applaud you for reaching out for information. I do so agree with all of the others who replied to this post. Diabetes is a disease you have to take into your own hands. The doctor does not live in your body, and it sounds like he/she has given you "one fits-all" advice, some of it not correct at all ( like injecting meal insulin after eating). I am type 1 for 47 years and have come to realize that medicine is indeed a "practice", and we have to take responsibility for our own wellness.

Take care.
God Bless,

Agree. You don't have to put up with a doc who doesn't know which end is up. A couple of years ago I went shopping and actually interviewed doctors until I found one who was on my wavelength and who treats me like a partner, not an incompetent subordinate.

It's not my Doc who is clueless so much as the CDE. But my doc didn't put up a fuss when I asked fro insulin even if her advice was off. She knows that I research my own health and is a great collaborater. The CDE sucked.