I'm new to tudiabetes and to diabetes, too. (A year after undergoing pancreatic surgery, what is left of my pancreas has almost stopped producing insulin). I'm on Levemir (PM and AM), and now started taking NovoRapid with meals. I am on very very low carbs (doing great with that, losing weight I needed to lose, and feeling good).
It's not so clear to me how the basal/bolus should be divided. My Endo does not seem to be so interested in helping me figure out exactly how much of each I need. First put me in basal, and told me to keep adding - so that basically I was covering all my food with basal. When I finally insisted on adding bolus, and she said, 'ok, try 2 units with each meal, and lower the basal a little...'.
Help me out with this someone please. Thanks
(and thanks for the warm welcome!!)
The first thing to do is get Think Like A Pancreas by Gary Scheiner, and Using Insulin by John Walsh. They, and TuD, are my bibles and will tell you everything your endo didn't plus. Available on Amazon and elsewhere, used as well.
You might also be interested in Dr. Bernstein's Diabetes Solution, really, really good info on low carb lifestyle and more.
How are your numbers preprandial? 2 hours post? One thing at a time. Do some basal testing first, and get those straightened out. Patience :)
You definitely don't want your basal covering meals. The books above will help you figure out your insulin:carb (I:C) ratios so you can actually bolus the correct amount of insulin for what you're eating. I have 3 different rates during the day. I assume since you said that you are eating low carb that you know how to carb count?
So glad you found us! TuD has been my main source of education and information. Have you considered finding a new endo? A good CDE (Certified Diabetes Educator)? Your current endo sounds as if she... well...needs a lot of improvement!
Hi jrtpup, Thanks for the quick reply. I read Dr. Bernstein, and that's why I decided to try low carb. I don't carb count, but at this point my carbs are so minimal - I eat 3 meals, plain yogurt for bkfst, chicken and cooked/raw vegs for lunch, fish/eggs and vegs for supper. Not much. (only the non-starchy vegs as he specifies). Sometimes a coffee (or decaf) with a little cream. Some pecans for evening snack.
When I was diagnosed my hba1c was 10, and my fbg was 292. I immediately started levemir (16 u, split am and pm) and careful no-carbing and I am almost always under 150 and usually closer to 100.
I didn't see the numbers go up a lot pp, but I think its the levemir. does that make sense?
I fasted one day - Jewish fast day - took only 3 units Levemir at night, fasted the entire next day, and my bg hardly went up. So does that mean that I really only need a little more than 3 units levemir altogether for my basal?
(When I was diagnosed 3 months ago they tested the insulin and my pancreas was still producing minimum amount).
The problem with fasting while taking below the normal amount of basal is that it doesn't give you a good read. In order to do a proper basal test, you need to choose a day where you aren't fasting for religious reasons (because you might have to stop abruptly. Start the test after four hours on an empty stomach. Test frequently until you have covered a reasonable time period (I usually try six hour stretches). Take your normal amout of levemir. If you drop below 70, break the fast. Wait a few days after altering your dose before trying another basal test. You're trying to remain within 20 points of where you started--so if you start a basal test at 100, you shouldn't go above 120 or below 80 for the duration of the fast.
The problem with lowering your dose of basal while fasting is that . . . Ok, stupid analogy time--imagine your personal basal dose is like a hand pushing a merry-go round. Once you're spinning, you need two pushes a day to keep you even. Now, imagine that you miss one push. The merry-go-round doesn't slow down right away. It could continue around on the last push for a while (particularly if you're normally on a high dose of basal because that does funny things with absorbsion) before the lack of a push slows it down and everything falls apart. If you lower your basal in order to fast for a day, you don't know whether you remained even because of residual basal from the day before or from the fasting.
Anecdotally, for me, if I miss or mistime my basal, I coast pretty well through the day in question. It's not until the next day that I have problems.
Hi Negg, yes ! hearing the details helps a lot, as we are all so different with our insulin, diets, etc.
Since you are still making some insulin, it will be more challenging for you to determine your 'true' I:C, to calculate bolus insulin based on carbs. And when you eat 'slow' carbs, with protein, your own pancreas is more capable to cover, because the time is extended. When you say it was tested 3 months ago, and insulin was minimal, it's possible it has increased since then, given the low dosage you required when fasting. The part of your pancreas that is remaining may be regenerating beta cells. Or it could be that your higher Levemir dose was covering meals. Only way to find out is to fast, as you did, and determined your basal. (I use a pump, and my total basal is about 9-10 units/day, but this varies greatly person to person).
Then you determine bolus by checking your before and after meal BGs. The 2 books mentioned are also great, especially the parts about the 'honeymoon' phase, which covers when some natural insulin is being produced.
Negg, Your Total Daily Dose, including both basal and bolus, would be based by physicians on 1/4 of your weight in lbs OR if you are using Kg, on 0.3 per Kg. for small people, or 0.5 units per Kg. for bigger people.
The Total Daily Dose is then halved, half for basal and half for bolus. In prior times, the half for bolus was then turned over to the nutritionist who divided it into certain % for carbs, protein, fat, etc. We have since learned that that half for bolus is way too much, and people don't need and shouldn't have all the carbs that they were given. Low low carb is best.
If you had stable blood glucose round the clock, no more deviation than 30 mmdL when you fasted, and you were within 20 of 100 either way, yes those 3 u of basal were an approximate dose. Was that 3u basal am and 3u basal pm or total 3u? That's mighty low in comparison with what you were on at 8 am and 8 pm. But the 3 is a starting point. Remember that your insulin needs when you started, when your A1c was at 10, have gone down as your body has become used to having insulin available. Remember it takes 3 days for your blood glucose to become stable on a dose of basal. Do not go switching it around a lot too fast. See what you're testing and write down every bit of food/kind/grams with the units given.
And be wise: set an alarm middle of the night to see what you're testing for a night or two til you become stable. Remember you need to learn exactly what one unit of insulin drops you: it can be 40 - 50 mmdL, so do a test on yourself, getting yourself up to 180, and give 1 unit of short acting insulin so you know. Keep a record. The only thing different about insulins is their period/peaks of action.
Your division of basal/bolus is entirely your own, no one else's. Trial and error. Start with basal to get your blood glucose as even around the clock as possible.
After that, you can start figuring a short acting insulin unit to carb gram ratio. Keep a record so you always know the insulin on board, figuring 18 hours for basal and 4 hours for short acting.
You're on the right track with your low carb. Endos do not know how much to tell someone to use; no one does. Use small numbers of carb, like 7 grams, see how high you go with different types of carb, and learn what one unit does.
Hope this helps. I'll be back if you have other questions.
Hi Negg. Glad you're here! "ok, try 2 units with each meal and lower the basal a little" is not very helpful. First of all I highly recommend you get the book Using Insulin by John Walsh; it goes over everything and I consider it my bible. If the basal is giving you good numbers between meals, waking and before bed, let it be for now.If it is marginally low, say before the next meal, then drop it a unit. Then you need to figure out your I:C ratio which is how you do mealtime doses. You wouldn't take the same insulin for a salad as for a plate of spaghetti! Some people start with a ratio of 1:15, that is one unit for every 15 grams of carbs you eat and then keep careful records of how that works for a few days, then lower or raise it depending on results two hours after you eat. You will probably find your ratios are different for the three meals. (Mine for example are 1:5, 1:10 and 1:18). Trial and error is the way to establish doses.
Figuring TDD by weight is inaccurate at best. For example if I did that I would be taking the twice the TDD I am! While weight figures into the equation, things like insulin resistance (or lack thereof) and activity are more factors. Basically the only way to figure out dosage is not by any formula but by trial and error. If you are low carb you will also find you are way off from the "50/50" of basal bolus and that is fine; that also is just a guideline.
Everyone's suggestions here are excellent. You definitely need to read Think Like a Pancreas because you are now your body's pancreas. Congratulations!!
And here's something most of us have learned - endos are pretty useless in determining insulin needs. It's not their fault, really. The issue is that we are all SO DIFFERENT when it comes to our insulin needs. We all experience different affects as a result of food, exercise, stress, etc. There are some general parameters, and the books recommended will help you understand those, but a lot of it is trial and error. I always tell people that administering insulin and being your own pancreas is definitely more art than science. There are some adjustments I make in my insulin administration that I just do based on intuition.
For example, many endos like to see a 50/50 divide between the basal and bolus. BUT, if you're doing low carb, you're going to have more basal than bolus (generally somewhere in the 60/40 range, but that difference could be even greater).
Keep in mind that it's not just carbs that affect your blood sugar level. Some people see increases in their BGs as a result of dairy, artificial sweeteners, and caffeine. For example, I have to take 0.3 units for each cup of coffee that I drink to stop a big spike as a result of the caffeine.
First of all, thanks again to all of you. It is my first time on any forum, and its really amazing to see people really interested and caring about a total stranger. I will get those two books and do the basal testing...
Question: what is a reasonable target? As I wrote, I'm already solidly under 130 (The highest is usually after exercise. I do weight training, 3x week. My BG goes up after I exercise - unusual, I know - It goes up about 25-30 points, consistently. I tried different things - eating a little before, my trainer tried to change the program a bit - anaerobic/aerobic mix - but nothing changes this.) Anyway, should I try for 100, 90 or low 80's?
Also, if my BG is low 80's an hour after a meal is that too low? (I mean if it doesn't continue to go lower). After taking short-acting, I would expect it to continue to go down for the next few hours, But a few times I've seen BG 80's an hour after meal, and then it sits there or goes up a little bit. What is this?
Many of us aim for under 140 2 hours after a meal, though others aim for 120. Remember you are in your honeymoon period now, so it might get harder down the road. Low 80's an hour after a meal is fine but you have to see what your own personal pattern is in terms of when your insulin spikes. If you are seeing your numbers going continuously down after a meal you are taking too much insulin. The idea is to take the minimum needed to either stay steady or go up by a small amount. Have you determined your I:C ratios for each meal?
Your I:C ratio is how you determine your mealtime insulin doses. See above where I explain briefly how to do this and also I highly recommend you read Using Insulin by John Walsh to get more detail on insulin dosing. Otherwise you are shooting in the dark which is inaccurate and can be dangerous as well.
If you have an endo who is even remotely helpful, talk with him/her about starting on an I:C dosing regimen. At least get him/her to pin down what your initial ratio would be. I think most folks start out around 1:30 and work up or down from there as needed (mostly down; better to start out less aggressive to avoid a scary low).
Unfortunately, a lot of managing diabetes is trial and error (and more error sometimes). But rest assured that you WILL figure it out and start understanding how different things affect you.
Also, be sure to log everything (insulin doses, time, carbs, BGs, etc). This will help you keep track of things and look at your data over time to understand the effects of insulin, exercise, food, etc. If you have a smartphone, find an app that helps you do this (was always easier for me than the paper logs). This will also help you if you ever decide to transition to a pump.
Oh, is there a possibility you can get a continuous glucose monitor (CGM)? Having that data might help you as you go through this transition.
A reasonable target for you is 100. Bernstein says 83 is normal. Since you're low carbing I would expect your own insulin can be depended on to move you back there for all meals that are primarily protein and that do not have heavy starches & breads/grains. Try out the following foods in 15 gram portions and see how high you go: cooked vegetables, raw vegetables. Some of these will be totally covered by your own insulin. Some will need insulin for faster return to normal. My guess is that cereals, rices, cakes, pancakes will not be covered by your own insulin. Milks/ice cream will have its own plot on a graph of hours. You may not be able to digest this last well and need to fall back on yogurt.
And that is where trial and error with small amounts of one food at a time will provide your information. Keep your meals small. Figure one unit will drop you 40-50 until you learn it's dropping you less.
