Each physiology is distinct, and so is each case of diabetes. That's one of the factors that makes management so intensely challenging.
Our exchange highlights this perfectly. You find it necessary to account for fat when bolusing whereas I don't. I eat a VERY low carb diet, a la Bernstein, and including carbs and protein (but not fat) in the bolus calculation gives exactly the right answer. That's not an opinion; it's what my meter reports.
I could never be a doctor. This sort of variability would drive me nuts. I don't think I could handle spending my entire working life chasing after moving targets.
My doctor likes the fact that I have figured it out, after half of my adult life I can manage on my own, we talk about many things not related to Diabetes...I think he enjoys the brake. Diabetes specialists never cure anything I don't think I would like the job, they really are just waiting around for something bad to happen to one of their PWD's...No real light at the end of the tunnel for them, one patent figures it out and there's 4 more newbies in the waiting room about to find out there's not a whole lot he can do for them. :-)
So very very true. My doc, like yours, is thrilled with the fact that I take management seriously and make it my business to learn everything I can about it. I'm his favorite patient.
It's my sense that some of the medical fatalism you describe (accurately, in my experience) derives from a sense of relative helplessness, as you point out. However, I am convinced that some of it also comes from the way doctors are educated.
Medical training focuses on fixing the immediate problem. Doctors are taught to attack and defeat acute illness; they are not trained in day in, day out ongoing control of lifelong conditions that require continuous detailed personalized management. They know exactly how to cure your pneumonia, and they can describe the chemical pathways involved in diabetes accurately; but they are, for the most part, not taught how to cope flexibly 24x7, every day, with conditions that will not respond properly to anything less.
Interesting discussion guys, thanks! I've struggled a lot with the Official Rules of Carbs & Insulin, versus y'know, what actually seems to happen. Dietary fat definitely makes a big difference in my metabolic world, and I've learned to adjust accordingly. Usually I stay low carb, but when visiting my grandkids, pizza is an occupational hazard, and it is the absolute worst when it comes to calculating my insulin dose. Theoretically the carbs are just in the crust, but if I figure it as the equivalent amount of bread and bolus accordingly I end up nowhere near covering it. If I just double what my bolus wizard says for the carbs I come out about right. LOTS of fat in that stuff, though, and that seems to be the problem.
As a type 2 who does not require insulin injections I'm less concerned with counting carbs than type 1s. However, I'm a bit confused about some of the info here about fat; I've always thought that the only consideration of fatty meals for a diabetic is that fat severely slows the absorption of carbs in the meal, making it sometimes difficult to predict when numbers will spike. (A classic example would be a big mac with all the trimmings which not only is a carb bomb but also a fat bomb.) This is actually the first time I've heard indications that fat itself can contribute to rising blood glucose numbers.
Dietary fat is not converted directly to glucose by the body as part of the digestive process. However, a fatty meal can sometimes produce higher BG readings. Perhaps the following excerpt will help:
". . . dietary fat's impact on blood sugar is usually of little significance. However, consumption of large amounts of fat can cause two distinct effects. First, it may slow the digestion of the carbohydrates that were consumed along with the fat, resulting in a slower, more gradual postmeal glucose rise. Second, large amounts of dietary fat, particularly saturated fat, can produce their own delayed rise in the blood sugar . . .
Step 1. You eat a high-fat meal or snack (this is the fun part).
Step 2. In a few hours the fat begins to digest; this continues for several more hours.
Step 3. The level of triglycerides in the bloodstream rises.
Step 4. High triglycerides in the bloodstream cause the liver to become resistant to insulin.
Step 5. When the liver is not responding well to insulin, it secretes more glucose than usual into the bloodstream.
Step 6. The blood glucose rises steadily as the liver's glucose output goes up."
Gary Scheiner, Think Like A Pancreas (Boston: Da Capo Press, 2011), pp. 51-52
Makes sense. My endo recommends a dual-wave bolus for this circumstance, with the second one scheduled 2.5-3 hours out to account for that delayed effect. Kinda-sorta works ok for me.
Thanks for providing that explanation David. If I understand the excerpt correctly a meal that is high both in fat and in carbohydrates results in a double whammy several hours later:
1. The carbohydrates are finally digested and converted to blood glucose
2. The liver, numbed by the fat, doesn't recognize that rise in BG and instead releases a glucose dump.
Many diabetics may miss this elevated-BG event entirely, given the current recommendation of testing bg levels two hours after eating, not after three or four hours when the above might occur.
Subjects were half with Type 2 diabetics, other half with three risk factors (high BP, smoker, obese, high cholesterol) not population at large.
The group eating Mediterranean diet in this study at the end were eating more olive oil, but still eating 40% calories from carb, or 225g carb per day. Not exactly a low-carb diet.
