I was diagnosed in 69 and went through all of the training relevant for that period until I aged off of insurance around 86. We were taught “Exchanges” at that point.
Now, I’m a weird T1D, my insulin needs are low, sometimes I start making insulin in larger quantities and my insulin needs are REALLY low. I never moved off of Humulin 70/30.
Can some of you kind people explain carb counting to me? I keep hearing it and have no clue what you’re talking about. I’ve been Keto since the early 80s, so it’s not really something I deal with, but I feel like there’s a big inside conversation that I just don’t get.
At its simplest, basal is a longer-acting insulin that provides for the “baseline” metabolic function of being alive, and bolus is shorter-acting, to deal with sugars of various forms (this is the carb counting part) and other weird things that can temporarily elevate blood glucose.
There’s a lot of literature out there. Think Like a Pancreas is a good place to start. If you are still making endogenous (internal) insulin, it does get more complicated.
The carb counting bit doesn’t make a lot of sense to me. I see a cracker, that’s a carb. A slice of bread is a carb, a grain of rice is a carb, grapes are sugar bombs, but are they still counted as a carb? And a grain of rice is a lot smaller than a cracker, which is smaller than a slice of bread, so they can’t be equivalent, can they?
Now, I’m well controlled, so I don’t plan on switching therapy, I’m just trying to understand the conversation.
If diabetes management is a bicycle, then mine is a weird version of a recumbent bike. In my case, less is more and I’ve had 57 years to fine tune it, so I’m not planning on switching over to an E Bike even if everyone says they’re better. I’d probably just wreck and knock out a few teeth. But I would like to understand the thing.
All those things are carbs. It’s the amount of carbs that’s the issue. Two grains of rice is a whole lot less than a slice of bread. Fats and proteins also eventually metabolize to sugars of one form or another, but nowhere near as quickly as rice or apples.
If you’ve got a plan that works for you, that’s wonderful!
Grams. All foods that aren’t totally fat or proteins have carbs, but each food has a certain amount (numbers of grams) of carbs. In carb-counting, each individual has a rate of how many units of insulin they will need to cover x number of carbs. So, for example, my carb ratio is one unit of insulin to 11 grams of carbs. How do I figure the amount of carbs in what I’m going to eat? Either I check the package’s nutrition information for what a portion size is (a cup, half cup, in some cases, weight in grams) and then I figure out how much I’m going to eat (one serving, two servings, half a serving) and divide the total number of carbs I plan to eat by 11, which then gives me the number of units I need to take to cover that food. The other source of information is a carb-counting book which lists nearly every food known to mankind and how big a serving is and how many carbs in each serving. Since I have a pump, carb-counting is much easier because my pump is programmed with my insulin to carb ratio, so all I have to do before eating is to tell the pump how many grams of carbs I’m going to eat,l and it figures out how many units of insulin I will need,
Does that answer your question? If not, post back and let’s see if we can figure out what further information you might need to more clearly understand this.
P.S. AS I was told when I was a kid, the only dumb question is the one we don’t ask!
Thanks Ruth, that really did help to clear this up.
Any idea on when they switched over?
I went Keto when I figured out that the whole “Exchange” system just wasn’t working. Once I cut out the majority of carbs, my insulin requirement just tanked. Since then, I’ve largely relied on diet and exercise as my primary control factors, with the insulin taking up the slack.
I aged off of my parent’s insurance, individual coverage was 3k per month and excluded anything having to do with T1D. Since everything is touched by T1D, I figured that I had better things to do with 3k per month and didn’t get it. Without insurance, I couldn’t find a physician who would see me, so I just didn’t go. I bought insulin, syringes and test strips at Walmart and just handled it myself.
I did that for 26, 27 years until my wife insisted that we get Obamacare. By that time, I was more than a little resentful with the insurance industry, the medical industry, etc ad nauseum.
So I went to my first Endo appointment since the late 80s. She was asking about my basal / bolus rate and I just looked at her like a dog doing algebra. She asked how I got insulin without a script. I told her that I walked up to the counter and asked for it. She yelled at me when I told her that I was using Humulin 70/30 as though I had just profaned God. She asked about carb counting, and I told her that I could identify carbs fairly readily, but I didn’t eat them, so counting them seemed silly.
I didn’t go back.
They called with my lab result - A1c was 6.5.
I still didn’t go back.
I’m seeing a NP at a PCP who has trouble with the difference between T1D and T2D but will happily write a script for whatever I need. As a result, I’m a little behind on the terminology. My A1c is still good and it turns out that my C Peptide is currently at .3, so I’m making insulin. I’m taking a total of 10u of 70/30 per day. Things are going well.
@Snowwhitetrash I won’t fault the endo too much as N & R insulins are rather twitchy for some. As your TDD of insulin is low you probably can do OK with it, and it seems like you are.
This may not always be the case. It sounds like you have very slow autoimmune destruction of insulin secreting Beta cells. The day may come when there’s no more endocrine insulin.
For this reason it would be good to educate yourself, “Think Like a Pancreas” and the 1st half of Dr Sheri Colberg’s “Athletes Guide to Diabetes” She wrote other books that are probably very good, but I own this one. Also keep asking questions here.
@snowhitetrash I don;t know when they stopped using the exchange diet. I was on it for the first five years, but then I went on insulin. NPH and Regular, and boy was that hard. I had so many lows I developed complete hypo-unawareness. Luckily I had a great doctor who put me on a pump, and that’s when I had to learn to count carbs. That was in 2002. But I suspect a lot of people were counting carbs before then, especially those who were on a pump.
But, no matter how you treat your diabetes, if it’s working for you, then it’s a good thing! And if your A1c consistently stays at 6.5 or lower, that’s also a good thing. As long as you’re not having a lot of lows, and no serious lows I don’t see any reason to change your routine. One thing my doctors have told me is that the older I get (just turned 79), the worse lows are for you, so you definitely want to watch out for that,
I had a really hard time on it at first as well. They phased out Beef/Pork and I was forced onto Humulin. It was like going from Beer to Vodka. So much more powerful, so much more unpredictable.
On Humulin, the lows, especially from the NPH, would just creep up on you. No warning signs, no symptoms, just the world stopped making sense, tunnel vision, nothing but ringing in your ears, rage, and then you would black out. It took years to figure out the patterns and to be on the lookout for them.
I really wish I could go back to beef / pork. That stuff was sublimely smooth.
I tried basal / bolus for about a week. It was WAY too strong. I totaled a brand new Tahoe on that stuff. I took down a Magnolia, ran over a Honda and then took out a traffic signal right in front of Tulane Hospital. Blood Glucose was under 20. The medic who cut me out of the wreck gave me an IV injection of Dextrose and I walked back to my hotel. I tossed the Humalog and Levemir in the trash and went back to Humulin.
79? Congrats! We should be friends. Granted, I’m only 58, but I do respect and celebrate my elders. Come to Costa Rica as soon as we get the hotel and bar up and running. We’ll show you a great time.
I was told by my pediatrician, when I was eight, that I wouldn’t live past 30 and that when death came for me, it would be a relief. I pee on his grave every year on my birthday. But, I’m on borrowed time and I’m not going to worry too much about what any doctor says. Too many of them have been too wrong in the past for me to believe them now. They guesstimate and when they don’t, they lie based on preconceived notions taught to them my pharma reps. They do the best they can, but I don’t trust them anymore. To date, they’ve done me more harm than good.
So, here’s to growing old - especially when your doctor told you you wouldn’t.
Thank you so much for explaining carb counting to me in a way that I could understand it. Very helpful. Thank You.
My friend, thank you for taking the time to respond. I appreciate the time, effort and thought.
I would like to point out that I’ve had T1D for 57 years. If I’m still in a honeymoon period, then I should be the spokesman for Trojan Brand Condoms, because I’ve been knocking on heaven’s door for over a half century.
I’m not trying to bust your balls here, seriously. I have a weird version of the disease. I really should be thankful. I’m NOT, but I should be. Things could be so much worse. It’s like having a mild version of syphilis - Not Thankful, not thankful at all.
So, look my dude, I’m going to keep living life as though it’s going to end on Friday. I’m going to keep BASE jumping, running class 4 whitewater, swimming with sharks, restoring reefs, doing construction, running three businesses and - late to the game - learning to surf.
I still suck at fishing…and golf…
I’m going to blame the Endo and I’m going to blame her HARD. That ■■■■■ almost killed me. She almost killed me with the nonsense she was taught by the Pharma Bros. I hold her accountable and in contempt. She took someone with pretty good numbers and adjusted my meds because she didn’t like them. She adjusted my meds because I spent too little on them.
Yeah, I may be a little angry, but I almost died because of her.
So, for future consideration - any management plan that results in decent numbers without the patient nearing room temperature is a valid plan to be celebrated. And if that plan results in an annual healthcare spend of less than 1k without insurance, it’s to be doubly celebrated.
So, when half of you guys lose insurance next year, or your insurance is going to cost you 5k per month, drop me a line and I’ll teach you some of the tricks I’ve learned after almost 30 years without health insurance.
You’ve actually been carb counting all along, you’re just counting in bigger volumes. At least if you’re still following the old carb exchange guidelines, which I’m not fully convinced of given your explanation.
Carb exchanges came about because we didn’t have nutritional labels until the mid-90s. It was a simple way to “guesstimate” carb content. 1 carb exchange = 15 grams of carbs, roughly.
See, those are examples of high carbohydrate foods, but they are not carb exchanges. You recognize carbs, but you’re missing the EXCHANGE part of the equation. It’s equating all those carbs to a specific amount/volume that puts them all on a level playing field. Did you have the book that broke down the specific measurements? One slice of bread = 1 carb exchange = 15 g carbs. Half a bagel = 1 carb exchange = 15 g carbs. Half a cup of “healthy” cereal = 1 carb exchange = 15 g carbs. 1/3 cup cooked rice = 1 carb exchange = 15 g carbs. 1 small apple or orange. Half a banana. On special occasions, that slice of angel food cake, which was like the only dessert in the book… They’re all equal, so long as you pay attention to portion size. How much insulin we need to cover 1 exchange is unique to the diabetic, though, and varies a lot between people.
If you’re still abiding by those exchanges, then you’re well adjusted to counting carbs in 15 g increments. This is actually how I bolus still, excerpt I take it a step farther. I know that I need 1.5 units of insulin per 15g carb exchange, so now I see the world in units of insulin rather than carb exchanges. I see that 1 exchange piece of bread as 1.5 units and that 2 exchange bagel as 3 units. Same with fruit, that small apple, orange, or handful of grapes is 1.5 units. That 2 exchange banana is 3. It’s also easy to adjust the insulin dose if I eat more than 1 serving. If it’s a big apple or a sweeter type of bread, then I can just dose a little extra. Subjectively deciding if the extra is worth another whole carb exchange, or maybe just half. I’m not eating 1/3 cup of rice. That’s nothing on the plate. I’m way more likely to eat 1 cup of rice, or 3 exchanges, so I see that as 4.5 units of insulin.
I’m a homesteader where we grow or trade locally for most of our food and almost nothing comes with a nutritional label. I’m actually really grateful I have the carb exchange knowledge under my belt. It’s not perfect by any means, but it’s still a solid reference that helps me a lot.
Going back to the carb exchange routine… Because of how slow the old insulins work, carb exchanges were typically combined with a meal plan. You dosed first and ate later. You doctor would tell you how much insulin to take, then give you a paper that said how many carb exchanges to eat to match that dose. For instance, my meal plan was usually 2 exchanges for breakfast and lunch (30g carbs), 3 exchanges for dinner (45 g carbs), and 1 for each snack (15g carbs), for a total of approximately 135 grams of carbohydrate in a day.
I don’t know how much of this is sounding familiar. Sounds like you’ve deviated from the structure over the years. Or maybe you’re just intuitively doing it without thinking about it?
But then in the 90s we got both nutritional labels on our food and rapid acting insulin. It’s no longer necessary to guess at the carb content of our food, and we also don’t have to dose 30-60 minutes before eating anymore. You can dose exactly the amount of insulin to cover what’s on your plate, instead of having to eat exactly enough food to cover the insulin you dosed. So now instead of 15 g approximations, you’re counting individual grams and calculating the amount of insulin needed to cover them.
To do this calculation, you need to know your insulin to carb ratio, i:carb for short. It is simply the amount of carbohydrate 1 unit of insulin can cover. For me, that’s 1unit:10g. I need to take 1 unit of insulin for every 10 grams of carbs I eat. That’s how I was able to say earlier, “I know I need 1.5 units of insulin per 15g carb exchange.”
So how does that play out in real life… Say I want to make a turkey sandwich. 2 slices of bread, 1 slice of cheese, mayo, pickles, and sliced turkey. I could look at the carbohydrate line on the nutritional labels, paying attention to serving size, and add up the numbers. 2 slices of bread at 14g each, 2 g for the cheese, 0g each for the pickles and mayo, and 3 g for the generous portion of turkey, totalling 33 grams of carbohydrate. Since my i:carb ratio is 1:10, my math is real easy. I just have to divide that 33 by 10 to know I need 3.3 units of insulin to cover that sandwich. Except that’s really not how I do it, since I learned carb exchanges. The exchange guidelines say mayo, pickles, and turkey are free foods I don’t need to dose for, but each slice of bread is 1 exchange. So I’d dose 3 units for the 2 exchanges. It’s not as perfect as counting each gram exactly, but it’s quick and dirty and works for me.
You asked about basal vs bolus insulin, too. We gotta start with a quick biology lesson. People are built to burn carbohydrates as our primary source of energy. Except, we can’t eat them around the clock to fuel our needs, so our livers step up to “feed” us carbohydrates when we’re not eating. The liver makes, stores, and releases a concentrated form of glucose called glycogen. People with healthy metabolisms can turn their liver on and off, only releasing that glycogen when needed for fuel. T1s cannot do that. In addition to insulin, we don’t make the hormone that controls that on/off switch, called amylin. That means our livers crank out glucose (glycogen) not stop around the clock, regardless of our current blood glucose or if we’ve eaten recently.
This is what basal insulin is for. It simply cancels out what the liver is doing. It’s also pretty important to equally match your basal dose to your liver’s output. Taking more basal insulin than you need leads to low BG, and not taking enough leads to high BG. It’s pretty much trial, error, and adjustment to figure out the right amount. Conversely, bolus insulin is to cover the carbohydrates you actually eat.
Before I switched to a pump and only taking rapid acting insulin, I also liked the 70/30 pre-mixed insulin. Mostly because it meant fewer shots, not because it gave me the best outcomes. Unfortunately, that NPH in the mix isn’t ideal for evolving into a carb counting regiment. It’s a quirky insulin that acts as both basal and bolus insulin. It’s too short acting to really be considered basal insulin, and it has a distinct activity peak that usually needs covered with a snack several hours after taking it. It also means that if you bolus more than usual for a meal/treat, then you wind up with extra basal insulin, too, that can cause low BG and other problems even as much as 6-12 hours later. If you’re trying to figure out how much of the 70/30 insulin you’re taking is basal or bolus, it’s a lot more complicated than it would be for someone taking a true long acting insulin for basal and a rapid acting insulin for meals.
I also want to mention that you’re right, it’s incredibly rare to still be making your own insulin after 57 years. After 30 years, less than 5% of the T1 population has any detectable c-peptide at all, let alone enough to be clinically significant. If you’re interested, you might want to ask your doctor about testing for MODY. It’s characterized primarily by being highly sensitive to insulin. While most of us have 11 busted genes associated with T1, MODY diabetics only have a single gene mutation. Your treatment may not change at all, but depending on which gene is, some MODY diabetics can even get off insulin altogether. There are oral medications (different than that that treat T2) that fix what the single gene mutation wasn’t doing right. Of course, I could be way off base here, but If I were as exceptionally unique as you, I’d want to explore the possibility!
@Snowwhitetrash I was thinking after reading your post that you may not be Type 1 but MODY. This requires testing for the genetic variant. With luck your insurance will cover the cost of the testing. Perhaps you could get an antibody profile test. If negative for the known T1 antibodies than the genetic test for MODY would be in order.
I remember reading of someone on this forum or another who finally got the test and was MODY not T1.
While this Wikipedia article is marked factually disputed it gives a pretty good explanation of MODY and the subtypes.
Robin, I’ve got to admit that I’m IMPRESSED. Somebody took notes when the nerdy bohemian chick sporting granny specs and Birkenstocks came in with the cart of rubber food. I’ll admit that I just zoned out for most of that.
What I did catch was that I had a caloric limit per meal and per day. I would swap out the exchanges in order to hit that limit but didn’t really pay attention to the carb ratios. If I was really hungry, I would gorge on salad - I could have all of that I wanted.
But, honestly, I’m really impressed by the clarity of what you’ve laid out here, Thank You. Very Helpful.
I was diagnosed when I was 6mo old, so, maybe I’m MODY? I’m certainly moody now, but I chalked that up to poor life experiences, sarcasm as therapeutic form of expression and a chronically bad attitude.
I’ll look into testing, but it’s going to take a while to get me back into a medical office. I’m an Iatrophobe and don’t just waltz into medical appointments, you pretty much have to trank dart me to get me into the office. I go in to get scripts renewed and that’s it. I haven’t been touched by a doctor in over a decade - I just don’t allow it.
I can never remember. Is it the MODYs or the LADAs that all trace their genes to the Faro Islands? I think it’s the LADAs???
I take 2 units of bolus (short acting insulin) per 15g of carb.
15g = 1 piece of bread
= 1 orange = 1 apple = 1 pear = 1/2 banana (because some of those tropical fruits just have higher sugar content)
= 1 Cup of milk
OK, so Neonatal Diabetes might fit and it falls in the MODY spectrum.
My birth mom has Ehlers Danlos as does my aunt on my birth father’s side. In that the condition is dominate, I was surprised that I dodged that cannon ball, but maybe I didn’t…
An “exchange” is 10g of carbohydrate, so if you do exchanges you carb count.
Diagnosed 72, introduced to exchanges, yeah, early-mid 80s. Before that it was a paper pamphlet with a few pages with carb counts on them, in the 80s it was a big book with exchanges.
Yep. I’m a T1 with a pump and a CGM and full AIDS to boot but what you say is correct. If I go full keto and I’m exercising, not much, a moderate amount my insulin sensitivity goes way up (low insulin) and my control goes way up too (many, many fewer lows or highs).
If I keep my activity level high this continues, even in cases where I am eating way-non-keto amounts - my seven day recorded average is 102g and I do eat things I don’t record so think at least 15 exchanges maybe 20.
It’s winter where I live now so my activity level is falling. My insulin resistance is rising. I’m again seeing all the problems everyone complains about; FOTF (BG rising through the roof when I step out of bed), brittle diabetes (BG rising after eating then crashing), sticky highs (nights at 200, someone should write a song.)
