The Strangest Thing

I am working with a Diabetes NP. She works with the NNMC Bethesda, for the Diabetes Institute. I am having trouble dealing with her ideas and need some feedback from you because what she is telling me doesn't make sense.

I was on a low carb diet, I feel best when my BGs are around 120 but I have lower than that BG all the time and feel good that way too. I do not feel good when my BG is high.

I have had these strange directions to follow until Tuesday. Lower my basal by 20 units, take 8 units when I eat of fast acting. Don't worry if your BGs are over 200 or even 300 for the next week. write everything down, don't make corrections and eat at least 30 carbohydrates with each meal.

Can't for the life of me figure out what the rationale is behind all this and I have felt awful this week with these high blood readings. I guess she is going to raise the short acting when I see her on Tuesday?

She has problems with the fact that my long acting and short acting is not 50/50. When I get ranges from her she likes my fasting to be 120-150! Just keeping things under 200! She keeps telling me that I have no complications and that I don't need tight control.

I don't care for eating all these carbohydrates, I feel bad with higher BGs and I plain and simple don't get it. I am not even hungry anymore.

My AIC was 6.4, I was low carbing and going for a lower one, now this. I am confused to say the least. Just tell me is this total craziness or what?

I think that having the long acting vs short acting be out of whack, can be an indication that it's time for a "reset".

A drop of 20 in basal, wow, not sure what your doses are, but that's unimaginable to me! Way too big of a reset!

Are you using MDI? What is your short acting, Regular or Humalog or Novolog or ???. Lots of times Regular is a better match to low carb meals. It is possible that your basal was creeping up if you had been trying to match the fast-acting analog insulins to low carb meals. (As in "been there done that"!)

Tim has some good ideas there

You should say to her what Donald Trump says:

Seriously. Who cares what she wants your BG to be or what your ratio is. If your body is set up so you need 60/40 or 40/60 or some other %age, I would stick with that and keep doing what you're doing. Why did you see her in the first place? At the same time, I've noticed that when I had a lot of "basal bumps" programmed into my settings, basically getting some extra that way around meals, which worked great during the week but not so well on the weekends when I didn't eat at consistent times. I deleted the bumps and went back to mostly flat basals and found that it worked better once I got it straight? If she thinks something like that is going on and bears adjustment, she ought to be able to artculate it, particularly since you or LotsOfShotsInsurance are paying her money.

She thinks either that you are, unfortunately, like most of the patients she sees,who do not do the things that you are doing to try to say in control, such carb counting, adjusting insulin dosages independently ,testing logging etc.(If she is their NP( CDE?),they probably have not been taught to do that. She may not have been educated to do that herself, and knows little else.

We on Tu d, with our knowledge base and skills, are a tiny minority of the diabetes population. She probably was not trained on anything else but sliding scale. She is useless to you. If you have to go there , just nod and smile and tell her that you KNOW how to stay away from hypoglycemia and will continue to do what works for you.
Another sad examople of how diabetes is treated at the level of these medical personnel thought processes:
"1.It is too complicated to present a more rigorous plan.
2.the patients will be overwhelmed with all that data, and not follow it: to say test then treat, No way...
3.It is too hard for us to manage all those individualized treatment plans: too many patients to see and be accountable for.
4.Tight control might cause a pass out from a low( and we might get sued)..
So just do enough to keep them alive, not well, but alive"
Such sad paradigms, but the nature of most diabetes education today.

Keep up with what you are doing and stay at peace.

God bless.

Following up on Tim's comments: It can make sense to rebalance basal and bolus insulin but it sounds like you're being asked to participate in a science fair project rather than a medical intervention. Fasting at 120-150 and post meal targets of under 200 are just too high. They might be appropriate targets for a brand new T1 trying to establish initial control but you've been doing this for 20+ years. I assume you carb count and therefore, don't understand instructions to take a fixed 8 units per meal. And telling you not to correct is simply cruel. Why should you feel sick so the NP can get nice little patterns.

I tend to be a compliant patient but I wouldn't go back.


I would/could not follow her directions. A shot of 8 units for 30 carbs would have me lower than low..and I guess no one has informed her that damage begins to other body sytems when bg is >140? And if my BG is @ 25o I can start getting Keytones so..yeah, I would not do what she is asking.

The other question I'd have, more for you than her, is what were you seeing her for in the first place? Is it just "you should see the nurse?" sort of deal from the doc or did you have a goal in seeing her?

In your heart, you know the answers to all these questions. You just need the confidence to hold your ground. You know that raising your blood sugar for no good reason is just nonsense. You choose your blood sugar goals. Unless you are placing yourself at risk of hypos, there is no logical reason to raise your blood sugar.

And if you are eating low carb, you won't have a 50/50 basal/bolus ratio. When you restrict carbs, your daily total bolus drops. Your basal requirements remain the same, as do your ICR and ISF and it just makes sense, you just bolus less when you don't eat as many carbs. My ratio is actually higher than 80/20.

You need medical care, not medical mistreatment.

If you lost 17 pounds that quickly it might indeed be time to lower your basal. Still 20 units lower, don't know your current doses, sounds like more than just a tweak!!!!

If you continue low carbing, seriously think about switching from Novolog (which acts over just an hour or two) and onto Regular. You might find your bolus doses going up a little and your basal dose going down a little after doing this. For me the fast acting analogs are just too fast for low carb.

I think Dr. Bernstein mentions something about Regular being a good match to low-carb. He has a point, Novolog or Humalog can kick in way too fast.

I agree completely with each and every reply, lotsofshots. You know more than this woman does, even though she has the letters after her name, she is woefully uneducated and just plain wrong. If you were going to her, because you are having some management problems you need help with, I would find a medical professional who you really think knows what they are talking about! I also wouldn't hesitate to ask questions on here. We may not be doctors but we have thousands of years of combined experience and knowledge. You may got various answers that you can sort through to see what applies, but you will get answers because someone on here has experienced the particular D issues that you have. It's worked for me so many times I should probably submit an insurance claim!
"Well you see, Anthem Blue Cross, they are the DOC so they really know their stuff!"

Yikes, that's the first time I noticed that DOC (Diabetes online community) spells "doc" as in "doctor"!

So it sounds like terrible advice to me. My first nurse said a lot of the same things about eating carbs, needing fuel for my brain. I just don’t feel good using a lot of insulin and I also feel terrible with huge swings in BG which can happen when you are trying to match carbs to insulin. What was your BG when you woke up after lowering your basal by 20 units?

Wow, you have been through a lot! And I can understand now that your medical issues are very complex and you have a team working to unravel and treat them. That does put you in a hard place not only because you are expected to comply with the team's advice, but because you need their help. The only time I've felt that feeling strongly was with my cardiologist because heart issues scare me and I don't know much about them. I may be totally off base here, but I also am very tuned to the fact that medical personnel treat patients differently when they have a past or current history of mental health issues. It makes me wonder if in addition to "not treating me like a person but like 'a diabetic' they are also treating you like a diabetic who has had mental health issue, translation: whose judgement is compromised. Like I said I could be reading too much into this but I've seen it many many times before.

You may not have the answers with the complex medical situation you are in (like I didn't/don't with cardiology) but you have lots of answers and knowledge about your own body when it comes to D and diet. I guess depending on how you read this NP, your choices are the old "smile and nod" to her nonsense or to stand up and say, "no that is not right for me" I always try to pick my battles.

Thanks for sharing that! I know you've mentioned some of this before and I apologize I didn't recall the sort of details that you put in there!
I think that with an "average" of 120 or 140 or whatever, if you are going up and down a lot it can make you feel very depressed. I am certain that if I had been honest with the doctors about what I felt like during my "rollercoaster" years I'd have been put on a bunch of psych meds too although, as a former "partier", I'd perhaps have wanted to argue with them about which ones? It's probably fortunate for me that I took a different path.

I had a cardiac "event" last year on Mother's day, overactive w/ a hypo, and the paramedics noted a wierd hiccup in my heart beat so I had the first round of tests, f/u w/ endo who said "if I were you, I'd see a cardiologist" but I asked her "is it possible that the heart was 'just' from being zonked out of my gourd on insulin" and she said something like "well, maybe" so I blew off the f/u and am trying to be more careful.

I wonder if she's trying to get a "baseline" for diabetes near the "national average" to see if that's affecting some of the neurological things you are approaching? That might make sense but I'd think that unless she can point to research showing that "if you don't eat 120G of carbs/ day, you will get neurologically fried" you should put your foot (or mouth?) down about the carbs and say "that's what I'm eating and my prior results are better and I'm going back to it". I don't think there is any such research other than rumor and innuendo (e.g. "Atkins causes kidney damage!"). I think the problem with doctors using "the national average" as our benchmark is that many people don't feel all that hot in the mid-100s, particularly if you are going up and down all the time to get there?

If there's a brouhaha with the team, then they should all get together and talk about it with you instead of shipping you around to doctors to only manage their own "specialty" in your group of symptoms.

You aren't wrong at all in your sense that your BG should be controlled the way you were controlling it. I'm not aware of any studies suggesting 6.4 is dangerous, unless you are running into the 40s all the time to get it, which I don't have a sense of. If you feel poorly at 275, I'd say "you know what, thanks for the idea but I felt horrible and needed to fix it".

[ed. put reply here to keep the thread going, sorry for any inconsistencies...]

Hi Lotsofshots,

You should eat the number of carbs you want but 30 per meal really isn't that high if you're eating 3 times per day especially if you actually count fiber and green vegetables


Glad you are off the meds and that was most definitely an old school cocktail!

Looking back at your original post, the thing about formulas: When I first read Using Insulin I compared the formulas to what I was actually doing and I didn't match any of them. I still don't. I have come to take those formulas as guidelines only and real-time data as way more important.

As for the carbs, I know you are used to low carb and you should absolutely do what feels right to you and gives you good results. But just for a little perspective: 30 carbs per meal - 90 carbs a day is not "high carb". It's about what I eat and I consider it moderate/low. Your average person eats way, way, more than that. But again, I totally respect and admire people who low carb and it obviously works well. I agree with your approach, that if she can show you documentation why any of what she is saying is correct, or more important if it has some special application to your medical condition that is one thing. In your place that is the question I would be asking. But frankly, her general approach - which I assume is irrespective of your medical issues and what she tells everyone: "Fasting 120-150, stay under 200 and under 80 is bad" lead me to have very little faith in her ideas.

Reading this thread I have two thoughts. I’m going to play devil’s advocate here. During periods of severe acute illness or where I’ve been medically unstable my endo has suggested I temporarily aim for a higher bg target of 120 to 180 premeal. I was skeptical at first but I tried it and I found the strategy to be extremely helpful. I’ve found it much easier to live with blood sugars of 100 to 250 than 30 to 600 which is what typically happens if I try to aim for my usual tight control during for example a severe asthma attack and high dose steroids. I’ve also used it postop etc. The key here is this higher target is only meant to be temporary and not long term which is something my endo made clear. Long term I keep my sugars in tighter control.

The other thing is if I had a sudden change in my neurological status like the original poster did I absolutely would be raising my bg targets in case undetected hypoglycemia was contributing to the symptoms. Even if this is unrelated to hypoglycemia any lows are just going to add insult to injury and confuse the issue. Eliminating lows from the equation may make it a lot easier to figure out what’s going on.

In these circumstances I can see a lot of advantages to running sugars a little higher for a few weeks. It’s very possible that these target bg’s are only meant to be temporary and not long term.

I feel that this is total crazy. There is absolutely no rationale behind a 50/50 split, especially since you are on a low-carb diet (those ratios might apply to someone on a carb-normal diet, but should not be applied slavishly to everyone). Your BGs and A1C is perfect.

You don't NEED carbs - you just need to balance your carbs with insulin, as you have been doing (perfectly I might add). High carbs is the major reason why so many people are overweight.

The ONLY reason they would do this, is if they suspected that you are getting low overnight (rebound effect), and therefore having massive doses of insulin to correct your BG down all the time.

I would ask them if they are looking for evidence of a rebound effect - if not, stick with what you are doing.

Then just smile and tell her you will treat everything below 80 mg/dl and do everything you already decided you would do. After all, how much can it harm you to agree to treat everything below 80 mg/dl but keep true to everything else you believe?

I agree with Brunetta. My Mom (diabetic) told me once "Never eat to cover your insulin".....You should take insulin to cover what YOU want to eat. If what you have been doing was working, why change? I wish you well, and you got alot of great advice. xoxo