At the moment, I do not have an endocrinologist or a diabetes educator or, indeed, anyone helping me. I believe passionately in the necessity -- FOR ME (I make no prescriptions for anyone else) -- of eating quite a low-carb diet, in order to try to manage my diabetes, but all the endo's I have seen (and I've seen four, all highly regarded and expensive, since April) buy into the American Diabetic Association guidelines, and want me to eat at least 180 grams of carbs per day. I think this would be disastrous.
I'm currently eating fewer than 40 grams of carbs/day, often fewer than 30, and I'm following the insulin guidelines I was given in April: check my blood sugars before meals, and take 3 units of Novolog if my BS is 100-150, 7 units if it's 150-200, etc.
This ain't working. I am struggling to get my blood sugar levels below 200, and in the morning (I take 28 units of Lantus at night), they are typically over 250. I know I need to increase my insulin, but I don't know how to do this safely. Can anyone advise?
Also, I am pretty desperate, at this point, to find an endocrinologist I can work with. I'm in NYC, but am willing to go just about anywhere to find the right doc. All suggestions WARMLY appreciated.
I can't help you with the doctor recommendations, maggiesara, but I have a few suggestions. I really recommend the book Using Insulin by John Walsh which will give you the guidelines for dosing your insulin. The sliding scale you mention is a very outdated way of dosing bolus (mealtime) insulin. You need to work out an Insulin:Carb ratio so you take the right amount of insulin for the food you are eating. You wouldn't take the same dose of insulin for salad as for pasta! Then you need to figure out your ISF (correction factor - how much one unit of insulin lowers your blood sugar) so you can correct highs. Finally if you are waking up at 250 you are not getting enough basal. I would suggest raising it a couple units at a time and seeing how it improves your fasting blood sugar. You also might try splitting the dose of Lantus, taking 1/2 at night and 1/2 in the morning beause that might work better. If you increase it to 30 keep that for a couple days to see the results before you increase it again.
Using Insulin will explain the I:C ratio, but basically start with 1:15. That is, one unit of insulin for each 15 grams of carbs. So if you eat 30 grams, take 2 units. See how you do. Since you are Type 2 and have some insulin resistance you will probably still be high. So after a couple days, you can try 1:12, etc. Also different meals might be different. For example my ratios for the three meals are 1:6, 1:11 and 1:16. (I am Type 1, so don't have insulin resistance).
I agree with you and Zoe, that the numbers you're seeing are not the numbers you want. Particularly if *you* don't want those numbers. I read John Walsh's other book and agree that Using Insulin will be a big help. "Think Like a Pancreas" is also a very good sort of "owner's manual" for diabetes that I found very readable, like I couldn't put it down.
More specifically, I also agree with Zoe's suggestion to increase your basal to try to fix the fasting numbers you're reporting. Carb counting and ratio balancing hopefully can improve your post-meal #s and then you'll be set. This is, of course, harder than it sounds to talk about but it sounds like you are very sharp in your perception of your numbers and desire to fix them so I think that you are ready to try to go beyond what your current docs are recommending. I hope you can work things out and that you keep coming back with more questions as you run into them!
Forst, I second the two recommendations above - "Using Insulin" and "Think Like a Pancreas". Learning how to self-adjust insulin is vital to maintaining good BG control, in my opinion.
Second, the doctors you spoke to are out of date. The American Diabetes Association (not to be confused with the American Dietetic Association!) started accepting low carb diets in 2008 as part of their clinical practice recommendations.
I've just bought both the Walsh and the Scheiner books, and thank you all for the recommendations. I have the Bernstein book, and am actually reading it right now, though it scares me a little: He seems to advocate a VERY low-carb regime, and I have spent too much of my life waltzing with failure in the form of diets I couldn't stick to. I'd be very interested in talking to anyone who works a Bernstein program.
SuperSally, would you mind telling me a bit about protein/insulin ratios? i'm pretty new to the notion that I need to monitor my protein as well as my carbs, but I hadn't heard at all that I would need to adjust insulin for it.
Folks, I can't tell you how grateful I am for the smarts. The medical establishment seems to me to be just out to lunch on this entire issue.
I disagree that eating more carbs reduces the effect of protein. I see protein effects all the time. I am not sure I can disprove the "the standard American diet" as I'm still eating about less carbs than the dietitian rx'ed, 100-150/day instead of the 180-270, the last time I had seen one (2008, when I got my pump...).
The conversion ratio I've seen here and maybe in some books is 53% of protein will convert to carbs. I just use 50% as that's as much math as I'm gonna do.
I would encourage you to focus on establishing your basal first. With a very low carb diet, your blood sugar will primarily be determined by the basal. If you are actually T2 and both insulin resistant and insulin sensitive, you may need much more than 28 units of Lantus. In the end, you need as much insulin as your require.
And to establish my basal, I basically increase the Lantus in 2-unit increments, holding each new level for a few days, until I get the fasting BS I need? And maybe try splitting it, with, say, 1/3 allocated to the morning?
I would recommend to split the Lantus evenly. Lantus will act for 24 hours with some degradation. The splitting helps to overcome the uneven distribution of insulin activity. By using uneven allocations you might work against this goal.
I'm certainly not going to offer specific advice since I don't have diabetes myself. I'm the mother of a son with type 1. He is following a very low carb regimen and it's working for him. I found Dr. Bernstein's book "The Diabetes Solution" to be particularly helpful. He gives detailed instructions on calculating I:C ratios while eating no more than 24-30 grams of carbs per day. This book has been our bible for diabetes mgmt. Dr. Bernstein does live in New York state. I'm not sure if he still sees patients, but you could try, or he might have recommendations for other doctors that are more in line for what you are trying to do.
-and hang in there. My son and I are early into the d thing, but we've already had to fire one endo. Trust yourself that you are doing what's right for you.
Definitely do not go by the ADA guidelines. Their advice will kill you! I had my worst A1C when I stuck to those guidelines. My favorite book is "Think Like A Pancreas." Before I started bolusing before meals I read it cover to cover in two nights.
My advice would be to go up on your Lantus, maybe by a couple of units and perhaps take it at an earlier time. I remember I would take my Lantus right at bedtime and I would still be waking up at 140. However, since it is long acting it takes awhile for it to kick in, thus not being fully able to combat the whole "Dawn Phenomenon". So I inject three hours before bed now.
I keep my diet to 70 carbs a day and I bolus all of my meals (between 2 and 6 units), unless it is a piece of baked chicken or something.
I think a lot of your problem might be dawn phenomenon. When I wake up high I know it's going to be a high day.
You know, I am thinking more and more that this is a Dawn Phenom issue. I woke up with a BS of 266, and it has not gotten below 240 all day, even though I have eaten fewer than 20 grams of carbs, and have been shooting 7-9 units of NovoLog before each meal. And FWIW -- though I have made this mistake in the past -- I haven't been binging on low-carb stuff or protein, either; my calories for the day are below 1000. So, yeah, I'm thinking more and more that it's a lot more about the basal and the DP than it is about what I eat.
I can't help you with DP, maggiesara, as I'm lucky enough not to experience it, but I was wondering if you do corrections when you are that high? To do that you need to know your ISF which is how much one unit of insulin lowers your blood sugar. Mine is 1:30 during the day and 1:60 at night but I'm Type 1, yours will probably be less. To determine it, start conservatively (like 1:30) and see how much your blood sugar comes down after 3 hours. Keep records, then adjust it accordingly. In other words if you don't come down enough after using 1:30 for awhile, try 1:25.
I'm afraid I'm a little unclear on this: The process seems to have too many variables. What I mean is, I'm trying to track both A) how many grams of carbs are 'covered' by 1 unit of insulin, and at the same time B) by how much 1 unit of insulin lowers my blood sugar. Could you clarify?
Yes, they are definitely two different things and I know it's overwhelming when you have to work out so many "math problems"..lol. You might want to focus on one at a time.
1. I:C ratio - is exactly what you said, "how many grams of carbs are covered by 1 unit of insulin....for you...we are all different and you might have different I:C ratios for different meals. This is what you have to figure out over time to accurately bolus for your food.
2. ISF (insulin sensitivity factor)- This is the formula you use to do corrections. The reason I brought this up (though some people don't start it right away) is because you mentioned being high all day. Corrections are a way to determine how much insulin to use when you are too high and want to bring yourself down into range. You can use them a couple hours after a meal (being sure to keep track of your insulin still active) or you can add the correction into your carb bolus (which is what your sliding scale was about).
So both formulas take time to figure out, both are important, but they have too different purposes. 1) to dose for your meals and 2) to correct highs that happen for whatever reason so you don't stay high for hours.
I just do it all at once. Most of the time, it's probably not more than a few oz of meat, maybe 6-7 if I'm really on a roll, and I'll count it as about 15-20G of carbs but usually it's more moderate and I'll just count 5-15, depending on eyeballing it. I've tried dual and square wave boluses but I get better results with the regular all at once boluses. If there's carbs floating around, I don't think the insulin gets too far ahead for a 5-10g hunk of carbs although I know there's lots of people who that's all they eat, in which case a slower hand might be better?
I do mine a little bit differently, although I also "cheat" with a pump and CGM so it may be easier but if a fasting # is high, I'll blame the basal and, if it's high a few days in a row and seems consistent, I'll try to nudge the bolus up 5-10% (like from .8u/ hour to .825U/ hour, like 19.2 vs 19.8U/ day...) and see what happens. In many cases, even a little change like this can move things in the right direction.
If it's the post-meal readings that are off, high or low, I'll turn the basal ratio a bit, again, usually a couple of "clicks", which are .1G of carb/ unit on the Medtronic pump. It will usually cause results.
I try to keep the new settings for a couple of days before thinking about it again. Soemtimes it will get way out of whack but other clues I look at are a lot of little corrections, either insulin or food, that might mean it's time to fix things. I don't worry about the ratio being correct, but moving it in the right direction. Theoretically, it should get it correct but things change so much that it's hard to say for sure sometimes what's going on. Which is probably horrible to say but I think that the being engaged and working is useful.
