Author: rwhita

How To: Turn My Pen Into Pump

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This section is for everyone.  If you are managing successfully on your pump you may skip this section and proceed to the How To: Cover a Strict Low Carb, Moderate Low Carb, and High Carb Diet with Insulin section.

Well, of course, you can’t really change your pen into a pump. But what you can do is look at why pumpers often get better meal coverage than the injectors.

Pumpers can do several things with their pumps to get better meal coverage.

They can pump in several units at once – an immediate bolus.
They can give the dose over a few hours – an extended bolus.
They can programme the pump to give two smaller boluses within a short time of each other – dual wave bolus.

Fortunately you can get the same results with your  pens and vials.

Pumpers are told that to avoid a lump of insulin under the skin they need to pump  5 units or less at an immediate bolus whether for correction doses or for covering meals.  They may go on to cover the meal with a dual wave or extended bolus if they need more insulin than this for that meal.

The absence of the lump of insulin under the skin makes its absorption much more predictable. Did you know that 70 units of insulin injected under the skin takes a week to fully absorb?

Dr Bernstein has found that 7 units injected at once is the  absolute highest amount of insulin per shot that will ensure accurate enough absorption of that insulin.  Otherwise the insulin you think is going to cover that meal won’t work as well as you expect and it is likely to release when you don’t really want it to.

Now the 7  units per shot tip is something that often fills newcomers with dread. They say things like, “You mean I’ll need four jags to cover one meal!  You have got to be kidding!”

Why is this? It’s not just because they can’t divide by 7. It’s not just because they object to the slightly increased time the injection procedure will take. It’s because up until now they have been having injections that are really quite unpleasant and often painful. They also worry about the lipoatrophy at their injection sites. Does this mean more of these?

The answer is no. Not only do the smaller amounts give you an insulin that “does what it says on the tin”.  They give you a lot less discomfort per shot and virtually no lipoatrophy at all.

You will have noticed  that I almost expect that you will be eating a high carb/low fat diet right now. Let’s face it, you are only doing what you have been told to do by your doctors and dieticians. As you get further into the low carb way of eating you will find that you need less and less insulin to cover your meals. And that means many fewer injections as time goes on.

When someone goes from a multiple daily injection regime to a pump they need to cut down on the total daily amount of insulin they go on with the pump.  This is usually a decrease of 20%.  This is because the slow leakage of insulin under the skin is more efficient at getting the insulin into the body. Its not just sitting in a big lump doing nothing any more.

The 7 unit per shot system is not quite as efficient as a pump but gets you results that can be pretty close. I therefore recommend that you also reduce your bolus amounts by 15% to start with.  You do this for your current basals as well as for your current meal boluses. This would not apply if you inject 7 units or less at that time normally of course.

Dual wave bolusing can be done by two or more injections to cover a meal of the more slowly digesting type such as meaty dishes, pizza,  and pasta with creamy sauces. You simply need to remember to give the second or third jag at the time you planned.

Fortunately there are different durations of insulins that can be used that can give you the same effect as an extended bolus.

Most  insulin users have been put on rapid acting analogues for meals.  Novorapid and Humalog. These peak at about 70 minutes and last about 3 and a half hours with a tail to about 5. What the usual blurb  says is that they cover “most meals” and so this is all you need.

Before analogues were invented however the older regular insulins were used to cover meals. These peak at about 2 and a half hours and last 5 hours with a tail to about 8 hours. What the usual blurb says is that these take longer to work and are less convenient than analogues to cover meals.

These characteristics are however just what you want to cover higher protein, higher fat, and more low glycaemic carbs. Its rather wonderful in fact.

When you give these regular insulins on their own to cover carb you need to remember two things. Firstly they do take longer to work so you need to inject them optimally 45 minutes before eating that carb.  30 minutes will do but is not optimal.  The second thing to remember is that these are less potent insulins and you need to give a third more of them than with analogues for the same amount of carb. Actrapid would cover 8g of carb compared to  one unit of humalog that would cover 12g.

When you use these insulins to cover protein and more slowly digesting meals the fact that they take longer to start working becomes an advantage and you can get on with injections optimally 15 minutes before a meal.  Just before you eat will often do.

Quick Quiz:
1.The same amount of insulin to cover the same high carb meal at the same time of day can have a varied effect on your blood sugars by:
a 5%
b 15%
c 30%
d 90%

2.Insulin effect predictability can be improved by one of these…
a Keeping injections to 7 units or less.
b Having regular snacks.
c Having a low fat/high carbohydrate diet.
d Taking plenty of aerobic exercise.

Have you got it?
1. C is correct. The Joslin Institute have put it as high as 30-50%.
2. A is correct. The other options are likely to make blood sugar control more difficult.

Reference Info:

Where to Next?
Please now continue to the How To: Cover a Strict Low Carb, Moderate Low Carb, and High Carb Diet with Insulin section.

How To: Calculate My Insulin Sensitivity

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This section is for everyone.

Insulin sensitivity may not change much at all throughout the day in pre-pubertal children.  After this most people find that they need more or less insulin at different times of the day.

To find out how much insulin you will need to take to cover carbohydrates taken at different meals you will need to find out your carb to insulin ratio.

An average insulin:carb ratio for type ones who are thin is one unit of novorapid or humalog for 12 g of carbohydrate.  As  regular insulin is a third less potent one unit of actrapid for instance covers 8g of carbohydrate.

If you eat the same amount of carbohydrate for breakfast, lunch, dinner and bedtime snack with the same dose of insulin you will find that sometimes it works better than at other times.

Most adolescents and adults need more insulin to cover the same amount of carb at breakfast than at lunch because the dawn phenomenon makes them more insulin resistant for a few hours, often up till 11am in the morning.

Most people have the best insulin sensitivity in the early afternoon eg 2-4pm.

Some people get a “dusk” phenomenon and become a bit more insulin resistant at dinner time.

My son Steven’s insulin to carb ratio is 9 at breakfast, 14 at lunch and 10 at dinner. Because I particularly want to avoid night time hypoglycaemia I give him only 2/3 of the amount of dinner insulin to cover a bedtime snack.  The figures are therefore 9-14-10-14.

You have to  guess and test to work your own figures out.

If you are writing down your blood sugar figures in a book or chart add and take the averages of your bs on  pre-lunch, pre-dinner and pre-bed for at least 3 and preferably 10-14 days.

If you have averages that are above your personal target figure or 5.0 for those who are seeking optimal control you need to have more insulin to cover your breakfast, lunch and dinner respectively.

Accurate basal insulin levels and carb counting skills are essential to do this accurately. If your sugars are running particularly high for any reason eg you have a dental infection or the flu or your exercise pattern has changed over the test period your figures will not be correct for you.

Quick Quiz:
1. Insulin sensitivity….
a Varies according to a person’s individual daily and monthly patterns.
b Worsens with the duration of type one diabetes.
c Is the same for a given amount of carbohydrate for any given person.
d Is irrelevant if a diabetic follows a low carb diet.

Have you got it?
1. A is correct. Once the honeymoon is over there is no particular reason for insulin sensitivity to decrease over time although weight gain and change in exercise and hormone patterns can affect insulin sensitivity in their own right.

Reference Info:
Acknowledgements: Dr. Bernstein’s Diabetes Solution and Dr Gary Scheiner’s Think Like a Pancreas.

Where to Next?
Please now continue to How To: Turn My Pen Into Pump section.

 

How To: Know How Different Insulin Regimes Compare

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This section is for everyone.

Basal insulin holds the blood sugar steady between meals and during sleep. A bolus is a dose of fast acting insulin given to cover meals or to reduce a high blood sugar.

Here are some popular ways of using these insulins.

Two mixed doses

Eg Novomix or Mixtard.  The basal and bolus insulin is premixed in a fixed combination so that only two injections are needed in a day.

A high level of consistency is needed for meals and snacks. What is eaten and when it is eaten can be manipulated to give good results. The difficulty is that there is very little flexibility and you can’t just miss meals or eat more than usual and get away with it.

If your blood sugars are running high with this regime the main technique to get back in track is to give the injection and wait till the blood sugar has dropped before eating. Lows can also occur and you need to develop snacking routines to even these out.

This regime is often used for people who need help with their injections or who want to avoid injections such as younger school children and in the elderly or visually impaired.

Where money is an issue mixtard is cheaper than then newer analogue insulins.

The best coverage with this insulin is at breakfast and the evening meal. The injections are usually given 15-45 minutes before these meals depending on the type of fast acting insulin used.  A lower carb meal can be eaten for lunch to help keep sugars normal. Alternatively a separate injection of regular or a rapid acting analogue can be given before lunch.

Morning mixed with evening split

Eg Mixtard am, Actrapid pm and Lente bedtime.

This regime covers the dawn phenomenon quite well because of the duration of the lente insulin. The mixed insulin in the morning means that injections during the school day can be avoided.

The minus points are a tendency for lows before lunch and high blood sugars after lunch.

This regime is not used frequently but it can suit some people very well. I know of a teenage girl who has a degree of intellectual impairment.  She has  a considerable dawn phenomenon.  She uses this regime to avoid having to give insulin injections while she is at school.

Multiple daily injections with long acting basal

Eg Humalog for meals and snacks with Lantus once or twice a day.

This regime gives much more flexibility for meals than mixed insulin regimes.

The disadvantages are the number of injections. There can be 4-10 a day.  Insulin pens are generally easier to carry but are more expensive than vials and syringes. The insuflon device can be useful for babies or toddlers on a MDI regime as the insulin is put in the same channel for a day or two so can be less uncomfortable.

This regime is the most popular for most older children and adults. In the USA all children are started on an intensive regime from diagnosis. In Europe there is more tendency to use a mixed regime at least to start with.

When it comes to advanced insulin techniques this is the method that I will mainly be discussing.

Insulin Pump Therapy

This is also known as a continuous subcutaneous insulin infusion system or CSII. It has been developed in the US and is much more popular there  than in the UK.

Plus points are that finer tuning with insulin is possible with this technique particularly due to the ability to alter basal rates.  Most people need to change the insertion device every 1-3 days.  Once this is done there are a greater variety of bolus patterns you can use without having to have another injection.  Many users love their pumps and greatly prefer it to the MDIs especially once over the first few months.

Disadvantages are that it is comparatively expensive. It costs about  £5000 for a pump for five years use with an additional £1000 a year for sterile consumable supplies. You still need to have pens or vials and syringes handy  in case of pump failure.  It is available in some UK centres but the cost is not borne by the NHS and must be paid for in person or from a charity.  A great deal of learning and monitoring is required to use this method successfully.

There are also problems that can occur on the short and long terms. Pump failure through the night can result in you going to bed with normal blood sugars and waking up in diabeticketoacidosis.  Long term scarring at the infusion sites and the occasional abcess can also be problems that result in users going back to MDIs.

Quick Quiz:
There is no quiz for this section.

Reference Info:
Acknowledgements to Dr Gary Scheiner’s Think Like a Pancreas.

Where to Next?
Please all continue to the How To: Calculate My Insulin Sensitivity section.

How To: Use Insulin to the Best Effect

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This section is for everyone.

In this section I am aiming to give you information on  what you need to know to use insulin not just to keep you alive, but to keep you as well as you would want to be if you didn’t have diabetes.

I will be discussing different sorts of insulins and different sorts of delivery devices.  Most basic techniques are covered in your diabetic clinic but here I want to help you take things further. I want to try to help you get the best match possible to cover your daily rhythms and food intake.

As in most of this course self experimentation is the key. Various techniques are described and you have to decide if you would like to use this technique to control your blood sugars or not.  You then need to change what you do in a gradual and controlled way.  Whenever you are experimenting with new food, exercise and insulin patterns you need to test more frequently and be prepared to adjust things according to the results you are getting.

I hope that you will have started to count up how much carbohydrate you are eating each day. You may still be seeking some more information before you begin to reduce it and this is okay.  Arm yourself with lots of test strips for this section!  And lets begin.

What is insulin?

Insulin is a big protein made by the beta cells of the pancreas. It controls several functions in the body.  The most important ones for diabetics are:

Insulin tells certain cells to take in sugar from the blood stream and so drops blood sugar levels.

Insulin tells your liver to reduce the amount of sugar it is making from protein.

Insulin is a growth hormone.

Insulin is a fat storage hormone.

High insulin levels tend to stiffen and age your blood vessels.

In 1922 researchers in Toronto, Banting and Best discovered how to extract insulin from animals to give to humans.

Fine tuning did not really exist until blood monitoring was popularised in the 1980s for all type one diabetics. Since then genetically engineered insulin has been produced from yeast and the e coli bacteria which is structurally identical to human insulin.

Different action times of insulin have been developed by altering the chemical structure of the insulins or by the addition of stabilising substances.

Syringes and vials have been supplemented by pen injectors, pumps, and now inhaled and oral insulins.

There are different potencies of insulin with different onsets and durations of action. Eg rapid acting, regular insulin, intermediate acting and slow acting.

Modern analogue insulins tend to have a more predictable pattern of action than some older insulins. Unfortunately their popularity and higher price has resulted in some older insulins becoming less profitable and there has been a decrease in the range of insulins available as a result. One of the most noticable is the lack of human  regular insulin available in pen form. You can use Novonordisk actrapid in vial and syringe but need to use a pork or beef derived actrapid to have this duration of insulin in pen form. This is available from Wockhardt in the UK and the Owen Mumford Autopen Classic is the delivery system but is only available in one and two unit increments.

In general the total carbohydrate content of a food is a more important consideration than the amount of sugar in it. Whether it is a starch or a sugar that is present the same amount of insulin is needed to deal with it and both types raise your blood sugar pretty fast. Your major challenge is to carefully match your insulin intake to your carbohydrate intake. There are also factors like exercise, stress and illness to be considered.

Where do I inject?

One of the best sites to inject insulin is in your bottom or on the fat pad above your trouser line. These areas usually are quite fatty and tend to hurt the least. You are also most unlikely to mistakenly inject into a muscle.

Other sites that you may use in public are your abdomen or your thighs. You can adjust your clothing or inject through it.

Some people prefer to inject in a washroom and others will be happy to inject at the table in a restaurant or plane.

How do I inject insulin?

If using a vial and syringe the best technique is to draw up the insulin smoothly and quickly and inject it smoothly and quickly.  Dr Bernstein has a video of this in his CD series.

If you use a pen you need to count to ten slowly, “one thousand, two thousand…” etc.  Otherwise the insulin tends to leak a bit more than you would like.

For pump users they need to change the site anything from daily to every three days. The abdomen and  rear trouser line are the most popular. Special hygeine routines are helpful in preventing infection.

If you are using plain needles you don’t need to clean the area with an alcohol swab. You just inject.

The needle depth and fineness can vary.  6, 8 and 12 mm needles are available in the UK.  If you are pretty thin or using your thighs a smaller needle is often used. If you are fatter or prefer your backside the longer needles are better.

In some circumstances you may want to put the needle into muscle. This could be for the purpose of achieving a more rapid effect which you may want to use if correcting for high blood sugars.

Basal Insulin

The basal insulin level should be matched to the liver’s normal secretion of sugar.  Because the liver tends to produce different amounts of glucose at different times of the day and night the insulin requirement will also vary. The right basal rate is one that keeps your blood sugar at a fairly constant level when you have not eaten or bolused for several hours and are not exercising.

An insulin pump gives the most flexibility over basal insulin dosages at different times of the day.

For people on a multiple daily injection regime the main analogue basal insulins are Lantus and Detemir known in Europe as Levemir.   Lantus should not be mixed with other insulins because it depends on its action for its acidic pH.  Detemir has 75% of the potency of Lantus. It is not acidic and does not sting like Lantus can when it is injected.

Lantus lasts about 22 hours in most people and Detemir lasts about 16. Either insulin can sometimes be given once a day successfully for some individuals but most people get on better with twice daily injections for both of them.  The best time to give them is right before bed and when you get up in the morning. If you have a marked dawn phenomenon no more than a 9 hour gap between the night and morning injection is recommended by Dr Bernstein.

It can take about three days for your blood sugars to stabilise after altering your twice daily basal so it is best to keep changes to three days apart or more so you can get a true reflection of the results of your insulin adjustments.

Older insulins have been stabilised so they last a long time such as  the Lente and Ultralente insulins. They are sometimes combined with shorter acting regular insulins so you can reduce the number of daily injections.  If you have a  cloudy insulin such as this it needs to be mixed thoroughly before injection. Rolling the vial or pen gently up to 20 times is advised.

Protecting Insulin

Your insulin stores can be kept stable for years in  a correctly maintained domestic refrigerator but once out and about insulin needs to be kept at room temperature or a bit cooler to retain its potency.

It can go off rapidly if overheated eg from being left in a car on a hot day.  Lantus is particularly fragile and light can affect it too. Lantus lasts in good condition for about 3 weeks and most others last about 4 to six weeks.

When you are going to be in a hot environment you can store your insulin in a frio wallet. These are available in the UK from Boots online. They are more widely available in the US. These come in different sizes and can hold insulin pens or vials.

When you travel on a plane you must keep your insulin in your hand luggage. If it goes in the hold it could freeze without you being aware of it and this too will seriously impair its effectiveness.

When you go skiing or out on a very cold day keep your insulin next to your body to prevent freezing too.

Missed a dose?

If you miss your basal by only a few hours you may simply give it as usual. If you are more than 4 hours late however the action you take may vary.  Let us assume you are awake during the day and sleep at night.

You miss your night basal which you normally give at 10 pm and remember when you get back from the party at 3am.

Check your blood sugar. You are a bit high. Give a proportion of your basal let say half of the usual dose and go to  sleep. You  probably need to sleep before work tomorrow more than worry about whether any correction dose you are thinking about is going to drop you too low through the night, especially if you have had more than one alcoholic drink.

You are likely to have to give a correction dose along with your morning basal but monitoring your sugars is easier during the day when you are awake. Put it down to experience.

You can even write essential tasks or times on ball point pen on the back your hand. Usual handwashing takes about a day to clear it and if you want to wipe off your “to do” list   little alcohol swabs come in handy.

You miss your morning basal You took your basal insulin with you to a friend’s last night and remember in the morning that it is still in your bag which is in her car. She lives across the city, and the pharmacy does not open till 2pm, and you have no spare because you have not been paying attention to the advice you were given in the organising your supplies section.

Give yourself a series of correction doses during  the day before your meals. You can use novorapid or humalog and these last about 3 and a half hours.  If you have regular insulin this is  even better as it lasts 5 hours.  Start your basal again with the night injection.

Missing a day dose is usually easier to deal with because you are awake and you can correct any lows easier.  Keeping a notebook or having one of the new pens that records your doses can be helpful. Because looking after your diabetes becomes so automatic you can easily get muddled up about whether you took the dose or not. When you are one of two parents or carers and not the diabetic person it is even more important to record what you do.  Without this it can be  even easier to make mistakes and give an infirm person or a child two doses of insulin or none !

It is human nature to muddle up from time to time. When you do, the most important things are  forgive yourself,  calm yourself down, and  THINK !

 

Quick Quiz:

Have you got it?

1. In a restaurant three of these places are suitable for insulin injections…

a In the washroom.
b In the abdomen at the table.
c Through your clothing.
d Hiding underneath the table.

 

2.The Glycaemic Load of a food is …

a Its relative effect on your blood sugar.
b A measure of the percentage of carbohydrate it contains.
c A measure of how much insulin is needed to cover the food.
d A measure of how much the food fills you up.

3. The Glycaemic Index…

a Has been extensively tested on diabetics.
b Tells how fast your blood sugar will go up with certain foods.
c Should be the basis for a sensible eating plan in every diabetic.
d Needs to be verified by personal experimentation.

4. For insulin users you need to monitor you blood sugars in three of these situations…

a Before and after exercising.
b Before you drive and at hourly intervals when driving.
c Before you go into a public place like a cinema.
d Whenever you feel hungry or suspect you could be running higher or lower than normal.

5. Three helpful tips for type one youngsters include…

a Have your bracelet, insulin, tester and food when you are on an outing.
b Carry a charge mobile phone.
c Carry money in case you need to buy food.
d Avoid telling your mates you are diabetic so you will fit in better.

6. Three of these statements about insulin are correct. Which one is not correct…

a Lantus must never be mixed with other insulins because it depends on its acidic pH for it’s action.
b Cloudy insulins must be mixed thoroughly before injecting.
c Detemir has twice the potency of Lantus insulin.
d Humalog and Novolog have 150% of the potency or regular insulins.

7. Three statements about basal insulin are true…

a It is used to cover meals.
b It should be matched to the liver’s normal secretion of sugar.
c It is needed to keep the blood sugar level steady between meals and during sleep.
d Can be most accurately obtained by using an insulin pump.

8. At college don’t bother with one of these…

a Testing your sugar before exams.
b Eating food when you drink alcohol.
c Getting your flu shot every year.
d Going to parties.

9. When you go on holidays it is silly to do one of these…

a Go to a theme park and forget a rendezvous point.
b Carry extra food and drinks on planes.
c Test draught drinks with diastix.
d Work out how you will deal with time zones before you go.

10. Advantages of being a type one diabetic can include three of these…

a Getting a fridge in your room at college.
b Getting a room nearer the kitchen at college.
c Sleeping in on the mornings on days off.
d Getting a pass to skip long queues at some theme parks.

Have you got it?
1. D is taking secrecy too far! Although many people still prefer the privacy of a washroom it is entirely acceptable to inject at the table. With the rise in the number of people with diabetes you can expect to see this happening more frequently.

2. A is correct. The GL is and indication on what effect you can expect that food to have on your blood sugars. The carbohydrate index is the percentage of carb a food contains. This can be a helpful technique in carb counting.

3. D is correct. Its all about self experimentation. The GI was tested on healthy non diabetics. It is a rough indication of how fast sugars are released and diabetics are wise to steer clear of very fast acting carbs. The precise rate of release however depends on so many factors such as quantity, chunk size, temperature and what sorts of foods are eaten along with them that personal experimentation is the only way to find out how a food that you eat regularly will affect you.

4. ABD are musts. Use your own discretion in other situations.

5. ABC are sensible. Not telling your mates isn’t!

6. ABD are all correct. Detemir is weaker in effect than Lantus unit for unit. Detemir has around 75% of the potency of Lantus. As these are both basal insulins it is unlikely that you need to remember this unless you swap one for the other for a particular reason.

7. BCD are correct. Pumps can be adjusted for the dawn phenomenon and exercise patterns with much more versatility than basal injections. This is one of their major advantages. There are trade offs in other respects of course. Bolus injections are used to cover meals.

8. D. Parties can be quite a challenge for young diabetics away from home. Always drink moderately and avoid drugs. Let your mates know about how to detect and treat hypos. If you have passed out they must get you to hospital.

9. A is correct. It is also sensible to write down exactly where you have parked the car! Diastix were originally used to detect sugar in urine but they can be very handy for testing whether your cola is the diet version or not.

10.ABD are correct. And you didn’t think there were ANY advantages to being insulin dependent did you? Unfortunately having a lie in is not on. You must get up at the usual time to test and give yourself your basal insulin at the very least.

Reference Info:
Acknowledgements to Dr. Bernstein’s Diabetes Solution and Dr Schiener’s Think Like a Pancreas.

Where to Next?
You could be a bit tired out by that long quiz. Take a break and lets all meet back at the How To: Know How Different Insulin Regimes Compare section.

How To: Follow Dr. Bernstein’s Dietary Plan

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This section is for everyone.

Dr Bernstein’s dietary plan is at the strict end of the low carb dietary scale. The diet consists of planned, carefully measured, prepared and consistent amounts of protein foods and non starchy vegetables. In addition double cream, cheese and soya products are allowed. You can have some low carbohydrate sweeteners and beverages.

He aims to give suitable and small amounts of carbohydrate required for good health with the trade off that minimal amounts of insulin with then be required from the pancreas in type twos and by injection for type ones.

The exact monitoring system and ways to trouble shoot problems that crop up along the way are described in detail with a full account of the rationale. The reasoning is impeccable, the results are impressive. The difficulty is that it is a tough plan for most of us who love eating fruit, grains and starches.

The food is pleasant to eat as tasty fats, spices and herbs are used to give a wide variety of flavour.  The Bernie forum members have experimented with ingredients so you can eat cakes, biscuits, bread as well as main course and starter dishes. I would say that the difficulty lies in the daily planning and meal preparation that is needed. It is the consistency in doing this day after day that can be particularly hard to do.

You do need motivation to follow Dr Bernsteins diet for long periods of time. If you are on insulin however you do need to be highly consistent with your meals for control and safety in any event.

If you already have the complications of diabetes and can see that you are steadily getting worse you may now be at the point that you will do what it takes. If you are a type two diabetic who is really keen to avoid insulin injections now or in the future this plan offers real help. Although diabetes is still an incurable chronic disease it is very treatable and the long term complications are almost fully preventable.

You will get the best results from reading Dr Bernstein’s book “Diabetes Solution” particularly if you are insulin dependent.  Those not on insulin could read “Diabetes Diet.” You may also find listening to his podcasts and CDs and joining the forum on his website to be of interest and informative. It can help to chat on line to people who have similar difficulties to you.

When you change your eating pattern so radically it can help if you live with someone who can help you with your diabetes and food preparation.  The transition phase is the most risky for insulin dependants having hypos. Although Dr Bernstein himself advocates a rapid transition to meals of 6 and 12 g of carb at a time, he can do this because he is very experienced and keeps a daily check on his patients till they are stable.  Outside of this situation I would always advocate a planned and stepwise reduction in carbohydrate intake.  You can read more about this in the “Atkins in Reverse”  chapters in the type 2 section.

You will need to monitor your sugars much more closely in the transition phase and adjust your insulins downwards with care and in response to your blood sugar readings. This does take considerably longer to get stability than if you were one of Dr Bernstein’s patients, and your carb cravings will continue for longer, but it is the only way to do this in safety without the direct supervision of an experienced health professional.

Due to the high level of consistency required and more time and effort into sorting out your diabetes than you have probably ever done before,  I do not recommend you start this plan until you have overcome any major outstanding personal or domestic issues. You can do this plan even if you don’t have much money, but if your life is chaotic and you don’t have support I suspect it would be just too hard.

Dr Bernstein’s entire plan is well worth reading for the detailed information he provides about all aspects of diabetes management that is not easily found in one place. I see his plan as an ideal to aim for if you are looking for optimal control over your blood sugars. The most helpful part I have found is that I don’t have to worry about hypos when my son goes to bed at night.

Even if you do not follow the plan to the letter you are very likely to get much better control than you are already getting now by a planned adoption of the aspects of the plan that you CAN achieve consistently. YOU have to find out how to get the best sugars you can for YOU with the food you are happy to eat day in and day out.

Quick Quiz:
There is no quiz for this section.

Reference Info:
Dr. Bernstein’s Diabetes Solution

Where to Next?
Please continue to How To: Use Insulin to the Best Effect section.

How To: Decide What To Eat When Using Insulin

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This section is for everyone.

The two dietary plans I wish to discuss in this section are Dr Bernstein’s and Dr Jovanovich’s plans.  Both of these diets call for a restricted amount of carbohydrate at each meal. Both doctors are type one diabetics themselves.

Dr Lois Jovanovich works in Santa Barbara California. She treats all kinds of diabetics but has a particular interest in improving the outcomes in pregnancy for type one, type 2  and gestational diabetic women.

Lois advocates a ceiling of 30 g of carb for each meal. If a snack is necessary it should be no more than 15g.

She admits pregnant patients for stabilisation of their diabetes as soon as a pregnancy is known about. By careful diet, exercise and insulin treatment her aim is to achieve non diabetic blood sugar levels. By this method she has greatly improved the outcome of these pregnancies for both mother and especially the babies.

It is imporant to note that the carbohydrate values she gives are limits not targets. The goal is to achieve as normal blood sugars as possible. If you can get there at 30g of carb a meal that’s okay but if you don’t you go lower.

Dr Richard Bernstein works in Marmaroneck New York State and has spent the last 25 years in practice dealing with diabetic and prediabetic patients. Richard was diagnosed with insulin deficient diabetes when he was 12. He followed standard dietary advice but by his 30s had severe and life threatening complications affecting his blood vessels, eyes, kidneys, heart and joints.

There were three factors that turned his life around. He was an engineer who was used to solving problems. His wife was a physician who helped him buy the first portable blood sugar meter that was only sold to physicians. He knew his life was on the line and this made him determined to beat diabetes.

After considerable research he found that the way to stop the painful and debilitating complications of diabetes was to maintain normal blood sugars as much of the time as possible.

“The Law of Small Numbers”  is the core of his method of controlling blood sugars.  There are many things about diabetes you cannot reliably control but the ones you can – you do.

Regarding diet you can predict what rise in blood sugar you are likely to have simply by eating foods that will affect your blood sugar in a small way. Even if you were to measure foods accurately there can be as much as 20% error allowed to the manufacturer when listing ingredients. If you stick to low levels of slow acting nutritious carbohydrates such as vegetables the results will be more predictable than large amounts of rapid acting carbohydrates such as bread, rice, potatoes or sugar.

Covering carbohydrates with insulin is a task full of uncertainty. There is about a 30-50% variation between the effects of the same insulin amount injected from jag to jag. This can be minimised by reducing the amount in any one injection to 7 units or less and keeping the carb count low with the gradual release of sugar that comes from vegetables high in cellulose.

For type one diabetics three meals a day is best. This minimises insulin injections and gives opportunities three or four times a day to correct the blood sugar to normal levels.

By careful experimentation Richard discovered what factors made his sugars stay normal and what factors made them go too high or too low. Many of his complications started to reverse including the kidney disease, neuropathy, heart and eye disease.

To his surprise and eventual dismay Richard  found that the medical profession of the time were not interested in his results, his method or his meter. So he decided he would need to become a doctor himself in order to let patients know of his success and he entered medical school at the age of 45.

Dr Richard Bernstein’s publications contain comprehensive and detailed advice that is based on what works for diabetics. In particular he emphasises the benefits of a very low glycaemic / carbohydrate diet. Much of what he says is still in conflict with the advice that is given out by The American Diabetes Association, Diabetes UK and most NHS dieticians and diabetologists. Unlike these people and organisations however he is absolutely rigorous in letting the reader know the scientific fact that underpins his advice.

The reason you are reading how to look after you diabetes on the web instead of from your local diabetes team is that the medical establishment are thoroughly entrenched in their high carb / low fat ways.

Unfortunately if you eat the way many diabetic clinics tell you to you will make it unnecessarily hard to control your blood sugars and this will make the development of diabetic complications inevitable.

This low carb diabetic course has been compiled by myself with the generous help of other diabetics, their carers and interested doctors and researchers. It takes a lot of nerve to do something very different from what a diabetic specialist or dietician tells you. My son Steven developed type one diabetes at the age of 12.  I am absolutely determined that he will have the same chance to enjoy a full and long life as his non diabetic brother. Fortunately many other people have the same aims for their relatives, friends and for themselves.  We have joined resources on Dr Bernstein’s forum to help you have normal sugars and prevent and reverse diabetic complications.

Quick Quiz:
There is no quiz for this section.

Reference Info:
Acknowlegements to Dr Lois Jovanovich’s many web published articles and lectures and Dr Richard Bernstein whose masterpiece “Diabetes Solution.” could be regarded as the core text of this course.

Where to Next?
Please all continue to How To: Follow Dr. Bernstein's Dietary Plan.

How To: Be the Star of Your Diabetic Clinic

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This section is for everyone.

If you haven’t been the star of the diabetes clinic yet, here is where to start:

1. Check your blood sugars before each meal and snack and write down the results.

2. Get advice on how to adjust your insulin doses appropriately based on your blood sugar results.

3.  Begin to record the carb content of your foods and write this down too along with your insulin doses.

4. Learn to adjust your insulin dose to your carbohydrate content.  You need to be very consistent about this with fixed insulin regimes and consistency will get you better results even if you are on a multiple daily injection regime.

5. Start some daily exercise and note what effects that is having on your blood sugars too.

6. Get advice on adjusting your insulin to physical exercise.

Quick Quiz:
There is no quiz for this section.

Reference Info:

Where to Next?
Please continue to the How To: Decide What To Eat When Using Insulin section.

How To: Prepare Myself for My CollegeYears with Diabetes

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This section is for type ones who are going off to college or leaving home for the first time.

You may wish to proceed to the How To: Know if My Insulin is Still Good article if you are not in this situation or when you have completed this module.

If you drive test before you set off and every hour on a long journey.

Keep supplies in your car.

Slightly impaired vision is often the first sign of a hypo. Have some small print stuck down to the dashboard from an old telephone book for instance.  If you have difficulty reading it you must check your blood sugar.

Set up your room at college the same as at home with a special “diabetes drawer.”

Make sure your friends know that certain foods are off limits. You need it to prevent hypos.

When you move to a new campus or area check out cafes and 24 hour food outlets like garages.

Register with the student health centre or a new Family Medicine Doctor and have a copy of your important notes sent to the new doctor.

Have a hard copy summary sheet of your computerised notes at your new room so you can take it with you if you need to attend a hospital.

Have all of your diabetes prescriptions sent to the new Pharmacy before you start or within a week of starting so you never run out.

Make out your own personalised hypoglycaemia card and put it in you car, your kit bag, your room and give it to your mates. (also reference the section How To: Deal with Low Blood Sugars)

If you DO run out most pharmacists will dispense for you in an emergency.

In your diabetes drawer you will need:

  • Insulins
  • Insulin kit eg needles, pens, syringes, lancets, needle clipping device
  • Spare meter batteries
  • Testing strips
  • medical id and summary sheet
  • cin bin
  • frio bags
  • ketone test strips – they go out of date 6 months after opening them.
  • Glucagon
  • Glucose drinks, tablets and gel.
  • Packets of cheese eg dairylea triangles, uht milk, crackers, cookies, nuts, crisps.
  • Possibly ice packs and a cooler

Spare insulin and food should be in a fridge.

If you have a pump remember to bring all your back up stuff as well eg pens, syringes and cartridges.

It is best to have two sets of insulin/pens/meter/lancets/glucose in case one gets left behind when you are out.

Keep a typed list of phone numbers beside your phone:

  • parents
  • doctor back home
  • diabetologist
  • new doctor
  • adult brothers and sisters

It is a big responsibility looking after yourself in college never mind diabetes.  Always carry your kit with you. Always get up at a reasonable time to test, give insulin and eat, even if you go back to sleep afterwards and miss class.

Quick Quiz:
There is no quiz for this section.

Reference Info:

  • Acknowledgements to Spike and Bo Loy’s “487 Tips for kids with diabetes.”
  • Their mother Mrs Loy has written a book to help college age kids and their parents help with the transition between home and college. I have not read this book but it sounds really useful and I would be grateful for any reviews.
  • www.youthhealthtalk.org/diabetes Is a UK based site where 38 type ones aged 15-25 have given video interviews about a wide range of issues that affect them. It includes how to deal with parents, travel abroad, eating disorders and much, much more.
  • College Diabetes Network: Preparing to Leave

Where to Next? 
Proceed to the How To: Know if My Insulin is Still Good section.