Author: rwhita

How To: Monitor My Blood Sugar Appropriately

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This section is for everyone.  It is somewhat more applicable to type one diabetics but type twos need to know some of this too.

Normal blood sugars for fit young non diabetics are 4.7 on waking and prior to meals and bedtime provided no snacks have been eaten.  Two hours after a meal such a persons blood sugar will be down to five or six. Blood sugars should not normally go below 4.0 even if a person has not eaten or has been exercising. A healthy young person can expect to have a hbaic of less than 5.0 although the range given in laboratories takes the not so fit into consideration and often gives an upper limit of normal as 6.0.

What we are trying to achieve with type one and type two diabetes is a replication of normal blood sugar patterns as much of the time as is achievable for you.

In the non diabetic person the pancreas secretes a small amount of insulin all the time. This small amount stops the liver from converting body proteins such as the muscles and vital organs such as the heart into sugar. This is called basal insulin. About the only time this is switched off completely is during very vigorous exercise.

When a meal is eaten an immediate surge of stored insulin enters the blood stream and tells the cells to grab hold of any glucose molecules that are circulating. This is called a first phase insulin response.

As eating continues the pancreas makes as much insulin as it needs to keep the blood sugar normal and it makes this insulin to order as it goes along. This is called the phase two insulin response.

There have been some advances recently in drugs and transplants that will help diabetics of both types one and two get better control or even cure the disease. Meanwhile, unless you are a mouse with a very good health insurance policy, you are best to  take charge of your diet and glucose monitoring. Lower carbohydrate diets particularly can help you keep damage from high or swinging bood sugars minimal.

What you want to get from a tight food plan and monitoring schedule

  • Normal blood sugar levels – or as near as you can get.
  • Improvements in hbaic, lipids and kidney tests.
  • Achieve a suitable weight for you.
  • Reverse at least some diabetic complications
  • Reduce the frequency and severity of low blood sugars.
  • Relief from mild neurological problems associated with high blood sugars such as chronic fatigue and short term memory impairment.
  • Blood pressure reduction.
  • Reduced demand on pancreatic beta cells – this is important for type 2s and type ones in honeymoon or earlier in the disease process.
  • Increased strength, stamina and sense of well being.
  • Sleep better.
  • Have fewer infections.
  • Have healthier skin.

 

When do I test my blood sugars?

In order to find out how well your body is dealing with your diet and any medication you are taking blood sugars need to be taken:

  • On waking
  • Immediately before breakfast
  • Before each meal
  • Two hours after each meal
  • At bedtime

When you are testing out new foods to see how they affect you testing every half hour or alternately at one hour after eating, two hours after eating and three hours after eating.  This gives you a good idea of what types and dosages of insulin may be needed to cover that food successfully. See the “Eat to Meter” section in the type two diabetes section of this course for more information on this.

You also need to check blood sugars before, during and after exercising till you know how that particular sport, duration and intensity of exercise affects you.

Shopping and running errands can drop your blood sugar so have your meter and glucose handy.

It is extremely important to check your sugars before you drive and after every hour of driving.

Intense brain work such as sitting an exam can use up glucose but adrenaline can also raise it.  Better check before the exam when you can correct a little or eat something.

Whenever you are hungry or suspect your blood sugars are running higher or lower than expected you should check.

It is useful to teach a toddler a nursery rhyme or song and get them to repeat it often.  If you suspect a low blood sugar get them to repeat the song. If they get muddled up they may well have a low blood sugar. Test to check this system works for you a few times and if it is reliable for you you may omit the fingerstick.

If your vision for small print starts to go this can be a sign of low blood sugars so check.

For new college students or those in new or different jobs from usual increased walking to different places and different work schedules can put your sugars way out.  You need to check your blood sugars more frequently than usual if your work pattern changes.

Shift work is a whole big problem area for diabetics. Your patterns will change with each type of shift and the transition periods will be particularly difficult as lack of sleep can seriously affect blood sugars too.

Women’s blood sugar patterns shift a lot in relation to their menstrual cycle, some hormonal methods of contraception and of course in pregnancy. You will need to check more frequently during these periods.

If you drink alcohol always eat along with it and be moderate. Alcohol can cause low blood sugars but sugary mixes can raise your blood sugar.  You must again test more frequently and  of course before you go to sleep no matter how late or early you get in.

Tell people you see regularly that you can get quite crabbit with high and low blood sugars and ask them not to take it personally. Make a deal to check your blood sugar if they ask you to.

Finger prick testing is more accurate than arms pricks if your blood sugar is falling rapidly or if you are very low. If you think you are low test the finger tips or base of the thumb. If you think you are high test wherever you fancy.

 

How to I monitor my blood sugars in hospital?

Apart from times that your are under an anaesthetic or extremely unwell the person who should take responsibility for your blood sugar monitoring in hospital is YOU.

You must bring in all your kit and continue to look after yourself as if you were at home.

You must have your kit by your bedside or with you if you go off on a hospital trolley for any tests and do not allow it to be disposed of or hidden by the nursing staff.

To reduce the number of finger pricks you need get the nurses to check your figures against theirs. As long as the first few are reasonably similar they should give their agreement to accept your figures.

It is NOT SAFE to assume that the medical or nursing staff know more about your diabetes than you. Given the wide range of medications, insulins and delivery devices it is indeed unfair to expect them to know better than you do.

For insulin dependants it is very important indeed that you administer your own insulin if you are at all able to do this. There have been deaths from staff making mistakes with this.

For people on insulin that should be administered prior to food it may be best to wait till the trolley arrives on the ward or at your bedside before you inject. You may not get it delivered at the time you are expecting and you may also have to count the carbs and estimate the protein before injecting. You may need the food to be kept warm for you to get the optimal time for eating or for allowing a high blood sugar to drop if you need to.

What laboratory test may I need to have regularly?

Thyroid function tests
Type one diabetics are prone to the development of other autoimmune diseases so this test should be done every so often and particularly if you begin to feel particularly cold, tired, you gain weight unexpectedly, you have more hypos than usual or your cholesterol suddenly rockets.

Lipids and Liver Tests
All diabetics in the UK over the age of 40 are routinely put on drugs called statins whether they have a raised lipid level or not. Recent guidance is that this should be extended to all type ones over 18 who have one or more complications from their diabetes.

Statins work because they reduce inflammation in the lining of blood vessels and reduce atheroma and clot formation which damage blood vessels and blood supply.  Statins can upset liver function and creatine kinase so these are tested routinely.

It is accepted by most doctors that there is a benefit in taking statins for people with diabetes and those with ischaemic heart disease. The problem is that a group benefit may not transfer into a personal benefit for YOU. One in 20 people get liver enzyme rises, muscle pain or general malaise and need to stop statins. They are dangerous to take if a woman is pregnant or at risk of becoming pregnant so women in their childbearing years need to think very carefully about them.

Kidney Tests
The albumin-creatinine ratio is as test that can detect early signs of kidney damage. If this or microalbumen tests in the urine are positive you may be asked for 24 hour samples and blood tests to clarify the extent of any problem.

The estimated glomerular filtration rate or eGFR is a new blood test done at the same time as the Urea and Electrolyte test. It gives an idea of what stage of kidney impairment may be going on.

ACE inhibitors or ARBs are new drugs that can reduce the rate of kidney deterioration. They  end in “pril” or “sartan” respectively.  They are also effective in reducing high blood pressure. If you start them for the first time you need a blood test after two weeks to see that they are not worsening kidney function. This can happen in some people who have a condition called renal artery stenosis which is hard to detect otherwise.

Coeliac Disease Tests
Coeliac disease is an autoimmune disease of gluten sensitivity. It can occur at any age.  The symptoms can be very vague and it can take a very long time to develop the raised enzyme tests of endomysial antibody and tissue transglutamase and obvious anaemia.  Tiredness and abdominal pains are probably the main symptoms. An easy and less expensive test to do is the ferritin level in the blood. This is the amount of stored iron and low levels occur frequently in coeliac disease.

CRP
The C reactive protein test is a non specific tests that indicates inflammation.  It is often raised in metabolic syndrome and type 2 diabetes.

In the absence of any inflammatory condition or infection you could have high levels of this if you are a type one who is getting quite tubby round the middle and you seem to need a lot of insulin to get your sugars down.  In other words it is a marker that you are getting both kinds of diabetes at once. A good exercise regime and lower carb diet is what you need to deal with this problem.  High insulin levels cause damage to blood vessels too. Getting insulin and blood sugar levels reduces cardiovascular deterioration.

HbAIC
The hbaic must be the diabetologists favourite blood test. It is also known as the haemoglobin AIC or the glycosylated haemoglobin. It is a test of your average blood sugar over the last 3 months. A truly normal level is less than 5.0 and more accurately 4.2-4.8%.

The average UK figures for 10-18 year old diabetics is a whopping 9.5%

The American Association of Endocrinologists have set a target of 6.5 % or less for diabetics and the UK National Institute for Clinical Excellence are going to recommend that level quite soon. Diabetes UK have set the level at 7.4% or less for children and teenagers but less than one in 7 meet this target at present.

Control of 8.0 or over is considered to be poor and can be an indication that insulin is necessary in type 2s who are struggling on maximal oral therapy.

Diabetic complications can come on in people who have never been diagnosed with diabetes but who have had hbaics of 5.5 or more for many years.  Type 2 diabetics are often discovered to have complications at the time of their diabetes diagnosis because of the slow and stealthy development of problems.  Visual troubles, breathlessness on exertion and subtle coordination problems are often seen as something to do with middle age or complications can entirely asymptomatic as in kidney disease.

The American Diabetes Association have decided that from next year they will provide patients with a measure of their average blood sugar to help them understand more about what the hbaic test really means.

Here is a chart to help you:

hbaic   =   average blood glucose value UK / US

5 = 5 / 90

6 = 6.6 / 119

7 = 8.3 / 149

8 = 10 / 180

9 = 11.6 / 209

10 = 13.3 /239

11 = 15 / 270

12 = 16.6 / 299

13 = 18.3 / 329

14 = 20 / 360

It is in your best interest to keep as low as you can towards normal without risking severe hypoglycaemia. Fortunately this is achievable with a low carbohydrate diet.

Why not find out what tests you have been getting done by your doctor ?
If you keep a record of them you will be in a much better position to understand more about how the diabetes has been affecting you. This can help if you need to see a different doctor from usual or you take ill on holiday.

 

Quick Quiz:
There is no quiz for this section. Type ones however will be getting questions on it later!

Reference Info:

Where to Next?
Please move on to the How To: Know How Proteins, Fats, and Carbs Affect My Blood Sugar section next.

How To: Safely Dispose of Needles and Other Sharps

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This section is for everyone.

Sharps are a problem because they can stick into other people legitimately handling your waste or animals who are raiding your garbage.

The worry that someone will get AIDs from being pricked by a used sharp is greatly in excess of the likelihood of this happening. But you never can tell. Hep C and B can also be transmitted from sharps and hepatitis C is the most transferable of these.

To treat a contaminated sharp injury in time a person has to get appropriate antiviral drugs within an hour. These are highly toxic and need to be taken for a month.

Please take the safest measures you can to dispose of your sharps. Here are the best ways:

Use a specially designed container. This is usually hard plastic with a lid that cannot be opened once it is locked.  They can often be obtained from pharmacies or your diabetic clinic.

Some pharmacies and hospitals provide a sharp box swap system. You may have to pay towards this service.

You can clip off the needle or lancet tip with a needle clipping device that stores the needles inside. This can then be thrown away when full. If you do this dispose of your syringes appropriately too.

A “cin bin” or sharps box is easiest to use because the whole syringe and needle can be disposed of at once. They can be bulky so having a needle clipper for use outside the house can be a great help.

If you have to dispose of sharps in your garbage as a last resort you can use a heavy opaque plastic bottle  eg a bleach bottle. When it is 3/4 full screw the lid back on and securely tape it down.

Keep your sharps and disposal box away from younger children or pets.

Reference Info:
Thanks to the BC (British Columbia) Children’s Hospital . They have a great selection of leaflets particularly aimed at younger type ones.

Where to Next?
Please all proceed to the  How To: Monitor My Blood Sugar Appropriately section.

How To: Know What Oral Medications I May Be Offered for Diabetes

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This section is for type twos and type ones with any degree of insulin resistance.  If you are a slim type one you may skip over to the How To: Use Bolus Insulins Effectively section.

For many years there were only two types of drugs offered to people with type two diabetes, metformin and sulphonureas.  More recently the glitazones and the meglitinides have been prescribed.  Last year several other medications such as januvia and byetta have come along too.

As the number of people with type one diabetes who have also developed insulin resistance has increased there has been more experimentation with oral drugs as well as insulin.  The insulin resistance is usually related to weight gain and high amounts of injected insulin which are necessary  to cover  a high carbohydrate diet.

As the number of people with type two diabetes who have not been able control their blood sugars on oral drugs increases there are more type twos on combinations of oral drugs and insulins. This rise is  related to worsening insulin resistance at least partly due to high amounts of ingested refined carbohydrate and beta cell failure partly due to the toxicity of high blood sugars on beta cells over a long period of time.

In this section I will be discussing some points about the older oral drugs for diabetes. As users of the newer drugs gain experience with them I would hope more information on this expanding area of prescribing can be given.

Sulphonureas

Sulphonureas work by making your pancreas release more insulin.  Although sulphonureas sometimes don’t work when first given they almost always stop working later on. Every year secondary sulphonurea failure occurs in 5-10 per cent of people taking them.  50% of people taking a sulphonurea will have beta cell failure by six years.

Going on this drug may seem like a good way of avoiding insulin injections to start with.  But it really just delays the point at which most people are likely to need an alternative treatment or insulin. Remember that your pancreas is smarter than you are when it comes to fine tuning your blood sugars.  Even a little bit of useful pancreatic function could make a big bit of difference later on.

There are also worries about increased cardiac mortalilty with sulphonurea use. An epidemiological association between hyperinsulinaemia and cardiovascular disease has raised concerns about the safety of sulphonureas.

Sulphonureas are popular with physicians and patients because they tend to be well tolerated. They do cause significant weight gain in many patients but this is not apparent right away.

The fear of injections in patients and the burden of patient education about insulin use in doctors seem to keep the prescriptions for this drug flowing along.  Before you start this drug however there are some things it may be helpful to ask both yourself and the doctor.

1. Is there any alternative medication or supplement that could help to get my blood sugars down?

2. Would a low carb diet be a better alternative course of action for me?

3. Would an exercise programme be a better alternative for me?

4. How much pain is involved with injections? Could I try one to see?

5. Have I a particularly reduced life expectancy that could make a sulphonurea a more favourable alternative to insulin injections?

6. How expensive is the insulin versus the sulphonurea?

Once you have asked these questions and  given realistic answers you will be in a much better position to make a well informed decision that your future self will be happy with.

Meglitinides :The Prandial Glucose Regulators

Repaglinide (Novonorm) and Nateglinide (Starlix) are chemically unrelated to sulphonureas. But again they work by squeezing more insulin out of the pancreas. They are taken just before meals to stimulate insulin for just that meal. They are usually taken three times a day. They are not used with sulphonureas but can be used with metformin. They can cause gut upset and hypoglycaemia.

At the moment we don’t know the long term effects that these drugs have in the way we do about sulphonureas.  Because they have a similar action on the pancreas they may also be expected to lead to premature beta cell failure but we just don’t know. They are active for a shorter time than sulphonureas and that may influence things.

Pragmatically it would be worth asking yourself and your physician the sulphonurea questions.  If you are leaning towards sulphonureas a meglitinide may be a better longer term option.  We just don’t know.

Metformin

Metformin does not tend to cause weight gain which is important for many people with type two diabetes. It is particularly useful when fasting hyperglycaemia is present. It causes some beneficial effects on blood lipids. It lowers blood glucose mainly by reducing the production of glucose from the liver. It may increase the sensitivity of the muscle cells to insulin and slow the uptake of glucose from the intestine. It does not depend on stimulating insulin secretion as the sulphonureas do. About ten percent of patients fail to respond to it when it is first used and the secondary failure rate is 5-10 per cent a year.

Metformin therapy in the prediabetic patient reduces the onset of type two diabetes mellitus by 31%. Visceral fat is reduced in metformin therapy.  Visceral fat is more metabolically active and produces adipocytokines which contribute to insulin resistance.

Metformin has benefits outwith the lowered hbaic compared to sulphonureas and insulin.

Gastrointestinal side effects can be minimised by starting with a single dose of 500mg after the evening meal. The maximum glucsose lowering dose is 2g daily.  A long acting version of this drug can be particularly helpful for those with gastric side effects on the regular medication and also can be given in the evening  to reduce the high morning blood sugars caused by the dawn phenomenon.

Important though uncommon side effects include lactic acidosis, especially if renal failure is present, and B12 deficiency.

Glitazones

The glitazones are the first group of drugs for diabetics that directly reverse insulin resistance. Rosiglitazone and pioglitazone were released in Europe in 2000. Neither drug has been linked to liver damage. They cause changes in the muscle and fat cells where the insulin resistance resides. They also enhance the actions of insulin in the liver.

The glitazones have their greatest effect on blood sugar after eating rather than the first morning glucose.

Glitazones are insulin sparing meaning that the body does not have to make as much insulin to control the blood sugar when a glitazone has been given.

So far secondary failure does not seem to be a problem.

Glitazones take 12 weeks to give the maximum benefit.  You should only be given a glitazone in combination with a sulphonurea if you can’t tolerate metformin or there is some other reason why you can’t take it.

You can be offered a glitazone in addition to metformin and a sulphonurea if your blood sugars aren’t well controlled enough as an alternative to starting on insulin.

Glitazones can cause hypoglycaemia if used with a sulphonurea or insulin.

Glitazones have demonstrated beta cell preservation which delays or prevents  insulin therapy.  This has not been seen in patients treated with sulphonureas or metformin.

Glitazones directly improve insulin resistance and reduce hyperinsulinaemia. They also raise HDL and give less dense LDL, give improved endothelial function and slightly reduce diastolic blood pressure.

The glitazones become less effective as the duration of diabetes goes on and endogenous insulin production from the pancreas lessens.

The data for beta cell preservation is good and makes glitazones a favourable choice early in the course of type two diabetes.  Problems are fluid accumulation and the effect of precipitating  heart failure.

Glitazones have been shown to give increased osteoporosis at unusual sites such as the upper limb. In addition Rosiglitazone may increase the risk of cardiac death. Until more is known about the effects of Rosiglitazone it may be best to use Pioglitazone if this class of drug is being considered. Pioglitazone has been shown to have a favourable effect on cardiac risk.

Both metformin and the glitazones have been used in insulin resistant type ones. Metformin seems to be a very helpful add on medication for this group but the glitazones have been disappointing.

 

Quick Quiz:
There is no quiz for this section.

 

Reference Info:
Acknowlegements to Dr. Bernstein’s Diabetes Solution and Sarah Jarvis and Alan Rubin’s book “Diabetes for Dummies, UK Edition / Diabetes for Dummies

Where to Next:
Please all continue to the How To: Use Bolus Insulins Effectively section.

How To: Know How Proteins, Fats, and Carbs Affect My Blood Sugar

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This section is for everyone.  The information is somewhat more applicable to type one diabetics but type twos need to know some of this as well.

You have read a lot about how carbohydrate affects your blood sugar but what is less known is the effect that protein has on your sugar levels.

About a third of the energy from protein is made into sugar. This process is slower than for carbohydrates and can take 2 or 3 hours or more. Delayed blood sugar rises are likely to happen if your meal has a significant amount of protein in it. By this I mean over 3- 4 oz of lean cooked meat, chicken, fish or 3 eggs.

A ready reckoner is to compare the size of the meat you intend to eat to a  pack of cards.  If you have steak the size of a woman’s hand or a deck of cards this is about 3 – 4 oz.  Chicken to the size of your palm plus the first finger joints or fish the size of a woman’s whole palm is about the same. When you have this amount you must give yourself extra insulin one way or another to cover it or you will go higher than you expect after the meal.

These are the average to small portion sizes such as you would be served in a hospital canteen. Restaurant servings can be a lot bigger. When looking at omlettes, quiches and scrambled egg you need to imagine how many eggs may be in there.  Three or more need extra insulin coverage. One egg is equivalent to about one ounce of protein. Big hamburgers eg quarter pounders are easier to recognise and also need extra insulin coverage.

Immediately delivered insulin which covers high and medium glycaemic carbohydrate dishes is no good for covering the much more slowly digested protein. The extended bolus and split bolus techniques familiar to pump users works well however. Using two or more rapid acting insulin boluses can work well and so can using meal insulins with longer action such as regular insulins.

In the UK actrapid is the regular insulin available.  It can be in pen form only from Wockhardt in the form of soluble pork or beef insulin. This is being exported now to several countries and can be used in the Owen Mumford Autopen Classic.  This pen comes in one unit or two unit increments. Genetically Modified Human Actrapid from Novonordisk is still available in vial and syringe form.  Sadly they discontinued their pen actrapid which could be delivered in half unit increments. Pens tend to be easier to carry and syringes can give more versatility over dosage.  It all comes down to personal preference.

These insulin delivery techniques and much more is discussed in Gary Scheiner’s excellent book, “Think Like a Pancreas”.  Gary was diagnosed as a type one diabetic at the age of 18. He became an exercise physiologist and diabetes educator and is particularly enthusiastic about pump therapy.  His book covers important details regarding insulin use that are not always covered in much depth in diabetic clinics. For anyone on insulin I recommend this book so you can get the best out of your current insulin regime and consider other helpful strategies to optimise control of your blood sugars. This book usually gives several different options regarding problem solving.  It goes into more depth about insulin than Dr Bernstein’s book regarding insulin use and takes a neutral stance on dietary aspects.

Meals that have a high glycaemic index or load will usually need a standard food bolus such as supplied by novorapid/novolog and humalog as the food is quickly converted into sugar in the blood stream.     Examples of these are bread, cereals, potatoes, parsnips, cooked carrots, rice, biscuits, cakes, tropical fruits and sweets.

Meals that have a very low glycaemic index / load may require a method to lengthen out the insulin delivery time just like meat.  Examples of these sorts of foods are pasta, especially with creamy or cheesey sauces like lasagne or spaghetti carbonara. Very high breakfast cereals eg all bran.  Curries made with lots of fat eg kormas. Battered fish and chips. Chocolate, most dairy food and nuts.

A major difficulty with the glycaemic index is that it gives artificial categories of supposed blood sugar rises for a given amounts of carbohydrate containing foods.  One problem is that these tests were done on healthy non diabetics who still have a phase one insulin response. Both type ones and type twos do not have this capacity to immediately release stored insulin. The rate of absorption is also dependent on the temperature of the food, bite size and what it is eaten with and in what order.

To really know what is going on in your body you need to do extensive testing to get the best results for each meal you eat.  This involves testing every 30 minutes or so for three or more hours after each meal  you eat.

You can only test a food accurately if your baseline blood sugar is normal. Even then insulin sensitivity can vary throughout the day. Typically you are quite insulin resistant at breakfast and are at your most insulin sensitive in the afternoon.

Although this sounds a terrible chore most people only eat about 20 different meals on a regular basis and some a lot less.  Please don’t ask me what to do if you are a type one restaurant critic!

To give smooth protein curves it is best to eat some of the protein and fat before you eat the carbohydrates.

If you are having a high glycaemic item leave it till the end of the meal if possible.  Can you add some fat to it?  This will reduce the rate of absorption. Eg fruit and cheese, potatoes with butter and cream, cake and cream.

Lots of fat in the diet improves the taste, fullness after meals, vitamin absorption and slows down carbohydrate induced sugar spikes.

Other Food Tips

If you are going to have a snack consider low glycaemic carbohydrates, protein and fat so you are fuller for longer and sugar spikes are minimised. Eg full fat yoghurt, crackers and peanut butter, toasted cheese with butter on thin sliced wholemeal bread.

In a restaurant you can take your regular insulin once the waiter has taken your order as long as there is bread on the table. You only eat this in an emergency however!

If you take rapid acting insulins take it with the starter if you have a normal blood sugar, your main meal if you are low and when the waiter takes your order if you are high.

Tell the waiter you are diabetic and need food right away if you have been waiting for a time or feel low.

It is best to let toddlers eat and then gave them rapid acting insulin to cover what they actually ate.

Quick Quiz:
1. Three of the following make food digest more slowly. Which one does not?
a A lot of sugar or starch in the meal.
b A lot of fat in the meal.
c A lot of protein in the meal.
d Delayed stomach emptying also called gastroparesis.

Have you got it?
1.A is correct. Protein and fat make meals digest more slowly. Sugar and starch are digested quickly. Gastroparesis is when stomach emptying is delayed or erratic due to nerve damage from chronically high blood sugars. Like foot neuropathy it can develop after around five years of having poorly controlled blood sugars.

Acknowledgements & Reference Info:

Where to Next?
Please continue to the How To: Know What Oral Medications I May Be Offered for Diabetes section.

How To: Do the Atkins Diet

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This section is for everyone. Even those of you who may have done the Atkins or lived with someone who has.

The easy way to do the Atkins diet is to buy one of Dr Robert Atkins books and do it.

The book I would particularly recommend is Atkins for Life the Next Level.

This is a simple introduction to low carbing and it covers all the basics you should know about.  The book discusses the research information, the relative importance of protein, fat and carbohydrate in the diet and gives you various meal plans and recipies that you can incorporate into various total daily carb plans.

What I like about it is its versatility between carb plans from 20-120g of carb a day.  Compared to the Zone diet it is more versatile about the amount of carb that may suit you and compared to the South Beach diet there is no unnecessary restriction on saturated fat.

When you do a traditional Atkins diet you start at 20g of carb a day and gradually increase your carbs as far as you can till your weight loss levels out.  For many people who are just plain fat and who are not on any medication that could affect their blood sugar this is usually fine.

For anyone who is on insulin or blood sugar lowering medication  such as sulphonureas which includes gliclazide or metaglinides this would not be such a good idea. In fact such a drastic reduction could be dangerous.

But the Atkins diet has in my opinion still a great deal to offer. For those people who have pre-existing heart disease or are otherwise at greater than average cardiac risk, or who are on medication or who perhaps are getting on a bit – over 45 – for instance why not do Atkins in REVERSE?

What I am proposing is to take things nice and slow.  If you have any glucose metabolism problem you are going to have to restrict your carb intake for the good of your long term health sooner or later. You have to face this sometime.

From my previous discussions about how to measure the carbohydrates you eat you can surely find some way that suits you to find out how much carb you are currently consuming.

Whatever this is you need to start here.

That’s right.

Start wherever you are and start to cut down.

Week on week. Day by day. Meal by meal. Carb by carb.

If you are over 120g a day that is okay. If you are already on say 90g a day that is okay too. Simply look at the weight loss and blood sugar goals you want to achieve for your future health and start right away.

Many people will get what they need at the higher ends of the Atkins range such as those following the Zone or perhaps Dr Lois Jovanovich’s guidelines at about 120g of carb a day.

Some will want to drop their carbs further such as those people who are following the Drs Eades Protein Power plan or the diet advocated by Dr Allen and Dr Lutz or Dr Jorgen Vestig-Nielsen or Barry Groves at around 70g a day.

Others will not get to what they want until they get to Dr Bernstein’s diet of between 30-42g of carb per day.

You decide.

What do you want to achieve?

What amount of carb restriction is likely to be necessary to acheive this?

How slowly must you go down for safety?

Whatever the answers are for you, I hope this internet course can help you get what you want with safety  and with the knowledge of companionship along the way.

Quick Quiz:
There is no Quiz in this section. All the questions in this section have been ones to ask of yourself.

Where to Next?
The last few sections may have been a lot tougher than you were expecting. Have you got an idea of the amount of food recording and sums that you are going to be doing from now on?

I think it’s time for a little change of scene.

It’s back to Home Economics 101 for your lessons on How To: Cook and Bake the Low Carb Way.

Even if you’ve never boiled an egg your life, the quality of food you will soon be able to serve to yourself your family and friends will greatly improve when you’ve taken the plunge.

 

How To: Look after yourself with Type 2 diabetes

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This section is for all type twos and any type ones who think they are developing insulin resistance. This is often recognisable by an increasing waist line, blood pressure and need for high doses of insulin relative to your thinner years.

Slim type ones may proceed to the How To: “Eat to Meter” section.

When you eat carbohydrate it gets broken down by the digestive system and appears in the blood stream as glucose.  Insulin is immediately released by the pancreatic beta cells.  Insulin is the hormone that tells certain types of cell in the body to take up glucose in the bloodstream.  In this way the glucose level in the blood stays within a narrow range.

In insulin resistant states such as metabolic syndrome and type 2 diabetes the cell wall insulin receptors are less sensitive to insulin and in an effort to keep blood sugar levels normal the pancreas releases more insulin.

High insulin levels causes inflammation and stiffening of the lining of your blood vessels. This lining is called the endothelium. This stiffening causes high blood pressure.

The pancreatic cells can initially make plenty of extra insulin to compensate for the weakened effect of the insulin but eventually become exhausted and start to die off. This causes higher blood sugars.  Unfortunately blood sugars higher than 6.1 are toxic to beta cells and they start to die off with higher and higher blood sugars. The whole thing is a vicious circle.

Type two diabetes is often thought of as being less serious in some ways than type one diabetes. It is certainly true that a type two will not die as rapidly if they don’t get insulin as in type ones. On the long term however type two diabetes causes all the same complications as type one and can be just as fatal. Instead of it being obvious that something is drastically wrong with your health as in type one, those with type two can have it creep up on them over many years, slowly causing damage to the blood vessels, eyes, kidneys and nerves and not even know about it.

In type two diabetes there is initially more insulin produced to try to overcome the effect of insulin resistance. In early type two diabetes there can even be episodes of low blood sugars when the pancreas releases too much insulin at the wrong time. As time goes on the beta cells become exhausted and produce less and less insulin and  die off. In many people insulin injections are eventually needed to give anything like normal blood sugar control.

Type two diabetics store less immediately available insulin than normal people. In addition they also need to produce more than normal because their cells are less sensitive to insulin. As their ability to produce insulin on demand declines they get higher blood sugars after eating and this persists for much longer than in non diabetic people.

High blood sugars after eating can be minimised by eating fats, protein and carbohydrates that release sugar gradually so that their pancreatic insulin factory (phase two insulin response) can keep up. This effectively means eating non starchy vegetables as the main source of carbohydrates.

For type two diabetics who do not need insulin they may get better results from eating  4 or 5 small meals a day rather than sticking to three bigger meals a day.

Many people have inherited their tendency to insulin resistance.  If your parents or grandparents had heart disease, high blood pressure, fat round the middle, high cholesterol, high triglycerides, type two diabetes or swollen ankles you are more at risk.

The diabetes tendency becomes noticed at times such as pregnancy, ageing and if the person tends to eat a high sugar or starch diet.  Lack of exercise also affects how rapidly the tendency will appear.

Insulin primarily affects blood sugar but also affects blood pressure, cholesterol and triglycerides and the storage of fat. No medications can reduce excess insulin production: only a low carb diet. A low carb diet works by reducing the oversecretion of insulin and helps restore balance.

Beta blockers and diuretics which are often used to control blood pressure also increase insulin resistance and are best avoided in some people.

Although there are cut off points in blood sugar tests to say who is normal, who has metabolic syndrome and who has diabetes, the condition is really a continuum.  Someone who has metabolic syndrome can get retinopathy, kidney disease and cardiovascular disease just the same as a diabetic.

The worse your sugar control is the worse your cardiovascular and complication risk.  A popular test to do is the hbaic. This is the percentage of sugar attached to your red cells in the blood. Although a normal range of 4-6 is often given for instance it has been found that your risk goes up progressively from levels of just 4.6.  It therefore makes sense to have as good blood sugar control as you can, particularly if you have a moderate to long life expectancy.

Tests that you can have done to find out your risk or severity of metabolic syndrome and type two diabetes include measuring your waist/hip ratio, hbaic, glucose tolerance test, fasting lipids and blood pressure.

There is a progression in how type two diabetes is treated:

Low carbohydrate diet
Appropriate weight loss
Exercise
Drugs that enhance insulin sensitivity or insulin action
Insulin injections with or without oral drugs.

People who have lived with high blood glucose levels for years can feel shakey or ill at normal blood sugar levels.  They also can have blurred vision. A gradual adjustment of the target blood range and progressive reduction in carbohydrates can help these symptoms settle down.

Quick Quiz:
1. One of these is true for type two diabetics…
a They get less serious complications than type ones.
b They can have slowly developing damage to tissues without realising it.
c They need the same level of daily monitoring as insulin using type ones.
d Those not on insulin get on best with three meals a day.

Have you got it?
1. B is correct. Unfortunately the myth that type twos get less serious complications than type ones persists. Diabetes is certainly not as dramatic in onset as in type ones. It’s insidious nature makes it harder to detect and so damage goes unchecked. It is the case that monitoring of blood sugars needs to be done a lot less often than in insulin dependants but dietary habits must be just as good. If reasonable amounts of a person’s own insulin are being made type two diabetics may have better sugar results with smaller and more frequent meals than the 3 or 4 a day advocated for type one diabetics.

Reference Info:
Most of the information in this section is from Dr. Bernstein’s Diabetes Solution: The Complete Guide to Achieving Normal Blood Sugars.
Where to Next?
You are now ready to proceed to the How To: “Eat to Meter” section.

How To: Use Bolus Insulins Effectively

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This section is for everyone. It is slightly more applicable towards type one diabetics but has information that will also help type twos.

Bolus insulins are given to cover your food and also to correct high blood sugars at meals and other times.

The total amount of carbohydrate and its rough glycaemic index, fat content, protein content, and  the presence or absence of delayed stomach emptying  all affect the speed and duration of blood sugar rises after meals.

If you are on the strict end of low carbing most of your meals will be meat/egg/fat/low starchy vegetable combinations which take longer to digest than if you were eating sugary or starchy foods such as breakfast cereal and milk. The techniques you use to cover different kinds of meals will therefore vary.  You are doing your best to match the insulin to the meal. The sorts of meals you will be choosing to eat will depend on your goals for your blood sugars and your health.

We will be discussing techniques to cover several types of meals.

Dr Bernstein’s strict low carb meals at 6-12g of low glycaemic carb, moderate protein and high fat.

This is the gold standard. It can give you truly normal blood sugars over the entire course of the meal when optimal insulin techniques are used. All diabetics need to seriously consider how far they could adapt themselves to this diet for the long term prevention and indeed reversal of complications.

Dr Jovanovich’s typical low carb meals at 13g- 30g of mixed glycaemic carb, moderate protein and high fat.

This is the typical diet that most low carbers and lower carbing diabetics use. All of the popular low carb diet books by eg Dr Atkins, Drs Eades, Barry Groves, Dr Agatson, Drs Allen and Lutz, and Dr Annika Dalquhist are in this meal range. It gives you more variety in fruit, vegetables and grains but probably not completely normal blood sugars. You may get some sugar spiking at meal times but are likely to have a normal blood sugar by the time the next meal comes with the appropriate insulin techniques.

If you are in transition from the high carb so called, “Healthy Eating Plan” this is where you want to be for some time. This gives you time to:

Adjust your insulin or oral medications downwards slowly and safely.

Helps reset your “Hypo clock” downwards.

Helps prevent a deterioration in  retinopathy from too rapid blood sugar improvements.

Gives your lenses in your eye time to adjust to lower sugar levels.

Gives you time to learn new low carb baking skills and improve on your range of meat, egg and vegetable dishes.

Gives your family time to adjust to a new eating routine.

Gives you time to organise your planning, shopping and meal preparation times.

Dr Morrison’s techniqes for dealing with  higher carb meals of 40-90g are a useful addition for times when you are having a planned indulgence or  when your  food choices are  extremely limited.

Eating meals with this carbohydrate content approaches what many consider to be “normal” eating. The problem is that if this is done too frequently it will certainly have an adverse effect on your diabetes. Blood sugars at meals will spike and for some time afterwards but you are likely to have normal blood sugars when the next meal comes.

Why do I have to change my eating and insulin routine?

If you have been doing what you have most likely been told at your diabetes clinic you will be here for a very good reason.  It isn’t working.

You are looking for solutions to your blood sugar problems:

Too high. Too low. Too wide blood sugar swings. No idea what number that meter will show next.

The techniques I will shortly be describing are often seen by newcomers as a bit of a drag. All those blood sugar tests! All those injections! All those donuts I’ve to bin!

What I would like to do here is explain what is wrong with the dietary advice given out in most diabetic clinics and why the simple insulin regimes they advise are not adequate.

The poor control you have been experiencing up till now is not because you haven’t listened, asked questions or done as you have been asked. It’s not worked because the advice you have been following has been wrong.

Here is what you are told to eat according to “Healthy Eating” guidelines.

Protein should be 15-20% of your total energy intake. Optimally 0.8g/kg body weight a day.  It is neither necessary or advisable to have more than 20% of your energy from protein. Cereal foods and pulses add considerably to the protein content of the diet.  Most adults eat at least 50% more protein than required.

What it should say is:  The minimum protein requirement for a healthy person is 1g/kg of their ideal body weight of protein a day.  You can find this amount by an easy calculation.

Take your ideal weight in kilograms and divide it by 6. This is the minimum amount of lean protein to eat in a day in ounces. Eg a 60kg woman would need at least 10 oz of lean protein a day.

If you are eating this and you are a healthy weight fine.

If you are eating more and are too heavy you may need to cut down.

If you have kidney problems keeping normal blood sugars are very important. You may need to reduce your protein intake a little but may need more if you are on dialysis. The help of a dietician with experience in this area is important if you have established severe kidney failure.

Cereals and pulses may have some protein in them but they are also high in carbohydrate.

Quick Quiz:
There is no quiz in this section.

Where to Next?
Please all continue our exploration of what passes for science in How To: Know the Truth About Fats section.

Reference Info:
The standard nutritional information “What they say ….” is based on the dietary guidelines in Dr L.Steven Levene’s “Management of Type 2 Diabetes in Primary Care: a practical guide.”

This book was published in 2003. I don’t think a second edition has been printed yet as I received it free of charge from Boehringer Ingelheim in 2006. General members of the public cannot buy this book.

In it’s present form this is just as well.

For General Practitioners who may be taking this course I can recommend the other chapters as sensible, well informed stuff.In particular the is not overburdened with information. It has just the right amount of information pitched at the right level of scientific detail and interesting and sometimes quite yuccky photos.

In the foreword Professor Alberti of the University of Newcastle, previously a President of the International Diabetes Federation, and Vice President of Diabetes UK has (sort of) stated:

( I took out some boring UK only details and changed lot of hard words like axiomatic, lacunae and educational armamentarium. Being working class I went to a state school in Scotland and I would have been duffed up if I had used this sort of language in public.)

“The prevalence of type two diabetes has reached pandemic proportions. Figures are set to rise by 50% in the next decade. In the UK there are 1.5 million diabetics and approximately another one million who have not been diagnosed.

The National Service Framework has identified the shortage of health professionals to deal with this pandemic. There are over 30,000 GPs compared to fewer than 600 specialists. Better, more convenient care can often be given when patients are in the familiar surroundings of their own general practice.

If GPs are to take an interest in managing diabetes they need knowledge, practice and continuing education. This is often not available. This book fills a large gap in the educational materials available.

It is a must for GPs who run diabetes services for their patients. I would go further and suggest that it should be read by practice nurses, community podiatrists and the rest of the team. With potentially two million plus people with diabetes in the UK alone to look after, we need all the help we can get!”

You certainly do!

Perhaps Steven would like to produce more accurate and helpful nutritional information in his next edition? Call me.

Perhaps Professor Alberti would like me to proof read his next foreword?

How To: Adjust My Basal Insulin

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Part of Dr.Katharine Morrison’s “How To” series as posted in this forum post (requires registration).

The best way to find out the best basal for you is usually to look at the 3am  bs.  Do this several times but don’t look at the averages, look at the lowest number you are getting. The aim is to give you normal night sugars but not hypoglycaemia.
If your lowest bs at 3am is 5.0 your basal is right for you.

If your lowest  am bs is less than 5.0 you are having too much basal.
If your  lowest 3am is less than 5.0 you are also having too much basal.

If your average am bs  over at least 3 but preferably 10-14 is higher than 5.0 with good 3am bs you are having the dawn phenomenon. If you gave a higher basal to get this down you would be giving yourself a high risk of night time lows.

If your lowest 3am is higher than 5.0 you can try a slight increase in basal.

Make changes in insulin doseage in the smallest increments your pen allows. Vial and syringes do give more flexibility.  Diluted insulin can also make incremental changes more precise and is particularly helpful for young children and babies who are on low amounts of insulin.

When you have made a change in basal insulin sit it out for about 3 days before you adjust again. This is the time it can take for this to stabilise.

How To: Organize My Supplies

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Part of Dr.Katharine Morrison’s “How To” series as posted in this forum post (requires registration).

 

Insulin dependants need to have their insulins, needles, needle clipping device, cin bin or other storage container, insulin pens and syringes, glucagon kit, glucose gel, glucose drinks, ketostix and a frio pack if you are in a hot environment.

You will need a blood sugar meter, lancets, finger pricking device, test strips and a notebook for recording reading for recording blood sugars. This can also contain your meal profiles, correction doses, carbohydrate sensitivities at various times of the day, carbohydrate weighting scales and whatever else you may find of use to you.

A medic alert or similar bracelet is very helpful if you are found in a confused or unconcious state. Medic alert will provide world wide phone information which you have previously given them regarding your condition and medications.

Oils that you use for your feet such as almond oil or coconut oil can be kept in your bathroom or bedroom.  Vegetable and animal oil derivatives are better absorbed than mineral oils to keep the skin of your precious feet less likely to dry out and crack.

You will need to develop your own routine about what you will carry in person, store at work, the car and at home, and how you will check on expiry dates and reordering.
Keep your supplies at the various locations in one spot or drawer. Insulin not in current use needs to be stored in the fridge. It will deteriorate if it freezes or is heated such as can happen in a car.  Have your own cupboard with your low sugar treats, special foods, diet drinks and lucozade or gatorade.

If you are going into hospital or are travelling abroad it can be helpful to prepare some laminated cards before you go.

The important ones for a planned hospital admission in your own country need to cover food choices and self monitoring. For going abroad hypoglycaemia and vomiting and diabetes information sheets in a language that will be likely to be understood are well worth carrying with you.

You can use internet language tools such as Google Translate to translate any text into many different languages.

Do consider typing a personalised sheet of information on your contact details, contact details of your doctor, diabetologist, family, friends, medical history, medications, insulin routine, allergies and needs if hospitalised for the country you are visiting or passing through.

How To: Match Insulin Reduction to Carb Reduction and Get The Best out of the Insulin Calculator

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This section is for everyone.  For the purposes of this module I am going to assume that you are currently on a high carb/ low fat diet, that you are on a basal bolus regime with a long acting insulin and a rapid acting insulin analogue. This could be in vial and syringe or pen form.

The total time that you can expect to take from going from where you are to normal blood sugars is about 3 months if you follow this programme. This can be considerably shortened if you already have a high degree of background knowledge and do not encounter any particular problems with your carb reduction and insulin adjustments.

 

THE FIRST MONTH

STEP ONE: KNOW YOUR STUFF ABOUT DIABETES, INSULIN AND DIET

This step can be expected to take 4 weeks if you allow 30 – 60 minutes a day.

Before you are ready to reduce your carbohydrate and therefore insulin it is best to do the modules appropriate for you and have a buddy to help you. Help from your diabetes team is most helpful but they may not have the time to help you or may not be happy with carbohydrate reduction. If you haven’t already joined an internet support group this could be the time to do it.

You should already have:

  • Read and understood all the course modules that have been selected for insulin users.

Reviewed thoroughly the modules:

You now know a great deal about your diabetes: the sort of insulin regime you are on, basal insulins, meal insulins, correction doses, carb sensitivity at different times of the day, how much insulin you need for most commonly eaten meals, and how much carbohydrate you are consuming for meals and snacks and the effect that exercise has on your blood sugars. You also will have an idea of what you are aiming to eat in the future compared to what you are doing now.

You may need to obtain extra testing stix, glucograph sheets, regular insulin and syringes/needles or pens. If you are already using a pen a half unit one is best. You will need one for each type of insulin you are on. Unfortunately the Autopen Classic which is used with Hypurin Pork (regular) insulin only comes in one unit pens.

 

THE SECOND MONTH

WEEK ONE

STEP TWO: SORT OUT ANY HYPOS

This step can be expected to take about a week. If you don’t have any hypos you won’t need to do this but you are likely to need to know about it once your insulin regime gets better control of your blood sugars.

Are you having regular hypos?  If so what time of day or night?

You need to cut back gradually on your insulin that governs that time of day.

Night hypos – reduce basal.

Morning hypos – reduce breakfast insulin

Afternoon hypos – reduce lunch insulin

Evening hypos – reduce lunch insulin

 

STEP THREE: GET YOUR INSULIN ACTING PREDICTABLY

In order to get the best match between insulin and food the insulin needs to be delivered in a predictable way. The key to this is the 7 units per shot rule.

BASAL

Write down how much basal you take in 24 hours.

If you are only on one injection of basal a day you can improve 24 hour coverage by changing to an injection on rising and an injection before bed. The gap between the night insulin is best to be 9 hours or less but up to a 12 hour gap may be fine if you don’t have a pronounced dawn phenomenon. The aim is to stop over dosage of basal which at some points during the day may make you need to eat to stop from going low. We also need to keep the basal high enough at other times of the day so you are not overdoing meal insulin to cover gaps that can arise in the evening if you are only on a single night dose of eg Lantus or  Detemir.

How much insulin will you need at each injection when you go to twice daily basal injections?

If this is over 7 units per shot you may need to reduce your basal slightly. You will be checking your 3 am blood sugar in this phase to check how accurate your basals are.  If your basal insulin is currently over a 24 hour total of 14 units you need to reduce the total insulin injected by 15%.

Example:  Mary is on Detemir 34 units once before bed.

This is going to need a reduction of 15% to start with. This leaves 29 units over 24 hours.

Divide this by two to find out the amount this will be when split into two injections:

14.5 units each.

The total number of injections to cover basal will therefore be expected to be 7u x 2 separate injections both night and morning. This does leave a deficit of 0.5 units but  as this is quite a small amount it would be okay to see how this regime goes. If this regime is tried for three nights and the 2-4 am blood sugar is 4.4-5.6 this would be satisfactory. If the readings were higher the additional half units or progressively more insulin could slowly be added. It is best not to change basals more than every 3 days as it takes a while for insulin levels to balance out. If hypos occur through the night and you are certain it is not the effect of two much meal insulin beforehand you would need to reduce the amount of insulin given at your basal injections eg to 6 units x 2 morning and night and gradually adjust upwards for fine control.

Within one to two weeks I would expect your basals to be much more stable. You are now ready to proceed to sorting out your meal insulins.

STEP FOUR: STOP SNACKING

The first step to sorting your meal insulins is to know what effect the insulin you gave yourself for the last meal actually had. You have little chance of getting this right till you stop snacking.

If you have a hypo and usually snack you need to change what you do when you have a hypo. The best thing is to have a small quantity of pure glucose in liquid or gel form and be careful not to overtreat.  Over correction of hypos is hard to prevent if less than very rapidly acting carb is taken as it acts too slowly to get you feeling better fast enough.

If you have a hypo due to exercise and this is a regular thing the best way of dealing with it is to have the snack – which could in this instance be a food item – before or during the particular exercise.  Getting this right can take some practice.  This is fine for regular activities eg twice weekly supermarket shop, a weekly game of tennis.  If the exercise is not a regular thing can you put it off till you have finished this run in phase? It will only take a few weeks.

Hunger and a need for snacks can also be due to basal insulin being too high. Is this well under control now?

You now have got the hang of the 7 shot rule, no snacking and have sorted out your basals and hypos.

 

WEEK TWO

STEP FIVE: SORT OUT YOUR BREAKFAST

REDUCE BREAKFAST CARB BY HALF

Breakfast is usually eaten at home. It is beneficial to eat a high protein meal to reduce the tendency to snack from hunger late on.  The lower amounts of carb usually eaten at this meal to help deal with the dawn phenomenon.  For the purposes of all your meal experiments in this second month  however we are going to aim for the following plan meanwhile.

Plan out the minimum amount of protein you need for the day.  This is your ideal body weight in kilograms divided by six.  Eat no less than one third of this in ounces of lean protein for breakfast.  Do the same for  lunch and dinner.

Lets assume you are a bit overweight but ideally are 60kg. You would be looking at 10oz of protein a day and would want to eat at least 4oz of protein at breakfast.

E.g. three egg omelette with some ham chopped into it.

It is amazing how filling this sort of breakfast is compared to a high carb one.

For carbohydrates you will already know the approximate carb count for what you eat.

Banana  30g

Glass of milk 15g

2 slices of toast 40g

Marmalade 5g

Breakfast cereal 40g

Coffee 0g

The total is 130g.

To start with reduce your carbohydrate by half of what you are on or to 30g whatever is the highest.

What of these foods could you do without?

Work it out.

Say you go for 65 g and go for the breakfast cereal, milk and a half slice of toast with butter instead of marmalade.

Give yourself the insulin you would normally give in proportion to the carb you intend to eat.

Eg  If you normally give 13 units for the 130g breakfast give yourself 6.5 units for the 65 g breakfast.

If the insulin injection is more than 7 units then you need to split the insulin into more than one shot.

STEP SIX: COVER BREAKFAST PROTEIN WITH REGULAR INSULIN

You may need to have obtained regular insulin in syringe and vial or pen form. In the UK pen regular insulin is only available in pork or beef versions from Wokhardt Pharmaceuticals. This is able to be imported to other countries however.

Use 2 units of regular insulin for each 3oz portion of lean protein you are eating. This is a starting dose to use till you start to profile your meals and fine tune them with different proportions of different insulins. Ideally inject this 15 minutes before eating. Alternatively you can use a small amount eg 1- 1.5 units of rapid acting insulin to cover protein but inject this 1.5 – 2  hours after eating.

STEP SEVEN: CUT BACK TO 30g of CARB FOR BREAKFAST

The next step is to cut back your breakfast carbs to 30g or less. Again adjust your insulin accordingly. At this stage you are aiming to have your blood sugar before your next meal within your target range. It is unlikely that you won’t spike at one or two hours on this amount of carb without running low before your next meal. The goal however at this stage is simply to work your way down gradually and particularly to avoid hypos.

WEEK THREE

STEP EIGHT:  SORT OUT YOUR LUNCH

 

Follow the same steps for your breakfast.

Your insulin sensitivity is likely to be best at this time of day.  You may well be able to cut insulin doses somewhat.

STEP NINE:  SORT OUT YOUR EVENING MEAL

Follow the same steps as your previous meals. Your insulin sensitivity will be a bit lower than at lunch but usually not quite as high as at breakfast.

WEEK FOUR

STEP TEN: SORT OUT YOUR BEDTIME SNACK

Follow the same steps as your previous meals. If you don’t usually have a bedtime snack you don’t need to have one just for the sake of it.

Your final level for this phase is a bedtime snack of 15g or less.

You should now be on three meals a day of 30g carb and an optional bedtime snack of 15g maximum of carb.  You may also be having some extra carb to cover planned daily exercise.   Your insulin doses should be much less than usual and your predictability should be much improved. You may have had hypos in this reduction phase and you should have been adjusting your insulin doses downwards to sort this out. The main blood sugars that are of most concern right now are the fasting, pre-meal and 3am blood sugars that you can expect to be around target by now.

THE THIRD MONTH

WEEK ONE

STEP ELEVEN:  FINE CONTROL OF CARB INTAKE

How low in total carbs would you be happy to go for each meal?

Can you reduce higher glycaemic carbs that you may have been eating?

Can you substitute lower glycaemic  options eg avocados at breakfast instead of bananas?

The optimal is 6g for breakfast  and 12g of carb for each other meal. This is based on Dr Bernsteins work which aims to give no blood sugar spikes at all and highly consistent blood sugars 24 hours a day.

It is perfectly acceptable to have higher amounts than this. The important thing is that you reckon you can be consistent about what you are going to do.

STEP TWELVE: FINE CONTROL OF PROTEIN INTAKE

You know how much protein is considered a minimum for you and you’ve been eating this for a few weeks. Is this completely satisfying for you?

If you are hungry before your next meal is due perhaps you could do with more? Some of us need a lot more!

Alternatively you may have delayed stomach emptying and need to reduce your dinner portion of protein?

You will now have good experience of varying your regular insulin to your protein at various times of day and you can adapt what you have found out to sorting out the right dose for the protein you prefer to consume.

STEP THIRTEEN: FINE CONTROL OF FAT INTAKE

The good news for variations in your fat intake is that you don’t need insulin to cover fat.

How is your weight doing?

Have you lost weight on this regime? Have you gained?

You need to adjust your fat intake to reflect the calorie balance you want to have. This is easier than previous adjustments. Eat enough fat to make your meals enjoyable as a reasonable minimum and up the fat as needed to keep your weight at a level that is ideal for you.

WEEK TWO

STEP FOURTEEN:  PROFILING YOUR MEALS

Now you are eating your ideal or near ideal diet regarding carb/ protein and fat proportions it is time to again fine tune your insulin.

For each actual meal that you are going to profile you need to:

Eat the same  food in the same proportions each time at around the same temperature and the same time of day.  Eat it at around the same speed.

Weigh or measure your portions. You may as well have the portion size you really want to eat.

You need to have a blood sugar in your target range, you need to avoid unusual exercise and you need to be well ie not coming down with a cold or have a gum infection for instance.

Take the insulin you think you should take at the time you should take it and then eat the meal when you plan to.  Check the bs every half hour – one hour after finishing the meal until the next meal is due.

You can see several patterns.

No hypos till next meal. Well done. You have not overdone the insulin.

Hypo in the first two hours after eating.  You need to reduce the rapid acting insulin for that meal.

Hypo in the 2.5- 5 hour mark after the meal. You need to reduced the regular acting insulin for that meal.

Spikes in the first 2 hours after the meal.  You need to increase the time interval between giving the rapid acting insulin and eating OR you need to up the dose.

Spikes in the 2.5 – 5 hours after the meal.  You need to increase the regular insulin for the protein or carbohydrate component of the meal.

Hypos in the early post meal period and spikes in the later post meal period may indicate that the meal is best covered by a higher proportion of regular insulin than rapid acting insulin. This is common for high fat meals as carbohydrate absorption is delayed. This phenomenon is called the “Pizza Effect”. It is discussed more in the insulin calculator section which follows.

Once you have hit the right dose for that meal put a note of it in your favourites list. You can add this to your insulin calculator should you choose to use this.

WEEK THREE

STEP FIFTEEN:  WHAT DO YOU REALLY MISS? CAN YOU SUBSTITUTE IT?

You are now almost at the end of the course. The next three sections are all about making life a bit easier for you.

What do you really miss, or know that you would like to eat sometimes?

Have a good look at the carb cooking and baking modules again. This is the time for you to experiment with something you haven’t tried so far. If you can find a good substitute and you won’t miss that item eg cauliflower mash instead of mashed potatoes or low carb muffins/ cheesecake you simply have to organise yourself to have a regular cooking/ baking day and prepare packed lunches for when you need them.

STEP SIXTEEN:  WHAT DO YOU STILL REALLY MISS? CAN YOU CARB WEIGHT IT?

If there is an item that you think you must have eg pizza, a burger bun or so forth you need to review the carb weighting technique section again. To do your experiments on this it is best to do these at lunch time and when you have company to help if you over do the insulin and have a hypo.

WEEK FOUR

STEP SEVENTEEN: PROGRAMMING YOUR PORTABLE INSULIN CALCULATOR.

There are two versions of the insulin calculator available. One is for downloading onto your pc and the other is a more sophisticated programme for a palm top which has the advantage of greater portability.

The insulin calculators have background tables that you programme yourself. What you are doing is putting in your particular information into several of these background tables. When you are using the calculator you will usually be putting in the carb values of the food you intend to eat, the particular meal involved and your current blood sugar.  The machine calculates the amount of insulin you need to take. As there are differences between the calculators I will explain them separately. For using either of them is essential that you have done all your experiments to find out the correction factors, carb sensitivities and weightings that work for YOU. It also helps to understand more about the “Pizza Effect” so that you can adjust the proportion of rapid acting and regular insulin for the type of meal you are having.

The Pizza Effect is the pattern of blood sugars you get when you use the correct carb sensitivity for the total carb content of the food but don’t take into consideration the effects of delayed glucose absorption when high amounts of fat or protein are also in the meal. It isn’t just pizza that can do this !

If you use a single injection of rapid acting insulin to cover these types of  meal you will end up with low blood sugars soon after eating the meal and a delayed rise in blood sugars after the meal. To counteract this you need to be prepared to allocate some of your total insulin dose to regular insulin taken at the same time as your pre-meal insulin or another separate injection of rapid acting insulin some time after eating the meal.  A pragmatic way of doing this is to allocate 50% of the carb allowance to rapid acting insulin and 50% to regular insulin. You then can see what results you get and vary the doses for that meal in the future accordingly. Some meals eg toast and jam are likely to need all rapid insulin. Others eg thin crust pepperoni pizza or a meaty lasagne are likely to need all regular insulin. Mixed meals like fish and chips could well be a 50: 50 split between the types.

There are a few things to remember:

  1. Rapid acting insulin has x 1.5 the potency of Regular insulin.

Say your carb content of the meal is 30g and you wish to give half of this to rapid insulin and half to regular insulin. Your sensitivity happens to be one unit of rapid for each 15g of carb. You would therefore need to give one unit of rapid acting insulin and 1.5 units of regular insulin.

  1. Correction doses are always rapid acting insulin.
  2. Protein cover is always regular acting insulin.
Personal Computer Insulin Calculator Version

This is the basic programme.  The background tables are needed for your:

Correction doses.

Insulin sensitivity for breakfast, lunch, dinner and bedtime snack.

Carb weighting values.

When you use the programme you will enter:

Current blood sugar.

Breakfast, lunch, dinner or bedtime snack.

Total carb count of the meal.

You will receive an insulin dose based on any correction dose needed, carb sensitivity you have registered for that particular meal and any additional carb needed for carb weighting factors. This will be the total  rapid acting insulin dose equivalent.

You then need to:

Consider how much of the total dose may need to be split between rapid and regular insulin if this applies to the type of meal you are having.

Calculate the conversion factor ( 1.5 ) to change rapid to regular insulin.

Visually estimate your protein amount in the meal and add this to the amount of regular you are going to inject. The sum is approximately 2 units of regular for each 3oz size of lean protein. This is the size of a pack of cards.

You should then have the total amounts of rapid and regular insulin you are likely to need. You need to profile each meal. Are you happy with the results? Feel free to adjust your insulin for that meal. From time to time you may also need to adjust the background tables. Remember the maximum your are going to inject is 7 units per shot.

Portable Palm Insulin Calculator Version

This programme has some extra features that are not available on the pc version.

The same background tables are filled in for correction doses, insulin sensitivities for different meals and carb weighting values.

When you use the programme you enter the same data regarding blood sugar, time of meal and total carb count of the meal.

These features are all exactly the same as the pc version.

The difference with this calculator is that additionally you have another programme in which you can:

  1. Add your estimate the amount of protein for your meals. The insulin needed to cover this is automatically added to the amount of regular insulin total.
  2. Decide how much of a percentage of the carb count should be allocated between rapid acting and regular insulin.
  3. Put your profiled meals on a favourites list. When you are going to eat any of these meals the calculator will adjust the doses according to the time of day you intend to eat it.

Things to be aware of:

  1. You do need to calculate any pre-meal correction doses separately when you use the protein calculator. A pop up box reminds you of this when this applies.
  2. When putting in the protein value from nutritional information on a meal packet you multiply the protein amount in grams for the portion you are eating by 4.6 and put this total in the protein box.
  3. When putting in the protein value from a visual estimate or measured amount of lean protein that does not have nutritional information you need to estimate the amount in ounces, multiply by 30 and put this total in the protein box.

The palm version offers the advantage of portability, a favourites list and calculates the protein insulin for you.  It is a bit more complex to use and programming the protein is not quite as straightforward as programming the carbs. It can be helpful to use to get specific meals sorted out. I would recommend that for most meals you start with a 50:50 rapid: regular split to avoid the worst of the  “Pizza Effect” and adjust according to your results from there.

Neither insulin calculator is a necessary feature of good meal profiling and manual collection of information is just as good. What they do is make the sums that you would be doing as a matter of course for new meals easier. This particularly applies to larger meals and processed ready meals that contain nutritional information.

Reference Info:

Where to Next:

We have now completed one of the toughest parts of this course. Well done. Congratulations to our helpers too.

To complete our journey I would like to read you a little story. There is no quiz in the next section.

Please all continue to the Endings and New Beginnings page.