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How To: Count Carbohydrates

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This section is necessary for everyone to read at least once. When you understand the complexities of carb counting you need to ask yourself if you need to learn it or not.

If you are an insulin user who wants to eat higher carb meals even just sometimes you do have to learn and become highly proficient at this skill.

If you are not on insulin you may prefer to have a “done it for you” sort of diet such as Dr Annika’s, the Life without bread diet or coming later in the How To: Follow Dr. Bernstein's Dietary Plan section.

If you are an insulin user who would prefer not to carb count you will still need to have some idea of what sorts of relative amounts of carb different foods have. Whether you choose Dr Annika’s, LWB or Dr Bernstein’s diet you are still going to have to cut your carbs gradually and be very consistent particularly in the run in phase when insulin doses are reducing. You need to give this carb counting a very good effort. When you are eventually stable on a low carb eating plan that suits you it is entirely possible to keep to doing what you know works and hardly carb count after that point.

There are several methods of carbohydrate counting that are commonly used.

1. Lists.

2. Exchange method.

3. Carb factors.

4. Nutritional labels.

5. Nutritional scales.

6. Eyeballing.

These all have their pros and cons. You need equipment or information sources for some of them. No matter how accurate you try to be you are likely to end up with an approximation of the carb content. The more of these methods you become comfortable with the more versatility you will have under different circumstances. In all cases you need to make the best estimate you can and notice the results you get. What would you change next time if your post meal blood sugars are not within your particular target range? By giving it your best guess and then testing you can build up a profile of how your body, medication doses,  and insulin can cope with that particular meal at that particular time of day.

 

HOW TO LOOK UP CARB LISTS.

Carb lists of food items can come from various sources. There are published books, web based resources and chain restaurants will often publish leaflets to give you an idea of the carb count or have the information on a web site.

One of the difficulties however is knowing what portion size they have actually measured. Sometimes a food is listed by the amount of carb in 100g which is a little over 3 ounces. Other times cups, tablespoons, handfuls or  the number of items eg grapes are listed with carb count. The most accurate way is when you have a standardised and individually packaged portion.

The website resources section in the metabolic syndrome section has some carb counting sites to help you get started. In addition here is list from some fast food and other restaurants.  To put these figures into context the Atkins diet ranges from 20-120g of carb a day.

Burger King
Whopper 48g
Cajun Chicken deli wrap 48g
Large fries 53g
Sachet ketchup 4g
Chocolate ice cream sundae 26g

McDonalds
Big Mac 44g
French fries regular 28g
BBQ dip 12g
Apple pie 27g
Regular vanilla milkshake 63g

Kentuky Fried Chicken
Original recipe chicken drumstick (one) 7g
Chicken fillet burger 36g
Corn 11g
Crispy strip (one) 6g

Pizza
One medium slice Italian pizza 27-38g
Portion of lasagne 63g
One slice of garlic bread 11g

Indian 
One portion of boiled basmati rice 110g
Chicken tandoori 2g
Chicken korma 16g
Vegetable curry 15g
Beef curry 6g
Naan bread 80g

Canteen/Bar food
Baked potato 70g
Chicken pie for one 32g
Meat pie for one 33g
Shepherds pie for one 37g
Battered fish 21g
Sweet and sour pork 34g
Chips/Fries small 31g
Chips/Fries medium 50g
Chips/Fries Large 73g

 

HOW TO USE THE EXCHANGE METHOD OF CARB COUNTING

The exchange method of carb counting was used for many years. Diabetics and their carers were taught what quantity of a carbohydrate containing food amounted to 10g, 12g or 15g of carbohydrate.  The Life Without Bread Diet which I have described in the Metabolic section uses a certain number of 12g carb portions a day.

In general this method can be more accurate than the list method. For instance a third of a cup of cooked rice is around 15g versus about 110g for your average Indian restaurant rice portion. It is still subject to some error of course.

The American Diabetes Association have come up with a rough quantity guide to help you. This is for a woman’s hand.

one clenched fistful = one cup

palms sized quantity = 3 oz

thumb tip = one teaspoon

handful = 1 or 2 oz of snackfood

whole thumb size = 1 oz

With all the inbuilt imprecision that this method of counting has you will always have to compare what you think you ate versus the results you got. When you do have such items as nutritional scales or relatively accurate portioned control amounts it is helpful to compare what they look like versus your usual portion size to improve your eyeballing accuracy.

American cup sizes are used throughout.

All of these portion sizes amount to about 15g of carbohydrate unless stated otherwise.

Easy Averages

1/2 cup beans
one small slice bread
1/2 cup cereal
one cup milk = 10g
1/2 cup cooked pasta
1/3 cup cooked rice

one large apple
5 small apricots
6 apricot halves in juice drained

one small banana
half a large banana
20 blackberries or blueberries

32 cherries
3 medium clementines or satsumas

3/4 cup fruit salad

one medium grapefruit
ten large grapes or 20 small grapes

2.5 kiwi fruit

3/4 of a medium mango
2 slices of melon

one large nectarine

one large orange

2 medium peaches
7 slices of canned peaches in juice drained
one medium pear
3 pear halves in juice drained
3 slices of pineapple
3 medium plums
4 dried prunes

1.5 tablespoons of raisins
1/2 cup raspberries

one tablespoon sultanas

One medium slice of bread 24g
one slice of french bread 1.5 cm in length

1.5 bridge rolls
1/2 medium sized roll

one slice currant or raisin bread

1/4 cup breadcrumbs

1/2 medium chapati

one toasted crumpet
1/2 currant bun
1/2 English muffin

2 small slices garlic bread
one medium hamburger bun 24g
one large hamburger bun 42g

1/2 hot cross bun

1/5 naan bread

1/2 sweet pancake 15cm diameter

2 large poppadoms
one pitta bread

one small scone

2 taco shells
1/2 corn or flour tortilla

For most breads a 30g serving has 15g of carb

2 tablespoons canned sweetcorn
one small corn on the cob
120g roast parsnips
1/2 cup frozen peas

1/2 small baked potato
one very small boiled potato
10 crisps
2 tablespoons mashed potato

For most vegetables

1/2 cooked = one cup raw = 5g carb
1 and a half cooked = 3 cups raw = 15g carb

1/2 cup of cornflakes, fruit and fibre or rice krispies

2 tablespoons muesli
1 cup puffed cereal
1/2 cup rolled oats made with water
one biscuit of weetabix

For most cereals a 20g serving has 15g of carb

Apple juice 150mls
drinking chocolate powder 20g
unsweetened grapefruit juce 180mls
Lucozade 85mls
unsweetened orange juice 170mls
unsweetened pineapple juice 150mls
soft drink 140mls

1/2 cooked barley
1/3 cup bulgar wheat
1 and a half teaspoons cornflour
1/3 cup couscous
2 and a half tablespoons wholewheat flour
2 tablespoons white flour
1/2 cup pasta
1/3 cup cooked rice
1 and a half tablespoons dried rice
1/2 cup tinned spaghetti

3 tablespoons baked beans
1/2 cup kidney beans
2 heaped tablespoons lentils or split peas

3/4 cup custard
3/4 cup evaporated milk
1 and a half cups milk
1/2 cup vanilla ice cream
2 heaped teaspoons sweetened yoghurt

1/2 standard bounty bar
25g bar of chocolate
1/3 standard mars bar
1.5 small milky way
1/2 snickers bar
3 fingers of kit kat
one finger of twix

3 cream crackers
3 crispbread

120g peanuts
3 cups cooked popcorn
25g packet of crisps

one penguin biscuit
two ginger nuts
one 9g shortbread biscuit

one 5cm square cake without icing
one 2.5 cm square cake with icing
one mr kipling french fancy 19g
one choc chip cookie 8g
one small slice chocolate cake

2/3 large croissant
one danish pastry
1/2 jam donut

1/2 slice fruit cake
one jaffa cake 9g

3 level teaspoons jam

one small slice madeira cake
1/2 an individual jam tart
1/2 mince pie

2 oatcakes

3 level teaspoons sugar

one small slice swiss roll
one small waffle

For most dry biscuits and cakes a 25-30g serving will have 15g of carb

For most sweets a 10-20g serving will have 15g of carb.

 

HOW TO COUNT CARBS USING CARB FACTORS 

The carb factor is the percentage of carbohydrate present in a food. If an apple has a carb factor of 0.13 this means that 13% of the weight of that apple is carbohydrate. If your apple weighs exactly 100g this would contain 13g of carb.

To use this method you need a list of carb factors and a set of scales to measure out the weight of your food portion. Nutritional scales have the carb and other factors built into them but you can use any scale provided it is sensitive enough.  Digital scales may therefore be preferable to analogue scales.

John Walsh and Ruth Roberts book, “Pumping Insulin” has a list of about 300 foods at the back.

The site Friends with Diabetes is a site for diabetics who wish to follow a kosher diet. There is lots of helpful information of help to everyone else too.

Also, this site www.medexplorer.com/nutrition/nutrition.dbm gives you carb content and other nutritional information too.

 

HOW TO COUNT CARBS FROM NUTRITIONAL LABELS

When you pick up many items of processed food you will find nutritional labels on them. How do you know how much carb is in the portion you intend to eat?

For the purposes of illustration lets say I decide to have a meal of a half can of lobster bisque soup, 3/4 of a can of spaghetti bolognese and half a can of mandarin oranges in light syrup with a dollop of tinned heavy cream.

I look at the lobster bisque. It lists :

Per  100g
Energy  51 kcal
Protein 3.4g
Carbohydrate 4.7g
(of which sugars 1.2g
Fat 2.1g
(of which saturates 1.2g)
Fibre 0.2g
Sodium 0.5g

I want to eat half a can and fortunately the figures for this are listed too.

How to I know how much carb to count? In this case it is easy because it is on the tin. Carbohydrate 9.8g per half tin (of which sugars 3.5g).

The important thing to remember is that it is the carb count and not just the sugar count that matters.

Now for the main course. Tinned spaghetti bolognese. The tin weighs 400g.

I pick up this can and go straight to the carb count.

It says carbohydrate 13.2 per 100g with sugars being 2.4g of this.
Per half can serving there is 26.3g  with sugars being 4.8g of this.

Ignoring the sugar content as usual I see that if I want 3/4 of the can I will need to do a little sum.

Although this is an easy sum to do I would like to go though what your old school teacher called “the working” so that it is easier to do this cross multiplication technique with more awkward amounts.

If 100g weight = 13.2 carbs  what does 300g weight contain?

Write it like this   100g = 13.2
300g = X

Now cross multiply like this:

100g x X = 13.2 x 300g

From algebra you may remember that if you want to know what X is you need to move the 100g to the other side of the equal sign. When you do this it has to go below the 13.2 x 300g sum to indicate that this  is  now going to be divided.

So  you get:

X = 13.2 x 300g
100

Using a calculator the answer is:

39.6

This cross multiplication technique can be used not only for counting how much carb is in a certain weight of food if you have the carb factor or carb count from a list but how much of a certain food you can have to stay within a certain carbohyrate limit.

Now dessert. Mandarin orange segments in light syrup. The can weighs 312g and the drained weight of the can is 170g.

Per 100g for the fruit and the syrup the carb count is  14g of which sugars is 14g.
For half a can the carb weight is 22g of which sugars is 22g. The fibre content is 1g.

This fibre content is pretty low so can be ignored in this calculation.  For certain foods with a significant fibre level you may be best to deduct it from the total carb count. Fibre affects the bulkiness of the meal but as it passes throught the gut without being absorbed you don’t need insulin to cover it. Because bulk can affect blood sugars through the effect of glucagon released from gut distention Dr Bernstein suggests a compromise by deducting half of the fibre from any given meal.

In this case we can find out how much carb is in half a can just by looking at the label. But what if this information was not supplied? What if the can contents had been shared out and you really had no idea what proportion of the can you had been given?

Lets go back to the carb factor information. 14g of the weight of the 100g of this food is carbohydrate.  If you weigh your portion on an accurate scale and it comes to 156g how much carb is this.

Cross multiply:

100g = 14g carb

156g = X carb

100 x X = 14 x 156

X = 14 x 156
100

X =  21.84g carb

Now lets add the cream.  Per 100g the carb count is 3.6g.  For a 50g serving size the carb count is 1.8g.  The can contains 283g so a serving size is  283/50 = 5.66th of the tin. A good couple of tablespoons by the look of this for a very low carb count.

Now add up your meal carb content:

Lobster bisque  9.8
Spaghetti bolognese 39.6
Mandarin oranges 22
Cream   1.8

Total = 73g

Now, you won’t be surprised to hear after what we’ve been telling you  about high amounts of carbohydrate messing up your blood sugar control, weight and metabolism that this menu is for carb counting lessons only. You want to eat much healthier meals that this canned rubbish don’t you?

 

HOW TO COUNT CARBS USING NUTRITIONAL SCALES

Nutritional scales come in two main types. The cheaper type has a booklet with food lists and you enter the code of what you are weighing into the machine. More expensive models have an inbuilt computer with the foods listed and you click on the food you are weighing. These tend to have a larger database and can be used without having to have a booklet.

The nutritional scales give you the calorie, salt, protein, fat, cholesterol, fibre and carbohydrate counts for any given weight of food. There are memory features too.

The Salter nutritional scale that I have has 800 foods listed from the USDA database. It cost me £32 from Amazon. If you go onto the USDA site to find an even larger range of foods and have an accurate enough scale you do not really need to have nutritional scales.  I have found it a convenient and useful method and our family even have guessing  games about how many carbs a particular food portion contains. I have even taken it into restaurants to carb count food!

 

HOW TO EYEBALL PORTIONS OF CARB CONTAINING FOOD

Out of all the carb counting methods I have discussed this is the method subject to the most error and yet it is the most commonly used.

To get success with this you have to practice and practice with the other more accurate methods of weighing out small portions of food and using packaging information, charts or nutritional scales to come to what still is an approximation of the amount.

It has been shown that eyeballing is reasonably effective up to about 30g of carb portions but once the portions get bigger the estimates get considerably less accurate. For this reason you are better to look at your food and even  move it about in your plate a bit try to replicate the portions you use at home with a known carb count and then add them up.

It always amazes me just how much carb potatoes have compared to for instance cauliflower, broccoli and green beans. Some  eye ballings rules are that a golf ball size of mashed potato is 10g of carb and a woman’s fist size of cooked low starch vegetable is 5g.

The lower the carb count of your meal the easier it is in general to figure out the carbs. There is less room for error with what you think is one golf ball size of mash compared to say six such estimated portions which is not unusual in some restaurant meals.  This goes of course for rice, bread, pasta, chips, cakes and sugary sauces too.

Partly for these reasons of difficulty in  carb estimation and also because of the variability in the absorption and effect of insulin injections it is far less troublesome to simply keep these food items to a minimum for insulin users.

Type 2s who don’t use insulin also find that their sugars spike with anything other than modest portions of these items because they don’t have a supply of immediately releasable stored insulin in their pancreases.

 

Quick Quiz:
Carb counting is not an exact thing. Different breads are sliced to different widths for instance. Cup sizes vary too. In the carb comparison questions one option will have at least twice or half of the relative amounts of the other three options.

1. 12g of carbohydrate is present in all of these except…
a one thin slice of bread.
b one cup of broccoli.
c one cup of rice.
d half a grapefruit.

2. 15g is present in all of these except…
a Half a cup of beans.
b Half a cup of cereal.
c Half a medium roll.
d One hamburger bun.

3. 15g of carb is present in all of these except…
a One large banana.
b One medium pear.
c Three pear halves in juice.
d 3 medium satsumas.

4. 15g of carb is present in all of these except..
a Half of a small baked potato.
b A packet of crisps.
c A small portion of Burger King chips.
d Two tablespoons of mashed potato.

5. 15g of carb is present in all of these except…
a Three fingers of kit kat.
b Half a standard bounty bar.
c One standard snickers bar.
d One finger of twix.

6. 30g of carb is present in all of these except…
a A slice of pizza (the size of the ones with a thin base served at the buffet in Pizza hut)
b A donut.
c Two oatcakes.
d An individual jam tart.

Have you got it?
1. C. A cup of rice is about 30g. More than twice the carb count of the others.

2. D. A small hamburger bun is around 24g and a large one 48g. The others are about half the carb count.

3. A. A large banana is about 30g.

4. C. A small portion of Burger King chips is about 32g. Even then the consistency between these small portions varies a lot. I know. I’ve sat counting chips to find out.

5. C. A standard snickers bar is 34g.

6. C. Two oatcakes at 7g each are around 15g.

Reference Info:
Jo Sutton an Australian Dietician compiled the carb lists that I have used here.

 

Where to Next?
We are all now going to move onto the  How To: Do the Atkins Diet diet section.  What? Did I hear this right? Surely everyone in the developed world knows how to do Atkins?  They all think they do! That’s for sure. For a different take on the most famous diet in history I’ll see you there.

 

 

How To: Know What Things Beyond Food Can Affect My Blood Sugar

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This section is for everyone.

Often you may notice that the blood sugar in the morning is higher than when you went to bed at night even when you have not had any bedtime snack. This can be due to a variety of causes including gluconeogenesis, the dawn phenomenon and delayed stomach emptying which is also known as gastroparesis.  There are many other variables that affect blood sugar besides just the macro nutrients of the food you eat.

Gluconeogenesis

Gluconeogenesis (Latin for “The making of new sugar”) is the process where the liver converts protein to glucose. This goes on all the time to some extent but is suppressed in the presence of adequate amounts of insulin and drinking alcohol. In type one patients who are no longer able to make enough  of their own insulin this  process accelerates and is what causes their sugars to rise so high and for them to lose so much weight.

Dawn Phenomenon

The Dawn phenomenon is called this because the liver clears away insulin more efficiently first thing in the morning compared to other times of the day. At the same time growth hormones and sex hormones are manufactured during the night and these make cells less sensitive to the action of insulin which normally moves sugar from the blood into the cells. These two mechanisms result in higher blood sugars in the morning for most people after puberty gets underway. Various dietary and insulin techniques can be used to minimise the effects of this phenomenon. Another great read on this topic can be found here: The Dawn Phenomenon – Why Are Blood Sugars High in the Morning?

Delayed Stomach Emptying / Gastroparesis

Delayed Stomach Emptying is due to the effects of long term nerve damage on the way the stomach works. The rate of stomach emptying is reduced and the bottom end of the stomach called the pylorus can go into spasm. It can be difficult to know how your stomach will respond from one meal to the next.

For type two diabetics who are not on insulin or drugs which stimulate insulin secretion this may simply give you very unpleasant indigestion.

For insulin  users and those on drugs that stimulate insulin secretion, these are usually timed to act over the time the food of the meal is getting digested.  When food digestion  becomes imbalanced, blood sugars can be too low immediately after a meal only to go too high some hours later.

Special dietary measures are needed to overcome the effects of this condition and they are carefully explained in Dr Bernstein’s book  Diabetes Solution.

Like many complications of diabetes it tends to become apparent after 5-20 years of diabetes depending on the level of blood sugar control. Although the condition can certainly make diabetes control much more difficult it is possible to reverse delayed gastric emptying and some other complications by careful maintenance of normal blood sugars for several years.

Genetic Factors

Blood sugars can rise over the long term from effects you can’t control like inheritance.  Excess weight has both genetic and environmental components from the womb onwards.  Excess weight gain  raises your blood sugars because it makes you more insulin resistant.

Infections

Undiagnosed  and untreated infections particularly  gum and dental infections can raise your blood sugar.  Careful examination by a dentist is often needed. Treatment  can take months.

Acute Illnesses

Dehydration and acute infections such as gastroenteritis, viral infections, acute injuries, surgical operations  or stress can raise blood sugars.

An important consideration is that once the blood sugar is high you become more insulin resistant because of this and vicious circles of high blood sugars, not being able to control them and dehydration can occur.  This topic is further explored in the section on sick days in the Type One Section.

Chinese Restaurant Effect

The Chinese Restaurant effect named so by Dr Bernstein is the high blood sugars that rise disproportionately to the carb count of the meal due to the actual bulk of the meal.  Moderate distention of the stomach produces the stimulation of the hormone glucagon which acts in opposition to insulin. This makes the liver produce more sugar from protein. The main thing to remember is not to stuff yourself at meals.

Exercise

Exercise affects blood sugars considerably.  Different sorts of exercise can raise or lower your blood sugar.  This also varies according to how much insulin you have working at the time. The factors are very complex and there will be more discussion and sources of information on this in the Type One Diabetes Section which follows soon.

Exercise can improve many aspects of your life. Even if you have never been to a gym in your life and like me ran away from the ball at  enforced school P.E. sessions there are so many activities you can enjoy.  You can be active indoors, outdoors, in teams, alone, with help from instructors or by self discovery.  Your mood, physique, strength, stamina and flexibility can all benefit in some way.

Insulin Effectiveness

Tainting a bottle of insulin or exposing it to extreme temperatures can both cause it to lose some of its effectiveness and hence will increase one’s blood sugar even though the same dosage is administered.

 

Quick Quiz:
1. The dawn phenomenon affects teenagers and…
a Makes their blood sugars particularly high when they wake up in the mornings.
b Makes them sleepy and unable to get up in the mornings.
c Makes their breakfast digest more slowly than usual.
d Makes their blood sugar high by releasing glucagon.

Have you got it?
1. A is correct. The DP as it is often referred to also affects many adults.

Reference Info:
This section is based on the work of Dr. Bernstein’s Diabetes Solution.

The Dawn Phenomenon – Why Are Blood Sugars High in the Morning?

Where to Next?
Please all proceed to the How To: Keep Healthy with Diabetes section?

How To: Deal with High Blood Sugars

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This section is for everyone. As you will need your helpers to help you deal with aspects of seriously high blood sugars they need to read this section and do the quiz too.

An excellent training course  for dealing with high  and low blood sugars can be found online at the online pump school at the medtronic minimed site .   Even though you may not even intend to use an insulin pump the course goes through a realistic and methodical training that is just as relevant for injectors.  Your immediate family and important carers should do it too. After all, what happens when you are too ill to help yourself?   You may  need to have a  calculator handy. The blood sugar levels are given using the US system and if you are used to UK figures, as indeed also happens in Canada and Australia, you will need to divide the US figures by 18.

Vomiting, Dehydrating Illness and Infection—When do I ask for professional help?
When you get vomiting on more than one episode, nausea to the extent you cannot eat, fever of more than 24 hours duration, severe diarrhoea or any form of infection you need to contact the triage nurse, diabetes nurse or your doctor for advice.

With diabetes it is much safer and easier to prevent the potentially dehydrating illnesses from getting worse than it is to fix you if you are in a severe state. Please don’t put off that phone call.

How does diabetic ketoacidosis develop?
Any infection will raise your blood sugars. This in turn leads to increased urine output and higher blood sugars. The higher the blood sugar the more insulin resistant you become. Higher insulin levels will then be needed to get things under control.

If your peripheral circulation shuts down your cells will start to metabolise fat and make ketones. Ketones take water from the body on the way out of your kidneys and you will get more dehydrated.

High levels of ketones also make you vomit.

Symptoms of DKA are:

  • nausea and vomiting
  • rapid deep breathing
  • loss of appetite
  • abdominal pain
  • weakness
  • visual disturbances
  • sleepiness

It is a truly awful vicious circle. The thing to do is to prevent it happening in the first place.

What do I do if I am not getting better ?
If you become unwell at any time it is important to keep your fluid intake up, continue your usual medication or insulin, check your blood sugar levels more frequently than usual eg every 2.5 hours.

Check your urine for ketones if your blood sugar level is above 13 / 230.  In fact even if your sugars are normal and you feel queasy check for ketones. Remember that ketone testing stix are unreliable 6 months after the container is opened regardless of whether they appear to be in date.

Get prompt medical advice if your symptoms don’t settle or your blood sugars are too high.  Information you can give about your current blood sugar, the trend in blood sugars, ketones or not, your insulin doses and your correction doses and how well you are keeping down fluids and passing urine are necessary for the doctor or nurse to make an accurate assessment.

If you attend A and E bring your Emergency Cards especially if you do not speak the language they are likely to speak in the hospital fluently. Bring all your kit and a reliable bi or multi lingual helper.

Do not sit politely at the back of the waiting room if you are a vomiting insulin dependent diabetic. They must assess you RIGHT NOW.  They may have to drip you RIGHT NOW to SAVE YOUR LIFE.

If you are incapacitated or having surgery a friend, parent or sibling who knows how to manage your diabetes must be with you at all times to test and treat you as needed.

They may have to insist on saline drips until your blood sugars are in your normal range. Current hospital practice is to switch to dextrose ie sugar drips when you go below 10 / 180.

They may need to bring you in diet drinks or special food when you are in the recovery phase.

How to Manage Blood Sugars When I Actually Feel Okay?

Well, I hope you understand. I just had to get the blood and thunder stuff out of the way first.

If you think your blood sugars could be running high check your blood sugars. Tiredness is probably number one symptom of high blood sugars. If you are high you can do some things to bring it down.

15-30 minutes of gentle walking or other exercise can bring it down.

Drink plenty  of water if you are high.

If you are high three days in a row at the same time you need to consider an adjustment to your insulin dose.

Watch out for high blood sugars due to old or contaminated insulin. If in doubt throw it out!

Then watch for lower blood sugars when you start a fresh vial.

If you have been high due to an illness, stress or surgery and have gradually upped your insulin to deal with it be prepared for low blood sugars when you recover.

Girls and women often go high just before their period starts.

Remember your flu jag each autumn. It could spare a lot of grief.

High sugars and widely swinging blood sugars both cause complications that among other things age your blood vessels.  So does smoking. You don’t need smoking on top of all this diabetes stuff. Do you?

Correction boluses can be given for high blood sugars.

One rule of thumb is that one unit of a rapid acting analogue will deal with about 2.5 /  45 units of blood sugar. But this is an adult average and you are not average. You are you.

The more you weigh and the higher your total daily insulin dosage the less your blood sugar level will drop for a given measure of insulin. For many people a given unit of insulin will drop you much more if it is given at night compared with during the day.

Your correction dose will also depend on your individual insulin sensitivity for the time of day just the same as for your meals. You’ve worked this out for your meal coverage haven’t you?

Dr Gary Schiener has charts you can use to estimate your correction doses in his great little book “Think Like a Pancreas.” Again this is simply a guide. It is safest to start at correction doses a little lower than he recommends and take it from there. Guess and test. Again and again.

Hang on a minute.  I’ve not done yet. You cannot go off and correct high blood sugars with insulin willy- nilly. You also need to consider how much previously injected insulin is still active or you could drop too low.  Gary has charts for this too. Gary has loads of charts!

If you do go ahead with a correction bolus please check your bs after an hour to make sure it is on the way down and that you are not going too low.

Dr Bernstein thinks that the residual insulin on board calculations just makes the whole correction dose thing just too complicated.  I agree with him.

Dr Bernstein recommends that you only correct with insulin at your pre-meal and pre -bed times.  This is so that you can assume that no residual effect from the insulin other than your basal is present. This is not quite true of course. Remember the tail effects of regular and rapid acting insulins?

You also need to consider if your sugars are high due to a meal that took longer to digest than usual. Pizza for instance is notorious in this respect. It takes 8 hours to digest and a minimum of two spaced doses of regular insulin or three spaced injections of rapid acting analogue insulin to cover it completely. You need a five hour space between strict low carb meals before food will be having no effect on your blood sugars at the next meal.

I found it easier to give half a unit for a high blood sugar of a certain figure at a certain time of day and then see what results I got.  Progressively I was able to chart Steven’s exact correction doses for different blood sugar levels at different times of day. If half a unit didn’t take him to his target blood sugar level of 5.0 I simply gave more the next time.

I don’t do correction doses for high blood sugars at bedtime. I am too worried about possible night time hypoglycaemia. I simply put it down to experience, give Steven his night basal insulin, a big glass of water, say “Night Night”. Then I figure out how I could have done it better for the next time.

For any teenagers out there who are now desperate to get on with managing their own sugars some final words of wisdom from Spike and Bo.

“Let your parents take as much care of you as they want and help you out as long as they can. Someday you will be on your own and they won’t be there to remind you to take your kit and make you a healthy high protein breakfast.”

Quick Quiz:
1. Three of these tend to raise your blood sugars….
a Menstrual hormones.
b Hypoglycaemia rebounds.
c Weight gain.
d Alcohol.

2. If you have a blood sugar that is unexpectedly high you could have…
a An infection brewing somewhere.
b Been drinking too much diet coke.
c Given yourself too much insulin at the last injection.
d  Eaten too little carbohydrate with your last meal.

3. If you are insulin dependent and your blood sugar is 13/235 or over the next thing you should do is…
a Call your doctor.
b Check for ketones.
c Exercise vigorously to bring your sugars down.
d Have your usual amount of insulin and food.

4. You decide to give yourself a correction bolus to bring down a  high blood sugar. After giving the injection there is one of these things you really should NOT do….
a Check your blood sugar 30-60 minutes later.
b Drink a large glass of water.
c Go for a gentle walk.
d Go to sleep.

5. Before you give a correction bolus you need to consider three of these…
a Whether any previously injected insulin is active and for how long.
b Your insulin senstitivity for that time of day.
c  Recent previous exercise.
d Your current weight.

6. If you are insulin dependent and ill and vomit more than once you should do one of these things..
a Go to bed till you feel better.
b Check your blood sugar and call the doctor or nurse for advice.
c Have some lucozade to aid recovery.
d Stop taking food and fluids so as to give your stomach a rest.

7. You are vomiting repeatedly. Your sugars are high and you have ketones. What single course of action is best…
a Go to bed.
b Call NHS 24 from some advice from a nurse.
c Phone a friend.
d Go straight to A and E with your overnight bag and diabetes kit.

Have you got it?
1.       ABC do. Alcohol tends to give low blood sugars due to its effect on the liver of suppressing gluconeogenesis.  Menstrual hormones give a cyclical monthy pattern. Weight gain has a very gradual effect. Whether hypoglycaemia rebounds are due to overtreated lows or adrenaline and cortisol rushing in to save the day is a controversial phenomenon.  You may have to find out for yourself.

2.       A is correct. Dental and gum disease can be a hidden cause. Any flu like illness can play havoc with your blood sugars.

3.      B is correct. Remember that ketostix lose effect even while in date if the container has been opened more than six months before.  Exercising when you have ketones and are relatively insulin deficient can push you into very high blood sugars and ketoacidosis.

4.      D. You must NEVER give a correction bolus and go to sleep. You may overcorrect and have a severe hypo.  Rechecking  is mandatory and the water and walk may help.

5.      ABC are correct.

6.      B is correct. Although the other things listed are often done by non diabetics these activities no longer apply to you. Don’t do what your mum did with you were six. Do what you need to do NOW. And don’t delay making that call.

7.      D is best. You need a DRIP and you need it NOW. Phoning a friend is absolutely fine. They can help you get your kit, drive you to hospital, collect your kids from school and look after any pets.  No  going to bed while they make you a pot of chicken soup though!

Reference Info:

 

Dr Bernstein’s Diabetes Solution has a particularly important chapter on the subject of dealing with vomiting, dehydrating illness and blood sugars. If your carers read nothing else they must read this. Diabeticketoacidosis is a frightening run- away- train sort of illness. There is significant mortality rate even if DKA is treated in the best of hospitals.

Prevention is therefore paramount. Dr Bernstein’s recommendations may vary a bit from those of your diabetic clinic. In particular he emphasises aggressive and early management of any condition that has the potential to develop into DKA, hydration with a non sugar electolyte mixture which you can easily make to his instructions and close liaison with an experienced and  knowledgable health professional early in the symptomatic phase.

There is no point in reading all about it when you are throwing up rings around yourself. You must have the supplies he recommends and know what you are going to do AHEAD of events.

Having metoclopramide injection (UK) at home with the appropriate syringes and needles came in really handy when Steven was in this situation. You would benefit from having this drug or similar one in your emergency kit. It can be necessary after vomiting from glucagon administration as well as to terminate a vomiting attack from a viral infection or high sugars.  It is not to be used instead of medical advice but as well as. After you have vomited twice you must contact your doctor. If they think that an injection is required at this stage you can give it yourself or have the diabetic person do it. This can save valuable time on a house call or trip to the clinic or A and E department.

Where to Next?

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

How To: Advise My Helpers of Low Blood Sugars

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This section is for everyone and their helpers.

If you are seriously impaired your helpers may need to give you glucose gel by rubbing it inside your cheek. Tell them not to put it beyond your teeth in case they get bitten.

If you are unconscious it is important that nothing is administered by mouth in case you choke.

Glucagon administration is now necessary. Are all your helpers trained how to use this?

If there is no clear improvement in ten minutes with glucagon they must dial 999 / 911 and get you to hospital.

After glucagon administration you can feel very sick indeed. Metoclopramide tablets or injection may be necessary. Your doctor may prescribe this for self administration at these times and if you vomit.

You will also need to build up your glycogen stores by eating your normal diet for 24 hours and meticulously avoiding low blood sugars during this time.  You will need to do more frequent testing eg every 2.5 hours instead of the usual pattern and you would correct for lows but not highs.

Children don’t have much glycogen to mobilise so if they have a severe hypo the best thing may be to get them straight to a hospital instead of waiting for glucagon to work.

Hypoglycaemia unawareness can occur more frequently in people who have chronically high or low blood sugars. Beta blockers can also cause this. Aiming for normal blood sugars long term if they are too high and correcting for levels below 4.0 every time can help.

After any episode of hypoglycaemia you need to figure out why you went so low so you can sort out any problems or plan to do things differently.

You may not catch every hypo but you will reduce the frequency and severity of every hypo by doing this.

Common Causes of Hypoglycaemia

  • Too long a delay in eating your meal after an insulin injection.
  • Delayed stomach emptying after a meal.
  • Eating less than you planned for the given insulin dose.
  • Drinking too much alcohol. What is too much? More than just one unit for many insulin users. Sorry.
  • Hormonal changes in certain phases of the menstrual cycle.
  • Sudden return to normal after a period of insulin resistance such as when recovered from an illness.
  • Injecting from a new bottle of insulin when the old one had lost some of its effectiveness.
  • Switching insulin types without considering different potencies of different insulins. Eg lispro and aspart the rapid acting analogues have 150% of the potency of regular insulin.  Levemir has 75% of the potency of Lantus.
  • Taking too much insulin.
  • Not rolling cloudy insulin suspensions adequately.
  • Mistakenly injecting insulin into a muscle.
  • Lying too long in a hot tub.
  • Effects of exercise that have not been covered by sufficient insulin reduction or carbohydrate intake.
  • Injecting near a muscle that will be strenously exercised.
  • Some medications cause hypos.
  • Some insulins are not as stable as you would like and are more prone to giving hypos eg NPH.
  • Two different carers give someone their insulin without checking first.

Quick Quiz:

There is no quiz for this section.
Reference Info:
Acknowledgements to Dr Bernstein.
Where to Next?
Please all continue to the How To: Deal with High Blood Sugars section.

How To: Help Diabetics Who Can’t Afford Insulin

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This section is for everyone.

From time to time I expect you feel pretty miserable about having diabetes. Especially about these interminable injections.

Diabetes for everyone is a life sentence. But for some poor people in developing countries parents cannot afford insulin for both a diabetic child and  food for the rest of the family. Hard choices have to be made.

Insulin for Life

The insulin for life organisation aims to help. They will ship your unwanted but in date insulin to those who would die without it.  They also help coordinate insulin supplies to disaster struck areas.

It is an Austrialian based organisation whose president is Ron Raab.  Ron has been a type one diabetic since he was 12 just like Dr Bernstein. He became one of Dr Bernstein’s patients and reversed many of his longstanding diabetes complications (read his success story here).

Insulin for Life is the website for the organisation that has affiliates in the US, Europe and the UK.

The Insulin Dependent Diabetes Trust

This is the UK organisation who will send your donated insulin to Insulin For Life.

Please send your no longer needed insulin – unused vials or cartridges and in date in a jiffy bag to:

Jenny Hirst
IDDT
PO Box
Northampton
NN1 4XS

The IDDT is a charity whose staff and membership is formed by diabetics and by those caring for diabetics. They aim to listen and support your needs.

They have an excellent website with articles of interest to insulin users about many different aspects of diabetes at: www.iddtinternational.org

Enquiries can be sent by e mail to:  enquiries@iddtinternational.org

The IDDT was formed from original members of Diabetes UK who were not being supported in their needs and preferences for animal insulins. Unlike Diabetes UK they receive no funding from pharmaceutical or food manufacturers.

Today is the 30th July 2007 and at the present time there is no pen form of regular insulin available in the UK apart form pork or beef soluble insulins. These are available for use in one unit increment  Owen Mumford Autopen Classic.
Thanks to the political lobbying that IDDT have continued for years the UK still manufactures animal insulins. These are obtained  and purified from pigs and cows that have been slaughtered for their meat.

A small variety of long acting, short acting and mixed duration animal insulins are available in pen cartridge formulations and  vials from Wockhardt Pharmaceuticals. These can be shipped overseas.

Prescriptions for the insulins and pens are available from your UK GP in the usual way. A GP however may want a diabetologist to approve.

If you are  keen on a pen form of regular insulin animal insulins are the only option currently available. The biggest drawback is that there is no half unit increment pens. Hypurin Pork Soluble insulin is what you need as it is a little quicker  acting than the Hypurin Beef Soluble insulin. You may remember that regular /actrapid/ soluble insulins are  a particularly good option for covering protein in meals.

Alternatively you can use Hypurin Pork Soluble or the GM Human Actrapid insulin  manufactured by Novonordisk in vial and syringe form. The advantage of the syringe is that you can still use half or quarter unit doses.

Quick Quiz:
1. Unopened and in date insulin vials and cartridges that you no longer need can be put to good use by two of these….a
a Pharmacies
b Diabetes UK, the ADA or your equivalent national diabetes organisation.
c Insulin for life.
d The Insulin Dependent Diabetes Trust.

Have you got it?
1. C and D are correct. IDDT in the UK will send it to Insulin for Life who will arrange for worldwide distribution.  Please send  insulin with at least 3 months to go to expiry.  You can read more about this organisation and how you can help on this site.

Where to Next?
Please now proceed to the How To: Deal with Low Blood Sugars section.

How To: Time Insulin Injections for Simple Insulin Regimes

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This section is for everyone.

If you are on a fixed dose insulin regime for any reason about the only thing you can manipulate to control blood sugar control is what you eat and the timing of your meals in relation to this.

These fixed insulin regimes are less common in the US but are very popular in the UK especially type 2s and also for type ones who are just starting on injections. Carb counting is not usually taught outwith special education courses such as DAFNE in the UK.

This educational course has given you lots of information that you can use to improve your diabetes control. If you have not yet got to grips with carb counting and the other advanced insulin techniques you may like to have some simple techniques that will improve your control meanwhile.

If you expect a meal to take longer to digest than is usual for sugars and starches eg it is high in protein, fat and low glycaemic carbohydrates (eg lasagne, pizza, lamb curry) you can:

  • Bolus 15 – 30minutes after you start eating for rapid acting analogues.(RAAs)
  • Split the bolus into two or three parts and give at 6-90 minute intervals. (RAAs)
  • Take regular insulin with the meal instead of a RAA.
  • Extend the bolus delivery time to over 2.5 hours if you are on a pump.

For people who are on or prefer to use a single injection of a RAAs:

  • For foods that are high GI foods – bolus before eating. eg a jam sandwich.
  • For moderate GI foods – bolus while eating. eg fish and chips.
  • For low GI foods- bolus after eating.

 

Your pre-meal blood sugar will also affect the optimal time you give your food boluses:

BS above target range:

High GI 30 – 45  minutes before a meal.

Medium GI 15 – 30 minutes before the meal.

Low GI 0-5 mins before the meal.

BS in target range:

High GI 15-30 mins before the meal.

Medium GI 0-5 mins before the meal.

Low GI 10-15 mins after you start the meal.

BS below your target range:

High GI 0-5 mins before the meal.

Medium  GI 10-15 mins after you start the meal.

Low GI 30-45 minutes after you start the meal.

If this sounds complicated, well it is!  But you have diabetes as your constant companion for the rest of your life. You will be having at least 2 meals and more usually 3 to 4 every day.  You have plenty of time to experiment to get the best results.

For people on or who prefer fixed basal/bolus regimes

If you are on a fixed basal/bolus regime much of what you have been learning about the versatility of different insulins will be irrelevant to you. You can only use the tools you have after all. One thing that is particularly relevant to you is the delaying or advancing injections in relation to breakfast and your evening meal.

If your pre-meal sugars are high you can give the insulin dose and then wait longer for your sugar to drop before eating. For instance on Mixtard you normally wait 30 minutes before a meal but you could extend this as far as an hour and a quarter depending on how high your sugars are. For novomix or humalog mix the usual instruction is to bolus just before eating. You could inject 14-40 minutes before depending on your level.

The opposite applies to low blood sugars. For mixtard users you would inject and eat right away or earlier than the usual 30 minutes. For novomix/humalog mix users the injection could be delayed part way into the meal or afterwards.  There is no substitute for experimentation and learning from your efforts.

How do I change my insulin regime if I am an NHS patient?

Many US readers will be splitting their sides laughing at the very idea of these detailed schedules for fixed insulin users. Why not learn to carb count and use separate bolus/ basal regimes? Why indeed?

As a UK General Practitioner I realise how difficult it is for patients to change their diabetologist’s mind about what insulin is considered right for them.  I hope you will read about all the different food patterns and insulin regimes so you can consider if what you are doing now is what you really want to do. Are you getting the results you want? How much effort would you be willing to put in to experiment to get the best results for you?

Fixed basal / bolus regimes offer little cover for lunch time meals.  To remedy this you can either eat a very low carb meal at lunch time or ask the diabetologist to give you some rapid acting analogue or regular insulin to inject to cover your lunch.

The diabetic staff  may not want to have to train you in the use of a multiple daily injection regime. They may not want to teach you carb counting. A lot of this has nothing to do with their perception about how you will cope or  whether they like you or not. It is to do with resource allocation in the NHS. NHS staff don’t call it the National Sickness Service for nothing!

Please consider going  through this entire  programme thoroughly.  Prove that you are better informed about what will work to improve your diabetes than they are.

If you get stuck your Member of Parliament or a letter of complaint to the Clinical Director of the Hospital may help.

And the Best of British Luck to you!

Quick Quiz:
1. When a type one is eating in a restaurant it could be risky to to one of these…
a Inject your regular insulin right after ordering.
b Inject your rapid acting insulin right after ordering.
c Ask for vegetables instead of potatoes or rice with the main course.
d Tell the waiter you are diabetic and need food right away if you have been waiting for a time or feeling low.

2. For insulin dependent diabetics they should avoid large amounts of alcohol at one go because…
a It will make them fat.
b It causes acute peripheral neuropathy.
c They will lose their inhibitions and eat sugary food too.
d It can suppress gluconeogenesis and give severely low blood sugars.

3. Type ones need to consider extra insulin when the protein portion to be eaten amounts to…
    a One pound of meat.
    b The size of a man’s palm.
    c The size of a woman’s palm.
    d The size of a boiled egg.
4. Three of these methods can effectively cover protein for insulin users…
     a  Using a single injection of rapid acting insulin such as novorapid/novolog orhumalog.
     b  Using  single injection of regular acting insulin such as actrapid.
     c  Using two insulin injection of rapid acting insulin separated by a length of time. (split bolus technique)
     d  Using an extended bolus of rapid acting insulin in a pump.
5. Ways of extending the length of time an insulin is active also helps to cover three of these foods such as…
     a Pizza
     b Lasagne
     c Mashed potatoes.
     d Chicken korma.
6.  You are using rapid acting insulin to cover your meals. Which three of these techniques could be appropriate around mealtimes…..
    a If your blood sugar was low you could take the appropriate amount of glucose and delay your meal till your blood sugar was back to normal….
    b If your bood sugar was low you could inject 15-30 mins after starting to eat.
    c If your blood sugar was on target you could inject 15-0 minutes before eating.
    d If your blood sugar was high you could inject 15-3 minutes before eating.
7.  You decide to have a  high carbohydrate dessert to celebrate your birthday.  What three measures could you take to minimise adverse effects on your blood sugars…..
    a Eat it early enough in the day when you can exercise vigorously after eating and have plenty of time to check your sugars and correct accordingly.
    b Add a little more insulin than the carb count and your insulin sensitivity would suggest to compensate for the relative insulin resistance caused by high blood sugars.
   c Add lots of unsweetened heavy /  double cream to the dessert to slow the blood sugar spike down.
   d Take the amount of insulin you think you will need but induce vomiting to prevent it digesting fully.
Have you got it?
1.B is unduly risky. Food tends to arrive 2-40 minutes after ordering and you may be putting yourself at risk of a hypo by injecting a rapid acting insulin too soon before the meal. The waiter is there to help you. Ask if you need done specially for you.

2. D is correct. Insulin users in particular should always be moderate about their drinking and eat slowly releasing carb or protein with drink to avoid delayed hypoglycaemia from alcohol. A and C apply to some extent too of course. Prolonged heavy drinking can cause peripheral neuropathy.

3. C is correct. This is around 3-4oz (apparently!) Other visual clues are the size of a deck of cards or a quarter pound burger.
4. BCD are correct. A single injection of rapid acting insulin will tend to spike too early and could give you a hypo soon after you start to eat.  It will have stopped working before the protein has been digested so will give you higher sugars a few hours after the meal.
5. ABD are correct. These have a high fat/protein content and digest fairly slowly. Mashed potatoes on the other hand are converted to sugar very quickly.
6. BCD are correct. With high blood sugars you do need to bring them down for optimal control before eating. Otherwise you would be starting off a meal with a degree of insulin resistance which then tends to require a disproportionately high amount of insulin to sort out after the meal is eaten compared to the levels needed to reduce a highish blood sugar before the meal is eaten. You don’t need to correct for low blood sugars with glucose though. Just eat earlier and  time your insulin a little later…
7.  ABC are correct.  High carb treats can be enjoyable. To eat them very sparingly will enhance the sense of specialnesss and need not damage your health.  The problem of course is if you can’t stop once you start or you eat them too frequently. Some people are best to avoid them completely.
Vomiting to control your blood sugars, your weight or anything else is a bad idea. It plays havoc with your teeth, blood sugars and metabolism.
Unfortunately diabetics have a higher rate of eating disorders such as bulimia and anorexia than the general population.  Sometimes the pressure to be thin can feel so great that insuln injections can be missed so that the calories are passed as sugar in the urine. Life threatening complications such as diabetic ketoacidosis can result. Rapid development of complications such as proliferative retinopathy can appear in a fraction of the time they would with just “average” control.
If you think you could be developing an eating disorder please seek help from your doctor or diabetic clinic. You need expert psychological help and they can get this for you.

Reference Info:
Acknowlegements to Gary Schiener.

Where to Next?
Please all continue onto the section  How To: Help Diabetics Who Can’t Afford Insulin section.

How To: Do Dr. Morrison’s Carb Weighting System

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This section is for everyone who wants to “cheat” on their low carb diet and minimise the consequences.  If you can see yourself happily low carbing without the need to cover higher carb meals you may skip to the How To: Time Insulin Injections for Simple Insulin Regimes.

You need to wean yourself gradually off your high carb diet.

You need to be in a typical transition period at the very least.

You need to adopt the 7 unit per shot guidelines.  Every single shot.

Your need to find out which methods of carb counting work best for you and do them every meal.

You need to keep your basals, exercise, and fat and protein intake consistent over the testing period.

You need to be well and free of infection or undue stress so your meal profiles will be accurate.

You need to test at 3am on an experiment day to see you have not over done your insulin.

Ready?

What you are going to do is find out at what level your insulin stops working in a linear way.

You will recognise this by high blood sugars before the next meal compared to when you eat low carb meals. I don’t know when this will kick in for you. For Steven it was good bs at 30g and higher bs at 40g for the same carb insulin ratio.

The best meal to test on is your lunch. Your dawn phenomenon is not active. Your dusk phenomenon is not active. Your carb sensitivity is usually at its best. You are awake and can deal with any adverse effects on your blood sugars by correction doses before your evening meal.

It is too risky to experiement on yourself at your evening meal. Throughout this experimentation process the only sugars that were consistently perfect for Steven were the before bed ones for this reason.

You need to add a smaller incremental dose of insulin to the one calculated for your carb sensitivity for that meal.

Test yourself on items that are easy to calculate eg breakfast cereals that are easily weighed and bread slices that are listed on the package. Packaged processed food with carb labels are helpful for these experiments.

Decide on how many units of insulin extra you will give per 10g over the baseline figure.

Make this a very low amount. If you can change to a half unit pen. The novonordisk demi pens and junior pens have this facility and humalog has just become available in half units too.  Of course this is not a problem with a syringe.  For a child you may wish to consider extra accuracy from diluted insulin.

We started on 0.5 units novorapid for each 10g extra increase in carb.

If your figures are showing that this is giving sugars higher than your next pre-meal target you can up the amount of additonal carb weighting insulin by a small amount.

If your figures are showing that the next pre-meal bs is too low then up the amount of carb stages eg in 5 or 10g increments till you figure out what works.

This carb weighting method is accurate for Steven up to 90g of carb per meal. After this our levels are inaccurate.  They are usually lower than expected on this exponential weighting but sometimes are higher.

You could find that you need to start carb weighting at levels of less than 40g.

You could find that you don’t need to start carb weighting till levels of 50g or higher.

You may find half unit increments  need to be used at additional carb levels of  5g, 10g or 15g or 20g levels.

You will need to determine when this system stops being accurate for you. This could be at levels considerably lower than 90g or could perhaps be higher.

Remember to only do the experiments when conditions are optimal for this.

You are well.
Your carb levels are accurate.
You are starting at normal bs.
It is lunch time.
No unusual exercise is involved.
You are not particularly stressed.
You have help to figure out what you are doing.

By a slow process of guess and test you can find out how to extend the carb in your meals and still get normal bs levels before the next meal.

I would again stress that low carbing is the safest option.

Once you know how to deal with higher carbs at lunch safely you can test this out at other meals.

Once you have learned this method use it wisely. It is for emergency situations and special indulgences. If you use it day in and day out you may indeed have normal bs levels before your meals and at bedtime, but you will be spiking a lot more than any non diabetic will.  It is not only high blood sugars but widely fluctuating blood sugars that are causes of complications.

Quick Quiz:
There is no quiz for this section.

Where to Next?
Please continue on to the How To: Time Insulin Injections for Simple Insulin Regimes section.

Reference Info:

NOTE: the calculator is no longer available, but the methodology below may be of interest for those interested in creating their own app or tool (e.g. spreadsheet).

The insulin calculator in the download section of this site is a great help AFTER you have done your personal experiments and calculations.

It is a simple programme with three background tables that can be adjusted by you if your insulin sensitivities change.

The first factor which you adjust for are your insulin sensitivity at breakfast, lunch, dinner and bedtime. This has been covered on a previous module on the course.

The second factor which you adjust for is the carb weighting factor. This module shows you how to do this.

The third factor which you adjust for is your correction bolus for certain high blood sugars. For simplicitity I recommend that this is only done before meals. The module on how to deal with high blood sugars further on in the course covers this aspect.

The insulin calculator is useless and even dangerous if you rely on it for your insulin doses without having done the necessary background study, experiments and personal calculations.

What it does do however is make it unnecessary to do the same calculations every time you are about to eat a meal. Once up and running you only need to change it if any of the three factors need adjusted. The one most frequently changed is the carb sensitivity factors which can vary according to monthly cycles in women and seasonally im most other type ones.

Steven has a portable version on a palm top and we are hoping to put a downloadable version on this site very soon.

How To: Cover a Strict Low Carb, Moderate Low Carb, and High Carb Diet with Insulin

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This section is for everyone.

HOW DO I COVER A STRICT LOW CARB REGIME WITH INSULIN?

Dr  Richard Bernstein, Dr Annika Dalquhist’s, and  Dr Atkins diet have been described in previous sections. They can all take you to the strict low carbing end of things amounting to about 30-42g a day of carbohydrate.
I have chosen this level of carb for your meals to differentiate a strict low carb diet from a typical low carb diet. All of these diets in this strict  range  will give you the possibility of entirely normal blood sugars.

Dr Bernstein’s diet is more specific about what sorts of macronutrients you eat and in what amounts. For simplicity of eating and insulin regime combined with effectiveness it is my opinion that this is the “Gold Standard.”

If you are eating faster digesting carbs even within the  12g total carb limit you would need to experiment to see if a single insulin type covers your meals to entirely normal blood sugar standards or not.  The levels you may be aiming for have been described previously. If you get what you want this is perfect and if you don’t you may wish to try the specific insulin regime for the typical section which follows.

Dr Bernstein recommends using regular insulin to cover meals. These are of no more than 12g of non starchy vegetables three times a day with 6g allowed for breakfast because of the effect the dawn phenomenon has on insulin resistance at this time of day.

The regular insulin is best injected 45 minutes before eating. Because you are having such small amounts of carb and therefore insulin at each meal you don’t really need a separate insulin for the carb and protein. Just a little more regular  such as actrapid to cover your protein.  The usual formula for most people is 2 units regular insulin to cover 3oz lean protein or meat the size of a deck of cards.

The protein amount and consistency depends on your goals concerning weight gain or loss.  For people with delayed gastric emptying they may be on quite small portions of protein at their evening meal such as 2oz.  With guess and test you will quickly learn what works best for you.

Rapid acting insulin analogues are used for correction doses.

HOW DO I COVER A TYPICAL LOW CARB REGIME WITH INSULIN?

I have chosen Dr Jovanovich’s carbohydrate limits as the border between what could still be considered low carb and what is out with that range.  Dr Atkins and Drs Allen and Lutz diet’s have been described previously and fall in this range.  If you are  on another diet such as Protein Power, South Beach or Barry Groves “Eat fat and Stay Slim” diet you are in this range.

Once you get to higher carbohydrate levels of 13-30 g a meal of carb you increasingly need a bit more oomph with your insulin to deal with more rapidly rising  blood sugar levels.  At the same time protein continues to digest slowly so you need techniques to deal with that.

The most accurate technique that I know of was perfected by Dave (Iceman) from Alaska.  Sadly he died of cardiovascular complications of his longstanding diabetes. For all our benefits he passed his method throught the Bernie forum onto Adam (Adam DMer) who graciously passed it onto me. It is a beautifully simple technique that can also be used at lower and higher carb levels than I am describing in this section if desired.

Use rapid acting analogues to cover carb. This can be done according to your individual carb sensitivity for that time of day.

Use regular insulin to cover protein. This is to the tune of 2 units of regular insulin for each portion of lean protein which is a deck of card in size.

Both are optimally injected 15 minutes before eating.

HOW DO I COVER A HIGHER CARB REGIME WITH INSULIN?

The higher carb your meals the harder it is to get perfect  or even acceptable blood sugar control.  You can usually get an improvement from what you have been getting however,from the techniques I will be describing.

Although I much prefer to eat a typical low carb diet myself I was aware that my son Steven did miss the occasional treat. What was more important was that the meals provided at school emphasised high carb /low fat dishes in keeping with the ubiquitous “healthy eating” guidelines. The odd high sugar due to either of these reasons didn’t bother us at first because it was so infrequent.

For almost 18 months from diagnosis Steven did excellently on a typical low carb diet and twice daily mixtard combinations. Due to his lower carb diet and lengthy honeymoon his hbaic was 4.8.

Then his growth spurt and reduction in endogenous insulin became obvious. We continued mixtard but started on novorapid for lunch coverage in a half unit increment pen.

After 4 months on this we started an intensive insulin regime on levemir and novorapid.  By this time he was growing faster than our high fat/mod/protein/ low carb diet could sustain and his bmi was just under 16.  This is the bmi of eg Liz Hurley the actress who is indeed slim.

The dietician and diabetologist started threatening me. “Feed your kid a high carb/low fat diet and he will fatten up. Or else.” Presumably child protection procedures.

They did have a point.  Indeed I had never seen a skinny diabetic  on a high carb/ low fat diet.  It did seem to work like magic to fatten people up.

The problem was that Steven was just not hungry.  Effectively reducing hunger is  a major reason for the success of low carb diets in weight loss . But it is a disadvantage if you are hitting adolescent growth spurts.

I increased the carb in his diet knowing that he needed to have more carb for weight gain but also knowing that this would play havoc with his beautiful blood sugar pattern.

I decided to go for it and fatten him up like a goose destined for pate de fois gras. “Have what you like Steven. We have to learn how to control whatever effect it has on your bloods sugars. You could eat a bit more bread and potatoes than that couldn’t you? Please.”

I started this intensive fattening regime while on holiday abroad when we had almost unrestricted access to foods of all types and while I could monitor his sugars day and night.

To start with it seemed quite fun to Steven. “You mean I can eat a whopper with fries?”

“You certainly can. You must.”

Soon the wildly fluctuating blood sugars and blurred vision got us both down. “Please mum. Can’t I go back to low carbing? ”

“Please, Steven. Just keep going with this a bit longer. I am getting nearer and nearer to perfecting the carb weighting figures.”

We had a three month period of hellish sugars.  We did loads of blood sugar measurements including most nights between 2-4 am.  I could hardly sleep with anxiety.

This is what your average mother with an average kid with type one diabetes goes through all the time. It was bloody awful. I had no idea how bloody awful till I did it myself.

Fortunately I had some ideas about why Dr Bernstein strongly advised limiting carbs. The reason is to stop any spikes after meals that normal people don’t have.

And why does Dr Jovanovich limit a meal to 30g of carb? The reason I figured out is that linear doses of insulin based on reliable carb insulin sensitivities become increasingly unreliable above this level.

The more carb you eat the higher your blood sugar goes.

The higher your blood sugar goes the more insulin resistant you become.

The more insulin resistant you become the more insulin you need.

There is no longer a linear relationship between carb and insulin dosage after 30g.

There is an exponential curve.

Figuring out the sweep of that curve will vary from person to person.

To do this you MUST do extensive self experimentation.

Your carb counting skills must be well developed.

You must increase your carb counts above 30g in a progressive way.

You must keep meticulous records.

Give yourself a break every so often.  It is best only to do these experiments when you have help around and you are able to monitor day and night.

Unless you absolutely have to, you are much, much better off on a typical and preferably strict low carb regime. Low carbing is extremely efficient at curbing your appetite. This is a major benefit for most diabetics but I can see where it can be a problem for skinny toddlers and teenagers. If you need to resume a higher carb diet I hope our experiences and learning of techniques can help you through this process.

I know that for many diabetics the hectic blood sugar patterns that they simply accept as the package deal that comes with diabetes is actually due to the high carb diet.

I found the high carbing process extremely traumatic.  Steven was unhappy. I was unhappy. Yet, no matter how much fat I added to his diet I could not fatten him up. He is not as much as a carnivore as me and carb seemed the only answer. The high carb diet has worked and now Steven has a healthy bmi at 18. Teenagers have lower bmis than adults but your dietician won’t know this. They don’t know a lot about a lot of things you no doubt are finding out.

Quick Quiz:
There is no quiz for this section.

Reference Info:
Acknowledgements to Dr Bernstein, Dave (Iceman) and Adam (AdamDMer) from the Bernstein Forum and my son Steven.

Where to Next?
Please continue onto the How To: Do Dr. Morrison's Carb Weighting System section.

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.