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The guidance for the use of MDI is that we should use a basal insulin to provide a background insulin level and boluses to counter mealtime carb caused BG increases.
Typically Basal insulin should provide a bg level that doesn't vary more than 1.7 mmol/l over a >5hour fasted state. It should effectively be used to counter the variation caused by the liver alone.
Bolus insulin has a much shorter life and peaks much more quickly.
When eating a low carb diet, we know that gluconeogenesis from protein generates a slow increase in blood glucose that typically doesn't fit the profile of the rapid acting insulin and that there is a glucagon related increase linked to the immediate ingestion of any protein. This has been readily discussed in this topic: http://www.diabetes.co.uk/forum/threads/insulin-load-index-most-ketogenic-foods.75704/
Taking this a step further, the existing MDI model doesn't work terribly well for the low carb diet. If we stick to the rules above, post the use of the mealtime bolus, there is a steady increase in BG level that is not countered by anything. In my view there are three ways to treat this:
What are your thoughts on dealing with this Low Carb linked phenomenon?
Typically Basal insulin should provide a bg level that doesn't vary more than 1.7 mmol/l over a >5hour fasted state. It should effectively be used to counter the variation caused by the liver alone.
Bolus insulin has a much shorter life and peaks much more quickly.
When eating a low carb diet, we know that gluconeogenesis from protein generates a slow increase in blood glucose that typically doesn't fit the profile of the rapid acting insulin and that there is a glucagon related increase linked to the immediate ingestion of any protein. This has been readily discussed in this topic: http://www.diabetes.co.uk/forum/threads/insulin-load-index-most-ketogenic-foods.75704/
Taking this a step further, the existing MDI model doesn't work terribly well for the low carb diet. If we stick to the rules above, post the use of the mealtime bolus, there is a steady increase in BG level that is not countered by anything. In my view there are three ways to treat this:
- Sugar Surfing: Using additional boluses to counter the steady protein induced rise - this requires multiple additional injections and comes with the down side of increased damage to tissue due to more injections.
- Provide multiple bolus insulins with different durations to be taken at slightly different times, e.g. Apidra for the meal and Actrapid for the protein increase post meal. This also requires additional shots, but not as many as multi-bolusing.
- Increase the basal insulin level so that is counters the protein caused rise. This reduces the number of injections required but runs the risk of basal hypo if the amounts used are too high.
What are your thoughts on dealing with this Low Carb linked phenomenon?