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Does DAFNE only work if you eat roughly the same carbs?

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the_anticarb

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Hello fellow basal-bolus-ers,

I have been trying to get my basal dosage and bolus ratios sorted, but I find that when I eat a lot more carbs it completely throws the basal dose out. Does anyone else find this?
According to DAFNE logic, the base dose should stay the same whether you have 10 or 1000g of carbs (not advocating anyone has 1000g btw!) and you 'd just increase your bolus dose to match the carbs.

But I find that if my overall carb consumption increases I defintely need a higher basal dose - like double if I've had a really carby day.

This makes it difficult for dafne to work for me unless I stick to roughly the same intake of carbs each day.
Now I've posted this in the T1 forum so all you dafne graduates can answer - but although I am functionally a t1 (not producing my own insulin) I'm actually a lesser-spotted MODY so I don't know if I just have a weird uncontrollable form of diabetes or if if other people find this too.

It keeps throwing my ratios out big time and I don't know what to change, basal or bolus, if I eat more carbs one day than another.

the dietician at the diabetes centre insists it is only the bolus dose which should change, but then if I do that I'm running high before meals/bed/on waking which is wrong, so DAFNE is not working for me!!!

Help!!
 
Are we talking about the difference between eating the same type of carb but a different portion size?

Several theories here!

This is probably the most likely one..

If the carb being eating is combined with Fat, then as the portion size goes up, so does the fat content goes up and fat is insulin resistant, so with the larger portion you need to use more insulin to over-come the insulin resistance!

Pretty similar if the carb is combined with protein, the increase in protein might go above the amount the body normal sorts before it impacts on the blood stream, the you might need to use insulin to cover the extra protein that's turning into glucose and impacting on the blood...

And the double whammy, the carb is combined with both protein and Fat, get a combined effect of the above!


Or you could go with Bernstein's 'Bulk' theory...

Where upon, bulk increases blood glucose, or in a manner creates carbs!

With this theory, he restricts salad to a max of 2 cups... If you add another cup or 2, even if it's within his prescribed 6g or 12g's of carbs allowance (depending on meal) your blood glucose levels will increase as though you've 12g's or 24g's !
 
jopar said:
Are we talking about the difference between eating the same type of carb but a different portion size?

Several theories here!

This is probably the most likely one..

If the carb being eating is combined with Fat, then as the portion size goes up, so does the fat content goes up and fat is insulin resistant, so with the larger portion you need to use more insulin to over-come the insulin resistance!

Pretty similar if the carb is combined with protein, the increase in protein might go above the amount the body normal sorts before it impacts on the blood stream, the you might need to use insulin to cover the extra protein that's turning into glucose and impacting on the blood...

And the double whammy, the carb is combined with both protein and Fat, get a combined effect of the above!



Or you could go with Bernstein's 'Bulk' theory...

Where upon, bulk increases blood glucose, or in a manner creates carbs!

With this theory, he restricts salad to a max of 2 cups... If you add another cup or 2, even if it's within his prescribed 6g or 12g's of carbs allowance (depending on meal) your blood glucose levels will increase as though you've 12g's or 24g's !
Click to expand...


Woah! Thanks for this info Jopar!!! I didn't know any of this, I've been type 1 for 19m now, and have learnt all about my eating /insulin from sites like this! NO-ONE on my medical team ever told me about carbs, fats,proteins etc... I have been struggling with yoyo readings and been so absolutely fed up with it all I feel like just chucking it all sometimes (I know I can't) but it makes you so annoyed!!! WHY does no one ever tell you this stuff on dx?? my nutritionist was absolutely useless. I've read stuff about low carbing, then just threw the books away! my Hba1c went up when I tried to cut down on carbs, and I feel like a wet rag, no energy.
I am taking a course (my request) DAFNE in august, I can't wait to glean all this information as to what to inject, as at the moment I just count carbs to what I think, guesstimate, really. and the basal was too low after about 18m so I upped it 2u and now it back on a more even keel. God! when you have diabetes isn't it up to the specialist to inform you of everything you need to know?? No wonder the NHS is paying zillions treating diabetics when they are so ill-informed as to their own health.
(sorry -- rant over)
 
Thanks Jopar,

Don't think I explained myself fully

Last week - not particularly hungry, busy with other stuff, lowish carb day perhaps 100g spread out over four meals/snacks.
Basal dose was 12u, bolus dose was 1unit per 8 g carbs

This week - being a bit munchy, bored, wanted to eat more - higher carb day perhaps 250g spread out over 8 meals /snacks (whether I should be doing this or not, well i'll admit it's probably not the best BUT according to dafne you should be able to do this so let's stick with the problem rather than debate whetehr or not this is the best eating pattern to have)

Base dose has had to be put up to 24 u, bolus dose a lot higher eg 1 unit per 5g carbs. I'm even correcting a lot more eg yesterday woke up at 10.2, took 4u correction dose and got me down to 7.2 a couple of hours later.

Does this sound at all like what should be happening or am I just really weird??? According to DAFNE the ratios and base dose shouldn't change, right?

Ideally, I'd just stick to the same amount of carbs each day but I'm a really erratic eater, some days I don't want to eat much others I will stuff my face - this is a hangover from an eating disorder I've had in the past but I'm trying not to let it affect my diabetes control.
 
the_anticarb said:
Thanks Jopar,

Don't think I explained myself fully

Last week - not particularly hungry, busy with other stuff, lowish carb day perhaps 100g spread out over four meals/snacks.
Basal dose was 12u, bolus dose was 1unit per 8 g carbs

This week - being a bit munchy, bored, wanted to eat more - higher carb day perhaps 250g spread out over 8 meals /snacks (whether I should be doing this or not, well i'll admit it's probably not the best BUT according to dafne you should be able to do this so let's stick with the problem rather than debate whetehr or not this is the best eating pattern to have)

Base dose has had to be put up to 24 u, bolus dose a lot higher eg 1 unit per 5g carbs. I'm even correcting a lot more eg yesterday woke up at 10.2, took 4u correction dose and got me down to 7.2 a couple of hours later.

Does this sound at all like what should be happening or am I just really weird??? According to DAFNE the ratios and base dose shouldn't change, right?

Ideally, I'd just stick to the same amount of carbs each day but I'm a really erratic eater, some days I don't want to eat much others I will stuff my face - this is a hangover from an eating disorder I've had in the past but I'm trying not to let it affect my diabetes control.
Click to expand...

Hiya,
I saw a discussion on another forum about increased carbs and ratio changes. The gist of it was
the more carbs you ate the higher your basal needs compared to a normal days eating (your normal) It was also stated by all the posters that they had a higher limit per meal that thye could go to carb wise. Once over that limit then the carb ratio changed as well. One persons limit was 75 carbs/meal and another chap said 95 carbs :shock:

Ps, if you do a lot of snacking and having to inject for it do be careful that you don't end up stacking your insulin. This could cause a major hypo if you get your sums wrong in working out insulin on board and blood sugar adjustments.
 
Thanks Carbsrok.

I'm more concerned that insulin stacking hasn't happened, to be honest!

I've gone from having about 12 u basal and 10 u bolus (and going hypo on that) to about 24u basal and 50 -60 or so units bolus in the space of less than a week, and I'm not even going hypo.

I know I haven't been moving around as much these week as I'm recovering from an op, but it's not like I was doing a lot of exercise before, I'm quite sedentary really.

I'll admit I have eaten more, but I wouldnt' have expected my insulin ratios to go up THAT much.

I've eaten less carbs today and needed a lot less insulin.

Coming to the conclusion that maybe for me, dafne only works when carbs are restricted.

But interested to find out if others can increase their carbs without it completely throwing all their numbers out or if its just me.

Makes it impossible to dose correctly, you're just guessing and then injecting more to correct, guessing again but doing a lot of testing so I know i haven't gone too high.
 
the_anticarb said:
I know I haven't been moving around as much these week as I'm recovering from an op, but it's not like I was doing a lot of exercise before, I'm quite sedentary really.
Click to expand...


I would say the above answers your original question. It was never mentioned on DAFNE about increasing basal insulin if you are having a high carb day and to be honest it makes no difference to myself if I eat 100g of carbs or 200g, I know when I was laid-up recovering from my OP my basal/bolus doses nearly doubled due to inactivity....not saying this is definitely the case with you AC but it does sound logical.
 
@Susieg

There's several reasons to the 'why's' firstly it's pure information overload so if they did you would be very unlikely to remember it! With Protein and fats, they kinda of ignore and the only explanation I can come up with (as I've never asked) is that a presumption that everybody eats what is considered a 'traditional healthy balanced diet' in this type of diet, the fat's and protein are normally contained with in limits that it's impact isn't noticed, as it's covered by normal insulin titrated to cabrs! And some of the impact will also be covered by the normal wave of the basal.. (background insulin when injected, doesn't flatten the background levels, but smooth's out the trough's and spikes into a smother wave)...


Another problem though, is it's very difficult to come up with a insulin/fat or insulin/protein ratio, this side of things is pretty much built on on experience based on trail and error... So I know that on a meal such as an cheese omelette I need 1.6u of insulin delivered on a square wave bolus over 15-30 minutes dependant on what my starting BG is.. And whether need to make an adjustment for any other factor...

And the HCP's face the sheer diversity of abilities amongst us, so it's trying to pitch treatment within individuals ability to grasp concepts etc... I actually did my pump training with another diabetic who hadn't even grasp the relationship between food and insulin, Trying to explain/teach her the concept of carb counting was a no-go and the pump training they were frightening indeed.. Then you get total lack on time where upon, both at an appointment and between one appointment to another, and they lose track of what information we've have or haven't been told, As the saying goes 'you'll either told a thousand times or not at all!'

But a good book to get though, is a book called Using Insulin by John Walsh... Very informative concerning the basal/bolus regime

@anticarb

Why did you double your basal?

Some of what happened will be based around the differences between your activity levels last week compared against this week, so you activity level was burning off some of the blood glucose levels...

So with a lot quieter this week it's not..

I've got 3 different basal rates set up on my pump, there's around 4 units different between them, and I use difference ones for different general activity levels..

Something you can't do with a background insulin, due to any adjustments take a day or so to kick in, so you would be relying more on using you quick acting ratio's to counter react from one days general activity level to another...

Another thing that might have effected the basal, if your were munching on high fat/protein type snacks/meals or eat carbs such as pastry, pasta etc... Then these take a long time to adsorb, so would be impacting on your blood glucose several hours after you've eaten them...

As for your bolus ratio's, they hadn't changed too much...

But with what you say I wonder if your insulin gone off or your pen isn't dosing probably!

I would suspect your background, so perhaps change your cartridge (new batch if you've got one in the fridge) but do go back to your old dose just to be one the safe side, otherwise you'll be given yourself a nasty hypo...

Check your pen's instruction book, as it gives you details how to 'test dosing accuracy', you basically dial up 20 units of insulin, and squirt this into the outer cover of the needle, if it's correct the it will fill up the bottom needle part until it meets the shoulders of the main body..

Then check out your quick insulin..
 
Thanks guys. I had not thought I was doing that much less activityas I'm not a very active person anyway but I guess I have been literally lying in bed all day whereas before I was at least doing light housework / pottering, looking after a small child, popping to the shops etc. Doesn't seem like much activity but prob all adds up.

I was just thinking about insulin effeciency, it's entirely possible some of my pens are older than a month as I tend to have 2 or 3 disposable pens on the go, that way I never have to look too hard to find one, I am going to replace my pens now with new ones out the fridge and see if that makes a difference.

Usually when i am injecting a lot of insulin particularly at less than four hourly intervals I will go hypo once or twice as I'm so afraid of going high now (due to complications) I will over estimate rather than under. but the fact I've not gone hypo once in a week is very telling. Even when I was pregnant, so my insulin resistance was massive, I was probably injecting as much as now but going hypo. But the lowest I've been all week is in the 5s and that was after a hefty correction dose! so I will definitely suspect the pens.

Does anyone know the definitive answer to how long they take to go off, I always thought a month but is that correct?

Incidentally Jopar, I seem to survive quite well on lantus alone (and metformin) if I cut the carbs right down to say 30g per day. I would never need to inject novo for just a cheese omelette and salad for example. I think I am definitely very carb-sensitive. More reason to give em up....but I just can't seem to so bolusing correctly for them is the only other option.
 
Thanks Jopar... Yes, I understand, after my initial rant I did realise that it would be somewhat of an overload of information! but I am so unsure myself as to what I am doing I just 'lose it' sometimes, I think, one day , that I got it! yeah, and then it turns around and kicks me up the backside the next day.
I suppose we can only gain the information that pertains to us individually over time, but during this time it's so frustrating. I struggle with my mornings and evening numbers, when I get a great evening (pre-bedtime) reading, I hypo during the night/or I wake up with a high, thanks to this dawn phenomenon thing, or if I eat to prevent the hypo I still wake up high. I can't seem to win. I wish someone would explain that to me. :)
Perhaps I am trying too hard to understand it all in a short space of time, but when I think I've worked something out, like trying to lower my carbs, something else turns up, like the hba1c thing going up. It's all very baffling.
But thanks to you guys at least I am getting some answers ! :D
 
Hi the Anticarb!

I have exactly the same issue as you describe. I am LADA, so not full Type 1. If I eat more carbs than usual, it affects my readings and my bolus dose for at least three days. I use Apidra and will have to increase this by at least a third for the same meal if I had more carbs the day before.

I keep my carbs to less than 50g per day usually and it keeps my BG far more stable. As for the basal, if you really want to consistently eat higher carb levels, your background BG level is likely to run consistently higher and you will need to increase your basal to accommodate this. You can't keep adjusting your basal depending on the carb content of different days though, so personally, I think you need to decide roughly on a level of carbs and stick to it. This is one of the areas where I believe DAFNE is completely flawed; if you reduce your daily carb level, you must decrease basal or you will suffer hypos and DAFNE simply doesn't account for that. Most of us who low-carb have lower basal requirements.

As for Jopar's theory about fat, I don't see this borne out in my diet and bolus requirements. On a low-carb diet I bolus for carb and, occasionally, add half a unit extra for protein, especially if I'm having a no-carb meal e.g bacon and eggs. I never add any bolus for fat. In fact, if I'm having a particularly fatty meal, I reduce my bolus slightly as fat slows the absorption of the glucose into the bloodstream. In that situation, I sometimes have to take an extra unit at the 3 hour mark when the glucose has finally absorbed. Not sure if this helps you as you now have contradictory information.

Jopar - if you're around, can you post some links to where you got your information on fat raising BGs as I have never heard that before and would like know more about when and how that occurs. Thanks.

Smidge
 
Thanks Smidge.

Good to know I am not the only one!

I think dafne does assume you will eat roughly a similar amount each day and just adjust for small variations.

I think I was feeling a bit sorry for myself after my op and I started having some biscuits to cheer myself up, problem with me is sometimes I will start eating and then just continue, I used to have a serious eating disorder (like an alcoholic but with refined carbs) hence the complications, but now I am a lot better and just have occasional pig outs when I bolus extra...dafne sure doesn't account for people like me!

I know the sensible answer is to moderate what I eat and stick to similar ish carb levels each day, perhaps with some flexibility for meals out or occasions.

I have just been shocked at how quickly and how much my insulin requirements have changed this past week, although sitting around doing literally nothing after my eye op has probably added to this as noblehead suggested.

Guess there's no way round the fact that if you have diabetes you have to eat sensibly
 
I keep my carbs to less than 50g per day usually and it keeps my BG far more stable. As for the basal, if you really want to consistently eat higher carb levels, your background BG level is likely to run consistently higher and you will need to increase your basal to accommodate this. You can't keep adjusting your basal depending on the carb content of different days though, so personally, I think you need to decide roughly on a level of carbs and stick to it. This is one of the areas where I believe DAFNE is completely flawed; if you reduce your daily carb level, you must decrease basal or you will suffer hypos and DAFNE simply doesn't account for that. Most of us who low-carb have lower basal requirements.
Click to expand...

Interestingly I found one old paper using lente and regular rather than modern insulins. I have a sneaking feeling this is the research that came prior to the move toward dose adjustment. I think some of the ideas may have been challenged since then
These results indicate that in type 1 diabetic subjects 1) increasing the amount of carbohydrate intake does not influence glycemic control if premeal regular insulin is adjusted to the carbohydrate content of the meals; 2) algorithms based on U/10 g of carbohydrate a re effective and safe, whatever the amount of carbohydrate in the meal; 3) the glycemic index, fib e r, and lipidic and caloric content of the meals do not affect premeal regular insulin re q u i rements; 4) wide variations in carbohydrate intake do not modify basal (ultralente) insulin re q u i rements; and, finally 5) the ultralente-regular insulin regimen allows dissection between basal andprandial insulin re q u i rements, so that each can be adjusted accurately and independentl

http://care.diabetesjournals.org/conten ... 7.full.pdf
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According to Walsh(Pumping insulin). A person without insulin resistance and no insulin of their own (and no 'teenage hormones' etc) is supposed to need about 0.5g U insulin per per kilo a day. 'Most' people on a 'normal' diet are supposed to need 50% basal, 50% bolus.In percentage terms people who eat lower carb diets are supposed (according to Walsh) use a higher percentage of their total daily dose as basal. He cites 40% basal for those on higher carb diets/people who are fit/ people with some insulin resistance contrasted with 60% for people with some insulin resistance , teens and those on low carb diets. Of course there are lots of variables, no-one is 'average'

Personally my basal ranges from about 40% to 48% and my TDD normally varies from 20-27 units a day. (so a max of 0.43u a kilo)
I test my basal by eating nothing ie fasting so in theory it shouldn't be affected by how many carbs I eat during the day.
To be honest most days I do eat a fairly consistent amount of carbs so it's hard to judge (if I have one meal with a lot I probably eat far fewer later in the day or the next day)

The one thing that does affect basal for me is activity.
When I eat more carbs my basal won't normally need to be increased but I will have a higher daily dose from the extra insulin used for bolus. (so the percentage from basal will decrease)

I have to increase my basal if I have been less active : ie lazy! .I also use higher basal rates for long journeys as my blood glucose really rises then.
I have to decrease it if I am very active. Sometimes by a huge amount and again this is regardless of carb intake.This is obviously less possible when on MDI, However after having loads of hypos on my first backpacking trip after starting insulin. I was advised to reduce lantus by half next time. ( By the next time I was on a pump and on such days I do indeed reduce my basal to a trickle, and eat lots of extra carbs with a reduced basal.

NB Re fat: There is a small band of PWD who use TAG, total available glucose to calculate boluses. This includes an element for fat and protein. If you google it you will find quite a few bloggers and a group on Tu Diabetes who use the method.
Meanwhile here is a comment from Joslin about it

http://blog.joslin.org/2012/01/should-t ... meal-plan/
 
It's well known that fat and protien has a prolonged affect on blood sugars.
Pumpers have the ability to to sort this using the different boluses on their pumps. People on MDI split their meal time boluses to counteract the problem.
There is no need to change basal for this at all as basal is just that a basal to keep your blood sugar stable without food.
Bolus is just that.. food consumption and correction if needed.
Have a look at this bloog post it might help you out http://www.everydayupsanddowns.co.uk/20 ... hirds.html
Look at dillingers posts at the amount of insulin he uses for a non carb high fat and protien breakfast :shock: What he uses for that meal I would use in one day. Yet his basal is fine so he says.
I am the same though carb free meal and the amounts of insulin I have to bolus is a joke.

As a general rule though if you have to change your carb ratio then the basal will need changing. Doing this for a day on MDI is not pratical obviously, esp if you are on Lantus as it takes at least 3 days to take effect.
Here is a link re basal testing where it warns no fatty foods before testing http://www.diatribe.us/issues/13/learning-curve

Bottom line is though it's fine to have days when you need or want to have the munchies but it is better to know what your upper limit is before you end up having to take gallons of insulin to correct things and yes your blood sugars will be a lot more stable if you keep to within you limits.
I have a balanced diet with low fat and find I need very little insulin compared to people that have very high fat diets. Others are completely the opposit.
There are a couple of books that might help you with your understang of using insulin..... using insulin and think like a pancreas which can be found on amazon.
 
In his book Think like a Pancreas Gary Scheiner talks about bg rising over 6-10 hours after a high fat meal, he says that when you consume a high-fat meal the level of triglycerides in your bloodstream rises, this sends your liver into a temporary state of insulin resistance resulting in greater secretion of glucose into the bloodstream.....all very complicated and who said diabetes is easy :lol:
 
Thanks, for the links Phoenix and Carbsrok!

It's really weird, because almost all the insulin-dependant low-carbers on here have to reduce their basal as they bring down their carb levels.

The fat thing is very interesting to me, because I find the complete opposite when I eat a fatty meal with a small amount of carbs. However, I did have a strange reaction to a bowl of low-carb ice-cream a few weeks back. My BG went into double-figures from a 5ish start. I didn't bolus because I didn't think there was much carb in it, so it could have been the fat content that caused the spike - although I still think it was more likely that it it had more carbs than I thought in it as my boyfriend made it and probably used a tonne of powdered Splenda (which does spike me significantly). He also put three eggs in it so it could have been the protein that casued it. Guess I'll never know :roll: As Nigel says, very complicated :crazy:

p.s. Nigel - does Gary Scheiner say whether the Trigs increase is temporary? I'm asking because my Trigs is very low but I do eat quite a fat-heavy diet as I low-carb. I guess I'm going to have to stop being lazy and read the book :lol:

Smidge
 
Yes it will only be temporary Smidge. It is interesting he what he says about a high fat meal causing a secondary bg rise, from my own experience it explains why I use to wake up much higher than before I went to bed.

Get the book it's an excellent read :thumbup:
 
Update, i have returned to more normal levels of carb intake, and quel suprise my insulin requirements (basal and ratios) have gone down a lot too.
I'm really gonna try to keep the carbs in check, not mega low carb, but enough to prevent this rapid escalation of insulin requirement, as it gets too difficult to manage if I keep chopping and changing
Thanks for the advice I wil also check out the books you mention :)
 
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