How did I get into this...

[Bluemarine Josephine]

Hello everyone,
Happy Friday (OMG, at last..)
I hope that you are all very well and that you are getting ready for a beautiful weekend!

My nutritionist and diabetes educator during DAFNE course told me to eat, at least 30 grams of carbs per meal x 3 meals = 90 grams per day aiming to the minimum required quantity of 120 grams per day. She insists that our brains function properly at 120 grams carbs per day.

So here I am, following her guideline religiously, bolusing with every meal (and correcting if I have to).
So far so good.

Life is life however, things need to be done. So, I am caught in the following difficulty:
I am at a nice pre-lunch 6.5.
I am supposed to eat for 30 grams of carbs.
I know I will have to drive, go to the banks, meet with my clients, do grocery shopping, have a yoga session and walk Charlie for 45 minutes prior dinner.

I have to either under-inject for the 30 grams of carbs or inject my usual 3 units (on a 1:1 ratio) and treat later (because the estimated activity will bring my BG lower than what I want it to be).

Here is me being a bad diabetic: Every time I have to do this, I am thinking “Why don’t I just have 10-15 grams of carbs – like an orange or a slice of bread with a carbs free meal- don’t bolus at all as I will need the energy to get me through the afternoon and skip an injection? I can always eat and bolus for breakfast or dinner… why cant I make things easier during the hours of the day that are most active for me so that I don’t have to keep wondering “Is my BG high enough? Am I walking too fast during the time that my Novorapid is peaking? I had lunch at 13:00 so my Novorapid should be peaking 14:30 – 16:00, better slow down a bit. What is this dizzy spell, shall I pull over and treat?"

Why don’t I save myself the headache?
What is this thing with the 30 grams in each meal as if it’s a religious matra that I cannot skip…

Please can I have your thoughts as, sometimes I feel that the guidelines I am given just don't work with my lifestyle or make things way more complicated than they should be.

Thank you so much!
Regards
Josephine

 

[tim2000s]

I'm fairly sure that you've asked this before in a different way @Bluemarine Josephine and I think I posted this then as well:

Myth: Eating less than 140g of carbs per day is dangerous for type 1 diabetics
I'm not sure when this started being communicated in Diabetes training courses, but I am sure of the origins of the idea that 140g of carbs is the minimum required to be eaten every day. It stems from research done by Cahill et al in 1968 that suggests that for the brain to run exclusively on glucose, it requires between 110g and 140g of glucose per day. This book details the studies where this value was determined.

Okay - we have the origin of the 140g - but note that this is glucose and what the brain requires if running exclusively on glucose. It doesn't say that we need to eat 140g of carbs.

Further research looking at the brain's use of fuel sources identified that the brain uses lactate when undergoing strenuous exercise (http://www.fasebj.org/content/22/10/3443.full) and on page 277 of this document the following statement is made:

In individuals fully adapted to starvation [or low carbohydrate diets], ketoacid oxidation can account for approximately 80 percent of the brain’s energy requirements (Cahill et al., 1973). Thus, only 22 to 28 g/d of glucose are required to fuel the brain. This is similar to the total glucose oxidation rate integrated over 24 hours determined by isotope-dilution studies in these starving individuals (Carlson et al., 1994; Owen et al., 1998).

Or in other words, when not running on a glucose metabolism, the brain requires less than 30g of carbs and can be 80% fuelled from ketones.

The human body is perfectly capable of creating less than 30g of glucose a day through gluconeogenesis, so will destroy muscle if there is not enough protein or carbs free to feed the brain.

If a T1 eats 140g of carbs per day, they will need (based on a standard insulin:carb ratio of 1u:10g) 14 units of insulin. If they eat 50g, they will need 5u. Eating a smaller amount of carbohydrate that requires less insulin provides much less likelihood of estimation error, or inconsistent insulin absorption.

But the key thing is that you don't need glucose to provide energy.

What this adds up to is that a human does not need 140g of carbs per day to feed the brain, to be healthy, or to be a safe T1. If anything, it suggests that you don't need more than 30g and that eating fewer carbs is more likely to be safer!

Coming back to your question. It's your Diabetes. Manage it in a way which works for you. If that means a low carb lunch with little or no insulin, that's entirely up to you! There is not requirement to do as your DSN or dietician says. Just that you should do what works and makes your life as easy and safe for you as possible. Safe means that you maintain glucose levels and don't find yourself in lows and worrying about them. Do it your way!

 

[azure]

I appreciate its not so easy to make tiny adjustments when you're on MDI @Bluemarine Josephine but if it was me, I'd be exploring adjusting my insulin according to what I eat - that is, maybe having 30g carbs for lunch one day, 50g the next, 35g when I go out for lunch in a restaurant, etc.

Alternatively, when I was on fixed dose mixed insulin, I simply ate a little more if I knew extra activity was coming up. So, if I had a busy afternoon of shopping, I'd eat a little extra carbs at lunch and carry top ups of glucose/carbs with me.

The worry about what your blood sugar is doing is just something that we have to carry around in our minds all the time. I think of it like a computer program running in the background.

Weather, stress, hormones, exercise, age - so many things affect our blood sugar, so there's never going to be a perfect formula that will guarantee exactly the same blood sugars at the same time each day. Our own pancreas doesn't work like this - it squirts out insulin as we need it. I know we can't do anything like as well as a pancreas, but I've learnt that, for me, at least, actively managing food and insulin as I need works best to maintain a good HbA1C.

 

[Totto]

She insists that our brains function properly at 120 grams carbs per day.

That just isn't true. I very rarely go above 50 grams in a day, usually below 30, and so far my brain isn't any worse compared to what it was before. And I don't think brains differ that much between T1 and T2.

There are quite a few T1 who do very low carb, @robert72 @Mrs Vimes @LucySW for example and of course Tim.

 

[Bluemarine Josephine]

You may hear about government officials say that they expect positive financial results, about production, recovery and a year of stronger financial position for the country.

And you might be thinking: Social security cuts, food banks, benefits stop through the sanctions regime.

New research indicates 370,000 small businesses are planning to cease trading over the next five years, putting more than 1.8m jobs under threat so unemployment rises and is expected to continue to rise.

Your tax is higher, your mortgage is higher, your expenses are more.
The same amount of salary cannot cover the costs that it used to cover a year ago…
But the numbers are positive… and the numbers don’t lie.

I am thinking that my diabetes consultant (or my diabetes nutritionist) is an accountant, as they both operate on the same mentality.

I see them, I present my data (my diabetes diary) and my Hba1c, they look at the numbers.
The numbers don’t lie.
If my numbers are good, they praise me for the good work I am doing and encourage me to keep on trying.
If my numbers are bad, they give me the same response that, I suspect, they give to everyone else “try to lower your levels in order to avoid future complications.”

They do not care if I wake up twice during the night to check my BG in my effort to monitor my blood glucose correctly so that by the end of the week I am so tired from sleep deprivation that I cannot even say my name.
They do not care if I am stressed and anxious from work and obligations that need to be satisfied and these affect my levels. They do not care if I am a carer and I cannot allow myself a hypoglycemia because others count on me…

They do not care how I achieve my levels, if I am exhausted, depressed, tired, fed up, afraid…
They see the numbers, and the numbers don’t lie.
I was looking at the diasend results, I have the link below:
https://twitter.com/diasend/status/729681521519538177?s=09

and, at first glance, I was thinking “are all these people just ignorant or/and lazy?” and then, I though… ‘what if they aren’t ignorant or lazy… what if, in real life, in actual, practical life, the targets cannot be met”.

What if, sometimes, we just need to do our best and if our best isn’t good enough well, we may all (physicians and diabetics alike) have to settle and that’s that.

My thread does not intent to question if low carbing is a good approach.
In fact, in this thread I am wondering if the guidelines we get from our physicians are actually realistic and can be put into effect or can we alter things maybe?

Regards
Josephine

 

[tim2000s]

My thread does not intent to question if low carbing is a good approach.
In fact, in this thread I am wondering if the guidelines we get from our physicians are actually realistic and can be put into effect.

My last point is critical in this @Bluemarine Josephine - and I'll post a different quote here:

"It's your diabetes to manage. Not your GP's, not the Government's, not Diabetes UK's or the JDRF's. Yours. You have permission to treat it. To make changes. To adjust insulin doses and experiment. Your diabetes team and GP grant that to you. They'd like you to do it. It's easier for them to manage their interaction with you if you take control. They'd really like you to grasp it with both hands, understand how it works and join the rest of us in the great "My Diabetes Science Experiment"."

This means that it's entirely up to you how you manage it. The targets are achievable. There are many on the forum here that achieve them. But what's more important is that you understand what works for you. Your diabetes, your way. To provide a different allegory, set up your bike with the handlebars where you find them comfortable.

That doesn't mean that you need to get up twice in the night every night to test your glucose levels. It means you can go to bed on a 7 and wake up on a 9 if you want to. That's your choice. The most critical part of all care in a chronic disease scenario is that you are allowed to make choices. Targets are there to provide guidance and give you an indication. As long as you know what they mean, you can elect whether or not they are what you want to aim for.

What's interesting is talking to the variety of different HCPs linked to Diabetes clinics. Senior Consultants and DSNs agree with this - for them what they want is that you are comfortable and able to carry on with your life. Often the more junior ones have much less experience and are more likely to look at and talk about the numbers.

We all know that high numbers can cause long term issues. But just because you aren't at the target, if a small improvement in the numbers is made, many consultants are now celebrating this fact. It shows willing and progress, and that's all they can ask.

The tricky bit with the Diasend numbers is that they represent the full demographic of those dealing with diabetes, and as I've posted elsewhere on the forum, when you do the stats, that includes 88,000 adult Type 1s in the UK that have the numeracy of primary school kids. We don't expect primary school kids to look after themselves when they have T1, so how do we expect these adults to cope well and have good results?

HCPs sincerely want people to improve the management of their diabetes. They know this isn't 100% possible across the board. The people who discuss this stuff on the forums aren't the ones they are worrying about really. They know we are capable enough of doing that for ourselves.

 

[Jaylee]

You may hear about government officials say that they expect positive financial results, about production, recovery and a year of stronger financial position for the country.

And you might be thinking: Social security cuts, food banks, benefits stop through the sanctions regime.

New research indicates 370,000 small businesses are planning to cease trading over the next five years, putting more than 1.8m jobs under threat so unemployment rises and is expected to continue to rise.

Your tax is higher, your mortgage is higher, your expenses are more.
The same amount of salary cannot cover the costs that it used to cover a year ago…
But the numbers are positive… and the numbers don’t lie.

I am thinking that my diabetes consultant (or my diabetes nutritionist) is an accountant, as they both operate on the same mentality.

I see them, I present my data (my diabetes diary) and my Hba1c, they look at the numbers.
The numbers don’t lie.
If my numbers are good, they praise me for the good work I am doing and encourage me to keep on trying.
If my numbers are bad, they give me the same response that, I suspect, they give to everyone else “try to lower your levels in order to avoid future complications.”

They do not care if I wake up twice during the night to check my BG in my effort to monitor my blood glucose correctly so that by the end of the week I am so tired from sleep deprivation that I cannot even say my name.
They do not care if I am stressed and anxious from work and obligations that need to be satisfied and these affect my levels. They do not care if I am a carer and I cannot allow myself a hypoglycemia because others count on me…

They do not care how I achieve my levels, if I am exhausted, depressed, tired, fed up, afraid…
They see the numbers, and the numbers don’t lie.
I was looking at the diasend results, I have the link below:
https://twitter.com/diasend/status/729681521519538177?s=09

and, at first glance, I was thinking “are all these people just ignorant or/and lazy?” and then, I though… ‘what if they aren’t ignorant or lazy… what if, in real life, in actual, practical life, the targets cannot be met”.

What if, sometimes, we just need to do our best and if our best isn’t good enough well, we may all (physicians and diabetics alike) have to settle and that’s that.

My thread does not intent to question if low carbing is a good approach.
In fact, in this thread I am wondering if the guidelines we get from our physicians are actually realistic and can be put into effect or can we alter things maybe?

Regards
Josephine

It's not that these professionals "do not care" Josephine. I feel they have to "switch off" because if they cared in minute detail emotionally for every patient that walks though the door? They would loose the plot with the stress & anxiety too..!

There is always the few that are "diamonds" & go the extra mile. But that's just good professional "customer service"..

 

[becky.ford93]

What I find interesting is that about 6 months into my diagnosis I had a consultation, and she said to me "whilst good control lowers your risk of getting complications, nothing can completely take that risk away. Sadly there are some people who have incredibly good control their whole lives and get complications, and others who don't manage it as well but seem to get away with it".
Which to me basically means this is a balancing act - I could spend all my energy, time and money on managing my blood sugar to a tee, but would my quality of life not deteriorate because of it? And how would I feel if in 20-30 years time I STILL got complications despite all my hard work?
I'm not saying that we shouldn't control our blood sugar well, because it inevitably has an impact, but I think we all have to find a level of control that reduces the risks of complications whilst also allowing us to let go and enjoy life a little. Who cares if they make it to 90 if they don't have many happy, carefree memories to look back on?

 

[richyb]

What I find interesting is that about 6 months into my diagnosis I had a consultation, and she said to me "whilst good control lowers your risk of getting complications, nothing can completely take that risk away. Sadly there are some people who have incredibly good control their whole lives and get complications, and others who don't manage it as well but seem to get away with it".
Which to me basically means this is a balancing act - I could spend all my energy, time and money on managing my blood sugar to a tee, but would my quality of life not deteriorate because of it? And how would I feel if in 20-30 years time I STILL got complications despite all my hard work?
I'm not saying that we shouldn't control our blood sugar well, because it inevitably has an impact, but I think we all have to find a level of control that reduces the risks of complications whilst also allowing us to let go and enjoy life a little. Who cares if they make it to 90 if they don't have many happy, carefree memories to look back on?

Yes think you are correct Becky to a large extent. It's all about balance and how we want to live. I have had it for 50yrs and tried very hard, last hba of 50. However I am now getting depressed and feel I have had enough. I see others getting pumps for possibly high hba's. So sometimes I now think it would have been better to not care so much about control (apart from the fact of my eye troubles)

 

[Mrs Vimes]

Hi, I eat vlc because I can control he roller coaster or actually just stay of it. My moods are much better. Mistakes are much safer.
I am at the gym most mornings at 6. I do legs, arms, back, shoulders, chest weights split. I do 2 spin classes a week, 1 insanity class, 1 LesMills grit class and a personal training session. Oh yes and I'm a secondary school science teacher. I tend to be in ketosis. I train fasted.
The big thing is the safety. Small numbers mean a lot less insulin on board for me so safe corrections. My rage bolus is 1-2 units of insulin instead of the 5-10 it used to be.
After a couple of weeks this way of eating is actually easier than the higher car recommended.
I like that my high may be an 8 in stead of 17 because I'm eating out and f@@@@@d it up. Mental capacity? I've always been a bit dozy haven't noticed it get worse? It's been about 3 years now.

 

[linda321]

Just want to say that I am finding this thread really interesting. I recently had 2 appointments, 1 with the consultant and 1 for a DAPHNE course followup. My hB1Ac was 7.9% and they were thrilled with my progress! Personally I think that is a bit high, but they were so pleased that it was under 8. And they were interested in my libre print outs. I think they realised that I am able to take control and have done so. I don't have another consultant appointment for 1 year now.
In a way, I would like more support, just this week I forgot to take my basal, and would have liked someone to call and speak to right away. On the other hand, I am capable of doing this my way, leaving the doctors and DSNs to spend more time who need their support.

 

[Bluemarine Josephine]

It's not that these professionals "do not care" Josephine. I feel they have to "switch off" because if they cared in minute detail emotionally for every patient that walks though the door? They would loose the plot with the stress & anxiety too..!

There is always the few that are "diamonds" & go the extra mile. But that's just good professional "customer service"..

Hello my friend, thank you for your comment, I hope you had a lovely weekend!
When I go to the chemist to get something trivial for a flu or a cold, she says:
‘ You are registered in the so&so surgery”
I reply “Yes”
Then, she asks me ‘…and who is you GP?”
I reply “I have absolutely no idea because I see a different one every time I visit…’
And it’s true.

In cases like this, where I may see a doctor once or twice a year, I do understand that I am just one more patient, one more appointment amongst the 50 appointments that he may have on that day. I am just a number.

However, with chronic conditions, I believe, the situation is different.
In chronic conditions, like diabetes, physicians see us every 3-4 months to help us with the management of our condition.
We are not healing our condition, there is nothing therapeutic about our appointments; we are only managing daily a situation which has a life span duration. This means that with chronic conditions, the doctor needs to have a holistic approach of the condition (body, mind, spirit) instead of just looking at the facts, prescribing a medication and sending us on our merry way.

Holistic caring for a patient with chronic disease is coming along with the territory (otherwise, an endocrinologist can very well choose to become a dentist instead and save oneself the burden.)

I feel that the fact that we have accepted their laziness/indifference, or the fact that we tend to justify it to a certain extent (too many patients/a heavy load of work) does not consist an adequate excuse for them. It is a reality of course but, like many other things in life, it shouldn't be.

As for those "diamonds" they are doing an excellent job in hiding...

Regards
Josephine

 

[PseudoBob77]

Yes think you are correct Becky to a large extent. It's all about balance and how we want to live. I have had it for 50yrs and tried very hard, last hba of 50. However I am now getting depressed and feel I have had enough. I see others getting pumps for possibly high hba's. So sometimes I now think it would have been better to not care so much about control (apart from the fact of my eye troubles)

What I have read in studies about an aging T1 population, this also refers to Joslin medalists in Canada is that longevity is associated with a certain physiology of the genetic makeup which has protective mechanisms. They are still trying to unravel which parts of the gene sequence are responsible for these protective factors.

No doubt you firstly need reasonable control over the duration, then it's what we are dealt in the genetic lottery, thirdly we make lifestyle choices that directly affect our chances of complication free lives in the longrun.

If we make our best caculated approach to what we feel we can control then the rest is a lottery in life. I seriously haven't needed any guidance from the diabetic team for several years now, they offered me an insulin pump last year so I declined. I have 1 hospital appointment a year then my surgery does a follow up, probably because they get funding by taking my Hba1c at the surgery and carrying out a detailed blood test for liver/kidney function etc.

All I want my medical team to do is sign my prescription for my medication and I'll get on with the rest myself. Any questions I'll grill the consultant or optometrist.

Sent from my SM-G900F using Diabetes.co.uk Forum mobile app

 

[Jaylee]

As for those "diamonds" they are doing an excellent job in hiding...

I must have been lucky & seen a few.. Though like the "real thing" they formed under immense pressure.