How low is too low for an HbA1c?

NewdestinyX

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205
Caleb Murdock said:
Grant, you and I seem to agree on everything. Diabetics should start insulin early (why wait until you have permanent nerve damage?), and it should be fast-acting insulin. In your case, you are using a very fast-acting engineered insulin; in my case, I am using regular insulin (I don't have insurance here in the U.S., and regular is cheapest). All this means is that you can eat one large meal on your shot, whereas I can eat two smaller meals on my shot. It's really the same thing. [q
. I've heard good and bad things about regular insulin. You have to get the dosing just right to prevent hypos too. But if it works for you - cool!
A lot of people take Lantus because they are in love with the idea of taking one shot a day, but Lantus is designed to cover your body's fasting needs, not your meals. Most type-2 diabetics have enough pancreatic function to cover their fasting needs;
Well this isn't entirely accurate. Almost no T2's have adequate pancreatic help for their fasting either. The fasting is what breaks first in fact.. but...
it is their meals that their pancreases can't handle.
..YES! quite right.. T2's have 'broken first phase insulin responses - so if it's from their liver's dumping before a meal (fasting) OR from a cortisol release causing the liver to dump early am (fasting) OR after eating a carby meal -- suffice it to say - it's the first phase insulin response that's pretty badly broken by the time full diabetes has set in and creates the elevated BG levels. The 2nd phase insulin response which helps pull us back down to fasting levels is what most T2's have enough pancreatic help for unless they're particularly obese which complicates things.
(When I took Lantus, I discovered that I would have to take a daily shot of 90 units to cover my meals adequately.)
Well slow acting insulin was never meant to cover meals. It's not for meals at all so it would only have given you massive hypos if you took enough to cover for meals. Your fasting numbers would have been WAY low. Even at 100lbs overweight when I started - the most Lantus I could take was 32 units without getting bad hypos. I settled in a 28 units and over 2 years worked my way to 'no units'. Don't need the Lantus anymore.
I agree also about carbs. What the fast-acting insulin does is it turns our bodies back into more-or-less normal bodies. A middle-aged non-diabetic can't eat 250 grams of carbs a day without gaining weight.
OH PRECIOUS TRUTH!!! Somebody else gets my point I've tried to make on SOOOO MANY forums. I couldn't state it better. One of the other big lies on forums is that IF YOU GO ON INSULIN YOU'LL GAIN WEIGHT!. What a terrible myth. People ONLY gain weight on INSULIN when they OVERUSE IT, OVEREAT STILL or start massively obese and can't get 'ahead of the curve', if you will. Using insulin resets our bodies to 'normal'. And as you rightly say -- no middle aged sedentary person needs 2500 calories a day. Not even close.
On insulin, we have to watch what we eat just as we did when we were younger.
Exactly.. Except I didn't have to watch things as much when I was young and more active. What I think you could more accurately say there is that we need to watch our intake like we did BEFORE we started getting diabetic. Diabetes does a terrible things as it's in onset: We start to overeat a little - and add a few pounds - though not diabetic yet.. Then as the genes allow the beginnings of the disease, which is a breakdown of the communication between pancreas and liver, to occur - the sugar from our food starts to stay in the blood and NOT GET DEPOSITED to OUR BELLY as quickly. We do get fatter, 80% of us T2's, but much slower. SO this lulls us into thinking we can eat 3000+ calories a day and 400-500grams of carbs and hey -- just a little more love handles. BUT insulin return us to NORMAL.. AND WOW -- can the weight come on REAL FAST if we eat ANYWHERE NEAR what we did prior to the onset of the disease.
and And I agree about the numbers you quote also. My experience is this: If I average more than 200 carbs a day, I gain weight. If I eat about 180 carbs a day, I plateau (but then, I need to lose weight). If I eat about 150 carbs a day, I lose weight very, very gradually.
Almost EXACTLY my experience. Except my numbers are 90/120/150'ish. And I use a little less insulin than my ACTUAL I:C ratio would call for. So I allow my numbers to be 5 - 5.5mmol fasting - and go up as high as 8.3 mmol and then after two hours can still be 6.6 and I don't take any more insulin than would create that outcome after 2 hours. So I take about a 1:20 ratio of fast acting rather than what would make for 'perfect numbers' if I use my 'actual' 1:11 ratio.
150 carbs a day is my goal. My problem is that I'm an emotional eater, and sweets are my best friend. I've just gone through 3 months of eating over 200 carbs a day, and I gained 5 lbs. I am trying to get my carbs under 200 now.
You're not alone in your approach to carbs. Food, for many people, is their main stress reliever. They don't drink or smoke but love a good starchy meal. And there are 'good feeling endorfins' released by many foods especially chocolate. I would see a therapist eventually about these kinds of ties to food as that can be very helpful. But so many diabetics who go so low in their carbs list in their signatures that they're also on 'anti depressant meds'. I think -- no wonder.... :roll: ..trying to be sensitive too..

I've had some thoughts about the original topic of the thread. How low is too low for an A1c? Someone said that Bernstein recommends 4.3%, but in my opinion, Bernstein is an extremist.
He is an extremist and considered a dangerous influcence by almost everyone in the endocrinology field. I believe for good reason. He makes people flirt with hypos by his goals and he says to have stay healthy you need to virtually eliminate carbs. Be assued he is ALONE in the medical field and I consider him a quack. Other don't. But very few follow his idea to the letter and yet they still invoke his name as a 'leader' in developing their thinking. Sheesh... I don't get it. But -- each to his own.. My kids and wife's A1c's are all in the mid to high 4s. None of them are at 4.3. There are several books that show normal A1c's starting at 3.9. So Bernstein is not just making this stuff up out of thin air. My doctor says most of his non-diabetic patients are between 4.5 and 4.9 - and though he has to follow the AMA guidelines in telling me what 'normal is' - he acknowledges that he'd like me in the mid to high 5s and not 6.5-7.0 - if I can get there; mostly because of retinopathy issues which are getting more and more widespread because of pre-diabetes and the ADA's looser guidelines allowing people to think that 6.5 is 'normal' - which it isn't. With regard to 'retinopathy' complications -- not even 5.3 is 'normal'. -- almost normal.. but not.

A normal person's BS may be 90 (5.0) with peaks of 125 (6.9) after meals, but Bernstein wants his patients to be at 83-90 at all times (4.6-5.0). Thus, the A1c that he considers to be optimal is lower than even a normal non-diabetic would have. So my view is that 4.5% is low enough for anyone. (Just a reminder: The A1c test measures a different blood factor than a glucose test measures, so the numbers are not equivalent -- an A1c of 4.5% is equivalent to an average blood glucose of 4.6. An A1c of 6% is equivalent to an average blood glucose of 7.)
Yes, we agree on all things Bernstein. He's 'alone' in his field. For good reason in my self-educated view.

There is a good balance of people here, Caleb, with different control regimens and general respect for one another. Better than the other big American forums I've visited. And there is no doubting that lower our carb intake IS effective in controlling this disease. So I can't push back on people who choose to try that method before any other method. And additionally - for so many people in mid-life, when T2 tends to set in, the idea of BEATING THIS DISEASE BY LIFESTYLE CHANGE sets up a GREAT mid life self-challenge - that's akin to an Australian 'walkabout' or 'pilgrimage' across the Pyrinees(sp?) Montains like that new American movie is about. You're at a little later stage in life I think I noticed and may have to accept some limitations in terms of the activity you can do - but I got diagnosed at 48 - and became and avid cyclist and really found it to be a mid life project getting back to my high school weight and being fitter than most people my age. It's been a great journey. But I admit this year's been harder.. I've been 'regressing'.. The good news - is ALL the work HAS paid off and I am used to eating about 1500 calories a day and 80-100g of carbs.. So I'm not totally off the wagon -- just feeling like I need a break from all the INTENSE focus on my eating and exercise. I'm 'tired'. I need a break.. So I'm gonna take one. But I really HAVE retaught myself to eat. It's quite liberating. I am no longer 'ruled by food'. And you'll get there too. But be hard on yourself at the beginning. Even though a lot of people on these forums were 'alarmists' (in my view) at the beginning of my journey -- the 'alarm' bells they sounded -DID HELP jumpstart me in the right direction. Even some of the 'scare-mongering - if I'm honest with myself -- was helpful as a means to an end (though I'm not alarmist to newbies here at all). Sadly though - there are WAY more T2's NOT taking their disease seriously than ones that are. I'm glad for people who tell me to 'hang in there' and keep reminding us that carb over-indulgence IS a problem for a T2 diabetic. It just is.
 

Unbeliever

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As a non-overweight T" who gets by with just cutting out starchy carbs and walks about 5 miles per day
although I also take medication [whch I have been able to cut down on considerably this year} I would just like to say that you are making certain assumptions about the reasons why people are reluctant to start insulin.
It is not all fear of needles and stigma. Most of us test our own bg and I am reliably informed that insulin injections are far less painful.

In my case I fear hypos and even more I fear the lack of knowledge and expertise in the HCps who would be guiding and instructing me.
My fear stems from the harm they have already inflicted upon me with the medication I have been prescribedin the past.You are probably right about insulin being the logical treatment. but with my experience of two large doctors practices and the hospital I feel a change o insulin would be tantamount to a suicide bid..
People are not so shallow aas you imagine. Everyone always assumes that people are afraid of injecting.
I regularly have injections in my eyes. Anaeshetic drops or not that is not a pleasant procedure , horis it painless.
As for fear of admitting that one has such a disease I can't even imagine feeling that way.
 

Caleb Murdock

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Grant, you say so much that I can't really respond to it all. Let me say a few things, however.

As I said above (I think), Jenny Ruhl turned me on to R insulin. My experience with R insulin is that if I cover my meals adequately, my BS returns to normal as the insulin wears off. That's not to say that I don't have the dawn effect -- I do -- but it is fairly mild (I wake up with readings of 115 [6.4] to 135 [7.5]). Many type-2 diabetics secrete more insulin than non-diabetics do; the problem for them is that their bodies are so insulin-resistant that their pancreases can't secrete the large amounts of insulin needed to overcome it. Thus, a lot of type-2 diabetics are walking around with both excess sugar AND insulin in their blood.

By the way, it is not my experience that I have to get the dosing just right -- but a lot depends on what you consider to be acceptable BS readings after a meal. If I peak at 160 (8.9), I don't mind as long as my BS returns to near normal by the time the shot wears off. To you, 8.9 might be unacceptable. When I am keeping my carbs down to 180 grams or lower, I have a lot of days when I peak at 140 (7.8).

Yes, insulin doesn't cause you to gain weight; eating carbs does. What happened to me was this: As my diabetes worsened, I discovered that I could eat almost anything and wouldn't gain weight above a certain plateau. What was happening was that the BS that used to be stored as fat on my body was just circulating in my blood and causing havoc. Once I started on insulin, that BS started to get stored on my body again. During the first 4 months on insulin when I was managing to keep my carbs to less than 200, I didn't gain weight; but when I started to go higher than that, the weight came on (5 lbs. in 3 months). (By the way, the numbers I gave you for how carbs affect my body [150/180/200+] were overly optimistic. I think I'll have to go to 125 daily carbs to really lose weight.)

You may have noticed that the last A1c given in my signature has increased from 6.0% to 6.2%. Both I and my doctor were so surprised by the 6.0, that we took a large blood sample and had the lab do the test, and it came out at 6.2%. Nonetheless, that result came after 2-1/2 months of eating very poorly. If I can get an A1c of 6.2% on a high-carbohydrate diet, then the regular insulin must be working pretty well. If I can get my carbs down to 150, I am sure that I can get an A1c of 5.5%.

I have more respect for Bernstein than you seem to. He is a perfectionist, and he expects his patients and readers to be perfectionists too. But if a non-diabetic's BS goes to 125 (6.9) after a meal, then why should he insist that his patients keep all their readings to 90 (5.0) or below? He wants his patients to do better than non-diabetics do. In a way, that's laudable, but it's also impractical. You have to have a particular type of personality to give up 90% of the carbs in your diet and still be happy. You have to understand where Bernstein is coming from: He was a pioneer who was one of the first people on the planet to use a glucose meter to regulate his diabetes. He has spent his whole life perfecting his treatment of diabetes; the problem is, he's gone a bit too far. He expects everyone else to be as fanatically dedicated as he is.

Bernstein likes to get his patients to a BS reading of 83 (4.6) all the time. That's too close to hypo territory for me. I aim for 100 (5.5), and that gives me a safe margin. I have a type-1 friend who uses an insulin pump, and he aims for a range of 100 (5.5) to 150 (8.3). I frequently fall to about 4.8 while aiming for 5.5; If I were aiming for 4.8, I might end up at 4, which is too low. Also, aiming for 5.5 means I can inject less insulin. (What a shame that we use different measuring systems across the pond; it makes it so much harder to communicate. Would people understand me if I just used American numbers?)

Unbeliever, I just want to make the point that insulin is a natural substance, and as such it has few side-effects (unless you overdose on it). Having taken harmful medications in the past shouldn't stop you from trying insulin. (I'm sorry, by the way, that you had that experience. I took Avandia for ten days, and it gave me permanent tinnitus in both ears. Thanks to Glaxo-Smithkline, I now have noise in my head which I didn't have before.)
 

Grazer

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NewdestinyX said:
..YES! quite right.. T2's have 'broken first phase insulin responses - so if it's from their liver's dumping before a meal (fasting) OR from a cortisol release causing the liver to dump early am (fasting) OR after eating a carby meal -- suffice it to say - it's the first phase insulin response that's pretty badly broken by the time full diabetes has set in and creates the elevated BG levels. The 2nd phase insulin response which helps pull us back down to fasting levels is what most T2's have enough pancreatic help for unless they're particularly obese which complicates things.

Hi! I'd be grateful if you could explain this bit for me. What is "first" and "second" phase? I thought insulin was produced whenever BG went too high, (bit like a thermostat), and that was it. What is the difference between these phases?
Thanks in anticipation of your help
 

Caleb Murdock

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60
Correct me if I'm wrong.

Your pancreas stores up insulin in the form of granules, and when you first start to eat, it squirts this stored insulin into your blood (there may be more than one squirt, a squirt when you start to eat and then a squirt or two later in the meal). That's called the phase I insulin response. Once the stored insulin is used up, your pancreas has to manufacture any more insulin that it releases as it is needed. That's the phase II insulin response. The phase I response is larger and more sudden than the phase II response, and that larger response is needed to cover the surge in blood sugar during a high-carbohydrate meal. A type-2 diabetic can't release that initial surge of insulin, and so the blood sugar goes up and stays up for hours, while the phase II insulin dribbles into the system and gradually brings it down. Eventually the phase II insulin response isn't enough to EVER get the blood sugar to normal, and the diabetic's blood sugar remains permanently high. That leaves the diabetic with a few choices: reduce carbs drastically so that not so much insulin is needed, or take insulin, or take some medication that decreases insulin-resistance or stimulates the pancreas to make more insulin. Eventually, if the diabetic doesn't make dietary improvements, any medications that are taken won't be enough, and the diabetic will be forced to go on a low-carb diet, or to take insulin.

All these changes take place gradually, of course. Initially your phase I response may be only slightly stunted, so that your blood sugar rises to, say, 140 (7.8) instead of 120 (6.6), and then takes an extra couple hours to get down to 90 (5.0) instead of getting to 90 rapidly.

Fast-acting insulins are designed to replace the phase I response, while long-acting insulins are designed to replace the phase II response. A type-1 diabetic who produces no insulin at all may need both long-acting and short-acting insulins, while a type-2 diabetic who is still producing phase II insulin may only need to take fast-acting insulin to cover meals. Also, you should be aware that many type-2 diabetics produce more insulin than many non-diabetics do, but it just isn't enough to overcome the insulin-resistance that has developed in their bodies.
 

pianoman

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332
I also understood phase 1 insulin (AKA first phase) to be a stored form (granules as you say) of insulin that has been saved for quick response such as when we eat... in a non-diabetic this might be released as soon as the food hits our mouth or possibly in anticipation of eating.

Also as you say: Phase 2 (AKA second phase) is secreted on demand but takes longer to respond. I recall from somewhere that it is effectively left-over" second phase insulin which is stored for the next first phase... and again as above: in Type 2 (especially with Insulin Resistance - IR) it is likely to be this first phase that fails; because (even if we are secreting large amounts to overcome IR) we barely have enough to keep up with the second phase demand let alone any "left over".

A clarification I might offer is that: I understood basal or long acting insulin to provide for our background needs for insulin; which is there whether we eat or not -- basal testing usually involves missing meals.While the fast-acting bolus insulins are to cover mealtime needs -- with the even faster-acting modern insulin analogs being developed to more closely approximate (but still not perfectly) the speed of a first phase response. Some people inject minutes before eating to try and more closely match the first phase -- in my experience it takes less insulin to keep the BG down that it does to correct it down once it has risen.

Medscape offers this on insulin secretion phases by Melissa K. Cavaghan, MD, Assistant Professor of Clinical Medicine, Division of Endocrinology and Metabolism, Indiana University School of Medicine, Indianapolis, Indiana...
Phases of Insulin Secretion

In nondiabetic individuals, approximately 50% of the total daily insulin is secreted during basal periods, suppressing lipolysis, proteolysis, and glycogenolysis. The remainder of insulin secretion is postprandial. In response to a meal, there is a rapid and sizable release of preformed insulin from storage granules within the beta cell. This "first phase" of insulin secretion promotes peripheral utilization of the prandial nutrient load, suppresses hepatic glucose production, and limits postprandial glucose elevation. First-phase insulin secretion begins within 2 minutes of nutrient ingestion and continues for 10 to 15 minutes. The second phase of prandial insulin secretion follows, and is sustained until normoglycemia is restored.

First-phase insulin secretion is often represented in clinical studies by the acute insulin response to an intravenous glucose bolus. While an intravenous glucose bolus is not equivalent to an oral mixed meal, it serves as a standardized beta-cell stimulus by which first-phase insulin secretion can be carefully compared among different subjects. Further, it demonstrates the sensitivity to and insulin response of the beta cell specifically to the glucose stimulus. It is this loss of beta-cell glucose sensitivity and responsiveness that declines early in the development of type 2 diabetes, even while responses to amino acid and other stimuli are preserved.
 

markd

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220
Now this graph - http://www.a1cbloodtest.net/a1c-complications.php - seems to be much less alarming than BS101 in terms of increasing risk with higher A1c.

If you estimate the curves to the left of 6.0, it looks as if there is still some excess risk and I suppose it depends on what your personal view is of that excess.

Of course this website looks to be trying to flog you a personal A1c meter, so their financial interest should be considered, but they do seem to be quoting reliable data (UKPDS).

For me, it seems worth aiming to push that excess risk down a bit more, if I can do so without significantly cramping my lifestyle. My father died with complications from a stroke, so it seems reasonable to me to try and reduce the excess cardiavascular/stroke risk that T2 generally brings with it.

mark
 

Grazer

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3,115
Thanks Caleb and Pianoman, I've learned a lot there. Explains why my fasting BG is often higher than desirable even though my levels through the day are well controlled, because my phase 1 doesn't control the "dawn effect" dump but my phase 2 later, after breakfast, does O.k. Are there any studies that suggest how long in years it takes after phase 1 failure before phase 2 failure also occurs? I guess it depends on the individual, their diet, their general fitness etc. Anyway, thanks again.
 

NewdestinyX

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Messages
205
Grazer said:
NewdestinyX said:
..YES! quite right.. T2's have 'broken first phase insulin responses - so if it's from their liver's dumping before a meal (fasting) OR from a cortisol release causing the liver to dump early am (fasting) OR after eating a carby meal -- suffice it to say - it's the first phase insulin response that's pretty badly broken by the time full diabetes has set in and creates the elevated BG levels. The 2nd phase insulin response which helps pull us back down to fasting levels is what most T2's have enough pancreatic help for unless they're particularly obese which complicates things.

Hi! I'd be grateful if you could explain this bit for me. What is "first" and "second" phase? I thought insulin was produced whenever BG went too high, (bit like a thermostat), and that was it. What is the difference between these phases?
Thanks in anticipation of your help
Grazer,
Caleb's answer is exactly on target. Phase I covers meals - quick bursts of sugar into
System and phase II is working to bring us back to fasting levels. Oddly the first kind of insulin that doctor's recommend is slow acting when really the fast acting more directly addresses the initial needs of a T2. I think the 'one shot a day' seems like the easier 'sell' to the patient. I echo Unbeliever's reticence about docs. Though there is so little risk in injecting insulin it still galls me that our doctors don't just shoot straight with us. There are so many legal issues to fear these days that docs have to practice medicine 'defensively'. It's such a shame.

Caleb - you're 100% right again about reaching a stage in pre diabetes where all weight gain just stops no matter what you eat. Exactly what happened to me. Then when starting Lantus I wanted those perfect am fasting numbers. I got them but at the expense of halting my weight loss, regaining some weight and 70's(low 4's) before lunch and dinner. There's just no way to beat Dawn Effect - as all humans secrete cortisol to make the liver dump glucose into the blood in the early am to wake us up. It's a natural process. Just in diabetics it's like eating a candy bar that you didnt eat and now need insulin for. I treat wake up highs like any other meal with carbs. I take a shot of the Novalog upon waking. There's a reason the instructions on Lantus and Levemir say titrate up until fasting is <110 upon waking. If you shoot lower in am it creates the weight gain potential and hypos later in the day. I learned the hard way.
 

Unbeliever

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1,551
Speaking of Drs "shooting straight with us" I recall a study I read on line some time last year but can't locate now.
It was apparentluy commissioned by the Australian givernment and concerned introducing insulin therapy in local health centres rather han hospitals for the same reasons it was introduced here.

The study actually recommende that T2s were not old of all the posssible problems with insulin , Hypus etc as this would put many of hem off. At the same time Doctors were advised o be careul of how far they went down this road as it might make them vulnerable to litigation.!
I wonder if a similar study was commissiond here?

When will hey understand that lying to patients is couner productive in the end?

In UK studies of course, for "doctor\\\2 read "nurse". They go on more course you know according to my GP.
 

Caleb Murdock

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60
Grant, about regular vs. fast-acting, the regular insulin dribbles into my system (from my fat) for a period of 5-6 hours, and that allows me to eat two smallish meals. What you seem to be doing with the fast-acting insulin is covering one large meal with one dose of insulin. Personally, I prefer to eat the way I'm eating (one serving of food an hour after injecting, and then a second serving a couple hours later).

Pianoman, a person who injects fast-acting insulin minutes before a meal would have to be injecting it into a vein (or perhaps muscle) in order to mimic the effect of the pancreas. Any insulin injected into fat will take hours to work its way into the system, no matter how it is formulated. So even if you are taking a fast-acting engineered insulin, you have to inject 30-40 minutes before the meal.

My experience with the dawn phenomenon is that when I keep my carbs to a good level (180 grams a day or lower), I wake up with numbers in the range of 115 to 135 (6.4 to 7.5), which is acceptable. However, when I'm slipping off my diet and eating 250 grams a day, I can wake up with much higher numbers. (I know that there are people on the board who probably think that 180 grams is a daily binge, but the average American is eating 250 to 350 every day. I don't know what your diet is like in England.)

I don't mean to hijack the discussion, but my problem with food is that I have favorite foods that I just can't stop eating. I adore sushi, and my local supermarket has a sushi chef come in every day to prepare it fresh. A small tray of that has 40-45 carbs. Then there is a local food company which makes the best soups I have ever tasted. Towards the end of the day, that same supermarket puts the cream soups on sale at half price, and I just can't resist getting a pint of clam chowder or corn chowder or lobster bisque. All the soups have potatoes and/or thickeners in them, and so that's another 40 carbs. Then I have to have my daily chocolate fix, and that's 30-60 carbs. Then I love iced coffee, and the packets of sweeteners I put into it have one gram each. It takes 8 packets to sweeten a large coffee, and the half & half brings it up to 12. (I'll drink 2 of those a day.) I'm also addicted to a gourmet brand of yogurts that have 20 grams each. I occasionally will make a low-carb meat-based dish to eat when I'm hungry, but even that has 10 carbs per serving. And then there are the impulse purchases. Yesterday I bought teriyaki wings on impulse, and they had about 50 carbs in them. I'm not eating such a bad diet for a non-diabetic, but I'm not a non-diabetic. It just goes on and on. I hate cooking, and there are very few prepared foods available that are low in carbs.

Oh, about that chart that you posted, Mark, it gives me a lot of hope that if I can't get my A1c below 6%, I'll still be all right. The fact that that's a commercial site, however, is very worrisome. The chart also explains why so many doctors are satisfied with an A1c of 7%, since it makes it look like a 7 isn't that bad.
 

pianoman

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332
pianoman said:
...While the fast-acting bolus insulins are to cover mealtime needs -- with the even faster-acting modern insulin analogs being developed to more closely approximate (but still not perfectly) the speed of a first phase response. Some people inject minutes before eating to try and more closely match the first phase.
Caleb Murdock said:
...a person who injects fast-acting insulin minutes before a meal would have to be injecting it into a vein (or perhaps muscle) in order to mimic the effect of the pancreas. Any insulin injected into fat will take hours to work its way into the system, no matter how it is formulated. So even if you are taking a fast-acting engineered insulin, you have to inject 30-40 minutes before the meal. ...
I said "minutes" as opposed to "hours" and of course we can never perfectly match an healthy pancreas. I have commonly heard of people who inject 15-20 minutes before eating... any longer that that carries its own risk such as what could happen if they end up not eating for one reason or another.

http://www.aafp.org/afp/980115ap/noble.html
Short-acting insulin analogs are designed to overcome the limitations of regular short-acting insulins. Compared with regular human insulin, the analog insulin lispro offers faster subcutaneous absorption, an earlier and greater insulin peak and a more rapid postpeak decrease. Insulin lispro begins to exert its effects within 15 minutes of subcutaneous administration, and peak levels occur 30 to 90 minutes after administration. Duration of activity is less than five hours.
 

NewdestinyX

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205
Caleb,
What you're saying about it taking hours for fast acting insulin to reach the bloodstream is just not correct. Read up a little more. Novalog and Humalog reach the bloodstream anywhere from 30-45 minutes after injected - max. Then keep working over several hours to a lesser degree and are gone from body between 4-5 hours. Not sure where you got your info there. Unless I'm misinterpreting you. Analog insulins are pretty darn close to 'a pancreas'. Especially the newest ones like Lispro. There's another new one too - name escapes me.
 

Caleb Murdock

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Messages
60
NewdestinyX said:
Caleb,
What you're saying about it taking hours for fast acting insulin to reach the bloodstream is just not correct. Read up a little more. Novalog and Humalog reach the bloodstream anywhere from 30-45 minutes after injected - max. Then keep working over several hours to a lesser degree and are gone from body between 4-5 hours. Not sure where you got your info there. Unless I'm misinterpreting you. Analog insulins are pretty darn close to 'a pancreas'. Especially the newest ones like Lispro. There's another new one too - name escapes me.

Regular insulin takes 45-60 minutes to begin acting, and then stays in the body for 4-5 hours. When I said 5-6 hours, I was including that initial hour before it starts to work. However, Bernstein says it can have a residual effect up to 8 hours.

According to Bernstein's book, the fast-acting engineered insulins take 30 minutes to start working and stay in the body for 2-3 hours. To get them to act like insulin released by the pancreas (which starts working in minutes), you would have to inject them into a vein or into muscle.
 

phoenix

Expert
Messages
5,671
Type of diabetes
Type 1
Treatment type
Pump
I use Apidra which is said to have one of the fastest onsets, as you can see it is quicker than regular to start working and far quicker to reach it's peak. Like all fast insulins it does have a tail, something one has to be aware of (not good to be too low at 2hours)
 

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pianoman

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332
To some extent it also depends on what you are eating and how fast it would tend to raise your BG... I doubt that a non-diabetic pancreas dumps all the first phase insulin as soon as we eat but rather it would respond on demand to the rising BG as the food is digested... it is just that by secreting the insulin directly into the blood stream it can have a far quicker response than we can possibly manage with a subcutaneous injection (or infusion). Some foods will start digesting as soon as they hit saliva but of course, others take longer.

As above, it has been my experience (5+ years on an insulin pump) that it takes less insulin to keep the BG down than it does to try and correct for an high BG later. As I recall, others have reported the same. The suggestion of injecting the fast acting some minutes prior to starting eating was to give the sub-q injection a head start, as it were.
 

Fallenstar

Well-Known Member
Messages
546
Hi Caleb
I was on Apidra and had to change on to Novorapid because it could work on me in literally minutes , I have no insulin resistance at all and very high muscle to body fat ration and do a lot of exercise daily.
I have hit a vein once...believe me that is scary :shock Took me from 13.6 on waking to 0.8 in the time it took me to get downstairs, that was one VERY intense weird Hypo I shall never forget among the many I have had. I have gone into the muscle a few times so know this used to take me Hypo from double figures in minutes also but not the same and as fast as hitting the vein.
But even going into fat the insulin could still work that fast that I could go Hypo at the start of a meal just after injecting it, from decent figures. So for some of us these new rapid acting Bolus insulins do work as a normal pancreas might but that dose would be adjusted naturally with no margin for mistakes ,we can't always replicate this as hard as we try.
I find Novorapid a lot more of a intermediate acting insulin for my sensitivity and so a lot better fast acting insulin for my needs
 

NewdestinyX

Well-Known Member
Messages
205
Caleb Murdock said:
NewdestinyX said:
Caleb,
What you're saying about it taking hours for fast acting insulin to reach the bloodstream is just not correct. Read up a little more. Novalog and Humalog reach the bloodstream anywhere from 30-45 minutes after injected - max. Then keep working over several hours to a lesser degree and are gone from body between 4-5 hours. Not sure where you got your info there. Unless I'm misinterpreting you. Analog insulins are pretty darn close to 'a pancreas'. Especially the newest ones like Lispro. There's another new one too - name escapes me.

Regular insulin takes 45-60 minutes to begin acting, and then stays in the body for 4-5 hours. When I said 5-6 hours, I was including that initial hour before it starts to work. However, Bernstein says it can have a residual effect up to 8 hours.
Oh. Well even that's a little different than what you actually said - to prompt my response of 'not correct'. Here's what you stated:
Caleb Murdock said:
Any insulin injected into fat will take hours to work its way into the system, no matter how it is formulated
That statement, as stated with no caveats, was incorrect - as others have point out too. Remember too that Bernstein's book was written quite some time ago now. I think even the newest formulation of Novalog wasn't even out. And for sure neither was Apidra or Lispro which are almost pancreas-like in their curve. Suffice it to say - that for a person desiring to stick to a normal 3 meal a day regimen - Regular insulin's response curve is too slow. But I've heard of people using Regular insulin like a really potent 'long' acting insulin to help them control certain period of carb sensitivity. Learning what works for your body and your eating style preference is HUGE and it sure sounds like you've done that.

As to WHICH measuring system we should use here on this forum - that you asked a few posts back - this is the Brit's forum and we should respect the metric system. Wouldn't it be JUST SO American to 'require' a British forum to know a measuring system that's only use is 'ONE PLACE' in the WHOLE WORLD: America. :roll: The Metric system is used around the entire globe except the US.. :lol: I made a little card for myself when I'm visiting here that converts mg/dL to mmol/l -- it's just a simple 'divide by 18'.

4mmol = 72mg/dL; 5mmol = 90mg/dL, 6mmol = 108mg/dL, 7mmol = 126mg/dL;
8mmol = 144mg/dL; 9mmol = 162mg/dL; 10mmol = 180mg/dL.

fallenstar said:
Hi Caleb
I was on Apidra and had to change on to Novorapid because it could work on me in literally minutes , I have no insulin resistance at all and very high muscle to body fat ration and do a lot of exercise daily.
I have hit a vein once...believe me that is scary :shock Took me from 13.6 on waking to 0.8 in the time it took me to get downstairs, that was one VERY intense weird Hypo I shall never forget among the many I have had. I have gone into the muscle a few times so know this used to take me Hypo from double figures in minutes also but not the same and as fast as hitting the vein.
But even going into fat the insulin could still work that fast that I could go Hypo at the start of a meal just after injecting it, from decent figures. So for some of us these new rapid acting Bolus insulins do work as a normal pancreas might but that dose would be adjusted naturally with no margin for mistakes ,we can't always replicate this as hard as we try.
I find Novorapid a lot more of a intermediate acting insulin for my sensitivity and so a lot better fast acting insulin for my needs
Great education on Apidra, fallenstar! Thanks!!
pianoman said:
it has been my experience (5+ years on an insulin pump) that it takes less insulin to keep the BG down than it does to try and correct for an high BG later.
This has also been my experience - though not on a pump - just using Novalog - a little with meals. If I time it well with the type of meal I'm eating (higher in fat - inject about 20 minutes after meal; higher carb - inject 5 minutes before meal) then it works pretty predictably. If I later need to take a corrective dose - that takes longer to work and requires more in the dose.
 

Caleb Murdock

Well-Known Member
Messages
60
To a certain extent, I think we are getting hung up on terminology. When I said that insulin injected into fat takes "hours to work its way into the system", I should have said "through", as in "work its way through the system". The point is, there is always a delay when injecting into fat. A person who doesn't experience much of a delay would be a person like Fallenstar who has no insulin resistance. Obviously, insulin resistance does a lot to slow down the apparent action of any insulin that is injected. Also, the volume of fat you have may make a big difference. The pad of fat that I inject my insulin into is pretty big (nonetheless, I once hit a vein).

Phoenix, that chart is very interesting. I had no idea that R insulin took so long to run through the system. That explains why I have sometimes eaten something 5 hours after my shot and my BS still returned to normal eventually. What I want is a medium-acting insulin, and it seems that that's was R insulin is. However, there are times when I am starved, and I take an injection, and then 45 minutes later eat a large meal (instead of eating two small meals spread out), and on those occasions my BS can spike. I like eating a small meal every 2-3 hours; it suits me.

Grant, a couple thoughts about the measuring systems we are using: First, this forum is supposedly an international forum, so it shouldn't insult anyone if I use American numbers. Also, American numbers have the distinct advantage that they cannot be confused with A1c measurements, and for that reason I think the American measuring system is better. No one will ever confuse a BS reading of 100 with an A1c measurement. I'm going to post a conversion chart on the wall behind my computer, and I'll refer to that when I make posts.
 

))Denise((

Well-Known Member
Messages
1,580
Type of diabetes
Type 2
Treatment type
Tablets (oral)
I disagree with you Caleb on the units matter. This is mainly a British forum on a co.uk domain name. We talk about our meter readings in mmol. The units for HbA1c are changing in the UK from % to mmol/mol. So there will be no confusion there.

We also talk about the UK healthcare system.