How To Stop Shooting Yourself in the Foot

[Dillinger]

I find that most of the problems I have with maintaining stable blood sugars relate to me making stupid mistakes rather than my approach to management. I eat a very low carb diet of <30 grams a day and it really works for me. Until I do something stupid.

This morning I woke with blood glucose of 5.6 now it is 12 - why is that? Well for breakfast I had three rashers of bacon and that was all (fridge deficiency/hurry) and amongst dealing with children and chores I forgot to take my bloody short acting insulin (although did take long acting and metformin). So a great blood sugar (for me) gets thrown away because I'm not paying attention.

I also find that I will sometime eat something that I assume will be low carb and then find out later how wrong I was; for instance I sometimes have sandwich fillers on their own as part of my lunch; Tesco does one called 'Sea Food Cocktail' or something like that which you would assume was just crab sticks and mayonnaise but if you look at the carb content it is something like 15 carbs a pot; because Tesco being Tesco can't resist stuffing everything they can lay their hands on with sugar. I've been caught out in that way a couple of times.

Do any other Type 1's have any tips or strategies for avoiding needless messing with your control? Other than 'take your insulin' and 'read the bloody label' ... :? :roll: :lol:

I get so frustrated by this sort of thing; essentially chucking away perfect control for no reason at all...

Best

Dillinger

 

[Grazer]

Can't help at all Dillinger for obvious reasons, but could you enlighten me? Why is it you have to have short acting insulin just for bacon, and why does it raise your BG so much if you forget? I sort of understand protein can turn to glucose in the absence of carbs, but that much? Excuse my ignorance, but never really looked into this and am interested.

 

[xyzzy]

Can't help at all Dillinger for obvious reasons, but could you enlighten me? Why is it you have to have short acting insulin just for bacon, and why does it raise your BG so much if you forget? I sort of understand protein can turn to glucose in the absence of carbs, but that much? Excuse my ignorance, but never really looked into this and am interested.

Snap!

 

[AMBrennan]

Other than 'take your insulin' and 'read the bloody label' ...

How about
a) Having a fixed routine for your insulin? If you always take your injection before you start eating then it's reasonably easy to not forget. Keep your pen in the wallet with a few needles - that way you can easily tell if you've taken the injection later (no used needles - bad; one used needle - good; more than one used - bad). There's a new product - Timesulin - but it's probably a scam (bought one, and it stopped working after 72h)
b) Always assume that the food industry is evil. They want to sell stuff. Putting lots of sugar (or salt, or fat) makes people buy moer stuff. So they'll put as much sugar, fat and salt into their products as they can get away with.
c) Buy only stuff you know. Only buy the sandwich filler you know will not affect your blood sugar every time.

why does it raise your BG so much if you forget? I sort of understand protein can turn to glucose in the absence of carbs, but that much?

That's simply because "BG up = carbs eaten" is an oversimplification. It works well enough for most people but is essentially a lie-to-children. In reality, the initial BG spike is due to liver releasing stored glucose when you start eating (because you'll be able to top up stores soon enough) - for most people, this correlates well enough with the carb content of the food, serving as the base for the above lie-to-children.

 

[Grazer]

That's simply because "BG up = carbs eaten" is an oversimplification. It works well enough for most people but is essentially a lie-to-children. In reality, the initial BG spike is due to liver releasing stored glucose when you start eating (because you'll be able to top up stores soon enough) - for most people, this correlates well enough with the carb content of the food, serving as the base for the above lie-to-children.

Thanks for that, but don't quite buy it. If I eat a pizza, my BGs rocket to double figures. I know that from testing. If I eat a steak and nothing else, or any meal with no or little carbs, my BG doesn't hardly move. So my liver doesn't just release stored glucose because I'm eating, only if I'm eating carbs. Maybe it's different for someone who's insulin dependant, but for me as a T2 on diet and exercise it's anything BUT a lie to children. (No offence, but not being a child I'd have found it out if it was a lie a long while ago)

 

[noblehead]

There's a fantastic product that has just come on the market recently called Timesulin which fits on the end of most insulin pens and reminds you when you last injected, I'm seriously thinking of purchasing one myself as there has been times where I've doubted if I've injected or not.

As for food the Tesco filling well that comes as no surprise, better making your own food and keeping in a tupperware boxes that way you know what goes in.

 

[xyzzy]

That's simply because "BG up = carbs eaten" is an oversimplification. It works well enough for most people but is essentially a lie-to-children. In reality, the initial BG spike is due to liver releasing stored glucose when you start eating (because you'll be able to top up stores soon enough) - for most people, this correlates well enough with the carb content of the food, serving as the base for the above lie-to-children.

Thanks for that, but don't quite buy it. If I eat a pizza, my BGs rocket to double figures. I know that from testing. If I eat a steak and nothing else, or any meal with no or little carbs, my BG doesn't hardly move. So my liver doesn't just release stored glucose because I'm eating, only if I'm eating carbs. Maybe it's different for someone who's insulin dependant, but for me as a T2 on diet and exercise it's anything BUT a lie to children. (No offence, but not being a child I'd have found it out if it was a lie a long while ago)

Well there's something strange going on as there was a similar kind of debate going on the other day. I can't believe either side in this discussion would want to tell porky's over the BG response of bacon! Obviously Dillinger as T1 gets a response from bacon whereas Grazer, me and I would suggest a lot of other T2's get no response at whatever time we test.

One possible stab in the dark way of explaining this would be to assume the bacon DOES produce a very short lived "squirt" of glucose. With no insulin production a T1 would measure this once the squirt had occurred. In a T2 insulin production in a lot of us isn't an issue so the short burst is pretty immediately mopped up. Pasta may be stimulating the production of a continuous release of glucose over a longer period of time. In a T1 they will still measure a rise in BG's for pasta but for a T2 it could well be their insulin resistance that comes into effect as the cause of the BG spike not a lack of insulin.

Like I say no idea if what I've written is remotely near what goes on but something must be different between the way a T1 and T2 is handling bacon and presumably other non carbohydrate based foods.

 

[noblehead]

This morning I woke with blood glucose of 5.6 now it is 12 - why is that? Well for breakfast I had three rashers of bacon and that was all (fridge deficiency/hurry) and amongst dealing with children and chores I forgot to take my bloody short acting insulin (although did take long acting and metformin). So a great blood sugar (for me) gets thrown away

Sorry I didn't comment on this. Yes I find I'm the same with protein based meals, a breakfast of eggs and bacon requires 4 units of novorapid compared to my usual breakfast of porridge made with milk, yogurt, blueberries and seeds which requires 5 units......don't know why it does but it does!!! :?

 

[Dillinger]

Thanks AMBrennan and Noblehead on the Timesulin idea - but I'm assuming that you both use flex pens? That seemed to be what it was aimed at? I use insulin pen with replaceable insulin cartridges; is there a benefit to using the disposable pen?

As to the blood sugar rise on bacon; it is a bit weird isn't it? I think that on a low carb diet I really need to count protein as 'carb' on the basis that 60% turns to glucose over time. I'm just not sure how long that takes.

Possibly such a hike is related to dawn phenomenon and as has been said my normal morning insulin is really covering that and/or a glycogen response rather than the low carb breakfast. Funny thing is a smallish amount of Greek yoghurt which would be about 6 carbs needs a pretty small amount of insulin, so for a purely protein meal like the bacon you would have thought that it would need even less? I find though that anything I eat I'll need to take insulin to cover; I would not skip insulin on the basis that there were no carbs unless it was a small snack.

I did have a small (tablespoon size) amount of milk in my coffee and would normally have cream but I'd be amazed if that could pretty much double my blood sugars...

Best

Dillinger

 

[noblehead]

Thanks AMBrennan and Noblehead on the Timesulin idea - but I'm assuming that you both use flex pens? That seemed to be what it was aimed at? I use insulin pen with replaceable insulin cartridges; is there a benefit to using the disposable pen?

I'm sure it fits nearly all makes of pens, here's the link to the website: http://timesulin.com/

As to the blood sugar rise on bacon; it is a bit weird isn't it? I think that on a low carb diet I really need to count protein as 'carb' on the basis that 60% turns to glucose over time. I'm just not sure how long that takes.

Complicated thing this diabetes lark! I remember when I first joined and went low-carb I was told about protein in the absence of carbs converting by around 60%.

Possibly such a hike is related to dawn phenomenon and as has been said my normal morning insulin is really covering that and/or a glycogen response rather than the low carb breakfast. Funny thing is a smallish amount of Greek yogurt which would be about 6 carbs needs a pretty small amount of insulin, so for a purely protein meal like the bacon you would have thought that it would need even less? I find though that anything I eat I'll need to take insulin to cover; I would not skip insulin on the basis that there were no carbs unless it was a small snack.

Covering DP also makes perfect sence.

I did have a small (tablespoon size) amount of milk in my coffee and would normally have cream but I'd be amazed if that could pretty much double my blood sugars...

Milk would have a minimal effect IMHO. I remember a while back you were concerned about your insulin resistance amounting to your high insulin usage (was it 1 unit of insulin to 1g of carb) and you mentioned then that your Endo says it could be related to the high fat content of your diet, did you follow this up with him/her as I would be interested in what they said.

 

[borofergie]

That's simply because "BG up = carbs eaten" is an oversimplification. It works well enough for most people but is essentially a lie-to-children. In reality, the initial BG spike is due to liver releasing stored glucose when you start eating (because you'll be able to top up stores soon enough) - for most people, this correlates well enough with the carb content of the food, serving as the base for the above lie-to-children.

That might be true of someone eating a "high-carb" diet but not of someone in deep ketosis. Dillinger is eating a <30g ketogenic diet. His liver is essentially empty (<10% of the glycogen stores of a non-ketogenic liver), and working as hard as it can to generate 25g of glucose a day to fuel his brain. It doesn't expect to be refilled and it won't waste resources dumping glucose when he starts eating.

 

[jopar]

Couple of things to remember!

Most diabetic's be they T1 or T2, are more insulin resistant in the morning than at any other part of the day... In the case of T1's we need a higher ratio of insulin to curtail BG's...

Basal profile, now our basal's profile isn't flat but a wave, and when you inject background insulin what you are doing is flattening out the peaks and trough's of the the wave into a much smoother wave to work from..

BG, the higher it is the more insulin resistant it becomes and the more resistant it is to insulin the quicker it can increase.

Looking at Dillinger's impact of his 3 rasher's of bacon and a missed injection..

Bacon is a protein, something like 50% plus will breakdown into carbs, so if as Dillinger says, he's needs 1u of insulin per 1g of carbs, he's missed a serious amount of insulin to counteract the carbs from the protein....

But that's probably not the whole story though.... Part of the story will be in his basal profile and his morning insulin resistance.. Which compounds together shooting the BG up over a period of time....

One thing Dillinger doesn't mention though..

Would he normally inject before he ate his breakfast or due to not immediately taking on board a visible carb that he injects after he's eaten his breakfast!

 

[jopar]

That's simply because "BG up = carbs eaten" is an oversimplification. It works well enough for most people but is essentially a lie-to-children. In reality, the initial BG spike is due to liver releasing stored glucose when you start eating (because you'll be able to top up stores soon enough) - for most people, this correlates well enough with the carb content of the food, serving as the base for the above lie-to-children.

That might be true of someone eating a "high-carb" diet but not of someone in deep ketosis. Dillinger is eating a <30g ketogenic diet. His liver is essentially empty (<10% of the glycogen stores of a non-ketogenic liver), and working as hard as it can to generate 25g of glucose a day to fuel his brain. It doesn't expect to be refilled and it won't waste resources dumping glucose when he starts eating.

This poses an interesting question!

Now our safety net for the T1 diabetic, is the ability that the liver can dump it's stores of glycogen into our blood stream in an emergency to bring our BG back into normal range...

Now as Dillinger's pointed out, that the best organised diabetic can be caught out by a situation..

Now if the situation catching the diabetic out, involves a hypo with no means of treating it with fast acting carbs, then the diabetic is relying of their liver's emergency stores of glycogen to bring them out of a hypo! The body can signal a dump but with nothing to dump you a have major problems...

Add to this, if the body is so fine tuned, that it has to work at full capacity to maintain the minimum amount of glucose to enable the brain to function... Then disrupt the supply of glucose to the brain it ability to function is impacted very quickly indeed... With absolutely no reserves anywhere in the body the the brain's ability to function is diminished very quickly, so the point between struggling to function to not being able to function at all is very small!

So doesn't this mean that the Window to start medical intervention to advert death (the brain not being able to function at all) is also very small...

 

[xyzzy]

That's simply because "BG up = carbs eaten" is an oversimplification. It works well enough for most people but is essentially a lie-to-children. In reality, the initial BG spike is due to liver releasing stored glucose when you start eating (because you'll be able to top up stores soon enough) - for most people, this correlates well enough with the carb content of the food, serving as the base for the above lie-to-children.

That might be true of someone eating a "high-carb" diet but not of someone in deep ketosis. Dillinger is eating a <30g ketogenic diet. His liver is essentially empty (<10% of the glycogen stores of a non-ketogenic liver), and working as hard as it can to generate 25g of glucose a day to fuel his brain. It doesn't expect to be refilled and it won't waste resources dumping glucose when he starts eating.

This poses an interesting question!

Now our safety net for the T1 diabetic, is the ability that the liver can dump it's stores of glycogen into our blood stream in an emergency to bring our BG back into normal range...

Now as Dillinger's pointed out, that the best organised diabetic can be caught out by a situation..

Now if the situation catching the diabetic out, involves a hypo with no means of treating it with fast acting carbs, then the diabetic is relying of their liver's emergency stores of glycogen to bring them out of a hypo! The body can signal a dump but with nothing to dump you a have major problems...

Add to this, if the body is so fine tuned, that it has to work at full capacity to maintain the minimum amount of glucose to enable the brain to function... Then disrupt the supply of glucose to the brain it ability to function is impacted very quickly indeed... With absolutely no reserves anywhere in the body the the brain's ability to function is diminished very quickly, so the point between struggling to function to not being able to function at all is very small!

So doesn't this mean that the Window to start medical intervention to advert death (the brain not being able to function at all) is also very small...

Surely there is a difference between the liver having a glucose store and that glucose store getting released? I seem to remember Stephen posting a while back that he was irritated he got a liver dump after exercise. That seems to imply that a store does exist for emergency use?

 

[Dillinger]

His liver is essentially empty (<10% of the glycogen stores of a non-ketogenic liver), and working as hard as it can to generate 25g of glucose a day to fuel his brain. It doesn't expect to be refilled and it won't waste resources dumping glucose when he starts eating.

Mostly my liver is working to get rid of all that wine I drank last night by mistake... :shock:

I'm not sure about the depleted glycogen store; that would be a worry, but on the whole why would that happen; if I'm in an active state of ketosis and I'm engaged in gluconeogenesis then wouldn't there be sufficient emergency stores left over? I don't know the mechanics just wondering?

I think having had a hypo that I've noticed the liver dump effect - so it's still there. Also in all my years of not low carbing but still being a Type 1 I've never ever relied on glycogen stores to see me through a hypo; slightly last chance saloon approach to things that..!

I would say that on reduced carbs and reduced insulin the hypos are reduced as well; certainly the frequency - the severity is dependent on the situation.

The thing is low carb stops at the door or a hypo - if I go low I obviously eat carbs to get back to a normal level; and actually that's another shooting myself in the foot area; I tend to eat what ever is to hand, but really I ought to tighten that up and only eat glucose tablets because it's easier to control, but when I hypo I get very hungry and it's extra hard to be prissy about things in that situation.

Best

Dillinger

 

[borofergie]

This poses an interesting question!

Now our safety net for the T1 diabetic, is the ability that the liver can dump it's stores of glycogen into our blood stream in an emergency to bring our BG back into normal range...

Now as Dillinger's pointed out, that the best organised diabetic can be caught out by a situation..

Not really, it's a virtuous circle. Ketosis is your body's response to glucose starvation (and hence hypoglycemia).

Jo's brain needs 100g of glucose per day to function properly, all of which is provided from dietary carbohydrate (your brain gets first call on any glucose in your blood). If you eat more than 100g, then it is used to fuel your muscles or ultimately stored in your liver.

Dillinger's brain needs 25g of glucose to function properly, with the other 75% of it's energy coming from ketones. His muscles are almost entirely fuelled by free-fatty acids. The 25g of glucose can be produced as required from gluconeogenesis (breaking down fat and protein).

Put simply, Jo is a sugar burner, and Dillinger is keto-adapted, fuelling his brain with ketones, and his muscles with fat. Dillinger's glucose requirements are much lower than Jo's, so less sugar is being sucked out of his blood (probably only 25g a day). His liver is empty BECAUSE he needs less glucose. In a non-insulin dependent diabetic the chance of him hypoing is much lower (although obviously if a T1 takes too much insulin then they'll force themselves into hypoing). Ketosis is nature's answer to hypoglycemia.

Providing they exercise at relatively low intensity, keto-adapted atheletes don't "bonk" or "hit the wall" for this reason (although as aerobic exercise is fuelled by glycogen, it can easily happen as the intensity increases). My intention is to run a marathon without eating any carbohydrates.

As xyzzy said, I've also proved to myself (through high-intensity exercise) that my depleted liver can still dump if it really needs to (as a genetic "flight" response), but I don't buy that your liver would dump glucose while eating when you are in a ketogenic state.

 

[noblehead]

I tend to eat what ever is to hand, but really I ought to tighten that up and only eat glucose tablets because it's easier to control, but when I hypo I get very hungry and it's extra hard to be prissy about things in that situation.

Depends on how long after injecting that the hypo occurs, if it's within 2 hours then I follow-up with a small carby snack after treating with glucose and bg is back to normal.....this way it stops the bg falling again, if it's 3-5 hours after then 2-3 Jelly babies/glucose tabs is sufficient to keep things steady until the next meal.

 

[jopar]

Borofergie

There’s no difference in the amount of glucose the brain requires to function based on diet!
Don’t forget gluconeogenesis can only work if carbs have already been turned into glycogen or fat… The difference between the two diets is based on the source of Carbs… Ketonic is based on using protein for its main source of carbs, normal diet relies on carbs found in vegetables, fruit and grains! The latter being easier and quicker for the body to turn the carbs from complex (of various complexities) into a simple carb and then into either Glycogen or fat…

The keto diet needs topping up on regular bases to prevent the cycle from being disrupted, whereas the normal diet will revert to gluconeogenesis to maintain functioning levels… A normal diet will during a starvation period keep the body going longer due to having more supplies of Glycogen and/or fat in its stores… For the non-diabetic or even for most T2 diabetic’s you would have to go for a for quite a while before the body really started to struggle if the carb source be it a veg/grain type carb or a protein carb is removed..

For T1’s the impact can be felt a lot quicker, in the main this is because unlike the T2 or the non-diabetic we can’t turn off our insulin to allow the gluconeogenesis process to catch up… We also have the problem that because our β cells are knackered it affects our αlpha cells that produces Glucogen hormones that signal’s our liver to increase or dump it’s Glycogen stores, to balance our blood glucose levels… It’s takes a long time for the dump signal to get through and can’t be guaranteed that this will happen before the lack of glucose the brain is receiving stops the brain from function at all…

So the problem relying on gluconeogenesis for the T1, if an hypo does happen and the glucogen hormone builds up enough to get the liver to dump what stores is available, then this might not be enough to bring the blood glucose levels back to normal or near normal to bring the brains ability to function enough to eat/drink fast acting carbs, to soak up excess insulin floating around in the blood stream… Another problem faced is once the stock of available Glycogen from the live is used, it has to be replenished before it starts delivering a continuous amount into the blood stream again, which means any insulin injected as background insulin, becomes quick acting insulin reducing blood glucose levels, putting the T1 at an higher risk of a rebound hypo!

If a paramedic uses a Glucogen kit to bring a diabetic out of a hypo (normally when they use this the diabetic is unconscious) they like to take the diabetic into A&E for monitoring, because once it’s been used it can’t be used again for several hours, and if the diabetic suffers a rebound hypo and becomes unconscious the only way of bringing them back is by a direct delivery of Glucose into the blood stream via a cannula…

Yet another problem for the T1, which ever diet they chose, is that tight control that sits near the bottom range of normal, can impair the body’s hypo symptoms (warnings) so the blood glucose levels are extremely low before hypo symptoms become apparent… The knock on effect of this the window between the T1 having brain function to treat the hypo and being unconscious is very slim and can be totally diminished so they go from fully functioning to unconscious non-function without any warning…

And if your store of Glycogen is diminished and you don't get a warning and you got excess insulin in the blood stream, you are in a very dangerous position indeed...

I have in pre insulin pump days, basically slept through an night-time hypo, had my liver dump on me pulling me out of the hypo, and the longer your body is in a hypo the worse you feel when you come out... In the liver dump over night, I would wake up feeling like I had a raging hangover but I don't drink, trying to see would be like trying to look through a very thick and dirty net curtain and my BG was a lot higher than when I went to bed...

 

[borofergie]

With respect Jo, I've spent the last 3 months reading almost every published reference on dietary ketosis (there aren't all that many). Almost everything you've written here is wrong:

There’s no difference in the amount of glucose the brain requires to function based on diet!

Yes there is. That's the whole point of ketosis: ketones are an alternative source of fuel for your brain in the absence of glucose.

From Wikipedia:

The brain gets a portion of its energy from ketone bodies when glucose is less available (e.g., during fasting, strenuous exercise, low carbohydrate, ketogenic diet and in neonates). In the event of low blood glucose, most other tissues have additional energy sources besides ketone bodies (such as fatty acids), but the brain does not. After the diet has been changed to lower blood glucose for 3 days, the brain gets 25% of its energy from ketone bodies.[4] After about 40 days, this goes up to 70% (during the initial stages the brain does not burn ketones, since they are an important substrate for lipid synthesis in the brain).

http://en.wikipedia.org/wiki/Ketone_bodies

Don’t forget gluconeogenesis can only work if carbs have already been turned into glycogen or fat…

No it doesn't. It only requires fat and protein, which are either supplied from body fat and lean body tissue (in the case of starvation) or from your diet. It requires no carbs. Zero. Nada. None.

From Wikipedia again:

Gluconeogenesis is a metabolic pathway that results in the generation of glucose from non-carbohydrate carbon substrates such as lactate, glycerol, and glucogenic amino acids.

It is one of the two main mechanisms humans and many other animals use to keep blood glucose levels from dropping too low (hypoglycemia). The other means of maintaining blood glucose levels is through the degradation of glycogen (glycogenolysis).[1]

http://en.wikipedia.org/wiki/Gluconeogenesis

The glycerol comes from the fat (tri-glycerides are one glycerol molecule attached to 3 fatty acid chains). The amino-acids come from proteins.

The difference between the two diets is based on the source of Carbs… Ketonic is based on using protein for its main source of carbs, normal diet relies on carbs found in vegetables, fruit and grains! The latter being easier and quicker for the body to turn the carbs from complex (of various complexities) into a simple carb and then into either Glycogen or fat…

Kind of. Ketosis does use protein and fat to supply it's entire glucose requirement if necessary, but it also involves switching the primary fuel source for your body to free fatty acids (and ketone bodies).

The keto diet needs topping up on regular bases to prevent the cycle from being disrupted, whereas the normal diet will revert to gluconeogenesis to maintain functioning levels… A normal diet will during a starvation period keep the body going longer due to having more supplies of Glycogen and/or fat in its stores… For the non-diabetic or even for most T2 diabetic’s you would have to go for a for quite a while before the body really started to struggle if the carb source be it a veg/grain type carb or a protein carb is removed..

This is all wrong. Your body can store only about 2000 to 3000 kcal in glucose, ie no more than a days worth. If you don't eat any carbohydrates for more than a day, then your body will enter ketosis, its starvation mode, and begin to burn fat (and protein).

"For the non-diabetic or even for most T2 diabetic’s you would have to go for a for quite a while before the body really started to struggle if the carb source be it a veg/grain type carb or a protein carb is removed.." Your glucose stores would last for not much more than a single day.

As I said above, the point about ketosis is that it reduces your body's dependence on glucose. You use less, you need less, and therefore your liver has to store less. These are well established medical facts...

 

[borofergie]

So the problem relying on gluconeogenesis for the T1

Everyone relies on gluconeogenesis, every morning when they wake up:

http://www.diabeteshealth.com/read/2008 ... at-to-eat/

It strikes me as odd that what most experts know about metabolism - diabetes is, after all, a metabolic disease - they learned in medical school from somebody like me [2]. The first thing we teach medical students at Downstate Medical Center is that there is no biological requirement for carbohydrate.

It is true that your brain needs glucose, but glucose can be supplied by the process of gluconeogenesis; that is, glucose can be made from other things, notably protein. This is a normal process: when you wake up in the morning, between thirty and seventy percent of your blood glucose comes from gluconeogenesis. There is no requirement for dietary glucose.

Capiche?