issues with insulin

[increasingly cynical]

Hi,

I wondered if anyone could advise me or share their experiences :

The medics want me to take insulin, but my blood glucose level and/or change in blood glucose since last reading vary rather widely under very similar conditions. For example, a slice of the same type of cheese on the same type of bread (exact same amounts of each) can change my blood glucose reading (again, at exactly the same time after the food intake) by between 0.2 mml/l up to a change of more than 10 mml/l.

The above takes into account exercise, time of day etc etc.

So: how on earth would I work out what insulin amount to take without a high risk of hypos?

Anyone had a similar experience or any ideas?

Thanks very much!

 

[totsy]

hya and welcome,
firstly it will depend what insulin u will be taking, have they told u what type it will be? ive now been on basal bolus for a few months and was similar to u and it was scary (still is at times) basically u see what your blood is before food for example if mine is 4.3 at tea time and im having say 20 grams of carb i inject 2 units of fast acting,
these 2 units will cover me for the meal i have just eaten and by next meal it is roughly the same reading, i hope this helps and keep asking questions

 

[increasingly cynical]

Hi Totsy,

Thanks for your reply. The insulin they are recommending is 'Lantus' ... but the problem is that whatever the insulintype, the theory is that you guage what you are going to eat (either all day or for a particular meal) on the assumption that 1 unit of 'food X' will take your blood glucose reading up by 'Y units', then you take the corresponding 'Z units' of insulin which will lower it by the necessary amount... if I have no way of knowing whether the same food will take my BG up by 1 unit or by 10 units, how do I know how much insulin to take?

Thanks again

 

[timo2]

Hello increasingly cynical,

You won't need to match the Lantus dose to your meals. Lantus is a basal insulin which has a very long, slow, steady release for 24 hours. It will help out with your bloodsugars between meals and
overnight, but it won't deal with specific mealtime spikes.

Regards,
timo.

 

[increasingly cynical]

Hi Timo2,

Thanks very much for your reply. I know that lantus is a '24 hour' option, but the issue still applies - if one can't judge fairly reliably that X units of insulin over 24 hours will deal with Y units of food, then hypos are inevitable. I'm also a bit disturbed to hear from another part of the forum (and indeed reserach papers) that over a 1 year period Lantus can only be expected to take HbA1c down by 1% (equivalent to 1 mml/l) - this would do absolutely nothing for me in the grand scheme of things (my BG can go up to 27 in a day with virtually no food intake - e.g 1 yoghurt, 3 slices of cheese) on other days under very similar conditions I can eat 2 three course meals and it stays at around 14)... :|

Thanks again

 

[totsy]

hya ,
its a matter of trial and error im afraid, you have to inject what u think,e.g 2 units and check bs after 1hr,2hr,3hr and if its the right dose great, if too high inject a bit more next time u eat same meal, if too low inject less next time, im still learning as i need different at different meals and if im going for a walk i need to lower, i do believe i made the right choice having basal bolus tho and im hoping my nxt mnths hba1c proves this

 

[timo2]

Hi increasingly cynical,

I'm afraid that diabetes may demand a slightly more uniform daily routine, particularly
once insulin is involved.

You certainly need to pay attention to your breakfast, as, thanks to the 'dawn Phenomenon',
blood sugars will continue to rise until around mid-morning unless you eat something.
(It doesn't need to be carbohydrate; Bacon and eggs will do the job nicely.)

Although Lantus is no magic bullet, it will help to reign in your high sugars and take
some of the load from your own body's insulin production. In turn, this will help to slow
the progression of your diabetes [1], meaning you get to keep what little meal time
insulin response you have left for as long as possible.

All the very best,
timo.

 

[increasingly cynical]

Hi Totsy & Timo2,

Many thanks again for your helpful comments (and thanks for the reference Tino2 that was very useful).

It sounds as if the answer may be that insulin leaves one between the Devil and the Deep Blue Sea. If, as seems to be the case with my BG, there is no constant association between a particular food and BG/change in BG (even controlling for all external variables such as stress, exercise etc.) then hypos are inevitable. Hypos are known over time to lead to short term memory loss and eventually dementia, on the other hand high BG over time definately also has its downsides (although not, apparently, for all people , some people seem able to maintain high BGs with no long term effects).

Given which, I guess the issue of whether to take insulin or not depends on the likely impact it will have on BG and whether this is worth the other risks it entails. If the research article I read is correct and Lantus would only reduce HbA1c by 1% (1mml/l reduction in BG readings) then, frankly, it doesn't seem worth it in my case, as the same level of reduction could be achieved by taking vit D, zinc, other fairly innocuous substances or indeed just a glass of dry red wine at mealtimes!

I take your point Timo2 that early use of insulin has a protective effect, but unfortunately, since the medics have left it over a year to do anything in my case, its probably too late for that (?) Regular meals are not an option unless I give up my profession, which is also not an option!

Have either of you got any feel for how much the insulin you are taking (on its own, rather than taking into account any food/lifestyle/weight changes etc) has reduced your own BGs over time? It would really be helpful to know what people have actually experienced the effect of insulin to be , as well as looking at the research .


Thanks again, it is really good of you to help.

 

[Trinkwasser]

One theory (which works for some people but not others as there are IMNSHO a whole bunch of similar but different diseases called "Type 2") is that offloading some of the work onto a basal insulin like lantus leaves your pancreas with more capacity to cope with the mealtime spikes. Of course keeping your mealtime spikes down with carb control will also help and hammering your insulin resistance with metformin and exercise will also help. Sometimes it works the opposite way though and other individuals may do better leaving the pancreas putting out the background insulin and taking bolus with meals.

 

[totsy]

okies,
before i went on basal bolus i was just on lantus and metformin, ive looked at my levels before lantus i was never under 10mmol, ok on just lantus as long as i virtually no carbed i was around 6mmol, on basal bolus im averaging 4/5 mmol before meals and under 7 2 hrs later,hope this helps

 

[increasingly cynical]

Hi again Totsy,

Thanks very much indeed for your experiences - that really helps and seems to fit in with what the research suggested, so may give me a way forward next time I discuss this with the medics.

 

[increasingly cynical]

Hi Trinkwasser,

Thanks very much also for your response - that sounds interesting. I agree that the correct treatment approach must very much depend on whether your pancreas needs to rest (is losing islet cells) or whether the cells are fine but you are resistant to the insluin which is produced. Given which it seems a bit absurd that the NHS is so reluctant to do any tests distinguishing between the two. The medics I have spoken with say that this is because the definitive tests are too expensive for the NHS to bother with and the cheap tests are inconclusive so they don't see the point in doing them . I wonder, as a result, how many people who actually needed to conserve what islet cells they had left have instead been shoved on gliclazide by 'default' (the latter as you probably know ends up destroying remaining islet cells by overworking them).

Sigh...

 

[Trinkwasser]

Look at it this way, if they don't save money on tests and treatment now how can you expect them to afford your amputations and dialysis later? <sigh>

One test which may be diagnostic (again IF you can get it) is Full Lipid Panel, the ratio of trigs to HDL corresponds roughly to degree of insulin resistance

mine went from nearly 7 to under 0.5 through BG control

Family history of Type 2 and also cardiovascular diseases may be a clue also

 

[increasingly cynical]

Hi Trinkwasser,

yep - you get the impression thats the way they think! Thanks again for getting back to me on the tests, you sound as if you are very well informed.... The full lipid panel sounds interesting, I'll ask about it, although my cholesterol is fine (I'm an 8 stone lifetime vegetarian who doesn't smoke and works out for an hour or two everyday...ho hum so much for the good life...)

One thing I'm very curious about now I've looked at the literature more, is that across all available studies the mean reduction in HBA1c for people on various types of insulin and/or anti-diabetic drugs is 1% (1mml/l) , the absolute maximum I have found in the studies is a reduction of up to 3% and the latter was just one small, poor quality, study which didn't control for much.

Initially I thought I had just read the wrong studies, but I've gone through pretty much all of the key studies now. Added to the very minimal decrease in average BG (which is not cumulative), up to 80% of people on insulin or glicalizde etc. experience hypos, which of course have very bad long-term effects themselves. So, assuming that one is 'just' resistent to natural insulin (rather than not producing any), where is the benefit? For a decrease of 1 unit of blood glucose to make any difference to long term outcomes, you would have to have relatively mild insulin resistance anyway, which would in all likelihood be controllable to the same degree by exercise, diet or lifestyle changes, etc. By the way, none of the studies actually look at long-term outcomes anyway, they focus on the reduction in average BG and assume that this will improve outcomes (in fact it would be unlikely to have a significant impact at the minimal levels of reduction they cite).

Have I missed something, or is medication just the biggest diabetic 'con' for 'type 2' treatment??

Thanks again,

 

[LittleSue]

Forgive me if I'm totally off here, being a type 1, poking my nose in. But, I find that if my basal dose is right, the main benefit is not that my bs is lower but that its more stable and less susceptible to variations in food etc. I wonder if this would apply in type 2 and Lantus may reduce the wild variations you describe - they sound similar to how I used to be before my basal was sorted out. Have any type 2s noticed this happening?

 

[increasingly cynical]

Hi Little Sue,

Any information is great - thanks very much for your comments. I would guess (?) that if you find it stabilises your BGs then the same would be true for 'type 2'... but, as I understand it, the damage due to high blood sugar is because it is high, it doesn't really matter if its stable or not so long as overall it pretty much stays low, if it doesn't then the complications develop anyway... (?) People who can't produce their own insulin (I'm assuming) don't have many options , but if the issue is insulin resistance then taking BGs down by 1 mmol/l or making them more stable arguably is not worth the risks 'artificial' insulin or drugs carry..


Thanks again, if you have any other insights about insulin/drugs you'ld be happy to share, I'ld love to hear them - it really helps to listen to someone who has 'trodden the path before'.

 

[Trinkwasser]

Hi Trinkwasser,

yep - you get the impression thats the way they think! Thanks again for getting back to me on the tests, you sound as if you are very well informed.... The full lipid panel sounds interesting, I'll ask about it, although my cholesterol is fine (I'm an 8 stone lifetime vegetarian who doesn't smoke and works out for an hour or two everyday...ho hum so much for the good life...)

BTDT, as a skinny ex-vegetarian and believer in Healthy Whole Grains, but my lipids were totally **** and probably for thirty years, and then when they finally noticed they told me to eat more carbs and less fat which made them even worse. I had to become well informed because no=one was doing it for me <G> It's the pattern which can be characteristic which is why the full panel is much more useful than the total.

One thing I'm very curious about now I've looked at the literature more, is that across all available studies the mean reduction in HBA1c for people on various types of insulin and/or anti-diabetic drugs is 1% (1mml/l) , the absolute maximum I have found in the studies is a reduction of up to 3% and the latter was just one small, poor quality, study which didn't control for much.

Yes there are almost no studies of well controlled diabetics. When you look at average A1c which is over 9 and the amount of carbs they are fed it's not surprising that little changes.

The ADA gives Medical Nutrition Therapy the potential to improve A1c by 1 - 2%, yet when you look in most forums and newsgroups you see people routinely achieving improvements like 5 - 8% and even into double figures. What does this tell you? Perhaps they are recommending the wrong diet?

Knocking down the numbers with meds after shooting them up with carbs is like trying to put out a fire using only a small quantity of petrol <G>

Forgive me if I'm totally off here, being a type 1, poking my nose in. But, I find that if my basal dose is right, the main benefit is not that my bs is lower but that its more stable and less susceptible to variations in food etc. I wonder if this would apply in type 2 and Lantus may reduce the wild variations you describe - they sound similar to how I used to be before my basal was sorted out. Have any type 2s noticed this happening?

In short, yes. In Type 2 it can be more complicated depending on IR and its changes at different times of day, and that also affects the other side of the equation involving the alpha cells, glucagon and the liver which may miss the signals to turn the glucose supply on and off, but in the US early use of insulin is much more common, usually lantus.

Lots of good information including links to papers here

http://www.bloodsugar101.com/

 

[increasingly cynical]

Hi Trinkwasser,

Many thanks again for your really helpful and detailed reply and also the website which looks good too. Your point about carbs is also interesting, when I saw the nutritionist she basically said "your diet is perfect, but you could perhaps do with eating more carbohydrate...." hmmm... I will go back to the research studies and see if they mention anything about the diet people were on in terms of carbs.

 

[Trinkwasser]

Hi Trinkwasser,

Many thanks again for your really helpful and detailed reply and also the website which looks good too. Your point about carbs is also interesting, when I saw the nutritionist she basically said "your diet is perfect, but you could perhaps do with eating more carbohydrate...." hmmm... I will go back to the research studies and see if they mention anything about the diet people were on in terms of carbs.

They do that! For a refreshing point of view check out posts here by Mrs Pugwash

Even some of the "low carb" studies use quantities only a dietician would call low

This is interesting

http://www.marksdailyapple.com/the-prim ... continuum/

other 21st century dietary authoritites might well agree with his numbers

 

[increasingly cynical]

Hi again Trinkwasser,

Many thanks again - you are a mine of information! I looked on the 'low carb' site you mentioned and will follow through the 'Mrs Pugwash' comments. My BG scores seem to be completely out of kilter... since 'diagnosis' (over 12 months ago) they have become increasingly high and increasingly labile. I've been keeping BG , blood pressure and food intake readings for the last 6 months, My average daily consumption is 779 kcal (average 240kcal per meal) , of which total carbs average 71g daily (22g per meal) and sugars 11g total per day (4g per meal). Each day the first BG reading is always the lowest and the count gets consistently higher as the day goes on. In the last couple of weeks I've started getting readings quite often in the 20s (e.g 25.4 today, 2 hours after eating 1/2 small bowl of cereal... I have largely given up on cereal, but this still seems an extreme response) ... the morning reading is always around 13-14 now (even on one morning when all I had had to eat the previous day was 2 slices of ryvita and 8 mushrooms!). My diastolic blood pressure (but not systolic) is also spiralling out of control with daily readings over 100... is this a 'normal' diabetic profile? I am getting a bit concerned as the consultants seem to be playing 'pass the buck' (so far I have seen 4 and each passess me on to another one). I'm not due to see the next consultant until the end of February.. If the above profile looks 'normal' as diabetes goes then perhaps I should just relax a bit more! Thanks in advance for any advice.

:?