Thoughts on insulin dosing before meals

[Odin004]

Hi all,

I just wanted to get the views of other T1s on this issue - I've always carb-counted, and prior to a hypo last year, I'd routinely inject 6-8 units of insulin for meals (1 unit to 10g carb), and would eat anything I wanted. Since the hypo, I've changed to a low carb diet, so don't ever inject more than 3 units of insulin at any one time; and now I can't imagine going back to injecting larger amounts.

According to the info on this site (http://www.diabetes.co.uk/diabetes_care/blood-sugar-level-ranges.html) the recommended target range for T1s pre-meals, is 4-7 mmol/L. I have to say, the thought of injecting 8 units, when my bloods are 4 or 5 (even if I know I'm going to eat 80g carbs) seems so irrational now. There's so much intrinsic error in dosing, with 101 seemingly random factors - absorption rate, calculation/estimation of carb content, time of day, peaking of basal dose, activity etc. It seems to me that a reasonable margin of error in these circumstances could cause a pretty severe hypo. I'd be interested to know whether this worries anyone else?

 

[gavin86]

I think quite a bit about it, as I'm still new and my pancreas randomly spits out some of its own insulin.
I tend to reduce my dose a bit if I'm below 5. It's pretty crude though, really just swapping possible hypos for more time with high BGL.

Lately I've been trying to take the full amount and monitor more closely, taking extra carbs if necessary. I need a bit more courage though in doing this, I often talk my self down a unit or two then end up hyper.

Would be interested to hear others thoughts. I am still very much figuring it out.

 

[dbr10]

Hi all,

I just wanted to get the views of other T1s on this issue - I've always carb-counted, and prior to a hypo last year, I'd routinely inject 6-8 units of insulin for meals (1 unit to 10g carb), and would eat anything I wanted. Since the hypo, I've changed to a low carb diet, so don't ever inject more than 3 units of insulin at any one time; and now I can't imagine going back to injecting larger amounts.

According to the info on this site (http://www.diabetes.co.uk/diabetes_care/blood-sugar-level-ranges.html) the recommended target range for T1s pre-meals, is 4-7 mmol/L. I have to say, the thought of injecting 8 units, when my bloods are 4 or 5 (even if I know I'm going to eat 80g carbs) seems so irrational now. There's so much intrinsic error in dosing, with 101 seemingly random factors - absorption rate, calculation/estimation of carb content, time of day, peaking of basal dose, activity etc. It seems to me that a reasonable margin of error in these circumstances could cause a pretty severe hypo. I'd be interested to know whether this worries anyone else?

Not type 1 but fully understand Berstein's contention that you should low carb. Low carb means lower insulin doses and less chance of making a mistake.

 

[Kristin251]

I stay very low carb as to not ride the rollercoaster and hypo. I found meals that work at different times of dayband different macros and I know my doses for each one. This way I have very few highs or lows. I don't eat the same food but I doneat the same macros and meal size at each one. Random eating doesn't work well for me. I never know what I'm going to get.

I do eat avocado at each meal as it keeps everything flatter. It slows and lowers any spikes or dips. All that fat and fiber I assume. I eat 1/3 for bf with celery. Then lunch and dinner are 1/3 with a moderate ( weighed as protein spikes me fast) and some veggies. Dinner is same as lunch but with the addition of ansmall salad.

I eat 4 small snack size meals a day and a few nuts or veggies as snacks

An hour after bf I need 1/2 unit bolus to stop the morning rise.

It took loads of testing to find this routine and my meals but it also took loads of anxiety out. Always some avocado but I have lots of protein and veggies options for variety. I don't weigh or count carbs ( as I only eat 20 or less per day) and I don't count fat. I just eat it until satisfied. However I donweigh protein as it has a very profound effect on my bs.

Hope this helps. Oh and bloods are usually between 80-100 US

 

[urbanracer]

Hi all,

I just wanted to get the views of other T1s on this issue - I've always carb-counted, and prior to a hypo last year, I'd routinely inject 6-8 units of insulin for meals (1 unit to 10g carb), and would eat anything I wanted. Since the hypo, I've changed to a low carb diet, so don't ever inject more than 3 units of insulin at any one time; and now I can't imagine going back to injecting larger amounts.

According to the info on this site (http://www.diabetes.co.uk/diabetes_care/blood-sugar-level-ranges.html) the recommended target range for T1s pre-meals, is 4-7 mmol/L. I have to say, the thought of injecting 8 units, when my bloods are 4 or 5 (even if I know I'm going to eat 80g carbs) seems so irrational now. There's so much intrinsic error in dosing, with 101 seemingly random factors - absorption rate, calculation/estimation of carb content, time of day, peaking of basal dose, activity etc. It seems to me that a reasonable margin of error in these circumstances could cause a pretty severe hypo. I'd be interested to know whether this worries anyone else?

I (now) have a moderate carb intake and although I eat roughly the same amount of carbs for each meal, and inject the same amount of insulin at the same time, I find I can experience fairly stable blood glucose levels for several days and then I will either start running low or high for a few days for no obvious reason. It's all a game.

 

[Snapsy]

It's all a game.

Ain't that the truth?! One day I'd love to harvest some dependable predictability!

 

[Odin004]

Hi @Kristin251 - thanks for your reply - it certainly seems that your meal-testing has paid off! I entirely agree that going low-carb hugely reduces anxiety. I posted a typical day of my diet here:

http://www.diabetes.co.uk/forum/thr...ve-you-eaten-today.88074/page-78#post-1479557

The avocado seems to work well for you - have you tried chia seeds? I find them almost miraculous - I have them with my oats. Normally, oats cause a sharp rise for me - but if I mix in 10-15g chia seeds (and then leave for a few hours to soak), my sugars are almost a flat line for the next few hours (I can tell as I have CGM).

 

[Odin004]

Thanks also for your reply @urbanracer - I really like the discipline of having the same amount carbs in each meal, the same insulin, and at the same time. The random highs and lows do seem to be just a normal part of diabetes - there are so many factors at play - but with low or moderate carb, at least we can try to make sure the swing is less than it might otherwise be. I take 1 unit for 10g carb - however, on taking 3 units recently, I found I actually needed 60g to maintain stable sugars, and had to constantly top up with Lucozade - there was no discernable difference in my activity, or any other factor I'm aware of.

 

[Kristin251]

Hi @Kristin251 - thanks for your reply - it certainly seems that your meal-testing has paid off! I entirely agree that going low-carb hugely reduces anxiety. I posted a typical day of my diet here:

http://www.diabetes.co.uk/forum/thr...ve-you-eaten-today.88074/page-78#post-1479557

The avocado seems to work well for you - have you tried chia seeds? I find them almost miraculous - I have them with my oats. Normally, oats cause a sharp rise for me - but if I mix in 10-15g chia seeds (and then leave for a few hours to soak), my sugars are almost a flat line for the next few hours (I can tell as I have CGM).

Chia seeds never come back out lol. Same with flax seeds. Stops my digestion in its track. I only eat pumpkin seeds as far as seeds go.

Avocado must be your chia to me. Miraculous.

I eat zero grains and starches. They cause no aches and fatigue. Avocado is my only fruit. Mostly above ground veggies, moderate amounts of protein and enough fat to satisfy.
No pulses, artificial sweeteners and limited dairy ( just started a bit of cheese recently) indonsnack on a few macadamia nuts ornpumpkin seeds. Nut butters don't raise me per se but they do make me insulin resistant and I require more insulin later. I keep that to very small amounts and only occasionally.

If you're still struggling you might look at protein though I think vegetarian protein acts differently than animal/ fish but not sure. I only eat small amounts of fish or animal protein at lunch and dinner.

The Bernstein solution taught me a bunch as did the Rosedale diet. Rosedale showed me how protein CAN turn to bs and as soon as I cut back to .8-1 g per kg lean body mass things fell right back into place. if I eat more than 3 oz (21g) at a meal I need to split my bolus. Otherwise I hypo then spike. I prefer to take smaller amounts at a time. I keep steadier butnif coursenis more finger sticks and tummy shots.

I am extremely carb sensitive butninsulin sensative too. I take unordinarily small doses.
I have been vlc ( sort of Atkins induction phase ) for over 25 years, way before DX. I became LADA at 50 years old. Yahoo!!!

 

[Kristin251]

Thanks also for your reply @urbanracer - I really like the discipline of having the same amount carbs in each meal, the same insulin, and at the same time. The random highs and lows do seem to be just a normal part of diabetes - there are so many factors at play - but with low or moderate carb, at least we can try to make sure the swing is less than it might otherwise be. I take 1 unit for 10g carb - however, on taking 3 units recently, I found I actually needed 60g to maintain stable sugars, and had to constantly top up with Lucozade - there was no discernable difference in my activity, or any other factor I'm aware of.

I think the carb ratio changes when you factor in fat, fiber and protein. That's why carb counting never worked for me. As you said, I was constantly topping off and feeding insulin. That's exactly why I keep the same macros at each meal. I also eat at the same time everyday. My lantus does not hold me at all after waking. Therefore I need a small bolus every 3 hours or I start rising hence the 4 small meals, 4 small doses.

 

[Scott-C]

Low carb means lower insulin doses and less chance of making a mistake.

I've never really found that to be the case. Sure, with a high carb meal, I'm taking more insulin, which might seem to make me more exposed to hypo risk, but I'm, by definition, also eating more carbs, so percentage wise the scope for error is probably not that different for a low carb meal.

Indeed, I've had quite a few occasions where results after a low carb meal have been as unpredictable as a high carb meal. Although that might just mean I'm really bad at carb counting!

If I do make a miscalc on a high carb meal, or some T1 randomness messes with the picture, it's never really more than something a couple of biscuits will sort out.

I suppose I'm quite lucky in that I tend not to have hard, fast drop hypos so I'm usually getting plenty of lead time warning, aided by libre (and now my fancy new toy, blucon nightrider - dexing my libre!) but I appreciate that others do get rapid drops, so, sure, a different take on carbs can be justified.

It's all relative, I suppose, on what is meant by low carb. The lowest carb meal I tend to have is an omelette with three slices of toast, then some raspberries, say 3 times 13 plus 7 is 46. (fry off some sliced chestnut mushrooms in goat milk butter, some ham, some capers, herbs: an omelette for kings!) The highest might be around 85, brown rice with a can of mackerel. Would the latter be regarded as high carb? If it is, I've never had any problems with it. White rice makes my sugars go mental, but brown rice, because of the fibre, actually seems to stabilise me for an extended period. Buckwheat too: on the face of it, high carb, but I barely shift. There's some interesting web stuff about it containing chiro-inositol which is thought to act as an insulin mimic and T2s have apparently had interesting results with it. Sorry to turn this into a food section post, but some buckwheat with quartered chestnut mushrooms, lardons of ham, shallots, tabasco chipotle sauce, plum tomatoes, and some samphire if I'm having a foodie moment, is pretty good.

One aspect of low carbing for T1s which worries me is the liver and muscles need to have a reserve supply of glycogen. Is that jeopardised by low carbing? If it comes from gluconeogenesis, isn't that just adding another layer of complexity to an already complex situation?

 

[becca59]

I've never really found that to be the case. Sure, with a high carb meal, I'm taking more insulin, which might seem to make me more exposed to hypo risk, but I'm, by definition, also eating more carbs, so percentage wise the scope for error is probably not that different for a low carb meal.

Indeed, I've had quite a few occasions where results after a low carb meal have been as unpredictable as a high carb meal. Although that might just mean I'm really bad at carb counting!

If I do make a miscalc on a high carb meal, or some T1 randomness messes with the picture, it's never really more than something a couple of biscuits will sort out.

I suppose I'm quite lucky in that I tend not to have hard, fast drop hypos so I'm usually getting plenty of lead time warning, aided by libre (and now my fancy new toy, blucon nightrider - dexing my libre!) but I appreciate that others do get rapid drops, so, sure, a different take on carbs can be justified.

It's all relative, I suppose, on what is meant by low carb. The lowest carb meal I tend to have is an omelette with three slices of toast, then some raspberries, say 3 times 13 plus 7 is 46. (fry off some sliced chestnut mushrooms in goat milk butter, some ham, some capers, herbs: an omelette for kings!) The highest might be around 85, brown rice with a can of mackerel. Would the latter be regarded as high carb? If it is, I've never had any problems with it. White rice makes my sugars go mental, but brown rice, because of the fibre, actually seems to stabilise me for an extended period. Buckwheat too: on the face of it, high carb, but I barely shift. There's some interesting web stuff about it containing chiro-inositol which is thought to act as an insulin mimic and T2s have apparently had interesting results with it. Sorry to turn this into a food section post, but some buckwheat with quartered chestnut mushrooms, lardons of ham, shallots, tabasco chipotle sauce, plum tomatoes, and some samphire if I'm having a foodie moment, is pretty good.

One aspect of low carbing for T1s which worries me is the liver and muscles need to have a reserve supply of glycogen. Is that jeopardised by low carbing? If it comes from gluconeogenesis, isn't that just adding another layer of complexity to an already complex situation?

I don't consider my diet to be particularly high carb. Average 150 a day. However, some participants to this forum would feel it is. They manage an exceptionally low carb diet, which, although I cannot help but admire their commitment, it does worry me that ultimately there will be an overall lack of nutritional balance. I am in agreement that the NHS food plate has too much emphasis on carbs over fats. But not all carbs are the enemy and deficiencies in other areas may cause other long term health issues on top of the accute condition we already have. Each to his own I suppose.

 

[noblehead]

There's so much intrinsic error in dosing, with 101 seemingly random factors - absorption rate, calculation/estimation of carb content, time of day, peaking of basal dose, activity etc. It seems to me that a reasonable margin of error in these circumstances could cause a pretty severe hypo.

Read this article a couple of years back and saved it to my favourites, it's quite good and goes into great detail about what can impact on bg levels:

https://diatribe.org/issues/68/adams-corner

I bolus on average 5-6 units at a time @Odin004 eating carbs in moderation, I find including some carbs in my meals makes bolusing so much easier than a very low-carb meal where my bg levels are less predictable (and I would need to split-dose when on injections/extend the bolus dose on my pump).

TBH we have to find what works for us as individuals, but having anxiety issues and type 1 diabetes must be awful and I do feel for you, however by the looks of things you've got a good handle on your diabetes so just keep doing what your doing.

 

[Odin004]

Thank you all for your replies - @Kristin251, I think we have a similar approach to diet - I don't go as low as 20g carb; but I've limited dairy, and am gluten-free (by choice); I'm also vegetarian - so the only animal protein I have (aside from the small amount of dairy) is eggs.

@Scott-C - it sounds like you have your diet sorted! You're right in that it's all relative, and I'm glad you've found what works for you. My logic in a lower carb approach is that, whilst you can't eliminate the error in insulin dosing, the same percentage error has less actual effect with a small dose - a 30% error on a 9 unit dose, is an overdose of 3 units - whereas the same error on a 3 unit dose, is just a 1 unit overdose. Also, with lower carb meals, the range over which your sugars fluctuate, is much narrower.

In relation to the concerns mentioned by @Scott-C and @becca59, about glycogen and nutritional deficiencies, I don't know if there's a definitive answer - even the nutritional science we believe to be established, is constantly shifting. I suppose, ultimately, the body is designed to let you know if something's wrong. I don't think a low carb intake necessary leads to a nutritional deficiency, providing overall calorie intake and micronutrients are taken care of, and food sources are whole and unprocessed; and human beings are not actually designed to eat high carb diets in the first place - which are an extremely new concept in our evolution (just food for thought!)

Thanks @noblehead for the article - I love that website, and have read many of Adam's articles - he's also done a couple of "low carb vs high carb" experiments, which are quite revealing. You're right that everyone needs to do what's right for them - I'm quite sure there are multiple health issues that can arise from being constantly racked with anxiety, so if a lower carb diet alleviates that, so be it! Thank you for your kind words.

Finally, @gavin86, my apologies but I seemed to have missed your earlier post - I completely understand the urge to reduce the dose - and then to find you go high. I think this just means you have a healthy respect for the power of the insulin, and perhaps haven't "normalised" the need to take it (I myself had normalised it for many years - which all changed because of a hypo last year). When you think about it, a hefty dose of insulin while your blood sugars are already 4 or 5, makes the meal you intend to eat a potentially life-saving operation. I'm just not comfortable with that fact - I prefer doses of insulin which mean that, even if I didn't eat, my body would be able to recover from it.

 

[Scott-C]

Thank you all for your replies - @Kristin251, I think we have a similar approach to diet - I don't go as low as 20g carb; but I've limited dairy, and am gluten-free (by choice); I'm also vegetarian - so the only animal protein I have (aside from the small amount of dairy) is eggs.

@Scott-C - it sounds like you have your diet sorted! You're right in that it's all relative, and I'm glad you've found what works for you. My logic in a lower carb approach is that, whilst you can't eliminate the error in insulin dosing, the same percentage error has less actual effect with a small dose - a 30% error on a 9 unit dose, is an overdose of 3 units - whereas the same error on a 3 unit dose, is just a 1 unit overdose. Also, with lower carb meals, the range over which your sugars fluctuate, is much narrower.

In relation to the concerns mentioned by @Scott-C and @becca59, about glycogen and nutritional deficiencies, I don't know if there's a definitive answer - even the nutritional science we believe to be established, is constantly shifting. I suppose, ultimately, the body is designed to let you know if something's wrong. I don't think a low carb intake necessary leads to a nutritional deficiency, providing overall calorie intake and micronutrients are taken care of, and food sources are whole and unprocessed; and human beings are not actually designed to eat high carb diets in the first place - which are an extremely new concept in our evolution (just food for thought!)

Thanks @noblehead for the article - I love that website, and have read many of Adam's articles - he's also done a couple of "low carb vs high carb" experiments, which are quite revealing. You're right that everyone needs to do what's right for them - I'm quite sure there are multiple health issues that can arise from being constantly racked with anxiety, so if a lower carb diet alleviates that, so be it! Thank you for your kind words.

Finally, @gavin86, my apologies but I seemed to have missed your earlier post - I completely understand the urge to reduce the dose - and then to find you go high. I think this just means you have a healthy respect for the power of the insulin, and perhaps haven't "normalised" the need to take it (I myself had normalised it for many years - which all changed because of a hypo last year). When you think about it, a hefty dose of insulin while your blood sugars are already 4 or 5, makes the meal you intend to eat a potentially life-saving operation. I'm just not comfortable with that fact - I prefer doses of insulin which mean that, even if I didn't eat, my body would be able to recover from it.

There's never any easy answers to any of this. I've had some truly shocking hypos in my time, mostly in my early days after dx, those ones where I wake up not knowing where or what or who I am. That idea of not knowing what you are is something that non-T1s will never truly understand. It's like a different place which I really don't want to go to.

A colleague at work was curious about it (she's a bit of a hypochondriac, and she's a good workmate, so I indulged her!) asked me about hypos. Best explanation I could come up with is imagine the drunkest you've ever been, multiply that by five, then add a couple of bad LSD trips on top. Almost getting there.

Like I say, I've had some pretty filthy hypos, but I take comfort from the fact that I've always woken up. Thirty years in and I'm not dead yet!

 

[DunePlodder]

Until I had a CGM I didn't properly appreciate how long it was before my insulin (Humalog) began to take effect. If I'm not active or taking a hot shower it is more than an hour before I see a change in my readings. Even allowing for a 10 or 15 minute CGM delay that's a long time. I now bolus much earlier than I did.
The "Eating Soon" technique is useful. You do a small early pre bolus, then bolus the remainder at the usual time. e.g. if my BG=7 an hour before a meal, from experience I know I can bolus 2 units without going low even if the meal was delayed a bit. It means there is some active insulin in my system when I do eat.

 

[TheBigNewt]

I watch my carbs, but don't consider myself ultra low carb diet. I usually use 5-7U boluses. If we have a paleo meal (we get 3 meals in the mail each week via Sun Basket and can choose paleo if we want) I take like 2-3.

 

[Mugwump]

The Type 1 I care for eats everything she ate before diagnosis - we just bolus accordingly.

I have to admit that timing of the bolus is something I initially found really difficult to get to grips with. Today, for example, she went into lunch in the high 4's, and was due to be very active in the afternoon. I bolused for a small portion of the meal (10g of 44g), and gave her some milk alongside her meal instead of water. I then put the balance in (she is a pumper) on a longer dual wave bolus and we managed to escape lunch without dropping too low (I didn't bolus for the milk but used that 5g to lift her BG slightly more quickly).

But that was one day! It is a learning curve and I think it's quite intuitive to know how/when to bolus before meals. As Scott-C mentioned in his great post, there's innumerable amounts of variables to take into consideration - weather, how you are feeling, how fast your BG is rising/falling, etc. This is why I think it's incredibly important to record BG, lunch carbs, etc, as you can then spot patterns during certain days/times/meals and adjust accordingly.

 

[Scott-C]

Today, for example, she went into lunch in the high 4's, and was due to be very active in the afternoon. I bolused for a small portion of the meal (10g of 44g), and gave her some milk alongside her meal instead of water. I then put the balance in (she is a pumper) on a longer dual wave bolus and we managed to escape lunch without dropping too low (I didn't bolus for the milk but used that 5g to lift her BG slightly more quickly).

@Mugwump , I just wanted to say that bolus calculations with all their variables and uncertainties can be difficult enough for grown up T1s to figure out when we're actually living it, so I'm deeply, deeply impressed by the thought and attention you've put into that bolus for the wee one you're looking after.

Being able to make judgement calls about what someone else needs when you don't have the condition yourself is a rare talent, and I think you have that talent in spades.

There was some serious, ok, we have this, then we have that, then we might have something else, analysis going on there. Impressive. Although, as you know, T1 being T1 sometimes doesn't really go according to plan....

I wouldn't trust anyone else to make a bolus decision for me, but I reckon the parents of your caree have put their kid into a really safe pair of hands.

When your T1 caree is able to do it on her own, as she inevitably will, you'll have lots of parents queuing up to employ you! Hell, I think some teens and adults will be queuing up too to ask you to look after them!

Don't know if you've read Breakthrough...by Thea Cooper, about the discovery of insulin (on Amazon). Some moving stuff about Elizabeth Hughes, on ultra-low carb pre-1922, then one of the first kids on insulin, her relationship with her carer, and then the moment she decides to be, "captain of her own ship", and deal with, "firing the shots" (injections), the "feels" (hypos), and, "kisses" (molasses for hypos). It's all from almost 100 years ago, but still totally relevant for all T1s, and carers. Your wee one will be "captain of her own ship" one day, and you'll be waving her off when she sails out of port!

 

[azure]

The Type 1 I care for eats everything she ate before diagnosis - we just bolus accordingly.

I have to admit that timing of the bolus is something I initially found really difficult to get to grips with. Today, for example, she went into lunch in the high 4's, and was due to be very active in the afternoon. I bolused for a small portion of the meal (10g of 44g), and gave her some milk alongside her meal instead of water. I then put the balance in (she is a pumper) on a longer dual wave bolus and we managed to escape lunch without dropping too low (I didn't bolus for the milk but used that 5g to lift her BG slightly more quickly).

But that was one day! It is a learning curve and I think it's quite intuitive to know how/when to bolus before meals. As Scott-C mentioned in his great post, there's innumerable amounts of variables to take into consideration - weather, how you are feeling, how fast your BG is rising/falling, etc. This is why I think it's incredibly important to record BG, lunch carbs, etc, as you can then spot patterns during certain days/times/meals and adjust accordingly.

Does her care plan guide you in your bolus calculations or do you go by what her parents say (ie check the details with them)?