Conventional food habits vs flexibility on basal-bolus insulin

Hi,
I just visited a diabetologist (not my regular doctor who is in another city) today and my HbA1c stands at 8.3% (which though still far off the ideal < 7%) is a big improvement from my previous level of 9.7%. Probably I could have edged closer to 7% if not for my hospitalization (for diabetic ketoacidosis, which was till now undiagnosed because the doctor who treated me during hospitalization didn't suspect or treat it :(, but the diabetologist immediately made sense when he told about diabetic ketoacidosis).

He was so adamant about me getting to the 7% mark to avoid complications as I am just 23 years old as of now and have a long life ahead to live.

I currently use a flexible food routine with my NovoRapid-Levemir regimen. Whatever I eat, I count the carbs and then take the bolus. I adjust the basal if and whenever needed. By flexible, I don't take sweets, bulbous/root vegetables and other things that any diabetic shouldn't take. But I take other food items that are higher in carbs than the very safe, but I scale my insulin to that level.

But this doctor and dietician advocated a food regimen that involves spreading my eating over 6 times (which imho is a good idea) and restricted the eatable things to include only the fully safe foods in very restricted quantities. (In fact almost all the doctors in India including my regular doctor do the same). This is a new, difficult change for me to try and get used to. I can understand that this will surely help better control, but I fear that I am losing the flexibility that is possible with the basal-bolus regimen.

The doctors approach sounds very orthodox, conventional and inflexible. My heart wants me to make full use of the flexibility without compromising control. But I am scared about the control that I'd actually end up achieving.

What could be the best position to draw the line between the 2 extreme approaches?

Tags: basal-bolus, flexibility, food, habits, orthodox

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I am always interested to hear about approaches to treating T1D in other countries. How often are you able to test each day? If you're able to test upwards of 6-8 times per day, I would think that you could achieve decent control while maintaining flexibility. I eat flexibly, but I use a pump and test upwards of 14 times/day. I avoid foods that I know cause me a lot of difficulty in controlling my BGs (pasta, rice, and bread products). If you can test frequently, you should be able to (more or less) successfully match your insulin to your carbs.

However, if you are unable to test that many times per day, sticking to a more regimented schedule and sticking to "safe" foods may be a better idea in the long-run. To be honest, this is the same approach I take (even with a pump and testing so many times per day) when I know my control is slipping and my A1C is creeping up.

I can test 6 times a day ideally to keep very good control, but considering the cost of the testing strips and the fact that there is no concept of medical insurance for diabetics in India, that would be quite a luxury and futile exercise. Since I am a vegetarian and the variety of dishes that I normally eat is very limited, once I have the carbs and the insulin effect on each of those dishes, occasional testing should do.

But I want to try that after I achieve the target control of 7% HbA1C. That is the first and foremost priority for a healthy living and I don't mind being a bit too restricted in terms of food and flexibility. This makes sense since my bad cholesterol is just above the threshold and that my doctor thinks I am a borderline case and has got me started on mild cholesterol tablets. But hearing from people from different countries would be great.

Also he has suggested switching to Lantus from Levemir to reduce the basal shots from 2 to 1. But I am not fully convinced.

Hi Guruprasad. A couple thoughts: I too am a vegetarian and it is definitely harder for us. It sounds like your doctor is recommending low carb which is kind of cool because few doctors do that, but they give you outdated suggestions to eat lots of carbs! The eating six times a day thing, however, is pretty outdated and based on the older insulins. If I ate six times a day I'd gain tons of weight, but you don't look like that is a problem for you, so whatever works!

For me, especially as a vegetarian (and one who loves to cook varied foods - at least for dinner). I compromise and eat what I call "low/moderate" carbs which for me is under 100 a day. I don't believe in the "eat whatever you want and bolus for it" theory, because it doesn't work (at least not for me), but I'm not willing to go truly low carb. There are many people who do it, most of them not vegetarians, but some who are, notably Gerri. So I would basically look into the various possibilities and find what works for you. You sound like you might end up compromising like me, with more flexibility than your doctor suggests, but less than you might eat now. (You don't say how many carbs you eat per day)

I do understand though the desire of both you and your doctor to get you down below 7%. I was diagnosed at 58 so I don't worry as much about developing complications over time as if I had been diagnosed at your age. Some other ways to get your numbers down unrelated to food: exercise of course, though that can be complicated. Some things that I do that got mine down is: test a lot I do understand the problem with affording strips though. I do have insurance but try and conserve for when I need them by tricks like eating breakfast soon enough after I get up that I just use my waking blood sugar. But testing with a purpose is a good way to go, like before meals to judge dose. But after meals is also important to correct highs. If I could say the single thing I do regularly that helps me it's correcting promptly so I don't stay high too long.

The switching from Lantus to Levemir to reduce shots from 2 to 1, doesn't make sense to me as Levemir is generally prescribed in two doses!

If there is any option at all, maybe down the road for you to get a pump, that would of course be a great way to improve control. In the U.S. at least some of the pump companies do have fee waivers for low income, but I don't know if that applies to people living in India. It's probably not an option for you, at least right now, but I just wanted to throw it out

And congratulations on getting your A1C down; that's a big drop!

Hi Zoe, thanks for sharing your insights. My doctor has recommended a 6-times eating schedule with the 3 main food times and the in-between times with very very low carb food. Don't know how practical and sensible it is to try following that.

Also he has asked me to switch to Lantus from Levemir to reduce one shot as I am taking two split shots of Levemir. Probably since this is a different doctor from the one I regularly go to, this could be due to the fact that the new doctor has been long prescribing Lantus to his patients.

I guess I eat somewhere between 200-300 carbs every day from a rough calculation.

One more question that keeps nagging me is that, whatever carbs we take, I match the bolus dose to that. This effectively means that my blood sugar level will be back to normal only after 4 hours (the acting period of my bolus). But my doctor vehemently asks to target normal blood glucose level 2 hours after food. Won't this put me in a risk of getting into frequent lows because there would still be 50% of unacted insulin. For example if I had taken 10 units of bolus, a scary 5 units will still be acting for the next couple of hours and will definitely lead to low sugar. But my doctor has suggested eating 6 times a day with a maximum gap of 2.5-3 hours between. So I guess the overlap will take care of the yet-to-act insulin, but I am kind of scared.

Good question, and I had to think a bit for the answer. First of all I don't know what the "normal bg level" your doctor asks you to target at 2 hours is. For me, it is under 140. So I still have room to slip down a bit more without running into danger of a low. Even the 120 many people target allows 60 more points before going low. Also, the insulin does not get distributed in even time. (there's a maths term but I can't think of it). The end period of your insulin is it's "tail" and it is less insulin than the first couple hours. I also use Apidra which has less of a tail which I like.

Bottom line if you are under 140 let's say at 2 hours and you are going low at 4 it is due to your basal being too high and driving you down between meals rather than keeping you level.

I don't know about eating and bolusing every 2-3 hours, that sounds complicated (and unnecessary).

Zoe,

I'm not a vegetarian. I was for about 30 years, but didn't have good BG being a diabetic vegetarian. I tried. My hat's off to anyone who can. To get enough protein, I had to eat higher carb than I could comfortably control.

Apologies, Gerri; I knew that! And I respect your choice because when I realized I had to make changes in diet (when I started insulin) I told myself that if I needed to give up being a vegetarian for my health I would do so. If I didn't have good insurance and lots of free time to "obsess" about my diabetes (check, correct, cook - wow, three "c's") I wouldn't be able to stay a vegetarian and have good blood sugars.

No problem, Zoe. Just didn't want Guruprasad to think I could help there.

I read this and your other post about morning lows and I think the best thing you can do for yourelf is learn more about using insulin to control your diabetes. Not sure if you can get a copy where you are, but if you can, I highly recommend "Think Like a Pancreas".

http://www.amazon.com/Think-Like-Pancreas-Practical-Managing/dp/156...

I'm sorry, but I don't agree with your doctor that you should be eating 6 times a day. You're taking quick-acting insulin, Novorapid, so this would require you to take 6 shots, plus the two you're taking of the Levemier. That's ridiculous!

I had good succes taking Levemier once at bedtime, having three balanced meals a day (and taking novorapid for them) then either having snacks with no carbs, or taking an extra dose of insulin if I was hungry and wanted a snack with a carb. My A1c was never over 6.5.

If you can, use this book to help you figure out the problems you're having. Once you understand how much you need to take and when, you will have the flexibility to eat when you want to.

Thanks for your feedback Kelly. These are testing times for my health and am easily getting confused by what the doctor says and what I have learnt from experimenting and experience. I have read "Using Insulin" by Walsh and a lot of things mentioned there make a lot of sense. Against that backdrop, whatever my doctor has recommended seems too rigid and orthodox and totally wasting the flexibility that the basal bolus regime gives me.

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