At the moment, I do not have an endocrinologist or a diabetes educator or, indeed, anyone helping me. I believe passionately in the necessity -- FOR ME (I make no prescriptions for anyone else) -- of eating quite a low-carb diet, in order to try to manage my diabetes, but all the endo's I have seen (and I've seen four, all highly regarded and expensive, since April) buy into the American Diabetic Association guidelines, and want me to eat at least 180 grams of carbs per day. I think this would be disastrous.
I'm currently eating fewer than 40 grams of carbs/day, often fewer than 30, and I'm following the insulin guidelines I was given in April: check my blood sugars before meals, and take 3 units of Novolog if my BS is 100-150, 7 units if it's 150-200, etc.
This ain't working. I am struggling to get my blood sugar levels below 200, and in the morning (I take 28 units of Lantus at night), they are typically over 250. I know I need to increase my insulin, but I don't know how to do this safely. Can anyone advise?
Also, I am pretty desperate, at this point, to find an endocrinologist I can work with. I'm in NYC, but am willing to go just about anywhere to find the right doc. All suggestions WARMLY appreciated.
I can't help you with the doctor recommendations, maggiesara, but I have a few suggestions. I really recommend the book Using Insulin by John Walsh which will give you the guidelines for dosing your insulin. The sliding scale you mention is a very outdated way of dosing bolus (mealtime) insulin. You need to work out an Insulin:Carb ratio so you take the right amount of insulin for the food you are eating. You wouldn't take the same dose of insulin for salad as for pasta! Then you need to figure out your ISF (correction factor - how much one unit of insulin lowers your blood sugar) so you can correct highs. Finally if you are waking up at 250 you are not getting enough basal. I would suggest raising it a couple units at a time and seeing how it improves your fasting blood sugar. You also might try splitting the dose of Lantus, taking 1/2 at night and 1/2 in the morning beause that might work better. If you increase it to 30 keep that for a couple days to see the results before you increase it again.
Using Insulin will explain the I:C ratio, but basically start with 1:15. That is, one unit of insulin for each 15 grams of carbs. So if you eat 30 grams, take 2 units. See how you do. Since you are Type 2 and have some insulin resistance you will probably still be high. So after a couple days, you can try 1:12, etc. Also different meals might be different. For example my ratios for the three meals are 1:6, 1:11 and 1:16. (I am Type 1, so don't have insulin resistance).
Zoe, I cannot thank you enough. I'll get the Walsh book and, if you don't mind, I'll holler if (when) I have questions.
I agree with you and Zoe, that the numbers you're seeing are not the numbers you want. Particularly if *you* don't want those numbers. I read John Walsh's other book and agree that Using Insulin will be a big help. "Think Like a Pancreas" is also a very good sort of "owner's manual" for diabetes that I found very readable, like I couldn't put it down.
More specifically, I also agree with Zoe's suggestion to increase your basal to try to fix the fasting numbers you're reporting. Carb counting and ratio balancing hopefully can improve your post-meal #s and then you'll be set. This is, of course, harder than it sounds to talk about but it sounds like you are very sharp in your perception of your numbers and desire to fix them so I think that you are ready to try to go beyond what your current docs are recommending. I hope you can work things out and that you keep coming back with more questions as you run into them!
Forst, I second the two recommendations above - "Using Insulin" and "Think Like a Pancreas". Learning how to self-adjust insulin is vital to maintaining good BG control, in my opinion.
Second, the doctors you spoke to are out of date. The American Diabetes Association (not to be confused with the American Dietetic Association!) started accepting low carb diets in 2008 as part of their clinical practice recommendations.
You need to do some basal testing. The Think like a pancreas book tells how so does "Diabetes Solutions" by Dr. Richard Bernstein, which may also suit you, particularly that you are already doing low carb.
Typically when increasing basal one does it slowly and in 1 or 2 unit increments depending how high your blood sugar is. With fasting of 250, the night time increase could be by 2 units every 2 - 3 days until numbers are in target, then by 1 unit as you get closer. Testing at 2 am may also be required to see what is happening (as you don't want to go low at night).
Ie. is the high fasting from being high all night, a rebound from a low, or is it dawn phenomenon. If it is high all night then an increase in lantus is the way to go, if it is rebound from a low, then the night time insulin may need ot be reduced. If it is dawn phemonenon then it may be necessary to take some novolog in the wee hours to catch and block it or switch to NPH (Humalin-N at night, which has a profile that is useful for some to counter the dawn phenomenon).
Working out your carb / insulin and protien / insulin ratio (also necessary seeing you are eating low carb) will then help fine tune post eating numbers.
You'll get lots of excellent feedback from here.
I've just bought both the Walsh and the Scheiner books, and thank you all for the recommendations. I have the Bernstein book, and am actually reading it right now, though it scares me a little: He seems to advocate a VERY low-carb regime, and I have spent too much of my life waltzing with failure in the form of diets I couldn't stick to. I'd be very interested in talking to anyone who works a Bernstein program.
SuperSally, would you mind telling me a bit about protein/insulin ratios? i'm pretty new to the notion that I need to monitor my protein as well as my carbs, but I hadn't heard at all that I would need to adjust insulin for it.
Folks, I can't tell you how grateful I am for the smarts. The medical establishment seems to me to be just out to lunch on this entire issue.
When one is eating SAD (Standard american diet - high carb), protein doesn't have too much of an impact on blood sugar (apparently). But when one is eating low carb,then protein does have an impact. I can't remeber what %, but maybe something like 50%. Ie. If your carb:insulin is say 20:1, then your protien may be 40:1.
You do have to determine your rates by trial and error. I honestly haven't calculated a protein ratio for myself and just tend to wing it, as I just know I need how much insulin to cover what typical meal now.
I disagree that eating more carbs reduces the effect of protein. I see protein effects all the time. I am not sure I can disprove the "the standard American diet" as I'm still eating about less carbs than the dietitian rx'ed, 100-150/day instead of the 180-270, the last time I had seen one (2008, when I got my pump...).
The conversion ratio I've seen here and maybe in some books is 53% of protein will convert to carbs. I just use 50% as that's as much math as I'm gonna do.
Do you just take the insulin for the protein up front or do you do dual wave or something like that?
I just do it all at once. Most of the time, it's probably not more than a few oz of meat, maybe 6-7 if I'm really on a roll, and I'll count it as about 15-20G of carbs but usually it's more moderate and I'll just count 5-15, depending on eyeballing it. I've tried dual and square wave boluses but I get better results with the regular all at once boluses. If there's carbs floating around, I don't think the insulin gets too far ahead for a 5-10g hunk of carbs although I know there's lots of people who that's all they eat, in which case a slower hand might be better?
I would encourage you to focus on establishing your basal first. With a very low carb diet, your blood sugar will primarily be determined by the basal. If you are actually T2 and both insulin resistant and insulin sensitive, you may need much more than 28 units of Lantus. In the end, you need as much insulin as your require.