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.
And to establish my basal, I basically increase the Lantus in 2-unit increments, holding each new level for a few days, until I get the fasting BS I need? And maybe try splitting it, with, say, 1/3 allocated to the morning?
I would recommend to split the Lantus evenly. Lantus will act for 24 hours with some degradation. The splitting helps to overcome the uneven distribution of insulin activity. By using uneven allocations you might work against this goal.
I'm certainly not going to offer specific advice since I don't have diabetes myself. I'm the mother of a son with type 1. He is following a very low carb regimen and it's working for him. I found Dr. Bernstein's book "The Diabetes Solution" to be particularly helpful. He gives detailed instructions on calculating I:C ratios while eating no more than 24-30 grams of carbs per day. This book has been our bible for diabetes mgmt.
Dr. Bernstein does live in New York state. I'm not sure if he still sees patients, but you could try, or he might have recommendations for other doctors that are more in line for what you are trying to do.
-and hang in there. My son and I are early into the d thing, but we've already had to fire one endo. Trust yourself that you are doing what's right for you.
Definitely do not go by the ADA guidelines. Their advice will kill you! I had my worst A1C when I stuck to those guidelines.
My favorite book is "Think Like A Pancreas." Before I started bolusing before meals I read it cover to cover in two nights.
My advice would be to go up on your Lantus, maybe by a couple of units and perhaps take it at an earlier time. I remember I would take my Lantus right at bedtime and I would still be waking up at 140. However, since it is long acting it takes awhile for it to kick in, thus not being fully able to combat the whole "Dawn Phenomenon". So I inject three hours before bed now.
I keep my diet to 70 carbs a day and I bolus all of my meals (between 2 and 6 units), unless it is a piece of baked chicken or something.
I think a lot of your problem might be dawn phenomenon. When I wake up high I know it's going to be a high day.
You know, I am thinking more and more that this is a Dawn Phenom issue. I woke up with a BS of 266, and it has not gotten below 240 all day, even though I have eaten fewer than 20 grams of carbs, and have been shooting 7-9 units of NovoLog before each meal. And FWIW -- though I have made this mistake in the past -- I haven't been binging on low-carb stuff or protein, either; my calories for the day are below 1000. So, yeah, I'm thinking more and more that it's a lot more about the basal and the DP than it is about what I eat.
I can't help you with DP, maggiesara, as I'm lucky enough not to experience it, but I was wondering if you do corrections when you are that high? To do that you need to know your ISF which is how much one unit of insulin lowers your blood sugar. Mine is 1:30 during the day and 1:60 at night but I'm Type 1, yours will probably be less. To determine it, start conservatively (like 1:30) and see how much your blood sugar comes down after 3 hours. Keep records, then adjust it accordingly. In other words if you don't come down enough after using 1:30 for awhile, try 1:25.
I'm afraid I'm a little unclear on this: The process seems to have too many variables. What I mean is, I'm trying to track both A) how many grams of carbs are 'covered' by 1 unit of insulin, and at the same time B) by how much 1 unit of insulin lowers my blood sugar. Could you clarify?
Yes, they are definitely two different things and I know it's overwhelming when you have to work out so many "math problems"..lol. You might want to focus on one at a time.
1. I:C ratio - is exactly what you said, "how many grams of carbs are covered by 1 unit of insulin....for you...we are all different and you might have different I:C ratios for different meals. This is what you have to figure out over time to accurately bolus for your food.
2. ISF (insulin sensitivity factor)- This is the formula you use to do corrections. The reason I brought this up (though some people don't start it right away) is because you mentioned being high all day. Corrections are a way to determine how much insulin to use when you are too high and want to bring yourself down into range. You can use them a couple hours after a meal (being sure to keep track of your insulin still active) or you can add the correction into your carb bolus (which is what your sliding scale was about).
So both formulas take time to figure out, both are important, but they have too different purposes. 1) to dose for your meals and 2) to correct highs that happen for whatever reason so you don't stay high for hours.
I do mine a little bit differently, although I also "cheat" with a pump and CGM so it may be easier but if a fasting # is high, I'll blame the basal and, if it's high a few days in a row and seems consistent, I'll try to nudge the bolus up 5-10% (like from .8u/ hour to .825U/ hour, like 19.2 vs 19.8U/ day...) and see what happens. In many cases, even a little change like this can move things in the right direction.
If it's the post-meal readings that are off, high or low, I'll turn the basal ratio a bit, again, usually a couple of "clicks", which are .1G of carb/ unit on the Medtronic pump. It will usually cause results.
I try to keep the new settings for a couple of days before thinking about it again. Soemtimes it will get way out of whack but other clues I look at are a lot of little corrections, either insulin or food, that might mean it's time to fix things. I don't worry about the ratio being correct, but moving it in the right direction. Theoretically, it should get it correct but things change so much that it's hard to say for sure sometimes what's going on. Which is probably horrible to say but I think that the being engaged and working is useful.
One of the things that drives me absolutely nuts is when my numbers shoot up for no reason. In an effort to get a handle on things, I have been checking my BS like crazy --at the one-, two- and three-hour mark after every meal. So my two-hour post-dinner reading was 179. Thank god, first time I'm under 200 in days. And my three-hour reading? 227. WATER. I had a glass of water. That was it. How could a glass of water make my blood sugar level jump by 50 points?
What did you have for dinner? Somewhere I sort of pooh-poohed protein taking longer to digest but it takes longer to digest. I read somewhere it also burns more calories in the act of digesting, perhaps another reason low-carb diets are effective? Other things to consider are meter accuracy, stuff on fingers, wiping the counter off, giving the dog treats, etc. There's all kinds of things.
I had broiled salmon, steamed asparagus, and a green salad for dinner. I was a freaking POSTER CHILD for responsible low-carb eating. (PHEEWWW, blew that off my chest.) I had just been washing the dishes, so maybe something...eh, who knows. Thank you for reminding me, though, that there are gremlins in the blood-sugar readings, and that sometimes you just have to chalk stuff up to their mischief at work.