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Diabetes and insulin
Posted: Aug 5, 2012
I've had type 2 diabetes for around 20 years and have been moderately controlled on pills - eventually reaching the maximum daily doses of metformin and glyburide. Over the past few months, the numbers have been creeping up, and my doctor wanted to add a third drug. I've opted to start on long-acting insulin (Levemir), since I think insulin is actually healthier for the body than the pills. On the day I started the insulin, a week-and-a-half ago, my glucose was only 103 (very unusual), so I was started on only 6 units. I took it for 3 days the the numbers were around 170s. Doc increased dose to 12 units with no results, then to 15 units, again with no results. It is actually now running in the 200s. She wants me to increase it by 3 units every 3 days. It seems that the numbers are getting worse with the increasing dose, and it's starting to worry me. I'm pretty much avoiding all carbs except vegetables at this point. My last A1c was 7.1. I'd appreciate any ideas on what's going on. I fear for my kidneys and eyesight! Thanks.;
Insulin titration is a - tricky subject
[ In Reply To ..]that really should be taken up with your physician, but there some other things in your post I feel more comfortable commenting on.
After 20 years, you certainly have more experience than I do with type 2 ddm, so forgive me if I end up stating what's already obvious for you. All I can do is speak from my own understanding of what has worked for me and my BIL, who did manage to get himself off insulin and back on pill management. I will be speaking from my own experience and point of view, hoping you can glean something new that may prove helpful.
About the fear. My understanding is the damage ddm inflicts is a function of long-term MISmanagement and should not be a significant factor in the short amount of time it will take you to find your correct insulin dosage. I'm told it occurs as a result of wildly spiking values as opposed to what you may perceive to be a "high" individual number value (i.e 200). That's actually not the kind of sustained "high" number that could do much organ damage...or at least I should say it would take a really long time for that to happen at that level.
Personally, I would not consider insulin management until I felt confident I had maximized all other lifestyle managements tools, including normalized weight, playing with the time of day (and how many times per day) you take your meds vs when you eat, between-meal snacks, what you eat and when, food groupings and the like. For example, I only dose once daily with meds in the morning, so that's when I can indulge fruits with cereal, even though they add to the sugar counts, since I know my meds will be them most potent during their first half-life. 3/4 cup Fiber One80, 1/2 cups raspberries or blackberries with a cup of Silk Vanilla Lite or 1/2 cup Greek yogurt and sweetener is my superbreakfast that gives me the best results.
When you get gnawing hunger between meals, do not ignore this signal. Eat a small high-fiber or protein snack. If you are eating 3 times daily, try breaking it down to 5-6 smaller meals. This was hard for me at first, but I got much benefit after making that adjustment, both in terms of BG control and weight loss.
You mentioned nothing about exercise. If you aren't doing that, you are short-changing your ddm mgmt BIGTIME. Adding exercise will definitely lower your medication requirements. Walking, swimming, biking and moderate housework is not that hard to manage. Add activity of any kind, something you enjoy doing. It helps with sleep and stress as well. One of the major changes my BIL made that help him go from HUGE insulin dosing back to pill mgmt was hydration, hydration and more hydration. He has a water bottle in tow at all times.
To avoid spikes and lower overall high numbers, I try to keep STRICT control over food groupings and by watching my nutritional content numbers like a hawk. The generic starting point for this is figuring 50% carbs, 30% fats and 20% protein, with (high-figer) QUALITY carbs ruling that category. Calculate percentages from gram contents for each meal and the daily totals if you don't already do that:
For carbs and protein, it's grams x 4 divided by total calories per meal or per day. For fats, it's grams x 9 divided by total calories.
That carb count may be high for you, so you will have to adjust those values according to the BG readings you get to arrive at your personal maximized nutritional content numbers.
With regard to food groupings within a meal or snack, for example, I don't eat fruit or any higher-sugar/higher carb vegetable without either a protein or fiber side-kick with it, such as low-fat-cheese, whipped cream cheese, cottage cheese, nuts, high-fiber crackers or toast. You can sprinkle fruit with chia seeds, which I consider to be a super-fiber-enriched addition to cereal, smoothies and really any meal that is fiber poor. Food group decisions are always made with the idea of slowing down the rate carbs and sugars metabolize.
For me personally, I am finding that STRESS plays a major role in spiking values, so it is a factor in ddm mgmt that cannot be overlooked. Do whatever you have to do to minimize the role it plays in your life and GET ENOUGH SLEEP. My first step was to learn how to pick my battles, don't sweat the small stuff and relearning how to "let go."
I do not know the specifics of your ddm mgmt care team, but if it were me, I'd want to be under the care of a diabetes specialist when switching from medical to insulin mgmt. Also, if you haven't seen dietician or nutritionist, get a referral. You know better than I that your food is the most powerful medicine available when trying to control diabetes.
Hope this helps. Good luck with it.
Cool - anon
[ In Reply To ..]Bless your heart! Thanks for your wonderful information.
I'm feeling a little less in the weeds now. I decided I was unhappy with my internist's effort to control my glucose with insulin and saw an endocrinologist last week. She never agreed with my request to get off the pills and start on the shots, "Why would anyone want to take shots?" (Because it's healthier!)
The new guy upped the dosage to 30 units of Levemir a day, with an increase by 3 units every 2-3 days until my fasting level is below 120. I'm up to 42 units, and I think one more increase will do it. He also did something I thought strange. He added NovoLog on a sliding scale 2 hours After breakfast and dinner. I'm presuming this is checking spikes in preparation to carb counting. I also have to go to 4 nutrition classes (eeeew)
I like your food suggestions, and actually bought a little yogurt maker. I don't like yogurt, but I'm trying, since I know it's way better than "no sugar added" ice cream! I can doctor it with almond extract and splenda, and if I drain it into Greek yogrut, I can live with that.
Maybe someday I'll catch up with everything you've already figured out!
Again, thanks for your reply!
The nutrition classes will help a lot with - food group strategies.
[ In Reply To ..]When I was first diagnosed, I was really overwhelmed with all the new info, but something that helped me out a lot was to monitor fasting and 2 hr PPG/BG readings while playing around with the reduced portion sizes, smaller meals, snack schedules and food combos. This is also beneficial when you add exercise because it will change your regimen, which will need tweaking. Take a reading after exercise.
IMO, the exercise should take place after an lite in-between-meal snack. It's another good time to sneak in a fruit. Pear is high fiber that does not bog you down. You can try splitting your breakfast up into two parts, taking a half of it before exercise and eating the rest of it afterwards. Take a small snack (nuts are great for this) and a bottle of water with you when exercising outdoors in case you lose track of time and get the "gnaw" signal. Also, always choose FRESH first, then frozen, and canned as a last resort, though some low-or-no-salt canned goods allow you to adjust those astronomical values yourself.
I was much LESS overwhelmed when I stopped fixating so much on BG readings and pounds of body weight and started counting calories, nutritional content grams, and percentages. I set short- and mid-term goals (5, 7 and 10 pound increments), established milestones (BMI and counting how near I was to getting to the "overweight" category from the "obese" category, and now how far away I am from "normal"), and weighed only once or twice a week.
The down side to this obsessing is that it's very time consuming to look up the numbers, figure out meal plans, and keep a food diary. The record-keeping also spills over into adding the nutritional info to your recipes, adding it up, and then figuring out what size portions will help you stay on your per meal and per day goal numbers.
The good news is that after a while (2-3 months for me, but I was relentless) I had saved a lot of recipes AND individual meal plans which I categorized in my computer files (breakfast, lunch, dinner, snacks, Main/meat dishes, vegetable sides, soups, salads, desserts, etc). By immersing myelf in the process, I began to develop a sixth sense about grouping contents and meal proportions. I was also able to eyeball my individual serving portions by then, which cut down on the need to constantly be measuring and referencing nutritional and meal-planning data. The pay-off was losing 47 pounds in 8 months (still have another 30 to go), and taking myself out of higher-number plus-size clothes and replacing them with high-number regular women's sizes. One of these days, I'd love to have at least ONE piece of clothing that has a single-digit size tag)!
BTW, not everything needs to be homemade. Try getting adventurous in the grocery store and hunt down as many sugar-free and multi-grain products as you can stand. My favorite is Tostatos MG scoops, which allows me to indulge in healthy fresh homemade salsas that make for a satifying lite vegetarian meal. Another trick I use is to add high-fiber veggies (beans, lentils, etc) to high-carb starches (brown rice, MG pasta), reduce the portion 3/4 cup or less, then load it up with fresh veggies and 2-3 ounces of meat. These meal-in-one concoctions fool the eye into believing there's a lot more food there than there really is, while keeping it's quasi-comfort food appeal. Hot vinegars, lemon, lime, fresh herbs and small amounts of pungent oils (the good cholesterol kinds) add surprising amounts of flavors to otherwise bland foods.
Make friends with your yogurt machine. There are many frozen dessert treats you can experiment with, and don't forget the smoothies, either for between meals or more pumped up versions that can be used for meals. You can even add in oatmeal, dry cereals and chia seeds. These can be made ahead of time and frozen for short durations (about a week or less). Use individual serving-size freexer bags for this unless you have a chainsaw handy. If you find that too much fruit in those recipes raise your levels, just cut back the portions and maybe try sugar-free fruit extracts. Another good friend you can make is the veratile sweet potato, which you can combine with cooked fresh fruits, nuts and sweetener, then eat either hot or cold like a pudding. Don't forget the fat-free whipped topping, which helps add deceptive lite volume to these dessert treats. We go through a carton every other day in hour house. I like boiled SP with apple, cranberries and cinnamon, hot next to pork or BBQ chicken, or cold as a dessert. Sugar-free mousses are another option.
PS: Try crossing cultures when on the recipe hunt and, whatever you do, have some fun with it.
Time consuming! - anon
[ In Reply To ..]Good thing I recently quit working. This is taking a huge amount of time! I've made two charts - one with the numbers and doses, and one with my meals. Right now I'm eating very few carbs at all. I know the nutrition class will free me up to eat fruit and some starches. I'm used the Atkins where fruit is forbidden. I also bought a fancy little electronic carb counter in preparation to what I think is coming.
I really hate to exercise, but if the weather ever cools down I'll make myself get dressed and go for a walk. Ewww! I think Maybe I have my long-acting insulin adjusted. My fasting was 98 this morning. I celebrated by having 2 slices of multigrain bread with my Egg Beaters!
I hear ya! - sm
[ In Reply To ..]It IS a good thing, or at least a mixed blessing. I would have NEVER been able to devote the time and energy it takes to do this right had I not stopped transcribing and gone on unemployment (which eventually ran out). In hindsight, all the obsessing, hair-pulling and paupership has been more than worth it. It may not seem like it now, but you will be reaping immediate short-term benefits (enough to keep you motivated) and the long term will be measured in just a few months, not years.
Logging BG and dosing is initially essential when making these kinds of major changes. Once your dose is established, you become more familiar with new eating patterns and are more in tune with your body’s signs and signals, the need to do so should diminish. One of the up sides to insulin mgmt that pill mgmt does not offer is you have a handy little weapon at your fingertips should you go off script by, say, eating out on a special occasion or infrequently “rewarding” yourself from time-to-time for a job well done.
However, I have to wonder if your glucometer could be taking on some of this detail work for you since, unlike the meals records, frequent review of a long history of your BG and dosing info is not necessary, nor is it particularly helpful. I use a Precision Xtra BG and ketone monitoring system that stores 450 “events” in memory. It also calculates 7, 14 and 30 day BG averages…more than enough to help with insulin dosing titration. The user’s manual also has instructions on how to transfer the glucometer’s memory info onto your computer. Though my monitor was given to me, I saw it displayed at WalMart and, from what I remember, it wasn’t all that costly. Your nutrition counselor or endocrinologist’s staff may be able to steer you in the right direction in this regard.
The meal records are another story all together. The time you invest initially in documenting recipes, meal plans, nutritional information, portion sizes, etc will save you much grief in the long run and will not relegate you to having these time-consuming chores rob you of the joys associated with eating on a daily basis, and will keep ddm mgmt from consuming large chunks of your life.
Your fancy electronic carb counter sounds like something handy that I should check out, but you will also need access to calorie, fat, fiber, sugar and protein contents. While I’m at it, I also keep track of cholesterol and sodium counts as well. My most helpful computer tool has been http://nutritiondata.self.com/ …..another friend you may consider becoming acquainted with
I’m familiar with Atkins, which I was using when I got diagnosed with ddm. My take on it is that it’s a good “go to” plan when eating away from home and those occasions where you don’t have control over what’s going on your plate. On the other hand, I think the kind of metabolism it sets up for your body may prove counterproductive over the long haul since it is evident, both by design and by personal experience, it tends to make you MORE carb intolerant. Also, it aims to keep you in a perpetual state of ketosis….counterproductive for diabetics, especially once weight has been normalized.
I live in Houston, so the weather factor is something I also contend with. The idea with exercise is to move, move and move some more. Aside from the "comforts" of indoor housecleaning regimens, there are some other pursuits you might consider. I do a lot of “window shopping” in the malls, take the stairs whenever possible, park my car far from the entrance of the stores, and always walk up and down all the aisles of the grocery store or WalMart TWICE every time I go there, even when only for an item or two. Establishing a walking regimen in better weather was hard at first since I am a sedentary computer nerd, but once you get through the first few weeks of having to beat yourself into submission, you’ll find that you are feeling better and even looking forward to the quiet down time away from cell phones and indoor distractions.
Short-term goal setting, like weekly 5-minute gradual increases in the amount of time spent walking, using a pedometer to measure distance, stepping up the pace to try to cover more area in less time, or adding alternating bursts of fast and slow walking intervals can be useful. I spent some time mapping out “scenic” walk routes at local parks within driving distance of my house and driving around measuring “mileage landmarks” inside my subdivision as well. After I had walked for a couple of months, I found that I was ready to add swimming and biking into the mix. You may want to check out a local community center, the “Y”, Leisure Learning, or (gasp) the gym for various kinds of low-cost exercise classes, where climate-controlled indoor swimming polls may be available. I feel lucky to have a pool on my condo property.
I’ve got a lot of recipes with nutritional values and portion calculations in my computer files that you may find helpful in cutting down on some of the time-consuming “craziness” you feel you’re facing....perhaps after you’re done with nutrition classes and feel ready to take the plunge. It would be easier to email those to you since they are set up on a narrow-margin, wide-page format. If you’re interested, just way the word.
Congrats on the 98. I have a prediction. There are more exciting celebrations in store for you MG breads and Egg Beaters….just around the corner.
Track 3 - anon
[ In Reply To ..]While I have it in front of me, this little electronic carb counter (Track 3) gives you all kinds of choices. You can track food, exercise, glucose/insulin/meds, quick entries, and reports. I
've only explored the "food." When you enter a food, it gives calories, fat, sodium, carbs, fiber, and protein. It also gives restaurant lists, recipe calculator, etc. It also can connect to the computer, which I haven't done.
The nutritionist also told me I should get a medic alert bracelet. Hard to find decent ones that aren't ungodly clunky, but I finally found one online.
I like the idea of walking up and down the aisles in stores. LOL! If I went to, say, Walmart to buy one item, and walked up and down every aisle, I'd wind up with a cart full! I think I'd rather touch a worm than go to the gym!
I'm off to check the website you sent. Thanks!
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