Confused about basal insulin and diet/weight gain following appt

[pawprint91]

Three weeks after diagnosis, this morning I had my second appt with my nurse.

We established that as I am most definitely in the honeymoon phase, my basal insulin isn't at the right dose - she explained that the point of basal is that it should be so that if you didn't eat, your bs should remain the same (at the moment I would have a hypo by mid morning I am sure if I ate nothing). During the day at the moment (taking food into consideration), my pre-meal readings have been in range, but before bed I am often somewhere between 11-14. I just put this down to it being closer to my evening meal, but the nurse said if it's 3 hours after, my readings should be dropping from having eaten, and these readings mean by background insulin is wrong and too high (both am and pm doses are quite low, now 6 and 1 respectively), which does confuse me as I thought too much insulin should result in a lower bs reading, not an out of range higher one?

Secondly, as I have ended up waiting 3 weeks for an appt for various reasons, I have been quite careful when it comes to my carb intake. Eaten very little chocolate, and weighed out my portions of rice, pasta etc to what I deemed a 'sensible' amount. I learned today (as I had been advised on here!) that I can eat whatever I like ( ), however with no novorapid added in to correct at this stage I am tentative to start eating things such as dairy milk and mars bars, however a bit happier to start eating bigger portions and just 'counting' them, instead of going by the portion size. I was told not to worry about seeing eating bigger carb portions reflected in my bs levels. However, we then moved onto the fact I am struggling to regain the weight I lost pre-diagnosis (over half a stone, which I would ideally like to regain as I am now a bit thin, hard life I know). It was explained to me that when my bs is over 10 (as it regularly seems to be in the evening, and probably after lunch too) I am probably losing calories in my urine, and this coupled with my tentative diet, is probably why I am struggling to gain weight. However, I'm being told to not be so tentative and eat what I wish, it has been acknowledged that my bs is going to spike - but if this is the case then how will I start to gain weight? And how is this all affected by the basal insulin? I feel as though I have more questions than answers now, so any help is greatly appreciated!

 

[Sally71]

Just my initial thoughts:
1. If you are going low without eating anything then your basal is definitely too high; but if you are high in the evening this might be because of whatever you have eaten in the day. Basal insulin is not designed to deal with food, only the background level of glucose which your liver trickles out to keep you going in between meals. What is your BG like in the morning? If it gradually drops overnight then your evening basal is also too high, if not then the evening dose might be OK and you just need to look at the morning one.
2. It is true that type 1s can theoretically eat whatever they like, but only if they are also using a rapid acting insulin with meals, you then work out exactly how much carbohydrate is in whatever you are about to eat and from this can calcluate the correct dose of rapid acting insulin to deal with it. Then the food will make you go up but that dose of insulin will bring you back down again. Basal insulin on its own can’t do that. If you aren’t using rapid acting insulin then you will have to be a lot stricter about what you eat.
3. If you are type 1 then I’m surprised you aren’t also on rapid insulin as well, I think this was talked about in another thread, do you know why this is? Is there a plan to get you onto it eventually? Maybe they think you are still in the honeymoon period and still making some of your own insulin, this could change quickly though and even when you’ve been on insulin for ages you still have to adjust the doses from time to time so it seems a bit strange that they haven’t at least got you on a low dose straight away.

 

[rebrascora]

Hi. It sounds like there are a lot of confusing issues going on and I think a big part of the problem is that it sounds like you haven't yet been started on a bolus insulin, just basal?? I am guessing that basal insulin is Levemir since you mention two different doses. When do you take those doses, particularly the evening dose? Just wondering if you take it at say 7pm or at bedtime? As you say, their suggestion that the evening dose is too much sounds nonsensical especially if you take it at bedtime and therefore it hasn't had time to act.
All that said, you really can't expect a basal insulin to deal with your evening meal and the introduction of a bolus (fast acting) insulin, even if only a very small dose for the evening meal to start with would be sensible.

As regards eating chocolate or a Mars bar I would hang fire on that for now as that will be trickier to manage and particularly if you don't have bolus insulin. As regards the larger portion sizes of carbs, yes, eating much smaller portions can confuse things by suppressing your BG levels and I am sure if your levels were regularly hitting 20s your DSN would be introducing a bolus insulin more promptly, so in some respects being careful with your carb portions is perhaps hampering your progress or appropriate treatment being introduced. This really shouldn't happen. It would be a different matter if they had started you on fixed doses of bolus insulin and advised you of roughly how many carbs you should be aiming for at each meal, but without bolus insulin you are essentially in a position where you restrict carbs to keep levels reasonable or eat normally and see your BG go into orbit. Basal insulin should not be used to try to manage those high BG levels from food. Unless you can utilize that BG by having the appropriate amount of insulin you will not gain weight. Your body will try to remove the excess via your kidneys once levels get persistently above 10 so you need to have bolus insulin to keep your levels below 10 as much as possible, so that your body can use that glucose and your kidneys are not having to work harder to remove it.

My advice would be to hang fire on the chocolate for now, but increase the "healthier" carbs and push for getting access to bolus insulin when your levels rise as they undoubtedly will. Sometimes you have to be a bit "politely pushy" about what you need to manage your diabetes.

Must ask.... Do you have Freestyle Libre to monitor your levels and if so, what are they doing overnight whilst you sleep? That would be the primary concern in deciding what to do with your evening basal dose.

Apologies if I have misunderstood and you do already have a bolus insulin.

 

[Inka]

Arrgghhhhh! Why won’t they give you a bolus insulin? You could reduce your basal then (and avoid the lows from it), and also inject boluses so that you could eat proper meals and not spike, thus putting on weight.

I know I’ve go on about this before, but it’s so frustrating to see adult Type 1s treated in what seems to be a more ‘whatever’ way than children.

You have two options - eat good amounts of carbs, watch your blood sugar go high, then they’ll give you the bolus insulin you need; or be blunt and pushy and insist on it now. I’d go with the former for a few days personally, then phone them up, read out your results and be pushy. This slackness is disgraceful. Why would they want you to be high? As you say, you won’t gain weight.

You’re not alone in this *rude word* treatment. It happens far too often. I can think of so many threads where the poor OP has gone on far too long without a bolus insulin. I’m annoyed (very!) on your behalf.

 

[helli]

My advice would be to hang fire on the chocolate for now, but increase the "healthier" carbs and push for getting access to bolus insulin when your levels rise as they undoubtedly will. Sometimes you have to be a bit "politely pushy" about what you need to manage your diabetes.

Due to the fat in chocolate, it may be easier to manage than some of the "healthier carbs" with a pancreas that still has some functioning beta cells. The fat in the chocolate will mean that the carbs are much slower acting giving the remaining beta cells time to push out some insulin. I am not suggesting a full on choco diet but thinking of chocolate as being full of sugar so to be avoided is not necessarily the case. Especially, if you try some darker chocolate.

However, I agree to be more pushy for bolus and share @Inka frustration that you are not getting the support you should.

 

[pawprint91]

Hi. It sounds like there are a lot of confusing issues going on and I think a big part of the problem is that it sounds like you haven't yet been started on a bolus insulin, just basal?? I am guessing that basal insulin is Levemir since you mention two different doses. When do you take those doses, particularly the evening dose? Just wondering if you take it at say 7pm or at bedtime? As you say, their suggestion that the evening dose is too much sounds nonsensical especially if you take it at bedtime and therefore it hasn't had time to act.
All that said, you really can't expect a basal insulin to deal with your evening meal and the introduction of a bolus (fast acting) insulin, even if only a very small dose for the evening meal to start with would be sensible.

My advice would be to hang fire on the chocolate for now, but increase the "healthier" carbs and push for getting access to bolus insulin when your levels rise as they undoubtedly will. Sometimes you have to be a bit "politely pushy" about what you need to manage your diabetes.

Must ask.... Do you have Freestyle Libre to monitor your levels and if so, what are they doing overnight whilst you sleep? That would be the primary concern in deciding what to do with your evening basal dose.

Apologies if I have misunderstood and you do already have a bolus insulin.

Thank you so much for your response, you are correct that I do not have a bolus insulin as of yet. I am indeed on Levemir, I take one in the morning (usually around 7am when I wake) and one before bed (usually between 10pm-11pm). I don't have a libre yet, I think that's coming. The nurse seemd particularly concerned that I drop quite fast overnight - that my morning reading can be "normal" yet my bed time reading can be 12/14. I understand this concern, but she wants my bedtime reading and my morning one to be more similar (so presumably, I'm supposed to still be above 10 in the morning too?!). Thank you for the politely pushy advice, this is totally what I intend to do!

 

[pawprint91]

Arrgghhhhh! Why won’t they give you a bolus insulin? You could reduce your basal then (and avoid the lows from it), and also inject boluses so that you could eat proper meals and not spike, thus putting on weight.

I know I’ve go on about this before, but it’s so frustrating to see adult Type 1s treated in what seems to be a more ‘whatever’ way than children.

You have two options - eat good amounts of carbs, watch your blood sugar go high, then they’ll give you the bolus insulin you need; or be blunt and pushy and insist on it now. I’d go with the former for a few days personally, then phone them up, read out your results and be pushy. This slackness is disgraceful. Why would they want you to be high? As you say, you won’t gain weight.

You’re not alone in this *rude word* treatment. It happens far too often. I can think of so many threads where the poor OP has gone on far too long without a bolus insulin. I’m annoyed (very!) on your behalf.

Thank you so much for your response - I feel frustrated, too. I intend to do as you say - watch the levels rise, then call them in the week. She did mention introducing bolus as the levels rise, so at least it has been acknowedged. I feel like a guinea pig to be honest, but they must know what they're doing (or so I keep telling myself!!). Feel like I've hampered my own process by trying to do slightly restrictive carbs (still eating on average 150g carb a day, so not massively restricted!). I'm still a bit terrified to go too carb heavy, as after seeing readings in the teens (high enough) don't really want to go back to the dizzy heights of the 20s! Thank you so much for your reassurance, this has made me feel a lot better than I did when I came off the phone!

 

[pawprint91]

Just my initial thoughts:
1. If you are going low without eating anything then your basal is definitely too high; but if you are high in the evening this might be because of whatever you have eaten in the day. Basal insulin is not designed to deal with food, only the background level of glucose which your liver trickles out to keep you going in between meals. What is your BG like in the morning? If it gradually drops overnight then your evening basal is also too high, if not then the evening dose might be OK and you just need to look at the morning one.
2. It is true that type 1s can theoretically eat whatever they like, but only if they are also using a rapid acting insulin with meals, you then work out exactly how much carbohydrate is in whatever you are about to eat and from this can calcluate the correct dose of rapid acting insulin to deal with it. Then the food will make you go up but that dose of insulin will bring you back down again. Basal insulin on its own can’t do that. If you aren’t using rapid acting insulin then you will have to be a lot stricter about what you eat.
3. If you are type 1 then I’m surprised you aren’t also on rapid insulin as well, I think this was talked about in another thread, do you know why this is? Is there a plan to get you onto it eventually? Maybe they think you are still in the honeymoon period and still making some of your own insulin, this could change quickly though and even when you’ve been on insulin for ages you still have to adjust the doses from time to time so it seems a bit strange that they haven’t at least got you on a low dose straight away.

Thank you so much for replying. My bg in the morning is often a lot lower than it is in the evening (last night for example was 12 in the evening and then 7.9 in the morning), and until I altered my evening dose I was waking up to a reading of 4.1, and the levels were not rising that much (pre-meals) throughout the day.
The introduction of rapid insulin was mentioned if the levels rise (particularly for the evening meal), but I think they want to see what my own pancreas can still cope with given that I am in the honeymoon period, personally. (Just a guess, though!). As I said in a reply to another poster, I wonder if I've hampered my own progress by trying to make better carb choices and therefore not eating 100% truthfully as I would have done pre-diagnosis.

 

[pawprint91]

Due to the fat in chocolate, it may be easier to manage than some of the "healthier carbs" with a pancreas that still has some functioning beta cells. The fat in the chocolate will mean that the carbs are much slower acting giving the remaining beta cells time to push out some insulin. I am not suggesting a full on choco diet but thinking of chocolate as being full of sugar so to be avoided is not necessarily the case. Especially, if you try some darker chocolate.

However, I agree to be more pushy for bolus and share @Inka frustration that you are not getting the support you should.

Thank you for your reply and for the chocolate tip, a treat would be good!

Apologies to everyone for replying individually, I've not worked how (if at all) you can quote multiple posters in one response!

 

[pawprint91]

Hi all,

Just thought I'd update everybody as to what's going on ... my sugars before meals seem to be playing ball (*fingers crossed*) - even my evening ones have been under 10 for the past two days, and a steady decline before that. I'm probably still spiking after meals, but the "in range" pre-meal readings for me make me think perhaps not as much as I was, if they are coming down within a few hours of each other ... good old honeymoon period I am guessing!

I haven't recieved another appt from my nurse yet (despite the fact she said she wanted to check in weekly ...) so I think I am going to see what happens with the rest of the week and then give them a call later in the week to 'check in' and just get a professional opinion that I am on 'the right track' (health anxiety!).

I am a bit baffled (but pleased!) at the numbers being in range, all I can attribute it to is the honeymoon period and basal insulin. I still have not gained any weight this week however, but going to put that down to eating healthier and naturally less with the warmer weather... trying not to worry for now!