1. health and fitness
2. disease
3. diabetes

Katharine Morrison
Katharine’s How to .... series
All about Diabetes
Edited By: Leah Fisher
First Draft
2007
Hello everyone and hello every one of you. Maybe a shorter document to edit..??
How I would like to take things forward with my patient/medical professionals education programme is to
start off a series of ”How to....” do things that will help people with glucose metabolism problems and diabetes
get better control and healthier in general.
I think more simple information could be better.
The trouble is that producing simple tips and procedures is a LOT harder than giving people lots of information and letting them rake through it themselves to find out what could be relevant to them.
I will therefore once again need your help to look at my efforts, add to them and correct anything that could
be put more simply or accurately.
The IDDT conference in Birmigham UK last autumn produced a consensus that diabetics wanted information on how to low carb on the IDDT site since they are not getting this information at their diabetic clinics.
Ryan’s D-solve site has similar aims as indeed does this site.
Eventually it would be great if we had a sort of International Diabetes University site for diabetics, their
carers and their attending medical professionals. The Diabetes in control site is starting something off soon.
There could be other folks who would like to contribute but we have to start somewhere.
I’m going to start with Weight Loss simply because this is the smallest booklet I have produced. I have
different ones for Weight Loss, Metabolic Syndrome, Type 2 and Type One Diabetes. A lot of the content is
shared between them of course.
I hope to hear from you soon.
Please add any personal tips or steps that have worked for you.
Thankyou.
Katharine.
Katharine’s How to .... series
2
Contents
1 HOW TO LOSE WEIGHT AND KEEP IT OFF
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2 METABOLIC SYNDROME
9
3 HOW TO FOLLOW A LOW CARBOHYDRATE DIET
Dr Annika’s Diet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
MEAL SUGGESTIONS FOR DR ANNIKA’S DIET . . . . . . . . . . .
HOW TO FOLLOW THE ”LIFE WITHOUT BREAD” DIET . . . . . . . .
HOW MANY CARBS AND CALORIES DO ALCOHOLIC DRINKS HAVE?
HOW TO EAT OUT IN A RESTAURANT . . . . . . . . . . . . . . . . . . .
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4 HELPFUL LOW CARB BOOKS
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5 MYTHS ABOUT LOW CARB DIETS
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6 HOW CAN YOU EXERCISE?
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7 HOW TO GET INFORMATION ON LINE
Low carb cooking . . . . . . . . . . . . . . . . . . .
Carb counting . . . . . . . . . . . . . . . . . . . . .
Exercise . . . . . . . . . . . . . . . . . . . . . . . .
Glucose metabolism disorders and diabetes . . . .
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23
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8 HOW DO I LOOK AFTER MYSELF WHEN I HAVE TYPE TWO DIABETES?
UNDERSTANDING THE PROCESS OF TYPE TWO — INSULIN RESISTANT — DIABETES
HOW TO ”EAT TO METER” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
HOW TO COUNT CARBOHYDRATES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
HOW TO LOOK UP CARB LISTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
HOW TO USE THE EXCHANGE METHOD OF CARB COUNTING . . . . . . . . . . . . . . .
HOW TO COUNT CARBS USING CARB FACTORS . . . . . . . . . . . . . . . . . . . . . . . . .
HOW TO COUNT CARBS FROM NUTRITIONAL LABELS . . . . . . . . . . . . . . . . . . . .
HOW TO COUNT CARBS USING NUTRITIONAL SCALES . . . . . . . . . . . . . . . . . . . .
HOW TO EYEBALL PORTIONS OF CARB CONTAINING FOOD . . . . . . . . . . . . . . . .
HOW TO DO THE ATKINS DIET . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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9 HOW TO COOK AND BAKE THE LOW CARB WAY
LOOKING AT INGREDIENTS: CARBOHYDRATE . . . . . .
FOODS TO EAT REGULARLY . . . . . . . . . . . . . . .
EAT IN MODERATION . . . . . . . . . . . . . . . . . . .
EAT VERY SPARINGLY . . . . . . . . . . . . . . . . . . .
WHAT FATS SHOULD I USE? . . . . . . . . . . . . . . . .
WHAT PROTEIN SHOULD I USE? . . . . . . . . . . . . .
HOW DO I SUCCESSFULLY SUBSTITUTE INGREDIENTS?
SUGAR CONVERSIONS . . . . . . . . . . . . . . . . . . .
RECIPE BOOKS . . . . . . . . . . . . . . . . . . . . . . . . . . .
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CONTENTS
INTERNET LOW CARB COOKING SITES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
10 HOW TO EAT FROM A HOSPITAL MENU
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11 HOW DO I LOOK AFTER MY FEET?
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12 WHAT THINGS APART FROM FOOD CAN AFFECT MY BLOOD SUGAR CON51
TROL?
13 WHAT DO I NEED TO KNOW TO KEEP HEALTHY WITH DIABETES?
MEAL PLANNING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
SELF MONITORING OF BLOOD SUGAR . . . . . . . . . . . . . . . . . . . . . . . . .
USE OF INSULIN AND DIABETES MEDICATIONS . . . . . . . . . . . . . . . . . . .
EXERCISE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
KNOWLEDGE OF HIGH AND LOW BLOOD GLUCOSE . . . . . . . . . . . . . . . .
FOOT CARE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
URINE TESTING FOR KETONES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YOUR HEALTH TEAM WILL DO THESE ANNUAL CHECKS AND TESTS . . . . .
YOU NEED TO BE VERY CONFIDENT ABOUT . . . . . . . . . . . . . . . . . . . .
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14 HOW TO KEEP HEALTHY IF YOU NEED TO TAKE INSULIN.
DIAGNOSIS of TYPE ONE DIABETES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
HOW CAN OUR FAMILY DEAL WITH THE STRESS OF HAVING A NEWLY DIAGNOSED
DIABETIC CHILD? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Join a Support Group . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Look After Yourself . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
HOW DO I ORGANISE MY SUPPLIES? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
EMERGENCY INFORMATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hypoglycaemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Vomiting and Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Food Choices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Self Monitoring of Blood Sugar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
HOW CAN MY DIABETIC CHILD BE PREPARED FOR LIFE OUTSIDE THE HOME? . . . . .
HOW CAN I PREPARE MYSELF FOR THE COLLEGE YEARS? . . . . . . . . . . . . . . . . . .
HOW LONG IS MY INSULIN GOOD FOR? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
HOW CAN I SAFELY DISPOSE OF NEEDLES AND OTHER SHARPS? . . . . . . . . . . . . . .
HOW DO I MONITOR MY BLOOD SUGARS APPROPRIATELY? . . . . . . . . . . . . . . . . .
HOW DO I BECOME THE STAR OF THE DIABETES CLINIC? . . . . . . . . . . . . . . . . . . .
HOW DO I DECIDE WHAT TO EAT WHEN I AM ON INSULIN? . . . . . . . . . . . . . . . . . .
HOW DO I FOLLOW DR BERNSTEIN’S DIETARY PLAN? . . . . . . . . . . . . . . . . . . . . .
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15 HOW DO PROTEIN, FATS AND CARBOHYDRATE AFFECT MY BLOOD SUGARS? 73
16 HOW DO I EXERCISE AND KEEP WELL?
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17 HOW TO GIVE YOUR FEET A PEDICURE.
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18 WHAT ORAL MEDICATIONS COULD I BE OFFERED
Sulphonureas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Meglitinides :The Prandial Glucose Regulators . . . . . . . . . . .
Metformin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Glitazones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Katharine’s How to .... series
FOR DIABETES?
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79
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4
CONTENTS
19 HOW CAN I USE INSULIN
What is insulin? . . . . . . . . .
Where do I inject? . . . . . . . .
How do I inject insulin? . . . . .
Basal Insulin . . . . . . . .
Protecting Insulin . . . . .
Missed a dose? . . . . . . .
TO THE BEST EFFECT?
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20 HOW DO DIFFERENT INSULIN REGIMES COMPARE?
Two mixed doses . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Morning mixed with evening split . . . . . . . . . . . . . . . . . . . .
Multiple daily injections with long acting basal . . . . . . . . . . . .
Insulin Pump Therapy . . . . . . . . . . . . . . . . . . . . . . . . . .
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21 HOW CAN I USE BOLUS INSULINS EFFECTIVELY?
Why do I have to change my eating and insulin routine? . . . . .
Protein . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Fat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Carbohydrate . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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22 HOW DO I CALCULATE MY INSULIN SENSITIVITY?
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23 HOW DO I ADJUST MY BASAL INSULIN?
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24 HOW TO I TURN MY PEN INTO A PUMP?
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25 HOW DO I COVER A STRICT LOW CARB REGIME WITH INSULIN?
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26 HOW DO I COVER A TYPICAL LOW CARB REGIME WITH INSULIN?
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27 HOW DO I COVER A HIGHER CARB REGIME WITH INSULIN?
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28 HOW DO I DO DR MORRISON’S CARB WEIGHTING SYSTEM?
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29 HOW DO I TIME INSULIN INJECTIONS MORE EFFECTIVELY FOR SIMPLE INSULIN REGIMES?
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30 HOW DO I CHANGE MY INSULIN REGIME IF I AM AN NHS PATIENT?
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31 HOW CAN I HELP INSULIN DEPENDENT DIABETICS WHO CAN’T AFFORD INSULIN?
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32 HOW DO I DEAL WITH LOW BLOOD SUGARS?
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33 HOW DO I ADVISE MY HELPERS TO DEAL WITH LOW BLOOD SUGARS?
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34 HOW DO I PREVENT LOW BLOOD SUGARS?
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35 HOW DO I DEAL WITH HIGH BLOOD SUGARS?
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Vomiting, Dehydrating Illness and Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
36 HOW DO I MANAGE HIGH BLOOD SUGARS WHEN I ACTUALLY FEEL OKAY? 129
Katharine’s How to .... series
5
CONTENTS
Katharine’s How to .... series
6
Chapter 1
HOW TO LOSE WEIGHT AND
KEEP IT OFF
• How motivated are you to achieve a healthy weight and stay there?
• Is it something that you have tried to do before and not reached a weight you were happy with? Perhaps
you did become slim again but somehow the weight gradually returned?
• Here are some tips from fellow health minded people to give you some inspiration and help.
• Have a clear picture in your head of how much worse you will look and feel if you keep on your current
habits for the next year, five years or ten years.
• Have a clear picture in your mind of what benefits you will have when you are a healthy weight or even a
little slimmer than you are right now. How will you feel? How will you behave differently?
• List the foods that you eat a lot of, that you know you can’t resist, and that you know are stopping you
losing body fat. If you really cannot resist them perhaps it is best to decide not to buy them and not to
eat them at all.
• Keep an accurate food and drink diary.
• Plan to eat or have a snack every 4 hours or so to prevent you overeating when you are hungriest.
• What activities can you do to relieve stress and boredom? List the sorts of things you can do indoors and
outdoors, in company and alone that you are going to do instead of eating to deal with emotions.
• Cut back on your portions. Measure them.
• Stop eating when you are not hungry any more. Not when the plate is empty.
• Eat a good breakfast. High protein is best as it fills you up for much longer than carbohydrates. What
sorts of high protein breakfast items are you going to stock up on to get your day off to a good start?
• Avoid anything other than small portions of sugar and starch. They can be very addictive for some people.
• Eat real food. Avoid the processed package meals that have lots of unhealthy fats, sugars and chemicals
added.
• Have a high protein or fibre afternoon snack to prevent you gorging at your evening meal.
• Eat your evening meal early enough that you have time to digest it before bed. You will be less hungry
with an earlier evening meal too.
• Carry a small high protein snack with you. Boiled eggs? Cheese triangles? These are more filling than a
danish pastry and will keep you out of trouble.
• Eat enough protein at your main meals to stop you becoming ravenous before the next meal.
7
• Shop for food on a full stomach. Your impulse buys are likely to be less.
• At a buffet fill a small plate once.
• If you have an indulgence get back on track right away. Not Monday and not tomorrow.
• How can you reward yourself without using food?
• Foods that fill you up include seafood, eggs, meats and high calcium dairy foods.
• Eat meals that contain a fixed amount of calories or have a fixed portion size.
• Think about how you are cooking your food. Fried food and dressings can easily add a lot of calories.
• Stick to your good habits once you are at a weight you are happy with.
• Wear attractive neat fitting clothes.
• Don’t allow yourself to go more than 5 pounds over your goal weight.
• Exercise every day if you can and at least three times a week.
• Think ahead about what healthy foods you need to buy so you don’t run out.
• Weigh yourself or put on a particular close fitting outfit (eg trousers) once a week. You need to know
when you are going off track.
• Cutting calories one way or another is usually needed to lose weight. A typical weight loss programme for
a woman will be 1,200 kilocals and day and 1,800 for maintenance. The type of food won’t change just
the higher quantity you can allow yourself when you have stabilised at a weight you are happy with.
• Look at the internet, books and speak to your friends about what works for them before deciding which
plan to commit to. What sort of programme would suit you best?
• Exercise during and after weight loss.
• Change aspects of your life that have been making you unhappy. This can help your mood considerably.
• Develop other interests in your life that don’t involve food and drink.
• Low carbohydrate diets tend to cause more weight loss through better compliance than low fat/ calorie
counting diets. Lack of hunger is a main advantage. For diabetics or people with metabolic syndrome there
are are other benefits such as more predictable blood sugar control, lower blood pressure and healthier
lipid patterns.
• Some kinds of diet work better for different people. Do your research and once you decide on a plan stick
to it consistently for best results.
Katharine’s How to .... series
8
Chapter 2
METABOLIC SYNDROME
Metabolic syndrome is a collection of disorders of metabolism which share a common outcome — much earlier
deterioration of your blood vessels.
The major factors related to metabolic syndrome are insulin resistance, hypertension, low HDL, high triglycerides, high oxidised LDL, atheroma formation, gout, polycystic ovary syndrome, renal disease, ischaemic heart
disease, dementia, peripheral vascular disease, central obesity, high inflammatory markers in the blood stream,
non alcoholic fatty liver disease, and defective insulin secretion or action so that blood sugars rise too high
particularly after meals.
Some of these effects you will see, some your doctor has to pick up doing tests and some are illnesses in
their own right.
The problem is that if you have one of these you are more likely to get others.
So how do you improve things or stop them getting worse? Broadly diet and excercise.
For most people wanting to lose weight they can restrict fat or calories as they like. For people with metabolic
syndrome or diabetes there are considerable benefits to be had from a low carbohydrate, moderate protein, high
fat diet. This is because other factors such as insulin resistance, high blood pressure and lipids also get better
on such a diet. These factors are even independent of weight loss.
Exercise can be geared to activities to improve your cardiovascular fitness such as brisk walking or cycling
and also for muscle building activities such as weight training as this particularly improves insulin resistance.
To know what a low carbohydrate diet is all about you need to know what sorts of food contain carbohydrates, protein and fats. What can you eat freely? What can you eat in small amounts? What do you have to
avoid?
9
Katharine’s How to .... series
10
Chapter 3
HOW TO FOLLOW A LOW
CARBOHYDRATE DIET
Most of the diets that I have chosen to discuss have three main structures:
1. Restriction in type or amounts of certain foods or both.
2. Carbohydrate counting which is important for metabolic control.
3. Calorie counting which can be important if additional weight loss or gain is needed.
In the metabolic syndrome part I will particularly discuss Dr Annika Dalquhist’s diet and Drs Allen and Lutz
Life without bread diet. Anna’s is food type restriction diet and Allen and Lutz’s diet is an easy ”block” method
of carb counting.
In the type two — insulin resistance — diabetes section I will discuss the Atkins diet and the Eat to meter method. These both give you suggestions on outcomes and you manipulate your diet to achieve them. More
advanced carb counting skills are needed for both methods.
In the type one — insulin dependence — diabetes section I will discuss Dr Richard Bernstein’s diet and Dr Lois
Jovanovich’s diet. Both these doctors have type one diabetes themselves. Dr Bernstein is at the strict end of
the scale and Dr Jovanovich’s diet is at the more liberal end. By understanding both concepts I hope you can
find an eating plan that suits you.
All the dietary plans are suitable for all ranges of glucose metabolism disorders. What will be important
is how much you need to control your blood sugars, how much weight you want to lose, how good your carb
counting skills are and how much carbohydrate you feel you ”must have.”
Dr Annika’s Diet
• Carbohydrates are food items that contain sugar and starch.
• Dairy products contain fat and variable amounts of carbohydrate and protein.
• You may eat full cream milk, yoghurt, feta cheese, cottage cheese, creme fraiche, cream cheese, butter and
mayonnaise.
• Avoid low fat, lite, or sugar added products.
• Meat contains protein with variable amounts of fat.
• Eat beef, pork, lamb, chicken, fish and shellfish. You don’t need to remove the fat.
• When eating ham, sausage and other processed meats be aware that they often contain sugar and starch
as binding and fillers. Choose items that are not more than 5g carbohydrate in 100g of the item.
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DR ANNIKA’S DIET
• Eggs are great. High protein and low in fat and carbs.
• Herbs, spices, stock, salt, pepper and low carbohydrate sauces will help your food taste pleasant and
exciting.
• Most vegetables, olives and linseed are good.
• Cold pressed oils can be used for dressing and cooking. Olive, rapeseed, linseed, coconut, palmoil and
macadamia nut oils are good. Avoid commercial vegetable oils as they contain partially hydrogenated
and trans fats.
• Unless you eat a lot of fatty fish such as sardines, trout, salmon and herring you may benefit from an
omega 3 oil supplement.
Foods to limit or avoid:
• Potato and potato products such as chips and crisps.
• Rice and rice products.
• Corn and corn products eg cornflakes.
• Grain based products eg pasta, bread, biscuits, breakfast cereals and porridge.
• Sweets, cakes, pastries, non diet fizzy drinks and fruit juice and cordials.
• All sugar and sugary products.
• Margarines and processed oils contribute to cardiovascular problems, diabetes, weight gain, cancer and
allergies.
• Oils with a high omega 6 content eg corn oil, sunflower oil, soya oil, peanut oil.
You may be crying when you read this list but I promise you that you can soon get into the way of making
much lower carb and healthier versions of many baked goods and desserts.
Many people have been brought up on potatoes and bread and find it particularly hard to let go. Reduce
them gradually. Not too gradually!
You may eat a little of these foods:
• Beans, lentils, nuts, sunflower seeds.
• Fresh fruit.
• Chocolate with a high cocoa content such as over 60%.
Avoid dried fruits and fruit juices as there is too much sugar in them.
When you are trying to lose weight the legumes, fruit and chocolate may stall your weight loss. Could you give
them up for a while ?
What about alcohol? It also can add to the calories and more importantly can affect your judgement on
portion sizes and will power. Beer in particular contains maltose which is a very fast acting carbohydrate. Dry
red and white wines are somewhat healthier for you. But only in small quantities.
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DR ANNIKA’S DIET
MEAL SUGGESTIONS FOR DR ANNIKA’S DIET
Breakfast options:
• Yoghurt with 1-2 tablespoons of linseed or sunflower seeds. Add wheat bran if you are prone to constipation.
• Eggs, sausage, bacon, ham, black pudding, mushroom, tomato.
• Omelettes with meat/fish/vegetables
• Low carb baking eg cheesecakes, muffins with double cream and small quantities of fruit as desired.
• Coffee or tea with cream or milk.
Lunch and supper options:
• Mainly meat/fish/eggs/cheese based dishes with vegetables or salad vegetables such as celery and avocado.
• Avoid low fat products. Many stews, soups and gratin dishes are naturally low in carbohydrate. You can
adjust most recipies to give a much lower carbohydrate alternative.
• Cooked cauliflower especially with cream, cheese and seasoning makes a great substitute for potatoes.
• Grated cabbage and carrot with an oil and vinegar dressing makes a good base for a salad.
• Quick snacks to tide you over till the next meal are cheese slices, ham, sausage, yoghurt, nuts, olives or
boiled eggs.
• Crisp breads can be loaded with butter, cheese, ham and other toppings.
• At a buffet load up with the high protein and fat items and leave the carbohydrates alone.
• Fruit does raise the blood sugar so avoid or take a lot less of the higher sugar tropical types such as
bananas and grapes and eat moderate portions of the temperate grown fruits such as apples and pears.
If you do eat a high carbohydrate meal you are likely to feel hungry or get another carb craving after about an
hour or two when the high blood sugar starts to drop. Just take a low carb snack at this point. This will help
your sugar and insulin levels get on an even keel again.
Low carb diets work because you don’t experience a raise in blood sugar after eating. You avoid the pancreas releasing excess insulin which lowers your blood sugar making you feel hungry again.
Insulin is a major fat storage hormone. It converts the carbohydrate you eat into fat.
Your body can make enough glucose and energy for essential processes all by itself from the protein and fat in
your food. Your muscles and brain work just fine with a mixture of ketones and bodily produced glucose. This
steady production of sugar in the body is called gluconeogenesis and it can occur in the liver, kidneys and intestinal tract. Reliance on mainly fat and protein for energy mean that you don’t need to load your body with fast
sugar releasing carbs that raise and lower your blood sugar and insulin levels causing unhealthy metabolic effects.
This low carbohydrate diet is very suitable for anyone who wishes to lose weight.
If you are on any medication or insulin to lower your blood sugar, for instance if you have type one or two
diabetes, you must reduce the carbohydrate in your diet gradually and do more frequent checks on your blood
sugar. This diet very effectively reduces your blood sugar and to balance this you will need to have a progressive
reduction in your medications and insulin.
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HOW TO FOLLOW THE ”LIFE WITHOUT BREAD” DIET
HOW TO FOLLOW THE ”LIFE WITHOUT BREAD” DIET
This diet is quite similar to the carbohydrate exchange method that was used for many years by diabetics.
The authors, Dr Christian Allen and Dr Wolfgang Lutz have counted out units worth 12g of carb each for
most food groups. They suggest that for most people eating 6 × 12g of carbohydate a day will give around 70g
of carb a day which is palatable and helps weight loss, diabetes control and other autoimmune illnesses.
For people over 45 or heart or autoimmune problems they suggest starting at 9 × 12g a day and slowly
reducing to 5 or 6 such portions (60-70g of carb a day).
This method gives a bit more flexibility over what foods you can eat compared to Annika’s diet. The basic diet free intake of fish, meat, eggs, cheese, dairy products, non starchy vegetables, moderate intake of nuts
and alcohol remains the same.
All carbohydrate containing foods such as grain products and potatoes, sweetened foods, sweet and dried
fruits must be accounted for.
For the full list of foods see their book, Life Without Bread.
For illustration purposes I will list a typical day that you may have on this diet.
Breakfast
• 3 egg omlette with onion and peppers
• half a grapefruit one unit
• Coffee with cream
Lunch
• Cold roast chicken
• lettuce, one medium tomato, half an avocado 1.2 units
• 1/4 cup of rice (before cooking and seasoning) 3 units
• Tea with small amount of milk
Evening meal
• Peppered steak with cream sauce and mushrooms one unit
• Slices of danish blue cheese and brie with celery
• Two glasses of wine 0.8 units
The trick is to fill up on a wide variety meat and fats and reserve your carbohydrates to give a bit of variety to
your meals. Instead of basing your meals on the same old bread, potatoes, rice and breakfast cereals base them
around meats/fish/eggs and cheese and non starchy vegetables.
For a lot of people it is harder to eat low carb away from home and if this true for you allocate more of
your allowance to these meals and make the effort to cook delicious low carb meals at home.
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HOW MANY CARBS AND CALORIES DO ALCOHOLIC DRINKS HAVE?
HOW MANY CARBS AND CALORIES DO ALCOHOLIC DRINKS
HAVE?
For non insulin users alcoholic drinks are just a matter of carbs and calories to worry about. For insulin users
however the issue of delayed hypoglycaemia needs to be understood. For diabetics of both types one and two
anything more than light or very modest alcohol drinking is not compatible with good control and safety. Many
people have no idea what drinks contain and this list aims to give you relevant information on that point.
Beer one pint
13g carb
Lager 500mls bottle
7.5g carb
Stout 275 mls bottle
11g
Cider dry one pint
15g
Cider sweet one pint
25g
Cider vintage strong one pint
42g
Dry wine (red or white) 125mls
trace carbs
Sweet sherry 50mls
3.5 carbs
champagne 125mls
2g
Any spirit 25mls
trace carbs
Bacardi Breezer 275mls
20g
Soft drink 120mls
14g
Tonic water 120mls
12g
Gin and Tonic 245mls
16g
Diet drinks and water have no carbs and no cals.
170 calories
146 cals
100 cals
207 cals
242 cals
580 cals
85 cals (some say allow 5-10g)
70cals
95 cals
60cals
170 cals
50 cals
45 cals
170 cals
HOW TO EAT OUT IN A RESTAURANT
Doctors Mike and Mary Dan Eades are the authors of Protein Power. This has an excellent section on eating
in international restaurants both the dos and the don’ts. It also gives clear scientific reasons for low carbing
and the advantageous effects fo this diet on the metabolic syndrome. There is also a good recipe section.
Here are a selection of what you can eat in restaurants.
• Drink a single glass of wine as 5g
• Drink mainly diet drinks, water, tea and coffee without sugar.
• Dessert can be berries and double unsweetened cream, fresh fruit salad or cheese.
Bistro
• Grilled meat fish or fowl, green salad, blue cheese or vinaigrette dressing.
• Eat vegetables instead of potatoes, pasta or rice. No bread or crackers.
• Chefs or caesar salad but no croutons.
• Quiche but don’t eat the crust.
• Tomato stuffed with chicken, tuna, crab or cottage cheese.
BBQ
• Beef, pork, chicken, dry ribs, tossed salad, devilled eggs.
Fast Food Burger Restaurants
• Eat the fillings of grilled chicken, burgers including cheese and bacon. No buns or chips.
• Chicken salad but miss out the croutons.
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HOW TO EAT OUT IN A RESTAURANT
Chinese
• Hot and sour soup
• Beef or chicken kebabs
• Beef, chicken, pork, prawn dishes with broccoli or assorted chinese vegetables. No noodles, rice, or
pancakes.
• Dry ribs. Avoid sweet sauces.
French
• Clear soups
• Green salads
• Beef, pork with butter or peppercorn sauce.
• Roast lamb, duck or other poultry.
• Grilled or poached fish.
• Mixed vegetables.
• Avoid sauces thickened with flour.
Indian Restaurants
• Tandoori chicken or lamb.
• Chicken, beef or lamb curry.
• Chicken tikki or chicken masala.
• Tossed green salad, tomato and cucumber salad, spinach, mushrooms.
• Vegetable accomaniments are often good choices. Try cauliflower instead of rice with a meat curry.
• Avoid breads and potato dishes.
Italian Restaurants
• Cured meats and melon
• Chicken or veal, grilled fish, pork. Avoid breaded items.
• Salad and vegetables instead of pasta, risotto or bread.
• Steak Diane.
• Veal in cream sauce.
• Cheese and a few grapes or apple slices for dessert.
Japanese
• Sushi but undereat the rice or order sashimi which has none.
• Miso soup.
• Terriyaki chicken, beef, fish, prawn. No tempura as it is battered.
Mexican
• Chicken or steak fahitas but miss out the torilla. You can have the guacamole, sour cream and vegetables.
• Meat and salad.
Pizza
• Pizza toppings only.
• Buffalo wings with the sour cream rather than bbq sauce.
• No pasta, bread dishes or ice cream.
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Chapter 4
HELPFUL LOW CARB BOOKS
Atkins for Life. Very good clear book for long term low carbers. Atkins is the standard text
on which many other low carb diets are variants. This is the most flexible regarding what fat and what carb
you can eat.
Dr Atkins New Diet revolution. The orange paperback. You can probably borrow someone’s. In every workplace or club someone has done Atkins or knows someone who has.
Dr Atkins Diabetes Revolution. More tailored to the type 2 diabetic.
The Protein Power Lifeplan by Drs Mike and Mary Eades has been recommended by diabetics.
I find it hard to choose between Atkins for Life and Protein Power as a basic book for people with metabolic
syndrome but due to a better cooking section and clearer reasoning of the scientific evidence in Protein Power
I recommend the Eades book if you are only going to buy yourself one book on the subject.
For other Low Carb books that are recommended by our members, please Click Here.
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Chapter 5
MYTHS ABOUT LOW CARB DIETS
Living the Low Carb Life by Jonny Bowden gives lots of reference material throughout his
book. One thing that always comes up when you tell your friends that you are going to go on a low carb diet
are what I call the ”Oh. Buts” Here are some of the commoner myths regarding low carb diets as explained by
Jonny Bowden.
Myth One. Low carb diets induce ketosis, a dangerous metabolic state.
Dietary ketosis is not the same as diabetic ketoacidosis. The ketosis of a low carb diet is also not the same as
the ketosis of starvation. Many studies have demonstrated the safety of ketogenic diets even for children.
Myth Two. Low carb diets cause calcium loss, bone loss and osteoporosis.
Higher protein intakes do not cause bone loss or osteoporosis especially in the presence of adequate mineral
intakes. In fact lower protein diets are associated with more bone loss.
Myth Three. High protein diets cause damage to kidneys.
Higher protein diets do not cause any damage whatsoever to healthy kidneys.
Myth Four. The only reason you lose weight on a low carb diet is because it is low in calories.
Calories count but so do hormones. Many studies show more weight loss on low carb diets than on high
carb diets with the same number of calories. Also more of the weight lost on low carb diets comes from fat.
Better blood biochemistry occurs too. Lowering fat intake is not the only answer to obesity.
Myth Five: Low carb diets increase the risk of heart disease.
Low carb diets do not increase the risk of heart disease and in fact they improve blood lipid profiles.
Reference: Scientific evidence for the erroneous myths have been gathered and presented in a paper by Anssi
H. Manninen. High Protein Weight Loss Diets and Purported Adverse Effects. Where is the Evidence? Sports
Nutrition Review Journal. 1 (1): 45-51, 2004. (www.sportsnutritionsociety.org)
Manninen works at the Dept of Physiology, Faculty of Medicine, University of Olulu, Finland.
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Very impressive.
The other day my husband got a few minutes looking at a sparrow hawk who was sitting near our bird feeder.
These bird feeders must be like the McDonalds / Pizza Hut signs to predators.
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Chapter 6
HOW CAN YOU EXERCISE?
If you are not used to exercise:
• Gentle walking building up to 30 minutes every day.
• Gentle weight training starting with very light weights or rubber bands.
• Gentle yoga or stretching
• Tai chi.
• Chair based exercises. In the UK both Lizzie Web and Rosemary Conley have dvds/videos with these
and other exercises. Amazon.co.uk rents fitness videos. Try before you buy.
• Why not see if you can join a pensioners keep fit class at your local hall? If you are not a pensioner
explain that you are extremely unfit and would appreciate a gentle introduction to fitness.
• ANYONE WITH MORE THAN BACKGROUND RETINOPATHY WHO HAS NEW
VESSELS NEEDS TO SEEK ADVICE ON EXERCISE. Any jarring activity such as jogging
or trampolining could rupture the delicate blood vessels and cause a bleed into the eye. Upside down
postures in yoga and serious weight training must not be done.
If you are somewhat used to exercise:
• Interval / Circuit training.
• Moderate weights
• Yoga. Pilates.
• Aerobics / Fitness / Dance classes building from 15-60 minutes.
• Video tapes and dvds. These cost almost nothing at car boot sales. You can also rent fitness videos from
amazon.
• Why not join a gym or regular class? You will get expert tuition. Weight machines tend to be safer than
free weights for novices.
• THOSE WITH CARDIOVASCULAR IMPAIRMENT OR AUTONOMIC OR PERIPHERAL NEUROPATHY NEED EXERCISE ADVICE. Unaccustomed exercise that raises your
heart rate could be risky. Shoes must be well fitting and suitable for the task.
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Chapter 7
HOW TO GET INFORMATION ON
LINE
This is a collection of websites that may help you to improve your low carb know how, cookery skills, exercise
routine and knowledge about glucose metabolism disorders and diabetes.
Low carb cooking
www.carb-lite.au.com * my favourite*
www.genaw.com/lowcarb/index.html
www.recipegoldmine.com *go to low carb recipies on list*
www.solitarydancer.wordpress.com
www.steviva.com/steviva.recipies.html
www.lowcarbluxury.com
www.lowcarbcafe.com
www.wilstar.net/lowcarbpavilion
www.holdthetoast.com
www.lowcarbrecipies.com
www.lowcarbresearch.org
www.lowcarbmegastore.com
www.lowcarbdiets.about.com
Carb counting
www.calorieking.com
www.nal.usda.gov/fnic
www.carbs-information.com/carbs-in-flour-baking-ingredients
www.dietfacts.com/fastfood.asp
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EXERCISE
Exercise
www.amazon.co.uk *dvd rental and books*
www.lowcarbmuscle.com
www.crossfit.com
www.exrx.net
www.diabetes.ca/files/Riddell-Final.pdf * for type ones*
Glucose metabolism disorders and diabetes
www.diabetes-normalsugars.com *meet the Bernies at the forum*
www.dsolve.com * the Bernie’s sister site*
www.iddtinternational.org
www.bcchildrens.ca/Services/SpecialisedPediatrics/EndocrinologyDiabetesUnit/ForFamilies
www.care.diabetesjournals.org/cgi/content/full/diacare;27/9/2266
www.mercola.com
www.second-opinions.co.uk
www.joslin.org
*I’m sure there are other sites that people would like to include. If so please post the address and the section
in which you think it would fit best*
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Chapter 8
HOW DO I LOOK AFTER MYSELF
WHEN I HAVE TYPE TWO
DIABETES?
UNDERSTANDING THE PROCESS OF TYPE TWO — INSULIN
RESISTANT — DIABETES
When you eat carbohydrate it gets broken down by the digestive system and appears in the blood stream as
glucose. Insulin is immediately released by the pancreatic beta cells. Insulin is the hormone that tells certain
types of cell in the body to take up glucose in the bloodstream. In this way the glucose level in the blood stays
within a narrow range.
In insulin resistant states such as metabolic syndrome and type 2 diabetes the cell wall insulin receptors are
less sensitive to insulin and in an effort to keep blood sugar levels normal the pancreas releases more insulin.
High insulin levels causes inflammation and stiffening of the lining of your blood vessels. This lining is called
the endothelium. This stiffening causes high blood pressure.
The pancreatic cells can initially make plenty of extra insulin to compensate for the weakened effect of the
insulin but eventually become exhausted and start to die off. This causes higher blood sugars. Unfortunately
blood sugars higher than 6.1 mmol/dL (110 mg/dL) are toxic to beta cells and they start to die off with higher
and higher blood sugars. The whole thing is a vicious circle.
Type two diabetes is often thought of as being less serious in some ways than type one diabetes. It is certainly true that a type two will not die as rapidly if they don’t get insulin as in type ones. On the long term
however type two diabetes causes all the same complications as type one and can be just as fatal. Instead of
it being obvious that something is drastically wrong with your health as in type one, those with type two can
have it creep up on them over many years, slowly causing damage to the blood vessels, eyes, kidneys and nerves
and not even know about it.
In type two diabetes there is initially a higher than normal amount of insulin present but after a long time
of struggling the pancreatic insulin producing cells die out and in many cases insulin injections need to give
anything like normal sugar control.
Type two diabetics store less immediately available insulin than normal people. In addition they also need
to produce more than normal because their cells are less sensitive to insulin. As their ability to produce insulin
on demand declines they get higher blood sugars after eating and this persists for much longer than in non
diabetic people.
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HOW TO ”EAT TO METER”
High blood sugars after eating can be minimised by eating fats, protein and carbohydrates that release sugar
gradually so that their pancreatic insulin factory (phase two insulin response) can keep up. This effectively
means eating non starchy vegetables as the main source of carbohydrates.
For type two diabetics who do not need insulin they may get better results from eating 4 or 5 small meals
a day rather than sticking to three bigger meals a day.
Many people have inherited their tendency to insulin resistance. If your parents or grandparents had heart
disease, high blood pressure, fat round the middle, high cholesterol, high triglycerides, type two diabetes or
swollen ankles you are more at risk.
The diabetes tendency becomes noticed at times such as pregnancy, ageing and if the person tends to eat
a high sugar or starch diet. Lack of exercise also affects how rapidly the tendency will appear.
Insulin primarily affects blood sugar but also affects blood pressure, cholesterol and triglycerides and the storage
of fat. No medications can reduce excess insulin production: only a low carb diet. A low carb diet works by
reducing the oversecretion of insulin and helps restore balance.
Beta blockers and diuretics which are often used to control blood pressure also increase insulin resistance
and are best avoided in some people.
Although there are cut off points in blood sugar tests to say who is normal, who has metabolic syndrome
and who has diabetes, the condition is really a continuum. Someone who has metabolic syndrome can get
retinopathy, kidney disease and cardiovascular disease just the same as a diabetic.
The worse your sugar control is the worse your cardiovascular and complication risk. A popular test to do
is the HbA1c. This is the percentage of sugar attached to your red cells in the blood. Although a normal range
of 4-6 is often given for instance it has been found that your risk goes up progressively from levels of just 4.6.
It therefore makes sense to have as good blood sugar control as you can, particularly if you have a moderate to
long life expectancy.
Tests that you can have done to find out your risk or severity of metabolic syndrome and type two diabetes
include measuring your waist/hip ratio, hbaic, glucose tolerance test, fasting lipids and blood pressure.
There is a progression in how type two diabetes is treated:
• Low carbohydrate diet
• Appropriate weight loss
• Exercise
• Drugs that enhance insulin sensitivity or insulin action
• Insulin injections with or without oral drugs.
People who have lived with high blood glucose levels for years can feel shakey or ill at normal blood sugar levels.
They also can have blurred vision. A gradual adjustment of the target blood range and progressive reduction
in carbohydrates can help these symptoms settle down.
HOW TO ”EAT TO METER”
The more normal your blood sugars are through the day and night and during and after meals the better able
you are to prevent or delay complications.
”Eat to meter” is a shortened way to say that you eat whatever you like, whenever you like AS LONG
AS YOUR BLOOD SUGARS STAY WITHIN THE NORMAL RANGE.
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HOW TO ”EAT TO METER”
This is perfectly easy if you don’t have metabolic syndrome or diabetes but causes considerable difficulty
for people with glucose metabolism problems.
Many diabetologists genuinely believe that diabetics cannot realistically acheive normal blood sugars. They
hope that the best they can do is to monitor your inevitable decline in health that high blood sugars produce
long term and sort out the worst of your complications with drugs, lasers and surgery.
There is no doubt that achieving normal blood sugars most of the time requires a lot of personal education, self
experimentation, time and effort. Whether this is worth it or not is a decision that is only your own. It is after
all your eyes, kidneys, feet and heart that are at risk.
Unfortunately the NHS and many other international health care systems do not currently provide an available,
affordable and appropriate educational package to help you achieve normal blood sugars. Helping you get the
degree of control you want is the purpose of this site. It is essential that you become an expert in your own
type of diabetes and its management. This site has lots of ideas, book and internet based resources to help you.
Joining a diabetes forum like the ”Bernies” can be a good way to get specific answers to your questions, get
emotional support and encouragement and even make friends.
Before you start to change your diet or other management it is essential that you consult a doctor or diabetic specialist nurse so that any changes can be done in a planned, step wise and consistent way that will
not have an adverse effect on your overall health. People on oral hypoglycaemic drugs and particularly insulin
are likely to see a dramatic reduction in their dosage requirements and any change of diet will require close
supervision and blood sugar monitoring so that dangerous and potentially fatal low blood sugars do not occur.
Normal fasting and between meal blood sugars for a fit young adult are 4.7 mmol/dL (84 mg/dL). Blood
sugars should not usually go below 4.0 mmol/dL (72 mg/dL) even if a fit young person has not been eating or
has been exercising vigorously. A healthy young person can expect to have a HbA1c of less than 5.0 although
the laboratory range takes the older and not so fit or slim population into consideration and often gives an
upper limit of 6.0.
Pancreatic beta cells start to die off at blood sugar levels of only 6.1 mmol/dL (110 mg/dL) and irreversible
damage to nerve cells starts at sugar levels of 7.8 mmol/dL (140 mg/dL). The blood sugar levels we therefore
recommend that you aim for are therefore:
• Fasting or before a meal assuming 3 spaced meals a day:
– Ideal: 4.7 mmol/dL (84 mg/dL)
– Type Ones: 5.0 mmol/dL (90 mg/dL)
– or at least below 6.1 mmol/dL (110 mg/dL)
• One hour after your meal has been finished a maximum blood sugar of 7.8 mmol/dL (140 mg/dL)
• Two hours after your meal has been finished a maximum blood sugar of 6.5 mmol/dL (117 mg/dL)
In order to achieve these most people will have to go on a pretty strict low carb diet. As well as this you will
need to understand about how other physiological events and exercise affect your blood sugars. Remember that
you are making long term decisions about your health every time you eat. Very tight control may not be for everyone. Have a look at the next section which is applicable to type ones as well to decide what you are aiming for.
This section is summarised from Gary Schiener’s excellent book for insulin users, Think Like a Pancreas and
Pumping Insulin by John Walsh and Ruth Roberts.
Extremely tight control:
Ideal for pregnant women or women who are planning a pregnancy. This reduces maternal and baby complications to almost non diabetic levels. In the USA some centres put these women on insulin pumps 9 months
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HOW TO ”EAT TO METER”
prior to a planned conception to help acheive this. Their blood sugar targets are much lower than in the UK.
The use of continuous blood glucose monitoring devices are used to detect night time lows and warn of pump
failure. A diet with no more than 40% calories from carbohydrate (which is still quite high) is given and high
glycaemic foods are banned.
• HbA1c target 4.8%
• Premeals and bedtime 3.6-5.2 mmol/dL (65-94 mg/dL)
• one hour after starting to eat 7.2 mmol/dL (112 mg/dL)
• 2am-6am 3.6-5.2 mmol/dL (65-92 mg/dL)
If these targets are not met the high or low blood sugars can cause damage to the mother and baby. A pregnancy
may be lost. These targets are aimed to mimic what goes on in a non diabetic pregnancy and the closer to
target the less risk their is of damage. If permanent damage from high blood sugars can manifest itself and be
crudely countable in the form of miscarriages, fetal deformity and birth complications after 9 months, what do
you think goes on in your body over say ten years or more?
Unfortunately the will and infrastructure is not geared in the UK to offer this sort of support to pregnant
women yet and in the USA it remains very expensive.
The plus point is that if you are willing to reduce your dietary carbohydrate sufficiently it is certainly possible to meet these targets and with less hypoglycaemia risk whether you are a type one or type two, male or
female, pregnant or not, youthful or not so youthful.
Tight Control
• For older children. They are going to have diabetes for a long time.
• For those in honeymoon. This phase can be prolonged with tight control.
• Experienced insulin pumpers. You have the technology to achieve this.
• Low carbers. You will find it easier than most to achieve this.
• HbA1c is 5-6
• premeal target range 3.3-7.8 mmol/dL (60-140 mg/dL)
• one hour post meal range less than 8.9 mmol/dL (160 mg/dL)
• specific premeal target 5.6 mmol/dL (100 mg/dL)
The majority of the Bernies achieve this level of control according to a recent poll. Of course some are at normal
”non diabetic” blood sugar levels and others are much higher but working their way down gradually.
Typical Control
• Ideal for drivers who wish to avoid hypoglycaemia.
• Most adults.
• New insulin pump users.
• Whenever you are switching to a new insulin or delivery method.
• HbA1c range 6-7
• premeal target range 3.9-8.9 mmol/dL (60-160 mg/dL)
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HOW TO ”EAT TO METER”
• one hour post meal target less than 10 mmol/dL (180 mg/dL)
• specific premeal target 6.7 mmol/dL (120 mg/dL)
These blood levels would have most diabetologists and endocrinologists cartwheeling down their hospital corridors with glee. These levels are great to get to when you have been struggling so hard with a high carb/low fat
diet on insulin or perhaps are quite insulin resistant. Please be aware however that you will be delaying rather
than preventing complications at these levels. I don’t want to take the wind out of anyone’s sails but when you
have been low carbing for a while it does get progressively easier to hit these targets. If this is you do you think
you could go a little lower?
Looser control
• Ideal for babies and toddlers and young children whose food intake and activity is unpredictable. Youngsters also tend to me more mentally affected by recurrent or severe hypoglycaemia.
• Adolescents may have great trouble keeping their levels other than this because of the great hormonal
changes that are occurring. Control will become easier in your twenties so just do the best you can do.
• Older diabetics and particularly those who live alone. Because diabetic complications develop slowly over
several to many years you may be able to be more relaxed.
• HbA1c range 7-8
• premeal target 4.4-10 mmol/dL (79-180 mg/dL)
• post one hour target 11 mmol/dL (198 mg/dL)
• specific premeal target 7.8 mmol/dL (140 mg/dL)
To get good control you need to have the appropriate tools and help from your medical support team. You
will need to test your blood sugars quite frequently and you will need to know something about carbohydrate
counting.
Good records help a lot because you can see patterns in your control. Frequent high or low blood sugars
at certain times of the day indicate that a change may be needed.
It is always best to sort out any low blood sugar problems first before you try to sort out the highs. Sort
out baseline blood sugars before dealing with meal issues. Sort out problems that occur early in the day before
tackling the problems that are going on later. More detailed advice on how to do this for insulin users is given
in the type one section.
Keeping your diabetes in control is what enables you to enjoy your life and fulfil your other obligations. People
who are consistent with their diet, avoiding unnecessary or frequent snacks tend to achieve much better blood
sugar control.
Because your and the doctor will be making decisions based on your blood sugar levels you can improve
accuracy by:
1. Washing and drying your hands.
2. Apply a sufficient amount of blood to the test strip.
3. Code your meter accurately.
4. Keep your meter with you or perhaps have one on your person and one in the house or car.
5. Have a regular checking system so you don’t run out of batteries, strips or lancets.
6. Record your findings at the time or before you go to bed for the night.
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HOW TO COUNT CARBOHYDRATES
7. Remember your record book when you visit the medical team.
8. Do averages of several readings at the same times of the day to look for patterns in control. Between 3
to 14 days works well for many people depending on how stable your diabetes is and how many changes
around exercise, meals and medications you are making.
9. Patterns may vary with shift work, work or weekends, monthy cycles, weather conditions and seasons.
10. Consider computer based logs that can produce graphs and charts to make this more visual and interesting.
HOW TO COUNT CARBOHYDRATES
There are several methods of carbohydrate counting that are commonly used.
1. Lists.
2. Exchange method.
3. Carb factors.
4. Nutritional labels.
5. Nutritional scales.
6. Eyeballing.
These all have their pros and cons. You need equipment or information sources for some of them. No matter
how accurate you try to be you are likely to end up with an approximation of the carb content. The more of
these methods you become comfortable with the more versatility you will have under different circumstances.
In all cases you need to make the best estimate you can and notice the results you get. What would you change
next time if your post meal blood sugars are not within your particular target range? By giving it your best
guess and then testing you can build up a profile of how your body, medication doses, and insulin can cope with
that particular meal at that particular time of day.
HOW TO LOOK UP CARB LISTS
Carb lists of food items can come from various sources. There are published books, web based resources and
chain restaurants will often publish leaflets to give you an idea of the carb count or have the information on a
web site.
One of the difficulties however is knowing what portion size they have actually measured. Sometimes a food is
listed by the amount of carb in 100g which is a little over 3 ounces. Other times cups, tablespoons, handfuls
or the number of items eg grapes are listed with carb count. The most accurate way is when you have a
standardised and individually packaged portion.
The website resources section in the metabolic syndrome section has some carb counting sites to help you
get started. In addition here is list from some fast food and other restaurants. To put these figures into context
the Atkins diet ranges from 20-120g of carb a day.
Burger King
• Whopper 48g
• Cajun Chicken deli wrap 48g
• Large fries 53g
• Sachet ketchup 4g
• Chocolate ice cream sundae 26g
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HOW TO LOOK UP CARB LISTS
McDonalds
• Big Mac 44g
• French fries regular 28g
• BBQ dip 12g
• Apple pie 27g
• Regular vanilla milkshake 63g
Kentuky Fried Chicken
• Original recipe chicken drumstick (one) 7g
• Chicken fillet burger 36g
• Corn 11g
• Crispy strip (one) 6g
Pizza
• One medium slice Italian pizza 27-38g
• Portion of lasagne 63g
• One slice of garlic bread 11g
Indian
• One portion of boiled basmati rice 110g
• Chicken tandoori 2g
• Chicken korma 16g
• Vegetable curry 15g
• Beef curry 6g
• Naan bread 80g
Canteen food
• Baked potato 70g
• Chicken pie for one 32g
• Meat pie for one 33g
• Shepherds pie for one 37g
• Battered fish 21g
• Sweet and sour pork 34g
• Chips small 31g
• Chips medium 50g
• Large 73g
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HOW TO USE THE EXCHANGE METHOD OF CARB COUNTING
HOW TO USE THE EXCHANGE METHOD OF CARB COUNTING
The exchange method of carb counting was used for many years. Diabetics and their carers were taught what
quantity of a carbohydrate containing food amounted to 10g, 12g or 15g of carbohydrate. The Life Without
Bread Diet which I have described in the Metabolic section uses a certain number of 12g carb portions a day.
In general this method can be more accurate than the list method. For instance a third of a cup of cooked rice
is around 15g versus about 110g for your average Indian restaurant rice portion. It is still subject to some error
of course.
The American Diabetes Association have come up with a rough quantity guide to help you. This is for a
woman’s hand.
• one clenched fistful = one cup
• palms sized quantity = 3 oz
• thumb tip = one teaspoon
• handful = 1 or 2 oz of snackfood
• whole thumb size = 1 oz
With all the inbuilt imprecision that this method of counting has you will always have to compare what you
think you ate versus the results you got. When you do have such items as nutritional scales or relatively accurate
portioned control amounts it is helpful to compare what they look like versus your usual portion size to improve
your eyeballing accuracy.
American cup sizes are used throughout.
All of these portion sizes amount to about 15g of carbohydrate unless stated otherwise.
Easy Averages
• 1/2 cup beans
• one small slice bread
• 1/2 cup cereal
• one cup milk = 10g
• 1/2 cup cooked pasta
• 1/3 cup cooked rice
• one large apple
• 5 small apricots
• 6 apricot halves in juice drained
• one small banana
• 1/2 a large banana
• 20 blackberries or blueberries
• 32 cherries
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HOW TO USE THE EXCHANGE METHOD OF CARB COUNTING
• 3 medium clementines or satsumas
• 3/4 cup fruit salad
• one medium grapefruit
• ten large grapes or 20 small grapes
• 2.5 kiwi fruit
• 3/4 of a medium mango
• 2 slices of melon
• one large nectarine
• one large orange
• 2 medium peaches
• 7 slices of canned peaches in juice drained
• one medium pear
• 3 pear halves in juice drained
• 3 slices of pineapple
• 3 medium plums
• 4 dried prunes
• 1.5 tablespoons of raisins
• 1/2 cup raspberries
• one tablespoon sultanas
• One medium slice of bread 24g
• one slice of french bread 1.5 cm in length
• 1.5 bridge rolls
• 1/2 medium sized roll
• one slice currant or raisin bread
• 1/4 cup breadcrumbs
• 1/2 medium chapati
• one toasted crumpet
• 1/2 currant bun
• 1/2 English muffin
• 2 small slices garlic bread
• one medium hamburger bun 24g
• one large hamburger bun 42g
• 1/2 hot cross bun
• 1/5 naan bread
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HOW TO USE THE EXCHANGE METHOD OF CARB COUNTING
• 1/2 sweet pancake 15cm diameter
• 2 large poppadoms
• one pitta bread
• one small scone
• 2 taco shells
• 1/2 corn or flour tortilla
• For most breads a 30g serving has 15g of carb
• 2 tablespoons canned sweetcorn
• one small corn on the cob
• 120g roast parsnips
• 1/2 cup frozen peas
• 1/2 small baked potato
• one very small boiled potato
• 10 crisps
• 2 tablespoons mashed potato
• For most vegetables
– 1/2 cooked = one cup raw = 5g carb
– 1 and a half cooked = 3 cups raw = 15g carb
• 1/2 cup of cornflakes, fruit and fibre or rice krispies
• 2 tablespoons muesli
• 1 cup puffed cereal
• 1/2 cup rolled oats made with water
• one biscuit of weetabix
• For most cereals a 20g serving has 15g of carb
• Apple juice 150mls
• drinking chocolate powder 20g
• unsweetened grapefruit juce 180mls
• Lucozade 85mls
• unsweetened orange juice 170mls
• unsweetened pineapple juice 150mls
• soft drink 140mls
• 1/2 cooked barley
• 1/3 cup bulgar wheat
• 1 and a half teaspoons cornflour
• 1/3 cup couscous
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HOW TO USE THE EXCHANGE METHOD OF CARB COUNTING
• 2 and a half tablespoons wholewheat flour
• 2 tablespoons white flour
• 1/2 cup pasta
• 1/3 cup cooked rice
• 1 and a half tablespoons dried rice
• 1/2 cup tinned spaghetti
• 3 tablespoons baked beans
• 1/2 cup kidney beans
• 2 heaped tablespoons lentils or split peas
• 3/4 cup custard
• 3/4 cup evaporated milk
• 1 and a half cups milk
• 1/2 cup vanilla ice cream
• 2 heaped teaspoons sweetened yoghurt
• 1/2 standard bounty bar
• 25g bar of chocolate
• 1/3 standard mars bar
• 1.5 small milky way
• 1/2 snickers bar
• 3 fingers of kit kat
• one finger of twix
• 3 cream crackers
• 3 crispbread
• 120g peanuts
• 3 cups cooked popcorn
• 25g packet of crisps
• one penguin biscuit
• two ginger nuts
• one 9g shortbread biscuit
• one 5cm square cake without icing
• one 2.5 cm square cake with icing
• one mr kipling french fancy 19g
• one choc chip cookie 8g
• one small slice chocolate cake
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HOW TO COUNT CARBS USING CARB FACTORS
• 2/3 large croissant
• one danish pastry
• 1/2 jam donut
• 1/2 slice fruit cake
• one jaffa cake 9g
• 3 level teaspoons jam
• one small slice madeira cake
• 1/2 an individual jam tart
• 1/2 mince pie
• 2 oatcakes
• 3 level teaspoons sugar
• one small slice swiss roll
• one small waffle
• For most dry biscuits and cakes a 25-30g serving will have 15g of carb
• For most sweets a 10-20g serving will have 15g of carb.
HOW TO COUNT CARBS USING CARB FACTORS
The carb factor is the percentage of carbohydrate present in a food. If an apple has a carb factor of 0.13 this
means that 13% of the weight of that apple is carbohydrate. If your apple weighs exactly 100g this would
contain 13g of carb.
To use this method you need a list of carb factors and a set of scales to measure out the weight of your
food portion. Nutritional scales have the carb and other factors built into them but you can use any scale
provided it is sensitive enough. Digital scales may therefore be preferable to analogue scales.
John Walsh and Ruth Roberts book, Pumping Insulin has a list of about 300 foods at the back.
The site www.friendswithdiabetes.org/carb factor.html has several very helpful links to help you with this
method including further internet resources. Friends with Diabetes has a link to 6000 foods and their carb
factors and also a convenient pocket sized list of carb factors that you can print out and take with you when
eating out. The set of scales may be a bit less portable but you can always measure and home and eyeball when
you go out.
NB: The Friends with Diabetes site’s links are not working as well as previously.
www.medexplorer.com/nutrition/nutrition.dbm is and gives not only carb content but other nutritional information too.
HOW TO COUNT CARBS FROM NUTRITIONAL LABELS
When you pick up many items of processed food you will find nutritional labels on them. How do you know
how much carb is in the portion you intend to eat?
For the purposes of illustration lets say I decide to have a meal of a half can of lobster bisque soup, 3/4 of
a can of spaghetti bolognese and half a can of mandarin oranges in light syrup with a dollop of tinned heavy
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HOW TO COUNT CARBS FROM NUTRITIONAL LABELS
cream.
I look at the lobster bisque. It lists :
Per 100g
Energy 51 kcal
Protein 3.4g
Carbohydrate 4.7g
(of which sugars 1.2g
Fat 2.1g
(of which saturates 1.2g)
Fibre 0.2g
Sodium 0.5g
I want to eat half a can and fortunately the figures for this are listed too.
How to I know how much carb to count? In this case it is easy because it is on the tin. Carbohydrate
9.8g per half tin (of which sugars 3.5g).
The important thing to remember is that it is the carb count and not just the sugar count that matters.
Now for the main course. Tinned spaghetti bolognese. The tin weighs 400g.
I pick up this can and go straight to the carb count.
It says carbohydrate 13.2 per 100g with sugars being 2.4g of this.
Per half can serving there is 26.3g with sugars being 4.8g of this.
Ignoring the sugar content as usual I see that if I want 3/4 of the can I will need to do a little sum.
Although this is an easy sum to do I would like to go though what your old school teacher called ”the working”
so that it is easier to do this cross multiplication technique with more awkward amounts.
If 100g weight = 13.2 carbs what does 300g weight contain?
Write it like this:
100g = 13.2
300g = X
Now cross multiply like this:
100g × X = 13.2 × 300g
From algebra you may remember that if you want to know what X is you need to move the 100g to the other
side of the equal sign. When you do this it has to go below the 13.2 x 300g sum to indicate that this is now
going to be divided.
So you get:
X=
13.2 × 300g
100
Using a calculator the answer is:
39.6
This cross multiplication technique can be used not only for counting how much carb is in a certain weight of
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HOW TO COUNT CARBS USING NUTRITIONAL SCALES
food if you have the carb factor or carb count from a list but how much of a certain food you can have to stay
within a certain carbohyrate limit.
Now dessert. Mandarin orange segments in light syrup. The can weighs 312g and the drained weight of
the can is 170g.
Per 100g for the fruit and the syrup the carb count is 14g of which sugars is 14g.
For half a can the carb weight is 22g of which sugars is 22g. The fibre content is 1g.
This fibre content is pretty low so can be ignored in this calculation. For certain foods with a significant
fibre level you may be best to deduct it from the total carb count. Fibre affects the bulkiness of the meal but
as it passes throught the gut without being absorbed you don’t need insulin to cover it. Because bulk can affect
blood sugars through the effect of glucagon released from gut distention Dr Bernstein suggests a compromise
by deducting half of the fibre from any given meal.
In this case we can find out how much carb is in half a can just by looking at the label. But what if this
information was not supplied? What if the can contents had been shared out and you really had no idea what
proportion of the can you had been given?
Lets go back to the carb factor information. 14g of the weight of the 100g of this food is carbohydrate. If
you weigh your portion on an accurate scale and it comes to 156g how much carb is this.
Cross multiply:
100g = 14g
156g = X
100 × X = 14 × 156
14 × 156
X=
100
X = 21.84g
Now lets add the cream. Per 100g the carb count is 3.6g. For a 50g serving size the carb count is 1.8g. The can
contains 283g so a serving size is 283/50 = 5.66th of the tin. A good couple of tablespoons by the look of this
for a very low carb count.
Now add up your meal carb content:
Lobster bisque 9.8
Spaghetti bolognese 39.6
Mandarin oranges 22
Cream 1.8
Total = 73g
Now, you won’t be surprised to hear after what we’ve been telling you about high amounts of carbohydrate
messing up your blood sugar control, weight and metabolism that this menu is for carb counting lessons only.
You want to eat much healthier meals that this canned rubbish don’t you?
HOW TO COUNT CARBS USING NUTRITIONAL SCALES
Nutritional scales come in two main types. The cheaper type has a booklet with food lists and you enter the
code of what you are weighing into the machine. More expensive models have an inbuilt computer with the
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HOW TO EYEBALL PORTIONS OF CARB CONTAINING FOOD
foods listed and you click on the food you are weighing. These tend to have a larger database and can be used
without having to have a booklet.
The nutritional scales give you the calorie, salt, protein, fat, cholesterol, fibre and carbohydrate counts for
any given weight of food. There are memory features too.
The Salter nutritional scale that I have has 800 foods listed from the USDA database. It cost me £32 from
Amazon. If you go onto the USDA site to find an even larger range of foods and have an accurate enough scale
you do not really need to have nutritional scales. I have found it a convenient and useful method and our family
even have guessing games about how many carbs a particular food portion contains. I have even taken it into
restaurants to carb count food!
Please add in any personal reviews of other types of nutritional scales with costs*
HOW TO EYEBALL PORTIONS OF CARB CONTAINING FOOD
Out of all the carb counting methods I have discussed this is the method subject to the most error and yet it
is the most commonly used.
To get success with this you have to practice and practice with the other more accurate methods of weighing out small portions of food and using packaging information, charts or nutritional scales to come to what
still is an approximation of the amount.
It has been shown that eyeballing is reasonably effective up to about 30g of carb portions but once the portions
get bigger the estimates get considerably less accurate. For this reason you are better to look at your food and
even move it about in your plate a bit try to replicate the portions you use at home with a known carb count
and then add them up.
It always amazes me just how much carb potatoes have compared to for instance cauliflower, broccoli and
green beans. Some eye ballings rules are that a golf ball size of mashed potato is 10g of carb and a woman’s
fist size of cooked low starch vegetable is 5g.
The lower the carb count of your meal the easier it is in general to figure out the carbs. There is less room for
error with what you think is one golf ball size of mash compared to say six such estimated portions which is
not unusual in some restaurant meals. This goes of course for rice, bread, pasta, chips, cakes and sugary sauces
too.
Partly for these reasons of difficulty in carb estimation and also because of the variability in the absorption and
effect of insulin injections it is far less troublesome to simply keep these food items to a minimum for insulin users.
Type 2s who don’t use insulin also find that their sugars spike with anything other than modest portions
of these items because they don’t have a supply of immediately releasable stored insulin in their pancreases.
Any of your own carb counting eyeballing techniques would be very welcome indeed*
HOW TO DO THE ATKINS DIET
The easy way to do the Atkins diet is to buy one of Dr Robert Atkins books and do it.
The book I would particularly recommend is Atkins for Life the Next Level.
This is a simple introduction to low carbing and it covers all the basics you should know about. The book
discusses the research information, the relative importance of protein, fat and carbohydrate in the diet and
gives you various meal plans and recipies that you can incorporate into various total daily carb plans.
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HOW TO DO THE ATKINS DIET
What I like about it is its versatility between carb plans from 20-120g of carb a day. Compared to the Zone
diet it is more versatile about the amount of carb that may suit you and compared to the South Beach diet
there is no unnecessary restriction on saturated fat.
When you do a traditional Atkins diet you start at 20g of carb a day and gradually increase your carbs as
far as you can till your weight loss levels out. For many people who are just plain fat and who are not on any
medication that could affect their blood sugar this is usually fine.
For anyone who is on insulin or blood sugar lowering medication such as the gliclazides or metaglinides this
would not be such a good idea. In fact such a drastic reduction could be dangerous.
But the Atkins diet has in my opinion still a great deal to offer. For those people who have pre-existing
heart disease or are otherwise at greater than average cardiac risk, or who are on medication or who perhaps
are getting on a bit - over 45 - for instance why not do Atkins in REVERSE?
What I am proposing is to take things nice and slow. If you have any glucose metabolism problem you are
going to have to restrict your carb intake for the good of your long term health sooner or later. You have to
face this sometime.
From my previous discussions about how to measure the carbohydrates you eat you can surely find some
way that suits you to find out how much carb you are currently consuming.
Whatever this is you need to start here.
That’s right.
Start wherever you are and start to cut down.
Week on week. Day by day. Meal by meal. Carb by carb.
If you are over 120g a day that is okay. If you are already on say 90g a day that is okay too. Simply look at
the weight loss and blood sugar goals you want to achieve for your future health and start right away.
Many people will get what they need at the higher ends of the Atkins range such as those following the
Zone or perhaps Dr Lois Jovanovich’s guidelines at about 120g of carb a day.
Some will want to drop their carbs further such as those people who are following the Drs Eades Protein
Power plan or the diet advocated by Dr Allen and Dr Lutz or Dr Jorgen Vestig-Nielsen or Barry Groves at
around 70g a day.
Others will not get to what they want until they get to Dr Bernstein’s diet of between 30-42g of carb per
day.
You decide.
What do you want to achieve?
What amount of carb restriction is likely to be necessary to acheive this?
How slowly must you go down for safety?
Whatever the answers are for you, I hope this internet course can help you get what you want with safety
and with the knowledge of companionship along the way.
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Chapter 9
HOW TO COOK AND BAKE THE
LOW CARB WAY
There are two ways of cooking and baking the low carb way.
By far the easiest way is simply to use ingredients that are naturally low in total carbohydrate and in glycaemic index and cook the way you usually do. For example many meat, fish, poultry and egg dishes can be
made just the same as usual and served with plenty of low starch vegetables and butter or olive oil instead of
rice, pastry, pasta, bread or potatoes.
The more tricky way is to substitute lower carb ingredients for the higher glycaemic, high carb items such
as sugar, flour, potatoes, rice and bread. This tends to be a lot more expensive and there is often some compromise regarding the texture and flavour of these dishes.
Learning how to cook and bake low carb well is a pleasure not only for the cook but for those who get to
eat the end result. You need not give up old favourites entirely. You simply enjoy them in a different way.
Before my son was diagnosed with type one diabetes I often bought entire meals from the cook chill cabinets at the supermarket. My son loves cakes and desserts and to maintain excellence in blood sugar control
without an apparent restriction in these food items I now make time to have a regular cooking and baking slot
about twice a week.
LOOKING AT INGREDIENTS: CARBOHYDRATE
What carbs raise your blood sugar very little and what ones raise it rapidly and a lot?
I have listed some of the commoner ingredients which Dr Atkins has listed according to how generous or
restricted you should be with them.
FOODS TO EAT REGULARLY
Asparagus, green beans, bok choy, broccoli, brussels sprouts, butter beans, cabbage, cauliflower, celery, chard,
collards, cucumber, aubergine, fennel, lettuce, mushrooms, okra, onion, mangetout, snow peas, peppers, radishes,
rutabaga, saukerkraut, spinach, sprouts, courgettes, tomato, water chestnuts.
Cottage cheese,ricotta.
Almonds, brazil nuts, coconut, hazelnuts, macadamias, pecans, pine nuts, pistachios, pumpkin seeds, sesame
seeds, sunflower seeds, walnuts.
41
LOOKING AT INGREDIENTS: CARBOHYDRATE
Chickpeas, hummus, kidney beans, lentils, lentil soup, minestrone soup, peas dried or split, soybeans, unsweetened soy milk, tofu.
Apple, blackberries, blueberries, cherries, cranberries, grapefruit, unsweetened grapefruit juice, oranges, peach,
pear, plum, raspberries, strawberries, tangerine.
All bran, cooked barley, low carb bread and muffins, low carb pasta, old fashioned oatmeal, wheat bran.
EAT IN MODERATION
IE infrequently or in small portions.
Carrots, green peas, mashed pumpkin, buttenut squash, tomato juice, tomato soup.
Whole milk, unsweetened yoghurt.
Cashew nuts, peanuts.
Black eyed beans.
Apricots, grapes, kiwifruit, mango, melon, papaya, pineapple.
Bran flakes, 100% wholegrain bread, pumpernickel bread, rye bread, sourdough, buckwheat, bulgur, whole
wheat couscous, egg fettucine, melba toast, no sugar added muesli, pasta, popcorn, raisin bran, brown rice, taco
shell.
EAT VERY SPARINGLY
These are the ”bad guys”.
Sweet corn, parsnips, pea soup, potato
Full fat ice cream with sugar
Baked beans
Apple juice, bananas, cranberry juice, tinned fruit cocktail, grape juice, orange juice, prunes, raisins.
White bread, wholewheat supermarket brand breads, cornflakes, couscous, semolina, crackers, croissants, pita
bread, pizza, pretzels, most breakfast cereals, all white rice, shredded wheat.
WHAT FATS SHOULD I USE?
Use lard, butter and macadamia nut oil in preference to refined vegetable cooking oil and margarine for frying
and in baked goods.
Use extra virgin olive oil, unrefined flax oil, hazelnut oil, walnut oil and macadamia nut oil for dressing salads.
Use grapeseed oil and canola oil for cooking at higher temperatures but stir fry instead when you can.
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HOW DO I SUCCESSFULLY SUBSTITUTE INGREDIENTS?
WHAT PROTEIN SHOULD I USE?
Free range meat, poultry, fish and eggs are best as they usually contain healthier fats and have less hormones
and antibiotics added.
Cold and cured meats may contain added sugar and preservatives that are not beneficial.
Lightly grill meats and fish and avoid getting them black.
Partly cook your barbeque meats in the oven to minimise the black on the outside and raw on the inside
health risks.
Use marinades to tenderise meat. Marinades with reduced levels of oil can reduce flaming that burns the
meat. Trimming fatty meat can reduce this too.
If you eat about the palm of your hand size minus the fingers of lean protein three times a day your are
having about the right amount for you.
HOW DO I SUCCESSFULLY SUBSTITUTE INGREDIENTS?
Some things lend themselves to substitution better than others.
Rice: Grate cauliflower and then gently fry it to simulate fried rice or steam it briefly to simulate boiled
rice.
Mashed potatoes: Steam or boil the cauliflower cauliflower for at least 7 minutes till it is tender and then
mash with butter and cream. You can add grated cheese or fried shallots or finely cut onions to taste. This can
also be used to top cottage pie and moussaka.
Pasta: Low carb pasta can be purchased in certain specialist stores. It usually has a high gluten content.
It seems to become high glycaemic again when it is overcooked or reheated so just cook lightly and once.
Spaghetti squash can be baked and then used in pasta dishes to mimic spaghetti.
Sauces: Instead of using flour to thicken sauces use cream instead of milk for white sauces. Very small quantities
of xanthan powder can also be used to thicken sauces.
Bread: Bread with a high soya content can be a reasonable bread substitute. Mandy Rodriguez from the
Bernie forum has produced ”The Best Tasting Microwave Bread” that is very popular.
add the link or the recipe with Mandy’s permission*
Pancakes: Instead of using flour use ground almonds and instead of sugar use a substitute.
Muffins: Instead of flour use such items as flaxseed meal, whey protein powder, soya flour, ground almonds.
Cheesecakes: These are very easy to low carb because the texture depends on the fat rather than the sugar.
They can have no base or a low carb pastry base can be made.
Chocolate: Dark chocolate is a very versatile and healthy ingredient when a high cocoa content, 70% or above
, version is used.
Cakes and Shortcrust Pastry: Such items as courgettes, almonds, ground hazelnuts, soya flour and whey protein
powder are used in various combinations as flour substitutes.
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RECIPE BOOKS
Because of oxidative damage caused by an excess of omega six vegetable oils and margarines it is better to
use unsalted butter, lard and macadamia nut oil for many baked goods. Hydrogenated fats have the advantage
of being cheaper and they produce lighter textured baked goods with a longer shelf life. On the long run though
we are aiming at not only improving your blood sugars but also your general health. As hydrogenated vegetable
fat consumption is related to higher obesity, diabetes, heart disease and cancer risks it is better to avoid them.
Baked goods may be heavier than you would like as a result. Beating egg whites separately till they peak and
then adding them in ito the cake mix is a technique that can help.
If you have a favourite family recipe that you can’t de carb successfully it is often possible to compromise
and use half the high glycaemic flour or sugar and substitute the rest. It is the texture that is more commonly
affected than the taste by going full low carb.
Sugar
All of the sugar substitutes are more expensive than sugar. There is not the same caramelisation and texture benefits or the range of sugar substitute types. To mimic brown sugar you can add a small quantity eg a
teaspoon of black treacle or black strap mollasses to eg a carrot, passion cake or gingerbread recipe along with
the sugar substitute.
To mimic white granulated sugar I have found the best one to be Steviva Blend.
To mimic icing sugar I have found Splenda to be the best. This is also more available and cheaper than
Steviva Blend. I find this sweeter than sugar and would recommend you use about half a cup or half the weight
of the amount of granulated sugar you would normally use in a recipe.
SUGAR CONVERSIONS
• I packet of sucralose (eg Splenda) = 2 teaspoons sugar in bulk but = 4 teaspoons in sugar of sweetness.
• 24 packets of sucralose (eg Splenda) = one cup splenda = 2 cups in sweetness
• NB Splenda is much lighter and sweeter than sugar so use HALF of the weight or bulk of the usual amount
of regular sugar on your first try of a recipe and increase to taste with your next go if necessary)
• Two tablespoons of Stevia Plus = one cup sugar
• One cup of Steviva Blend = one cup sugar
• One and a half tablespoons of Sweet and Slender = one cup of sugar
*any other sugar substitute conversions would be very welcome here*
RECIPE BOOKS
These are my personal selection of books that I cook from regularly.
500 Low Carb Recipies Dana Carpender
500 More Low Carb Recipies Dana Carpender
The Low Carb Gourmet Karen Barnaby
Low Carb Italian Cooking Francis Anthony
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INTERNET LOW CARB COOKING SITES
Low Carb Vegetarian Celia Brooks Brown
The Illustrated Atkins Low Carb Cookbook Robert Atkins
Low Carb Meals on the Go Sharron Long
Low Carb Sinfully Delicious Desserts Victor Kline
George Stella’s Living Low Carb George Stella
Eating Stella Style George Stella
INTERNET LOW CARB COOKING SITES
I have listed some helpful sites for you in the metabolic section. My favourite is:
www.carb-lite.com
The Bernies have been experimenting for years and have a very varied selection of recipies for you.
Bernie Forum Recipies*
Please add any favourite cooking or baking site here*
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INTERNET LOW CARB COOKING SITES
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Chapter 10
HOW TO EAT FROM A HOSPITAL
MENU
Ironically one of the most risky places for a diabetic to eat is as an inpatient in a hospital.
Because you are a diabetic you will be told by nursing and dietetic staff that you must choose from the ”Healthy
Eating” section of the menu. This ”Healthy Eating” section is specifically designed to be high in carbs, lowish
in protein and very low in fat. I’m not at all sure what kind of metabolism is suitable for this sort of diet but
it it’s certainly not a good idea if you have the sort of metabolism that cannot handle sugar and starch. This
is the situation for all those people with glucose intolerance or diabetes. Yes. You!
It is necessary for you and your relatives to be very firm at the outset that you must be able to choose
from the whole menu, be able to choose large or small portions as you desire and to bring in supplementary
food items if necessary. This could include olive oil and vinegar to dress your salads, fresh temperate grown
fruits, cheese, cooked meats, oatcakes and diet drinks.
For breakfast ignore the toast and cereals and porridge and go for the cooked breakfast and eggs in a large
portion. Supplement this with a small portion of fresh fruit. Grapefruit and mandarin orange segments are
often offered on hospital menus but they are usually tinned and sweetened with sugar so are best avoided.
Instead of digestive biscuits as a midmorning and midafternoon snack try some cheese and oatcake with butter.
Many hospitals routinely offer diabetics snacks as this used to be necessary with twice daily insulin regimes.
You may not really need a snack however. If you are hungry at a snack time you may not have eaten as much
protein and fat as you really needed to at the previous meal. If you are insulin dependent you will need to have
lucozade or gatorade or snacks available for low blood sugar treatment. A longer acting carb and some protein
can work well provided you are not too low.
For lunch and dinner pick large portions of meat, fish, poultry, cheese and egg dishes with vegetables or salad.
Ignore any potatoes, chips, rice, pasta or bread items. Avoid deep fried battered food if possible due to the
high hydrogenated fat content and carb content of the batter.
Before bedtime toast and biscuits are about the only thing that is offered in hospital. These are likely to
be too high glycaemic for you and cheese and cold meat or cheese and oatcakes usually work better to prevent
a blood sugar spike or nightime lows.
Despite the difficulties in getting fed properly in hospital it is well worth the effort to keep your sugars normal.
Your infection rate is decreased and your recovery will be faster.
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Chapter 11
HOW DO I LOOK AFTER MY
FEET?
Nerve damage to the feet due to the effects of high blood sugars takes between 5-20 years to become evident
from diagnosis for most diabetics. Lack of sensation makes your feet more vulnerable from things that you may
not even feel like tight shoes or a little gravel in the shoe. High blood sugars provide a nice growing medium for
bacteria. Blood vessel damage to the area supplying the feet make injuries take much longer to heal in diabetics.
Dr Bernstein runs a specialist wound clinic for diabetics and has studied the causes of injury which have led to
amputations. His book Diabetes Solution has a long list of dos and don’ts some of which you may know and others which you may not. I have not included every tip but would encourage you to buy the book and follow them.
Some tips are:
• Buy your shoes late in the day and make sure they do not pinch.
• Before putting on your shoes shake them out and make sure the linings are smooth.
• Have at least two pairs of shoes that you alternate every few days.
• Examine your feet for any injury or undue redness every day or get someone else to.
• Apply vegetable or animal oil every day to keep the skin soft eg olive or almond oil.
• Don’t smoke.
• Keep your feet away from direct heat and avoid overly hot or prolonged baths.
• Wear warm socks when it is cold.
• Avoid beta blockers if you have dry feet.
• Don’t file down or shave callouses or corns. These are natures way to protect you from abnormal pressure.
Get appropriate insoles, padding or bigger shoes. A specialist podiatrist or biomechanical evaluation may
be required for this.
• Get someone who can see what they are doing to trim your toenails if your vision is poor or not that
flexible. Get a podiatrist to teach you how to care for your feet and nails.
• See an experienced nurse or doctor if you get any foot injury right away. It can be a disaster if infection
gets hold. You may require high dose antibiotics, dressings and even hospital admission.
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Chapter 12
WHAT THINGS APART FROM
FOOD CAN AFFECT MY BLOOD
SUGAR CONTROL?
Often you may notice that the blood sugar in the morning is higher than when you went to bed at night even
when you have not had any bedtime snack. This can be due to a variety of causes including gluconeogenesis,
the dawn phenomenon and delayed stomach emptying which is also known as gastroparesis.
Gluconeogenesis
Gluconeogenesis (Latin for ”The making of new sugar”) is the process where the liver converts protein to
glucose. This goes on all the time to some extent but is suppressed in the presence of adequate amounts of
insulin and drinking alcohol. In type one patients who are no longer able to make enough of their own insulin
this process accelerates and is what causes their sugars to rise so high and for them to lose so much weight.
Dawn Phenomenon
The Dawn phenomenon is called this because the liver clears away insulin more efficiently first thing in the
morning compared to other times of the day. At the same time growth hormones and sex hormones are manufactured during the night and these make cells less sensitive to the action of insulin which normally moves
sugar from the blood into the cells. These two mechanisms result in higher blood sugars in the morning for
most people after puberty gets underway. Various dietary and insulin techniques can be used to minimise the
effects of this phenomenon.
Delayed Stomach Empting / Gastroparesis
Delayed Stomach Emptying is due to the effects of long term nerve damage on the way the stomach works. The
rate of stomach emptying is reduced and the bottom end of the stomach called the pylorus can go into spasm.
It can be difficult to know how your stomach will respond from one meal to the next.
For type two diabetics who are not on insulin or drugs which stimulate insulin secretion this may simply
give you very unpleasant indigestion.
For insulin users and those on drugs that stimulate insulin secretion, these are usually timed to act over
the time the food of the meal is getting digested. When food digestion becomes imbalanced, blood sugars can
be too low immediately after a meal only to go too high some hours later.
Special dietary measures are needed to overcome the effects of this condition and they are carefully explained
in Dr Bernstein’s book Diabetes Solution.
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Like many complications of diabetes it tends to become apparent after 5-20 years of diabetes depending on
the level of blood sugar control. Although the condition can certainly make diabetes control much more difficult it is possible to reverse delayed gastric emptying and some other complications by careful maintenance of
normal blood sugars for several years.
Genetic Factors
Blood sugars can rise over the long term from effects you can’t control like inheritance. Excess weight has both
genetic and environmental components from the womb onwards. Excess weight gain raises your blood sugars
because it makes you more insulin resistant.
Infections
Undiagnosed and untreated infections particularly gum and dental infections can raise your blood sugar. Careful
examination by a dentist is often needed. Treatment can take months.
Acute Illnesses
Dehydration and acute infections such as gastroenteritis, viral infections, acute injuries, surgical operations
or stress can raise blood sugars.
An important consideration is that once the blood sugar is high you become more insulin resistant because
of this and vicious circles of high blood sugars, not being able to control them and dehydration can occur. This
topic is further explored in the section on sick days in the Type One Section.
Chinese Restaurant Effect
The Chinese Restaurant effect named so by Dr Bernstein is the high blood sugars that rise disproportionately to the carb count of the meal due to the actual bulk of the meal. Moderate distention of the stomach
produces the stimulation of the hormone glucagon which acts in opposition to insulin. This makes the liver
produce more sugar from protein. The main thing to remember is not to stuff yourself at meals.
Exercise
Exercise affects blood sugars considerably. Different sorts of exercise can raise or lower your blood sugar.
This also varies according to how much insulin you have working at the time. The factors are very complex
and there will be more discussion and sources of information on this in the Type One Diabetes Section which
follows soon.
Exercise can improve many aspects of your life. Even if you have never been to a gym in your life and
like me ran away from the ball at enforced school P.E. sessions there are so many activities you can enjoy. You
can be active indoors, outdoors, in teams, alone, with help from instructors or by self discovery. Your mood,
physique, strength, stamina and flexibility can all benefit in some way.
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Chapter 13
WHAT DO I NEED TO KNOW TO
KEEP HEALTHY WITH DIABETES?
The Joslin Diabetes Centre have a check list so you can see what sort of things you need to know to look after
yourself with diabetes. This list covers type one and type two diabetes. For each heading I will list what we
have already covered on this course and what we will be covering in more depth in the Type One Section *
There is a considerable overlap between both types of diabetes. To start with most people with insulin dependent diabetes diagnosed in childhood or young adulthood are not overweight or insulin resistant. As time
goes on this may change so Type Ones would benefit from reading the earlier sections to see if any of it applies
to them. The majority of the carb counting methods have also already been covered in the Metabolic and Type
2 section.
For type twos who start of on diet or oral medications they may find that after a while this is no longer
sufficient to maintain normal blood sugars. You may benefit to read on to find out how to deal with insulin
now or in the future.
If you don’t feel really confident about any of the things I have listed please take advantage of some of the
books and internet resources in the help sections. It is important that you know what to do ahead of any
emergency developing so please contact your diabetes support team for further personal training.
MEAL PLANNING
• Your own meal plan
• know how carbs, proteins* and fats affect the body
• special foods and occasions
• dining out
• portion control
• label reading
• how to fit in treats*
• alcohol*
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SELF MONITORING OF BLOOD SUGAR
SELF MONITORING OF BLOOD SUGAR
• blood glucose goals
• how to use the meter
• monitoring schedule*
• storing supplies*
• interpreting blood glucose values and making decisions in diabetes treatment plan*
USE OF INSULIN AND DIABETES MEDICATIONS
• Action and side effects of medication*
• timing and schedule*
• insulin injection techniques*
• storage, refrigeration and disposal of supplies*
• what to do if you miss a dose*
EXERCISE
• What type, how long, how hard, how often and when.*
• snacking adjustments*
• preventing high and low blood sugars*
KNOWLEDGE OF HIGH AND LOW BLOOD GLUCOSE
• Factors that cause high and low blood glucose*
• symptoms*
• how to treat*
• when to call a healthcare provider*
• how to prevent*
FOOT CARE
• daily foot care*
• emergency treatment for cuts, sores and abrasions.
• how to do a proper foot exam*
• proper footwear
URINE TESTING FOR KETONES
• When and how to check for ketones*
• What ketones mean*
• When to call a doctor*
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YOUR HEALTH TEAM WILL DO THESE ANNUAL CHECKS AND TESTS
YOUR HEALTH TEAM WILL DO THESE ANNUAL CHECKS
AND TESTS
• A1C ( 2-4 times a year)*
• kidney function*
• cholesterol, ldl, hdl, triglycerides*
• foot exam*
• eye exam*
• blood pressure*
• general health check eg thyroid, tests for coeliac disease and anything relevant to you*
YOU NEED TO BE VERY CONFIDENT ABOUT
• Your own meal plan
• The medication you are taking
• Your glucose monitoring system
• The treatment of high and low blood sugars
• How to manage your sick days
• Your risk factors for developing other health problems
• Your foot care
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YOU NEED TO BE VERY CONFIDENT ABOUT
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Chapter 14
HOW TO KEEP HEALTHY IF YOU
NEED TO TAKE INSULIN.
DIAGNOSIS of TYPE ONE DIABETES
For most children or young people they will find out very quickly after diagnosis that they will need to be on
injected insulin for life. Perhaps they will have had symptoms of weight loss, drinking a lot and passing urine
a lot. Others will have become very ill with diabetic ketoacidosis and will have been hospitalised.
More and more often younger people are being diagnosed with metabolic syndrome and type 2 diabetes. This
is usually related to being overweight, sedentary and genetic influences. Women with type 2, gestational or
type one diabetes may find themselves being intensively treated with insulin during the planning or carriage of
a pregnancy. Outwith pregnancy most people with type 2 diabetes will remain on diet and oral medications
to control their diabetes. After about six years around half of type 2 diabetics will have needed to add insulin
to their medication regimes to maintain good control. Diabetics who use certain drugs to stimulate the pancreas to produce more endogenous insulin from their own pancreatic beta cells are more at risk of beta cell failure.
Type one diabetes results when the pancreas can no longer make enough insulin to prevent high blood sugars.
For early onset patients it is an autoimmune disease that used to be a death sentence. Now that insulin is widely
available for most people it is rarely as rapidly fatal. But until a real cure can be found and made available it
can still feel like a life sentence.
Insulin is a drug that needs to be used very carefully. It can rapidly lower blood sugars and cause hypoglycaemia which can cause death if it is very severe and is untreated. Lower levels of hypoglycaemia may not be
obvious to drivers or their passengers and yet can cause impaired reaction times and judgement which can lead
to accidents. High blood sugars are less of a worry on the short term but on the long term damage accumulates
that can severely affect the nerves, eyes, kidneys and heart.
Pancreatic beta cells start to die in tissue culture at sugar levels of 6.1 or higher. This is not a threshold
effect and if blood sugar levels are brought below this level soon enough the cells can start to recover.
At the time of diagnosis and for up to decades afterwards type one diabetics still produce a small amount
of insulin. The remaining beta cells are still subject to attack by autoimmune antibodies but can be nursed
along for many years if high blood sugars can be avoided.
The more of your own pancreatic beta cells that are still active the easier it is to control your diabetes as
the pancreas can still fine control sugar levels in a way that injections cannot. This is a major reason for all
new diabetics to strive for normal blood sugars so they can prolong the ”honeymoon” phase of diabetes.
Even the most rapidly effective injected insulins eg novorapid and humalog cannot replicate the immediately
effective blood sugar lowering effect of the stored insulin from a normal pancreas beta cells. This means that
57
HOW CAN OUR FAMILY DEAL WITH THE STRESS OF HAVING A NEWLY
DIAGNOSED DIABETIC CHILD?
blood sugars will be inappropriately high for at least some time after even small amounts of very fast releasing
carbohydrates are eaten in eg bread or fruit. Over the long term these sugar spikes can add up to a lot of
damage to body tissues.
We have already discussed what level of control you already have and what level of control may be optimal for certain groups of people in the Type Two Section. Please take a moment or two to review this.
This Type One section aims to give you more specific information on the use of insulin and other information to help you achieve the best health you can.
HOW CAN OUR FAMILY DEAL WITH THE STRESS OF HAVING A NEWLY DIAGNOSED DIABETIC CHILD?
It may help you to know that even in medical families the diagnosis of a child with diabetes can come as a
profound shock. Most people know something about diabetes. But this may not be accurate. Having to have
lots of painful jags, being likely to need a guide dog and amputations before old age are some of the catastrophic
things things that can go through a parent’s mind.
When any life changing event happens what people have been accepting as their likely future changes too.
Life is full of pathways where doors open and close to various opportunities. The diagnosis of diabetes can even
feel like a death has occurred in the family. The reality is that life has certainly changed for everyone in that
family and it usually does take some time to adjust to the different expectations that come with the diagnosis.
The BC (British Columbia) Children’s Hospital in Canada has produced an excellent series of handouts that
will benefit not only children and their carers but type one and two diabetics of all ages. This is partly due to
effort that has gone into the carb counting and insulin adjusting sections but also the more general sections.
They also give addresses of diabetes organisations and sites.
This is how they suggest you help yourself and your family through difficulties that surface at the time of
diagnosis.
Join a Support Group
The Juvenile Diabetes Research Foundation at www.jdrf.org has a link to ”Life with Diabetes” and then
”One-to-One Support”.
There is a chat room at www.childrenwithdiabetes.com/chat/.
If you look in the presentations section there is a very good series of slide shows from diabetes health professionals and parents to help you understand more about managing the condition and the effects on your child
in the home and at school.
At Dr Bernstein’s Diabetes Forum at www.diabetes-normalsugars.com the Bernies are there to help people
who are considering or who are doing a lower carbohydrate diet to help themselves or their child.
Look After Yourself
You can’t let diabetes rule your life to the point where your own emotional and mental health suffers. How can
you help your child as much as you want to if you are in a poor state?
Find babysitters and relatives you trust and teach them all they need to know about diabetes care. Here
are links below with advice on this.
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HOW DO I ORGANISE MY SUPPLIES?
Canadian Diabetes Association
www.diabetes.ca/Section-about/ChildrenIndex.asp
American Diabetes Association
www.diabetes.org/for-parents-and-kids.jsp
If you have a teen with diabetes who you think could be experimenting with alcohol or drugs educate yourself
about how these can affect diabetes.
Keep or make a supportive network of friends to help you. These can be in person or you can meet online.
If You are Separated or Divorced
Both parents should educate themselves as much as they can about diabetes management so that your child
feels comfortable in either home.
Keep your child’s diabetes separate from any ongoing disputes you may have.
Either both go to the child’s medical appointments together or alternate so that you both are confident about
dealing with your child’s diabetes. Communicate freely about any regime or dietary changes that have been
agreed.
Keep Optimistic
Focus on what CAN be done about diabetes. Reading about diabetic people who have enjoyed life to the
full and achieved remarkable things in all walks of life can inspire you.
Consider joining a local network for your national diabetes association for company, support, to help educate others, and fundraise.
If you are just not coping or you are nearing the end of your tether see your doctor or social worker or
the diabetes teams psychologist for help.
HOW DO I ORGANISE MY SUPPLIES?
Insulin dependants need to have their insulins, needles, needle clipping device, cin bin or other storage container,
insulin pens and syringes, glucagon kit, glucose gel, glucose drinks, ketostix and a frio pack if you are in a hot
environment.
You will need a blood sugar meter, lancets, finger pricking device, test strips and a notebook for recording
reading for recording blood sugars. This can also contain your meal profiles, correction doses, carbohydrate
sensitivities at various times of the day, carbohydrate weighting scales and whatever else you may find of use
to you.
A medic alert or similar bracelet is very helpful if you are found in a confused or unconcious state. Medic
alert will provide world wide phone information which you have previously given them regarding your condition
and medications.
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EMERGENCY INFORMATION
Oils that you use for your feet such as almond oil or coconut oil can be kept in your bathroom or bedroom.
Vegetable and animal oil derivatives are better absorbed than mineral oils to keep the skin of your precious feet
less likely to dry out and crack.
You will need to develop your own routine about what you will carry in person, store at work, the car and at
home, and how you will check on expiry dates and reordering.
Keep your supplies at the various locations in one spot or drawer. Insulin not in current use needs to be
stored in the fridge. It will deteriorate if it freezes or is heated such as can happen in a car. Have your own
cupboard with your low sugar treats, special foods, diet drinks and lucozade or gatorade.
If you are going into hospital or are travelling abroad it can be helpful to prepare some laminated cards
before you go.
The important ones for a planned hospital admission in your own country need to cover food choices and
self monitoring. For going abroad hypoglycaemia and vomiting and diabetes information sheets in a language
that will be likely to be understood are well worth carrying with you.
You can use internet language tools such as ”Babelfish” to translate any text into many different languages.
Do consider typing a personalised sheet of information on your contact details, contact details of your doctor,
diabetologist, family, friends, medical history, medications, insulin routine, allergies and needs if hospitalised
for the country you are visiting or passing through.
EMERGENCY INFORMATION
Hypoglycaemia
I have diabetes and I take insulin or medicine which can lower my blood sugar. Low blood sugar levels can
cause death and brain damage. Please help me.
If I cannot be woken up or walk or talk easily please take me to a hospital with an accident and emergency
department or call an emergency ambulance right away. I will need to have a glucose drip to raise my blood sugar.
If I am confused please give me a glucose drink. I may have glucose gel, tablets or a sugar drink in my
pockets or bag.
I have already taken a glucagon injection.
I have not taken any glucagon.
Thank you.
Name
DOB
Passport Number
Contact Phone No
Vomiting and Diabetes
I have insulin dependent diabetes.
I need to see a doctor at an accident and emergency department right away.
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EMERGENCY INFORMATION
I am very ill and need an intravenous saline drip.
I think I am developing diabetic ketoacidosis.
I have been vomiting repeatedly. I cannot stop.
Please phone an emergency ambulance right away.
My blood sugar is now.................................................
I am showing ketones in my urine.
I am not showing ketones in my urine.
I think the cause of the high blood sugars is:
I have an infection.
I did not take enough insulin.
I got dehydrated.
Thank you for helping me.
Name
DOB
Passport Number
Contact Phone Number
Food Choices
I have diabetes. To keep my blood sugars as normal as possible I need to eat more of some foods and less of others.
I particularly find that eating certain grains and starches can make me feel very ill.
It is very important that I am able to choose food from the entire menu and choose the portion size of the foods
that I need.
Thank you for your understanding.
Self Monitoring of Blood Sugar
I have diabetes. I do my best to keep my blood sugars as normal as I can when I am at home.
Having very good blood sugar control is particularly important in a hospital and when getting over illnesses or
operations when infection can so easily get a hold in someone with diabetes.
Because I have developed such a fine personal awareness of exactly how best to manage my blood sugars
it is essential that I continue to do this for myself while I am here.
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HOW CAN MY DIABETIC CHILD BE PREPARED FOR LIFE OUTSIDE THE HOME?
I would therefore ask you to respect the need for my blood sugar monitoring kit to be beside me at all times.
I will also need to have:
My insulin delivery kit.
My ”hypo” food and drink kit.
My drinking water.
Thank you with your help for this most important part in getting me well again.
I really appreciate it.
HOW CAN MY DIABETIC CHILD BE PREPARED FOR LIFE
OUTSIDE THE HOME?
Equip your child with a ”survival pack” that contains everything they will be likely to need if they are out for
the day. A small rucksack, big bum bag or shoulder bag can work well.
• In it put the insulin, tester and glucose drink, tablets or gel.
• Wear the alert bracelet or dog tag.
• Put some carbohydrate containing food in the bag or carry it in a pocket.
• Carry a charged mobile phone.
• Carry some money to buy food if necessary.
• When going on a lengthy outing encourage them to go with others rather than alone.
• Take the glucagon trip on an overnight stay.
• Always ask what food they can eat if you go low if you are staying at someone’s house.
• Advise them to take more supplies than they think they will need if going on a bike ride or long hike.
• Have a stash of fast acting carb in one place that can be used for lows.
• Bring diet drinks to a party.
• Ask for a locker at school or storing extra food/diet drinks/juice. They may not be available to everyone
but they may give one to an insulin dependent diabetic.
HOW CAN I PREPARE MYSELF FOR THE COLLEGE YEARS?
• If you drive test before you set off and every hour on a long journey.
• Keep supplies in your car.
• Slightly impaired vision is often the first sign of a hypo. Have some small print stuck down to the
dashboard from an old telephone book for instance. If you have difficulty reading it you must check your
blood sugar.
• Set up your room at college the same as at home with a special ”diabetes drawer.”
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HOW CAN I PREPARE MYSELF FOR THE COLLEGE YEARS?
• Make sure your friends know that certain foods are off limits. You need it to prevent hypos.
• When you move to a new campus or area check out cafes and 24 hour food outlets like garages.
• Register with the student health centre or a new Family Medicine Doctor and have a copy of your important
notes sent to the new doctor.
• Have a hard copy summary sheet of your computerised notes at your new room so you can take it with
you if you need to attend a hospital.
• Have all of your diabetes prescriptions sent to the new Pharmacy before you start or within a week of
starting so you never run out.
• If you DO run out most pharmacists will dispense for you in an emergency.
• In your diabetes drawer you will need:
– Insulins
– Insulin kit eg needles, pens, syringes, lancets, needle clipping device
– Spare meter batteries
– Testing strips
– medical id and summary sheet
– cin bin
– frio bags
– ketone test strips - they go out of date 6 months after opening them.
– Glucagon
– Glucose drinks, tablets and gel.
– Packets of cheese eg dairylea triangles, uht milk, crackers, cookies, nuts, crisps.
– Possibly ice packs and a cooler
– Spare insulin and food should be in a fridge.
• If you have a pump remember to bring all your back up stuff as well eg pens, syringes and cartridges.
• It is best to have two sets of insulin/pens/meter/lancets/glucose in case one gets left behind when you
are out.
• Keep a typed list of phone numbers beside your phone:
– parents
– doctor back home
– diabetologist
– new doctor
– adult brothers and sisters
It is a big responsibility looking after yourself in college never mind diabetes. Always carry your kit with you.
Always get up at a reasonable time to test, give insulin and eat, even if you go back to sleep afterwards and
miss class.
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HOW LONG IS MY INSULIN GOOD FOR?
HOW LONG IS MY INSULIN GOOD FOR?
• Never use insulin that doesn’t look right. Humalog, Novorapid, Regular, Lantus and Levemir/Detemir
should look clear.
• Novorapid lasts six weeks.
• Lantus can go off after 3 weeks and is the most vulnerable to going off if exposed to heat or light.
• Most others last a month.
• If your sugars are going a bit high consider if old insulin may be the problem and open a new vial. New
insulin can be more potent than month old insulin.
• Heat can cause long lasting insulin to act like short acting insulin and give you low blood sugars. Leaving
it in a hot car can cause this effect.
• Get a big cin bin from a pharmacy or your diabetes clinic to dispose of your sharps. Take it back for a
new one when it is full.
HOW CAN I SAFELY DISPOSE OF NEEDLES AND OTHER SHARPS?
• Sharps are a problem because they can stick into other people legitimately handling your waste or animals
who are raiding your garbage.
• The worry that someone will get AIDs from being pricked by a used sharp is greatly in excess of the
likelihood of this happening. But you never can tell. Hep C and B can also be transmitted from sharps
and hepatitis C is the most transferable of these.
• To treat a contaminated sharp injury in time a person has to get appropriate antiviral drugs within an
hour. These are highly toxic and need to be taken for a month.
• Please take the safest measures you can to dispose of your sharps. Here are the best ways:
– Use a specially designed container. This is usually hard plastic with a lid that cannot be opened
once it is locked. They can often be obtained from pharmacies or your diabetic clinic.
– Some pharmacies and hospitals provide a sharp box swap system. You may have to pay towards this
service.
– You can clip off the needle or lancet tip with a needle clipping device that stores the needles inside.
This can then be thrown away when full. If you do this dispose of your syringes appropriately too.
– A ”cin bin” or sharps box is easiest to use because the whole syringe and needle can be disposed of
at once. They can be bulky so having a needle clipper for use outside the house can be a great help.
– If you have to dispose of sharps in your garbage as a last resort you can use a heavy opaque plastic
bottle eg a bleach bottle. When it is 3/4 full screw the lid back on and securely tape it down.
– Keep your sharps and disposal box away from younger children or pets.
HOW DO I MONITOR MY BLOOD SUGARS APPROPRIATELY?
Normal blood sugars for fit young non diabetic are 4.7 on waking and prior to meals and bedtime provided no
snacks have been eaten. Two hours after a meal such a persons blood sugar will be down to five or six. Blood
sugars should not normally go below 4.0 even if a person has not eaten or has been exercising. A healthy young
person can expect to have a hbaic of less than 5.0 although the range given in laboratories takes the not so fit
into consideration and often gives an upper limit of normal as 6.0.
What we are trying to achieve with type one and type two diabetes is a replication of normal blood sugar
patterns as much of the time as is achievable for you.
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HOW DO I MONITOR MY BLOOD SUGARS APPROPRIATELY?
In the non diabetic person the pancreas secretes a small amount of insulin all the time. This small amount
stops the liver from converting body proteins such as the muscles and vital organs such as the heart into sugar.
This is called basal insulin. About the only time this is switched off completely is druing very vigorous exercise.
When a meal is eaten an immediate surge of stored insulin enters the blood stream and tells the cells to
grab hold of any glucose molecules that are circulating. This is called a first phase insulin response.
As eating continues the pancreas makes as much insulin as it needs to keep the blood sugar normal and it
makes this insulin to order as it goes along. This is called the phase two insulin response.
There have been some advances recently in drugs and transplants that will help diabetics of both types one and
two get better control or even cure the disease. Meanwhile, unless you are a mouse with a very good health
insurance policy, you are best to take charge of your diet and glucose monitoring. Lower carbohydrate diets
particularly can help you keep damage from high or swinging bood sugars minimal.
What you want to get from a tight food plan and monitoring schedule
• Normal blood sugar levels - or as near as you can get.
• Improvements in hbaic, lipids and kidney tests.
• Achieve a suitable weight for you.
• Reverse at least some diabetic complications
• Reduce the frequency and severity of low blood sugars.
• Relief from mild neurological problems associated with high blood sugars such as chronic fatigue and short
term memory impairment.
• Blood pressure reduces.
• Reduced demand on pancreatic beta cells - this is important for type 2s and type ones in honeymoon or
earlier in the disease process.
• Increased strength, stamina and sense of well being.
• Sleep better.
• Have fewer infections.
• Have healthier skin.
When do I test my blood sugars?
In order to find out how well your body is dealing with your diet and any medication you are taking blood
sugars need to be taken:
• On waking
• Immediately before breakfast
• Before each meal
• Two hours after each meal
• At bedtime
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HOW DO I MONITOR MY BLOOD SUGARS APPROPRIATELY?
When you are testing out new foods to see how they affect you testing every half hour or alternately at one
hour after eating, two hours after eating and three hours after eating. This gives you a good idea of what types
and dosages of insulin may be needed to cover that food successfully. See the ”Eat to Meter” section in the
type two diabetes section of this course for more information on this.
You also need to check blood sugars before, during and after exercising till you know how that particular
sport, duration and intensity of exercise affects you.
Shopping and running errands can drop your blood sugar so have your meter and glucose handy.
It is extremely important to check your sugars before you drive and after every hour of driving.
Intense brain work such as sitting an exam can use up glucose but adrenaline can also raise it. Better check
before the exam when you can correct a little or eat something.
Whenever you are hungry or suspect your blood sugars are running higher or lower than expected you should
check.
It is useful to teach a toddler a nursery rhyme or song and get them to repeat it often. If you suspect a
low blood sugar get them to repeat the song. If they get muddled up they may well have a low blood sugar.
Test to check this system works for you a few times and if it is reliable for you you may omit the fingerstick.
If your vision for small print starts to go this can be a sign of low blood sugars so check.
For new college students or those in new or different jobs from usual increased walking to different places
and different work schedules can put your sugars way out. You need to check your blood sugars more frequently
than usual if your work pattern changes.
Shift work is a whole big problem area for diabetics. Your patterns will change with each type of shift and the
transition periods will be particularly difficult as lack of sleep can seriously affect blood sugars too.
Women’s blood sugar patterns shift a lot in relation to their menstrual cycle, some hormonal methods of
contraception and of course in pregnancy. You will need to check more frequently during these periods.
If you drink alcohol always eat along with it and be moderate. Alcohol can cause low blood sugars but
sugary mixes can raise your blood sugar. You must again test more frequently and of course before you go to
sleep no matter how late or early you get in.
Tell people you see regularly that you can get quite crabbit with high and low blood sugars and ask them
not to take it personally. Make a deal to check your blood sugar if they ask you to.
Finger prick testing is more accurate than arms pricks if your blood sugar is falling rapidly or if you are
very low. If you think you are low test the finger tips or base of the thumb. If you think you are high test
wherever you fancy.
How to I monitor my blood sugars in hospital?
• Apart from times that your are under an anaesthetic or extremely unwell the person who should take
responsibility for your blood sugar monitoring in hospital is YOU.
• You must bring in all your kit and continue to look after yourself as if you were at home.
• You must have your kit by your bedside or with you if you go off on a hospital trolley for any tests and
do not allow it to be disposed of or hidden by the nursing staff.
• To reduce the number of finger pricks you need get the nurses to check your figures against theirs. As
long as the first few are reasonably similar they should give their agreement to accept your figures.
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HOW DO I MONITOR MY BLOOD SUGARS APPROPRIATELY?
• It is NOT SAFE to assume that the medical or nursing staff know more about your diabetes than you.
Given the wide range of medications, insulins and delivery devices it is indeed unfair to expect them to
know better than you do.
• For insulin dependants it is very important indeed that you administer your own insulin if you are at all
able to do this. There have been deaths from staff making mistakes with this.
• Fo people on insulin that should be administered prior to food it may be best to wait till the trolley
arrives on the ward or at your bedside before you inject. You may not get it delivered at the time you
are expecting and you may also have to count the carbs and estimate the protein before injecting. You
may need the food to be kept warm for you to get the optimal time for eating or for allowing a high blood
sugar to drop if you need to.
What laboratory test may I need to have regularly?
• Thyroid function tests
Type one diabetics are prone to the development of other autoimmune diseases so this test should be done
every so often and particularly if you begin to feel particularly cold, tired, you gain weight unexpectedly,
you have more hypos than usual or your cholesterol suddenly rockets.
• Lipids and Liver Tests
All diabetics in the UK over the age of 40 are routinely put on drugs called statins whether they have a
raised lipid level or not. Recent guidance is that this should be extended to all type ones over 18 who
have one or more complications from their diabetes.
Statins work because they reduce inflammation in the lining of blood vessels and reduce atheroma and
clot formation which damage blood vessels and blood supply.
Statins can upset liver function and creatine kinase so these are tested routinely.
It is accepted by most doctors that there is a benefit in taking statins for people with diabetes and those
with ischaemic heart disease. The problem is that a group benefit may not transfer into a personal benefit
for YOU. One in 20 people get liver enzyme rises, muscle pain or general malaise and need to stop statins.
They are dangerous to take if a woman is pregnant or at risk of becoming pregnant so women in their
childbearing years need to think very carefully about them.
• Kidney Tests
The albumin-creatinine ratio is as test that can detect early signs of kidney damage. If this or microalbumen tests in the urine are positive you may be asked for 24 hour samples and blood tests to clarify the
extent of any problem.
The estimated glomerular filtration rate or eGFR is a new blood test done at the same time as the Urea
and Electrolyte test. It gives an idea of what stage of kidney impairment may be going on.
ACE inhibitors or ARBs are new drugs that can reduce the rate of kidney deterioration. They end in
”pril” or ”sartan” respectively. They are also effective in reducing high blood pressure. If you start them
for the first time you need a blood test after two weeks to see that they are not worsening kidney function.
This can happen in some people who have a condition called renal artery stenosis which is hard to detect
otherwise.
• Coeliac Disease Tests
Coeliac disease is an autoimmune disease of gluten sensitivity. It can occur at any age. The symptoms can
be very vague and it can take a very long time to develop the raised enzyme tests of endomysial antibody
and tissue transglutamase and obvious anaemia. Tiredness and abdominal pains are probably the main
symptoms. An easy and less expensive test to do is the ferritin level in the blood. This is the amount of
stored iron and low levels occur frequently in coeliac disease.
• CRP
The C reactive protein test is a non specific tests that indicates inflammation. It is often raised in
metabolic syndrome and type 2 diabetes.
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HOW DO I BECOME THE STAR OF THE DIABETES CLINIC?
In the absence of any inflammatory condition or infection you could have high levels of this if you are a
type one who is getting quite tubby round the middle and you seem to need a lot of insulin to get your
sugars down. In other words it is a marker that you are getting both kinds of diabetes at once. A good
exercise regime and lower carb diet is what you need to deal with this problem. High insulin levels cause
damage to blood vessels too. Getting insulin and blood sugar levels reduces cardiovascular deterioration.
• HbAIC
The hbaic must be the diabetologists favourite blood test. It is also known as the haemoglobin AIC or
the glycosylated haemoglobin. It is a test of your average blood sugar over the last 3 months. A truly
normal level is less than 5.0 and more accurately 4.2-4.8%.
The average UK figures for 10-18 year old diabetics is a whopping 9.5%
The American Association of Endocrinologists have set a target of 6.5 % or less for diabetics and the UK
National Institute for Clinical Excellence are going to recommend that level quite soon. Diabetes UK have
set the level at 7.4% or less for children and teenagers but less than one in 7 meet this target at present.
Control of 8.0 or over is considered to be poor and can be an indication that insulin is necessary in type
2s who are struggling on maximal oral therapy.
Diabetic complications can come on in people who have never been diagnosed with diabetes but who have
had hbaics of 5.5 or more for many years. Type 2 diabetics are often discovered to have complications
at the time of their diabetes diagnosis because of the slow and stealthy development of problems. Visual
troubles, breathlessness on exertion and subtle coordination problems are often seen as something to do
with middle age or complications can entirely asymptomatic as in kidney disease.
It is in your best interest to keep as low as you can towards normal without risking severe hypoglycaemia.
Fortunately this is achievable with a low carbohydrate diet.
HOW DO I BECOME THE STAR OF THE DIABETES CLINIC?
If you haven’t been the star of the diabetes clinic yet, here is where to start:
1. Check your blood sugars before each meal and snack and write down the results.
2. Get advice on how to adjust your insulin doses appropriately based on your blood sugar results.
3. Begin to record the carb content of your foods and write this down too along with your insulin doses.
4. Learn to adjust your insulin dose to your carbohydrate content. You need to be very consistent about
this with fixed insulin regimes and consistency will get you better results even if you are on a multiple
daily injection regime.
5. Start some daily exercise and note what effects that is having on your blood sugars too.
6. Get advice on adjusting your insulin to physical exercise.
HOW DO I DECIDE WHAT TO EAT WHEN I AM ON INSULIN?
The two dietary plans I wish to discuss in this section are Dr Bernstein’s and Dr Jovanovich’s plans. Both
of these diets call for a restricted amount of carbohydrate at each meal. Both doctors are type one diabetics
themselves.
Dr Lois Jovanovich works in Santa Barbara California. She treats all kinds of diabetics but has a particular interest in improving the outcomes in pregnancy for type one, type 2 and gestational diabetic women.
Lois advocates a ceiling of 30 g of carb for each meal. If a snack is necessary it should be no more than
15g.
She admits pregnant patients for stabilisation of their diabetes as soon as a pregnancy is known about. By
careful diet, exercise and insulin treatment her aim is to achieve non diabetic blood sugar levels. By this method
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HOW DO I DECIDE WHAT TO EAT WHEN I AM ON INSULIN?
she has greatly improved the outcome of these pregnancies for both mother and especially the babies.
It is imporant to note that the carbohydrate values she gives are limits not targets. The goal is to achieve
as normal blood sugars as possible. If you can get there at 30g of carb a meal that’s okay but if you don’t you
go lower.
Dr Richard Bernstein works in Marmaroneck New York State and has spent the last 25 years in practice
dealing with diabetic and prediabetic patients. Richard was diagnosed with insulin deficient diabetes when
he was 12. He followed standard dietary advice but by his 30s has severe and life threatening complications
affecting his blood vessels, eyes, kidneys, heart and joints.
There were three factors that turned his life around. He was an engineer who was used to solving problems. His wife was a physician who helped him buy the first portable blood sugar meter that was only sold to
physicians. He knew his life was on the line and this made him determined to beat diabetes.
After considerable research he found that the way to stop the painful and debilitating complications of diabetes was to maintain normal blood sugars as much of the time as possible.
”The Law of Small Numbers” is the core of his method of controlling blood sugars. There are many things
about diabetes you cannot reliably control but the ones you can - you do.
Regarding diet you can predict what rise in blood sugar you are likely to have simply by eating foods that
will affect your blood sugar in a small way. Even if you were to measure foods accurately there can be as much
as 20% error allowed to the manufacturer when listing ingredients. If you stick to low levels of slow acting
nutritious carbohydrates such as vegetables the results will be more predictable than large amounts of rapid
acting carbohydrates such as bread, rice, potatoes or sugar.
Covering carbohydrates with insulin is a task full of uncertainty. There is about a 30-50% variation between
the effects of the same insulin amount injected from jag to jag. This can be minimised by reducing the amount
in any one injection to 7 units or less and keeping the carb count low with the gradual release of sugar that
comes from vegetables high in cellulose.
For type one diabetics three meals a day is best. This minimises insulin injections and gives opportunities
three or four times a day to correct the blood sugar to normal levels.
By careful experimentation Richard discovered what factors made his sugars stay normal and what factors
made them go too high or too low. Many of his complications started to reverse including the kidney disease,
neuropathy, heart and eye disease.
To his surprise and eventual dismay Richard found that the medical profession of the time were not interested in his results, his method or his meter. So he decided he would need to become a doctor himself in order
to let patients know of his success and he entered medical school at the age of 45.
Dr Richard Bernstein’s publications contain comprehensive and detailed advice that is based on what works for
diabetics. In particular he emphasises the benefits of a very low glycaemic / carbohydrate diet. Much of what
he says is still in conflict with the advice that is given out by The American Diabetes Association, Diabetes UK
and most NHS dieticians and diabetologists. Unlike these people and organisations however he is absolutely
rigorous in letting the reader know the scientific fact that underpins his advice.
The reason you are reading how to look after you diabetes on the web instead of from your local diabetes
team is that the medical establishment are thoroughly entrenched in their high carb / low fat ways.
Unfortunately if you eat the way many diabetic clinics tell you to you will make it unnecessarily hard to
control your blood sugars and this will make the development of diabetic complications inevitable.
This low carb diabetic course has been compiled by myself with the generous help of other diabetics, their
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HOW DO I FOLLOW DR BERNSTEIN’S DIETARY PLAN?
carers and interested doctors and researchers. It takes a lot of nerve to do something very different from what
a diabetic specialist or dietician tells you. My son Steven developed type one diabetes at the age of 12. I
am absolutely determined that he will have the same chance to enjoy a full and long life as his non diabetic
brother. Fortunately many other people have the same aims for their relatives, friends and for themselves. We
have joined resources on Dr Bernstein’s forum to help you have normal sugars and prevent and reverse diabetic
complications.
HOW DO I FOLLOW DR BERNSTEIN’S DIETARY PLAN?
Dr Bernstein’s dietary plan is at the strict end of the low carb dietary scale. The diet consists of planned,
carefully measured, prepared and consistent amounts of protein foods and non starchy vegetables. In addition
double cream, cheese and soya products are allowed. You can have some low carbohydrate sweeteners and
beverages.
He aims to give suitable and small amounts of carbohydrate required for good health with the trade off that
minimal amounts of insulin with then be required from the pancreas in type twos and by injection for type ones.
The exact monitoring system and ways to trouble shoot problems that crop up along the way are described in
detail with a full account of the rationale. The reasoning is impeccable, the results are impressive. The difficulty
is that it is a tough plan for most of us who love eating fruit, grains and starches.
The food is pleasant to eat as tasty fats, spices and herbs are used to give a wide variety of flavour. The
Bernie forum members have experimented with ingredients so you can eat cakes, biscuits, bread as well as main
course and starter dishes. I would say that the difficulty lies in the daily planning and meal preparation that is
needed. It is the consistency in doing this day after day that can be particularly hard to do.
You do need motivation to follow Dr Bernsteins diet for long periods of time. If you are on insulin however you do need to be highly consistent with your meals for control and safety in any event.
If you already have the complications of diabetes and can see that you are steadily getting worse you may
now be at the point that you will do what it takes. If you are a type two diabetic who is really keen to avoid
insulin injections now or in the future this plan offers real help. Although diabetes is still an incurable chronic
disease it is very treatable and the long term complications are almost fully preventable.
You will get the best results from reading Dr Bernstein’s book ”Diabetes Solution” particularly if you are
insulin dependent. Those not on insulin could read ”Diabetes Diet.” You may also find listening to his podcasts
and CDs and joining the forum on his website to be of interest and informative. It can help to chat on line to
people who have similar difficulties to you.
When you change your eating pattern so radically it can help if you live with someone who can help you
with your diabetes and food preparation. The transition phase is the most risky for insulin dependants having
hypos. Although Dr Bernstein himself advocates a rapid transition to meals of 6 and 12 g of carb at a time, he
can do this because he is very experienced and keeps a daily check on his patients till they are stable. Outside
of this situation I would always advocate a planned and stepwise reduction in carbohydrate intake. You can
read more about this in the ”Atkins in Reverse” chapters in the type 2 section.
You will need to monitor your sugars much more closely in the transition phase and adjust your insulins
downwards with care and in response to your blood sugar readings. This does take considerably longer to get
stability than if you were one of Dr Bernstein’s patients, and your carb cravings will continue for longer, but it
is the only way to do this in safety without the direct supervision of an experienced health professional.
Due to the high level of consistency required and more time and effort into sorting out your diabetes than
you have probably ever done before, I do not recommend you start this plan until you have overcome any major
outstanding personal or domestic issues. You can do this plan even if you don’t have much money, but if your
life is chaotic and you don’t have support I suspect it would be just too hard.
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HOW DO I FOLLOW DR BERNSTEIN’S DIETARY PLAN?
Dr Bernstein’s entire plan is well worth reading for the detailed information he provides about all aspects
of diabetes management that is not easily found in one place. I see his plan as an ideal to aim for if you are
looking for optimal control over your blood sugars. The most helpful part I have found is that I don’t have to
worry about hypos when my son goes to bed at night.
Even if you do not follow the plan to the letter you are very likely to get much better control than you
are already getting now by a planned adoption of the aspects of the plan that you CAN achieve consistently.
YOU have to find out how to get the best sugars you can for YOU with the food you are happy to eat day in
and day out.
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Chapter 15
HOW DO PROTEIN, FATS AND
CARBOHYDRATE AFFECT MY
BLOOD SUGARS?
You have read a lot about how carbohydrate affects your blood sugar but what is less known about it the effect
that protein has on your sugar levels.
About a third of the energy from protein is made into sugar. This process is slower than for carbohydrates and
can take 2 or 3 hours or more. Delayed blood sugar rises are likely to happen if your meal has a significant
amount of protein in it. By this I mean over 3- 4 oz of lean cooked meat, chicken, fish or 3 eggs.
A ready reckoner is to compare the size of the meat you intend to eat to a pack of cards. If you have steak the
size of a woman’s hand or a deck of cards this is about 3 - 4 oz. Chicken to the size of your palm plus the first
finger joints or fish the size of a woman’s whole hand is about the same. When you have this amount you must
give yourself extra insulin one way or another to cover it or you will go higher than you expect after the meal.
These are the average to small portion sizes such as you would be served in a hospital canteen. Restaurant servings can be a lot bigger. When looking at omlettes, quiches and scrambled egg you need to imagine
how many eggs may be in there. Three or more need extra insulin coverage. One egg is equivalent to about
one ounce of protein. Big hamburgers eg quarter pounders are easier to recognise and also need extra insulin
coverage.
Immediately delivered insulin which covers high and medium glycaemic carbohydrate dishes is no good for
covering the much more slowly digested protein. The extended bolus and split bolus techniques familiar to
pump users works well however. Using two or more rapid acting insulin boluses can work well and so can using
meal insulins with longer action such as regular insulins.
In the UK actrapid is the regular insulin available. It can be in pen form only from Wockhardt in the form
of soluble pork or beef insulin. This is being exported now to several countries and can be used in the Owen
Mumford Omnipen. This pen comes in one unit or two unit increments. Genetically Modified Human Actrapid
from Novonordisk is still available in vial and syringe form. Sadly they discontinued their pen actrapid which
could be delivered in half unit increments. Pens tend to be easier to carry and syringes can give more versatility
over dosage. It all comes down to personal preference.
These insulin delivery techniques and much more is discussed in Gary Scheiner’s excellent book, ”Think Like
a Pancreas”. Gary was diagnosed as a type one diabetic at the age of 18. He became an exercise physiologist
and diabetes educator and is particularly enthusiastic about pump therapy. His book covers important details
regarding insulin use that are not always covered in much depth in diabetic clinics. For anyone on insulin I
recommend this book so you can get the best out of your current insulin regime and consider other helpful
strategies to optimise control of your blood sugars. This book usually gives several different options regarding
73
problem solving. It goes into more depth about insulin than Dr Bernstein’s book regarding insulin use and
takes a neutral stance on dietary aspects.
Meals that have a high glycaemic index or load will usually need a standard food bolus such as supplied
by novorapid/novolog and humalog as the food is quickly converted into sugar in the blood stream. Examples of these are bread, cereals, potatoes, parsnips, cooked carrots, rice, biscuits, cakes, tropical fruits and sweets.
Meals that have a very low glycaemic index / load may require a method to lengthen out the insulin delivery time just like meat. Examples of these sorts of foods are pasta, especially with creamy or cheesey sauces
like lasagne or spaghetti carbonara. Very high breakfast cereals eg all bran. Curries made with lots of fat eg
kormas. Battered fish and chips. Chocolate, most dairy food and nuts.
A major difficulty with the glycaemic index is that it gives artificial categories of supposed blood sugar rises for
a given amounts of carbohydrate containing foods. One problem is that these tests were done on healthy non
diabetics who still have a phase one insulin response. Both type ones and type twos do not have this capacity
to immediately release stored insulin. The rate of absorption is also dependent on the temperature of the food,
bite size and what it is eaten with and in what order.
To really know what is going on in your body you need to do extensive testing to get the best results for
each meal you eat. This involves testing every 30 minutes or so for three or more hours after each meal you eat.
You can only test a food accurately if your baseline blood sugar is normal. Even then insulin sensitivity
can vary throughout the day. Typically you are quite insulin resistant at breakfast and are at your most insulin
sensitive in the afternoon.
Although this sounds a terrible chore most people only eat about 20 different meals on a regular basis and
some a lot less. Please don’t ask me what to do if you are a type one restaurant critic!
To give smooth protein curves it is best to eat some of the protein and fat before you eat the carbohydrates.
If you are having a high glycaemic item leave it till the end of the meal if possible. Can you add some fat
to it? This will reduce the rate of absorption. Eg fruit and cheese, potatoes with butter and cream, cake and
cream.
Lots of fat in the diet improves the taste, fullness after meals, vitamin absorption and slows down carbohydrate induced sugar spikes.
Other Food Tips
If you are going to have a snack consider low glycaemic carbohydrates, protein and fat so you are fuller for
longer and sugar spikes are minimised. Eg full fat yoghurt, crackers and peanut butter, toasted cheese with
butter on thin sliced wholemeal bread.
In a restaurant you can take your regular insulin once the waiter has taken your order as long as there is
bread on the table. You only eat this in an emergency however!
If you take rapid acting insulins take it with the starter if you have a normal blood sugar, your main meal
if you are low and when the waiter takes your order if you are high.
Tell the waiter you are diabetic and need food right away if you have been waiting for a time or feel low.
It is best to let toddlers eat and then gave them rapid acting insulin to cover what they actually ate.
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Chapter 16
HOW DO I EXERCISE AND KEEP
WELL?
• If you are trying to lose weight, exercising after meals can work well. You don’t need to eat extra food
and cutting back on insulin promotes the loss of body fat.
• Physical activity can make muscle cells more sensitive to insulin for many hours after activity eg 12-24
hours for vigorous and prolonged activity say at a school sports day or a strenous hill walk.
• Certain exercises have little or no impact on blood sugars eg light weights with frequent repetitions.
• Other exercises can produce a short term bood sugar rise:
– Heavy weight lifting with low repetitions.
– Sports with bursts of activity eg golf, running, swimming and rowing, sprinting.
– Sports where you are being judged eg gymnastics.
– Sports when winning is the primary objective eg football.
• Measures you can take to offset hypoglycaemia after exercise include:
– Lowering the basal insulin at night if you are on a pump or on Lantus or Detemir at bedtime.
– Have an extra snack.
– Reduce any meal boluses or correction boluses at bedtime.
• If you have high blood sugars and not enough insulin available, you can tip yourself into Diabetic Ketoacidosis by more exercise.
• As long as you have sufficient basal insulin however light exercise that does not stress you can be a helpful
way to get your blood sugar down. This tip is especially helpful for people on fixed insulin doses who are
not in a position to give a correction bolus.
• You can see that matching up food and insulin to sports can be a tricky business. Unfortunately advice
from exercise physiologists does not appear to be available in the UK in the way it is for diabetics in the
US.
• Joining an internet forum for diabetic exercisers may be the most pragmatic approach to getting advice
on this if you are particularly sporty or competetive.
• If you are a fitness fanatic
– Keep doing what you are doing.
– Add in any missing components to your regime such as stretching, relaxation, balance, aerobics or
weights / toning.
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– Type ones may need detailed advice about their insulin regimes especially at competetive level. This one to one work is not available on the NHS but would be well worth having.
www.diabetes-exercise.org is the home page of the Diabetes, Exercise and Sport Association.
(USA)
– Why not buy Gary Scheiner’s book, ”Think Like a Pancreas.” It is a good start and he says he will
answer questions online. He is a type one pumping exercise physiologist.
– Sheri Colberg has written a book, ”The Diabetic Athlete.”
– John Walsh and Ruth Roberts book, ”Pumping Insulin” has a detailed section on how to modify
diet, basals and boluses for certain activities, intensities and durations. It could be adapted by those
on a multi dose injection regime.
– If you are working very hard physically you may wish to consider switching to an insulin pump
because the basal levels can be altered with considerably more finesse than with one or two basal
injections a day. This can help a great deal with the post exercise delayed hypoglycaemia problem.
– If you are not working to any extent physically you may wish to consider looking at the types of
exercise that could suit you in the metabolic section. If you are working out a little and feel you
could handle a little more there is information for you too.
• Exercise Tips for Kids of all ages
– Spike and Bo Loy have edited a book of tips from diabetic kids called, ”478 Tips for Kids with
Diabetes.” This is published by the ADA. Here are somethings their young contributors would like
everyone to think about when it comes to exercise.
– Always tell your teacher, team mates and class mates that you have diabetes and give them information about how to recognise and handle emergencies such as low blood sugar or vomiting.
– Carry a bottle of water with you.
– If you feel low come out of the activity, consider testing, eat a snack, then return.
– Test frequently to see how your body reacts to different patterns of exercise.
– Test before you start. If you are low or normal have a small snack to prevent a drop later on.
– While you are active you may want to drink diluted gatorade or lucozade as you go along.
– If you get overheated blood sugars can drop fast.
– Because insulin absorption soars in hot water don’t inject right before you get in a hot tub or bath.
– When you go swimming disconnect your pump and put a cap on the infusion site.
– When you take your pump off keep it in a cool place.
– You may want to give yourself a lower temporary basal rate to avoid low blood sugars after exercise.
– Many pumps are waterproof but none of them float. If they are lost they cost !
– Watersports need more vigilance than others.
– Never swim alone.
– Eat before you go.
– Consider putting a little tube of hypostop gel/icing in your trunk pocket.
– Come back every hour to test, eat and drink.
– If you are pumping you may need to come back for more insulin.
– Consider lowering your short acting insulin before heavy exercise.
– If you have forgotten your hypo kit at an exercise session sprint as fast as you can in 30 second bursts
towards the end of the session to stop you going low.
– If you are skiing, keep the insulin pump next to your body to prevent the insulin from freezing. Keep
your meter warm too or the batteries won’t work.
– Being at high altitude lowers blood sugar.
– The deeper and colder the water, the more carbs you burn when you are diving.
– If you leave food on the beach make sure animals cannot get into the cooler and eat it.
– Test 30 minutes and right before exercise to see if your blood sugars are tending to rise or drop.
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Chapter 17
HOW TO GIVE YOUR FEET A
PEDICURE.
Its lovely to have nice looking, comfortable, happy feet. After you’ve been doing all that exercising your feet
could do with a little pampering. The more you can make this part of your daily routine the happier your feet
will be.
• Fill a basin or bath with some warm water.
• Test it with your hand to see its not too hot.
• Add a good sprinkle of salt.
• Add some bath gel, liquid soap or use a bar of soap.
• Add a favourite aromatherapy oil - just a few drops - if you like.
• Put your feet in and give them a gentle wash.
• You may leave them to soak for up to five minutes.
• Take your feet out and put them on a towel.
• Give them a thorough dry particularly between the toes.
• Place your feet where you can see them and if you are not flexible enough to see the sole of your foot use
a mirror.
• Are there any rough areas, unusually reddened areas?
• Any sores? Any cuts? Any blisters?
• How are your nails?
• Any breaks in the skin between your toes?
If any problems are apparent you may need to deal with them yourself, see your podiatrist within the week or
even see a doctor as an emergency if you suspect you have an infection.
Do your nails need cut?
To cut them use nail clippers or scissors. Be sure to look exactly where you are going with the scissors. Cut
the big nail straight across so the nail edge does not cut into your skin.
Now for a massage.
• Bring out your container of vegetable or animal oil. Pour some into your palms and then stroke it all over
your feet.
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• Rub it into the nails, between the toes, and on the sole of your foot.
• Give the ball of your foot which takes a lot of pressure a good massage.
• You can extend the massage up your leg to your knee. Sweep your hand upwards towards the heart. The
shin area and round the ankle area can be affected by poor circulation in later years so keeping the skin
supple here is helpful.
• To finish off gently use the towel to absorb any excess oil on your legs or feet.
• Put on a fresh pair of socks for a while. This will keep your carpets, bedcovers and shoes from becoming
oily.
Make a date with your feet to have the same loving experience very soon.
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Chapter 18
WHAT ORAL MEDICATIONS
COULD I BE OFFERED FOR
DIABETES?
For many years there were only two types of drugs offered to people with type two diabetes, metformin and
sulphonureas. More recently the glitazones and the meglitinides have been prescribed. Last year several other
medications such as januvia and byetta have come along too.
As the number of people with type one diabetes who have also developed insulin resistance has increased
there has been more experimentation with oral drugs as well as insulin. The insulin resistance is usually related
to weight gain and high amounts of injected insulin which are necessary to cover a high carbohydrate diet.
As the number of people with type two diabetes who have not been able control their blood sugars on oral
drugs increases there are more type twos on combinations of oral drugs and insulins. This rise is related to
worsening insulin resistance at least partly due to high amounts of ingested refined carbohydrate and beta cell
failure partly due to the toxicity of high blood sugars on beta cells over a long period of time.
In this section I will be discussing some points about the older oral drugs for diabetes. As users of the newer
drugs gain experience with them I would hope more information on this expanding area of prescribing can be
given.
Sulphonureas
Sulphonureas work by making your pancreas release more insulin. Although sulphonureas sometimes don’t work
when first given they almost always stop working later on. Every year secondary sulphonurea failure occurs
in 5-10 per cent of people taking them. 50% of people taking a sulphonurea will have beta cell failure by six years.
Going on this drug may seem like a good way of avoiding insulin injections to start with. But it really just
delays the point at which most people are likely to need an alternative treatment or insulin. Remember that
your pancreas is smarter than you are when it comes to fine tuning your blood sugars. Even a little bit of useful
pancreatic function could make a big bit of difference later on.
There are also worries about increased cardiac mortalilty with sulphonurea use. An epidemiological association between hyperinsulinaemia and cardiovascular disease has raised concerns about the safety of sulphonureas.
Sulphonureas are popular with physicians and patients because they tend to be well tolerated. They do cause
significant weight gain in many patients but this is not apparent right away.
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MEGLITINIDES :THE PRANDIAL GLUCOSE REGULATORS
The fear of injections in patients and the burden of patient education about insulin use in doctors seem to
keep the prescriptions for this drug flowing along. Before you start this drug however there are some things it
may be helpful to ask both yourself and the doctor.
1. Is there any alternative medication or supplement that could help to get my blood sugars down?
2. Would a low carb diet be a better alternative course of action for me?
3. Would an exercise programme be a better alternative for me?
4. How much pain is involved with injections? Could I try one to see?
5. Have I a particularly reduced life expectancy that could make a sulphonurea a more favourable alternative
to insulin injections?
6. How expensive is the insulin versus the sulphonurea?
Once you have asked these questions and given realistic answers you will be in a much better position to make
a well informed decision that your future self will be happy with.
Meglitinides :The Prandial Glucose Regulators
Repaglinide (Novonorm) and Nateglinide (Starlix) are chemically unrelated to sulphonureas. But again they
work by squeezing more insulin out of the pancreas. They are taken just before meals to stimulate insulin for
just that meal. They are usually taken three times a day. They are not used with sulphonureas but can be used
with metformin. They can cause gut upset and hypoglycaemia.
At the moment we don’t know the long term effects that these drugs have in the way we do about sulphonureas.
Because they have a similar action on the pancreas they may also be expected to lead to premature beta cell failure but we just don’t know. They are active for a shorter time than sulphonureas and that may influence things.
Pragmatically it would be worth asking yourself and your physician the sulphonurea questions. If you are
leaning towards sulphonureas a meglitinide may be a better longer term option. We just don’t know.
Metformin
Metformin does not tend to cause weight gain which is important for many people with type two diabetes. It is
particularly useful when fasting hyperglycaemia is present. It causes some beneficial effects on blood lipids. It
lowers blood glucose mainly by reducing the production of glucose from the liver. It may increase the sensitivity
of the muscle cells to insulin and slow the uptake of glucose from the intestine. It does not depend on stimulating
insulin secretion as the sulphonureas do. About ten percent of patients fail to respond to it when it is first used
and the secondary failure rate is 5-10 per cent a year.
Metformin therapy in the prediabetic patient reduces the onset of type two diabetes mellitus by 31%. Visceral
fat is reduced in metformin therapy. Visceral fat is more metabolically active and produces adipocytokines
which contribute to insulin resistance.
Metformin has benefits outwith the lowered HbA1c compared to sulphonureas and insulin.
Gastrointestinal side effects can be minimised by starting with a single dose of 500mg after the evening meal.
The maximum glucsose lowering dose is 2g daily.
Important though uncommon side effects include lactic acidosis, especially if renal failure is present, and B12
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GLITAZONES
deficiency.
Glitazones
The glitazones are the first group of drugs for diabetics that directly reverse insulin resistance. Rosiglitazone
and pioglitazone were released in Europe in 2000. Neither drug has been linked to liver damage. They cause
changes in the muscle and fat cells where the insulin resistance resides. They also enhance the actions of insulin
in the liver.
The glitazones have their greatest effect on blood sugar after eating rather than the first morning glucose.
Glitazones are insulin sparing meaning that the body does not have to make as much insulin to control the
blood sugar when a glitazone has been given.
So far secondary failure does not seem to be a problem.
Glitazones take 12 weeks to give the maximum benefit. You should only be given a glitazone in combination with a sulphonurea if you can’t tolerate metformin or there is some other reason why you can’t take it.
You can be offered a glitazone in addition to metformin and a sulphonurea if your blood sugars aren’t well
controlled enough as an alternative to starting on insulin.
Glitazones can cause hypoglycaemia if used with a sulphonurea or insulin.
Glitazones have demonstrated beta cell preservation which delays or prevents insulin therapy. This has not
been seen in patients treated with sulphonureas or metformin.
Glitazones directly improve insulin resistance and reduce hyperinsulinaemia. They also raise HDL and give
less dense LDL, give improved endothelial function and slightly reduce diastolic blood pressure.
The glitazones become less effective as the duration of diabetes goes on and endogenous insulin production
from the pancreas lessens.
The data for beta cell preservation is good and makes glitazones a favourable choice early in the course of
type two diabetes. Problems are fluid accumulation and the effect of precipitating heart failure.
Both metformin and the glitazones have been used in insulin resistant type ones. Metformin seems to be a very
helpful add on medication for this group but the glitazones have been disappointing.
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GLITAZONES
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Chapter 19
HOW CAN I USE INSULIN TO THE
BEST EFFECT?
In this section I am aiming to give you information on what you need to know to use insulin not just to keep
you alive, but to keep you as well as you would want to be if you didn’t have diabetes.
I will be discussing different sorts of insulins and different sorts of delivery devices. Most basic techniques
are covered in your diabetic clinic but here I want to help you take things further. I want to try to help you
get the best match possible to cover your daily rhythms and food intake.
As in most of this course self experimentation is the key. Various techniques are described and you have
to decide if you would like to use this technique to control your blood sugars or not. You then need to change
what you do in a gradual and controlled way. Whenever you are experimenting with new food, exercise and
insulin patterns you need to test more frequently and be prepared to adjust things according to the results you
are getting.
I hope that you will have started to count up how much carbohydrate you are eating each day. You may
still be seeking some more information before you begin to reduce it and this is okay. Arm yourself with lots of
test strips for this section! And lets begin.
What is insulin?
Insulin is a big protein made by the beta cells of the pancreas. It controls several functions in the body. The
most important ones for diabetics are:
• Insulin tells certain cells to take in sugar from the blood stream and so drops blood sugar levels.
• Insulin tells your liver to reduce the amount of sugar it is making from protein.
• Insulin is a growth hormone.
• Insulin is a fat storage hormone.
• High insulin levels tend to stiffen and age your blood vessels.
• In 1922 researchers in Toronto, Banting and Best discovered how to extract insulin from animals to give
to humans.
• Fine tuning did not really exist until blood monitoring was popularised in the 1980s for all type one
diabetics. Since then genetically engineered insulin has been produced from yeast and the e coli bacteria
which is structurally identical to human insulin.
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WHERE DO I INJECT?
• Different action times of insulin have been developed by altering the chemical structure of the insulins or
by the addition of stabilising substances.
• Syringes and vials have been supplemented by pen injectors, pumps, and now inhaled and oral insulins.
• There are different potencies of insulin with different onsets and durations of action. Eg rapid acting,
regular insulin, intermediate acting and slow acting.
• Modern analogue insulins tend to have a more predictable pattern of action than some older insulins.
Unfortunately their popularity and higher price has resulted in some older insulins becoming less profitable
and there has been a decrease in the range of insulins available as a result. One of the most noticable is
the lack of human regular insulin available in pen form. You can use Novonordisk actrapid in vial and
syringe but need to use a pork or beef derived actrapid to have this duration of insulin in pen form. This
is available from Wockhardt in the UK and the Owen Mumford Optipen is is the delivery system but is
only available in one and two unit increments.
• In general the total carbohydrate content of a food is a more important consideration than the amount
of sugar in it. Whether it is a starch or a sugar that is present the same amount of insulin is needed to
deal with it and both types raise your blood sugar pretty fast. Your major challenge is to carefully match
your insulin intake to your carbohydrate intake. There are also factors like exercise, stress and illness to
be considered.
Where do I inject?
• One of the best sites to inject insulin is in your bottom or on the fat pad above your trouser line. These
areas usually are quite fatty and tend to hurt the least. You are also most unlikely to mistakenly inject
into a muscle.
• Other sites that you may use in public are your abdomen or your thighs. You can adjust your clothing or
inject through it.
• Some people prefer to inject in a washroom and others will be happy to inject at the table in a restaurant
or plane.
How do I inject insulin?
• If using a vial and syringe the best technique is to draw up the insulin smoothly and quickly and inject it
smoothly and quickly. Dr Bernstein has a video of this in his CD series.
• If you use a pen you need to count to ten slowly, ”one thousand, two thousand...” etc. Otherwise the
insulin tends to leak a bit more than you would like.
• For pump users they need to change the site anything from daily to every three days. The abdomen and
rear trouser line are the most popular. Special hygeine routines are helpful in preventing infection.
• If you are using plain needles you don’t need to clean the area with an alcohol swab. You just inject.
• The needle depth and fineness can vary. 6, 8 and 12 mm needles are available in the UK. If you are pretty
thin or using your thighs a smaller needle is often used. If you are fatter or prefer your backside the longer
needles are better.
• In some circumstances you may want to put the needle into muscle. This could be for the purpose of
achieving a more rapid effect which you may want to use if correcting for high blood sugars.
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HOW DO I INJECT INSULIN?
Basal Insulin
The basal insulin level should be matched to the liver’s normal secretion of sugar. Because the liver tends to
produce different amounts of glucose at different times of the day and night the insulin requirement will also
vary. The right basal rate is one that keeps your blood sugar at a fairly constant level when you have not eaten
or bolused for several hours and are not exercising.
An insulin pump gives the most flexibility over basal insulin dosages at different times of the day.
For people on a multiple daily injection regime the main analogue basal insulins are Lantus and Detemir
known in Europe as Levemir. Lantus should not be mixed with other insulins because it depends on its action
for its acidic pH. Detemir has 75% of the potency of Lantus. It is not acidic and does not sting like Lantus can
when it is injected.
Lantus lasts about 22 hours in most people and Detemir lasts about 16. Either insulin can sometimes be
given once a day successfully for some individuals but most people get on better with twice daily injections for
both of them. The best time to give them is right before bed and when you get up in the morning. If you have a
marked dawn phenomenon no more than a 9 hour gap between the night and morning injection is recommended
by Dr Bernstein.
It can take about three days for your blood sugars to stabilise after altering your twice daily basal so it is
best to keep changes to three days apart or more so you can get a true reflection of the results of your insulin
adjustments.
Older insulins have been stabilised so they last a long time such as the Lente and Ultralente insulins. They are
sometimes combined with shorter acting regular insulins so you can reduce the number of daily injections. If
you have a cloudy insulin such as this it needs to be mixed thoroughly before injection. Rolling the vial or pen
gently up to 20 times is advised.
Protecting Insulin
• Your insulin stores can be kept stable for years in a correctly maintained domestic refrigerator but once
out and about insulin needs to be kept at room temperature or a bit cooler to retain its potency.
• It can go off rapidly if overheated eg from being left in a car on a hot day. Lantus is particularly fragile
and light can affect it too. Lantus lasts in good condition for about 3 weeks and most others last about
4 to six weeks.
• When you are going to be in a hot environment you can store your insulin in a frio wallet. These are
available in the UK from Boots online. They are more widely available in the US. These come in different
sizes and can hold insulin pens or vials.
• When you travel on a plane you must keep your insulin in your hand luggage. If it goes in the hold it
could freeze without you being aware of it and this too will seriously impair its effectiveness.
• When you go skiing or out on a very cold day keep your insulin next to your body to prevent freezing too.
Missed a dose?
If you miss your basal by only a few hours you may simply give it as usual. If you are more than 4 hours late
however the action you take may vary. Let us assume you are awake during the day and sleep at night.
You miss your night basal which you normally give at 10 pm and remember when you get back from
the party at 3am.
Check your blood sugar. You are a bit high. Give a proportion of your basal let say half of the usual dose and
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HOW DO I INJECT INSULIN?
go to sleep. You probably need to sleep before work tomorrow more than worry about whether any correction
dose you are thinking about is going to drop you too low through the night, especially if you have had more
than one alcoholic drink.
You are likely to have to give a correction dose along with your morning basal but monitoring your sugars
is easier during the day when you are awake. Put it down to experience.
You can even write essential tasks or times on ball point pen on the back your hand. Usual handwashing
takes about a day to clear it and if you want to wipe off your ”to do” list little alcohol swabs come in handy.
You miss your morning basal You took your basal insulin with you to a friend’s last night and remember
in the morning that it is still in your bag which is in her car. She lives across the city, and the pharmacy does
not open till 2pm, and you have no spare because you have not been paying attention to the advice you were
given in the organising your supplies section.
Give yourself a series of correction doses during the day before your meals. You can use novorapid or humalog and these last about 3 and a half hours. If you have regular insulin this is even better as it lasts 5 hours.
Start your basal again with the night injection.
Missing a day dose is usually easier to deal with because you are awake and you can correct any lows easier. Keeping a notebook or having one of the new pens that records your doses can be helpful. Because looking
after your diabetes becomes so automatic you can easily get muddled up about whether you took the dose or
not. When you are one of two parents or carers and not the diabetic person it is even more important to record
what you do. Without this it can be even easier to make mistakes and give an infirm person or a child two
doses of insulin or none !
It is human nature to muddle up from time to time. When you do, the most important things are forgive
yourself, calm yourself down, and THINK !
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Chapter 20
HOW DO DIFFERENT INSULIN
REGIMES COMPARE?
Basal insulin holds the blood sugar steady between meals and during sleep. A bolus is a dose of fast acting
insulin given to cover meals or to reduce a high blood sugar.
Here are some popular ways of using these insulins.
Two mixed doses
Eg Novomix or Mixtard. The basal and bolus insulin is premixed in a fixed combination so that only two
injections are needed in a day.
A high level of consistency is needed for meals and snacks. What is eaten and when it is eaten can be manipulated to give good results. The difficulty is that there is very little flexibility and you can’t just miss meals or
eat more than usual and get away with it.
If your blood sugars are running high with this regime the main technique to get back in track is to give
the injection and wait till the blood sugar has dropped before eating. Lows can also occur and you need to
develop snacking routines to even these out.
This regime is often used for people who need help with their injections or who want to avoid injections
such as younger school children and in the elderly or visually impaired.
Where money is an issue mixtard is cheaper than then newer analogue insulins.
The best meal coverage is at breakfast and lunch with the two mixed dose insulins. The injections are usually
given 15-45 minutes before these meals depending on the type of fast acting insulin used. A lower carb meal can
be eaten for lunch to help keep sugars normal. Alternatively a separate injection of regular or a rapid acting
analogue can be given before lunch.
Morning mixed with evening split
Eg Mixtard am, Actrapid pm and Lente bedtime.
This regime covers the dawn phenomenon quite well because of the duration of the lente insulin. The mixed
insulin in the morning means that injections during the school day can be avoided.
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MULTIPLE DAILY INJECTIONS WITH LONG ACTING BASAL
The minus points are a tendency for lows before lunch and high blood sugars after lunch.
This regime is not used frequently but it can suit some people very well. I know of a teenage girl who has
a degree of intellectual impairment. She has a considerable dawn phenomenon. She uses this regime to avoid
having to give insulin injections while she is at school.
Multiple daily injections with long acting basal
Eg Humalog for meals and snacks with Lantus once or twice a day.
This regime gives much more flexibility for meals than mixed insulin regimes.
The disadvantages are the number of injections. There can be 4-10 a day. Insulin pens are generally easier to carry but are more expensive than vials and syringes. The insuflon device can be useful for babies or
toddlers on a MDI regime as the insulin is put in the same channel for a day or two so can be less uncomfortable.
This regime is the most popular for most older children and adults. In the USA all children are started on
an intensive regime from diagnosis. In Europe there is more tendency to use a mixed regime at least to start with.
When it comes to advanced insulin techniques this is the method that I will mainly be discussing.
Insulin Pump Therapy
This is also known as a continuous subcutaneous insulin infusion system or CSII. It has been developed in the
US and is much more popular there than in the UK.
Plus points are that finer tuning with insulin is possible with this technique particularly due to the ability
to alter basal rates. Most people need to change the insertion device every 1-3 days. Once this is done there
are a greater variety of bolus patterns you can use without having to have another injection. Many users love
their pumps and greatly prefer it to the MDIs especially once over the first few months.
Disadvantages are that it is comparatively expensive. It costs about 5000£for a pump for five years use with an
additional 1000£a year for sterile consumable supplies. You still need to have pens or vials and syringes handy
in case of pump failure. It is available in some UK centres but the cost is not borne by the NHS and must be
paid for in person or from a charity. A great deal of learning and monitoring is required to use this method
successfully.
There are also problems that can occur on the short and long terms. Pump failure through the night can
result in you going to bed with normal blood sugars and waking up in diabeticketoacidosis. Long term scarring
at the infusion sites and the occasional abcess can also be problems that result in users going back to MDIs.
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Chapter 21
HOW CAN I USE BOLUS INSULINS
EFFECTIVELY?
Bolus insulins are given to cover your food and also to correct high blood sugars at meals and other times.
The total amount of carbohydrate and its rough glycaemic index, fat content, protein content, and the presence
or absence of delayed stomach emptying all affect the speed and duration of blood sugar rises after meals.
If you are on the strict end of low carbing most of your meals will be meat/egg/fat/low starchy vegetable
combinations which take longer to digest than if you were eating sugary or starchy foods such as breakfast
cereal and milk. The techniques you use to cover different kinds of meals will therefore vary. You are doing
your best to match the insulin to the meal. The sorts of meals you will be choosing to eat will depend on your
goals for your blood sugars and your health.
We will be discussing techniques to cover several types of meals.
Dr Bernstein’s strict low carb meals at 6-12g of low glycaemic carb, moderate protein and high fat.
This is the gold standard. It can give you truly normal blood sugars over the entire course of the meal
when optimal insulin techniques are used. All diabetics need to seriously consider how far they could adapt
themselves to this diet for the long term prevention and indeed reversal of complications.
Dr Jovanovich’s typical low carb meals at 13g- 30g of mixed glycaemic carb, moderate protein and high fat.
This is the typical diet that most low carbers and lower carbing diabetics use. All of the popular low carb
diet books by eg Dr Atkins, Drs Eades, Barry Groves, Dr Agatson, Drs Allen and Lutz, and Dr Annika
Dalquhist are in this meal range. It gives you more variety in fruit, vegetables and grains but probably not
completely normal blood sugars. You may get some sugar spiking at meal times but are likely to have a normal
blood sugar by the time the next meal comes with the appropriate insulin techniques.
If you are in transition from the high carb so called, ”Healthy Eating Plan” this is where you want to be
for some time. This gives you time to:
• Adjust your insulin or oral medications downwards slowly and safely.
• Helps reset your ”Hypo clock” downwards.
• Helps prevent a deterioration in retinopathy from too rapid blood sugar improvements.
• Gives your lenses in your eye time to adjust to lower sugar levels.
• Gives you time to learn new low carb baking skills and improve on your range of meat, egg and vegetable
dishes.
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WHY DO I HAVE TO CHANGE MY EATING AND INSULIN ROUTINE?
• Gives your family time to adjust to a new eating routine.
• Gives you time to organise your planning, shopping and meal preparation times.
Dr Morrison’s techniqes for dealing with higher carb meals of 40-90g are a useful addition for times
when you are having a planned indulgence or when your food choices are extremely limited.
Eating meals with this carbohydrate content approaches what many consider to be ”normal” eating. The
problem is that if this is done too frequently it will certainly have an adverse effect on your diabetes. Blood
sugars at meals will spike and for some time afterwards but you are likely to have normal blood sugars when
the next meal comes.
Why do I have to change my eating and insulin routine?
If you have been doing what you have most likely been told at your diabetes clinic you will be here for a very
good reason. It isn’t working.
You are looking for solutions to your blood sugar problems:
Too high. Too low. Too wide blood sugar swings. No idea what number that meter will show next.
The techniques I will shortly be describing are often seen by newcomers as a bit of a drag. All those blood
sugar tests! All those injections! All those donuts I’ve to bin!
What I would like to do here is explain what is wrong with the dietary advice given out in most diabetic
clinics and why the simple insulin regimes they advise are not adequate.
The poor control you have been experiencing up till now is not because you haven’t listened, asked questions or done as you have been asked. It’s not worked because the advice you have been following has been
wrong.
Here is what you are told to eat according to ”Healthy Eating” guidelines.
Protein
Protein should be 15-20% of your total energy intake. Optimally 0.8g/kg body weight a day. It is neither
necessary or advisable to have more than 20% of your energy from protein. Cereal foods and pulses add considerably to the protein content of the diet. Most adults eat at least 50% more protein than required.
What it should say is: The minimum protein requirement for a healthy person is 1g/kg of their ideal body
weight of protein a day. You can find this amount by an easy calculation.
Take your ideal weight in kilograms and divide it by 6. This is the minimum amount of lean protein to
eat in a day in ounces. Eg a 60kg woman would need at least 10 oz of lean protein a day.
If you are eating this and you are a healthy weight fine.
If you are eating more and are too heavy you may need to cut down.
If you have kidney problems keeping normal blood sugars are very important. You may need to reduce your
protein intake a little but may need more if you are on dialysis. The help of a dietician with experience in this
area is important if you have established severe kidney failure.
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Cereals and pulses may have some protein in them but they are also high in carbohydrate.
Fat
What the ”healthy eating” guidelines say:
Saturated fat is the main dietary determinant of LDL ”bad”cholesterol.
Intake of saturated fat in most European countries is above the 10% limit recommended.
Diabetics appear to be more sensitive to dietary cholesterol than the rest of the population. Eggs, offal and
shellfish are particularly high in cholesterol.
Trans-unsaturated fatty acids (often found in manufactured confectionery products and some margarine) and N6-polyunsaturated fatty acids raise plasma LDL cholesterol. Trans fatty acids also lower HDL ”good” cholesterol.
Diets low in saturated fat and high in carbohydrate or enriched in mono-unsaturated fatty acids with a cisconfiguration lower serum LDL. eg cashew nuts, hazelnuts, almonds, herring, salmon, pilchards, mullet, peanut
butter, olive oil, rapeseed oil, goose fat and avocado.
N-3-polyunsaturated fatty acids are found in foods such as oil-rich fish such as mackerel, herring, sardines,
pilchards, trout, and mullet. N-3-polyunsaturated fatty acid supplements have been shown to lower plasma
triglyceride levels in type 2 diabetics but they raise serum LDL levels.
Reduced fat diets when maintained over the long term, can help to bring about a modest weight loss and
an improvement in dyslipidaemia.
Regular use of foods with fat replacers or substitutes is safe and may help to reduce saturated fat and cholesterol
intake, but will not reduce total energy intake or weight.
Less than 10% of energy should be from saturated fats. If the serum LDL is greater than 2.60 mmol/litre
this should be reduced to less than 7%. If weight loss is desirable or replaced with either carbohydrate or
mono-unsaturated fat if weight is to be maintained.
Dietary cholesterol intake should be less than 300mg/day. If the serum LDL is greater than 2.60 this should be
reduced to less than 200mg/day.
The intake of trans-unsaturated fatty acids and N-6-polyunsaturated acids should be minimised.
What they should say:
Well they got one thing completely right. Trans and N-6 polyunsaturated fats should be minimised. Well
done!
Trans, hydrogenated, partially hydrogenated, refined vegetable oils and margarine should not be used for cooking and baking. You can use lard, butter, macadamia nut oil and extra virgin olive oil instead.
As correctly stated these oils are extensively used in processed food products. They are cheap, taste bland
and prolong the shelf life of food. In baked goods they also give a lighter texture than butter and lard for
instance. The safest way to avoid them is to make your own food from ingredients that you know are safe.
Hydrogenated oils have been found to increase inflammation in the body and are one of several causative
factors in metabolic syndrome and the development of diabetes, heart disease and cancers.
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FAT
The most important lipid markers for the development of cardiovascular disease are having low HDL, high
fasting triglycerides and a high amount of very low density lipoprotein.
It is true that high saturated fat intake increases LDL but it is the most dense particles of this that are
the problem as they are easily oxidised. This is the process that is involved in atheroma formation in blood
vessels. Just plain LDL levels are irrelevant to the formation of atheroma.
High saturated fat intakes are associated with higher HDL levels. This is the protective ”good” cholesterol.
Saturated fats also promote the absorption of vitamins from vegetables and fruit which are natural anti-oxidants.
Saturated fats themselves are chemically stable and are not prone to oxidation.
The formation of superoxides is one of the major contributors to the aging of blood vessels and thus the
complications of diabetes. High blood sugars, wide blood sugar swings, free radicals given off from heated
polyunsaturates, overheated monounsaturates and hydrogenated / trans fats are major causes of the tissue
damage caused by superoxides.
Low saturated fat intake is associated with obesity in children. It also seems to act as an antidepressant.
It is a source of the vitamins A, D, E and K in its own right.
Some low carbers feel best with saturated fat intakes as high as 80%. About 50% of calories from fat which is
mainly from saturated and animal sources is common in a ”typical” low carbohydrate diet as described. Some
of the healthiest people in the world are the Masai Mara tribes in Kenya. They drink cow’s milk mixed with
cow’s blood and a small amount of beef. Cardiovascular disease is almost unheard of.
High fat/moderate protein/ low carb diets are adhered to better than low fat/low protein/ high carb diets.
Weight loss from fat stores tends to be better in low carb /high fat than in high carb/low fat diets. In addition
the low carb diets improve lipids levels, inflammatory markers and blood pressure independent of weight loss.
Diabetics are particularly sensitive to dietary carbohydrate because both types one and two have do not have a
type one insulin response to deal with the rapidly high blood sugars from digested sugars and starches. Diabetics either lack insulin or the insulin they do make is much less effective than in non diabetics. 90% of ingested
carbohydrate becomes sugar in the blood starting at 15 minutes and peaking anything from 30 to 70 minutes.
Very careful matching of insulin with the amount and type of ingested carbohydrate is needed to mimic the
actions of a normal pancreas.
High amounts of dietary carbohydate are harder to count accurately. The more carbohydrate eaten, the higher
the blood sugars. The higher the blood sugars the more insulin resistant you become. The more insulin resistant
you become the more insulin you need to bring down high blood sugar levels.
After about 30 g of carbohydrate is eaten, injected insulin, even when correctly given stops acting in a linear dose response line. More and more insulin is needed to bring the higher sugar levels down. This makes the
proper dosing of insulin difficult. High blood sugars, low blood sugars and wide blood sugar swings often result
from this unpredictability associated with higher carb meals.
Low blood sugars can be dangerous to brain function and can cause incoordination, confusion, loss of consiousness, fits, brain damage and death.
High blood sugars can damage tissues by the aldose reductase pathway which leads to burst cells eg nerve
cells.
High blood sugars can stick onto proteins and impair their function as occurs in the immune system and
connective tissue. This process is called glycation.
High blood sugars and wide blood sugar swings activate superoxides which are free radicals which cause
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widespread tissue damage as occurs in blood vessels and in cancer development.
High blood sugar levels can affect protein kinase enzymes which affect cell function in places such as the
retina of the eye.
Yes. Diabetics are particularly sensitive to dietary carbohydrate.
Dietary cholesterol hardly influences blood cholesterol levels at all. In most people if they don’t eat enough
cholesterol their liver will make more. Eggs, offal and shellfish are high in cholesterol and were particularly
prized in so called primitive societies for their health benefits. These foods are also high in protein, vitamins
and minerals and may be enjoyed by diabetics as well as anyone. Pregnant women are best to avoid undercooked eggs and liver pate due to salmonella and listeria concerns. Care is needed in sourcing shellfish from
uncontaminated waters and eating it fresh. People with an allergy to eggs or shellfish should of course avoid
them.
Oily fish, most nuts, extra virgin olive oil, goose fat and avocado contain healthy oils and may consumed
as desired within carbohydrate limits determined by the desired goals of the person. Any effect on LDL is
irrelevant.
There is no need to use fat replacers whatsoever. There are concerns about gastrointestinal side effects such as
cramp and diarrhea and impaired absorption of fat soluble vitamins. Eat real healthy fats and enjoy them.
Carbohydrate
What they say:
When referring to carbohydrate the terms sugars, starch and fibre are preferred to the terms simple sugars,
complex carbohydrates and fast acting carbohydrates as the latter are not well defined.
Carbohydrate exchange systems based on 10g portions do not improve glycaemic control and are no longer used.
Many factors including the type of sugar, nature of starch, method of food processing and cooking, food
form, other food components, blood glucose levels, severity of glucose intolerance, can affect patient’s glycaemic
response to foods.
The total amount of carbohydrate in the dietary intake seems to be more important than the source or type.
Intake of foods with a low glycaemic index has not been shown to improve glycaemic control in type 2 diabetics but may improve the lipid profile.
Consumption of the sugar sucrose does not increase glycaemia more than isocaloric amounts of starch.
Fibre containing foods such as whole grains, fruit and vegetables, provide vitamins, minerals and other substances important for good health. However both diabetic and non diabetic individuals would need to consume
very large amounts of fibre to produce metabolic improvements to glycaemia and lipid profiles.
Intake of foods that contain naturally occurring resistant starch (corn starch) may modify post prandial glycaemic response and reduce more extreme fluctuations in blood glucose levels but there is no published evidence
of long term benefits to diabetics.
When calculating optimal intake, greater attention should be paid to the total amount of carbohydrate than to
its source or type.
Food with carbohydrate from fibre rich foods, wholegrains, fruits and vegetables and from low fat milk should
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be included in the diet. There is no evidence to support increasing fibre intake in diabetics above the levels
recommended for the rest of the population.
Sucrose or sucrose containing foods should not be restricted for diabetics, but can be used in substitution
for other carbohydrate sources in the context of a healthy diet with appropriate hypoglycaemic medication
cover.
The expert consensus is that carbohydrate and mono-unsaturated fat together should provide 60-70% of intake,
but precise and relative proportions may vary according to individual factors, such as age, activity levels and
weight.
What they got right:
Quite a lot of what is said in this carb section is factually correct.
The terms sugar, starch and fibre are better than simple sugars or complex carb or fast acting carb. The
latter terms do tend to confuse people.
Carbohydrate exchange systems on their own do not improve glycaemic control.
Many factors do affect how an individual will respond to a given amount of carbohydrate.
The total amount of carb is indeed a more important consideration than the source or type.
The intake of low glycaemic foods versus high glycaemic foods is insignificant in getting good control when
high amounts of total carb are consumed. I do o not know whether the lipid profile will be better or not on a
high total carb/low glycaemic diet.
Sucrose, which is the usual table sugar is certainly no worse than many starches in raising blood sugar levels.
Fibre eaten in palatable amounts has indeed no proven health benefits in diabetics or anyone else.
The consumption of corn starch may indeed result in less post prandial blood sugar drops if a high carb
diet is consumed.
The total amount of carb is indeed a more useful consideration than type or source when it comes to glycaemic control.
What they should have said:
Sugar and starch have about the same effect on raising blood sugars. They both raise blood sugars quickly, often
within 15- 30 minutes. Fibre tends to retard the process somewhat. In addition fibre is remains undigested and
does not contribute to the total effect on blood sugar or on calories taken in.
The term complex carbohydrate tends to confuse people the most. Many would assume that brown bread
is a complex carb and it is often described as such but most versions of brown bread are made into sugar just
as fast as white bread or sucrose.
The truly complex carbs are non starchy vegetables such as celery, broccoli or cauliflower that have a cellulose structure that is more difficult for humans to digest so sugar release is quite slow.
Exchange systems can work well if the total amount of carb consumed at each meal is kept moderate to
low. Dr Allen and Dr Lutz’s 70g carb diet is an example of this.
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Many factors affect an individual’s response to a meal. Charts and guides can offer some help but experimenting on yourself is the only way to really find out.
The total amount of carb consumed is certainly more important than the type or source when high amounts of
carb are consumed. When you lower the amounts it becomes more obvious what the relative glycaemic effects
of different carbs are.
Low glycaemic index foods when consumed in moderate to low amounts do tend to produce lower sugar spikes
than higher glycaemic foods in equivalent amounts.
Consumption of sugar and starch raises blood sugar fast and predictably high. This can be very helpful
when dealing with hypoglycaemia but is less useful when planning meals that are aimed at keeping blood sugars
within the normal non diabetic range.
Strictly scientifically no carbohydrates are required to be consumed by humans whatsoever. Essential fatty
acids - Yes. Essential amino acids - Yes. Essential carbohydrates - Well, no actually.
In real life, if you are on injected insulin you can’t rely on getting it perfect 100% of the time. So, fast
acting sugars such as glucose to deal with hypos IS necessary.
Many people enjoy eating carbohydrates even though their body can function fine without them. These days
we don’t eat the lightly cooked or raw organ meats that our ancestors ate. We therefore could become deficient
in certain nutrients eg vitamin C if we did not eat exactly as they did. Lightly cooked liver has more vitamin
C than an apple weight for weight. But what would you rather have in your lunch box?
For a diabetic you would certainly have a lower effect on your blood sugars if you ate the raw liver compared to an apple. So what is the best of both worlds?
Fortunately nature has provided us with a wide variety of non starchy vegetables. These generally grow above
ground.
There is no nutrient present in whole grains, fruit or milk that is not available from either a meat/ egg source
or non starchy vegetable. Usually the nutrients are present in much greater quantities too.
And there is no adverse effect on your blood sugars that often occurs with fruit, milk and wholegrains unless consumed in very small quantities, and preferably with a lot of fat added.
Sucrose and starches should be regarded by diabetics as poisonous until proven otherwise. You can probably get away with eating small quantities of these infrequently. But you are kidding yourself if you think you
can eat these as in a five year old’s birthday party and get away with it.
What the ADA and Diabetes UK say about sugar and starch is just plain wrong. You may not want to
believe this. It may be tough.
But do you know how much funding the food and drug industries give national diabetes associations such
as the ADA every year? I’m not talking about the organic vegetable and free range chicken farms. I’m talking
about sugar, confectionary, soft drink, breakfast cereal, bread , cake, biscuit and other processed food suppliers
give in donations and for endorsement of their products.
You can try to cover high carb/glycaemic items with insulin. Because of the 30-50% injection to injection
variation in glycaemic effect you do put yourself at a rather high risk of overly low or overly high blood sugars.
This is if your insulin matching and carb ratios are perfect.
Expert consensus about anything just means that a lot of people with common interests agree on something. I
call this ”over the garden fence” opinions because they are just as scientifically valid.
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They may be right. They may be wrong. But we just don’t know.
• We don’t know what evidence they examined.
• We don’t know what evaluation process they went through.
• We don’t know what evidence they did look at.
• We don’t know what evidence they didn’t look at.
• We don’t know if they are bright or not.
• We don’t know if they are going a bit batty-bat or not.
• We don’t know if they took their medication that day or not.
• We don’t know what they were offered for agreeing to someone else’s agenda or not.
• We don’t know nuthin’ about that decision.
If you are happy to accept consensus decisions that is okay. Please give some tolerance to others who are a bit
worried about accepting those decisions.
What is a typical NHS dietary and insulin regime?
Your advised diet should you be a diabetic in Britain’s National Health Service is us usually something like this:
• Consume plenty of starches at each meal.
• Try to have wholegrain versions when possible.
• Eat sugary foods in low to moderate amounts.
• Eat at least 5 portions of fruit and vegetables a day.
• Avoid diabetic products.
• Drink diet versions of soft drinks.
• Fruit juices may be consumed in moderate amounts.
• Eat your usual amount of protein especially white meat such as chicken and fish.
• You may eat eggs and red meat but only in small amounts.
• Eat some oily fish each week.
• Avoid saturated fat.
• Avoid fried foods.
• Avoid butter or lard. Use margarines instead.
• Use olive oil in low to moderate amounts.
• Drink alcoholic drinks sparingly.
A typical ”healthy eating” day could be:
• 7.30 am
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– Breakfast cereal, semi skimmed milk.
– Toast thinly spread with marmalade.
– A glass of tropicana.
– Tea.
– A banana.
• 10.30 am
– Small scone with small quantity of margarine and jam. (optional)
– Coffee
• 1pm
– Tinned cream of tomato soup.
– Tuna sandwiches with margarine and wholegrain bread.
– An apple.
– Diet coke.
• 4pm
– A small quantity of raisins and mixed nuts. (optional)
– Coffee.
• 6.30 pm
– Spaghetti Bolognese.
– Tea.
• 9.30pm
– Wholemeal toast and margarine.
– A glass of semi skimmed milk.
The insulin regime to cover this could be:
• Novorapid at breakfast, lunch and dinner and possibly before snacks.
• Lantus at bedtime.
• No carb counting is usually taught.
• Dose adjustments are made on the trend in the blood sugars.
• Blood sugars are preferred to be 4- 8 before meals and on rising.
• Blood sugar is preferred to be over 5.0 at bedtime.
• If blood sugar is 10 or over three days running at the same time of day the insulin to cover that period of
time needs to be raised.
• If 7.30 am bs is over 10 raise night Lantus.
• If 1pm bs is over 10 raise breakfast insulin.
• If 6.30pm bs is over 10 raise lunch insulin.
• If 9.30 pm bs is over 10 raise evening meal insulin.
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This sort of dietary and insulin regime is commonly used for type ones.
For insulin using type twos simple basal Lantus or other long acting insulin such as Levemir is commonly
given on its own. No meal insulin is usually started unless the hbaics are over 8.
Twice daily mixed insulins such as Mixtard, Humalog Mix or Novomix may then be given.
Sometimes type 2s are given separate basal and rapid acting insulins to cover all meals.
The results of following this regime tend to be blood sugars set at a considerably higher points throughout the
day and night. This is needed to reduce hypoglycaemia which can occur due to unpredictable absorption and
action which is worsened by high amounts of insulin given at each injection.
The amount injected is whatever you have worked out works best and it is given in a single injection. When
high carb diets are consumed high amounts of insulin are needed to cover this.
There is usually not enough fat consumed to reduce the speed of digestion of the carbohydrate. Snacking
due to hunger results in a need for more insulin injections to cover the snacks. This can still be active when the
next meal insulin is given.
This can increase the chances of hypoglycaemia. Hypoglycaemia can often be overtreated and so blood sugars
before the next meal are high.
No strategies such as correction doses, limiting the amount of insulin injected in one shot, using different
types of bolus insulin, timing the insulin injection so it is optimally effective are taught.
No wonder the results that insulin users get are so far away from what your pancreas would do if only it
could.
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Chapter 22
HOW DO I CALCULATE MY
INSULIN SENSITIVITY?
Insulin sensitivity may not change much at all throughout the day in pre-pubertal children. After this most
people find that they need more or less insulin at different times of the day.
To find out how much insulin you will need to take to cover carbohydrates taken at different meals you will
need to find out your carb to insulin ratio.
An average insulin:carb ratio for type ones who are thin is one unit of novorapid or humalog for 12 g of
carbohydrate. As regular insulin is a third less potent one unit of actrapid for instance covers 8g of carbohydrate.
If you eat the same amount of carbohydrate for breakfast, lunch, dinner and bedtime snack with the same
dose of insulin you will find that sometimes it works better than at other times.
Most adolescents and adults need more insulin to cover the same amount of carb at breakfast than at lunch
because the dawn phenomenon makes them more insulin resistant for a few hours, often up till 11am in the
morning.
Most people have the best insulin sensitivity in the early afternoon eg 2-4pm.
Some people get a ”dusk” phenomenon and become a bit more insulin resistant at dinner time.
My son Steven’s insulin to carb ratio is 9 at breakfast, 14 at lunch and 10 at dinner. Because I particularly want to avoid night time hypoglycaemia I give him only 2/3 of the amount of dinner insulin to cover a
bedtime snack. The figures are therefore 9-14-10-14.
You have to guess and test to work your own figures out.
If you are writing down your blood sugar figures in a book or chart add and take the averages of your bs
on pre-lunch, pre-dinner and pre-bed for at least 3 and preferably 10-14 days.
If you have averages that are above your personal target figure or 5.0 for those who are seeking optimal control
you need to have more insulin to cover your breakfast, lunch and dinner respectively.
Accurate basal insulin levels and carb counting skills are essential to do this accurately. If your sugars are
running particularly high for any reason eg you have a dental infection or the flu or your exercise pattern has
changed over the test period your figures will not be correct for you.
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Chapter 23
HOW DO I ADJUST MY BASAL
INSULIN?
The best way to find out the best basal for you is usually to look at the 3am bs. Do this several times but don’t
look at the averages, look at the lowest number you are getting. The aim is to give you normal night sugars
but not hypoglycaemia.
If your lowest bs at 3am is 5.0 your basal is right for you.
If your lowest am bs is less than 5.0 you are having too much basal.
If your lowest 3am is less than 5.0 you are also having too much basal.
If your average am bs over at least 3 but preferably 10-14 is higher than 5.0 with good 3am bs you are having
the dawn phenomenon. If you gave a higher basal to get this down you would be giving yourself a high risk of
night time lows.
If your lowest 3am is higher than 5.0 you can try a slight increase in basal.
Make changes in insulin doseage in the smallest increments your pen allows. Vial and syringes do give more
flexibility. Diluted insulin can also make incremental changes more precise and is particularly helpful for young
children and babies who are on low amounts of insulin.
When you have made a change in basal insulin sit it out for about 3 days before you adjust again. This
is the time it can take for this to stabilise.
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Chapter 24
HOW TO I TURN MY PEN INTO A
PUMP?
Well, of course, you can’t really change your pen into a pump. But what you can do is look at why pumpers
often get better meal coverage than the injectors.
Pumpers can do several things with their pumps to get better meal coverage.
• They can pump in several units at once - an immediate bolus.
• They can give the dose over a few hours - an extended bolus.
• They can programme the pump to give two smaller boluses within a short time of each other - dual wave
bolus.
Fortunately you can get the same results with your pens and vials.
Pumpers are told that to avoid a lump of insulin under the skin they need to pump 5 units or less at an
immediate bolus whether for correction doses or for covering meals. They may go on to cover the meal with a
dual wave or extended bolus if they need more insulin than this for that meal.
The absence of the lump of insulin under the skin makes its absorption much more predictable. Did you
know that 70 units of insulin injected under the skin takes a week to fully absorb?
Dr Bernstein has found that 7 units injected at once is the absolute highest amount of insulin per shot that will
ensure accurate enough absorption of that insulin. Otherwise the insulin you think is going to cover that meal
won’t work as well as you expect and it is likely to release when you don’t really want it to.
Now the 7 units per shot tip is something that often fills newcomers with dread. They say things like, ”You
mean I’ll need four jags to cover one meal! You have got to be kidding!”
Why is this? It’s not just because they can’t divide by 7. It’s not just because they object to the slightly
increased time the injection procedure will take. It’s because up until now they have been having injections
that are really quite unpleasant and often painful. They also worry about the lipoatrophy at their injection
sites. Does this mean more of these?
The answer is no. Not only do the smaller amounts give you an insulin that ”does what it says on the tin”.
They give you a lot less discomfort per shot and virtually no lipoatrophy at all.
103
You will have noticed that I almost expect that you will be eating a high carb/low fat diet right now. Let’s
face it, you are only doing what you have been told to do by your doctors and dieticians. As you get further
into the low carb way of eating you will find that you need less and less insulin to cover your meals. And that
means many fewer injections as time goes on.
When someone goes from a multiple daily injection regime to a pump they need to cut down on the total
daily amount of insulin they go on with the pump. This is usually a decrease of 20%. This is because the slow
leakage of insulin under the skin is more efficient at getting the insulin into the body. Its not just sitting in a
big lump doing nothing any more.
The 7 unit per shot system is not quite as efficient as a pump but gets you results that can be pretty close.
I therefore recommend that you also reduce your bolus amounts by 15% to start with. You do this for your
current basals as well as for your current meal boluses. This would not apply if you inject 7 units or less at that
time normally of course.
Dual wave bolusing can be done by two or more injections to cover a meal of the more slowly digesting type
such as meaty dishes, pizza, and pasta with creamy sauces. You simply need to remember to give the second
or third jag at the time you planned.
Fortunately there are different durations of insulins that can be used that can give you the same effect as
an extended bolus.
Most insulin users have been put on rapid acting analogues for meals. Novorapid and Humalog. These peak at
about 70 minutes and last about 3 and a half hours with a tail to about 5. What the usual blurb says is that
they cover ”most meals” and so this is all you need.
Before analogues were invented however the older regular insulins were used to cover meals. These peak at
about 2 and a half hours and last 5 hours with a tail to about 8 hours. What the usual blurb says is that these
take longer to work and are less convenient than analogues to cover meals.
These characteristics are however just what you want to cover higher protein, higher fat, and more low glycaemic
carbs. Its rather wonderful in fact.
When you give these regular insulins on their own to cover carb you need to remember two things. Firstly
they do take longer to work so you need to inject them optimally 45 minutes before eating that carb. 30
minutes will do but is not optimal. The second thing to remember is that these are less potent insulins and you
need to give a third more of them than with analogues for the same amount of carb. Actrapid would cover 8g
of carb compared to one unit of humalog that would cover 12g.
When you use these insulins to cover protein and more slowly digesting meals the fact that they take longer to
start working becomes an advantage and you can get on with injections optimally 15 minutes before a meal.
Just before you eat will often do.
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Chapter 25
HOW DO I COVER A STRICT LOW
CARB REGIME WITH INSULIN?
Dr Richard Bernstein, Dr Annika Dalquhist’s, and Dr Atkins diet have been described in previous sections.
They can all take you to the strict low carbing end of things amounting to about 30-42g a day of carbohydrate.
I have chosen this level of carb for your meals to differentiate a strict low carb diet from a typical low carb diet.
All of these diets in this strict range will give you the possibility of entirely normal blood sugars.
Dr Bernstein’s diet is more specific about what sorts of macronutrients you eat and in what amounts. For
simplicity of eating and insulin regime combined with effectiveness it is my opinion that this is the ”Gold Standard.”
If you are eating faster digesting carbs even within the 12g total carb limit you would need to experiment
to see if a single insulin type covers your meals to entirely normal blood sugar standards or not. The levels you
may be aiming for have been described previously. If you get what you want this is perfect and if you don’t
you may wish to try the specific insulin regime for the typical section which follows.
Dr Bernstein recommends using regular insulin to cover meals. These are of no more than 12g of non
starchy vegetables three times a day with 6g allowed for breakfast because of the effect the dawn phenomenon
has on insulin resistance at this time of day.
The regular insulin is best injected 45 minutes before eating. Because you are having such small amounts
of carb and therefore insulin at each meal you don’t really need a separate insulin for the carb and protein. Just
use a little more or regular such as actrapid to cover your protein.
The protein amount and consistency depends on your goals concerning weight gain or loss. For people with
delayed gastric emptying they may be on quite small portions of protein at their evening meal such as 2oz.
With guess and test you will quickly learn what works best for you.
Rapid acting insulin analogues are used for correction doses.
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Chapter 26
HOW DO I COVER A TYPICAL
LOW CARB REGIME WITH
INSULIN?
I have chosen Dr Jovanovich’s carbohydrate limits as the border between what could still be considered low
carb and what is out with that range. Dr Atkins and Drs Allen and Lutz diet’s have been described previously
and fall in this range. If you are on another diet such as Protein Power, South Beach or Barry Groves ”Eat fat
and Stay Slim” diet you are in this range.
Once you get to higher carbohydrate levels of 13-30 g a meal of carb you increasingly need a bit more oomph
with your insulin to deal with more rapidly rising blood sugar levels. At the same time protein continues to
digest slowly so you need techniques to deal with that.
The most accurate technique that I know of was perfected by Dave (Iceman) from Alaska. Sadly he died
of cardiovascular complications of his longstanding diabetes. For all our benefits he passed his method throught
the Bernie forum onto Adam (Adam DMer) who graciously passed it onto me. It is a beautifully simple technique that can also be used at lower and higher carb levels than I am describing in this section if desired.
Use rapid acting analogues to cover carb. This can be done according to your individual carb sensitivity for that time of day.
Use regular insulin to cover protein. This is to the tune of 2g of regular insulin for each portion of
lean protein which is a deck of card in size.
Both are optimally injected 15 minutes before eating.
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Chapter 27
HOW DO I COVER A HIGHER
CARB REGIME WITH INSULIN?
The higher carb your meals the harder it is to get perfect or even acceptable blood sugar control. You can
usually get an improvement from what you have been getting however,from the techniques I will be describing.
Although I much prefer to eat a typical low carb diet myself I was aware that my son Steven did miss the
occasional treat. What was more important was that the meals provided at school emphasised high carb /low
fat dishes in keeping with the ubiquitous ”healthy eating” guidelines. The odd high sugar due to either of these
reasons didn’t bother us at first because it was so infrequent.
For almost 18 months from diagnosis Steven did excellently on a typical low carb diet and twice daily mixtard
combinations. Due to his lower carb diet and lengthy honeymoon his hbaic was 4.8.
Then his growth spurt and reduction in endogenous insulin became obvious. We continued mixtard but started
on novorapid for lunch coverage in a half unit increment pen.
After 4 months on this we started an intensive insulin regime on levemir and novorapid. By this time he
was growing faster than our high fat/mod/protein/ low carb diet could sustain and his bmi was just under 16.
This is the bmi of eg Liz Hurley the actress who is indeed slim.
The dietician and diabetologist started threatening me. ”Feed your kid a high carb/low fat diet and he will
fatten up. Or else.” Presumably child protection procedures.
They did have a point. Indeed I had never seen a skinny diabetic on a high carb/ low fat diet. It did seem to
work like magic to fatten people up.
The problem was that Steven was just not hungry. Effectively reducing hunger is a major reason for the
success of low carb diets in weight loss . But it is a disadvantage if you are hitting adolescent growth spurts.
I increased the carb in his diet knowing that he needed to have more carb for weight gain but also knowing that this would play havoc with his beautiful blood sugar pattern.
I decided to go for it and fatten him up like a goose destined for pate de fois gras. ”Have what you like
Steven. We have to learn how to control whatever effect it has on your bloods sugars. You could eat a bit more
bread and potatoes than that couldn’t you? Please.”
I started this intensive fattening regime while on holiday abroad when we had almost unrestricted access
to foods of all types and while I could monitor his sugars day and night.
To start with it seemed quite fun to Steven. ”You mean I can eat a whopper with fries?”
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”You certainly can. You must.”
Soon the wildly fluctuating blood sugars and blurred vision got us both down. ”Please mum. Can’t I go
back to low carbing? ”
”Please, Steven. Just keep going with this a bit longer. I am getting nearer and nearer to perfecting the
carb weighting figures.”
We had a three month period of hellish sugars. We did loads of blood sugar measurements including most
nights between 2-4 am. I could hardly sleep with anxiety.
This is what your average mother with an average kid with type one diabetes goes through all the time.
It was bloody awful. I had no idea how bloody awful till I did it myself.
Fortunately I had some ideas about why Dr Bernstein strongly advised limiting carbs. The reason is to stop
any spikes after meals that normal people don’t have.
And why does Dr Jovanovich limit a meal to 30g of carb? The reason I figured out is that linear doses of
insulin based on reliable carb insulin sensitivities become increasingly unreliable above this level.
• The more carb you eat the higher your blood sugar goes.
• The higher your blood sugar goes the more insulin resistant you become.
• The more insulin resistant you become the more insulin you need.
• There is no longer a linear relationship between carb and insulin dosage after 30g.
• There is an exponential curve.
• Figuring out the sweep of that curve will vary from person to person.
• To do this you MUST do extensive self experimentation.
• Your carb counting skills must be well developed.
• You must increase your carb counts above 30g in a progressive way.
• You must keep meticulous records.
Give yourself a break every so often. It is best only to do these experiments when you have help around and
you are able to monitor day and night.
Unless you absolutely have to, you are much, much better off on a typical and preferably strict low carb
regime. Low carbing is extremely efficient at curbing your appetite. This is a major benefit for most diabetics
but I can see where it can be a problem for skinny toddlers and teenagers. If you need to resume a higher carb
diet I hope our experiences and learning of techniques can help you through this process.
I know that for many diabetics the hectic blood sugar patterns that they simply accept as being part of
the package deal that comes with diabetes.
I found the high carbing process extremely traumatic. Steven was unhappy. I was unhappy. Yet, no matter how much fat I added to his diet I could not fatten him up. He is not as much as a carnivore as me and carb
seemed the only answer. The high carb diet has worked and now Steven has a healthy bmi at 18. Teenagers
have lower bmis than adults but your dietician won’t know this. They don’t know a lot about a lot of things
you no doubt are finding out.
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Chapter 28
HOW DO I DO DR MORRISON’S
CARB WEIGHTING SYSTEM?
• You need to wean yourself gradually off your high carb diet.
• You need to be in a typical transition period at the very least.
• You need to adopt the 7 unit per shot guidelines. Every single shot.
• Your need to find out which methods of carb counting work best for you and do them every meal.
• You need to keep your basals, exercise, and fat and protein intake consistent over the testing period.
• You need to be well and free of infection or undue stress so your meal profiles will be accurate.
• You need to test at 3am on an experiment day to see you have not over done your insulin.
Ready?
What you are going to do is find out at what level your insulin stops working in a linear way.
You will recognise this by high blood sugars before the next meal compared to when you eat low carb meals. I
don’t know when this will kick in for you. For Steven it was good bs at 30g and higher bs at 40g for the same
carb insulin ratio.
The best meal to test on is your lunch. Your dawn phenomenon is not active. Your dusk phenomenon is
not active. Your carb sensitivity is usually at its best. You are awake and can deal with any adverse effects on
your blood sugars by correction doses before your evening meal.
It is too risky to experiement on yourself at your evening meal. Throughout this experimentation process
the only sugars that were consistently perfect for Steven were the before bed ones for this reason.
You need to add a smaller incremental dose of insulin to the one calculated for your carb sensitivity for that meal.
Test yourself on items that are easy to calculate eg breakfast cereals that are easily weighed and bread slices
that are listed on the package. Packaged processed food with carb labels are helpful for these experiments.
Decide on how many units of insulin extra you will give per 10g over the baseline figure.
Make this a very low amount. If you can change to a half unit pen. The novonordisk demi pens and junior pens have this facility and humalog has just become available in half units too. Of course this is not a
problem with a syringe. For a child you may wish to consider extra accuracy from diluted insulin.
We started on 0.5 units novorapid for each 10g extra increase in carb.
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If your figures are showing that this is giving sugars higher than your next pre-meal target you can up the
amount of additonal carb weighting insulin by a small amount.
If your figures are showing that the next pre-meal bs is too low then up the amount of carb stages eg in 5
or 10g increments till you figure out what works.
This carb weighting method is accurate for Steven up to 90g of carb per meal. After this our levels are
inaccurate. They are usually lower than expected on this exponential weighting but sometimes are higher.
You could find that you need to start carb weighting at levels of less than 40g.
You could find that you don’t need to start carb weighting till levels of 50g or higher.
You may find half unit increments need to be used at additional carb levels of 5g, 10g or 15g or 20g levels.
You will need to determine when this system stops being accurate for you. This could be at levels considerably lower than 90g or could perhaps be higher.
Remember to only do the experiments when conditions are optimal for this.
• You are well.
• Your carb levels are accurate.
• You are starting at normal bs.
• It is lunch time.
• No unusual exercise is involved.
• You are not particularly stressed.
• You have help to figure out what you are doing.
By a slow process of guess and test you can find out how to extend the carb in your meals and still get normal
bs levels before the next meal.
I would again stress that low carbing is the safest option.
Once you know how to deal with higher carbs at lunch safely you can test this out at other meals.
Once you have learned this method use it wisely. It is for emergency situations and special indulgences. If
you use it day in and day out you may indeed have normal bs levels before your meals and at bedtime, but you
will be spiking a lot more than any non diabetic will. It is not only high blood sugars but widely fluctuating
blood sugars that are causes of complications.
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Chapter 29
HOW DO I TIME INSULIN
INJECTIONS MORE EFFECTIVELY
FOR SIMPLE INSULIN REGIMES?
If you are on a fixed dose insulin regime for any reason about the only thing you can manipulate to control
blood sugar control is what you eat and the timing of your meals in relation to this.
These fixed insulin regimes are less common in the US but are very popular in the UK especially type 2s
and also for type ones who are just starting on injections. Carb counting is not usually taught outwith special
education courses such as DAFNE in the UK.
This educational course has given you lots of information that you can use to improve your diabetes control. If you have not yet got to grips with carb counting and the other advanced insulin techniques you may
like to have some simple techniques that will improve your control meanwhile.
If you expect a meal to take longer to digest than is usual for sugars and starches eg it is high in protein,
fat and low glycaemic carbohydrates eg lasagne, pizza, lamb curry.
You can:
• Bolus 15 - 30minutes after you start eating for rapid acting analogues.(RAAs)
• Split the bolus into two or three parts and give at 6-90 minute intervals. (RAAs)
• Take regular insulin with the meal instead of a RAA.
• Extend the bolus delivery time to over 2.5 hours if you are on a pump.
For people who are on or prefer to use a single injection of a RAAs:
• For foods that are high GI foods - bolus before eating. eg a jam sandwich.
• For moderate GI foods - bolus while eating. eg fish and chips.
• For low GI foods- bolus after eating.
Your pre-meal blood sugar will also affect the optimal time you give your food boluses:
BS above target range:
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• High GI 30 - 45 minutes before a meal.
• Medium GI 15 - 30 minutes before the meal.
• Low GI 0-5 mins before the meal.
BS in target range:
• High GI 15-30 mins before the meal.
• Medium GI 0-5 mins before the meal.
• Low GI 10-15 mins after you start the meal.
BS below your target range:
• High GI 0-5 mins before the meal.
• Medium GI 10-15 mins after you start the meal.
• Low GI 30-45 minutes after you start the meal.
If this sounds complicated, well it is! But you have diabetes as your constant companion for the rest of your life.
You will be having at least 2 meals and more usually 3 to 4 every day. You have plenty of time to experiment
to get the best results.
For people on or who prefer fixed basal/bolus regimes
If you are on a fixed basal/bolus regime much of what you have been learning about the versatility of different
insulins will be irrelevant to you. You can only use the tools you have after all. One thing that is particularly relevant to you is the delaying or advancing injections in relation to breakfast and your
evening meal.
If your pre-meal sugars are high you can give the insulin dose and then wait longer for your sugar to
drop before eating. For instance on Mixtard you normally wait 30 minutes before a meal but you could extend
this as far as an hour and a quarter depending on how high your sugars are. For novomix or humalog mix the
usual instruction is to bolus just before eating. You could inject 14-40 minutes before depending on your level.
The opposite applies to low blood sugars. For mixtard users you would inject and eat right away or
earlier than the usual 30 minutes. For novomix/humalog mix users the injection could be delayed part way into
the meal or afterwards. There is no substitute for experimentation and learning from your efforts.
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Chapter 30
HOW DO I CHANGE MY INSULIN
REGIME IF I AM AN NHS
PATIENT?
Many US readers will be splitting their sides laughing at the very idea of these detailed schedules for fixed
insulin users. Why not learn to carb count and use separate bolus/ basal regimes? Why indeed?
As a UK General Practitioner I realise how difficult it is for patients to change their diabetologist’s mind
about what insulin is considered right for them. I hope you will read about all the different food patterns and
insulin regimes so you can consider if what you are doing now is what you really want to do. Are you getting
the results you want? How much effort would you be willing to put in to experiment to get the best results for
you?
Fixed basal / bolus regimes offer little cover for lunch time meals. To remedy this you can either eat a
very low carb meal at lunch time or ask the diabetologist to give you some rapid acting analogue or regular
insulin to inject to cover your lunch.
The diabetic staff may not want to have to train you in the use of a multiple daily injection regime. They
may not want to teach you carb counting. A lot of this has nothing to do with their perception about how you
will cope or whether they like you or not. It is to do with resource allocation in the NHS. NHS staff don’t call
it the National Sickness Service for nothing!
Please consider going through this entire programme thoroughly. Prove that you are better
informed about what will work to improve your diabetes than they are.
If you get stuck your Member of Parliament or a letter of complaint to the Clinical Director of the Hospital may help.
And the Best of British Luck to you!
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Chapter 31
HOW CAN I HELP INSULIN
DEPENDENT DIABETICS WHO
CAN’T AFFORD INSULIN?
From time to time I expect you feel pretty miserable about having diabetes. Especially about these interminable
injections.
Diabetes for everyone is a life sentence. But for some poor people in developing countries parents cannot
afford insulin for both a diabetic child and food for the rest of the family. Hard choices have to be made.
The insulin for life organisation aims to help. They will ship your unwanted but in date insulin to those who
would die without it. They also help coordinate insulin supplies to disaster struck areas.
It is an Austrialian based organisation whose president is Ron Raab. Ron has been a type one diabetic since he
was 12 just like Dr Bernstein. He became one of Dr Bernstein’s patients and reversed many of his longstanding
diabetes complications.
www.insulinforlife.org is the website for the organisation that has affiliates in the US, Europe and the
UK.
The Insulin Dependent Diabetes Trust
This is the UK organisation who will send your donated insulin to Insulin For Life.
Please send your no longer needed insulin - unused vials or cartridges and in date in a jiffy bag to:
Jenny Hirst
IDDT
PO Box
Northampton
NN1 4XS
The IDDT is a charity whose staff and membership is formed by diabetics and by those caring for diabetics.
They aim to listen and support your needs.
They have an excellent website with articles of interest to insulin users about many different aspects of diabetes at: www.iddtinternational.org
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Enquiries can be sent by e mail to: [email protected]
The IDDT was formed from original members of Diabetes UK who were not being supported in their needs
and preferences for animal insulins. Unlike Diabetes UK they receive no funding from pharmaceutical or food
manufacturers.
Today is the 5th March 2007 and at the present time there is no pen form of regular insulin available in
the UK apart form pork or beef soluble insulins. These are available for use in one unit increment Owen Mumford Optipens.
Thanks to the political lobbying that IDDT have continued for years the UK still manufactures animal insulins. These are obtained and purified from pigs and cows that have been slaughtered for their meat.
A small variety of long acting, short acting and mixed duration animal insulins are available in pen cartridge
formulations and vials from Wockhardt Pharmaceuticals. These can be shipped overseas.
Prescriptions for the insulins and pens are available from your UK GP in the usual way. A GP however
may want a diabetologist to approve.
If you are keen on a pen form of regular insulin animal insulins are the only option currently available. The
biggest drawback is that there is no half unit increment pens. Hypurin Pork Soluble insulin is what you need as
it is a little quicker acting than the Hypurin Beef Soluble insulin. You may remember that regular /actrapid/
soluble insulins are a particularly good option for covering protein in meals.
Alternatively you can use Hypurin Pork Soluble or the GM Human Actrapid insulin manufactured by Novonordisk
in vial and syringe form. The advantage of the syringe is that you can still use half or quarter unit doses.
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Chapter 32
HOW DO I DEAL WITH LOW
BLOOD SUGARS?
It is essential that you, your family and work colleagues know exactly what to do if you become
low in blood sugar.
If you are a kid tell the bus driver, your friends and your teachers that you have diabetes and what to do
if you look low.
Make out a personalised sheet and give it to anyone who may be in a position to rescue you out of a hypo.
For example:
I am Jenny Smith. I have insulin dependent diabetes.
When I show these symptoms:
a. I am unusually irritable.
b. I go pale.
c. I start to sweat.
Do this:
a. give me some lucozade. It is in my back pack.
b. look for the glucose tabs in my pocket.
c. Give me a drink of milk.
These symptoms happen when my brain is not getting enough sugar. I cannot think and act appropriately
for myself and may be bad tempered. If I don’t get sugar I could pass out.
In case of any difficulty please call:
a. parents.... Joe and Mary Smith Number 1234 456789
b. friend.....Carol Swanson Number 2468 101213
c. doctor.....Dr Reilly 3579 111315
If you don’t know what to do, or my medical condition does not improve or I pass out please call 999 or
911.
Thankyou.
When it comes to going out on dates with new people you don’t have to go as far as this! On the other
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hand diabetes is not something to hide either. If they aren’t okay with you having diabetes do you really want
to go out with them anyway?
Keep supplies to deal with hypoglycaemia in your home, your car, your office, your sports locker, at school
and on your person. Always carry a little something to eat in case you go low.
Having a medic alert bracelet on your wrist or a special dog tag round your neck as long as it is visible
can help bystanders figure out what could be wrong and get appropriate help for you.
Effects of too low blood sugar on the brain as the condition worsens are:
Delayed reaction time.
Difficulty reading small print.
Irritable stubborn behaviour.
Confusion
Clumsiness
Difficulty in speaking
Weakness.
Sleepiness.
Unresponsiveness.
Loss of consiousness.
Convulsions.
Death.
If you suspect a hypo the first thing you should do is check your blood sugar. Ask your helpers
to ask you to check your blood sugar if they think your sugar level is low.
This will cause less fighting than trying to force you to eat something.
If you are out with your mates and have had drugs or drink and you pass out you MUST
tell them to ring 999 / 911 and get you to an Emergency Department right away. They might
think you are just drunk. You may not be. You may be dying.
If you have been doing drugs and get into a mess call your parents. They may be angry and shocked but
it is a rare parent who won’t help. They will do their best to get you safe and sorted.
These are things you may notice yourself if you are going low:
Hunger can be a symptom you are going low but about half the time it is just plain hunger and you aren’t so
check your blood sugar first.
Blurred vision
Headache
Hand tremors
Tingling sensation in the fingers or tongue
Buzzing in the ears
Tight feeling in throat or tongue
Anxiety
Sudden awakening from sleep
Feeling light headed
Hot feeling
Insomnia
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Nightmares
Nausea
These are signs other people may notice as you go low:
Dilated pupils
Violent behaviour
Shouting while asleep or awake
Rapid shallow breathing
Cold or clammy skin
Restlessness
Pale complexion
Slurred speech
Nystagmus - jerky movements of the eyes when looking slowly from ear to ear.
Self treatment of hypos
Hypoglycaemia symtoms and signs often follow a typical pattern for each person. If you feel very low it may
be best to give yourself glucose or eat right away - then test.
Low blood sugars often occur right before meals, after exercising and when insulin is peaking and sometimes in
the middle of the night.
Try not to eat too much when you are low because it will make you go too high afterwards.
If your sugar level has been too high and you have taken a correction dose your sugar can drop fast. This
makes you feel low. A way to stop this is to eat a small amount just after you inject.
To raise blood sugars cleanly and predictably it is best to use pure glucose. This can be in gel, liquid
or tablet form.
Food substances like milk, juice and sweets are a bit slower in onset and the amount of carbohydrate is difficult
to measure.
If you don’t raise your blood sugar rapidly enough you will often end up having more to eat and then having
high blood sugars for hours later.
A dextrosol tablet contains 3g of glucose
If you weigh in kilograms: 3g will raise your blood sugar UK / US
16kg 3.33 / 59.9
32kg 1.68 / 30.2
48kg 1.17 / 21.0
64kg 0.84 / 15.1
80kg 0.66 / 11.8
95kg 0.54 / 9.7
111kg 0.51 / 9.1
128kg 0.42 / 7.5
143kg 0.36 / 6.4
Most glucose tablets start to take effect in 3 minutes and have worn off by 40 minutes. Test 15 minutes after
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you take glucose to see you are rising.
Sometimes due to the effect of adrenaline you can be quite shaky for an hour or more after your blood sugar
has come back to normal. You may also be quite hungry and you may need to eat a meal or snack.
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Chapter 33
HOW DO I ADVISE MY HELPERS
TO DEAL WITH LOW BLOOD
SUGARS?
If you are seriously impaired your helpers may need to give you glucose gel by rubbing it inside your cheek. Tell
them not to put it beyond your teeth in case they get bitten.
If you are unconscious it is important that nothing is administered by mouth in case you choke.
Glucagon administration is now necessary. Are all your helpers trained how to use this?
If there is no clear improvement in ten minutes with glucagon they must dial 999 / 911 and
get you to hospital.
After glucagon administration you can feel very sick indeed. Metoclopramide tablets or injection may be
necessary. Your doctor may prescribe this for self administration at these times and if you vomit.
You will also need to build up your glycogen stores by eating your normal diet for 24 hours and meticulously avoiding low blood sugars during this time. You will need to do more frequent testing eg every 2.5 hours
instead of the usual pattern and you would correct for lows but not highs.
Children don’t have much glycogen to mobilise so if they have a severe hypo the best thing may be to
get them straight to a hospital instead of waiting for glucagon to work.
Hypoglycaemia unawareness can occur more frequently in people who have chronically high or low blood
sugars. Beta blockers can also cause this. Aiming for normal blood sugars long term if they are too high and
correcting for levels below 4.0 every time can help.
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Chapter 34
HOW DO I PREVENT LOW BLOOD
SUGARS?
After any episode of hypoglycaemia you need to figure out why you went so low so you can sort out any problems
or plan to do things differently.
You may not catch every hypo but you will reduce the frequency and severity of hypos by doing this.
Common Causes of Hypoglycaemia
• Too long a delay in eating your meal after an insulin injection.
• Delayed stomach emptying after a meal.
• Eating less than you planned for the given insulin dose.
• Drinking too much alcohol. What is too much? More than just one unit for many insulin users. Sorry.
• Hormonal changes in certain phases of the menstrual cycle.
• Sudden return to normal after a period of insulin resistance such as when recovered from an illness.
• Injecting from a new bottle of insulin when the old one had lost some of its effectiveness.
• Switching insulin types without considering different potencies of different insulins. Eg lispro and aspart
the rapid acting analogues have 150% of the potency of regular insulin. Levemir has 75% of the potency
of Lantus.
• Taking too much insulin.
• Not rolling cloudy insulin suspensions adequately.
• Mistakenly injecting insulin into a muscle.
• Lying too long in a hot tub.
• Effects of exercise that have not been covered by sufficient insulin reduction or carbohydrate intake.
• Injecting near a muscle that will be strenously exercised.
• Some medications cause hypos.
• Some insulins are not as stable as you would like and are more prone to giving hypos eg NPH.
• Two different carers give someone their insulin without checking first.
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Chapter 35
HOW DO I DEAL WITH HIGH
BLOOD SUGARS?
An excellent training course for dealing with high and low blood sugars can be found online at the online
pump school at the medtronic minimed site.
To find it google onto ”medtronic minimed”.
On this side of the screen are several boxes.
Click on online pump school.
Log on.
Even though you may not even intend to use an insulin pump the course goes through a realistic and methodical training that is just as relevant for injectors.
Your immediate family and important carers should do it too. After all, what happens when you are too
ill to help yourself?
You may need to have a calculator handy. The blood sugar levels are given using the US system and if
you are used to UK figures, as indeed also happens in Canada and Australia, you will need to divide the US
figures by 18.
Vomiting, Dehydrating Illness and Infection
When do I ask for professional help?
When you get vomiting on more than one episode, nausea to the extent you cannot eat, fever of more than 24
hours duration, severe diarrhoea or any form of infection you need to contact the triage nurse, diabetes nurse
or your doctor for advice.
With diabetes it is much safer and easier to prevent the potentially dehydrating illnesses from getting worse
than it is to fix you if you are in a severe state. Please don’t put off that phone call.
How does diabetic ketoacidosis develop?
Any infection will raise your blood sugars. This in turn leads to increased urine output and higher blood sugars.
The higher the blood sugar the more insulin resistant you become. Higher insulin levels will then be needed to
get things under control.
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VOMITING, DEHYDRATING ILLNESS AND INFECTION
If your peripheral circulation shuts down your cells will start to metabolise fat and make ketones. Ketones
take water from the body on the way out of your kidneys and you will get more dehydrated.
High levels of ketones also make you vomit.
Symptoms of DKA are:
• nausea and vomiting
• rapid deep breathing
• loss of appetite
• abdominal pain
• weakness
• visual disturbances
• sleepiness
It is a truly awful vicious circle. The thing to do is to prevent it happening in the first place.
What do I do if I am not getting better ?
If you become unwell at any time it is important to keep your fluid intake up, continue your usual medication or insulin, check your blood sugar levels more frequently than usual eg every 2.5 hours.
Check your urine for ketones if your blood sugar level is above 13 / 230. In fact even if your sugars are
normal and you feel queasy check for ketones. Remember that ketone testing stix are unreliable 6 months after
the container is opened regardless of whether they appear to be in date.
Get prompt medical advice if your symptoms don’t settle or your blood sugars are too high. Information
you can give about your current blood sugar, the trend in blood sugars, ketones or not, your insulin doses and
your correction doses and how well you are keeping down fluids and passing urine are necessary for the doctor
or nurse to make an accurate assessment.
If you attend A and E bring your Emergency Cards especially if you do not speak the language they are
likely to speak in the hospital fluently. Bring all your kit and a reliable bi or multi lingual helper.
Do not sit politely at the back of the waiting room if you are a vomiting insulin dependent
diabetic. They must assess you RIGHT NOW. They may have to drip you RIGHT NOW to
SAVE YOUR LIFE.
If you are incapacitated or having surgery a friend, parent or sibling who knows how to manage your diabetes must be with you at all times to test and treat you as needed.
They may have to insist on saline drips until your blood sugars are in your normal range. Current hospital
practice is to switch to dextrose ie sugar drips when you go below 10 / 180.
They may need to bring you in diet drinks or special food when you are in the recovery phase.
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Chapter 36
HOW DO I MANAGE HIGH BLOOD
SUGARS WHEN I ACTUALLY FEEL
OKAY?
Well, I hope you understand. I just had to get the blood and thunder stuff out of the way first.
If you think your blood sugars could be running high check your blood sugars. Tiredness is probably number
one symptom of high blood sugars. If you are high you can do some things to bring it down.
15-30 minutes of gentle walking or other exercise can bring it down.
Drink plenty of water if you are high.
If you are high three days in a row at the same time you need to consider an adjustment to
your insulin dose.
Watch out for high blood sugars due to old or contaminated insulin. If in doubt throw it out!
Then watch for lower blood sugars when you start a fresh vial.
If you have been high due to an illness, stress or surgery and have gradually upped your insulin to deal with it
be prepared for low blood sugars when you recover.
Girls and women often go high just before their period starts.
Remember your flu jag each autumn. It could spare a lot of grief.
High sugars and widely swinging blood sugars both cause complications that among other things age your
blood vessels. So does smoking. You don’t need smoking on top of all this diabetes stuff. Do you?
Correction boluses can be given for high blood sugars.
One rule of thumb is that one unit of a rapid acting analogue will deal with about 2.5 / 45 units of blood
sugar. But this is an adult average and you are not average. You are you.
The more you weigh and the higher your total daily insulin dosage the less your blood sugar level will drop for
a given measure of insulin. For many people a given unit of insulin will drop you much more if it is given at
night compared with during the day.
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Your correction dose will also depend on your individual insulin sensitivity for the time of day just
the same as for your meals. You’ve worked this out for your meal coverage haven’t you?
Dr Gary Schiener has charts you can use to estimate your correction doses in his great little book ”Think
Like a Pancreas.” Again this is simply a guide. It is safest to start at correction doses a little lower than he
recommends and take it from there. Guess and test. Again and again.
Hang on a minute. I’ve not done yet. You cannot go off and correct high blood sugars with insulin willynilly. You also need to consider how much previously injected insulin is still active or you could drop too
low. Gary has charts for this too. Gary has loads of charts!
If you do go ahead with a correction bolus please check your bs after an hour to make sure
it is on the way down and that you are not going too low.
Dr Bernstein thinks that the residual insulin on board calculations just makes the whole correction dose thing
just too complicated. I agree with him.
Dr Bernstein recommends that you only correct with insulin at your pre-meal and pre -bed times. This is
so that you can assume that no residual effect from the insulin other than your basal is present. This is not
quite true of course. Remember the tail effects of regular and rapid acting insulins?
You also need to consider if your sugars are high due to a meal that took longer to digest than usual. Pizza for
instance is notorious in this respect. It takes 8 hours to digest and a minimum of two spaced doses of regular
insulin or three spaced injections of rapid acting analogue insulin to cover it completely. You need a five hour
space between strict low carb meals before food will be having no effect on your blood sugars at the next meal.
I found it easier to give half a unit for a high blood sugar of a certain figure at a certain time of day and
then see what results I got. Progressively I was able to chart Steven’s exact correction doses for different blood
sugar levels at different times of day. If half a unit didn’t take him to his target blood sugar level of 5.0 I simply
gave more the next time.
I don’t do correction doses for high blood sugars at bedtime. I am too worried about possible night time
hypoglycaemia. I simply put it down to experience, give Steven his night basal insulin, a big glass of water, say
”Night Night”. Then I figure out how I could have done it better for the next time.
For any teenagers out there who are now desperate to get on with managing their own sugars some final
words of wisdom from Spike and Bo.
”Let your parents take as much care of you as they want and help you out as long as they can. Someday
you will be on your own and they won’t be there to remind you to take your kit and make you a healthy high
protein breakfast.”
Katharine’s How to .... series
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