Guest guest Posted January 19, 2004 Report Share Posted January 19, 2004 Thanks, I met a middle aged man last week who is a type 2 insulin dependent diabetic. he takes 80 ! units of N in the morning and 60 in the evening-plus coverage with H. His A1C's were around 10. he started going to an herbalist, who not only put him on hervbs,but told him to start lowereing his carbs. His insulin dosage was even higher before this and now his A1C has gone down to 7 (which is still too high, but ceertainnly better). I don't think the herbs have done much, but the decrease in carbs has sure helped him. I was appalled at the amount of insulin he is taking. He is also loosing weight, so hopefully his extreme insulin resistance will go down too. He has Kaiser, which has done nothing aobut diabetic education and because of the cost, will not use Lantis. (this particular Kaiser has a bad reputation for treating diabetics.) Dr. Bernstein For those new to the list, Dr. Bernstein is one of the number one experts for low carbing for diabetics. He himself is a type 1 diabetic for 60 years and is a medical doctor. He has 0 diabetic complications and has been low carbing for years. That's right! 60 years a type 1 diabetic with 0 diabetic complications. He practices out of New York and people world wide come to him for treatment. His patients run a1c levels of 4.5 to give you an idea of how well his regimen works. He recently published a revised version of his book, diabetes solution, and it is now called diabetes solution revised by Bernstein copyright 2003. Below, I am going to paste in a chapter from his first edition, the chapter is still the same in his new edition, about the laws of small numbers. I got this online since from his first edition book copyright 1997, you can read a few of the chapters online. Here is the link to the page to let you read some of the chapters from his first edition online then the chapter about the laws of small numbers. This is one of the best chapters IMO in the book and is crucial to understand: http://www.diabetes-normalsugars.com/readit/readit.shtml and now the chapter. it is long just to warn you but is worth the reading. You'll be amazed at this man's knowledge. This email, you'll want to save in your stored box: The Law of Carbohydrate Estimation The old ADA dietary recommendations allowed 150 grams of carbohydrate per meal. This, as you may know by now, is grossly excessive. Here is one reason why. Typically, 150 grams of carbohydrate would be a good-sized bowl of cooked pasta. Let's say that you're a whiz at estimating the amount of carbohydrate in the pasta and can usually estimate it to within 20 percent from one day to the next. Twenty percent of 150 grams is 30 grams of carbohydrate. Now, if you're a nonobese Type I diabetic who makes no insulin, 1 gram of carbohydrate will raise your blood sugars by about 5 mg/dl. So, even with your finely tuned ability to " guesstimate " the amount of carbohydrate, your blood sugar is off by a whopping ±150 mg/dl for just this one meal. If your target blood sugar level is approximately 85 mg/dl, you've now got a blood glucose level of 235 mg/dl, or, alternately, 0 mg/dl. Either situation is clearly unacceptable. If a 20 percent margin of error is your average, then there will be some days you're off by only 10 percent, but others when you're off by 30 percent. Let's try another example. Say you're a Type II diabetic, obese, and make some insulin of your own but also inject insulin. You've found that 1 gram of carbohydrate only raises your blood sugar by 3 mg/dl. Your blood sugar would be off by ±90 mg/dl. If your target blood sugar value is, say, 90 mg/dl, you're looking at a postmeal blood sugar level of anywhere from 180 mg/dl to 0 mg/dl. That's the chief problem with the old ADA diet. Big inputs. But if you can eat food that will affect your blood sugar by one-tenth of that margin of error, then you're going to have a much simpler time of normalizing blood sugar levels. My diet plan, which we will get into in Chapters 9-11, aims to keep these margins in the realm of about 10-20 mg/dl. How do we accomplish this? Small inputs. Eating only a half-cup of pasta is not the answer. Even small amounts of some carbohydrate can cause big swings in blood sugar. And anyway, who would feel satisfied after a meal of a half-cup of pasta? The key is to eat foods that will affect your blood sugar in a very small way. Small inputs, small mistakes. Sounds so simple and straightforward, so elegant, it may make you want to ask why no one has told you about it before. Say that instead of eating pasta as the carbohydrate portion of your meal, you eat salad. If you estimate 2 cups of salad at 12 grams of carbohydrate and are off not by your usual 20 percent but by 30 percent, that's still only four grams of carbohydrate-a maximum potential 20 mg/dl rise or fall in blood sugar. A bowl of pasta for a couple of cups of salad? Not much of a trade, you may say. Well, we don't intend that you starve. As you decrease the amount of fast-acting carbohydrate you eat, you can often simultaneously increase the amount of protein you eat. Protein can, as you may recall, also cause a blood sugar rise, but this takes place much more slowly, to a much smaller degree, and is more easily prevented with medication. In theory, you could weigh everything you eat right down to the last gram and make your calculations based on information provided by the manufacturer or derived from some of the books we use. Still, there are problems with that approach. Say you weigh dried pasta-the manufacturer's estimate of how much carbohydrate exists in a serving is exactly that, an estimate, with a margin for error. The Food and Drug Administration allows for a margin of error in labeling. And there are other variables-some pastas are made with egg yolks and wheat flour, some with water and durum semolina flour. If the manufacturer's estimate proves to be off by 20 percent, and then your estimate is off by 20 percent, you're in a realm of complete unknown. You will have only a vague idea of what you're actually consuming, and of the effect it will have on blood sugar. The idea here is to stick with low levels of carbohydrates. In addition, stick with foods that will make you feel satisfied without causing huge swings in blood sugar. Simple. The Law of Insulin Dose Absorption If you do not take insulin, you can skip this section. Think again of traffic. You're driving down the road and your car drifts slightly toward the median. To bring it back into line, you make a slight adjustment of the steering wheel. No problem. But yank the steering wheel, and it could carry you into another lane, or could send you careening off the road. When you inject insulin, not all of it reaches your bloodstream. Research has shown that there's a level of uncertainty as to just how much absorption of insulin takes place. The more insulin you use, the greater the level of uncertainty. When you inject insulin, you're putting beneath your skin a substance that isn't, according to your immune system's way of seeing things, supposed to be there. So a portion of it will be destroyed as a foreign substance before it can reach the bloodstream. The amount that the body can destroy depends on several factors. First is how big a dose you inject. The bigger the dose, the more inflammation and irritation you cause, and the more of a " red flag " you send up to your immune system. Other factors include how deep you injected it, how fast you injected it, and where you injected it. Your injections will naturally vary from one time to the next. Even the most fastidious person will unconsciously alter minor things in the injection process from day to day. So the amount of insulin that gets into your bloodstream is always going to have some variability. The bigger the dose, the bigger the variation. A number of years ago, researchers at the University of Minnesota demonstrated that if you inject about 20 units of insulin into your arm, on average, you'll get a 39 percent variation in the amount that makes it into the bloodstream from one day to the next. They found that abdominal injections had only a 29 percent average variation, and so recommended that we use only abdominal injections. On paper that seems fine, but in practice the effects on blood sugar are intolerable. Say you do inject 20 units of insulin at one time. Each unit lowers the blood sugar of a typical 150-pound adult by 40 mg/dl. A 29 percent variability will create a 7-unit discrepancy in your 20-unit injection, which means a 280 mg/dl blood sugar uncertainty (40 mg/dl x 7 units). The result is totally haphazard blood sugars and complete unpredictability, just by virtue of the different amounts of insulin absorption. Research and my own experience demonstrate that the smaller your dose of insulin, the less variability you get. For Type I diabetics who are not obese, we'd ideally like to see doses anywhere from H unit to 6 units or at the most 7. Typically, you might take 3-5 units in a shot. At these lower doses, the uncertainty of absorption approaches zero. I have a very obese patient who requires 27 units of long-acting insulin at bedtime. He's so insulin-resistant that there's no way to keep his blood sugar under control without this massive dose. In order to ameliorate the unpredictability of large doses, he splits his bedtime insulin into four small shots given into four separate sites using the same disposable syringe. As a rule, I recommend that a single insulin injection not exceed 7 units. The Law of Insulin Timing Again, it's very difficult to use any medication safely unless you can predict the effect it will have. With insulin, this is as true of when you take it as it is of how much you take. If you're a Type I diabetic, fast-acting (regular) insulin can be injected 30-40 minutes prior to a meal tailored to your diet plan to cover the ensuing rise in blood sugar. Regular, fast-acting insulin, despite the name, doesn't act very fast, and cannot come close to approximating the phase I insulin response of a nondiabetic. To a lesser degree this is also true of the new, faster-acting lispro insulin. Still, these are the fastest we have. Small doses of regular start to work in about 40 minutes and finish in about 5 hours; lispro starts to work in about 15 minutes and finishes in 4-5 hours. This is considerably slower than the speed at which fast-acting carbohydrate raises blood sugar. If you eat a meal not specifically tailored to our restricted-carbohydrate diet, you'll get a postprandial increase in blood sugar, eventually followed by a decrease as the fast-acting insulin catches up. This means that you'll have high blood sugars after every meal, and you could still fall prey to the long-term complications of diabetes. If you try to prevent the inevitable postprandial blood sugar spike by waiting to eat until after the start-time of your insulin, you may easily make yourself hypoglycemic, which could in turn cause you to overcompensate and overeat-that is, presuming you don't lose consciousness first. Type II diabetics have a diminished or absent phase I insulin response, and so they face a problem similar to that of Type I's. They have to wait hours for the phase II insulin to catch up if they eat fast-acting carbohydrate. The key to timing insulin injection is to know how carbohydrates and insulin affect your blood sugar and to use that knowledge to minimize the swings. Since you can't approximate phase I insulin response, you have to eat foods that allow you to work within the limits of the insulin you make or inject. (If you think you'll miss out on the great high-carbohydrate, low-fat diet many have been raving about, there is considerable evidence that restricting carbohydrate is healthier not only for diabetics but for everyone. See Protein Power, by and Dan Eades, Bantam Books, 1996, for more details on this point.) If you consume only small amounts of slow-acting carbohydrate, you can actually prevent postprandial blood sugar elevation even with injected regular insulin. In fact, by restricting carbohydrate intake, many Type II diabetics will be able to prevent this rise with their phase II insulin response, and will not need preprandial (premeal) injected insulin. Obeying the Laws of Small Numbers Essential to " obeying " the laws of small numbers is to eat only small amounts of slow-acting carbohydrate when you eat carbohydrate, and no fast-acting carbohydrate. Even the slowest-acting carbohydrate can outpace injected or phase II insulin if consumed in greater amounts than recommended later in this book (Chapters 10 and 11). If you eat a small amount of slow-acting carbohydrate, you might get by with a very small postprandial blood sugar increase. If you double the amount of slow-acting carbohydrate, you'll double the potential increase in blood sugar (and remember that high blood sugar leads to even higher blood sugar). If you fill up on slow-acting carbohydrate, it will work as fast as a lesser amount of fast-acting carbohydrate, and if you feel stuffed, you'll compound it with the Chinese Restaurant Effect. All of this not only points toward eating less carbohydrate, it also implies eating smaller meals 4 or 5 times a day rather than three large meals. If you're a Type II diabetic and require no medication, eating like this may work well for you. The difficulty with this sort of plan is its inconvenience, but some people don't mind and actually prefer to eat this way. I have one patient, a Type I diabetic who still makes some insulin. She eats a couple of bites of protein every 15 minutes and takes long-acting insulin. In a 16-hour day, that adds up to a lot of meals and a lot of clock-watching. This routine would drive a lot of people nuts, but it works for her. As long as she keeps up with her frequent little meals and covers the insulin, she's fine. If she misses a few " meals, " there could be trouble. For the Type II diabetic who doesn't need insulin injections, smaller meals throughout the day can be a very effective way of maintaining a constant level of blood sugar. Since this kind of diet would be tailored to work with a phase II insulin response, blood sugars should never go too high. It would, however, involve a certain amount of daily preparation and routinization that could be thrown off by changes in schedule-illness, travel, houseguests, and so forth. (People with gastroparesis, or delayed stomach-emptying, may have to eat this way. We discuss this phenomenon further in Chapter 21.) end of chapter Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 19, 2004 Report Share Posted January 19, 2004 Hi Pat. Ya, an a1c of 7 cost me my eyesight in only 4 years. Like I've said before, passive family doctors told me I was doing great. Heck, even several specialists said an a1c of 7 was good. We both know that is terribel considering my last a1c was 5.3. Yes, I am amazed at my insulin requirements having gone down on a moderate carb diet. Previously, following the ADA exchange diet, I took 50 units of insulin in the morning, 12 at noon, and 18 at dinner. This was to cover all the carbs they had me on and that was only on a 2200 calorie exchange diet. Now, having abandoned the old ADA exchange diet, and going low/moderate carb approach, eating about 60 to 90 grams of carbs a day, my total daily insulin requirement is only 26. That is eating quick acting carbs but not many. I.E maybe 1 piece of bread at each meal etc. When I was eating 15 grams per meal, total of 45 grams a day, and no quick acting carbs only slow acting via green leafy veggies, my insulin requirement was 9 units total per day. I began to ease back in some carbs into my diet and am amazed that just eating 1 piece of bread per meal bumped the insulin up to 26 units from 9 units. I'm telling you folks, carbs are the killer of diabetics. Well, that and just not caring and eating what you want to eat. food for thought, Dr. Bernstein > > > For those new to the list, Dr. Bernstein is one of the number one > experts for low carbing for diabetics. He himself is a type 1 diabetic for > 60 years and is a medical doctor. He has 0 diabetic complications and has > been low carbing for years. That's right! 60 years a type 1 diabetic with 0 > diabetic complications. He practices out of New York and people world wide > come to him for treatment. His patients run a1c levels of 4.5 to give you an > idea of how well his regimen works. He recently published a revised version > of his book, diabetes solution, and it is now called diabetes solution > revised by Bernstein copyright 2003. Below, I am going to paste in a > chapter from his first edition, the chapter is still the same in his new > edition, about the laws of small numbers. I got this online since from his > first edition book copyright 1997, you can read a few of the chapters > online. Here is the link to the page to let you read some of the chapters > from his first edition online then the chapter about the laws of small > numbers. This is one of the best chapters IMO in the book and is crucial to > understand: > > http://www.diabetes-normalsugars.com/readit/readit.shtml > > and now the chapter. it is long just to warn you but is worth the reading. > You'll be amazed at this man's knowledge. This email, you'll want to save in > your stored box: > > > The Law of Carbohydrate Estimation > The old ADA dietary recommendations allowed 150 grams of carbohydrate per > meal. This, as you may know by now, is grossly excessive. Here is one reason > why. > > Typically, 150 grams of carbohydrate would be a good-sized bowl of cooked > pasta. Let's say that you're a whiz at estimating the amount of carbohydrate > in > the pasta and can usually estimate it to within 20 percent from one day to > the next. Twenty percent of 150 grams is 30 grams of carbohydrate. Now, if > you're > a nonobese Type I diabetic who makes no insulin, 1 gram of carbohydrate will > raise your blood sugars by about 5 mg/dl. So, even with your finely tuned > ability to " guesstimate " the amount of carbohydrate, your blood sugar is off > by a whopping ±150 mg/dl for just this one meal. If your target blood sugar > level is approximately 85 mg/dl, you've now got a blood glucose level of 235 > mg/dl, or, alternately, 0 mg/dl. Either situation is clearly unacceptable. > If a 20 percent margin of error is your average, then there will be some > days you're off by only 10 percent, but others when you're off by 30 > percent. > > Let's try another example. Say you're a Type II diabetic, obese, and make > some insulin of your own but also inject insulin. You've found that 1 gram > of > carbohydrate only raises your blood sugar by 3 mg/dl. Your blood sugar would > be off by ±90 mg/dl. If your target blood sugar value is, say, 90 mg/dl, > you're > looking at a postmeal blood sugar level of anywhere from 180 mg/dl to 0 > mg/dl. > > That's the chief problem with the old ADA diet. Big inputs. But if you can > eat food that will affect your blood sugar by one-tenth of that margin of > error, > then you're going to have a much simpler time of normalizing blood sugar > levels. My diet plan, which we will get into in Chapters 9-11, aims to keep > these > margins in the realm of about 10-20 mg/dl. How do we accomplish this? Small > inputs. > > Eating only a half-cup of pasta is not the answer. Even small amounts of > some carbohydrate can cause big swings in blood sugar. And anyway, who would > feel > satisfied after a meal of a half-cup of pasta? The key is to eat foods that > will affect your blood sugar in a very small way. > > Small inputs, small mistakes. Sounds so simple and straightforward, so > elegant, it may make you want to ask why no one has told you about it > before. > > Say that instead of eating pasta as the carbohydrate portion of your meal, > you eat salad. If you estimate 2 cups of salad at 12 grams of carbohydrate > and > are off not by your usual 20 percent but by 30 percent, that's still only > four grams of carbohydrate-a maximum potential 20 mg/dl rise or fall in > blood > sugar. A bowl of pasta for a couple of cups of salad? Not much of a trade, > you may say. Well, we don't intend that you starve. As you decrease the > amount > of fast-acting carbohydrate you eat, you can often simultaneously increase > the amount of protein you eat. Protein can, as you may recall, also cause a > blood sugar rise, but this takes place much more slowly, to a much smaller > degree, and is more easily prevented with medication. > > In theory, you could weigh everything you eat right down to the last gram > and make your calculations based on information provided by the manufacturer > or > derived from some of the books we use. Still, there are problems with that > approach. Say you weigh dried pasta-the manufacturer's estimate of how much > carbohydrate exists in a serving is exactly that, an estimate, with a margin > for error. The Food and Drug Administration allows for a margin of error in > labeling. And there are other variables-some pastas are made with egg yolks > and wheat flour, some with water and durum semolina flour. If the > manufacturer's > estimate proves to be off by 20 percent, and then your estimate is off by 20 > percent, you're in a realm of complete unknown. You will have only a vague > idea of what you're actually consuming, and of the effect it will have on > blood sugar. > > The idea here is to stick with low levels of carbohydrates. In addition, > stick with foods that will make you feel satisfied without causing huge > swings > in blood sugar. Simple. > > > The Law of Insulin Dose Absorption > If you do not take insulin, you can skip this section. > > Think again of traffic. You're driving down the road and your car drifts > slightly toward the median. To bring it back into line, you make a slight > adjustment > of the steering wheel. No problem. But yank the steering wheel, and it could > carry you into another lane, or could send you careening off the road. > > When you inject insulin, not all of it reaches your bloodstream. Research > has shown that there's a level of uncertainty as to just how much absorption > of > insulin takes place. The more insulin you use, the greater the level of > uncertainty. > > When you inject insulin, you're putting beneath your skin a substance that > isn't, according to your immune system's way of seeing things, supposed to > be > there. So a portion of it will be destroyed as a foreign substance before it > can reach the bloodstream. The amount that the body can destroy depends on > several factors. First is how big a dose you inject. The bigger the dose, > the more inflammation and irritation you cause, and the more of a " red flag " > you send up to your immune system. Other factors include how deep you > injected it, how fast you injected it, and where you injected it. > > Your injections will naturally vary from one time to the next. Even the most > fastidious person will unconsciously alter minor things in the injection > process > from day to day. So the amount of insulin that gets into your bloodstream is > always going to have some variability. The bigger the dose, the bigger the > variation. > > A number of years ago, researchers at the University of Minnesota > demonstrated that if you inject about 20 units of insulin into your arm, o n > average, you'll > get a 39 percent variation in the amount that makes it into the bloodstream > from one day to the next. They found that abdominal injections had only a 29 > percent average variation, and so recommended that we use only abdominal > injections. On paper that seems fine, but in practice the effects on blood > sugar > are intolerable. > > Say you do inject 20 units of insulin at one time. Each unit lowers the > blood sugar of a typical 150-pound adult by 40 mg/dl. A 29 percent > variability will > create a 7-unit discrepancy in your 20-unit injection, which means a 280 > mg/dl blood sugar uncertainty (40 mg/dl x 7 units). The result is totally > haphazard > blood sugars and complete unpredictability, just by virtue of the different > amounts of insulin absorption. > > Research and my own experience demonstrate that the smaller your dose of > insulin, the less variability you get. For Type I diabetics who are not > obese, > we'd ideally like to see doses anywhere from H unit to 6 units or at the > most 7. Typically, you might take 3-5 units in a shot. At these lower doses, > the > uncertainty of absorption approaches zero. > > I have a very obese patient who requires 27 units of long-acting insulin at > bedtime. He's so insulin-resistant that there's no way to keep his blood > sugar > under control without this massive dose. In order to ameliorate the > unpredictability of large doses, he splits his bedtime insulin into four > small shots > given into four separate sites using the same disposable syringe. As a rule, > I recommend that a single insulin injection not exceed 7 units. > > The Law of Insulin Timing > Again, it's very difficult to use any medication safely unless you can > predict the effect it will have. With insulin, this is as true of when you > take it > as it is of how much you take. If you're a Type I diabetic, fast-acting > (regular) insulin can be injected 30-40 minutes prior to a meal tailored to > your > diet plan to cover the ensuing rise in blood sugar. Regular, fast-acting > insulin, despite the name, doesn't act very fast, and cannot come close to > approximating > the phase I insulin response of a nondiabetic. To a lesser degree this is > also true of the new, faster-acting lispro insulin. Still, these are the > fastest > we have. Small doses of regular start to work in about 40 minutes and finish > in about 5 hours; lispro starts to work in about 15 minutes and finishes in > 4-5 hours. This is considerably slower than the speed at which fast-acting > carbohydrate raises blood sugar. > > If you eat a meal not specifically tailored to our restricted-carbohydrate > diet, you'll get a postprandial increase in blood sugar, eventually followed > by a decrease as the fast-acting insulin catches up. This means that you'll > have high blood sugars after every meal, and you could still fall prey to > the > long-term complications of diabetes. If you try to prevent the inevitable > postprandial blood sugar spike by waiting to eat until after the start-time > of > your insulin, you may easily make yourself hypoglycemic, which could in turn > cause you to overcompensate and overeat-that is, presuming you don't lose > consciousness first. > > Type II diabetics have a diminished or absent phase I insulin response, and > so they face a problem similar to that of Type I's. They have to wait hours > for the phase II insulin to catch up if they eat fast-acting carbohydrate. > > The key to timing insulin injection is to know how carbohydrates and insulin > affect your blood sugar and to use that knowledge to minimize the swings. > Since > you can't approximate phase I insulin response, you have to eat foods that > allow you to work within the limits of the insulin you make or inject. (If > you > think you'll miss out on the great high-carbohydrate, low-fat diet many have > been raving about, there is considerable evidence that restricting > carbohydrate > is healthier not only for diabetics but for everyone. See Protein Power, by > and Dan Eades, Bantam Books, 1996, for more details on this > point.) > > If you consume only small amounts of slow-acting carbohydrate, you can > actually prevent postprandial blood sugar elevation even with injected > regular insulin. > In fact, by restricting carbohydrate intake, many Type II diabetics will be > able to prevent this rise with their phase II insulin response, and will not > need preprandial (premeal) injected insulin. > > Obeying the Laws of Small Numbers > Essential to " obeying " the laws of small numbers is to eat only small > amounts of slow-acting carbohydrate when you eat carbohydrate, and no > fast-acting > carbohydrate. Even the slowest-acting carbohydrate can outpace injected or > phase II insulin if consumed in greater amounts than recommended later in > this > book (Chapters 10 and 11). > > If you eat a small amount of slow-acting carbohydrate, you might get by with > a very small postprandial blood sugar increase. If you double the amount of > slow-acting carbohydrate, you'll double the potential increase in blood > sugar (and remember that high blood sugar leads to even higher blood sugar). > If > you fill up on slow-acting carbohydrate, it will work as fast as a lesser > amount of fast-acting carbohydrate, and if you feel stuffed, you'll compound > it with the Chinese Restaurant Effect. > > All of this not only points toward eating less carbohydrate, it also implies > eating smaller meals 4 or 5 times a day rather than three large meals. If > you're > a Type II diabetic and require no medication, eating like this may work well > for you. The difficulty with this sort of plan is its inconvenience, but > some > people don't mind and actually prefer to eat this way. I have one patient, a > Type I diabetic who still makes some insulin. She eats a couple of bites of > protein every 15 minutes and takes long-acting insulin. In a 16-hour day, > that adds up to a lot of meals and a lot of clock-watching. This routine > would > drive a lot of people nuts, but it works for her. As long as she keeps up > with her frequent little meals and covers the insulin, she's fine. If she > misses > a few " meals, " there could be trouble. > > For the Type II diabetic who doesn't need insulin injections, smaller meals > throughout the day can be a very effective way of maintaining a constant > level > of blood sugar. Since this kind of diet would be tailored to work with a > phase II insulin response, blood sugars should never go too high. It would, > however, > involve a certain amount of daily preparation and routinization that could > be thrown off by changes in schedule-illness, travel, houseguests, and so > forth. > (People with gastroparesis, or delayed stomach-emptying, may have to eat > this way. We discuss this phenomenon further in Chapter 21.) > > end of chapter > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 19, 2004 Report Share Posted January 19, 2004 I know what you mean, . My total insulin for the day with the pump and bolusing for extra carbs is only 14 units-but goes up considerably if I eat too many carbs. Re: Dr. Bernstein Hi Pat. Ya, an a1c of 7 cost me my eyesight in only 4 years. Like I've said before, passive family doctors told me I was doing great. Heck, even several specialists said an a1c of 7 was good. We both know that is terribel considering my last a1c was 5.3. Yes, I am amazed at my insulin requirements having gone down on a moderate carb diet. Previously, following the ADA exchange diet, I took 50 units of insulin in the morning, 12 at noon, and 18 at dinner. This was to cover all the carbs they had me on and that was only on a 2200 calorie exchange diet. Now, having abandoned the old ADA exchange diet, and going low/moderate carb approach, eating about 60 to 90 grams of carbs a day, my total daily insulin requirement is only 26. That is eating quick acting carbs but not many. I.E maybe 1 piece of bread at each meal etc. When I was eating 15 grams per meal, total of 45 grams a day, and no quick acting carbs only slow acting via green leafy veggies, my insulin requirement was 9 units total per day. I began to ease back in some carbs into my diet and am amazed that just eating 1 piece of bread per meal bumped the insulin up to 26 units from 9 units. I'm telling you folks, carbs are the killer of diabetics. Well, that and just not caring and eating what you want to eat. food for thought, Dr. Bernstein > > > For those new to the list, Dr. Bernstein is one of the number one > experts for low carbing for diabetics. He himself is a type 1 diabetic for > 60 years and is a medical doctor. He has 0 diabetic complications and has > been low carbing for years. That's right! 60 years a type 1 diabetic with 0 > diabetic complications. He practices out of New York and people world wide > come to him for treatment. His patients run a1c levels of 4.5 to give you an > idea of how well his regimen works. He recently published a revised version > of his book, diabetes solution, and it is now called diabetes solution > revised by Bernstein copyright 2003. Below, I am going to paste in a > chapter from his first edition, the chapter is still the same in his new > edition, about the laws of small numbers. I got this online since from his > first edition book copyright 1997, you can read a few of the chapters > online. Here is the link to the page to let you read some of the chapters > from his first edition online then the chapter about the laws of small > numbers. This is one of the best chapters IMO in the book and is crucial to > understand: > > http://www.diabetes-normalsugars.com/readit/readit.shtml > > and now the chapter. it is long just to warn you but is worth the reading. > You'll be amazed at this man's knowledge. This email, you'll want to save in > your stored box: > > > The Law of Carbohydrate Estimation > The old ADA dietary recommendations allowed 150 grams of carbohydrate per > meal. This, as you may know by now, is grossly excessive. Here is one reason > why. > > Typically, 150 grams of carbohydrate would be a good-sized bowl of cooked > pasta. Let's say that you're a whiz at estimating the amount of carbohydrate > in > the pasta and can usually estimate it to within 20 percent from one day to > the next. Twenty percent of 150 grams is 30 grams of carbohydrate. Now, if > you're > a nonobese Type I diabetic who makes no insulin, 1 gram of carbohydrate will > raise your blood sugars by about 5 mg/dl. So, even with your finely tuned > ability to " guesstimate " the amount of carbohydrate, your blood sugar is off > by a whopping ±150 mg/dl for just this one meal. If your target blood sugar > level is approximately 85 mg/dl, you've now got a blood glucose level of 235 > mg/dl, or, alternately, 0 mg/dl. Either situation is clearly unacceptable. > If a 20 percent margin of error is your average, then there will be some > days you're off by only 10 percent, but others when you're off by 30 > percent. > > Let's try another example. Say you're a Type II diabetic, obese, and make > some insulin of your own but also inject insulin. You've found that 1 gram > of > carbohydrate only raises your blood sugar by 3 mg/dl. Your blood sugar would > be off by ±90 mg/dl. If your target blood sugar value is, say, 90 mg/dl, > you're > looking at a postmeal blood sugar level of anywhere from 180 mg/dl to 0 > mg/dl. > > That's the chief problem with the old ADA diet. Big inputs. But if you can > eat food that will affect your blood sugar by one-tenth of that margin of > error, > then you're going to have a much simpler time of normalizing blood sugar > levels. My diet plan, which we will get into in Chapters 9-11, aims to keep > these > margins in the realm of about 10-20 mg/dl. How do we accomplish this? Small > inputs. > > Eating only a half-cup of pasta is not the answer. Even small amounts of > some carbohydrate can cause big swings in blood sugar. And anyway, who would > feel > satisfied after a meal of a half-cup of pasta? The key is to eat foods that > will affect your blood sugar in a very small way. > > Small inputs, small mistakes. Sounds so simple and straightforward, so > elegant, it may make you want to ask why no one has told you about it > before. > > Say that instead of eating pasta as the carbohydrate portion of your meal, > you eat salad. If you estimate 2 cups of salad at 12 grams of carbohydrate > and > are off not by your usual 20 percent but by 30 percent, that's still only > four grams of carbohydrate-a maximum potential 20 mg/dl rise or fall in > blood > sugar. A bowl of pasta for a couple of cups of salad? Not much of a trade, > you may say. Well, we don't intend that you starve. As you decrease the > amount > of fast-acting carbohydrate you eat, you can often simultaneously increase > the amount of protein you eat. Protein can, as you may recall, also cause a > blood sugar rise, but this takes place much more slowly, to a much smaller > degree, and is more easily prevented with medication. > > In theory, you could weigh everything you eat right down to the last gram > and make your calculations based on information provided by the manufacturer > or > derived from some of the books we use. Still, there are problems with that > approach. Say you weigh dried pasta-the manufacturer's estimate of how much > carbohydrate exists in a serving is exactly that, an estimate, with a margin > for error. The Food and Drug Administration allows for a margin of error in > labeling. And there are other variables-some pastas are made with egg yolks > and wheat flour, some with water and durum semolina flour. If the > manufacturer's > estimate proves to be off by 20 percent, and then your estimate is off by 20 > percent, you're in a realm of complete unknown. You will have only a vague > idea of what you're actually consuming, and of the effect it will have on > blood sugar. > > The idea here is to stick with low levels of carbohydrates. In addition, > stick with foods that will make you feel satisfied without causing huge > swings > in blood sugar. Simple. > > > The Law of Insulin Dose Absorption > If you do not take insulin, you can skip this section. > > Think again of traffic. You're driving down the road and your car drifts > slightly toward the median. To bring it back into line, you make a slight > adjustment > of the steering wheel. No problem. But yank the steering wheel, and it could > carry you into another lane, or could send you careening off the road. > > When you inject insulin, not all of it reaches your bloodstream. Research > has shown that there's a level of uncertainty as to just how much absorption > of > insulin takes place. The more insulin you use, the greater the level of > uncertainty. > > When you inject insulin, you're putting beneath your skin a substance that > isn't, according to your immune system's way of seeing things, supposed to > be > there. So a portion of it will be destroyed as a foreign substance before it > can reach the bloodstream. The amount that the body can destroy depends on > several factors. First is how big a dose you inject. The bigger the dose, > the more inflammation and irritation you cause, and the more of a " red flag " > you send up to your immune system. Other factors include how deep you > injected it, how fast you injected it, and where you injected it. > > Your injections will naturally vary from one time to the next. Even the most > fastidious person will unconsciously alter minor things in the injection > process > from day to day. So the amount of insulin that gets into your bloodstream is > always going to have some variability. The bigger the dose, the bigger the > variation. > > A number of years ago, researchers at the University of Minnesota > demonstrated that if you inject about 20 units of insulin into your arm, o n > average, you'll > get a 39 percent variation in the amount that makes it into the bloodstream > from one day to the next. They found that abdominal injections had only a 29 > percent average variation, and so recommended that we use only abdominal > injections. On paper that seems fine, but in practice the effects on blood > sugar > are intolerable. > > Say you do inject 20 units of insulin at one time. Each unit lowers the > blood sugar of a typical 150-pound adult by 40 mg/dl. A 29 percent > variability will > create a 7-unit discrepancy in your 20-unit injection, which means a 280 > mg/dl blood sugar uncertainty (40 mg/dl x 7 units). The result is totally > haphazard > blood sugars and complete unpredictability, just by virtue of the different > amounts of insulin absorption. > > Research and my own experience demonstrate that the smaller your dose of > insulin, the less variability you get. For Type I diabetics who are not > obese, > we'd ideally like to see doses anywhere from H unit to 6 units or at the > most 7. Typically, you might take 3-5 units in a shot. At these lower doses, > the > uncertainty of absorption approaches zero. > > I have a very obese patient who requires 27 units of long-acting insulin at > bedtime. He's so insulin-resistant that there's no way to keep his blood > sugar > under control without this massive dose. In order to ameliorate the > unpredictability of large doses, he splits his bedtime insulin into four > small shots > given into four separate sites using the same disposable syringe. As a rule, > I recommend that a single insulin injection not exceed 7 units. > > The Law of Insulin Timing > Again, it's very difficult to use any medication safely unless you can > predict the effect it will have. With insulin, this is as true of when you > take it > as it is of how much you take. If you're a Type I diabetic, fast-acting > (regular) insulin can be injected 30-40 minutes prior to a meal tailored to > your > diet plan to cover the ensuing rise in blood sugar. Regular, fast-acting > insulin, despite the name, doesn't act very fast, and cannot come close to > approximating > the phase I insulin response of a nondiabetic. To a lesser degree this is > also true of the new, faster-acting lispro insulin. Still, these are the > fastest > we have. Small doses of regular start to work in about 40 minutes and finish > in about 5 hours; lispro starts to work in about 15 minutes and finishes in > 4-5 hours. This is considerably slower than the speed at which fast-acting > carbohydrate raises blood sugar. > > If you eat a meal not specifically tailored to our restricted-carbohydrate > diet, you'll get a postprandial increase in blood sugar, eventually followed > by a decrease as the fast-acting insulin catches up. This means that you'll > have high blood sugars after every meal, and you could still fall prey to > the > long-term complications of diabetes. If you try to prevent the inevitable > postprandial blood sugar spike by waiting to eat until after the start-time > of > your insulin, you may easily make yourself hypoglycemic, which could in turn > cause you to overcompensate and overeat-that is, presuming you don't lose > consciousness first. > > Type II diabetics have a diminished or absent phase I insulin response, and > so they face a problem similar to that of Type I's. They have to wait hours > for the phase II insulin to catch up if they eat fast-acting carbohydrate. > > The key to timing insulin injection is to know how carbohydrates and insulin > affect your blood sugar and to use that knowledge to minimize the swings. > Since > you can't approximate phase I insulin response, you have to eat foods that > allow you to work within the limits of the insulin you make or inject. (If > you > think you'll miss out on the great high-carbohydrate, low-fat diet many have > been raving about, there is considerable evidence that restricting > carbohydrate > is healthier not only for diabetics but for everyone. See Protein Power, by > and Dan Eades, Bantam Books, 1996, for more details on this > point.) > > If you consume only small amounts of slow-acting carbohydrate, you can > actually prevent postprandial blood sugar elevation even with injected > regular insulin. > In fact, by restricting carbohydrate intake, many Type II diabetics will be > able to prevent this rise with their phase II insulin response, and will not > need preprandial (premeal) injected insulin. > > Obeying the Laws of Small Numbers > Essential to " obeying " the laws of small numbers is to eat only small > amounts of slow-acting carbohydrate when you eat carbohydrate, and no > fast-acting > carbohydrate. Even the slowest-acting carbohydrate can outpace injected or > phase II insulin if consumed in greater amounts than recommended later in > this > book (Chapters 10 and 11). > > If you eat a small amount of slow-acting carbohydrate, you might get by with > a very small postprandial blood sugar increase. If you double the amount of > slow-acting carbohydrate, you'll double the potential increase in blood > sugar (and remember that high blood sugar leads to even higher blood sugar). > If > you fill up on slow-acting carbohydrate, it will work as fast as a lesser > amount of fast-acting carbohydrate, and if you feel stuffed, you'll compound > it with the Chinese Restaurant Effect. > > All of this not only points toward eating less carbohydrate, it also implies > eating smaller meals 4 or 5 times a day rather than three large meals. If > you're > a Type II diabetic and require no medication, eating like this may work well > for you. The difficulty with this sort of plan is its inconvenience, but > some > people don't mind and actually prefer to eat this way. I have one patient, a > Type I diabetic who still makes some insulin. She eats a couple of bites of > protein every 15 minutes and takes long-acting insulin. In a 16-hour day, > that adds up to a lot of meals and a lot of clock-watching. This routine > would > drive a lot of people nuts, but it works for her. As long as she keeps up > with her frequent little meals and covers the insulin, she's fine. If she > misses > a few " meals, " there could be trouble. > > For the Type II diabetic who doesn't need insulin injections, smaller meals > throughout the day can be a very effective way of maintaining a constant > level > of blood sugar. Since this kind of diet would be tailored to work with a > phase II insulin response, blood sugars should never go too high. It would, > however, > involve a certain amount of daily preparation and routinization that could > be thrown off by changes in schedule-illness, travel, houseguests, and so > forth. > (People with gastroparesis, or delayed stomach-emptying, may have to eat > this way. We discuss this phenomenon further in Chapter 21.) > > end of chapter > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 19, 2004 Report Share Posted January 19, 2004 I presently eat one slice of bread per meal, and my total insulin requirement per day is Lantus 29 units and Humalog 10 units per meal or around 30 units of Humalog per day for a total insulin requirement on a 15 gram carb per meal three times a day. This makes my combined insulin total per day around 59 to 60 units per day. I know I have insulin resistance, but are you saying that if I just comsumed slow acting carbs, no bread, my insulin requirements per day would decrease? Dr. Bernstein > > > > > > For those new to the list, Dr. Bernstein is one of the number one > > experts for low carbing for diabetics. He himself is a type 1 diabetic for > > 60 years and is a medical doctor. He has 0 diabetic complications and has > > been low carbing for years. That's right! 60 years a type 1 diabetic with > 0 > > diabetic complications. He practices out of New York and people world wide > > come to him for treatment. His patients run a1c levels of 4.5 to give you > an > > idea of how well his regimen works. He recently published a revised > version > > of his book, diabetes solution, and it is now called diabetes solution > > revised by Bernstein copyright 2003. Below, I am going to paste in > a > > chapter from his first edition, the chapter is still the same in his new > > edition, about the laws of small numbers. I got this online since from his > > first edition book copyright 1997, you can read a few of the chapters > > online. Here is the link to the page to let you read some of the chapters > > from his first edition online then the chapter about the laws of small > > numbers. This is one of the best chapters IMO in the book and is crucial > to > > understand: > > > > http://www.diabetes-normalsugars.com/readit/readit.shtml > > > > and now the chapter. it is long just to warn you but is worth the reading. > > You'll be amazed at this man's knowledge. This email, you'll want to save > in > > your stored box: > > > > > > The Law of Carbohydrate Estimation > > The old ADA dietary recommendations allowed 150 grams of carbohydrate per > > meal. This, as you may know by now, is grossly excessive. Here is one > reason > > why. > > > > Typically, 150 grams of carbohydrate would be a good-sized bowl of cooked > > pasta. Let's say that you're a whiz at estimating the amount of > carbohydrate > > in > > the pasta and can usually estimate it to within 20 percent from one day to > > the next. Twenty percent of 150 grams is 30 grams of carbohydrate. Now, if > > you're > > a nonobese Type I diabetic who makes no insulin, 1 gram of carbohydrate > will > > raise your blood sugars by about 5 mg/dl. So, even with your finely tuned > > ability to " guesstimate " the amount of carbohydrate, your blood sugar is > off > > by a whopping ±150 mg/dl for just this one meal. If your target blood > sugar > > level is approximately 85 mg/dl, you've now got a blood glucose level of > 235 > > mg/dl, or, alternately, 0 mg/dl. Either situation is clearly unacceptable. > > If a 20 percent margin of error is your average, then there will be some > > days you're off by only 10 percent, but others when you're off by 30 > > percent. > > > > Let's try another example. Say you're a Type II diabetic, obese, and make > > some insulin of your own but also inject insulin. You've found that 1 gram > > of > > carbohydrate only raises your blood sugar by 3 mg/dl. Your blood sugar > would > > be off by ±90 mg/dl. If your target blood sugar value is, say, 90 mg/dl, > > you're > > looking at a postmeal blood sugar level of anywhere from 180 mg/dl to 0 > > mg/dl. > > > > That's the chief problem with the old ADA diet. Big inputs. But if you can > > eat food that will affect your blood sugar by one-tenth of that margin of > > error, > > then you're going to have a much simpler time of normalizing blood sugar > > levels. My diet plan, which we will get into in Chapters 9-11, aims to > keep > > these > > margins in the realm of about 10-20 mg/dl. How do we accomplish this? > Small > > inputs. > > > > Eating only a half-cup of pasta is not the answer. Even small amounts of > > some carbohydrate can cause big swings in blood sugar. And anyway, who > would > > feel > > satisfied after a meal of a half-cup of pasta? The key is to eat foods > that > > will affect your blood sugar in a very small way. > > > > Small inputs, small mistakes. Sounds so simple and straightforward, so > > elegant, it may make you want to ask why no one has told you about it > > before. > > > > Say that instead of eating pasta as the carbohydrate portion of your meal, > > you eat salad. If you estimate 2 cups of salad at 12 grams of carbohydrate > > and > > are off not by your usual 20 percent but by 30 percent, that's still only > > four grams of carbohydrate-a maximum potential 20 mg/dl rise or fall in > > blood > > sugar. A bowl of pasta for a couple of cups of salad? Not much of a trade, > > you may say. Well, we don't intend that you starve. As you decrease the > > amount > > of fast-acting carbohydrate you eat, you can often simultaneously increase > > the amount of protein you eat. Protein can, as you may recall, also cause > a > > blood sugar rise, but this takes place much more slowly, to a much smaller > > degree, and is more easily prevented with medication. > > > > In theory, you could weigh everything you eat right down to the last gram > > and make your calculations based on information provided by the > manufacturer > > or > > derived from some of the books we use. Still, there are problems with that > > approach. Say you weigh dried pasta-the manufacturer's estimate of how > much > > carbohydrate exists in a serving is exactly that, an estimate, with a > margin > > for error. The Food and Drug Administration allows for a margin of error > in > > labeling. And there are other variables-some pastas are made with egg > yolks > > and wheat flour, some with water and durum semolina flour. If the > > manufacturer's > > estimate proves to be off by 20 percent, and then your estimate is off by > 20 > > percent, you're in a realm of complete unknown. You will have only a vague > > idea of what you're actually consuming, and of the effect it will have on > > blood sugar. > > > > The idea here is to stick with low levels of carbohydrates. In addition, > > stick with foods that will make you feel satisfied without causing huge > > swings > > in blood sugar. Simple. > > > > > > The Law of Insulin Dose Absorption > > If you do not take insulin, you can skip this section. > > > > Think again of traffic. You're driving down the road and your car drifts > > slightly toward the median. To bring it back into line, you make a slight > > adjustment > > of the steering wheel. No problem. But yank the steering wheel, and it > could > > carry you into another lane, or could send you careening off the road. > > > > When you inject insulin, not all of it reaches your bloodstream. Research > > has shown that there's a level of uncertainty as to just how much > absorption > > of > > insulin takes place. The more insulin you use, the greater the level of > > uncertainty. > > > > When you inject insulin, you're putting beneath your skin a substance that > > isn't, according to your immune system's way of seeing things, supposed to > > be > > there. So a portion of it will be destroyed as a foreign substance before > it > > can reach the bloodstream. The amount that the body can destroy depends on > > several factors. First is how big a dose you inject. The bigger the dose, > > the more inflammation and irritation you cause, and the more of a " red > flag " > > you send up to your immune system. Other factors include how deep you > > injected it, how fast you injected it, and where you injected it. > > > > Your injections will naturally vary from one time to the next. Even the > most > > fastidious person will unconsciously alter minor things in the injection > > process > > from day to day. So the amount of insulin that gets into your bloodstream > is > > always going to have some variability. The bigger the dose, the bigger the > > variation. > > > > A number of years ago, researchers at the University of Minnesota > > demonstrated that if you inject about 20 units of insulin into your arm, o > n > > average, you'll > > get a 39 percent variation in the amount that makes it into the > bloodstream > > from one day to the next. They found that abdominal injections had only a > 29 > > percent average variation, and so recommended that we use only abdominal > > injections. On paper that seems fine, but in practice the effects on blood > > sugar > > are intolerable. > > > > Say you do inject 20 units of insulin at one time. Each unit lowers the > > blood sugar of a typical 150-pound adult by 40 mg/dl. A 29 percent > > variability will > > create a 7-unit discrepancy in your 20-unit injection, which means a 280 > > mg/dl blood sugar uncertainty (40 mg/dl x 7 units). The result is totally > > haphazard > > blood sugars and complete unpredictability, just by virtue of the > different > > amounts of insulin absorption. > > > > Research and my own experience demonstrate that the smaller your dose of > > insulin, the less variability you get. For Type I diabetics who are not > > obese, > > we'd ideally like to see doses anywhere from H unit to 6 units or at the > > most 7. Typically, you might take 3-5 units in a shot. At these lower > doses, > > the > > uncertainty of absorption approaches zero. > > > > I have a very obese patient who requires 27 units of long-acting insulin > at > > bedtime. He's so insulin-resistant that there's no way to keep his blood > > sugar > > under control without this massive dose. In order to ameliorate the > > unpredictability of large doses, he splits his bedtime insulin into four > > small shots > > given into four separate sites using the same disposable syringe. As a > rule, > > I recommend that a single insulin injection not exceed 7 units. > > > > The Law of Insulin Timing > > Again, it's very difficult to use any medication safely unless you can > > predict the effect it will have. With insulin, this is as true of when you > > take it > > as it is of how much you take. If you're a Type I diabetic, fast-acting > > (regular) insulin can be injected 30-40 minutes prior to a meal tailored > to > > your > > diet plan to cover the ensuing rise in blood sugar. Regular, fast-acting > > insulin, despite the name, doesn't act very fast, and cannot come close to > > approximating > > the phase I insulin response of a nondiabetic. To a lesser degree this is > > also true of the new, faster-acting lispro insulin. Still, these are the > > fastest > > we have. Small doses of regular start to work in about 40 minutes and > finish > > in about 5 hours; lispro starts to work in about 15 minutes and finishes > in > > 4-5 hours. This is considerably slower than the speed at which fast-acting > > carbohydrate raises blood sugar. > > > > If you eat a meal not specifically tailored to our restricted-carbohydrate > > diet, you'll get a postprandial increase in blood sugar, eventually > followed > > by a decrease as the fast-acting insulin catches up. This means that > you'll > > have high blood sugars after every meal, and you could still fall prey to > > the > > long-term complications of diabetes. If you try to prevent the inevitable > > postprandial blood sugar spike by waiting to eat until after the > start-time > > of > > your insulin, you may easily make yourself hypoglycemic, which could in > turn > > cause you to overcompensate and overeat-that is, presuming you don't lose > > consciousness first. > > > > Type II diabetics have a diminished or absent phase I insulin response, > and > > so they face a problem similar to that of Type I's. They have to wait > hours > > for the phase II insulin to catch up if they eat fast-acting carbohydrate. > > > > The key to timing insulin injection is to know how carbohydrates and > insulin > > affect your blood sugar and to use that knowledge to minimize the swings. > > Since > > you can't approximate phase I insulin response, you have to eat foods that > > allow you to work within the limits of the insulin you make or inject. (If > > you > > think you'll miss out on the great high-carbohydrate, low-fat diet many > have > > been raving about, there is considerable evidence that restricting > > carbohydrate > > is healthier not only for diabetics but for everyone. See Protein Power, > by > > and Dan Eades, Bantam Books, 1996, for more details on this > > point.) > > > > If you consume only small amounts of slow-acting carbohydrate, you can > > actually prevent postprandial blood sugar elevation even with injected > > regular insulin. > > In fact, by restricting carbohydrate intake, many Type II diabetics will > be > > able to prevent this rise with their phase II insulin response, and will > not > > need preprandial (premeal) injected insulin. > > > > Obeying the Laws of Small Numbers > > Essential to " obeying " the laws of small numbers is to eat only small > > amounts of slow-acting carbohydrate when you eat carbohydrate, and no > > fast-acting > > carbohydrate. Even the slowest-acting carbohydrate can outpace injected or > > phase II insulin if consumed in greater amounts than recommended later in > > this > > book (Chapters 10 and 11). > > > > If you eat a small amount of slow-acting carbohydrate, you might get by > with > > a very small postprandial blood sugar increase. If you double the amount > of > > slow-acting carbohydrate, you'll double the potential increase in blood > > sugar (and remember that high blood sugar leads to even higher blood > sugar). > > If > > you fill up on slow-acting carbohydrate, it will work as fast as a lesser > > amount of fast-acting carbohydrate, and if you feel stuffed, you'll > compound > > it with the Chinese Restaurant Effect. > > > > All of this not only points toward eating less carbohydrate, it also > implies > > eating smaller meals 4 or 5 times a day rather than three large meals. If > > you're > > a Type II diabetic and require no medication, eating like this may work > well > > for you. The difficulty with this sort of plan is its inconvenience, but > > some > > people don't mind and actually prefer to eat this way. I have one patient, > a > > Type I diabetic who still makes some insulin. She eats a couple of bites > of > > protein every 15 minutes and takes long-acting insulin. In a 16-hour day, > > that adds up to a lot of meals and a lot of clock-watching. This routine > > would > > drive a lot of people nuts, but it works for her. As long as she keeps up > > with her frequent little meals and covers the insulin, she's fine. If she > > misses > > a few " meals, " there could be trouble. > > > > For the Type II diabetic who doesn't need insulin injections, smaller > meals > > throughout the day can be a very effective way of maintaining a constant > > level > > of blood sugar. Since this kind of diet would be tailored to work with a > > phase II insulin response, blood sugars should never go too high. It > would, > > however, > > involve a certain amount of daily preparation and routinization that could > > be thrown off by changes in schedule-illness, travel, houseguests, and so > > forth. > > (People with gastroparesis, or delayed stomach-emptying, may have to eat > > this way. We discuss this phenomenon further in Chapter 21.) > > > > end of chapter > > > > > > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 19, 2004 Report Share Posted January 19, 2004 I think the only way you wil find out, harry is by trying it! you just might get too bored with no carbs at all however. I know I would. Re: Dr. Bernstein I presently eat one slice of bread per meal, and my total insulin requirement per day is Lantus 29 units and Humalog 10 units per meal or around 30 units of Humalog per day for a total insulin requirement on a 15 gram carb per meal three times a day. This makes my combined insulin total per day around 59 to 60 units per day. I know I have insulin resistance, but are you saying that if I just comsumed slow acting carbs, no bread, my insulin requirements per day would decrease? Dr. Bernstein > > > > > > For those new to the list, Dr. Bernstein is one of the number one > > experts for low carbing for diabetics. He himself is a type 1 diabetic for > > 60 years and is a medical doctor. He has 0 diabetic complications and has > > been low carbing for years. That's right! 60 years a type 1 diabetic with > 0 > > diabetic complications. He practices out of New York and people world wide > > come to him for treatment. His patients run a1c levels of 4.5 to give you > an > > idea of how well his regimen works. He recently published a revised > version > > of his book, diabetes solution, and it is now called diabetes solution > > revised by Bernstein copyright 2003. Below, I am going to paste in > a > > chapter from his first edition, the chapter is still the same in his new > > edition, about the laws of small numbers. I got this online since from his > > first edition book copyright 1997, you can read a few of the chapters > > online. Here is the link to the page to let you read some of the chapters > > from his first edition online then the chapter about the laws of small > > numbers. This is one of the best chapters IMO in the book and is crucial > to > > understand: > > > > http://www.diabetes-normalsugars.com/readit/readit.shtml > > > > and now the chapter. it is long just to warn you but is worth the reading. > > You'll be amazed at this man's knowledge. This email, you'll want to save > in > > your stored box: > > > > > > The Law of Carbohydrate Estimation > > The old ADA dietary recommendations allowed 150 grams of carbohydrate per > > meal. This, as you may know by now, is grossly excessive. Here is one > reason > > why. > > > > Typically, 150 grams of carbohydrate would be a good-sized bowl of cooked > > pasta. Let's say that you're a whiz at estimating the amount of > carbohydrate > > in > > the pasta and can usually estimate it to within 20 percent from one day to > > the next. Twenty percent of 150 grams is 30 grams of carbohydrate. Now, if > > you're > > a nonobese Type I diabetic who makes no insulin, 1 gram of carbohydrate > will > > raise your blood sugars by about 5 mg/dl. So, even with your finely tuned > > ability to " guesstimate " the amount of carbohydrate, your blood sugar is > off > > by a whopping ±150 mg/dl for just this one meal. If your target blood > sugar > > level is approximately 85 mg/dl, you've now got a blood glucose level of > 235 > > mg/dl, or, alternately, 0 mg/dl. Either situation is clearly unacceptable. > > If a 20 percent margin of error is your average, then there will be some > > days you're off by only 10 percent, but others when you're off by 30 > > percent. > > > > Let's try another example. Say you're a Type II diabetic, obese, and make > > some insulin of your own but also inject insulin. You've found that 1 gram > > of > > carbohydrate only raises your blood sugar by 3 mg/dl. Your blood sugar > would > > be off by ±90 mg/dl. If your target blood sugar value is, say, 90 mg/dl, > > you're > > looking at a postmeal blood sugar level of anywhere from 180 mg/dl to 0 > > mg/dl. > > > > That's the chief problem with the old ADA diet. Big inputs. But if you can > > eat food that will affect your blood sugar by one-tenth of that margin of > > error, > > then you're going to have a much simpler time of normalizing blood sugar > > levels. My diet plan, which we will get into in Chapters 9-11, aims to > keep > > these > > margins in the realm of about 10-20 mg/dl. How do we accomplish this? > Small > > inputs. > > > > Eating only a half-cup of pasta is not the answer. Even small amounts of > > some carbohydrate can cause big swings in blood sugar. And anyway, who > would > > feel > > satisfied after a meal of a half-cup of pasta? The key is to eat foods > that > > will affect your blood sugar in a very small way. > > > > Small inputs, small mistakes. Sounds so simple and straightforward, so > > elegant, it may make you want to ask why no one has told you about it > > before. > > > > Say that instead of eating pasta as the carbohydrate portion of your meal, > > you eat salad. If you estimate 2 cups of salad at 12 grams of carbohydrate > > and > > are off not by your usual 20 percent but by 30 percent, that's still only > > four grams of carbohydrate-a maximum potential 20 mg/dl rise or fall in > > blood > > sugar. A bowl of pasta for a couple of cups of salad? Not much of a trade, > > you may say. Well, we don't intend that you starve. As you decrease the > > amount > > of fast-acting carbohydrate you eat, you can often simultaneously increase > > the amount of protein you eat. Protein can, as you may recall, also cause > a > > blood sugar rise, but this takes place much more slowly, to a much smaller > > degree, and is more easily prevented with medication. > > > > In theory, you could weigh everything you eat right down to the last gram > > and make your calculations based on information provided by the > manufacturer > > or > > derived from some of the books we use. Still, there are problems with that > > approach. Say you weigh dried pasta-the manufacturer's estimate of how > much > > carbohydrate exists in a serving is exactly that, an estimate, with a > margin > > for error. The Food and Drug Administration allows for a margin of error > in > > labeling. And there are other variables-some pastas are made with egg > yolks > > and wheat flour, some with water and durum semolina flour. If the > > manufacturer's > > estimate proves to be off by 20 percent, and then your estimate is off by > 20 > > percent, you're in a realm of complete unknown. You will have only a vague > > idea of what you're actually consuming, and of the effect it will have on > > blood sugar. > > > > The idea here is to stick with low levels of carbohydrates. In addition, > > stick with foods that will make you feel satisfied without causing huge > > swings > > in blood sugar. Simple. > > > > > > The Law of Insulin Dose Absorption > > If you do not take insulin, you can skip this section. > > > > Think again of traffic. You're driving down the road and your car drifts > > slightly toward the median. To bring it back into line, you make a slight > > adjustment > > of the steering wheel. No problem. But yank the steering wheel, and it > could > > carry you into another lane, or could send you careening off the road. > > > > When you inject insulin, not all of it reaches your bloodstream. Research > > has shown that there's a level of uncertainty as to just how much > absorption > > of > > insulin takes place. The more insulin you use, the greater the level of > > uncertainty. > > > > When you inject insulin, you're putting beneath your skin a substance that > > isn't, according to your immune system's way of seeing things, supposed to > > be > > there. So a portion of it will be destroyed as a foreign substance before > it > > can reach the bloodstream. The amount that the body can destroy depends on > > several factors. First is how big a dose you inject. The bigger the dose, > > the more inflammation and irritation you cause, and the more of a " red > flag " > > you send up to your immune system. Other factors include how deep you > > injected it, how fast you injected it, and where you injected it. > > > > Your injections will naturally vary from one time to the next. Even the > most > > fastidious person will unconsciously alter minor things in the injection > > process > > from day to day. So the amount of insulin that gets into your bloodstream > is > > always going to have some variability. The bigger the dose, the bigger the > > variation. > > > > A number of years ago, researchers at the University of Minnesota > > demonstrated that if you inject about 20 units of insulin into your arm, o > n > > average, you'll > > get a 39 percent variation in the amount that makes it into the > bloodstream > > from one day to the next. They found that abdominal injections had only a > 29 > > percent average variation, and so recommended that we use only abdominal > > injections. On paper that seems fine, but in practice the effects on blood > > sugar > > are intolerable. > > > > Say you do inject 20 units of insulin at one time. Each unit lowers the > > blood sugar of a typical 150-pound adult by 40 mg/dl. A 29 percent > > variability will > > create a 7-unit discrepancy in your 20-unit injection, which means a 280 > > mg/dl blood sugar uncertainty (40 mg/dl x 7 units). The result is totally > > haphazard > > blood sugars and complete unpredictability, just by virtue of the > different > > amounts of insulin absorption. > > > > Research and my own experience demonstrate that the smaller your dose of > > insulin, the less variability you get. For Type I diabetics who are not > > obese, > > we'd ideally like to see doses anywhere from H unit to 6 units or at the > > most 7. Typically, you might take 3-5 units in a shot. At these lower > doses, > > the > > uncertainty of absorption approaches zero. > > > > I have a very obese patient who requires 27 units of long-acting insulin > at > > bedtime. He's so insulin-resistant that there's no way to keep his blood > > sugar > > under control without this massive dose. In order to ameliorate the > > unpredictability of large doses, he splits his bedtime insulin into four > > small shots > > given into four separate sites using the same disposable syringe. As a > rule, > > I recommend that a single insulin injection not exceed 7 units. > > > > The Law of Insulin Timing > > Again, it's very difficult to use any medication safely unless you can > > predict the effect it will have. With insulin, this is as true of when you > > take it > > as it is of how much you take. If you're a Type I diabetic, fast-acting > > (regular) insulin can be injected 30-40 minutes prior to a meal tailored > to > > your > > diet plan to cover the ensuing rise in blood sugar. Regular, fast-acting > > insulin, despite the name, doesn't act very fast, and cannot come close to > > approximating > > the phase I insulin response of a nondiabetic. To a lesser degree this is > > also true of the new, faster-acting lispro insulin. Still, these are the > > fastest > > we have. Small doses of regular start to work in about 40 minutes and > finish > > in about 5 hours; lispro starts to work in about 15 minutes and finishes > in > > 4-5 hours. This is considerably slower than the speed at which fast-acting > > carbohydrate raises blood sugar. > > > > If you eat a meal not specifically tailored to our restricted-carbohydrate > > diet, you'll get a postprandial increase in blood sugar, eventually > followed > > by a decrease as the fast-acting insulin catches up. This means that > you'll > > have high blood sugars after every meal, and you could still fall prey to > > the > > long-term complications of diabetes. If you try to prevent the inevitable > > postprandial blood sugar spike by waiting to eat until after the > start-time > > of > > your insulin, you may easily make yourself hypoglycemic, which could in > turn > > cause you to overcompensate and overeat-that is, presuming you don't lose > > consciousness first. > > > > Type II diabetics have a diminished or absent phase I insulin response, > and > > so they face a problem similar to that of Type I's. They have to wait > hours > > for the phase II insulin to catch up if they eat fast-acting carbohydrate. > > > > The key to timing insulin injection is to know how carbohydrates and > insulin > > affect your blood sugar and to use that knowledge to minimize the swings. > > Since > > you can't approximate phase I insulin response, you have to eat foods that > > allow you to work within the limits of the insulin you make or inject. (If > > you > > think you'll miss out on the great high-carbohydrate, low-fat diet many > have > > been raving about, there is considerable evidence that restricting > > carbohydrate > > is healthier not only for diabetics but for everyone. See Protein Power, > by > > and Dan Eades, Bantam Books, 1996, for more details on this > > point.) > > > > If you consume only small amounts of slow-acting carbohydrate, you can > > actually prevent postprandial blood sugar elevation even with injected > > regular insulin. > > In fact, by restricting carbohydrate intake, many Type II diabetics will > be > > able to prevent this rise with their phase II insulin response, and will > not > > need preprandial (premeal) injected insulin. > > > > Obeying the Laws of Small Numbers > > Essential to " obeying " the laws of small numbers is to eat only small > > amounts of slow-acting carbohydrate when you eat carbohydrate, and no > > fast-acting > > carbohydrate. Even the slowest-acting carbohydrate can outpace injected or > > phase II insulin if consumed in greater amounts than recommended later in > > this > > book (Chapters 10 and 11). > > > > If you eat a small amount of slow-acting carbohydrate, you might get by > with > > a very small postprandial blood sugar increase. If you double the amount > of > > slow-acting carbohydrate, you'll double the potential increase in blood > > sugar (and remember that high blood sugar leads to even higher blood > sugar). > > If > > you fill up on slow-acting carbohydrate, it will work as fast as a lesser > > amount of fast-acting carbohydrate, and if you feel stuffed, you'll > compound > > it with the Chinese Restaurant Effect. > > > > All of this not only points toward eating less carbohydrate, it also > implies > > eating smaller meals 4 or 5 times a day rather than three large meals. If > > you're > > a Type II diabetic and require no medication, eating like this may work > well > > for you. The difficulty with this sort of plan is its inconvenience, but > > some > > people don't mind and actually prefer to eat this way. I have one patient, > a > > Type I diabetic who still makes some insulin. She eats a couple of bites > of > > protein every 15 minutes and takes long-acting insulin. In a 16-hour day, > > that adds up to a lot of meals and a lot of clock-watching. This routine > > would > > drive a lot of people nuts, but it works for her. As long as she keeps up > > with her frequent little meals and covers the insulin, she's fine. If she > > misses > > a few " meals, " there could be trouble. > > > > For the Type II diabetic who doesn't need insulin injections, smaller > meals > > throughout the day can be a very effective way of maintaining a constant > > level > > of blood sugar. Since this kind of diet would be tailored to work with a > > phase II insulin response, blood sugars should never go too high. It > would, > > however, > > involve a certain amount of daily preparation and routinization that could > > be thrown off by changes in schedule-illness, travel, houseguests, and so > > forth. > > (People with gastroparesis, or delayed stomach-emptying, may have to eat > > this way. We discuss this phenomenon further in Chapter 21.) > > > > end of chapter > > > > > > > > > > > > Quote Link to comment Share on other sites More sharing options...
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