Conflicting plans

[ScottEnsink]

I was diagnosed about a month ago with Type 1 diabetes. I started Novolog, using a sliding scale based on my BG reading to determine my dose, before each meal (3x per day). I also started Lantus, beginning with 10 U at bedtime, increasing 1-2 U each day if my fasting BG was above 150. I got to about 20 U of Lantus.

At my last doctor's (family practice, not specialist) visit, he said if I ate a consistent amount of carbs at each meal, I could find and use a consistent dose of Novolog at each meal each day. I had been reading about more intensive management, using a correction + carb-covering bolus, and asked about that. He said fine, however, because of consistent strenuous morning exercise (running before breakfast), we agreed on a compromise plan.

Since I eat a consistent breakfast each day, I would do a consistent dose of Novolog (3U) at each breakfast. I would then do a correction + carb bolus at lunch and dinner. He said not to worry about between meals or evening snacks--as long as I was reasonable, I did not need to cover those carbs. The Lantus would help, and I could correct at the next meal. I liked this plan, I felt very free, and more like my old self.

Then I visited the diabetes educator nurse a few days later. She was horrified with that plan! What if I was spiking betwen meals? She insisted (although it's "up to me, and everyone is different") that I needed to cover every single carb that I ate. She's got me testing 10 times a day and logging everything.

So now what? I like the freedom of the doctor's "no worry" plan. I also feel a little guilty (now) for not covering each carb. Plus, if I cover each carb, I can be a little "less reasonable" for some snacks (hello ice cream!).

My head is spinning, my stress is rising, what should I do? Any advice? Does anyone follow a plan similar to the "no worries" plan? Any advice would be appreciated!

[Beckernj]

I was told the same thing when I was diagnosed. Me and my diatrition decided that I would take a BG 2 hours after I eat to make sure I am not spiking. That pretty much handled it.

[Jan B]

Scott,

Please don't let this stress you too much. You are a smart guy, and will have many years to get it all under control for yourself. Your doctor sounds like he's trying to relieve some of the pressure, and the nurse wants you to understand that all carbs do matter. In the long run, it will benefit you to do a lot of testing right now to understand the effects of small amounts of carbs, combined with activity, and your life!

I have found that with Lantus, I have to sneak in 10-15 carbs every few hours to keep from going low. Maybe that is what your doctor is referring to when saying you don't have to account for every little carb. Ideally Lantus would be a perfect basal option, kind of like pumping is when all your personal basals are set (I use 6 rates now on the pump). On the other hand, when I'm pumping (and all basals are correct), I do have to account for every little carb.

Things are easier if you eat the same breakfast every morning. However, you do not have to be that "stuck". Once you learn how many carbs each unit of fast-acting insulin covers, you can use more freedom in changing up your meals.

Before I go on and on, please ask any direct questions that I haven't covered! Of course, you'll get more advice/opinions and you can tailor all our input to your needs . . .

[ScottEnsink]

Thanks for the advice Jan.

I've found that with the Lantus too I need to have between meal snacks, or I go too low. I'm thinking of dropping the dose down a unit or two. I think you're right, the doctor expects this and is okay with it. I don't want to have to "feed the insulin".

After I left the doctor, I was elated. Things seemed easier, less burdensome to count and log everything, more like my pre-diagnosis life (almost!). I'm okay with the same breakfast everyday--I love my cereal and skim milk!

I think the nurse is used to putting "fear' into newly diagnosed Type 2 patients, but that's not me. I'm 6'-5" 210 lbs, I eat okay (thanks to my beautiful loving wife) and exercise 6 days a week. But I'm still feeling some fear.

I guess it's up to me in the end, right?

[sarahspins]

You shouldn't have to "feed the insulin" as some have put it.. and you definitely don't want to fall into that trap, as it's a sure way to gain unwanted weight. Eat if you're hungry, not because it's "time". There are ways to bring down your fasting BG if the lantus doesn't seem to be enough overnight, but works great for basal coverage the rest of the day - I used to take NPH while I was honeymooning because I needed more insulin at night. Before that, by the time I got my Lantus dose high enough to fix my fasting numbers, I was having lows in the 30's every day around 3 or 4pm, and having a snack around that time wasn't always enough to counteract it, so something had to give.

I don't cover snacks where I'd have to give myself less than a unit of insulin (which pretty much equates to anything under 10g) - generally for me, just a little extra activity (a 15 minute walk, for example) is enough to bring that down between meals.