Thursday, May 13, 2010

Carbo-licious or Carbo-idiotic? Problem solving is key, not costly pumps.

Today's topic is to carb or not to carb. We've been asked to blog about what we eat. And perhaps what we don't eat. Some believe a low carb diet is important in diabetes management, while others believe carbs are fine as long as they are counted and bolused for. Which side of the fence do you fall on? What kind of things do you eat for meals and snacks? What foods do you deem bolus-worthy? What other foodie wisdom would you like to share?

There is a debate among people with diabetes, particularly among those with type 1 diabetes (and/or their caregivers) about whether carbohydrates (referred to herein as "carbs") should be severely restricted in order to maintain normalized glucose levels. Theoretically at least, it makes sense.

While it's true that carbs have the most immediate impact on blood glucose levels because they are readily converted into blood glucose, contrary to what many have been taught to believe, other nutritional components, especially proteins, do in fact also raise blood glucose levels. The main difference is that while a piece of bread will show up in your blood glucose test results within a matter of minutes, protein usually takes anywhere from 6 to 8 hours before hitting your bood glucose. Most practitioners will say that theoretically at least, basal insulin is supposed to address this, but I disagree. First, the reality is there's not really any such thing as basal insulin in normal physiology, instead the beta cells respond whenever there's a bodily need for insulin, which makes artificial insulin replacement such a challenge (insulin supplementation, which is often the case with type 2 diabetes, does not have the exact same issues). In any event, metabolism is highly individualized, so claims that half of your total daily insulin dosage should be comprised of basal insulin have little if any scientific fact to validate those claims. Some people may require a constant stream of a small amount of insulin, others do not require it.

It took quite some time for me to figure all of this out and prove it, as it was conveniently excluded from any and all diabetes and nutritional education I had ever received, but after much experimenting and testing, I proved it unequivocally to myself. I probably would not have learned it if I wasn't wearning an insulin pump. Back when I did wear an insulin pump (I wore the
Animas IR1000
, which was the company's first generation pump), I performed (and repeated) a number of dietary experiments and proved that most land-sourced proteins have a rather significant impact on blood glucose, while poultry had less of an impact, fish had almost no impact, and eggs had none that I could discern, yet ALL are called proteins.

For example, one evening for dinner (I usually eat dinner about 7:00 PM, incidentally), I ate a measured piece of meat (although I don't usually eat beef because I don't care for it, this was an experiment for the purpose of science) only, in this case, steak, and sure enough, the next morning I woke up with hyperglycemia. When I ate no protein, just some vegetable soup which was mostly water and vegetables containing some carbs (carrots, potatoes, and the fruit that tastes and acts like a vegetable, tomotoes) as well as more fibrous veggies such as celery (which is mainly salt and water), and some green beans, plus some breadsticks (which are pure carbs with, a glycemic index of 100). I kept my basal rate unchanged, and woke up hypoglycemic by the middle of the night. The next time, I ate protein-only again in the same amounts, and increased my basal rates (I ended up having to increase my basals by 60% if that tells you anything) until I woke up with perfect numbers. Then I tried it with different types of proteins, and found slightly different but still consistent results. For example, after beef, pork (such as ham) has a very similar effect, although it is metabolized slightly faster than beef (at least for me). By comparison, measured portions of chicken or turkey had a far less significant impact. And two proteins, notably eggs (which I ate as Spinach Quiche, which admittedly had a few extra ingredients such as Spinach which really added flavor more than anything else, and cheese which is mostly fat and a small amount of carbs -- I made crust-less Quiche in case you were wondering) and fish of any type (whether it was freshwater or seawater fish; shellfish, or lean fish steaks such as Chilean Sea Bass or Tuna Steaks), had virtually no impact at all, and again, I woke up in the middle of the night with hypos. I tested this over a lengthy period of time, and repeated the both what I ate, my basal configurations, and the timing, and found the results worked exactly the same way each and every time, so it was not a one-time fluke of nature, as is often the case with diabetes.

After documenting all of this, I then I asked both my CDE and nutritionist about it, and neither denied the impact that protein can have, instead saying that basals "usually" cover it (but they don't with every person), and that I did everything I should have to investigate the issue, and that both of them (both my CDE and nutritionist at the time had type 1 themselves and wore insulin pumps) would have recommended doing exactly the same thing. In effect, I was rewarded with a compliment for what I had done to test my theory and validate the findings and I suppose the knowledge would reward me for many years to come, but to me, that seemed like a cop-out. Why hadn't anyone advised me of this in training? Why did I have to go through several weeks (or months, if you consider the daily fasting highs I dealt with, only to be told that I should try raising my basal rates, to which I responded, "Uh duuuuuh, thanks for that extremely valuable recommendation" (that's saracasm ... can someone remind me again what the hell my insurance company is paying these people for if I'm doing all the work myself)?

The reason I mention all of this is because first, I do believe that wearing an insulin pump enables people with diabetes to problem solve that isn't always possible with a traditional short/long-acting insulin regimen. In that regard, even if one returns to MDI (multiple daily injections) as was the case for me, I still believe that my experience in wearing a pump was valuable because I was able to learn so much. I believe everyone should try it for themselves at some point.

On the other hand, I did not find wearning a pump to be my salvation, as many had suggested it would be, nor did it eliminate hypos as many salespeople are only too willing to suggest. On the other hand, wearing a pump did teach me problem solving, and that expertise, which I gained from the experience that helped me most. On the other hand, the pump was a costly impetus that I really did not require, and there are many people who can do just as well without a pump. The notion of claiming everyone with type 1 diabetes is an example of how wasteful the healthcare "system" has become. The tools themselves are not a panacea, rather the notion of problem-solving really is the key to good glycemic management, not the costly devices. To be sure, pumps can make life easier for many patients, and at the very least, patients with chronic diseases like diabetes should be allowed access to these costly tools, but I firmly believe that the devices themselves are an example of inherent waste that's been firmly built into the system. Some people do much better with a pump, especially children whose insulin needs can vary widely, or anyone who can benefit from the level of precision in dosages that only a pump can provide. Usually, that is people whose basal rates vary widely benefit most over the course of a day, or people whose sensitivity to insulin remains high, but I do believe that the device itself is behind that.

So what does this mean for insulin dosages?

Well, first of all, the more carbs a patient consumes, the more widely their insulin dosages will vary throughout the day. That, I think, is amounts to a fact. And one element I agree with is that the a diet that is loaded with carbs will amount to glycemic instability. One way to improve control, therefore, is to reduce the consumption of carbs. But that does not equate to elimination, as many seem to suggest, especially those who are on the paleo diets or similar types of dietary restriction. Does that improve glycemic control? Absolutely it will, but to those who suggest that you should eat a meat-only diet, I think they're nuts.

When one drastically reduces their consumption of carbs, I believe they will see dramatically improved glycemic "control", although I think that word control should be dropped in favor of "management" or "influence", but for many people, that's an exercise in semantics. On the other hand, I do not subscribe to the belief that carbs should necessarily be restricted. To do so day after day, for a lifetime, amounts to what I would argue is cruel and unusual punishment. Carbs are fine in moderation, and should be consumed carefully so that insulin can be dosed accordingly. But carbs are part of a varied diet that I believe IS a part of a rich part of life. I will give the (in)famous Dr. Bernstein appropriate credit where due: he's 100% correct about the law of small numbers. His law of small numbers is basically the less medicine (of any type) you take, the less risk of something terrible going wrong and the greater the likelihood of the medication (and that's especially true with injected insulin) working in a consistently reliable fashion. Therefore, anything you can do to reduce the amount of insulin required will be beneficial, but within reason, naturally.

But complete carb restriction, especially over a lifetime, is not necessarily something I would recommend to anyone, because it amounts to a lifetime of restrictions that are neither desirable nor sustainable. For example, we know that in people with impaired kidney function, an all-protein diet would amount to an accelerated death, besides who really wants to live a life like that? Not me. So the key, in my humble opinion (IMHO) is to try and minimize insulin dosages as much as feasible, but one shouldn't have to avoid bread to do it.


Jenny said...


Dr. Bernstein was writing as long ago as 1998 that you should cover protein at 58% with R insulin (long activity curve.)

He also documents very well that high protein does not damage kidneys in the absence of glucose, and there is research data that backs this up. I have personally known some people with intermediate stage kidney disease who returned to normal values after eating low carb meat-heavy diets for a few years. The tide is turning in mainstream medicine on the protein/kidney link. Research cites at the bottom of Blood Sugar 101: Diabetic Kidney Damage

Boz said...

I think every body that is insulin dependent goes through the same trials and tribulations that you have bee. I'm type 2 but also insulin dependent. Living a very active and unpredictable life style, meal planning is near impossible at times. I take Lantus in the a.m, and metforman with meals. Sometimes my best guess is all I can do. But one thing that I do know for sure is that the longer and more intense I exercise, the longer the benefit on my blood sugar and the more carbs I can tolerate. For my management, exercise is the #1 key.

Bennet said...

I have never been a fan of one size fits all. In that context I like your point that learning to problem solve is key.

I worry that technology is seen or sold by some as a solution to problem solving. Tools are tools and it the hand of the craftsman that makes the art. T1 management is art.

Thanks for the post.

Gretchen said...

I suspect it was the fat in the various "protein" meals you had rather than the protein that was causing the differences in fasting BG levels.

Many people with type 1 report that a fatty meal on one day will elevate fasting levels the next day.

Have you tested this? i.e., a fatty beef meal vs a lean beef meal, or a skinless chicken meal vs a meal with lots of chicken fat.

Gretchen said...

Nondiabetics *do* secrete "basal" insulin in pulses. That pulsatile secretion seems to be lost in people with type 2.



Harold said...

Bernstein never says you should eat an all protein diet. His diet is not a high protein diet but a high fat diet. He suggests increasing protein if you are having trouble gaining weight otherwise the diet is low carb and high fat which works for me. A1c under 5 with insulin.