My chat with a Type 1

[Rose1942]

The other day I had an appointment at the hospital lab for an unrelated to diabetes condition. During the blood draw, I was chatting with the lab tech, who I see frequently, and I told her that I had just recently been DX as diabetic. I mentioned my success so far with a low carb diet. At that point she told me that she was also diabetic. So I naturally asked her if she had ever tried doing low carb too.

Her response was 'Oh no, I'm a Type 1 and I have an insulin pump. I can eat anything I want, in fact they tell me to because I lose weight easily and they don't want me to lose.' So I said 'Wow, you mean you eat everything? Like even dessert?' She said 'Oh sure, I can have everything!'

At that point all I could say was that I was glad she was managing it, but that since I am Type 2 and not on insulin, I want to try and control my diabetes with diet. But I was secretly thinking that her situation could probably be improved by following a better diet as well, right? Isn't that what Dr. B (and others) tells us? Is the mainstream medical community really telling sereiously diabetic, Type 1 patients to eat anything they want because they are covered with insulin? This blew my mind.

[Lottadata]

Rose,

I've been reading diabetes boards for almost a decade since discovering Dr. B's book. What I learned is that Type 2 and Type 1 are very different, and Type 2s really shouldn't give diet advice to Type 1s.

Bernstein's diet works extremely well for Type 1s who have extremely hard times getting control. However, there really are some Type 1s who can do exactly what that woman described doing with her pump. I know quite a few. They can eat up to 150 g a day and get great bgs.

It really depends on exactly how much damage there was to the beta cells, alpha cells (the ones that produce glucagon--something Type 2s don't have to worry about) and how smart they are about figuring out their ratios.

I ended up finding out I'm not Type 2, I have something that is functionally Type 1.5 and I can get bettert blood sugars injecting insulin at meals and eating 30-50 g of carbs than I ever could when controlling with a very low carb diet alone.

But you have to keep in mind that Bernstein's services aren't covered by insurance and they are expensive enough that he only sees patients who are having a terribly hard time controlling their blood sugars. That probably affects his viewpoint.

The newer insulins make better control easier too. Bernstein developed his plan in the days when there was only R. He uses fast-acting, but only with tiny amounts of carbs. Some of us can match fast acting to meals without problems.

Bernstein also has an attitude towards pumps that was formed years ago, and the issue he rails about--scarring, doesn't seem to be reported by many of the long-term pumpers I know. Again, I think he only sees the people who do have that problem, as why would someone whose blood sugar control was fine pay $$$$ to see him?

[Rose1942]

Thank you for enlightening me Jenny. I didn't realize that there were some diabetics who could eat carbs (and especially sugars) safely. That makes me feel better because although I certainly didn't give advice to this lady (only asked in innocence if she did low carb too), I was worried about her! She's very nice and I would hate to think she was not getting good care.

[eddiemcm]

And you must remember that Bernstein is a type 1 DX.A lot of his advice simply does not apply to a type 2.
Eddie

[dancinbr]

OK, now lets think more about this.

The Type 1 you met is on a pump.

Have you ever seen what they do?

They calculate every single carb they are about to eat at a meal and then they program that into the pump to assure the proper amount of fast acting insulin is released.

The pump also has a setting for basal insulin (now I keep flip-flopping on the spelling sorry), that the pump also provides.

However, where the good advice of the Doctor B's approach does come in and make it easier for the type 1 is the "theory of small numbers".

If the person is truly familiar with all the foods they eat and how quickly they metabolize then they are doing great with the pump and avoiding huge swings of BG that still may come out looking like a good A1C.

So most people on the pump are still watching their carbs very closely. Many are lowering them just so that they don't need so much fast acting insulin.

The timing is still critical albeit I can see that the newer insulins Novolog seem to cover roughly the same period of time that most carbs will metabolize.

But I would caution any of them for being so frivolous. Close monitoring and knowing how much they need and calculating and inputting and monitoring is something they must constantly do.

It is more easily managed with lower carb numbers; not necessarily the 6-12-12 that Dr. B does recommend. And perhaps they do not regulate as tightly as he gets his patients to do; like trying to flat-line the BG level at their target.

Rather, the appropriate amount of carbs and roughly emulate the curve of a non-diabetic that will have a pre-meal reading of 85 or so, peak at 120 and be back down to 85 within 2 hours after eating.

So, I hope the person you talked to is watching closely anyhow.

A lot of Dr. B's advice is good for both T2 and T1; a lot of his advice is definitely optimized for a T1.

As to insurance, many insurance plans have an "out of network" provision. I would have to deal with him in an "out of network" category. I figure I would still see about 1/3 to 1/2 re-imbursement if I were to go to him. I have checked it out quite thoroughly

Ralph

[RobLL]

The two people I know on the pump do terribly, they are both type 2s, and use their pump as an excuse to eat their former diet.

ps - I obviously don't know many diabetics
pps - this does not mean pumps are bad - just that any tool can be misused

[v-effect]

Interesting topic. When I first read Dr.B I was amazed! I had been diagnosed as Type 1 and given a 300 carb a day diet. I was on a crazy roller coaster. My reducing my carb intake I realized I could stabalize BGs and maintain a healthy weight. As I became a diabetes veteran I made some changes to Dr.B's rules based on technologies and skills he is simply too old-fashioned to incorporate into his plan. I love my pump; I also love carb counting. I *can* eat anything I want with predictable results. And sometimes I need to. For example, the day before a loooong run, I carb load a bit. (By carb load I mean maybe 100 carbs total). If I don't do this, I spike very high during that run. I also think the pump is crucial for a low carb, protein rich diet since I have found that I need one unit for every 20 grams of protein- and I need that unit delivered over 4-5 hours. But yes- if you are well trained with a pump you *can* eat anything you want and achieve good results.
V.

[Rose1942]

I have no idea how good she is with the pump, we didn't talk long. Also I am not well informed about it - the most I know has come from you guys here, in fact. But I gathered that she didn't count carbs at all from the way she said 'Oh no, I can eat anything I want to (including desserts)' as I mentioned above. Her only other comment was that her doctors told her to eat this way because she isn't supposed to lose weight.

From this, I think she is probably not getting very good advice because to eat 'anything you want' doesn't quite fit the picture I get from Dr. B, for either Type 1 or 2. he is a Type 1 and he certainly counts carbs! Being on a pump is just another method of delivery but if you are taking in a lot of sugar and carbs, I don't see how that cannot be dangerous in some way, in the long term especially. Dr. B warns always about trying to prevent complications - well, diet has a lot to do with that no matter how you get your insulin, right? I guess that is just the way I am interpreting it .........

[dancinbr]

My friend manages her carbs closely and uses her pump. It is not abuse.

She does things in small amounts.

She had a terrible time controlling her BG before she went on the pump.

She is very diligent.

That is a good use of the pump.

I suspect, like anywhere, there can be use or abuse of anything.

Ralph

[Lottadata]

As to insurance, many insurance plans have an "out of network" provision. I would have to deal with him in an "out of network" category. I figure I would still see about 1/3 to 1/2 re-imbursement if I were to go to him. I have checked it out quite thoroughly

Ralph

Ralph,

Great post!

Re Dr. B and out of network payments. He explained in one of his teleconferences why most insurance WON'T pay for his services in network or out. That is because insurers will not pay for "diabetes education" when provided by an M.D. Crazy but true. Only from CDEs and nutritionists. And at much lower reimbursement rates.

All Type 1s have to pay obsessive attention to what they eat and how they dose or they end up in the ER, we Type 2s don't end up with DKA at the high end and bgs of 20 at the low.

After years of carb counting, it gets pretty simple to do. I've been doing it for a decade now, and I can pretty much eyeball anything and get a carb count accurate enough to match my insulin dose.

The most difficult part of it for me is that my insulin/carb ratio changes a lot, based on other meds I'm taking and the like, which is why I still have to test a lot.

I am convinced that normal people do go up to 120 and then back down into the 80s, not because they are eating too many carbs, but because there is a specific system built into the body--the incretin hormones--that don't even kick in until you reach 120 mg/dl and then immediately lower blood sugar to normal.

And because I can't find any data pointing to damage to the organs when blood sugars rise to 120 for 15 minutes. To the contrary I've seen data that makes it very clear that there is a time threshold at which damage starts with elevated blood sugars as well as a concentration threshold. The results of a blood test at half an hour after eating, for example, does NOT correlate with any increase in complications, while that at 1 hour most definitely does.

I'm getting readings in the 90s one hour after eating 30-40 grams with 3 units of Novolog, and that's good enough for me. It's better than my "normal" spouse gets. I will pack on weight if I do it three times a day, so I don't, but I will also pack on weight if I eat 1750 calorie a day, so my situation isn't like that of most people.

[dancinbr]

Ralph,

Great post!

Re Dr. B and out of network payments. He explained in one of his teleconferences why most insurance WON'T pay for his services in network or out. That is because insurers will not pay for "diabetes education" when provided by an M.D. Crazy but true. Only from CDEs and nutritionists. And at much lower reimbursement rates.

All Type 1s have to pay obsessive attention to what they eat and how they dose or they end up in the ER, we Type 2s don't end up with DKA at the high end and bgs of 20 at the low.

After years of carb counting, it gets pretty simple to do. I've been doing it for a decade now, and I can pretty much eyeball anything and get a carb count accurate enough to match my insulin dose.

The most difficult part of it for me is that my insulin/carb ratio changes a lot, based on other meds I'm taking and the like, which is why I still have to test a lot.

I am convinced that normal people do go up to 120 and then back down into the 80s, not because they are eating too many carbs, but because there is a specific system built into the body--the incretin hormones--that don't even kick in until you reach 120 mg/dl and then immediately lower blood sugar to normal.

And because I can't find any data pointing to damage to the organs when blood sugars rise to 120 for 15 minutes. To the contrary I've seen data that makes it very clear that there is a time threshold at which damage starts with elevated blood sugars as well as a concentration threshold. The results of a blood test at half an hour after eating, for example, does NOT correlate with any increase in complications, while that at 1 hour most definitely does.

I'm getting readings in the 90s one hour after eating 30-40 grams with 3 units of Novolog, and that's good enough for me. It's better than my "normal" spouse gets. I will pack on weight if I do it three times a day, so I don't, but I will also pack on weight if I eat 1750 calorie a day, so my situation isn't like that of most people.

Hi,

Talking about weight and weight loss.

I have to be below 1500 net calories (actual calories minus exercise calories) to lose weight.

It is really tough. Always has been.

I can approach this easily by staying low carbs. It is carbs that really add up so very quickly.

Of course, you must watch the protein as well.

I haven't quite figured out my ratio of Novolog to carb. I am still zeroing in on it.

I also have some standard lunches I can have at certain restaurants that I may not have the carb count down exactly but I am sneaking up on the right amount of Novolog to offset that lunch when I do decide to have more carbs.

I love going to Panera's with my wife and having a nice salad with a piece of Panera bread.

Breakfast, I have completely under control; two eggs and one low cal slice of bread with some coffee using half and half. That adds up to about 15 or so carbs counting the half and half in the morning. If I wanted to be 6 I would skip the low cal slice of bread and I would be right on. But I like soaking up the egg yolks, which by the way are so GOOD for you; forget about this cholesterol myth. It is genetics that is controlling most of that.

Lunch I can control quite well also.

Dinner as well. So most days I can stay well within the 30-60 carb range and do well with minimal or no Novolog. It is that big dinner or those tempting treats that I have to avoid.

Ralph