“…men and women of conscience must not consent
to be controlled by fear, convention, or the will of the masses.”
–Brendon Burchard, The Motivation Manifesto
A client with type-1 diabetes in California had to visit her family doctor. “Of course,” she later told me, “it was a horrible experience.” During the appointment the doctor saw that she is averaging about nine jabs of insulin a day. The white-coated authority greatly disapproved. She said her other diabetic patients take less than four shots a day.
Of course, my wife Nicole – and many other people with type-1 diabetes who sport HgbA1Cs below 5.5% (the normal range) – take as many as 11 shots per day:
- 2 Shots Upon Arising: Long-acting insulin + Regular to cover the dawn phenomenon.
- 2 Shots at Each Meal (6 total): One to correct a high blood sugar (if any) and another to cover the incoming food.
- 1 Shot Before Bed: Another long-acting.
- 2 Shots Three Hours Later: Another long-acting + a a corrective dose of Humalog (if necessary).
I’ll explain why taking so many shots helps produce better blood sugar control. But first, let me address the claim that taking less shots is better (or at least sufficient).
First off, my client’s doctor says that her other patients have A1C less than 7.0%. Probably between 6-7%. 7% is better than 9%. But still deadly. Healthy people have A1Cs of 5.5% or lower according to any lab report or study I’ve seen.
Secondly, is her doctor just talking? Does she really know how many shots her patients are taking? Does she really track their A1Cs that carefully? Maybe. But I’d like to see the table and charts she’s referencing.
Thirdly, is her doctor talking about patients with type-ONE diabetes? Or is she also tossing in a generous helping of type-2 diabetics? People with type-2, if they use insulin at all, may only need one shot of long-acting insulin each day. In addition, they usually take insulin sensitizing agents to boost their already over-producing pancreas. How can one compare type-1 and type-2? They appear to be radically different diseases that merely share similar symptoms. It’s like comparing grapes and grapefruit.
Fourthly, of her miraculous type-1 patients… how many of them are suffering from 100% beta-cell failure like Nicole? Four decades of type-1 diabetes takes its toll. Many newbies may still have some beta-cell function — which I would think helps a lot. One of my clients doesn’t need any long-acting insulin to stay below 6mmol/L (which isn’t low enough). Others are still in the honeymoon phase. Others may still produce insulin but have difficulty delivering it to the cells. How can you fairly compare one person with another?
Fifthly, many people with type-1 diabetes often tell me they don’t need to take insulin before or after their meals. They don’t see much of a rise. They just use a high dose of long-acting insulin and take a corrective shot of fast-acting insulin once or twice a day. In my experience, this is almost always the result of delayed stomach emptying. The nerves that open the pyloric splincter between the stomach and the intestine are not working properly. Once we correct this problem, the same people suddenly see a drastic (albeit appropriate) spike in blood sugar 45-minutes after they begin eating (if they don’t take one of those extra shots of insulin before meals, of course).
Lastly… Sure, even a person with zero beta cells can get by with just ONE shot of insulin a day. First thing in the morning try injecting (well, don’t…) 50 or 100 units of Lantus, Levemir or Tresiba. You won’t need any more insulin for the rest of the day. What you will need is a big box of candy…Once your blood glucose levels drops below 8mmol/L (150mg/dL)… eat something. Quickly! And not a salad. Something sweet. Something sugary. Get the sugar back up to 11mmol/L (200mg/dL). Then in another hour it’ll drop back down. So just eat more junk food. And then before bed, eat a lot of ice cream… hopefully the sugar, when mixed with the cream, will slowly release into your bloodstream all night. But, if not, just have a bagel a 2am. Who needs sleep when you got sugar?
I’m exaggerating (at least, I hope I am). Still, this is close to what many people with type-1 diabetes have been advised. They are covering insulin with carbs (instead of carbs with insulin). Take an “industrial dose” and then eat, eat, eat… One 12-year old boy, upon developing type-1 diabetes, said he had to start eating more carbs at each meal (than he did prior to developing life-threatening glucose intolerance) to placate the prescribed dose of insulin.
In addition, this wonderfully convenient one to four shots-a-day comes with one big side-effect: Namely that you’ll get BIG. That insulin is going to store all those incoming carbs as fat. Along with that comes all the usual problems associated with weight gain: high triglycerides, fatty liver, heart attacks, inflammation, impotence and a closet full of clothes that don’t fit.
Of course, you may also suffer some pretty bad lows if you can’t get your hands on a cupcake fast enough… but that’s okay, you won’t feel so guilty about all that GMO high-fructose corn syrup when your blood sugar is 2mmol/L (36mg/dL). Besides… junk food manufacturers need to make a living. Those yachts aren’t cheap.
In the end, my client’s family doctor called a endocrinologist. The endo gave a “green light” saying that her approach was fine as long as my client “doesn’t mind giving 9 shots a day.”
Doesn’t mind? Is this how they decide the most effective treatment — based on what the patient minds doing? We’re talking life-support therapy here, not whether a five-year old prefers laces or Velcro.
“Yes, you can take just three shots a day, if you don’t mind losing yours legs, developing Alzheimer and going on dialysis.”
So why did switching to as many as 11 individual doses of insulin help bring my wife’s A1C down from the 8s into the 4s? Here are the five reasons I promised 935 words ago:
1. It’s really just a matter of math… The bigger the dose the bigger the margin for error. Between the liver and muscles’ storehouse of sugar, wavering insulin absorption, the stresses of life and the unpredictable effect even a cauliflower will have on blood sugar, we are looking at least at a 30% margin for error. Logic would suggest that it’s far safer to make a 30% mistake with 3 units of insulin every few hours than 15u of insulin once or twice a day. 30% of 3 units is only 1 unit. 1 unit would drop my wife’s blood sugar 3.0mmol/L (54mg/dL). While 30% of 15 units will plummet her blood sugar 9mmol/L (162mg/dL)
2. Multiple shots per day mimic what a functioning pancreas does. How many times a day do you think a healthy pancreas adjusts insulin levels? Probably thousands. As far as I understand the research, every slight rise in blood sugar causes beta cells to release more insulin. If we could, I would prefer Nicole injected 24 times a day. Sadly, this would be counterproductive as even fast-acting insulin remains active for at least 5 hours. For this reason we always space injections 5 hours apart (or 4 hours if she injects into muscle).
3. My client’s doctor said that multiple injections would increase her risk of infection. If this is the case, why are not people with insulin pumps dropping dead? They have a needle in their side 24/7. Nicole’s been averaging 9-11 shots a day for three years and has not seen a single infection. What has reduced, however, is swelling, scarring and accumulation of fat at injection sites. Large doses of insulin in one spot appear to build up resistance to insulin.
4. Nicole uses three different types of insulin: Levemir, Humalog and Regular. Many people don’t use Regular. But when it comes to eating low-carbohydrate meals, Regular has proven itself more effective at maintaining a low post-meal blood sugar. And when it comes to lowering A1C, low-carbohydrates meals are critical. On the other hand, Nicole relies on Humalog to lower high blood sugars as quickly as possible.
5. Typically, nighttime and daytime fasting blood sugars levels are quite different. Nighttime requires more insulin than daytime. There’s probably several reasons why this is true. Blood vessels can constrict at night, because of lack of movement, impairing circulation of insulin. And then there’s the liver who has a hobby of cleaning insulin out of the blood in the early morning hours. Either way, Nicole has found that she needs a slightly higher dose of Levemir at night. And, not just one, but two separate doses. Otherwise, she’ll either go low at 1am or high at 5am.
Another client had a similar run-in while being hospitalized in Croatia. The resident criticized him for taking so many shots of insulin. The next day, a senior endocrinologist with a platoon of medical students marched up to his bed. He examined his insulin protocol, turned to the students and said something to the effect: “Here is an example of a diabetic who is using a new protocol developed by a doctor in the United States. It involves taking many small doses of insulin. It produces far better control. He should be commended.”
Managing blood sugar is delicate work. I can’t understand why anybody would think you can drop a few “insulin bombs” into fat tissue and expect stability. Instead, like a driver on the road, you need to be constantly making small adjustments to avoid a high or low blood sugar crash. Yes, it’s a lot of work. But it works.
Editor’s Note: Who was the doctor that Croatian endocrinologist was referring to (that developed a new insulin regimen)? It was, I assume, Dr. Richard Bernstein. Nicole has been meticulously following the instructions in his book, Diabetes’ Solution, for four years now. Within the first six months she obtained an HgbA1C of 4.5%.
About the Author: John C. A. Manley researches and writes about alternative treatments for type-1 diabetes and its many complications. His wife, Nicole, of 13.5 years has had type-1 diabetes for nearly four decades. Together they have lowered her HgbA1c below 5.5%, regained thyroid function, increased kidney function and reversed gastroparesis.