The Case for Regular (R) Insulin

The Case for Regular (R) Insulin


As a teen athlete with Type 1 diabetes, I achieve normal blood sugars using a few key tricks from Dr. Bernstein. One of the most important of these tricks I discussed was the use of Regular insulin (Humulin-R) as my bolus insulin. “R” insulin is a core Bernstein concept which I have implemented for just about 7 years and it has been an absolute game changer. In this article, I would like to share what I learned about Regular insulin from Dr. Bernstein, how I use R, and why it works so well for me.

First, let me provide some motivation. Consider the standard diabetes management method we are taught at diagnosis: carb counting. The idea is that we can simply add up all the carbs on our plate, dose the corresponding amount of insulin, and everything will magically work out. If you have Type 1 diabetes, you know that doesn’t work. Just look at the data – the average A1C for a Type 1 kid is about 8%, which is an average blood sugar around 200 mg/dL! And that high average often comes with constant fluctuations from very low to very high blood sugar. Sometimes these fluctuations are so fast they outpace the response time of the CGM, which is particularly scary. Essentially, as people with Type 1, we are taught to use a method that will fail. So, if you are trying hard to get carb counting to work and feeling frustrated or being admonished by your physician  for poor results, please realize it is not your fault.

It’s important to understand why carb counting fails. The basic problem is that it is impossible to consistently match a dose of fast acting insulin and a meal of fast acting carbohydrate. There’s enough variation in the action of each that you can never get the peaks of the insulin and the peaks of the carbohydrate to line up. The resulting blood sugars are different every time. Dr. Bernstein explains it perfectly:

Moreover, it is not just the fast-acting carbohydrate that is the problem with carb counting. Protein also requires insulin to metabolize and this effect is totally ignored (protein has to be accounted for due to complicated physiologic reasons, but suffice to say it is not because protein is somehow carbohydrate). 

How does Dr. Bernstein solve this problem? He uses physics. To put it simply, Dr. B turns the sharp peaks of BOTH the food AND the insulin into shallow hills which, unlike peaks, can be matched. Let’s discuss this strategy in a little more detail.

First, the food. To solve the food aspect of this problem, Dr. Bernstein removes blood sugar spiking high carb foods and instead uses a low carb/high protein diet. This diet generates slow rates of glycemic action on blood sugar. For me, this simply means that meals consist of healthy combinations of protein foods and fibrous veggies with the occasional low carb dessert. These meals have a very slow effect on glucose levels working over a period of several hours rather than mere minutes.

TED_ food pyramid
(Image courtesy of Dr. Ted Naiman)

 

Now, how do we cover these low carb slow acting meals? That’s where Dr. B’s ingenious use of Regular insulin comes in to play. We want a slow acting insulin to match these slow acting, low carb/high protein meals, and as it turns out Regular insulin is PERFECT for the job.

The Case for Regular (R) Insulin

 

Dr. Bernstein has a great video on how to determine the timing and dose of Regular insulin for a given low carb/high protein meal at a given time of day. The short of it is, that you use an initial estimate based on the amount of carb AND protein in that meal combined with a bit of trial and error to home in on the timing and dose of R insulin to cover a given meal. Dr. Bernstein’s method does require some initial effort – everyone is a little different regarding how much insulin and how much, if any, prebolus will be required – but if you stick with it, you can determine the amount and timing of R insulin for all your meals. Dr. B’s video explaining how to do it is here:

 

 

I’ll give an example of Dr. B’s strategy in action. I wake up for school and eat breakfast – right now I like to have two almond flour/protein waffles, three eggs, and some bacon. For this meal, I’ve used Dr. B’s strategy to determine that I need 6u of Regular insulin dosed right at mealtime. If I start my breakfast around 85 mg/dL, for example, I’ll be able to get to lunch right around that number. I then repeat the process for lunch which allows me to get to football or basketball practice right at a normal blood sugar range and with no extra insulin on board. Do I ever trend higher or lower? It happens and I still have to fingerstick and use my CGM. But the blood sugar changes I experience move very, very slowly and therefore, safely. If I happen to drift higher over the next few hours…say 110 mg/dL, or if I start trending down to the low 70s, I can easily catch it and use very small corrections to get back to normal – that’s a real game changer and allows me to almost always safely be in a healthy, truly nondiabetic range.

Using low carb matched with Regular insulin has really minimized how much effort and mental energy is required to manage my diabetes, which in turn, preserves my daily quality of life. My overall experience with Regular insulin has been incredible: using Regular in combination with a consistent menu of low carb/high protein meals has been a total game changer. The false promise taught to us at diagnosis – that carb counting could be effectively used to manage blood sugars – is just plain wrong. Injected insulin just doesn’t work that way. The carb counting system results in unpredictable and wildly fluctuating blood sugars and it is just miserable to be always up then down. On the other hand, Dr. Bernstein’s diet combined with Regular insulin really does work. Regular insulin has made my diabetes management nearly ‘set it and forget it’. Not only do I feel like I’m winning by getting normal blood sugars year-round and thus, removing the threat of complications, but I also do not have any episodes of scary hypoglycemia, nor do I worry about having one. The cost? None. I simply eat healthy foods and abandon the junk high carb foods – that’s it – and to me that’s actually a massive benefit.



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