Basal-Bolus Insulin Therapy

Diabetes is a disease that affects the way the body produces and uses insulin. Basal-bolus insulin therapy is a way of managing this condition. In type 2 diabetes, both the production and use of insulin are affected.

In people without diabetes, insulin is produced by the pancreas to keep the body's blood glucose levels under control throughout the day.

The pancreas produces enough insulin, whether the body is active, resting, eating, sick, or sleeping. This allows people without diabetes to eat food at any time of the day, without their blood sugar levels changing dramatically. For people with diabetes, this doesn't happen. However, a similar level of blood sugar control can be achieved by injecting insulin.

Injections can be used throughout the day to mimic the two types of insulin: basal and bolus. People without diabetes produce these throughout the day and at mealtimes, respectively

What is a basal-bolus insulin regimen? A basal-bolus insulin regimen involves a person with diabetes taking both basal and bolus insulin throughout the day. It offers them a way to control their blood sugar levels. It helps achieve levels similar to a person without diabetes.

There are several advantages to using a basal-bolus insulin regimen. These include:

• flexibility as to when to have meals
• control of blood sugar levels overnight
• they are helpful for people who do shift work
• they are helpful if traveling across different time zones

The downsides to a basal-bolus regimen are that:

• people may need to take up to 4 injections a day
• adapting to this routine can be challenging
• it can be hard to remember to take the injections
• it can be hard to time the injections
• it's necessary to keep a supply of insulin with you

These things can make it harder to manage diabetes well. To make it easier, some experts suggest introducing the regimen gradually. When this happens, bolus insulin is taken, beginning with just one meal at a time.

What is basal insulin? Basal insulin is also sometimes known as "background insulin." It is usually taken once or twice a day to keep blood sugar levels consistent. This is important when the body is releasing glucose to supply cells with energy, during fasting.

By keeping sugar levels steady during fasting, basal insulin allows the cells to change sugar into energy more easily. Basal insulin makes up about half of the total amount of daily insulin. It is sometimes called "long-acting insulin" because it needs to be effective for a long time.

Examples of long-acting basal insulin for people with diabetes include:

• glargine (Lantus)
• detemir (Levemir)

These insulins reach the bloodstream several hours after injection and are effective for up to 24 hours. However, people using these treatments will also need to use rapid-acting insulin when they eat. This applies for people with type 2 diabetes.

As well as using long-acting basal insulin, some people with type 2 diabetes may need to take oral medication. In addition, they may need a weekly injection of a medicine called a "GLP-1 agonist".

What is bolus insulin? People with diabetes take bolus insulin at meal times, to keep blood sugar levels under control after eating.

Bolus insulin needs to act quickly, and so is known as "short-acting" or "rapid-acting" insulin. It works in about 15 minutes, peaks in about 1 hour, and continues to work for 2 to 4 hours.

Brands of rapid-acting bolus insulins include:

• NovoRapid
• Humalog
• Apidra

Bolus insulin needs to reflect the amount of food eaten during a meal. So, carbohydrate counting and insulin-to-carbohydrate ratios are important tools for people with diabetes who use. However, some people find it easier to use an "insulin scale" instead.

An insulin scale is a list of how much insulin should be given before a meal. It takes into account both the pre-meal blood sugar level and the amount of carbohydrate that would usually be eaten at that meal.

However, it is still important for people using insulin scales to think about the dose of insulin they will take. They should compare it to the amount of food they are eating and what activities they have planned for after they eat.

This is because if they are going to eat more than usual then they may need more insulin than is listed on the scale. Or, they may need less insulin than is listed on the scale if they are planning on being more active than usual that day.

Insulin for people with diabetes is usually injected. However, in recent years, some alternatives to syringe injections have become available.

One alternative to injections is insertion aids, which are spring-loaded devices with a shielded needle. Insertion aids release insulin at the simple touch of a button.

Infusers are another option. An infuser is a device containing a needle or catheter (a flexible plastic tube) that remains under the skin for up to 72 hours.

When a person needs to administer insulin, they inject the insulin directly into the infuser, rather than into the skin. This method reduces the number of times they would need to insert a needle into their skin.

Yet, another method is the use of jet injectors. This does not use needles. Instead, a thin, high-pressure stream of insulin is forced through the skin.

Although jet injectors do not involve needles, the pressure can cause bruising.

Insulin can also be delivered using insulin pumps, if you can afford them. These are small, computerized devices that provide a steady, measured, and continuous dose of basal insulin, or a surge of bolus insulin at mealtimes. The insulin is delivered through a catheter that is taped in place on the skin.

Using Long Acting Insulin

I am adapting this discussion for people with type 2 diabetes. Long-acting insulin can help to stabilize blood glucose levels throughout the day, with only one or two shots.

Fast-acting insulin replaces the surge of insulin that a healthy pancreas would release at mealtime. In contrast, long-acting insulin mimics the low-level flow of insulin normally released between meals and overnight.

In this way, long-acting insulin works to establish a healthy baseline blood glucose level for the body to work around.

Long-acting insulin cannot be delivered in pill form because it would be broken down in the stomach. Instead, it must be injected into the fatty tissue under the skin. From here, it can be gradually released into the bloodstream.

According to the National Institute of Diabetes and Digestive and Kidney Diseases, there are a few ways to deliver long-acting insulin. These include:

• Needle and syringe: a dose of insulin is drawn from a vial into a syringe. Different types of insulin must not be mixed in the same syringe.
• Pen: this can be loaded with a cartridge containing a premeasured dose, or prefilled with insulin and discarded after use.
• Injection port: a short tube is inserted into the tissue beneath the skin. Insulin can be delivered using either a syringe or a pen. This only requires the skin to be punctured when the tube needs to be replaced.

Long-acting insulin can be injected into the abdomen, upper arms, or thighs.

Abdomen injections deliver insulin into the blood most quickly. The process takes a little more time from the upper arms, and it is even slower from the thighs.

It is important to stay consistent with the general injection area, but the exact injection site should be rotated frequently. Repeat injections at the same spot on the skin can cause lumps to develop under the skin, making it harder for the insulin to work.

Each type of long-acting insulin has its own suggested dose. These vary depending on whether the diabetes is type or for people who have never used insulin before. When a person is starting to use new insulin, it is recommended that they begin with a smaller percentage of the target dose. This is so that the body has time to adapt to the drug. That dosage is then gradually increased under the guidance of a doctor.

Long-acting insulin dosage may also be adjusted if diet or amount of daily physical activity changes, or if a person becomes ill. This is because these factors all affect blood sugar levels.

Adjustments can also be made to address any negative reactions to insulin, such as weight gain. Finding the ideal long-acting insulin regimen is a trial and error process that requires careful monitoring of blood sugar levels.

According to the American Diabetes Association, the periods that long-acting insulin works for differs from insulin that is faster-acting in three main ways:

• Onset: how quickly a dose of insulin begins to work. Short and rapid-acting insulin starts to lower blood sugar levels within 15 to 30 minutes. Long-acting insulin takes effect several hours after injection.
• Peak time: when a dose of insulin has its strongest effect. Rapid and short-acting insulin peaks at around one to three hours after injection. Long-acting insulin does not have a peak time. It works to lower blood sugar levels at a fairly stable rate throughout the day.
• Duration: how long the effects of an insulin injection last. Faster-acting insulin can control blood sugar levels for only a few hours. Long-acting insulin can work for around 24 hours or more, depending on drug type.

Long-acting insulin cannot stabilize post-meal blood sugar spikes.

When scientists create long-acting insulin, they change the structure of natural insulin. This is so that it can be absorbed into the bloodstream more gradually.

The United States Food and Drug Administration (FDA) explain that there are three forms of long-acting insulin currently on the market:

• detemir
• glargine
• degludec

Below is a summary detailing how each of these work.

Detemir

This insulin works over the course of the day. Here are some additional details about how it works:

• Duration: 18 to 24 hours.
• Administration: can be taken once or twice daily, at the same time each day.
• Brand name: Levemir.

Glargine

When injected, insulin glargine forms clusters in the fatty tissue beneath the skin. These clusters break down slowly, so that small amounts of insulin are released into the bloodstream gradually.

• Duration: up to 24 hours.
• Administration: taken once daily, at the same time each day.
• Brand names: Lantus, Toujeo, and Basaglar.

Degludec

This type of insulin works by slowing down the rate at which insulin molecules are absorbed into the bloodstream.

• Duration: up to 42 hours.
• Administration: taken once daily, and it can be at different times each day.
• Brand name: Tresiba.

Some research suggests that degludec works better than the older versions of long-acting insulin. However, because of pricing and health insurance coverage, insulin degludec is not very affordable.

According to an article recently published in Business Insider, Basaglar is currently the most affordable brand of degludec long-acting insulin.

Testing Blood Glucose at Home – Part 3

I thought I had seen just about everything that medical writers can mess up, but this article just proves how wrong I was. These two women that wrote and checked the article obviously do not know diabetes equipment and I have some serious doubts about even diabetes.

They don't understand that many doctors do not recommend blood glucose testing and will not make any attempts to help them obtain additional test strips for the first three or four months to even come close to what they recommend.

“Read the manual for the blood glucose monitor and testing strips.” Yes, you should read the manual for your blood glucose meter and instructions that come with your test strips.

“In most cases, testing strips should only be inserted into the monitor immediately before a reading.” I could be in error, but I am familiar with using one test strip (not testing strips) at a time. Since we are talking test strips, I know that the equipment is a meter (not a monitor). The next problem I question is inserting immediately before a reading. Normally, you need to with most meters insert the test strip in the meter and insert the test strip in the meter into the blood your lancet has brought to the surface of your finger.

“Wash and dry hands.” Yes, you need to wash your hands with soap and water.

“Cleanse the testing area with an alcohol swab.” It is seldom advised to use an alcohol swab because this will not remove fruit sugars from the area you will test on. In the winter season, using alcohol swabs will cause dry and cracked skin, which will cause testing to be very painful.

“If testing on the finger, test on the side of the finger, and use different fingers with each test.” Most people I know do test on the side of the finger and use both sides of a finger and then move to the next finger. Many of us use the sides of our thumbs as well. Some of us also use the sole of our finger tips, but many cannot use all finger soles or any finger soles because of the many nerves there.

“Squeeze the finger while holding it at chest level, and allow a drop of blood to flow onto the test strip.” This is a totally bogus statement to me, as most meters require the test strip be inserted in the slot on the meter and then moved into the blood to be wicked into the test strip. There may be a meter that allows the blood to be flowed onto the test strip and then the test strip is inserted into the slot in the meter; however, I am not aware of any. The meters that I am aware of will return an error reading if operated this way. I don't like wasting money.

Sometimes known as A1c, this test provides a picture of blood sugar readings over several weeks. Several weeks is not 120 days or four months. The most current 30 days accounts for 50 percent of the test. The next 30 days accounts for 25 percent and the remaining 60 days account for the last 25 percent of the HbA1C test (A1C).

Part 3 of 3 parts

Testing Blood Glucose at Home – Part 2

Diabetes cannot be diagnosed solely by home testing. People with unusual readings will need further testing by a doctor.

Tests might include fasting tests, plasma glucose test, tests following consumption of a glucose solution (or oral glucose tolerance test - OGTT), HbA1c tests, or a combination of these.

When deciding on a blood glucose meter to purchase, a few factors should be considered. A blood glucose meter, testing strips, and a lancet that holds the lances to draw the blood are all necessary for testing. Some testing kits offer all four, while others require purchasing each piece separately.

People should consider the cost of testing strips as well as the meter itself, since people with diabetes use many testing strips. Some other tips for buying a meter include:

• selecting one with automatic coding
• checking insurance plans to see if the insurer only covers certain meters
• looking at whether the unit stores previous data
• considering portability, since larger units can be harder to carry
• weighing blood sample size, particularly for people who do not like pricking themselves

Meters that use a smaller sample size will also use a less painful stick. Many people with diabetes have no symptoms at all. As a result, the absence of symptoms does not necessarily mean the absence of diabetes.

Many of the symptoms of type 1 and type 2 diabetes are the same, since both affect the body's ability to regulate blood glucose. Those symptoms include:

• increased hunger and thirst
• increased urination, particularly at night
• unexplained weight loss
• tiredness that is not well-explained by something else, such as sleep deprivation
• blurred vision
• slow-healing sores, or wounds that appear to heal and then reopen
• high blood pressure

Pregnant women who suddenly experience these symptoms should consider the possibility of diabetes. The placenta releases hormones during pregnancy that can make it more difficult for the body to control blood sugar. Left untreated, gestational diabetes can cause a range of pregnancy complications.

Diabetes is the seventh leading cause of death in the United States and can lead to a host of complications. These include:

• Increased hunger and thirst, as well as increased urination at night, may be symptoms of diabetes.
• cardiovascular problems, including stroke, heart attack, and blood clots
• wounds, numbness, tingling, and even loss of feet or limbs
• kidney failure
• nerve damage
• chronic headaches
• blindness

Early interventions can reduce the risk of severe or fatal diabetes complications. The right combination of medication and lifestyle changes may even help reverse some cases of diabetes.

People performing home diabetes testing who have unusually high results, particularly more than once, should see their doctors. People with diabetes whose blood glucose is poorly controlled, or whose blood glucose suddenly changes, should also consult a doctor.

Changes in diet, medication, or both may be recommended. Diabetes can be well-controlled by managing carbohydrate intake, and exercising regularly,

People with prediabetes are at risk for developing diabetes if blood glucose is not managed. It's especially important for people with prediabetes to talk to their doctors, and to continue regular blood glucose testing.

Part 2 of 3 parts

Testing Blood Glucose at Home – Part 1

Home blood glucose testing is a safe and affordable way to detect diabetes before it becomes a health issue. Yes, this is very true and an excellent way to meet prediabetes head on before it becomes full-blown diabetes. Yet, many people refuse to even consider doing this. Diabetes, especially in the early stages, does not always cause symptoms. It still is wise to diagnose it early when you can control it and not let it control you.

For people already diagnosed with diabetes, a simple diabetes home test is vital in the management of blood sugar levels. It could even be lifesaving. A blood glucose test before breakfast will be the baseline for blood glucose levels for the rest of that day. Home blood glucose testing is designed to offer a picture of how the body is processing glucose.

A great doctor might recommend testing at three different times, and often over the course of several days:

• Morning fasting reading: This provides information about blood glucose levels before eating or drinking anything. Morning blood glucose readings give a baseline number that offers clues about how the body processes glucose during the day.
• Before a meal: Blood glucose before a meal tends to be low, so high blood glucose readings suggests difficulties managing blood sugar.
• After a meal: Post meal testing gives a good idea about how your body reacts to food, and if glucose is able to efficiently get into the cells for use. Blood glucose readings after a meal can help diagnose gestational diabetes, which happens during pregnancy. Most doctors recommend testing about 2 hours after a meal.

Most doctors will tell you to not test as the American Diabetes Association generally recommends relying on the A1C results.

For the most accurate testing, people should log the food they eat, and notice trends in their blood glucose readings. Whether you consume a high or low carbohydrate meal, if your blood glucose reading is higher than normal afterwards, this suggests the body is having difficulty managing meals and lowering blood glucose.

After consulting a doctor about the right testing schedule and frequency, people should take the following steps:

1. Wash with soap, water, and dry hands thoroughly.
2. Cleanse the testing area with an alcohol swab only if you cannot wash with soap and water. Some glucose meters allow testing on the arm or another area of the body that is less sensitive.
3. Read the manual for the blood glucose meter and read the instructions for the test strips. Test strips should be inserted into the meter immediately after removing it from the test strip container.
4. If testing on the finger, test on the side of the finger, and use different fingers with each test. Most lancets allow the user to set how far it penetrates the skin. People with thicker or drier skin should set the penetration higher.
5. Position the finger against a firm surface, before lancing.
6. Squeeze the finger while holding it at chest level, and allow a drop of blood to flow onto the test strip.
7. Note the blood glucose reading and record it.

Some people with diabetes use an alternative blood test for glycated hemoglobin (HbA1c). The testing procedure is largely the same, but will produce different readings. Sometimes known as A1c, this test provides a picture of blood sugar readings over 120 days.

For most people, blood glucose readings should be as follows:

Fasting (morning testing or before a meal)

• Without diabetes: 70-99 milligrams per deciliter (mg/dl).
• Target for people with diabetes: 70-110 mg/dl.

Two hours after meals

• Without diabetes: Below 120 mg/dl.
• Target for people with diabetes: Below 140 mg/dl.

HbA1c

• Without diabetes: 5.6 percent or lower.
• Target for people with diabetes: 6.5 percent or lower.

Target numbers may vary from person to person and may change over time depending on health, age, weight, and other factors. Before beginning home testing, it is important to get clear guidelines about target figures from a doctor.

Diabetes cannot be diagnosed solely by home testing. People with unusual readings will need further testing by a doctor.

Tests might include fasting tests, plasma glucose test, tests following consumption of a glucose solution (or oral glucose tolerance test-OGTT), HbA1c tests, or a combination of these. 

Part 1 of 3 parts

Soy Protein – Good or Bad for Humans - P2

So, you got the memo that soy is very bad for the hormonal system. If you think that is the extent of the damage the lowly soybean can wreak on your health, you may be surprised to learn that soybeans are also notoriously hard to digest with GMO soybeans – widely used in processed foods – the absolute worst.

The culprit is the protease inhibitors found in all soybeans whether organic or GMO. As the name suggests, protease inhibitors suppress some of the key enzymes that help us digest protein.

The best known and most important of the protease inhibitors is trypsin. GMO soybeans including edamame have more of them than organic or conventional beans, and to make matters worse, those protease inhibitors are stubbornly resistant to deactivation by cooking or other processing methods.

Soybeans are not the only foods that contain protease inhibitors. All beans contain them, as do grains, nuts, seeds, vegetables of the nightshade family, egg whites, and other foods. However, the protease inhibitors in those foods rarely contribute to health problems because few of those foods are eaten excessively and cooking deactivates most of them.

In contrast, there are more protease inhibitors in soybeans than in any other commonly eaten food. While protease inhibitors are not a problem for people who enjoy the occasional soy dish, the quantities add up quickly when people consume soy daily in the mistaken belief that it is a “healthy” meat and dairy substitute.

For decades, USDA and other researchers put their efforts into finding safe and inexpensive ways to deactivate the protease inhibitors found in soy. Boiling, roasting and modern processing methods help, but cannot destroy all of these troublesome components. The only way to come close is through the old-fashioned fermentation methods used to make miso, tempeh and natto. Modern industrial processing techniques involving heat, pressure and chemical treatments have been reported to kill off as much as 80 to 90 percent, but that’s a promise, not a guarantee.

The numbers of live protease inhibitors remaining in soy products varies from batch to batch, and investigators have found unexpectedly high levels of protease inhibitors present in some soy foods, and startlingly high levels in some soy formulas.

Protease inhibitors are an especially bad problem in GMO soybeans. With more than ninety percent of commercial soybean crops now genetically modified — up from around fifty percent in 2007 — there are very real health risks. Monsanto, of course, claims these beans are substantially equivalent to the conventional soybean, hence safe.

In fact, tests have shown significantly higher concentrations of protease inhibitors in the toasted GMO soybean compared to conventional soybeans. Furthermore, those found in the GMO strain proved stubbornly resistant to deactivation by the heat treatment known as “toasting.”

When the results first came in, Monsanto took the bad news to mean that the GM beans had not been properly cooked and asked for retreatment of the sample. Further heating, however, widened the difference even more. The logical conclusion would be that a substantial difference exists between the GMO and conventional soybeans, and that the GMO soybean is more likely to cause digestive distress and growth problems in humans and animals.

Monsanto, however, concluded that the second toasting was still not enough and toasted twice more until they got the result they wanted, namely that ALL proteins were denatured and inactivated. At this point, most of the soybean’s protein value was also destroyed, but it gave Monsanto the “proof” it needed to conclude that where protease inhibitors were concerned, GM and normal soybeans were equivalent.

Protease Inhibitors Do a Number on the Pancreas

Why be concerned about protease inhibitors? They are the reason soybeans are notoriously hard to digest, and why soybean consumption stresses the pancreas. Because the protease inhibitors in soy inhibit the protease enzyme we need to digest protein, the pancreas has to work overtime to produce more. If this happens only occasionally, the pancreas quickly recovers. But if soy is consumed day after day, week after week, year after year, there will be no rest for the weary pancreas. The result is an increase of both the number of pancreatic cells (hyperplasia) and the size of those cells (hypertrophy).

The extent of soy-caused pancreatic hypertrophy and hyperplasia varies widely from species to species in the animal kingdom. In some soy-fed animals, the pancreas swells quickly, in others more slowly, and in some not at all. However, all animals — including the human animal — will suffer from the loss of the ability to secrete sufficient enzymes if regularly consuming protease inhibitors. That means digestive distress for nearly everyone and growth problems for the young.

With pancreatic stress and cell proliferation, cancer becomes a distinct possibility. Pancreatic cancer currently ranks as the fourth leading cause of cancer deaths of men and women in the United States, and is predicted to move into second place by 2020. Back in the 1970s and 1980s, researchers studying damage to the pancreas caused by protease inhibitors noted that pancreatic cancer had then moved up to fifth place, and suggested a soybean-protease inhibitor connection. Since then, the rise has been even more alarming.

The fact that it has occurred along with increased human consumption of soybeans — and over the past decade GMO soybeans — is probably not coincidental. Association, of course, does not prove cause and effect, but looking at the rise of pancreatic cancer alongside the evidence of so many animal studies is suggestive and sobering.

Irvin Liener, PhD, professor emeritus at the University of Minnesota and the world’s leading expert on anti-nutrients and toxins in plant foods, sums it up well, “Soybean trypsin inhibitors do in fact pose a potential risk to humans when soy protein is incorporated into the diet.”

Soy Protein – Good or Bad for Humans - P1

Soy has both good and bad sides for humans. This part will discuss the good soy protein can do and the second part covers the problems of soy.

Researchers from Pennsylvania State University have discovered that adding soy protein to the diet alleviates symptoms associated with inflammatory bowel diseases, such as colon inflammation and the loss of gut barrier function. The mouse study could pave the way for human studies to develop effective treatment strategies for the condition.

Substituting other protein in the diet with soy protein may help to improve symptoms of inflammatory bowel disease, find researchers.

Researchers Zachary Bitzer and Amy Wopperer, former graduate students in the Department of Food Science at Pennsylvania State University (Penn State), conducted the research alongside Joshua Lambert, associate professor of food science in the College of Agricultural Sciences, and colleagues.

The team's findings were published in The Journal of Nutritional Biochemistry.

Inflammatory bowel diseases (IBD), such as Crohn's disease and ulcerative colitis, have affected an estimated 3.1 million adults in the United States.

Finding ways to mitigate symptoms of IBD is of importance because the chronic inflammation that characterizes the disease is a major risk factor for colon cancer. Colonic inflammation is also responsible for the loss of gut barrier function and increased gut permeability.

Previous studies have explored the preventive effects that soybeans may have on cancer. While some studies have shown that consuming soy may reduce the risk of cancer, other studies have yielded mixed results.

Recent studies have uncovered that soy protein has promising outcomes in animal models of IBD. However, many questions about the underlying mechanisms behind the anti-inflammatory effect remain.

The Penn State team examined the impact of soy protein concentrate on inflammation and gut barrier function in mice in the new study. They replaced 12 percent of other sources of proteins in the diets of the mice with soy protein concentrate. The doses of soy protein concentrate substituted were equivalent to the amount that could potentially be used in humans.

"We didn't want to get carried away with using doses that were really high and would crowd out all the other protein that was there," explains Bitzer. "Instead, we wanted to find a scenario that was going to fit into a more human-relevant situation."

The researchers found that soy protein concentrate has an antioxidant and cytoprotective effect in human bowel cells cultured in a laboratory. Furthermore, in the mice with induced IBD, substituting just 12 percent of other protein with soy protein concentrate was enough to stop body weight loss in its tracks and improve spleen swelling, reveals Lambert. This evidence indicates that soy protein concentrate might be able to moderate the severity of inflammation.

Soy protein concentrate mitigates markers of colonic inflammation and loss of gut barrier function in the mice with induced IBD," says Wopperer.

Future studies by the investigators will try to determine whether their findings could be replicated in humans. Soy protein is a readily available food ingredient that is already used as a substitute for meat. Lambert believes that because of this, human studies could be just around the corner.

"Since it is already out there commercially, that makes it more straightforward. But practically speaking, the actual clinical studies are a little bit out of our area of expertise. I think the most likely thing to happen will be for us to try to identify a collaborator either through the Clinical Translational Science Institute on campus or with someone at the Penn State College of Medicine Inflammatory Bowel Disease Center."

Lambert and collaborators are currently evaluating whether the inflammatory-moderating effects they have observed in mouse colons are due to the soy protein or whether soy fiber may play a part. While soy protein concentrate contains around 70 percent protein by weight, it is also comprised of soybean fiber, Lambert concludes.