Growing up with diabetes I was exposed to the nutritional science of starch exchanges and then later, the elusive art of carb counting. I followed it all as closely as possible, but noted periodically that something must be wrong with my math. I was often making mistakes, correcting, and correcting again. I called it chasing down my blood sugar. I figured I wasn’t astute enough and that if I tried harder it would eventually work. I did try harder, and it still looked the same. I was always disappointed with myself. I even thought I might be a “bad” diabetic. I was in a cycle that didn’t really end, a constant chase. And, since I was fearful of hypos I often hung out in the other end of the pool, the hyperglycemic deep end.
My typical meals required five units of rapid acting insulin, and often required correcting later. My corrections were usually another five units, because under-estimating carbs was a habit. I ran my glucose levels between 150-250 mg/dl most of the time. I told myself I was doing my best. But my endocrinologist told me that my A1c didn’t reflect “best” results.
In 2003, I was 30-years-old, and our third child was on the way. I wanted to get life insurance. I applied, went through the medical testing and was denied. Apparently, my chasing of high glucose levels all day long wasn’t doing the trick and my A1c wasn’t low enough for the insurance standards. I was annoyed. I’m not used to failing. I had a normal BMI, no other health issues, and felt as good as I could remember feeling. I counted carbohydrates; I corrected, I took my insulin several times a day. To me, the A1c standard seemed kind of arbitrary and unrealistic. Well, being annoyed didn’t help me to qualify for life insurance, so I was motivated to try something different.
I dusted off a book, Diabetes Solution, by Dr. Richard K. Bernstein, that had been sitting on a shelf since my parents had sent it to me earlier in the year. I hadn’t read it because I wasn’t just busy chasing my blood sugar. I was chasing my kids, too. I read Diabetes Soultion and started to follow the recommendations, especially the Law of Small Numbers. Amazingly, things changed in my body. For the first time in my life with diabetes, I was seeing my glucose levels hover in the normal range most of the time. I wasn’t even exercising. I was just eating differently, dosing differently and thinking about insulin differently.
Many people living with diabetes have heard of Dr. Bernstein. He was diagnosed with diabetes as a child, and in his mid-thirties he began to develop diabetes complications. Bernstein acquired a hospital-grade glucometer and experimented on himself to figure out how to maintain “normal” blood sugars around the clock. He did, and he reversed his diabetic complications. He subsequently started his second career in medicine, and became a very successful diabetes specialist.
So, about the magic of Bernstein’s Law of Small Numbers: Bernstein says three factors make blood sugar control with exogenous insulin problematic. I think everyone on insulin will be familiar with these variables.
1. Carb estimation (even on nutritional data) is typically off by 20%.
2. Insulin absorption is inconsistent.
3. Injected/infused synthetic insulin timing is different than natural insulin.
What, then, does Dr. Bernstein say we should do to overcome these issues?
Berstein says we should keep the numbers small, and thus, the margin of error small. He calls for small carbohydrate values which means small insulin doses, which means smaller mistakes, smaller corrections, and less time out of the normal glucose range.
For me, the key benefit has been smaller mistakes. Like everyone else with diabetes, I’m very concerned with preventing hypoglycemia. It’s uncomfortable, scary, disorienting, and can carry an immediate risk to our health/life. When we are bolusing for a large starchy meal or a tasty dessert (or both), we have a chance of being off by ±20%. In the case of meals that contain 84 grams of carbohydrate the bolus might land you somewhere between 0-170 mg/dl. It’s like using a shotgun when accuracy matters. Using the Law of Small Numbers is a fantastic tool to help avoid hypos. Extreme hypoglycemia is not something I am no longer afraid of, but because my doses of insulin are small, I rarely overshoot my target.
This data on carb estimation was corroborated by a study presented at the ADA 2004 Scientific Sessions and reported in childrenwithdiabetes.com. In the study titled Accuracy of Repeated Meal Carbohydrate Content Estimation by Persons with Type 1 Diabetes Using Continuous Subcutaneous Insulin Infusion, Dr. Guido Freckmann showed that most diabetics had about 68% accuracy in carb counting, and with extensive training in carbohydrate counting, the best results achieved were 83% accurate. The most inaccurate results were achieved when the carbohydrate values were higher. As it turns out, it’s quite common for people with diabetes to underestimate carbohydrate content out of fear of hypos.
Using the Law of Small Numbers, I started eating slowly-digested carbohydrates (like green veggies), protein, and fat. My insulin needs dropped by about 40% and I stayed in range most of the time. It was surreal for me. I hadn’t thought it was possible. My poor carb-counting math skills didn’t matter anymore. I became a new kind of a carb genius. I took1.5-2 units of insulin with meals. If my carb count was off, my mistake would usually only land me at 140 mg/dl, so the correction to get me back in range would only be a micro amount. This revolutionized my glucose control and for the first time in 20 years I discovered what normal glucose levels felt like. I had good energy, clear thinking and felt great. That same year, six months after being denied life insurance, I qualified. Small numbers allowed me to cruise along much closer to normal glucose numbers. Now, almost ten years later, I’m still improving my control and learning new things about our very complicated metabolic system.
Most people with diabetes have figured out that carbohydrates matter in their lives. But, I think the issue sometimes not taken into account is the speed of digestion. The insulin we take can only really keep up with the processing of the slowly digested types of carbohydrate. The quantity of insulin we take is only safe when the margin of error is manageable.
Using the Law of Small Numbers hasn’t fixed all my glucose control events. But, it was the biggest step I’ve ever made in the right direction. As I continue to experiment and tweak things, the Law of Small Numbers is the template that I hang everything on. Finally, with reasonable stability and predictable control as part of my daily experience, I can start to work towards something even better, perfect blood sugar levels.
You can read the “Small Numbers” chapter from Bernstein’s online book here.
Nathan Shackelford writes the blog Edibles… (the diabetic edition)