Category Archive: Management
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Intensive Diabetes Management
It takes time and effort, but intensive diabetes management can increase your freedom and flexibility and help you avoid or delay long-term complications.
When Katherine was diagnosed with diabetes, she was heartbroken. She had witnessed the devastation of the disease through her mother, who had lived with diabetes for 30 years. She stood by as her mother first lost her eyesight, then suffered a leg amputation, and finally succumbed to kidney failure. Katherine did not want to face the same ordeal. She learned from her diabetes educator that these complications were not always inevitable. There were steps she could take to greatly reduce her risk for these complications.
It always seemed obvious that keeping blood glucose levels as close to normal as possible would prevent diabetes complications. That’s what researchers thought, but they couldn’t prove it for sure. What if something else related to diabetes caused the complications? What if lowering blood glucose had no effect on complications?
But in recent years, two major research studies confirmed what many diabetes health professionals and people with diabetes had long suspected. The Diabetes Control and Complications Trial (Diabetes Control and Complications Trial) showed that by tightly managing blood glucose levels, people with type 1 diabetes could delay or even prevent many of the complications of diabetes. The results of another study, called the United Kingdom Prospective Diabetes Study (UKPDS), showed that tight blood glucose and blood pressure management can help people with type 2 diabetes delay or prevent the complications as well. These studies confirmed that it was the excess blood glucose that, after many years, caused people with diabetes to develop problems with their eyes, nerves, blood vessels, and kidneys.
The results of these two studies are very clear. The researchers in the Diabetes Control and Complications Trial found that after 10 years, intensive management reduced the risk of developing diabetic eye disease (retinopathy) by 76 percent. Among individuals who already had early signs of eye disease before entering the trial, intensive management slowed the progression of retinopathy by 54 percent. Tight blood glucose control also reduced the risk of kidney disease by 50 percent and that of nerve disease by 60 percent. Study volunteers, who ranged in age from 13 to 39, were too young to develop many heart-related problems, but were monitored for some of the signs of cardiovascular disease. The study found that those on intensive management had a 35 percent lower risk of developing high cholesterol levels, a major contributor to heart disease. Before the Diabetes Control and Complications Trial, many people with diabetes thought that complications would progress no matter what they did. After the Diabetes Control and Complications Trial, we know that way of thinking is wrong — keeping glucose levels close to nor mal does matter. The graph shows the relationship of A1C levels to complications as shown by the Diabetes Control and Complications Trial.
Graph : The relationship of A1C levels to the risk of complications.
The other study — the United Kingdom Prospective Diabetes Study — showed that people who used an intensive program reduced their risk for microvascular complications by 25%, and if they lowered their blood pressure, they significantly reduced their risk of virtually all cardiovascular complications. That means far fewer strokes, heart attacks, and problems with atherosclerosis, as well as improved circulation to the legs and feet, which helps reduce problems with neuropathy.
The study found that for every 1 percent decrease in A1C, complications were reduced by 35 percent, heart attacks were reduced by 18 percent, and diabetes-related deaths were reduced by 25 percent. Tight blood pressure control reduced the risk of stroke by 44 percent and the risk of heart failure by 56 percent.
What do all these numbers mean? Intensive management of blood glucose and blood pressure can significantly reduce your risk of diabetes complications.
Benefits of Intensive Diabetes Management Demonstrated by the Diabetes Control and Complications Trial
Keeping blood glucose levels close to normal reduces the risk of
► eye disease by 76 percent
► kidney disease by 50 percent
► nerve disease by 60 percent
Intensive diabetes management also has some drawbacks. It is more expensive and takes more time and effort. People in the Diabetes Control and Complications Trial using tight control had three times as many severe low blood sugar episodes than those on the standard treatment program. This happened because their overall blood glucose levels were much lower. And those practicing intensive management tended to gain more weight than those using a standard management plan. This is because they were no longer losing calories in the form of glucose in the urine. Taking more insulin made their bodies more efficient at capturing and storing calories. While these things are important to think about, it is also true that they are less likely to be problems with the insulins that are now available.
Is Intensive Management Right for You?
Education
The idea of embarking on an intensive diabetes management plan may seem a little overwhelming. There is a lot to remember. But keep in mind that it is an ongoing process. You can’t learn it overnight and no one expects that of you. Your health care team is there to help you. You’ll have many questions as you begin. How many units of insulin should I take if my blood glucose is a little high? How should I change what I eat at my next meal? It will require trial and error and the coordination and advice of your team members as you learn to make adjustments. Over a short period of time, you will gain the confidence to make these adjustments on your own.
Talk to your health care team members about the best way to approach intensive management. Maybe your local community hospital or health care team offers classes in intensive management. Or maybe your diabetes educator wants to arrange several one-on-one sessions to teach you what you need to know to make the program work for you. Whether you enroll in formal classes or arrange several individual sessions with your diabetes educator, check to see if the following subjects will be covered:
■ nutritional guidelines and carbohydrate counting to determine the effect of food on blood glucose levels
■ insulin action and dosage adjustment
■ measuring the effects of exercise
■ blood glucose and urine ketone monitoring and interpretation of the results
■ strategies to help you make changes in your lifestyle and cope more effectively with diabetes
Choosing Glucose Goals
Type 1 Diabetes
If you have type 1 diabetes, you will need to use multiple daily injections of rapid-acting or regular insulin or an insulin pump for intensive diabetes management. You may also find that combinations of rapid-acting or regular and glargine or NPH work for you. For more information on the insulin pump, see site.
You will need to set a target range for your premeal blood glucose levels, say between 90 and 130 mg/dl. If your blood glucose levels fall below 70 mg/dl or rise above 130 mg/dl, then you’ll need to take action to increase or decrease them. For example, if glucose levels are too low, you’ll need to treat yourself for hypoglycemia, unless you’re about to eat a meal. If levels are too high, you may need an extra dose of insulin. It will be the same routine when you check your blood glucose after mealtime. If your results are over 180 mg/dl, you’ll need to take action. If your blood glucose is under 100 mg/dl before bedtime, you may need a little more food. You will need to talk with your provider about the best way for you to deal with high and low blood glucose levels. Supplemental doses of insulin are one way for you to deal with high blood glucose levels, but if you take too much insulin, you could be at risk for hypoglycemia. Your health care team can help you learn how to make adjustments based on patterns, your food intake, and activities and how to safely give supplemental doses of insulin.
“Intensive diabetes management means I’ll have more hypoglycemic reactions.”
This, unfortunately, turns out to be true. When you’ve worked out a plan that narrows your range of blood glucose highs and lows, you’re always closer to low than you were on standard diabetes therapy. Your room for “error” becomes much narrower. This doesn’t mean you need to avoid intensive management, however, unless hypoglycemic reactions would aggravate other health conditions.
You need to become an expert at telling when to pull out the meter and do a test and treat your hypoglycemia. The secret to keeping hypoglycemia from turning you away from intensive management is to prevent severe reactions. Act early, think clearly, and avoid letting your low level go so low that you need help to treat it.
Here’s a sample chart for treating hypoglycemia. It’s based on your blood glucose result. This chart gives an average: in general, each 5 grams of carbohydrate raises blood glucose about 15 mg/dl. After treating, your blood glucose goal is about 120 mg/dl. You’ll need to figure out how much 5 grams of carbohydrate raises your blood glucose level.
| If your blood glucose is: | Eat this much carbohydrate: |
| Under 40 mg/dl | 30 grams |
| 40 to 50 mg/dl | 25 grams |
| 51 to 60 mg/dl | 20 grams |
| 61 to 70 mg/dl | 15 grams |
Of course, the goals mentioned previously are guidelines only. Discuss your needs with your health care team to create a plan that will work for you. Your target glucose levels may change over time. For instance, you could find it harder and harder to detect hypoglycemia. This would call for increasing your target range and perhaps new training at recognizing your symptoms.
You’ll probably want to check your blood glucose often: at least as often as you inject insulin (or take your bolus dose via a pump) and sometimes more. You could be monitoring seven times a day: before your three meals, after each meal, and before bedtime. You may even check at 3 a.m. once or twice a week. For instance, you will not want your blood glucose level to become too low during the night. But if you have experienced several severe hypoglycemic reactions, you may want to aim for a higher overnight blood glucose level. Every bit of testing gives you more knowledge of how your body reacts to food, exercise, and insulin (and stress or illness). Once you’ve settled into a comfortable routine, you may be able to do fewer tests. Remember that you are monitoring to get the information you need to make wise decisions as you manage your diabetes.
Type 2 Diabetes
The blood glucose targets for a person with type 2 diabetes who wants to pursue intensive diabetes management are not much different from those for individuals with type 1 diabetes. Almost all people with diabetes can gain benefits from keeping blood glucose ranges close to normal. But the way someone with type 2 diabetes goes about reaching those targets may differ from someone with type 1 diabetes. It will still take a bit of trial and error to figure out what works best for you.
If you manage your diabetes with meal planning and exercise, adding an oral medication may help. If you already take oral medications, adding another pill or a once-a-day insulin injection may work. Ask your health care team whether it may be time for you to start insulin.
If you already take oral diabetes medications or insulin, you may need to take a more aggressive approach. Your therapy might even be similar to that of a person with type 1 diabetes who is pursuing intensive diabetes management. If you are on pills, you may need to switch to insulin. If you take insulin once or twice a day, you may need to increase to three or four shots a day.
Whatever methods you and your health care team choose for intensifying your diabetes management, you need to tailor your targets to your particular needs. For instance, you may want to watch out for weight gain that can accompany lowering your blood glucose levels. Adding an extra workout a week may be enough to counteract the fact that you’re not losing as much glucose in your urine anymore. If you are just learning to treat low blood glucose levels, you’ll want to make sure you’re not adding more calories than you need when you have a reaction. Eating 15 grams of carbohydrate is usually enough. If you’re still low after 10-15 minutes, repeat your treatment and test again.
Pregnancy and Gestational Diabetes
Getting and keeping tight blood glucose control is especially important during pregnancy. If newly developed diabetes is left untreated, or if blood glucose levels are often out of range, several problems can develop for both mother and baby. However, keeping blood glucose levels near normal decreases the risks to mother and baby to the same level as women without diabetes. This is why intensive diabetes management is recommended for mothers-to-be with diabetes.
If you have diabetes, it’s important to plan your pregnancy. Your blood glucose levels need to be as close to normal as possible before you get pregnant. Too much glucose in the blood in the first 2 months of pregnancy, while the baby is developing its nervous system, limbs, and organs, can cause birth defects. It also increases your risk of miscarriage. It’s important to take care of your general health, too. Pregnant women with diabetes are more likely to develop high blood pressure, hypoglycemia, and a temporary worsening in the complications of diabetes, including retinopathy, if their blood glucose levels are not closely managed. Blood glucose goals for you are likely to be even lower than for people who are not pregnant. Tight pre-meal blood glucose levels for you may be 70 to 110 mg/dl. Ideal after-meal blood glucose levels might be less than 130 mg/dl.
Gestational diabetes shows itself a little more than halfway through the pregnancy. The baby is mostly developed and puts its energy into getting bigger. If you have too much glucose in your blood, the baby will take in the glucose, produce more insulin, and grow too big. Delivering a baby too large for its age is dangerous for baby and mother. For this reason, you will need a meal plan. About three-quarters of women with gestational diabetes manage their blood glucose levels with a meal plan. Regular exercise can also help to lower blood glucose levels.
Because you are aiming for a very tight range, your risk of hypoglycemia will increase. Make sure you can recognize early warning symptoms of low blood glucose. Check your blood glucose level often. When low, follow guidelines so that you can avoid overtreatment. Take 15 grams of carbohydrate, wait 10 to 15 minutes, and retest your blood. If you are still low, repeat this treatment. Try to avoid causing your blood glucose to go any higher than your target range.
Striving for these blood glucose targets requires extra effort and diligence. Although it is hard work, you are doing all that you can to ensure good health for yourself and your baby.
Intensive Management Strategies
How do you go about keeping your blood glucose close to normal? Your tools are insulin and insulin delivery, oral medications, food, exercise, and blood glucose monitoring. Learning to use these old friends in new ways takes some practice.
Insulin Plans
Food
Coping
As you embark on an intensive approach to diabetes management, you may find that you need more support and encouragement in adjusting to the new routines. Sometimes you might just need someone to talk to, to discuss common problems, to air your concerns, or to just ask questions. Sometimes it will help to know that someone cares and understands what you are going through. You can look to several sources for the support and encouragement you will need. Your health care team, a special friend or family member, a religious organization, or a diabetes support group are all potential sources of support.
You may find that you want different kinds of support from different people. Friends and family may provide you with the encouragement you need to affirm your commitment to the intensive management. Maybe you need someone to reassure you — a cheerleader to help you stay on track. You may also need technical support — someone to answer your questions as they arise and reassure you that you are doing the right thing and making wise decisions. You might also need financial support or help with locating financial resources. Your health care team can help you in these areas. And you might just want someone to commiserate with. Look to support groups to find others who can listen and let you know that you’re not alone. Support groups also give you the opportunity to help others, which can be therapeutic.
Is Intensive Management Right for You?
You may already be reaching your glucose goals. Your A1C and blood pressure may be right where you want them to be. Or you may firmly believe that you are doing fine without intensifying your diabetes management. But even if you have your diabetes settled into a manageable routine, you may not like the idea of having your life dictated by your diabetes care or a schedule. So the idea of taking on intensive diabetes management, with even more blood glucose monitoring and more injections of insulin, may seem out of the question. But the truth is, intensive diabetes management may actually give you more freedom, not less.
If you take insulin, your schedule and activities are often dictated by when you took your last dose of insulin or when your next one is due. But the idea with intensive management is that, by monitoring frequently, you can make adjustments in your insulin dose to accommodate variety in your eating and activity patterns. Thus, by learning how to interpret your monitoring results and predict the effect your food and activities will have on your blood glucose level, you can learn to adjust your insulin doses to get greater flexibility in day-to-day living.
Here’s a simple example of how it works.
To keep his blood glucose levels predictable, Jerry was used to eating the same thing for breakfast and lunch and injecting a certain dose of insulin before breakfast and another fixed dose of insulin before dinner. At dinner, he never knew what he might be having, so sometimes his blood glucose was really high in the morning, and sometimes he even had lows overnight. Jerry felt frustrated and guilty and sometimes avoided checking his blood glucose. He talked to his provider, who referred him to a diabetes education program. Jerry learned how food and insulin and exercise increased and decreased his blood glucose levels. He started taking four shots and testing four times a day instead of two. Over several weeks, Jerry learned to predict how much his blood glucose would go up when he ate certain foods. He also learned how much his blood glucose would go down if he added an extra unit or two of insulin, or when he rode his bicycle to work. After a few months, Jerry found he was able to eat at different times, or eat more or less food, and still get similar blood glucose readings because he increased or decreased his insulin dose to suit his carbohydrate intake. Jerry was able to add variety to his daily meals and lower his glucose levels.
Adopting an intensive management program does not happen overnight. It works better if you have the help and support of your family and your health care team. Intensive diabetes management takes commitment on your part. If you find that your current diabetes plan interferes with living the kind of life you would like, you may be more likely to stick with an intensive program. When you and your health care team decide to forge ahead, they will probably recommend that you attend classes or a series of training sessions to learn how to make adjustments in your diet, exercise, and insulin doses.
Intensive diabetes management can benefit almost any person with diabetes. For years, women with type 1 or type 2 diabetes who were planning a pregnancy and women who developed gestational diabetes have been advised to take an intensive approach to their diabetes. It is particularly important during pregnancy to keep glucose levels close to normal to avoid problems in the development and growth of the baby.
There are some people for whom intensive diabetes management is not safe. For instance, because tighter blood glucose levels bring a higher risk of severe hypoglycemia, intensive insulin therapy in children is risky. Severe hypoglycemia can interfere with normal brain development, particularly in very young children. Intensive diabetes management in children requires close supervision, usually from a diabetes specialist.
Special Considerations for Intensive Diabetes Management
Aiming for near-normal blood glucose ranges may not be for you if you have a history of severe hypoglycemic episodes or hypo-glycemia unawareness;
are younger than age 10, unless you have motivated and supportive parents and/or caregivers;
are elderly, with other health problems or impairments; have cardiovascular disease, angina, or other medical conditions that can be aggravated by hypoglycemia; have severe complications of diabetes;
have conditions such as debilitating arthritis or severe visual impairment that would functionally limit intensive management;
have drug or alcohol abuse problems or are unable to make reasonable decisions about your everyday diabetes management;
are unable or unwilling to carry out the tasks associated with intensive management.
Intensive diabetes management can be risky for the elderly because of the increased risk for hypoglycemia. Hypoglycemia may also make it harder to live alone or be independent. Some older people may find the potential benefits not worth the risk, particularly if they have other health problems or impairments. However, if you are an older person who believes that you will live long enough to reap the benefits (about 10 years) and are willing to take on this responsibility, then let your health care team know.
No, Thanks, I’m Intense Enough Alrea
Even if you decide not to use an intensive diabetes management plan, there are still several simple things you can do to improve your blood glucose levels.
Eat about the same amount and type of carbohydrate every day, at about the same time in relation to when you take your insulin or oral diabetes medication dose. Learn how to make adjustments from your health care team. For example, if your blood glucose check shows a level higher than your target range, take a small supplemental dose of rapid-acting or regular insulin, skip a snack, or if mealtime is coming up, eat less than usual. Getting extra exercise can also help sometimes. Increase your dose of rapid-acting or regular insulin (or plan to get some extra exercise) when you know you’ll be eating more carbohydrates than usual. Take less insulin if you plan to eat less than usual. Learn how to make these adjustments from your health care team.
If you feel like you’re having low blood glucose, check. If you are low, eat 15 grams of carbohydrate, and recheck 10 to 15 minutes later. If you’re still low, repeat: eat 15 grams of carbohydrate and recheck. This will keep you from having your blood glucose levels to go too high after a low. You may need less than 15 grams of carbohydrate to correct a low. Careful experimentation can help you find out what is best for you.
Intensive diabetes management may not be appropriate for people who are already experiencing severe complications of diabetes. Although intensive therapy can slow down the development of complications, there is no evidence to date that it can reverse the process.
Other health conditions can make intensive management unsafe. For example, individuals with coronary artery disease, irregular heart beats, cerebrovascular disease, angina, or other types of heart disease may not be suitable candidates for intensive therapy. Anyone taking medications, such as beta blockers, that may make it more difficult to detect hypoglycemia may be at higher risk when trying to achieve tight control.
Choosing Glucose Goals
The idea behind intensive diabetes management is to keep your blood glucose levels as close to normal as possible. If you decide that intensive management is for you, you will want to choose blood glucose goals as close to those of people without diabetes as is reasonable and safe for you. It’s a group decision that you, your family, and your health care team need to make together. For people without diabetes, blood glucose levels rarely go over 120 mg/dl, even after eating a meal. Their bodies take care of it for them. But when your body no longer does this for you, you need to take action to lower it: by injecting more insulin or compensating (with food or insulin) at the next mealtime. But 130 is not the magic number for everyone. Your target range may be a little higher (if you live alone) or lower (if you’ve just found out you’re pregnant). What suits an otherwise healthy young adult with recently diagnosed type 1 diabetes may be very different from that for an elderly person with type 2 diabetes who has coronary artery disease or severe retinopathy. And an 11-year-old with working parents who spends lots of time alone may have different needs still. There are many factors to consider in setting your personal glucose goals:
■ your age
■ how long you’ve had diabetes
■ the type of diabetes you have
■ frequency and severity of hypoglycemia
■ your lifestyle and occupation
■ other medical conditions
■ how much support you get from family and friends
■ your personal motivation for diabetes self-management
One piece of information that came out of the Diabetes Control and Complications Trial is that even if you set goals that seem reasonable, they can be hard to reach. The Diabetes Control and Complications Trial goals for people in the intensive management group were to have near-normal blood glucose levels before and after meals and at bedtime. Most people just couldn’t consistently reach these goals. No matter how hard you and your health care team work, it is difficult to keep blood glucose levels close to those found in people without diabetes.
The American Diabetes Association has established recommended targets for glucose levels. These recommendations are based on research findings about preventing complications. You may choose these or different goals. But remember: The Diabetes Control and Complications Trial showed that any improvement in lowering blood glucose levels will definitely gain you real benefits.
Another way to measure blood glucose control is to measure A1C levels. In the Diabetes Control and Complications Trial, A1C measurements were taken to know how well people in the intensive treatment group were doing with overall control. Despite being unable to consistently reach the daily blood glucose goals, they lowered their A1C values dramatically. This improvement was seen after about 3-6 months of intensive management. Most had A1C values around 7 percent. This is a reasonable goal for most people with diabetes. The risk for nephropathy, retinopathy, and other complications increases as A1C goes up. The ADA recommends a target A1C value of <7 percent.
Blood Glucose Goals
| Before meals | 90 to 130mg/dl |
| After meals | less than 180 mg/dl |
Insulin Plans
Intensive management means more than simply taking extra insulin. In fact, you may not increase the total amount of insulin you take at all. What does change is how and when you deliver it. You’ll need to decide when to take it and how much to take to effectively cover your meals and your background (basal) glucose levels. You’ll need to plan your insulin therapy to cover you throughout the day and night. The goal is to mimic the natural secretion of insulin from the pancreas as much as possible. As you recall, the pancreas continually secretes a low level of insulin at all times and secretes a higher level when there is more glucose in the blood, including after a meal. Therefore, your insulin plan needs to have low levels of insulin around at all or most times, with more available at meals. But just how do you do that? By taking several doses of rapid-acting or regular insulin or combinations of fast- and slower-acting insulins or by using an insulin pump.
If you decide not to use an insulin pump, your schedule will include three or more insulin doses each day. For example, you might take one injection before each meal and another before bed. You might want to inject an intermediate- or long-acting insulin at bedtime and a rapid-acting insulin before each meal. The insulin plans in site show different ways to do this. You will also have the opportunity to make adjustments during the day. If you are exercising after lunch, you might want to reduce the amount of your noontime insulin dose. If you are going out to a fancy dinner where you know you’ll be eating more than usual, you may want to take more insulin. Your diabetes educator can help you learn how to adjust your insulin doses.
Elements of Intensive Management
- checking blood glucose levels four or more times each day
- three or four daily insulin injections or an insulin pump
-adjusting insulin doses according to food intake, exercise, and blood glucose levels -using a meal plan and exercising
-requent contact with your health care team (once care routine is established)
You may want to try an insulin pump. The pump is usually worn on a belt clip or in a pocket and delivers insulin via tubing through the needle or catheter. With a pump, you keep a needle or catheter fixed in one position for a couple of days to provide insulin to your body continuously. Insulin pumps are programmed to deliver a steady supply of rapid- or short-acting insulin throughout the day. This is the basal infusion rate. You will program your basal infusion rate; it may change over the course of a day, delivering more when you need it (in the early morning hours when insulin resistance is high) or less at other times. When you need a burst of insulin to cover meals (the bolus infusion), you’ll program the pump to deliver it. The amount may change depending on your blood glucose level and what you plan to eat. (For more about pumps, see site.)
Your starting insulin doses for either injections or the pump will be based on your weight and current insulin program. For instance, for people with type 1 diabetes who are within 20 percent of their ideal body weight, the total daily insulin dose needed for intensive therapy is 0.5 to 1.0 units per kilogram of body weight. That means if you weigh 127 pounds (1 kilogram equals 2.2 pounds), you would take about 29 to 57 units of insulin each day. You would be at the high end of the range if you were insulin resistant and at the lower end of the range if you were very sensitive to insulin. About one-third to one-half of your total daily dose would provide your basal insulin level, and the rest would be used to cover meals. Most people start out with lower doses and gradually increase the amount of insulin until they reach their target.
Whichever formula or calculation you use, you will most likely have to make adjustments as you find the program that best suits you. You will probably have a plan for how to adjust your dose, but you will also need to be in close contact with your health care team. If you are pregnant, your total daily insulin dose will go up as you gain weight and develop more insulin resistance. Your insulin dose may even triple during the course of your pregnancy.
Here is one formula that some people find helpful as a starting point for deciding how to distribute nsulin throughout the day:
- 40 to 50 percent total insulin as the basal dose
- 15 to 25 percent before breakfast » 15 percent before lunch
- 15 to 20 percent before supper
- 0 to 10 percent, as needed, to cover a bedtime snack
You will be able to make small adjustments throughout the day to accommodate your meals and activities. If monitoring shows that your blood glucose levels are too high, you need to take extra insulin or reduce the amount of carbohydrate in your next meal. Generally, 1 unit of insulin will lower blood glucose levels by about 25 to 100 mg/dl. You need to find out what is true for your body. You can also adjust your insulin intake to account for changes in meal patterns. In general, 1 unit of insulin will cover 10 to 15 grams of carbohydrate. You also need to find out if this is true for you.
It may be worth the effort. You will no longer have to keep a rigid schedule. The short-term benefits include, for example, going to a birthday party and eating cake or jogging an extra mile while keeping your blood glucose on track. Keeping complications at bay is the long-term benefit. Make sure to talk to your health care team about creating a starting plan and then making adjustments as your needs change.
Food
The food you eat plays a big role in intensive diabetes management. In the past few years, the guidelines for food choices for people with diabetes have broadened to include more previously “forbidden” foods. This fits in well with intensive diabetes management, where you can adjust your therapy to suit your food preferences.
For example, a reasonable goal would be to derive 15 to 20 percent of all your calories from protein and less than 10 percent from saturated fat. The remaining calories can be divided between carbohydrates and monounsaturated fats. In addition, 20 to 35 grams per day of fiber and less than 2,400 milligrams of sodium per day are recommended. You and your dietitian will create a plan that works for you. For more information on healthy eating, see site.
If You Use Insulin. Work with your health care team, especially your dietitian, to create an eating plan:
■ Start with a meal plan that takes into account your usual food intake. Your meal plan should have about the same number of calories, carbohydrates, and meal timing that you are already used to.
■ Create an insulin schedule that follows your usual patterns of meals, exercise, and sleep.
1 Time your insulin doses to match your meals. Your insulin should peak at the same time blood glucose levels from your meal are also peaking. By monitoring your blood glucose levels, you can adjust your insulin doses to suit your needs.
■ Work with your health care team to explore “what if” situations and develop contingency plans that will guide you as you make adjustments in eating, exercise, and insulin patterns.
With these strategies in mind, you and your nutritional counselor can come up with a meal plan that uses basic carbohydrate counting as a system for quantifying food intake. You may find it easier at first to draw from a list of measured food exchanges. This will make it easier to match insulin doses to your carbohydrate intake. It will probably take a few months for you to get used to matching your food intake with your insulin dose to achieve your target blood glucose levels.
Once you have established insulin doses for different meals, you can practice predicting what insulin doses will match your food intake. It usually takes practice to estimate your insulin need in terms of the amount of carbohydrate you eat and adjust for changes in food intake and exercise. The next step is to learn to calculate and take extra or a corrective dose of rapid- or short-acting insulin when your blood glucose is higher than your target range. This is how you begin to fine-tune your insulin doses.
Counting Carbohydrates. Counting carbohydrates gives you maximum variety in your eating plan. It is based on calculating your personal carbohydrate to insulin ratio. This gives you a good idea of how your body uses the insulin you inject to process the carbohydrate you eat. Your dietitian or diabetes educator can teach you to count carbohydrates.
The idea behind carbohydrate counting is to add up the grams of carbohydrates you eat in a meal and adjust the amount of insulin you take to handle the rise in blood glucose following a meal. With today’s rapid-acting insulins, you can even take your insulin after your meal when you know exactly how many grams of carbohydrate you have eaten. This is especially useful for parents of young children who do not know in advance how much a child will eat at a meal.
Meet with your dietitian to learn how to count the carbohydrates in the foods you eat and adjust your insulin doses, to mimic the natural insulin release of a functioning pancreas. There are two basic methods for counting carbohydrates: counting carbohydrate choices and counting grams of carbohydrate. Counting carbohydrate choices is a little easier, but not as accurate. Counting grams of carbohydrate requires more effort but is more exact and may help you better achieve your blood glucose targets.
In general, if you are counting carbohydrate choices, you will use a meal plan that lists the serving size of one carbohydrate choice, also known as a carb choice. On average, carb choices contain 15 grams of carbohydrate. However, carb choices are based on averages, and there may be a significant difference between your estimate and the actual amount of carbohydrate you eat in a meal. Your dietitian can provide you with a list of carbohydrate choices for most of the foods you typically eat.
Counting grams of carbohydrates is a bit more work, but in the long run, will give you more flexibility in your meals and activities and help you better manage your blood glucose. For most packaged and processed foods, the number of grams in a serving is printed on the label. Some restaurants also provide dietary information. Most foods report the total grams of carbohydrate as well as the number of grams of dietary fiber. Because dietary fiber is included in the total grams of carbohydrate but is not digested into glucose, you will overestimate the carbohydrate content of high-fiber foods. When a food has 5 or more grams of fiber, you can subtract the number of grams of fiber from the number of grams of total carbohydrate to get a more accurate number of grams of carbohydrate that will be converted to glucose.
Once you know how many grams of carbohydrate you eat at each meal, you can then begin to make adjustments in the amount of insulin you take with each meal. In general, most adults with type 1 diabetes need 1 to 3 units of rapid- or short-acting insulin to handle 15 to 30 grams of carbohydrate. Most children need 1 unit for every 8 to 50 grams. If you count carbohydrate choices, figure on 1 unit of insulin for each carb choice (15 grams) as a starting point.
A good way to begin is with a fixed meal plan. And you will probably want to keep a detailed log of the food you eat, your activity level, your blood glucose readings, and the amount of insulin you take with each meal. Because everyone is different, you may need 1 unit for every 15 grams of carbohydrate, whereas someone else may need 1 unit of insulin for every 30 grams of carbohydrate.
Once you know how your body handles a given amount of insulin, you and your dietitian or nurse educator will meet and fine-tune your plan. Take into account any physical activities and how they affect your blood glucose levels, too.
However you decide to go about fine-tuning your insulin doses, remember that you still need to pay attention to your food choices. It’s easy to get in the habit of eating fries and a shake and just taking more insulin. But even though you are counting carbohydrates, calories still count, too. Also check out Carbohydrate Counting Made Easy, a Fast Facts book from the American Diabetes Association.
It will take a while before you feel like you’ve mastered these food and insulin adjustments, but they can buy you greater flexibility in your activities and meals while keeping your blood glucose level where you want it.
If You Are Pregnant One strategy for keeping blood glucose levels steady and low throughout the day is to distribute your total daily calories as follows:
■ 10 to 15 percent of calories at breakfast
■ 5 to 10 percent of calories at a mid-morning snack
■ 20 to 30 percent of calories at lunch
■ 5 to 10 percent calories at a mid-afternoon snack
■ 30 to 40 percent of calories at dinner
■ 5 to 10 percent of calories at a bedtime snack.
If You Want to Lose Weight Intensive diabetes management sometimes causes weight gain. If this is a concern for you, the following strategies may help:
■ Review your normal eating habits, including total calories, types of food, and how much fat and carbohydrate you eat, with your health care team, especially your dietitian.
■ Distribute the food you eat throughout the day so that you don’t eat too many calories or carbohydrates at one sitting. This can help even out glucose levels.
■ Eat fewer calories each day. Your health care team can help you decide how many calories you need.
■ If you’re not exercising regularly, you can start. This will help counteract the better job your body is doing at capturing and storing glucose, as your glucose levels improve.
■ Be careful not to overtreat the lows that are more common in intensive diabetes management. Follow the guidelines for doses of carbohydrates given on page 217 of this post.