NUTRITION

  By admin | November 3, 2011 - 12:34 pm | Type 1 diabetes Comments Off

The American Dietetic Association recommends a diet that emphasizes fruits, vegetables, whole grains, and fat free milk. This diet includes lean meats, poultry, fish, beans, eggs, and nuts. It is low in saturated fats, trans fats, cholesterol, salt, and added sugars. There is no perfect diet for everyone and diet should be individualized for each person based on age, activity, and preferences. My Pyramid can be found on the American Dietetic Association’s website and the patient can input his or her own information and receive recommendations for dietary consumption.

Carbohydrate counting is generally accepted as the “state of the art” in diabetes management. Every patient with diabetes should be taught carbohydrate counting from the onset/diagnosis of diabetes. Carbohydrate counting is easy and practical and anyone can understand the concept. All food items have carbohydrates listed on the package somewhere. Patients need to be taught to look at the total carbohydrates since this is the most critical to blood glucose levels. Patients of any age are quite good at counting carbohydrates; even the elderly are able to master this task. If patients understand how many carbohydrates to consume, they are able to manage blood glucose levels and control weight. Women should not consume more than 45 to 60 g of carbohydrate per meal and 15 to 30 g for snacks. This should be individualized based on physical activity. If an elderly woman moves very little, she may need fewer than 45 g of carbohydrate per meal. If a woman is athletic, she may need more than 60 g of carbohydrate per meal, but this is a good starting point. Men need 60 to 75 g of carbohydrate per meal and 30 to 45 g for snacks. This also needs to be adjusted based on the activity level and age of the man.

Carbohydrate, protein, and fat all raise blood glucose levels. Carbohydrate raises glucose levels more quickly than protein or fat and usually has a peak effect of 90 to 120 minutes after the meal is consumed. Protein raises glucose levels closer to 4 hours after the meal and fat closer to 8 hours after the meal. This is critical to know in order to take the appropriate amount of insulin to cover the meal. Most insulin users have an insulinxarbohydrate ratio. This means that they take a certain amount of insulin to cover a certain amount of carbohydrate. They must be taught, however, the effect of high protein meals and high fat meals. The average starting point for an adult is one unit of insulin for 15 g of carbohydrate. This needs to be adjusted based on postprandial glucose levels. If glucose levels 1 to 2 hours after the meal are greater than 180 mg/dL, the insulinxarbohydrate ratio is not adequate. This, of course, is assuming that the preprandial glucose level is 70 to 120 mg/dL and the person bolused at least 15 minutes before the meal. Small changes can be made if the person is treated with an insulin pump as the pump can be programmed with small changes of the insulinxarbohydrate ratio. If a person were taking 1 unit/15 g of carbohydrate and was > 180 mg/dL 1.5 to 2 hours after the meal, the insulinxarbohydrate ratio could be changed to 1:12. This would also need to be tested until appropriate postprandial glucose levels are reached. If a person is consuming a large amount of fat at the meal, the bolus may need to be increased and extended. When a person with diabetes consumes a meal such as pizza, he or she will need to add extra carbohydrates to their estimate and set a combination bolus with a percent given immediately and a percent extended over several hours. My suggestion to patients eating a meal such as pizza is to add 20 to 30 g of carbohydrate to their estimate and take 70% before the meal and 30% over the next 5 to 6 hours. This helps to cover the initial rise of glucose from the carbohydrates and the later increase in absorption of the fat content. People usually continue to make adjustments to this until they achieve success, that is, glucose levels less than 180 mg/dL after the meal and 70 to 120 mg/dL before the next meal. A correction factor also needs to be calculated into the bolus dose of insulin. The pump will also do this once the correction factor/sensitivity factor is calculated for the patient. The patient would enter the glucose, if it is not already there, and the pump will calculate the amount of insulin it takes to reach the target glucose (my suggestion is 100 mg/dL for the target) so that the glucose comes closer to the desired range. If a patient is on injections, it is more difficult to determine all these calculations and draw them up in a syringe as you cannot calculate to an exact amount this way. Most people have to do this on multiple daily injections, but the outcome is not as good as it is with a pump simply because the dose is an estimate and not exact and syringes can only measure down to 0.5 unit where pumps can measure all the way to the 0.05 unit of insulin. It is simply not possible to duplicate this with injections.

When all is said and done, we simply eat too much in this country and this needs to be addressed in our nutrition counseling. In a survey of > 2000 adults with diabetes, the most frequently cited barrier to achieving self-management goals was adherence to diet and exercise. We eat too much fat and not enough vegetables and fruits, and do not exercise enough. Everyone is looking for the easy way out, a pill, that will fix it all for them. We know that medical nutrition therapy does make a difference. Diabetes medical nutrition therapy trials and outcome studies have demonstrated reductions in HbAlc of approximately 1% in type 1 diabetes. When a health-care provider advises a patient on weight loss (not just telling them they need to lose weight), patients are nearly three times as likely to act on the recommendation. Patients are more satisfied with their interactions with health-care providers when they receive information, support, and resources, especially when our messages are positive, nonjudgmental, and understanding of the difficulties of changing behavior. Patients should be referred to a dietitian who is knowledgeable and skilled in developing an individualized diabetes meal plan.

Tagged

EXERCISE

  By admin | November 3, 2011 - 12:32 pm | Type 1 diabetes Comments Off

Exercise is an essential part of any plan of care. It should be emphasized to all patients with diabetes that this is as important as the other aspects of care. It is something that is generally overlooked and not discussed in a busy office visit, but patients need to understand the importance of this aspect of diabetes management. Patients often have a misconstrued idea of what exercise is. They can incorporate exercise into their daily life. It does not mean they need to join a gym or jog every day, though this would be good. They can take the stairs instead of the elevator, park far away from the store or workplace so that they have to walk further, wear a pedometer to work and get up and walk periodically, walk for 10 minutes after lunch, go visit a coworker on a different floor or up the hall, stand up at every commercial on TV and do some jumping jacks. These are all small ways to incorporate exercise into daily routines.

Exercise training raises high density lipoprotein cholesterol, lowers blood pressure, and leads to a 20 to 40% increase in insulin sensitivity by enhancing insulin action in skeletal muscles. Therefore, all diabetic patients should be encouraged to engage in 30 minutes of modest aerobic exercise (such as brisk walking, aerobics, swimming, or bicycling) three to four times per week. The intensity should be gauged to produce an increase in pulse rate to 60 to 70% of maximum, which can be calculated as 220 minus age. This level of exercise is referred to as “conversational exercise” because it is not intense enough to prevent the patient from conversing with a partner during the workout.

Exercise usually lowers blood glucose levels. If someone is a real competitive athlete, glucose levels will go up during competition due to adrenaline being released during this activity. Many times, the same person will have a low glucose level at a practice but a high one at a game even in the same sport. It takes a lot of insulin dose adjustments before normal glucose levels are achieved with exercise. There are many ways to deal with this. First, do the exercise without changing anything to see what happens. Many people prefer to take their pumps off for exercise. This can usually be worked out if the sport is not too long, like baseball or cross country running. If the patient is on injections, it is more difficult to address, but a plan needs to be developed. This patient may need to lower the bolus prior to the previous meal or snack or he/she may need to decrease the long acting insulin during the sport season. This makes it difficult to figure out what to do if there is no exercise that day as long-acting insulins (Lantus, Levimir) last for several days so changing based on the same day simply does not work for the patient. He or she would probably need to increase the fast-acting insulin on off days to counteract high glucose levels.

For athletes competing in sports, it is advisable to remove the pump during the sport (if using a pump), but reattach it as soon as the sport is over and replace at least 1 hour of basal insulin as a bolus. This will keep the glucose from rising within the first hour after the sport is finished. The Diabetes Research in Children Network (DirecNet) studied this and found that if the pump was kept on at the usual basal rate, hypoglycemia occurred, but if it was removed, hyperglycemia occurred very soon after the exercise was completed. Therefore, to prevent the hypoglycemia during exercise, pump should be removed or basal decreased significantly, but insulin needs to be replaced soon after exercise to prevent hyperglycemia. Exercise also cause delayed hypoglycemia in most patients with diabetes. In order to prevent this, patients are instructed to decrease basal rate at bedtime to 70 to 80% of their usual dose for 4 to 5 hours. This prevents nocturnal hypoglycemia in these patients. It was shown by Bussau, et al., that a sprint at the end of practice or a game reduces hypoglycemia due to increase in catecholamines. Since many athletes do this as part of their sport, it is no wonder that they come off the field with extremely high glucose levels that need to be corrected. Sprinting does raise glucose and many sports require sprinting.

Health-care providers must recommend exercise to their patients. The success rate is not very good for patients continuing an exercise plan, but if it is not discussed, the success rate is even poorer. Exercise is extremely difficult to maintain as is diet but if patients are not encouraged, they surely will not see any necessity for it. It should be addressed at every visit as a part of the visit. Sometimes hearing things over and over does eventually make a difference to a patient. Even if the motivation wears off, the patient will usually follow a plan for a while and if they are seen every 3 months, they may have more time that they exercise than they do not exercising. In a study at the Joslin Diabetes Center located at the University Health Care Center in Syracuse, NY, patients were asked to develop their own meal and exercise plan. At 2 and 6 months respectively, 89% and 92% of the participants felt that they were following the meal plan either some or most of the time. One hundred percent of respondents were able to determine their own exercise plan, with 98% indicating they could adhere to the plan, and 85.7% felt that the new plan would be easier than previous ones. At 2 and 6 months respectively, 70% and 73% felt that they were following their exercise plan either some or most of the time. Individualized meal and exercise plans can be successfully created by the patients themselves. In an integrative literature review, Dr. Nancy Allen, examined the literature on diabetes research using social cognitive theory (15) to determine its predictive ability in explaining exercise behavior and to identify key interventions that enhance exercise initiation and maintenance. The results showed that a statistically significant relationship between self-efficacy and exercise behavior was found in correlational studies. Results from the predictive study support the predictability of self-efficacy for exercise behavior. Self-efficacy was predictive of exercise initiation and maintenance over time. The evidence for successful interventions to increase self-efficacy and exercise behavior over time was inconclusive.

In conclusion everyone is in agreement that exercise is an important and even essential part of any diabetes management plan. It is also one of the most difficult parts of the regimen for patients to adhere to.

Tagged , ,

TRAVEL

  By admin | November 3, 2011 - 12:31 pm | Type 1 diabetes Comments Off

Traveling with diabetes is always an adventure. Many people have a job that requires travel and many others travel for pleasure. If a patient is traveling on an airplane, he or she needs to do the following according to the American Diabetes Association and the Transportation Security Administration:

Notify the screener that you have diabetes and are carrying your supplies with you. Please note that while Transportation Security Administration is not currently requiring a prescription label, it recommends having the label available to identify the medication in order to expedite the security checkpoint screening process. The following diabetes-related supplies and equipment are allowed through the checkpoint once they have been screened:

• Insulin and insulin loaded dispensing products (vials or box of individual vials, jet injectors, pens, infusers, and preloaded syringes) that are clearly identified with a prescription label containing a name that matches the passenger’s name on his or her ticket.

•   Other liquid prescription medicines such as Smylin, Byetta, or a Glucagon Emergency Kit that are clearly identified with a prescription label containing a name that matches the passenger’s name on his or her ticket.

•   Note that essential nonprescription liquid medicines (such as regular insulin, where in some states a prescription to dispense is not required) should be clearly labeled.

•   Multiple containers of liquids and gels (including cake mate) to treat hypoglycemia. If containers are more than 3 oz, then passengers need to declare these items to security checkpoint personnel.

•   Unlimited number of unused syringes when accompanied by insulin or other injectable medication.

•   Blood glucose meters, blood glucose meter test strips, continuous blood glucose monitors, lancets, alcohol swabs, meter-testing solutions, and monitor supplies.

•   Insulin pump and insulin pump supplies (cleaning agents, batteries, plastic tubing, infusion kit, catheter, and needle).

•   Urine ketone test strips.

•   Unlimited number of used syringes when transported in Sharps disposal container or other similar hard-surface container.

In addition to the information providers above, it is recommended that passengers review Transportation Security Administration’s 9/26/06 Q&A (PDF) PersonswithDisabilitiesQuestionsandAnswers.pdf) regarding changes to liquids ban at airport security checkpoints.

Pump Wearers

Although insulin pump manufacturers indicate that pumps can safely go through airport security systems, pump wearers may request a visual inspection rather than walking through the metal detector or being hand-wanded. Note that this may subject you to closer scrutiny or a “pat-down.”

•   Advise the screener that the insulin pump cannot be removed because it is connected to a catheter inserted under your skin.

•   Insulin pumps and supplies must be accompanied by insulin with a label clearly identifying the medication.

If You Experience Hypoglycemia During the Security Procedure

Immediately inform screeners if you are experiencing low blood sugar and are in need of medical assistance.

If You Request a Visual Inspection of Your Supplies

You have the option of requesting a visual inspection of your insulin and diabetes associated supplies. Keep in mind that

•   you must request a visual inspection before the screening process begins otherwise your medications and supplies will undergo X-ray inspection.

•   you should separate your medication and associated supplies from your other property in a pouch or bag.

•   medications should be labeled so they are identifiable.

•   in order to prevent contamination or damage to medication and associated supplies and/or fragile medical materials, you will be asked at the security checkpoint to display, handle, and repack your own medication and associated supplies during the visual inspection process.

•   any medication and/or associated supplies that cannot be cleared visually must be submitted for X-ray screening. If you refuse, you will not be permitted to carry your medications and related supplies into the sterile area.

Contact Transportation Security Administration

If you have an immediate need while being screened, you should ask for a screener supervisor. You may also contact the Transportation Security Administration contact center to report unfair treatment or to obtain additional information by calling toll-free 866-289-9673 during the following hours of operation (all times are Eastern Standard Time):

•   Monday through Friday 8 a.m-10 p.m.

•   Saturday, Sunday, and Holidays 10 a.m.-6 p.m.

Complaints about discriminatory treatment (http://airconsumer.ost.dot.gov/ DiscrimComplaintsContacs.htm) by federal security screeners should be directed to Transportation Security Administration. Transportation Security Administration accepts complaints by mail to Transportation Security Administration, Transportation Security Administration Headquarters, 12th Floor, Room 1203 N, Transportation Security Administration-1, 400 Seventh St., SW, Washington, DC 20590.

In addition to filing a complaint with a federal agency, passengers alleging discriminatory treatment by air carrier personnel (pilots, flight attendants, gate agents, or check-in counter personnel) may download and print a complaint form and follow instructions provided by Department of Transportation’s (DOT’s) Web site (http://airconsumer. ost.dot.gov/problems.htm). They should also notify their airline carrier. Other consumer complaints may be directed to the Department of Transportation’s Office of Consumer Protection Division, 400 Seventh St., S.W., Washington, DC, 20590, U.S.A. More information on where passengers may file complaints for travel service problems, contact DOT by calling 1-800-255-1111.

The association recommends packing at least twice the number of supplies needed during travel, and bringing a quick-acting source of glucose to treat low blood glucose, as well as an easy to carry snack such as a nutrition bar. Carry or wear medical identification and carry contact information for your physician while traveling. It may also be helpful to have contact information for a health-care professional available at your destination, and be prepared to adjust medication when traveling in different time zones.

•   You should separate your medication and associated supplies from your other property in a pouch or bag.

•   Medications should be labeled so they are identifiable.

•   In order to prevent contamination or damage to medication and associated supplies and/or fragile medical materials, you will be asked at the security checkpoint to display, handle, and repack your own medication and associated supplies during the visual inspection process.

•   Any medication and/or associated supplies that cannot be cleared visually must be submitted for X-ray screening. If you refuse, you will not be permitted to carry your medications and related supplies into the sterile area.

Contact Transportation Security Administration

If you have an immediate need while being screened, you should ask for a screener supervisor.

In addition, blood glucose levels tend to increase while traveling in any mode, therefore, increase the basal rate by approximately 30% while traveling. If on injections, increase the bolus doses and may need more doses during travel. When traveling across time zones and wearing a pump, the time needs to be changed on arrival. This is essential to maintain basal rates at the right times of day. If on injections with Lantus or Levimir, these need to be adjusted by approximately 2 hr/day. If on NPH, it may need to be given as much as 3 hours earlier or later depending on the time zone.

If traveling to high altitudes, 3000 to 5000 m (10,000 to 16,000 ft), barometric pressure decreases linearly with increasing altitude. Inspired P02 at the summit of Mount Everest (8848 m) is < 30% of that at sea level. Acclimatization refers to the physiological changes that occur consequent to prolonged exposure to the hypoxia and low barometric pressure of altitude, and it includes hyperventilation, with the resultant respiratory alkalosis being reduced over time by compensatory renal bicarbonate excretion. Although erythrocyte levels also increase, this occurs much more slowly, over the course of several weeks. It is also important to note that acclimatization does not imply normalization because, despite continued hyperventilation, alveolar P02 levels remain well below that at sea level even in fully acclimatized individuals.

Those who seem to do well and are successful on these climbs are those who are in excellent control (HbAlc < 7%) and have no complications. Acute mountain sickness can occur causing dizziness and nausea. This can effect glucose control. Symptoms of acute mountain sickness may mask symptoms of hypoglycemia in some people with diabetes. Diabetes control deteriorated in climbers consistently due to elevation and decreases in temperature. Climbing requires much preparation and consideration of the consequences.

Traveling should be fun and it should be an adventure, but to keep it that way, much planning needs to take place. Patients should discuss travel plans with their health-care provider well before taking the trip. This greatly reduces the risk of problems related to travel in those with diabetes. Make sure that all the guidelines that the ADA puts forth are followed. Always take twice as many supplies as necessary.

Tagged , , ,

Planning for Sick Days, Surgery, and Travel

  By admin | June 22, 2011 - 10:52 am | Diabetes and Lifestyle Comments Off

Diabetes control can be adversely affected by stressful situations related to physical or emotional distress. Health care providers must be able to advise patients with diabetes who become ill with infections, injuries, or other ailments that complicate their diabetes management routine and cause hyperglycemia.

Definition of a sick day: A sick day could be caused by a variety of situations, from a common cold to a broken bone to a death in the family. If the patient is thrown off of his/her usual diabetes management routine, or experiences persistent hyperglycemia despite self-management techniques that usually maintain glucose control, he or she is having a sick day.

Risks associated with concurrent illness

The most critical complication of concurrent illness is diabetic ketoacidosis. Although diabetic ketoacidosis usually does not occur in those with type 2 diabetes, studies in recent years indicate that it does occur more than was once thought in younger people and in people of color who have type 2 diabetes. diabetic ketoacidosis is present in the patient who is producing ketones and has a blood pH below normal. Ketones are produced when the body is unable to metabolize carbohydrate for energy. This situation is caused by insulin levels that are insufficient to promote glucose transport inside cells where its metabolism occurs. Therefore, since diabetic ketoacidosis is caused by insulin deficiency, it can usually be prevented by adequate insulin administration.

Another life-threatening complication is called hyperglycemic hyperosmolar nonketotic syndrome, also called hyperosmolar nonketotic hyperglycemia. In this situation, which is most commonly found in elderly people with type 2 diabetes, severe hyperglycemia and dehydration occur in the absence of ketone production.

Both diabetic ketoacidosis and hyperosmolar nonketotic syndrome are life-threatening situations. Preparing patients to safely and effectively manage sick days ahead of time can mean the difference between life and death.

Patient recommendations for nutritional intake and medication adjustment

Type 1 Diabetes

Insulin Adjustment

The most common trigger for diabetic ketoacidosis is the omission of insulin. Health care providers have consistently taught patients that they must eat after taking their insulin. Patients can misinterpret this information, and omit their insulin if they know they are unable to eat due to illness. It is important to explain to patients that their long-acting (basal) insulin is required even if they are not eating. Most patients with type 1 diabetes are now on peakless basal insulin analogs (such as insulin glargine) that do not cause hypoglycemia during fasting (if appropriately dosed). Those patients who are on a basal/bolus insulin regimen should understand that the basal insulin has no relationship to food intake, and their bolus (short-acting) insulin is meant to cover meals and to correct hyperglycemia when it occurs. Patients who are taking older basal insulins may experience hypoglycemia during the insulin’s peak time when they are fasting or unable to eat. Regular insulin, which is still used by some patients to cover meals, is actually closer to an intermediate-acting than a short-acting insulin. The short-acting insulin analogs (such as lispro or aspart) are more effective for meal coverage and for correcting hyperglycemia than is regular insulin. In the event that patients are not eating, basal insulin should be continued, and regular insulin and the short-acting analogs should be used only to correct hyperglycemia.

Other Medications

Antiemetics. Vomiting is a very potent trigger for diabetic ketoacidosis, and can also be a symptom of diabetic ketoacidosis. In any case, if vomiting persists the patient will almost certainly decompensate and require a hospital admission. Thus, it is crucial to attempt to prevent or stop vomiting in patients with diabetes. Antiemetic suppositories are a practical treatment for nausea, and can be called in to the pharmacy if the patient complains of nausea and/or vomiting. Patients who have had recurring diabetic ketoacidosis associated with vomiting should have an active prescription for antiemetics at all times.

Nutritional Recommendations

To prevent or limit dehydration and electrolyte imbalance, it is important for food and/or fluid intake to continue. In general, patients should be encouraged to drink 4-6 ounces of noncaloric fluids every 30 minutes. Carbohydrate (sugar) intake is also important, and a goal of 50 g every 4 hours will simulate typical meals. Foods and fluids that may be used to replace usual meals include:

• Sports drinks

• Crackers

• Jell-o (not sugar-free)

• Soup

• Applesauce

• Bananas

• Fruit juice

• Soft drinks (not sugar-free)

Type 2 Diabetes

Medication Adjustment

Patient taking oral medications to treat diabetes should continue to take them. If they are nauseated and unable to eat solid food, they may have to temporarily omit their met-formin, since it can exacerbate nausea if taken on an empty stomach. Insulin secretagogues such as glyburide and glipizide should be taken to maximize the patient’s ability to secrete insulin during the illness. This insulin production is necessary and is similar to the exogenous basal insulin discussed in type 1 diabetes. Therefore, patients should not omit these medications even if they are not eating.

Patients with type 2 diabetes who are taking insulin should be advised as if they have type 1 diabetes — always take the basal insulin even if unable to eat; take extra short-acting insulin if necessary.

Nutritional Recommendations

Nutritional recommendations during sick days for those with type 2 diabetes are similar to those for type 1.

Surgery and other medical procedures

Surgery certainly qualifies as extreme stress, and as such promotes a physiological response similar to a sick day, and usually more extreme. Medical procedures such as vascular studies or endoscopies usually require special preparations that disrupt the patient’s usual routine and may or may not alter medication requirements. Risks of surgery include severe hyperglycemia, fluid and electrolyte imbalance, hypoglycemia, and diabetic ketoacidosis.

Patients with diabetes should also be prepared for other challenges associated with hospitalization, such as receiving appropriate nutrition. Despite current, evidence-based of nutritional recommendations for patients with diabetes provided by the American Diabetes Association and others, most hospital food service departments continue to provide meals according to calorie level, or “no sugar (sucrose) added” limits, not carbohydrate content. Patients who are managing their total carbohydrate intake may be frustrated with the high carbohydrate meals they receive in the hospital. In some situations, a regular diet would be more beneficial to patients who know how to estimate their own carbohydrate intake.

Patient recommendations for the perioperative period

Summary

Sick days, surgery, and travel are situations in which routines are disrupted. Careful planning can help avoid diabetes complications during these challenging times.

Patient guide to sick day management

Tagged , , , , ,

Patient recommendations for the perioperative period

  By admin | June 22, 2011 - 10:51 am | Diabetes and Lifestyle Comments Off

Ideally, a patient with diabetes who is scheduled for surgery should discuss their perioperative management with the diabetes care provider prior to the surgical preparation. Often, patients receive insufficient or inaccurate recommendations from the anesthesia and/or operative team. Many times older patients with type 1 diabetes are assumed to have type 2, and are thought to be safe temporarily without basal insulin. Iatrogenic diabetic ketoacidosis is fairly common due to omission of insulin during the perioperative period. In contrast, if hospital professionals have a poor understanding of the differences in insulin requirements between insulin-resistant patients with type 2 diabetes (very large doses) and insulin-sensitive type 1 patients (sometimes very small doses), all patients with diabetes might receive similar insulin doses for the same blood sugar level. This is seen in the outmoded “sliding scale” insulin orders using regular insulin, which is not recommended.

Type 1 Diabetes

• Patients should never be advised to omit a dose of basal insulin. If the basal insulin is NPH or Lente, due to the potential for hypoglycemia during the peak action, the dose may be adjusted:

If NPO:

■ If basal insulin is glargine or another peakless insulin, do not change the dose. This insulin should already be adjusted to fasting glucose levels.

■ If basal insulin is NPH or Lente, give the usual night time dose; decrease the morning dose by 30%.

■ Use short-acting insulin only to correct hyperglycemia (if the patient does not have individualized instructions, 15% of total daily dose 4 to 6 hours apart is a good starting point).

If on clear liquids:

■ No change in the basal insulin.

■ Use short-acting insulin to correct hyperglycemia (as above).

■ Recommend a combination of carbohydrate-free and carbohydrate-containing beverages, aiming for 50 g to replace one meal.

Type 2 Diabetes

Packing

If the patient takes oral diabetes medication, they should continue to take it until a strict NPO situation is necessary. If a potential exists for renal compromise during or after the procedure, metformin should be discontinued until after a postprocedure creatinine level less than 1.4 mg/dl. Patients who take insulin should be given the same insulin-adjustment guidelines as type 1 patients.

Travel

Patients with diabetes are able to safely travel as long as a few precautions are taken. High and low blood sugars can occur due to changes in meal timing and content. Medication adjustments may be necessary for a minority of travelers. In order to control diabetes during travel, patients must have adequate monitoring supplies, medications, and knowledge regarding the foods that will be available and a method of estimating carbohydrate content.

Foot Care

Travel often includes using public transportation, sightseeing, and other activities that cause more wear and tear than usual on already vulnerable feet. Foot problems during travel are so common that a new term has been coined by the podiatry community — “Diabetic Holiday Foot Syndrome.” Patients with diabetes should be prepared to walk more than they usually do in a typical day. Encourage travelers to wear athletic or other walking shoes, to limit friction on skin by wearing socks, to examine feet frequently (especially in the middle of the day to detect early problems), and to carry supplies for minor foot problems such as blisters or abrasions. Patients with neuropathy will not be able to detect early skin problems and must actively seek them by examining their feet frequently.

Regardless of the mode of travel, people with diabetes should have the following items in a “carry-on” bag, easily accessible:

• all the insulin and syringes you will need for the trip

• all oral medications (an extra supply is a good idea)

• blood glucose testing supplies (include extra batteries for your glucose meter)

• urine ketone strips if using an insulin pump or history of diabetic ketoacidosis

• other medications or medical supplies, such as glucagon, antidiarrhea medication, antibiotic ointment, antinausea drugs

• personal ID and diabetes identity card

• a well-wrapped, air-tight snack pack of crackers with cheese or peanut butter, a juice box, and some form of sugar (hard candy or glucose tablets) to treat low blood glucose.

Airline Security

The American Diabetes Association has worked closely with the Transportation Security Administration to ensure that people with diabetes are treated fairly in light of recent increases in airport security. A full set of recommendations can be found at www.diabetes.org. In general:

• Notify the security screener that you have diabetes and are carrying your supplies with you.

• Make sure your insulin vials, insulin pens, jet injectors, and insulin pump are accompanied by a professionally printed pharmaceutical label identifying the medication (insulin), which is usually on the outside of the box.

• Lancets, blood glucose meters, blood glucose test strips can be carried through the security checkpoint.

• Notify screeners if you are wearing an insulin pump, and request that they visually inspect the pump rather than removing it from your body.

• Advise screeners if you experience symptoms of a low blood glucose level and are in need of medical assistance.

• The above protocol applies only to travel within the 50 United States and is subject to change. International passengers should consult their individual air carriers for applicable international regulations.

Dealing with Time Zone Changes

Time zone changes are not usually problematic unless the change increases the risk of hypoglycemia. The risk of hypoglycemia is increased if insulin is taken and carbohydrate is not consumed during the time the insulin peaks. People taking oral agents, basal/bolus insulin, or using insulin pumps typically do not need to make major adjustments during travel. Those who take pre-mixed insulin, intermediate-acting insulin, or a combination of intermediate-acting and short-acting insulins may need to make some adjustments.

Adjusting Insulin for Travel

Newer insulins have made travel much less of a burden for insulin-treated diabetes. If a peakless basal insulin is used, the timing of the injection need not be changed since it has no relationship to food intake. If the patient expects to be asleep during the time of the usual injection, the time could safely be adjusted by up to 2 hours per day until reaching a convenient local time to take the injection. Depending on the length of the trip and the difference in time zone, another option would be to premeasure the insulin and keep the syringe at the bedside, set an alarm and take the injection at the same time as at home. Short-acting insulin should be taken to cover meals and correct hyperglycemia as usual.

Older basal and premixed insulins are more difficult to adjust, since they do influence meal times. The more time zones the patient crosses, the more complicated the adjustment will be. In general, traveling East shortens the day, and less insulin may be needed. Traveling West lengthens the day, and more insulin (additional injections) may be needed. In general, patients will be safe taking the usual dose the morning of travel, if two daily injections are taken, the larger dose is usually (not always) taken in the morning, to control meal-related glucose excursions during the day. When traveling to another time zone, the patient should be advised to take the usual dose the morning of travel, and to adjust amounts the rest of the day. For example, if traveling West, take half the evening dose with a meal at the usual (home) time, and the remaining half with another meal at the local dinner time.

It should be apparent that the basal/bolus regimen is less complicated and people who travel extensively should be offered this regimen if they are still taking intermediate-acting or premixed insulin.

Tagged , , , ,