Living with Diabetes

Managing Diabetes: Tips & Resources

Managing diabetes is a daily challenge. There are so many variables to keep in mind --  food, exercise, stress, general health, etc. -- that keeping blood sugar levels in the desired range is a constant balancing act.

We want to make managing diabetes easier. So, the DRI's Education Team has developed short brochures about the topics listed below -- offering useful tips on many of the day-to-day issues facing people living with diabetes. And, most of the materials are offered in English and Spanish.

If you can benefit by learning about one or more of these subjects, just click on the title to expand.

Do you know what foods have the greatest impact on your blood sugars? If you answered CARBOHYDRATE’re right!

Carbohydrates -- "carbs" -- are broken down into glucose. So if you eat too much of them, your blood sugar level may rise.

For this reason, people with diabetes find it helpful to keep track of the “carbs” they eat in order to manage their blood sugars.

This is called “carb counting.”

Carb counting is easy. It just takes some practice at first.

To learn the basics, read the DRI's brochure "Carbohydrate Counting" in English or "Contando Carbohidratos" in Spanish

Caring for older people with diabetes requires special thought and consideration. The older individual is more likely to have other health problems and may be taking a variety of different medications.

The Diabetes Research Institute has prepared a brochure that provides useful tips to help you manage the diabetes of an older person. Read "Care of Older People with Diabetes" in English or "El Cuidado de las personas mayors con diabetes" in Spanish.

Many people are frightened to check their blood sugar -- or "blood glucose" -- levels because they do not want to see levels that are higher or lower than their target range.

But, checking blood sugar at home, in school, and in the workplace is key to managing diabetes. It puts you in control of your diabetes.

Remember, your blood sugar levels remain the same whether you know about them or not.

Checking blood sugar levels is the most accurate way to see if your lifestyle changes and medications are helping you to better manage your diabetes. If levels are above or below your target range, blood glucose monitoring provides you with the ability to identify what is causing the problem and to correct it.

To learn the basics about checking blood sugar, read the DRI's brochure "Blood Glucose Monitoring" in English or "El Monitoreo de la Glucosa Sanguínea" in Spanish.

School can be difficult for any child, but adding diabetes to the picture can make it even harder. Managing diabetes with a child at school can be seen as a challenge, but it is possible.

It requires collaboration between the school, the child, the parents/guardians and the treating doctor/health care team.

Success begins with education – in terms of both knowledge and skills.

For tips on managing diabetes in school, read the Diabetes Research Institute's brochure "Diabetes at School" or download this eight-page guide to provide to your child's caregivers at school, "Facts About Diabetes: A Guide for School Personnel."

So you find it difficult to exercise? Do you feel that you just don’t have enough time in the day to go to the gym?

Do you feel too tired at the end of your work day?

Exercise has so many health benefits, but a lot of times getting started can be difficult. The good news is that to reap the benefits of physical activity, you just have to move more during the day. Gyms and expensive exercise equipment are not necessary at all!

For helpful tips on how to work exercise into your routine, read the DRI's brochure "Get Moving" in English or "Moviendose Para la Salud" in Spanish.

Did you know that insulin works like a key to a door?

Insulin opens the doors to the cells of our body. When the doors swing open, the sugar in our bloodstream enter our cells, and our body uses that sugar for energy.

This is an example of one way to explain diabetes to kids.

For other helpful tips, plus educational word games, read the DRI's brochure "Diabetes & Kids".

Controlling intake of fats is important to everyone, especially people with diabetes.

There are several kinds of fats, including: saturated fats, trans fatty acids, cholesterol, monounsaturated fats, polyunsaturated fats, and omega 3 fatty acids.

For helpful hints on how to eat the "right" fats, and the right amount of fats, read the DRI's brochure "Facts About Fat" in English  or "Hechos Sobre la Grasa" in Spanish.

People with type 1 diabetes, and some people with type 2 diabetes, need to replace the insulin that they are unable to produce, to maintain normal body functions.

Insulin is given by subcutaneous injection, using a syringe, pen device, or may be delivered via an insulin pump.

To learn more about such topics as

• "Where Can You Inject?" and
• "Different Types of Insulin And Their Action"

Read the DRI's brochure "Insulin Therapy" in English or "Terapia de Insulina" in Spanish.

Did you know diabetes increases your chances of having coronary heart disease, heart attack and stroke?

Statistics show that heart disease and stroke account for approximately 65% of deaths in people with diabetes.

To protect yourself, you must maintain a healthy heart and healthy blood vessels. You can do this by making just a few lifestyle changes.

For useful tips on how to do that, read the DRI's brochure "Healthy Heart" in English or "Un Corazón Sano" in Spanish.

Q: With the tools available now to monitor blood sugar that help to keep numbers as normal as possible, is there more potential for hypoglycemic reactions?

A:  Most people with diabetes strive to achieve blood glucose levels within a specified target range that’s closest to normal physiologic levels.  In my experience, too many people have set unrealistic, low targets, believing lower (often too low) is better because of fear of complications from high blood glucose levels.
Unfortunately, this mind set of low is better, can often lead to overtreatment and frequent hypoglycemia, which must be avoided if we want to help preserve hypoglycemia signs and symptoms. Glucose monitoring tools have the ability to both help and hinder.

The three tools that determine the level of glucose control are a blood glucose meter, glycated hemoglobin (HbA1c) test result and a continuous glucose monitor (CGM). Looking at these tools collectively will provide you and your healthcare team with the most complete glucose picture.

A blood glucose meter provides the most accurate (excluding user error) real-time blood glucose level by providing you with an immediate capillary glucose result. It is this capillary result that we ask you to use for insulin determination in hyperglycemia and treatment with glucose for hypoglycemia. We generally recommend 4-6 blood glucose checks per day to optimize control, providing 4-6 photo snapshots of the blood glucose levels. Even with this incredible commitment to self-management, information regarding blood glucose levels between these readings is unknown.

The elusive 6-7 percent HbA1c is, for me, an over-rated determinant of glucose control. Your 3 monthly HbA1c result provides you with an average of your glucose control over the previous 2-3 months. Many people strive for years to obtain the elusive 6-7 percent HbA1c result, only to find when they do achieve it, the healthcare team may still want more.

To explain my point, in a recent Mastering Your Diabetes Program, those participants who did have their HbA1c under 7 percent, demonstrated the greatest swings in blood glucose levels from hypoglycemia to hyperglycemia.   Remember, an average blood glucose level of 120mg/dL (the midpoint of 80-160mg/dL), would equate with an HbA1c result of 6 percent and who wouldn’t be happy with that – right? But you can also achieve the same HbA1c with blood glucose levels ranging from 30-210mg/dL – riding the diabetes rollercoaster. An HbA1c result must be assessed in conjunction with capillary and / or CGM data to identify its true value. 

Our third tool, CGM, in essence, provides a DVD of the individual’s glucose control. Although invaluable in providing data regarding glucose trends, CGM can lead to reactive management when you are receiving up to 288 glucose readings every 24 hours – information overload! Hypoglycemia, from over-correction, is a significant education point. We must remember that because CGM measures interstitial fluid glucose levels, there can be up to a 20 percent variability compared to capillary glucose readings and sometimes more when the glucose level is changing rapidly. Confirmation of data with a capillary reading is essential for accuracy and takes priority.

In essence, each glucose-monitoring tool has value, but true value comes from collective review.

The word "hypo" means "low." Hypoglycemia means having a low blood sugar. It can occur in people who take medication to treat their diabetes. But hypoglycemia is usually avoidable.

It's important that, if you do experience a low blood sugar level, you know how to recognize and treat the situation. Prevention of low blood sugar levels is the primary goal.

For useful tips on how to prevent low blood sugar -- and to react properly if it happens -- read the DRI's brochure "Low Blood Sugar-Hypoglycemia" in English or "Azúcar Sanguínea Baja-Hipoglicemia" in Spanish.

Understanding portion sizes is the first step in healthy eating -- and a big part of managing diabetes.

The DRI has developed a portions guide, along with meal planning tips, to assist you in making educated choices regarding your food choices.

Read the DRI's brochure "Portions Guide" in English or "Guia de las porciones" in Spanish.

Diabetes can affect all of the blood vessels in the body, and can cause potential harm to your eyes, heart, kidneys, nerves, other organs and body parts.

But these diabetes complications are not an inevitable part of living with diabetes.

There is a lot you can do to stay well and remain healthy with diabetes. 

To learn how to take a "wellness" approach to diabetes, and to help prevent diabetes complications, read the DRI's brochure "Diabetes Complications" in English or "La Salud y la Diabetes" in Spanish.

The number of people with diabetes -- especially type 2 diabetes -- is increasing rapidly world wide.

People with type 2 are able to produce some of their own insulin. Often, it’s not enough. And sometimes, the insulin will try to serve as the “key” to open the body’s cells, to allow the glucose to enter. But the key won’t work. The cells won’t open. This is called insulin resistance.

For many people, it is possible to prevent type 2 diabetes.

To learn the symptoms and how to prevent type 2 diabetes -- how to take control -- read the DRI's brochure "Diabetes Prevention" in English or "Prevención de la Diabetes" in Spanish.

Diabetes can impact all aspects of life. And, all aspects of life can impact diabetes.

With all the challenges of managing diabetes, it can be difficult for people living with disease to stay on track.

Setting goals can help you to achieve this -- goals for things like eating, exercise, checking blood sugar, reducing stress, etc.

To begin managing your diabetes more effectively by setting goals, read the DRI's brochure "Keeping On Track With Diabetes" in English or "Mantenerse Bien Con Diabetes" in Spanish.

Living with diabetes can be challenging enough on a good day. But, when you're sick, managing diabetes becomes even more difficult.

Illness can cause your blood sugar levels to rise, and lead to a serious complication called diabetic ketoacidosis.

You can prevent this from happening.

To learn how to manage diabetes sick days, read the DRI's brochure "Sick Day Management" in English or "Diabetes y la Enfermedad" in Spanish.

Provided by: DRI Education Team

Well, the long summer break is over, and the school year has begun!

With that comes excitement about connecting with friends and meeting new teachers, and of course, some anxieties about embracing a new curriculum and getting good grades. For our children with diabetes, we know there are extra factors to consider. 

For parents, students and school personnel, these quick tips might calm your concerns:

1.    Develop a Written Plan
Created and implemented as a team between the health care provider, the school and the family. The written plan begins with a Diabetes Medical Management Plan (DMMP), which forms the basis for care of the child with diabetes at school. Also ensuring you complete a 504 Accommodations Plan is important to ensure diabetes does not create barriers to opportunities for education.  The main focus of the plan is to promote open communication between the child’s team, reduce unnecessary anxiety and create clarity in the diabetes care needs of the child. The American Diabetes Association website has great information pertaining to written plans – Talk to your health care team too!

2.    Educating School Personnel and Students
Challenges for children with diabetes at school can often arise because of a lack of accurate and specific information about the safety needs of your child with diabetes. Arranging to meet with school personnel prior to the start of the school year is always best, to identify any learning opportunities early. Informing fellow students is also a smart move because they are the ones who are usually with your child in the classroom and the playground.  Diabetes Educators are often open to meeting with school personnel and students to provide education and reduce anxieties. There are many free education materials that can be provided to the school to make diabetes just a part of the school day. Also – what a great project if your child can take the lead on providing helpful information – be an ambassador for the school and other children living with diabetes by giving a classroom presentation! Super cool!

3.    Diabetes Supplies
Being prepared at school is really important. Ensure there is room in your child’s school bag or school locker for all the supplies needed to check glucose levels, administer insulin and of course, test for ketones and treat hypoglycemia. If using an insulin pump, placing all the supplies you would need in a ziplock bag makes changing sites much easier in a stressful moment. I always tell children and adults on insulin therapy to ensure they always have 3 things with them at all times to be safe: “Your meter, your insulin and rapid acting glucose (Rule of 15g).” You never want to have to walk somewhere to get these items – always have them by your side (especially your meter and rapid glucose).

4.    Carb Counting
Everyone with diabetes needs to learn carb counting. However, if you are determining your insulin dose based on the amount of carbs you are eating, then it is a good idea to be accurate. For school lunches from home, label each food item separately. Your child may not always want to eat all of the wonderful lunch you have prepared, or may want to share with their friends. If the lunch is from the school cafeteria, learn about the foods that the school prepares and identify the weekly food schedule, so your child has a better idea of what to expect to eat for their meal. If math is a challenge, place a small calculator in the lunch box or if they have a smart phone, download an insulin bolus app to assist with accurate insulin dosage determination.  Get children involved in carb counting early – we know parents are usually excellent – let’s help the kids be superstars, too!

5.     Exercise
Sadly, we are seeing less and less formal exercise in schools, but exercise is an important consideration for children with diabetes. The main challenge can be hypoglycemia (low blood glucose levels) with increased physical activity. The opposite challenge can be exercising when experiencing high blood glucose levels. When glucose levels are above 250-300mg/dl, you should always check for ketones in the urine before exercising – never exercise with ketones present. The key to having fun with exercise is to monitor the glucose levels before and after exercise to learn how your child responds to different forms of activity. Perhaps your child could present it as a game for their friends to see which friend can guess the blood glucose change with different types of exercise. Get everyone involved.     

Of course – You should also join the Parents Empowering Parents/PEP Squad group. The best way to reduce anxieties about the school year is to learn and share with those who know best – other parents and children!

Provided by: DRI education team

Currently, insulin can be administered via syringe, insulin pen or insulin pump. It’s a personal choice; however, pumps are increasingly becoming more popular with people with type 1 diabetes and insulin requiring type 2. There are a few key tips for optimizing your success…

Are you a pump candidate?

        • Who wants the pump? You, your family or health care provider?
          Except for a young child, it should be the person with diabetes making the decision.

        • Are you technically capable?
          If you can text on a cell phone, the answer is yes!

        • Are you monitoring your blood sugar levels at least four times a day?
          This is essential with pump therapy given use with rapid acting insulin.

        • Can you carb count accurately?
          This is also essential given insulin dosage is based on the carb information provided.

Explore all your pump options. There are many insulin pumps available in the U.S., with the number and features continually evolving. Be sure you review all your pump options to ensure you make the best decision for you and your life. Essentially all pumps come with smart features and you are generally basing your choice on the different “bells and whistles” available with each pump.

Obtain insurance verification. Know if you are likely to have any out-of-pocket expenses with pump therapy implementation. Each insulin pump company has representatives who assist with this verification process. There should be no surprises!

Get optimal pump training! Most problems associated with pump therapy arise from improper implementation due to a lack of optimal training. There are four phases to pump therapy training:

Phase 1: Technical Training – Learn how to push the buttons on your pump, program settings and undertake a complete site insertion and site change.

Phase 2: Pump Management – Learn how to manage your pump in various life situations. It is essential you receive this information at the time you start insulin pump therapy – not weeks, months or years later.

Phase 3: Follow-up – Ensure you contact your health care team within the first week on an insulin pump to notify them how you are progressing. Your health care team will notify you whether this should be in the form of a telephone call, email or visit, with the latter essential if you are experiencing any challenges. Also, arrange a formal follow-up session with a member of your health care team within three to four weeks for full evaluation and pump download to identify any early opportunities for improved management.

Phase 4: Advanced Pump Features – All pumps come with advanced features to assist people with diabetes to handle different life situations that arise. These advanced features pertain largely to exercise, carbohydrate coverage, sick days or monthly cycles and are unfortunately grossly underutilized or unknown by many people using insulin pump therapy. As I tell my patients, “Why have a Ferrari if you are going to drive it like my Jeep!” So get the best from your insulin pump technology by knowing its full capabilities.

Diabetes Ketoacidosis, or DKA, can be a life threatening situation in type 1 diabetes and is typically a combination of:

Beyond the potential for DKA at the time of diagnosis, our number one focus must be DKA prevention and therefore being forewarned means being forearmed. Below are some key tips to help you reduce your risk for life threatening DKA.

1. Stay on top of illness

Did you know that illness is a key reason for the occurrence of DKA? Illness can place the body under enormous stress, causing release of hormones (counter-regulatory hormones) that raise blood glucose levels. Therefore during times of illness, it is essential to stay on top of your blood glucose levels, insulin administration and keep well hydrated.

Checking for ketones (via urine or blood), especially when blood glucose levels are above 300mg/dl, is an essential management need. Also, if you can’t tolerate fluids due to vomiting, seek immediate urgent medical assistance. General rule: If you vomit twice, get immediate medical attention!   

2. Be prepared

Do you have ketone strips? If so, have your ketone strips expired? Many people are often unprepared to monitor ketones. Just like having your ‘hurricane preparedness kit,’ un-expired ketone strips need to be a part of your ‘diabetes preparedness kit’ if you have type 1 diabetes.    

3. Report changes in ketones early

Don’t wait for the ketone strip to change to purple, like the color of Barney ("I love you, you love me!") before you seek medical help. Detect changes in ketones early (blood glucose levels  above 300mg/dl) and notify your health care team when you identify small ketones. Appropriate insulin and hydration management can stop DKA development.

4. Take your insulin!

Ketone development is a sign that the body is using fat for energy. The body will typically use fat for energy when it is unable to get its preferred source of glucose, due to a lack of insulin. Remember, insulin is needed to get glucose into the cells of the body.

Please let your health care team know if you are having problems getting your supply of insulin or have concerns or difficulties injecting your insulin. This is not a time to be fearful of your health care team, rather the time to embrace their support.

5. Don’t exercise if ketones are present
It is well known that cardio exercise tends to lower blood glucose levels for many people with diabetes. It is important however to check for ketones before exercising if you are experiencing elevated blood glucose levels.

Exercising in the presence of ketones, could actually lead to increased ketone development, due to the lack of circulating insulin in the body (high blood glucose levels). You should always wait until the ketones have gone before exercising and this could take up to 24 hours with correct management.

6. Be aware of the signs and symptoms of DKA

If you experience any of the following symptoms go to your closest Emergency Care Center and tell them the fast track letters of ‘DKA’:

•    “Fruity” smelling breath
•    Nausea
•    Vomiting
•    Stomach cramps
•    Confusion
•    Unconsciousness

Provided by: DRI Education Team

1.    Use heels rather than sensitive fingers to reduce the discomfort of self blood glucose monitoring (SBGM).

2.    Administering insulin immediately after eating might be recommended due to the unpredictability in food behaviors at this age.

3.    Never sneak up on little ones hoping not to distress them with SBGM or insulin injections, as the child may become anxious then when the parent comes closer anticipating a possible shot or blood glucose stick – instead talk them through it calmly and with a hug at the end!

4.    Set up a diabetes station for checks – not at the child’s bed – leave this as their comfort area.  

5.    Review your technique with your health care team if injections seem to hurt.  Ice or a numbing cream might be recommended to help numb the area or devices like ‘inject ease’ could help.  Pumps are also utilized more frequently due to the very small doses of insulin needed in this tiny population – reduces injections to once every 3 days typically.

6.    Check your child’s blood glucose level if he/she is acting out of sorts.  Behavior change may be the first sign of BG changes, typically low BG levels.  Other signs might include sweating, trembling, unusual unsteadiness or a particular cry.

7.    Identify the required amount and type of foods / fluids to treat lows – maybe as little as 5-10 grams of carbs in infants and toddlers.  An oral syringe on hand is a good idea for administering syrup type fluids if low.  Never give anything by mouth if unconscious – instead turn the child on their side and call 911 immediately.

8.    Identify high sugars by an increase in frequency of: diaper changes, infections, sleepiness or fussiness.

9.    Remember increased activity usually lowers blood glucose levels.  Toddlers in particular can have a varied activity level, therefore, more carbs may be required during times of additional activity.

10.    Let toddlers assist with SBGM and insulin injections whenever possible.  For instance, have them choose the site for BG checks or insulin injections.

11.    Check BG more frequently when infants/toddlers get sick.  There is an increased risk for BG elevation.  Remember to encourage lots of fluids.  Check for signs of dehydration: a reduction in wet diapers will be a sure sign as will a dry looking and sounding mouth.

12.    Ask questions and ensure you have an accessible health care team to address any concerns

13.    Don’t use food as rewards.  Instead use stickers, toys, hugs and kisses, or play time.

14.    Make diabetes a family condition.  It is always best when all family members are involved in the care so that the responsibility does not fall on any one person.

15.    Don’t neglect the emotional aspects of diabetes!  It can be frightening to have an infant or toddler with diabetes because of an inability to let you know what he/she is feeling.  Share these thoughts and feelings with other family members or friends, with your health care team or reach out to the PEP Squad (Parents Empowering Parents).

Additional activities and schedule changes associated with the holidays can often bring challenges when managing diabetes.  The holidays are usually a special time for families and children but often celebrations center around food and activities that can bring unexpected stresses, but with some forward planning and creative ideas, can be thoroughly enjoyed.

1. Set realistic expectations for the holidays – expect that with the excitement of the holidays, blood glucose fluctuations, high or low, are most likely going to occur at some point during the holiday season. Keep with the holiday spirit  - Put your energy into the solution, rather than the problem, if undesired blood glucose levels occur.

2. Maintaining your routine of blood sugar checks and insulin administration will help monitor and reduce the impact of the holiday season 

3. If you have family visiting for the holidays, this can pose challenges and stresses on the child’s schedule, especially if their favorite bed and pillow has been given up, even for their favorite grandparent. We all know about the impact of stress on diabetes. 

4. Children with diabetes can have treats – the key is moderation with candy and foods high in carbohydrates and including them within the established meal plan. Think of some creative ways to deal with extra treats – such as trading them or spacing them out over the following months.

5. Try to limit food extravaganzas to the holiday itself rather than to the entire holiday season.

6. Look for opportunities to revise some of the traditional recipes such as reducing the sugar or fat content, including sugar substitutes, cinnamon, nutmeg, vanilla, and other sweet-tasting spices and flavorings. Not only is this better for the child with diabetes but for the entire family!

7. Look for non-food treats and activities to celebrate the holiday season – creating fun artwork, holiday stickers and family events such as a karaoke competition of holiday songs, outings and experiences. 

8. Balance an increase in food intake with fun activities that get children moving – you want to try to limit time in front of the television or on the computer – but make it a family affair, not just something the child with diabetes needs to do.

9. If you are traveling, remember extra supplies, medical alert identification, hypoglycemia kit, time changes and if going to a foreign country, research food choices and key phrases in the local language regarding emergency care.

10. Enjoy the holidays – the key focus should be on spending quality time together with family and friends and collecting lots of fabulous memories that you can talk about for years to come. 

1. Educate yourself and your child. Knowledge is an important key to managing diabetes.

2. Talk to all relevant school personnel. Start with the principal and school teachers, all the way through to the bus driver. Share important information regarding the progress of your child's diabetes self-management activities.

3. Get ongoing support. Speak openly and frequently to your diabetes health care team (physician, nurse educator, dietitian, social worker, psychologist). Share experiences with other families living with diabetes. Join a support group.

4. Provide ample supplies and equipment. Don't only ensure that all the necessary tools are available to your child; know that they're accessible.

5. Know your resources. Parents are their child's No. 1 advocate. Know your legal rights - be patient but diligent. The Diabetes Research Institute Foundation, American Diabetes Association, National Diabetes Education Program and other organizations and websites are invaluable resources to parents.

A Multilevel Approach

As school enrollments grow, so do the health care needs of children in schools. Unfortunately, there has not been equivalent increase in the supply of school nurses, and in fact, many schools operate without full-time school nurses largely due to budgetary restraints. Individual attention to students is often not possible. Clearly, diabetes management in school requires a multilevel approach.

Even if your child has access to a full-time school nurse, the 24/7 nature of diabetes requires that your child and all of his/her caregivers are ready to respond to routine or emergency care needs - eg., field trips, athletic/sporting events, bus rides to and from home, etc. Open and frequent communication between the child, parents and school personnel is essential to the child's success - scholastically, socially and in terms of his/her diabetes management outcomes.

There are sederal and state laws to help protect students with diabetes. It is important to compare federal and state requirements for:

• Americans with Disabilities Act of 1990 (ADA
• Section 504 of the Rehabilitation Act of 197
• Individuals with Disabilities in Education Act (IDEA
• Family and Medical Leave Ac
• Family Education Rights and Privacy Act (FERPA)

It is absolutely essential that parents be aware of the child and their federal and state legal rights. Essentially, the school cannot discriminate against a child with diabetes (disability) and is required to make reasonable changes in its practices and policies to avoid discrimination - to allow children to participate with equal opportunity unless doing so poses "undue burden."

Public schools prohibit discrimination on the basis of disability regardless of whether they receive federal funds. Private entities receiving federal funding may not exclude a child with diabetes if the school can make minor amendments to provide an appropriate education. Private, nonreligious schools are covered by Title III of the ADA.

 1.   Know the actions of your insulin(s)
Knowing the onset of action, the peak action and duration of action of the insulin(s) that you use to treat your diabetes will help you to know when and how to use your insulin(s) to optimize your blood glucose control. Many people for instance are tempted to correct a high blood glucose level two hours after eating, not considering that the rapid acting insulin they are using (Apidra, Humalog or Novolog) lasts for typically four hours – this can lead to possible overcorrection of the blood glucose level and hypoglycemia (low blood glucose). Know your insulin actions to take the right action! 

2.   Site rotation of insulin injections is essential
A key element to insulin effectiveness relates to the site in which insulin is injected. Many people with diabetes have ‘favorite’ sites to give their injections or place their pump catheters, often leading to over-use of the site. Over-use of an injection or pump site can lead to the development of hardened areas which can significantly affect the way the insulin is absorbed from the area. Erratic blood glucose levels can result. Also, there is the possibility for infection and / or abscess formation. So let’s get the best from your insulin injection / pump site and rotate sites widely.  Areas for injection include the back of the upper arm, abdomen, outer thigh and upper-outer buttock / hip region.  Be an equal opportunist! 

3.   Use the insulin delivery tool that best suits your lifestyle
Insulin therapy is essential for life in Type 1 diabetes. Currently available insulin delivery tools consist of syringes, insulin pens and insulin pumps. The choice of insulin delivery tool is very individualized and should (excluding young children) be left to the individual living with diabetes to decide. There have been many times when the insulin delivery tool being used by the individual has been a significant factor in poor diabetes control – wrong tool for the wrong person. It is essential that all people living with diabetes receive optimal education about all the choices of insulin delivery tools that are available, so that they can make an informed and educated decision. Remember to get updated at least annually because technology is changing very rapidly regarding insulin delivery and blood glucose monitoring devices.  Keeping informed keeps you ahead!

4.   Correct basal insulin delivery should lead to the greatest flexibility in meal plans
Before the availability of our current injected basal insulins of Lantus and Levemir or if using an insulin pump, typically Apidra, Humalog or Novolog, the insulin choices we had did not provide true basal insulin. Basal insulin refers to background insulin – it helps to control your liver’s output of stored glucose and is the insulin your body uses to control blood glucose levels when you are not eating. If the dose is set correctly, most people should be able to inject their basal insulin dose (syringe, pen or pump) and be able to not eat for 24 hours without their blood glucose level rising or falling more than approximately 30-40mg/dl. If your basal dose is correct, then you have flexibility in the timing of your meals because your basal insulin dose will keep you steady in between the meals you eat, whenever you choose to eat them. Flexibility is key!   

5.   Matching insulin to the carbohydrate you eat is most physiologic
Except in the cases of hypoglycemia (low blood glucose) or perhaps intensive exercise, insulin is required to cover the carbohydrate that you eat. The dosage of insulin required for carbohydrate coverage will vary depending on the amount and possibly type of carbohydrate eaten, as well as the individual’s specific insulin needs for carbohydrate. Rapid acting insulin (Apidra, Humalog or Novolog) is usually the insulin of choice for carbohydrate coverage because of its rapid onset of action and 4 hour (typically) duration of action. Many people who match insulin to the carbohydrate that they eat have been given a carbohydrate ratio to use. A carbohydrate ratio states how many grams of carbohydrate are covered by 1 unit of rapid acting insulin. Some people may require a different carbohydrate ratio for the various meals of the day or for certain tricky foods, such as sushi, chinese food and high fat foods. Everybody is unique!        

6.   Monitoring your blood glucose levels is key!
Diabetes cannot be managed successfully by using the ‘How you feel method’ – unfortunately the glucose thermostat is just not that sensitive or specific enough. Blood glucose monitoring is essential. For instance, fasting and pre-meal blood glucose values can give you important information regarding your basal insulin doses and 2 hour post prandial (post meal) blood glucose values can give you valuable data regarding meal coverage. It is very important not to constantly react to specific blood glucose values because you risk a reactive management style. You are best to look for patterns in the blood glucose information and make informed insulin changes based on patterns that you see. This is the key advantage of continuous glucose monitors – pattern recognition. Just like the story of the tortoise and the hare – you will get faster to your desired blood glucose destination by taking a proactive and informed approach rather than a rapid and reactive approach.  The tortoise always wins!