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How To: Know How Different Insulin Regimes Compare

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This section is for everyone.

Basal insulin holds the blood sugar steady between meals and during sleep. A bolus is a dose of fast acting insulin given to cover meals or to reduce a high blood sugar.

Here are some popular ways of using these insulins.

Two mixed doses

Eg Novomix or Mixtard.  The basal and bolus insulin is premixed in a fixed combination so that only two injections are needed in a day.

A high level of consistency is needed for meals and snacks. What is eaten and when it is eaten can be manipulated to give good results. The difficulty is that there is very little flexibility and you can’t just miss meals or eat more than usual and get away with it.

If your blood sugars are running high with this regime the main technique to get back in track is to give the injection and wait till the blood sugar has dropped before eating. Lows can also occur and you need to develop snacking routines to even these out.

This regime is often used for people who need help with their injections or who want to avoid injections such as younger school children and in the elderly or visually impaired.

Where money is an issue mixtard is cheaper than then newer analogue insulins.

The best coverage with this insulin is at breakfast and the evening meal. The injections are usually given 15-45 minutes before these meals depending on the type of fast acting insulin used.  A lower carb meal can be eaten for lunch to help keep sugars normal. Alternatively a separate injection of regular or a rapid acting analogue can be given before lunch.

Morning mixed with evening split

Eg Mixtard am, Actrapid pm and Lente bedtime.

This regime covers the dawn phenomenon quite well because of the duration of the lente insulin. The mixed insulin in the morning means that injections during the school day can be avoided.

The minus points are a tendency for lows before lunch and high blood sugars after lunch.

This regime is not used frequently but it can suit some people very well. I know of a teenage girl who has a degree of intellectual impairment.  She has  a considerable dawn phenomenon.  She uses this regime to avoid having to give insulin injections while she is at school.

Multiple daily injections with long acting basal

Eg Humalog for meals and snacks with Lantus once or twice a day.

This regime gives much more flexibility for meals than mixed insulin regimes.

The disadvantages are the number of injections. There can be 4-10 a day.  Insulin pens are generally easier to carry but are more expensive than vials and syringes. The insuflon device can be useful for babies or toddlers on a MDI regime as the insulin is put in the same channel for a day or two so can be less uncomfortable.

This regime is the most popular for most older children and adults. In the USA all children are started on an intensive regime from diagnosis. In Europe there is more tendency to use a mixed regime at least to start with.

When it comes to advanced insulin techniques this is the method that I will mainly be discussing.

Insulin Pump Therapy

This is also known as a continuous subcutaneous insulin infusion system or CSII. It has been developed in the US and is much more popular there  than in the UK.

Plus points are that finer tuning with insulin is possible with this technique particularly due to the ability to alter basal rates.  Most people need to change the insertion device every 1-3 days.  Once this is done there are a greater variety of bolus patterns you can use without having to have another injection.  Many users love their pumps and greatly prefer it to the MDIs especially once over the first few months.

Disadvantages are that it is comparatively expensive. It costs about  £5000 for a pump for five years use with an additional £1000 a year for sterile consumable supplies. You still need to have pens or vials and syringes handy  in case of pump failure.  It is available in some UK centres but the cost is not borne by the NHS and must be paid for in person or from a charity.  A great deal of learning and monitoring is required to use this method successfully.

There are also problems that can occur on the short and long terms. Pump failure through the night can result in you going to bed with normal blood sugars and waking up in diabeticketoacidosis.  Long term scarring at the infusion sites and the occasional abcess can also be problems that result in users going back to MDIs.

Quick Quiz:
There is no quiz for this section.

Reference Info:
Acknowledgements to Dr Gary Scheiner’s Think Like a Pancreas.

Where to Next?
Please all continue to the How To: Calculate My Insulin Sensitivity section.

How To: Use Insulin to the Best Effect

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This section is for everyone.

In this section I am aiming to give you information on  what you need to know to use insulin not just to keep you alive, but to keep you as well as you would want to be if you didn’t have diabetes.

I will be discussing different sorts of insulins and different sorts of delivery devices.  Most basic techniques are covered in your diabetic clinic but here I want to help you take things further. I want to try to help you get the best match possible to cover your daily rhythms and food intake.

As in most of this course self experimentation is the key. Various techniques are described and you have to decide if you would like to use this technique to control your blood sugars or not.  You then need to change what you do in a gradual and controlled way.  Whenever you are experimenting with new food, exercise and insulin patterns you need to test more frequently and be prepared to adjust things according to the results you are getting.

I hope that you will have started to count up how much carbohydrate you are eating each day. You may still be seeking some more information before you begin to reduce it and this is okay.  Arm yourself with lots of test strips for this section!  And lets begin.

What is insulin?

Insulin is a big protein made by the beta cells of the pancreas. It controls several functions in the body.  The most important ones for diabetics are:

Insulin tells certain cells to take in sugar from the blood stream and so drops blood sugar levels.

Insulin tells your liver to reduce the amount of sugar it is making from protein.

Insulin is a growth hormone.

Insulin is a fat storage hormone.

High insulin levels tend to stiffen and age your blood vessels.

In 1922 researchers in Toronto, Banting and Best discovered how to extract insulin from animals to give to humans.

Fine tuning did not really exist until blood monitoring was popularised in the 1980s for all type one diabetics. Since then genetically engineered insulin has been produced from yeast and the e coli bacteria which is structurally identical to human insulin.

Different action times of insulin have been developed by altering the chemical structure of the insulins or by the addition of stabilising substances.

Syringes and vials have been supplemented by pen injectors, pumps, and now inhaled and oral insulins.

There are different potencies of insulin with different onsets and durations of action. Eg rapid acting, regular insulin, intermediate acting and slow acting.

Modern analogue insulins tend to have a more predictable pattern of action than some older insulins. Unfortunately their popularity and higher price has resulted in some older insulins becoming less profitable and there has been a decrease in the range of insulins available as a result. One of the most noticable is the lack of human  regular insulin available in pen form. You can use Novonordisk actrapid in vial and syringe but need to use a pork or beef derived actrapid to have this duration of insulin in pen form. This is available from Wockhardt in the UK and the Owen Mumford Autopen Classic is the delivery system but is only available in one and two unit increments.

In general the total carbohydrate content of a food is a more important consideration than the amount of sugar in it. Whether it is a starch or a sugar that is present the same amount of insulin is needed to deal with it and both types raise your blood sugar pretty fast. Your major challenge is to carefully match your insulin intake to your carbohydrate intake. There are also factors like exercise, stress and illness to be considered.

Where do I inject?

One of the best sites to inject insulin is in your bottom or on the fat pad above your trouser line. These areas usually are quite fatty and tend to hurt the least. You are also most unlikely to mistakenly inject into a muscle.

Other sites that you may use in public are your abdomen or your thighs. You can adjust your clothing or inject through it.

Some people prefer to inject in a washroom and others will be happy to inject at the table in a restaurant or plane.

How do I inject insulin?

If using a vial and syringe the best technique is to draw up the insulin smoothly and quickly and inject it smoothly and quickly.  Dr Bernstein has a video of this in his CD series.

If you use a pen you need to count to ten slowly, “one thousand, two thousand…” etc.  Otherwise the insulin tends to leak a bit more than you would like.

For pump users they need to change the site anything from daily to every three days. The abdomen and  rear trouser line are the most popular. Special hygeine routines are helpful in preventing infection.

If you are using plain needles you don’t need to clean the area with an alcohol swab. You just inject.

The needle depth and fineness can vary.  6, 8 and 12 mm needles are available in the UK.  If you are pretty thin or using your thighs a smaller needle is often used. If you are fatter or prefer your backside the longer needles are better.

In some circumstances you may want to put the needle into muscle. This could be for the purpose of achieving a more rapid effect which you may want to use if correcting for high blood sugars.

Basal Insulin

The basal insulin level should be matched to the liver’s normal secretion of sugar.  Because the liver tends to produce different amounts of glucose at different times of the day and night the insulin requirement will also vary. The right basal rate is one that keeps your blood sugar at a fairly constant level when you have not eaten or bolused for several hours and are not exercising.

An insulin pump gives the most flexibility over basal insulin dosages at different times of the day.

For people on a multiple daily injection regime the main analogue basal insulins are Lantus and Detemir known in Europe as Levemir.   Lantus should not be mixed with other insulins because it depends on its action for its acidic pH.  Detemir has 75% of the potency of Lantus. It is not acidic and does not sting like Lantus can when it is injected.

Lantus lasts about 22 hours in most people and Detemir lasts about 16. Either insulin can sometimes be given once a day successfully for some individuals but most people get on better with twice daily injections for both of them.  The best time to give them is right before bed and when you get up in the morning. If you have a marked dawn phenomenon no more than a 9 hour gap between the night and morning injection is recommended by Dr Bernstein.

It can take about three days for your blood sugars to stabilise after altering your twice daily basal so it is best to keep changes to three days apart or more so you can get a true reflection of the results of your insulin adjustments.

Older insulins have been stabilised so they last a long time such as  the Lente and Ultralente insulins. They are sometimes combined with shorter acting regular insulins so you can reduce the number of daily injections.  If you have a  cloudy insulin such as this it needs to be mixed thoroughly before injection. Rolling the vial or pen gently up to 20 times is advised.

Protecting Insulin

Your insulin stores can be kept stable for years in  a correctly maintained domestic refrigerator but once out and about insulin needs to be kept at room temperature or a bit cooler to retain its potency.

It can go off rapidly if overheated eg from being left in a car on a hot day.  Lantus is particularly fragile and light can affect it too. Lantus lasts in good condition for about 3 weeks and most others last about 4 to six weeks.

When you are going to be in a hot environment you can store your insulin in a frio wallet. These are available in the UK from Boots online. They are more widely available in the US. These come in different sizes and can hold insulin pens or vials.

When you travel on a plane you must keep your insulin in your hand luggage. If it goes in the hold it could freeze without you being aware of it and this too will seriously impair its effectiveness.

When you go skiing or out on a very cold day keep your insulin next to your body to prevent freezing too.

Missed a dose?

If you miss your basal by only a few hours you may simply give it as usual. If you are more than 4 hours late however the action you take may vary.  Let us assume you are awake during the day and sleep at night.

You miss your night basal which you normally give at 10 pm and remember when you get back from the party at 3am.

Check your blood sugar. You are a bit high. Give a proportion of your basal let say half of the usual dose and go to  sleep. You  probably need to sleep before work tomorrow more than worry about whether any correction dose you are thinking about is going to drop you too low through the night, especially if you have had more than one alcoholic drink.

You are likely to have to give a correction dose along with your morning basal but monitoring your sugars is easier during the day when you are awake. Put it down to experience.

You can even write essential tasks or times on ball point pen on the back your hand. Usual handwashing takes about a day to clear it and if you want to wipe off your “to do” list   little alcohol swabs come in handy.

You miss your morning basal You took your basal insulin with you to a friend’s last night and remember in the morning that it is still in your bag which is in her car. She lives across the city, and the pharmacy does not open till 2pm, and you have no spare because you have not been paying attention to the advice you were given in the organising your supplies section.

Give yourself a series of correction doses during  the day before your meals. You can use novorapid or humalog and these last about 3 and a half hours.  If you have regular insulin this is  even better as it lasts 5 hours.  Start your basal again with the night injection.

Missing a day dose is usually easier to deal with because you are awake and you can correct any lows easier.  Keeping a notebook or having one of the new pens that records your doses can be helpful. Because looking after your diabetes becomes so automatic you can easily get muddled up about whether you took the dose or not. When you are one of two parents or carers and not the diabetic person it is even more important to record what you do.  Without this it can be  even easier to make mistakes and give an infirm person or a child two doses of insulin or none !

It is human nature to muddle up from time to time. When you do, the most important things are  forgive yourself,  calm yourself down, and  THINK !

 

Quick Quiz:

Have you got it?

1. In a restaurant three of these places are suitable for insulin injections…

a In the washroom.
b In the abdomen at the table.
c Through your clothing.
d Hiding underneath the table.

 

2.The Glycaemic Load of a food is …

a Its relative effect on your blood sugar.
b A measure of the percentage of carbohydrate it contains.
c A measure of how much insulin is needed to cover the food.
d A measure of how much the food fills you up.

3. The Glycaemic Index…

a Has been extensively tested on diabetics.
b Tells how fast your blood sugar will go up with certain foods.
c Should be the basis for a sensible eating plan in every diabetic.
d Needs to be verified by personal experimentation.

4. For insulin users you need to monitor you blood sugars in three of these situations…

a Before and after exercising.
b Before you drive and at hourly intervals when driving.
c Before you go into a public place like a cinema.
d Whenever you feel hungry or suspect you could be running higher or lower than normal.

5. Three helpful tips for type one youngsters include…

a Have your bracelet, insulin, tester and food when you are on an outing.
b Carry a charge mobile phone.
c Carry money in case you need to buy food.
d Avoid telling your mates you are diabetic so you will fit in better.

6. Three of these statements about insulin are correct. Which one is not correct…

a Lantus must never be mixed with other insulins because it depends on its acidic pH for it’s action.
b Cloudy insulins must be mixed thoroughly before injecting.
c Detemir has twice the potency of Lantus insulin.
d Humalog and Novolog have 150% of the potency or regular insulins.

7. Three statements about basal insulin are true…

a It is used to cover meals.
b It should be matched to the liver’s normal secretion of sugar.
c It is needed to keep the blood sugar level steady between meals and during sleep.
d Can be most accurately obtained by using an insulin pump.

8. At college don’t bother with one of these…

a Testing your sugar before exams.
b Eating food when you drink alcohol.
c Getting your flu shot every year.
d Going to parties.

9. When you go on holidays it is silly to do one of these…

a Go to a theme park and forget a rendezvous point.
b Carry extra food and drinks on planes.
c Test draught drinks with diastix.
d Work out how you will deal with time zones before you go.

10. Advantages of being a type one diabetic can include three of these…

a Getting a fridge in your room at college.
b Getting a room nearer the kitchen at college.
c Sleeping in on the mornings on days off.
d Getting a pass to skip long queues at some theme parks.

Have you got it?
1. D is taking secrecy too far! Although many people still prefer the privacy of a washroom it is entirely acceptable to inject at the table. With the rise in the number of people with diabetes you can expect to see this happening more frequently.

2. A is correct. The GL is and indication on what effect you can expect that food to have on your blood sugars. The carbohydrate index is the percentage of carb a food contains. This can be a helpful technique in carb counting.

3. D is correct. Its all about self experimentation. The GI was tested on healthy non diabetics. It is a rough indication of how fast sugars are released and diabetics are wise to steer clear of very fast acting carbs. The precise rate of release however depends on so many factors such as quantity, chunk size, temperature and what sorts of foods are eaten along with them that personal experimentation is the only way to find out how a food that you eat regularly will affect you.

4. ABD are musts. Use your own discretion in other situations.

5. ABC are sensible. Not telling your mates isn’t!

6. ABD are all correct. Detemir is weaker in effect than Lantus unit for unit. Detemir has around 75% of the potency of Lantus. As these are both basal insulins it is unlikely that you need to remember this unless you swap one for the other for a particular reason.

7. BCD are correct. Pumps can be adjusted for the dawn phenomenon and exercise patterns with much more versatility than basal injections. This is one of their major advantages. There are trade offs in other respects of course. Bolus injections are used to cover meals.

8. D. Parties can be quite a challenge for young diabetics away from home. Always drink moderately and avoid drugs. Let your mates know about how to detect and treat hypos. If you have passed out they must get you to hospital.

9. A is correct. It is also sensible to write down exactly where you have parked the car! Diastix were originally used to detect sugar in urine but they can be very handy for testing whether your cola is the diet version or not.

10.ABD are correct. And you didn’t think there were ANY advantages to being insulin dependent did you? Unfortunately having a lie in is not on. You must get up at the usual time to test and give yourself your basal insulin at the very least.

Reference Info:
Acknowledgements to Dr. Bernstein’s Diabetes Solution and Dr Schiener’s Think Like a Pancreas.

Where to Next?
You could be a bit tired out by that long quiz. Take a break and lets all meet back at the How To: Know How Different Insulin Regimes Compare section.

How To: Follow Dr. Bernstein’s Dietary Plan

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This section is for everyone.

Dr Bernstein’s dietary plan is at the strict end of the low carb dietary scale. The diet consists of planned, carefully measured, prepared and consistent amounts of protein foods and non starchy vegetables. In addition double cream, cheese and soya products are allowed. You can have some low carbohydrate sweeteners and beverages.

He aims to give suitable and small amounts of carbohydrate required for good health with the trade off that minimal amounts of insulin with then be required from the pancreas in type twos and by injection for type ones.

The exact monitoring system and ways to trouble shoot problems that crop up along the way are described in detail with a full account of the rationale. The reasoning is impeccable, the results are impressive. The difficulty is that it is a tough plan for most of us who love eating fruit, grains and starches.

The food is pleasant to eat as tasty fats, spices and herbs are used to give a wide variety of flavour.  The Bernie forum members have experimented with ingredients so you can eat cakes, biscuits, bread as well as main course and starter dishes. I would say that the difficulty lies in the daily planning and meal preparation that is needed. It is the consistency in doing this day after day that can be particularly hard to do.

You do need motivation to follow Dr Bernsteins diet for long periods of time. If you are on insulin however you do need to be highly consistent with your meals for control and safety in any event.

If you already have the complications of diabetes and can see that you are steadily getting worse you may now be at the point that you will do what it takes. If you are a type two diabetic who is really keen to avoid insulin injections now or in the future this plan offers real help. Although diabetes is still an incurable chronic disease it is very treatable and the long term complications are almost fully preventable.

You will get the best results from reading Dr Bernstein’s book “Diabetes Solution” particularly if you are insulin dependent.  Those not on insulin could read “Diabetes Diet.” You may also find listening to his podcasts and CDs and joining the forum on his website to be of interest and informative. It can help to chat on line to people who have similar difficulties to you.

When you change your eating pattern so radically it can help if you live with someone who can help you with your diabetes and food preparation.  The transition phase is the most risky for insulin dependants having hypos. Although Dr Bernstein himself advocates a rapid transition to meals of 6 and 12 g of carb at a time, he can do this because he is very experienced and keeps a daily check on his patients till they are stable.  Outside of this situation I would always advocate a planned and stepwise reduction in carbohydrate intake.  You can read more about this in the “Atkins in Reverse”  chapters in the type 2 section.

You will need to monitor your sugars much more closely in the transition phase and adjust your insulins downwards with care and in response to your blood sugar readings. This does take considerably longer to get stability than if you were one of Dr Bernstein’s patients, and your carb cravings will continue for longer, but it is the only way to do this in safety without the direct supervision of an experienced health professional.

Due to the high level of consistency required and more time and effort into sorting out your diabetes than you have probably ever done before,  I do not recommend you start this plan until you have overcome any major outstanding personal or domestic issues. You can do this plan even if you don’t have much money, but if your life is chaotic and you don’t have support I suspect it would be just too hard.

Dr Bernstein’s entire plan is well worth reading for the detailed information he provides about all aspects of diabetes management that is not easily found in one place. I see his plan as an ideal to aim for if you are looking for optimal control over your blood sugars. The most helpful part I have found is that I don’t have to worry about hypos when my son goes to bed at night.

Even if you do not follow the plan to the letter you are very likely to get much better control than you are already getting now by a planned adoption of the aspects of the plan that you CAN achieve consistently. YOU have to find out how to get the best sugars you can for YOU with the food you are happy to eat day in and day out.

Quick Quiz:
There is no quiz for this section.

Reference Info:
Dr. Bernstein’s Diabetes Solution

Where to Next?
Please continue to How To: Use Insulin to the Best Effect section.

How To: Decide What To Eat When Using Insulin

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This section is for everyone.

The two dietary plans I wish to discuss in this section are Dr Bernstein’s and Dr Jovanovich’s plans.  Both of these diets call for a restricted amount of carbohydrate at each meal. Both doctors are type one diabetics themselves.

Dr Lois Jovanovich works in Santa Barbara California. She treats all kinds of diabetics but has a particular interest in improving the outcomes in pregnancy for type one, type 2  and gestational diabetic women.

Lois advocates a ceiling of 30 g of carb for each meal. If a snack is necessary it should be no more than 15g.

She admits pregnant patients for stabilisation of their diabetes as soon as a pregnancy is known about. By careful diet, exercise and insulin treatment her aim is to achieve non diabetic blood sugar levels. By this method she has greatly improved the outcome of these pregnancies for both mother and especially the babies.

It is imporant to note that the carbohydrate values she gives are limits not targets. The goal is to achieve as normal blood sugars as possible. If you can get there at 30g of carb a meal that’s okay but if you don’t you go lower.

Dr Richard Bernstein works in Marmaroneck New York State and has spent the last 25 years in practice dealing with diabetic and prediabetic patients. Richard was diagnosed with insulin deficient diabetes when he was 12. He followed standard dietary advice but by his 30s had severe and life threatening complications affecting his blood vessels, eyes, kidneys, heart and joints.

There were three factors that turned his life around. He was an engineer who was used to solving problems. His wife was a physician who helped him buy the first portable blood sugar meter that was only sold to physicians. He knew his life was on the line and this made him determined to beat diabetes.

After considerable research he found that the way to stop the painful and debilitating complications of diabetes was to maintain normal blood sugars as much of the time as possible.

“The Law of Small Numbers”  is the core of his method of controlling blood sugars.  There are many things about diabetes you cannot reliably control but the ones you can – you do.

Regarding diet you can predict what rise in blood sugar you are likely to have simply by eating foods that will affect your blood sugar in a small way. Even if you were to measure foods accurately there can be as much as 20% error allowed to the manufacturer when listing ingredients. If you stick to low levels of slow acting nutritious carbohydrates such as vegetables the results will be more predictable than large amounts of rapid acting carbohydrates such as bread, rice, potatoes or sugar.

Covering carbohydrates with insulin is a task full of uncertainty. There is about a 30-50% variation between the effects of the same insulin amount injected from jag to jag. This can be minimised by reducing the amount in any one injection to 7 units or less and keeping the carb count low with the gradual release of sugar that comes from vegetables high in cellulose.

For type one diabetics three meals a day is best. This minimises insulin injections and gives opportunities three or four times a day to correct the blood sugar to normal levels.

By careful experimentation Richard discovered what factors made his sugars stay normal and what factors made them go too high or too low. Many of his complications started to reverse including the kidney disease, neuropathy, heart and eye disease.

To his surprise and eventual dismay Richard  found that the medical profession of the time were not interested in his results, his method or his meter. So he decided he would need to become a doctor himself in order to let patients know of his success and he entered medical school at the age of 45.

Dr Richard Bernstein’s publications contain comprehensive and detailed advice that is based on what works for diabetics. In particular he emphasises the benefits of a very low glycaemic / carbohydrate diet. Much of what he says is still in conflict with the advice that is given out by The American Diabetes Association, Diabetes UK and most NHS dieticians and diabetologists. Unlike these people and organisations however he is absolutely rigorous in letting the reader know the scientific fact that underpins his advice.

The reason you are reading how to look after you diabetes on the web instead of from your local diabetes team is that the medical establishment are thoroughly entrenched in their high carb / low fat ways.

Unfortunately if you eat the way many diabetic clinics tell you to you will make it unnecessarily hard to control your blood sugars and this will make the development of diabetic complications inevitable.

This low carb diabetic course has been compiled by myself with the generous help of other diabetics, their carers and interested doctors and researchers. It takes a lot of nerve to do something very different from what a diabetic specialist or dietician tells you. My son Steven developed type one diabetes at the age of 12.  I am absolutely determined that he will have the same chance to enjoy a full and long life as his non diabetic brother. Fortunately many other people have the same aims for their relatives, friends and for themselves.  We have joined resources on Dr Bernstein’s forum to help you have normal sugars and prevent and reverse diabetic complications.

Quick Quiz:
There is no quiz for this section.

Reference Info:
Acknowlegements to Dr Lois Jovanovich’s many web published articles and lectures and Dr Richard Bernstein whose masterpiece “Diabetes Solution.” could be regarded as the core text of this course.

Where to Next?
Please all continue to How To: Follow Dr. Bernstein's Dietary Plan.

How To: Be the Star of Your Diabetic Clinic

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This section is for everyone.

If you haven’t been the star of the diabetes clinic yet, here is where to start:

1. Check your blood sugars before each meal and snack and write down the results.

2. Get advice on how to adjust your insulin doses appropriately based on your blood sugar results.

3.  Begin to record the carb content of your foods and write this down too along with your insulin doses.

4. Learn to adjust your insulin dose to your carbohydrate content.  You need to be very consistent about this with fixed insulin regimes and consistency will get you better results even if you are on a multiple daily injection regime.

5. Start some daily exercise and note what effects that is having on your blood sugars too.

6. Get advice on adjusting your insulin to physical exercise.

Quick Quiz:
There is no quiz for this section.

Reference Info:

Where to Next?
Please continue to the How To: Decide What To Eat When Using Insulin section.

How To: Prepare Myself for My CollegeYears with Diabetes

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This section is for type ones who are going off to college or leaving home for the first time.

You may wish to proceed to the How To: Know if My Insulin is Still Good article if you are not in this situation or when you have completed this module.

If you drive test before you set off and every hour on a long journey.

Keep supplies in your car.

Slightly impaired vision is often the first sign of a hypo. Have some small print stuck down to the dashboard from an old telephone book for instance.  If you have difficulty reading it you must check your blood sugar.

Set up your room at college the same as at home with a special “diabetes drawer.”

Make sure your friends know that certain foods are off limits. You need it to prevent hypos.

When you move to a new campus or area check out cafes and 24 hour food outlets like garages.

Register with the student health centre or a new Family Medicine Doctor and have a copy of your important notes sent to the new doctor.

Have a hard copy summary sheet of your computerised notes at your new room so you can take it with you if you need to attend a hospital.

Have all of your diabetes prescriptions sent to the new Pharmacy before you start or within a week of starting so you never run out.

Make out your own personalised hypoglycaemia card and put it in you car, your kit bag, your room and give it to your mates. (also reference the section How To: Deal with Low Blood Sugars)

If you DO run out most pharmacists will dispense for you in an emergency.

In your diabetes drawer you will need:

  • Insulins
  • Insulin kit eg needles, pens, syringes, lancets, needle clipping device
  • Spare meter batteries
  • Testing strips
  • medical id and summary sheet
  • cin bin
  • frio bags
  • ketone test strips – they go out of date 6 months after opening them.
  • Glucagon
  • Glucose drinks, tablets and gel.
  • Packets of cheese eg dairylea triangles, uht milk, crackers, cookies, nuts, crisps.
  • Possibly ice packs and a cooler

Spare insulin and food should be in a fridge.

If you have a pump remember to bring all your back up stuff as well eg pens, syringes and cartridges.

It is best to have two sets of insulin/pens/meter/lancets/glucose in case one gets left behind when you are out.

Keep a typed list of phone numbers beside your phone:

  • parents
  • doctor back home
  • diabetologist
  • new doctor
  • adult brothers and sisters

It is a big responsibility looking after yourself in college never mind diabetes.  Always carry your kit with you. Always get up at a reasonable time to test, give insulin and eat, even if you go back to sleep afterwards and miss class.

Quick Quiz:
There is no quiz for this section.

Reference Info:

  • Acknowledgements to Spike and Bo Loy’s “487 Tips for kids with diabetes.”
  • Their mother Mrs Loy has written a book to help college age kids and their parents help with the transition between home and college. I have not read this book but it sounds really useful and I would be grateful for any reviews.
  • www.youthhealthtalk.org/diabetes Is a UK based site where 38 type ones aged 15-25 have given video interviews about a wide range of issues that affect them. It includes how to deal with parents, travel abroad, eating disorders and much, much more.
  • College Diabetes Network: Preparing to Leave

Where to Next? 
Proceed to the How To: Know if My Insulin is Still Good section.

How To: Deal with Low Blood Sugars

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This section is for everyone and their helpers. Because hypos can rapidly render you confused and helpless, everyone needs to know what to do about them. There is  quiz at the end which all of you should do.

It is essential that you, your family and work colleagues know exactly what to do if you become low in blood sugar.

If you are a kid tell the bus driver, your friends and your teachers that you have diabetes and what to do if you look low.

Make out a personalised sheet and give it to anyone who may be in a postion to rescue you out of a hypo. Put a copy in the survival pack.

For example:

I am Jenny Smith. I have insulin dependent diabetes.  When I have low blood sugars I show these symptoms:

  1. I am usually irritable.
  2. I go pale.
  3. I start to sweat.
In this event, do this:
  1. Give me some lucozade. It is in my backpack. Look for some glucose tablets in my pocket and give me those.
  2. Give me a drink of milk or sugary water or fruit juice.
These symptoms happen when my brain is not getting enough sugar. I cannot think and act appropriately for myself and may be bad tempered. If I don’t get sugar I could pass out.

In case of difficulty please call:

  1. Parents… Joe and Carol Smith 1234 456789
  2. Friend…Mary Swanson 2468 101213
  3. Doctor…Dr Margaret Reilly 3579 111315

If you don’t know what to do, or my medical condition does not improve or I pass out please call 999 or 911.

Thankyou.

For those that own cell phones there is a movement underway due to the many terrorist-type events that is useful for diabetics which is an ICE (In Case of Emergency) entry (or entries) in their cell phones.  For more info on creating an ICE entry see this USA Today article.  In the event of an emergency if they don’t see a bracelet or necklace with medical info it can give someone the same 3 numbers above in your letter.

When it comes to going out on dates with new people you don’t have to go as far as this!  On the other hand diabetes is not something to hide either.  If someone isn’t okay with you having diabetes would you really want to go out with them anyway?

Keep supplies to deal with hypoglycemia in your home, your car, your office, your sports bag, locker, at school and on your person.

Having a medic alert bracelet on your wrist or a special dog tag round your neck as long as it is easily visible can help bystanders figure out what could be wrong and get appropriate help for you.
After any episode of hypoglycaemia you need to figure out why you went so low so you can sort out any problems or plan to do things differently.   You may not catch every hypo but you will reduce the frequency and severity of hypos by doing this.

Effects of low blood sugars on the brain as the condition worsens are:

  • Delayed reaction time.
  • Difficulty reading small print.
  • Irritable stubborn behaviour.
  • Confusion
  • Clumsiness
  • Difficulty in speaking
  • Weakness
  • Sleepiness
  • Unresponsiveness
  • Loss of consiousness
  • Convulsions
  • Death

If you suspect a hypo the first thing you should check is your blood sugar.  Ask your helpers to ask you to check your blood sugar if they think your sugar level is low.

This will cause less fighting than trying to force you to eat something.

If you are out with your mates and have drugs or drink and pass out they MUST ring 999 / 911 and get you to an Emergency Department right away. They may think you are just drunk. You may not be. You may be dying.

If you have been doing drugs and get into a mess call your parents. They may be shocked and angry but it is a rare parent who won’t help.  They will do their best to get you safe and sorted.

These are things you may notice when you are going low:

  • Hunger can be a symptom you are going low but about half the time it is just plain hunger and your sugar is in the normal range. So check your sugar before treating lows unless you are very sure.
  • Blurred vision
  • Headache
  • Hand tremors
  • Tingling sensation in the fingers or tongue
  • Buzzing in the ears
  • Tight feeling in throat or tongue.
  • Anxiety
  • Sudden awakening from sleep.
  • Feeling light headed
  • Hot feeling
  • Insomnia
  • Nightmares
  • Nausea

These are signs other people may notice as you go low:

  • Dilated pupils
  • Violent behaviour
  • Shouting while asleep or awake
  • Rapid shallow breathing
  • Cold or clammy skin
  • Restlessness
  • Pale complexion
  • Slurred speech
  • Nystagmus- jerky movements of the eye when looking slowly from ear to ear.

Self treatment of hypos

Hypoglycaemia symptoms and signs often follow a typical pattern for each person. If you know that you become a certain way only when you are very low you could be best to give yourself glucose right away – then test.

Low blood sugars often occur right before meals, after exercising, and when insulin is peaking and sometimes in the middle of the night.

Try not to eat too much when you are low because overtreatment of hypos will make you go too high afterwards.

If your sugar level has been too high and you have taken a correction dose your sugar can drop fast. This can make you feel low. A way to stop this feeling is to eat a small amount just after you inject.

To raise blood sugars cleanly and predictably it is best to use pure glucose.  This can be in gel, tablet or liquid form.

Food substances like milk, juice and sweets are a bit slower in onset and the amount of carbohydrate is difficult to measure.

If you don’t raise your blood sugar rapidly enough you will often end up having more to eat and then having high blood sugars for hours later.

A dextrosol tablet contains 3g of glucose.  If you can get them Smarties  candy are great as they are easy to keep in a pocket or  in your blood tester and are about 1/2g of dextrose each.

If you weigh in kilograms: 3g of carb will raise your blood sugar UK / US

  • 16kg     3.33 / 59.9
  • 32kg     1.68 / 30.2
  • 48kg     1.17 / 21.0
  • 64kg     0.84 / 15.1
  • 80kg     0.66 / 11.8
  • 95kg     0.54 / 9.7
  • 111kg   0.51 / 9.1
  • 128kg   0.42 / 7.5
  • 143kg   0.36 / 6.4

Most glucose tablets start to take effect in 3 minutes and have worn off by 40 minutes. Test 15 minutes after you take glucose to see that you are rising if you are not feeling an improvement by then.

Sometimes due to the effect of adrenaline you can be quite shaky for an hour or more after your blood sugar has come back to normal. You may also be quite hungry and you  may need to eat a meal or snack.

Common Causes of Hypoglycaemia

  • Too long a delay in eating your meal after an insulin injection.
  • Delayed stomach emptying after a meal.
  • Eating less than you planned for the given insulin dose.
  • Drinking too much alcohol. What is too much? More than just one unit for many insulin users. Sorry.
  • Hormonal changes in certain phases of the menstrual cycle.
  • Sudden return to normal after a period of insulin resistance such as when recovered from an illness.
  • Injecting from a new bottle of insulin when the old one had lost some of its effectiveness.
  • Switching insulin types without considering different potencies of different insulins. Eg lispro and aspart the rapid acting analogues have 150% of the potency of regular insulin.  Levemir has 75% of the potency of Lantus.
  • Taking too much insulin.
  • Not rolling cloudy insulin suspensions adequately.
  • Mistakenly injecting insulin into a muscle.
  • Lying too long in a hot tub.
  • Effects of exercise that have not been covered by sufficient insulin reduction or carbohydrate intake.
  • Injecting near a muscle that will be strenously exercised.
  • Some medications cause hypos.
  • Some insulins are not as stable as you would like and are more prone to giving hypos eg NPH.
  • Two different carers give someone their insulin without checking first.
Quick Quiz:
Because low blood sugars can incapacitate you so quickly this quiz should also be done by your nearest and dearest.
1. Three of these lower the blood sugars….
     a Heat and humidity.
     b Depression.
     c Previous intense exercise.
     d Intense brain work.
2.  Three causes of low blood sugars include…
     a.  Sudden return to normal after a period of insulin resistance during an illness.
     b   Urinary tract infection.
     c   Injecting from a new vial of insulin.
     d   Lying too long in a hot tub.
3. Three signs of low blood sugar are….
a Raised pulse rate.
b Jerky movements of the eyes when looking slowly from ear to ear.
c  Pale skin.
d Vomiting.
4. When you suspect a hypoglycaemic attack you should do one of these things…
a Check your blood sugar.
b Go for a walk.
c Drink a big glass of water.
d  Phone for an ambulance to take you to hospital.5. Effects of low blood sugar on the brain include three of these…
a Delayed reaction time.
b Irritable, stubborn behaviour.
c Dry mouth.
d Difficulty reading small print.

Have you got it?
1. ACD are correct. Depression and stress cause a rise in cortisol that usually raise your blood sugars somewhat.

2. ACD.  Infections tend to increase blood sugars.

3.  ABC are correct. Vomiting can be a sign of high blood sugars. It also happens if you have had to inject glucagon to treat a low blood sugar.

4  A. Many people find it is only low about half the time.

5. ABD are correct. Dry mouth is more commonly associated with high blood sugars.

Reference Info:

Acknowlegements to Dr Bernstein.

Where to Next?
Please now continue to the How To: Advise My Helpers of Low Blood Sugars section.  If you have successfully got your nearest and dearest handy for this section don’t let them out of the house.  They have to do the next section too!

How To: Prepare a Diabetic Child for Life Outside the Home

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This section is for children and their parents and carers.  You can skip this section if you are not in this situation and proceed to the How To: Know if My Insulin is Still Good section.

Equip your child with a “survival pack” that contains everything they will be likely to need if they are out for the day.  A small rucksack, big bum bag or shoulder bag can work well.

  • In it put the insulin, tester and glucose drink, tablets or gel.
  • Wear the alert bracelet or dog tag.
  • Put some carbohydrate containing food in the bag or carry it in a pocket.
  • Carry a charged mobile phone.
  • Carry some money to buy food if necessary.A container of diastix for testing draft “diet” drinks.
  • A copy of the “Hypoglycaemia” emergency card with your home contact and mobile numbers on it.
  • A copy of the personalised “How to deal with hypoglycaemia” information (see How To: Deal with Low Blood Sugars)

When going on a lengthy outing encourage them to go with others rather than alone.

Take the glucagon trip on an overnight stay.

Always ask what food they can eat if you go low if you are staying at someone’s house.

Advise them to take more supplies than they think they will need if  going on a bike ride or long hike.

Have a stash of fast acting carb in one place that can be used for lows.

Bring diet drinks to a party.

Ask for a locker at school or storing extra food/diet drinks/juice. They may not be available to everyone but they may give one to an insulin dependent diabetic.

 

Quick Quiz:
There is no quiz for this section.

Reference Info:

Acknowledgements to Spike and Bo Loy’s, 487 Really Cool Tips for Kids with Diabetes

Where to Next?
Please now continue to the How To: Prepare Myself for My CollegeYears with Diabetes section.

If college is a long way off yet you may skip this section and proceed to the How To: Know if My Insulin is Still Good section.

How To: Know if My Insulin is Still Good

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This section is for everyone.

Never use insulin that doesn’t look right. Humalog, Novorapid, Regular, Lantus and Levemir/Detemir should look clear.

Novorapid lasts six weeks.
Lantus can go off after 3 weeks and is the most vulnerable to going off if exposed to heat or light.
Most others last a month.

If your sugars are going a bit high consider if old insulin may be the problem and open a new vial. New insulin can be more potent than month old insulin.

Heat can cause long lasting insulin to act like short acting insulin and give you low blood sugars. Leaving it in a hot car can cause this effect.

Get a big cin bin from a pharmacy or your diabetes clinic to dispose of your sharps. Take it back for a new one when it is full.

 

Quick Quiz:
There is no quiz for this section.

Reference Info:
Acknowlegements to Spike and Bo Loy. 487 Really Cool Tips for Kids with Diabetes

Where to Next?
Please continue to How To: Be the Star of Your Diabetic Clinic

How To: Create An Emergency Information Pack

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This section is for everyone.

Hypoglycaemia

I have diabetes and I take insulin or  medicine which can lower my blood sugar.
Low blood sugar levels can cause death and brain damage. Please help me.

If I cannot be woken up or walk or talk easily please take me to a hospital with an accident and emergency department or call an emergency ambulance right away.
I will need to have a glucose drip to raise my blood sugar.

If I am confused please give me a glucose drink. I may have glucose gel, tablets or a sugar drink in my pockets or bag.

I have already taken a glucagon injection.

I have not taken any glucagon.

Thank you.

Name
DOB
Passport Number
Contact Phone No

Vomiting and Diabetes

I have insulin dependent diabetes.

I need to see a doctor at an accident and emergency department right away.

I am very ill and need an intravenous saline drip.

I think I am developing diabetic ketoacidosis.

I have been vomiting repeatedly.  I cannot stop.

Please phone an emergency ambulance right away.

My blood sugar is now………………………………………….

I am showing ketones in my urine.

I am not showing ketones in my urine.

I think the cause of the high blood sugars is:

I have an infection.

I did not take enough insulin.

I got dehydrated.

Thank you for helping me.

Name
DOB
Passport Number
Contact Phone Number

Food Choices

I have diabetes.  To keep my blood sugars as normal as possible I need to eat more of some foods and less of others.

I particularly find that eating certain grains and starches can make me feel very ill.

It is very important that I am able to choose food from the entire menu and choose the portion size of  the foods that I need.

Thank you for your understanding.

Self Monitoring of Blood Sugar

I have diabetes.  I do my best to keep my blood sugars as normal as I can when I am at home.

Having very good blood sugar control  is particularly important  in a hospital and when getting over illnesses or operations when infection can so easily get a hold in someone with diabetes.

Because I have developed such a fine personal awareness of exactly how best to manage my blood sugars it is essential that I continue to do this for myself while I am here.

I would therefore ask you to respect the need for my blood sugar monitoring kit to be beside me at all times.

I will also need to have:

My insulin delivery kit.

My “hypo” food  and drink kit.

My drinking water.

Thank you with your help for this most important part in getting me well again.
I really appreciate it.

Foreign Travel

It is a good idea to construct personalised emergency information before you ever need admitted to hospital.

If you plan to travel to an area where you are NOT fluent in the language you can use Google Translate  to translate any text that you type in. Many languages are available from the Google Translate  site. There are also many mobile apps to do the same thing.

Quik Quiz:
There is no quiz in this section.

Reference Info:

Where to Next?
If you are carer for a child with diabetes or you are that child please continue to How To: Prepare a Diabetic Child for Life Outside the Home section.

Otherwise please continue to the How To: Know if My Insulin is Still Good section.