diabetes management lecture 8

Your Diabetes Regimen(Putting everything together)

Lecture 8

by Eric Holzman

A Diabetic’s Guide to Managing Diabetes

by Eric Holzman9-20-07 2

The Do’s and Don’ts of good diabetes management

• Do aim for a normal blood glucose level: 80-100 mg/dl

– Don’t go to sleep or wake up above your goal range.

• Diet

– Don’t eat “worthless” carbohydrate (potatoes, bread, rice,…).

– Don’t overeat—limit carbohydrate intake to 40-50 grams per meal.

– Do count carbs: weigh all food and calculate carbohydrate content.

• Do exercise at least 30 minutes every day.

• Do measure blood glucose before & after each meal—6 to 8 times a day.

– Do use the data to select insulin dosing.

• Do record daily in writing carbohydrate eaten, medication taken, and minutes of exercise.

• Do take an HbA1c blood test twice a year.

– Independent confirmation of how you are doing.

• Do get an annual physical.



Managing Diabetes Means Controlling Blood Glucose All the Time

• Doctors and other medical professionals are on the periphery.

– diagnose, provide occasional advice, write prescriptions, & treat complications.

• We diabetics must control our disease every day.

• Our goal: a normal blood glucose level all the time.

• Success may require a permanent diet, daily physical activity, frequent blood glucose testing and medication.

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Understanding what makes your blood glucose rise and fall is fundamental to diabetes management

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All diabetics should have annual physicals

• A physical is an independent evaluation of your health, including your overall diabetes management.

• An annual physical will help prevent other health problems from arising unnoticed.

– Type 1 diabetics can develop other autoimmune diseases—there are worse diseases than diabetes.

– All diabetics are susceptible to cardiovascular disease.

• A full set of blood tests reveals your general health

– HDL (good) and LDL (bad) cholesterol, triglycerides

– Kidney function

– HbA1c

• Consider seeing a couple of other specialists annually.

– Ophthalmologist (eye doctor): checks for retinopathy.

– Endocrinologist: a specialist on diabetes who will know much more about the disease than most general practitioners.



Use a spreadsheet to track your most important test results

• Ask your doctor for a copy of your blood test results.

• I keep a separate record of my HbA1c, cholesterol (HDL, LDL, triglycerides), Creatin/Albumin.

Date HbA1c Total Chol HDL LDL TriG Crea/Albu When Where Total/HDL LDL/HDLSep-00 12.2 S. Deerfield MedJan-01 6.5 S. Deerfield Med

02-Apr-01 6.0 1:00 PM S. Deerfield Med10-Jul-01 6.2 1:00 PM S. Deerfield Med20-Jul-01 5.3 8:00 AM Cooley-DickensonSep-01 5.7 132 44 76 62 5 8:30 AM S. Deerfield Med 3.00 1.72

11-Jan-02 5.5 9:00 AM S. Deerfield Med26-Jun-02 5.5 9:30 AM S. Deerfield Med03-Dec-02 4.9 140 48 80 60 2 8:30 AM S. Deerfield Med 2.92 1.6713-May-03 5.7 9:15 AM S. Deerfield Med06-Jan-04 5.2 136 51 76 44 1 8:30 AM S. Deerfield Med 2.67 1.4902-Jun-04 5.5 9:00 AM S. Deerfield Med16-Nov-04 5.2 150 56 82 58 8:15 AM LabCorp 2.68 1.47

Goal < 5.8 < 150 > 45 < 100 < 20



Medication—both you and your doctor have a say

• Your doctor prescribes your medication, but you determine the dose.

• Insulin—acts over the short term (minutes, hours).

– The size of each dose is 100% your decision.

– The dose changes continuously.

• meal-to-meal,

• morning to night,

• day-to-day,

• during sickness,

• with activity level

• Pills—act over long term (days and weeks).

– Your doctor selects a particular medication and initial dose.

– You observe the effect on your blood glucose level.

– You provide feedback to the doctor, who changes your dose.



You Cannot Manage Diabetes Without a Diet

• If you eat whatever you want, you will not live a normal lifespan.

• Medication cannot enable you to eat whatever you want.

• Carbohydrates (foods from plants) are the problem.

• You will have to eliminate most “worthless” carbs from your diet.

• How low carb is low enough? Depends on how well you control yourblood glucose level.

Source: Harvard School of Public Health

A diabetic’s perspective on the food pyramid.A diabetic’s perspective on the food pyramid.

These are “no-no’s”

Yogurt instead of milkLow-carb & healthy way to maintain weight (for thin Type 1 diabetics)

A high-carb luxury (with few exceptions)

Eat as much as you can (low-carb source of vitamins, minerals, fiber)

Mostly high carb & low in nutrition—be careful!

Can make all the difference



Your weight—is it satisfactory, too high or too low?

• What is your target weight?

• Weigh yourself at least weekly.

• Weigh yourself more times, the more your weight is varying.

• If your weight is below your target, you are most likely a Type 1, and you need to eat more.

– Foods high in good fat, low in CHO such as nuts are easiest to add.

– I use walnuts as my calorie control valve.

• healthy, concentrated calories (200 in 1 ounce)--primarily unsaturated fat.

• a daily snack that is satiating.

• If your weight is above your target, you need to reduce your food intake and/or increase your calorie consumption with more exercise.

– Just losing weight is only the beginning.

– A permanent lifestyle change may be necessary to keep lost weight off.

– Seek help from weight-loss organizations.



Exercise is Worth the Time and Effort

• Improves your health.

• Makes diabetes management easier by increasing insulin sensitivity: reduces your body’s need for insulin.

• One of only two ways (the other is insulin) to lower blood glucose rapidly.

• Just half an hour a day can make a difference.

– Immediate benefit.

– Short term lowering of blood glucose level.

– Can eat some forbidden food.

• The more you do, the more your body’s insulin needs will be reduced.



How intensive does my diabetes management need to be?

• Intensive treatment

– Type 1 diabetics will require intensive management.

– The more your blood glucose can vary, the more intensive your management.

– If you are taking medication that can cause a hypoglycemic reaction, you need to watch your blood glucose level carefully.

• Some type 2 diabetics can regain normal glycemia simply by losing weight.

• If you are a type 2 diabetic with an HbA1c just above normal (<6.5%):

– Take a HbA1c test twice a year

– Eliminate must useless carbs: deserts and sweets, potatoes and rice

– Exercise daily

– Maintain normal weight

– Take diabetes pills



Try to hit your blood glucose targetevery time you test

• Determine your target blood glucose range.

– A normal person will have a target level of 90 mg/dL.

– For insulin users, your target range is determined by the smallest dose of insulin you can administer. 90 +/- 10 mg/dL for me.

• What you can achieve depends on how you do with the rest of your regimen.

– how accurately you can count CHO

– how much CHO you eat at a meal

– how accurately you know your blood glucose metric

– how low your blood glucose can go.



A written record makes all the difference

• You need a written record to keep track of trends in your diabetes.

• Use a record book that displays at least a week of information on two adjacent pages.

• Collect the data--write everything down and when it happens: meter readings,medication, carb intake, exercise.

• Carb Metric: calculate and record after each post-prandial test.

• Record information in abbreviated form but with consistent notation that you will understand a week later.

– “10mB” means 10 minutes of biking

– “2.5A” means 2.5 units of Insulin Aspart

• A week of my records:

– 50 glucometer readings

– 28 meals (4 per day)

– 35 fast acting insulin injections

– 14 slow acting insulin injections

– 10-15 sessions of exercise



Let’s dissect one week of my life…

Date Time

BG, Meds, Exercise Breakfast Time

BG, Meds, Exercise Lunch Time

BG, Meds, Exercise Dinner Time

BG, Meds, Exercise Evening Snack Lantus

6:30 86 112g Yogurt 6g 11:35 93 2 chick sandwiches 5:57 58 Salad 8g 8:33 65 26 gram CHO AM: 6.52A 48g Pineapple 6g 6A 2 pickles 3.5A 264g Lo Mein 33g 8:46 2A BGM=105/26=4.0 PM: 6.5

10 mB Total CHO: 12g 1:54 115 4 tomatoes Total CHO: 41g 11:05 908:46 75 BGM=89/12=7.4 0.5A BGM=??? BGM=147/41=3.6

eat 4g

7:35 76 112g Yogurt 6g 11:57 82 Salad 9.5g 6:28 69 200g Salad 5g 9:00 82 22 gram CHO AM: 6.51.5A 48g Pineapple 6g 5A Chicken 1g 3.5A 190g Lo Mein 24g 2A BGM=84/22=3.8 PM: 6.5

10 mB Total CHO: 12g 25 mW 160g beans 20g 122g peach 13.5g 11:03 8667 BGM=71/12=5.9 1:58 80 14g chips 4.5g Total CHO: 42.5g eat 2g

eat 5g Total CHO: 35g BGM=153/42.5=3.6BGM=248/35=7.1

6:33 81 68g Waffle 12 12:01 82 Salad 8.5g 6:23 71 100g tomato 3.5g 8:28 107 21 gram CHO AM: 6.51.5A Strawberry 1g 5.5A Chicken 3.5A 2 enchilladas 29g 1A BGM=79/21=3.8 PM: 6.5

10 mB Total CHO: 13g 25 mW Muffin 16.5g Ice cream 9g 8:48 1.5A8:49 111 BGM=110/13=8.5 2:12 94 122g peach 13.5g Total CHO: 41.5g 10:54 86

0.5A Total CHO: 38.5g BGM=176/41.5=4.2 eat 2gBGM=278/38.5=7.2

8:02 83 1 bread 11.5g 1:05 89 240g Couscous 30g 6:40 94 190g bread pd 34g 9:00 138 20.5 gram CHO AM: 6.52A omelette 3g 4.5A Fish 7:03 4A 180g Ratatou 9g 1.5A BGM=101/20.5=4.9 PM: 6.5

10 mB 156g Strawb 7.5g swim 114g orange 10.5g Total CHO: 43g 2A11:19 79 Total CHO: 22g 3:54 78 Total CHO: 40.5g BGM=204/43.5=4.7 11:00 99

eat 4g BGM=96/22=4.4 eat 4g BGM=???

8:24 76 2 French Tst 23g 1:15 3.5A Salad 8.5g eat 4g 2 Tortillas 16g 9:00 113 24 gram CHO AM: 6.58:47 2A BGM=102/23=4.4 3:14 110 160g Cous-Bean 20g 6:20 107 Fajitas & Salsa 12g 1A BGM=121/24=5.0 PM: 6.5

10 mB 0.5A BGM=??? 3.5A Ice cream 9g 2.5A10:30 78 4:38 102 Total CHO: 37g 10:52 94

eat 4g 25 mW BGM=146/37=3.96:31 90 112g Yogurt 6g 11:40 112 Salad 8g 6:15 82 300g bread pd 35g 8:59 100 22 gram CHO AM: 6.5

2A 48g Pineapple 6g 0.5A 160g Cous-Bean 20g 4.5A 180g Ratatou 9g 1A BGM=94/22=4.3 PM: 6.510 mB Total CHO: 12g 5A Total CHO: 28g Total CHO: 44g 9:15 2A

8:28 88 BGM=98/12=8.2 1:39 87 BGM=195/28=7.0 BGM=198/44=4.5 11:02 74eat 1g eat 3g

6:32 95 112g Yogurt 6g 12:01 77 96g orange 8.5 6:45 71 2 Tortillas 16g 9:02 101 25 gram CHO AM: 6.52A 48g Pineapple 6g 5A 160g Cous-Bean 20g 1A Fajitas & Salsa 12g 1A BGM=111/25=4.4 PM: 6.5

10 mB Total CHO: 12g 25 mW Salad 9.5 g 2A Ice cream 9g 9:15 2A8:43 81 BGM=86/12=7.2 3:35 67 Total CHO: 38g Total CHO: 37g 10:36 92

eat 1g eat 4g BGM=240/38=6.3 BGM=150/37=4.1

8/5 sun

8/6 mon

8/7 tue

8/1 wed

8/2 thu

8/3 fri

8/4 sat



Day 1 Breakfast—high insulin resistance means low carb

Date Time

BG, Meds, Exercise Breakfast

6:30 86 112g Yogurt 6g2A 48g Pineapple 6g

10 mB Total CHO: 12g8:46 75 BGM=89/12=7.4

eat 4g

8/1 wed

Day of the week--my insulin sensitivity is different on weekdays and weekends.

Took post-prandial reading about 2 hours after eating.

Morning fasting readingshould be near my goal. Otherwise, adjust medication.

Post-prandial reading was below 80—I took ½ unit too much insulin; eat 4 grams of CHO.

Blood glucose metric:Points rise: 2 units x 40 pts/unit +(75-86) pts + 10 min Bike x 2 pts/min=80-11+20=89 pts.BGM=89 pts / 12 grams = 7.4 pts/gram

weight of food

CHO of food

10 minutes on a stationary bike

Took 2 units of fast acting insulin

Just a few numbers record a lot of information



Time

BG, Meds, Exercise Lunch

11:35 93 2 chick sandwiches6A 2 pickles

1:54 115 4 tomatoes0.5A BGM=???

Day 1 Lunch—I didn’t make it myself, so I have to guess at the carbs

• We had a meeting through lunch, and sandwiches were provided.

• I had to guess at the number of grams of carbs in my lunch.

• I could not walk at lunch, so my BG level probably spiked high after I ate.

• I missed my post-prandial goal of 90 mg/dL

Take post-prandial reading about 2 hours after eating.

Lunch fasting reading

Post-prandial reading is above 100; take ½ unit of insulin. Blood glucose metric—I couldn’t

compute it because I didn’t know how many carbs were in the meal.

I had to guess how much CHO was in the food I ate

Take 6 units of fast acting insulin



Time

BG, Meds, Exercise Dinner Time

BG, Meds, Exercise Evening Snack Lantus

5:57 58 Salad 8g 8:33 65 26 gram CHO AM: 6.53.5A 264g Lo Mein 33g 8:46 2A BGM=105/26=4.0 PM: 6.5

Total CHO: 41g 11:05 90BGM=147/41=3.6

Day 1 Dinner—low insulin resistance means I can eat more

• I have a low BGM at dinner time, so I eat more carbs than at any other meal.

• I eat my snack 2 hours after dinner and 2 hours before bed time.

• I keep my insulin dose at snack time to 3 units max, so my BG level does not drop too much while I sleep.

Blood glucose metric—3.6 is my lowest of the day.

Fasting level before dinner is low—6A taken at lunch has a significant “tail”. I took ½ U too much insulin.

Evening snack—26 grams CHO 2 hours before bed time.

My bedtime blood glucose level is 90—perfect!



Day 2—breakfast, learn from Day 1

Date Time

BG, Meds, Exercise Breakfast

6:30 86 112g Yogurt 6g2A 48g Pineapple 6g

10 mB Total CHO: 12g8:46 75 BGM=89/12=7.4

eat 4g

7:35 76 112g Yogurt 6g1.5A 48g Pineapple 6g

10 mB Total CHO: 12g67 BGM=71/12=5.9

eat 5g

8/1 wed

8/2 thuDay 2

Day 1

• I always study previous results before I take my dose.

• My breakfast on Day 2 is the same as Day 1, so I assume my BGM is the same.

• The significant variation in my BGM from Day 1 to Day 2 is a key reason I don’t eat a lot of carbs for breakfast.

Use Day 1 BGM to calculate insulin dose on Day 2.

Goal is 90 after 2 hrs.Point rise =7.4x12 -10x2 = 69Insulin:1.5U drops BG 60 pointsNet rise should be: 69-60=9 pts

My BGM was lower than I expected, so my post prandial BG was too low.

14 pt fall through the night means by long acting dose might be slightly high.



My Blood Glucose Metric at Lunch on Day 2 accurately predicts Day 3

Day 2

Day 1 Use Day 2 BGM to calculate insulin dose on Day 3.

Goal is 90 after 2 hours.Point rise =7.1x38.5 -25x2 = 223Insulin: 5.5U drops BG 220 pointspredicted rise: 223-220 = 3 ptsActual rise: 94-82 = 12 pts

11:57 82 Salad 9.5g5A Chicken 1g

25 mW 160g beans 20g1:58 80 14g chips 4.5g

Total CHO: 35gBGM=248/35=7.1

12:01 82 Salad 8.5g5.5A Chicken

25 mW Muffin 16.5g2:12 94 122g peach 13.5g

Total CHO: 38.5gBGM=278/38.5=7.2

25 minutes of walking after eating reduces my insulin dose and helps limit spiking in my blood glucose level after eating.

• I eat more for lunch because my BGM does not vary from day to day.

• I prevent short term spiking of my blood glucose by walking for 25 minutes.



6:33 81 68g Waffle 121.5A Strawberry 1g

10 mB Total CHO: 13g8:49 111 BGM=110/13=8.5

0.5A

8:02 83 1 bread 11.5g2A omelette 3g

10 mB 156g Strawb 7.5g11:19 79 Total CHO: 22g

eat 4g BGM=96/22=4.4

8/3 fri

8/4 sat

The Weekend Effect: my insulin sensitivity often increases significantly on the weekend

Day 4

Day 3

On Friday, my blood glucose metric is 8.5. On Saturday, it has dropped to 4.4.

• I hold a desk job during the week.

• On the weekend, I am more active.

• If I didn’t compensate for a big reduction in my blood glucose metric, I would have a hypoglycemic reaction every Saturday morning.

High insulin resistance is one reason desk jobs are not healthy.



8:24 76 2 French Tst 23g8:47 2A BGM=102/23=4.4

10 mB10:30 78

eat 4g6:31 90 112g Yogurt 6g

2A 48g Pineapple 6g10 mB Total CHO: 12g

8:28 88 BGM=98/12=8.2eat 1g

8/5 sun

8/6 mon

When the work-week starts up, my insulin resistance increases again

Day 6

Day 5On Sunday, my blood glucose metric is 4.4. On Monday, it has increased to 8.2.

• A written record helps me keep track of the weekly cycles in by BGM.

• I can look back several weeks.

I keep my weekday breakfast carb load below 12g to control my BG even when my BGM fluctuates.



Years of diabetes management and careful record keeping have taught me about my body

• My BGM (insulin resistance) is highest and most variable in the morning.

– I keep my breakfast carb load low.

– I exercise after breakfast to reduce spiking of blood glucose.

• On the weekend, my BGM drops at breakfast and lunch.

• Dinner is always the best time to eat carbs since my BGM (insulin resistance) is always at its lowest.

• My current long-acting, Lantus insulin dose is 13 units a day.

• Most exercise I do drops my blood glucose level about 2 points/minute.

• In a week, my BG is below 100 mg/dL during 80-90% of my tests.

• On vacations away from home, my BG test results rise about 10 points on average because my lifestyle changes and is less predictable.

– I eat at restaurants and can’t count carbs.



Dealing with a hypoglycemic reaction (for insulin users)

• Understand the causes (too much insulin, too few carbs, too much exercise)

• Learn to recognize the symptoms (they may be subtle)

• If you think your blood glucose level is low, test immediately.

– Eat. Wait twenty minutes and retest.

– If you don’t have your meter, then eat 5-10 grams of fast-acting carbs.

• In case your blood glucose level falls so low that you need assistance:

– Have oral glucose gel and a glucagen emergency kit on hand

– At home and at work, be sure there is someone who can help you.



The challenges of restaurants

• You don’t how many carbs are in the food.

• Order food grilled not fried or breaded to eliminate unnecessary carbs.

• Salads are the best food choice

– Ask for the dressing on the side. Don’t eat the croutons.

• Eat pasta rather than rice or potatoes.

• Bring a measuring cup with you.

• It’s easy to overeat. Don’t do it!

– Your body will take hours to digest the food.

– Your blood glucose level will take hours to return to your target range.

• Avoid most fast food.

– High carb, nutrition-poor: hamburger buns, French-fries

– The exception are salads.

– Some chains provide lists of macronutrients in their foods (Wendy’s).

• Your best option is learning to cook at home.

– the food will be the most nutritious, the most satiating and the least costly, and your blood glucose control will be the tightest.

– Even if you are busy, you can cook extra portions on weekends and eat the leftovers during the week. Microwaves are great for reheating.



Overnight travel away from home—be prepared

• Always pack more medication and glucose monitoring supplies than you will need.

– Plane reservations change; flights can be delayed,…

• Going to a place with hot weather? Bring something to keep your insulin below its maximum storage temperature.

– Ice chest, cold pack

• In cold weather, keep insulin from freezing.

– If you are outside, carry it in your inside coat pocket.

– Many glucometers won’t function if the temperature is too low or too high.

• Don’t leave insulin in a car, even for short periods (more than a few minutes).

• Try to carry your meter and medication together on your body.

– Try a waist pack fastened to your belt.

www.frious.com



What should you know about diabetes management?

• It’s up to you. Don’t depend on your doctor.

• Weight control, diet, exercise and medication are the tools you have to lower your blood glucose level.

• Obtain and use a glucometer.

• Take an HbA1c test 2-4 times a year.

• Get an annual physical.

• Keep records.

• Don’t quit.



Metric Units and Terms

• Normal blood glucose level: 90 mg/dL

• Post prandial: after eating

• Pre prandial: before eating

• Blood glucose Metric: blood glucose metric rise per gram of carbs.

• Insulin Metric: blood glucose drop per unit of insulin.

• Exercise Metric: blood glucose level drop per minute of exercise.



References

1. Images from Google™ Image Search at http://images.google.com

diabetes management lecture 8

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