Islets of Hope for persons with diabetes
Article by Lahle Wolfe, Founder, Islets of Hope.
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Information on normal and acceptable target blood glucose ranges for both diabetics and nondiabetics. Our chart considers factors such as age and whether or not a person is newly diagnosed.
Two types of hypoglycemia can occur in people who do not have diabetes: reactive (postprandial, or after meals) and fasting (postabsorptive). Reactive hypoglycemia is not usually related to any underlying disease; fasting hypoglycemia often is.
Onset: Over time; hours or days.
Causes: Too little insulin, stress, illness, dehydration, exercise or inactivity, too much food, certain medications, or a combination of these things.
ALERT: Untreated highs can lead to diabetic ketoacidiosis (DKA) which can result in coma and/or death. Over time, high blood glucose damages nerves and organs and disrupt normal digestive system processes.
Increased thirst and urination
Did You Know?
... that dehydration can cause hyperglycemia? Check your blood glucose before you exercise and afterwards. If you are active for a long time, or, feel any of the symptoms of abnormal blood glucose levels (high or low) check during exercise as well.
Ten Rules of Managing Blood Glucose
1. Thou shalt always have fasting acting sugars handy.
2. Thou shalt always carry glucagon.
3. Thou shalt wear proper medical identification and carry instructions for emergency personnel.
4. Thou shalt remember to test, and test often.
5. Thou shalt eat a well- balanced diet, limit processed carbs, fat, and avoid excessive amounts of protein.
6. Thou shalt exercise regularly.
7. Honor thy A1C results and make adjustments to improve anything over 7.
8. Know thy numbers. What are your A1c, fasting, pre- and postprandial numbers?
9. Thou shalt not lie to thy physician. Be honest when reporting problems and habits.
10. Love thyself -- how you manage your care today will add quality years to your life -- or take them away!
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Important Medical Disclaimer
All material found on this site is intended to provide you with general information.
No information found on this site should be used for self- diagnosis or as a substitute for professional medical care. IOH recommends that you seek the advice of a health professional for diagnosis and treatment options, or before making any changes to your current diabetes care plan
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How Insulin Works in the Body
Previous Section & Additional Information
How Insulin Works in the Body
Glucose, a form of sugar, is an important fuel for your body. Carbohydrates are the main dietary sources of glucose. Rice, potatoes, bread, tortillas, cereal, milk, fruit, and sweets are all carbohydrate-rich foods. After a meal, glucose molecules are absorbed into your bloodstream and carried to the cells, where they are used for energy. Insulin, a hormone produced by your pancreas, helps glucose enter cells. If you take in more glucose than your body needs at the time, your body stores the extra glucose in your liver and muscles in a form called glycogen. Your body can use the stored glucose whenever it is needed for energy between meals. Insulin is a "fat-storing" hormone because it helps glucose to be converted to fat and stored in fat cells.
When blood glucose begins to rise, insulin, a hormone produced by the pancreas, acts like a key to open cells so that the glucose can enter into them. Without insulin, glucose remains in the blood stream and can build up to dangerous levels. Persons with diabetes take insulin in order help glucose from the blood stream enter into, and nourish cells. If a person takes too much insulin their blood glucose can go too low (se Hypoglycemia). If they do not take enough insulin their blood glucose levels will remain too high.
The key to avoiding complications with diabetes is to manage blood glucose levels judiciously. Long-term complications of diabetes are very serious, diminish quality of life, and can take years off your life span. But long-term problems don't develop magically on their own, they happen slowly over time when daily care is mismanaged. This is one of the reasons why so many health care professionals are advocates of tight diabetes control.
Preventing Hyperglycemia During the Day
For All People Using Insulin
Keep records and communicate with your doctor. Keeping an accurate log book of your blood glucose levels, food eaten, activities, stress or illness, and insulin and medications taken, is the best tool you have for understanding just how your body reacts to insulin and what your needs are. This information is vital for your doctor to best set up, or make changes to, your diabetes care plan.
Don't use the pump as an excuse to eat all the time. Pumping is convenient; you simply give a food bolus any time that you eat. People using pumps may feel that it is okay to graze all day, or eat frequently. Even though you may correctly bolus yourself you can still have chronically high blood glucose levels because your body needs time to react to the insulin after eating and return to target range. Try not to eat or snack more frequently than every 2-4 hours. If you blood glucose is still high from a recent meal or snack, wait until your glucose is back on target before eating again.
Pumps are not a cure. Remember that an insulin pump is a tool to help you manage your diabetes; it is not a cure. You still need to eat sensibly even while on an intensive (flexible) insulin therapy like insulin pumping.
Understand how and when your insulin works. Different types of insulin begin to work at different times, peak at different times and last for various durations. It is as important that you understand when to take insulin as it is to know how much to take.
Plan your exercise. Exercise can either decrease or increase your blood glucose levels. Always check your glucose before exercising and afterwards. If you are not feeling well, exercising hard, or for more than an hour, stop and check your blood glucose level. Hyperglycemia can result from exercise because the body is stressed, or becomes dehydrated.
Snack before exercising. Many doctors recommend having a snack prior to exercising and reducing the amount of insulin given to cover the food (usually about 15 grams of carbohydrate will go uncovered if you are in your target range, but check with your doctor). Your body needs insulin while working out as well as energy from food. It is not wise to exercise without eating or having enough insulin circulating in your body prior to exercise.
When not to exercise. If your blood glucose is over 240 mg/dL or, if you have any ketones in your urine, postpone activity until you are ketone-free and in a safe target range for exercising.
See your doctor for an HbA1c test 3-4 times per year. It is important to understand that a person with diabetes can be in target range 4 hours after a meal, but easily climb 300-500 mg/dL 1-3 hours after eating. Even though your target is met at 4 hours, you are still experiencing hyperglycemia that should be addressed. Aside from potential nerve and organ damage, most people just don't feel good when their blood glucose levels are too high. Regular HbA1c testing can help determine if your highs are damaging your body.
Know your target range. Some doctors aim to keep blood glucose levels under 180 mg/dL even 1-2 after eating. This requires dedication on the part of the patient and a good diabetes care plan from their doctor. Make sure you inject enough insulin to cover the food you are eating and calculate any correction bolus insulin needed.
Be aware of the time of day. Most people with diabetes are more sensitive to insulin at certain times of the day and less sensitive at other times. You may need more insulin for breakfast than you do at dinner time. This is not only true for calculating your insulin-to-carb ratio for food boluses, but also true for basal (background) insulin and even your correction factors may be vary.
Sick days may require more or less insulin. Illness can cause a rapid rise in blood glucose levels and the added stress from sickness or infection can increase the amount of insulin needed. Have a sick day care plan BEFORE getting sick. Your doctor should provide you with instructions about handling illness. Many doctors will prescribe anti-nausea drugs to keep on hand in case of stomach flu. Vomiting can lead to dehydration and hyperglycemia if you stop taking insulin because you cannot hold down food. Especially when sick, your body needs insulin.
Children may need to be hospitalized if they are too sick to eat. The may require an intravenous glucose solution just so that insulin can continue to be administered. When there is no circulating insulin in the body (either from the pancreas, shots, or an insulin pump, etc.) a person is more likely to experience DKA sooner, and at a lower glucose level than are persons who have some insulin in their body.
There seems to be one exception to the increased need for insulin during illness and that is, with a rotavirus. Many with diabetes report an almost "honeymoon-like" state where they require little or no insulin other than basal insulin. The reason is not clear, but may have to do with the extreme intestinal irritation with certain rotaviruses causes. This can interfere with the body's ability to absorb carbohydrates. You may need reduced insulin, but only because your body is not absorbing carbohydrates. And, you still need to keep circulating insulin (basal, or background) going or risk DKA.
Tips For Those on Conventional Shot Therapy
Those on conventional shot therapy who take only 1-3 injections per day, may be advised to only check your blood glucose 4 or 5 times per day. If your HbA1c levels are high, it is an indication that you are not testing often enough to detect hyperglycemia. Be sure to test 2 hours after a meal and during the night at least once to see if your glucose levels are elevated. Report what you learn to your doctor in case changes in your diabetes care plan need to be made.
If you are on conventional shot therapy it is important to eat and take your insulin on time. Your diabetes care program was designed with the intention that you would eat about the same time each day, and eat about the same amount at each meal and snack. If your lifestyle is not suited for this type of therapy talk with your doctor about other options.
For Those on Insulin Pumps
Vary your basal rates. Basal rates on insulin pumps are not usually one setting that is used in just one increment for 24 hours, but are often set at different rates for different times of the day or night. Insulin pumps allow for greater control in covering your metabolic needs for insulin than shots because basal rates on an insulin pump can also be temporarily increased or decreased according to need. Once a shot is injected, you can always take an additional injection but you can't turn down your "basal insulin" because it is already in your system.
Don't turn off your pump. Turning off your insulin pump is never a good idea even if your blood glucose levels are good. Turning off your pump for more than an hour (only do this occasionally and as necessary) stops basal insulin from being administered. This diminishes the amount circulating insulin in your body and can set the stage for onset of diabetic ketoacidosis (DKA).
Unhooking your pump. If you wish to go "unteathered" (unhook your pump) ask your doctor how to inject Lantus or other long-acting insulin to replace the basal rate function of the pump. You can go off and on the pump (reverting to shots) but you cannot go off insulin. Only your doctor should advise you how to switch back and forth between shots and the pump.
Preventing Hyperglycemia During the Night
There are three main causes of hyperglycemia during the night:
Depending upon the exact cause of your nighttime hyperglycemia, that contributed to high glucose levels in the morning, your doctor may recommend:
If you suspect lows may be occurring during the night check your blood glucose at 3:00 a.m. If your blood glucose is low at that time, you may need a smaller dose of intermediate insulin (NPH) or long-lasting insulin (Lantus® or Ultralente) in the evening. If you are on an insulin pump your basal rates may need adjusting. Never change your insulin guidelines without discussing them with your doctor first!
High-Fat Induced Hyperglycemia
Eating a high-fat snack close to bedtime (for others, even having a high-fat dinner) can cause delayed hyperglycemia. This means that blood glucose may appear in range shortly after eating, but elevate higher over time. Fat can also keep blood glucose levels elevated many hours after eating. During the night, when you may not be checking your blood glucose as frequently your glucose can elevate and stayed elevated due to a high-fat meal.
The Dawn Effect (also called Dawn Phenomenon)
The Dawn Effect is an increase in insulin resistance (decrease in insulin sensitivity) caused by hormones released about two hours before you wake. These hormones are under the control of the pituitary gland in the brain. The Dawn Effect is also influenced by testosterone and tends to be more significant in men and in women with polycystic ovarian syndrome who may have elevated testosterone levels.
This resistance to insulin can cause you to need more insulin at certain times during the night. The Dawn Effect mildly occurs in nondiabetics as a means to elevated blood glucose to prepare for the day. In people without diabetes, the body adjusts so that blood glucose levels do not go too high. In those with diabetes, however, the Dawn Effect can cause blood glucose levels to rise too high and lead to morning fasting hypoglycemia.
Your overnight insulin is taken to counter the Dawn Effect, and on average, diabetics take 20% of their total daily insulin overnight due to an increase in metabolic needs during the night. People using insulin pumps often have increased basal rates after 3 a.m. for this reason.
It is a normal occurrence in all people to experience a slight rise in blood glucose levels before rising, but this phenomenon is more pronounced in persons who need to take insulin. The Dawn Effect is also the most common cause of nighttime highs.
Somogyi Effect (Rebound Hyperglycemia)
The Somogyi Effect occurs after a rapid drop in blood glucose levels sometime during sleep. The body responds by releasing stored glucose (released from glycogen stores) from the muscles and liver in an attempt to elevate blood glucose levels. The body may overcompensate, releasing large amounts of glycogen which results in a "rebound" effect, causing hyperglycemia. Waking with a headache and feeling tired may be an indication that early morning hyperglycemia is due to the Simogyi Effect.
This may happen anytime during sleep, but hypoglycemia usually occurs around 3.a.m. The hypoglycemic episode is followed by an elevated blood glucose level towards morning. Inadequate food intake for exercise or too much insulin may contribute to this response. Getting this under control often requires monitoring around 3 a.m. and advice from your doctor how to prevent lows during the night that rebound with highs.
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Page Updated 03/09/2006