2. A Diabetic’s Guide to
Managing Diabetes
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.
9-20-07 by Eric Holzman 2
3. A Diabetic’s Guide to
Managing Diabetes
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.
Medication testing
testing Exercise
testing
Blood Glucose
Level
Diet
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4. A Diabetic’s Guide to
Managing Diabetes
Understanding what makes your blood glucose
rise and fall is fundamental to diabetes management
Exercise Insulin Insulin
pancreas
pancreas
injected
injected
muscles
muscles
Blood Glucose Concentration
digestion
glucagon
adrenal
liver
Stress Hypoglycemia Eating Fasting
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5. A Diabetic’s Guide to
Managing Diabetes
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.
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6. A Diabetic’s Guide to
Managing Diabetes
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/HDL
Sep-00 12.2 S. Deerfield Med
Jan-01 6.5 S. Deerfield Med
02-Apr-01 6.0 1:00 PM S. Deerfield Med
10-Jul-01 6.2 1:00 PM S. Deerfield Med
20-Jul-01 5.3 8:00 AM Cooley-Dickenson
Sep-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 Med
26-Jun-02 5.5 9:30 AM S. Deerfield Med
03-Dec-02 4.9 140 48 80 60 2 8:30 AM S. Deerfield Med 2.92 1.67
13-May-03 5.7 9:15 AM S. Deerfield Med
06-Jan-04 5.2 136 51 76 44 1 8:30 AM S. Deerfield Med 2.67 1.49
02-Jun-04 5.5 9:00 AM S. Deerfield Med
16-Nov-04 5.2 150 56 82 58 8:15 AM LabCorp 2.68 1.47
Goal < 5.8 < 150 > 45 < 100 < 20
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7. A Diabetic’s Guide to
Managing Diabetes
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.
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8. A Diabetic’s Guide to
Managing Diabetes
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 your
blood glucose level.
These are “no-no’s”
Yogurt instead of milk
Low-carb & healthy way to maintain
weight (for thin Type 1 diabetics)
Eat as much as you can
(low-carb source of A high-carb luxury
vitamins, minerals, fiber) (with few exceptions)
Mostly high carb & low in A diabetic’s perspective
A diabetic’s perspective
nutrition—be careful!
on the food pyramid.
on the food pyramid.
Can make all
the difference Source: Harvard School of Public Health
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9. A Diabetic’s Guide to
Managing Diabetes
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.
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10. A Diabetic’s Guide to
Managing Diabetes
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.
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11. A Diabetic’s Guide to
Managing Diabetes
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
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12. A Diabetic’s Guide to
Managing Diabetes
Try to hit your blood glucose target
every 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.
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13. A Diabetic’s Guide to
Managing Diabetes
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
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15. A Diabetic’s Guide to
Managing Diabetes
Day 1 Breakfast—high insulin resistance
means low carb
Took 2 units of fast acting insulin Morning fasting reading
should be near my goal.
10 minutes on a stationary bike Otherwise, adjust medication.
weight of food
Day of the week--my insulin BG,
sensitivity is different on Meds,
Date Time Exercise Breakfast CHO of food
weekdays and weekends.
6:30 86 112g Yogurt 6g
2A 48g Pineapple 6g
8/1
10 mB Total CHO: 12g
wed
8:46 75 BGM=89/12=7.4
eat 4g
Took post-prandial reading
about 2 hours after eating.
Blood glucose metric:
Points rise: 2 units x 40 pts/unit +(75-86) pts
Post-prandial reading was below + 10 min Bike x 2 pts/min=80-11+20=89 pts.
80—I took ½ unit too much BGM=89 pts / 12 grams = 7.4 pts/gram
insulin; eat 4 grams of CHO.
Just a few numbers record a lot of information
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16. A Diabetic’s Guide to
Managing Diabetes
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
Lunch fasting reading
Take 6 units of fast acting insulin
BG,
Meds,
Time Exercise Lunch I had to guess
11:35 93 2 chick sandwiches how much
6A 2 pickles
Take post-prandial reading CHO was in
1:54 115 4 tomatoes
about 2 hours after eating. 0.5A BGM=??? the food I ate
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.
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17. A Diabetic’s Guide to
Managing Diabetes
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.
Fasting level before dinner Evening snack—26 grams
is low—6A taken at lunch CHO 2 hours before bed time.
has a significant “tail”. I took ½ U too much insulin.
BG, BG,
Meds, Meds,
Time Exercise Dinner Time Exercise Evening Snack Lantus
5:57 58 Salad 8g 8:33 65 26 gram CHO AM: 6.5
3.5A 264g Lo Mein 33g 8:46 2A BGM=105/26=4.0 PM: 6.5
Total CHO: 41g 11:05 90
BGM=147/41=3.6
Blood glucose metric—3.6 My bedtime blood glucose
is my lowest of the day. level is 90—perfect!
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18. A Diabetic’s Guide to
Managing Diabetes
Day 2—breakfast, learn from 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.
14 pt fall through the night
BG, means by long acting dose
Meds, might be slightly high.
Date Time Exercise Breakfast
6:30 86 112g Yogurt 6g Use Day 1 BGM to calculate
2A 48g Pineapple 6g insulin dose on Day 2.
Day 1 8/1
10 mB Total CHO: 12g
wed
8:46 75 BGM=89/12=7.4
eat 4g
7:35 76 112g Yogurt 6g Goal is 90 after 2 hrs.
1.5A 48g Pineapple 6g Point rise =7.4x12 -10x2 = 69
8/2 10 mB Total CHO: 12g Insulin:1.5U drops BG 60 points
Day 2 thu 67 BGM=71/12=5.9 Net rise should be: 69-60=9 pts
eat 5g
My BGM was lower than I
expected, so my post prandial
BG was too low.
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19. A Diabetic’s Guide to
Managing Diabetes
My Blood Glucose Metric at Lunch on Day 2
accurately predicts Day 3
• 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.
11:57 82 Salad 9.5g
5A Chicken 1g
Day 1 25 mW 160g beans 20g Use Day 2 BGM to calculate
1:58 80 14g chips 4.5g insulin dose on Day 3.
Total CHO: 35g
BGM=248/35=7.1
Salad 8.5g
Goal is 90 after 2 hours.
12:01 82
Point rise =7.1x38.5 -25x2 = 223
5.5A Chicken
Insulin: 5.5U drops BG 220 points
25 mW Muffin 16.5g
Day 2 predicted rise: 223-220 = 3 pts
2:12 94 122g peach 13.5g Actual rise: 94-82 = 12 pts
Total CHO: 38.5g
BGM=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.
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20. A Diabetic’s Guide to
Managing Diabetes
The Weekend Effect: my insulin sensitivity
often increases significantly on the weekend
• 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
6:33 81 68g Waffle 12 is one reason desk jobs
1.5A Strawberry 1g are not healthy.
Day 3 8/3 10 mB Total CHO: 13g
fri 8:49 111 BGM=110/13=8.5
0.5A
On Friday, my blood
8:02 83 1 bread 11.5g
glucose metric is 8.5.
2A omelette 3g On Saturday, it has
8/4
Day 4 sat
10 mB 156g Strawb 7.5g dropped to 4.4.
11:19 79 Total CHO: 22g
eat 4g BGM=96/22=4.4
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21. A Diabetic’s Guide to
Managing Diabetes
When the work-week starts up, my insulin
resistance increases again
• A written record helps me keep track of the weekly cycles in by BGM.
• I can look back several weeks.
8:24 76 2 French Tst 23g
8:47 2A BGM=102/23=4.4
Day 5 8/5
10 mB
sun On Sunday, my blood
10:30 78 glucose metric is 4.4.
eat 4g On Monday, it has
6:31 90 112g Yogurt 6g increased to 8.2.
2A 48g Pineapple 6g
8/6
Day 6 10 mB Total CHO: 12g
mon
8:28 88 BGM=98/12=8.2
eat 1g
I keep my weekday breakfast carb load below 12g
to control my BG even when my BGM fluctuates.
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22. A Diabetic’s Guide to
Managing Diabetes
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.
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23. A Diabetic’s Guide to
Managing Diabetes 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.
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24. A Diabetic’s Guide to
Managing Diabetes
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.
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25. A Diabetic’s Guide to
Managing Diabetes 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. www.frious.com
– 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.
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26. A Diabetic’s Guide to
Managing Diabetes
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.
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27. A Diabetic’s Guide to
Managing Diabetes
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.
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28. A Diabetic’s Guide to
Managing Diabetes
References
1. Images from Google™ Image Search at http://images.google.com
9-20-07 by Eric Holzman 28
