Consensus Guidelines for the Management of
Insulin-Dependent (Type 1) Diabetes Chapter 3

Index of chapters

3.0 TARGETS, INSULIN, HYPOGLYCAEMIA, DIET, and LIPIDS

3.1 Biomedical Targets for Diabetes Management
3.2 Insulin Therapy
3.3 Hypoglycaemia
3.4 Nutritional management
3.5 Lipids and ischaemic heart disease


IDDM CONSENSUS GUIDELINES Chapter 3 MANAGEMENT: Targets
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3.1 Biomedical Targets for Diabetes Management


Table 3.1.1 Biomedical targets for diabetes control

                               Good     Borderline    Poor

  Self-monitored blood glucose
       fasting/pre-prandial
            mg/dl              80-110    111-140      >140
            mmol/l            4.4-6.1    6.2-7.8      >7.8
       post-prandial
            mg/dl             100-145    146-180      >180
            mmol/l            5.5-8.0    8.1-10.0     >10.0
  Glycated Hb (%Hb)*          <+3SD      3SD-5SD      >5SD
       HbA1c (normal <6.1%)   <6.5       6.5-7.5      >7.5
       HbA1  (normal <7.5%)   <8.0       8.0-9.5      >9.5
  Total serum cholesterol
            mg/dl             <200       200-250      >250
            mmol/l            <5.2       5.2-6.5      >6.5
  Fasting serum triglycerides
            mg/dl             <150       150-200      >200   
            mmol/l            <1.7       1.7-2.2      >2.2   
  Body mass index  (kg/m/m)                                  
       male                   <25.0      25.0-27.0    >27.0  
       female                 <24.0      24.0-26.0    >26.0  

*, see text for warnings in regard of undetected hypoglycaemia; assays vary so check normal range used


3.1.1 Recommendations for metabolic targets (see Table 3.1.1)

IDDM CONSENSUS GUIDELINES Chapter 3 MANAGEMENT: Targets

IDDM CONSENSUS GUIDELINES Chapter 3 MANAGEMENT: Insulin
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3.2 Insulin Therapy

3.2.1 Aims of insulin therapy

The aims of insulin therapy are:

3.2.2 Recommendations for insulin therapy

3.2.2.1 General advice


Table 3.2.1 Time-action characteristics of available insulin preparations

                                 Time (hours)
                           onset    maximum    extent

Short-acting             0.25-1.0   1.5-4.0   5.0- 8.0
Intermediate-acting*     0.5 -2.0   3.0-6.0   8.0-14.0

*, includes human ultralente; beef insulin-zinc insulin preparations have much longer time-action characteristics
These properties vary between individuals and with dose



3.2.2.2 Insulin regimens

3.2.2.3 Insulin dose

3.2.2.4 Insulin delivery devices

3.2.2.5 Injection sites

3.2.2.6 Injection technique

3.2.2.7 Special circumstances

3.2.3 Education for insulin therapy

Objectives of an education programme for patients starting insulin therapy should include:

3.2.4 Failure of insulin therapy

If poor blood glucose control persists despite good education and attention to insulin dose adjustment consider:
IDDM CONSENSUS GUIDELINES Chapter 3 MANAGEMENT: Insulin

IDDM CONSENSUS GUIDELINES Chapter 3 MANAGEMENT: Hypoglycaemia
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3.3 Hypoglycaemia



Table 3.3.1 Factors affecting the risk and degree of hypoglycaemia
     missing meals                   errors in insulin dosage
     smaller meals than usual        inappropriate regimens
     increased physical activity     hypoglycaemia unawareness
     alcohol                         errors in administration
     renal insufficiency             change in injection site
     ß-adrenergic blocker therapy    inappropriate doses
     previous hypoglycaemic events

Taken together, the evidence does not support the hypothesis that the species of insulin is associated with any change in hypoglycaemia unawareness or severe hypoglycaemia in some patients



3.3.1 Recommendations for the management of hypoglycaemia

Prevention of hypoglycaemia requires:

Diagnosis can be by:

Management involves:

3.3.2 Special problems in the management of hypoglycaemia

3.3.2.1 Hypoglycaemia unawareness

This can be a major source of psychological, social, and work-related problems. It occurs with increasing duration of diabetes and is then common, in particular in those patients with good blood glucose control. Hypoglycaemia unawareness may increase after an episode of hypoglycaemia, and during sleep or with lowered body temperature.

It is managed by:

3.3.2.2 Nocturnal hypoglycaemia

This often goes undetected by patients and professionals, but less often by companions. It may present as a severe night-time reaction. Detection is by morning symptoms, measurement of 0300 h blood glucose levels, and questioning of companions. Normal glycated haemoglobin levels should be treated as suspicious. It is not a significant cause of pre-breakfast hyperglycaemia.

Its occurrence may be affected by the dose of intermediate-acting insulin preparations given in the evening, but also from larger doses of evening short-acting insulin, and even morning intermediate-acting insulin preparations. Pre-bed snacks should be of longer-acting carbohydrate.

IDDM CONSENSUS GUIDELINES Chapter 3 MANAGEMENT: Hypoglycaemia

IDDM CONSENSUS GUIDELINES Chapter 3 MANAGEMENT: Nutrition
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3.4 Nutritional Management

The objectives of nutritional management are:

Nutritional management should be an integral part of initial and continuing education programmes.

3.4.1 Recommendations on Dietary Management

3.4.2 Meal patterns

3.4.2.1 Twice daily insulin regimens ( insulin )

Start with three meals and three snacks, but modify these according to self-monitored blood glucose levels. Thus a small breakfast is often all that is needed, and is often preferred by patients. The afternoon snack only exacerbates hyperglycaemia in some patients. The evening snack may be better taken at bedtime, or split into two.

3.4.2.2 Multiple injection regimens ( insulin )

Snacks can still help attain better blood glucose control, but again self-monitoring should be used to learn what is necessary and desirable.

On multiple injection regimens it is generally easier to adjust meal timing and content (together with insulin doses) without affecting blood glucose control. Care must be taken to avoid extra total calories however, or weight gain will result

3.4.3 Physical exercise

Physical exercise can benefit insulin sensitivity, hypertension, and blood lipid control and should be taken regularly for optimum effect; however it does increase the risk of acute and delayed hypoglycaemia ( hypoglycaemia ).

IDDM CONSENSUS GUIDELINES Chapter 3 MANAGEMENT: Nutrition

IDDM CONSENSUS GUIDELINES Chapter 3 MANAGEMENT: Lipids/Heart
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3.5 Lipids and Ischaemic Heart Disease

3.5.1 A strategy for the management of arterial risk in people with IDDM:

IDDM CONSENSUS GUIDELINES Chapter 3.5 MANAGEMENT: Lipids/Heart


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