IDF - working for people with diabetes around the world© IDF (Europe) 1998

A Desktop Guide to
Type 1 (Insulin-dependent) Diabetes

Sections 9-14: Glucose, lipid, and arterial risk factor control ( including insulin and dietary therapy )

9 Assessing blood glucose control
10 Providing eating and drinking advice
11 Physical exercise
12 Using insulin effectively     ( insulin section contents list )
13 Hypoglycaemia problems
14 Managing arterial risk factors and ischaemic heart disease


TYPE 1 DIABETES - 9 - ASSESSING BLOOD GLUCOSE CONTROL
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9 ASSESSING BLOOD GLUCOSE CONTROL

9.1 Using assessment levels to set targets

Use the published assessment levels :
Ask questions of yourself continually :
Be concerned about targets :

9.2 Assessment of blood glucose control

Measure glycated haemoglobin 2-4 monthly in every patient ( depending how stable )
Think of hypoglycaemia if glycated haemoglobin level is normal or close to normal
Use the assessment levels ( below ) to set blood glucose targets
Attention to the non-metabolic target of "diabetes interfering little with
the patient's general and social well-being" will help metabolic control

9.3 Glucose control assessment levels

( Top of 'Assessing glucose control' )
Non-diabetic Adequate Inadequate

HbA1c( DCCT standardized )
%Hb <6.1 6.2-7.5 >7.5
Self-monitored blood glucose
Fasting / pre-prandial
mmol/l4.0-5.0 5.1-6.5 >6.5
mg/dl70-90 91-120 >120
Post-prandial ( peak )
mmol/l 4.0-7.5 7.6-9.0 >9.0
mg/dl 70-135 136-160 >160
Pre-bed
mmol/l 4.0-5.0 6.0-7.5 >7.5
mg/dl 70-90 110-135 >135

It can be dangerous to strive for non-diabetic glucose levels
( Top of 'Assessing glucose control' )
TYPE 1 DIABETES - 9 - ASSESSING BLOOD GLUCOSE CONTROL

TYPE 1 DIABETES - 10 - PROVIDING EATING AND DRINKING ADVICE
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10 PROVIDING EATING AND DRINKING ADVICE

10.1 Reviewing dietary management

Make recommendations and review eating :
Review dietary management regularly :
Nutritional management is an integral part of initial and continuing education programmes

10.2 Meal patterns

Multiple injection regimens :
Advise snacks will help to attain better blood glucose control, but use self-monitoring to learn what is necessary and desirable
Advise on flexibility to adjust meal timing and content ( together with insulin doses ) without affecting blood glucose control. But warn about the temptations of extra total calories
Rapid-acting insulin analogue regimens :
Advise snacks only if self-monitoring suggests a need; check particularly if a high insulin analogue dose is needed to correct hyperglycaemia present pre-prandially

10.3 Healthy eating

Advise carbohydrate intake should be higher, and fat intake lower than that of most Europeans, but not different from recommendations for the population in general

The proposed contribution to energy intake should be :

  • Fat: saturated fat <10 %; replace excess saturated fat with monounsaturates, or polyunsaturates ( up to 10 % ), or carbohydrate
  • Carbohydrate: around 50-55 %. Use foods containing soluble fibre in a carbohydrate rich diet. Simple sugars need not be rigorously excluded from the diet, but often need to be limited
  • Protein: around 15 % or less
Recommend a high intake of fresh fruit and vegetables ( five items a day )
( Top of 'Eating and drinking' )
TYPE 1 DIABETES - 10 - PROVIDING EATING AND DRINKING ADVICE

TYPE 1 DIABETES - 11 - PHYSICAL EXERCISE
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11 PHYSICAL EXERCISE

11.1 Management

Advise that physical exercise :
Manage physical exercise using :
( Top of 'Physical exercise' )
TYPE 1 DIABETES - 11 - PHYSICAL EXERCISE

TYPE 1 DIABETES - 12 - INSULIN THERAPY
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12 USING INSULIN EFFECTIVELY

12.1 Insulin, injections, and associated education

Advise :
  • the use of unmodified ( soluble, regular ) human insulin before each meal, and human NPH insulin in combination unless :
    • multiple injection therapy is not wanted by the person with diabetes
    • flexibility of life-style is not important
    • insulin secretory capacity is high ( honeymoon period )
    • insulin analogue therapy is indicated ( see below )
  • the use of pen systems for insulin delivery
  • the use of the abdominal wall for meal-time injections, and the thigh for extended-acting insulin; advise also rotation of sites within these areas
Enable the person with diabetes to :
( Top of 'Insulin' )

12.2 Insulin dose requirements - general considerations

Review :
Expect :
Monitor :
Adjust :
( Top of 'Insulin' )

12.3 Rapid-acting insulin analogue regimens

Anticipate different diurnal profiles of blood glucose control and hypoglycaemia than for human insulin, and thus a need for different dose regimens and different monitoring schemes

Give careful attention to these details, as any improvement in glycated haemoglobin concentration will be dependent on this

Make the following changes when using rapid-acting analogues compared to unmodified human insulin:

Our knowledge of the optimal use of rapid-acting ( and new long-acting ) analogues is evolving month by month - we anticipate a need to modify this advice early on

12.4 Insulin dose adjustment

This section deals with insulin dose adjustment for optimization of long-term blood glucose control
( Top of 'Insulin' )
12.4.1 Background essentials
Review first :
Review section 13 if hypoglycaemia problems

Ensure then that :

( Top of 'Insulin' )
12.4.2 Dose adjustment for different insulin preparations
Consider Sections 12.1 to 12.4.1 first

Short-acting unmodified insulin

Consider :
  • the median glucose level at the time of the injection to be adjusted
  • the median glucose level at the time of the next injection
  • the experience of hypoglycaemia or subnormal glucose levels ( <4.0 mmol/l; <70 mg/dl ) between the two injections
If : glucose levels are high at the beginning of the relevant period
    • review the insulin dose affecting the previous time period first
Otherwise if : glucose levels are above target, and hypoglycaemia is not an issue
    • increase insulin dose by 10 %; arrange to monitor and review result
Otherwise if : hypoglycaemia is an issue or glucose levels <4.0 mmol/l ( <70 mg/dl )
    • decrease insulin dose by 10 %; arrange to monitor and review result
Otherwise : no simple adjustment is possible; consider more complex adjustment, or accept the status quo
Rapid-acting insulin analogues
Read the advice on insulin analogues above

Consider the median post-prandial ( 2-4 h ) glucose level / hypoglycaemia experience ( and not the next pre-prandial / pre-injection level )

Proceed otherwise as for short-acting unmodified insulin ( see above )

Extended-acting NPH insulin at bed-time
Consider :
    • the median glucose level at bed-time
    • the median glucose level before breakfast
    • any information on glucose levels during the night
Adjust insulin dosage as for short-acting unmodified insulin ( see above )
Extended-acting NPH insulin at other times
Consider :
    • the blood glucose profile over the 12 h after the injection
    • the experience of hypoglycaemia or subnormal glucose levels ( <4.0 mmol/l; <70 mg/dl ) over the same time period
    • the expected effect of other insulin used in the same time interval
Adjust insulin dosage as for short-acting unmodified insulin ( see above )

( Top of 'Insulin' )

12.4.3 Algorithm for insulin adjustment when glucose levels are ABOVE target

If Median blood glucose >7.0 mmol/l ( >125 mg/dl )
or median pre-prandial 5.0-7.0 mmol/l ( 90-125 mg/dl ) and 80% 4.0-8.0 mmol/l ( 70-145 mg/dl )
or median post prandial >10.0 mmol/l ( >180 mg/dl ) ( 1.5-2.0 h after meal )
Yes
?Hypoglycaemia ( symptoms or measured )YesNo change. Review diet and reasons
OrSome tests <4.0 mmol/l ( <70 mg/dl )for hypoglycaemia
No
?Stress / illness ( transient hyperglycaemia )YesNo change
No ( treat acutely if indicated )
IfPre-breakfast hyperglycaemia, andNo change; review diet and evening
0200 h glucose <6.0 mmol/l ( <110 mg/dl )unmodified insulin
IfPre-breakfast hyperglycaemia, andIncrease night-time NPH insulin
0200 h glucose >=6.0 mmol/l ( >=110 mg/dl )
IfMorning, or afternoon, or eveningIncrease relevant unmodified insulin
hyperglycaemia
If0200 h hyperglycaemia, andNo change
bed-time <7.0 mmol/l ( <125 mg/dl )
If0200 h hyperglycaemia, andIncrease evening unmodified insulin
bed-time >=7.0 mmol/l ( >=125 mg/dl )
( Top of 'Insulin' )

12.4.4 Algorithm for insulin adjustment when glucose levels are BELOW target

IfHypoglycaemia requiring assistance ( and unexplained )
orhypoglycaemia inconveniencing the person with diabetes
ormeasured glucose <4.0 mmol/l ( <70 mg/dl )
Yes
?Isolated / non-recurrent, andYes No change. Review diet and reasons
median glucose >7.0 mmol/l ( >125 mg/dl )for hypoglycaemia
No
IfDay-time or eveningDecrease relevant unmodified insulin
IfNight-time 2300-0300 h, andDecrease pre-dinner unmodified
pre-bed glucose levels lowinsulin
IfNight-time 0300-0800 h, orIncrease evening unmodified
Pre-bed glucose levels highinsulin

The insulin algorithms on this page :

( Top of 'Insulin' )
TYPE 1 DIABETES - 12 - INSULIN THERAPY

TYPE 1 DIABETES - 13 - HYPOGLYCAEMIA
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13 HYPOGLYCAEMIA PROBLEMS

Recurrent hypoglycaemia
at a particular time or times of day implies a mismatch of insulin therapy to meal pattern and/or physical activity :

Review whether a repeated change in meal or activity behaviour is occurring; if so advise on a specific insulin adjustment for that change

Consider change in underlying insulin sensitivity ( age / renal / endocrine )

Refer to the insulin dose adjustment section

Erratic hypoglycaemia
needs thorough assessment of a range of possible causes :
Consider :
  • missed / varied meals or snacks
  • erratic physical activity
  • alcohol
  • injection site abnormalities
  • rotation between injection sites
  • errors in insulin administration / dose
  • inappropriate dose distribution
  • gastroparesis

Hypoglycaemia unawareness

is often partially reversible; hypoglycaemia can induce hypoglycaemia unawareness :

Consider ( by self-testing ) the possibility of undetected night-time or other hypoglycaemia, especially if HbA1c is lower than average

    • Use adjustment of insulin doses or food intake to ameliorate such problems
    • Avoid any glucose excursion to <4.0 mmol/l ( <70 mg/dl )

Provide education and training in recognizing early cognitive dysfunction for people with the problem and their carers

Provide counselling on any resultant life-style problems; caution over driving

Nocturnal hypoglycaemia
can be ameliorated by careful attention to insulin therapy :

Consider :

Hypoglycaemic coma / fitting
Give 20 % glucose IV if unconscious, or 1 mg glucagon IM. Beware of poor glucagon effect in the starved or inebriated patient. Follow with oral carbohydrate and review for possible relapse

Train carers to use glucagon if recurrent, unresolved problem; ensure supplies remain in date

( Top of 'Hypoglycaemia' )
TYPE 1 DIABETES - 13 - HYPOGLYCAEMIA

TYPE 1 DIABETES - 14 - ARTERIAL RISK MANAGEMENT
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14 MANAGING ARTERIAL RISK FACTORS AND ISCHAEMIC HEART DISEASE

14.1 Managing arterial risk

Manage arterial risk aggressively in people with Type 1 diabetes
if any other risk factor is abnormal including family history of arterial disease
Review arterial risk factors :
  • blood lipid profile
  • smoking
  • blood pressure
  • family history
  • albumin excretion rate
  • arterial / heart symptoms

Educate people :

Prescribe :

Diagnose :

Manage :

14.2 Blood lipid control targets

Low risk At risk High risk

Serum total cholesterol
mmol/l <4.8 4.8-6.0 >6.0
mg/dl <185 185-230 >230
Serum LDL cholesterol
mmol/l <3.0 3.0-4.0 >4.0
mg/dl <115 115-155 >155
Serum HDL cholesterol
mmol/l >1.2 1.0-1.2 <1.0
mg/dl >46 39-46 <39
Serum triglycerides
mmol/l <1.7 1.7-2.2 >2.2
mg/dl <150 150-200 >200

14.3 Blood pressure control targets

Kidney status mmHg

Normal albumin excretion rate <135/85
Abnormal albumin excretion rate <130/80, or lower if easily attained

14.4 Smoking cessation and control

Identify smoking habits :

Emphasize importance :

Provide information on :

( Top of 'Arterial risk' )
TYPE 1 DIABETES - 14 - ARTERIAL RISK MANAGEMENT

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