Insulin

Insulin lowers blood sugar by allowing it to leave the blood stream and enter cells. Everyone needs insulin. People with type I diabetes can't make their own insulin, and they must take insulin every day.

Insulin is injected under the skin using a syringe, or in some cases, an infusion pump delivers the insulin continuously. It is not available in an oral form.

Insulin preparations differ in how fast they start to work and how long they last. The health care professional reviews blood glucose levels to determine the appropriate type of insulin the person should use. More than one type of insulin may be mixed together in an injection to achieve the best control of blood glucose.

The injections are needed, in general, from 1 to 4 times a day. People are taught how to give insulin injections by their health care provider or a diabetes nurse educator. Initially, a child's injections may be given by a parent or other adult. By age 14, most children can be expected (but should not be required) to give their own injections.

DIET

Meal planning for type 1 diabetes requires consistency to allow food and insulin to work together to regulate blood glucose levels. If meals and insulin are out of balance, extreme variations in blood glucose can occur.

The American Diabetes Association and the American Dietetic Association has information for planning healthy, balanced meals. Consultation with a registered dietitian or nutrition counselor is an invaluable tool for meal planning and dietary control for diabetics.

PHYSICAL ACTIVITY

Regular exercise is especially important for the person with diabetes, as it helps control the amount of sugar in the blood and helps burn excess calories and fat to achieve optimal weight.

Before people with diabetes begin any exercise program, they should obtain medical approval. Type 1 diabetics must take special precautions before, during and after participation in intense physical activity or exercise.

SELF-TESTING

Blood glucose monitoring is done by checking the glucose content of a small drop of blood. The testing is done on a regular basis and will inform the person with diabetes how well diet, medication, and exercise are working together to control diabetes.

The results can be used to adjust meals, activity, or medications to keep blood-sugar levels within an appropriate range. It will provide valuable information for the health care provider to suggest changes to improve care and treatment. Testing will identify high and low blood-sugar levels before serious problems develop.

FOOT CARE

People with diabetes are prone to foot problems because of complications related to the illness. Diabetes causes damage to the blood vessels and nerves, which can result in a decreased ability to sense trauma or pressure on the foot. A foot injury could go unnoticed until severe infection develops.

Additionally, diabetes alters the bodies immune system, decreasing the body's ability to fight infection. Small infections can rapidly progress to death of the skin and other tissues, necessitating amputation of the affected limb.

To prevent injury to the feet, diabetics should adopt a daily foot care routine.

TREATING LOW BLOOD SUGAR

Low blood sugar, known as hypoglycemia, can occur in diabetics when they use too much insulin, exercise too much, or have not eaten enough food. Hypoglycemia can develop quickly in people with diabetes. Symptoms of low blood sugar typically appear when the sugar level falls below 70. Watch for weakness, shaking, sweating, headache, nervousness, and hunger.

If these symptoms occur and you have a blood sugar test kit available, do a blood sugar check. If the level is low, the person with diabetes should eat something with sugar: fruit juice, several teaspoons of sugar, a cup of skim milk, or regular soda. If you don't have a test kit handy, sugar should be eaten anyway - it can't hurt. Symptoms should subside within 15 minutes. If the symptoms don't subside, more sugar should be eaten and the sugar level tested again.

AFTER the symptoms subside, more substantial food can be eaten. Eat simple sugar FIRST to get the situation under control. Even if you or your child is hungry, "real" food should not be eaten until the sugar level comes up - real food won't produce enough sugar and takes too long to digest.

You should have some glucagon stored for emergencies. Make sure everyone in your home, as well as babysitters and caregivers, knows how to use it. Periodically remind everyone how to use it, and check the expiration date.

Don't panic. Glucagon works very fast - usually within 15 minutes. While you are waiting for the person to revive, keep him on his side to prevent choking. If the person is not better in 15 minutes, call 911.

TREATING HIGH KETONES

When there is not enough insulin to move glucose into cells, glucose can build up in the blood. The body then looks for other forms of energy and uses fat as a fuel source. As fats are broken down, acids called ketones build up in the blood and urine. In high levels, ketones are poisonous to body tissue. This condition is known as ketoacidosis.

You can check for ketones using a simple urine test available at pharmacies. This test should be performed every 4-6 hours anytime a person with diabetes is registering blood sugar above 240; sick; unusually thirsty or has a dry mouth; urinating frequently; or vomited.

The warning signs that ketoacidosis is getting serious might include flushed face, dry skin and mouth, nausea or vomiting, stomach pain, deep, rapid breathing, or fruity breath odor.

If these symptoms occur, call the doctor or go to the emergency room right away. If left untreated, this condition will lead to coma and even death.

MONITORING

Visit your physician and/or diabetes educator at least 4 times a year.

Have your glycosylated hemoglobin (HbA1c) measured 2-4 times a year to evaluate your overall glucose control. (Ask your doctor how often you should be tested.)

Have your cholesterol and triglyceride levels and kidney function evaluated yearly.

Visit your ophthalmologist (preferably one that specializes in diabetic retinopathy) at least once a year, more frequently if signs of diabetic retinopathy develop.

Every 6 months have a thorough dental cleaning and examination. Inform your dentist and hygienist that you have diabetes.

Monitor your feet every day for early signs of injury or infection. Make sure your health care provider inspects your feet at each visit.

Stay up-to-date with all of your vaccinations (including pneumococcal), and get a flu shot every year in the fall.

EDUCATION

You are the most important person in managing your diabetes. Diabetes education is a crucial part of the treatment plan. Diabetes education basically involves learning how to live with your diabetes.

Knowledge of disease management is imperative to avoid developing short-term complications such as hypoglycemia and hyperglycemia and to delay or slow the onset of long-term complications of the disease such as diabetic retinopathy (eye disease) or nephropathy (kidney disease).

You should be knowledgeable about the basic principles of diabetes management. Basic "survival skills" include:

1. How to recognize and treat low blood sugar(hypoglycemia)

2. How to recognize and treat high blood sugar (hyperglycemia)

3. How to administer insulin

4. How to monitor blood glucose and urine ketones

5. How to adjust insulin and/or food intake during exercise

6. How to handle sick days

7. Where to buy diabetic supplies and how to store them

EXPECTATIONS (PROGNOSIS)

The outcome for people with diabetes varies. Recent studies show that tight control of blood glucose can prevent or delay the progression of eye disease, kidney disease and nervous system disease that is caused by diabetes. However, complications may occur even when good diabetes control is achieved with insulin and diet.

COMPLICATIONS

Emergency complications:

Diabetic ketoacidosis

In a person with type 1 diabetes, the body will use fat as a fuel if insulin is not present. The by-products of fat metabolism are ketones. Ketones build up in the blood and "spill" over into the urine.

A condition called ketoacidosis develops when the blood is made acidic by the ketones.

Hypoglycemia

Hypoglycemia (low blood glucose) occurs when the balance between insulin, food intake, and exercise is disturbed. Symptoms of mild hypoglycemia include hunger, nervousness, and fast heart rate. More serious hypoglycemia can lead to confusion and even loss of consciousness. Loss of consciousness due to low blood sugar is called hypoglycemic coma.

Long-term complications:

People who have had diabetes for several years are likely to develop long-term complications, which can be minimized but not entirely eliminated by proper diabetic management: