Improving control: practical advice for people with type 1 diabetes

 

Click here to open a booklet containing advice on how to improve glucose control in type 1 diabetes

 

 

People with type 1 diabetes are more likely to have good control if they check blood glucose levels at least 4 times per day.  Many people find it difficult to perform blood glucose checks as frequently as this and, in that situation, even a short spell of frequent monitoring just before a clinic appointment can prove very useful.

A brief period of ‘Intensive blood glucose monitoring’, where glucose levels are checked several times each day, can be useful in helping improve control and avoiding dangerously low blood sugars (hypoglycaemia or ‘hypo’). 

For patients on multiple daily injections* (MDI, also known as basal bolus) of insulin or using an insulin pump, we have developed an ‘intensive glucose control’ diary in which to collect detailed information for a few days (we typically recommend around 6 days of ‘intensive’ monitoring).  This is likely to be of use to any patients who feel their control could be fine-tuned and provides hugely useful information to the doctors and nurses in the clinic. An example of the information collected in the ‘intensive control’ diary is provided here:

Intensive control diary example page

Each page represents a single day.  If you do not ‘carbohydrate count’ you can ignore the ‘carbohydrate portion’ entry, but the diary can still be used.  You can print off blank diary pages here:

Blank intensive control diary page

or download an excel spreadsheet version here

IF YOU HAVE COMPLETED AN INTENSIVE CONTROL DIARY, PLEASE FEEL FREE TO CONTACT US TO DISCUSS THIS OR, ALTERNATIVELY, SCAN OR PHOTOGRAPH THE COMPLETED DIARY AND SEND IT TO US AT:

diabetesclinic.rie@nhslothian.scot.nhs.uk

WE WILL GET BACK TO YOU WITH ADVICE

 

Extra blood glucose tests during 'intensive monitoring'

In addition to the standard recommended blood glucose tests for people on multiple insulin injections – before breakfast, before lunch, before evening meal (tea-time) and before bed – the following extra tests can be very useful, when performed occasionally:

 

Blood glucose two hours after meals (also called 2 hour post-prandial)

Checking blood glucose levels 2 hours after a meal can provide useful information regarding how well matched your dose of quick acting insulin has been to the food eaten.  It can also help determine what effect the timing of quick acting insulin (in relation to the meal) has had (e.g. 15 minutes before eating, just before eating, just after eating etc.).  For the best effect on blood sugar control, quick acting insulin should, whenever possible, be taken before meals.  The ideal target for 2 hours after meals is between 5 and 9 mmol/L (or not much more than 2 mmol/L higher than the pre-meal glucose).

We would suggest that during a six day spell of ‘intensive monitoring’, you consider checking ‘2 hours after meals’ blood glucose levels perhaps once or twice a day.

 

Blood glucose at 3 o’clock in the morning

This is obviously quite an unappealing prospect and is not something we would recommend on a regular basis.  However, in the context of a short spell of intensive monitoring, it can be very valuable to see what happens to blood glucose levels between the last check at night (i.e. before bed time) and the middle of the night (around 3 a.m.).  In particular, it is hugely important to exclude low blood glucose levels overnight, which can often go unrecognised but potentially have a huge impact on overall glucose control.

We would not suggest doing this any more than once or twice during a six day spell of ‘intensive monitoring’.

 

Carbohydrate free meals (‘Carb free’)

Carbohydrate free meals are suggested as a component of intensive monitoring to help assess how effectively you background insulin (Lantus or Levemir) is working.  Carbohydrate free meals do not require a quick acting insulin injection (Novorapid, Humalog or Apidra) and therefore any change in blood glucose following a ‘carb free meal’ is likely to reflect how effectively the long acting, background insulin is working.

For example, if the blood glucose level was 6.0 before a carb free breakfast but was 11.3 by lunch time, this would suggest that the background insulin coverage was not adequate to control glucose between breakfast and lunch.  The same is true of a carb free lunch (assessing background insulin from lunch to tea time) and carb free evening meal (assessing background insulin cover from tea time to bed time). 

Carbohydrate containing meals include anything with sugar or food types such as potatoes, pasta, rice and bread. The following sheet gives example of carb free meals:

Carb free meal sheet

We would suggest that during a six day spell of ‘intensive monitoring’, you consider checking ‘a carb free meal on 2 or 3 occasions - ideally at different meal times and on different days.

Some other factors which can affect glucose levels

  • Injection sites:  If you inject too often into the same place this can hugely affect how much insulin is absorbed - aim to rotate the location of injections as much as possible.  Injections in the abdomen (tummy) are absorbed quicker than those in the legs / buttocks - consider using the abdomen for quick acting injections (eg. Novorapid, Apidra, Humalog etc.) and the legs/buttocks for long acting injections (eg. Lantus, Levemir etc.).  Are you using the correct needle size? - ask your diabetes nurse / doctor at your next appointment.
  • Exercise:  Exercise can have a number of effects on blood sugar, depending on the individual, the duration of exercise and the intensity.  See the exercise section of the website for more details.
  • Food: This is perhaps the most obvious influence on blood sugar levels.  The amount of insulin required to cover a pizza is hugely different from that required to cover a chicken salad.  For this reason we recommend 'carbohydrate counting' for most patients with type 1 diabetes.  If you do not do this and wish to learn more about it, please contact the nurse specialists for further information or look at our carb counting guide. The philosophy of carbohydrate counting is to allow patients to adjust their insulin dose based on the food they eat - not to adjust the food they eat to match their insulin.
  • Hypos: Low blood sugar levels can have an impact on blood sugar levels later in the day, particularly when the low blood sugar has been 'over corrected' by taking more carbohydrate than necessary. The following link provides useful practical tips for managing hypoglycaemia.

 

*Examples of MDI insulin regimens would be:  one or two injections of long acting insulin per day (e.g. Lantus or Levemir) plus quick acting insulin injections with each meal (e.g.  Novorapid, Humalog, Apidra)

 

Other resources to help improve diabetes control:

 

DAFNE (Dose Adjustment For Normal Eating)

If you have Type 1 Diabetes and have not done the DAFNE course, we would strongly recommend this.  Click here to find out more about DAFNE.  If you would like to do the course, please ask your doctor in clinic or contact the nurse specialists.

Carbs and Cals

Carbs and Cals is a book (and smartphone app) which helps with 'carb counting':

Click here for a link to the Carbs and Cals website.

BDEC online course for type 1 diabetes management

This is an online education programme for people with type 1 diabetes, developed by the Bournemouth Diabetes and Endocrine Centre (BDEC).  It focuses on insulin dose adjustment and carbohydrate counting and is a valuable resource for patients who are unable to attend our local DAFNE courses:

Link to the Bournemouth Diabetes Course

Accu-Chek e-learning for carbohydrate counting

This online learning module is provided by one of the blood glucose manufacturers.  You do not need to have an Accu-Chek meter to sign up to use this resource but you are required to complete a registration process:

Accu-chek carbohydrate counting module