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Diabetes Care...What you need to know

Please remember to consult with your diabetes care team before making any changes to your diabetes care.  Information provided is for your consideration only and is not meant to be taken as medical advice in any way.

You may also be interested in our Diabetes Terms section.

Blood Glucose Testing

 

Testing can be done using the tips of the fingers, as well as Alternate Site Testing (AST) on such places as the sides of the hands, the forearm and the leg.  When in doubt or if a low is suspected always use the finger tip for most reliable results.  While most people do not find a time lag when using AST, current research recommends that lows be monitored through finger testing. 

 

Why is it important to test?  

In order to properly control your diabetes, it is important to know what you blood glucose levels are.  Too high or too low can lead to disastrous complications.

 

When to test?

This depends on if you have Type 1 Diabetes or not and how active you are. Current Canadian Diabetes Association Clinical Practice guidelines suggest testing blood glucose levels at least four times per day.  Many doctors suggest testing before each meal, before, after and during strenuous  physical activity, and before bed.  It may also be preferable to test at least once throughout the night to ensure that night-time basal insulins are working properly. Please consult with your diabetes team to see how often you should test your blood glucose levels. 

 

But what does "blood glucose testing" mean? 

Glucose is a type of sugar.  The body forms glucose when it  breaks down the food we eat into a useable form of energy. Glucose is the body's main source of energy. Measuring the amount of glucose found in your blood helps to show how the body is breaking down food into energy, as well as how the liver is working.

 

Blood glucose testing may be Fasting--which is done after you have not eaten for 12-14 hours and is often used in a clinical setting to diagnose diabetes.  It may be a 2-hour Postprandial test which is testing done 2 hours after a meal. Finally, Random testing can be done.  This testing that occurs at various times throughout the day. 

 

What do the numbers on the meters mean?

 

Over 10mmol/L Over 180mg/dL Hyperglycemia--Caused by greater than normal levels of glucose in the blood.  Can produce symptoms such as thirst, frequent urination, fruity smelling breath, and lethargy. If left untreated prolonged hyperglycemia can lead to such complications as heart and kidney disease, neuropathy, and erectile dysfunction.  Insulin adjustment may be needed. Consult with your diabetes team
5-10mmol/L 90-180mg/dL Normal range within two hours of eating a meal No further action is necessary
4-7mmol/L 72-126mg/dL Normal range after fasting No further action is necessary
under 4mmol/L under 72mg/dL Hypoglycemia--occurs when the blood glucose level drops too low.  Symptoms may include sweating, trembling, fatigue, dizziness, moodiness, confusion, blurred vision and/or hunger.  Immediate treatment with fast- acting sugar (such as 1/2 cup of regular pop, 1/2 cup of juice or 3 glucose tablets) is required.  Retest after 15 minutes.  If left untreated, the person may become unconscious, have a seizure and possibly die.  If the person is unconscious do NOT administer anything by mouth.  Inject Glucagon according to instructions provided.  Insulin adjustment may be required. Consult with your diabetes team.
The above chart is a guide based on the Canadian Diabetes Association's 2003 Clinical Practice Guidelines.  It does not replace instructions or guidelines provided by your diabetes care team.

Alternate Site Testing

  • Under certain conditions, blood glucose test results obtained using samples taken from your arm may differ significantly from fingertip samples.
  • The conditions in which these differences are most likely to occur are when your blood glucose is changing rapidly such as following a meal, an insulin dose or associated with physical exercise.
  • When blood glucose is changing rapidly, fingertip samples show these changes more quickly than arm samples.
  • When your blood glucose is falling, testing with a fingertip sample may identify a hypoglycemic (low blood sugar) level sooner than a test with an arm sample.
  • Use arm samples only for testing prior to, or more than 2 hours after, meals, insulin dosing or physical exercise.
  • Testing performed within two hours after a meal, an insulin dose or physical exercise, or whenever you feel that your glucose levels may be changing rapidly, should be done from the fingertip.
  • You should also use fingertip testing whenever you have a concern about hypoglycemia (insulin reactions) such as when driving a car, particularly if you suffer from hypoglycemic unawareness (lack of symptoms to indicate an insulin reaction), as arm testing may fail to detect hypoglycemia.   
 Testing on the side of the hand using the Freestyle Mini ™ (Freestyle Flash in the US) by Therasense. The FreeStyle Mini uses .3 microlitres of blood in its sample size. Backlight lights up readings as well as test strip. Great for night testing.    AST.  Testing on the forearm with the FreeStyle Mini
Testing on the side of the arm.

Postprandial Readings

 

The postprandial reading is that reading taken 1 hour after a meal.  Ideally, for children under 5 years old the reading should be under 13.7 mmol/L (250mg/dl). For children 5-11 years old, the reading should be under 12.5 mmol/L(225 mg/dl) and adults would aim to keep it under 11.1 mmol/L(200 mg/dl).  It is felt that high postprandial numbers may account for higher A1c readings.  High postprandial readings may also lead to kidney disease 9 years earlier than in those with lower readings. 

 

For many people, postprandial ideals are hardest to achieve after breakfast.  One way to avoid this "spike" is to look at adjusting the time at which one boluses.  If the bg levels are low before breakfast and you have having a low Glycemix Index meal, you may wish to bolus within 15 minutes of the meal.  If you have a high bg level and a high glycemic index meal, one would try to bolus 15-20 minutes before the meal.  For normal to moderate glycemic index meals, one would one to bolus about 5 minutes before the meal. 

 

Another option is of course to try John Walsh's "super bolus".  This incorporates some of the basal rate into the initial bolus. 

 

*From Gary Scheiner's Strike the Spike

 

Ketone Testing

 

Ketones occur when the body breaks down fat for energy instead of getting energy from the carbohydrates found in your diet.  If your diet does not contain enough carbohydrates to supply the boyd with sugar(glucose) for energy or if your body cannot use blood sugar (glucose) properly, stored fat is broken down and ketones are made.  This can be very dangerous for people who have diabetes.  The most accurate method of testing to see if the body is "spilling ketones" is to use a home blood ketone meter such as the Precision Xtra ™.  A urine test will also detect ketones but it is less accurate than a blood test.

*From information found at http://diabetes.webmd.com/ketones-14241

 

 

 

 

Readings below 0.6mmol/L are considered normal

Readings between 0.6 and 1.5mmol/L may indicate the development of a problem that may require medical attention.

Readings above 1.5mmol/L indicate that the person is at risk of developing diabetic ketoacidosis (DKA).  Contact your health care provider immediately for advice.


What is the difference between glucose testing and using a CGM?

Glucometers are portable devices that read glucose levels from a blood sample that is placed on a tiny test strip. Test strips are discarded after a single use.  Some meters store a limited number of glucose results in memory. The results can be downloaded into a computer.   A glucose sensor is a tiny electrode that is inserted under a patient’s skin (subcutaneous tissue) and continuously records glucose levels around the clock. The sensor is worn for up to three days before it is discarded and replaced by the patient.  Glucose readings are transmitted to a monitor or insulin pump where the values are displayed. Trend reports and charts can be viewed after data is downloaded to a computer.  
*posted with permission from 2006 Medtronic Inc.
For more information on Continuous Glucose Monitors, please visit our webpage dedicated to these products.

Methods of Insulin Delivery

For people who no longer produce insulin, like those living with Type One Diabetes, there are two methods of insulin delivery available to them--insulin injections or the use of an insulin pump.

 

Insulin injections can be taken once a day or for more intensive management, multiple times throughout the day to manually mimic the actions of the pancreas.  Usually a combination of long and short/rapid acting insulins are used to achieve this.

 

Animas 2020Insulin pumps are small, computerized devices that deliver specific amounts of insulin to the wearer through tubing. This is not a closed loop or artificial pancreas but an insulin delivery method. For a complete listing and detailed information, please see our Insulin Pump page

 

Types of insulin available in Canada 

 

Type Name Start to Work in Peak Action Duration
Fast-acting Insulin Apidra®

Humalog®

NovoRapid® (Novolog® in US)

15-20 minutes

5-15 minutes

10-20 minutes

n/a

1/2-1 1/2 hours

1-2 1/2 hours

n/a

3 1/2-4 1/2 hours

3-5 hours

Short-acting Insulin Regular (R) or Toronto 30-45 minutes 2-4 hours 3-7 hours
Intermediate-acting Insulin NPH (N) or Lente(L) 1-3 hours 2-14 hours 4-16 hours
Long-acting Insulin UltraLente(U) 2-4 hours 4-18 hours 18-24 hours
24-hour basal Insulin Glargine (Lantus®)

Insulin Detemir (Levemir®

1-2 hours

1-3 hours

6 hrs

8-10 hours

18-26 hours
PreMixed Insulin

(%R/%N)

10/90, 20/80, 30/70,
40/60, 50/50
1/2-1 hour 2-12 hours 18-24 hours
Premixed insulin analog analog Humalog® Mix25™ 5-15 minutes 1/2-12 hours 18-24 hours

 

*Based on data from the Canadian Diabetes Association  and http://www.diabetesnet.com/diabetes_treatments/insulin_action_times.php

 

What is an A1c 

 

A1C (or Hb A1c) is a measure of how much glucose is stuck to your haemoglobin. Haemoglobin is a protein inside your red blood cells. It is the part of the red blood cell that carries oxygen from your lungs to the rest of your body. Haemoglobin also carries glucose, because glucose can stick to all kinds of proteins in your body. Once glucose sticks to haemoglobin, it is stuck there for the life of the red blood cell, about three or four months. The more glucose there is in your blood, the more will end up stuck to the haemoglobin.  Your A1C reading tells you  what your average blood glucose level has been over the last two or three months. If you have lots of glucose in your blood and your average blood glucose has been high for the past few months, then your A1C will be high.  Canadian Diabetes Clinical Practice Guidelines recommend that anyone living with diabetes have their A1c checked every 6 months.

For more details go to the Ascensia website

A1c mmol/L mg/dL (US measure) Meaning
14.0% 20.0 360 Very poorly managed, take immediate action to lower
12.0% 19.5 345  
11.0% 17.5 310  
10.0% 15.5 275 Poorly managed, take action to lower 
9.0% 13.5 240 Poorly managed, take action to lower
8.0% 11.5 205  
7.0% 9.5 170 Within DCCT recommendations to reduce complications
6.0% 7.5 135  Very well-managed

5.0% 
 
5.5 100  
4.0% 3.5 65  

*These are just guidelines.  Please check with your doctor to see what he/she recommends for your diabetes care!!

 

Glucagon...what is it?

 

Glucagon is a hormone that raises the level of glucose in the blood. The alpha cells of the pancreas, in areas called the islets of Langerhans, make glucagon when the body needs to put more sugar into the blood.

 

Everyone who uses insulin should have a glucagon emergency kit on hand at all times to counteract severe hypoglycemia that causes loss of consciousness, or if sugar cannot be given. The glucagon kit should be stored where all the family members know where to find it. Storage temperatures should be under 90 degrees F (28 degrees C).

 

Glucagon, like insulin, must be injected. Within the glucagon kit are a syringe pre-filled with a liquid and a vial of powdered glucagon. You prepare the glucagon for injection immediately before use by following the instructions that are included with the glucagon kit. In general, small children (under 20 kg, or 44 pounds) are given 1/2 cc (half the syringe), while older children and adults are given 1cc (the entire syringe). In kids, some authorities advise using 1/2 cc to start with, then giving the other 1/2 about 20 minutes later if needed. This method can lessen the rebound hyperglycemia that usually ensues after use of glucagon. There is no danger of overdose, however. Injection is given in a large muscle, such as the buttocks, thigh or arm. (The needle on the syringe is usually larger than those on insulin syringes.) 

*from  http://www.childrenwithdiabetes.com/d_0n_022.htm

 

What do you do when Glucagon expires? 

Expired kits can be great for retraining and practicing. Ensure that all family members, teachers and coworkers know what to do in an emergency situation!

 

Glucagon Step1 Glucagon step 2 glucagon step 3 

 

How to handle illness and diabetes...

Below is general information regarding sick day management. It is not meant to replace the advise of your healthcare professional.  Should you require further information regarding your condition or treatment, PLEASE speak with your healthcare professional.

 

  • Always take some insulin (even if vomiting). When you are ill you may actually require more insulin as you may have higher blood glucose levels despite eating less. 
  • Always check your blood sugar and ketones.  Whether you are high or not, you should always check for ketones when ill. It is preferable that you check for blood ketones as it gives a more real-time reading than urine. Blood ketones can be tested for by using the Precision Meter with the proper blood ketone strips (these strips are significantly more expensive than the regular blood glucose test strips.)

Blood Ketone Reading Action Needed
<0.6 mmol/L Use usual insulin dose as for non-sick days
>0.6 mmol/L Take a 10% (of TDD) supplement of rapid or fast-acting insulin, in addition to usual baseline insulin doses
<0.6 mmol/L Take a 10% (of TDD) supplement of rapid or fast-acting insulin, in addition to usual baseline insulin doses
>0.7-1.4 mmol/L Take a 15% (of TDD) supplement of rapid or fast-acting insulin, in addition to usual baseline insulin doses
>1.5-3.0 mmol/L Take a 20% (of TDD) supplement of rapid or fast-acting insulin, in addition to usual baseline insulin doses CALL YOUR HEALTHCARE TEAM AS SOON AS POSSIBLE!

The above was developed at the Leadership Sinai Center for Diabetes, Mt. Sinai Hospital, Toronto with an educational grant from Abbott Laboratories, Limited, MediSense Products (9-02)

 

Using Glucagon During Illness for Children with Type 1 Diabetes

Please note that following is NOT meant to replace the advise of your healthcare professional.  Should you require further information regarding your condition or treatment, PLEASE speak with your healthcare professional.

 

A team from  the Texas Children's Hospital Diabetes Care Center came up with a novel idea: use very small doses of glucagon, injected subcutaneously using a regular insulin syringe, to stave off hypoglycemia in kids with a stomach illness (gastroenteritis) or who were not cooperating and needed food. Whereas a typical glucagon injection delivers 500 to 1,000 µg, the Texas Children's team suggested the following dosing schedule:

* 20 µg for kids ages 2 or under, and
* 10 µg per year of age for kids from 2 to 15 (20 µg at age 2, 30 µg at age 3, etc.)
* 150 µg for kids 15 or older 

e corresponds to 10 µg of glucagon. Thus kids two or under received two "units" of glucagon, while a 10-year-old would receive 10 "units," based on the dosing schedule above. Parents monitored blood glucose every 30 minutes. If the child hadn't improved in 30 minutes, the dose was doubled and given again.

The results were excellent. Given in the doses outlined, blood sugars rose an average of 3.33-5.00 mmol/l (60-90 mg/dl) within 30 minutes and lasted for about an hour. Also, in the doses given as described, the glucagon did not cause an increase in nausea as is typical with large dose glucagon, and none of the kids vomited from the glucagon.

The team stressed that their approach is suitable for relative hypoglycemia in the face of stomach illness or lack of cooperation in eating, not unconsciousness due to severe hypoglycemia.

Reference: Mini-Dose Glucagon Rescue for Hypoglycemia in Children With Type 1 Diabetes, Diabetes Care 24:643-645, 2001. (Full text)

http://www.diabetes.ca/files/Professional%20Pub%20Archives/DiabetesQuarterly/Diabetes%20Quarterly--FINAL--Autumn2003.pdf

 

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Parents were instructed to dilute the glucagon as instructed in the glucagon emergency kit, but then to use a standard U-100 insulin syringe (30, 50, or 100 units) to draw up the glucagon. Each "unit" on the U-100 insulin syring