Type 1 diabetes, and type 2 diabetes with insulin
Dr Sharon Jones
- Why and when do you need insulin?
- Insulin with food
- Basal insulin requirement
- Type 1 and Type 2 diabetes
- Basic insulin rules
- Controlling your diabetes, day to day
- Continuous glucose monitoring
- Controlling your diabetes, long term checks (HbA1c)
- What types of insulin do you need?
- Adjusting dose of insulin with food
- detail carbohydrate counting
- Adjusting long acting insulin
- Hypos in brief
- Night time hypos
- Hypo unawareness
- Diabetes education programs
- Autonomic neuropathy
- NICE guidelines BMJ 15
- NICE august 15 children and young adults
- NICE august 15 adults
Adjusting insulin dose pages from DAFNE
- Metabolic control Insulin
- QA = quick-acting insulin
- long-acting insulin
- injection sites, absorption
- food and insulin dose
- carbohydrate count & portion = CP
Carb Counting 16mb, a presentation
- Carb counting booklet pdf, Diab.UK
- snacks glycaemic index
- Physical exercise
- Driving (link)
- excellent site, read carefully
- insulin... frequent questions this site
- pumps this site
- insulin dose simulations this site
- testing glucose this site
- hypo unawareness this site
This is covered in more detail. Insulin is one of the most important of your body's hormones. Normally it is made in the pancreas, and is secreted into the blood stream. From the blood the insulin travels to muscles and other tissues.
In the muscle cell it acts as a 'door opener' and lets glucose pass from the bloodstream into the muscle cell. The muscle cell stores the glucose for use later. Some glucose is used for energy, and excess glucose is converted to fat.
Without insulin, your muscle has no energy stores to use, so you become very weak. In addition, because the sugar is not used up it reaches very high levels in the bloodstream. This can be very dangerous and needs treatment in hospital, and is called diabetic ketoacidosis.
Detail In brief, the normal pancreas secretes half its insulin as a 'bolus' after eating. To replace this insulin you need a quick acting insulin. This dose of insulin has to match the amount of food you eat, and particularly the amount of carbohydrate.. Adjusting insulin for carbohydrate.
Detail The normal pancreas secretes the other half of the insulin gradually during the day and night, the so called 'basal' secretion. To replace this insulin, you need insulin a long acting insulin to work when you are not eating. You need much less insulin when you exercise, because exercise allows glucose to enter the muscle cell for immediate use (exercise acts 'like' insulin).
Type 1 diabetics have very little insulin remaining, and can get severe problems without insulin. See below.
People who have type 2 diabetes and still need insulin should read the type 2 page as well as this page: not being overweight and plenty of exercise if at all possible is important. If the pancreas produces no insulin, effectively the diabetes can be treated as type 1.
But if the pancreas still secretes a moderate amount of insulin, certain problems are less common, such as hypos. Normally, the pancreas produces less and less insulin, so after many years of type 2 diabetes, hypos and other problems become a lot more common.
- Without insulin you become weak, your sugar levels rise, and the high sugar level damages your body. You are diabetic when your 'natural' insulin runs out. Here we assume you need insulin for you diabetes, (otherwise see type 2). That is patients with type 1 diabetes need insulin to keep healthy. Many patients with type 2 diabetes menage with diet and tablets alone, but some progress to need insulin, and this page is appropriate if so.
- You need half your insulin throughout the day, the other half (in divided doses) when you eat.
- There are many types of insulin. Some act very quickly and the effect wears off, others more slowly and their effect continues. You need the first for meals, and the long acting for your basic requirement. Sometimes the two type of insulin are combined (a mixture).
- Your will always need insulin, even if you are ill and not eating (a serious situation: you need to call your doctor or go to hospital).
- You generally need more insulin
if you have an infection, and can reduce the dose as you get better. If
you have an infection your sugar levels rise. People with diabetes often
need antibiotics for infections, so see your doctor to see if you need
You are in the best place to adjust your insulin as your sugar rises with the infection. Your practice nurse can usually advise you if you do not know what to do.
- If your sugar rises for no apparent reason you may have a hidden infection, such as a chest or urinary tract infection. Also, as soon as the infection gets better your sugar levels drop, so you will need less insulin. If you do not reduce your insulin levels in time you may notice hypos.
- You need to test your sugar regularly, usually 4-6 times a day for good control, less often if you are elderly and do not need such tight control.
- You are at risk of hypos (when the sugar goes low) and will need to treat the hypo, perhaps with orange juice and a banana. You need to read and learn about hypos, as for each hypo you notice you are getting two others. A serious hypo is a coma when you become unconscious.
- You need to keep your insulin in a cool safe place, have a spare supply, have some identification to indicate to others that you are diabetic (for instance, if you are in a coma this will help to tell people why and what they should do).
- Glucagon injections may help if you have hypos.
- see the hypos page
- driving..you should test glucose levels before start driving and every 90 minutes
- exercise.. other than moderate activity for a short time, you should similarly test
- It is important to attend a DAFNE program or equivalent, to learn how to control the diabetes well.
- Help must be available from the diabetes care team to enable patients to achieve good diabetic control NICE 15.
- The general HbA1c target is 48mmol/mol (6.5%).
- your diabetes team should provide a walk in and telephone service during working hours
- a 24 hour helpline
- HbA1c should be tested every 3-6 months
- pancreas transplant with very severe hypos
You have to test you blood glucose detail , and aim for
- 5-7.0 mmol/l on waking
- 4-7.0 mmol/l before meals and other times of the day NICE 15
- at least 90 minutes after a meal 5-9 mmol/l (except if pregnant)
- bedtime levels..discuss with team
- test using finger pricks
See when to test. Keeping to these glucose levels is a problem for many patients. See shift work; driving. High levels of glucose levels cause the diabetic complications, such as retinopathy. People needing insulin have a choice..taking action to keep low glucose levels, or having more complications.
Blood glucose levels should be tested 4 times a day, or more often if NICE 15
- you are trying to lower your HbA1c
- you are getting frequent hypos
- before driving
- during illness
- be fro re, during and after sport
- when planning or during pregnancy and breast-feeding
- if you have hypo-unawareness
- NICE 15
- recommend if there are problems
- if patient is prepared to calibrate
- one or more severe hypo episode a year
- hypo-unawareness (loss of awareness of hypoglycaemia
- more than two episodes a week of hypos patient is not aware of
- extreme fear of hypo severe hyperglycaemia that persists despite testing 10 times a day
Glucose sticks to the red blood cells and tissues of the body. The higher the blood glucose, the greater amount of glucose that attaches to the blood cells and tissues. The more glucose that is attached, the greater the risk of diabetic complications.
HbA1c measures the amount of glucose attached to the red blood cells The HbA1c gives a good guide to the blood glucose level over the previous 8-10 weeks. It is used as a measure of long-term measure of diabetic control. The usual result in someone without diabetes is 27-42 mmol/l ( 4.0-6.0%).
The best result in diabetes is 42-58 mmol/mol (6.0-7.5%). At this level most long term complications can be prevented, whilst at the same time avoiding severe hypos (hypoglycaemia). Below this level there is a higher risk of a bad hypos. Above this level here is an increased risk of complications. Before conception and during pregnancy, slightly lower levels are preferred.
The HbA1c is not the same as the average blood glucose is always slightly lower. For example, someone who has a blood glucose ~17mmol/l with have an HbA1c of ~120mmol/l (13%) . Convert HbA1c to glucose.
Detail. You need
- quick acting insulin with food
- Long acting insulin (sometimes termed 'background' insulin)
- Lantus (Glargine) insulin for people with a very regular lifestyle
- Levemir (detemir) if you exercise more one day than another day, or want flexibility with twice daily, and better control (type 1 and more severe type 2)
Detail If you are going to control your diabetes well, and keep low blood sugars as above, the dose of insulin has to be adjusted with food.
- primarily the dose of quick acting insulin has to match the carbohydrate in the meal
- sweet food produces glucose spikes that the insulin cannot prevent, and these are harmful. These foods should be avoided except to treat a hypo
- foods that cause dramatic rises in glucose, apart from fruit, are best avoided...they are called 'high glycaemic index' foods. Safer foods have low glycaemic index.
- if you are exercising after a meal you will need less meal-time quick acting insulin
- for fine tuning, the quick acting dose should take into account the glucose level before the meal (more insulin if higher etc)
- you can see computer simulations of this adjustment AIDA computer simulation; our simulations
- see the dose adjustment pages approach fine tuning
a low fibre meal with cakes etc. will cause a rapid rise in sugar whatever insulin you use, and the high levels damage your body (in practice sugar levels may be higher than shown here)
Detail It is hard to know whether high/low glucose levels are due to the quick acting or long acting insulin. Here are some ideas.
- any glucose level more than 4 hours after a quick-acting injection is due to the long-acting insulin (as by this time the quick acting insulin will have worn off).
- so all glucose levels on waking, more than 4 hours after the quick-acting insulin, most levels during the night, are due to the long-acting
- a lot of exercise will cause low levels for 6-24 hours....that night for instance
- illness and stress will affect levels
- general advice is that if glucose levels are high/low for 3 days (in the time period of the long-acting insulin) , then the long-acting dose should be increased/reduced. You will learn how to do this on the DAFNE program or can be taught this by your nurse.
- Sometimes the long-acting insult can cause low levels before or after meals (in the rapid-acting time period). Such a problem takes a long time to sort out, but frequent tests can help. Expert help is often needed.
- Long-acting insulins are often termed 'background' insulin.
Trying to lower your HbA1C to improve your control may mean more hypos (episodes of low blood sugar, <4mmol/l). Hypos are explained in detail on the hypo page.
You need to be prepared, to know what to do, to avoid hypos. Learn to monitor your blood sugar, and learn to adjust your diet and insulin according to the blood sugar level.
|Hypo warning symptoms|
If you are getting hypos it is best to eat regularly and control your diabetes well, and only then gradually learn to change your eating patterns as you wish, yet still control your diabetes.
Try and work out the cause of the hypo, and if you think you can find the cause take corrective action. Examples..see FAQ.
It is naturally stressful trying to achieve good control, and can be disappointing
when you get a hypo. This is a real challenge, but if you can take it on,
with the help of your specialist nurse, friends, and others, then the results
can be very worthwhile.
Really you need to find the lowest HbA1c that still allows you not to have any hypos.
Research suggests pumps may be helpful if you have trouble reaching levels less than 8% / 64mmol/l, but they only lower the HbA1c 5mmol/l / 0.5% on average.
Indeed, if you are pregnant and use insulin you need slightly different advice than is on this page, and must be extra careful. Normally if pregnant you need a complex carbohydrate snack before you go to sleep, and specialist advice. See retinopathy in pregnancy.
Detail. These are a real problem...all of a sudden, without any warning, sugar levels can drop and you can become unconscious. Hypo-unawareness suggest you care getting may hypos and have lost your warnings as above. This page tells you what you can do to get them back, but it is essential to get advice from your diabetes nurse and doctor. For every hypo you notice, research has shown you are likely to be having 2 others. For professionals.
Fluctuating sugar levels may occur if your diabetes is not well controlled; you only notice one out of 3 hypos
At last the NHS has started running these programs in many parts of the country, and the diabetes NSF Diabetes p16 indicates your Primary Care Trust must fund places on these programs.
People with diabetes face some tremendous problems. If you are trying to achieve better control, perhaps advised to do so by an ophthalmologist, in theory it may be best to change the type of insulin you use (see some examples above). In practice if there is a lot going on in your life, this may not be a good time. For instance, it is not ideal to change insulin if you are moving house, job, or changing partner.
Generally you need advice from your diabetes nurse before changing. This is particularly so if the type of insulin is new to you, or if the pen device for injection is different from that you have used previously. You will need on-going advice, and need to be able to phone for advice when problems develop.
The autonomic nervous system controls automatic bodily functions, such as how the bowels work and how we sweat to cool our bodies. Normally a low blood sugar makes you feel sweaty and trembly, and this feeling can tell you your sugar is too low, and you need some food. If this system becomes damaged you are said to have 'autonomic neuropathy'.
High sugar levels from diabetes may cause this condition. It normally develops after many years of diabetes.
Unfortunately if you have 'autonomic neuropathy' and other changes from diabetes you may not notice your sugar is low. So if you have a hypo you would normally feel sweaty and shaky, but if you have this neuropathy you may not feel anything, and so the hypo will go unnoticed. However, the low sugar will affect your brain, and you will not be able to think clearly or drive safely. This is called 'masking' of hypos or 'unawareness'.
Unexplained diarrhoea is commonly caused by autonomic neuropathy.
These changes can make your diabetes difficult to control. This is one of
the 'catch 22' situations of diabetes, you need a low sugar to prevent complications,
but the complications (which include the neuropathy) prevent you achieving
the levels you need. A lot of research is taking place to address these issues,
but it does not make life easy if you have them. To prevent more hypos, testing
your sugar regularly and using the results to adjust your insulin is the
only way to prevent or slow down diabetic complications. If you have hypo
unawareness and have low sugars without knowing, this indicates you are probably
getting frequent hypos, with the result that your body's reaction to them
To correct this you really need expert advice from you diabetes specialist nurse, but this is what one patient was advised
- reduce most of your insulin doses 2-4 units
- test frequently, 6 times a day
- your tests should then reveal no hypos, otherwise you may have to reduce your insulin more
- when your body adjusts to the higher sugar levels, perhaps in a 2 weeks or so, you should start to recognise hypos again. You need to keep testing your sugar levels.
- Gradually increase your insulin levels so that your sugar reaches reasonably low levels, but not the very low hypo levels you had before.