Managing blood glucose levels

In the time before you had type 1 diabetes (T1D), your pancreas used to produce insulin in low levels all day to help move glucose from your bloodstream into the various cells of your body to provide them with energy. When you ate, your blood glucose would rise, and your pancreas would respond by producing a surge of insulin. This would help move blood glucose into your muscles and liver to be stored as glycogen. If your blood glucose level dropped during the day, this glycogen would be broken down and released back into the bloodstream as glucose. By constantly sensing how much glucose was in the bloodstream, and adjusting how much insulin it secreted, your pancreas kept your blood glucose level within normal limits.

Without a properly functioning pancreas, your body cannot move glucose from the bloodstream into the cells of your body, leaving them without the energy to function. If your body can’t use glucose for fuel, it starts to break down fat to use for energy instead. When fat is broken down, the body produces chemicals called ketones, which are released into the bloodstream. High levels of ketones cause the blood to become more acidic and can lead to a condition known as ketoacidosis. Symptoms of ketoacidosis include nausea, vomiting, abdominal pain, and rapid breathing. In severe cases, it is life threatening. In addition to your body burning fat, your bloodstream is accumulating the glucose that would normally be used by cells or stored. High blood glucose levels also result in serious health complications.

By replacing insulin through injections or the use of an insulin pump, your body can resume using glucose for energy and you will no longer be at risk of harm from ketoacidosis and high blood glucose in the short term.

The main aims of treatment are:

  1. To allow you to live a long, fulfilling and healthy life
  2. To keep your blood glucose level as near to normal as possible
  3. To reduce any other factors that may increase your risk of developing complications, such as lowering your blood pressure if it is high, and keeping your cholesterol low 
  4. To detect any health problems related to your diabetes (i.e., complications such as heart disease, kidney failure, blindness) as early as possible

A reminder that this publication is not intended to replace medical advice. Please discuss with your physician what would be considered a normal blood sugar range for you. 

Aiming for a normal blood glucose level
To maintain normal blood glucose levels, you now need to do the job your pancreas won’t do anymore. This means:

  • Administering insulin during the day
  • Regularly testing blood glucose levels
  • Making constant decisions about how much insulin is needed to balance your blood glucose 

How do you know if your blood glucose is in good control?
Checking the level of glucose in your blood and keeping a record of the levels is an important part of managing your diabetes. This allows you to identify the patterns of high or low blood glucose levels. This information will also help you and your doctor or health care team balance food, exercise, and insulin doses. To get the most out of testing, your health care team may advise you to test your blood glucose levels before eating, and then again two to three hours afterward. Testing at bedtime is especially important, because it allows you to determine if your blood sugar is lower than your goal – and if so, to know to eat a snack to avoid hypoglycemia in the middle of the night. It is also a good idea to test before and after exercise. If your blood glucose level is high, you should also test for ketones, based upon the advice of your doctor. You can do this by testing your blood using a blood glucose meter that also tests for ketones, or by testing your urine. Ketones in the blood or urine can also indicate that your insulin levels are too low and that additional insulin needs to be taken as a matter of urgency so that your body can use glucose, rather than fat, for energy.

There is no avoiding the fact that pricking your finger can be painful. However, there are various finger pricking devices on the market; and you may find one more comfortable than another. Most devices allow you to adjust the depth of the needle if you are not getting a large enough drop of blood. The tips of your fingers are also more sensitive, so try pricking your finger off to one side. Also, be careful how vigorously you pump your finger for blood once your finger is pricked--this can squeeze blood into the surrounding tissue, causing bruising and discomfort. It might be encouraging to know that testing your blood glucose becomes less painful over time. There are continuous glucose sensors, which will be described later, which may require less frequent finger pricking, and may give more glucose information. 

Tips to make testing easier 

  • Instead of using alcohol wipes, just wash your hands (and then make sure hands are dry) prior to testing 
  • Use a fresh lancet every time—they hurt more when they’re blunt 
  • Once you’ve pricked your finger, hang your hand down and let gravity do the work for you, or you could try gently massaging your finger prior to using the lancet 
  • Look at different blood glucose monitors before choosing one—some need less blood than others or use blood from sites other than the fingertip 
  • Try different lancets. Some are thicker than others—look for a shorter and finer variety 
  • Try setting your lancet to a shorter puncture: the deeper the finger prick, the more tissue you damage 
  • Alternate your sites—don’t just use one finger 
  • Target the sides of your fingers instead of the soft center area where there are more nerve endings 

Advancements in blood glucose control 
JDRF has been working hard to help patients improve their T1D control and to make the management aspect of diabetes easier. One of the JDRF-funded initiatives working toward this goal is called the Artificial Pancreas Project. An artificial pancreas will integrate two currently available technologies – continuous glucose monitors and insulin pumps – in a “closed loop” system. The system will use an algorithm to calculate and automatically provide the right amount of insulin at the right time. It will enable people with diabetes to achieve tight blood glucose control, avoiding both highs and dangerous lows, and thereby significantly reducing the risk of developing complications. 

Continuous Glucose Monitor (CGM) 
A continuous glucose monitor (CGM) is a device for people with diabetes that provides continuous “real-time” readings and data about trends in glucose levels. This information allows people with diabetes to understand their glucose level, and whether it is rising or falling. They can then intervene by eating food or taking insulin to prevent it from going too low or too high. A major clinical trial funded by JDRF has found that most people with T1D who use a CGM experience significant improvements in blood sugar control. 

Be realistic 
Living with diabetes can sometimes be incredibly frustrating. Over the course of a couple of days, you can eat the same amount of food, take the same amount of insulin, and do the same amount of exercise, but your blood glucose levels from day-to-day can be completely different. While food and exercise help determine how much insulin your body needs each day, other factors which you may not understand or control play an important role as well. 

You may also find that your blood glucose levels run high for many hours after an episode of hypoglycemia. These levels may be the result of overeating to correct the low blood glucose level. However, if your blood glucose has been low for some time, your body will make and release stress hormones to try to protect you from having a serious low blood glucose. One of these hormones is glucagon (same as what is in the emergency kit you were asked to obtain). Glucagon triggers the release of the stored glucose (glycogen) from your liver. The glycogen is converted to glucose, and this raises your blood glucose level. It takes hours to refill the glycogen “storage” in your liver. So if you become low and your body makes glucagon (or someone gives you a glucagon shot) – causing glycogen release – you may have no more glycogen to release if you become low again in a short period of time. Your body also produces stress hormones when you are stressed or unwell that can also affect your day-to-day blood glucose control.

Today’s insulin therapies are much better than previous ones, but they are still not perfect. If your blood glucose is outside the normal range, try not to think of it as being bad. Rather, look for a pattern and talk to your health care team about developing strategies to improve your blood glucose level. 

Keep a record of your blood glucose levels
Someone very wise once said, “Sometimes you can’t see the forest for the trees.” This is true of managing diabetes when, over time, little by little, your blood glucose control may change in ways you can’t determine by just looking at one or two days of test results. By keeping a record of your blood glucose levels over time, you can often see trends that will help you make changes to improve your blood glucose levels, reduce hypoglycemia and/or hyperglycemia, and manage your diabetes better.
There are a few ways you can keep track of how your blood glucose levels are fluctuating.

  • Diabetes record books: One of the most popular ways to keep track of your blood glucose levels over time is to use a small book to record your blood glucose levels, food intake, insulin, and activity levels. 
  • Blood glucose meters: One benefit of some blood glucose monitors is that they automatically store your test results. A limitation is that viewing the historic data on the screen can make it difficult to see recurring patterns throughout the day, week, or month. Monitors generally don’t provide the means to track other aspects of your management, such as exercise, food, stress, and insulin.
  • Computer software: Blood glucose monitors and insulin pumps often have the ability to download their data to a computer so you can view your blood glucose and/or insulin history. The software is available from the pump or monitor manufacturer (do a quick search online for the manufacturer’s website to see what it has available) and generally gives you the ability to see graphs and statistics that can help you spot trends and make adjustments to your management plan in consultation with your health care team.
  • Mobile Devices: Diabetes self-management apps are available for smartphones. These applications allow for easy access to information, and also offer a convenient way to record your personal data. You can search online for options that are available for your mobile device.
  • Hemoglobin A1C test: Your doctor or diabetes team will arrange for you to have a special blood test, known as a hemoglobin A1C (HbA1c), in addition to testing your blood glucose levels at home. When you test your blood glucose level, you are measuring how many molecules of glucose are in your bloodstream at the time of testing. However, your HbA1c result is measured as a percentage, and looks at your overall blood glucose control for the preceding two to three months. Glucose in your bloodstream will attach itself to the hemoglobin part of your red blood cells. If there is a lot of glucose in your bloodstream over time, this will result in a higher percentage of hemoglobin with glucose attached. The hemoglobin with attached glucose is referred to as HbA1c or glycated hemoglobin. Since your blood cells, and therefore your hemoglobin, live for around 120 days, the HbA1c test gives you an idea of how your blood glucose levels have been tracking over the same time period.

Diabetes management involves more than just blood glucose control.

You may be surprised that your endocrinologist does not focus exclusively on blood glucose levels. Optimum management of diabetes also requires a focus on blood pressure, renal function, and cholesterol levels. This is because the risk of diabetes-related complications is reduced when blood glucose levels, blood pressure, and blood fats are kept under control. Have your blood pressure checked regularly (at every visit to the doctor) and treated if necessary. 

Tips to improve your blood glucose control

  • Keep a good record of your blood glucose levels
  • Review your blood glucose records regularly to look for patterns of highs/lows
  • Work with your doctor or diabetes educator to make adjustments to your insulin intake, diet, and exercise until your control improves
  • Learn what causes highs and lows for you—the more you recognize what triggers them, the better you will be able to adjust your insulin, carbohydrate intake, or exercise to avoid problems
  • Manage hemoglobin A1C (HbA1c) based upon your doctor’s suggestions
  • Don’t expect perfection! Just aim to get more of your readings within target
  • Ask for help from your doctor or diabetes educator when you need it 

Everything to know about hypoglycemia
When you inject or pump insulin, there will be times when you have too much insulin in circulation. This may be because you accidentally gave yourself more than you needed, you have been more active than you anticipated, your meal is delayed, or your meal has fewer carbohydrates than you thought. It may also be because the insulin preparations you use aren’t perfect and don’t work exactly the same each day. No matter what the cause, there will be times when you have too much insulin and your blood glucose level drops. As discussed earlier in this toolkit, this is known as hypoglycemia, or low blood sugar. Having hypoglycemia can be a frightening experience. Symptoms are different for different people, but they may include:

  • Shaking
  • Sweating
  • Dizziness
  • Hunger
  • Blurred vision
  • Difficulty concentrating
  • Feeling anxious, irritable
  • Changes in behavior

Examples of a quick hypoglycemia fix are:

  • Two to four glucose tablets
  • Two packets of sugar
  • A glass of regular (not diet) soft drink or fruit juice

You should check your blood glucose 10 to 15 minutes after you have treated your low blood sugar. If your blood glucose level is still low, you should eat another 15 grams of carbohydrates and retest your blood glucose in another 10 to 15 minutes. Depending on the timing and cause of your low, you may also need to eat a snack to prevent another episode (for example, if it’s due to increased exercise or taking too much insulin).

You can’t always predict when your blood glucose is going to drop too low, so you need to carry a treatment for hypoglycemia with you at all times. Some useful places to keep a treatment for a low blood sugar include:

  • The glove compartment of your car
  • Your handbag or backpack
  • Beside your bed
  • In your desk drawer
  • In your back pocket

You may find that your blood glucose levels run high for many hours after a low. This may be related to overeating to try to correct the low blood glucose level or due to your body trying to help you raise your glucose levels by producing extra stress hormones. To stop the highs, you have to stop the lows. Doing some blood glucose tests throughout the day will help you and your endocrinologist or health care team work out where you need less insulin and where you might need more.

If you start having too many low blood glucose levels, you will find it harder to recognize signs and symptoms of hypoglycemia. The obvious signs of shaking and sweating may not occur, and you may just feel vaguely out of sorts. This condition is called hypoglycemia unawareness. To avoid this, you should let your doctor or health care team know if your blood glucose level is dropping low regularly (more than three to four lows in a week). 

Getting help in an emergency
If you are not able to recognize signs and symptoms of low blood glucose levels or you ignore them, your blood glucose may drop so low that you are unable to treat it yourself. For this reason, you should teach your family, friends, and work colleagues how to recognize and treat a low if you cannot. They should only give you something to eat or drink if you can respond to their commands. If you can’t, they need to call an ambulance right away or give you an injection of glucagon. It is very important to always wear a bracelet, necklace or other identification stating that you have diabetes.

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