Managing Type 1 Diabetes
The aims of diabetes management are threefold:
- To keep blood glucose levels within target range as much as possible
- To minimise the risk of developing long-term complications
- To enable you to enjoy a happy and well-adjusted life
If you have Type 1 diabetes then your diabetes management will hinge on your insulin injections or insulin pump settings, your blood glucose monitoring, and how you fit them to your daily life. You will find that it is a bit of a juggling act, getting everything just right. Don’t worry if it doesn’t all come together immediately; there are a lot of things to learn about before you can apply the principles of diabetes management to your own life.
Basic Principles of Type 1 Diabetes Management
Your ultimate aim is to keep blood glucose levels close to the normal range in order to feel good from day to day and to give you the best possible odds in the fight against long-term complications.
You will need to learn what makes the blood glucose level rise and fall and how you can minimise the swings in your own blood glucose level.
Food, stress and illness all raise the blood glucose level. Insulin and exercise lower the blood glucose level. Normally your pancreas would produce just the right amount of insulin at just the right time to cope with the fluctuations in blood glucose level that all of these factors cause. Successful diabetes management involves continually juggling these factors, and assessing what’s going on by regular finger-prick blood glucose testing (or using continuous glucose monitoring). In order to keep on top of your diabetes, you will frequently need to try to second-guess what’s going to happen.
Insulin needs to be injected. It provides you with a background level of insulin needed to keep the body ticking over and it deals with the glucose that is absorbed into the blood after meals. There are a number of different types of insulin and you may be prescribed a combination of insulins, to be injected at different times during the day. This forms your insulin regimen. Having the right insulin regimen to fit your lifestyle is one of the most crucial aspects of diabetes management. An alternative to insulin injections is insulin pump therapy, whereby insulin is continuously infused into the body.
Depending on your insulin regimen, you may need to eat regularly, at set times throughout the day. Your diet should be healthy and nutritious. You will need to consider how much you eat and when you eat it. You will also need to look at the types of foods that you eat and assess the effects that they will have on your blood glucose level.
>> More on Food and Type 1 Diabetes
You will hear time and time again that exercise is good for diabetes and that it will help you to control your blood glucose levels. In fact, this is really only true for people with Type 2 diabetes. Although exercise has many benefits for all people – with or without diabetes – it can complicate blood glucose control in Type 1 diabetes unless it is properly handled. You will need to learn how to incorporate exercise into your daily life whilst keeping good control.
>> More on Exercise and Type 1 Diabetes
Illness plays havoc with the workings of most of our body systems, so it is not surprising that diabetes control is affected during periods of illness. It is very important that blood glucose levels don’t become dangerously high if you are ill or have an infection of some sort. So, in order to prevent diabetic emergencies it is wise to follow sick day management guidelines.
>> More on Sick Days with Type 1 Diabetes
What other things need to be considered?
Important factors will include:
- Types of insulins used
- Timing of injections or insulin pump settings
- Choice of injection or infusion site and other factors affecting the absorption of insulin
- How well your insulin regimen is matched to your body’s natural insulin needs
- How well insulin doses are matched to food intake
- Making appropriate adjustments (e.g. to insulin doses) to cater for changes in the daily routine (e.g. exercising)
- Using finger-prick or continuous glucose monitoring results effectively
You can learn about different types of insulin and factors affecting insulin absorption on the page “Injecting Insulin”
In addition to the above, the successful management of your diabetes will also depend on:
- Access to adequate information, education and support (Learn More About Diabetes – INDEX is a good place to start!)
- A good working relationship with your diabetes healthcare team
- Regular check-ups to monitor your progress and detect any early signs of complications.
Setting Targets
An important element of diabetes management is setting targets or goals for yourself. This can be especially useful in the early days or if you feel that you’re not too in control of things.
First, you will need to identify your goals, and then prioritise them. If you have just been diagnosed, then your goals will be different from someone who has had diabetes for some time, but has decided to take steps to improve their diabetes self-care.
Make sure that your goals are realistic. Remember, Rome wasn’t built in a day!
For more guidance on setting and achieving goals, see “Setting Goals and Making Changes”.
Insulin
Problems with insulin lie at the root of all types of diabetes. With Type 1 diabetes, it is a complete lack of insulin that is the problem, resulting from the loss of the insulin-producing beta cells in the pancreas. Daily insulin injections or continuous insulin infusion is needed for survival.
To understand more of the relationship between insulin and blood glucose, take a look at “Diabetes and Insulin”. Important information about insulins and injecting insulin can also be found in the section “Injecting Insulin”. Here, we look at how insulin injections can be used to successfully control blood glucose levels in the management of Type 1 diabetes.
Keep blood glucose levels close to your target range is important for your health now and in the future. Understanding your insulin treatment will help you to take charge of your diabetes; it will help you to fit the diabetes into your life, as opposed to trying to fit your life around the diabetes.
There are a number of things that you will need to find out about. Most importantly, you will need to learn about your insulin regimen and how it relates to your food intake and blood glucose levels.
| Insulin regimens
We often refer to ‘insulin regimens’ – but what exactly do we mean by this? It is the way that your insulin injections are organised through the day. Most people with Type 1 diabetes need more than one injection per day and use more than one type of insulin. The combination of insulins and the times that you have your injections make up your insulin regimen. |
Your body’s insulin needs
Glucose is the body’s primary source of fuel; it comes from the food that we eat and is transported around the body in the bloodstream. Insulin enables the body’s cells to take glucose from the bloodstream. The cells might use it straight away or put it down to storage.
In people who do not have diabetes, insulin is produced by the body in response to the rise in blood glucose level that follows the digestion of food. This enables the body to either use or store glucose from the meal. The liver will take up and store a good deal of the glucose (it will then release it again later, when the body is fasting).
In addition to the spurts of insulin produced in response to eating, a trickle of insulin is released constantly, throughout the day and night. This looks after the body’s resting needs for insulin and ensures that cells can take up glucose (released form the liver) to keep ticking over.
Insulin therapy in people with diabetes needs to fulfil both of these needs. In other words, it should provide:
- peaks of insulin at (or just after) mealtimes
- background levels of insulin throughout the day and night
People with Type 1 diabetes usually need a combination of different types of insulin (or an insulin pump) in order to fulfill these needs.
Dawn effect
The amount of background insulin needed by the body changes throughout the day. Different people have different patterns, but as a rule more insulin is needed during the morning. Some people find that they have trouble with high blood glucose levels when they wake up – this is because insulin needs increase in the early hours of the morning and is called the ‘Dawn effect‘. It is thought to be caused by an increase in the levels of other hormones circulating in the blood at this time of the day (these hormones have the effect of raising the blood glucose level).
People who do not have diabetes automatically produce more insulin when it is needed. People with diabetes need to try to counter the Dawn effect with appropriate administration of insulin (not always easy!)
Honeymoon period
If you have recently been diagnosed with Type 1 diabetes, you may still be producing a little insulin yourself. This is because diabetes is often diagnosed before all of the beta cells in the pancreas have been destroyed. The few remaining cells may produce insulin for a few weeks or months and you may not need to inject much insulin at all. How long this ‘honeymoon period‘ lasts depends on how fast the beta cells are being destroyed by your immune system (see “Stages of Type 1 Diabetes”, for more details). The honeymoon period tends to last much longer in adults.
When the honeymoon period is over, the amount of insulin that you need to inject may increase dramatically. You may also find that controlling your blood glucose levels becomes much more difficult.
Types of insulin regimen
There are numerous types of insulin regimen. Ideally, you will develop an individualised regimen that fits in with your life. However, your diabetes team will probably start you on one of the standard types of insulin regimen – this can then be adapted later, if necessary.
Twice-daily mixture of short acting and intermediate or long acting insulin
This type of insulin regimen is sometimes referred to as ‘conventional’ therapy. Generally, a mixture of short and longer acting insulin is given in the morning and then again before the evening meal. Insulins are either drawn up from different bottles into the same syringe, or pre-mixed insulin (often supplied in pen injectors) is used.
How does the regimen work?
In theory:
- the morning short acting insulin takes care of breakfast
- the morning longer acting insulin takes care of lunch
- the evening short acting insulin takes care of the evening meal
- the evening longer acting insulin takes care of overnight insulin needs
One obvious advantage is that no injection is required at lunchtime – this is useful for many people, including school children.
A disadvantage of this type of insulin regimen is that mealtimes become very important (especially lunch and the evening meal) and snacks are often needed in order to prevent hypoglycaemia (low blood glucose) between meals.
Another disadvantage, again relating to lack of flexibility, is that if pre-mixed insulin is used, it is harder to vary the insulin dose to accommodate changes in your daily routine. This is because the doses of short and longer acting insulin cannot be varied independently of one another. So, if you want more (or less) short acting you will need to have more (or less) long acting too.
[Note: To a certain extent, the consequences of changing insulin doses will depend on the ratio of the two insulins in the mixture.]
Of course, an advantage of using pre-mixed insulins is that they are available as disposable pen injectors – this means that insulin does not need to be drawn up with a needle and syringe – it is quick and easy, and definitely more convenient.
Multiple daily injections of short or fast acting insulin with one or two separate injections of intermediate or long acting insulin
This type of insulin regimen is sometimes referred to as ‘intensive’ or ‘flexible’ insulin therapy.
Generally, short or fast acting insulin is given before meals and longer acting insulin is given at bedtime. Sometimes longer acting insulin is also needed in the morning.
This insulin regimen is much more flexible. Although a lunchtime injection is usually required, the use of a pen injector can make this a quick and easy task.
How does the regimen work?
In theory:
- the short or fast acting insulin takes care of meals
- the longer acting insulin takes care of background insulin needs
This type of injection regimen provides a supply of insulin that can be tailored more closely to the body’s natural needs. It also increases flexibility in terms of mealtimes.
Putting the theory into practise
Knowing how things are supposed to work is just the first step. Living with diabetes in real life means that you often have to relate what does happen to what should happen.
We are all different. Not just in terms of our hair colour or the shape of our noses – our body chemistries work differently too. With respect to diabetes, this means that what works for one person often doesn’t always work for another. It means that you will have to find out what works for you – and how it works for you.
This is where blood glucose testing comes in. Only by testing your own blood glucose level on a regular basis will you be able to see how well your insulin regimen is working and identify any problem areas.
Factors complicating insulin therapy
Unfortunately, insulin therapy in diabetes is far from the perfect solution, especially when the insulin is injected*. There are a number of things which can affect how your insulin behaves. In most cases, if you are aware of the possible factors that can complicate matters, you will be able to take steps to minimise any problems.
Absorption of insulin from the injection site
There are many things which can affect how the insulin is absorbed from the injection site into the bloodstream. Ideally, you need to be able to rely on your insulin being absorbed in a regular fashion from one day to the next.
- It is important that the correct injection technique is used. If the injection is too shallow (into skin) or too deep (into muscle) the insulin will not be absorbed properly.
- Insulin is absorbed most rapidly from the abdomen, then the arms, thighs and buttocks. Short acting insulins are best injected into the arms or abdomen.
- Problems at the injection site itself can affect the absorption of insulin (see “Using Insulin” for more details).
- Smoking can cause unpredictable or erratic blood glucose levels in some people. Nicotine causes changes in small blood vessels and this, in turn, can affect the absorption of insulin from the injection site.
- Heat, massage and exercising a limb close to the injection site can increase insulin absorption. Sometimes this can cause a sudden drop in blood glucose levels and an unexpected hypo.
Unfortunately there is often some day-to-day variation in insulin absorption, even when using the same injection site; this is more notable with some of the intermediate and long acting insulins.
Exercise
Exercise can have a number of effects on blood glucose levels, depending on the duration and intensity of the exercise, as well as your food intake and insulin levels.
>> More on Exercise and Type 1 Diabetes
Variable lifestyle or work schedule
Appropriate timing of insulin injections and meals is essential for good control. Sometimes though it is not easy to time insulin and meals to perfection and this is especially true for people who lead active or variable lifestyles or work variable hours.
It usually possible to work out ways to get round these problems but it does require commitment and lots of blood glucose testing on your part, as well as support from your diabetes team.
Weekends and Holidays
It is often the case that we follow quite different schedules when at home compared to when we are at work. If your routine is significantly different at weekends from weekdays then you may need to develop two insulin regimens that are tailored to your activities.
Holidays are all about leaving the stresses and strains of everyday life behind, relaxing and enjoying yourself. Any change in circumstances can affect your insulin needs and going on holiday is no exception. However, there is no reason whatsoever why diabetes should get in the way of having a good time on holiday; just remember to be aware of your needs and don’t neglect your diabetes completely.
*Providing insulin continuously with a pump can overcome some of the above difficulties (although it does introduce a new set of potential problems!) – see “Using Insulin“, for more information.
Summary of the main points to consider
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