How blood sugar works. What blood sugar levels cause diabetic complications. How to lower blood your sugar. What diabetes drugs are safe.
Source: Blood Sugar 101
How blood sugar works. What blood sugar levels cause diabetic complications. How to lower blood your sugar. What diabetes drugs are safe.
Source: Blood Sugar 101
This section is for everyone. It is somewhat more applicable to type one diabetics but type twos need to know some of this too.
Normal blood sugars for fit young non diabetics are 4.7 on waking and prior to meals and bedtime provided no snacks have been eaten. Two hours after a meal such a persons blood sugar will be down to five or six. Blood sugars should not normally go below 4.0 even if a person has not eaten or has been exercising. A healthy young person can expect to have a hbaic of less than 5.0 although the range given in laboratories takes the not so fit into consideration and often gives an upper limit of normal as 6.0.
What we are trying to achieve with type one and type two diabetes is a replication of normal blood sugar patterns as much of the time as is achievable for you.
In the non diabetic person the pancreas secretes a small amount of insulin all the time. This small amount stops the liver from converting body proteins such as the muscles and vital organs such as the heart into sugar. This is called basal insulin. About the only time this is switched off completely is during very vigorous exercise.
When a meal is eaten an immediate surge of stored insulin enters the blood stream and tells the cells to grab hold of any glucose molecules that are circulating. This is called a first phase insulin response.
As eating continues the pancreas makes as much insulin as it needs to keep the blood sugar normal and it makes this insulin to order as it goes along. This is called the phase two insulin response.
There have been some advances recently in drugs and transplants that will help diabetics of both types one and two get better control or even cure the disease. Meanwhile, unless you are a mouse with a very good health insurance policy, you are best to take charge of your diet and glucose monitoring. Lower carbohydrate diets particularly can help you keep damage from high or swinging bood sugars minimal.
In order to find out how well your body is dealing with your diet and any medication you are taking blood sugars need to be taken:
When you are testing out new foods to see how they affect you testing every half hour or alternately at one hour after eating, two hours after eating and three hours after eating. This gives you a good idea of what types and dosages of insulin may be needed to cover that food successfully. See the “Eat to Meter” section in the type two diabetes section of this course for more information on this.
You also need to check blood sugars before, during and after exercising till you know how that particular sport, duration and intensity of exercise affects you.
Shopping and running errands can drop your blood sugar so have your meter and glucose handy.
It is extremely important to check your sugars before you drive and after every hour of driving.
Intense brain work such as sitting an exam can use up glucose but adrenaline can also raise it. Better check before the exam when you can correct a little or eat something.
Whenever you are hungry or suspect your blood sugars are running higher or lower than expected you should check.
It is useful to teach a toddler a nursery rhyme or song and get them to repeat it often. If you suspect a low blood sugar get them to repeat the song. If they get muddled up they may well have a low blood sugar. Test to check this system works for you a few times and if it is reliable for you you may omit the fingerstick.
If your vision for small print starts to go this can be a sign of low blood sugars so check.
For new college students or those in new or different jobs from usual increased walking to different places and different work schedules can put your sugars way out. You need to check your blood sugars more frequently than usual if your work pattern changes.
Shift work is a whole big problem area for diabetics. Your patterns will change with each type of shift and the transition periods will be particularly difficult as lack of sleep can seriously affect blood sugars too.
Women’s blood sugar patterns shift a lot in relation to their menstrual cycle, some hormonal methods of contraception and of course in pregnancy. You will need to check more frequently during these periods.
If you drink alcohol always eat along with it and be moderate. Alcohol can cause low blood sugars but sugary mixes can raise your blood sugar. You must again test more frequently and of course before you go to sleep no matter how late or early you get in.
Tell people you see regularly that you can get quite crabbit with high and low blood sugars and ask them not to take it personally. Make a deal to check your blood sugar if they ask you to.
Finger prick testing is more accurate than arms pricks if your blood sugar is falling rapidly or if you are very low. If you think you are low test the finger tips or base of the thumb. If you think you are high test wherever you fancy.
Apart from times that your are under an anaesthetic or extremely unwell the person who should take responsibility for your blood sugar monitoring in hospital is YOU.
You must bring in all your kit and continue to look after yourself as if you were at home.
You must have your kit by your bedside or with you if you go off on a hospital trolley for any tests and do not allow it to be disposed of or hidden by the nursing staff.
To reduce the number of finger pricks you need get the nurses to check your figures against theirs. As long as the first few are reasonably similar they should give their agreement to accept your figures.
It is NOT SAFE to assume that the medical or nursing staff know more about your diabetes than you. Given the wide range of medications, insulins and delivery devices it is indeed unfair to expect them to know better than you do.
For insulin dependants it is very important indeed that you administer your own insulin if you are at all able to do this. There have been deaths from staff making mistakes with this.
For people on insulin that should be administered prior to food it may be best to wait till the trolley arrives on the ward or at your bedside before you inject. You may not get it delivered at the time you are expecting and you may also have to count the carbs and estimate the protein before injecting. You may need the food to be kept warm for you to get the optimal time for eating or for allowing a high blood sugar to drop if you need to.
Thyroid function tests
Type one diabetics are prone to the development of other autoimmune diseases so this test should be done every so often and particularly if you begin to feel particularly cold, tired, you gain weight unexpectedly, you have more hypos than usual or your cholesterol suddenly rockets.
Lipids and Liver Tests
All diabetics in the UK over the age of 40 are routinely put on drugs called statins whether they have a raised lipid level or not. Recent guidance is that this should be extended to all type ones over 18 who have one or more complications from their diabetes.
Statins work because they reduce inflammation in the lining of blood vessels and reduce atheroma and clot formation which damage blood vessels and blood supply. Statins can upset liver function and creatine kinase so these are tested routinely.
It is accepted by most doctors that there is a benefit in taking statins for people with diabetes and those with ischaemic heart disease. The problem is that a group benefit may not transfer into a personal benefit for YOU. One in 20 people get liver enzyme rises, muscle pain or general malaise and need to stop statins. They are dangerous to take if a woman is pregnant or at risk of becoming pregnant so women in their childbearing years need to think very carefully about them.
The albumin-creatinine ratio is as test that can detect early signs of kidney damage. If this or microalbumen tests in the urine are positive you may be asked for 24 hour samples and blood tests to clarify the extent of any problem.
The estimated glomerular filtration rate or eGFR is a new blood test done at the same time as the Urea and Electrolyte test. It gives an idea of what stage of kidney impairment may be going on.
ACE inhibitors or ARBs are new drugs that can reduce the rate of kidney deterioration. They end in “pril” or “sartan” respectively. They are also effective in reducing high blood pressure. If you start them for the first time you need a blood test after two weeks to see that they are not worsening kidney function. This can happen in some people who have a condition called renal artery stenosis which is hard to detect otherwise.
Coeliac Disease Tests
Coeliac disease is an autoimmune disease of gluten sensitivity. It can occur at any age. The symptoms can be very vague and it can take a very long time to develop the raised enzyme tests of endomysial antibody and tissue transglutamase and obvious anaemia. Tiredness and abdominal pains are probably the main symptoms. An easy and less expensive test to do is the ferritin level in the blood. This is the amount of stored iron and low levels occur frequently in coeliac disease.
The C reactive protein test is a non specific tests that indicates inflammation. It is often raised in metabolic syndrome and type 2 diabetes.
In the absence of any inflammatory condition or infection you could have high levels of this if you are a type one who is getting quite tubby round the middle and you seem to need a lot of insulin to get your sugars down. In other words it is a marker that you are getting both kinds of diabetes at once. A good exercise regime and lower carb diet is what you need to deal with this problem. High insulin levels cause damage to blood vessels too. Getting insulin and blood sugar levels reduces cardiovascular deterioration.
The hbaic must be the diabetologists favourite blood test. It is also known as the haemoglobin AIC or the glycosylated haemoglobin. It is a test of your average blood sugar over the last 3 months. A truly normal level is less than 5.0 and more accurately 4.2-4.8%.
The average UK figures for 10-18 year old diabetics is a whopping 9.5%
The American Association of Endocrinologists have set a target of 6.5 % or less for diabetics and the UK National Institute for Clinical Excellence are going to recommend that level quite soon. Diabetes UK have set the level at 7.4% or less for children and teenagers but less than one in 7 meet this target at present.
Control of 8.0 or over is considered to be poor and can be an indication that insulin is necessary in type 2s who are struggling on maximal oral therapy.
Diabetic complications can come on in people who have never been diagnosed with diabetes but who have had hbaics of 5.5 or more for many years. Type 2 diabetics are often discovered to have complications at the time of their diabetes diagnosis because of the slow and stealthy development of problems. Visual troubles, breathlessness on exertion and subtle coordination problems are often seen as something to do with middle age or complications can entirely asymptomatic as in kidney disease.
The American Diabetes Association have decided that from next year they will provide patients with a measure of their average blood sugar to help them understand more about what the hbaic test really means.
Here is a chart to help you:
hbaic = average blood glucose value UK / US
5 = 5 / 90
6 = 6.6 / 119
7 = 8.3 / 149
8 = 10 / 180
9 = 11.6 / 209
10 = 13.3 /239
11 = 15 / 270
12 = 16.6 / 299
13 = 18.3 / 329
14 = 20 / 360
It is in your best interest to keep as low as you can towards normal without risking severe hypoglycaemia. Fortunately this is achievable with a low carbohydrate diet.
Why not find out what tests you have been getting done by your doctor ?
If you keep a record of them you will be in a much better position to understand more about how the diabetes has been affecting you. This can help if you need to see a different doctor from usual or you take ill on holiday.
There is no quiz for this section. Type ones however will be getting questions on it later!
Where to Next?
Please move on to the How To: Know How Proteins, Fats, and Carbs Affect My Blood Sugar section next.
This section is for everyone. The information is somewhat more applicable to type one diabetics but type twos need to know some of this as well.
You have read a lot about how carbohydrate affects your blood sugar but what is less known is the effect that protein has on your sugar levels.
About a third of the energy from protein is made into sugar. This process is slower than for carbohydrates and can take 2 or 3 hours or more. Delayed blood sugar rises are likely to happen if your meal has a significant amount of protein in it. By this I mean over 3- 4 oz of lean cooked meat, chicken, fish or 3 eggs.
A ready reckoner is to compare the size of the meat you intend to eat to a pack of cards. If you have steak the size of a woman’s hand or a deck of cards this is about 3 – 4 oz. Chicken to the size of your palm plus the first finger joints or fish the size of a woman’s whole palm is about the same. When you have this amount you must give yourself extra insulin one way or another to cover it or you will go higher than you expect after the meal.
These are the average to small portion sizes such as you would be served in a hospital canteen. Restaurant servings can be a lot bigger. When looking at omlettes, quiches and scrambled egg you need to imagine how many eggs may be in there. Three or more need extra insulin coverage. One egg is equivalent to about one ounce of protein. Big hamburgers eg quarter pounders are easier to recognise and also need extra insulin coverage.
Immediately delivered insulin which covers high and medium glycaemic carbohydrate dishes is no good for covering the much more slowly digested protein. The extended bolus and split bolus techniques familiar to pump users works well however. Using two or more rapid acting insulin boluses can work well and so can using meal insulins with longer action such as regular insulins.
In the UK actrapid is the regular insulin available. It can be in pen form only from Wockhardt in the form of soluble pork or beef insulin. This is being exported now to several countries and can be used in the Owen Mumford Autopen Classic. This pen comes in one unit or two unit increments. Genetically Modified Human Actrapid from Novonordisk is still available in vial and syringe form. Sadly they discontinued their pen actrapid which could be delivered in half unit increments. Pens tend to be easier to carry and syringes can give more versatility over dosage. It all comes down to personal preference.
These insulin delivery techniques and much more is discussed in Gary Scheiner’s excellent book, “Think Like a Pancreas”. Gary was diagnosed as a type one diabetic at the age of 18. He became an exercise physiologist and diabetes educator and is particularly enthusiastic about pump therapy. His book covers important details regarding insulin use that are not always covered in much depth in diabetic clinics. For anyone on insulin I recommend this book so you can get the best out of your current insulin regime and consider other helpful strategies to optimise control of your blood sugars. This book usually gives several different options regarding problem solving. It goes into more depth about insulin than Dr Bernstein’s book regarding insulin use and takes a neutral stance on dietary aspects.
Meals that have a high glycaemic index or load will usually need a standard food bolus such as supplied by novorapid/novolog and humalog as the food is quickly converted into sugar in the blood stream. Examples of these are bread, cereals, potatoes, parsnips, cooked carrots, rice, biscuits, cakes, tropical fruits and sweets.
Meals that have a very low glycaemic index / load may require a method to lengthen out the insulin delivery time just like meat. Examples of these sorts of foods are pasta, especially with creamy or cheesey sauces like lasagne or spaghetti carbonara. Very high breakfast cereals eg all bran. Curries made with lots of fat eg kormas. Battered fish and chips. Chocolate, most dairy food and nuts.
A major difficulty with the glycaemic index is that it gives artificial categories of supposed blood sugar rises for a given amounts of carbohydrate containing foods. One problem is that these tests were done on healthy non diabetics who still have a phase one insulin response. Both type ones and type twos do not have this capacity to immediately release stored insulin. The rate of absorption is also dependent on the temperature of the food, bite size and what it is eaten with and in what order.
To really know what is going on in your body you need to do extensive testing to get the best results for each meal you eat. This involves testing every 30 minutes or so for three or more hours after each meal you eat.
You can only test a food accurately if your baseline blood sugar is normal. Even then insulin sensitivity can vary throughout the day. Typically you are quite insulin resistant at breakfast and are at your most insulin sensitive in the afternoon.
Although this sounds a terrible chore most people only eat about 20 different meals on a regular basis and some a lot less. Please don’t ask me what to do if you are a type one restaurant critic!
To give smooth protein curves it is best to eat some of the protein and fat before you eat the carbohydrates.
If you are having a high glycaemic item leave it till the end of the meal if possible. Can you add some fat to it? This will reduce the rate of absorption. Eg fruit and cheese, potatoes with butter and cream, cake and cream.
Lots of fat in the diet improves the taste, fullness after meals, vitamin absorption and slows down carbohydrate induced sugar spikes.
If you are going to have a snack consider low glycaemic carbohydrates, protein and fat so you are fuller for longer and sugar spikes are minimised. Eg full fat yoghurt, crackers and peanut butter, toasted cheese with butter on thin sliced wholemeal bread.
In a restaurant you can take your regular insulin once the waiter has taken your order as long as there is bread on the table. You only eat this in an emergency however!
If you take rapid acting insulins take it with the starter if you have a normal blood sugar, your main meal if you are low and when the waiter takes your order if you are high.
Tell the waiter you are diabetic and need food right away if you have been waiting for a time or feel low.
It is best to let toddlers eat and then gave them rapid acting insulin to cover what they actually ate.
1. Three of the following make food digest more slowly. Which one does not?
a A lot of sugar or starch in the meal.
b A lot of fat in the meal.
c A lot of protein in the meal.
d Delayed stomach emptying also called gastroparesis.
Have you got it?
1.A is correct. Protein and fat make meals digest more slowly. Sugar and starch are digested quickly. Gastroparesis is when stomach emptying is delayed or erratic due to nerve damage from chronically high blood sugars. Like foot neuropathy it can develop after around five years of having poorly controlled blood sugars.
Acknowledgements & Reference Info:
Where to Next?
Please continue to the How To: Know What Oral Medications I May Be Offered for Diabetes section.
This section is for everyone.
Often you may notice that the blood sugar in the morning is higher than when you went to bed at night even when you have not had any bedtime snack. This can be due to a variety of causes including gluconeogenesis, the dawn phenomenon and delayed stomach emptying which is also known as gastroparesis. There are many other variables that affect blood sugar besides just the macro nutrients of the food you eat.
Gluconeogenesis (Latin for “The making of new sugar”) is the process where the liver converts protein to glucose. This goes on all the time to some extent but is suppressed in the presence of adequate amounts of insulin and drinking alcohol. In type one patients who are no longer able to make enough of their own insulin this process accelerates and is what causes their sugars to rise so high and for them to lose so much weight.
The Dawn phenomenon is called this because the liver clears away insulin more efficiently first thing in the morning compared to other times of the day. At the same time growth hormones and sex hormones are manufactured during the night and these make cells less sensitive to the action of insulin which normally moves sugar from the blood into the cells. These two mechanisms result in higher blood sugars in the morning for most people after puberty gets underway. Various dietary and insulin techniques can be used to minimise the effects of this phenomenon. Another great read on this topic can be found here: The Dawn Phenomenon – Why Are Blood Sugars High in the Morning?
Delayed Stomach Emptying is due to the effects of long term nerve damage on the way the stomach works. The rate of stomach emptying is reduced and the bottom end of the stomach called the pylorus can go into spasm. It can be difficult to know how your stomach will respond from one meal to the next.
For type two diabetics who are not on insulin or drugs which stimulate insulin secretion this may simply give you very unpleasant indigestion.
For insulin users and those on drugs that stimulate insulin secretion, these are usually timed to act over the time the food of the meal is getting digested. When food digestion becomes imbalanced, blood sugars can be too low immediately after a meal only to go too high some hours later.
Special dietary measures are needed to overcome the effects of this condition and they are carefully explained in Dr Bernstein’s book Diabetes Solution.
Like many complications of diabetes it tends to become apparent after 5-20 years of diabetes depending on the level of blood sugar control. Although the condition can certainly make diabetes control much more difficult it is possible to reverse delayed gastric emptying and some other complications by careful maintenance of normal blood sugars for several years.
Blood sugars can rise over the long term from effects you can’t control like inheritance. Excess weight has both genetic and environmental components from the womb onwards. Excess weight gain raises your blood sugars because it makes you more insulin resistant.
Undiagnosed and untreated infections particularly gum and dental infections can raise your blood sugar. Careful examination by a dentist is often needed. Treatment can take months.
Dehydration and acute infections such as gastroenteritis, viral infections, acute injuries, surgical operations or stress can raise blood sugars.
An important consideration is that once the blood sugar is high you become more insulin resistant because of this and vicious circles of high blood sugars, not being able to control them and dehydration can occur. This topic is further explored in the section on sick days in the Type One Section.
The Chinese Restaurant effect named so by Dr Bernstein is the high blood sugars that rise disproportionately to the carb count of the meal due to the actual bulk of the meal. Moderate distention of the stomach produces the stimulation of the hormone glucagon which acts in opposition to insulin. This makes the liver produce more sugar from protein. The main thing to remember is not to stuff yourself at meals.
Exercise affects blood sugars considerably. Different sorts of exercise can raise or lower your blood sugar. This also varies according to how much insulin you have working at the time. The factors are very complex and there will be more discussion and sources of information on this in the Type One Diabetes Section which follows soon.
Exercise can improve many aspects of your life. Even if you have never been to a gym in your life and like me ran away from the ball at enforced school P.E. sessions there are so many activities you can enjoy. You can be active indoors, outdoors, in teams, alone, with help from instructors or by self discovery. Your mood, physique, strength, stamina and flexibility can all benefit in some way.
Tainting a bottle of insulin or exposing it to extreme temperatures can both cause it to lose some of its effectiveness and hence will increase one’s blood sugar even though the same dosage is administered.
1. The dawn phenomenon affects teenagers and…
a Makes their blood sugars particularly high when they wake up in the mornings.
b Makes them sleepy and unable to get up in the mornings.
c Makes their breakfast digest more slowly than usual.
d Makes their blood sugar high by releasing glucagon.
Have you got it?
1. A is correct. The DP as it is often referred to also affects many adults.
This section is based on the work of Dr. Bernstein’s Diabetes Solution.
Where to Next?
Please all proceed to the How To: Keep Healthy with Diabetes section?
Dr Katharine Morrison IDDT October 2007
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