Standards of CARE

But what is good care?
What You Should Expect From Your Health Care Providers

When you have diabetes, it is important that you get good medical care. Now that it’s clear that high blood sugar (glucose) levels play a role in many complications, your doctor’s skill is more vital than ever. Good

care helps you live a full life with as few complications as possible.

But what is good care? The American Diabetes Association provides standards of medical care for people with diabetes. These guidelines give the most up-to-date information on taking care of your diabetes. Also, the guidelines let you know what to expect from your doctor and health care team.

The Team Approach

You should be receiving your diabetes care from a team put together by your doctor. Diabetes is complicated. Your doctor alone cannot be an expert in every area. For this reason, your diabetes care team may include an eye doctor, nurses, and a dietitian. Depending on what complications you have, your doctor may send you to other specialists as well, such as a foot doctor.

The Goal

Too-high levels of sugar in the blood are a feature of all forms of diabetes. The main goal of diabetes treatment is to bring sugar levels down to as close to normal as is safely possible. How far down? Suggested goals are 80–120 milligrams per deciliter (mg/dl) before meals and 100–140 mg/dl at bedtime. Your doctor may set different targets for you, depending on other factors, such as how often you have low blood sugar reactions. Most aspects of your treatment plan—measuring your sugar levels, taking diabetes pills or insulin shots, exercising, losing weight, planning meals—are aimed at helping you reach your target sugar level.

High sugar levels can affect many parts of the body. They can lead to eye, nerve, and kidney diseases. High sugar levels also make it easier to get infections. They can blur your vision or make you feel tired or thirsty all the time. People with diabetes also are more likely to develop other health problems, including high blood pressure, high cholesterol and fat levels, and heart disease.

As you can see, keeping your sugar levels under control is vital to your future health and happiness. Your team can advise you on ways to reach this goal. But much rests on your shoulders. For this reason, your treatment team should spend a lot of time teaching you about diabetes and how to make diabetes care part of your life.

The First Visit

Your first visit to a doctor who will treat your diabetes should have four parts. 1) The doctor should take a medical history (ask questions about your life, complications, and previous diabetes treatment plan). 2) The doctor should give you a complete physical examination. 3) The doctor should run tests on your blood and urine to find out your blood sugar level, your glycated hemoglobin level (a measure of average blood glucose levels over the past 2–3 months), your cholesterol and fat levels, and your urine protein level. Your age, complications, and symptoms dictate which other laboratory tests your doctor does. 4) Your health care team should work with you to make a plan for managing your diabetes.

This checklist will help you make sure your health care team is thorough at your first visit. They should

• measure your height and weight

• measure your blood pressure

• look in your eyes, ask you about any problems you have seeing, and refer you to an eye doctor for a dilated eye exam

• look in your mouth, and ask about your dental health

• feel your neck to check your thyroid gland, and do tests if necessary

• feel your abdomen to check your liver and other organs

• take your pulse

• look at your hands and fingers

• listen to your heart and lungs through a stethoscope

• look at your bare feet, and check the sensation and pulses in your feet

• check your skin, especially the places where you inject insulin

• test your reflexes

• take blood and urine samples for tests

• ask how and when you were diagnosed with diabetes

• ask for results of laboratory tests you had in the past

• ask about your eating habits and weight history

• ask about your current

diabetes treatment plan

• ask how often and how hard you exercise

• ask about times you’ve had ketoacidosis as well as low blood sugar reactions

• ask about infections you’ve had

• ask what complications you’ve had and what treat-ments you’ve received for them

• ask what medicines you are taking

• ask about factors that make you more likely to get heart disease, such as smoking, high blood pressure, eating and exercise habits, cholesterol levels, and family history

• ask what other medical problems you’ve had

• ask who else in your family has diabetes

• ask about problems you may have had while pregnant

Putting together a diabetes care plan is an important part of your first visit. Your diabetes care plan will not be the same as everyone else’s. To work well, the plan must be adapted to your own life. For example, it needs to take account of your work or school schedule, how active you are, what and when you like to eat, your cultural background, and other medical problems you have.

You need to be involved in devising your diabetes care plan. Otherwise, it’s unlikely that the plan will fit into your life or that you will understand what you need to do.

Is your diabetes care plan complete? If so, it should include

• a list of goals (both short term and long term)

• a list of the medicines that you will use to control your diabetes

• advice from a dietitian on eating

• a list of changes you have agreed to make in your life, such as getting more exercise or stopping smoking

• teaching sessions for you and your family on how and when to measure your blood sugar levels and urine ketones, how to keep records of these, and how to treat low blood sugar reactions

• a plan for seeing an eye doctor

• a plan for seeing a foot doctor, if you need to

• a plan for seeing other specialists, if you need to

• instructions on when to come back and when you should call

• a birth-control and prepreg-nancy plan

• a plan for caring for your teeth and seeing the dentist

• a plan for sick days

Future Visits

How often you should return to your diabetes doctor depends on many things. If you take insulin for your diabetes or if you’re having trouble controlling your sugar levels, you should see your doctor at least 4 times a year. Otherwise, you should see your doctor 2–4 times a year. You may need to visit your doctor more often if you have complications or if you are starting a new medicine or insulin program. Your doctor will advise you about when to return. He or she should also tell you other times to call or come back. For example, your doctor may want you to call if you’ve had nausea or vomiting that make you unable to eat or if you’ve had a fever for more than a day. You will need to stay in touch with your doctor by phone every week or even every day if you are making big changes in your diabetes care plan.

When you return, expect the doctor and other members of your health care team to give you a physical examination, take a medical history, run laboratory tests, and fine-tune your treatment program. These later visits are not as in-depth as your first visit, although you should get a complete physical examination once a year. Also, your doctor may order new tests, do other examinations, or refer you to a specialist depending on test results and your needs.

This checklist will help you make sure your health care team does a good job at your follow-up visits. They should

• ask about times you’ve had high or low blood sugar levels

• ask to see your blood sugar records

• ask what adjustments you’ve made to your diabetes care plan

• ask what problems you’ve had in following your diabetes care plan

• ask about symptoms that might indicate you are getting a diabetes complication

• ask what other illnesses you had since your last visit

• ask what medicines you are taking now

• ask if your life has changed in any way

• measure your weight and blood pressure

• look in your eyes

• look at your feet

• take blood for glycated hemoglobin measurement

• once a year, take a urine sample to look for protein and

take blood for cholesterol and blood fat tests

• review your treatment plan to measure your progress in meeting goals and see where you are having problems

Children and Teenagers

Standards of care for children are somewhat different. Children whose diabetes is not well controlled sometimes are slow to grow and mature. So the doctor should measure height at every visit, not just the first. And the doctor should check the progress of sexual maturation. The types of laboratory tests the doctor does also can differ, because children are not at risk for certain complications.

The diabetes care plan must take children’s needs into account. Children need enough nourishment to grow properly. It’s important to prevent low blood sugar reactions, which can easily happen to children when they are too young to know the warning signs of a reaction. The dietitian may

recommend more snacks and different foods than for adults to help with these special needs. Also, children tend to get more illnesses than adults. Parents need instructions about sick days and when to call.

Treatment plans need to be adapted for teens as well. The busy schedules of many teenagers can make it hard for them to stick to their diabetes meal plan.

For these reasons, children with their parents and teenagers should meet with a dietitian each year to review their meal plans and work out problems.

Other related materials: For additional information on diabetes, visit the American Diabetes Association Book Store or follow the hyperlinks to view our Complete Guide to Diabetes, The Uncomplicated Guide to Diabetes Complications, and 101 Medication Tips for People with Diabetes.

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All About Insulin

The ins and outs of the hormone you need

What Is Insulin?

Inside the pancreas, beta cells make the hormone insulin. With each meal, beta cells release insulin to help the body use or store the glucose it gets from food.

In people with type 1 diabetes, the pancreas no longer makes insulin. The beta cells have been destroyed. They need insulin shots to use glucose from meals.

People with type 2 diabetes make insulin, but their bodies don’t respond well to it. Some people with type 2 diabetes need diabetes pills or insulin shots to help their bodies use glucose for energy.

Insulin cannot be taken as a pill. It would be broken down during digestion just like the protein in food. Insulin must be injected into the fat under your skin for it to get into your blood.

There are more than 20 types of insulin sold in the United States. These insulins differ in how they are made, how they work in the body, and price. Insulin comes from animals (pigs or cows) or is made in labs to be identical to human insulin.

There are four types of insulin, based on

• how soon the insulin starts working (onset)
• when it works the hardest (peak time)
• how long it lasts in your body (duration).

However, each person responds to insulin in his or her own way. That is why onset, peak time, and duration are given as ranges.

Rapid-acting insulin (Lispro) reaches the blood within 15 minutes after injection. It peaks 30 to 90 minutes later and may last as long as 5 hours.

Short-acting (regular) insulin usually reaches the blood within 30 minutes after injection. It peaks 2 to 4 hours later and stays in the blood for about 4 to 8 hours.

Intermediate-acting (NPH and lente) insulins reach the blood

2 to 6 hours after injection. They peak 4 to 14 hours later and stay in the blood for about 14 to 20 hours.

Long-acting (ultralente) insulin takes 6 to 14 hours to start working. It has no peak or a very small peak 10 to 16 hours after injection. It stays in the blood between 20 and 24 hours.

Some insulins come mixed together. For example, you can buy regular and NPH insulins already mixed in one bottle. They make it easier to inject two kinds of insulin at the same time. However, you can’t adjust the amount of one insulin without also changing how much you get of the other insulin.

Strength. Insulins come dissolved in liquids at different strengths. Most people use U-100 insulin. This means it has 100 units of insulin per milliliter (ml) of fluid. Be sure that the syringe you use matches the insulin strength. U-100 insulin needs a U-100 syringe. In Europe and Latin America, U-40 insulin is also used. If you’re outside the United States, be certain to match your insulin strength with the correct size syringe.

Additives. All insulins have added ingredients to keep them fresh and help them work better. Intermediate- and long-acting insulins also have ingredients to make them act longer. Today’s insulins are very pure. Allergic reactions are rare.

Storage and safety. Using cold insulin can make your shot more painful. You can keep the bottle of insulin you are currently using at room temperature or warm the bottle by gently rolling it between your hands before you fill the syringe. If you buy more than one bottle of insulin at a time, store the extra bottles in the refrigerator until you start to use them.

Never store insulin at very cold (under 36 degrees Fahrenheit) or very hot (over 86 degrees Fahrenheit) temperatures. Extreme temperatures destroy insulin. Do not put your insulin in the freezer or in direct sunlight.

Insulin may lose some potency if the bottle has been opened for more than 30 days. Look at the bottle closely to make sure the insulin looks normal. If you use regular, it should be perfectly clear—no floating pieces or color. If you use NPH or lente, it should be cloudy, with no floating pieces or crystals on the bottle. Do not use insulin past the expiration date.

Insulin Therapy

With the help of your health care team, you can find an insulin routine that will keep your blood sugar near normal, help you feel good, and fit your lifestyle.

People diagnosed with type 1 diabetes usually start with two injections of insulin per day of two different types of insulin. People with type 1 diabetes generally progress to three or four injections per day of insulin of different types. The types of insulin used depend on their blood sugar levels. Studies have shown that three or four injections a day give the best blood sugar control and can prevent or delay the eye, kidney, and nerve damage caused by diabetes.

Most people with type 2 diabetes may need one injection per day without any diabetes pills. Some may need a single injection of insulin in the evening (at supper or bedtime) along with diabetes pills. Sometimes diabetes pills stop working, and people with type 2 diabetes will start with two injections per day of two different types of insulin. They may progress to three or four injections per day.

Insulin Delivery

Many people who take insulin use a syringe. Other choices are insulin pens and pump therapy. Some insulin pens contain a cartridge of insulin that is inserted into the pen. Some pens come already filled with insulin and are discarded after all the insulin has been used. The insulin dose is dialed on the pen, and the insulin is injected through a needle, much like using a syringe. Cartridges and prefilled pens only contain one type of insulin. Two injections must be given with an insulin pen if using two types of insulin.

Fine-Tuning Your Blood Sugar

Many factors affect your blood sugar levels. These include:

• what you eat
• how much and when you exercise
• where you inject your insulin
• when you take your injections
• illness
• stress

Self-monitoring. Checking your blood sugar and looking over results can help you understand how exercise, an exciting event, or different foods affect your blood sugar level. You can use it to predict and avoid low or high blood sugar levels. You can also use this information to make decisions about your insulin dose, food, and activity.

Site rotation. The place on your body where you inject insulin affects your blood sugar level. Insulin enters the blood at different speeds when injected at different sites. Insulin shots work fastest when given in the abdomen. Insulin arrives in the blood a little more slowly from the upper arms and even more slowly from the thighs and buttocks.

Injecting insulin in the same general area (for example, your abdomen) will give you the best results from your insulin. This is because the insulin will reach the blood with about the same speed with each shot. Don’t inject in exactly the same place each time but move around the same area. Each meal-time injection of insulin should be given in the same general area for best results. For example, giving your before-breakfast injection in the abdomen and your before-supper injection in the leg each day give more similar blood sugar results. If you inject near the same place each time, hard lumps or extra fatty deposits may develop. Both of these problems are unsightly and make the insulin action less reliable. Ask your health care provider if you aren’t sure where to inject your insulin.

Timing. Insulin shots are most effective when you take them so that insulin goes to work when glucose from your food starts to enter your blood. For example, regular insulin works best if you take it 30 minutes before you eat.

Too much or not enough insulin? High morning blood sugar levels before breakfast can be a puzzle. If you haven’t eaten, why did your blood sugar level go up? There are two common reasons for high before-breakfast blood sugar levels. One relates to hormones that are released in the early part of sleep (called the Dawn Phenomenon). The other is from taking too little insulin in the evening. To see which one is the cause, set your alarm to self-monitor around 2 or 3 a.m. for several nights and discuss the results with your health care provider.

Injection Technique and Syringe Reuse

Many people safely reuse their syringes. However, if you are ill, have open wounds on your hands, or have poor resistance to infection, you should not risk syringe reuse. Syringe makers will not guarantee the sterility of syringes that are reused. Keep the needle clean by keeping it capped when you’re not using it. Cleaning it with alcohol removes the coating that helps the needle slide into the skin easily. Never let the needle touch anything but clean skin and the top of the insulin bottle. Most important, never let anyone use a syringe you’ve already used, and don’t use anyone else’s syringe.

Reusing syringes may help you cut costs, avoid buying large supplies of syringes, and reduce waste. However, talk with your doctor or nurse before you begin reusing. They can help you decide whether reuse would be a safe choice for you.

Syringe Disposal

It’s time to dispose of a syringe when the needle is dull or bent or if it has come in contact with anything other than clean skin. Your syringe is medical waste. If you can do it safely, clip the needles off the syringes. When you remove the needle, no one can use the syringe. It’s best to buy a device that clips, catches, and contains the needle. Do not use scissors to clip off needles—the flying needle could hurt someone or become lost. If you don’t destroy your needles, recap them. Place the needle or entire syringe in an opaque (not clear) heavy-duty plastic bottle with a screw cap or a plastic or metal box that closes firmly. Do not use a container that will allow the needle to break through or recycle your syringe container.

Your area may have rules for getting rid of medical waste such as used syringes. Ask your refuse company or city or county waste authority what method meets their rules. When traveling, bring your used syringes home. Pack them in a heavy-duty holder, such as a hard plastic pencil box, for transport.