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How Well Do You Know Your Diabetes Management Plan?

As a person with diabetes, you are in charge of your diabetes management. Your doctor, diabetes educator, dietitian, and other members of your team are there to give input on your plan, but between checkups, your diabetes care is your responsibility.

Having the information you need is key to successfully managing your diabetes. It’s important to truly know what your diabetes plan is and to understand how to carry it out. It also helps to know why you’re doing the things you’re doing. For example, your doctor may tell you that you need an HbA1c test result below 7%, but you may not feel that striving for that is worth the effort unless you know that a result under 7% is directly associated with fewer long-term complications. In addition, knowing what, knowing how, and knowing why can help you problem-solve should something go wrong.

The following questions are designed to get you thinking about how well you know your diabetes control plan, while encouraging you to seek out the missing answers.

Medicine
Do you know the names of the medicines you take for your
diabetes?
Drugs often go by two different names: the generic name, which is the scientific name of the drug, and the brand name, which is the name you’ll see in large print in TV or magazine ads. Drugs sold as generics are labeled only with their generic names, while brand-name drugs are labeled with both the generic name and the brand name. For example, the long-acting insulin Lantus is marked with both its brand name, Lantus, and its generic name, insulin glargine. In most cases, knowing one or the other is probably sufficient, but there may be instances where it’s important to know both names.

When do you need to know the names of your medicines? If you were ever separated from your diabetes supplies while traveling or because of a natural disaster and couldn’t easily contact your doctor or pharmacy, you would likely be able to replace your medicines faster if you knew what you needed.

Another instance when it’s important to know what you take is if you require the services of emergency medical personnel. Some medicines can react badly with other medicines, and if you develop a serious illness or injury that could be helped with the administration of certain drugs, the people helping you need to know what drugs are already in your system so they don’t give you a drug that could interact with them. “This could be a very dangerous situation,” says endocrinologist Steven Edelman, MD, “especially if a person is having a serious problem like a heart attack and the physicians need to administer some heavy-duty drugs.” These drugs can have bad interactions, he says, so knowing types of medicines and the amounts is incredibly important to staying safe.

It’s also useful to know what drugs you take for your diabetes (and any other medical conditions you may have) if you see more than one doctor. Before a doctor prescribes a new medicine for you or changes a dose, he wants to know that it won’t conflict with any others you already take. Having a list of what you take at the ready can save a lot of time that might otherwise be spent contacting other doctors or your pharmacy.

What if you can’t remember the names and doses of the drugs you take? Write them down! In fact, even if you can remember, it’s a good idea to write this information down, just in case you’re ever in a situation where you can’t communicate it. Write down both the generic name and the brand name (if any) and the dose you take. Include when you take each and how (for example, by mouth, syringe, or insulin pump), then make a few photocopies of your list and stick them in your wallet, purse, or briefcase; your emergency evacuation kit; a desk drawer or locker at work; and an accessible place at home. You might also give one to a friend or family member.

Do you know what to do if you miss a dose of your medicine?
If your answer to this question is no, ask your doctor about this at your next appointment, and write down the answer.

What to do about a missed dose will depend on what drug you forgot to take, when you realize you missed a dose, and how long it is until your next scheduled dose. Don’t assume that you should take your dose immediately upon remembering it or that you should take a double dose at the time of your next scheduled dose. Either of these moves could have negative, even serious, side effects.

If you miss a dose and don’t have instructions from your doctor on what to do, read the drug information that came with your medicine. If it doesn’t tell you what to do, call your doctor or pharmacist for advice.

Do you know how the medicines you use work?
Knowing how your medicines work can be helpful in the event of a missed dose, in sorting out blood glucose control difficulties, and in determining whether a new symptom may be a drug side effect. This information may be particularly important when first starting a new drug.

Insulin directly lowers your blood glucose level by enabling glucose in your bloodstream to enter the cells in your body. The main differences among types of insulin are their “action times,” or how quickly they start lowering blood glucose after being injected or infused into your subcutaneous tissue, when they reach their peak blood-glucose-lowering effectiveness, and for how many hours they continue lowering blood glucose after being injected or infused. The package insert that comes with your insulin contains some information about these times, but there is individual variation from person to person. You can discover your own action times through careful monitoring. The most common side effect of insulin is low blood glucose.

The oral medicines taken for Type 2 diabetes work in a number of ways to lower blood glucose. Some cause the pancreas to release more insulin, some slow the rate at which the liver releases glucose into the bloodstream, some enable muscle and fat cells to better use insulin, and some slow the rate at which certain types of carbohydrate are absorbed. Some work quickly and are meant to be taken just before meals (and skipped if a meal is skipped), while others stay in the body for a longer time and are meant to be used continuously. Side effects vary from drug to drug.

Two injected drugs, exenatide (brand name Byetta) and pramlintide (Symlin), are taken before meals and lower blood glucose levels by suppressing the release of glucagon, a hormone that signals the liver to release glucose, and by slowing the rate at which food moves through the stomach. Byetta additionally signals the pancreas to release insulin when blood glucose levels are high; Byetta is taken only by people with Type 2 diabetes. Both are known to cause nausea, which often subsides with continued use.

Dr. Edelman says, “People with diabetes need to know about the drugs and insulins they take. This would include how they work, who they are intended for, what to expect with their control, and the side effects that are most common. They need to be careful not to ‘get all of the symptoms they read about’ and stop the medicine without talking to their primary-care physician.”

When was the last time you updated your list of medicines?
Having a list of the medicines and doses you take is only useful if it’s current. Is yours? If you only have small changes to make, you don’t need to rewrite the whole thing; just cross out the old information and write in the new. (Don’t forget about updating your various photocopies, too.) If you have a computer, consider making an electronic file of your medicines; it’ll be easier to update and reprint than rewriting by hand.

Many people who take insulin are encouraged by their doctors to be proactive about changing their insulin doses between visits, if necessary. If you do this, keeping a record of those changes will help keep your doctor up to date on your blood glucose control efforts. If you’d like to do this but haven’t been instructed on how, speak to your doctor. Changing your insulin doses without proper instruction can lead to dangerously low or high blood glucose levels.

For people who are on insulin pumps, having a current list of your basal rates, insulin-to-carbohydrate ratios (for bolus doses), and insulin sensitivity factor (for correction boluses) will help you reprogram a replacement insulin pump accurately in the event that your pump malfunctions and you get a new one. Your doctor will have records of these specifics on file from your last appointment, but if you have made any changes since then, there will be no written record unless you have created one.

Monitoring
At what times have you been told to monitor your blood glucose, and why?
Measuring your blood glucose level isn’t very useful unless you know what the numbers mean and how to respond to them.

For people with Type 1 diabetes and people with Type 2 who take insulin, monitoring is generally recommended before meals and before bedtime. Monitoring at these times helps you see trends in your blood glucose levels and enables you to make modifications in your insulin doses, if necessary. It helps you gauge how much short-acting insulin to take before meals (to cover the carbohydrate and correct high blood glucose) and to see whether a bedtime snack may be needed to keep blood glucose within the recommended range overnight. The before-breakfast check can also give you some information about your level of blood glucose control overnight. Monitoring is also recommended before driving (to help prevent the possibility of developing hypoglycemia while driving) and any time a person has symptoms of hypoglycemia.

For people with Type 2 diabetes who don’t take insulin, the recommendations are less clear. According to Dr. Edelman, “Diabetes professionals debate all the time on the importance of home glucose monitoring in people with Type 2 diabetes who don’t take insulin. For people with Type 2 diabetes who do take insulin, monitoring is important for making day-to-day adjustments, avoiding hypoglycemia, knowing when to use a correction factor, etc. For people who take oral medicines and/or Byetta, monitoring is extremely important, in my view, because it tells the person if the medicines are working and what time of day there are potential problems.”

The American Diabetes Association recommends aiming for before-meal blood glucose levels between 70 and 130 mg/dl.

If you don’t know when to monitor or why you are monitoring at certain times, talk to your doctor. Also let your doctor know if your before-meal levels are usually higher than 130 mg/dl, and ask what can be done to bring these levels down. Your doctor may be able to suggest additional times to check your blood glucose level to help with your management.

Do you know when and why to monitor after meals?
Checking your blood glucose level both before and after meals can tell you what effect your food choices and any medicines you took before the meal had on your blood glucose level. Some people routinely check after every meal, and some check after meals only occasionally or when making changes to their diabetes treatment plan.

If you check after meals, the time to do it is two hours after your first bite of a meal. If your after-meal blood glucose level is significantly higher than your premeal level, there are several possibilities to consider: Your premeal medicine dose (whether insulin, Symlin, Byetta, another injected drug such as long-acting exenatide [Bydureon] or liraglutide [Victoza] , or an oral drug) may not be large enough; your timing of your dose, particularly insulin, may need adjustment; or you may have consumed more carbohydrate or fat than you thought.

The American Diabetes Association recommends aiming for after-meal blood glucose levels below 180 mg/dl.

Lowering after-meal blood glucose levels can help lower your HbA1c level, the subject of the next question.

Do you know what your HbA1c level is?
Your HbA1c level (also known as A1C or glycosylated hemoglobin) is a measure of your overall blood glucose control over the past two to three months. It’s also the measure most commonly used in research studies that examine the relationship between blood glucose control and risk of long-term diabetes complications. Most studies have found that the lower your HbA1c, the lower your chance of developing complications. Therefore, if you keep tabs on your HbA1c, you have a better sense of whether your daily blood glucose control efforts are effective for protecting your long-term health.

Knowing your HbA1c can also fill in some of the gaps left by routine blood glucose monitoring. Unless you use a continuous glucose monitor, your usual monitoring gives only “snapshots” of information, and there are large stretches of time during which you have no idea what your blood glucose level is. If all of your daily monitoring results are within your target range but your HbA1c level is high, it means there are times when you are not monitoring that your blood glucose level is high.

The American Diabetes Association currently recommends maintaining an HbA1c level below 7% to prevent complications, but depending on your age and possibly other considerations, your goal may be different. No matter what your goal, however, an HbA1c level that is rising over time is a concern. Even relatively small increases in HbA1c level (when sustained over time) are associated with large increases in the risk of developing certain diabetes complications, including neuropathy (nerve damage), nephropathy (kidney disease), and retinopathy (eye disease). Typically, doctors order an HbA1c test every three to six months to see whether a person’s regimen is working as desired.

If you haven’t had an HbA1c test in the past six months or don’t know what your most recent test result was, ask your doctor about it at your next appointment.

Hypoglycemia
Do you know how to treat hypoglycemia?
Hypoglycemia can be dangerous if not treated quickly and appropriately. If you have symptoms of low blood glucose, which may include shakiness, weakness, and disorientation, check your blood glucose with your meter to confirm that you are having a low.

The best way to treat low blood glucose is with a fat-free source of glucose such as fruit juice, hard candy such as SweeTarts or LifeSavers, or glucose tablets. For most people, 15–20 grams of carbohydrate — the amount in half a cup of juice, 6–8 SweeTarts, or 3–5 LifeSavers or glucose tablets — are enough to bring your blood glucose back up to the normal, safe range. However, because the brain is looking for a quick source of sugar, it’s very common for people to feel the need to eat much more than this. You don’t need to eat an entire meal to raise your blood glucose; if you do, you risk overtreating it and ending up with high blood glucose. Finding the source of glucose that seems to work quickest for you, and keeping premeasured amounts on hand, may help you fight the urge to eat lots of food when treating hypoglycemia.

Exercise
Do you know how exercise affects your blood glucose level?
Exercise most commonly lowers blood glucose level. If you’ve been feeling unmotivated to exercise for whatever reason, checking your blood glucose level after a walk or bike ride may be just the positive reinforcement you need. Once you see the positive effects physical activity has on blood glucose, you may look forward to an after-dinner walk.

That being said, however, the major risk associated with exercise is hypoglycemia, so it’s important to make sure your exercise routine isn’t lowering your blood glucose level too much. The degree to which exercise lowers (or raises) blood glucose level may depend on the person, the type of exercise, the time of day, the person’s blood glucose level when starting to exercise, and other factors, as well. By checking your blood glucose level before, during, and after exercise, you will see what is happening in your body. You may find that your blood glucose level drops rapidly, drops slowly, stays in range during exercise but drops several hours later, rises during exercise then drops later, or rises and stays high. The pattern may be different for different activities or different intensities of exercise.

To develop a plan for keeping your blood glucose level from dropping too much or going too high with exercise, share your monitoring results with your doctor or diabetes educator. You may need to change the amount or timing of your insulin doses or other medicines, add snacks to your workout plan, or change the timing or content of your meals.

Even if you have an exercise plan that usually prevents too-high or too-low blood glucose, be sure to carry water and some sort of treatment for hypoglycemia with you when you exercise or are physically active just in case.

Food
Do you know how much carbohydrate you consume at each meal?
You’ve most likely heard that carbohydrate is the component of food that has the most immediate effect on blood glucose level. You may also have been advised by your doctor or dietitian to limit the amount of carbohydrate you consume at each meal or snack to a particular number of grams or number of “carbohydrate choices,” with each choice containing 15 grams of carbohydrate. Or maybe you’ve learned how to adjust your premeal insulin doses to the amount of carbohydrate in the meal or snack you’re about to eat. Both of these approaches can limit the amount your blood glucose rises after meals and contribute to overall blood glucose control.

But do you really know how much carbohydrate you eat? If you see your blood glucose levels rising higher than expected after meals, it may be worth reviewing the basics of carbohydrate counting.

The first question to ask is whether or not a food contains carbohydrate. If it’s made from grains, beans, fruits, vegetables, or milk or contains caloric sweeteners, it does. But it’s worth having a look at the Nutrition Facts panel of any packaged food to see what’s listed under Total Carbohydrate. The amount of carbohydrate in certain condiments, prepared dishes (including meat-based dishes), nuts, and sugar-free products may surprise you — and be enough to have an effect on your blood glucose level.

The second question to ask is how much carbohydrate is in the portion of food you plan to eat. Again, check the Nutrition Facts panel. While you might think that a slice of bread from one loaf has about the same amount of carbohydrate as a slice from another, in fact, the amount can vary by as much as 20 grams, depending on the ingredients used to make the bread and the size of the slices. The carbohydrate difference between a small apple and a large apple can also be substantial. (You may need to weigh apples and other fresh produce to determine the amount of carbohydrate they contain.) Even nonstarchy vegetables, which many people think are carbohydrate-free, can have enough carbohydrate to make a difference if you eat enough of them. (See “How Vegetables Stack Up” for some carbohydrate counts.)

There are many online resources that list nutrition information for packaged foods, fresh produce and other foods that often don’t come with Nutrition Facts panels, and selected restaurant foods. Examples include Calorie King and Nutrition Data. Checking one of these sites before eating out can help you choose foods that fit your meal plan.

Once you know how much carbohydrate you are eating, you can begin to address any blood glucose control problems that may be related to carbohydrate consumption.

Do you know how much carbohydrate you “should” eat?
There’s no single correct amount of carbohydrate that all people with diabetes should consume at meals or on a daily basis. The amount you need depends on your overall nutrition needs, dietary preferences, physical activity level, and level of blood glucose control. A registered dietitian can help you work out a meal plan that has adequate nutrients and an amount of carbohydrate that will help with blood glucose control.

Your own trial and error is important, too. By noting what and how much you eat, and monitoring your blood glucose level before meals and two hours after meals, you will learn how different foods (and amounts) affect you, allowing you to tailor your food choices accordingly. This kind of monitoring can also help to tailor the size and timing of premeal insulin doses.

Blood pressure
What is your blood pressure control plan?
While blood glucose control still gets top billing in diabetes care, it is now known that controlling blood pressure is also very important for the prevention of long-term complications, particularly stroke, heart attack, and kidney failure.

People who have been diagnosed with high blood pressure most likely have a plan that includes taking medicines and that should include lifestyle measures such as following a nutritious diet and getting regular exercise. But even people with blood pressure in the normal range should be aware of how their daily choices and habits can prevent — or contribute to — high blood pressure in the future. Among the choices you probably make every day are what to eat and whether to sit still or to get some movement.

Food choices. Following a diet high in fruits, vegetables, whole grains, legumes, and other unprocessed foods can help to prevent high blood pressure, while the opposite — a diet low in these foods and high in processed foods and sodium — can raise it. Excessive alcohol consumption — more than two drinks a day for men and one drink a day for women — can also raise blood pressure. And being overweight can raise your blood pressure, while losing weight can help to lower it.

Activity choices. Sedentary living can contribute to high blood pressure, while regular physical activity can prevent it or help to lower it. Even moderate activity, such as daily walking, has significant benefits.

In addition, ask your health-care providers how the medicines you take — both prescription and over-the-counter — affect your blood pressure. Some medicines are known to raise blood pressure, so if you have to take one or more of them regularly, it may be worth discussing whether there are alternatives that won’t raise your blood pressure or steps you could be taking to counter this side effect.

Knowledge is power
Understanding your diabetes management plan empowers you to be a fully participating member of your diabetes team and gives you the tools to work out problems independently. There are dozens of resources available to help you learn more about managing diabetes (see “Self-Help Resources”). If you’re unclear about any aspect of your diabetes management plan, speak to your doctor or your diabetes educator. The more information you have, the healthier you can be.

Statements and opinions expressed on this Web site are those of the authors and not necessarily those of the publishers or advertisers. The information provided on this Web site should not be construed as medical instruction. Consult appropriate health-care professionals before taking action based on this information.