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Planning Ahead for Sick Days

Having a bad cold or the flu can make anyone want to crawl into bed and stay there until it’s over. But when you have diabetes, hiding under the covers and sleeping until you feel better isn’t the best option (although getting plenty of rest is still a good idea). That’s because any illness or infection can make your blood glucose more difficult to control, which increases the risk of serious acute complications. So just when you’re feeling your worst is when it’s most important to stay vigilant about your diabetes care and to take good care of yourself to help your body heal.

What happens when you’re sick
Your body may know it’s sick even before you feel any symptoms, and a good clue can be an unexplained steady rise in blood glucose.

Everybody has a high release of stress hormones when they’re battling or about to battle an illness. Typically, stress hormones cause a rise in blood glucose level because they cause the liver to release more glucose than normal into the bloodstream. People who don’t have diabetes can compensate by releasing more insulin, but people who have diabetes may produce no insulin, or their bodies may not use insulin efficiently, so blood glucose levels stay high unless something is done (such as taking insulin) to lower them.

The release of stress hormones and consequent rise in blood glucose level is why people with diabetes are advised to continue taking their diabetes medicines (insulin or oral medicines) when they are sick, even if they’re vomiting. Monitoring blood glucose levels every 2–4 hours and sipping liquids every 15 minutes to stay hydrated are also important.

Not taking diabetes medicines during an illness raises the risk of developing diabetic ketoacidosis (DKA), a medical emergency characterized by high blood glucose levels, the presence of ketones in the blood and urine, and dehydration. When the body doesn’t have enough insulin available to use glucose as its primary fuel source, it breaks down stored fat for energy, which leads to the production of acidic metabolic by-products called ketones. An accumulation of ketones causes the blood — and eventually the body’s tissues — to become acidic, throwing off the delicate mechanisms that regulate bodily functioning.

While diabetic ketoacidosis is more likely to develop in a person with Type 1 diabetes, it can also occur in people who have Type 2 diabetes, so everyone with diabetes should discuss when and how to test for ketones in their blood or urine with their health-care provider. Symptoms of DKA include dry mouth, sleepiness, extreme nausea, stomach pain, vomiting or diarrhea, and shallow breathing. Contact your doctor immediately if you experience symptoms of DKA. If not caught early, it can develop into a very serious condition that needs to be treated at a hospital.

People with Type 2 diabetes, especially older people, can also develop a condition called hyperosmolar hyperglycemic syndrome, in which blood glucose levels are very high and a person is dehydrated, but ketones are not present in the blood or urine. This condition can also lead to coma and death. Symptoms include thirst, impairment of one or more of the five senses, hallucinations, rapid eye movements, paralysis on one side of the body, and seizures. Hyperosmolar hyperglycemic syndrome is a medical emergency that must be treated in a hospital.

Having a sick-day plan
One of the best things you can do in preparation for being sick is to have a discussion about sick-day care with your diabetes care providers. This will not only help you know what to do, but it may also ease some stress since you won’t be facing an illness completely in the dark. It will also give you an idea of how long to manage your illness alone and when to call for help.

Topics to discuss include when to call for help, how often you should monitor your blood glucose and ketones, what medicines to take and how much of each to take, and how and what to eat. Typically, doctors want to hear from you in the following circumstances:

• When you have been sick or have had a fever for 2–3 days and aren’t getting any better.
• When you have been vomiting or having diarrhea for more than six hours.
• When you have moderate to large amounts of ketones.
• When your blood glucose is consistently higher than 250 mg/dl despite having taken extra insulin.
• When you have taken only oral medicines and your blood glucose has stayed above 250 mg/dl for more than 24 hours.
• When you have any symptoms of DKA.
• When you don’t know how to take care of yourself.

However, these are only general guidelines. Be sure to ask your doctor for guidelines that fit your diabetes and life on when he wants you to call, as well as what kinds of information he will want to know when you call. Some likely questions include how long you have been sick, whether you have lost weight during your illness, how much fluid you have been able to drink, your current blood glucose level, whether you’ve had any episodes of very high or very low blood glucose, whether you’re taking your usual medicines or any additional medicines called for in your sick-day plan, and whether you have a fever.

With this in mind, a critical aspect of helping yourself and your doctor manage your illness is to keep a log of what is going on with your body. Through record-keeping, you may be able to identify patterns. It will be especially important to monitor your blood glucose level every two to four hours while your levels are elevated or until symptoms of your illness subside. Ketones should be monitored every four hours until they are no longer present. Since your body is going through a small trauma, you might not have or notice your normal signs of high or low blood glucose. By checking your blood glucose level often, you may be able to catch any problems early and treat them quickly.

Some items to log and keep track of include the following:

• Blood glucose readings
• Results of ketone tests
• Fluid intake
• Any symptoms such as vomiting, diarrhea, stomach pain, or headache
• Your temperature

Sick-day tool kit
The last thing you want to do when you feel sick is go to the store for medicine, food, or tissues. Having shelf-stable foods in your kitchen cupboards and other supplies on hand can be a lifesaver when you realize you may be planting yourself on the couch or in your bed for a while. Some items to stock in your kitchen include fluids with calories such non-diet soda, fruit juice, and regular Jell-O, as well as some sugar-free items such as diet soda and sugar-free Jell-O or pudding. Include things that taste good to you when you are ill. Other items you will want include the following:

• Thermometer
• Over-the-counter pain reliever such as acetaminophen or ibuprofen
• Sugar-free cough syrup or throat lozenges (In addition to looking for the word sucrose in the ingredients list, look for dextrose, fructose, glucose, and just about anything else that ends in –ose. These are usually types of sugar. However, if you don’t have sugar-free products in the house, the amount of sugar you receive in a regular product is small and shouldn’t have much effect on your blood glucose level.)
• Decongestant (Even if sugar-free, decongestants can raise blood glucose level. Nasal sprays, however, may have less of a blood-glucose-raising effect than decongestant products that are swallowed.)
• Ketone strips (Make sure they’re not expired.)
• Lancets
• Glucagon kit in case of severe hypoglycemia (Check the expiration date on this, too. A glucagon kit requires a prescription, which most doctors are willing to write for anyone with Type 1 diabetes.)
• Notebook or pad and a pen so you don’t have to go hunting for something to write on
• If needed, a sliding scale showing dosage adjustments for your diabetes medicines according to blood glucose and ketone levels
• Several bottles of water so you don’t have to get up to refill your glass

If possible, share your sick-day plan with family members or those you live with. That way, you won’t be the only one managing your illness. One easy way to make your information readily available to others is to write it down and keep it with your sick-day food and supplies. Be sure to include on it the daytime and evening phone numbers for your doctor(s), other health-care providers, and the local hospital, just in case a friend or family member needs to call for help on your behalf. (Click here for more about what to include in your sick-day kit.)

Medicines
It may be counterintuitive to take blood-glucose-lowering medicines if you’re not eating much and particularly if you’re vomiting. But your body needs help combating the elevation in blood glucose level caused by stress hormones. If you take oral diabetes medicines and can’t keep any foods or liquids down, you may need to take insulin for a short time. This is something to discuss with your health-care team ahead of time since you will need both supplies and training to inject insulin.

People who take insulin may find that their insulin needs increase during an illness, and they may need to take more insulin to bring down high blood glucose. Your log of blood glucose readings will be critical to your insulin management for you and your doctor.

If you take multiple daily injections, it is wise to continue taking both long-acting and rapid- or fast-acting insulins while sick. Supplemental doses of fast-acting insulin may be necessary if blood glucose levels stay high, if large amounts of ketones are present, or if ketones persist over time. Check with your health-care team about when to take supplemental insulin, how much to take, and how frequently to inject it.

If you use an insulin pump, you should be able to utilize your temporary basal rate feature or customize additional basal patterns specifically designed for sick days.
There are some medicines to watch out for because they can affect your blood glucose level even if they don’t contain sugar. Aspirin, for example, can lower your blood glucose if taken in large doses. Also, some antibiotics have been known to lower blood glucose levels in people who take oral diabetes medicines. When you talk to your physician about sick-day care, be sure to ask about any drugs you take regularly and whether to continue taking them during an illness.

Eating and drinking
If you’re dealing with a stomach bug or the flu, eating is likely the farthest thing from your mind. Even if you have a cold you may not have as much of an appetite as normal. But your body still needs nourishment when you’re sick. If possible, eat 45–50 grams of carbohydrate (or 3 carbohydrate choices) every 3–4 hours. If your stomach can’t tolerate regular food, try to consume liquids or soft foods that contain carbohydrate such as regular soft drinks, juice, soups, and ice cream.

Some food portions that contain 15 grams of carbohydrate include the following:

• ½ cup regular ice cream
• 3-ounce frozen fruit juice bar
• ½ cup frozen yogurt
• ½ cup sherbet
• 1 slice of toast
• 1 cup of soup
• 6 saltine crackers
• 5 vanilla wafers
• ¼ cup regular pudding

If you are losing fluids because of vomiting or diarrhea, try to drink plenty of water in addition to other fluids, if possible. A good rule of thumb is to drink 1 cup of fluid every hour. If your blood glucose is running high, drink sugar-free liquids such as water, tea, sugar-free ginger ale, or broth. Increased liquids will help to flush high blood glucose or ketones from your system. If you need to raise your blood glucose, try drinks with 10–15 grams of carbohydrate per serving, such as the following:

• ½ cup fruit juice
• ½ cup regular ginger ale or regular soda
• 1 cup milk
• 1 cup sports drink

When you’re starting to feel better following a bout with a stomach bug, ease back into your normal daily carbohydrate intake; base your food choices on what you feel your stomach can tolerate.

How to help your sick child
Keeping calm may be the best thing you can do for your child when he’s sick, and having a written sick-day plan can help you to stay calm. Talk to your child’s pediatrician, endocrinologist, and dietitian about formulating a personal sick-day plan and a sick-day tool kit — complete with some comfort items such as a comic book, coloring book, or even a get-well card — for your child with diabetes.

When you’re sick and pregnant
Recommendations for sick-day care during pregnancy are generally the same as those for people who are not pregnant. However, check with your obstetrician before taking any over-the-counter medicines, and increase your fluid intake to stay hydrated. Since tight blood glucose control is extremely important during pregnancy for the health of both mother and baby, check your blood glucose level and ketones at least every two hours.

Prevention
Unless you live in a bubble, it’s natural that you will get sick once in a while. But you can keep yourself from getting sick more often than necessary.

Wash your hands frequently, especially after coming into contact with other sick people or objects that others have touched (such as shopping cart handles or escalator handrails). To remove as many germs as possible, use soap and warm water, and rub your hands together for at least 20 seconds (the time it takes to sing “Happy Birthday” twice). Use a clean paper towel to turn the handle on the faucet and to open the door of public restrooms. Avoid touching your eyes, nose, or mouth unless you’ve just washed your hands.

Getting a yearly flu shot is extremely important because having diabetes puts you at an increased risk for developing complications of the flu, such as pneumonia. Getting a flu shot is not a 100% guarantee against getting the flu, but it will make it more difficult for you to contract the illness for about six months. It may be wise for those you live with to also get a flu shot for your protection. If the people around you are healthy, it’s more likely that you’ll stay healthy, too.

Scheduling regular checkups with your primary-care physician, endocrinologist, and others on your health-care team will help you stay on top of your diabetes, which will help you fend off sickness. Eating well and getting enough sleep are important, too, for staying healthy.

Furthermore, reducing your stress level can be a key to remaining healthy. Be realistic about the load you carry at home and work. If you’re overwhelmed, say so and ask for help. Keep in mind that perfect blood glucose control doesn’t exist, even when you’re in perfect health. Regular exercise and enjoying hobbies are other great ways to keep your body and mind healthy.

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.