By Gary Scheiner, MS, CDE
There are many famous books out there — The Book of Life, The Book of Psalms, The Book of Mormon, even the Kelley Blue Book, just to name a few. In the diabetes world, we have a book of our own: The Book of Adjustments.
Everyone who takes insulin has a standard program to follow: basal/long-acting insulin and, for those on intensive insulin therapy, mealtime/rapid-acting insulin. The standard program should work fine, as long as you always play by the rules and live your life exactly the same, day after day after day. But nobody can (or should) live like that. After all, variety is the spice of life!
And that’s where the Book of Adjustments comes in. It’s an individualized, personalized, customized guide for managing glucose levels through the nuances of day-to-day living. It can take the form of a set of notecards, a computerized document, a smartphone text or, if you’re really into the book idea, a notebook dedicated to nothing but your diabetes management strategies. Whether you carry it around or commit it to memory, you should use it on a daily basis.
What goes into your Book of Adjustments? Some topics should be included in just about everyone’s book, while others will depend on your lifestyle and unique needs and interests. Work with your health-care team to make sure all the essentials are given adequate coverage.
For example, whether you take basal insulin only or multiple daily injections or use an insulin pump, it is important to know how to adjust your insulin in the event of illness or infection. You may need to adjust your dose or add doses that you normally don’t take to ensure a timely recovery and prevent dehydration and ketoacidosis, a life-threatening condition.
Every Book of Adjustments should address how to deal with elevated glucose levels. Through sickness and health, when glucose levels are elevated, adjustments will be needed to bring the blood sugar back down toward normal. This is a “correction dose” of rapid-acting insulin. A chart or formula for correcting above-target glucose levels should do the trick.
Most insulin users, particularly those who take rapid-acting insulin at mealtimes, should learn how to adjust doses based on the sizes of meals and snacks. This can be based on the amount of carbohydrate in the meal (using an insulin-to-carbohydrate ratio) or by using a basic small-medium-large concept. Accommodation also can be included for meals that contain significant amounts of fat or protein.
Likewise, every Book of Adjustments should include strategies for preventing hypoglycemia (low blood sugar) during and after exercise. This may include a combination of insulin dose reductions and/or snacks. For more intense activities, modifications may be necessary following the activity to prevent delayed-onset hypoglycemia, a low blood sugar level that sometimes occurs several hours after completing heavy exercise. And don’t forget to include adjustments for those run-of-the-mill daily rituals such as shopping, cleaning, and doing yard work and home improvement projects! These sometimes can lower blood glucose even more than aggressive exercise. Some competitive events and anaerobic activities actually may produce a short-term blood sugar rise. The adjustments for these types of activities obviously will be quite different.
Timing is yet another critical issue for those who use mealtime insulin. Since the goal is to have the insulin working at the same time the blood sugar is rising, a Book of Adjustments should include details regarding the timing of insulin in relationship to meals. Attention should be paid not only to preventing post-meal blood sugar spikes, but also to preventing lows followed by highs after consumption of slowly digesting foods.
There is virtually an unlimited number of sections that can be included in one’s Book of Adjustments.
• Menses. Many women find their glucose levels rising prior to their menses and dropping once their period starts. Modifications to the insulin program may be needed on a monthly basis to manage glucose levels effectively.
• Stress. Mental stress (anger, fear, anxiety) can cause a dramatic increase in glucose levels; physical stress (rushing, multi-tasking) can have the opposite effect. Your Book of Adjustments may include strategies for preventing glucose control issues resulting from predictable forms of stress.
• Insulin pump site changes. Some pump users find their glucose levels are temporarily higher or lower than usual following infusion set changes, due mainly to new absorption patterns at the fresh site. Plans can be made to avoid these types of patterns when changing sets.
• Travel days. Those who travel on a regular or semi-regular basis may note higher than usual glucose levels due to frequent dining out and long periods of sitting. Others note lower levels due to increased physical activity and less stress. Having an insulin-adjustment plan in place for various forms and phases of travel can help you get the most out of your travel experiences.
• Changes in altitude. When transitioning to higher altitudes, it is common for glucose levels to rise due to the production of hormones that help compensate for lower oxygen levels. The opposite can occur when descending to lower altitudes.
• Steroid medications. Use of prednisone or cortisone for treatment of inflammatory illnesses or injuries can result in significant insulin resistance and markedly high glucose levels for several days. Whether these medications are needed on a regular basis or only once, it is helpful to have an insulin adjustment plan in place to keep glucose levels within an acceptable range.
• Weather changes. Is there anything that doesn’t affect glucose levels? As weather becomes warmer and more humid, those who spend time outdoors tend to see glucose levels drop. The opposite sometimes happens when the weather turns cold. Those who experience these types of changes may require seasonal adjustments to their insulin programs.
• Off days/Work and school days. Many people find their glucose levels consistently are higher or lower on off days versus days at work or school. This may be related to changes in sleep patterns, activity levels, diet or stress. Regardless of the cause, managing glucose levels effectively may require alternative insulin programs based on one’s weekly schedule.
• Shift Work. Changing work shifts and concurrent sleep and mealtime schedules may require an adjustment in both the timing and amounts of insulin taken. Those who work multiple shifts should have a plan in place for managing their insulin doses for each type of work scenario.
• Caffeine. Lest we forget the java effect? For most people, consumption of foods or beverages that contain large amounts of caffeine results in a glucose rise. Caffeinated coffee and non-herbal tea are the most common culprits, although some people notice an effect from lesser sources of caffeine such as cola and chocolate. Those who consume caffeine should have an insulin dosing plan ready to prevent rising blood sugars.
• Post-hypoglycemia. Recurrent episodes of hypoglycemia almost always require an adjustment to one’s insulin program. In some cases, preventing and treating the “rebound” high that follows hypoglycemia might require an uncommon approach.
• Surgery. People with diabetes who must undergo surgical procedures must prepare for: missing meals (when anesthesia will be used), the stress of the procedure, medications that may raise glucose levels and changes in diet and activity during the recovery phase.
• Brain work. Physical exercise isn’t the only thing that burns glucose! Mental work (concentration, multi-tasking, creative projects, socializing, adjusting to new surroundings) also can lower blood glucose. Plans may be necessary to prevent hypoglycemia when burning significant mental energy.
• Alcohol. Many alcoholic drinks contain carbohydrates that can cause a short-term rise in blood glucose. But consuming several alcoholic drinks can produce a delayed drop. Adjustments to insulin (or extra snacks) may be needed to prevent hypoglycemia after drinking.
• Fasting. Those who choose to fast for religious or personal reasons usually can do so safely, but it will take special preparation and an insulin dosing plan to prevent both hypoglycemia and hyperglycemia.
The Book of Adjustments should be a collaborative effort, co-authored by you and your health-care team. Seek out the input of all members of your diabetes care team in compiling the chapters and sections. Bring the book to all your appointments so it can be updated. Between appointments, work on it yourself. Every day presents new opportunities to learn what works and what doesn’t and to add new chapters to your personal Book of Life.
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