Diabetes (Type 1), Part 2 — Treatment and Monitoring

Treatment

When type 1 diabetes is first diagnosed, the goal is stabilization of the patient. Often, the patient presents in diabetic ketoacidosis (sometimes called "DKA") with elevated blood glucose levels (hyperglycemia). The severity of the symptoms frequently require hospitalization for the initial management of the diabetes.

Following the initial stabilization, the goal shifts to education of the patient and family regarding the treatment of diabetes. The long-term goals of treatment are to prolong life, improve quality of life and prevent diabetes-related complications, which can include blindness, kidney failure and amputation of limbs. Achieving these goals requires careful attention to diet, exercise, medication and monitoring of blood glucose levels. Thorough education is a vital part of this transition.

Blood glucose levels must be monitored regularly. A very small drop of blood is tested to measure the blood glucose level. This enables the person with diabetes to determine how well diet, medication and exercise are working together to control diabetes. Food intake, activity and insulin can be adjusted if needed to keep the blood sugar levels within the desired range.

Treatment of type 1 diabetes comprises insulin injections, diet, physical activity, self-testing, treatment of low blood sugar, treatment of high blood sugar, treatment of high ketones, monitoring of diabetic status, foot care, wound care and other aspects of care. As stated previously, education is central in diabetes control. Each of these components is explained in detail below.

Insulin

Insulin lowers the level of glucose in the blood by allowing it to leave the bloodstream and enter the cells. Without insulin, the body cannot metabolize glucose for energy. Therefore, people with type 1 diabetes must take insulin every day. Insulin cannot be taken trough a pill; it must be injected. Generally, insulin is injected into the tissue just below the skin. Sometimes, it is administered through a pump. The endocrinologist and other health care professionals will help determine the best way to manage the patient's blood glucose levels. The dosage, schedule and type of insulin are matched to the patient's needs. Most people with type 1 diabetes need insulin injections two to four times each day. Adults typically give their own injections. Young children might need an adult, often a parent, to administer the injections until the child can master the technique and "fly solo".

Diet

Diet is important in glucose control.

In addition to the dosage and timing of insulin injections, blood glucose levels are also regulated by ensuring that food intake matches the insulin dosage. When insulin administration and food intake are out of balance, blood glucose levels will vary greatly. Balance is the key to properly manage diabetes and prevent long-term complications. Both the American Diabetes Association and the American Dietetic Association recommend balanced meals from six food exchange groups. Although this might seem complicated, with a little help from a registered dietitian or nutrition counselor, the task of meal planning will become much clearer.

Physical Activity

Physical activity is extremely important in helping a person with diabetes maintain normal blood sugar levels. Exercise and activity help control the amount of sugar in the blood, help burn excess calories and fat, and aid in achieving optimal weight. Even though increased activity is beneficial for diabetic patients, individuals with type 1 diabetes should take special precautions before, during and after strenuous physical activity. This caution extends to any intense exercise and sports. Medical approval and guidance should be obtained before beginning any exercise program.

Glucose Self-Testing

Checking blood sugar levels.

Even when a person follows a regimen of appropriate diet, exercise and insulin injections, blood glucose can still vary widely. Regular measurement of blood glucose levels is the only way to know whether changes are needed in diet or insulin. The procedure involves a prick with a tiny needle to the side of the finger, where it is less sensitive. A small drop of blood is tested to determine the amount of glucose it contains. Normal blood glucose levels typically range between 80 and 120 mg/dL (milligrams per deciliter). The patient's healthcare providers will determine the target range and the steps that should be taken when the level exceeds that range. Meticulous record-keeping will provide the doctor with invaluable insight into the course of the diabetes. Through regular testing of blood glucose levels, the patient and the doctor can identify high and low levels before serious health problems develop.

Foot Care

Diabetes can result in damage to nerves and blood vessels, especially in the foot. As a result, individuals with diabetes are more likely to have a minor foot injury go unnoticed until a serious infection develops. Diabetes also affects the body's immune system, and decreases the ability to fight infection. Minor infections can result in destruction of skin and other tissues (necrosis), resulting in the need for amputation of part or all of the affected limb. Following a daily routine of foot care can help prevent these serious foot problems.

Treatment of Hypoglycemia (Low Blood Sugar)

Checking blood sugar levels.

Hypoglycemia, or low blood sugar, is something that can result from too much insulin, too much exercise or not enough food. Hypoglycemia can occur very quickly and unexpectedly. When the blood sugar falls below 70 mg/dL, symptoms of hypoglycemia often appear. Typical symptoms include weakness, confusion, shaking, sweating, headache, nervousness and hunger.

If these symptoms occur, the person's blood sugar should be tested immediately. Assuming the individual is alert and able to eat, food with glucose or sugar should be given. Examples include fruit juice, a cup of skim milk and soda (non-diet). Within 15 minutes, symptoms should subside. If they do not, give more sugar and retest the blood glucose level.

After symptoms have subsided, the person should eat more substantial food. Simple sugars, as listed above, are necessary to bring the blood glucose level into a tolerable range. A regular meal takes too long to digest to provide immediate help, but eating real food is necessary to stabilize the glucose after the simple sugars have been given.

Low blood sugar is a very serious matter, and the person must be monitored very closely. If the person becomes very confused, disoriented, unconscious, or has a seizure, a shot of glucagon should be given. If no glucagon is available, call 911 immediately.

Glucagon kit.

Glucagon should be stored for emergencies, and all adults at home and those responsible at school should be trained in how to use it. The proper use of glucagon should be reviewed periodically, and the expiration date on the vial should be checked. Glucagon usually works within 15 minutes after it is given. If improvement is not seen during that time, call 911. Constant, close monitoring is essential to ensure that no worse problem develops.

Treatment of High Blood Sugar or High Ketones

Glucose normally acts as fuel to provide energy for the cell of the body. When a person has diabetes, there is not enough insulin to move glucose into the cells and it builds up in the blood. The body must seek other sources of energy, and uses fat as a fuel source. By-products called ketones are produced as the fat breaks down. Ketones build up in the blood and spill into the urine. Ketones can be toxic when they are present in large amounts, a condition known as ketoacidosis.

Ketones can be detected by a simple urine test. This readily available test should be performed every four to six hours whenever a person with diabetes:

  • has a blood glucose reading of 240 or above
  • is sick
  • is unusually thirsty or has a dry mouth
  • is urinating frequently
  • is vomiting.

Other indications that ketones might be elevated include:

  • flushed face
  • dry skin or mouth
  • nausea or vomiting
  • stomach pain
  • deep or rapid breathing
  • "fruity" odor on the breath

If an individual with diabetes has any of these symptoms or has a high ketone reading in the urine, call the doctor or go to the emergency room immediately. High ketones, left untreated, can lead to coma or death.

Monitoring Diabetes

There are many ways that a person with diabetes (and the family) can help control the disease. Monitoring the patient's status is essential to maintaining good health. The individual with diabetes should:

  • visit the doctor at least 4 times per year
  • have the glycosylated hemoglobin (HbA1C) checked at least twice every year (or as frequently as the doctor recommends) because this measures overall glucose control
  • have yearly evaluations of cholesterol, triglyceride levels and kidney functioning
  • visit the ophthalmologist at least yearly, more often if there are any signs of diabetic retinopathy
  • schedule dental cleaning and examinations regularly (every six months would be a good minimum), and ensure that the dentist is aware of the patient's diabetic status
  • perform adequate foot care and make sure the doctor checks the feet at each visit
  • stay current with immunizations and flu shots

For more information, see:

Part 1 — Introduction, Incidence, Symptoms and Complications

Part 3 — Education, Restrictions, and Implications for School

American Diabetes Association

ATTN: National Call Center
1701 North Beauregard Street
Alexandria, VA 22311
http://www.diabetes.org/

Contributed by:

Kathy Davis, MSEd, PhD
Associate Professor
Project Director, Connected Kansas Kids
Director, KU Kids Healing Place
University of Kansas Medical Center