Carolyn Robertson

The Key to Success: Recognizing the Patterns

Introduction
You take three to four shots a day; you eat a balanced meal plan; but your blood sugar levels are still not where you want them. Maybe, something is missing. Maybe, what you are missing is information - targeted information that could help you to understand the blood sugar results. While today’s treatment plans offer more options, diabetes remains a complex disorder. It is still very difficult to mimic the blood sugar levels of a non diabetic individual. What you eat, when you eat it, how much you eat; when you exercise, how hard and how long; when you take your insulin, how much and what kind; as well as, your state of mind all can impact your blood sugar levels. To be successful at controlling blood sugar, you need to know how what information to gather as well as how to make sense of the information. You need to be able to analyze the data. In other words, you need to be able to recognize blood sugar patterns and develop strategies to change those that make you uncomfortable.

Pattern Recognition
How is it done? First, it is necessary to monitor blood sugar levels. Next, review the results and then determine if you are comfortable with them. If not, you will need to determine what factors might have influenced the results. Ask the question - what was the same and what was different? Once you gather this information, the answers need to be deciphered and a plan developed to use the findings to alter future results. In other words, you need to utilize some basic problem solving skills. What follows is an abbrevieated paradigm for initiating the process of problem solving. Diabetes professionals including your physcian and diabetes educator have the expertise that can help you yo use these guidelines and "make sense" of your blood sugars.

Step One:
Gather the information by monitoring your blood sugar. When you review the results, look a minimum of three days and study the blood sugar levels at a variety of different times. Be sure to look at all the blood sugars - not just the ones that make you uncomfortable. Also, avoid focusing on an isolated blood sugar level.
  1. Blood sugar levels obtained before and 1 hour after meals can give you information about the workings of the insulin you took for that meal.
  2. A blood sugar checked after a meal and before the next meal tells you if the base insulin was adequate.
  3. Bedtime to the next morning tells you about the overnight insulin.

Step Two:
Identify variables that might have influenced the effectiveness of insulin. Always try to find several factors that could have affected your blood sugar level. Look at the past 24 hours to determine if the undesired blood sugar was a reaction to a past event. Don’t stop searching for clues until you have considered at least three to four possibilities. Remember, you are looking for possible suspects. So, consider all possibilities, even those that might not look initially promising.

  1. Has the blood sugar been fluctuating over the past 24 hours? A blood sugar that falls more than 60 - 80mg/dl between meals or overnight, or an insulin reaction can cause a future rise in blood sugar by stimulating the liver to release sugar. To make matters confusing, this release does not always occur immediately after the blood sugar lowering. In some cases, it can take 2 to 24 hours to occur and the it can increase the blood sugar level from 60 to 200 mg/dl. This can occur even if you did not have an insulin reaction.
  2. Are you getting sick; or could you have an infection? If you are a woman, are you premenstrual, pre menopausal or pregnant? What are your stress levels? Stress whether it is physical, chemical or mental can impact your blood sugar. While stress usually causes the blood sugar to rise, stress can also cause it to lower.
  3. What injection site did you use? Was it a different site or a site that was thick or tough; or a site that was lean? Different sites absorb insulin at different speeds. Insulin injected into the abdomen absorbs the fastest while insulin injected into the buttocks absorb the slowest. Sites with lipohypertrophy (thickened sites) can trap the insulin for as long as 48hours. Injections into the muscle can cause the insulin to absorb erratically.
  4. Is your insulin working properly? Has it lost potency or has it become contaminated? Insulin must be protected from excessive temperature. Temp above 86 or less than 38 will alter the effectiveness of the insulin. Insulin that has been opened, whether refrigerated or not, needs to be discarded after 30 days. The manufacturer has stated that the insulin could lose potency if used past this date. Reusing syringes that have contained any of the longer acting insulin could cause bottles of short acting insulin to be contaminated
  5. Did you eat at a different time; or did the time interval between the shot and the meal change? Insulin needs to be ‘fed" at very specific times. If you eat sooner or later, the insulin will have a different impact on the blood sugar levels. Usually, Humalog needs food 5 to 15 minutes after the injection. It does not have residual activity to "handle" a snack. Regular insulin should be given food at least 30 minutes after injection and again in 2 to 2.5 hrs later. Lente insulin needs food 4 to 5 hrs after the injection and a snack 7-8 hrs later.
  6. Did you change what you ate? Insulin is needed to "store" carbohydrates. The type and the amount of carbohydrate as well as its form and fiber content can influence how quickly the blood sugar will raise post meal. A meal containing more or less protein or more or less fat might change how quickly the carbohydrate enters the bloodstream. A high protein meal might cause the blood sugar to be higher three to four hours after the meal. Could the food contain hidden sources of sugar? Bagels, pizza, french fries, Chinese food often contain sugar or sugar like substances that cause the blood sugar levels to rise more than you would expect. Could you be eating too little carbohydrates? If your system thinks that you are starving, your liver may release extra glucose to compensate for the perceived lack.
  7. Have you had any alcohol? Ingesting beer, mixed drinks or sweet cordials might raise your blood sugar. While drinking more than 12 ounces of beer, 3 ounces of distilled alcohol or more than 6 ounces of wine might cause your blood sugar levels to fall 3 to 6 hours later.
  8. Has you activity changed - the time , the intensity or the frequency? Activity can affect the blood sugar for as long as 2 to 24 hours. While exercise often lowers blood sugar, if your insulin levels are too low, or if the body is "stressed", exercise can cause the blood sugar to rise.

Step Three:
Review the list and rank them in order of most likely to least likely factor. If there were several blood sugars that made you uncomfortable, you might want to pick only two or three to study. Start with the first blood sugar of the day, attempt to "analyze ’ that one and then proceed through the day.

Step Four:
Take the highest ranking factor and develop a plan to change it. Limit the changes to only one factor. You will then be able to assess the impact of the change - whether or not the change worked and if it did not, allow you to consider why. For example, you have decided that the high blood sugars before lunch were due the rapid fall that occurred between bedtime and breakfast (bedtime was 250mg and breakfast was 80mg) and not due to the composition of breakfast or to the insulin dose taken before breakfast. To remedy the problem, you could add a bigger bedtime snack, lower the bedtime insulin or decrease the activity the evening before. But, you make no change in the composition of the morning meal

Step Five:
Gather the information. Look to see how the pattern changed. Did the intervention do what you expected? If not, go back and reconsider the second and third possibilities. Perhaps, the second reason was the better option. Or perhaps, you now have more information. Consider the example where the fall overnight was excessive. You changed the insulin and now the morning BS is lower than bedtime by less than 50 mg. However, the pre lunch blood sugar is still elevated. You now need to review the breakfast meal and consider other factors that might be responsible.

Step Six:
Go to step one and start the process again. Yes, the process is timeconsuming and challenging. Remember, that you need not do it alone. Don’t forget to utilize the resources that are available to you. Your diabetes team has the knowledge and expertise to help you master the technique of problem solving.

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