Diabetes Management

Glucose, a simple monosaccharide sugar, is one of the most important carbohydrates and is used as a source of energy in animals and plants. Glucose is one of the main products of photosynthesis and starts respiration. The natural form (D-glucose) is also referred to as dextrose, especially in the food industry.

In respiration, through a series of enzyme-catalyzed reactions, glucose is oxidized to eventually to form carbon dioxide and water, yielding energy, mostly in the form of ATP.

Chemically joined together, glucose and fructose form sucrose. Starch, cellulose, and glycogen are common glucose polymers (polysaccharides).

The older name dextrose arose because a solution of D-glucose rotates polarized light towards the right. In the same vein D-fructose was called “laevulose” because a solution of laevulose rotates polarized light to the left.

Normal Regulation of Blood Glucose

The important roles of insulin and glucagon: Diabetes and Hypoglycemia

The human body wants blood glucose (blood sugar) maintained in a very narrow range. Insulin and glucagon are the hormones which make this happen. Both insulin and glucagon are secreted from the pancreas, and thus are referred to as pancreatic endocrine hormones. Note that the pancreas serves as the central player in this scheme. It is the production of insulin and glucagon by the pancreas which ultimately determines if a patient has diabetes, hypoglycemia, or some other sugar problem.

Insulin and glucagon are hormones secreted by islet cells within the pancreas (more about islet cells of the pancreas). They are both secreted in response to blood sugar levels, but in opposite fashion!

Insulin is normally secreted by the beta cells (a type of islet cells) of the pancreas. The stimulus for insulin secretion is a HIGH blood glucose…its as simple as that! Although there is always a low level of insulin secreted by the pancreas, the amount secreted into the blood increases as the blood glucose rises. Similarly, as blood glucose falls, the amount of insulin secreted by the pancreatic islets goes down. As can be seen in the picture, insulin has an effect on a number of cells, including muscle, red blood cells, and fat cells. In response to insulin, these cells absorb glucose out of the blood, having the net effect of lowering the high blood glucose levels into the normal range.

Glucagon is secreted by the alpha cells of the pancreatic islets in much the same manner as insulin…except in the opposite direction. If blood glucose is high, then no glucagon is secreted. When blood glucose goes LOW, however, (such as between meals, and during exercise), more and more glucagon is secreted. Like insulin, glucagon has an effect on many cells of the body, but most notably the liver. The effect of glucagon is to make the liver release the glucose it has stored in its cells into the blood stream, with the net effect of increasing blood glucose. Glucagon also induces the liver (and some other cells such as muscle) to make glucose out of building blocks obtained from other nutrients found in the body (e.g., protein).

Our bodies desire blood glucose to be maintained between 70 mg/dl and 110 mg/dl (mg/dl means milligrams of glucose in 100 milliliters of blood). Below 70 is termed “hypoglycemia”. Above 110 can be normal if you have eaten within 2 to 3 hours. That is why your doctor wants to measure your blood glucose while you are fasting…it should be between 70 and 110. Even after you have eaten, however, your glucose should be below 180. Above 180 is termed “hyperglycemia” (which translates to mean “too much glucose in the blood”). If you have two blood sugar measurements above 200 after drinking a sugar-water drink (glucose tolerance test), then you are diagnosed with diabetes. We have many pages on diabetes which go into this in much more detail.


Types of Diabetes

The two main types of diabetes that we see in a personal care home are:

Type 1 Diabetes

Type 1 diabetes is an autoimmune disease. An autoimmune disease results when the body’s system for fighting infection (the immune system) turns against a part of the body. In diabetes, the immune system attacks the insulin-producing beta cells in the pancreas and destroys them. The pancreas then produces little or no insulin. A person who has type 1 diabetes must take insulin daily to live.

At present, scientists do not know exactly what causes the body’s immune system to attack the beta cells, but they believe that autoimmune, genetic, and environmental factors, possibly viruses, are involved. Type 1 diabetes accounts for about 5 to 10 percent of diagnosed diabetes in the United States. It develops most often in children and young adults, but can appear at any age.

Symptoms of type 1 diabetes usually develop over a short period, although beta cell destruction can begin years earlier. Symptoms include increased thirst and urination, constant hunger, weight loss, blurred vision, and extreme fatigue. If not diagnosed and treated with insulin, a person with type 1 diabetes can lapse into a life-threatening diabetic coma, also known as diabetic ketoacidosis.

Type 2 Diabetes

The most common form of diabetes is type 2 diabetes. About 90 to 95 percent of people with diabetes have type 2. This form of diabetes is associated with older age, obesity, family history of diabetes, previous history of gestational diabetes, physical inactivity, and ethnicity. About 80 percent of people with type 2 diabetes are overweight.

Type 2 diabetes is increasingly being diagnosed in children and adolescents. However, nationally representative data on prevalence of type 2 diabetes in youth are not available.

When type 2 diabetes is diagnosed, the pancreas is usually producing enough insulin, but for unknown reasons, the body cannot use the insulin effectively, a condition called insulin resistance. After several years, insulin production decreases. The result is the same as for type 1 diabetes–glucose builds up in the blood and the body cannot make efficient use of its main source of fuel.

The symptoms of type 2 diabetes develop gradually. Their onset is not as sudden as in type 1 diabetes. Symptoms may include fatigue or nausea, frequent urination, unusual thirst, weight loss, blurred vision, frequent infections, and slow healing of wounds or sores. Some people have no symptoms.

Managing a System

1) Assemble a good medical team.

Primary physician:
Everyone with diabetes needs to be in the care of a capable physician. But it doesn’t necessarily have to be the person who diagnosed the diabetes. The individual is going to be seeing a doctor at least three-to-four times a year, and relying this physician to recommend the other members of their health care team. So find someone they like, trust, and are comfortable with. Don’t settle for just anyone. Find a doctor who has experience treating patients with diabetes and is willing and able to take the time to listen to all concerns and answer any questions.

Make sure the doctor keeps up with the latest developments in diabetes treatment. Diabetes care is rapidly evolving, and unless the doctor keeps up with the latest advances, the resident may not get the quality of care they deserve and need. If the doctor doesn’t take care of a lot of people with diabetes, you may be better off with an endocrinologist — a doctor who has advanced training in dealing with diabetes and other hormone-related diseases — or a diabetologist, a specialist who only takes care of people with diabetes.

It’s our residents’ health that’s at stake here. If the doctor doesn’t help them get your blood sugars at near normal levels in short order, do not be afraid to change doctors until they find one who will!

Certified Diabetes Educator:
Ideally, in addition to their physician, the family might also want to see a certified diabetes educator. A diabetes educator will teach you the practical techniques of dealing with diabetes, including how to take insulin or other medicine, how to measure blood glucose levels, and much more. Doctor may recommend an educator, or anyone can call the American Association of Diabetes Educators at 800 832-6874.

Registered dietitian
Eating the right diet is a critical part of diabetes therapy. The Certified Diabetes Educator can answer many of questions about diet, but you may also want to see a registered dietitian. Again, your doctor may recommend one who works with people with diabetes. Or you can call the American Dietetic Association at 800-366-1655.

Because diabetes can damage the eye, they will definitely want an ophthalmologist (an eye doctor) on your health care team.

Experts recommend that people with Type 1 diabetes get a dilated retinal examination once a year, starting five years after the onset of diabetes. People with Type 2 diabetes should have a yearly dilated retinal examination starting immediately after diagnosis — because Type 2 diabetes is often not diagnosed until you have had the disease for many years. (Many people first learn they have diabetes when their ophthalmologist finds diabetes retinopathy during a routine eye exam.) Women with gestational diabetes are particularly at risk for diabetic retinopathy, and some experts recommend that they have their eyes examined every three months during their pregnancy.

Early detection is the key. Much can be done to prevent and treat diabetic eye disease. The sooner an ophthalmologist spots it, the better job he or she can do of stopping it.

Unfortunately, one of the complications of diabetes is dental problems, including cavities and gum disease. When diabetes is poorly controlled, the levels of sugar in the saliva are just as high as in your blood, and that causes tooth decay. High blood sugar levels also damage the blood vessels in your mouth, reducing the flow of oxygen and nutrients to the gum tissues and weakening their resistance to infection.

Your best defense is good diabetes control. Keep your blood sugar levels at normal levels, and they are not likely to have any more dental problems that someone who does not have diabetes.

But it doesn’t hurt to practice good dental hygiene, too! Brush your teeth twice a day, and floss to get at the plague between your teeth that the brush can’t reach. Replace the brush regularly. See a dentist regularly. And have your teeth professionally cleaned at least every six months.

If they have circulatory problems or nerve damage in the feet, they will also need to see a podiatrist (a foot doctor).

Unfortunately, people with diabetes — especially if it’s poorly controlled — often experience some degree of diabetic neuropathy, the impairment or damage of nerve function due to increased blood sugars. This can result in tingling, burning or numbness in the hands or — even more frequently — the feet. It can also result in a decreased ability to feel pain, especially in the extremities.

The way to prevent neuropathy is to carefully control the blood sugar levels. Good diabetes control has been proven to dramatically decrease the risk of neuropathy.

In any case, people with diabetes are encouraged to visually inspect their feet every day. If anyone does have some degree of neuropathy, it is possible they may have a cut or blister that they are not able to feel. It’s important to take care of any kind of injury to the foot right away, because foot injuries in people with diabetes can be very hard to heal. It’s also a good idea to see a podiatrist (foot doctor) at least once a year.

2) Learn everything you can about diabetes.

People with diabetes manage their own health. Doctors and the rest of their healthcare team will help, of course. But, day-to-day, you must monitor their treatment. The medical team can help get diabetes under control. It’s generally accepted that 5 percent of diabetes care is up to the doctor, and 95% is up to the individual.

Diabetes care is constantly changing. Important new products that can help control diabetes come on the market virtually every month. The Facility would be wise to subscribe to at least one magazine to keep up with the latest advances. In addition to “Diabetes Positive!,” good choices include “Diabetes Interview,” “Diabetes Self-Management” and “Diabetes Forecast.”

It also helps to surf the Web. The American Diabetes Association has a Web site, as do many other organizations that can help you live well in spite of the challenge that diabetes represents. Almost all of the major manufacturers of diabetes medicines, supplies, equipment, and insulin also have their own sites, many of which are very helpful.

3) Get organized!

Gather the supplies needed including insulin or other drugs the physician may have prescribed, and a blood glucose meter.

4) Maintain a positive attitude

One of the major hazards of diabetes is depression. Don’t let them be! Long-term, there health depends on maintaining a positive attitude as much as anything else.

If you think they are seriously depressed, by all means tell the family right away. It’s nothing to be ashamed of. People with diabetes suffer from depression at a rate that is two-to-four times higher than the general population. The key is to do something about it! Professional counseling, support groups and antidepressant medications can all help get them back on track. Exercise is also a highly effective antidepressant.

5) Accept the changes you’re going to have to make and get started.

The people who do best with diabetes are the people who, first of all, accept it. They take positive steps to deal with it. And then — they get on with their lives. They feel they have a mission, a purpose, a reason for living. They feed their minds a steady diet of positive thoughts. They love, they work, they laugh, they play, they plan for the future and they live their lives, just like everybody else.

The Food Guide Pyramid

The Food Guide Pyramid can help you put the Dietary Guidelines into action. The pyramid illustrates the research-based food guidance developed by the U.S. Department of Agriculture and supported by the Department of Health and Human Services. It is based on USDA’s research on what foods Americans eat, what nutrients are in these foods, and how to make the best food choices to promote good health. It outlines what to eat each day, but it is not a rigid prescription. You can use it as a general guide in choosing a healthful diet that is right for you. The pyramid calls for eating a variety of foods to get the nutrients you need, and, at the same time, the right amount of calories to maintain a healthy weight.

The food guide pyramid is shown below:

Food Pyramid

Using the food label to help with food choices

Under regulations from the Food and Drug Administration of the Department of Health and Human Services and the Food Safety and Inspection Service of the U.S. Department of Agriculture, the food label offers more complete, useful and accurate nutrition information than ever before.

With today’s food labels, consumers get:

  • Nutrition information about almost every food in the grocery store
  • Distinctive, easy-to-read formats that enable consumers to more quickly find the information they need to make healthful food choices
  • Information on the amount per serving of saturated fat, cholesterol, dietary fiber, and other nutrients of major health concern
  • Nutrient reference values, expressed as % Daily Values, that help consumers see how a food fits into an overall daily diet
  • Uniform definitions for terms that describe a food’s nutrient content–such as “light,” “low-fat,” and “high-fiber”–to ensure that such terms mean the same for any product on which they appear
  • Claims about the relationship between a nutrient or food and a disease or health-related condition, such as calcium and osteoporosis, and fat and cancer. These are helpful for people who are concerned about eating foods that may help keep them healthier longer.
  • Standardized serving sizes that make nutritional comparisons of similar products easier
  • Declaration of total percentage of juice in juice drinks. This enables consumers to know exactly how much juice is in a product.

Begin with the Nutrition Facts panel, usually on the side or back of the package. The Nutrition Facts panel has two parts: The main or top section, which contains product-specific information (serving size, calories, and nutrient information) that varies with each food product; and the bottom part, which contains a footnote. This footnote is only on larger packages and provides general dietary information about important nutrients.

Several features of the Nutrition Panel help people with diabetes manage their diets. First of all, serving sizes now are more uniform among similar products and reflect the amounts people actually eat. The similarity makes it easier to compare the nutritional qualities of related foods. People who use the Exchange Lists should be aware that the serving size on the label may not be the same as that in the Exchange Lists. For example, the label serving size for orange juice is 8 fluid ounces (240 milliliters). In the exchange lists, the serving size is 4 ounces (one-half cup) or 120 mL. So, a person who drinks one cup of orange juice has used two fruit exchanges.

The label also gives grams of total carbohydrate, protein and fat, which can be used for carbohydrate counting. The values listed for total carbohydrates include all carbohydrates, including dietary fiber and sugars listed below it. Not singled out is complex carbohydrates, such as starches. The sugars include naturally present sugars, such as lactose in milk and fructose in fruits, and those added to the food, such as table sugar, corn syrup, and dextrose. The listing of grams of protein also is helpful for those restricting their protein intake, either to reduce their risk of kidney disease or to manage the kidney disease they have developed.

Elsewhere on the label, consumers may find claims about the food’s nutritional benefits. These claims signal that the food contains desirable levels of certain nutrients. Some claims, such as “low fat,” “no saturated fat,” and “high fiber,” describe nutrient levels. Some of these are particularly interesting to people with diabetes because they highlight foods containing nutrients at beneficial levels.

Other claims, called health claims, show a relationship between a nutrient or food and a disease or health condition. FDA has authorized a number of claims, which are based on significant scientific agreement.

Three claims that relate to heart disease are of particular interest to people with diabetes:

  • A diet low in saturated fat and cholesterol may help reduce the risk of coronary heart disease.
  • A diet rich in fruits, vegetables and grain products that contain fiber, particularly soluble fiber, and are low in saturated fat and cholesterol may help reduce the risk of coronary heart disease.
  • Soluble fiber from whole oats, as part of a diet low in saturated fat and cholesterol, may help reduce the risk of coronary heart disease.

Nutrient and health claims can be used only under certain circumstances, such as when the food contains appropriate levels of the stated nutrients.

Overweight, Obesity, and Weight-Loss

More than 60 percent of U.S. adults are either overweight or obese, according to the Centers for Disease Control and Prevention (CDC). While the number of overweight people has been slowly climbing since the 1980s, the number of obese adults has nearly doubled since then.

Excess weight and physical inactivity account for more than 300,000 premature deaths each year in the United States, second only to deaths related to smoking, says the CDC. People who are overweight or obese are more likely to develop heart disease, stroke, high blood pressure, diabetes, gallbladder disease and joint pain caused by excess uric acid (gout). Excess weight can also cause interrupted breathing during sleep (sleep apnea) and wearing away of the joints (osteoarthritis).

To address the public health epidemic of being overweight or obese, former Surgeon General David Satcher issued a “call to action” in December 2001. Satcher’s report, The Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity, outlined strategies that communities can use in helping to address the problems. Those options included requiring physical education at all school grades, providing more healthy food options on school campuses, and providing safe and accessible recreational facilities for residents of all ages.

Dietary Supplements

Congress defined the term “dietary supplement” in the Dietary Supplement Health and Education Act (DSHEA) of 1994. A dietary supplement is a product taken by mouth that contains a “dietary ingredient” intended to supplement the diet. The “dietary ingredients” in these products may include: vitamins, minerals, herbs or other botanicals, amino acids, and substances such as enzymes, organ tissues, glandulars, and metabolites. Dietary supplements can also be extracts or concentrates, and may be found in many forms such as tablets, capsules, softgels, gelcaps, liquids, or powders. They can also be in other forms, such as a bar, but if they are, information on their label must not represent the product as a conventional food or a sole item of a meal or diet. Whatever their form may be, DSHEA places dietary supplements in a special category under the general umbrella of “foods,” not drugs, and requires that every supplement be labeled a dietary supplement.

In October 1994, the Dietary Supplement Health and Education Act (DSHEA) was signed into law by President Clinton. Before this time, dietary supplements were subject to the same regulatory requirements as were other foods. This new law, which amended the Federal Food, Drug, and Cosmetic Act, created a new regulatory framework for the safety and labeling of dietary supplements.

Under DSHEA, a firm is responsible for determining that the dietary supplements it manufactures or distributes are safe and that any representations or claims made about them are substantiated by adequate evidence to show that they are not false or misleading. This means that dietary supplements do not need approval from FDA before they are marketed. Except in the case of a new dietary ingredient, where pre-market review for safety data and other information is required by law, a firm does not have to provide FDA with the evidence it relies on to substantiate safety or effectiveness before or after it markets its products.

Also, manufacturers do not need to register themselves nor their dietary supplement products with FDA before producing or selling them. Currently, there are no FDA regulations that are specific to dietary supplements that establish a minimum standard of practice for manufacturing dietary supplements. However, FDA intends to issue regulations on good manufacturing practices that will focus on practices that ensure the identity, purity, quality, strength and composition of dietary supplements. At present, the manufacturer is responsible for establishing its own manufacturing practice guidelines to ensure that the dietary supplements it produces are safe and contain the ingredients listed on the label.

People with diabetes should be sure to consult a doctor or pharmacist before purchasing or taking any supplement. Many supplements contain active ingredients that have strong biological effects and their safety is not always assured in all users. Other supplements may interact with prescription and over-the-counter medicines. By taking these products, you may be placing yourself at risk.

(From the Food and Drug Administration)

Blood Glucose Level

What is blood glucose level?

Blood glucose level is the amount of glucose (sugar) in the blood. It is also known as serum glucose level. The amount of glucose in the blood is expressed as millimoles per litre (mmol/l).

Normally, blood glucose levels stay within narrow limits throughout the day (4 to 8mmol/l). But they are higher after meals and usually lowest in the morning.

If a person has diabetes, their blood glucose level sometimes moves outside these limits.

Why control blood glucose levels?

When you have diabetes it’s very important that your glucose level is as near normal as possible. The primary goal of any diabetes treatment is simply to keep the glucose level stable.

Stable blood glucose significantly reduces the risk of developing late-stage diabetic complications. These may start to appear 10 to 15 years after diagnosis with Type 1 diabetes and often less than 10 years after diagnosis with Type 2 diabetes. They include:

  • Neuropathy (nerve disease)
  • Retinopathy (eye disease)
  • Nephropathy (kidney disease)
  • Cerebrovascular disease, such as stroke
  • Cardiovascular disease, such as heart attack, hypertension and heart failure.

How can I measure blood glucose levels?

Blood glucose levels can be measured very simply and quickly with a home blood glucose level testing kit. These come in a wide variety of shapes and sizes, but they all consist of at least two things: the measuring device itself and a strip. A pharmacist will be able to advise you about the most appropriate model for you.

To check your blood glucose level put a small amount of blood on the strip and place the strip into the device. After about 30 seconds it will display the blood glucose level. The best way to take a blood sample is by pricking the finger with a surgical knife, called a lancet.

What should glucose levels be?

The best values are:

  • 4 to 7mmol/l before meals
  • Less than 10mmol/l one-and-a-half hours after meals
  • Around 8mmol/l at bedtime

How often should blood glucose levels be measured?

People who have Type 1 diabetes should measure their blood glucose level once a day, either in the morning before breakfast or at bedtime.

In addition, they should do a 24-hour profile a couple of times a week. That means measuring blood glucose levels before each meal and before bed.

People who have Type 2 diabetes and are being treated with insulin should also follow the schedule above.

People who have Type 2 diabetes and who are being treated with tablets or a special diet should measure their blood glucose levels once or twice a week either before meals or one-and-a-half hours after a meal. They should also do a 24-hour profile once or twice a month.

The main advantage for insulin-treated diabetics in measuring blood glucose levels in the morning is that appropriate amounts of insulin can be taken if the blood glucose level is high or low. This will reduce the risk of developing late-stage diabetic complications.

Blood glucose levels at bedtime

The blood glucose level at bedtime should be between 7 and 10 mmol/l.

If blood glucose is very low or very high at bedtime, you may need to adjust your food intake or insulin dose. Make sure you discuss this with your doctor.

At what other times should blood glucose levels be measured?

Blood glucose should be measured any time you don’t feel well, or think your blood glucose is either too high or too low.

People who have Type 1 diabetes with a high level of glucose in their blood (more than 20mmol/l), in addition to sugar traces in the urine, should check for ketone bodies in their urine, using a urine strip.

If ketone bodies are present, it’s a warning signal that they either have, or may develop, diabetic acidosis. If this is the case, they should consult their doctor.

What is glycated hemoglobin?

Glycated hemoglobin or HbA1c – also known as long-term glucose – shows how much of the hemoglobin in the blood is glycated. This means that a hemoglobin cell in your blood has picked up a glucose molecule. The normal amount is 6 to 7 per cent.

This test is usually done using a blood sample from the patient’s arm. It shows how high the glucose levels have been over the last six to eight weeks.

Unfortunately, different hospitals have different guidelines, but generally speaking a level of:

  • 7 to 8 per cent is usually fine
  • 8 to 10 per cent is not quite acceptable
  • above 10 per cent is unacceptable.

(By Professor Ian W Campbell, consultant physician Patrick Davey, cardiologist.

Insulin – General Information

What is Insulin?

Insulin is a hormone, and therefore, a protein. Insulin is secreted by groups of cells within the pancreas called islet cells. The pancreas is an organ that sits behind the stomach and has many functions in addition to insulin production. The pancreas also produces digestive enzymes and other hormones. Carbohydrates (or sugars) are absorbed from the intestines into the bloodstream after a meal. Insulin is then secreted by the pancreas in response to this detected increase in blood sugar. Most cells of the body have insulin receptors which bind the insulin which is in the circulation. When a cell has insulin attached to its surface, the cell activates other receptors designed to absorb glucose (sugar) from the blood stream into the inside of the cell.

Without insulin, you can eat lots of food and actually be in a state of starvation since many of our cells cannot access the calories contained in the glucose very well without the action of insulin. This is why Type 1 diabetics who do not make insulin can become very ill without insulin shots. Insulin is a necessary hormone. Those who develop a deficiency of insulin must have it replaced via shots or pumps (Type 1 Diabetes). More commonly, people will develop insulin resistance (Type 2 Diabetes) rather than a true deficiency of insulin. In this case, the levels of insulin in the blood are similar or even a little higher than in normal, non-diabetic individuals. However, many cells of Type 2 diabetics respond sluggishly to the insulin they make and therefore their cells cannot absorb the sugar molecules well. This leads to blood sugar levels which run higher than normal. Occasionally Type 2 diabetics will need insulin shots but most of the time other methods of treatment will work.

Insulin was the first hormone identified (late 1920’s) which won the doctor and medical student who discovered it the Nobel Prize (Banting and Best). They discovered insulin by tying a string around the pancreatic duct of several dogs. When they examined the pancreases of these dogs several weeks later, all of the pancreas digestive cells were gone (died and were absorbed by the immune system) and the only thing left was thousands of pancreatic islets. They then isolated the protein from these islets and behold, they discovered insulin. Note that there are other hormones produced by different types of cells within pancreatic islets (glucagon, somatostatin, etc) but insulin is produced in far greater amounts under normal conditions making the simple approach used by Banting and Best quite successful.

Where Does Commercial Insulin Come From?

The first successful insulin preparations came from cows (and later pigs). The pancreatic islets and the insulin protein contained within them were isolated from animals slaughtered for food in a similar but more complex fashion than was used by our doctor and med-student duo. The bovine (cow) and porcine (pig) insulin were purified, bottled, and sold. Bovine and porcine insulin worked very well (and still do!) for the vast majority of patients, but some could develop an allergy or other types of reactions to the foreign protein (a foreign protein is a protein which is not native to humans). In the 1980’s technology had advanced to the point where we could make human insulin. The advantage would be that human insulin would have a much lower chance of inducing a reaction because it is not a foreign protein (all humans have the exact same insulin, so we do not “see” this as a foreign protein). The technology which made this approach possible was the development of recombinant DNA techniques. In simple terms, the human gene which codes for the insulin protein was cloned (copied) and then put inside of bacteria. A number of tricks were performed on this gene to make the bacteria want to use it to constantly make insulin. Big vats of bacteria now make tons of human insulin. From this, pharmaceutical companies can isolate pure human insulin.


What is insulin resistance?

Insulin resistance occurs when the normal amount of insulin secreted by the pancreas is not able to unlock the door to cells. To maintain a normal blood glucose, the pancreas secretes additional insulin. In some cases (about 1/3 of the people with insulin resistance), when the body cells resist or do not respond to even high levels of insulin, glucose builds up in the blood resulting in high blood glucose or type 2 diabetes. Even people with diabetes who take oral medication or require insulin injections to control their blood glucose levels can have higher than normal blood insulin levels due to insulin resistance.

Why is insulin resistance in the news?

More and more people in the U.S. are becoming obese, physically inactive, or both. Obesity and physical inactivity aggravate insulin resistance. Also, people who are insulin resistant typically have an imbalance in their blood lipids (blood fat). They have an increased level of triglycerides (blood fat) and a decreased level of HDL (good) cholesterol. Imbalances in triglycerides and HDL cholesterol increase the risk for heart disease. These findings have heightened awareness of insulin resistance and its impact on health.

What is Syndrome X?

Another term heard in the news is Syndrome X. Syndrome X is a cluster of risk factors for heart disease associated with insulin resistance. These risk factors include: hypertriglyceridemia (high blood lipid), low HDL-cholesterol, hyperinsulinemia (high blood insulin), often hyperglycemia (high blood glucose), and hypertension (high blood pressure).

Who has insulin resistance?

Almost all individuals with type 2 diabetes mellitus (diabetes) and many with hypertension, cardiovascular disease, and obesity are insulin resistant. These diseases and conditions are predominantly found in countries with an improved economic status such as the U.S. And in the U.S., these diseases and conditions are among the leading contributors to morbidity and mortality. Also, about 20-25% of the healthy population may be insulin resistant.

What are the symptoms of insulin resistance?

There are no outward physical signs of insulin resistance. A glucose tolerance test, during which insulin and blood glucose are measured, can help determine if someone is insulin resistant. Many people who are insulin resistant produce large enough quantities of insulin to maintain near normal blood glucose levels.

What causes insulin resistance?

No one knows for sure. Some scientists think a defect in specific genes may cause insulin resistance and type 2 diabetes. Researchers continue to investigate the cause. What we do know is that insulin resistance is aggravated by obesity and physical inactivity both of which are increasing in the U.S.

Do all people with insulin resistance develop diabetes?

No. Science has not yet determined why some people with insulin resistance eventually develop diabetes and others do not. By maintaining an appropriate weight and a physically active lifestyle many individuals are able to reduce their chances of becoming insulin resistant and developing diabetes.

What is the best diet for people with insulin resistance?

Research indicates that low fat diets may aggravate the effect of insulin resistance on blood lipids. Therefore, for individuals who are insulin resistant, a diet low in saturated fat (less than 10 percent of total calories) and more moderate in total fat content (40% of total calories) may be beneficial. This recommendation is different from the low-fat, high-carbohydrate diet that many health organizations recommend to help prevent heart disease. Specifically, they recommend decreasing fat intake to less than 30 percent of calories. Some groups recommend even lower levels of dietary fat. It is also beneficial to maintain an appropriate body weight because obesity can aggravate insulin resistance. To maintain an appropriate weight, regulate caloric intake and maintain a physically active lifestyle. A registered dietitian can assist with developing a proper diet plan for people with insulin resistance, or a family history of type 2 diabetes.


Blood Glucose
Sugar in the blood that is used by the body cells for energy or stored as glycogen for future energy needs.

Blood Lipid
Fat that is present in the blood, includes triglycerides and cholesterol.

A waxy, fat-like substance produced by the liver and contained in selected foods (e.g., egg yolks, coconut oil). Cholesterol is a form of lipid. The body produces all the cholesterol it needs to function normally. 200mg/dl or less is the desired blood level.

Storage form for glucose in the body.

High Density Lipoprotein (HDL)
Also called the “good” cholesterol because it removes cholesterol from the bloodstream preventing it from accumulating in the vessels.

Hormone produced by the pancreas; essential for proper use of glucose in the body.

Insulin Resistance
Insulin resistance occurs when the normal amount of insulin secreted by the pancreas is not able to remove glucose from the blood into the cells for use as energy or storage for future use.

Low Density Lipoprotein (LDL)
Also called the “bad” cholesterol because it carries most of the cholesterol in the blood. If the LDL level is too high, cholesterol and fat can build up in the arteries.

Organ in the body that produces the hormone insulin.

One of the components of a lipoprotein (in addition to cholesterol and other components). Triglycerides are the main constituents of stored fat.

Type 2 Diabetes Mellitus
Often referred to as adult onset diabetes or noninsulin dependent diabetes mellitus. Disease state in which glucose is not able to move efficiently from the blood to the cells. There are two possible causes. First, the pancreas produces enough insulin but the insulin is not effective in removing glucose from the blood. Second, the pancreas eventually may not produce enough insulin to properly remove glucose from the blood.


Insulin Pumps

Keeping your blood sugar level as close to the normal range (about 70 to 115 mg/dL) as possible is important in minimizing the complications that can result after years of diabetes. An insulin pump is a useful device for achieving this control, especially in patients who have a drop in blood sugar during the night, an erratic work schedule requiring flexible therapy, or inadequate control with other methods.

What equipment is involved?

Just a pump unit and an infusion set. The pump unit is a plastic case that’s about the size of a deck of cards. It contains a reservoir or cartridge holding several days’ worth of insulin, a tiny battery-operated pump, and a computer chip regulating how much insulin is pumped. The infusion set is a thin plastic tube with a fine needle at the end. It carries the insulin from the pump to the site of infusion beneath your skin.

How does an insulin pump work?

It delivers insulin in two ways: continuously at a low dose and rapidly in a larger dose. The low dose is delivered every few minutes 24 hours a day to maintain a “basal” level of insulin, as the pancreas does in people without diabetes. Maintaining a low level of insulin cuts down on bouts of low blood sugar occurring in the morning and with unexpected exercise or stress. The larger, or “bolus,” doses are given before meals. With the press of a button, you program how much additional insulin the pump is to release, depending on results of blood sugar monitoring and the amount of food you intend to eat. Your body’s rhythms and requirements are unique, so you must work very closely with your physician to get the doses just right for you.

Isn’t wearing a pump all the time a bother?

Most people quickly adapt to wearing a pump. When the infusion set is properly inserted and the skin at the site is not irritated, you should not be aware of the device. The most common infusion site is the abdomen, and tubing comes in lengths long enough to allow you to put the pump in your pocket or clip it on your belt. The pump can be put in waterproof coverings during showering and swimming and protective cases during sports. Some pumps have a quick-release device for temporary detachment. Most patients feel that the adjustments they have to make are minor and that having their diabetes well controlled makes the effort worthwhile.

This information is not a substitute for medical treatment.


Lantus Insulin

(LANTUS insulin glargine [rDNA origin] injection)

What is unique about Lantus It is the only insulin analog used once a day that is proven to lower basal glucose levels for a full 24 hours with no pronounced peak.

Indications and Usage

Lantus is indicated for once-daily subcutaneous administration at bedtime in the treatment of adult and pediatric patients with type 1 diabetes mellitus or adult patients with type 2 diabetes mellitus who require basal (long-acting) insulin for the control of hyperglycemia.

Only a doctor can decide for sure if Lantus is the right therapy. However, patients may want to discuss Lantus with their doctor if any of these apply:

Patient’s blood sugar is too high despite efforts to control it with diet, exercise or oral diabetes medication.

Patient is currently using an intermediate-acting insulin (such as NPH) once a day and wants 24-hour basal coverage.

Patient would rather take one injection of Lantus than two of NPH.

Mechanism of Action

Lantus is a long-acting insulin analog that helps the body regulate the removal of glucose from the bloodstream. It is the first analog with a 24-hour glucose lowering effect with no pronounced peak of action, providing a continuous, steady release. Lantus also demonstrates a slower, more prolonged absorption and a relatively constant concentration/time profile over 24 hours.

Lantus could be considered an alternative insulin medication to intermediate or long-acting insulins, including neutral protamine Hagedorn (NPH), Lente, and Ultralente. The potency of Lantus is approximately the same as human insulin.

What Lantus is not meant to replace is short-acting insulins such as Regular or Humalog, which provides a bolus at mealtime. Oral diabetes medications and/or short acting insulin to control diabetes can be used with Lantus.

Key Benefits

Only insulin analog used once a day, proven to lower basal glucose levels for a full 24 hours.

Can be used with oral diabetes medications and/or short-acting insulin to control diabetes.

Clinical Studies

More than 4,000 people with diabetes, including people with type 1 diabetes age six and above, and adults with type 2 diabetes, participated in clinical studies that compared the safe and efficacy of once-daily Lantus injections with the same attributes of once-daily and twice-daily injections of NPH human insulin, the most commonly used intermediate-acting insulin.

Safety and Precautions

Lantus must not be diluted or mixed with any other insulin or solution. If mixed or diluted, the solution may become cloudy, and the onset of action/time to peak effect may be altered in an unpredictable manner.

Potential Adverse Events

The adverse effects most commonly associated with Lantus including hypoglycemia, lipodystrophy, skin reactions and allergic reactions.


Insulin Sliding Scale Protocol for Type II Diabetic Patients


  • Low Dose Regimen: Suggested as starting point for the thin and elderly
  • Medium Dose Regimen: Suggested as starting point for average weight
  • High Dose Regimen: Suggested as starting point for overweight patients
  • Very High Dose Regimen: Suggested as starting point for patients with infections or those receiving steroids

Insulin Type:

Regular Insulin, Rapid Acting Insulin(Humalog, Novolog)

Frequency of Monitoring:

AC & HS (Before Breakfast & Before bedtime Q 6 H (12 MN, 6 AM, 12 N, 6 PM)

(If patient is NPO or on continuous tube feeding)


  1. If Potassium is low (< 3.5 mEq/L), call M.D.
  2. Advance to next higher dose regimen if glucose level is > 250 two (2) times in 24 hours and all readings were > 100.
  3. Decrease to the next lower dose regimen if glucose level is between 60 and 100 twice in 24 hours.
  4. Physician should complete a new sliding scale protocol order sheet with dose regimen changes and send a copy to pharmacy.

Insulin Chart for Diabetes