How To Treat Type 1 Diabetes

After the diagnosis of type 1 diabetes, insulin therapy can be started outpatient, ie without a hospital stay, if the person is in good general condition. If the general condition has deteriorated, diabetes has reached the degree of acid poisoning, or any other illness possibly related to the onset of diabetes so requires, the person is initially admitted to the hospital.

Your doctor will instruct you on insulin doses and how to adjust them according to your blood sugar level. The goals and methods of treatment are agreed upon together and individually. The diabetes nurse will teach you the initial essentials (such as using an insulin pen, getting insulin, injecting insulin, measuring your blood sugar, appropriate doses of insulin, evaluating carbohydrates, symptoms, and treatment of low blood sugar) to cope with diabetes in the coming weeks.

During the first year, the skills and knowledge needed for self-care in diabetes will be progressively reviewed. Based on treatment guidance and glucose sensing, a person with diabetes learns how blood sugar varies in different situations and learns to adjust their own insulin dose to suit different diets, exercise, and different daily rhythms.

Insulin therapy

Type 1 diabetes requires basal insulin, which acts around the clock and regulates the release of sugar from the liver into the bloodstream at night and between meals. Injection therapy uses long-acting insulin derivatives (glargine, detemir, degludecin) as basal insulin. In pump therapy, the need for basal insulin is met by continuous infusion of rapid-acting insulin.

Taken in connection with eating a meal insulin meal, the carbohydrate content. Fast-acting insulin derivatives (insulin aspart, glulis, lispro) are used as meal insulin. The insulin-to-carbohydrate ratio (IHS), i.e. the amount of carbohydrate covered by one insulin unit, is individual and may vary at different times of the day. In an adult, usually, 1 unit of fast-acting insulin covers 5 to 20 g of carbohydrate. In other words, 10 g of carbohydrate requires 2 to ½ units of rapid insulin.

Small doses of rapid-acting insulin, called so-called correction insulin, are used to correct temporary high blood sugar levels before a meal and on sick days. Insulin sensitivity factor (IHT), the magnitude of the blood glucose effect of one unit of insulin, is individual and may vary at different times of the day. In adults, 1 unit of fast-acting insulin usually lowers blood sugar by 1 to 4 mmol / l (unit of blood sugar mmol / l = millimoles per liter).

Insulin requirements are individual. It varies at different times of the day, on different days and periods, and depending on the amount of exercise. The usual total daily insulin requirement is usually 0.6 to 0.8 units per kilogram body weight (eg 42 to 56 units for a 70 kg body weight). Insulin-sensitive, for example, those with high mobility and normal weight, may have a lower need, and correspondingly insulin-resistant, the need may be higher. Most have a basal insulin requirement of just under half (30-50%) and a mealtime insulin requirement of just over half (70-50%) of the total daily insulin.

Blood glucose management goals

In self-monitoring of blood glucose, the general objectives of good management are generally pre-meal values of 4 to 7 mmol / l and post-meal values of less than 8 to 10 mmol / l. In glucose sensing, the target is a level of 3.9 to 10.0 mmol / l for at least 70% of the sensing time. Individual, temporary deviations are common and do not need to be worried about. Temporarily high blood sugar before a meal or on sick days is corrected with an additional dose of fast-acting insulin. It is also good to remember that the self-monitoring meter or glucose sensor result can vary by about 10% up or down. As your blood sugar rises or falls rapidly, your glucose sensor reading may differ even more from your actual blood sugar.

To assess long-term sugar balance, red blood cell “sugaring”, or sugar hemoglobin HbA 1c, is measured at the treatment site 2 to 4 times a year. The unit of measurement for sugar hemoglobin is mmol/mol (millimoles per mol) (previously expressed as a percentage). Ideally, the value is less than 53 mmol/mol (7%) without the blood sugar falls too low (ie no hypoglycemia). If the hemoglobin value has been briskly elevated, a value of 53-64 mmol/mol (7-8%) is already a good target for many.

Insulin treatment is occasionally associated with hypoglycemia, ie low blood sugar because insulin preparations act schematically and not as needed. In patients with type 1 diabetes, symptomatic hypoglycemias usually occur weekly and can be treated quickly with an intake of extra carbohydrates. If hypoglycemia occurs daily or if you need the help of another person to cope with the hypoglycemia, your insulin dose should be adjusted, glucose sensing should be used, and pump therapy instituted if necessary.

Insulin injections

Generally, 1 to 2 basal insulin injections are required, depending on the quality of the insulin, and 3 to 5 meal insulin injections, depending on the meal. With existing insulin pens and needles, injecting is effortless and almost painless. Insulin dosing is individual and the correct doses are sought through blood glucose measurements. All insulins are injected under the skin in adipose tissue. The most common injection sites are the abdomen and thigh and buttocks areas.

Injection times and insulin doses are tailored to suit each person's daily rhythms. Glucose sensing and meal-specific carbohydrate evaluation should be used to determine dosages.

Insulin pump

Insulin can also be delivered with an insulin pump, which comes in several models. The pump is connected to a small tube attached under the skin, a cannula, which is changed itself every 2-3 days. The insulin pump delivers fast-acting insulin subcutaneously at a controlled rate, usually varying according to the time of day (for example, 0.4 to 1.2 units per hour), which takes care of the need for basal insulin. In pump therapy, basal insulin is called a basal. The user of the pump adjusts the appropriate meal insulin dose, which is transferred subcutaneously at the touch of a button or with the remote control. In pump therapy, meal insulin is called a bolus. The pump does counter helps to assess the appropriate dose of meal insulin.

Glucose sensing can be combined with pump therapy. In the latest models, the sensor can control the delivery of the pump's basal insulin. If your blood sugar drops or threatens to drop too low or rises or threatens to rises too high, the pump will automatically reduce or increase your insulin delivery.

Pump therapy is used if replacement of varying insulin needs and achievement of treatment goals with multi-injection therapy and a glucose sensor is not possible, or if the pump provides better treatment and quality of life options. Pump therapy is especially useful in insulin-sensitive individuals with high blood sugar levels that are too low and even small changes in insulin doses have a strong effect on blood sugar levels.

Blood glucose self-monitoring and glucose sensing

Self-monitoring of blood glucose with fingertip measurements or a glucose sensor is essential for the good treatment of type 1 diabetes. This is the only way to dispense insulin according to varying needs. Before visiting a diabetes nurse or doctor, or if hemoglobin HbA 1c is not on target, it is useful to have a more accurate self-measurement period of 1 to 2 weeks or glucose sensing to record carbohydrate, evening and morning carbohydrate and insulin doses.

Periodic or continuous glucose monitoring is recommended for self-monitoring. A small sensor that measures tissue sugar (glucose from the cell medium) for 1 to 2 weeks is easily inserted into the fatty tissue under the skin. The reading it gives is scanned or the sensor sends the reading and its direction of change to the reading device or to the pump display. The reading of the glucose sensor is close enough (± 10%) to the value of the blood sugar when there is steady blood sugar, ie before a meal, for example, when it is possible to dispense meal insulin. The difference in reading and the delay in blood sugar may be greater as blood sugar falls or rises, and is indicated by arrows on the reading device.

A small blood glucose meter can also be used for self-monitoring of blood sugar. A drop of blood from a small injection into the fingertip is transferred to a strip from which the meter reads the blood sugar value. Blood glucose readings are stored on the meter and can be transferred to a mobile app, computer, or cloud server.

Achieving your target blood sugar level usually requires continuous glucose sensing or multiple self-measurements per day. The effect of basal insulin is best described by the change in blood sugar during the night (evening-morning pair measurement) and the value of blood sugar measured before breakfast and during the day before dinner or dinner. The appropriate dose and timing of meal insulin are described by the change in pre-meal blood glucose from about 2 hours after the start of a meal to the value measured (meal pair measurement).

Monitoring of ketones

Acidic ketones are produced in the blood and excreted in the urine when the body burns fat for energy. The amount considered normal with a quick meter is less than 0.6 mmol / l. If there is a lack of or insufficient insulin relative to the need, for example on sick days, fat burning will be accelerated. In this case, the formation of ketones increases. Excessive amounts of ketones begin to acidify the body (pH decreases), and without additional insulin administration and hydration, acid poisoning, or ketoacidosis, develops.

Ketones are measured with a quick meter in the blood in case of sudden illnesses (fever, diarrhea, etc.) or if the blood sugar is repeatedly above 14 mmol / l for no apparent reason. If the amount of ketones has clearly increased, it is advisable to contact your own treatment center and seek treatment regardless of the time of day.

Food and eating

A person with type 1 diabetes can eat the usual healthy food according to their preferences. Diabetes recommends a qualitatively similar diet as the rest of the population (see Health Promoting Diet ). The general recommendations apply individually. There is no need for a separate meal plan, diabetes products, or a sugar-free diet. Due to the increased risk of arterial disease in patients with type 1 diabetes, the overall health of the food should also be assessed in terms of the prevention and treatment of the risk factors for arterial disease, ie hypertension, and lipid metabolism disorders.

The general principles of the recommendations are:

Rich in vegetables (vegetables, legumes, berries, fruits) and whole grains
Foods and beverages of low nutritional value and containing sugar and white grains
Low in hard fat (saturated and trans fat) and moderately soft fat
A little salt
No more than moderate alcohol.

Patients with celiac disease, renal insufficiency, severe lipid metabolism disorders, severe obesity, or intestinal dysfunction are referred to a nutritionist for individual diet planning.

Evaluation of carbohydrates

Carbohydrates have an immediate effect on blood sugar from food ingredients. In the small intestine, they break down into sugars by digestive enzymes and are absorbed into the bloodstream.

The dose of fast-acting insulin administered with a meal is crucially affected by the number of carbohydrates in the meal eaten and the pre-meal blood glucose value. Therefore, a person with type 1 diabetes needs to learn how to estimate the number of carbohydrates in meals. The need for meal insulin is individual, but the rough rule of thumb is that in a normal-weight adult who gives a total of 40 to 50 units of insulin a day, 10 g of carbohydrates raises blood sugar by about 2 mmol / l and needs 1 unit of insulin to "clear" it. Glucose sensing should be used to determine the appropriate dosage at different times of the day.

Examples of the amounts of carbohydrates in different dishes are shown in the picture. The goal is for the diabetic to be able to adjust their meal insulin dose according to the number of carbohydrates in the food and the pre-meal blood sugar.

Exercise and other physical work

Regular exercise is beneficial for general fitness and heart health for everyone, including those with type 1 diabetes. Virtually all sports can be practiced. Endurance exercise and other muscle work consume sugar stores and increase the absorption and potency of injected insulin, which can cause blood sugar to fall too low during or after these. Low blood sugar can be prevented by eating extra carbohydrates or by reducing the dose of insulin that works during exercise. There is a separate instruction for this: see Exercise instructions for type 1 diabetes.

Alcohol

Alcohol prevents the formation of sugar in the liver, so when low blood sugar is suddenly, the body’s own remedies are lacking. The detection of low blood sugar is easily delayed because the associated symptoms can be considered alcohol-induced. For these reasons, precautions in the presence of high alcohol consumption are aimed at preventing low blood sugar (hypoglycemia); see separate help Diabetes and alcohol.