Type 1 Diabetes

Treatment overview

There is as yet no cure for diabetes. But when a treatment plan results in blood glucose levels that are normal or nearly so, a person's risk of developing complications drops dramatically.

There are certain things that you need to do religiously in order to be healthy: Take insulin injections, follow a meal plan, and be physically active (physical activity can help the body better use insulin, so it can convert glucose into energy for cells). You'll have to monitor your blood glucose closely; regular testing will help determine how well the steps you're taking are working to keep blood glucose levels in a normal range. For more information, see our page on home monitoring.

This section has more information on:

• Treatment during the disease's early stages
• Meal planning
• Insulin injections

Treatment during the disease's early stages

People with type 1 diabetes must take daily insulin injections, since they produce little or none on their own. Insulin is a vital hormone that helps your body convert food into energy. Without it, glucose builds up to intolerable levels in the bloodstream; untreated, patients die.

But in the early stages, shortly after diagnosis, many patients experience a "honeymoon period" during which insulin needs are minimal; some people can actually maintain normal or near-normal blood glucose taking little or no insulin. This occurs because at this point in the disease's progression, a small percentage of the body's insulin-producing cells are still in operation. The disease may even appear to go away, since symptoms may emerge when the patient has an illness, then subside along with the illness as insulin needs decrease.

But the process that has destroyed most of the insulin-producing cells will ultimately destroy the remaining cells.

Meal planning

Your body changes much of the food you eat into glucose. The amount of blood glucose that comes from your diet is important, because your dose of insulin will be calibrated to match the amount of food that you eat every day. If you eat more food than usual without an insulin adjustment, you will have high blood glucose (hyperglycemia). If you eat less food than usual, you will have low blood glucose (hypoglycemia).

When you eat is also important. Your meals and medication work together so that your body can use the sugar from the food for energy or store it for a later time. A dietitian can help you formulate a meal plan.

This section has more information on:

• Carbohydrate counting
• Portion control
• Alcohol consumption

Carbohydrate counting

One way people with diabetes can manage their food intake to keep their blood glucose as close to normal as possible is by calculating how many grams of carbohydrate they eat. Carbohydrates tend to have the greatest effect on blood glucose.

The balance between the amount of carbohydrate you eat and the available insulin determines how much your blood glucose level goes up after meals or snacks. To help control your blood glucose, you need to know which foods contain carbohydrate, the size of a "serving" of different foods, and how many carbohydrate servings to eat each day. There's no magic number of daily servings that's right for everyone; instead, it is important to work with a dietitian to determine what will work for you. By checking your blood glucose, you can see whether changes are needed. If your levels are too high, for example, you may need to eat fewer carbohydrate servings, be more physically active, or work with your diabetes team to adjust your insulin.

Foods that contain carbohydrate include grains, pasta, and rice; breads, crackers, and cereals; starchy vegetables such as potatoes, corn, peas, and winter squash; legumes such as beans, peas, and lentils; fruits and fruit juices; milk and yogurt; and sweets and desserts. Nonstarchy vegetables such as broccoli, salad greens, and green beans are very low in carbohydrate.

Carbohydrate counting can ensure that the right amount of carbohydrate is eaten at each meal and snack. Likewise, insulin may be adjusted based on what the person wants to eat. For example, if you want to eat a much larger meal, this approach can help you determine how much extra insulin to take.

Portion control

The amount of food you eat is closely related to blood glucose control. If you eat more food than is recommended on your meal plan, your blood glucose goes up. Although foods containing carbohydrates have the most impact on blood glucose, most foods will have some effect.

The only way you can tell if you are eating the right amount is to measure your foods carefully:

• Practice, practice, practice. Don't rely on measuring once and then just "guesstimating." Pull out the scales at least once a week to check yourself.
• Use a glass that you know holds only 4 or 8 ounces. You can also place a piece of tape on the outside of a glass to mark off a serving.
• A bread serving is based on a 1-ounce slice of bread. Many single bread servings may weigh more than 1 ounce and therefore have more impact on blood glucose. Check labels of such items as light breads, bagels, or rolls.
• Know the weight of fruit servings for portion control.
• Check your cereal portion using measuring cups.

Alcohol consumption

The use of alcohol should be discussed with your physician and healthcare team. As a general guideline, people using insulin can have two alcoholic beverages in addition to their regular meals, but no food should be omitted in exchange for an alcoholic drink.

Some alcoholic beverages are higher in sugar and carbohydrates: sweet wines, sweet vermouth, and wine coolers, for example. Use these sparingly.

When making the decision about whether to use alcohol, you should understand what the potential effects of alcohol are on your health. Although alcohol has little effect on blood glucose control, it may worsen other medical problems. Make sure you discuss the use of alcohol with your doctor. Here are some general guidelines:

• With your doctor's approval, alcohol should be limited to two drinks a day. A "drink" is defined as a 12-ounce beer (preferably light beer); a 4-ounce glass of wine; a 2-ounce glass of dry sherry; or 1.5 ounces of a distilled beverage, such as whiskey, rye, vodka, or gin. Even if your doctor approves the use of alcohol, however, you may want to avoid the extra calories if you are trying to lose weight.
• Alcoholic beverages can make your blood glucose drop. Avoid the risk of low blood glucose by having your drink at mealtime, or having a snack along with the drink.
• Avoid drinks that contain large amounts of sugar.
• Drink with caution, and carry identification that says you have diabetes. Signs of low blood glucose are similar to those of intoxication. Make sure your companions know how to treat an insulin reaction.

Insulin injections

There are several types of insulin, classified by how soon and how long they act. It is helpful to know when the insulin you take starts to work, its peak (when the insulin is working its hardest), and the duration (how long the insulin works). Premixed combinations of slower- and fast-acting insulins are also available.

• Rapid-acting insulins include insulin aspart (Novolog) and insulin glulisine (Apidra). They begin to act in 10 to 30 minutes and reach their peak in 30 minutes to three hours, and their effects last between three and five hours.
• Short-acting insulin is regular insulin. It begins to work in 30 to 60 minutes, peaks in one to five hours, and lasts as long as eight hours.
• Intermediate-acting insulins such as NPH begin working in between one and four hours. They peak at between four and 12 to 15 hours, and last up to 26 hours.
• Long-acting, peakless insulins include insulin glargine (Lantus), which begins working in between one and two hours, does not peak but has consistent effects, and lasts as long as 24 hours.

This section has information on:

• Inhaled insulin
• Insulin pumps
• Hints for storing and using insulin
• Weight gain

Inhaled insulin

You may want to talk to your physician about Exubera, a new rapid-acting insulin in powder form that is inhaled into the lungs through your mouth using a specially designed inhaler about the size of an eyeglasses case. It is important to note that Exubera does not replace intermediate-acting or long-acting insulin, however, so anyone using those forms will still need to take them by injection. Generally, inhaled insulin is taken before meals, though timing and dosage will be guided by your healthcare provider.

Inhaled insulin is not approved for anyone younger than 18 and shouldn't be used by people who smoke or who have given up cigarettes within the past six months--though it's considered safe for people who live with smokers. It's not recommended for patients with asthma, bronchitis, emphysema, or any form of active lung disease. Baseline tests for lung function are recommended before starting treatment, after the first six months of treatment, and every year thereafter, even if no pulmonary symptoms such as lung or breathing problems exist.

According to the Food and Drug Administration, which recently approved Exubera, it has been extensively studied for safety. The manufacturer, Pfizer, has said it will continue to study the product over the long term to confirm that it is safe and effective. Several other companies are developing inhaled insulin, too.

Insulin pumps

An insulin pump is a small, computerized device that delivers insulin continuously throughout the day. It attempts to mimic the normal pancreas's release of insulin, but you must tell the pump how much insulin to inject. It delivers insulin in two ways: a basal rate, which is a continuous, small trickle of insulin that keeps blood glucose stable between meals and overnight, and a bolus rate, which is a much higher rate of insulin taken before eating to "cover" the food you plan to eat.

Effective, safe use of the pump requires a commitment to checking blood glucose at least four times a day, counting carbohydrates, and adjusting your insulin doses based on blood glucose levels, carbohydrate intake, and physical activity.

The main advantages of pump therapy are increased flexibility of lifestyle; predictable and precise insulin delivery; the ability to accurately deliver one tenth of a unit of insulin; tighter blood glucose control, while reducing the risk of low blood glucose; reducing episodes of severe hypoglycemia; reducing wide fluctuations in blood glucose, and helping manage the "dawn phenomenon" (the early-morning rise in blood glucose).

The main disadvantages of pump therapy are risk of skin infections at the catheter site; risk of diabetic ketoacidosis (DKA) from pump malfunction or absorption problems; the cost; and the need to check blood glucose at least four times per day.

Hints for storing and using insulin

To make sure your insulin is safe and effective:

• Store unopened bottles in the refrigerator and do not use after the expiration date. Don't freeze them.
• Store bottles you are using at room temperature (59 to 86 degrees Fahrenheit) for 28 to 30 days. The strength of the insulin may be altered after that.
• Avoid exposing the bottles to temperature extremes (less than 36 degrees Fahrenheit or more than 86 degrees Fahrenheit).
• Don't use regular insulin if it becomes cloudy in appearance.
• Don't use NPH if it becomes clumped or crystallized or if the bottle becomes frosted.
• Make sure that you recheck your dosage whenever you change insulin.
• Get guidance from your healthcare team before mixing insulins or prefilling syringes.

Weight gain

Taking insulin is often associated with weight gain, which can prompt people to cut back on their insulin intake. Causes for the weight gain include:

• People who have poorly controlled diabetes sometimes experience weight loss because their bodies are unable to properly convert food into energy. Taking insulin helps reverse that process and can result in a weight gain.
• When blood glucose runs high, you can become dehydrated as your body works to clear itself of all that excess glucose. Getting your blood glucose under better control may cause you to retain fluid.
• Once you start taking insulin injections, glucose in your blood can get into the body's cells and be used rather than remaining in your bloodstream and being excreted in your urine.
• High blood glucose may cause people to feel hungry and eat more, because not all the food taken in can be properly processed to nourish the cells. Frequently, eating patterns continue after insulin has been started and is allowing more-efficient use of nutrients.

Some people cut back on their insulin once they discover they can lose a few pounds quickly by doing so. But when they go back to using the right amount of insulin, they discover that they gain the weight back--and perhaps more--in equally rapid fashion. Manipulating insulin to lose weight is an unhealthy habit to get into. Letting your blood glucose run high can lead to long-term complications. Better to make careful adjustments in how much you eat.