Starting mealtime insulin
This booklet is designed for people with type 2 diabetes who are moving from a basal insulin regimen to a mealtime insulin regimen. A mealtime insulin regimen may include an insulin mixture or the addition of rapidacting insulin to basal insulin. The insulin regimens discussed in this booklet refer to analogue insulins only. 02
Personal details Name: Contact details: Diabetes Healthcare Professional (HCP) name: Contact details: Emergency contact name: Emergency contact no: Appointments: Date Time Who (e.g. doctor, podiatrist, dietitian) Notes: 03
In this booklet 05 05 05 06 10 06 07 08 09 10 13 19 13 15 19 21 2618 21 22 23 24 25 26 27 32 27 Your Guide Your guide to understanding mealtime insulin Your Body Diabetes is a progressive condition Why do you need mealtime insulin? Why start mealtime insulin? Why is testing important? Discovery sheet Your Options What are my mealtime insulin options? Insulin mixtures Basal (long-acting) + rapid-acting insulin Your Questions How much mealtime insulin should you take? Monitoring diabetes control after changing your insulin Injection sites What is a hypo and why does it happen? How do you treat hypoglycaemia? How to prevent hypoglycaemia Frequently Asked Questions FAQs 04
Your Guide Your guide to understanding mealtime insulin We understand how daunting starting mealtime insulin may be and we want to help you understand what mealtime insulin is and the options that are available to you. Use this guide along with the advice from your diabetes team to help you make the move to mealtime insulin. 05
Your Body Diabetes is a progressive condition Is it my fault that my diabetes has progressed? It s not your fault. Unfortunately, type 2 diabetes is a progressive condition. This means that over time, your pancreas makes less and less insulin. Your body may also not be able to properly use the insulin that it does make. As a result, your blood glucose levels are no longer controlled by your current medication. Moving to mealtime insulin won t happen overnight. It s a process that takes time. What s important to remember is that you re not alone. There are people and resources out there to help you along the way. 06
Why do you need mealtime insulin? Your basal (long-acting insulin) covers your blood glucose (sugar) levels between meals and at night. When you eat, your blood glucose levels rise. As your pancreas produces less and less insulin and your body can no longer properly use the insulin it has, the basal (longacting) insulin is no longer enough to manage this. Insulin profile for someone without Diabetes Basal insulin profile BREAKFAST LUNCH DINNER 07
Why start mealtime insulin? Mealtime insulin is taken when you eat and this will help to lower your blood glucose to your individual target. It requires you to add injections and possibly increase the number of blood glucose tests each day. Your management plan will be individually developed to meet your needs and lifestyle. 08
I have so many thoughts and feelings flying around inside me. How can I begin to make sense of them all? Why is testing important? Always record your blood glucose levels in your diary. It s a convenient way to record when you tested, what you ate and what your blood glucose levels were at that time. Use the discovery sheet on the next page to record your blood glucose and what you eat in a regular week. You can then share this with your diabetes team and this may help you with your decisions when starting mealtime insulin. 09
Discovery Sheet One-off monitoring sheet to be filled out by you and discussed with your HCP. Blood glucose before breakfast Breakfast foods eaten Blood glucose 1 2 hrs after breakfast Blood glucose before lunch Lunch foods eaten Blood glucose 1 2 hrs after lunch Example 8.5 Scrambled eggs on 2 slices of toast 8.7 Chicken, salad and 3 small new potatoes.1 orange 7.9 Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 10
Record blood glucose monitoring and food eaten. Plus any other comments, e.g. hypo and hyperglycaemia symptoms. Blood glucose before evening meal Evening meal foods eaten Blood glucose 1 2 hrs after evening meal Blood glucose before bedtime Snacks Exercise and general comments 6.1 Prawn curry with rice 16.5 9.1 2 chocolate digestives 15-minute walk in the evening 11
I ve been feeling down for months now and I feel tired most of the time. I ve done everything I ve been told to do, so why should I take even more injections? Will I ever be able to eat out in restaurants again? I don t want to inject in front of my friends I feel like people judge me for having diabetes Mealtime 2Moving Your Options 12
Your Options What are my mealtime insulin options? When choosing which mealtime insulin is right for you, there are a number of options. Use the information in this booklet and advice from your diabetes team to make the best decision for you and your needs. 13
I m feeling nervous that mealtime insulin will disrupt my life. I m uncomfortable about injecting at work Ok, I m feeling more like I can do this now. It s nice to know I m not on my own, but who can I turn to in case I need support? Mealtime 2Moving Your Options 14
Twice daily insulin mixture Insulin mixtures contain both basal (intermediate) insulin and rapid-acting (mealtime) insulin. There are different types which may be injected two times a day. Pros: One insulin and one insulin pen Two injections Simplicity: inject and eat Covers breakfast and evening meal Cons: Lack of flexibility Regular meals, timing and quantity of carbohydrate at each meal Insulin profile for someone without Diabetes Twice daily insulin mixtures profile BREAKFAST LUNCH DINNER 15
I feel a bit overwhelmed by mealtime insulin; I need to know how it works and how to use it. What if I give myself the wrong dose? It s hard at first but each day gets a little bit easier I want to feel better, but it s so difficult to make a change Mealtime 2Moving Your Options 16
Three times daily insulin mixtures Insulin mixtures contain both basal (intermediate) insulin and rapid-acting (mealtime) insulin. There are different types which may be injected three times a day. Pros: One insulin and one insulin pen Three injections Simplicity: inject and eat Covers breakfast, lunch and evening meal Cons: Lack of flexibility Regular meals, timing and quantity of carbohydrate at each meal Insulin profile for someone without Diabetes Three times daily insulin mixtures profile BREAKFAST LUNCH DINNER 17
I was worried at first about adding more injections, but now it has become a way of life and I feel much better for it I get frustrated with my diabetes sometimes, it feels like my whole world has been turned upside down! Mealtime 2Moving Your Options 18
Basal (long-acting) + rapid-acting insulin Basal (long-acting) insulin is injected once or twice a day and helps to lower your blood glucose in between meals. Rapid-acting insulin is usually injected shortly before meals or when necessary can be given soon after. This is to cover the rise in your blood glucose level from from that meal. This usually starts with the largest meal of the day although you may need to add further injections, depending on your specific needs. This helps to lower your blood glucose after meals. Pros: Flexibility to have irregular meal times and quantities of carbohydrate Inject and eat Cons: Two insulin pens with different insulins Often requires more injections (four to five) Requires self titration and carbohydrate counting Insulin profile for someone without Diabetes Rapid-acting insulin profile Basal insulin profile BREAKFAST LUNCH DINNER 19
Mealtime insulin scares me. I don t think I can deal with it I m starting to feel like I might be able to do this, but who or where can I turn to if I m looking for support? Mealtime 2Moving Your Options 20
Your Questions How much mealtime insulin should you take? When and how much mealtime insulin you take is based on a variety of factors and will be determined based on your individual needs such as: What foods you eat and how much carbohydrate they contain Activity levels e.g. amount of exercise or a hectic lifestyle Your average blood glucose levels You should discuss your individual requirements with your HCP. 21
Monitoring diabetes control after changing your insulin When and how often you test is based on your specific situation, your other medications, and how many insulin injections you take. You may need to test more often when you first start mealtime insulin to get a better understanding of how your body responds. You may also need to test more frequently if you drive. Regular blood glucose testing is an important part of managing your diabetes. Checking your blood glucose levels: Shows if you are within your individual target levels Helps determine if your dose needs to be adjusted Helps you avoid hypoglycaemia. It s nice to know I have choices, I m ready to start taking control of my diabetes 22
Injection sites There are many areas on your body where you can inject. It s important to rotate within the area of the injection site and not to overuse any one site. I want to feel more healthy and be there for my family. I think mealtime insulin will help me be able to do this 23
What is a hypo and why does it happen? A blood glucose reading of less than 4mmol/L is hypoglycaemia (a hypo). This occurs when blood glucose falls too low. People feel different things when a hypo is starting. You may find that some of your hypos feel different from others. A hypo can happen for a number of reasons: If you ve missed a meal or had one later than usual If you ve not had enough food or eaten less food than normal If you ve had too much insulin or more tablets than necessary If you ve been more active than usual If you ve been drinking alcohol If you ve experienced extremes in temperature, either hot or cold Occasional hypos are a normal part of life for people with diabetes, but they shouldn t take over your life. If you are having frequent hypos, speak to your diabetes team. 24
How do you treat hypoglycaemia? Hypoglycaemia can be serious, but it is manageable. If you feel like your blood glucose (sugar) might be low, test your blood. If your reading is less than 4mmol/L, eat or drink approximately 15g of sugar, such as: Half a glass (150 200mL) of pure fruit juice e.g. orange 90 120mL of original Lucozade 5 7 Dextrosol tablets (or 4 5 Glucotabs ) 3 4 heaped teaspoons of sugar dissolved in water If you start to feel better after 10 15 minutes or so, have some longer-acting carbohydrate such as two biscuits, one slice of bread/toast or a 200 300mL glass of milk (not soya). This will help to make sure your blood glucose doesn t go down again. If you don t start to feel better after 10 15 minutes, take more sugar or quick acting carbohydrate up to three times. If your blood glucose does not rise above 4mmol/L after taking a quick acting carbohydrate three times, please contact your HCP. 25
How to prevent hypoglycaemia There are a number of things you can do to help prevent hypoglycaemia. Discuss some of the following suggestions with your diabetes team: Increase your carbohydrates or reduce your insulin dose before exercise Monitor your blood glucose more often Make sure you take your medication at the right time Eat regular healthy meals and snacks Take care to rotate your injection sites to prevent the formation of fatty tissue which could cause variability in insulin absorption. Getting my blood glucose levels in control will help me to manage the symptoms of my diabetes 26
Frequently Asked Questions 1Is it my fault that my diabetes has progressed? No, unfortunately type 2 diabetes is a progressive disease and while there are things you can do to slow the progression such as healthy eating and staying active it does naturally get worse over time. So, try not to be too hard on yourself. What does my mealtime insulin do? 2 After we eat, our blood glucose (sugar) levels naturally rise. Because your diabetes has progressed, you re now at a point where your pancreas isn t making enough insulin, or your body can t properly use the insulin it does make. So, your body isn t able to manage the raised blood glucose levels that happen after meals. Mealtime insulin regimens include a fast-acting insulin that works by quickly lowering your blood glucose levels after you eat. Sometimes my diabetes makes 3me feel scared, depressed, and even angry. Is this normal? Absolutely. It s common for many people with diabetes to go through several emotional stages before finally coming to terms with their disease. After all, there are a lot of issues surrounding mealtime insulin that might make you feel scared, overwhelmed, or frustrated. Speak to your diabetes team to find out ways to address these feelings. 27
Will I have to inject insulin outside of my home? Say, at work or in a 4restaurant? It s normal to feel uncomfortable about injecting outside of your home. You might be scared that people will judge you, or you might not like the idea of being so open about your disease. Take it slowly. For example, inject in private until you re comfortable with giving yourself mealtime insulin. You may then want to try injecting in front of people you trust, like family or friends. How am I going to fit all these insulin injections into 5my day-to-day life? Remember that your diabetes team will work closely with you when you re ready to start a mealtime insulin regimen. They ll help you get used to the new routine. Also, adding mealtime insulin to your life doesn t put an end to the flexibility you ve had in the past. There are insulin pens that are portable and don t require refrigeration after first use you can take them just about anywhere and inject your insulin discreetly. How will I know what dose 6of mealtime insulin to give myself? Your diabetes team will work closely with you when you start mealtime insulin. They ll decide with you things such as your insulin dose, when to inject, and when and how often to test your blood glucose (sugar) levels. They ll also teach you where and how to inject. Remember that your diabetes team is there to help you move to a mealtime insulin regimen. So don t ever hesitate to ask them questions. 28
Are there 7different types of insulin? Yes. There is both long-acting (basal) insulin and fast-acting (mealtime) insulin. Long-acting insulin helps lower blood glucose (sugar) in between meals, and fast-acting insulin helps lower blood glucose after meals. There are also insulin mixtures available that contain both longer-acting (intermediate) and fast-acting insulin. I m worried that adding mealtime insulin to my regimen will make me gain weight. What 8can I do about it? Insulin treatment and weight gain do often go hand in hand. It doesn t mean, however, that everyone who uses mealtime insulin will gain weight. What s more, there are things you can do to help prevent insulin-related weight gain. Try to continue to make healthier food choices and incorporate some physical activity into your routine. Experts suggest 30 minutes/day most days of the week of moderately intense physical activity such as fast-paced walking, swimming or cycling. Be sure to speak to your diabetes team to see if these exercises are safe for you. How do I know if my mealtime insulin dose will need to be adjusted? When and 9how often do I take mealtime insulin? Your insulin dose may change throughout your life. But remember that your diabetes team will work with you and help you learn how to do this yourself. Your diabetes team will determine if adjustments need to be made to your insulin dose based on your blood glucose (sugar) results. That s why it s so important to keep track of your blood glucose levels carefully. In most cases, you ll review your blood glucose records to your diabetes team on a regular basis. From your records, they can see how you re doing and whether or not any dosing adjustments need to be made. 29
10 How do I inject mealtime insulin? Your diabetes team should go over how to inject correctly and further instructions should also come with your insulin pen. Possible injection sites are shown on page 23 of this booklet. Why do I have to test my blood glucose regularly? 11 Blood glucose (sugar) testing is very important for people with diabetes. Keeping a record will help your healthcare provider to see how well your diabetes is being managed, and whether or not any adjustments need to be made to your insulin dose. If you re driving by car, remember to check your blood glucose regularly. Check it before you leave, and again every 2 hours during your journey. Your blood glucose targets will be tailored specifically to you. do I know what blood glucose levels to aim for? 12How The recommended average blood glucose level for someone with Type 2 diabetes is between 4-7mmol/l (before meals) and >8.5mmol/l (2 hours after meals). However, it is important to note that this is individual to each person and may vary slightly, the target levels must be agreed between the person and their diabetes team. 30
What happens if I get sick? Even if you do get sick and can t eat, you ll still need your insulin. It s important to work with your diabetes team to establish a sick day plan. Also, make sure you continue to check your blood glucose (sugar) regularly, at least four times a day. Below are a few other tips if you get sick: Do not stop taking your insulin If you re considering using a cold or flu remedy, check with a pharmacist for a sugar-free product. Many cough syrups contain sugar Drink lots of extra sugar-free fluids or water. Try to avoid coffee, tea and soft drinks If you are vomiting or unable to eat your usual foods, you should maintain your fluid intake with sugar-free fluids to prevent dehydration and replace usual meals with fluids containing some carbohydrate Any illness is difficult to manage with diabetes. It is good advice to contact your diabetes team for individual guidance Always check urine or blood for ketones (they can make you sick) 13 If you have moderate or high ketones and high blood glucose levels this is a good indication you may need more insulin If high blood glucose and ketones lead to vomiting and dehydration, you may require hospital admission. You must contact your diabetes team 31
How do I treat low blood glucose (sugar)? 14 this Sometimes people with diabetes get low blood glucose, or hypoglycaemia. If you have hypoglycaemia, you might feel shaky, light-headed, nauseous, nervous, irritable, anxious, confused or unable to concentrate, hungry, sweaty, weak or drowsy. You may also have a fast heart rate, a headache, or experience numbness or tingling in your tongue or lips. If you know or think you have hypoglycaemia, eat or drink approximately 15g of sugar, such as: Half a glass (150 200mL) of pure fruit juice e.g. orange 90 120mL of original Lucozade 5 7 Dextrosol tablets (or 4 5 Glucotabs ) 3 4 heaped teaspoons of sugar dissolved in water If you start to feel better after 10 15 minutes or so, have some longer-acting carbohydrate such as two biscuits, one slice of bread/toast or a 200 300mL glass of milk (not soya). This will help to make sure your blood glucose doesn t go down again. If you don t start to feel better after 10 15 minutes, take more sugar or quick acting carbohydrate up to three times. If your blood glucose does not rise above 4mmol/L after taking a quick acting carbohydrate three times, please contact your HCP. For more information on hypoglycaemia, see pages 24 26 of booklet. 32
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Additional Lilly diabetes materials Please ask your diabetes team for any of the following additional Lilly diabetes leaflets: Diabetes and pregnancy Gestational diabetes Your eyes Looking after your feet Insulin Travel Tablets for diabetes What to expect from a consultation Type 1 diabetes Type 2 diabetes Impact on sexual health Hypoglycaemia ( Hypos ) Complications Illness Driving and employment Blood testing Healthy living Sharing responsibility Many Lilly diabetes leaflets can be found in a number of languages online at www.lillydiabetes.co.uk Further information is available from: Customer Care Eli Lilly and Company Limited Lilly House Priestley Road Basingstoke Hampshire RG24 9NL Tel: (01256) 315000 Provided as a service for patient care UKDBT00378a January 2013