Frequently Asked Questions

1. Why are my blood sugars higher in the morning than when I went to bed?

2. Why does my blood glucose go up and down like a toilet seat?

3. Do I need to wear a medical alert?

4. How do I adjust my insulin?

5. What is the difference between type 1 and type 2 diabetes (and what if I don't fit either group)?

6. If I have type 2 diabetes why would I have to take insulin injections? And now that I'm taking insulin does that mean I now have type 1 diabetes?

7. I don't have kidney disease or high blood pressure, but should I take an ACE inhibitor (like ramipril) anyhow?

8. I eat a low fat diet, so why is my cholesterol level still high?

9. Why are my blood sugars getting worse even thought I'm working so hard to keep them down?

10. When will there be a cure for diabetes?

11. What is the likelihood that I (or my child) will get diabetes?

12. Is A1C (Hemoglobin A1C) the same thing as blood sugar level?

13. Does it matter where I inject my insulin?

1. Why are my blood sugars higher in the morning than when I went to bed the night before?

This can occur for several reasons:

The Dawn Phenomenon: This is the usual cause and is due to the rise of certain hormones (such as adrenaline, growth hormone and cortisol) overnight. These hormones cause the liver to release glucose into the blood stream (often beginning about three a.m.). Some people call this a 'liver leak.' How much sugar (glucose) gets released from the liver you ask (well; I asked anyhow)? How about this: Almost as much as is contained in TWO CANS OF COLA!

Rebounding: If your blood sugar goes too low in the middle of the night your liver may recognize this and compensate by pouring out sugar. Sometimes it doesn't know when to shut off and continues to release sugar-even well after the blood glucose level is back to normal.  I suspect that this is over-diagnosed and likely doesn't occur very often.

Insulin Wane: If you are on bedtime or suppertime insulin with NPH then it could be wearing off as the night progresses. Too little insulin at night...too high blood sugar in the morning.

2. Why does my blood glucose go up and down like a toilet seat?

This is much more likely to be a problem if you have type 1 (rather than type 2) diabetes. There can be many possible explanations including variable rates of food absorption/digestion, variable levels of stress hormones (such as adrenaline), what time of your menstrual cycle you are at (ah, this applies only to females), whether you injected your insulin into areas of scar tissue or fat buildup (lipohyertrophy), if you have (undiagnosed/untreated celiac disease), and so forth, however, likely the most common reason is that insulin absorption can vary quite a bit. Indeed, even if you give the same insulin dose into the same area of your body, the actual peak insulin level in the blood can vary by up to forty percent! So what may be a ten unit dose of insulin you've just given, can, in fact, have the effect of an eight unit dose one time and a twelve unit dose another. As I see it, the question shouldn't be 'why does my blood sugar vary so much?' It should be 'why doesn't it vary EVEN MORE!' Erratic insulin absorption is more likely to be a problem for older insulins such as NPH and regular compared to newer insulins such as Humalog, NovoRapid, Lantus or Levemir. (See the answer to FAQ number 13 for more info related to this topic)

3. Do I need to wear a medical alert?

If you are on insulin I consider this a must (assuming your job allows you to safely wear it; if not, then at least wear it when you are not at work). I have seen more than one patient who was about to be arrested for impaired driving only to be spared this and treated for an insulin reaction when the police officer noticed the medical alert bracelet. If you are on pills ("oral hypoglycemic agents") for your diabetes then a medical alert is generally only necessary if you have had problems with low blood sugar. Some people are worried about being stigmatized by wearing a medical alert and that is understandable. Nonetheless some medical alerts are very discrete yet effective when the situation demands it.

4. How do I adjust my insulin?

If you are going to have the best possible blood glucose control, it is essential that you learn how to adjust your insulin dose. Insulin is perhaps unique among prescribed drugs in that it is strongly recommended that you NOT take it in a fixed, specific amount. Quite the opposite, in fact. Insulin levels in a person without diabetes vary day-to-day, moment-to-moment. Insulin therapy tries to mimic what the pancreas does. So, it follows that you too should adjust your insulin frequently-at times for every single dose. Because there are so many different factors involved (food selection, exercise, time of day, stress levels, etc.) this can seem a daunting task, but it is in fact very "do-able." The trick is to "think like a pancreas."

There are two keys to success. One is to be taught by a diabetes educator (and STAYING IN TOUCH) with her/him. And two is to follow the general rule of thumb that the insulin dose should be adjusted PRO-ACTIVELY, not retroactively. That is, in general, give your dose of insulin based on what you expect your sugar to be later (typically after your meal, before your next meal and at bedtime).

I'll give an example. Let's say your blood glucose levels (mmol/L-multiply this by eighteen for U.S. units of measure) and insulin doses for the preceding few days have been averaging as follows:

Most people would look at this and say "the breakfast sugar level is too high (target sugar being, let's say, 4-7) so I need more insulin at breakfast." But that is being retroactive (i.e., responding to what has already happened). Better to say, "sure, I need a bit more insulin this morning, but what can I do today so that my sugar level isn't high again tomorrow?" And the answer is found by thinking about which insulin impacts on what reading. It is the insulin that precedes the next measurement. In this case, it is the bedtime (NPH) insulin that impacts on the morning ("fasting") readings and hence you would need more insulin at bedtime (in this case, it would be appropriate to increase the bedtime dose to 12 units and see how things are the next morning).
 
Many people tell me that they do not need to keep a log book, "because my meter has a memory." True enough. It does. BUT, if you don't keep a log book then unless you have an absolutely prodigious memory, you are not going to have the maximal potential to recognize trends and patterns in your readings. An up-to-date log book stares you in the face. It reveals the patterns. It gives you the clues as to what changes to make, be they dietary, insulin or otherwise. A log book is not meant to simply be a historical record. It is an interactive tool to assist you in deciding how much insulin to give every time you are due for an injection. Otherwise it is no better than entering data into a computer every day and never running the software to analyze it. Basically, just a waste of time. (Click here for an illustration of how I feel a glucose/insulin log book should be organized).

I will give you another example. Let's say your blood glucose levels and insulin doses for the preceding few days have been averaging as follows:

This would indicate that your dinner-time readings are too high and what you need is more insulin at lunch-time. Going up to 6 units for your lunch-time injection would be appropriate. Remember; be pro-active.

The flip-side to all this is that if you are having low readings at a certain time of day, then you may well need to reduce the insulin that precedes those readings. For example, if you are running into problems with blood glucose measurements in the two's between supper and bed-time you likely need a lower dose of supper-time insulin.

In general, until you become very comfortable/familiar with insulin adjustment, plan on making changes of no greater than one or two units every day or two. First concentrate on getting your breakfast readings good by adjusting your bedtime insulin, then work on your meal-time insulin doses. Starting the day off with a good reading is crucial. How goes the breakfast reading, so goes the rest of the day.

One other thing-and a potentially very important thing at that-is the concept of "carbohydrate counting" wherein you adjust your meal-time insulin dose based on the amount of "carbs" you are about to consume. The idea is that a certain amount of carbohydrates is likely to raise your blood sugar level by a predictable amount and thus, you can take an amount of insulin to prevent this rise from occurring. Carbohydrate counting is essential if you are using an insulin pump and is often of major value if you are taking injections of rapid-acting (Humalog, NovoRapid, Apidra) or regular insulin before meals. Speak to your diabetes educator to see if this is a good technique for you.

Also see my discussion about intensive insulin therapy. Remember to read my disclaimer.

5. What is the difference between type 1 and type 2 diabetes (and what if don't fit either group)?

Typically people with type 1 diabetes develop it when young (often as children, adolescents or teenagers), are found to be very ill at the time of diagnosis and require immediate institution of insulin. Typically type 2 diabetes develops in middle to older age groups, in individuals who are overweight, comes on gradually and can be managed without insulin. However with quite some regularity there are people who don't fit into either of these groups; individuals in their twenties or thirties (or forties) who are not overweight, who can be managed for a time on lifestyle therapy and pills ("oral hypoglycemic agents"), but eventually require insulin. Such individuals, though fitting more an age profile of type 2 diabetes, nonetheless have pancreatic antibodies such as we see in type 1 diabetes and, eventually have a failure of insulin production. This condition is called LADA (Latent Auto-immune Diabetes in Adults), Slowly Progressive Diabetes (SPIDDM) or type 1 1/2 diabetes (though I should add that some people consider type 1 1/2 diabetes to be a somewhat different-though related-condition, but hey, let's not complicate an already complicated issue). "Borderline diabetes" does not exist. (Just like one cannot be "borderline pregnant." You either is or you ain't). More information on LADA. Sometimes in order to distinguish type 1 from type 2 diabetes we do a test called a C-peptide level which can reveal the presence (seen with DM 2 or LADA) or absence (seen with DM 1) of insulin production by the pancreas, but this test is generally neither necessary nor helpful in making management decisions. If you are a physician and receive the Canadian Journal of CME, on pages 31-32 of the April, 2002 issue, I discuss LADA in greater detail as I answer the question: "How do you treat a newly diagnosed 40-year-old slim person with diabetes?" (a clue...it all depends).

6. If I have type 2 diabetes, why would I have to take insulin injections?  And now that I'm taking insulin injections, does that mean I now have type 1 diabetes?

If you have type 2 diabetes, your pancreas is gradually losing its ability to produce insulin. Often, as time passes, your pancreas simply can't make enough insulin to keep up with your body's needs and all the pills in the world won't be sufficient to keep your blood glucose levels in check.  When that happens, insulin injections become a necessity.  If you have type 2 diabetes and are on insulin therapy you still have type 2, not type 1 diabetes.

7. I don't have kidney disease or high blood pressure, but should I take an ACE inhibitor (like ramipril) anyhow?

I'll hedge on this one and say "maybe." If you are older than fifty-five, there is excellent evidence for their use as a routine measure (if you have some other risk factor for heart disease such as high cholesterol or smoking). For other age groups the current medical literature is less conclusive but still is increasingly compelling. More information.

8. I eat a low fat diet, so why is my cholesterol level still high?

Yet another example of the injustice that people with diabetes have to face! Although you may be doing all the right things, one thing that you cannot control is your genetic makeup. It may well be that you have been genetically programmed from the time that you were conceived to have a liver that manufactures too much cholesterol. Few people realize that most of the cholesterol in our bodies, we make ourselves. And it is for this reason that lifestyle measures are often insufficient to get cholesterol levels down to an optimal range; hence the reason why cholesterol-lowering medication is frequently required. Indeed, for most people with high cholesterol, dietary therapy will reduce your cholesterol levels by only about ten to, at most, twenty percent.

9. Why are my blood sugars getting worse even though I'm working so hard to keep them down?

As patients of mine often say: "Doctor, I'm SO FRUSTRATED. I've been doing everything you've asked. I'm taking my pills, I'm working hard with my diet (look, I won't lie to you; sure sometimes I cheat, but usually I eat what I'm supposed to), but my sugars are getting worse and worse. When you started me on the pills they came down, but now I can't even get them to stay under ten. What in the world am I doing wrong?"

This is one of the easiest and, at the same time, one of the hardest questions for me to answer. Not because the answer is complex. Rather, the difficulty is that I'm afraid you may not like what I have to say. Oh well, you asked (or clicked as the case may be) so... The short answer is that YOU ARE DOING NOTHING WRONG. Sure, you don't follow a perfect diet. So what; who does? You probably are "pretty careful" and you know what, I can't ask you to do more than that. Sure you don't exercise as much as you should. But you work all day and by the time evening comes exercise is the last thing you want to do. Or the kids need help with their homework. Or the charity bingo needs you to help out or your arthritis is acting up or ... These aren't "excuses." These are real life. Besides - and this is the part you may not want to hear - even if you followed a perfect lifestyle, if you've had diabetes long enough, the sad fact is that diabetes tends to progress. This was demonstrated all too well in a landmark study called the UKPDS. Have a look at this graph. You can see from the graph that the longer you have had diabetes the less insulin your pancreas is able to produce. And this happens despite your (and my) best efforts. But that does not mean we have to be passive or fatalistic about it. All it really means is that we have to continue to be aggressive in managing your diabetes to counter this tendency. Which in turn may mean more pills or insulin (or more insulin if you're already on insulin). You can rule your diabetes. It may not be easy, but it can be done! And incidentally, don't use the word "cheating" when you're talking about your diet. This isn't a school exam. Let's just say that occasionally you are "liberal" with your diet.

10. When will there be a cure for diabetes?

I simply don't know the answer to this question.  I can tell you that we are much further ahead in our quest to find a cure than we were only a few short years ago, but a cure may still be frustratingly distant. There are, however, thousands of researchers hunting for a cure and there will be one found; it's not a matter of if, it's a matter of when.  But 'when' can never be soon enough.

11. What is the likelihood that I (or my child) will get diabetes?

This is not so straightforward a question as it sounds. The answer would be easy if we had no control over our destiny, BUT we do know from recent research that if we make appropriate changes in our lives (that's high falutin' talk for saying if we eat properly, exercise regularly and achieve/maintain a proper weight) we CAN greatly improve our chances of not getting diabetes-at least of the type 2 variety. For the sake of simplicity, I have drafted a table which can serve as a rough guide. Click here to proceed to the table.

12. Is A1C (Hemoglobin A1C) the same thing as blood sugar level?

One of the most important tests in assessing your overall blood glucose control is your A1C level. It is a crucial test and one that should be done every 3 to 6 months. Unfortunately, it is also one of the least understood tests. An A1C of 7, for example, is NOT the same as saying your blood sugar is 7. I discuss the A1C test in more detail here.

13. Does is matter where I inject my insulin?

I'll make this answer simple. The answer is YES. Now, I'll make it a bit more complicated. The answer is YES and NO. Confused? Sorry. Well, basically it's like this. For most people with type 2 diabetes on an insulin like 30/70, where you inject makes little difference. On the other hand, if you have type 1 diabetes and are taking regular insulin then the site that you use can markedly affect your blood glucose levels.  It does so because different areas of the body absorb regular insulin at different rates.  This is illustrated in the following table (as published in the diabetes journal, Diabetes Care):

As you can see, what this means is that if you give regular insulin into your abdomen it will get absorbed a lot faster than if you inject it into your arms or legs. As a general rule this gives better glucose control since the peak action of the insulin will better match with the rise in sugar after a meal. What you may also have figured out is that if you change your injection site every time you give yourself an injection, you will be having a very different effect each time. I'd suggest you speak to your diabetes educator or physician to find out what kind of injection site/rotation strategy would be best for you.

Newer, mealtime insulins (Humalog, NovoRapid, Apidra) are not nearly so influenced by where you inject as is regular insulin.