Diabetes Forecast

Diabetes Basics: Tuning Up Your Skills

Take this true-or-false quiz to see what you know

By Tracey Neithercott with Erika Gebel, PhD ,

As any sympathetic diabetes educator will tell you, things aren't always black and white when it comes to diabetes management. Sure, there are practice guidelines and recommendations for ideal care, but people are imperfect and sometimes life throws you for a loop. Which is why many educators have realistic expectations.

In fact, after getting the skinny on eight oft-repeated self-care tenets, you may be surprised at how flexible diabetes management really is. Plus, you'll take away some basic knowledge you may have forgotten since you were diagnosed. And experts say everyone could use a refresher now and again. "Medications change. Recommendations change," says Dawn Sherr, RD, CDE, a diabetes educator with the American Association of Diabetes Educators. "It's always good to brush up … every few years."

① True or False?
"The exchange lists for diabetes is the best meal plan."

Truth: Carb counting is more precise, and the plate method is easier.

Tip #1

Get familiar with portion sizes by using measuring cups while eating at home.

In the past, most people with diabetes followed the exchange system meal plan. Here's how it works: Nutritionally similar foods are grouped into categories—carbohydrate, fat, and protein—and then into subcategories such as meat, fruit, and starches. Each food on a given subcategory list is interchangeable with the rest, so you could exchange a half cup of corn with eight animal crackers or a quarter of a bagel. You can eat "free foods," which have 5 grams of carb or fewer and are under 20 calories, as often as you like without worry.

Though there's little math involved in the exchange system (compared with carb counting), educators don't often recommend it. "I can't remember the last time I thought of the exchange system," says Janet Zappe, RN, MS, CDE, a nurse and diabetes educator at the Diabetes Research Center at the Ohio State University Wexner Medical Center. That's because carbohydrate counting allows for more precise insulin dosing and the plate method is even easier to understand than the exchange system. The plate method allows one quarter of a 9-inch plate for lean protein, one quarter for grains or starches, one half for nonstarchy vegetables, and a serving each of fruit and lean dairy on the side. Plus, both give people with diabetes more freedom in their meal planning than the exchange system does.

Does that mean you should drop the practice if it's working for you? Not necessarily. "It's important to understand that the plan you're on is specific to you, and yours might be entirely different [from someone else's]," says Amber Wilhoit, RD, LDN, CDE, CPT, a registered dietitian and diabetes educator with the University of Florida Diabetes Center of Excellence. That said, you may want to talk to a diabetes educator or registered dietitian about whether a different meal plan may be more effective for you.

② True or False?
"When carb counting, always deduct half of a food's fiber content from the total carbohydrate amount."
Truth: Some people who use advanced carb counting may find the practice useful, but it's not necessary.

Tip #2
People using rapid-acting insulin may want to take sugar alcohols into account, too: Divide any sugar alcohols in half, then deduct that number from your total carb count.

There's a saying in the diabetes world that "your mileage may vary." When it comes to carb counting, the adage is especially true. Some people with diabetes manage their blood glucose by fine-tuning their carb counting, such as by using an insulin-to-carb ratio or taking into account fat or fiber in a food.

If you use advanced carb counting, you may deduct half the amount of fiber from the total number of carb grams, as long as a product has 5 or more grams of fiber per serving. So for a product with 25 grams of carbohydrate and 8 grams of fiber, you'd count 21 grams of carbohydrate. For people not on insulin or those who are less exact with carbohydrate counting, using the total grams of carbohydrate is completely fine.

Tip #3

When treating a low, skip sweets with chocolate and nuts. Because of the fat in the candy, it can take longer for your blood glucose to rise.

③ True or False?
"Have a snack after treating hypoglycemia."
Truth: Eat or drink 15 grams of carbohydrate when low, wait 15 minutes, then check blood glucose, and treat again if needed.

It used to be that hypoglycemia required two remedies: fast-acting glucose and a small snack. After eating 15 grams of carbs, people whose blood glucose was too low would have a snack with about 30 grams of carb—such as fruit or crackers with peanut butter.

But the practice is mostly a relic, says Wilhoit. Instead, focus on the "rule of 15": If your blood glucose is 70 mg/dl or below, treat with 15 grams of fast-acting carbohydrate, such as glucose tablets, juice, or sugary soda. Wait 15 minutes, and then test your blood glucose again. If it's still too low, treat with another 15 grams of carb. Repeat the process until your glucose level is within a safe range. Continue to monitor blood glucose if it's a long time until your next meal or you engage in physical activity.

There's a reason diabetes educators prefer the rule of 15: Many people see hypoglycemia as their cue to eat whatever they want. "People don't realize that the fat [in many snacks] can slow down the rise in blood sugar after a hypoglycemic event," says Wilhoit. "That, and eating too much, [can cause] your blood sugar to go from 50 to 400." And, finally, those calories can add up.

Tip #4
Each time you replace your pen needle, prime your pen: Click to 2 units and flush out the air inside the pen. Skip this step and you'll risk injecting less insulin than you require. The air, however, won't reach the brain and cause a stroke, as some fear.

④ True or False?
"Never reuse lancets."
Truth: If you're going to reuse, be sure to change your lancet once daily.

In a perfect world, everyone would use a brand spankin' new lancet each time they checked their blood glucose. Real life is a bit messier than that. People sometimes use the same lancet again and again because, well, it's easier. Plus, it saves money.

Reusing a lancet is OK for people who are generally healthy (people with pneumonia, kidney disease, cancer, and similar conditions should use each lancet only once), provided they wash their hands beforehand. "If you're doing pre- and postmeal [testing], you can use the same lancet for that," says Wilhoit. "After about four hours, the bacteria can grow and proliferate." Zappe agrees that most people can reuse a lancet, but she says it needs to be changed at least once daily.

What's more, the longer you use the same lancet, the blunter it becomes, which translates to added pain for you.

Tip #5
Don't wipe syringe and pen needles with alcohol swabs if you reuse them. Doing so can remove some of the coating that makes injecting less painful.

⑤ True or False?
"Always use an alcohol wipe before testing your blood sugar."
Truth: Soap and water are enough.

The need to swab alcohol onto a finger before checking blood glucose is more of a historic fact than today's reality. In the early days of blood glucose testing, nurses would use alcohol on hospitalized patients before testing in order to prevent infections, mostly because patients couldn't easily step aside to wash their hands, Zappe says. The practice stuck, even when people began using meters at home.

The added step isn't necessary, provided you use soap and water to wash your hands before testing. Aside from lessening your chance of infection, hand washing makes for more accurate readings. Residue such as sugar, fruit juice, and even some lotions can impact a reading.

If you're unable to wash your hands, using an alcohol swab is a good alternative. But keep in mind: Even alcohol and hand-sanitizing products can affect your reading. Alcohol can thin the blood, so if you don't allow it to dry fully before you test, you may get an inaccurate reading. And Zappe says some alcohol-based hand sanitizers, most often the scented ones, can result in an incorrectly high reading.

Tip #6
Tiny bits of food and sugar on your hands can seriously skew meter readings, so be sure to wash up before each test.

⑥ True or False?
"Run a control test every time you open a box of test strips."
Truth: It's OK to do a control test just when you suspect a problem.

The Food and Drug Administration recommends checking your meter regularly with control solution, the sweet liquid that delivers a glucose reading within a certain range if the meter and strips are working properly. Package inserts for meters may offer more specifics. For example, Roche recommends performing a control test every time "you open a new box of test strips, you left the test strip container open or you think the test strips have been damaged, the test strips were stored in extreme temperatures and/or humidity, you want to check the meter and test strips, you dropped the meter, your test result does not match how you feel, or you want to check if you are testing correctly."

Using control solution with each new vial is a lot of testing. "I believe it to be a waste of money," says Jane Seley, DNP, MPH, BC-ADM, CDE, a nurse practitioner at New York-Presbyterian Hospital. "Save it for a rainy day. If you think your meter isn't working properly, then crack open that bottle and run that test."

Then there's the question of proper testing procedure. Some meters say to drop the control solution on the test strip while others direct users to place a drop on a surface, such as the top of the control solution's cap, and bring the test strip to the drop. The difference is important, as some test strips are designed to suck solution in through a side window, making dropping the solution on the window tricky. The best course is to "follow the directions on the package," says Daniel Lorber, MD, FACP, CDE, an endocrinologist at New York Hospital Queens. "If people have questions, we suggest they bring their meters into the office." That way, you and your provider can figure out what the problem is together.

Tip #7
If your syringe or pen needle is less than 5 mm long, you don't need to pinch your skin to inject.

⑦ True or False?
"If your glucose is too high at a meal, bring it down with a dose of insulin according to a sliding-scale chart."
Truth: Sliding scales are out of date. But you can use a "correction factor" recommended by your provider for this purpose.

Use of sliding-scale insulin—a chart with information on how much insulin to dose for a given blood glucose level range—started in hospitals as an easy way for doctors to dose insulin at mealtime based solely on the current glucose levels and not on what the patient was about to eat. When people asked their doctors how to treat highs on their own, some were given a sliding-scale chart, bringing this flawed practice home, says Lorber.

The problem: Insulin doesn't work backwards. "Don't think about insulin as a medication that lowers high sugars," Lorber says. "Think about it as a medication that keeps blood glucose from going up." Plus, the sliding scale doesn't take food into account, which can lead to low blood glucose levels if too much insulin is given for the amount of carbohydrate in a meal.

The gold standard these days is basal-bolus insulin therapy, a personalized regimen that uses long-acting insulin (the basal dose or doses) and mealtime insulin (the bolus doses). The long-acting dose is adjusted based primarily on fasting and premeal blood glucose monitoring results, while the mealtime dose is calculated to cover the number of carbohydrate grams in a meal. Testing about two hours after the first bite can tell you if your insulin-to-carb ratio needs to be adjusted in the future.

But what if blood glucose is high at mealtime? Some doctors recommend a "correction factor." It lays out how much insulin to add to a mealtime dose to bring blood glucose down. Correction doses shouldn't be given based on an after-meal blood glucose level, though. That risks stacking up insulin, causing lows.

The same correction factor won't work for all. "I start people with guidelines [for the correction factor]," says Lorber, "but then tell people to adjust them according to their own body." If large correction doses are often needed, talk to your doctor about how best to prevent highs.

Tip #8
To reduce the pain of finger sticks, prick the side of your finger instead of the pad.

⑧ True or False?
"Always test on your fingers."
Truth: Alternate-site testing is a good option for less-painful checks when blood glucose levels are stable.

Don't expose test strips to extreme temperatures, moisture, or direct sunlight, which can damage them.

You probably learned to check your blood glucose on your finger—it's the most common testing spot. That doesn't mean you have to do finger sticks forever. Many meters today allow for what is called "alternate-site testing," meaning you can prick your arm, hand, or leg instead. Pricking those areas of the body may be less painful.

But note: Readings from an alternate test site will tell you what your blood glucose was 15 to 30 minutes ago. For times when your blood glucose is or may be changing rapidly—say, after eating, when you have symptoms of a low, or after treating hypoglycemia—it's safest to test from
the finger.



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