Type II Diabetes - now on insulin

dansingrn · Mar 23, 2008

The current dietary advice for those with type 2 diabetes is to maintain a healthy, balanced diet, limiting simple carbohydrates. We no longer tell patients that they can't have any "sugar." Eliminating carb containing beverages such as soda and fruit juices is important. All forms of carbohydrate, simple or complex, raise blood glucose levels. Carbs are important for growth, development, and proper metabolism, so they are not eliminated altogether. We do encourage healthy, complex carbs such as whole grains, beans/legumes,low-fat dairy, and whole fruits while limiting simple carbs. Portion control is a very important aspect of dietary advice for those with type 2 diabetes, especially when indulging in a treat.

As far as the insulin goes...you most often see a basal/bolus regimen. This means a long acting insulin given once daily (Lantus or Levemir) and a rapid acting insulin given with meals/snacks (Humalog, Novolog, Apidra). The rapid insulins are dosed using an insulin to carb ratio, so the dose varies with the carb content of the meal. For example, if the meal contains 60 grams of carb, if the ratio is 1 unit for 15 grams, the dose is 4 units. If the ratio is 1 unit for 10 grams, the dose is 6 units. The ratio is determined by comparing a pre-meal blood glucose level with a 2 hour post meal blood glucose level. The goal is to get the post meal level to be (usually) within 30-50 points of the premeal level. If a patient is eating "at will" between meals, it is difficult to accurately assess the action of the premeal insulin.

The fasting glucose level in the morning determines how well the long acting insulin has been dosed.

It is important to remember that it is carbohydrate in general, not just "chocolate and cookies" that are raising blood glucose. So the patient shouldn't be eating any carbs between meals while determining the dose, be it candy, bread, mashed potatoes, cereal, etc.

The length of the hospitalization will vary according to the patient, and often hospitalization isn't required. The reason is that in the hospital their food, activity levels, etc., are different than they are at home, and the dose may change again as soon as they assume their usual routines at home. Weight loss and activity greatly affect insulin sensitivity in those with type 2 diabetes, so the ratios and long acting insulin doses may very well change as children grow, change weight, change activities, etc.

Hope that helps!

classicdame, MSN, EdD · Mar 24, 2008

As a diabetic and nurse I can tell you the real secret to contolling BS is to have a routine diet/medication. The scenario you described might teach the patient to just "take more insulin if you want to eat more". That is not appropriate and can cause many problems. Preferably, the diet, exercise and medication regimen should be mutually effective.

UKPedsRN · Mar 24, 2008

The reason I posed the question is that my mum was hospitalised two weeks ago and ended up in ICU, after a virus led to dehydration and acute renal failure due to long term use of metformin. Now that she is on a medical ward I was highly surpised to find her eating cookies and chocolate whilst she is being transitioned onto insulin. When her blood sugar was 315, no one was concerned except me. When I spoke to the nurse I was told that she could have anything in moderation. I pointed out that her recent blood sugar was 315, and was told "thats because we are trying to fiqure out her insulin levels! When I made my feelings clear, she did not want to hear - hence I thought my own knowledge of diabetic teaching was wrong - hence my question.

Thank you both for your responses

nightmare, RN · Mar 24, 2008

I'm not on insulin,but the only sure way of keeping down blood sugars is to watch the carbs!I manage to keep mine down to about 5.7(102) just by carb counting and that definitely does not include cookies and chocolate(OK ,sometimes:saint:)I know a lot of type two's who follow the same regime.This ,of course,is not hospital based.I don't know what the hospital protocols are at the moment for introducing insulin.

classicdame, MSN, EdD · Mar 27, 2008

315 is not appropriate for a hospitalized patient. She will never be in control at home if she does not learn how to eat while in the hospital. You are right. Push this question up the totem pole - or whatever you call the chain of command.

markEmark · Sep 28, 2008

i know that type two can be controlled by diet and exercise alone. i didnt know that insulin is given to diabetics (type 2) now... is this practiced in the Us?

blondy2061h, MSN, RN · Sep 30, 2008

i know that type two can be controlled by diet and exercise alone. i didnt know that insulin is given to diabetics (type 2) now... is this practiced in the Us?

Not all type 2 diabetics can control their glucose on diet and exercise alone. There's different progressions of the condition and different circumstances surrounding everyone's situation.

ex1140 · Oct 3, 2008

Not all type 2 diabetics can control their glucose on diet and exercise alone. There's different progressions of the condition and different circumstances surrounding everyone's situation.

True...some people simply need to lose weight and practice better eating habits and they will get lower A1c levels in no time. While others are genetically predisposed to the disease.

blondy2061h, MSN, RN · Oct 9, 2008

True...some people simply need to lose weight and practice better eating habits and they will get lower A1c levels in no time. While others are genetically predisposed to the disease.

It's thought that most type 2's have lost 50% of their pancreas's ability to make insulin by the time of diagnosis. Fast forward a few years and it's not unreasonable to expect some of them to be truly insulin-dependent.

Bicycleboy · Oct 21, 2008

I was at a diabetes conference the other day where Dr. Geremi Bolli was speaking and there were some interesting ideas about DM2 and insulin. The information went like this:

Start someone on insulin and metformin as soon as the are Dx'ed with DM2. The reason being is that the insulin allows the beta cells to rest and the metformin reduces the amount of glucose released from the liver, as well as increasing insulin sensitivity. This reduces the gluco-toxicity on the beta cells. Research has shown that DM2 goes into remission after intense therapy and stays that way for a year on a majority of cases.

Sulfonylureas make the problem worse by overworking the pancreas leading to cellular apoptosis sooner than if they were not used. Early treatment can induce remission but the remission does not last as long as insulin therapy.

Another part of the message was to avoid premixes and NPH. Studies of radiolabeled NPH have shown that the variability in absorption ranged from 30% to 100% because of its insolubility. The premixes also fail to have the peak of rapid acting insulins, in effect they can cause more inter-prandial hypo events.

dansingrn · Oct 22, 2008

Couldn't agree more. At our diabetes center, the T2DMs get metformin and a basal/bolus insulin regimen (Lantus and Humalog or Novolog). They usually can wean down on the the insulin quite a bit after a short period of time.

We never use premix or NPH! We also don't hesitate to start insulin on a type 2. In the peds population where I work, type 2 kids present much like type 1, often in full-blown DKA, in the PICU, etc. It sometimes isn't obvious if they are T1 or T2 at first, so of course they must have insulin. When labs are back, if it looks more like T2 and if they appear insulin resistant, we start the metformin. As the glucose toxicity resolves and the metformin is gradually increased, the insulin doses decrease.