Maya Antoinette AbouKhater
Paediatric Dietitian
June 2011
Aim for blood glucose level
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4 mmol/l or above.
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Readings before meals 4-7 mmol/l.
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Readings 2 hours after meals less than 9 mmol/l.
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Adjust insulin dose according to the trend in pre-prandial, bedtime and
night-time blood glucose measurements
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Measure blood glucose more than 4 times/day during intercurrent illness: ill or injured have short‐acting insulin or rapid‐acting insulin analogues and blood and/or urine ketone testing strips available for use even if you are not eating‐ Keep drinking, it’s important you don’t become dehydrated, this can include sugary drinks eg fruit juice, Lucozade, regular coke as well as sugar‐free drinks such as water
* Your personal targets may be different it may be helpful to write it down.
Aim for HBA1c levels
HbA1c New Hba1c result Average glucose What it means Below 7%
52 mmol/mol
6.5 - 7 mmol/l
Low risk of diabetes
complications, risk of
Hypos will be higher.
7%
53 mmol/mol
7.5 – 8.5 mmol/l
Fantastic! (if there are no
hypos)Blood glucose pattern
monitoring would be useful
8%
64 mmol/mol
10 mmol/l
Take some action to lower
9-10%
75 – 86 mmol/mol
11 - 14 mmol/l
Higher complications risk,
treatment needs improving
11 - 12%
97 – 108 mmol/mol
18 - 20 mmol/l
Very high risk, treatment
should be intensified now
Consider the impact of different insulin preparations on diet
Analogue Preparation
Onset Duration
Relation to Meal Time
15 minutes
2–5 hours
Given before eating but can
be given just after eating if
eating habits are erratic
(children under 5 years)
Short-acting
30–60 minutes
up to 8 hours
Given before eating
Intermediate-acting
1–2 hours
16-35 hours
patient should consider
eating a bedtime snack and
discuss timing of snacks
with diabetes care team
1–2 hours
> 24 hours
* patient should consider
eating a bedtime snack and
discuss timing of snacks
with diabetes care team
Rapid-acting
Long-acting
Consider Insulin to carbohydrate ratio
• Insulin to carbohydrate ratio=
depends on carbohydrate consumed using the 500 rule which is 500/total daily dose of insulin
• For example, 1 unit of mealtime insulin for every 10g of carbohydrate (CHO), or for younger children 1 unit of meal‐time insulin for every 12‐15g of CHO. My correction factor is x unit/s of insulin will bring my blood glucose levels down by 1mmol/L
• Calculate your total daily pump dose as above e.g. 30 units. Divide this into 100 e.g. 100 ÷ 30 = 3.3.  This means that 1 unit of insulin will reduce your blood glucose level by approx 3mmol/l
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Checking Your Insulin to Carbohydrate Ratio
If your insulin to CHO ratio is right for you, your blood glucose level
should be no more than 2mmol/l higher or lower than pre meal blood
glucose level two to four hours after eating. For example if your blood
glucose is 5.9 mmol/l before breakfast and is 7.8 mmol/l two hours
later, you are using the right ratio.
Have a look at these examples
Diet Sheet
Example 1
Andrea takes I unit for every 10g carbohydrate she eats. Here are her blood glucose readings over a couple of days
• Time • Blood glucose • Amount of Carbs
• Insulin for food
• Correction dose
• Comments
Andrea’s example
• Day 1
0730 7.2 45g 4.5 Normal day
1030 3.2 Felt hypo
1330 5.2 45g 4.5
1800 6.7 60g 6
2200 4 15g
• Day 2
0730 6.5 45g 4.5 Normal day
1030 3.0 Felt hypo
1330 6.2 40g 4
1800 7.1 70g 7
2200 4.1 20g
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What pattern have you identified?
Which options have you considered?
What changes would you make?
List of food that does not have carbohydrates
Carbohydrate free meals
‐ Plain meat eg chicken, beef, pork, ham, turkey, lamb, bacon etc
Without sauces, dressings, breadcrumbs
‐ Plain fish eg cod, haddock, tuna etc
Without sauces, dressings, breadcrumbs
‐ Scrambled egg (without milk)/ Omelette with mushrooms, ham, cheese
‐ Meat, egg or cheese salads (without dressings, sauces or
bread/croutons)
‐ No added sugar squashes, diet drinks
List of food that does have carbohydrates
• starchy food e.g potatoes, rice, pasta, noodles, bread breakfast cereals, chocolate, sweets, cakes, biscuits
• fruits • some dairy foods e.g milk yogurt
• Consider effects of low glycaemic index, fruit and vegetables, and types and amounts of fats
• fizzy drinks, fruit juices, squashes Consider
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Age
Weight
Height
Growth Chart/BMI
Pre existing knowledge of diabetes Cultural background
How does it feel to have diabetes
Wishes of child/young person
Impact social interaction
Consider •
problems associated with fasting •
problems associated with feasting
• Consider travel
–e.g. when best to eat and inject insulin when travelling across time zones
‐Don’t get scared if your diabetes isn’t as well controlled as normal while you’re travelling or on holiday – different food and running around more or less might make your blood glucose levels go up and down a bit.
‐not to order a diabetic meal for the plane as they don’t have enough carbohydrate in them so you might have a hypo.
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Consider effects of hot/cold climates
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Patients should have glucose or sucrose when they experience hypoglycaemia
Low Glycaemic Index Foods
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Milk chocolate Milk
3%+ fat Ice cream
Banana Fructose (fruit sugar) Yogurt
Orange
Soya
beans (dried) Lentils
green
Apple
Peanuts Kidney beans
Consider effects of exercise on glycaemic control
Encourage all form of exercise on a regular basis
Prevent exercise-induced hypoglycaemia by monitoring blood glucose levels before and
after exercise and making appropriate changes in insulin/food intake
–change in exercise may require insulin dose and/or carbohydrate intake to be altered
Monitor the glycaemic response to different exercise conditions
– if blood glucose levels are less than 7 mmol/litre before exercise additional
carbohydrate should be consumed
– if blood glucose levels are greater than 15 mmol/litre in the presence of ketosis. Do not
exercise as there will not be enough insulin to enable your muscles to use the sugar in
your body
Be aware that hypoglycaemia may occur several hours after prolonged exercise
What to eat before sport
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Easy energy activity Maybe you're just walking to your friend's house
around the corner - three minutes away. In this case, nothing special is
needed.
• Medium energy activity This could include a 30-minute swimming lesson
at school or an hour of dancing at a disco on holiday. Make sure you eat an
extra snack and have glucose nearby.
• High energy activity This might be something like a sponsored walk for
charity where you are walking for two hours. You will need to do a blood test
and eat an extra snack before starting. And make sure you carry extra
glucose in your bag.
• Tips:
 Take a blood test to check blood glucose before you start. If your blood
glucose is lower than usual – eat a snack before starting
 Don’t forget to eat and drink when you finished your activity
 Have an extra bed time snack if you have been very active during the day
There is no special diet for children or young people with diabetes. The food you eat should be based on healthy eating and is suitable for the whole family.
Eat regular meals and snacks All food will cause your blood glucose to rise but some foods do it quicker than others. The aim is to keep your blood glucose levels as steady as possible. If you do not normally have snacks you do not need to start having them (if you are on insulin twice a day speak with the diabetes team about snacks). Eat to your appetite.
• Include some starchy food or slow acting carbohydrate at each meal and snack, e.g. breakfast cereals, bread, potatoes, pasta, rice, crackers, fruit, milk
• Cut down on sugary foods Replace sugar and sugary foods and drinks with low sugar or sugar‐free alternatives. Choose no added sugar drinks, diet drinks or water. Very high sugar foods, e.g. sweets, will cause a quick rise in blood glucose. A small amount of sugar in foods will not cause a very quick rise in blood glucose, e.g. yoghurt, fromage frais, tinned/fresh fruit.
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No special diet
• Reduce your intake of fried foods and high fat foods
It is important you and your family eat a healthy balanced diet. It is best to bake, grill or microwave food rather than frying or roasting. Avoid foods such as pies, pastries, and fried snack foods.
• Do not use special diabetic food and drink products
These foods tend to be higher in fat and more expensive. They also contain a large amount of sweetener which can cause a laxative effect.
Suitable foods for snack time:
Fruit Twiglets
Tinned fruit
Cereal and milk
Teacakes
Crisps
Hot cross buns
Yoghurt/fromage frais
Plain biscuits e.g. Rich Tea, Mini cheddars
Bread sticks
Scones (plain/fruit)
Mini pitta
Digestive
Malt loaf
Know what to do if you are eating out
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Fast food... you can still have your favourite foods now you have diabetes. Fast
food (things like burgers and chips) aren’t very good for you if you have lots of
them, but it’s OK to have them sometimes.
• Fish and chips Take off some of that thick batter, and have chunky chips rather than french fries.
Or you could have a small portion or share a portion with a friend.
• Pizza Choose vegetable toppings rather than meat or extra cheese, and don’t go for the cheese stuffed crusts. Try new vegetables, or experiment with different toppings. Thin bases are better for you than thick ones, and try having a salad with it instead of garlic bread.
• Burgers Leave off the extra cheese and mayo, and have a salad with it rather than chips.
Save milkshakes for special occasions because they’ve got lots of fat and sugar in them.
• Chinese Choose plain rice or noodles because they’re better for you than fried rice. And go for stir‐fries or soups rather than spring rolls and prawn toasts – keep those for special occasions as they’re not so healthy.
• Indian
Go for tandoori or tikka dishes instead of deep fried things. And choose a biriani instead of korma or massala dishes, which have a lot of fat in them. And again, boiled or basmati rice is better for you than pilau or fried rice. Treating Hypoglycaemia
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Bring the blood glucose up quickly by eating or drinking one of the following which all contain about 10‐15gm of carbohydrate:
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Gluco juice 59mls = 15gms carbs
Lucozade 100mL
Ribena 200mL
Fruit juice 150‐200mL
Coke 150mL
Jelly babies 4
Jelly beans 8
Glucotabs 5 tabs
Dextro energy 7 tabs
Fruit pastilles 5
GlucoGel 2 tubes.
Potential Reasons for Low Blood Glucose Values
• Overestimating carbohydrates and giving too much insulin as a
bolus
• Giving large bolus with food (may be better to use a different
type of bolus)
• Slow digestion of food
• Basal rate too high (Long acting insulin)
• More activity than usual without setting a temporary basal rate
• Over correction for high blood glucose value
• Alcohol
• Stress causes hypos in some people
• Around time of menstrual cycle
Reasons for high blood glucose levels
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Increased insulin requirements
Infection
Illness
Stress
Inflammation at insertion site
Reduced exercise
Hormonal (pregnancy / menstruation)
Steroids
What to do with results
• _ If blood glucose stays within 2 mmol/l ‐ no change
• _ If blood glucose rises more than 2 mmol/l –
increase basal rate by 0.1u one to two hours before rise
• _ If blood glucose falls more than 2 mmol/l –
reduce basal rate by 0.1u one to two hours before fall
• _ Re‐ check by repeat fasting periods
Further support
There are several websites with useful information, including:
• www.diabetesuk.org.uk
• Croydon’s own site for families with children who have diabetes www.PCDC.co.uk
• www.childrenwithdiabetes.org
• www.runsweet.com
• Good book to read/buy: 'Type 1 diabetes in children, adolescents and young adults’ by Dr Ragnar Hanas