When you try to fix a problem pattern, do it one step at a time. If you change too many things at once, you will not know what is causing what! It is best to make one change at a time, wait for the result, then make another as needed. A good idea is to wait three days to see if a pattern forms.
1. When you cannot explain a low blood glucose level by too much insulin, inadequate food, or exercise, an insulin dose adjustment should be made before the next dose. Do not wait for a second low blood glucose level! Call your doctor
or health care team for help right away. Always be prepared for a low blood glucose reaction by having carbohydrates such as milk, soda, hard candies or glucose
tablets available.
2. If patternsof “lows” are occurring that can be explained by too much insulin, not enough food, skipping meals, or exercise, then try to change whatever the problem may be. (One high blood sugar, although not desirable, will happen occasionally but is not something you should worry about.)
3. If you do make changes to your insulin dose, do not do so by more than 10 percent of the dose4
unless you are advised to do so by your doctor. For example, if your usual dose is 10 units, you can safely make changes in 1 unit increments, so that you could take 9 units as needed. 4. Make the change that is easiest to do first. 5. If one type of adjustment doesn’t work,
try something else.
6. Always remember to call your diabetes educator, dietitian or doctor for help.
Practice Problems:
Stella’s Blood Sugars Are Usually High At Lunch: What Should She Do?
Pattern: When Stella noticed that she had a pattern
of high blood glucose readings at lunch, she thought about the different ways she could fix the problem.
Possible Adjustments:
Stella considered three possibilities. • Exercise after breakfast.
• Eat less breakfast or morning snack. • Take more insulin at breakfast.
Stella decided that her busy schedule did not give her enough time to exercise after breakfast. She thought that the breakfast she ate was adequate and didn’t
want to change it. But, she decided to omit the mid-morning snack that she sometimes had with her coffee, as she wasn’t really hungry anyway. However, her lunch blood glucose levels were still high even on the days when she didn’t eat a snack.
Solution: Stella decided that the easiest and best thing
to do would be to take more insulin at breakfast. She called her diabetes educator the first few times she made the adjustment, just to be sure she was
doing it correctly.
In the Following Examples See If You Can Recognize A Problem Pattern and Figure Out the Solution
Dave’s Blood Glucose Diary
Target Blood Glucose: Pre-meal: 90-130 mg/dl
Post-meal: Less than 180 mg/dl
Pattern: These blood glucose levels look excellent.
They are in the 90-130 mg/dl target range before meals and under the 180 target after meals.
Solution: No problem! No changes are necessary.
Breakfast Lunch Dinner
Pre Insulin Post Pre Insulin Post Pre Insulin Post
99 12 H 145 133 3 H 178 14 H 144
105 181 81 137 10 L 130
Marita’s Blood Glucose Diary
Target Blood Glucose: Pre-meal: 90-130 mg/dl
Post-meal: Less than 180 mg/dl
Pattern: Blood glucose levels are in target range before
breakfast and lunch and seem to be fine even after dinner. However, blood glucose 1 to 2 hours after breakfast and lunch are quite high.
Consider the Possible Causes:
• Too much food at breakfast and lunch. • Not enough insulin at breakfast and lunch.
(The amount of carbohydrate eaten is not well covered by insulin.)
Solution:
1. Cut the amount of carbohydrate eaten at breakfast and lunch. 2. Increase the Humalog®/Novolog®
insulin at breakfast and lunch
Marita decided to cut 15 g. of carbohydrate from breakfast as she was always in a rush and didn’t have time to enjoy it anyhow. She wanted to eat all of her lunch, however, so she added a unit on to her lunchtime Humalog® dose.
Breakfast Lunch Dinner
Pre Insulin Post Pre Insulin Post Pre Insulin Post
94 5 H 253 129 3 H 299 5 H 138
107 320 86 180 12 L 140
Bill’s Blood Glucose Diary
Target Blood Glucose: Pre-meal: 90-130 mg/dl
Post-meal: Less than 180 mg/dl
Pattern: The breakfast blood sugars are a bit higher
than desired for a 90 to130 target, lunch and dinner are okay, and bedtime numbers are too low.
Possible Causes:
1. Morning highs could be high because too much food is eaten at bedtime, or because more bedtime insulin is needed.
2. Bedtime low blood glucose readings could have several causes (not enough dinner eaten, too much insulin is given at dinner, or exercise after dinner).
Possible Solutions:
1. Reduce amount of bedtime snack or change types of foods.
2. Either eat more dinner or take less insulin. 3. Stop exercising after dinner.
Breakfast Lunch Dinner
Pre Insulin Post Pre Insulin Post Pre Insulin Post
180 10 H 98 5 H 178 10 H 96
156 103 87 15 L 68
201 89 125 70
Bill always took his dog for a long walk after dinner and decided that was the most likely reason that his blood glucose levels dropped in the evening. However, he did not want to give it up (neither did his dog) as he knew that the exercise was good for him. He decided to cut back his dinner insulin a bit. He discovered that when his blood glucose was normal at bedtime, he did not overeat. He realized that he had been “over- treating” his low blood sugars and that made the morning numbers high. Once he no longer had low blood glucose in the evening, his morning blood glucose fell into the target.
Kelly’s Blood Glucose Diary
Target Blood Glucose: Pre-meal: 90-130 mg/dl
Post-meal: Less than 180 mg/dl
Kelly is taking Lantus® insulin at bedtime with Humalog® to cover meals.
Breakfast Lunch Dinner
Pre Insulin Post Pre Insulin Post
(3pm) Pre Insulin Post
112 6 H 134 8 H 59 172 10 H 93
156 98 44 187 12 L 210
85 87 77 122 117
Pattern: Breakfast, lunch and bedtime numbers look generally okay. Although a few are above target, there is no pattern. However, blood glucoses
are generally too low at 3 PM.
Consider the Possible Causes:
1. Kelly isn’t eating enough at lunch.
2. She needs less insulin at lunch. 3. Kelly needs to cover her
afternoon exercise with food.
Solution: Kelly’s lunch was early, at 11AM.
As a schoolteacher, she was busy all day.
Therefore, although she thought that eating more lunch or taking less insulin at lunch time might help, she decided that instead of eating more at lunch time, she would eat some crackers around 2:30 PM, to avoid the mid-afternoon slump.
Keep Up the Good Work!
We hope that this introduction to Pattern Management has helped you understand how to identify problem patterns in your diabetes control and decide on possible ways of fixing the problem. Of course, if you cannot fix the problem yourself, it is most important to call your diabetes health professional for guidance. Do not make insulin adjustments without having learned how to do so or without your doctor’s permission. In time and with a little practice, Pattern Management can help put you on the path to good control.
Educational Information from BD Medical Diabetes Care. BD, BD Logo and Staying on Target are the property of
BD provides this brochure for informational purposes only. It is not intended to be a substitute for professional medical advice, diagnosis or treatment. Always seek the advice of you physician or other qualified healthcare provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read in this brochure.
Written by:
Kris Knutson, RN, BSN, CDE Joyce Malaskovitz, PhD, RN, CDE Margaret Riedl, RD, CDE
Las Vegas, NV
We wish to acknowledge the following health professionals for reviewing this publication and providing their valuable insights: Jean E. Betschart Roemer, CPNP, MSN, MN, CDE
Pittsburgh, PA
Linda Urso, APRN, BC-ADM Warren, MI
Kathleen C. Arnold, CS-ANP, BC-ADM, CDE Gulfport, MS
BD Medical Diabetes Care
1 Becton Drive
Franklin Lakes, NJ 07417-1883 1.888.BDCARES (232.2737)