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TARGET THERAPY
Staying on Target
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My Doctor Says:
“Pattern Management
Will Help Me...”
Taking Care of Your Diabetes
You check your blood glucose several times a day
and record them in a logbook. When you visit your
healthcare provider, he or she always asks to see your
logbook. What is he looking for and what does he find
in those records? Your doctor is looking for a pattern of
blood glucose numbers. For instance, your blood glucose
may be higher before lunch than the rest of the day.
He will then try to determine what may
be the cause of the high readings at lunch.
By looking at these “patterns“ your health
care provider will make changes to your
treatment plan. Looking at blood glucose
records and determining a treatment
plan based on those records is called
pattern management.
Pattern Management is a skill that you
can learn in order to manage your
diabetes. The following information
will help you learn about this important
method of diabetes care.
1
Insulin Dose Changes:
Changing your insulin dose may seem
difficult and confusing. Health care
professionals may ask you to make two
different kinds of changes: Correction
doses and pattern changes. If your
blood glucose before lunch is almost
always normal, but today it is high,
you may take 1 or 2 extra units of insulin to “correct”
the high reading. This is called a correction dose. This
is a temporary change in your dose. If your blood
glucose tomorrow before lunch is normal you will
not need a correction dose. In contrast, if your blood
glucose results before lunch are high for more than
3 days in a row, you will need to make a pattern change.
This is a permanent change in your insulin dose. Once
you have made a pattern change you continue to take
this dose of insulin until you see that it is no longer
keeping your blood glucose “in target” and you then
make another pattern change.
YOU Can Make a Big Difference
With some diseases you can take a pill, forget about it
and go about your daily routine. Diabetes is different.
When you have diabetes, you must take
a lot of responsibility for your treatment.
Studies have actually proved you can
prevent or delay eye, kidney, heart,
blood vessel, and nerve complications
2
of diabetes by 10 years or more just by keeping your
blood glucose levels as close to normal as possible!1
Taking the time and effort to learn how to care for
your diabetes can really help reward you with long-term
health and well-being. Your goal is to keep your blood
glucose as close to normal as possible. To do this you
should develop “Stay Healthy Goals.”
Your Stay-Healthy Goals
To take care of yourself, you will need to:
1. Develop healthier eating habits.
2. Stay at a healthy weight.
3. Get regular exercise.
4. Monitor your blood glucose (blood sugar).
5. Take medication such as insulin.
Skills You Will Need
To succeed at your stay-healthy goals you will learn to:
• Analyze the variables that affect your
glucose levels.
• Make changes to avoid glucose levels
that are too high or too low.
• Make decisions about exercise, meals,
and maybe even insulin doses.
• Keep most blood glucose levels in your
target range.
1
3
The Writing Team for the Diabetes Control and Complications Trial/Epidemiology
of Diabetes Interventions and Complications Research Group. Effect of Intensive
Therapy on the Microvascular Complications of Type 1 Diabetes Mellitus. JAMA,
287:19, pp. 2563-2569, 2002.
Pattern Management:
Your Key to Staying in Good Control
Be a Detective
People who are in good control of their diabetes learn
how to prevent frequent high and low blood glucose
levels. If you have diabetes, analyzing the patterns of
your blood glucose results that you have recorded over
a period of time can help prevent blood glucose levels
that are too high or too low. This method of diabetes
control is called “pattern management.” Detecting
certain patterns from your results can help you see
when and how to make changes in your daily routine.
Stay on Target
Your blood glucose target is the range of blood glucose
that you can safely achieve without having hypoglycemia
(low blood glucose). Your blood glucose reading should
fall into your target blood glucose range most of the time.
Using pattern management will help you to meet your
target blood glucose goals.
Learn the Alert Signals
Pattern management works best when you notice a
pattern showing that your blood glucose levels were out
of your target range over a period of time. Three days
is usually a good time period. You should not be making
pattern changes in response to just one or two readings.
This is your signal to stop and think about what may
have affected your blood glucose levels during that
specific time frame. Taking these steps will help you
understand the changes you can make to bring your
blood glucose levels to or near your target goal.
4
Your Tools for Pattern Management
Written Records:
Keep Them Daily
The first step in pattern management is writing down
your blood glucose levels in your logbook or recording
them with a data management software program on
your computer. There are meters
that can also record your readings.
The pattern of your blood glucose
readings shows you if the balance
of your insulin, food, and exercise
is working. If your blood glucose
levels are in your target range,
your balance is working well. But
if your numbers are too high, too low, or vary a great
deal you are not in balance. You need to consider what
is causing your blood glucose to be out of your target
range, and what you can do to improve them.
You will find that you will feel better overall when your
blood glucose is within your target range. To stay in
your range, you need to understand what happens
to your blood glucose levels when you take insulin,
exercise, eat or drink.
Variables:
5
Know What Makes Blood Glucose Go Up and Down
There are many different causes or events that can make
your blood glucose go too high or too low. These are
called “variables” and are the possible causes that
influence your blood glucose. With pattern management,
you will be looking for patterns of highs and/or lows
to help you know what kind of changes to make.
Some variables might be:
• How quickly your insulin is released or
absorbed into your blood stream.
• The way you body responds to physical activity.
• The effect of stress or illness on your
blood glucose.
• The amount and kind of food that you eat.
• How fast your food is digested and changed
into glucose in your stomach.
The best way for you to understand the effect of variables
on your blood glucose levels is to keep written records
using a logbook or a computer data management system.
Either way, it is important to show your records to your
health care provider. He or she can provide useful
information to guide changes in the variables that affect
your diabetes control, including medication, food intake
or exercise.
Variables That Can Change the Level of Your Blood Glucose
What Makes Blood Glucose Rise?
What Makes Blood Glucose Fall?
Foods or drink with carbohydrates
*Exercise
Stress
Insulin
Illness (cold, fever, flu or other infection)
Some oral medications
For more information about the relationship between
blood glucose and exercise, read the BD Getting Started™
brochure, My Doctor Says I Need to Exercise… which may be
found on-line at: www.bddiabetes.com/us/download/download.asp
*Blood glucose levels mostly drop during or after exercise. However, sometimes when
blood glucose is already high and your exercise is intense, blood glucose levels can rise.
6
Target Blood Glucose Goals:
What is Your Target?
Normal blood glucose levels are 70 to 120 mg/dl. If you
don’t already know your target blood glucose goals, ask
your Health Care Provider for assistance. Generally, it
is good to keep blood glucose levels as close to normal
as possible, but that is often hard to do without having
frequent or severe low blood glucose episodes. The
American Diabetes Association (ADA) recommends the
following targets as a starting point
for most people.
Recommended Target Blood Glucose Levels2
ADA Recommended Targets For Blood Glucose (Sugar) Control
In Non-Pregnant Individuals With Diabetes
Normal
Target
Before eating
Less than 100
90 to 130
2 hours after eating
Less than 130
Less than 180
A1C
Less than 6%
Less than 7%
Adapted from Standards of Medical Care in Diabetes Mellitus-2006,
Diabetes Care, Volume 29, Supplement 1, p. S10-11, January 2006.
2
7
Your Medications:
Learn How They Work
The Action of Insulin in People without Diabetes
In people who do not have diabetes, there is a perfect
balance of insulin in response to changes in blood glucose
levels. When they eat and their blood glucose rises,
their bodies automatically release the right amount of
insulin to keep their blood glucose in a normal range.
The Normal Action of Insulin
Glucose
(mg/dl)
Insulin
(µU/ml)
Breakfast
Lunch
Snack
Dinner
Figure 1: Represents 24-hour action of blood glucose and insulin action in a person
without diabetes.
The Body Normally Releases Insulin in Two Ways
Basal (background) insulin: This type of insulin is
released every few minutes in small amounts to maintain
a stable level of glucose in the blood. Basal insulin
keeps blood glucose levels stable between meals and
during the night.
Bolus (fast-acting) insulin: When you eat or drink, the
food is broken down into glucose and absorbed into the
blood stream. The pancreas releases a bolus (burst) of
insulin in response to the rapid rise in blood glucose
that occurs after a meal.
8
Injected Insulin Acts at Different Speeds
Intermediate and long-acting insulin: These are NPH,
Lantus® (insulin glargine), Levemir®
(insulin detemir) and are used to mimic
the basal (background) insulin action.
Rapid-acting and short-acting insulin:
This group includes Humalog® (insulin
lispro) Novolog® (insulin aspart),
Apidra® (insulin gluslisine) and/or the
short acting Regular insulin. These
are used to imitate the bolus
(burst) of insulin action that
acts to “cover” high blood
glucose levels that occur
after eating.
The Timing of Injected Insulin
Name of Insulin
Type of Insulin
Humalog®
Novolog®
Apidra®
Rapid
30 min. to
1.5 hours
5 hours
*Regular
Short
2 to 4 hours
6 hours
*NPH
Intermediate
4 to 12 hours 8 to 14 hours
Lantus®
Levemir®
Long
No peak
action
Peak Action
*Not commonly used in Flexible Insulin Therapy.
9
Effect on Blood Glucose
16 to 24 hours
Long-acting (basal) insulin
• NPH insulin peaks or works the hardest at 4 to 12
hours after they are taken. They will continue
to work for a total of 8 to14 hours.
• Levemir® (Insulin Detimir) is similar to Lantus®
(Insulin Glargine) and both work for a 24-hour
period of time with no peak.
Rapid-acting (bolus) insulin
• Humalog®, Novolog®, and Apidra® are rapid
acting insulins – used to cover the glucose
released from the food eaten or bring
down high blood glucose quickly.
• Regular insulin works a little slower
and is described as short acting.
The Action of Basal and Bolus Insulin at Meals and Bedtime
Figure 2: Represents the action of three injections of rapid acting insulin before
meals and one injection of Insulin Glargine or Detemir at bedtime.
10
How Do You Know Your Insulin is Working?
Your blood glucose readings reflect the action on insulin given earlier
in the day. When you take blood glucose readings at any given
time you are actually checking to see how well the last dose of
insulin worked. (See below.)
A Blood Glucose Reading Taken:
Matches Insulin Given Earlier:
Before Breakfast
Dinner or bedtime
background insulin
Before Lunch
Breakfast
Before Dinner
Lunch rapid or short-acting
insulin or breakfast NPH or
Levemir® insulin
Two Hours After Meals
Short or rapid acting insulin
before that meal
Before Bedtime
Dinner rapid or
short-acting insulin
3 AM
Dinner or bedtime NPH,
Lantus® or Levermir®
Ask your diabetes educator about
the insulin that you are taking and
how it works. For more information
about insulin action, read the BD
booklet, Staying on Target™: Your
Insulin Adjustment Workbook.
Yes, You Can Do It! It may
be found on-line at:
www.bddiabetes.com/us/down
load/download.asp
11
Your Plan for Eating
Did You Know That Everything
You Eat Affects Your Blood Glucose?
When you have diabetes you need to learn the impact
of foods on your blood glucose (remember that glucose
is another word for sugar). Over time, everything you
eat breaks down into glucose. This causes changes to
your blood glucose levels. To better understand this,
it is important to know that foods are classified into
three major categories: Carbohydrates, Proteins,
and Fats.
1. Carbohydrates (carbs)
come from plants (fruits,
vegetables, grains, cereal
products, and desserts).
Carbs convert 100 percent
into glucose, 1 to 2
hours after eating!
12
2. Proteins are from animals (beef, poultry, fish,
eggs, cheese) as well as some plants (tofu and
peanut butter). Proteins convert 50 to 60 percent
into glucose, 3 to 4 hours after eating.
3. Fats are foods that make everything taste
good (butter, margarine, oils, mayonnaise,
cream cheese). Fats convert 10 percent into
glucose, taking place gradually over six hours
after eating.
Amount of Time it Takes Nutrients to Convert to Blood Glucose
Figure 3: The speed at which the three nutrients convert to blood glucose.
13
‘Flexible’ Insulin Therapy
and the Food You Eat
Flexible insulin therapy provides
most people with diabetes with
a better match between their insulin and food. This
therapy is called “flexible” because it can help give you
more freedom and flexibility in your lifestyle. The key is
to learn how to bolus (give rapid or short-acting insulin)
before your meals in combination with basal (long-acting)
insulin at other times. Deciding on the correct bolus
dose you should take before meals will depend on the
amount of carb you have eaten.
Carbohydrate (Carb) Counting
Carbohydrate is the nutrient that
most affects your blood glucose.
It is important to remember that
100 percent of the carb you eat
appears in your bloodstream as
blood glucose within a few hours
after you have eaten! When you
use the carb counting method
of meal planning, you add up
all the carb that you eat for a
period of time.
14
Your Carb-to-Insulin Ratio
Once you know the amount of carb you have eaten in
a specific time frame, you can figure out the amount
of insulin that you will need to “cover” a specific amount
of carbohydrate. This is called your carb : insulin (carb-toinsulin) ratio. Knowing your ratio will help you decide
how much insulin you need to take to match the
amount of carbohydrate that you are planning to eat.
The carb : insulin ratio can be different for each meal.
Your carb : insulin ratio should help you
keep your blood glucose in its target
range after meals. Since the grams of
carb you have eaten determine the
amount of insulin to be given, you will
need to learn to weigh and measure
your foods – especially when you are
beginning to use this method. Reference
charts and nutrition labels will also help
you find out the grams of carbohydrate
in the food you eat.
Learn About Bolus Insulin Dosing
You will learn how to practice bolus insulin dosing by
writing down your blood glucose and your carb intake.
This will help your healthcare team develop the right
carb : insulin ratio for you. This ratio will tell you the
amount of rapid acting insulin (Humalog®, Novolog®,
Apidra®) you should take for a specific amount of carb
that you plan to eat. The example below shows how
a carb : insulin ratio is used.
15
Example:
Jane’s Breakfast Carb
Food
Grams of
Carbohydrate
1/2 cup branflakes
15
1 cup 2% milk
15
1/2 banana
15
1 slice toast
15
1 egg
0
TOTAL:
60 grams
Question:
Jane’s Carb : Insulin Ratio is 15:1.
She has eaten 60 grams of carbohydrate.
How much insulin should Jane take?
Answer:
Since 1 unit of insulin covers 15 grams of carbohydrate,
Jane should take 4 units of rapid acting insulin. She will
know that this ratio is working if she checks her blood
glucose two hours after the meal and finds that it is
within 20-40 mg/dl of her before-meal glucose level.
For more information about determining carb : insulin
ratios, read the BD booklet, Staying on Target™: Your
Insulin Adjustment Workbook. Yes, You Can Do It!
May be found on-line at: www.bddiabetes.com/us/
download/download.asp
16
Know Your Carb!
Once you know how to count carb you should also
be aware that the type of carb selected might impact
your blood glucose levels two hours after eating.
Here is how it works.
If your carbohydrate choices are:
• Refined or Processed Carb (white rice, mashed
potatoes, desserts, white flour grain products,
fruit juices, etc.) and if they are more then 10
percent of the total amount of carbohydrate
you have eaten, your blood glucose may rise
too quickly for your insulin dose to “match”
the glucose “rise.”
• High Fiber Carb (whole grains, brown rice,
potato with skin, soy protein, or whole fruits)
your blood glucose will rise more slowly.
When you choose high fiber foods
combined with protein and fat – and
spread food portions throughout the day
– this will usually result in better blood
glucose readings two hours after a meal.
Balance Your Total Nutrients
Carbohydrate has a dramatic effect
on your blood glucose levels, while
protein and fat play a minor role
in the rise of your blood glucose
levels after meals.
17
When you eat protein and fat in reasonable amounts
(3 to 6 ounces of protein and 1 to 3 servings of fat),
then your basal (background) insulin (NPH, Lantus®,
Levemir®) and your daily activity levels will usually
compensate for the glucose you get from these foods.
However, if you eat very large protein and fat portions,
your blood glucose may be within target range at
2 hours after your meal, but will be too high 4 to
6 hours after the meal.
Check your Ratio
To make sure that your insulin : carb ratio is correct, you
should check your blood glucose before meals and two
hours after meals. If your blood glucose rises 20-40
mg/dl after your meal compared to the reading before
the meal, then your insulin dose matched. However, if
your blood sugar is greater than 20-40 mg/dl, then your
insulin dose did not match your blood glucose. In this
case you might consider the following actions:
1. Decrease your total amount of carb.
2. Decrease the amount of refined
foods you eat.
3. Replace the refined foods with
high fiber food, or
4. Increase the amount of insulin
to match the amount of carb.
For more information about
carbohydrate counting and carb :
insulin ratios, read the booklet,
BD Staying on Target™, Carb
Counting: Eat to Win! May be
found on-line at: www.bddiabetes.com/
us/download/download.asp
18
Your Plan for Exercise
Did You Know That Your Physical Activity Affects
Your Blood Glucose?
Physical activity is important for everyone, but is especially
important for people with diabetes because it can help
lower your blood glucose. The best way to be physically
active is to stick to a regular routine and do something
you like. Even routine chores can be counted as physical
activity. Moving your muscles in any way is considered
physical activity. Make sure that you check with your
doctor before starting any exercise or physical activity
that is more than what you are doing now.
When You Are More Active Than Usual
When you increase the amount of exercise you are
getting, you may need to make some adjustments in
your food or schedule to prevent hypoglycemia (low
blood glucose). The cells in your muscles use glucose
at an increased rate with activity. Sometimes, blood
glucose levels can drop too low. The low blood glucose
can also happen hours after exercise or physical activity,
as there is a sustained increased uptake of glucose by
the muscles.
19
Regular physical activity helps to lower your blood
glucose because it helps insulin work better. This means
that when you are exercising, you may need to:
• Eat or drink more.
• Take less insulin.
If you are more active than usual, it is also wise to check
blood sugar levels at 3:00 AM to make sure that you are
not having a low blood glucose reaction at that time.
Protecting Against Low Blood Glucose
To prevent low blood glucose reactions
(hypoglycemia) during activity, make
sure that you have eaten enough
carbohydrate to balance the amount
of activity or exercise you plan to do.
Carb provides the glucose that your
muscles will need to use for energy.
20
When You Are Involved
in Unexpected Exercise
During unplanned physical activity, carb
replacement may be needed to prevent
low blood glucose when:
• Insulin adjustments
are not made
• Exercise occurs several
hours after a meal
• Exercise lasts for a long time
The amount of extra carb you will need depends on
the amount of time spent exercising related to your:
• Medication;
• Meal;
• Type, intensity and duration of exercise; and
• Pre-exercise glucose level.
Use the following guide to help decide how much
carb to eat before you exercise.
Carbohydrate Replacement During Exercise 3
Intensity of
Exercise
Duration
(minutes)
Carbohydrate
Replacement
Mild to
Moderate
< 30
May not be
needed
Moderate
30 to 60
15 grams
Each hour
High
60+
30 to 50 grams
Each hour
Frequency
Leborvitz, H.E., ed. Therapy for Diabetes Mellitus and Related Disorders. Fourth
Edition, American Diabetes Association. 2004, pp.154.
3
21
If you are watching your weight, it may be advisable
to decrease the amount of insulin you take before the
exercise or activity. Check with your health care provider.
Check Your Blood Glucose Levels
Before and After Activity
By doing so you will be able to see
how well your adjustment of insulin
or carb worked. Making note of your
pattern of glucose levels after your
adjustments can help guide your
future insulin doses and pre-activity
carb intake. Be sure to record your
blood glucose results, amount of
carb eaten, insulin dose and type
of activity in a logbook. It can
be very helpful to download
the memory feature
of your meter to
a computer
program for
this purpose.
22
Using Pattern Management
Step 1: Write down your blood glucose numbers
over a period of days.
Use columns according to time of day and
relationship to meals or snacks.
Step 2: Look at the numbers for general patterns.
Note the time of day (before breakfast,
before lunch, before dinner and at bedtime).
Step 3: Identify readings above or below
your target levels.
Use a highlighter pen to clearly
mark out-of-target readings.
Step 4: Once you have identified the
pattern, decide which variables
may have caused readings
outside your targets.
Step 5: Making sure you only adjust one
variable at a time, take the following actions:
• Change the amount or timing of the
carb eaten.
• Increase or decrease the length of time
or day that you exercise.
• Adjust the dose of insulin or the time
the insulin is given.
Step 6: If the insulin dose needs to be adjusted,
decide which insulin needs to be changed.
23
To help you with this decision,
please scroll back to the section
entitled “Injected Insulin Acts
at Different Speeds” and check
the chart called “The Timing
of Injected Insulin” that lists
Names of Insulin, Types, Peak
Action and Effect on Blood
Glucose. Your next step is to consult your healthcare
team members (physician and certified diabetes educator).
They will assist you and answer questions as you learn
to do this. It is important to understand why your
doctor or diabetes educator recommends the changes.
After you analyze a few of your records in this way,
you may be comfortable making insulin changes on
your own.
Practice Example:
Sam’s blood glucose patterns:
Sam’s Three-Day Blood Glucose Diary
Target Blood Glucose: 90-130 mg/dl
Breakfast
Lunch
Dinner
Bedtime
Before Insulin After Before Insulin After Before Insulin After
Insulin
158
8H
215
4H
117
6H
78
15 L
173
8H
226
4H
135
6H
63
15 L
142
8H
262
4H
102
6H
84
15 L
24
Did you notice these patterns?
1. Before-breakfast numbers are somewhat high
2. Before-lunch numbers are very high
3. Before-dinner numbers are in the target range
4. Bedtime readings are low
Breakfast:
Why are Sam’s breakfast numbers high?
Sam needs to think backwards. What
did he eat the night before? Did he
have a snack before he went to bed?
Was it larger than usual? What time did
he eat dinner? Did he eat more or less
carbs than usual? Eating a larger snack
at night or a larger meal with more carbs or later in
the evening will increase the blood glucose level in the
morning. Sam should consider the following changes:
1. Eating his snack or meal earlier in the evening.
2. Eating fewer carbs at the evening meal
or snack.
3. Plan to exercise in the evening, this will help
the blood glucose remain low overnight.
Lunch:
What could be making Sam’s blood glucose the highest
before lunch? It could be that if he improves his lunch
numbers, which are the highest of the day, the rest of
the day will improve automatically.
1. Sam is not getting enough rapid acting insulin
(such as Humalog®) before breakfast, or
25
2. He is eating too much high-carbohydrate,
high-fat foods for his breakfast.
Sam should consider the following actions:
1. Take more Humalog® at breakfast or
2. Eat less breakfast, or less
carbohydrate at breakfast, or
3. Exercise in the morning
to help to correct the
blood glucose level.
Dinner:
Sam’s dinner numbers are in his target range,
so no changes are necessary!
Bedtime:
Sam’s bedtime numbers are low, so he may
need changes. He should consider:
1. Less Humalog® at dinner, or
2. More carbohydrate, or protein at dinner
3. Or perhaps a snack before evening exercise to
prevent a low blood glucose level at bedtime.
Remember: You must consider all the variables before
you make a decision about the action you should take.
26
Balancing Your Variables
To better control your blood
glucose levels, it is best to
maintain a regular schedule of
daily meal and exercise times.
If there are many variables that
change on a daily basis, such as food, meal times, insulin
doses, and/or type and duration of exercise, it will take
more time to get all these factors balanced. Once you
understand how each variable affects your blood glucose,
you will be able to vary each, one at a time, to achieve
more flexibility in your lifestyle.
Preventing Low Blood Glucose Before it Happens:
When you are having patterns of low blood glucose,
try to prevent them before they happen. Some people
are able to easily recognize and treat low blood glucose
and do not think it is a problem. However, if you often
have low blood glucose at certain times of the day or
night, you are at risk for having a more severe low
blood glucose that may be more difficult to treat.
Be Aware of High Blood Glucose Levels
On the other hand, it is also very common to have
a high blood glucose level sometime after a low
one because:
1. Your body makes hormones to counteract
the low blood glucose.
2. Most people have a tendency to “over-treat”
a low blood glucose because they feel
uncomfortable.
27
Troubleshooting your Blood Glucose
Questions to Ask Yourself When You
See Patterns Of Low Blood Glucose:
1. Have I been too busy
to check my blood glucose
before meals so that I am
not sure if I am taking
the right amount
of insulin?
2. Have I been
taking too
much insulin?
3. Have I been eating
less than usual?
4. Am I eating different types of foods?
5. Are meals being skipped or delayed?
6. Do I have a new activity, or has my
activity increased?
A YES answer to any one of the
questions above could cause low
blood glucose.
28
Questions to Ask Yourself When You See Patterns
Of High Blood Glucose:
1. Have I forgotten to check my blood
glucose before meals so that I am
not sure if I am taking the right
amount of insulin?
2. Have I been taking
my insulin on time
and in the right
amount?
3. Have I been eating
more then usual?
4. Have I been eating extra
snacks or sweets?
5. Has my physical activity been
less than usual?
6. Do I have a cold, infection or illness?
7. Am I having more stress in my life?
A “yes” answer to any one of the questions above could
cause high blood glucose. A combination of any of the
events listed could cause high or low blood glucose.
29
Pattern Management Guidelines
for Making Adjustments
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 patterns of “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.)
30
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
4
31
Childs, B, Cypress, M., Spollett, G, editors, Complete Nurse’s Guide
to Diabetes Care. American Diabetes Association, pp. 41-42, 2005.
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
Breakfast
Lunch
Pre
Insulin Post
Pre
99
12 H
145
133
105
181
110
166
Dinner
Insulin Post
3H
Pre
Insulin Post
178
14 H
144
81
137
10 L
130
111
166
135
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.
32
Marita’s Blood Glucose Diary
Target Blood Glucose:
Pre-meal: 90-130 mg/dl
Post-meal: Less than 180 mg/dl
Breakfast
Pre
94
Lunch
Insulin Post
5H
Pre
253
129
107
320
102
290
Dinner
Insulin Post
3H
Pre
Insulin Post
299
5H
138
86
180
12 L
140
115
203
130
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.
33
Bill’s Blood Glucose Diary
Target Blood Glucose:
Pre-meal: 90-130 mg/dl
Post-meal: Less than 180 mg/dl
Breakfast
Pre
Insulin
180
10 H
Lunch
Post
Pre
Insulin
98
5H
Dinner
Post
Pre
Insulin
Post
178
10 H
96
15 L
68
156
103
87
201
89
125
70
144
148
99
57
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.
34
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 “overtreating” 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
Breakfast
Pre
Insulin
112
6H
Lunch
Post
Dinner
Pre
Insulin
Post
(3pm)
Pre
Insulin
Post
134
8H
59
172
10 H
93
12 L
210
156
98
44
187
85
87
77
122
117
144
151
82
101
138
Kelly is taking Lantus® insulin at bedtime with Humalog®
to cover meals.
35
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.
36
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 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.
BD Medical Diabetes Care
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Franklin Lakes, NJ 07417-1883
1.888.BDCARES (232.2737)
www.BDDiabetes.com
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