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Six principles of managing type 1 diabetes (Part 1/2)

Written by: Dr David Cavan
Edited by: Nicholas Howley

If you have type 1 diabetes, you will know just how difficult it can be to get under control.

It takes a lot of effort – several injections every day, regular checks of your glucose level, keeping tabs on what you eat – and even if you do all that is required, sometimes the diabetes just takes on a life of its own and throws a spanner in the works.

Sometimes this just causes a bit of inconvenience, like having to manage a high glucose level; sometimes however, you can experience a really bad hypo, for what might seem like no reason at all.

Type 1 diabetes results from an immune attack on the beta cells that produce insulin. That means a person with type 1 diabetes lacks the hormone insulin.

Unlike type 2 diabetes, type 1 diabetes is not a condition related to unhealthy lifestyles, obesity or excess liver fat causing problems with insulin resistance. A person just diagnosed with type 1 diabetes is usually young, fit and healthy, but with a pancreas that no longer produces insulin.

So, the theory of treating type 1 diabetes is relatively simple - to replace the missing insulin, just as those whose thyroid gland no longer works have to take tablets to replace the missing thyroid hormone.

However, while the theory is relatively simple, the practice is very complex. It is because it is so complex, that I have published a book to help people with type 1 diabetes put the theory into practice.

My book, Take Control of Type 1 Diabetes, aims to provide you with all the information you need to ensure you are in the driving seat of managing your diabetes, rather than it managing you. In the book, I introduce six principles that underpin successful management of type 1 diabetes. In this article, I will introduce the first three principles.


Think like a pancreas

The pancreas normally secretes a low amount of insulin continuously (called basal insulin) and then produces rapid spikes or boluses of insulin when glucose levels rise, for example after eating a meal. Replacing insulin to mimic a fully working pancreas therefore requires what is known as a ‘basal bolus regimen’, to reflect the two types of normal insulin secretion.

The basal insulin is the background insulin that is injected every day (usually once or twice daily), regardless of any food eaten. It is important to establish the correct dose of basal insulin that will keep your blood glucose levels stable (if no food is eaten), so that it does the same as your pancreas would do if it were working normally. I see so many people who are on the wrong dose of basal insulin, that often means they are at risk of having hypos during the night

The bolus insulin is the insulin that is injected before each meal. It is important that you adjust the dose of each bolus according to the carbohydrate content of the meal to be taken, your anticipated activity level and your current blood glucose level.

In the past, most people took the same dose with each meal, regardless of how much carbohydrate they eat. Unfortunately too many people are still on fixed doses, which means that they are at risk of their glucose level going too high or too low within hours of each injection.

One of the best-known books that promotes the principle of flexible insulin dosing is called Think Like a Pancreas by Gary Scheiner. And ‘thinking like a pancreas’ is a good place to start, by using a combination of basal and bolus insulin every day, and crucially, by ensuring that each injection is at the correct dose.


Aim for normal blood glucose levels

Insulin does many useful things in the body but as far as type 1 diabetes is concerned, the most important is to keep the level of blood glucose as near-normal as possible.

This will ensure that you avoid glucose levels that are dangerously low or high, which can cause immediate and unpleasant symptoms and potentially lead to a medical emergency. It will also ensure than in the longer term, your diabetes does not cause harm your health as a result of high glucose levels.

Achieving near-normal blood glucose levels means aiming to keep your glucose between 4 and 7 mmol/l (70 – 125 mg/dl) before meals and no higher than 9 mmol/l (160 mg/dl)two hours after meals.

Maintaining this level of glucose control is not easy and requires regular measurement of glucose levels, using a meter and test strips. As a minimum, it is recommended that the glucose level is checked before each meal and before bedtime (that is, before every insulin injection) and also if feeling unwell; before, during and after exercise; and before driving – this may require up to 10 tests a day.


Four is the floor

An important aim of treatment is that your blood glucose level should never drop below 4mmol/l (or 70mg/dl).

This is because any blood glucose level below this risks falling further and leading to hypoglycaemia. Once the glucose level is below 3mmol/l (54mg/dl), there will not be enough glucose available for the brain and other organs to function properly.

This causes a number of symptoms that result from the effect of hormones such as adrenaline (causing tremor, sweating, hunger) as it tries to counter the effect of insulin and increase the glucose levels. Other symptoms (such as drowsiness and confusion) result from the brain being starved of glucose. Unless corrected by taking in glucose, the blood glucose level can fall further to cause fits, coma and even death.

It is therefore essential that you are able to recognise the early warning symptoms and act to prevent a dangerous hypo.

You will notice that the ‘floor’ has been set at 4, which is a little higher than the level normally associated with hypoglycaemia. This is to provide a ‘safety buffer’ to allow for the fact that insulin treatment is not an exact science and blood glucose meters are not always 100 per cent accurate.

This is very important, as if the glucose level drops to 3 or below on a regular basis, the body adapts by losing the warning symptoms of hypoglycaemia. It is as if it accepts low glucose values as the ‘new normal’, and therefore decides there is no need to react with symptoms.

This is called hypoglycaemic unawareness and means that a person can be running along with a glucose level of less than 2mmol/l (36mg/dl) and still feel they are functioning normally. Yet their brain is being starved and they are at risk of becoming unconscious with no warning.

It used to be thought that hypoglycaemic unawareness was a permanent feature that happened in people who have had type 1 diabetes for many years. However, it is now known that if a person with hypoglycaemic unawareness can avoid hypoglycaemia (by making ‘four the floor’) then their symptoms will return and they again become aware of hypoglycaemia.

So the principle of ‘four is the floor’ is extremely important.

It also means that if you are experiencing both low and high glucose levels, it is important to work on preventing the lows as a priority. Very often then the highs will sort themselves out, as they often are a result of over-correcting a low with too much sugar.

What next?

These three principles emphasise the importance of ensuring you are on the correct doses of insulin. Far too often, I meet people who are on the wrong dose of insulin and as a result experience hypos very frequently. In the old days, having hypos was part and parcel of having type 1 diabetes. Nowadays it should not be, and a combination of regular review of insulin doses, regular glucose monitoring and doing everything possible to avoid hypos will greatly help you achieve this. My book, Take Control of Type 1 Diabetes shows you how to use the information from your glucose testing to make sure you are on the correct insulin doses.

I spend a lot of time in my consultations discussing these issues. If they affect you, I would be delighted to help out. Why not book an appointment to see me at The London Diabetes Centre?


To carry onto the second part of this series, click here.

By Dr David Cavan
Endocrinology, diabetes & metabolism

Dr David Cavan is one of the UK's leading diabetes physicians with considerable experience and expertise in all aspects of the management of the condition. He has particular interest in the intensive management of type 1 diabetes including insulin pump therapy, and lifestyle management in those with type 2 diabetes.

Dr Cavan strongly believes in the importance education and self-management for people with diabetes, and he has developed educational programmes for those with type 1 & 2 diabetes. He has worked on a number of global projects, including most recently the development of programmes in Bermuda to tackle the high prevalence of type 2 diabetes there. 

Dr Cavan has contributed to numerous peer-reviewed publications on many aspects of diabetes. In 2014, he published his first book, 'Reverse your diabetes: the step by step plan to take control of type 2 diabetes'. This was followed in 2016 by 'Reverse your diabetes diet'. In 2018 he published two books, 'Take control of type 1 diabetes' and, together with food writer Emma Porter, 'The low carb diabetes cookbook'.   

He consults at London Medical on Wednesday afternoons, usually twice a month.  Please call to book an appointment.  Alternatively, he is available for e-consultations via Topdoctors. 

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